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intra - cardiac thrombosis is a rare cardiac disorder characterised by the development of clot formation in the cardiac chamber with or without other identifiable predisposing factors . the combination of left ventricular ( lv ) thrombosis with normal systolic function and hypercoaguability can cause thromboembolic complications including systemic thrombi.1 there are only one case reports of left ventricle thrombosis with transient deficiency of protein c in a hepatitis case in the literature to date,2 our case illustrates the first case of lv thrombosis with thrombophilia and illustrates the use of extensive laboratory exam in young patient with left ventricular clot formation to roll out predisposing factors for prevention of recurrent intra - cardiac thrombosis formation . we present a case of a 33-year - old woman with normal cardiac ejection function who was admitted to our hospital in severe dyspnoea : her left ventricular ejection fraction was 60% the patient had no history of thromboembolic events , and perioperative transesophageal echocardiography ( tee ) show large thrombus in lv [ figures 1 and 2 ] . on physical examination , she was tachycardic with a heart rate of 95bpm and a normal blood pressure of 110/70 mmhg initial blood work including the complete blood count , electrolytes , liver function tests and cardiac biomarkers were within normal limits . the electrocardiogram demonstrated sinus tachycardia and the chest x - ray confirmed normal cardiac sellout without pulmonary venous congestion . with a diagnosis of thrombi , recent myocardial infarction was ruled out by electrocardiography and cardiac enzyme measurements . left ventricular function was normal and the aortic and mitral valves were normal , as were left atrial dimensions and contours . complete blood count and blood biochemistry were within normal limits , except for prolonged erythrocyte sedimentation and a reduced protein c and s level . the protein c level was 30% ( normal : > 70 ) and protein s level was 50% ( normal:65% ) . there are no abnormal values of antithrombin iii , lupus anticoagulant , and anticardiolipin antibodies , hla - b5 , hla - b27 , anti - nuclear antibody and rheumatoid factor were negative . on echocardioghraphic exam in four chamber view , a rounded mass was seen attached to the anterior wall of the left ventricle [ figures 1 and 2 ] . its shape and characteristics , on echocardiography , were consistent with a mural thrombus . under standard cardiopulmonary bypass , left atrial was opened between the interatrial grooves . lower than the trabeculi at the apex , was a 4 4.0-cm mass that was held against the septum by fibrous trabeculi . the mass was not attached to the papillary muscles , and was excised with its trabecular attachments . the patient had an uneventful postoperative recovery and thrombosis formation was not occurred with periodical follow - up examination . four chamber echocardiography showed left ventricular mass m - mode echocardiography revealed a mass in left ventricule it is unusual for cardiac intraventricular thrombus to form in the high shear environment of the left ventricle when the heart is structurally and functionally normal . we find no previous report of this happening in protein c deficiency.3 esmon demonstrated that protein c binds to the endothelial cell surface protein thrombomodulin and is converted to activated protein c ( apc ) by thrombin . the apc molecule then interacts with protein s to inactivate two critical coagulation cofactors , factors va and viiia.4 marlar reviewed genetic , clinical manifestation and diagnosis of protein c deficiency and found that deficiency of protein c is usually transmitted in an autosomal dominant manner . in the heterozygous state the typical manifestations are recurrent venous thrombosis and associated pulmonary embolism.5 gruber exhibits that the homozygous state , which is rare , shows itself as fulminant intravascular coagulation.6 seligsohn demonstrated that absence of protein c activity despite normal amounts of the protein is due to the presence of a dysfunctional protein c molecule.7 the clinical importance of lv thrombosis is the difficulty in making the diagnosis based on the initial clinical findings . clinicians should be aware of this differential diagnosis in a particular patient who has not risk factors for intra - cardiac thrombosis presenting with dyspnoea . a tte should be the initial diagnostic resource that would prompt tee assessment in cases highly suggestive of lv thrombosis . results of the patient 's laboratory tests for hypercoagulability showed a protein c - s deficiency ( 47% of normal activity ) . an echocardiogram showed no evidence of recurrent clot in the patient 's lv , and the patient 's protein c - s levels had not normalised ; therefore , the warfarin was continued .

we report an exceptional case of , 33-year - old woman presenting with , dyspnoea and chest pain , cardio respiratory sign and symptom related to diastolic dysfunction caused by mass effect of thrombosis on diastolic filling of left ventricule ( lv ) . the common aetiologies of these devastating complication results in thrombophillia diagnosis , and echocardioghraphy showed a large mass in left ventricular cavity . in laboratory exam , protein c - s deficiency was confirmed however , others related test of thrombophillia were negative . the patient underwent cardiopulmonary bypass with thrombosis extraction and her sign and symptom , recovered uneventfully . this case report illustrates an exceedingly rare case of thrombophilia - induced left ventricular clot formation .

acute pancreatitis is an inflammatory process of the pancreas which is characterized clinically by abdominal pain and biochemically elevated pancreatic enzymes in the serum . the pathogenesis of acute pancreatitis is not clearly determined ; however , several factors have been identified to induce pancreatitis . gallstones and alcohol use great number of drugs have been reported to cause acute pancreatitis , and classified as class 1 to 4 based on the number of cases reported , consistent latency period and reaction with challenge . several drugs that are associated with drug - induced pancreatitis act with various mechanisms . in this case first , codeine - induced pancreatitis is well - established ; however , there have been only few cases reported in the literature . second , however , the most important reason is to underline the possible association between codeine use and cholecystectomy . a 68-year - old man admitted to our emergency department with complaints of sudden onset of epigastric pain and vomiting . he had a history of coronary by - pass 6 years ago , but he had no history of myocardial infarct . his regular medications were atorvastatin 10 mg / day , acetylsalicylic acid 100 mg / day and ramipril 10 mg / day . since he had a history of coronary artery disease , he first evaluated for acute coronary syndrome although he had not typical cardiac symptoms . repeated electrocardiograms and cardiac enzymes were normal . on biochemical work - up amylase [ 167 u / l ( 27 - 131 ) ] , lipase [ 234 u / l ( 8 - 78 ) ] , liver enzymes [ ast 146 u / l ( 5 - 34 ) , alt 250 u / l ( 0 - 55 ) , ggt 324 u / l ( 12 - 64 ) ] , total bilurubin [ 1.80 mg / dl ( 0.2 - 1.0 ) ] , and direct bilurubin [ 1.1 mg / dl ( 0 - 0.2 ) ] were found moderately elevated on admission . he underwent cholecystectomy 35 years ago and he had no symptoms since then . on a detailed anamnesis he was asked to use any other drugs . he stated that , because he had non - suppurative dry cough and mild muscle ache due to common cold , his family physician prescribed him a pain - killer which includes ( 300 mg acetaminophen and 30 mg codeine ) with a third time daily dose . he stated that almost 60 minutes after taking the drug he experienced a blunt epigastric pain radiating to his back . abdominal ultrasonograpy was normal with no dilation of intra - hepatic and extra - hepatic bile ducts and with no sign of bile stones . amylase and lipase levels returned normal after 48 hours and all other labs normalized within 5 days . codeine is known to cause acute pancreatitis . however , codeine - induced pancreatitis is extremely rare . the first report was published by hastier et al . in this report pancreatitis episode developed just after 1.5 hours after taking a pain killer including 1 g acetaminophen and 60 mg codeine . , with virtually the same presentation and with the same doses . in the year of 2000 more recently torres et al . reported a codein - induced pancreatitis 1 hour after taking a combination of 500 mg acetaminophen and 30 mg codeine pill . according to the drug - induced pancreatitis classification potential drugs falls into four categories ( 1-iv ) . codeine is included in class 1 . however , the evidence for codeine to fall into class i drug category is only based on the few published reports that we mentioned above . the most important point that we want to emphasize is that nearly all the reported cases of codeine - induced pancreatitis were cholecystectomized patients . similarly , as we mentioned in the case report our patient underwent cholecystectomy 35 years ago . the possible explanation about why cholecystectomy predisposes to acute pancreatitis is the lacking of the reservoir capacity of gallbladder , hence increasing intraductal pressure . the other explanation is the alteration of oddi sphincter motility because of damaging the nerves that pass between the gallbladder and sphincter of oddi after cholecystectomy . the first one is all physicians should be cautious giving medications that are known to cause oddi sphincter spasm to a cholecystectomized patient . this point is particularly important in pain medicine since codeine and codeine - included agents are commonly prescribed for pain relieving . secondly , we believe that this issue should be questioned when a morphine is decided to be given to a patient . even if we have not clear evidence that morphine induce acute pancreatitis , effect of morphine on human sphincter of oddi was clearly shown . in summary , the clinically important point is that cholecystectomy predispose to acute pancreatitis when a patient is given a drug that increase oddi sphincter spasm .

in this paper , we report a case of drug - induced pancreatitis just after taking a pain pill including a low - dose combination of acetaminophen and codeine . codeine - induced pancreatitis has been rarely reported , however , well - established . the proposed mechanism for codeine - induced pancreatitis is by increasing oddi sphincter pressure . however , the clinically important point is that the codeine - induced pancreatitis is seen almost only in the cholecystectomized patients due to lacking of its reservoir capacity . codeine is commonly used alone or in combination in pain medicine . therefore , it is fairly important to question whether a patient underwent cholecystectomy when a physician decides to prescribe codeine - included preparations .

intermuscular lipomas are rare and tend to develop in the anterior portion of the abdominal wall and rarely in the extremities . unlike its common counterpart ; subcutaneous lipomas which are conspicuous by their bumps , an intermuscular lipoma may not become obvious till it attains an enormous size or produces symptoms due to pressure affect . we treated a case of intermuscular lipoma of the anterior abdominal wall in a 4-years - old girl , presenting like spigelian hernia . to our knowledge , intermuscular lipoma of the abdominal at such young age a 4-year - old girl was brought to us with history of a swelling at her anterior abdominal wall at right lower quadrant , which appeared only during crying , coughing , or straining ; typical of an intermuscular hernia [ figure 1 ] . the child was hyperactive and did not allow proper examination and no lump could be palpated . clinical diagnosis of spigelian hernia was made and the patient was prepared for hernia repair . but under general anesthesia , one globular lump was palpable at the right iliac fossa . a transverse incision was made over the mass and further dissection revealed a lipomatous tumor between abdominal wall muscles . as dissection proceeded , muscle groups were separated and a dumb - bell shaped tumor was removed completely [ figure 2 ] . bulge at right iliac fossa during crying intraoperative picture showing the dumb - bell shaped lump lipomas are one of the most commonly encountered benign mesenchymal tumors of mature adipose tissue and commonly found in subcutaneous plane in the extremities and trunk . lipomas may occasionally be found within a muscle ( intramuscular lipomas ) or between muscles ( intermuscular lipomas ) . intermuscular lipomas account for 0.3% of fatty tumors , arise predominantly in middle and late adult life , and occur most often in the anterior abdominal wall . lipomas that occur in the subcutaneous layers is the most noticeable , as they create visible bumps underneath the skin . inter- and intramuscular lipomas lay within the body surface are not noticeable unless they grow to a large size . a large intermuscular lipoma may produce symptoms such as muscle aches or shooting pains , which can occur if the lipoma presses on a nerve . ultrasonography is the initial diagnostic procedure employed , but it may not visualize the mass . though our case had a large intermuscular lipoma it was not obvious during normal activities of the child and even ultrasonography could not visualize the mass . spigelian hernia occurs through slit - like defect in the anterior abdominal wall adjacent to the semilunar line . spigelian hernia can be congenital or acquired , but spigelian hernia is in itself very rare . most of spigelian hernias occur in the lower abdomen where the posterior sheath is deficient . the diagnosis of spigelian hernia is difficult ; few surgeons suspect it , it has no characteristic symptoms , and the hernia may be interparietal with no obvious mass on inspection or palpation . it may present as a swelling adjacent to the iliac crest . the patient may have a classic lump when he / she strains and disappears on lying down . ultrasound is recommended as first - line imaging investigation , but the correct diagnosis is not always obtained . after complete resection , there is 1% chance of recurrence for a usual lipoma as compared to 19% recurrence rate for an intermuscular lipoma , which is most likely due to incomplete surgical excision , especially for an infiltrative type of intermuscular lipoma . thus , the possibility of recurrence after a long tumor - free period is probable , and therefore an extended period of follow - up is desirable .

lipomas are commonest benign tumor and can occur at any part of the body , but intermuscular lipomas are very rare and usually occur at middle age or later . intermuscular lipomas remain hidden till they attain a large size . they commonly appear on anterior abdominal wall . we treated a case of intermuscular lipoma in a 4-year - old girl . it presented as a bulge at right iliac fossa during straining ; its location and symptoms were similar to that of spigelian hernia . actual diagnosis was made under general anesthesia and complete surgical excision was done . this is a rare mode of presentation of an intermuscular lipoma . intermuscular lipoma of the abdominal wall at this young age was not reported earlier .

the hemophagocytic lymphohistiocytosis ( hlh ) is a clinical syndrome that occurs due to unregulated activation of lymphohistiocytic cells and results in hemophagocytosis , hypercytokinemia , and multiorgan system dysfunction . the diagnostic criteria for hlh are shown in table 1 , established by the histiocyte society . diagnostic criteria for hlh the hlh has been classified into two forms : primary or familial and secondary or acquired . primary hlh is an autosomal recessive condition linked to mutations in the gene coding perforin . more than 70% of patients with familial hlh develop the disease at 1-year of age . the secondary hlh is most commonly associated with viral infections , including epstein - barr virus ( ebv ) , cytomegalovirus ( cmv ) , varicella zoster virus ( vzv ) , herpes simplex virus ( hsv ) , parvovirus , and human immunodeficiency virus ( hiv ) . we present a case of ebv - associated hlh in a young women who recovered successfully due to early recognition and prompt therapy . a 27-year - old female admitted to intensive care unit ( icu ) of our hospital with fever and back pain for 5 days , widespread maculopapular rash for 2 days and difficulty in breathing for 1-day . after her last relapse , she has received oral corticosteroids for 6 months . on admission , laboratory evaluation on critical care admission revealed a low white blood cell count , severe pancytopenia , low hemoglobin , elevated lactate dehydrogenase , ferritin and triglycerides level [ table 2 ] . the clotting test revealed hypofibrinogenemia with a normal value of international normalized ratio and activated partial thromboplastin time [ table 2 ] . laboratory results of the patient magnetic resonance imaging ( mri ) brain with contrast revealed findings consistent with multiple sclerosis . based on the clinical features and laboratory results , a provisional diagnosis of the macrophage activation syndrome was made . bone marrow aspiration and additional serology tests were performed . in bone marrow aspiration , macrophages showed evidence of hemophagocytosis . hepatitis ( b and c ) as well as hiv serology were found to be negative . blood and urine cultures were negative at the time of admission and throughout her hospitalization . the cerebrospinal fluid ( csf ) biochemistry was normal , and its aerobic culture was negative . hsv and mycobacterium tuberculosis polymerase chain reaction ( pcr ) on csf were negative . the ebv visceral capsid antigen igm and igg were positive while epstein - barr nuclear antigen igg was negative . this was included solely as a check for the source of false positive igm reaction . the ebv dna quantitative pcr performed on plasma was positive with a viral load of 22,959 dna copies / ml . the patient was subsequently started on high doses of corticosteroids and immunoglobulin . as the clinical condition did not improve , etoposide etoposide was administered in a dose of 150 mg / m on day 4 and day 7 . she was extubated on day 7 of her icu admission , her rashes start to resolve and she became afebrile . the ebv dna copies number decreased , platelets count improved significantly , and hyperferritinemia also showed improvement . she was shifted to the ward on day 10 , and later discharged on day 21 . at discharge from the hospital , she was advised to come for her regular follow - up in the neurology clinic . ebv - induced hlh can affect any age group , ranging from infant to young adult and tends to occur in apparently immunocompetent individuals . although associated with substantial morbidity and mortality , early diagnosis and precise therapy may result in successful treatment of this condition . in addition to corticosteroids and immunoglobulin , treatment of ebv - associated hlh often requires administration of etoposide . the hlh should be included in the differential diagnosis of clinical conditions such as fever of unknown origin , hepatitis with coagulopathy ( 30% of the hlh patients present with transaminases above 100 any severe or unusual progression of symptoms in a common disease should raise the suspicion of an hlh complicating the underlying condition . ebv induced hemophagocytosis can occur in patients with underlying multiple sclerosis on prolonged steroid therapy . our case highlights that hlh should be included in differential diagnosis of a patient admitted in critical care with atypical and severe febrile syndrome . the ebv dna quantitative pcr helps in diagnosis and monitoring of ebv - associated secondary hlh patient .

we report a case of 27-year - old female diagnosed with hemophagocytic lymphohistiocytosis ( hlh ) following a recent epstein barr virus ( ebv ) infection . a known case of relapsing remitting multiple sclerosis on corticosteroids for last 6 months presented to the critical care unit with fever , maculopapular rash and difficulty in breathing . a rapid and correct diagnosis with the precise treatment led to complete recovery of this patient . the hlh is a rare complication of primary ebv infection .

smitz et al . reported that predictive accuracy depends on both operator technique and quality of instrumentation1 . thus , expensive equipment for precise measurement of temperature , such as digital infrared thermographic imaging devices , was necessary for use in research2 . however , in clinical use , the need for expensive equipment to measure temperature is limited , and therefore tympanic thermometers are popular and commonly used . the tympanic thermometer measures body temperature using infrared rays3 . the eardrum is a readily accessible hypothalamic thermostat , and therefore measuring the temperature of the eardrum is theoretically very precise4 . reported that the accuracy of infrared ear thermometry in children is poor , and can not replace rectal thermometry in clinical pediatric practice3 . many authors still recommend measuring rectal or oral temperature when precise body temperature is required1 , 3 , 5 . however , in measuring rectal and oral temperatures , hygienic management of the thermometer is difficult , and more time is needed to measure temperature . thus , this study investigated intra - rater reliability when using a tympanic thermometer under different self - measurement conditions . the study subjects included 10 males aged 25.0 2.1 years ( mean sd ) , with a mean height and weight of 174.2 2.5 cm and 65.5 5.3 kg , respectively . the subjects received an explanation about the purpose and methods of the study prior to participation and provided informed consent according to the principles of the declaration of helsinki . in this study , body temperature was measured with a tympanic thermometer in current use by hospitals and produced by b company . condition 1 : passive measurement by professional medical staff ; condition 2 : self - measurement before learning measurement technique using a tympanic thermometer ; condition 3 : self - measurement after learning measurement technique using a tympanic thermometer . a professional nurse with more than three years of experience measured the temperature under condition 1 . body temperature of the ten subjects was then measured under condition 2 . after watching a 5-minute video describing measurement technique using a tympanic thermometer and eardrum anatomy , intra - rater reliability using a tympanic thermometer was assessed by comparing the measured values under these three conditions of measurement . intraclass correlation coefficients ( iccs ) were used to assess intra - rater reliability under the three conditions . according to the icc analysis , reliability was high in the order of condition 3 ( 0.97 ) , condition 1 ( 0.92 ) , and condition 2 ( 0.90 ) . the shape of the eardrum differs among individuals , and a tympanic thermometer is designed for non - experts to use to measure temperature3 , 4 . self - measurement of body temperature is more precise when combined with common sense and basic education about the anatomy of the eardrum . use of a tympanic thermometer in children or patients with a mental disorder is difficult ; however , in the case of adult patients hospitalized for a prolonged period because of a febrile illness , self - measurement data should be taken into account along with measurement by a professional . in addition , a tympanic thermometer is designed to present the highest of multiple readings as the measured value4 . statistical analysis was not performed , but the average of the measured values under condition 3 was highest . if simple common sense combined with knowledge of the anatomy of the eardrum is applied to the technique of temperature measurement using a tympanic thermometer distributed to caregivers , precision of use will be enhanced for both adults and children .

[ purpose ] this study investigated intra - rater reliability when using a tympanic thermometer under different self - measurement conditions . [ subjects and methods ] ten males participated . intra - rater reliability was assessed by comparing the values under three conditions of measurement using a tympanic thermometer . intraclass correlation coefficients were used to assess intra - rater reliability . [ results ] according to the intraclass correlation coefficient analysis , reliability could be ranked according to the conditions of measurement . [ conclusion ] the results showed that self - measurement of body temperature is more precise when combined with common sense and basic education about the anatomy of the eardrum .

little is known about the genetic variation of henipaviruses because few sequences are available ; most sequences came from the niv outbreak in malaysia and singapore . from the niv outbreak in malaysia , sequences were obtained for isolates from 4 humans , 4 pigs , and 1 bat . one sequence is available for the original hev isolate and 1 isolate each of niv from bangladesh and india . a limited sequence for the n and g genes for 2 isolates from cambodia has been deposited in genbank . five additional isolates from horses were obtained from outbreaks in murwillumbah ( 2006 ) , peachester ( 2007 ) , clifton beach ( 2007 ) , redlands ( 2008 ) , and proserpine ( 2008 ) . these isolates provided us with a unique opportunity to examine hev sequence variation over time and geographic separations . all isolates had the identical genome length of 18,234 nt , with the sequence variation across the full genome being < 1% . all open reading frames ( orfs ) were the same length as those of the original hev isolate ( hendra virus / australia / horse/1994/hendra ) . the n orf had the highest percentage of changes in both nucleotide and amino acid variation ( table 2 ) . the number of nucleotide changes was lower than those in other rna viruses ; for example , the n gene of measles virus showed up to 7% variation in nucleotide sequence ( 14 ) . the predicted size of each of the p gene products ( v , w , and c ) was conserved in all isolates . the small basic ( sb ) protein orf identified in the original hev isolate of hev , but not seen in any of the niv strains , was present in all isolates with an identical length of 65 aa . the variation in this orf was higher than that for other orfs , with 06% aa variation . although sb is in an alternate frame within the p gene , the variation was much higher than that of the c orf , which is also in an alternate orf . phylogenetic analysis was performed by using both dna and amino acid sequences for individual genes and for the complete genome . the multiple branches of the phylogenetic tree , particularly for the n gene ( figure ) , suggest that all these isolates branched from an ancestor earlier than 1994 when the first identified outbreak occurred . for example , the 2006 isolate from murwillumbah shows greatest similarity to the 1994 isolate , whereas the other isolates are in a separate branch on the tree . phylogenetic trees based on the n open reading frame ( orf ) ( a , b ) and the g orf ( c , d ) , with dna sequences used for a and c and amino acid sequences for b and d. all sequences were compared with the reference sequences for each of the known henipavirus strains ; hendra virus / australia / horse/1994/hendra ( genbank accession no . af212302 ) , nipah virus / bangladesh / human/2004/rajbari , r1 ( genbank accession no . ay988601 ) , nipah virus / cambodia / bat/2004/khm / csur381 ( genbank accession no . ay858110 [ n orf ] and ay858111 [ g orf ] ) and nipah virus / india / human/2007/gf ( genbank accession no . phylogenetic trees were constructed by using the neighbor - joining algorithm in the mega4 software package ( 15 ) . hev , hendra virus ; niv , nipah virus . the data reported here are consistent with each of these individual spillover events that occurred after exposure to viral variants coming from a large pool of quasispecies in the bat population in australia . this genetic conservation in hev isolates may suggest that hev is genetically stable in the reservoir bat population , although because of the lack of hev isolates from bats , the possibility can not be excluded that this genetic similarity resulted from selection both for variants that can infect horses and selection within the infected horse . further analysis of this sequence data and future sequence information will help with understanding of differences in the clinical picture and may provide evidence to explain the apparent increase in regularity of recent spillover events . our results demonstrated that hev isolates from horses are genetically similar , with variation at both the nucleotide and amino acid levels , uniformly small , and < 1% across the 18.2-kb genome . furthermore , data show that different outbreaks resulted from independent spillover events from a pool of hev quasispecies in the fruit bat populations in australia . the genetic relatedness of hev isolates from horses is not correlated with the time the corresponding hev outbreaks occurred . the presence of sb orf in all hev isolates , but not in niv isolates , warrants further functional analysis of this intriguing putative protein .

bat - to - horse transmission of hendra virus has occurred at least 14 times . although clinical signs in horses have differed , genome sequencing has demonstrated little variation among the isolates . our sequencing of 5 isolates from recent hendra virus outbreaks in horses found no correlation between sequences and time or geographic location of outbreaks .

two monkeys were trained to perform a ball grasp task ( fig . 1 ) and , one , a controlled - force palmar grip task . the monkeys were allowed five seconds to grasp one of several balls ( ranging in size from 2540 mm diameter and 55130 g ) and place it into the top of a dispenser tube . the palmar grip task required the monkey to squeeze a pneumatic tube which controlled movement of a cursor . force targets were chosen from a set of two or three non - overlapping levels . all procedures were approved by the institutional animal care and use committee of northwestern university . inputs consisted of roughly 100 single and multi - unit signals from a 100-electrode array ( blackrock microsystems inc . , decoders consisted of multiple - input impulse response functions between the neural inputs and each muscle , transformed by a 2 order static nonlinearity to reduce the baseline noise in the predictions and to increase the gain near the emg peaks . we computed decoders at the beginning of each week , which were used in daily sessions for the remainder of the week . we conducted 20 sessions with 7 decoders across seven weeks for monkey t and 27 sessions with six decoders across eleven weeks with monkey j. all muscles were stimulated at a single , fixed rate of either 25 or 30 hz to achieve nearly fused contractions . the emg predictions were transformed into stimulus pulse widths by mapping the predicted emg noise floor to the stimulus force threshold , and the maximum predicted emg to the maximum pulse width ( 200 s ; see supplemental fig . the current , typically 28 ma , was chosen independently for each electrode , to yield forces of roughly 50% of the maximal evocable force at 200 s pulse width . two monkeys were trained to perform a ball grasp task ( fig . 1 ) and , one , a controlled - force palmar grip task . the monkeys were allowed five seconds to grasp one of several balls ( ranging in size from 2540 mm diameter and 55130 g ) and place it into the top of a dispenser tube . the palmar grip task required the monkey to squeeze a pneumatic tube which controlled movement of a cursor . force targets were chosen from a set of two or three non - overlapping levels . all procedures were approved by the institutional animal care and use committee of northwestern university . inputs consisted of roughly 100 single and multi - unit signals from a 100-electrode array ( blackrock microsystems inc . , decoders consisted of multiple - input impulse response functions between the neural inputs and each muscle , transformed by a 2 order static nonlinearity to reduce the baseline noise in the predictions and to increase the gain near the emg peaks . we computed decoders at the beginning of each week , which were used in daily sessions for the remainder of the week . we conducted 20 sessions with 7 decoders across seven weeks for monkey t and 27 sessions with six decoders across eleven weeks with monkey j. all muscles were stimulated at a single , fixed rate of either 25 or 30 hz to achieve nearly fused contractions . the emg predictions were transformed into stimulus pulse widths by mapping the predicted emg noise floor to the stimulus force threshold , and the maximum predicted emg to the maximum pulse width ( 200 s ; see supplemental fig . the current , typically 28 ma , was chosen independently for each electrode , to yield forces of roughly 50% of the maximal evocable force at 200 s pulse width .

patients with spinal cord injury lack the connections between brain and spinal cord circuits essential for voluntary movement . clinical systems that achieve muscle contraction through functional electrical stimulation ( fes ) have proven to be effective in allowing patients with tetraplegia to regain control of hand movement and to achieve a greater measure of independence in activities of daily living 1,2 . in typical systems , the patient uses residual proximal limb movements to trigger pre - programmed stimulation that causes the paralyzed muscles to contract , allowing use of one or two basic grasps . instead , we have developed , in primates , an fes system that is controlled by recordings made from microelectrodes permanently implanted in the brain . we simulated some of the effects of the paralysis caused by c5-c6 spinal cord injury 3 by injecting a local anesthetic to block the median and ulnar nerves at the elbow . then , using recordings from approximately 100 neurons in the motor cortex , we predicted the intended activity of several of the paralyzed muscles , and used these predictions to control the intensity of stimulation of the same muscles . this process essentially bypassed the spinal cord , restoring to the monkeys voluntary control of their paralyzed muscles . this achievement represents a major advance toward similar restoration of hand function in human patients through brain - controlled fes . we anticipate that in human patients , this neuroprosthesis would allow much more flexible and dexterous use of the hand than is possible with existing fes systems .

small colony variants ( scv ) originate from wild - type staphylococcus aureus by mutation in metabolic genes , leading to the emergence of auxotrophic bacterial subpopulations . s. aureus scv are characterized as electron transport deficient bacteria because of their auxotrophism to hemin or menadione or are recognized as thymidine - dependent . due to deficient components of electron transport chain , aminoglycoside antibiotics , can not be transported across their cell membrane , thus explaining resistance to this class of antibiotics . diagnosis is very difficult due to atypical phenotypic features like lack of hemolysin and slow growth . we here describe isolation of carbon dioxide auxotrophic scv of s. aureus in a case of breast abscess . kd , a 23-year - old female patient , resident of patna , bihar , presented to the general surgery out - patient department of the institute with chief complaints of pain and lump in lower part of left breast with purulent nipple discharge , since last 1-year . she also gave a history of consumption of multiple antibiotics over last 6 months , prescribed by local practitioners , but could not specify the antibiotics . on examination , the lower part of left breast was tender and showed black discoloration . transmammary ultrasonography showed duct atresia of the left breast . under ultrasonographic guidance , about 10 ml of pus was drained from her left breast . gram - stain of the sample showed copious leucocytes and gram - positive cocci arranged in clusters . culture on 5% sheep blood agar and macconkey agar showed nonhemolytic , low convex , opaque , lactose - fermenting colonies of 0.1 mm diameter after 24 h of aerobic incubation . gram - stain of the colonies showed gram - positive cocci of variable size , in grape - like clusters . slide coagulase test was positive but delayed , and came positive only after addition of excess pooled human plasma . antibiotic susceptibility was carried out by kirby - bauer disk diffusion method as per clinical and laboratory standards institute protocol . the following antibiotic discs were used : cefotaxime ( 30 g ) , amoxiclav ( 30 g ) , clindamycin ( 2 g ) , erythromycin(15 g ) , cefotaxime ( 30 g ) and levofloxacin ( 5 g ) . simultaneously , colonies were subcultured on 1 mueller - hinton agar ( mha ) plate and grown inside a glass candle jar ( desiccator ) containing a burning candle , at 37c . furthermore , lawn culture of the isolate was performed on 1 mha plate and a disc containing 15 g vitamin k ( menadione ) was placed on it . next day , the plate placed in the candle jar grew large ( 1.5 mm diameter ) colonies . small colony variants of s. aureus can persist inside host cells and modulate host defences . they form small , colorless , nonhemolytic colonies after 48 h of incubation , are only slowly coagulase positive , fail to ferment mannitol , and can revert to the parental wild phenotype . scvs are characterized by a strong reduction in growth rate , an atypical colony morphology , and unusual biochemical characteristics , which causes them to be commonly undetected or misidentified by standard clinical microbiology procedures . these types of scvs have been recovered from cases of endocarditis , wound infections , respiratory infections and others . although the prevalence of scvs of s. aureus in clinical specimens in a general microbiology laboratory has been estimated to be around 1% , scvs are recovered more frequently from certain groups of patients , such as those with cystic fibrosis . they also have reduced -toxin gene expression and hence cause less damage to host cells , thus producing subclinical , persistent infections . co2 auxotrophic scvs are characterized by fastidious growth characteristics and an atypical , small - colony morphology ( nonpigmented and nonhemolytic colonies ) that may be entirely overlooked in mixed cultures . when they are recognized , scvs may still be misidentified as coagulase - negative staphylococcus spp . , and susceptibility test results can be difficult to interpret . to reduce the potential of missing co2 auxotrophic scv isolates , it is important to observe the microbiological characteristics of colonies on plates incubated in a co2 rich atmosphere and to extend conventional cultures to at least 72 h. as far as we know , this is the first case of abscess caused by co2 auxotrophic scvs in a female patient from this region .

small colony variants ( scv ) are persistent , intracellular morphotypes of staphylococcus aureus causing indolent , subclinical infections . they are usually auxotrophic for thymidine , menadione or carbon dioxide . diagnosis is often misleading due to small colony type , delayed coagulase activity and lack of hemolysis . we hereby describe a case of co2-auxotrophic scv of s. aureus causing left breast abscess in a young female with duct atresia of breast , detected by increased colony size in co2 rich environment . scvs can often be missed and have to be identified and treated properly .

although surgical excision is curative , their location near important organs may make complete excision very challenging . this report entails successful surgical excision of a large teratoma in the gluteal region , which clinically appeared to be a lipoma in a young girl . pg , a 6-year - old girl presented with a swelling in her left buttock , which was present since birth . the swelling was gradually increasing in size , and she had pain and discomfort while seating . the tumor was bulky and soft on palpation and could be separately felt from the sacrum and coccyx . a contrast computed tomography and magnetic resonance imaging ( mri ) scans showed well - encapsulated contrast - enhanced bowel loops with other soft tissue elements [ figure 1 ] . serum alpha - fetoprotein level was normal . on exploration , well - developed colon and small bowel loops were seen along with small cysts , bones , and muscle elements [ figure 2 ] . the tumor was completely excised along with its sac ; redundant skin and subcutaneous tissues were excised . the histology showed the structure of normal colon and small bowel with areas of fetiform structure in soft tissues . the patient has been on follow - up for 16 months . at last follow - up magnetic resonance imaging scan showing encapsulated mass with bowel loops and soft tissues the mass with well - developed colon segment extragonadal teratomas of childhood are rare tumors and may occur in unusual locations such as , retroperitoneum , mediastinum , craniofacial region or even in the solid organs ( liver , kidney ) . these tumors often present with acute symptoms and may have some distinctive features such as an unusual location and a fetiform histotype of the lesion . some tumors are detected on antenatal ultrasound and treatment in such cases can be initiated early to prevent complications . tumors occurring in unusual sites may cause problem because of their anatomical location and size . reported 267 cases of teratomas , of which 10 cases occurred at rare sites , such as retroperitoneal space ( 3 cases ) , floor of the mouth ( 3 ) and one each in the kidney , mediastinum , thyroid gland , and the urinary bladder . reported 4 cases of teratomas at unusual sites in 2 neonates , 1 infant , and one 4-year - old child . two neonates had tumors detected on antenatal ultrasonography and 3 patients presented with acute symptoms requiring emergency surgery . the infant had a tumor arising from the liver and the older child had a retroperitoneal tumor . perez carro et al . used mri to differentiate a gluteal teratoma from more common tumors in this site arising from fat or fibrous tissue . fetiform teratoma is a distinct entity with highly organized differentiation but without visceral organ differentiation . however , kuno et al . described a fetiform teratoma with both a highly developed axial skeleton and organs that included a brain , eyelike structure , trachea , thyroid gland , blood vessels , gut , and phallus like structure . remarkably , skeletal muscle has never been documented in a teratoma . in the present case most of the gluteal teratomas reported in the literature are , in fact , sacrococcygeal teratomas presenting in a lateral location . reported an 11-year - old girl who presented with a fetiform gluteal mass attached to the sacrum by a fibrous band . gajbhiye et al . also reported a 4-month - old girl with anorectal malformation , who had a gluteal mass . jan et al . described a case of lateralized cystic sacrococcygeal teratoma mimicking gluteal abscess . , it is ideal to have estimation of serum alpha - fetoprotein level and proper imaging studies to know about the characteristics and extent of the tumor . serial section of the excised mass is important , especially in older children to detect any immature neuroepithelial elements or elements of yolk sac tumor .

extragonadal teratomas are rarely encountered in infants and children . these tumors are reported in retroperitoneum , floor of the mouth , mediastinum , craniofacial region or even in the solid organs of the body . most of the gluteal teratomas reported in the literature are in fact , lateralized sacrococcygeal teratomas . we are reporting a case of unilateral big gluteal teratoma in a 6-year - old girl . the tumor did not have any connection with the sacrum or coccyx and was successfully removed . histology showed well - differentiated bowel as well as fetiform structures .

pregnant women have an increased need for iron that might not be met with diet alone . due to physiologic anemia and population differences , no set criteria for defining iron deficiency anemia ( ida ) are available globally . studies have reported an association between poor iron status and negative health outcomes such as low birth weight , premature birth , and perinatal death for women and their infants , although the evidence is weak . prenatal screening for ida and routine iron supplementation may allow clinicians to diagnose and preemptively treat iron deficiency and ida in pregnant women , leading to a decreased risk of future negative health outcomes . however , there is a lack of one consistent set of guidelines that can be applied safely to all populations globally . one such effort was made by the united states preventive services task force ( uspstf ) , which last reviewed evidence on prenatal screening for ida in 2006 and recommended routine screening on the basis of fair - quality evidence . according to the usptf , although there is insufficient evidence for screening asymptomatic or treating nonanemic asymptomatic pregnant women , treatment of asymptomatic ida has moderate health benefits . this summary reports the evidence for routine screening and iron supplementation for ida in nonsymptomatic pregnant women . researchers from the uspstf conducted a systematic review and meta - analysis of studies reporting routine screening and iron supplementation for asymptomatic ( anemic and nonanemic ) women and the intervention 's effect on any health outcomes for women and infants . the review included randomized controlled trials , nonrandomized , controlled trials and cohort studies including asymptomatic pregnant women receiving screening or supplementation for ida , and the studies were in english . when good- and fair - quality studies were available , poor - quality studies were excluded as were studies only published with abstracts or without original data . the review focused on studies using iron supplementation and treatment regimens commonly used in clinical practice in the united states and those conducted in countries with high or very high human development based on the united nations 's human development index . study quality was assessed by the two reviewers who used predefined criteria set by the uspstf , which rates study quality as good , fair , or poor . after conducting a thorough search , researchers from the uspstf selected 12 trials that compared the effects of routine prenatal iron supplementation versus no supplementation . no trials reporting on the benefits or harm of routine screening on pregnant , maternal , or infant health outcomes evidence from new trials supports the previous findings of routine supplementation improving maternal ida and other blood indices . however , there is still insubstantial evidence for the effect of routine iron supplementation or screening on maternal or infant health outcomes as reported in table 1 . this means that the current evidence supports the previous usptf recommendations of routine prenatal iron supplementation . studies included were of good and fair quality ; however , due to low number of trials , there is a lack of generalizability , no consistent amount of iron dose used , and clinical outcomes mostly reported as ad hoc events . evidence supports routine supplementation in terms of maternal hematologic health but does not have any impact on maternal and infant clinical health outcomes . for the second question , evidence was not strong enough to support or oppose the effect of routine screening on anemic and nonanemic women in terms of future health benefit(s ) or harm(s ) for the involved woman or infant . for physicians , the message is that routine supplementation of iron during pregnancy does improve hematologic markers in women reducing future risk of ida , so it should be continued . however , routine screening for ida in asymptomatic women may or may not be conducted since there is still a lack of sufficient evidence to develop a recommendation for this procedure . the previous usptf report identified certain research gaps that included whether routine iron supplementation and ida screening impacted future clinical outcomes of women and their children as well as whether routine ida screening should be implemented in asymptomatic women . this report , albeit able to corroborate the findings for routine iron supplementation , found inadequate evidence for routine ida screening and did not address whether routine ida screening will impact the hematologic indices of asymptomatic women . these gaps need to be filled with strong long - term clinical trials needed to evaluate the effect of screening and routine iron supplementation on maternal and infant short- and long - term health outcomes . trials need to be conducted on a large scale in high- , middle- , and low - income countries that focus on certain regimens , stratify populations based on risk factors , and are powered to report clinical outcomes . trials support the use of routine iron supplementation in anemic and nonanemic asymptomatic pregnant women ; however , there is a lack of evidence for or against routine screening in this population .

clinical scenariopregnant women have an increased need for iron that might not be met with diet alone . due to physiologic anemia and population differences , no set criteria for defining iron deficiency anemia ( ida ) are available globally . serum ferritin and transferrin levels are often used to guide therapy by clinicians . studies have reported an association between poor iron status and negative health outcomes such as low birth weight , premature birth , and perinatal death for women and their infants , although the evidence is weak .

although a mechanical ventilator is primarily a life - saving device , its recordings of pressure and flow offer a means for undertaking detailed assessment of respiratory function . over the course of a few seconds , it is possible to obtain a more complete assessment of lung and chest - wall mechanics than can be achieved after an hour 's assessment of an ambulatory patient in a pulmonary - function laboratory . in both settings , this omission is partly because assessment involves use of a distinct set of techniques , such as co2 rebreathing , but the major reason is cognitive : interpretation of the results is highly complex and difficult to incorporate into routine clinical decision - making . the introduction of a new ventilator mode makes it possible for intensivists to outperform the diagnostic capabilities of pulmonologists one more time . in the previous issue of critical care , barwing and colleagues evaluate the usefulness of neurally adjusted ventilatory assist ( nava ) , which requires esophageal electrodes to record electrical activity of the diaphragm ( eadi ) , in patients being considered for a trial of weaning from mechanical ventilation . that the g?ttingen investigators should turn to this group of patients is not surprising . investigators can select a time when they are able to assemble their research armamentarium at a patient?s bedside and observe the natural history of acute respiratory failure unfold over the course of a half - hour or so . if a struggling patient is not reconnected to the ventilator , he or she will die . few experiments in medicine come closer to life - or - death circumstances . in this feasibility study , barwing and colleagues observed increases in respiratory motor output in weaning - failure patients . although the values of eadi were numerically higher in weaning - failure than in weaning - success patients , the difference between the groups did not attain statistical significance - in large part because eadi displayed considerable variability on a breath - to - breath basis ( see figure three of their paper ) , and also because of considerable overlap in the individual values in the two groups ( evident in figure one of their paper ) . in 1986 , my colleagues and i published a study on control of breathing in patients undergoing weaning trials . we recorded mean inspiratory flow ( vt / ti ) as a measure of respiratory motor output . contrasted with eadi , which is recorded with electrodes lying immediately adjacent to the source of respiratory muscle contraction , vt / ti provides a less direct measure of respiratory motor output because it is also influenced by changes in respiratory mechanics . despite this technical limitation , we observed increases in vt / ti in every patient who failed a weaning trial . this finding was surprising because conventional wisdom dictated that the development of acute hypercapnia , consequent to alveolar hypoventilation , was caused by a decrease in respiratory motor output . instead , rapid shallow breathing with a low tidal volume , and inevitable increase in dead space - to - tidal volume ratio , was the reason for the patients ? indeed , hypercapnia and activation of other sensory afferents lead to an increase in respiratory drive . the reason we were successful in detecting significantly higher values of respiratory motor output in weaning - failure than weaning - success patients , in contrast to barwing and colleagues , relates to the methods of data analysis . we collected hundreds of vt / ti values in each patient , sufficient to perform frequency - histogram analysis in individual patients . through signal averaging , we were able to compensate for the marked breath - to - breath variations in respiratory motor output . as originally shown in our 1986 study , and in hundreds of studies since then , rapid shallow breathing is the physiological hallmark of weaning failure . based on our observations , karl yang and i subsequently tested the accuracy of an index of rapid shallow breathing , the frequency - to - tidal volume ratio ( f / vt ) , as a means to screen for weaning readiness . we found it more reliable than all other weaning predictors , and so it remains to this day . barwing and colleagues did not find f / vt to be significantly different between their two groups of patients , but here the explanation lies in the occurrence of test - referral bias . entry into their study required patients to have an f / vt value of less than 105 , which means the investigators were no longer in a position to test the reliability of f / vt as a predictor of weaning outcome . while we know more about weaning failure than we did in the 1980s , we still do not know the mechanism of its physiological hallmark - rapid shallow breathing - and our understanding of neuromuscular control of breathing remains superficial . barwing and colleagues believe that the nava ventilator may prove useful in unraveling these mechanisms . from the raw data evident in their report , it is evident that gaining physiological insights through use of eadi will require sophisticated approaches to time - series analysis to minimize the influence of biological noise . eadi : electrical activity of the diaphragm ; f / vt : frequency - to - tidal volume ratio ; nava : neurally adjusted ventilatory assist ; vt / ti : mean inspiratory flow . mjt declares receipt of royalties from mcgraw - hill for two books published on critical care medicine .

neurally adjusted ventilatory assist operates through recordings of electrical activity of the diaphragm ( eadi ) . barwing and colleagues found increases in eadi in weaning - failure patients , although the values were not significantly different from weaning - success patients . future studies will need to carefully control for the considerable biological noise evident in eadi recordings .

pilomatricoma , or pilomatrixoma , or calcifying epithelioma of malherbe is a benign skin neoplasia originating from hair follicle matrix cells . it usually develops slowly and is known as a single or sometimes multiple benign solid lesions lying just under or in the skin . we report here a case of pilomatricoma diagnosed after surgical excision with the help of histopathology . a 30-year - old female presented to skin department with complaint of swelling over the middle of neck on right lateral side since 1 year . the onset was gradual and initially the size was very small ( pea sized ) but slowly over last 1 year it had grown to the size of an almond . it was painless to begin with but there was an occasional dull ache in the swelling . on examination there was swelling in the right side of neck of 2.5 2.0 cm size [ figure 1 ] . it was smooth on palpation , moderately firm to hard in consistency and minimally tender to touch . it appeared to be fixed with the skin with no attachment to the underlying tissues . there was no rise of local temperature , scar , sinus , or any other remarkable feature . a subcutaneous swelling on right middle of neck a provisional clinical diagnosis of sebaceous cyst was made . the swelling was excised under local anesthesia and sent for histopathological examination . on gross examination photomicrograph showing basaloid cell at the periphery and ghost cells on the right side of the field ( h and e , 100 ) pilomatrixoma . . it may affect individuals at any age , incidence peaks on the first and sixth decades of life . it is more common in women ( 1.5 to 2.5:1 ) among young people , 40% happen before 10 years of age and 60% before 20 years . new hair follicles are not formed after birth , only some are activated during puberty . if they are located in very deep layers , differentiation induction agents will not act properly on them . these tumors can be familial related to gardner 's syndrome , steinerd 's disease , and sarcoidosis . pilomatricomas are often mistaken for small round blue cell tumors in children , or for merkel cell carcinoma , basalioma , and metastatic small cell carcinoma in adults , with possible over aggressive therapeutic approach . a recent study suggests that trisomy-18 is a consistent feature in pilomatricoma , suggesting that genes carried on this chromosome such as that for the antiapoptotic oncoprotein bcl2 may have a role in the growth and differentiation of this benign self - limited tumor . the clinical history of pilomatricama is typical of a slowly enlarging mass , irregularly contoured , which is fixed to the skin but slides freely over the underlying tissues , often with a discoloration , which varies from red to bluish - purple . pilomatrixomas are often misdiagnosed on preoperative evaluation . in a series of 51 histologically proven pilomatrixomas , wells et al found that the diagnosis during reference was incorrect in 94% of cases , and the preoperative diagnosis was incorrect in 57% . in a recent series of 346 pilomatrixomas , the preoperative diagnosis was accurate and consistent with the pathological diagnosis of pilomatrixoma in only 28.9% of cases . finally , kumaran et al reported a correct preoperative clinical diagnosis in 46% following retrospective review of 78 excised pilomatrixomas . incorrect preoperative diagnoses most commonly included unidentified masses , as well as epidermoid cysts , sebaceous cysts , dermoid cysts , nonspecified cysts , and foreign bodies . histological characteristics include ghost cells in the center with basophilic nucleated cells in the periphery . , clinically skin and adjacent tissue infiltration , ulceration , and histologically - presence of nuclear pleomorphism , atypical mitosis , central necrosis is suggestive of malignancy cytomorphologic characteristics of pm are reliable enough for correct preoperative diagnosis in adequate specimens . however , the best results are achieved when fine - needle aspiration cytology is performed by an experienced cytologist after obtaining all clinical data . a rare malignant counterpart , pilomatrix carcinoma , has been described and nearly 90 cases have been reported in the literature . many key features are similar between these benign and malignant counterparts ; the primary differentiating characteristics include a high mitotic rate with atypical mitoses , central necrosis , infiltration of the skin and soft tissue , and invasion of blood and lymphatic vessels . surgical excision with clear margins is the treatment of choice , otherwise there may be recurrence due to incomplete resection . pilomatricoma is a benign tumor of the skin , which is not rare in occurrence but rarely diagnosed preoperatively and it is imperative that it be kept in the differential diagnoses of all benign skin tumors by dermatologists .

pilomatricoma is a benign skin neoplasia , which is not commonly encountered in general practice . the diagnosis is often made only after histopathology . the present case report is of a 30-year - old woman who presented with swelling in neck , which was diagnosed as pilomatricoma only after excision . the idea of reporting this case is that pilomatricoma is not rare in occurrence but rarely diagnosed because of lack of confirmation of excised swelling and it is imperative that it should be kept in the differential diagnoses of all superficial skin tumors by dermatologists and surgeons .

a 48-year - old female patient visited our cardiovascular outpatient department for treatment of a mass - like dilated neck vein as a procedure concomitant with thyroid cancer surgery . we could detect the gross engorgement of the neck mass in the supine position or by using the valsalva maneuver when the patient was in an erect position ( fig . preoperative contrast - enhanced computed tomography ( ct ) of the neck showed a venous dilatation , similar to a cystic mass ( size : 2.52.2 cm ) communicating with the left external jugular vein ( fig . 2 ) . after thyroidectomy under general endotracheal anesthesia , an additional separate skin incision ( length : approximately 2.5 cm ) along the neck dermatome was made because of the distance from the collar incision ( approximately 5 cm ) . we accomplished aneurysmectomy by the division of both ends of the external jugular vein and a tributary of the aneurysm in the subcutaneous layer ( fig . in contrast to focal thinned media with thickened intima by fibrous tissue in a varicose vein , the vascular wall thickness of a venous aneurysm is relatively homogenous with thickened media and localized thickened intima ( fig . acquired venous aneurysm in the neck area is a very rare disease and requires a differential diagnosis including enlarged cervical lymph node , tumor of the adjacent organs , laryngocele , and various cystic formations . according to the incidence rate , the internal jugular vein is a more frequent site of aneurysm development than the external vein , but the anterior jugular vein is the least frequent site . fusiform venous dilatation is frequently diagnosed in children with a congenital etiology and right - side predominance but appears in adults as an acquired form with left - side predominance ; the suggested mechanism in adults is the patient 's hypertensive aorta compressing the left innominate vein , resulting in venous dilatation . in addition , the etiology of an acquired venous aneurysm can involve tumors , inflammation , trauma , or spontaneous development . of the aneurysms resulting from iatrogenic causes , pseudoaneurysm at the internal jugular vein appears most frequently ; a case at the external jugular vein has also been reported . however , the patient in the present case had no previous neck procedures or trauma history . clinically , although painful swelling is associated with intraluminal thrombus , saccular aneurysm appears with painless swelling . the valsalva maneuver , performed by moderately forceful attempted exhalation against a closed airway , usually performed by closing one 's mouth and pinching one 's nose shut while pressing out as if blowing up a balloon , can induce venous engorgement characteristically . however , by manual compression of an engorged neck mass in the case of the external jugular vein , the valsalva maneuver can not make the swelling prominent . because the patient had already undergone contrast - enhanced ct imaging for thyroid cancer , ultrasonography was not required in this case . cosmetic concerns , painful swelling due to intraluminal thrombosis , or phlebitis of the jugular vein are all motives for surgical treatment . otherwise , reassurance and regular follow - up can be a substitute for prompt treatment of an asymptomatic venous aneurysm . although embolic complications have been reported at a lower incidence rate in jugular venous aneurysms , active treatment can not be neglected . a recent report documented a pulmonary thromboembolism derived from an external jugular venous aneurysm , and large - scale studies are needed to overcome the limitations of rare case reports . surgical resection can minimize the risk of pulmonary thromboembolism as well as aneurismal rupture induced by growth and can confirm the histopathological diagnosis . aneurismal resection is accomplished by excision with ligation in the saccular form , and exclusion via bypass in fusiform aneurysms .

saccular aneurysm of the external jugular vein presenting as a neck mass is very rare . we report the surgical treatment of an external jugular venous aneurysm in a 48-year - old female patient due to the cosmetic problem of neck engorgement , concomitant with thyroidectomy for cancer .

the term clonal nevus is used to describe a variant of benign melanocytic nevus that histologically exhibits a localized proliferation of pigmented epithelioid dermal melanocytes within an otherwise ordinary nevus . alternative names for these nevi include inverted type a nevus and nevus with focal clonal hyperplasia . clonal nevi have been well described histologically and huyhn et al have published several clinical photographs of a clonal nevus . a search of the literature has not discovered any previously published dermatoscopic images , however . there are certainly no serial dermatoscopic images of a clonal nevus arising from a previously banal nevus over time . a 30-year - old woman presented for a routine annual skin check in a primary care skin cancer clinic in the outer south eastern suburbs of melbourne , australia . she gave no personal or first - degree family history of melanoma or non - melanoma skin cancer . she had worked on the ski fields in australia for three seasons during the preceding five years . an irritated benign acral nevus had been excised from the third / fourth webspace of her right foot the previous year . a whole body skin examination was undertaken with the aid of a heine delta 20 non - polarizing dermatoscope ( heine optotechnik , herrshing , germany ) . digital clinical and dermatoscopic images were taken with a medicam 800 fotofinder non - polarizing camera ( fotofinder systems gmbh , aichner , birnbach , germany ) , the dermatoscopy images being at 20 magnification . examination showed fitzpatrick skin type 2 with solar lentigines of the face , upper trunk and distal limbs . the lesion in question was located on the central back , was slightly domed and measured 6 mm diameter . it was a uniform pale tan color with a centrally located blue , grey circular area 1 mm in diameter ( figure 1 ) . this was consistent with the clinical description of a clonal nevus by huynh et al , however , on referring to the digital dermoscopic image of the same lesion taken 15 months earlier , there was no central focus of pigmentation of any kind in this image . there had just been a clinically banal benign melanocytic nevus ( figure 2 ) . the central focus of pigmentation the differential diagnosis thus consisted of benign clonal nevus or possible melanoma in view of the documented changes on serial digital dermatoscopy . in one study , bolognia et al concluded that a small percentage of small dark dots within melanocytic nevi are due to melanoma , finding 3 ( 5% ) of 59 such nevi to be melanoma . an excisional biopsy was performed using an 8 mm punch excision , and the specimen was submitted for assessment by a specialist dermatopathologist . examination of the histological sections revealed an intradermal proliferation comprised predominantly of bland nevus cells that matured with descent and tracked down around adnexal structures consistent with a congenital pattern . centrally , there was a small population of somewhat more epithelioid appearing cells surrounded by pigmented melanophages . the findings were consistent with a benign clonal nevus ( figures 3 to 6 ) . a search of the literature has discovered no previously published dermatoscopy images of an evolving clonal nevus . the images we present thus add a further small piece of information to our overall knowledge base of this melanocytic nevus variant . in the case we present the clonal nevus appears to have arisen from a pre - existing clinically banal melanocytic nevus over some 15 months . it is noted that the five cases of clonal nevi presented by huyhn et al were between the ages of 37 and 80 years , all older than the case we present . it is postulated that this dynamic process of evolution may occur in the first three decades of life . a recent case report of clonal nevus on the back of a 9-year - old girl is consistent with this hypothesis . serial digital dermatoscopy is a relatively new diagnostic tool and appears helpful in recording the dynamic nature of melanocytic nevi . the authors feel it is important to publish dermatoscopic images such as ours to as wide an audience as possible to aid in greater understanding of this particular variant of benign melanocytic nevi in the future .

we present a case of a clonal nevus arising from a previously banal melanocytic nevus over a 15-month period on the central back of a 30-year - old woman in a primary care skin cancer practice in melbourne , australia . clinical , dermatoscopic and dermatopathologic images are presented . a search of the literature has discovered no previously published dermatoscopy images of an evolving clonal nevus .

cutaneous vasculitis , a disease with an annual incidence rate ranging from 39.6 to 59.8 per million , can be classified as primary or idiopathic ; or secondary , when it presents as a manifestation of connective tissue diseases , infections , drug reactions or malignancies . although most of the idiopathic cases are self - limited and responsive to supportive measures ( limb elevation , warming , avoid standing ) and nonsteroidal anti - inflammatory drugs , potent immunosuppressants are sometimes required for the management of the refractory situations . we herein describe a case of a 32-year - old caucasian female patient with history of idiopathic cutaneous deep vasculitis unresponsive to methotrexate , dapsone , and cyclophosphamide , who was effectively treated with infliximab . the patient felt well until september 2005 , when palpable painful nodules and multiple ulcerated lesions developed in both legs and ankles . there was no history of arthritis , rashes , photosensitivity , other skin lesions , mouth ulcers , gastrointestinal , or urogenital symptoms . antinuclear antibody ( ana ) , rheumatoid factor ( rf ) , anti - neutrophil cytoplasmatic antibodies ( anca ) , anti - ro , anti - la , anti - hiv , hbsag , hcv , antistreptolysin o ( aso ) , and cryoglobulins tested negative ; complete blood count and a serum thyroid - stimulating hormone ( tsh ) determination were normal , as were a chest x - ray . erythrocyte sedimentation rate ( esr ) and c - reactive protein ( crp ) were markedly elevated ( 90 mmhg on the first hour and 45 mg / dl normal : 06 mg / dl ; resp . ) , and there was a polyclonal gammopathy on a serum protein electrophoresis test . examination of a skin smear sample to identify mycobacterium leprae was negative . a cutaneous biopsy revealed fibrinoid degeneration of the perivascular and vessels walls collagen , as well as mononuclear and neutrophilic infiltrates extending to the deeper dermis and the presence of leukocytoclasia , corroborating the diagnosis of cutaneous deep vasculitis . the patient was given 60 mg / day of prednisone ( approximately 1 mg / kg ) , with merely partial resolution of the signs and symptoms , even after 2 months of appropriate usage ( figure 1 ) . as a steroid - sparing drug , methotrexate was given in a dosage up to 25 mg / week , unsuccessfully . five monthly pulses of cyclophosphamide ( 0.75 g / m / body surface ) and dapsone 200 mg / day were also ineffective in reducing the oral prednisone dosage , and when the reduction was attempted , the vasculitis signs and symptoms recurred promptly . in august 2007 , taking into consideration these therapeutic failures , the patient was started on infusions of 3 mg / kg infliximab on days 0 , 15 , and 45 and then every 8 weeks . as early as by the fourth infusion , prednisone dosage had already been tapered to zero and no vasculitis recurrence was observed ( figure 2 ) . as of january 2009 , about 40% of all cases of cutaneous vasculitis are idiopathic and , currently , no guidelines for its treatment are available . most of the episodes are self - limiting , lasting only a few days or weeks , but in about 20% of cases , a chronic , unremitting course , takes place , when immunosuppressants ( azathioprine , methotrexate , cyclophosphamide , cyclosporine , or mycophenolate mofetil ) must be required . infliximab , a chimeric anti - tnf- antibody , has been shown to be effective in a variety of inflammatory and autoimmune diseases , as rheumatoid arthritis , ankylosing spondylitis , and crohn 's disease . higher serum levels of the proinflammatory cytokines tnf- , il-1 has already been observed in small vessels cutaneous vasculitis patients when compared to healthy subjects , suggesting a possible role for these molecules in the pathogenesis of the disease . also support the benefit of infliximab in cases of difficult - to - treat deep cutaneous vasculitis , even though in none of the cases reported by those authors cyclophosphamide was tried prior to the usage of biological therapy . interestingly , mccain et al . described a case of cutaneous vasculitis related to previous infliximab infusions , probably due to antidrug antibodies formation . although infliximab is a drug that has been related to serious side effects , these can be properly monitored , identified , and managed , and its rapid onset of action certainly favors its use in refractory idiopathic deep cutaneous vasculitis .

cutaneous vasculitis can be classified as primary or idiopathic ; or secondary , when it presents as a manifestation of connective tissue diseases , infections , drug reactions or malignancies . although most of the idiopathic cases are self - limited and responsive to supportive measures and nonsteroidal anti - inflammatory drugs , potent immunosuppressants are sometimes required for the management of the refractory situations . here we describe a case of a 32-year - old caucasian female patient with history of idiopathic cutaneous deep vasculitis unresponsive to methotrexate , dapsone , and cyclophosphamide who was effectively treated with infliximab .

angiosarcoma is a rare malignant neoplasm comprising 1% of all soft tissue sarcomas with a predilection for the skin and superficial soft tissues of the face and scalp . most lesions are diagnosed once the presence of an advanced ulcerated plaque or nodule has been identified . early lesions , however , may mimic an infectious or inflammatory process , leading to a potential delay in diagnosis and treatment . we describe an unusual case of angiosarcoma presenting as isolated eyelid swelling , without a plaque or nodule , illustrating the sometimes benign clinical appearance of this very aggressive and deadly tumor . a 76-year - old man presented with slowly progressive swelling in his left upper eyelid for three months . he denied any pain , trauma , fever , eyelid lesions , or sinus disease . he had quit smoking fifty years prior . on exam , best corrected visual acuity was 20/40 ou . no afferent pupillary defect , diplopia , or proptosis was present . external examination revealed an area of red , indurated skin near the glabella with soft tissue edema extending into the left upper lid ( fig . 1 ) . slit lamp examination was unremarkable . computed tomography ( ct ) of the orbits demonstrated non - specific soft tissue changes corresponding to the areas of edema found on clinical examination ( fig . the patient presented one week later with worsening forehead and upper eyelid swelling ( fig . 1 ) . magnetic resonance imaging ( mri ) revealed a soft tissue lesion lateral to the left orbit that extended medially into the mid - forehead ( fig . a diagnostic biopsy was performed , revealing poorly differentiated pleomorphic tumor cells with mitotic activity and focal slit - like vascular formation infiltrating the deep dermis . the tumor cells were immunoreactive to cd31 and factor 8 immunohistochemical staining , which was consistent with a diagnosis of angiosarcoma ( fig . 3 ) . positron emission tomography ( pet ) scanning was negative for evidence of metastases . the patient declined surgery due to the likelihood of significant morbidity from extensive tissue removal needed to clear the tumor margins . the patient underwent chemotherapy with docetaxel and bevacizumab , as well as radiation therapy to the affected region . due to development of a grade iv skin reaction additionally , bevacizumab was temporarily withheld due to proteinuria and then was later resumed at a reduced dose . biopsies of the treatment field showed a partial response , but tumor metastasis was eventually found in the parotid gland and lungs . despite treatment , the patient passed away eight months following initial diagnosis . an ecchymotic appearance suggested a vascular lesion , but lack of a mass on ct imaging made his disease process appear non - neoplastic . clinically , early angiosarcoma can present with mild erythema , facial edema and a bruised - like appearance . longstanding lesions may show an overlying indurated plaque or nodular neoplasm associated with hemorrhage and ulceration . histologically , a well - differentiated angiosarcoma is composed of dilated , anastomosing vascular channels lined by enlarged endothelial cells . poorly differentiated lesions contain solid or sheath - like proliferations of polygonal or spindle - shaped endothelial cells . a lymphocytic infiltrate may also be present , making it difficult to distinguish between angiosarcoma and other immune or inflammatory disorders . angiosarcoma has the potential to arise in any soft tissue of the body , however , cutaneous angiosarcoma is the most common presentation of which head and neck tumors account for up to 62% of cases . eyelid or periorbital lesions are reported infrequently [ 5 , 6 , 7 , 8 , 9 ] . primary orbital lesions , as well as metastasis to the orbit , have been described in only a handful of cases . age less than fifty , localization to the trunk or face , and size less than 5 cm are all good prognostic indicators [ 4 , 10 ] . ultraviolet exposure is a presumed risk factor , although a direct correlation has not been proven . cutaneous angiosarcoma can be a rare complication of radiotherapy , and visceral organ tumors have been linked to environmental toxin exposure [ 1 , 4 ] . survival rates for head and neck angiosarcomas range from 10 to 51% at 10 years . ideally , smaller lesions are treated with complete wide local excision followed by aggressive chemoradiation . in advanced cases with periorbital involvement monotherapy with paclitaxel has been shown to be uniquely effective in reducing disease extent and prolonging disease - free intervals . anti - vegf agents have also been shown to be effective . given the size and ill - defined borders of his lesion angiosarcoma is an extremely rare tumor that is not often encountered by either ophthalmologists or oculoplastic surgeons . this tumor should , however , be considered in the differential diagnosis for any patient presenting with isolated eyelid swelling , particularly in the absence of infectious or inflammatory signs .

a 76-year - old man presented with slowly progressive swelling in his forehead and left upper eyelid over the course of three months . ct scanning showed non - specific enhancement of subcutaneous tissues , suggesting a low - grade cellulitis . poor response to treatment prompted an mri , which revealed the presence of a soft tissue lesion . biopsy of this lesion was positive for angiosarcoma . the patient underwent chemotherapy and radiation , but unfortunately succumbed to his malignancy eight months later . this case illustrates a rare example of facial / periorbital angiosarcoma , a benign - appearing but aggressive tumor associated with a high incidence of mortality . a review of the literature and current treatment options are discussed .

axillary artery injury caused by blunt trauma to the shoulder is uncommon and its association with fracture of the neck of the humerus is rare . a 14 year old boy was referred to the hospital with pain , tenderness and deformity of the left shoulder following a motor vehicle accident . the results of a general physical examination were normal except for the left arm , where the examination revealed pain , tenderness , and swelling in the left shoulder . distal radial , ulnar and brachial pulses were not palpable and could not be detected by doppler sonography despite the behavior of the normothermic the extremity . capillary refill times were 4 seconds in the left and 3 seconds in the right arm . radiography of the left shoulder revealed a salter - harris type i proximal humeral epiphyseal separation ( fig 1 ) . closed reduction of the physeal injury was performed in the operating room under general anesthesia to reduce compression on the axillary artery . however , distal pulses were not palpable following the anatomic reduction and we could not detect any change in vascular status . a vascular surgeon was consulted . angiography of the left arm revealed disruption of arterial flow in the axillary artery ( fig 2 ) . intra - operative findings included a hematoma and arterial contusion , but no active bleeding or axillary artery laceration was not located . the axillary artery was contused and thrombosed , and the brachial plexus was intact on inspection . a. disruption of blood flow in axillary artery angiography . b. some blood flow through collateral circulation . after resection of the contused segment of the axillary artery a reverse saphenous vein interposition graft was performed . the patient was monitored for 3 days in the intensive care unit , where his radial and ulnar pulses remained palpable . after 4 weeks , radial innervated muscle weakness resolved , the sling was removed , and rehabilitation for regaing shoulder and elbow motion was started . the muscle power of wrist and hand extensors returned to normal condition after 3 months . axillary artery injury caused by blunt trauma to the shoulder is uncommon and its association with fracture of the neck of the humerus is rare ( 14 ) . yagubyan ( 5 ) presented 4 cases of axillary artery thrombosis from humeral neck fracture . his review of the literature revealed 24 cases of axillary artery injury associated with humeral neck fracture . in all reviewed cases , the mean age was 66.6 years and fall the most common mechanism of injury the ( 79% ) . some 46% of patients presented with a neurologic deficit and acute ischemia was present in 68% of patients . epiphyseal fracture of the proximal humerus in childhood is a relatively uncommon , injury , accounting for less than 5% of all pediatric fractures . most of those that do occur are salter - harris type i or type ii injuries ( 6 ) . fracture of the proximal humerus with absent distal pulses is extremely rare in children . in a review of 57 proximal humeral epiphyseal fractures , baxter and wiley ( 2 ) the patient had a completely displaced salter - harris type ii fracture and presented with a cool , pulse - less arm . the combination of the extensive mobility of the glenohumeral joint and the significant contribution of the proximal physics to over - all humeral growth allow these injuries to be treated nonsurgically in most cases ( 7 ) . the goal of treatment was to stabilize the fracture and ensure the child 's comfort until healing occurs . there are a few limited indications for surgical intervention in the proximal humeral epiphyseal separation ( 8) . in the case presented here , because of the stability achieved after reduction , we decided to treat this fracture non - operatively . we believe that the patient 's wrist and hand extensor weakness was the result of a neuropraxia of the posterior cord of the brachial plexus . an enlarged hematoma within the common sheath may explain a progressive or delayed neurologic deficit ( 1 ) . a pulseless upper extremity may indicate a complete vascular disruption , and when the vascular integrity of the extremity was in question , an emergency arteriogram performed followed by surgical repair if necessary .

fracture of the proximal humerus associated with vascular injury has rarely been reported in children , and only two cases have been reported in the literature . in adults this combination has been reported more frequently.we present the case of a 14 year old boy with proximal humeral epiphyseal separation and axillary artery injury .

cdph created a laboratory testing plan to detect or rule out mers - cov infection in patients who , after review by cdph clinicians , met specific clinical and travel criteria , per cdc case definitions ( 10 ) , to be considered a patient under investigation ( pui ) . once a mers pui was identified , the patient s specimens were transported from the hospital or local public health laboratory to cdph in richmond , california , for mers - cov testing . specimens tested for each pui consisted of > 1 of the following : upper respiratory tract sample ( nasopharyngeal and oropharyngeal swab specimens ) , lower respiratory tract sample ( sputum and lower respiratory tract aspirates or washes ) , serum , or stool . time from specimen collection to receipt at cdph was up to 48 hours for most puis ( 37/52 [ 71% ] ) . because subsequent steps in infection control and patient management heavily depended on the test results , mers - cov testing at cdph was expedited ; the typical turnaround time was 4 hours from receipt of specimens to reporting of results . during february june 2013 , specimens from mers puis were tested at cdph for mers - cov by using an in - house real - time reverse transcription pcr ( rrt - pcr ) assay that amplified the following 3 targets in the mers - cov genome : upe , n2 , and n3 ( 11 ) . cdph implemented cdc s novel coronavirus 2012 real - time rt - pcr assay protocol subsequent to its emergency use authorization by the us food and drug administration in june 2013 ( 12 ) . for persons with a suspected past mers - cov infection , cdph sent serum specimens to cdc for mers - cov serologic testing . once mers - cov infection was ruled out , cdph tested the remaining respiratory specimens from mers puis for other respiratory pathogens . specimens were tested by real - time pcr and rrt - pcr for the following agents ( 13 ) : influenza a and b viruses , human metapneumovirus , respiratory syncytial virus , adenovirus , parainfluenza virus ( types 1 , 2 , 3 , and 4 ) , enterovirus , rhinovirus , and mycoplasma spp . if an adequate amount of specimen remained , specimens were also tested for the presence of human coronaviruses 229e , oc43 , nl63 , and hku1 by rrt - pcr ( 13 ) . during february 2013november 2014 , cdph investigated 54 mers puis in california , of whom 52 ( total of 188 specimens ) had testing conducted by cdph and 2 had testing conducted by cdc ( figure ) . the median age for mers puis was 53 years ( range 10 months89 years ) , and 57% were male and 43% female . a total of 51 ( 94% ) mers puis reported travel from the middle east , and 2 ( 4% ) were secondary contacts of travelers to the middle east . a mers pui short form or equivalent was submitted to cdc and reported the following clinical outcomes for 42 mers puis : 30 ( 71% ) hospitalized , 11 ( 26% ) admitted to an intensive care unit , 6 ( 14% ) intubated , 21 ( 50% ) received a diagnosis of pneumonia , and 5 ( 12% ) received a diagnosis of acute respiratory distress syndrome . middle east respiratory syndrome ( mers ) coronavirus patients under investigation ( puis ) tested at the california department of public health ( cdph ) , 20132014 . one or more respiratory viruses were detected in 32 ( 62% ) of the 52 mers puis tested by cdph ; 5 of the 32 patients had a co - infection with rhinovirus plus another respiratory virus . influenza , the most commonly identified respiratory agent , was detected in 18 ( 35% ) of the 52 mers puis tested by cdph ( table ) . was not detected in any specimen tested . * mers , middle east respiratory syndrome . the frequency of mers puis tested by cdph varied with no apparent seasonality , except for the weeks following the hajj in 2013 and 2014 ( figure ) . cdph also noted an increase in reported mers puis in may 2014 ( n = 9 ) after announcement of the first detected mers cases in the united states ( 3 ) . this increase likely resulted from media reports that heightened the level of concern among the public and health care workers , which increased the number of suspect mers cases that cdph and local partners had to evaluate for subsequent mers - cov testing . as of may 7 , 2015 , mers - cov had not been detected in california . however , mers - cov poses a potential threat to global public health because mers cases continue to be reported in saudi arabia , and the reservoir for the virus remains unclear , although camels have been implicated in disease transmission ( 14 ) . cdph has established a coordinated statewide system working with local partners to identify potential mers cases in california travelers returning from mers - affected regions and their contacts . cdph has investigated and conducted laboratory testing on > 50 mers puis and identified a respiratory virus in 62% of those patients , 35% of which were positive for influenza virus . the high rate of influenza detection underscores the need for all travelers to be immunized for influenza . cdph continues to evaluate each mers pui and expedite mers - cov laboratory testing so that prompt implementation of containment procedures and contact investigations may proceed if needed .

since middle east respiratory syndrome coronavirus ( mers - cov ) first emerged , the california department of public health has coordinated efforts to identify possible cases in travelers to california , usa , from affected areas . during 20132014 , the department investigated 54 travelers for mers - cov ; none tested positive , but 32 ( 62% ) of 52 travelers with suspected mers - cov had other respiratory viruses .

sets of plasmonic structures , placed in between electrode pairs with a gap of 1 m , were exposed by electron - beam lithography in a leo 1530 gemini feg sem and a raith elphy plus lithography system with laser interferometer stage . metallization was carried out by evaporating 5 nm cr + 40 nm au followed by lift - off in an ultrasonic bath . each set consisted of 90 electrode pairs , 45 of which contained plasmonic structures . ultrapure , unsorted swcnts ( http://www.nanointegris.com ) in an aqueous surfactant solution were used in this work . a dilution of 4 10 mg / ml was prepared and a droplet of 0.5 l was placed on top of the substrate . an ac electric field of 6 vpp at a frequency of 200 khz was generated by a tg1010 programmable 10 mhz function generator . a karl suss probe station with tungsten probes was used to connect the electrodes array with the function generator in order to accurately position the swcnts at the desired sites by dielectrophoresis . after 1 min , di water was used to rinse the substrate and a gentle stream of n2 was used to dry it . the nanostructures were characterized before and after cnt deposition using a veeco dimension 3100 afm , a park systems xe 150 afm and an xl30 sirion fei feg sem . a 50 , na 0.55 , ir - corrected microscope objective was used to collect the scattered light that is directed to a spectrometer that is equipped with a ccd detector to obtain the spectra in the visible range . the spectra were acquired at isolated plasmonic structures outside the electrode array to avoid contributions from the electrode tips . we simulated a gold dimer ( disk diameter 100 nm , height 40 nm , and separation 24 nm ) , compare figure 2 , on top of a 5 nm cr adhesion layer on a 300 nm sio2/si substrate . for our numerical calculations , three - dimensional ( 3d ) simulations were performed to calculate the scattering cross sections ( not shown ) and the near - field enhancement of the coupled nanostructures by using a commercially available finite - difference - timedomain code ( lumerical fdtd ) . the dielectric functions of au used in the simulations were extracted from data by johnson and christy . the cr adhesion layer and raman spectra were obtained with a witec single - grating spectrometer using a 100 objective with integration times between 1 and 30 s. the laser power on the sample was kept below 0.5 mw . to change the polarization , we rotate the sample by 90 while all other experimental parameters are left unchanged . spatial raman scans were performed using a piezo stage with a stepsize of 50 nm .

we realize the coupling of carbon nanotubes as a one - dimensional model system to near - field cavities for plasmon - enhanced raman scattering . directed dielectrophoretic assembly places single - walled carbon nanotubes precisely into the gap of gold nanodimers . the plasmonic cavities enhance the raman signal of a small nanotube bundle by a factor of 103 . the enhanced signal arises exclusively from tube segments within the cavity as we confirm by spatially resolved raman measurements . through the energy and polarization of the excitation we address the extrinsic plasmonic and the intrinsic nanotube optical response independently . for all incident light polarizations , the nanotube raman features arise from fully symmetric vibrations only . we find strong evidence that the signal enhancement depends on the orientation of the carbon nanotube relative to the cavity axis .

the most common dirofilarial species isolated from humans have been d. tenuis , d. immitis , and d. repens . determining the species of dirofilaria is sometimes difficult , especially if a male worm is not present , and the final diagnosis is often based on the presumed location of acquisition ( i.e. , d. tenuis if in the united states , d. repens elsewhere ) . rarely , lesions corresponding to its migration have been reported in the posterior segment , as active areas of choroiditis . although our patient had no such active retinal lesions in the right eye , the lesion in the left eye pointed to the possible site of entry of the worm . the hypotheses are that the adult worm penetrates the sclera , or the larva penetrates the blood - ocular barrier , and matures inside the eye . we suspect that the lesion in the left eye occurred as an inflammatory response to a dead dirofilarial worm , similar to subcutaneous nodules . on cross - section of these lesions , a degenerated worm is usually seen , with necrotic area surrounded by a granulomatous reaction with epithelioid cells , giant cells , lymphocytes , macrophages , and eosinophils . the present case report underscores the necessity to perform a comprehensive examination in a case of red eye , including examination of the fellow eye to detect any sign of parasitic infestation .

ocular dirofilariasis mostly presents as a subconjunctival or eyelid lesion.[1 ] intraocular dirofilarial infestation is rare.[23 ] we report a case of a young woman who was accidentally detected to have a live motile worm in the anterior segment in one eye and a cystic lesion on the optic disc in the other eye . to our knowledge , bilateral intraocular dirofilariasis has never been reported .

lymphedema is a common complication of breast cancer treatment , especially after axillary lymph node dissection and radiotherapy . this condition may become apparent during routine bone imaging with tc-99 m methylene diphosphonate ( mdp ) . a 42-year - old female patient with a history of right breast cancer reported recent onset swelling of the right forearm . she had undergone modified radical mastectomy 2 years previously , with subsequent chemotherapy and radiotherapy . a routine whole - body bone scan was performed to assess any skeletal involvement . following intravenous injection of 740 mbq ( 20 mci ) of tc-99 m mdp , imaging was performed after 3 hours under a dual head gamma camera ( ecam , siemens , germany ) fitted with a low - energy high - resolution collimator . diffuse soft tissue uptake of tracer in the right forearm , extending to the right elbow anterior ( a ) and posterior ; ( b ) whole - body bone scan images showing diffuse soft tissue uptake of tracer in the right forearm ( arrows ) a provisional diagnosis of lymphatic obstruction in the right upper limb was made and lymphoscintigraphy was performed during the patient 's next visit , 7 days later . unfiltered tc99m - sulphur colloid ( 20 mbq ) was injected intradermally into the second and third web spaces of each hand , and whole body images were acquired after 10 min and 2 hours under the same gamma camera , with the arms raised above the head . the 10-min image showed rapid movement of tracer into the left trochlear and axillary lymph nodes , with minimal tracer movement in the region of the distal right forearm . the delayed image showed diffuse soft tissue concentration of tracer only in the distal part of the right forearm , with no further ascent , indicating lymphatic obstruction [ figure 2 ] . ( b ) with the arms raised , showing rapid movement of tracer into the left trochlear and axillary lymph nodes ( arrows ) , and diffuse soft tissue tracer uptake in the distal part of the right forearm ( arrowhead ) lymphedema is a common complication of breast cancer treatment , with a significantly higher incidence reported after axillary lymph node dissection and radiotherapy ( 38.3 - 42.4% ) as compared to that by any one treatment modality alone ( 7.4 - 13.4%).[13 ] post - mastectomy edema may be early and occur shortly after surgery , resulting from acute lymphatic overload , and decrease as compensatory pathways develop . this condition is often progressive , attributed to lymphatic obstruction by surgical interruption or fibrosis and precipitates overload in already compromised lymphatic channels . extraosseous soft tissue concentration of bone imaging agents like tc-99 m mdp and tc-99 m hmdp has been reported in conditions that cause hyperemia ( i.e. , inflammation , neovascularity , altered sympathetic tone with resultant vasodilatation ) and altered capillary permeability , resulting in increased distribution of the tracer within the soft tissues.[57 ] the exact mechanism of non - osseous accumulation of bone scanning agents is still unclear ; however , it has been proposed that tc-99 m mdp accumulates in serous effusions by directly exuding from the peripheral blood vessels to the serous cavity along with the increased blood flow , the increased vascularity and vascular permeability .

a 42-year - old female patient with a past history of right breast cancer and recent onset swelling of the right forearm underwent routine whole - body bone scintigraphy with tc-99 m methylene diphosphonate , 2 years after a modified radical mastectomy . diffuse soft tissue tracer concentration was seen in the right forearm . subsequent lymphoscintigraphy using tc-99 m sulphur colloid revealed obstructed lymphatic drainage in the right upper limb .

maxillary sinus retention cysts ( msrcs ) are very common and most of them are asymptomatic and incidentally found on radiographs . nevertheless , a few of them increase in size and cause symptoms by obstructing natural ostia of the maxillary sinus ( ms ) . occasionally , they protrude into the middle meatus through the ostia and mimic antrochoanal polyps . i report here 2 cases with msrc protruding into the inferior meatus by making a large defect on the medial wall of ms . a 30-year - old male was referred from a local clinic for unilateral nasal obstruction that he had experienced for 3 years . he had undergone the bilateral sagittal split ramus osteotomy for correction of mandibular prognathism 6 years before . computed tomogram ( ct ) showed a 4.03.0 sized non - enhancing mass occupying most of ms and protruded into the inferior meatus through the defect on the medial wall of ms ( fig . however , when we grasped and pulled the mass , it was torn and yellowish serous fluid flowed out . there was a large defect with a clear margin on the medial wall of ms , which looked like a healed opening for the inferior meatal antrostomy ( fig . 1 ) . we removed the remnant cystic wall originating from the anterolateral wall of ms through the defect . another patient was a 36-year - old male who complained of his unilateral nasal obstruction beginning 4 years before . on endoscopic examination , a mass lesion occupying the left inferior meatus was found ( fig . however , he had a retention cyst confined to the right ms and a 4 mm - sized hole on the medial wall of this sinus ( fig . the cystic mass on the left side looked the same as the msrc on the right side . we removed that lesion in the same way that we had used in the surgery of the former patient . there was also a large defect with a clear margin on the medial wall of ms ( fig . a 30-year - old male was referred from a local clinic for unilateral nasal obstruction that he had experienced for 3 years . he had undergone the bilateral sagittal split ramus osteotomy for correction of mandibular prognathism 6 years before . computed tomogram ( ct ) showed a 4.03.0 sized non - enhancing mass occupying most of ms and protruded into the inferior meatus through the defect on the medial wall of ms ( fig . however , when we grasped and pulled the mass , it was torn and yellowish serous fluid flowed out . there was a large defect with a clear margin on the medial wall of ms , which looked like a healed opening for the inferior meatal antrostomy ( fig . 1 ) . we removed the remnant cystic wall originating from the anterolateral wall of ms through the defect . another patient was a 36-year - old male who complained of his unilateral nasal obstruction beginning 4 years before . on endoscopic examination , a mass lesion occupying the left inferior meatus was found ( fig . however , he had a retention cyst confined to the right ms and a 4 mm - sized hole on the medial wall of this sinus ( fig . the cystic mass on the left side looked the same as the msrc on the right side . we removed that lesion in the same way that we had used in the surgery of the former patient . there was also a large defect with a clear margin on the medial wall of ms ( fig . the wide use of various radiographic imaging study in practice and popularized dental implantation has led to coincidental detection of msrc . the majority of them are unchanged during the follow - up period and , therefore , no treatment is needed for most of them . reported that those who have a large cyst ( > 20 mm ) or bilateral cysts at initial diagnosis are at risk for progression . however , their natural course or risk factors for progression are not fully elucidated yet . however , there have been no reports that they erode bony walls or protrude into the inferior meatus . in this study , each of the 2 patients had a large defect on the medial wall of ms , through which his msrc protruded into the inferior meatus . it should be noted that both of them had history of nasal or sinus surgery ( bilateral sagittal split ramus osteotomy and bilateral inferior meatal antrostomy ) . after those surgeries , they must have had a small or slit - like defect on the medial wall of ms . and their msrc had increased in size with their wall thickened , widened the defects , protruded into the inferior meatus through the defect and occupied most of the inferior meatus . however , it is still unknown why they chose the defects rather than natural ostia as an exit from ms to the nasal cavity . in conclusion , when a patient has a mass lesion in his or her inferior meatus , if he or she has history of previous nasal or sinus surgery , the possibility of msrc protruding into the inferior meatus should also be considered .

although most of the maxillary sinus retention cysts are asymptomatic , a few of them increase in size and cause symptoms . however , they rarely erode bony walls nor protrude into the inferior meatus . i present 2 cases with maxillary sinus retention cysts protruding into the inferior meatus by making a large defect on the medial wall of the maxillary sinus .

paraganglioma is benign and slow growing neuroectodermal tumor commonly found in the adrenal medulla , carotid body and glomus - jugulare . we report a case of paraganglioma of the cauda equina region in 60 year lady who underwent successful surgical resection . clinical presentation and imaging appearances of paraganglioma involving the spine is nonspecific and most of the time diagnosis is on post operative histopathology . paraganglioma should be kept in mind as the differential diagnosis of extra medullary tumor contracted in the cauda equina region . catecholamine secretory paraganglioma is uncommon but preoperative screening for hyper adrenergic state is necessary to prevent hypertensive crises during tumor removal . paraganglioma is benign and slow growing neuroectodermal tumor commonly found in the adrenal medulla , carotid body and glomus - jugulare . paraganglioma of cauda equina is relatively rare , only a few 100s of cases are being reported in literature . we report a case of paraganglioma of the cauda equina region who underwent successful surgical resection . no past history of trauma , diabetes , hypertension or antitubercular medications . on examination , she had local tenderness in the lumbosacral region . neurological examination revealed sensory deficits in the distribution of l3 - 4 region of the right leg . the mri of lumbosacral spine showed a mass 2.11.03 cm sized space occupying lesion isointense to cord , extra medullary intradural lesion at the level of l3 vertebral body ( fig 1a & b ) . intraopeatively the tumor -a red encapsulated and firm mass found attached to a nerve root at l3 level . cut section showed grey brown with grey white area the postoperative course was uneventful with complete disappearance of pain and the neurological examination was normal . the mri of lumbosacral spine showed a mass 2.11.03 cm sized space occupying lesion isointense to cord , extra medullary intradural lesion at the level of l3 vertebral body histopathology examination of the encapsulated lesion showed tumor cells arranged in a well defined nest of organized pattern ( zellballen fig-3a - nests of cells in zellballen pattern surrounded by rich vascular network , original magnification ( 100x ) fig-3b polygonal cells having round nuclei with stippled salt and pepper chromatin , original magnification ( 400x ) paraganglioma is tumor derived embryologically from autonomic nervous system commonly from adrenal medulla or occasionally from extra - adrenal paraganglion system . these is collections of neural crest derived , neurosecretory and chemoreceptor cells of the autonomic nervous system belonging to a diffuse neuro - endocrine system or the apudsystem ( amine precursor uptake decarboxylase ) with the possibility of hormone secretion ( adrenaline , noradrenaline and dopamine ) . paraganglioma of cns is a very rare finding . the first reports dates back to 1970 by lerhman and kaplan . in the cauda equina region , they may arise from paraganglia located in the cauda equina , but it has also been suggested that some constituents of the diffuse neuro - endocrine system can be the result of a local differentiation from tissues not derived from the neural crest , and the participation of the ependymal cells in their development can not be excluded explaining the reason for the non - secretory type . it 's more common in male subpopulation and the mean age of presentation is from 13 to 70 years ( mean age= 48 , 45 years ) . patients commonly present with low - back - ache with radicular pain as in our patient . these tumors are misdiagnosed as meningioma or schwannomas or ependymoma because of their rarity and vascularity . typically paraganglioma appear isointense to the conus medullaris on t1-weighted sequences and hyperintense on t2 , as seen in our case , because of high vascularity these tumors flair up with contrast study . total surgical excision is the best option to achieve greater chance of cure and also the option to reduce the recurrences paraganglioma should be kept in mind as the differential diagnosis of extra medullary tumours contracted in the cauda equina region . catecholamine secretory paraganglioma is uncommon but preoperative screening for hyper adrenergic state is necessary to prevent hypertensive crises during tumor removal . mri may shed some light on diagnosis whihc mught be important to prevent any inadvertant hyper - adrenergic reactions .

introduction : paraganglioma is benign and slow growing neuroectodermal tumor commonly found in the adrenal medulla , carotid body and glomus - jugulare . paraganglioma of cauda equina is relatively rare.case report : we report a case of paraganglioma of the cauda equina region in 60 year lady who underwent successful surgical resection . clinical presentation and imaging appearances of paraganglioma involving the spine is nonspecific and most of the time diagnosis is on post operative histopathology . few mri features and contrast mri can be helpful if paraganglioma is suspectedconclusion : paraganglioma should be kept in mind as the differential diagnosis of extra medullary tumor contracted in the cauda equina region . catecholamine secretory paraganglioma is uncommon but preoperative screening for hyper adrenergic state is necessary to prevent hypertensive crises during tumor removal .

acidithiobacillus ferrooxidans is a gram - negative , motile , moderately thermophilic ( 20 to 40 c ) , acidophilic ( ph 1.0 to 4.5 ) and strictly chemolithoautotrophic bacterium . it utilizes ferrous iron or reduced inorganic sulfur compounds as energy source and fixes carbon dioxide from the atmosphere as a carbon source , . strains of a. ferrooxidans are abundant in iron and sulfur bearing acidic environments and considered as important participants in the iron , sulfur and carbon cycles of the acid mine drainage ecosystem . research on a. ferrooxidans has been a promising area of study as this bacterium is known to be an important member of microbial consortia that is used to recover metals via a process known as bioleaching or biomining . in this study , a. ferrooxidans yqh-1 was isolated from a river in wudalianchi volcano , northeast china ( 48 40 14 n , 126 10 16 e ) . the 16s rrna sequence of yqh-1available in genbank database ( accession number : kt633236 ) showed 99.64% identity with that of a. ferrooxidans atcc 19859 ( accession number : aj457808 ) . to better understand the important information regarding the bioleaching capabilities genomic dnas were extracted using a bacterial genomic dna extraction kit ( biomed , beijing , china ) according to the manufacturer 's instructions . the genome of yqh-1 was sequenced using the illumina miseq platform at the biomarker technologies co. , ltd . a library with a fragment length of 500 bp was constructed , and a total of 854,755,347 bp paired - end reads of 300 bp were generated . the high - quality reads , which provided an approximately 285-fold depth of coverage were assembled with velvet version 1.2.10 . protein - coding sequences were predicted by glimmer software version 3.0 , while ribosomal rna ( rrna ) and transfer rna ( trna ) genes were predicted using an rnammer 1.2 server and trnascan - se search server version 1.21 , respectively . genes annotated using blast searches of nonredundant protein sequences from the ncbi , swiss - prot , ncbi refseq , cog , and rapid annotation using subsystem technology ( rast ) version 2.0 . the assembled genome size of a. ferrooxidans yqh-1 was estimated to be 3,111,222 bp from 96 scaffolds with a mean g + c content of 58.63% ( table 1 ) . in the whole genome , 2281 genes ( 73.84% ) that encode known function proteins and 635 ( 20.55% ) genes were considered to encode hypothetical proteins . of the total , 173 ( 5.61% ) rast functional annotation predicted 183 genes were linked to carbohydrate metabolism , out of which 58 genes were predicted to be involved in carbon dioxide fixation ( fig . the presence of these genes may explain the ability of yqh-1 in the natural carbon cycle . a. ferrooxidans yqh-1 contains several genes involved in iron and sulfur metabolism , such as encapsulating protein for dyp - type peroxidase and ferritin - like protein oligomers , sulfate and thiosulfate import atp - binding protein cysa , sulfate transport system permease protein cysw , sulfate and thiosulfate binding protein cysp et al . 1 ) . they may be responsible for the oxidation of ferrous iron and reduced inorganic sulfur compounds . additionally , 23 nif genes involved in nitrogen metabolism were found , which indicated that a. ferrooxidans yqh-1 has nitrogen - fixation potential ( fig . the nif genes were also detected in the genomic sequences of a. ferrooxidans atcc 23270 and a. ferrooxidans atcc 53993 ( cp001132 ) . these indicated that a. ferrooxidans has the genes involved in dinitrogen fixation and they are able to grow in diazotrophic conditions . fifteen genes related to potassium metabolism were detected , of which 14 were related to potassium homeostasis ( fig . 1 ) , which may be responsible for the strain yqh-1 inhabiting an extreme acid environment . there are 41 genes involved in heavy metal resistance and 35 genes involved in oxidative stress response . the presence of these genes may explain why a. ferrooxidans can live in hostile condition with high concentrations of heavy metal ions . this whole genome shotgun project has been deposited at ddbj / embl / genbank under the accession ljbt00000000 .

acidithiobacillus ferrooxidans yqh-1 is a moderate acidophilic bacterium isolated from a river in a volcano of northeast china . here , we describe the draft genome of strain yqh-1 , which was assembled into 123 contigs containing 3,111,222 bp with a g + c content of 58.63% . a large number of genes related to carbon dioxide fixation , dinitrogen fixation , ph tolerance , heavy metal detoxification , and oxidative stress defense were detected . the genome sequence can be accessed at ddbj / embl / genbank under the accession no . ljbt00000000 .

intussusception following a roux - en - y gastrojejunostomy was first described by agha in 1986 . in the last decade , approximately 20 papers have reported intussusception as a post - operative complication of roux - en - y gastric bypass ( rygbp ) . this has correlated with the rapid increase in the rate of bariatric surgery over that time period . the patient was a 43-year - old african american female who presented to the emergency room with paroxysmal , severe abdominal pain as well as nausea and vomiting that began soon after a large meal . she reported losing approximately 100 lbs since her laparoscopic , retrocolic rygbp . on examination , her abdomen was soft , and there were no signs of peritoneal irritation or distension . laboratory data were unremarkable . computed tomography scan revealed high - grade small bowel obstruction adjacent to the jejuno - jejunal anastamosis with dilation of the biliopancreatic limb and the gastrojejunal limb [ figure 1 ] . this obstruction was associated with a loop of small intestine which had telescoped into itself , consistent with intussusception . visualization of the abdomen under pneumoperitoneum revealed massively dilated small bowel necessitating conversion to an open procedure . there was an area of intussuscepted bowel just past the small bowel anastomosis of the gastric bypass . approximately six inches of distal small bowel had telescoped in a retrograde fashion towards the anastomosis [ figure 2 ] . , there was a petersen defect identified and closed ; there was no incarcerated bowel within the defect . pathologic analysis of the specimen revealed a segment of small bowel that was focally hemorrhagic and necrotic . intussusception of small intestine ( small arrow ) towards jejuno - jejunal anastamosis ( large arrow ) the patient had an unremarkable post - operative course and was discharged on post - operative day five . intussusception is an underappreciated complication of rygbp . in one review of 15 553 gastric bypass surgeries at a single institution , 23 patients developed a retrograde intussusception . given the rapid increase in the rate of bariatric surgery over the past 20 years , intussusception is becoming an increasingly prevalent entity . pathologic lead points such as malignancy or meckels diverticulum have traditionally been thought to be the etiology of small bowel intussusception in adults . previous literature has hypothesized a iatrogenic lead point created by the suture or staple line at the enteroentero anastamosis , thereby allowing hyperperistalsis of the excluded segment to telescope the biliopancreatic limb into the common limb.[36 ] a post - operative adhesion could do the same . others have suggested roux stasis syndrome as another possible etiology in this patient population . hocking and colleagues described a possible physiologic etiology related to dysmotility of the roux limb in 1991 . hocking theorized that disorderly peristaltic activity in the roux limb could create adjacent areas of high and low - pressure thus allowing for an intussusception . this explanation fits in the case presented here as no intraluminal , intramural , or extraluminal cause could be found which may have led to the retrograde jejunojejunal intussusception . computer tomography is the most reliable investigation when suspicion for intussusception presents in a rygbp patient . when recognized , it can be diagnosed by virtue of its pathognomonic appearance as a complex soft tissue mass consisting of outer and inner portions of the intussusceptions . a crescent shaped piece of mesenteric fat is often appreciated within the intussusception . in summary , symptomatic intussusception may occur many years after rygbp and may present with non - specific signs and symptoms . its incidence may be higher than previously believed , occurring in as many as 1/1000 of patients who undergo rygbp . given the enormous popularity of this procedure , intussusception should be on the differential for complaints of post - operative abdominal pain . the etiology of intussusception in the rygbp population is largely unknown , although dysmotlity associated with the roux limb may be the etiology in most instances .

intussusception after roux - en - y gastric bypass is more common than previously believed . it usually occurs between one and three years post - operatively , though we present a case that presented with a retrograde intussusception necessitating bowel resection seven years after a laparoscpic roux - en - y gastric bypass . the diagnosis and etiological theories are discussed based on findings from the literature .

spontaneous hematomas in the deep spaces of neck are rare in this age of antibiotics and modern dental care . sublingual hematoma , also described as pseudo - ludwig's phenomenon , has been described in 1978 by lepore in patients with coagulation disorders . it has been described in patients with ill - fitting dentures . however , to the best of our knowledge , spontaneous sublingual hematoma secondary to hypertension , in the absence of coagulation disorders , being managed conservatively , has not been described yet . here , we describe a case of spontaneous sublingual hematoma , secondary to hypertension . a 65-year - old male patient presented in the emergency room complaining of a sudden progressive swelling of the floor of mouth with hemorrhagic discoloration . he denied any history of trauma , denture use , anticoagulant use , or tooth infection . general examination revealed an uncontrolled blood pressure of 200/100 mmhg in supine position at rest . he was maintaining saturation at room air with respiratory rate of 20/min with spo2 97% . on local examination , the floor of mouth was grossly swollen and tense , with hemorrhagic discoloration suggestive of recent submucosal bleed . the swelling was mildly tender on palpation and appeared to continue with the submental space in the neck , with hemorrhagic discoloration of the overlying skin till the suprasternal notch [ figure 2 ] . hematoma over floor of mouth skin discoloration over midline of neck a complete coagulation profile of this patient was done and was found to be normal . contrast - enhanced computed tomography ( ct ) scan was done , which was suggestive of a non contrast - enhanced space - occupying lesion in the submental region extending upto the right base of tongue and supraglottis and extension into right parapharyngeal space [ figures 3 and 4 ] . he was advised magnetic resonance ( mr ) angiogram but was unable to do so due to financial constraints . contrast - enhanced ct scan showing non - enhancing mass in right parapharyngeal space ( axial view ) . ct = computed tomography coronal section showing extension of mass from sublingual space a clinical diagnosis of sublingual hematoma secondary to hypertension was made , and he was managed conservatively . however , the hematoma seemed to enlarge with resultant respiratory distress , and so , an urgent tracheotomy was done to secure the airway . patient was followed up for a month posttreatment and was doing well with no recurrence . sublingual space is a potential space between the mucosa of floor of mouth and mylohyoid muscle and is a part of suprahyoid group of fascial spaces . the sublingual space communicates with submandibular space along the posterior border of mylohyoid muscle and below with submental space . collectively , these three spaces are sometimes termed as perimandibular spaces or submaxillary space . pseudo - ludwig 's phenomenon , in which the tongue and floor of mouth become elevated and can cause airway obstruction . the common causes of sublingual space hematoma are anticoagulant - induced coagulopathy , trauma , or tongue bite . spontaneous hemorrhage in sublingual space due to uncontrolled hypertension is very unusual and only one such case has been reported to the best of our knowledge . the etiology of sublingual hematoma in our case is probably the rupture of atherosclerotic vessels supplying the musculature of tongue or other muscles related to the space . history taking should include details of anticoagulant use . a careful and through study of the coagulation profile of the patient needs to be done . the decision to surgically evacuate sublingual hematoma is controversial with several authors reporting good results even with conservative management once the causative factors have been corrected . they have been found to have spontaneous resolution without surgical intervention once the coagulation profile normalizes . use of leeches has also been described to aid in the resolution of this hematoma . however , a risk of anaerobic infection is possible , along with the psychological trauma of such intervention . a surgical evacuation would also carry risk of aspiration if the airway has not been previously secured . some authors believe that surgical attempt to evacuate the blood may cause further swelling and subsequent worsening of condition in postoperative period . we managed our case conservatively , and the patient was successfully treated by 3 weeks of treatment and no complications in the postoperative follow - up .

sublingual hematoma is a rare complication of oral anticoagulant use . spontaneous sublingual hematoma secondary to hypertension is even rarer and their management remains enigmatic . we present such a case that we successfully managed conservatively along with a review of relevant literatures .

a 45-year - old woman was admitted to our hospital 9 days after the apparition of asthenia and progressive jaundice . she was working as a nutritionist in the darfur region of western sudan , had no personal or family history of liver disease and was not consuming illicit drugs or alcohol . she had received hepatitis a and b vaccines . the day prior to transfer in geneva , she developed grade iv hepatitis e , was electively intubated and given intravenous mannitol . diffuse cerebral edema was evident both at cranial computed tomography and mri scans ( fig . laboratory values were as follows : aspartate aminotransferase 436 iu / l ( n : 1 - 42 ) , alanine aminotransferase 1,813 iu / l ( n : 9 - 42 ) , total bilirubin 436 mol / l ( n : 7 - 25 ) , alkaline phosphatase 107 iu / l ( n : 30 - 125 ) , ammonium 118 mol / l ( n : 11 - 35 ) , creatinine 72 mol / l ( n : 35 - 88 ) , phosphate 0.63 mmol / l ( n : 0.8 - 1.5 ) , prothrombin time 59 s , inr 6 , and factor v 20% . she tested negative for autoimmune , toxic and metabolic diseases as well as for hepatitis a , b , c , and hiv . however , high titers of anti - hev antibodies ( enzyme immunoassay abbott hev eia ) were detected in the serum . the levels of anti - hev igg and igm were 3,000 ( threshold level at 520 ) and 1,848 ( threshold level at 420 ) optical densities , respectively . thus , in the presence of acute liver failure ( factor v < 30% ) complicated by rapid neurological deterioration and brain edema on imaging studies , spontaneous survival was estimated below 10% according to clichy 's criteria , and the patient was listed for urgent liver transplantation while receiving standard supportive care but no hypothermia or liver support device . she remained stable during the two following days and progressively started to breathe spontaneously and to respond to painful stimuli . figure 1 illustrates the spontaneous progressive improvement in biological tests starting from day 2 of hospital admission . she was then delisted . on day 4 , she was fully conscious and oriented high mortality was initially described in pregnant women from endemic countries , but sporadic cases , sometimes fatal , have been described both in males and nonpregnant females from western europe . in acute liver failure , prognostic markers that dictate the need for urgent liver transplantation include the king 's college and clichy 's criteria , and more recently the meld . our patient fulfilled all these criteria . although useful , these tools are not 100% accurate in predicting spontaneous outcome . factors that may positively influence the course of the hepatitis include viral cause , hyperacute presentation , elevated afp and no infection , while the presence of profound hepatitis e complicated by cerebral edema is clearly associated with a poor prognosis without urgent liver transplantation . whether the particular evolution of our case with fulminant hepatic failure relates to host factors or to the causative agent remains unclear . neurological symptoms associated with hepatitis e include meningoencephalitis with seizures and spontaneously reversible grade iii hepatitis e in the setting of both acute liver and renal failure . the combined action of acute hepatitis and associated hyperammonemia - induced increased permeability of the blood brain barrier may increase the risk of hepatitis e and brain edema . although the present case underlines the limitations of prognostic scoring in this life - threatening condition , the treatment of patients with fulminant hepatic failure remains urgent liver transplantation .

fulminant hepatic failure is characterized by the presence of hepatic encephalopathy in the setting of acute liver injury that occurs in a noncirrhotic organ . brain edema is the ultimate complication of advanced hepatic encephalopathy as it often leads to cerebral herniation and death . thus , the presence of fulminant hepatic failure indicates the need for urgent liver transplantation to prevent death or irreversible brain damage . we report a very unusual evolution of fulminant hepatic failure complicated by brain edema and hepatic coma in a 45-year - old woman admitted with acute viral hepatitis e infection .

to further investigate the distribution of this new group of viruses , we investigated the prevalence of virus antibodies in other members of the genus pteropus in cambodia . in restaurants where bats are eaten in phnom penh , we collected 2-ml blood specimens from each bat as it was prepared for food . the restaurant owners purchased bats from a hunter who trapped them in kampong cham province and transported them alive to restaurants in phnom penh . we stored the whole blood on wet ice for as long as 48 h , then transported it to the u.s . naval medical research unit no . 2 , national institute of public health laboratory , in phnom penh on wet ice , and centrifuged it to separate the serum from the clot . frozen serum specimens were sent from cambodia to the special pathogens branch , division of viral and rickettsial diseases , centers for disease control and prevention , atlanta , georgia . on arrival , the serum specimens were tested for antibodies to nipah virus by enzyme immunoassay ( eia ) . of 96 serum specimens from the fruit bat ( pt . lylei ) , 11 ( 11.5% ) were positive ( > 1/10 ) for nipah virus antibodies by eia . we also screened sera ( when sufficient quantities were available ) by neutralization test against hev . our results suggest that the virus circulating in cambodia is neither nipah nor hev , but another closely related virus . several species of the genus pteropus show serologic evidence of nipah or hev infection . attempts by several groups to recover virus from tissues of serologically positive bats have been unsuccessful , as have immunohistochemical tests to detect the infection in tissues ( 9 ) . several possible reasons may account for the inability to recover virus from serologically positive bats . antibody - positive bats may represent the portion of those infected that survived and cleared the virus . experimental inoculation of a small number of australian pteropus bats with a related paramyxovirus resulted in findings that the virus replicates , causes microscopic lesions , and is shed ; the virus appears to clear as the antibody response appears ( 13,14 ) . we did not attempt to isolate virus from blood , and our attempts to detect virus antigen in tissues by immunohistochemical tests in one bat were unsuccessful . we observed no evidence that hev ( 15 ) or nipah viruses move directly from bats to humans . however , during the outbreak of nipah virus encephalitis outbreak in malaysia , several laboratory - confirmed nipah cases that lacked exposure to infected pigs were identified ( p. kitsutani , pers . lylei is limited to sites where they are protected from hunting , including urban areas and temples , where the human - bat interaction may be increased . the fact that these large bats are caught and used for food further increases the risk for exposure and infection in humans . future studies should include an evaluation of the risk of nipah virus infection among populations intensely exposed to bats , such as those who capture , transport , slaughter , and butcher bats , as well as bat rehabilitators , animal caretakers , and wildlife conservationists . we suggest that future studies also include a cross - sectional survey of swine in cambodia . unlike workers on the large , commercial swine production farms of malaysia , typical swine farmers in cambodia raise several swine for their own use and for the local market . the potential for amplification of the virus , unlike that observed in the large concentrated pig population in malaysia , remains very limited . finally , a systematic study of encephalitis causes may show whether nipah virus causes disease in humans in cambodia and elsewhere in the region .

serum specimens from fruit bats were obtained at restaurants in cambodia . we detected antibodies cross - reactive to nipah virus by enzyme immunoassay in 11 ( 11.5% ) of 96 lyle s flying foxes ( pteropus lylei ) . our study suggests that viruses closely related to nipah or hendra viruses are more widespread in southeast asia than previously documented .

the landmark study of intensive insulin therapy conducted by van den berghe and colleagues highlighted to critical care physicians the vital importance of the metabolic substrate an impressive 3.4% absolute reduction in intensive care unit mortality was achieved in predominantly surgical patients managed with insulin to achieve a blood glucose level of 4.06.0 mmol / l ( 80110 mg / dl ) as compared with a ' control ' target range of 10.011.1 mmol / l ( 180200 mg / dl ) . thus , it is clear that blood glucose levels exceeding 10.0 mmol / l ( 180 mg / dl ) are unacceptable in such patients , although the merits of further increasing doses of exogenous insulin by either supplying additional substrate or aiming to achieve tighter glycaemic control have been debated . thus , the roles of insulin administration , avoidance of hyperglycaemia , and other metabolic substrates have been examined [ 2 - 4 ] . these studies were complicated by the strong associations between variables . whether the results can be extrapolated to the critically ill patient admitted for nonsurgical reasons has not been defined , although this is the subject of planned investigations . in the present issue of critical care , rusavy and they examined the effects of two very different levels of insulinaemia during a euglycaemic clamp in 20 patients with sepsis . first , one variable glucose was controlled while the effects of insulin were examined . those investigators demonstrated that patients with sepsis but not diabetes mellitus are significantly hyperinsulinaemic relative to healthy volunteers before institution of the clamp . furthermore , increasing levels of insulinaemia during the clamp resulted in increased glucose uptake , oxidation and storage in patients with sepsis . the increases in glucose uptake and storage were significantly less than those in volunteers . increased insulin significantly reduced plasma alanine levels and tended to reduce free fatty acid levels in patients with sepsis . in the setting of increased glucose oxidation , this suggests that high doses of exogenous insulin can reduce the catabolism of protein and the oxidation of fat stores . although energy expenditure was higher in patients with sepsis , it remained constant , whereas respiratory quotient fell at the higher level of insulinaemia ; this implies that increased insulinaemia can induce a reduction in tissue oxygen demand . one theory for why glucose insulin potassium regimens are beneficial after myocardial infarction is that they promote myocardial utilization of glucose rather than free fatty acids , resulting in a greater number of molecules of atp generated per molecule of oxygen utilized . the more efficient use of oxygen may benefit ischaemic myocardium at the penumbra of an infarction . however , 1 tissues from patients with sepsis are not hypoxic and are replete in atp . first , the definition of sepsis employed in the study was not standard , although it is broadly similar to the american college of chest physicians / society of critical care medicine consensus definition of severe sepsis . furthermore , only those patients who no longer required vasoactive agents at a point 37 days after admission to the intensive care unit were studied . this implies that the patient population was restricted with respect both to severity and to the time point in the natural course of their illness . second , patient numbers are relatively low , limiting the power of the study . finally , as the authors themselves acknowledge , gluconeogenesis may not be entirely suppressed by the clamp in patients with sepsis , resulting in a potential underestimation of glucose storage . in particular , defects in glucose storage were partially overcome by supraphysiological levels of insulin . they also demonstrate that , at the time point studied , increased doses of insulin ( and glucose ) are able to reduce the catabolism of protein and fat stores . although limitation in protein catabolism may improve outcome by preserving muscle strength and aiding withdrawal of mechanical ventilation , this is not proven . finally , it is likely that the effects and relative importance of hyperinsulinaemia will change during the course of a critical illness . the metabolic changes demonstrated in the study were the consequence of large doses of insulin given during the early but not immediate stages of sepsis .

rusavy and colleagues recently endeavoured to dissect out the metabolic effects of insulin in patients with severe sepsis , in the setting of normoglycaemia . twenty stable patients were studied 37 days after admission using a euglycaemic clamp at two supraphysiological insulin levels . increased doses of exogenous insulin caused preferential use of glucose as a metabolic substrate , while total energy expenditure remained constant . consequently , hyperinsulinaemia reduced tissue oxygen demand and catabolism of protein in patients with sepsis ; the benefits of these effects are not proven . the effects of insulin at different time points in sepsis were not examined .

silica is the second most common mineral on earth . chronic inhalation of silica causes silicosis ( 1 ) . inhalation of crystalline silica occurs mostly in occupational settings , particularly such occupations as mining , sandblasting , stone cutting , surface drilling , pottery making , silica flour mill operations and other occupations in which silica dust exposure occurs . herein , we report the first known instance of a case of silicosis due to chronic inhalation shell powder of freshwater snail . a 70-yr - old woman visited our hospital for shortness of breath at october 18th , 2008 . chest ct showed ground glass opacity and traction bronchiectasis at right middle , lower lobe and left upper lobe lingular division ( fig . 1 ) . other laboratory analysis revealed nothing of note and spirometry data ( fvc , fev1 and dlco ) was within normal limits . she lived in a remote mountain village located 40 kilometer away from the nearest city . she was a housewife and did not smoke at all . during her lifetime , she had never been employed where silica dusts might be inhaled . she has been taking aspirin , olmesartan medoxomil , hydrochlorothiazide and paroxetine due to hypertension and a major depressive disorder . she has taken about 400 - 500 mg of freshwater snails as a health - promoting food on average per month for 40 yr ( fig . after then , resultant mixture of snail meat and ground shell powder was flushed with water over a fine mesh . once the meat had been collected , the filtered , shell powder was piled up on her backyard where she spent a lot of time doing house chores . a video - assist thoracic surgical ( vats ) biopsy was performed at right lower lobe . the multiple fibrotic nodules were distributed in the perivascular and peribronchiolar interstitia and were composed of mixtures of fibroblasts and dust - laden macrophages . polarized optical microscopy revealed that these lesions were consisted of silica and carbon materials ( fig . we analyzed the shells of snail by energy dispersive x - ray spectroscopy ( edx ) , which were sent by a daughter of the patient . the shell was composed of 52.9% cao , 0.77% sio2 , 0.36% na2o , 0.06% al2o3 , 0.05% fe2o3 , 0.01% mgo and 0.01% p2o5 . mineral composition of the lung lesion was analyzed by scanning electron microscopy with energy dispersive x - ray spectroscopy ( edx ) ( fig . the lesion was made up of 34.12% ca , 32.93% fe , 23.81% si and 9.13% al . because she did not present airflow limitation ingestion of an extract of freshwater snails is one of korean folk remedies . in oriental medicine , the meat of freshwater snails is usually extracted by grinding the shell and flushing it with water . in the present case , three types of lesions are typically seen in individuals who are exposed to dusts containing a mixture of crystalline silica and silicates . these include macules , mixed - dust fibrotic lesions ( mdfs ) and silicotic nodules ( 2 ) . macules are nonpalpable lesions consisting of interstitial accumulation of dust - laden macrophages without obvious collagenization . silicotic nodules are essentially the pathologic lesions due to silicosis , and are composed of refractile particles of silica surrounded by whorled collagen in concentric layers with macrophages , lymphocytes , and fibroblasts around the periphery ( 3 ) . in the present case , there were nodules composed of dust - laden macrophages and collagen with fibroblasts , which is known as mixed dust fibrosis . silicosis refers to a spectrum of respiratory diseases caused by inhalation of free crystalline silica . it encompasses such diseases as acute silicosis , accelerated silicosis , chronic silicosis and conglomerate silicosis . a common complication is tuberculosis and chronic obstructive lung disease and it is related with increased lung cancer formation ( 4 ) . thus , silicosis can occur in many industries such as mining or sandblasting ( 5 ) . silica can become airborne in dry and windy conditions or during urban activities when the soil contains abundant crystalline silica . indeed , pulmonary changes and lung fibrosis associated with environmental silica and mixed dust exposures have been observed in the lungs of farm humans and animals ( 6 , 7 ) . considering her environmental situation , inhalation of the shell powder of the freshwater snails when it was made airborne by the breeze appears to be the cause of her affliction . analysis of composition of shell of freshwater snails retrieved from the same river and sent to us by her daughter and electron microscopic examination with elemental analysis of lung lesion were consistent with our hypothesis . taken together , authors concluded that her silicosis was derived from chronic inhalation of powder of ground freshwater snails . herein we report the first known case of silicosis due to non - occupational exposure to shell powder of freshwater snail .

a 70-yr - old woman visited our hospital for shortness of breath . chest ct showed ground glass opacity and traction bronchiectasis at right middle , lower lobe and left lingular division . video - assisted thoracic surgical biopsy at right lower lobe and pathologic examination revealed mixed dust pneumoconiosis . polarized optical microscopy showed lung lesions were consisted of silica and carbon materials . she was a housewife and never been exposed to silica dusts occupationally . she has taken freshwater snails as a health - promoting food for 40 yr and ground shell powder was piled up on her backyard where she spent day - time . energy dispersive x - ray spectroscopy of snail shell and scanning electron microscopy with energy dispersive x - ray spectroscopy of lung lesion revealed that silica occupies important portion . herein , we report the first known case of silicosis due to chronic inhalation of shell powder of freshwater snail .

more than half of the cases are directly associated with irradiation of breast carcinoma and primary angiosarcoma is very rare . in younger patients , the lesion was not associated with previous radiotherapy but older patients are usually presented after radiotherapy . a 29-year - old unmarried lady was presented with bilateral breast swelling for 6-month duration . after bilateral mastectomy with axillary dissection histopathology report showed low - grade angiosarcoma of left breast and high - grade angiosarcoma of right breast . a 29-year - old unmarried female presented with complaints of bilateral breast swelling for past 6-month duration . during october 2006 she had a similar swelling in the right breast , fnac of which showed phylloides tumor . she underwent wide local excision in december 2006 , biopsy of which showed angiosarcoma of the breast with free margins . the swelling in the right breast had recurred with another new swelling in left breast . histopathology report of surgical specimen showed low - grade angiosarcoma of the left breast [ figure 1 ] and high - grade angiosarcoma of the right breast [ figure 2 ] . immunohistochemistry of right breast was done which showed cells positive for factor viii . on microscopic examination , histology of low grade showed irregularly dilated vascular channels lined by flat endothelial cells and histology of high grade showed proliferated polygonal or spindle - shaped , pleomorphic endothelial cells with anastomosing vascular channels . none of the bilateral axillary node was positive for malignancy . in view of the histopathology , she was advised further adjuvant therapy with local irradiation over right breast . during evaluation before radiotherapy , ct scan thorax revealed right hilar and right mediastinal lymph . the patient was given adjuvant chemotherapy with anthracycline / ifosfamide - based regime in dose of ifosfamide 2 g / m iv ( days1 - 5 ) and doxorubicin 25 mg / m iv ( days 1 - 3 ) every 3 weeks for six cycles . angiosarcoma of breast is usually an aggressive lesion that recurs locally and may metastasize primarily to lung . mri features of angiosarcoma shows a heterogeneous mass with low - signal intensity on t1-weighted images but signal intensity is high in images that are heavily t2-weighted . a histologically distinguishable low - grade variant has been identified that does not metastasize frequently but is still prone to local failure . antecodal evidence suggests that they respond to therapies associated with sarcoma treatment better than used for carcinoma of breast . in primary angiosarcoma initial presentation high - grade lesions appear to benefit from adjuvant radiotherapy in addition to complete surgical excision . of 15 published adjuvant studies included in the meta - analysis , only two rizzoli and bergonie showed improved survival with the adjuvant chemotherapy in soft tissue sarcomas . these studies since the 1997 meta - analysis showed conflicting results regarding the benefit of anthracycline and ifosamide - based chemotherapy . several chemotherapy treatment options have been tried in patients with angiosarcoma including paclitaxel gemcitabine , docetaxe gemcitabine , doxorubicin ifosamide , cisplatin , etoposide and various combinations of these agents . these studies may be a rationale for some physicians or patients to proceed with adjuvant chemotherapy . the 5-year disease - free survival rate is 76% for low grade , 70% for intermediate grade and 15% for high grade .

we report a young lady with bilateral angiosarcoma of breast because of its rarity . a 29 year old unmarried female presented with bilateral breast lump . she underwent bilateral mastectomy with axillary dissection histopathology of which showed low grade angiosarcoma of left breast and high grade angiosarcoma of right breast . ct thorax revealed right hilar and right mediastenal lymph nodes . she was treated with radiotherapy and chemotherapy postoperatively .

germ cell tumors secreting human chorionic gonadotropin ( hcg ) may lead to incomplete isosexual precocity in boys . germinomas account for approximately two - thirds of germ cell tumors and usually develop in the midline at the pineal and suprasellar regions . ectopic sites most notably the basal ganglia and thalamus when they usually present with gradually progressive hemiparesis and are almost always unilateral . a 9.5-year - old boy presented with enlargement of penis and appearance of pubic hair for 1 year and breaking of voice for 6 months . there was no history suggestive of raised intracranial tension and no history of head trauma , radiation exposure , cranial surgery or seizure . he was the first born child of a non - consanguineous union and had a younger brother who was healthy . he had a normal perinatal and developmental history had no history of any central nervous system infection or androgen exposure and his family history was non - contributory . on examination , his height was 124.4 cm ( standard deviation score [ sds ] 1.7 ) , weight was 24.8 kg ( sds 1.3 ) and his target height was 156.4 cm ( sds 2.9 ) . testes were 5 ml in volume each and were firm , symmetric and without any irregularity . spl was 8 cm and pubic hair was tanner stage 4 [ figure 1 ] . examination of other systems including a detailed examination of the nervous system ( with fundoscopic examination ) revealed no abnormality . external genitalia and pubic hair suggestive of puberty biochemical tests showed an elevated testosterone ( 637 ng / dl ) with prepubertal basal luteinizing hormone ( lh ) ( 0.128 miu / ml ) and post decapeptyl lh levels ( 30 min = 0.325 miu / ml and 60 min = 0.334 miu / ml ) and a bone age of 12 years . serum -hcg was elevated ( 22.47 miu / ml ; normal = non - detectable to 5.3 miu / ml ) while 17-hydroxyprogesterone was normal ( 1.96 ng / ml ) gadolinium contrast enhanced magnetic resonance imaging ( mri ) revealed an ill - defined , heterogenous patchy enhancing lesion in bilateral basal ganglia with minimal compression and contralateral diaplacement of the third ventricle [ figures 2 and 3 ] . cerebrospinal fluid ( csf ) -hcg was elevated ( 47.9 miu / ml ; normal = non - detectable to 5.3 miu / ml ) but -fetoprotein was normal ( 0.02 iu / ml ; normal = 0 - 5.5 ) . the next investigative step entailed a biopsy of the lesion , which could not be done in our institution for logistic reasons . t1w coronal and t2w axial magnetic resonance imaging showing ill - defined , heterogeneous hyperintense lesion in bilateral basal ganglia gd - contrast sagittal magnetic resonance imaging showing heterogeneous patchy uptake in lesion in basal ganglia he was diagnosed to have isosexual precocity due to germ cell tumor involving bilateral basal ganglia , which in all likelihood was a germinoma and was referred to a specialty oncology institute . he received conformal radiotherapy following which serum testosterone dropped down to 137 ng / dl and mri showed a slight decrease in the size of the lesion [ figure 4 ] . post - radiotherapy t2w axial magnetic resonance imaging showing slight reduction in lesion the germ cell tumor was most likely a germinoma considering the age group , location , absence of elevated csf -fetoprotein and response to radiotherapy . incomplete isosexual precocity in males may occur due to hcg secretion from intracranial germ cell tumors , which constitutes 2% of primary intracranial neoplasms below 20 years of age . of the non - midline germ cell tumors , those arising within the basal ganglia are most often germinomas . the usual sites of intracranial germinoma are the pineal and suprasellar region and location in the basal ganglia is very rare occurring in only 5 - 10% of cases . a higher incidence of basal ganglia germinoma is seen in asian populations occurring in patients aged 7 - 20 years with a striking male predominance ( 20:1 ) . the major signs and symptoms include progressive hemiparesis , cognitive decline and psychosis with precocious puberty being a rare , atypical manifestation . signs of raised intracranial pressure are usually not present as these tumors are non - invasive and do not obstruct the ventricular system . the clinical course is usually slow , with the duration of clinical symptoms ranging from 1 month to 4.5 years and diagnosis at an early stage is extremely difficult . in this regard , our patient could be considered lucky as his atypical presentation led to the diagnosis of his condition before more sinister neurologic manifestations could creep in . an early diagnosis in this condition is of prime importance on account of its excellent response to radiotherapy and chemotherapy . there are only a handful of case reports of bilateral basal ganglia germinoma and only a single report of it presenting with precocious puberty in published medical literature . this is only the 2 report of bilateral basal ganglia germinoma presenting with precocious puberty and as providence would have it , his sexual precocity proved to be a blessing in disguise!.

germ cell tumors may lead to incomplete isosexual male precocity and are commonly located in the pineal gland . germinomas of the basal ganglia are almost always unilateral and precocious puberty is a rare manifestation in them . we report a 9.5-year - old boy who presented with incomplete isosexual precocity due to bilateral basal ganglia germinoma .

indicated numbers of nave gbt - i transgenic cd8 t cells from the spleens of cd45.1gbt - i or cd45.1cxcr3 gbt - i mice were adoptively transferred into recipient mice . in some experiments , the donor cells were labeled with 0.05 m cfse ( invitrogen ) before transfer . cd4 t cells from recipient mice were depleted by injection of 200 g of gk1.5 antibody ( > 99.5 % depletion ) . depo - proveratreated 68 weeks - old female recipient mice were infected intravaginally ( ivag ) with 10 pfu of 186tkkpn ( tk hsv-2)9 or with uninfected vero lysate ( mock infection ) control as described previously10 . effector ctls were isolated from the spleen at 6 days post infection , and transferred into day 4 hsv-2-infected recipients . the numbers of cd45.1 gbt - i cells in the primary or secondary hosts were analyzed by flow cytometry . single suspensions were prepared from each experimental group using modified protocol as described21 . to analyze chemokine receptor expression , the h-2k - gb498 - 505 tetramer used here was prepared by nih tetramer core facility . samples were acquired on a facscaliber ( bd bioscience ) and analyzed with flowjo software ( treestar ) . the amount of cytokine / chemokine in the vaginal wash was measured using a multiplex luminex beads assay ( millipore ) or elisa according to manufacturers instructions . indicated numbers of nave gbt - i transgenic cd8 t cells from the spleens of cd45.1gbt - i or cd45.1cxcr3 gbt - i mice were adoptively transferred into recipient mice . in some experiments , the donor cells were labeled with 0.05 m cfse ( invitrogen ) before transfer . cd4 t cells from recipient mice were depleted by injection of 200 g of gk1.5 antibody ( > 99.5 % depletion ) . depo - proveratreated 68 weeks - old female recipient mice were infected intravaginally ( ivag ) with 10 pfu of 186tkkpn ( tk hsv-2)9 or with uninfected vero lysate ( mock infection ) control as described previously10 . effector ctls were isolated from the spleen at 6 days post infection , and transferred into day 4 hsv-2-infected recipients . the numbers of cd45.1 gbt - i cells in the primary or secondary hosts were analyzed by flow cytometry . single suspensions were prepared from each experimental group using modified protocol as described21 . to analyze chemokine receptor expression , the h-2k - gb498 - 505 tetramer used here was prepared by nih tetramer core facility . samples were acquired on a facscaliber ( bd bioscience ) and analyzed with flowjo software ( treestar ) . the amount of cytokine / chemokine in the vaginal wash was measured using a multiplex luminex beads assay ( millipore ) or elisa according to manufacturers instructions .

cd4 + t helper cells are well known for their role in providing critical signals during priming of cytotoxic cd8 + t lymphocyte ( ctl ) responses in vivo . t help is required for the generation of primary ctl responses as well as in promoting protective cd8 + memory t cell development1 . however , the role of cd4 help in the control of ctl responses at the effector stage is unknown . here , we show that fully helped effector ctls are not themselves self - sufficient for entry into the infected tissue , but rely on the cd4 + t cells to provide the necessary cue . cd4 + t helper cells control the migration of ctl indirectly through the secretion of ifn- and induction of local chemokine secretion in the infected tissue . our results reveal a previously unappreciated role of cd4 help in mobilizing effector ctl to the peripheral sites of infection where they help to eliminate infected cells .

central neurocytomas are slow - growing neuronal primary intracranial tumors , found mostly in young adults , usually located in the lateral ventricles . pediatric presentation of central neurocytoma is very rare , and no significant data have been published regarding their incidence . rades et al . in their series of neurocytoma in children reviewed 59 patients , which is so far considered the largest case series of this rare neoplasm of children under 18 years , reported only 13 ( 22% ) patients who were in the first decade . we are reporting this case because of its rarity , especially in this age and its location . our case is of a 9year - old girl who was diagnosed with central neurocytoma of the third ventricle . a 9-year - old previously healthy girl presented with headache of 1-month duration , which was continuous and holocranial in nature . there was also associated nausea and several episodes of vomiting for the past 1 month . on detailed clinical examination , the only positive the vital signs were within normal limits , and there were no focal neurological deficits . her blood reports were unremarkable . on magnetic resonance imaging of the brain , a well - defined globular mass with mixed intensity the tumor measured 47 mm 59 mm 55 mm in craniosacral and craniocaudal dimensions . bilateral thalamic compression was noted along with upstream hydrocephalus . on t2 imaging [ figure 1b ] , the mass appeared heterogeneously hyperintense , and on t1-weighted [ figure 1a ] , a hyperintense area with multiple cystic areas was noted . magnetic resonance spectroscopy revealed high choline and glycine peaks with low n - acetylaspartate peaks . ( a ) t1 axial section of brain showing a hyperintense lesion with multiple cystic areas within the third ventricle . ( b ) t2 axial section of the brain showing a heterogeneously hyperintense lesion in the third ventricle . ( c ) sagittal section of brain on contrast study showing intense enhancement of the solid part of the lesion the patient was operated with right frontoparietal craniotomy using the anterior interhemispheric transcallosal approach . corpus callosotomy of around 2 cm was done the choroid plexus was seen and followed to reach the foramen of monro , and the tumor was approached transforaminally . total removal of the tumor was achieved by piecemeal excision through the foramen of monro . bone flap was replaced , and wound was closed in layers after achieving absolute hemostasis . intraoperatively , the tumor was found to be globular , pale , grayish - white , soft , suckable , and moderately vascular . the tumor sample was sent for histopathologic examination and immunohistochemistry ( synaptophysin and neuron - specific enolase [ nse ] ) . on histopathology [ figure 2a ] , small sheets of atypical round-/oval-/epithelial - like cells with enlarged round / oval / hyperchromatic nuclei with occasional nucleoli with definite cellular - nuclear pleomorphism were seen , and rare mitotic activity was noted . on immunohistochemistry [ figure 2b and c ] , both synaptophysin and nse were positive helping us to arrive at the diagnosis of central neurocytoma . ( a ) histopathologic examination suggesting degenerated cellular neoplasm with definite cytologic atypia corresponding to the who grade ii tumor . ( b ) synaptophysin ( c ) neuron - specific enolase positive the patient was discharged without any neurological deficits and with relief of headache on the 10 postoperative day . till date initially , it was termed as a who grade i tumor and was updated to grade ii in 1993 . fifty percent are located in the lateral ventricles , 13% in both lateral and third ventricles , and solitary third ventricle central neurocytomas amount to only 3% . classically , central neurocytomas present with features of increased intracranial pressure associated with obstructive hydrocephalus . in a study , schild et al . reviewed 27 patients of which 93% had headache , 37% had visual problems , and 30% had nausea and vomiting as their chief complaints , which was similar to the complaints of our patient . the most commonly used approaches are anterior transcallosal approach and anterior transcortical approach . in our case , the previous approach , i.e. central neurocytoma is confirmed diagnostically by immunohistochemistry for neuronal antigens such as synaptophysin and nse . among the two , synaptophysin is most remarkable and nse is considered nonspecific . both these tests were positive in our study . radiotherapy might prove beneficial in adult cases , in which there is incomplete tumor removal although it is still a matter of concern in children .

central neurocytomas are slow - growing primary brain tumors of neuronal origin having a predilection to arise mostly in the lateral ventricles . we report a case of a 9-year - old girl who presented with headache and vomiting of 1-month duration . her magnetic resonance imaging was suggestive of central neurocytoma of the third ventricle and was surgically managed , and tumor tissue was sent for histopathology and immunohistochemistry which confirmed the diagnosis .

a 16yearold male with no significant past or family medical history presented to the pediatric emergency department with a 1month history of a macular rash in both palms that in the following weeks spread to the face , trunk , and all four extremities 1 , 2 . clinical examination revealed a diffuse symmetric macular rash involving the face , the entire trunk , and the extremities , including the palms ( fig . 1 ) and soles . upon questioning , the patient mentioned a history of unprotected sexual intercourse and further examination revealed a midshaft one centimeter ulcer ( fig . laboratory investigations confirmed the diagnosis of secondary syphilis with positive venereal disease research laboratory ( vdrl ) and treponema pallidum hemagglutination assay ( tpha ) tests . he was treated with penicillin 2.4 million units intramuscular and referred to the outpatient clinic . six months after diagnosis , he presented a complete clinical resolution and a fourfold decline in vdrl titer .

key clinical messagedespite being an uncommon disease in pediatrics , the incidence of syphilis has increased in the last years both in europe and in the united states . upon a suggestive clinical presentation , especially if including genital lesions and palmar rash , secondary syphilis must be included in the differential diagnosis .

its pathophysiology has been well identified and progresses from otitis externa to a skull base osteomyelitis secondary to pathogens spreading through anatomical planes within and surroudning the temporal bone ( 2 ) . the most common pathogen identified is pseudomonas aeruginosa and it is treated with anti - pseudomonal antimicrobial agents unless cultures indicate otherwise . a 70 year old gentleman with a background of type two diabetes mellitus first presented to his family doctor in februrary of 2011 with left sided , throbbing otalgia that had been present for a week . a swab was taken and clioquinol / flumetasone pivalate ear drops were prescribed for a working diagnosis of otitis externa . imaging demonstrating extent of disease the patient presented one month later with continuing ear pain and a new headache . framycetin sulphate / gramicidin / dexamethasone drops were prescribed for a diagnosis of ongoing otitis externa and analgesia was prescribed for the headache . over the next three weeks the patient presented on multiple occasions with worsening headache , impaired balance and trismus . again imaging demonstrating extent of disease two months after his initial presentation , he presented to his family doctor with ongoing otalgia , headache , unsteadiness and had now developed anoxeria . an urgent otorhinolaryngology review found a polyp in the left ear canal with ongoing signs of otitis externa associated with a retained cotton bud . imaging demonstrating extent of disease now three months after his initial presentation , the patient still had ongoing symptoms including headaches , vomiting and 10 kg of weight loss over this time . the headache was atrributed to cervical osteoarthritis , previously diagnosed on ct scanning the year prior . his family doctor admitted him to a small peripheral hospital for management of his pain . at this time a repeat ct scan showed extensive abnormality of the left temporal bone and opacification of the left middle ear , external auditory canal and mastoid air cells . he had a t - tube inserted and was continued on oral and topical ciprofloxacin for a working diagnosis of mastoiditis secondary to otitis externa and media . imaging demonstrating extent of disease despite the intensification of antimicrobial therapy , over the next few weeks his condition worsened with weakness , headaches , dizziness , falls and otorrhea . he was admitted to a large tertiary hospital for nuclear medicine imaging for suspected moe . imaging demonstrating extent of disease at the tertiary hospital the patient was found to be clinically wasted and weak . he also had rightward uvular deviation , absent gag reflex , weakness of the left sternocleidomastoid and trapezius , house brackman grade 2 left facial nerve weakness and an immobile left vocal cord . mri and spect / ct with gallium tracer was performed , the images acquired from which illustrate the severe extent of disease ( figures 1 to 5 ) . he was diagnosed with moe with extensive skull base osteomyelitis producing multiple lower cranial neuropathies . biopsy performed by orl / ent surgeons grew scedosporium apiospermum and given the extent of the infection a palliative approach was agreed upon with the patient and family . advanced age and immunocompromised states including diabetes mellitus are the primary pre - disposing factors to developing moe ( 3 ) . diabetes is an integral aetiological factor for moe in the elderly and this has been attributed to small vessel disease and impairment of phagocytic function ( 3 ) . the vast majority of otitis externa is due to bacterial pathogens and so is the case for moe . the most common pathogen identified is pseudomonas aeruginosa and up until a decade ago fungal moe was considered extremely rare ( 4,5 ) . there are however a number of cases in the literature reporting fungal organisms causing moe , including asperigillus species ( 6 - 8 ) , candida parapsilosis ( 9 ) , candida ciferri , pseudoallescheria boydii , malassezia sympodialis and scedosporium apiospermum ( 5,10 ) . this case adds to the growing evidence that fungal moe is becoming more prevalent in our community . a possible cause for this is that there is ready access to ciprofloxacin and other anti - pseudomonal agents in the modern era , therefore reducing the disease burden of otitis externa due to pseudomonas in the community while not addressing the relatively unidentified burden of fungal species . careful clinical judgement is therefore needed when laboratory culture results reveal unusual non - bacterial species . this is particularly important in patients who have a poor response to anti - pseudomonal agents . this case also highlights the dangers of attributing headaches in the context of other symptoms to simple causes such as cervical osteoarthritis and it is a reminder to always consider an alternative diagnosis to the working diagnosis . care should always be taken when a patient presents with headaches and systemic upset in the context of otalgia and ear discharge , as the consequences of failing to treat moe are dire . the mortality rate is currently around 10% with early detection and modern anti - microbials , but if it is identified late moe can be very difficult to treat due to its propensity to spread .

a recent case report in this journal highlighted the pathophysiology and management of bacterial malignant otitis externa ( moe ) ( 1 ) . we describe the case of an elderly gentleman who had a delayed diagnosis of fungal moe with advanced diseased at time of diagnosis . this case highlights the changing microbiology of this serious disease and the difficulty in diagnosis given the rarity of this form of otitis externa relative to its uncomplicated form .

hernias through the foramen of winslow are rare and constitute only 8% of internal hernias . the rate of preoperative diagnosis has been reported to be < 10% of the intraoperatively confirmed cases . a delay in diagnosis and treatment is often observed and may be responsible for the high mortality rate of up to 49% associated with this hernia type . internal hernia is often revealed by intestinal obstruction associated with non - viable bowel at the time of operation . we present a case of a patient with moderate epigastric pain in whom a computed tomography ( ct ) scan of the abdomen revealed the unexpected finding of right colonic herniation through the foramen of winslow . a 69-year - old patient presented to our emergency room with progressive dull abdominal pain and distension without nausea , vomiting or change in bowel habits . physical examination showed pain with moderate guarding in the right upper and lower quadrants . a plain abdominal x - ray and a ct scan were performed . radiological findings suggested the diagnosis of an internal hernia through the epiploic foramen and containing the right colon with important distension of the caecum ( fig . 1 ) . surgical exploration was then performed using an open approach . at laparotomy , we found an internal herniation of the caecum and the entire ascending colon through the foramen of winslow ( figs 2 and 3 ) . after hernia reduction , multiple patchy areas of caecal necrosis were observed ( fig . figure 1:axial section through upper abdomen showing distended caecum with air - fluid level ( a ) with the displacement of the stomach ( b ) laterally . figure 3:coronal slice showing herniation of right colon through the foramen of winslow . axial section through upper abdomen showing distended caecum with air - fluid level ( a ) with the displacement of the stomach ( b ) laterally . foramen of winslow hernia can be defined as peculiar variant of internal abdominal hernia , since it is a normal peritoneal orifice kept closed by normal intra - abdominal pressure that may be permeated by the intra - abdominal viscera . there are multiple anatomical abnormalities reported as possible predisposing factors for a visceral herniation through this foramen : ( i ) abnormally enlarged foramen ; ( ii ) the presence of an unusually long small - bowel mesentery or persistence of the ascending mesocolon ; ( iii ) an elongated right hepatic lobe , which could be directing the mobile intestinal loop into the foramen ; ( iv ) a lack of fusion between caecum or ascending colon to the parietal peritoneum ; ( v ) a defect in the gastrohepatic ligament , ( vi ) incomplete intestinal rotations or malrotation . since the first report in 1834 by blandin in autopsies , < 200 cases of foramen of winslow hernia have been reported in the medical literature . the typical presentation is an acute severe mid - epigastric pain associated with nausea and vomiting . the severity of the pain is related to the presence of bowel strangulation with subsequent necrosis . in some very particular cases , the internal hernia through the winslow hiatus is revealed by an obstructive jaundice due to direct compression of the hepatic pedicle . the key to diagnosis relies on prompt radiologic studies and the ct scan is nowadays considered the technique of choice . various , more or less specific findings have been reported , such as an air - fluid collection in the lesser sac or signs of small bowel obstruction associated with the presence of mesenteric vessels stretching anterior to the inferior vena cava and posterior to the portal vein ; the absence of the ascending colon in the right gutter and an antero - lateral displacement of the stomach . the treatment invariably requires urgent surgery , and even if symptoms are limited as in our case , it should be considered in order to assess intestinal viability because of the risk of intestinal strangulation . treatment is based on careful inspection with subsequent hernial reduction that is frequently possible with simple and gentle traction . occasionally , this can be difficult ; in these situations the gastrocolic or gastrohepatic ligaments must be opened or , alternatively , a wide kocher manoeuvre performed . in the case of massive colonic dilatation a colotomy for decompression with a suction device can be useful [ 5 , 6 ] . in the case of overt intestinal necrosis an adequate resection is obviously mandatory ; nevertheless there is no clear and established consensus on surgical management when the herniated contents are grossly viable . some surgeons report right colonic fixation or caecopexy to the lateral wall , whereas others advocate right colectomy especially when there is a lack of fusion between caecum or ascending colon to the parietal peritoneum in order to avoid subsequent volvulus . furthermore , in order to prevent recurrent herniation , some surgeons decide to definitively close the foramen of winslow . this option can however lead to meaningful complications such as accretions and/or portal vein thrombosis . thus , leaving the foramen open may be justifiable since the inflammatory post - operative adhesions will most often obliterate the foramen entrance with no evidence of recurrent herniation [ 3 , 6 ] .

herniation through the foramen of winslow is a rare condition that can lead to a delayed diagnosis and treatment with a high mortality rate . in most reported cases , patients present to the emergency department with symptoms suggesting intestinal obstruction or with sudden and severe pain in the upper abdomen . symptoms are non - specific . clinical diagnosis may be difficult or even missed . the widespread availability of cross - sectional imaging can improve the percentage of correct preoperative diagnosis . we report a case of a caecal and right colic herniation through the foramen of winslow found incidentally on abdominal computed tomography in a patient presenting with mild epigastric pain .

a 40-year - old woman was referred for electroconvulsive therapy ( ect ) for a severe depressive illness . she had a background of severe psoriasis for which she received methotrexate for nearly 20 years and adalimumab by subcutaneous injection every 2 weeks . she had been commenced on prednisolone , amoxycillin and ipratropium and her first session was cancelled owing to her dyspnea and widespread wheeze , although she was apyrexial . it had already been agreed with the patient that she would commence unilateral ect owing to concerns about cognitive side effects . on the first session the patient was given a 5% stimulus from a thymatron iv machine using the delia placement , producing a 39-s seizure which was taken to be the seizure threshold . no ill effects were noted at any point and the patient made a full recovery . on the second session however the patient received a stimulus of 30% in the same position and administered by the consultant , in line with recent developments in unilateral application . as she recovered , she complained of pain around her right eye and was dysarthric . on clinical examination she was noted to have an injected right conjunctiva and a right facial palsy affecting her right eye , and mouth . the patient made a full recovery but ect was suspended while she had further investigations advised by the neurologist . this included a c - reactive protein which was normal and mri brain which revealed no abnormality . the patient subsequently continued with bilateral ect for 20 sessions and made a good recovery from the depressive disorder and no further neurological sequelae were observed . todd 's paralysis is described as a temporary weakness usually affecting one or more limbs and which usually occurs after a focal seizure . however , a similar phenomenon resulting in language , somesthetic and visual deficits can occur depending on the focal area involved . the rationale for converting to bilateral ect was to avoid a focal seizure which may have been significant in producing this focal neurology . this condition has not been described in connection with ect as far as we are aware . this may represent a rare indication of the need to convert from unilateral to bilateral ect .

this case describes a woman undergoing unilateral electroconvulsive therapy ( ect ) who developed a todd 's palsy following the treatment , and which resolved when converted to bilateral ect . we go on to hypothesize that this rare side effect may be an indication of the need to switch laterality during a course of ect .

a maxillary oral squamous cell carcinoma ( scc ) is generally treated with a conventional surgical excision . the resultant surgical defect often includes part of the hard and soft palates , which results in an oro - antral communication . the hard and soft palates are anatomical structures that have widely recognized roles in speech and deglutition . when these structures must be removed , partially or completely , because of malignancies , a team approach is critical . a surgical approach alone without reconstruction or obturation of the surgical defect will result in air , liquid , and food escaping into the maxillary sinus and nasal cavities , causing severe speech and swallowing dysfunction with significant reduction in quality of life . speech is often unintelligible as a result of the marked defects in articulation and nasal resonance resulting from the anatomical and structural defect . thorough pre- and postsurgical reconstructive and prosthetic treatment planning will ensure the best rehabilitation of a maxillectomy patient . numerous techniques and materials for making obturators have been suggested.[417 ] this clinical technique describes oral rehabilitation of a patient with sub - total maxillectomy with a maxillary obturator . a 55-year - old female diagnosed with scc of the right maxillary sinus had undergone hemimaxillectomy . sub - total maxillectomy was performed and after proper healing , she was referred to the department of prosthodontics , government dental college , bangalore , india . extra - oral examination revealed reduced fullness due to loss of support [ figure 1 ] . on intraoral examination , a big communication was present between nasal and oral cavity except a minor part of the palatine process of maxilla and horizontal plate of palatine bone [ figure 2 ] . pre - treatment photograph showing reduced fullness intra - oral photograph showing the defect speech pathology , head and neck , and maxillofacial prosthetics / dental oncology services were consulted to evaluate the extent of resection and functional deficits . a consensus among the specialists recommended an obturator to restore speech and swallowing abilities and esthetics . the impression was boxed and poured in type iv stone ( ultrarock , kalabhai karson pvt . record bases were made with heat cure acrylic resin ( lucitone 199 , dentsply int . ) [ figure 5 ] . the jaw relation was recorded . after the try - in , the solid obturator was processed in heat polymerized acrylic resin ( lucitone 199 , dentsply int . ) . maxillary impression along with the defe master cast showing the resected area heat - cure acrylic record base after curing of the prosthesis , the flash was trimmed . the prosthesis was pumiced , polished , and delivered to the patient [ figures 68 ] . maxillary obturator in patient 's mouth patient 's frontal view along with the prosthesis post treatment photograph with increased fullness and improved esthetics the prosthetic retention and stability were evaluated subjectively . speech intelligibility improved and the patient was then referred to the speech pathology department for further evaluation of his speech and swallowing abilities . obturator prosthesis for maxillary defects is frequently associated with problems that result from the lack of retention and stability . maxillofacial reconstruction of the partition between the nasal and oral cavities in the edentulous patient relies on anatomical undercuts and structures , such as remnants of the soft palate , palatine process of maxilla , and horizontal plate of palatine bone , for retention . an appropriate prosthetic fit and functional success ensure that the patient ultimately uses the device during daily routines . it is important that clinicians do not overlook the importance of referral to the speech pathologist , particularly in patients for whom the success of a prosthetic obturator after total or sub - totalmaxillectomy depends on the ability to adequately speak and swallow . subtotal and total bilateral maxillectomydefects represent a complex challenge for the maxillofacial prosthodontist . in this clinical report , preoperative treatment planning involving the head and neck surgeon , the maxillofacial prosthodontist , and the speech pathologist resulted in a obturator that enabled the patient to speak and swallow successfully .

this clinical report describes oral rehabilitation of a patient with sub - total maxillectomy with palatine process of maxilla and horizontal plate of palatine bone intact to retain the maxillary obturator . clinical examination has been performed to know the amount of favorable undercuts to be used for retention of the obturator for better functional efficiency . successful prosthetic reconstruction of hemimaxillectomy defect is a challenging procedure that requires multidisciplinary expertise to achieve acceptable functional speech and swallowing outcomes . this article describes the oral rehabilitation of a patient with sub - total maxillectomy with a maxillary obturator . oral rehabilitation of sub - total maxillectomy patient is a challenging task . obturation of the defect depends on volume of the defect , and positioning of remaining hard and soft tissues to be used to retain , stabilize , and support the prosthesis . a maxillary obturator for edentulous patient must provide for retention , stability , support , patient comfort , and cleanliness .

a 60-year - old man presented to our institute with a swelling in the superior medial aspect of his right orbit . it has been noticed for the last 1 year and has been gradually increasing in size . there was no history of defective vision , pain , or sudden increase in size . on examination , a soft to firm globular mass in the superomedial aspect of the orbit displaced the right eye downward and outward . it was not compressible or reducible , and the deeper margins were not palpable [ fig extraocular movements in the right eye showed restriction in elevation , levo - elevation , and adduction . clinical photograph showing right eye eccentric proptosis with a mass in the superomedial aspect of the eye on magnetic resonance imaging , a 39 mm 26 mm lobulated well - encapsulated lesion was seen in the superomedial aspect of the right orbit . it was hyperintense in t2 and flair sequence and isointense in t1 imaging [ fig . 2 ] . the mass displaced the medial rectus , encircling the superior rectus , and was extra- and intra - conal . an orbitotomy was performed after obtaining consent the mass was excised . t2 and flair sequence hyperintense lobulated well - encapsulated lesion was seen in the superomedial aspect of the right orbit involving both intra- and extra - conal space histopathological examination revealed areas of hemorrhage and clusters of short spindle cells in eosinophilic fibrillary background [ fig . 3 ] . cells have elongated nucleus and scanty eosinophilic cytoplasm along with foci of myxoid stroma and irregular vascular channels , thick- and thin - walled lined by flat endothelial cells ( a ) glial tissue in a fibrocollagenous background ( h and e , 10 ) . ( b ) short spindle cells in an eosinophilic fibrillary background along with foci of myxoid stroma and irregular vascular channels ( h and e , 40 ) postoperatively , the patient had improved extraocular motility , no diplopia , and the proptosis showed regression . at 1 year follow - up , glial heterotopia is abnormally located collection of normal glial tissue distant to the central nervous system . the most common location is around the nasal cavity , and it can occur in sites such as ethmoid sinus , middle ear , pharyngeal area , parapharyngeal space , pterygopalatine fossa , submandibular region , scalp , head , neck , and lung . they are generally present at birth but can manifest at any time in life . of the previously reported orbital glial heterotopia , the age of presentation has varied between 15 days and 20 years . our patient presented in the sixth decade , and the glial tissue was present in the orbit without any bony defect . there is only one other case reported in literature in a 59-year - old man who presented with optic disc swelling , and the orbital mass was found to be ectopic glial tissue . patients may present with varying symptoms of proptosis , diplopia , ptosis , or lid swelling due to mass effect . the most widely accepted theory in the pathogenesis of heterotopic glial tissue is that there is embryological herniation of glial tissue through a bony defect which subsequently may close , leaving no communication with the cranial cavity . on histopathology , heterotopic glial tissue found in the orbit is composed of astrocytes , gemistocytic astrocytes , fibrovascular connective tissue , lacrimal gland , cerebellar tissue , primitive retina , and skeletal muscle in varying proportions . there can be associated laminated calcific bodies or calcospherules ; it can be cystic filled with cerebrospinal fluid or clear fluid . some authors opine that this could be dysembryogenic in origin , and some opine that it could have got admixed with the developing muscle . surgery may be difficult and bony defects have to be looked for , which may then need multi - specialty approach . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .

heterotopic glial tissue is very rare in the orbit . our case was an adult , which is unique since most cases reported in literature involve children . we describe a case of a 60-year - old man who presented with an orbital mass , which histopathologically revealed heterotopic glial tissue .

it is caused mainly by three species wuchereria bancrofti , brugia malayi and brugia timori . in india , filariasis has been reported in cytologic smears from various organs and sites like male genital organs , thyroid , breast , lymph node , liver , soft tissue swellings , bone marrow , cervical smears , body fluids etc.[17 ] detection of microfilaria in voided urine sediment , especially in achylous hematuria specimen , is extremely rare . we report a case with microfilariae of w. bancrofti in a 25-year - old patient who presented with achylous hematuria . a 25-year - old male patient presented in urology out - patient department ( opd ) with history of intermittent painless hematuria for three weeks . there was no history of fever , trauma , instrumentation , flank pain , ureteric colic or passage of milky white urine . a voided urine sample was collected and sent to the cytopathology laboratory for routine cytological examination . smears revealed urothelial cells along with neutrophils , lymphocytes , red blood cells and few microfilariae [ figure 1 ] . high power examination of the microfilaria showed a sheathed parasite with central axis of nuclei which ended abruptly before the tip of tail [ figure 1 ] . with this , characteristic morphology the microfilariae were identified as w. bancrofti . photomicrograph of urine sediment showing a sheathed microfilaria with central axis of nuclei ending abruptly before the tip of tail along with few urothelial cells , inflammatory cells and red blood cells ( mgg , 400 ) subsequent to the cytological diagnosis patient was treated with 21 days course of diethylcarbazine ( dec ) after which he became asymptomatic . w. bancrofti accounts for majority of the filarial infection in india ; accounting for approximately 95% of cases . infection by this sheathed species is commonly seen in india , china , indonesia and eastern pacific . the common presentations include microfilaremia , lymphedema , hydrocele , acute adenolymphangitis ( adl ) , chronic lymphatic disease and less common presentations are like chyluria and tropical eosinophilia . shedding of microfilaria in urine is possibly determined by local factors like inflammation , trauma or stasis , which mainly affect the lymphatics and small vessels causing either lymphatic blockage or damage to the vessel wall . to the best of our knowledge , only few cases of w. bancrofti have been reported in voided urine sample in literature . in most of these reported cases , there was a history of chyluria . webber et al . first reported microfilaria in a 23-year - old male patient during a routine workup for intermittent painless hematuria . reported w. bancrofti in a 45-year - old man who presented with painless hematuria and clinical suspicion of malignancy . in the present case , microfilaria was incidentally detected in a voided centrifuged urine sample of a young male patient who presented with complaints of intermittent painless hematuria . the explanation of non - chyluric hematuria may be that significant lymphatic obstruction may not have taken place ; therefore , patient did not present with chyluria . the microfilaria can be detected in blood , various body fluids , fine needle aspiration smears and histological examination as well as by serological and immunological tests . among these , elisa and rapid format immunochromatographic card test have a very high sensitivity and specificity . detection of parasite dna by polymerase chain reaction ( pcr ) is now considered as the most sensitive technique for definite diagnosis of this infection . diethylcarbamazine ( dec , 6 mg/ kg daily for 12 days ) remains the treatment of choice for the individual with active infection even after many decades since it was first used in w. bancrofti infection . most of the infected individuals do not have microfilaremia at the time of clinical manifestation , and definitive diagnosis in such cases can be difficult . it saved the patient from undergoing the trauma of invasive investigations and prevented further complications .

filariasis is a widespread public health problem seen commonly in tropical countries . microfilariae have been reported in aspiration smears from various sites . however , it is very rare to detect these organisms in voided centrifuged urine cytology . we , report this rare finding in a 25-year - old patient who presented with achylous hematuria .

residual and delayed sequelae include postpericardiotomy syndrome , fistulas , valvular dysfunction , ventricular aneurysms , and pseudoaneurysms.1 traumatic coronary artery - cameral fistulas ( tcaf ) are uncommon sequelae of trauma that require early surgical intervention to prevent complications.2 although the left coronary artery is the most frequently injured vessel of the heart , traumatic fistulas appear more often in the right coronary vessels , as the initial injury to the left coronary artery usually results in early death prior to hospitalization.3 we report the case of a patient with left anterior descending ( lad ) artery to right atrium fistula following cardiac penetrating trauma . a 17-year - old man presented to the emergency room with a stab wound to the heart about 45 minutes prior to arrival . at arrival , he was in a shock state and was pale , dyspnic , and agitated with blood pressure of 80/40 mmhg , heart rate of 130 beat / min , and respiration rate of 30/min . there was a 45 cm laceration located at the level of the 3 and 4 ribs in the left midclavicular line with active bleeding . he was transferred to the operating room immediately while his bleeding was controlled by finger pressure and initial resuscitation was administered . anterolateral thoracotomy and repair of the left ventricular rupture at the line of the lad were performed , but the patient suffered dyspnea two hours postoperatively and his electrocardiography ( ecg ) showed st - t segment elevation in the pericardial leads and st - t segment depression in the inferior leads . transesophageal echocardiography revealed severe left ventricular hypokinesia and apical akinesia with a left ventricular ejection fraction of 40% and possibility of the lad fistula . emergency coronary angiography , conducted approximately twelve hours postoperatively , showed an lad cut - off at mid part with poor distal run - off and fistula of the lad to the right ventricle ( figures 1 ) . on post - admission day 7 , the patient underwent reoperation , during which he was placed on cardiopulmonary bypass and high - potassium blood cardioplegia was administered . the fistula of the lad to the right ventricle was repaired with prolene 5 - 0 and the left interior mammary artery was grafted to the lad , distal to the site of the suture ligation of the lad fistula . coronary arteriovenous fistulas were first described by krause in 1865.4 they commonly have a congenital origin but can be acquired as complications of surgical procedures and traumas . the venous side of the coronary arteriovenous fistula can be the coronary sinus , the great cardiac vein , the right atrium , or the right ventricle.5 most of the reported cases of accidental traumatic coronary artery fistulas were diagnosed several months to years after the initial operation when there was morbidity secondary to the fistula such as congestive heart failure and pulmonary hypertension . our case was diagnosed early postoperatively and underwent reoperation on post - admission day 7 . early intervention in tcaf prevents the late complications of high flow left - to - right shunting , including the development of pulmonary artery hypertension and congestive heart failure.2 shimabukuro et al . reported the case of a patient with cardiac penetrating trauma who presented with congestive heart failure and tricuspid regurgitation due to coronary arteriovenous fistula 8 years after trauma . they suggested that early surgical repair be undertaken in cases of traumatic coronary artery fistula , even if the shunt is minimal and early symptoms are mild.6 bernard maitre et al . reported the unusual case of a patient with left ventricular aneurysm and coronary - pulmonary artery fistula detected 23 years after a thoracic wound ; the patient presented with severe hemoptysis and anemia.1 reubendra and associates reported the case of a patient with traumatic lad - to - pulmonary artery fistula that developed delayed pericardial tamponade and underwent emergency intervention ; they believe that survival is not unlikely with fistulas occurring in the mid - lad to right ventricle , as indicated by the significant number of reported cases . early repair seems indicated given the life - threatening sequelae such as delayed pericardial tamponade.7 depending on whether the drainage is into the left or right heart , coronary artery fistulas are classified into two major types . akhras et al . reported a right coronary artery - right atrial fistula about 40 years after shrapnel injury.8 alberto rangel and associates presented the case of a 17-year - old man who sustained a knife chest wound and secondarily developed a traumatic coronary arteriovenous fistula communicating the left main coronary artery to the pulmonary artery , associated with pulmonary valvular insufficiency and endocarditis.9 survivors of traumatic coronary artery fistulas have an excellent prognosis after successful closure of the fistula.10 we suggest that patients with traumatic coronary artery fistulas be considered for elective surgical repair to prevent the development of complications . most patients with traumatic coronary artery fistulas should undergo early surgical intervention to prevent the sequelae of a left - to - right shunt since survivors of traumatic coronary artery fistulas have an excellent prognosis after a successful closure of the fistula .

traumatic coronary artery - cameral fistulas ( tcaf ) are rare and may present secondary to penetrating injuries ( 80% ) or iatrogenic traumas . early operative intervention remains the recommended treatment modality for accidental traumatic coronary artery fistulas . we report the case of a 17-year - old man who presented with left anterior descending coronary artery - right ventricle fistula following penetrating cardiac trauma , which was successfully repaired surgically .

the incidence of the coarctation of the aorta ( coa ) in children with congenital heart disease is 5 to 8% . most frequently , it is associated with a bicuspid aortic valve , different levels of aortic stenosis , and congenital mitral valve stenosis . the significant after - load increase affects the left ventricle ( lv ) in the coa , resulting in increased wall stress , compensatory lv hypertrophy , and finally lv dysfunction . life expectancy will be reduced in patients without correction due to accelerated coronary artery disease , stroke , and congestive heart failure . in adult life , some cases of the coa have been treated during childhood , some others are re - coarctations following previous transcatheter or surgical therapy , and others are missed cases of native coarctations . diagnosis is made by clinical suspicion and physical findings such as blood pressure difference between the upper and lower extremities , pulse delay in the femoral artery , and systolic murmur over the thoracic spine . different methods are employed for the treatment of the coa in adults , including surgical or percutaneous balloon angioplasty with or without stent placement . today , transcatheter approaches have been increasingly utilized , because of improved balloon and stent technology , which confers improved safety and success of these procedures . a 26-year - old male with a severe coa diagnosed by computed tomography angiography referred to our center for an attempted stent implantation . cardiac catheterization and aortography revealed a long coa after the origin of the left subclavian artery with a 60 mmhg gradient . moreover , there was a large aneurysm in the site of the coarctation ( figure 1 ) . under general anesthesia and fluoroscopic guidance , two balloon - expandable covered cheatham - platinum ( cp ) stents ( size 18 in 44 millimeters and size 18 in 50 millimeters ) were successfully implanted across the coa . a post - procedural aortography showed an excellent result , and the gradient had decreased to 8 mmhg . on follow - up multi - slice computed tomography , performed before discharge and 4 weeks after the procedure , there were no complications ( figure 2 ) . aortography , showing a long coarctation after the left subclavian artery origin with a large aneurysm multi - slice computed tomography after the procedure , illustrating the successful deployment of the stents and no residual aneurysm or coarctation the coa in adulthood is challenging and different complications even with proper treatment can occur . in these patients , associated aneurysm , near - atretic aortic isthmus , and recurrent pathology need special attention . in complex cases , surgical procedures may not be as effective as those for simple childhood coarctations . furthermore , controlling the hemostasis of large intercostal arteries is important , especially when an aneurysm is present . percutaneous techniques are promising , and their limitations are vessel dissection or aneurysm formation at the time of stent deployment and risk of restenosis . these limitations were relatively overcome with the use of covered cp stents . with the introduction of cp stents , balloon angioplasty has been mostly replaced by stenting . also , bare metal stents are less popular due to the risk of stent fracture and aneurysm formation . cp stents have rounded edges with safer placement and less injury to the native vessels , reducing risk of dissection . covered stents are indicated in concomitant aneurysm , older age , and tight coarctation and their use even in simple cases is increasing . however , a potential concern in using covered stents is related to distal embolization of the stent . with a bare stent , the problem is easier to address because the stent can be dilated without occluding any side branch in the abdominal or thoracic aorta , whereas with covered stents , important arteries may be closed by the polytetrafluoroethylene ( eptfe ) coverage . another issue is the need for a larger diameter sheath compared to a similar - sized bare stent . nonetheless , there are no reports of access - related complications in the previous studies . in the case presented herein , the use of a covered stent within the aneurysm was safe and effective . recent reports of patients treated with stents have demonstrated significantly lower acute complications compared to surgery and balloon angioplasty methods and better hemodynamic and imaging outcome on intermediate follow - up , although there has been more planned reintervention required . the coa in adulthood and in patients with associated aneurysm is challenging , and different complications even with proper treatment can occur . covered stents are indicated in concomitant aneurysm , older age , and tight coarctation . in this case , the use of a covered stent within the aneurysm proved safe and effective .

abstractthe coarctation of the aorta ( coa ) is rare in adulthood . diagnosis is made by clinical suspicion and physical findings such as blood pressure difference between the upper and lower extremities , pulse delay in the femoral artery , and systolic murmur over the thoracic spine . the coa in adulthood and in patients with associated aneurysm is challenging and different complications even with proper treatment can occur . covered stents are indicated in concomitant aneurysm , older age , and tight coarctation.a 26-year - old male with resistant hypertension due to a coa diagnosed by computed tomography angiography referred to our center for an attempted stent implantation . cardiac catheterization and aortography revealed a long coa after the origin of the left subclavian artery with a 60 mmhg gradient . moreover , there was a large aneurysm in the site of the coarctation . under general anesthesia and fluoroscopic guidance , two balloon - expandable covered cheatham - platinum stents ( size 18 in 44 millimeters and size 18 in 50 millimeters ) were successfully implanted across the coa with no residual gradient . on 2 years ' follow - up , the patient had no symptoms except for mild hypertension . in this patient , the use of a covered stent within the aneurysm was safe and effective .

we and others have shown that it is possible to transfer phenotypes via microbial transplantation in antibiotic - treated animals , superseding the need for gf recipients in these types of studies , though potential problems with reproducibility and concerns of spreading antibiotic resistance genes should be acknowledged . nevertheless , gf animals still seem to be the best controlled model systems for microbial transplantation and thus , given the lack of reliable phenotype transfers , the antibiotic - treated models can not be regarded to serve as good models for discovering novel roles of gut microbiota in disease states where gut microbiota has not previously been implicated . the antibiotic - treated recipients should rather be considered when studying phenotype transfers in conditions already known to be associated with alterations in gut microbiota , such as obesity ( table 1 ) . when it is necessary to use gf animals , an approach where gf parents receive the microbial transplant and the subsequent offspring generations are used as study subjects is advisable to overcome the problems associated with an early gf life . when antibiotic treatment is used as an alternative to the gf state , e.g. , because of limited access to certain gf mouse and rat strains , it should thoroughly be evaluated if the approach is truly applicable in the given situation . with this addendum , we identify a need for systematic experiments investigating the stability of microbial transplantations by addressing 1 ) the recipient status as either gf , antibiotic - treated or spf , and 2 ) different levels of protected housing systems . in addition , the developmental effect on host functions , in particular the immune system should be evaluated in the different recipient types . different research aims within translational microbiome research and the recommended use of either antibiotic - treated or germ - free rodent hosts for the purpose . status of hostresearch aimantibiotic - treatedgerm - freeinvestigate microbial phenotype transfer of manifestations known to be microbiota dependentxxinvestigate microbial phenotype transfer of manifestations not known to be microbiota dependent xinvestigate effect of disrupting the microbiome in certain life stages of the hostx investigate effect of targeting certain groups of bacteriax investigate effect of monocolonization xinvestigate effect of colonization with a few , defined organisms x applicability of antibiotic - treated or germ - free rodents . different research aims within translational microbiome research and the recommended use of either antibiotic - treated or germ - free rodent hosts for the purpose . randi lundberg is partly funded by innovation fund denmark and collaborates with the strategic research center 3 g ( gut , grain & greens ) .

abstractwe recently investigated the applicability of antibiotic - treated recipient mice for transfer of different gut microbiota profiles . with this addendum we elaborate on perspectives and limitations of using antibiotics as an alternative to germ - free ( gf ) technology in microbial transplantation studies , and we speculate on the housing effect . it is possible to transfer host phenotypes via fecal transplantation to antibiotic - treated animals , but problems with reproducibility , baseline values , and antibiotic resistance genes should be considered . gf animals maintained in isolators still seem to be the best controlled models for long - term microbial transplantation , but antibiotic - treated recipients are also commonly utilized . we identify a need for systematic experiments investigating the stability of microbial transplantations by addressing 1 ) the recipient status as either gf , antibiotic - treated or specific pathogen free and 2 ) different levels of protected housing systems . in addition , the developmental effect of microbes on host physiological functions should be evaluated in the different scenarios .

nearly one third of the patients develop perivalvular abscesses leading to an increased rate of systemic embolization and death . we report a rare case of infective endocarditis in a patient with a biological aortic valve prosthesis with paravalvular abscess that acutely penetrated into the right atrium . acute left - to - right shunting caused severe hemodynamic depression and multiple organ failure . a 62-year - old , hiv positive , male patient , who underwent bioprosthetic aortic valve replacement five years previously , was admitted to an external hospital with sepsis . no specific focus was found by an initial ct - scan of the chest and abdomen . a transesophageal echocardiography ( tee ) , performed upon admission , showed no endocarditis . exactly one week after admission the patient developed symptoms of a stroke and ct detected a thromboembolism in the region of the posterior cerebral artery . subsequent tee , revealed a vegetation on the right coronary cusp of the aortic valve bioprothesis and an aortic root abscess . his neurological symptoms declined during the following days . on day 12 after admission , however , acute deterioration of the patient 's hemodynamic conditions required urgent transfer to our hospital . on admission to the intensive care unit the patient required high dose vasopressor therapy . transthoracic echocardiography ( tte ) showed hyperdynamic biventricular function and shunting from the aortic root to the right atrium ( fig . 1 ) . position , dimension and exact anatomic conditions of the fistula were obtained by contrast enhanced computed tomography ( fig . after removal of the bioprosthesis , a large periannular abscess opening into the right atrium was uncovered ( fig . 3 ) . a pericardial patch plasty was performed to exclude the abscess and another to seal the right atrium interiorly . postoperatively , his clinical status improved quickly and the patient left the icu nineteen days after surgical treatment in stable physical condition and without any neurological deficit . a high in - hospital mortality rate of up to 40% has been documented in prosthetic valve endocarditis . in this case , several risk factors such as immunodeficiency , presence of an intracardiac abscess , transient cerebral ischemia and in particular staphylococcal sepsis were present . the european society of cardiology guidelines for the treatment of infective endocarditis recommends cardiac surgery in these cases within a few days . . recently showed that cardiac surgery performed within 48 h after diagnosis of infective endocarditis with severe valve disease and large vegetations results in a significantly improved outcome . to our best knowledge this work is the first randomized trial confirming the superiority of early surgical intervention . in a linear regression model with the data from 24 non - randomized studies thuny et al . also presented a significant enhanced correlation between early cardiac surgery and survival . they occur in about one third of all patients with infective endocarditis . in the absence of cerebral hemorrhage , cardiac surgery could be performed with a moderate rate of 36% for neurological detoriation . less invasive interventions , such as atrial or ventricular septal defect occluder , the amplatzer duct occluder or coils , described feasible in patients with paravalvualar leaks . however , they seem not to be beneficial under time - critical conditions and implantation of non - biologic material in an infected field can not be recommended . finally , detection of a fistula in a cardiac chamber or the pericardium resulting in shock remains an inescapable indication for emergent cardiac surgery . in our case the patient was not yet intubated , so we did not perform tee to prevent further aggravation of the hemodynamic conditions due to sedation . two - dimensional tte reliably detects left - to - right shunting but only the ct - scan allowed exact description of the lesion and planning of cardiac surgery . to reduce further risk of deterioration in - hospital transfer of the critically ill patient it is described as effective point of care imaging method with high sensitivity and specificity to verify diagnosis in several case reports . therefore , in the intensive care setting this new technique should be taken into account in future . our case report supports the early surgery strategies and shows that maximum therapeutic efforts can achieve good outcomes even in complex medical situations associated with poor prognosis . r. schramm added the surgical parts of the text and took the picture of the intraoperative view of the heart .

introductionheart failure is the most common cause of death due to infective endocarditis . we report a case of a patient presenting with severe shock due to an infection - associated left - to - right cardiac shunt.presentation of casea 62-year - old man , who underwent aortic valve replacement five years previously , was admitted to icu due to acute hemodynamic deterioration . a few days earlier , he had a septic episode with blood cultures positive for staphylococcus aureus and clinical features of infective endocarditis . in icu , transthoracic echocardiography revealed shunting from the aortic root to the right atrium resulting in severe cardiogenic shock.discussionthis case report describes a near fatal complication of infective endocarditis , detected by routine use of transthoracic echocardiography.conclusionour case outlines the relevance of early cardiac surgery strategies in patients with infective endocarditis and we briefly discuss the current literature .

uterovaginal prolapse ( uvp ) presenting at birth is very rare . to the best of our knowledge , utero - vaginal prolapse is the downward descent and protrusion of the uterus and vagina to the exterior via the introitus . it is as a result of weakness of the cardinal ligaments and uterosacral ligaments which provide support to the uterus . this is a report of a congenital uvp ( 3 degree ) in a 12 h - old - child noticed at delivery . a 12-hour - old female neonate was presented to us with a fleshy mass protruding from the vulva since birth . the baby passed meconium on the 1 day of birth and tolerated breast milk feeding . the mother , a 31-year - old , para 3 , seamstress had recurrent febrile conditions throughout the pregnancy and was treated at the primary health center where she booked . there was a fleshy , reddish , and edematous mass protruding from the vulva [ figure 1 ] . she has a sacral dimple with tufts of hair in it [ figure 2 ] . lower limb motor activity , sensations , respiratory , and cardiovascular systems were all normal . uterovaginal prolapse at birth sacral dimple with tuft of hair under sedation , size 6 foley 's urethral catheter was passed into the bladder . the mass was reduced by gripping it with the right hand and gently pushing it inwards . to prevent re - protrusion on straining , both lower limbs were strapped together using crepe bandage which was applied in a mermaid fashion extending from the buttocks to the lower legs sparing the anus for defecation . both catheter and bandaging were removed after 72 h. following successful reduction , the parents were unwilling to neither subject the child to further investigations nor comply with follow - up schedules . however , through contact tracing , the prolapse has not recurred 6 months after , and the child is growing appropriately . the uterus and the vagina are essentially supported by the muscular pelvic diaphragm and the three condensations of the endopelvic fascia ( cardinal ligaments , uterosacral ligaments , and pubocervical fascia ) . congenital uvp usually results from the weakness of the pelvic muscular support and the ligaments . this may be secondary to either congenital weakness in the pelvic musculature or defects in innervation . in adults the uterovaginal junction is angulated with the uterus lying almost horizontal to the muscular pelvic diaphragm . in the fetus and the neonate there is minimal or no angulation and the orientation is almost vertical , as the true pelvis is not well - formed yet and the pelvic organs are essentially abdominal . hence , raised intra - abdominal pressure as occurs during prolonged breech delivery is transmitted straight down the uterus and out through the vagina and introitus . most of the few reported cases were often associated with some identifiable risk factors [ table 1 ] . spina bifida , especially myelomeningocele is the most common risk factor ( 85% of cases ) . risk factors associated with congenital uterovaginal prolapse defective innervations of the pelvic floor muscle in meningomyelocele may lead to weakened support of the uterus and vagina . the rise in fetal intra - abdominal pressure during breech delivery stretches the pelvic floor muscle and the ligaments thus increasing the risk of prolapse . this is a genetic disorder characterized by generalized loose and redundant skin with reduced elasticity . early treatment of prolapse is important to prevent injury and metaplasia of the endometrial lining from prolonged exposure . several modalities which can be either conservative or operative have been used in the treatment of genital prolapse in the neonates . , conservative management has a success rate of more than 90% , though long - term outcome could not be ascertained yet . the major challenge after the initial digital reduction is the recurrence of prolapse once the intra - abdominal pressure rises during crying or straining . these methods include the use of various forms of pessaries , vaginal tampons , use of a two - way catheter partially inflated in the vagina to prevent recurrence of reduced prolapse , purse string suturing of vaginal wall with 2 - 0 catgut , and even temporary fusion of the labia . baskaran et al . , reported a successful outcome with purse string suturing of the vaginal wall in two rows in a neonate with myelomeningocele . with the resolution of the edema , reduction in the maternal derived estrogen level , surgical procedures like uterine ventrosuspension , sling , sacral cervicopexy , or abdominal sacrocolpopexy have also been used in recalcitrant cases . in our patient , we solved this by strapping the buttocks together by applying crepe bandage from the lower abdomen down to the lower third of the legs in a this method has the advantage of simplicity and easy applicability by even the labor attendants at the primary centers soon after the prolapse is observed , before edema and mucosal ulceration sets in . in conclusion , the possible risk factors present in this patient include breech delivery and spina bifida occulta . successful reduction was achieved by digital reduction and strapping the buttocks together with crepe bandage in a mermaid fashion .

uterovaginal prolapse presenting at birth is very rare . the cause is attributed to conditions that can cause poor innervation or weakness of the pelvic floor muscle and the supporting ligaments . different methods of treatment have been used in the past to reduce and maintain reduction of the prolapse . we report a case of a congenital uvp in a day old child noticed at delivery . he was delivered breech and had a sacral dimple with a tuft of hair . he was successfully managed conservatively with digital reduction and strapping of the buttocks down to the legs with crepe bandage for 72 h.

gastrointestinal duplication cysts ( gidc ) are rare congenital malformations that predominantly present before the age of 2 years . they are infrequently found within the colon with only a small number having been described in adults . colonic duplication cysts most commonly cause obstruction or perforation . we present the very rare case of a colonic duplication cyst causing bowel ischaemia in an elderly female . a 74-year - old female , with a background history of hypertension and hypothyroidism , presented to the emergency department with a 6-h history of sudden onset generalized abdominal pain . blood tests were normal except for a mild neutrophilia ( 7.5 10/l ) and lactate of 2.5 mmol / l . a computed tomography ( ct ) scan of her abdomen and pelvis was performed which showed abnormal loops of small bowel along the right side of the abdomen with mesenteric fat stranding . a partially calcified structure was noted lying medial to the loops of bowel ( figs 1 and 2 ) . intraoperative findings revealed an ischaemic loop of small bowel wrapped around a mass in the mesentery adjacent to the sigmoid colon ( fig . the patient underwent a partial small bowel resection with primary anastomosis and en - bloc resection of the mass with the formation of an end colostomy . the final histological revealed a 6 4 4 cm cystic colonic duplication cyst separate but adjacent to the sigmoid colon . the wall of the cyst was sclerotic with occasional lymphoid aggregates , smooth muscle and neurovascular bundles ( fig . figure 1:axial ct scan showing a partially calcified structure adjacent to loops of small bowel . figure 2:coronal ct scan showing a partially calcified structure adjacent to loops of small bowel . figure 3:intraoperative image black arrow pointing to intra - abdominal calcified structure . figure 4:haemolysin and eosin stain showing occasional lymphoid aggregates , smooth muscle and neurovascular bundles within the duplication cyst . haemolysin and eosin stain showing occasional lymphoid aggregates , smooth muscle and neurovascular bundles within the duplication cyst . gastrointestinal duplication cysts are rare congenital malformations the aetiology of which is not fully understood . they are predominantly found in childhood with 6780% presenting before the age of 2 years [ 1 , 2 ] . to the best of our knowledge , they can occur at any point along the gastrointestinal tract from oral cavity to anus with the majority found within the abdominal cavity ( 75% ) . they most commonly involve in the ileum ( 60% ) but can also occur in the stomach , oesophagus and colon . duplication cysts are found adjacent to or within the gi tract and and consist of two types , cystic duplications ( 80% ) and tubular duplications ( 20% ) . the cysts vary in size and have been reported as large as 20 15 cm . multiple theories have proposed the reason for the development of gidc , recanalization , split notochord , environmental factors or presence of embryologic diverticula [ 47 ] . colonic duplication cysts are rare and account for a very small percentage of duplication cysts . the exact percentage is not fully known but one of the largest studies of 73 patients over a 22-year period found that gi duplication cysts accounted for 6.8% . colonic duplication cysts are often asymptomatic but can present with abdominal pain , vomiting or bleeding . however , our case demonstrates small bowel ischaemia as a rare complication of duplication cyst . in this case , ischaemia resulted from a segment of small bowel becoming adherent to the cyst with resulting vascular compromise . colonic duplication cysts can be identified using endoscopic ultrasound , ct or rarely contrast enema . other case reports describe a cystic gas filled structure that may be identified on plain abdominal x - ray . this is due the fact that intraoperatively , it is often difficult to differentiate duplication cysts from other causes of mesenteric masses . in our case , surgical resection is often only considered in those that are symptomatic , however , some would advocate removal due to the potential to avoid complications including the possibility of neoplastic transformation [ 9 , 10 ] . in conclusion ,

colonic duplication cysts are rare congenital malformations that predominantly present before the age of 2 years . we report the case of a 74-year - old lady who presented with sudden onset abdominal pain . a computed tomography scan noted a calcified structure adjacent to abnormal loops of bowel . intraoperative findings revealed an ischaemic loop of small bowel wrapped around a mass in the mesentery adjacent to the sigmoid colon . final histology revealed a colonic duplication cyst . colonic duplication cysts are rare entities that most commonly cause obstruction or perforation . we present the very rare case of a colonic duplication cyst causing bowel ischaemia in an elderly female .

kluyvera spp . are gram negative bacilli that had been initially thought to be benign saprophytes . water , sewage , soil , milk , hospital sinks , and cows have been reported as environmental sources , suggesting that kluyvera spp . the biochemical profile is similar to that of other enterobacteriaceae . a member of the enterobacteriaceae , although initially described in 1936 , the genus kluyvera was not well characterized until 1981 by farmer et al . . previous to 1981 , the organism has also been referred to as cdc enteric group 8 and as api group 1 . currently the genus kluyvera has four species , k. cryocrescens , k. ascorbata , k. georgiana and k. cochleae . k. cryocrescens is known to be an opportunistic pathogen and its infection is considered to be rare , , , , . we report k. cryocrescens bacteremia in an adult and review the literature in order to highlight the clinical features , antimicrobial susceptibilities and treatments used in recent clinical reports . an 81-year - old japanese man with a history of interstitial lung disease and 3 years of home oxygen therapy made regular clinic visits and took a blood test every month . anemia was detected and he was admitted to the hospital to treat the anemia . on admission , blood test findings included hemoglobin 6.6 g / dl , serum iron 16 g / dl and serum ferritin 4.2 ng / ml . the fecal occult blood test was negative . he had no other significant clinical history including injection drug use , human immunodeficiency virus infection and treatment with immunosuppressive agents . a proton pump inhibitor and a blood transfusion were administered . on admission day 3 , upper gastrointestinal endoscopy was carried out and multiple superficial gastric ulcers without bleeding ( forrest classification : iii ) were found around cardia . administration of the proton pump inhibitor was continued . on admission day 4 , fever of 39.3 c developed , along with an altered level of consciousness and hypotension . laboratory findings revealed elevated serum c - reactive protein and serum and urine white blood cell counts . two samples of blood and one sample of urine were cultured and k. cryocrescens was detected from the blood samples . piperacilin / tazobactam ( 4.5 g every 6 h ) was initiated on hospital day 5 . it was suspected that the k. cryocrescens bacteremia was related to the peripheral venous catheter because the urine culture was negative and there were no significant findings to suggest an alternative source , though peripheral catheter tip was not cultured . k. cryocrescens isolates from blood were susceptible to extended spectrum cephalosporins , ampicillin / sulbactam , piperacillin / tazobactam , fluoroquinolones , aminoglycosides , tetracycline , and carbapenems , and resistant to ampicillin and 1st and 2nd generation cephalosporins . on admission day 11 , two blood samples were cultured and no microorganisms were detected . on admission day 16 , administration of the antimicrobial agent was terminated . however , on admission day 19 , there was an acute and fatal exacerbation of the interstitial pneumonia . we present a case of bacteremia due to k. cryocrescens in a patient with interstitial lung disease . clinical features of k. cryocrescens bacteremia remain unclear because there are few pertinent published reports . we reviewed the previously published cases , and the results , along with those of the current case , are summarized in table 1 . in contrast , there were some similarities of clinical backgrounds : 8 of 9 patients had severe comorbidities and another was a premature infant , suggesting that k. cryocrescens can cause severe infections such as septicemia in immunosuppressed patients . in all , 8 of the 9 cases were nosocomial infections , consistent with previous descriptions of k. cryocrescens as an opportunistic microorganism . primary infection sites were determined in only 2 cases , which were both central catheter - related blood stream infections . although primary infection sites were undetermined in the remaining 7 cases , all of these had peripheral and/or central intravenous catheters . results of catheter tip culture or culture of blood drawn through the catheter were not described in any of those 7 cases , suggesting that catheter - related blood stream infections might have been present in some of these . intravenous catheter use might be a major risk factor . through production of beta - lactamases ,

kluyvera cryocrescens infection has been considered rare ; clinical features of k. cryocrescens bacteremia remain unclear because few reports have been published . we report a case of k. cryocrescens bacteremia in an adult male patient and review the literature.our case was one with nosocomial bacteremia in a patient with interstitial lung disease . the primary infection site was undetermined , although he had an indwelling peripheral intravenous catheter and a urinary catheter.piperacilin/tazobactam was administered for 2 weeks and the bacteremia resolved . unfortunately , there was acute exacerbation of the interstitial lung disease , which was fatal . according to our review , including our case , k. cryocrescens bacteremia tends to occur in immunocompromised hosts , and indwelling catheters might be risk factors . extended spectrum cephalosporins , carbapenems , fluoroquinolones and tetracyclines are generally adequate agents for empiric therapy based on susceptibilities of k. cryocrescens clinical isolates .

most of our decisions are made under uncertainty , and many of our actions are geared toward reducing this uncertainty . information seeking actions take many shapes and forms that span the gamut of cognitive function . at one end of the range are simple orienting acts whereby we use our sensory receptors to sample task - relevant information such as looking at a relevant stimulus or listening for a relevant sound . at the other end are elaborate behaviors such as scientific research , which systematically search for information over extended time scales . and at an intermediate level there are exploration / exploitation tradeoffs , whereby we may temporarily forego a valuable action in order to learn about more uncertain but potentially more lucrative paths . understanding how the brain regulates its information seeking behaviors is significant for understanding core cognitive functions . it is key for understanding the control of attention , which is our main information selection mechanism and is implicated in a range of psychiatric disorders . it is critical for understanding the active control of learning and memory how a neural system determines which ones of our experiences will leave a lasting trace . it is critical for understanding development and the ways in which infants and children actively choose which task they wish to learn or investigate . last but not least , it is critical for understanding curiosity , the drive to know . one question is how subjects build explanatory models of their environment , and how these models further constrain the sampling of additional information . a related question is how the brain generates the intrinsic motivation to seek information when physical rewards are absent or unknown , and how this impacts cognitive development in the long term . at the level of neuronal systems , a key question concerns the relationship between neural processes encoding uncertainty and risk , and cognitive mechanisms of learning , memory and attention . the goal of this collection is to provide a home for papers on these and related topics . we accept studies using a range of methodologies including computations , behavioral , cognitive and neural systems investigations , and a broad range of format including full research articles , brief communications and review / opinion or correspondence articles .

the importance of exploratory behaviors by which agents actively sample information has been long appreciated in a range of disciplines . however , because of their complexity and cognitive nature , these behaviors have been difficult to characterize . in recent years , a resurgence of interest in this question has been based on a confluence of ideas from multiple fields , including machine learning , development , perceptual learning and attention and decision making . this collection of articles in f1000research aims to provide a home for a broad range of studies addressing this topic . we welcome full length research articles , brief communications , single figure studies , and review / opinion articles , and studies using computational , behavioral or neural approaches . here , we provide an introduction to the collection which we hope will grow and become a valuable resource for the researchers exploring this topic .

this case refers to a shearing type osteochondral humeral head fracture following a traumatic posterior shoulder subluxation . the spectrum of the pathoanatomical findings after posterior shoulder subluxations or dislocations have already been described in the literature . this is the first reported case to our knowledge where an osteochondral fracture is associated with posterior labral lesion after a traumatic posterior subluxation . this important case presents a trauma of the shoulder which has potential to be misdiagnosed . posterior glenohumeral dislocations represent only 2% of all shoulder dislocations , and their initial diagnosis is missed in more than 60% of cases . posterior shoulder dislocations result from axial loading of the adducted and internally rotated shoulder , violent muscle contractions resulting from seizers or electrocution , or a direct posterior force applied to the anterior shoulder . a 26-year - old male patient was referred to our hospital presenting with a traumatic posterior subluxation on his left shoulder . the patient reported that he sustained a direct impact injury on his left shoulder in which he felt severe shoulder pain and a popping sensation . after clinical and radiological work - up he was diagnosed with an osteochondral shearing type fracture of the humeral head [ figure 1 ] . the patient suffered no other injuries . also , the patient reported no history of shoulder dislocation or subluxation or any other chronic or acute diseases . preoperative anteroposterior x - ray of the shoulder showing the osteochondral fracture in the axillary pouch the patient was managed operatively under general anesthesia in a beach chair position . the delto - pectoral approach was performed with maximum deltoid muscle preservation and tenotomy of the upper third of the subscapularis . with the arm in abduction and external rotation the osteochondral defect was evident at the antero - medial aspect of the humeral head [ figure 2 ] . the osteochondral fragment missing from the humeral head was fished out of the posterior - inferior axillary pouch [ figure 3 ] . following inspection of the glenohumeral joint , a posterior slap ( superior labral anteroposterior ) type ii lesion with a posterior extension till the 1.00 o'clock position was found . the osteochondral fragment was anatomically reduced using two k - wires and finally fixed in place with two headless 16 mm screws ( herbert , wemmel , belgium ) . the slap lesion and the posterior labral capsular detachment were repaired with two absorbable suture - anchors ( panalock , depuy mitek , inc . the subscapularis tendon was anatomically repaired with non - absorbable ultra - braided sutures ( orthocord , depuy mitek , inc . , a johnson & johnson co , ma ) . the patient was fitted with a 15 abduction sling with the arm in neutral rotation for 5 weeks . one year postoperatively the patients ' range of motion was comparable to the non - affected shoulder . the radiological work - up showed full fragment integration , without any absorption or necrosis . intraoperative osteochondral defect of the humeral head free osteochondral fragment of the humeral head anatomical provisional reduction of osteochondral fragment with k - wires and final with herbert screws final postoperative radiograph a traumatic posterior subluxation or dislocation are relatively rare injuries and account for approximately 2% of all shoulder dislocations . in the literature , lesions commonly associated with traumatic posterior subluxation / dislocation are the reverse hill - sachs ( or mclaughlin lesion ) , a posterior labral detachment , glenohumeral ligament lesions , rotator cuff tears or posterior bony fractures . after such an accident and type of blunt force trauma on the shoulder we would expect to see a reverse hill - sachs lesion , an impression fracture on the anteromedial humeral articular surface as first described by mclaughlin . this is the first case to our knowledge in which a shearing type osteochondral fracture was observed in a traumatic posterior subluxation . the intraoperative pathoanatomic findings of the posterior labrocapsular detachment , the anteromedial aspect of the fracture of the humeral head , the patient 's description with the direct impact of the shoulder toward posterior direction and the sensation of his shoulder popping enforces our diagnosis for the posterior shoulder subluxation . yun sun choi et al . ( 2005 ) reported a shearing osteochondral fracture of the humeral head in a 12-year - old right - handed - dominant boy injured while playing football following an anterior dislocation . to the best of our knowledge , our patient represents the first reported case of an osteochondral shearing fracture of the humeral head . this fracture resulted from a traumatic posterior subluxation of the shoulder . because imaging techniques may be unreliable in such fractures

traumatic posterior shoulder subluxations are rare entities which require clinical suspicion upon presentation . although literature presents many sequels of posterior shoulder subluxations , we have not come across any shearing type osteochondral fracture in the literature . in this case report we present diagnosis , treatment and follow - up results of this rare fracture in a 26-year - old male following a fall from a motorcycle .

after repeated previous consultations , a 73-year - old woman suffering for several months from itchy plaques and nodules on the face and neck presented for her follow - up visit ( figures 1 , 2 ) . a biopsy had been performed during previous consultations and the histopathologic diagnosis lay between lymphoma and pseudo - lymphoma . dermoscopy of the lesions revealed a perfectly demarcated burrow and , at its end , a scabies mite ( figure 3 ) . the accuracy of dermoscopy for the diagnosis of scabies has been assessed as at least equal to microscopic examination after skin scraping . in fact , dermoscopy has the advantage of rapidly screening several lesions of the patient , in contrast to the microscopic examination which is performed by scraping only one or two lesions . given that in otherwise healthy individuals , no more that 45 mites exist on the skin at on time point , scanning all the lesions of the patient minimizes the possibility of a false negative result . in our patient , the atypical clinical manifestation and , especially , the distribution of the eruption on the face , misled the clinicians on repeated visits , whereas dermoscopy was not performed during the initial visits , because scabies was not even included in the differential diagnosis . this resulted in unnecessary surgical procedures and histopathologic exams , which might have been continued if dermoscopy was not eventually performed . this case highlights a basic principle of dermoscopy application , namely , that dermoscopy should be applied on every skin lesion and not only in clinically pre - selected cases .

dermoscopy is already considered a fairly established method for diagnosing scabies . this is because dermoscopy enables the visualization both of the burrow and the mite itself , forming the so - called jet with a contrail structure . in the present report we present an extraordinary case of a patient with scabies lesions on the face and neck , which was misdiagnosed during sequential visits and underwent unnecessary surgical diagnostic procedures . finally , the diagnostic problem was solved when dermoscopy was applied .

clinical manifestation of superior vena cava syndrome ( svc syndrome ) results from complete or partial obstruction of the svc . the svc carries approximately one - third of the venous return to the heart and collects blood from the arms , head , and upper chest to the heart . when the svc is obstructed , blood flows through a collateral vascular network to the lower body and the inferior vena cava or the azygus vein . therefore , obstruction below or at the level of azygus vein results blood bypassing from superficial venous system . during several weeks however , if the obstruction occur above the level of azygus vein , svc bypasses and no clinical manifestation of syndrome occur . like other veins in body therefore , any compression of the vein results in increasing in pressure inside the vein . symptoms develop over a period of 2 weeks in approximately a third of patients , and over longer periods in other cases physical signs include plethora , swelling of neck or chest veins and tackypnea . rarely , cyanosis , horner 's syndrome and a paralyzed vocal cord may also be present . although infectious causes of svc syndrome included syphilitic and tuberculosis , but these etiologic factors are rare in these years . the most common etiology of svc syndrome is malignant disease and most common malignancies , including non - small - cell lung cancer ( in 50% of patients ) , small - cell lung cancer ( approximately 25% of patients ) , lymphoma , and metastatic lesions ( each approximately 10% of patients ) . currently , obstruction of the svc caused by thrombosis or non - malignant condition 's accounts for approximately 35% of cases , reflecting the increased use of long - term central venous catheters or permanent pacing electrodes . a 30-year - old man was admitted to alzahra hospital , isfahan , iran in january , 2012 , because of dyspnea and facial edema . the patient had been well until 4 days before admission , when sudden onset dyspnea and orthopnea developed . medications included brome hexin syrup , theophylin and antihistamins without any effects . on examination , the blood pressure was 120/80 mm hg , the pulse 80 beats per min , the temperature 37c , the respiratory rate 16 breaths per minute , the oxygen saturation 92% while the patient was breathing ambient air , and the weight 80 kg . results of a complete blood count blood levels of urea nitrogen , albumin , total and direct bilirubin , creatine kinase , prothrombin time ( pt ) , activated partial thromboplastin time ( aptt ) , international normalized ratio ( inr ) , aspartate aminotransferase and arterial blood gas were normal . an electrocardiogram showed sinus rhythm at a rate of 90 beats per min , without any problem . in echocardiography left ventricular ejection fraction was 55% and other finding was normal . in analysis , thoracic computed tomography ( ct ) with intravenous contrast performed as illustrate in figure 2 . in order to reducing his respiratory symptoms and improving respiratory distress , the patient received intravenous corticosteroid ( dexamethasone 8 mg 3 times a day for 3 days . ) . immunohistochemistry revealed leukocyte common antigen ( lca ) and terminal deoxynucleotidyl transferase ( tdt ) positive . chest x - ray of patient in arrival day chest ct scan of patient treatment with hyper cyclophosphamide , vincristin , adriamycine , dexamethasone ( cvad ) regimen done and respiratory symptoms resolved after 5 days completely . patient was selected for bone marrow transplantation . the svc syndrome , occurs in approximately 15,000 persons in the united states each year . if the syndrome occurs after the use of intravascular devices , diagnosis of the cause is straightforward . in other situations imaging with ct scanning of chest with intravascular media made diagnosis correctly . initial management of patient with svc syndrome includes supportive measures such as providing supplemental oxygen and elevating the head of the bed . other treatments like diuretic therapy for reducing the intravascular volume , or a short course of parenteral steroids ( dexamethasone , 4 mg every 6 h ) to decrease edema and tumor burden are controversies . several treatments have been introduced for svc syndrome depending on the underlying disease like thrombolytic therapy or stenting in thrombosis of svc in patients that svc damaged in introducing intravascular devices . mainstem of treatments in svc syndrome induce malignancies is chemotherapy and radiotherapy after definite tissue diagnosis via ct scan - guided biopsy of mediastinal mass . surgical bypass grafting is infrequently used to treat the svc syndrome . in malignant cause of svc syndrome , untreated symptom reduces life expectancy less than 30 days . however , treated cases expectancy depends on type of malignancy and applying proper therapy like chemotherapy . in our case , after chemotherapy introduced , symptoms and signs of disease disappear and patient arrives to complementary treatments .

when superior vena cava ( svc ) compress or obstructed by internal or external pressure , we encounter to svc syndrome . the cause of this compression is malignant or benign . although the widespread use of permanent central venous access catheters coupled with the improved success of chemotherapy has increased the incidence of svc syndrome not caused by direct tumor infiltration ( non - malignant svc syndrome ) but svc syndrome may be a sign of advanced malignancy . in this report , we present a 30-year - old man with lymphoma that present with svc syndrome at presentation . with chemotherapy , patient was recovered from signs and symptoms .

( 1,2,3,4 ) they can present in the acute setting by causing complications such as cyst rupture or intestinal volvulus . ( 5,6 ) we are presenting a rare case of and infected dermoid cyst that presented with an acute abdomen . an eleven year old boy presented to the accident and emergency department complaining of pain in the lower abdomen . initially his signs and symptoms were felt to be consistent with a non - specific cause . he re - presented a week later with persistent localised pain in the right iliac fossa and was noted to have a tender palpable mass , suggestive of appendicular pathology . an ultrasound revealed a cystic lesion measuring 38 mm by 39 mm by 38 mm in the right iliac fossa containing complex debris . the wall of the cyst appeared to be multilayered , possibly consistent with a duplication cyst . the appendix was not visualised.(figure 1 ) ultrasound images showing a spherical cystic lesion with layering within diagnostic laparoscopy was performed expecting to find a duplication cyst . a right lower quadrant incision was used to mobilize the caecum and deliver the cyst out of the abdomen . a limited right hemicolectomy with ileocolic anastomosis was performed.(figure 2 ) intraoperative picture showing a spherical lesion at the ileocaecal junction histopathology of the specimen demonstrated an unilocular cyst lined by keratinising squamous epithelium with inflammatory changes . mesenteric cysts are a rare group of lesions that have been classified into six subtypes based on their histopathology.(1 ) these include ( a ) cysts of lymphatic origin ( lymphangioma ) ; ( b ) cysts of mesothelial origin ( benign cystic mesothelioma , malignant cystic mesothelioma ) ; ( c ) cysts of enteric origin ( duplication cyst ) ; ( d ) cysts of urogenital origin ; ( e ) mature cystic teratoma ( dermoid cysts ) , and ( f ) pseudocysts ( infectious and traumatic cysts ) . dermoid cysts are commonly described in the head , neck , gonads , mediastinum , retroperitoneal and sacrococcygeal regions . there are four case reports in english literature of dermoid cysts occurring in the mesentery of children . dermoid cysts are postulated to occur as a result of abnormal migration of primordial germ cells . ( 7 ) this is a complex and poorly understood process , reliant on a host of migratory and homing factors ( 8) , making it difficult to explain why our patient s cyst occurred at the ileocaecal region . we can only postulate that these cells may have migrated from the dorsal mesogastrium , in the midline , and then traversed in the mesentery to the ileocaecal region . ( 3 ) they may cause vague gastrointestinal symptoms or present with acute pain due to cyst rupture or intestinal volvulus . ( 5,6 ) it has also been reported in a patient with autoimmune haemolytic anaemia . ( 4 ) ultrasound imaging identified a cystic lesion , but was not able to differentiate it from the more commonly presenting lymphangiomas and duplication cysts . this was in keeping with the more commonly occurring dermoid cyst in the head and neck regions e.g. external angular dermoid . our report is unique in that our patient presented in a way that mimicked appendicitis . to our knowledge

mesenteric dermoid cysts are a rare cause of abdominal pain . although dermoid cysts occur in many parts of the body there have been only a few case reports involving the bowel mesentery . we present a case of a symptomatic mesenteric dermoid cyst involving the ileocaecal junction in a child .

congenital intrascleral cysts are unusual clinical conditions with uncertain etiology . the lesions are usually located at the limbus with corneal and scleral components . in this report , we present a case with progressively enlarging congenital intrascleral cyst without corneal involvement in a 30-month - old boy , and describe its clinical and histopathologic features and surgical management . a 30-month - old boy presented to the clinic with a bulbar subconjunctival cystic mass of the right eye ( figure 1a ) . a thin - walled , multilocular scleral cyst , measuring 5 mm 8 mm in its largest dimensions , was identified at the inferior nasal quadrant , extending from the medial canthus to the limbus of the right eye ( figure 1a , b , and c ) . the rest of the ocular examination in the right eye and the left eye was normal . during surgery , saline hydrodissection was carried out with a 30-gauge needle to separate the underlying cyst wall from conjunctiva , confirming that the lesion was intrascleral . a conjunctival incision was made through the upper margin of the mass from the 3 oclock position to the inner canthus to expose the anterior portion of the lesion by blunt dissection without perforating the cyst . the posterior aspect of the cyst was then gently cleaned with a weck - cell sponge to be sure that no residual epithelium was left behind . after the total removal of the cyst , the sclera at the posterior aspect was noted to be very thin and the underlying choroid was clearly visible . this thin area was patched with preserved fascia lata using 8.0 vicryl sutures to prevent staphyloma formation ( figure 1b ) . conjunctiva above the patch was also closed with 8.0 vicryl sutures . at the end of the surgery , histopathologic examination revealed that the cyst wall was lined with multiple layers of nonkeratinized epithelial cells . no other complications or recurrence took place during the 6 years postoperatively ( figure 1d ) . congenital intrascleral cysts are seen less frequently than their acquired counterparts , which typically occur after ocular surgery or trauma.1 these congenital lesions are considered to be developmental defects that usually enlarge at the first year of life , as was the case in our patient . generally , they are located at the limbus at birth as a nidus , but expansion of the cyst into the cornea may develop later in childhood.2,3 vision is often affected due to the distortion and scarring caused by the lesion on and around the limbus . in our case , the vision was normal because of the absence of the corneal component . in one reported case , mahmood and awad3 stated that corneal involvement may not occur in patients up to 3 years of age , but the cyst may enlarge in later years to disturb visual acuity . considering this possibility and due to the large size of the cyst in our patient , we operated early . histopathologic examination revealed that the cyst wall was lined with nonkeratinized epithelial cells without goblet cells . the presence of goblet cells is said to favor congenital origin.3 rao et al2 reported the presence of glandular structures simulating lacrimal gland tissue and stated that this indicates the developmental nature of the lesion . careful removal of the cyst wall , denaturation of remnants with saline and distilled water , and chemical coterization with trichloroacatic acid and tetracyclin injection are advised to prevent recurrence.4 in limbal cysts , peripheral lamellar keratoplasty is known to be effective to prevent the development of staphyloma and recurrence.5 in order to prevent staphyloma formation in our case , we utilized banked fascia lata , which worked well without complications . based on our experience in this case , we would suggest that banked fascia lata may be considered as an alternative grafting material in defect restoration when banked human sclera is not readily available . in conclusion , we report our experience with a congenital intrascleral cyst that was surgically repaired with the use of banked fascia lata and had an uncomplicated postoperative course of 6 years .

congenital intrascleral cysts are rare . they are mostly located at the limbus with corneal involvement . we report a case of a 30-month - old boy with a bulber conjunctival cyst noticed at birth . the lesion enlarged over the following months but did not involve the cornea . during surgery the cyst proved to be intrascleral and a complete excision was carried out . the remaining defect was repaired with banked fascia lata . the histopathology revealed a scleral cyst wall lined by nonkeratinizing squamous epithelium with no goblet cells . we conclude that congenital intrascleral epithelial cysts are rare but should be considered in differential diagnosis of external eye cystic lesions . in our case , early excision and repair with fascia lata led to an uncomplicated postoperative course of 6 years .

a 26-year - old male presented with painless decrease of vision in the right eye following trauma with an iron particle 4 days prior to presentation . on examination , the visual acuity in the right eye was 20/60 , intraocular pressure ( iop ) was 12mmhg and there was localized conjunctival congestion superonasally [ fig anterior segment was unremarkable , while on fundus evaluation there was clear media with normal disc , few internal limiting membrane striae in the macular area , areas of retinal vasculitis associated with isolated white - centered retinal hemorrhages , and perivascular white - colored retinal exudates localized inferiorly [ fig . 1 ] . the protruding vitreous knuckle present beneath the insertion of the medial rectus muscle at its superior margin was cut with vitrector and the 2-mm - long scleral tear was sutured with 7 - 0-vicryl . after taking an undiluted vitreous biopsy with a 23-gauge vitrectomy cutter , intravitreal antibiotics , based on the microbiological culture , biochemical tests and mini api i d 32 staph strip , s. epidermidis was isolated . antibiotic susceptibility testing of the isolate was done by the kirby - bauer disk diffusion method as per clinical and laboratory standards institute guidelines ( clsi , 2009 ) . the organism was found to be resistant to ciprofloxacin , ofloxacin , cefuroxime , oxacillin and cefoxitin ( methicillin ) , and sensitive to amikacin , cefazoline , gentamicin , vancomicin , gatifloxacin , moxifloxacin and chloramphenicol . postoperative treatment with tablet gatifloxacin ( 400 mg stat followed by 200 mg twice daily for 7 days ) , eye drop gatifloxacin 0.3% ( 12 times per day ) and eye drop prednisolone acetate 1% ( 2 hourly initially , followed by tapering doses ) resolved the infection . final uncorrected visual acuity was 20/20 at 6 weeks postoperatively with resolution of all retinal signs [ fig . 2 ] . ( a ) area of occult scleral injury marked by localized congestion and chemosis ; ( b ) fundus photograph showing macular internal limiting membrane striae ; ( c ) white - centered retinal hemorrhages ; ( d ) midperipheral and peripheral retinal vasculitis postoperative fundus photograph showing resolution of retinal signs . various authors[357 ] have documented the appearance of hemorrhages and vasculitis as an early feature of bacterial endophthalmitis . a case of fungal endophthalmitis with vasculitis experimental inoculation of bacteria into the vitreous cavity revealed retinal periphlebitis to be the first clinical feature observed . the pathogenesis of hemorrhages and periphlebitis is attributed to the breakdown of blood retinal barrier , and thus perivascular exudation of plasma proteins and white blood cells . this could be because of the lack of awareness , rarity of this sign , more fulminant cases or delayed diagnosis or delayed presentation leading to a poor view of fundus . a medline search revealed only eight similar cases reported so far [ table 1 ] . these findings may mimic the picture of retinal vein occlusion , eales disease , behcet 's , sarcoidosis , pars planitis , infectious retinochoroiditis and non - specific uveitis , but a history of recent open globe trauma or surgery or systemic infection should indicate the possibility of an infectious etiology . in post - surgical eyes with increased anterior chamber reaction , dilated inferior retinal examination should be done to look for such white - centered retinal hemorrhages and vasculitis to rule out early endophthalmitis . a delay in the diagnosis and treatment of endophthalmitis awareness about retinal vasculitis being an early presenting feature could lead to early diagnosis of endophthalmitis and good visual outcome .

the article reports a case and review of the literature of endophthalmitis presenting as isolated retinal vasculitis . a 26-year - old male was observed to have white - centered retinal hemorrhages and retinal vasculitis following an occult scleral perforation . at presentation , the visual acuity was 20/60 . with clinical suspicion of early endophthalmitis , he underwent wound exploration , scleral tear repair , vitreous biopsy and administration of intravitreal antibiotics . microbiology evaluation revealed significant presence of methicillin - resistant coagulase - negative staphylococcus epidermidis . final visual acuity improved to 20/20 at 6 weeks postoperatively . literature search revealed eight similar cases , all of them due to staphylococcus species . retinal vasculitis and white - centered retinal hemorrhages can be a presenting sign of early endophthalmitis , especially with non - fulminant pathogens like s. epidermidis .

mary s hospital , and the patient gave consent for video recording and academic use . the patient , a 47-year - old woman , had suffered from insidious onset of blepharospasm , oromandibular dystonia , and spasmodic dysphonia for 2 years before visiting our neurology outpatient clinic . the patient complained of decreased social activity during the course of her disease due to hyperkinesia of facial muscles and functional blindness secondary to blepharospasm . the patient was never exposed to neuroleptics , nor did she have a family history of dystonia or any perioral trauma . upon examination , the patient demonstrated severe blepharospasm and oromandibular dystonia , which became aggravated when the patient attempted to open her eyes or tried to speak ( video 1 in the online - only data supplement ) . the results of neuropsychological testing for memory and frontal lobe functions were within normal limits . evaluations were normal , including magnetic resonance imaging of the brain , serum chemistries , a complete blood count , serum ceruloplasmin , serum and urine copper levels , thyroid function tests , and genetic testing for the dyt1 mutation in the torsion a gene . the patient had been treated with 50 mg quetiapine , 8 mg trihexiphenidyl , and 40 mg baclofen , but these drugs were not effective , and side effects of somnolence were observed . considering both the treatment - resistant symptoms and the severe disabilities , we decided to perform bilateral gpi dbs to control her dystonic symptoms . the initial stereotactic coordinates determined by mri - stereotactic planning were established to target the posteroventral lateral gpi . postoperative ct and mri were used to verify electrode position within the gpi and to exclude asymptomatic cerebral hemorrhage ( figure 1 ) . postoperative programming of the dbs was performed 1 day after the staged implantation of the pulse generator . all major clinical symptoms indicated significant improvement in blepharospasm and in oromandibular and orofacial dystonia ( video 2 in the online - only data supplement ) . speech difficulties caused by spasmodic dysphonia and/or oromandibular dystonia also responded well to pallidal stimulation . no clinically relevant bradykinesia or other abnormal movement was observed in our patient , nor were depressive mood or emotional instability . the parameters of gpi dbs were as follows : a pulse width of 60 sec , frequency of 130 hz , and stimulation amplitude of 2.1 v on the right side , and a width of 90 sec , frequency of 130 hz , and amplitude of 1.9 v on the left side . the exact mechanism of the observed effect of pallidal stimulation on dystonia remains unclear , but it is possible that dbs improves dystonic symptoms by changing the plasticity in the cortical - basal ganglia circuit . thus , symptoms do not return immediately after the discontinuation of therapy , and continuous stimulation may not be needed in some of these patients . the most effective target area within the gpi for controlling this symptom by dbs remains under debate . moreover , which phenotypes among the symptoms constituting meige syndrome will respond best to dbs also remain unknown . all of these uncertainties make the publication of all previous case series and our case report important for understanding the efficacy of gpi - dbs in meige syndrome . hypothesized that in patients with meige syndrome and segmental dystonia , the gpi - dbs response may be better than in patients with purely cranio - facial dystonia . houser and waltz , in contrast , hypothesized that improvement could be predicted simply by the presence of isolated cranio - facial dystonia . recently , the important observation was made that although disease duration can be a good predictor of the outcome of pallidal stimulation in patients with primary dystonias , no particular predictive value should be assigned to age at onset , age at surgery , severity of disease , dyt1 status or the presence of phasic or tonic involuntary movements . two recent reports indicated bradykinesia as a therapy - related adverse effect of pallidal neurostimulation in meige syndrome at high voltage . cases of mania , depression , suicide and suicide ideations were observed in connection to pallidal stimulation . , who reported two suicides in 16 gpi - dbs treated dystonic patients , stated that these findings illustrate that there is a prominent risk of suicide after dbs of the gpi in medication - refractory dystonia . in summary , this case report , in combination with other previous reports , suggests that bilateral gpi dbs may be an effective treatment for medically refractory meige syndrome , without significant adverse effects .

medical therapies in patients with meige syndrome , including botulinum toxin injection , have been limited because of incomplete response or adverse side effects . we evaluated a patient with meige syndrome who was successfully treated with deep brain stimulation ( dbs ) in the globus pallidus interna ( gpi ) . this case report and other previous reports suggest that bilateral gpi dbs may be an effective treatment for medically refractory meige syndrome , without significant adverse effects .

the major complications of colonoscopy are postcolonoscopy bleeding ( 0.2% ) and perforation ( 1% ) . a 56-year - old man presented with a history of 6 months hypogastric pain . in order to investigate the cause , colonoscopy was performed using conscious sedation with intravenous midazolam ( 2.5 mg ) and meperidine ( 25 mg ) . the rectal mucosa was normal , but there were multiple diverticula in sigmoid colon and also some small sessile polyps ( < 1 cm ) near the junction between sigmoid and descending colon . there were multiple scattered diverticula up to ascending colon and another small sessile polyp was also found in cecum , from which other biopsy sample was taken ( figure 1 ) . about 5 minutes later , the patient complained of severe colicky abdominal pain , which recurred every 5 minutes and was accompanied by diaphoresis . on physical examination , blood pressure was 110/80 mmhg , heart rate was 80/min and the patient had no fever . the abdomen seemed distended and bowel sounds were high - pitched . also , the abdomen was tympanic on percussion , but there was no tenderness or guarding . plain abdominal radiography showed multiple colonic air - fluid levels and distention of the colon , especially in the right side ( figure 2 ) . abdominal radiography after the first colonoscopy showed distention of cecum , ascending colon , and transverse colon with a transition point in descending part indicating an obstructive cause in distal colon . since there was no subdiaphragmatic free air and no free air between intestinal loops , the probability of perforation was ruled out . immediately , the patient underwent second colonoscopy , but the scope could hardly pass through sigmoid colon because of spasm and edema at the site of previous polyp biopsies . the scope was gently advanced toward cecum and simultaneously decompressed the entire colon by suctioning the entrapped air . after performing the second colonoscopy , the colicky abdominal pain was relieved and abdominal distention was significantly decreased . after 2 hours , the patient passed flatus and after 12 hours , he passed liquid stool . the next day , white blood cell count was reduced to 1010/l and the patient had no pain or diaphoresis . he tolerated liquids and then full meals , and therefore , he was discharged during the second day . in recent publications , there are only few reports of postcolonoscopy small bowel obstruction , incarcerated internal hernia , ileus , and volvulus of cecum , ileum , and sigmoid colon . postcolonoscopy small intestinal obstruction usually occurs in patients with previous history of small intestinal surgery . in patients who did not respond to conservative treatments , laparotomy had mostly shown internal hernia or entrapment of small intestinal loops in adhesions . our patient did not have previous history of intestinal surgery or any complaint referring to the probability of intestinal obstruction before colonoscopy . the occurrence of symptoms immediately after colonoscopy made coincidental causes almost impossible . the most common cause of abdominal pain and distention after colonoscopy is ileus , which is mostly caused by sympathetic over - stimulation , excessive air insufflations , and the effects of opiates used for sedation . but in our patient , exaggerated , high - pitched bowel sounds , together with radiographic findings ( including distention and air - fluid levels mostly confined to cecum and ascending colon ) , made the diagnosis of ileus impossible and led to the diagnosis of large bowel partial obstruction . the diagnosis was supported by further demonstration of narrowing at the site of polyp biopsies , which made second colonoscopy to be very hard . in our patient , the most possible explanation for sigmoid colon obstruction was the edema and spasm at the site of polyp biopsy , which was situated near multiple diverticula . fortunately , obstruction was relieved with conservative management and did not lead to surgery . in conclusion the diagnosis should be considered in case of postcolonoscopy abdominal pain , because ignoring the pain and the progression of distention may lead to intestinal perforation or even air emboli .

postpolypectomy bleeding and perforation are the major complications of colonoscopy . this report presents a rare case of colon obstruction immediately after colonoscopy . a 56-year - old man underwent colonoscopy because of 6 months lower abdominal pain . colonoscopy revealed diverticulosis and multiple small sessile polyps in sigmoid colon . biopsy samples were taken from the polyps and the procedure was continued up to cecum . soon after the procedure , the patient complained of colicky abdominal pain accompanied by diaphoresis . in physical examination , the abdomen seemed distended and bowel sounds were high - pitched . there was no abdominal tenderness or guarding . plain and upright abdominal radiography showed multiple colonic air - fluid levels . immediately , the patient underwent second colonoscopy , but passage of scope through sigmoid colon ( at the site of biopsies ) was somewhat hard because of edema and spasm . the colonoscope proceeded gently up to cecum and decompressed the entire colon by suctioning the air that was entrapped in proximal parts . by second colonoscopy and further conservative treatments , the patient s condition improved without any surgical procedure and was discharged after 24 hours .

osseous bridging of adjacent lumbar transverse processes has been reported as a rare complication following trauma to the back in adults2,6 ) . after trauma , heterotopic ossification develops in surrounding soft tissues , and can lead to bridging or pseudarthrosis of transverse processes4,5 ) . in the literature , congenital bridging has been reported much less frequently than traumatic bridging and usually these reports concern adults . here , we present the simple radiographic and computed tomographic findings of a youngest girl with congenital transverse process bridging . the clinical features of this rare anomaly are discussed with a review of the literature . a 13-year - old girl was referred to our hospital due to low back pain ( lbp ) and stiffness in the left lower back region . the pain had gradually increased in severity over 1 year , and at presentation she was unable to sit comfortably . she reported that the pain was aggravated by extension of the lower back and prolonged by hours of standing . her detailed medical history was unremarkable , and there was no history of back injury . a deep , firm fullness was palpable in the paravertebral muscles in the left lumbar area , and was tender to percussion . lumbar motion was limited in all directions , but the findings of a neurological examination , including the straight leg - raising test ( slrt ) were within normal limits . an anteroposterior simple radiographs of the lumbar spine demonstrated the presence of osseous bridging between the left transverse processes of the third and fourth lumbar vertebrae with minimal scoliosis at the bridging site and simultaneous disc space narrowing at the l3-l4 level ( fig . 1 ) . computed tomography revealed articulation between left transverse processes of the third and fourth lumbar vertebrae ( fig . the left lateral contour of the vertebral body and the bridging transverse processes resembled the shape of the letter ' o ' , and the components of bone bridge had smooth , regular contours . because of her young age and parents ' wishes , the patient was treated conservatively , that is , by medical and physical therapy . after 6 months of follow up , although her symptoms were still present , they had ameliorated in some degree . osseous bridging between two transverse processes of the lumbar spine mostly has a traumatic origin in middle aged patients3 ) . yoslow et al.7 ) , in their review of lumbar osseous bridging in the literature , found that an association exists with back injury and that pseudarthrosis may form in heterotopic bone . in 1991 billet et al.1 ) also found that only 15% of their cases had a congenital etiology . in this study , the youngest patient treated was 23 year old , but the origin of the osseous bridge was not obvious . in addition , criteria were suggested for the differentiation of congenital and traumatic osseous bridges . the localizations of hematoma and myositis ossificans play important roles during bony bridge modeling , and the configurations and shapes of traumatic osseous transverse process bridges show acute angles and irregular , asymmetric outlines . on the other hand , osseous bridges of a congenital - developmental etiology are ' o ' shaped with symmetrical , contour with convexity of the lumbar spine on the contralateral side and the absence of degenerative changes in the corresponding intervertebral space . other congenital skeletal anomalies , such as , spina bifida occulta , sacralization of the fifth lumbar vertebra may accompany congenital bone bridges but these findings are not obligatory6 ) . in the present case , the patient had experienced no evident traumatic episode before admission and had a symmetrical smooth regular contour , which was considered indicative of a congenital - developmental etiology . bone bridging is usually asymptomatic , but low back pain is the most frequent symptom when it becomes symptomatic . although , the exact mechanism of pain in bony bridge is still not clear , we believe congenital bone union itself , radiculopathy or spinal deformity caused by imbalanced mechanical stress , can contribute to manifestation of symptoms . our patient showed motion restriction and back pain , but surgical management was not attempted due to improvement of symptoms after medical and physical therapy . restricted motions of adjacent joints are known to be ameliorated by freeing muscles from the heterotopic mass and by subsequent physical therapy . however , when symptoms are not relieved by conservative treatment , surgical removal of pseudarthrosis should be considered2 ) . the elimination of pain following pseudarthrosis excision is related to local denervation , increased lumbar motion , and the re - establishment of pseudarthrosis in a plane that does not restrict lumbar motion . it would seem appropriate to remove bony bridge when magnetic resonance image or discography fails to show any significant abnormality of the intervertebral disc . we present the imaging findings of this rare anomaly in a young girl with lbp . this is the youngest case reported to date of congenital bridging of transverse processes without back injury . although rare , this rare anomaly should be borne in mind when evaluating the lumbar spine for the etiology of lbp even in children or adolescents .

osseous bridging between lumbar transverse processes is an uncommon condition that may cause low back pain . in most cases , its etiology is alleged to be trauma to the back and only rarely has a congenital origin been indicated . furthermore , most reported cases involved adults , the majority of whom were middle - aged . here , the authors describe the case of the youngest girl reported to date with congenital transverse process bridging . as far as the authors ' knowledge , there has been no report of congenital bridging of transverse processes in children or adolescents in korea .

the recent international consensus conference on the reduction in mortality in cardiac anesthesia and intensive care considered pexelizumab among the drugs that could reduce mortality in cardiac surgery . pexelizumab is a recombinant humanized single - chain monoclonal antibody to the component 5 of the complement system ( c5 ) . c5a is a powerful anaphylatoxin and proinflammatory mediator , and c5b is the precursor of the latter is a transmembrane channel involved in thrombosis and inflammation , which also causes direct tissue injury through osmotic lysis . pexelizumab administration on top of conventional treatment has been tested in st elevation myocardial infarction ( stemi ) and on - pump coronary artery bypass grafting ( cabg ) . in the stemi setting , utility of pexelizumab has been ruled out by the results of our systematic review and meta - analysis . conversely , within the same manuscript we suggested that pexelizumab administration in patients undergoing cabg surgery could significantly reduced the relative risk of all - cause death by 26% : ( or 0.74 [ 0.5 - 0.94 ] , p=0.01 ) with a number needed to treat of 100 ( 95% ci 33 - 167 ) . the lack of benefit of pexelizumab in the setting of patients with stemi clearly contrast with the apparent benefit observed in patients undergoing cabg . in other words , the diverse effect of pexelizumab might reflect crucially important differences of the two settings in which it has been tested . indeed , in animal models of tissue reperfusion injury ( common in stemi setting ) an increased accumulation of mac ( c5b-9 ) was demonstrated as well as quite stable levels of c5a during cardiopulmonary bypass . conceivably , in the setting of stemi once microvascular damage and myocardial death due to necrosis , local inflammation , and apoptosis have become irreversible , complement activation could have already led to mac formation , thus nullifying any benefit from pexelizumab . furthermore , penetration of pexelizumab into myocardial tissue may be limited as a consequence of microvascular obstruction and local metabolic derangement . on the other hand , upstream administration of pexelizumab could reduce the generalized inflammatory process accompanying cardiopulmonary bypass . when considering the unconvincing evidences and knowledge of its beneficial effect , it does nt surprise that pexelizumab is no longer on the market and only 32% to 35% of the participants to the consensus conference included it among the life - saving drugs in cardiac surgery . the discouraging results of pexelizumab led to the end of the drug , not to the end of the concept , perhaps the way to an effective antinflammatory / anti - complement drug should probably start from a better knowledge of the underlying mechanisms of such an innate immune response in patients undergoing cabg , and then on possible preventive strategies which might positively affect the outcome .

a recent international consensus conference on the reduction in mortality in cardiac anesthesia and intensive care included pexelizumab , a recombinant monoclonal antibody to the component 5 of the complement system , among the ancillary ( i.e. non - surgical ) drugs / techniques / strategies that might influence survival rates in patients undergoing cardiac surgery . the consensus conferences state that a subgroup analysis of a meta - analysis of randomized controlled trials suggested that pexelizumab might reduce mortality ( longest follow up available , up to 6 months ) in patients undergoing coronary artery bypass grafting . pexelizumab was not included among the most important topics of the consensus conference as it was the only topic that did not receive a sufficient percentage of votes from the audience ( 32% at the first round and 35% at the second round ) . pexelizumab is no longer on the market , however , the concept of reducing the generalized inflammatory process accompanying cardiopulmonary bypass deserves further investigation .

desanto studied 238 cases with laryngeal cystic lesions and mainly classified them into two types as follows . the first type , laryngocele , contains air in the cyst , and the second , laryngeal cyst , has mucus . since both laryngoceles and laryngeal cysts are rare in japan , we present the results of physical examination , image findings and treatment . the patient was a 64-year - old japanese man who underwent digestive endoscopy at a clinic , where a laryngeal mass was pointed out . laryngeal fiberscope revealed a swelling of the left false cord ( figure 1 ) that we diagnosed as a laryngocele . under general anesthesia , the laryngocele was removed by laryngomicrosurgery using an oral approach and the content of the specimen was confirmed to be air . the postoperative course was good . a 57-year - old japanese man presented with a one - month history of left laryngeal swelling with pain . laryngeal fiber - scope revealed a swelling of the left false cord and laryngeal ventricle . magnetic resonance imaging demonstrated a dumbbell - type cyst with mucus widely extending from the laryngeal lumen to the neck through the thyroid cartilage ( figure 2 ) . we performed fine needle aspiration and confirmed the presence of mucus ( figure 3 ) . the patient was a 64-year - old japanese man who underwent digestive endoscopy at a clinic , where a laryngeal mass was pointed out . laryngeal fiberscope revealed a swelling of the left false cord ( figure 1 ) that we diagnosed as a laryngocele . under general anesthesia , the laryngocele was removed by laryngomicrosurgery using an oral approach and the content of the specimen was confirmed to be air . a 57-year - old japanese man presented with a one - month history of left laryngeal swelling with pain . laryngeal fiber - scope revealed a swelling of the left false cord and laryngeal ventricle . magnetic resonance imaging demonstrated a dumbbell - type cyst with mucus widely extending from the laryngeal lumen to the neck through the thyroid cartilage ( figure 2 ) . we performed fine needle aspiration and confirmed the presence of mucus ( figure 3 ) . small lesions localized at the laryngeal lumen are generally treated by laryngeal microsurgery using an oral approach . large cysts growing from the laryngeal lumen to the neck through the thyroid cartilage require extirpation by an external approach , often adding tracheotomy to maintain the air way . our case # 2 with a laryngeal cyst was under chemotherapy for advanced renal carcinoma with multiple metastases of both lung and bone . therefore , we performed only fine needle aspiration rather than aggressive surgery for extirpation of the cyst using an external approach . this fine needle aspiration could improve the quality of life by decreasing both the laryngeal swelling and pain .

we experienced two rare cases with laryngeal cystic lesions ( laryngocele and laryngeal cyst ) . in the first case , the laryngocele case was removed by laryngomicrosurgery using an oral approach under general anesthesia . in the second case , the magnetic resonance imaging demonstrated a dumbbell - type cyst with mucus widely extending from the laryngeal lumen to the neck through the thyroid cartilage . the patient had undergone chemotherapy for renal carcinoma with multiple lung and bone metastases . therefore , we performed only fine needle aspiration rather than aggressive surgery for extirpation of the cyst using an external approach . this fine needle aspiration could improve the quality of life by decreasing both the left laryngeal swelling and the resulting pain , which were the chief complaints .

capsular tension rings are used to stabilize the capsular bag , reduce the tension on zonules and to provide safer conditions for phacoemulsification in patients , especially those with pseudoexfoliation or trauma - induced breakdown in zonular support . we present here an unusual case of retinal detachment secondary to a capsular tension ring - induced retinal tear . a 45-year - old man who had undergone cataract surgery elsewhere 2 years previously on the left eye presented to our clinic complaining of decreased vision of 2 months duration in the same eye . the patient was treated and followed up at the ophthalmology department of cukurova university . visual acuity was at hand motion level and the intraocular pressure was 14 mm hg in the left eye . slit lamp examination showed a well - located posterior chamber intraocular lens and intact posterior lens capsule . the retinal periphery was not optimally visualized because of peripheral posterior capsular opacification , but showed multiple retinal tears with the largest one located between 3 and 5 o'clock . ultrasonography of the left eye showed retinal detachment as well as the large retinal tear ( fig . fundus examination during 20-gauge vitrectomy showed a large retinal tear located between 3 and 5 o'clock and multiple tears located peripherally , and also a dislocated capsular tension ring around the tear . one end of the ring was found under the retina just next to the large tear at the 3 o'clock position . the ring was freed from all vitreous adhesions , divided into 2 pieces with scissors and removed using vitrectomy forceps through the sclerotomy site . barrier photocoagulation was done around the tear , and the vitrectomy was terminated after perfluorocarbon - silicone oil exchange . on the first postoperative day , visual acuity in the left eye was 20/200 . during follow - up , intraocular pressure in the left eye increased and was controlled with the use of topical brimonidine and fixed dorzolamide / timolol combination . capsular tension rings are mainly preferred to maintain the contour of the capsular bag in patients who have capsular instability in complicated cataracts . indicated in their large series including 9,528 cataract surgeries that the frequency of capsular tension ring use was 0.7% . the primary indications for the ring were found to be as mature cataract , traumatic cataract , pseudoexfoliation syndrome and lens subluxation due to marfan syndrome . in the present case , zonular weakness and phacodonesis probably led to the use of a tension ring , and dislocation of the capsular tension ring was thought to have occurred during its placement through a possible site of capsular tear ; however , the dislocation could have been caused by a late capsular contraction which resulted in capsular shrinkage and ring displacement . another possible explanation is the misplacement of the ring in the sulcus during cataract surgery . possible complications of intraocular lens dislocation are retinal tears , retinal detachment , cystoid macular edema and vitreous hemorrhages . spontaneous in - the - bag intraocular lens dislocations have also been reported in the literature [ 3 , 4 , 5 , 6 ] . removal of the ring has been achieved through sclerotomy sites or limbal incisions [ 7 , 8 ] . described a case of retinal detachment which occurred after removal of a dislocated capsular tension ring with pars plana vitrectomy . the present case differs from this case by the presence of an accompanying retinal detachment at presentation . to the best of our knowledge , this is the first case of isolated dislocation of a capsular tension ring into the vitreous , which possibly led to a retinal detachment with a large tear , while the posterior chamber lens was safely located in the capsular bag with an intact posterior lens capsule . the posterior capsule was thought to be intact during slit lamp examination before vitrectomy , but the integrity of the entire capsular bag could have been impaired by a small tear located at the equatorial region . the ring may have been placed in the sulcus or fallen into the vitreous through a tear . in the present case , the tear was considered to have occurred secondary to ring dislocation because of the critical localization of the ring around the tear area . whatever the underlying mechanism is , it should be kept in mind that the application of a capsular tension ring requires experience and a careful follow - up because it may be associated with unexpected and very rare posterior segment complications .

we aim to present a case of retinal detachment secondary to capsular tension ring dislocation following cataract surgery . a 45-year - old man who underwent cataract surgery 2 years previously presented with decreased vision in his left eye . the patient 's posterior capsule was intact with a well - located posterior chamber intraocular lens . fundus examination revealed retinal detachment with retinal tears , and a capsular tension ring located around the tear was noticed during pars plana vitrectomy ; it was removed through the sclerotomy site . in conclusion , dislocation of the capsular tension ring is a rare and unexpected complication of cataract surgery . although the integrity of the posterior lens capsule is partially preserved , the ring may shift through a small tear in the bag even during its placement , and may cause retinal tears , retinal detachment or just remain silently suspended in the vitreous .

segmental neurofibromatosis ( sn ) is a rare variant of a common autosomal dominant neurocutaneous disorder wherein a postzygotic mutation in the nf1 gene is thought to cause lesions distributed in one area of the body . unilateral , bilateral , and late - onset cutaneous segmental neurofibromas have been described , as well as isolated deep - seated plexiform neurofibromas . there is also one case of multiple recurring schwannomas in deep and superficial locations , yet there have been no reported cases with deep schwannoma and clinically apparent multisegmental neurofibromas ; increased knowledge and awareness of this phenotype is important . a 70-year - old woman presented to dermatology outpatient clinic for evaluation of two clusters of small , fleshy tumors that appeared over the previous three years . twenty - five years prior , she had undergone a surgery for a deep nerve - based tumor lateral to her left knee . she had no other family members with similar lesions or a personal history of malignancy . on examination , several skin - colored to violaceous , fleshy , pedunculated papules and nodules were clustered over her left anterior shoulder and lateral left leg [ figure 1 ] . biopsy confirmed that the cutaneous lesions were neurofibromas ( figure 2 , showing non - encapsulated peripheral nerve elements and schwann cells with wire - like collagen fibrils ) . given the clustered distribution of lesions and lack of other stereotypic findings of neurofibromatosis ( caf - au - lait macules , musculoskeletal deformities , axillary freckling , lisch nodules of the iris ) , the patient was diagnosed with sn . cluster of fleshy , pedunculated papules on ( a ) left lateral leg and ( b ) left anterior shoulder ( a and b ) h and e staining of tissue consistent with neurofibroma ( description of histopath image required ) ( a : 4 and b : 10 ) sn , classified by riccardi as neurofibromatosis type v ( nfv ) , was traditionally described as caf - au - lait spots , freckling , and neurofibromas restricted to a discrete area . however , roth et al . realized that several patients with apparent sn did not meet these criteria and developed four subsets of nfv to better stratify and classify patients : true sn according to riccardi are localized deep neurofibromas only , hereditary segmental , and bilateral segmental . recently , hardin et al . reported that sn should not be regarded as a distinct entity from neurofibromatosis i. they believe cases previously referred to as unilateral or bilateral sn are now best referred to as mosaic generalized or mosaic localized neurofibromatosis . they found 55% had pigmentary changes only , 8.6% had neurofibromas only , 22.4% had neurofibromas and pigmentary changes , and 13.8% had plexiform neurofibromas only . the lesions often followed a dermatomal distribution , with the cervical areas being affected most commonly . sn has been reported to be associated with malignant melanoma , breast , colon , gastric , and lung cancer , affecting 5.3% of patients . as the current prevalence of cancer in the general population is lower , it seems that patients with sn are at an increased risk for certain malignancies . most patients were diagnosed with cancers after their diagnosis of neurofibromatosis ; therefore , a prudent review of systems and general examination for any neoplastic process could be of benefit in these patients . no report of late - onset multi - sn in two different dermatomes with associated deep schwannoma has been reported ; this appears to be a new nf phenotype . given the association of neurofibromatosis and plexiform lesions with various comorbidities , it is important to study the natural history of the disease to better counsel patients on risks , prevention , and family planning

an elderly patient presented with two clusters of asymptomatic fleshy and pedunculated papules . biopsy of the papules was consistent with neurofibromas . decades prior she had undergone a surgery for the excision of a large schwannoma . given her lack of other neurofibromatosis findings , the patient was diagnosed with multisegmental neurofibromatosis ( multi - sn ) with deep schwannoma , a possible new phenotype of sn . because this entity may be associated with internal malignancy , it is important to screen and educate these patients as well as to provide regular follow - up .

subcutaneous implantable cardioverter - defibrillator ( s - icd ) is a novel treatment modality to prevent sudden cardiac death that does not require lead implantation in or on the heart . s - icd automatically analyzes optimal sensing vectors , and the optimal sensing vector is usually selected based on this analysis . this analysis is usually performed in the supine position at rest . in patients with brugada syndrome ( brs ) , icd is the main treatment modality to prevent sudden cardiac death , and s - icd is a therapeutic option designed to avoid complications related to the transvenous system . however , the brs - pattern electrocardiogram ( ecg ) is known to show dynamic changes , and evaluation of ecgs after s - icd implantation in patients with brs should be undertaken in various situations . moreover , little is known about the method of selection of the optimal sensing vector in patients with brs based only on the automatic analysis of the s - icd at rest . here , we report the case of a patient with brs who experienced inappropriate shock ( ias ) due to t - wave oversensing ( twos ) during exercise . a 51-year - old man with brs was referred to our hospital to be evaluated for indications for icd . he exhibited a spontaneous type 1 baseline ecg and had a family history of sudden cardiac death . s - icd ( emblem , boston scientific , marlborough , massachusetts ) was successfully implanted in the standard position using a standard technique ( fig . 1a ) , and the secondary vector was selected as the optimal sensing vector based on automatic s - icd analysis at rest . the patient experienced a strong impact during exercise 30 days after the s - icd implantation . the secondary vector was still acceptable as the optimal sensing vector , again based on automatic re - analysis by the s - icd at that time . he therefore underwent an exercise test to confirm whether the secondary vector was appropriate . during exercise , 1b ) , and twos was observed in the primary and secondary vectors on the cardiac signals of the s - icd ( fig . 2d ) , which was then selected as the optimal sensing vector of s - icd instead of the secondary vector . after changing the sensing vector , this is the first report of ias due to twos in a japanese patient with brs after s - icd implantation . a previous registry revealed that the incidence of ias with s - icd was 13.1% at 3 years after implantation . the most common cause of ias was oversensing of the cardiac signal , such as twos , apart from heart rate increase due to supraventricular tachycardia in the shock zone . a recent report showed that patients exhibiting an st segment change during exercise , including patients with hypertrophic cardiomyopathy , were at risk for twos . brs ecg patterns show dynamic changes that affect the qrs complex and st segment amplitude and morphology . a recent report showed that the acceptable sensing vector in s - icd could be changed by injecting ajmaline . ecg changes in brs occur not only due to drugs but also during exercise ; therefore , specific attention to twos is needed in this population . while s - icd is a therapeutic option for patients with brs , it is important to pay close attention to the selection of the optimal sensing vector in s - icd . furthermore , if all sensing vectors are not available , we can not use s - icd appropriately . in that case , we have to change the lead location or extract the s - icd system and implant transvenous icd . from this point of view , it is still important to adequately evaluate the acceptability of the sensing vector in s - icd before implantation . exercise testing shortly after s - icd implantation should be considered for patients with brs to evaluate the acceptability of the sensing vector in s - icd .

we report the case of a 51-year - old patient with brugada syndrome ( brs ) who experienced inappropriate shock due to t - wave oversensing ( twos ) during exercise when the optimal sensing vector was selected based on the automatic analysis by a subcutaneous implantable cardioverter - defibrillator ( s - icd ) . after selecting another vector during exercise testing , twos did not re - occur . selection of appropriate sensing vector based on analyses under various conditions , including during exercise after s - icd implantation , should be considered for patients with brs .

the nurse and doctor , both inexperienced and sincerely wishing they were n't there , watch the monitor anxiously . they have left the security of one hospital for that of another ; like in a circus trapeze act , they hang suspended for a moment . for at that instant the sickest patient in the region is travelling at over 100 km / hour down an unknown highway . will they catch the trapeze , or will they fall ? in an era in which we want to know the physiology and status of our patients continuously throughout their hospital stay , patients who are in transit between institutions are almost completely unobserved . so how good is the care they receive ? in this issue of critical care , ligtenberg and coworkers try to answer just this question . in truth , many studies have examined the effects of transferring critically ill patients . some have focused on changes in physiology and monitoring , finding few changes of questionable consequence . indeed , others have focused on later outcomes [ 3 - 5 ] , showing a moderate effect on mortality and length of stay . however , the study by ligtenberg and coworkers goes one step further and takes a pragmatic , patient - centred view of the consequences of transfer . half of the time this can be related to failure to follow advice from the receiving centre . of these events 70% are , in the authors ' opinion , avoidable and 30% are related to technical problems . it is not due to lack of guidelines or expert opinion [ 6 - 8 ] . this is a problem that has truly been out of sight and out of mind . how then do we make things better ? first , transfer equipment must be standardized , because many of the adverse events described in the report by ligtenberg and coworkers are equipment related . publication of european standards for ambulance vehicles ( cen 1789 ) may represent an opportunity to achieve this . that document sets out standards for safety that will mean the end of syringe drivers lying on stretchers , ventilators clipped on trolleys and monitors lying on shelves . noncompliance will technically invalidate any eu ambulance 's motor insurance policy . each hospital must nominate a specialist with responsibility for critical care received during transfer such a small change would generate the sense of discomfort necessary to finally stimulate improvement .

how good is the care patients receive during interhospital transfer ? the results of a study in this journal make for some disturbing reading . adverse events occur in about one - third of cases . half the time this can be related to not following advice from the receiving centre . of these events , 70% are , in the author 's opinion , avoidable and 30% are related to technical problems . so how do we make things better ? all transfer equipment needs to be standardized and be " fit - for - purpose " . each hospital needs to take responsibility for the quality of care received in transfer , and this should include guidelines , training and equipment .

isolated bone affection due to fungi are rare and we present one such case with fungal osteomyelitis of terminal phalanx of second toe . we present a rare case of fungal osteomyelitis of right second toe in a 30 year old indian female who presented with swelling of 8 months duration . the patient was treated with surgical debridement and amphotericin - b was given for 6 weeks after debridement . isolated aspergillus osteomyelitis of the bone are very rare and mostly seen in immunocompromised patients and larger bones like spine , femur and tibia . treatment with wound debridement and subsequently followed up with a course of amphotericin - b for 6 weeks provided good results . fungi should be kept in mind for differential diagnosis of osteomyelitis and culture should be appropriately ordered . author 's photo gallery fungal osteomyelitis is a rare disease and generally present in an indolent fashion [ 1 - 4 ] . incidence of fungal infection has been on rise with immunodeficiency diseases and invasive surgical procedures [ 5 - 7 ] . it is rare to find an isolated fungal bone affection in a immunocompetent person without any obvious predisposing factors . we report one such rare case with isolated affection of terminal phalanx of the second toe . a 30 year old female presented with swelling of right second toe for the past 8 months following direct trauma to the right foot when she hit a wooden door ( fig.1 ) . she consulted local doctors and was given pain medication but the symptoms did not subside . when she presented to us there was swelling of the toe with moderate tenderness and bogginess around the nail bed . radiographs of right foot was taken which showed irregular margins , lytic and sclerotic edges of the terminal end of distal phalanx of 2nd toe ( fig . routine blood investigations were within normal limits with a slightly elevated esr ( 35mm / hr ) . a preliminary diagnosis of chronic osteomyelitis was made and decision for excision biopsy was taken . under local anesthesia a fish mouth incision was taken ( fig . distal phalanx was found to be completely involved and a decision to excise the whole distal phalanx was taken . the excised bone was sent as a specimen ( fig.4 ) for the histo - pathological examination . bacterial culture was negative but histology showed that bone contained fungal hyphae and subsequently the bone culture showed growth of aspergillus . treatment was started with amphotericin - b according to her body weight for 6 weeks . the patient was followed regularly at 1 month , 3 months , 6 months and one year and no signs of recurrence was noted . clinical photograph showing swelling of the second toe radiograph showing irregular margins and scerotic lesion with lytic areas fish mouth incision used to expose the lesion excised terminal phalanx fungii such as aspergillus are known to be ubiquitus in nature and are the common commensals of the respiratory tract . in patient with immunosupression , these organisms multiply and cause widespread infection involving respiratory system and sometimes even skeletal system . there have been published accounts of fungal osteomylitis in literature but aspergillus osteomyelitis is infrequently reported [ 3,7 - 12 ] . fungi infections are common in cases of polytrauma where multiple surgeries cause a break in the natural barriers of skin and mucous membrane and compromises the patients immune system . in such cases staphylococcus aureus is the most common cause of osteomyelitis and the long bone metaphysis is the most common localization of osteomyelitis . cases of fungal osteomylities in literature that were reviewed showed that surgery with systemic antifungals had a lower recurrence and higher success rate as compared to those that were treated with antimycotics alone , which may be due to the fact that penetration of most drugs into the bone tissue is low . we treated our patient with surgical debridement along with amphotericin - b with good results . this is a rare case of apsergillus osteomyelitis affecting the terminal phalanx of the toe . sclero - lytic lesion with suspicion of chronic osteomyelitis can be fungal in origin even in immunocompetent host . this needs to be kept in differential diagnosis and also while sending cultures for such lesions

introduction : fungal osteomyelitis is an uncommon diseases and generally present in an indolent fashion . isolated bone affection due to fungi are rare and we present one such case with fungal osteomyelitis of terminal phalanx of second toe.case report : we present a rare case of fungal osteomyelitis of right second toe in a 30 year old indian female who presented with swelling of 8 months duration . diagnosis was based on the histo - pathological report and culture showing aspergillus growth . the patient was treated with surgical debridement and amphotericin - b was given for 6 weeks after debridement . there was no recurrence one year post surgery.conclusion:isolated aspergillus osteomyelitis of the bone are very rare and mostly seen in immunocompromised patients and larger bones like spine , femur and tibia . treatment with wound debridement and subsequently followed up with a course of amphotericin - b for 6 weeks provided good results . there was no recurrence noted at 1 year follow up . fungi should be kept in mind for differential diagnosis of osteomyelitis and culture should be appropriately ordered .

calculi may lead to obstruction and infection , causing loss of renal tissue and function . this complication , often referred to as pyonephrosis , is considered a urological emergency and warrants prompt drainage and management . presentation of pyonephrosis may vary from asymptomatic bacteriuria to septicemia , and is occasionally complicated further by spread of purulent exudate into the surrounding spaces . we report a rare case where stone - induced pyonephrosis contiguously spread to the liver and presented as a hepatic abscess . a 25-year - old lady presented to the urological emergency with complaint of episodes of dull aching colicky pain in the right lumbar region for the past 1 year , which had increased in severity and become continuous for the past 2 weeks . she also reported weakness and malaise , but did not give any history of urinary or bowel complaints . physical examination revealed a pulse rate of 104/min , low blood pressure of 104/60 mm of hg , respiratory rate of 22/min , and a temperature of 101f . there was tenderness in the right hypochondrium and the right renal angle , but no visible fullness . keeping a differential diagnosis of gall stone disease and pyonephrosis , an urgent ultrasound examination was done which showed grade iii dilatation of the right kidney with internal echoes and multiple calculi , largest of size 18 mm , located in the pelvis . the liver showed a hypoechoic lesion of 10 10.2 cm in the right lobe . a breach in the renal capsule was demonstrated , communicating with the lesion in the liver . laboratory investigations revealed marked leukocytosis , severe anemia ( 5.5 g / dl ) , mildly deranged renal function ( blood urea 60 mg / dl , serum creatinine 1.6 mg / dl ) and coagulopathy ( international normalised ratio 1.63 ) . based on a working diagnosis of pyonephrosis with liver abscess with septicemia , the patient was resuscitated with fluids and given intravenous antibiotics and blood transfusion . dehydration and coagulopathy were corrected and a contrast - enhanced computed tomography ( ct ) was obtained , revealing a hypodense peripherally enhancing lesion with air in the right lobe of the liver communicating with the upper calyx of the hydronephrotic right kidney with multiple calculi [ figure 1 ] . right pleural effusion with consolidation of the right lower lobe of the lung was also seen . the patient 's condition improved on antibiotics , and right dj stenting was performed along with an ultrasound - guided drainage of 800 ml pus from the right lobe of the liver . she responded well to treatment and was discharged with a plan for right percutaneous nephrolithotomy after 6 weeks . on subsequent follow - up visits , it produces obstruction to the passage of urine and acts as a nidus for microorganisms , creating perfect conditions for accumulation of pus and destruction of functional parenchyma . pyonephrosis has been better defined as a disease spectrum ranging from infected hydronephrosis , where kidney function is preserved , to xanthogranulomatous pyelonephritis , where the renal function is severely affected . this is further complicated when necrosed renal tissue gives way to the accumulating pus , leading to spread of infected exudates outside the kidney . a review of literature showed that rupture of pyonephrosis is relatively common into the peritoneum , and sometimes the retroperitoneum , both of which act as free spaces in immediate vicinity of the kidney for collection of pus . rare reports of pyonephrosis causing nephro - bronchial fistula , splenic abscess , and renal vein and caval thrombosis also exist . our search for literature regarding reno - hepatic communication revealed only one case where xanthogranulomatous pyelonephritis led to the formation of a pyelo - hepatic fistula in a middle - aged lady . considering the strong anatomical barrier offered by the gerota 's fascia and the gilsson 's capsule , it seems rather difficult to have pyonephrosis cause an ascending infection to the liver . however , a thorough history was suggestive of a primary renal pathology giving rise to a secondary liver abscess . the management of pyonephrosis is by urgent antegrade or retrograde drainage followed by definitive management of the underlying pathology . in view of the deranged coagulopathy , an urgent dj stenting was done followed by aspiration of the residual liver abscess after correcting the coagulation profile . patient was empirically managed on third - generation cephalosporin and aminoglycosides and she responded well . the only reported case demonstrating the possibility of a renal infective pathology spreading to the liver is that of a pyelo - hepatic fistula following xanthogranulomatous pyelonephritis by chung et al . , which was managed by partial hepatectomy and nephrectomy , a treatment befitting this more severe spectrum of pyonephrosis . our case demonstrates the success of a conservative approach in managing this rare complication of renal calculi when detected early in its course .

neglected renal calculi can lead to a variety of complications secondary to obstruction and infection . pyonephrosis arising in this scenario often presents as a urological emergency and requires urgent surgical intervention . in rare circumstances , when left unaided , the kidney is unable to contain the infection and spread of pus may occur into the surrounding spaces like the retroperitoneum and the peritoneum . we report a very unusual complication of pyonephrosis leading to a hepatic abscess . we believe this is the first reported case of an acute renal infection due to stone disease ascending into the liver .

spinal epidural hematoma was first described by jackson in 1869 . since then , only about 40 other pediatric cases have been reported so far , pointing toward the rarity of this lesion . the majority of these cases are spontaneous epidural hematomas , where only few have a traumatic origin . in all these case reports , the prime importance was early diagnosis and urgent evacuation of the hematoma for a good functional outcome . in this pretext , we report the case of a six -year - old boy who was admitted and managed surgically at our institution . a six - year - old boy presented to the emergency department because of severe neck pain and acute onset of quadriparesis , more prominent in the lower limbs than in the upper limbs . his symptoms had started a few hours earlier when he was practicing judo karate and had a blow on the nape of the neck and fell down . his motor examination revealed bilateral ( b / l ) upper extremity weakness ( power grade - 4/5 ) and b / l lower limb weakness ( power grade 3/5 ) . the patient 's radiographic evaluation included a plain x - ray and mri cervical spine . x - ray of the cervical spine showed no fracture and the anatomical alignment was maintained . sagittal t1-weighed mri images showed a large slightly hyperintense , space - occupying lesion extending from c3 to t4 and displacing the spinal cord . the sagittal t2-weighed image showed the same space - occupying lesion , but it was isointense . on axial imaging the same findings were found on t1 and t2 , demonstrating cord compression . hemilaminectomy and surgical evacuation of the hematoma was done by a vertical midline skin incision , extending from the external occipital protuberence to the t4 spinous process . the patient improved neurologically and at the time of discharge had power grade 5/5 in all four limbs . the patient is on a regular follow - up and is totally asymptomatic and neurologically intact . the annual incidence of spontaneous epidural spinal hematoma has been reported to be 0.1 in 100,000 population , whereas , in the pediatric population this incidence is significantly lower . only 40 cases have been reported in literature , out of which 34 were non - traumatic and the rest were traumatic ( as in our case ) . the cause of the hematomas in the non - traumatic cases was probably related to tumors , arteriovenous malformations , epidural hemangiomas , coagulopathies , infections , and bleeding diatheses.[57 ] the location of the hematoma in the vast majority of cases was cervical ( as in the present case ) , but thoracic and lumbar epidural hematomas have also been reported . the clinical presentation of epidural hematomas in pediatric patients varies significantly ; abnormal crying might be the only symptom in infants , which makes an appropriate diagnosis even more challenging . neck pain and tenderness , torticollis , focal motor or sensory deficits ( depending on the location of the hematoma ) , irritability , and the brown sequard syndrome are some of the most commonly reported presenting symptoms . the progression of symptomatology and clinical signs is usually very rapid as was seen in our case , although slower progression over a few days is also possible . the neuroimaging workup of patients with suspected spinal epidural hematoma must include an mri , not only to delineate the hematoma and the relationship with the thecal sac , but also to rule out any underlying vascular or other disorder . in addition , obtaining a preoperative spinal angiogram , and newer noninvasive imaging modalities like computed tomography ( ct ) angiography and cervical magnetic resonance angiography ( mra ) could be good supplementary techniques for visualizing suspected vascular abnormalities . furthermore , appropriate laboratory tests are a prerequisite to rule out any bleeding diathesis or coagulation disorders . hemilaminectomy ( as in our case ) appears to provide adequate exposure for hematoma evacuation , even in the case of large lesions that cross the midline , and it minimizes the risk of developing a postlaminectomy deformity , which has been reported to be as high as 46% in patients younger than 19 years of age . multilevel laminoplasty is another surgical option for evacuating spinal epidural hematomas as this procedure minimizes the risk of developing postlaminectomy deformity . we have not found any comparative analysis of multilevel hemilaminectomy or laminoplasty , for development of postoperative deformities . as far as we know , the development of long - term , postoperative deformities has not been investigated in any comparative study of multilevel hemilaminectomy or laminoplasty . in adult patients , however , laminoplasty appears to be superior to hemilaminectomy in avoiding postoperative worsening of the cervical curvature , although the postoperative range of motion is similar with both techniques . we selected hemilaminectomy in our cases because of the shorter operating time and because we were more familiar with the procedure , but laminoplasty definitely represents a valid surgical option in the management of these cases . in our patient spinal epidural hematoma in pediatric patients is a rare entity , but it does occur . early diagnosis of this condition and rapid surgical evacuation are of paramount importance for a better neurological outcome . unfortunately , the nonspecific presenting symptomatology and clinical signs , especially in infants , makes the diagnosis quite challenging . the clinician should be suspicious of this entity and always include cervical spine epidural hematoma in the differential diagnosis of pediatric patients , who present with acute neck deformity or pain .

pediatric cervical epidural hematoma is an uncommon diagnosis and very few cases have been reported so far . the condition is difficult to diagnose and requires immediate surgical intervention to obtain the best possible neurological outcome . most of the cases are of a spontaneous origin . we report a case of traumatic cervical epidural hematoma , which was managed surgically , resulting in complete neurological recovery .

a 74-year - old woman , with a firm , slow - growing , variably pigmented nodule on her thigh was referred to our unit . the lesion was elevated at the periphery and partially ulcerated , well delimited and asymptomatic ( figure 1a ) . dermoscopy showed asymmetry , white - blue color at the periphery and polymorphous vessels in the center associated with crystalline structures and multiple erosions ( figure 1b ) . analysis of rcm images revealed a well - demarcated tumor ( figure 2a ) composed of dark homogeneous islands surrounded by bright stroma ( figure 2b ) . tumor cells were small and uniform in size and shape and vessels were well represented ( figure 2c ) . the rcm features were not indicative of basal cell carcinoma because of the lack of palisading , clefting and typical shape of tumor nests . furthermore , no melanocytic proliferation was detected upon rcm and thus a diagnosis of melanoma was excluded . histologic examination , at scanning view , showed a well - circumscribed lesion with a pattern of growth in broad anastomosing bands ( figure 3a ) . , it was composed of monomorphous cuboidal cells with features of poroid maturation into small ductal lumina ( blue arrows ) and containing variably sized melanin granules ( arrows ) ( figure 3c d ) . atypical mitoses , cytologic atypia or other features suggestive of malignant transformation were not seen . this benign adnexal neoplasm often appears as a firm , flesh - colored to reddish nodule , papule or plaque , at the acral sites , which are the sites with higher concentration of eccrine sweat glands . it is more frequent between the fourth and sixth decades of life without sex predilection . its pathogenesis is unknown , but may be related to trauma , radiation or scars . this variant seems to be more frequent in non - white people and on non - acral sites . frequently it is confused clinically with seborrheic keratosis , epithelialized pyogenic granuloma , basal cell carcinoma ( bcc ) , squamous cell carcinoma ( scc ) , angiofibroma , and cutaneous melanoma . for these reasons it can be regarded as big simulator , and thus diagnostic tools can be of help in differentiating eccrine poroma from other entities . ferrari et al . summarized dermoscopic structures in a series of non - pigmented poroma in which the main dermoscopic clues were : a white - to - pink halo surrounding the vessels , pink - white structureless areas , vascular structures of glomerular and linear irregular vessels , hairpin vessels , and linear irregular vessels . valuated pep , describing 12 cases in which vascular structures , globule - like structures and comedo - like openings were the hallmarks . more recently , it has been shown that eccrine poroma might mimic several benign and malignant tumors also from a dermoscopic aspect . additional to the use of dermoscopy , reflectance confocal microscopy is currently used to increase diagnostic accuracy of skin tumors since it provides skin imaging in vivo at cellular level resolution close to conventional histology . in the current case , rcm highlighted the presence of tumor nests with clearly visible outline , small sized tumor cells and overall symmetric silhouette . although the diagnosis of pigmented eccrine poroma was not possible since diagnostic rcm criteria have been not previously identified , the findings were not suggestive of bcc or melanoma : furthermore , the overall analysis of the architecture and cytology suggested the diagnosis of an epithelial benign lesion . on histology basaloid cells growing in nests and solid nodules are , by definition , characterized by more or less evident poroid differentiation , that is , small ductal lumina bordered by an eosinophilic cuticle . poroid differentiation occurs also in other entities such as hydroacanthoma simplex , dermal ductal tumor and poroid hidradenoma . benign tumors arising from the eccrine ducts often are difficult to differentiate from an eccrine poroma . even if the diagnosis of eccrine poroma remains histopathological still , as in this case report , noninvasive tools such as dermoscopy and rcm examinations can be of help to rule out the diagnosis of melanoma and non - melanoma skin cancers . larger studies on this rare pigmented variant of eccrine poroma could shed new light on the identification of specific diagnostic dermoscopic and confocal features .

eccrine poroma is a rare benign adnexal tumor of epithelial cells originating from the terminal ductal portion of the sweat glands that is typically located on palms and soles , although other cutaneous sites can be affected [ 1 ] . it is usually nonpigmented even if there is a pigmented variant that corresponds to 17% of cases and it is usually underdiagnosed , since it is mistakenly confused with other pigmented tumors [ 2,3 ] . dermoscopy and reflectance confocal microscopy ( rcm ) may assist in the correct diagnosis of this tumor.herein , we report one case of pigmented eccrine poroma ( pep ) that simulated clinically a cutaneous melanoma or a basal cell carcinoma . dermoscopy and rcm excluded the possibilities of those two diagnoses ; the overall confocal findings were suggestive for a benign epithelial tumor . histology was fundamental to diagnose this lesion as a pigmented eccrine poroma . even if the diagnosis of eccrine poroma remains histopathological still , as in this case report , noninvasive tools such as dermoscopy and rcm examinations can be of help to rule out the diagnosis of melanoma . larger studies on this rare pigmented variant of eccrine poroma could shed new light on the identification of specific diagnostic dermoscopic and confocal features .

in the previous issue of critical care , wang and colleagues present interesting data from a large cohort of unselected medical intensive care unit ( icu ) patients which examined the prognostic utility of two well - established biomarkers : n - terminal pro - brain natriuretic peptide ( nt - probnp ) and c - reactive protein ( crp ) . in fact , the authors ' observations nicely complement the picture that is emerging from several recent studies [ 1 - 14 ] . like most of the previous studies , their findings leave the majority of icu physicians in doubt about whether biomarkers are utile or futile . biomarkers complement other clinical information by proving quantitative data regarding a pathophysiological mechanism that can be used for the early diagnosis of a specific disease , to monitor and guide treatment , and to predict the risk of death or other adverse events . the stronger the link between the information provided by the biomarker and the immediate clinical course of action that we physicians take in response , the higher the clinical utility of the biomarker . in most patients finally being admitted to an icu , the diagnosis is made prior to icu admission , most commonly in the emergency department ( ed ) . of course , we still face diagnostic uncertainty in many patients who develop new symptoms or signs during their stay in the icu ( for example , respiratory deterioration or fever ) . to appropriately examine the diagnostic accuracy of a biomarker in these settings , we need to define a gold standard diagnosis against which the blinded biomarker results are then compared . unfortunately , owing to , for example , the low specificity of chest x - ray findings , the adjudication of a final diagnosis often is challenging for many common icu disorders , such as ventilator - associated pneumonia and hypoxemic respiratory failure . in addition , the extent to which experience and diagnostic cutoff levels can be transferred from studies performed in the ed to the critically ill patients in the icu is questionable [ 7,10 - 14 ] . major differences in patient characteristics , disease severity , comorbidity , resources available for the individual patient , and therapies applied between the icu and the ed require that the potential clinical use of biomarkers in the icu be defined by specific icu studies . what about the utility of biomarkers in monitoring treatment ? for example , urine output and serum creatinine are used to quantify renal function ; tidal volumes , oxygen saturation , and arterial partial pressure of oxygen [ pao2 ] are used to tailor ventilator settings ; and body temperature , crp , and procalcitonin are used to assess the response to antibiotics . although the use of biomarkers in many of these indications is mainly empirical and only partly supported by large prospective studies , it is perceived by most clinicians as utile as the links between the biomarker information and therapeutic consequences are strong . the link to a specific consequence is weakest for prognostic biomarkers applied in patients with a wide variety of diseases , such as in unselected icu patients . the added value of most , if not all , previously examined biomarkers on top of current icu mortality scores seems to be too low to justify clinical use [ 1 - 6 ] . the prognostic accuracy for icu or in - hospital death of most biomarkers is modest and inferior to that provided by , for example , the apache ( acute physiology and chronic health evaluation ) score [ 1 - 7 ] . this observation seems to be well explained by the wide range of disorders leading to icu admission and the fact that different organ systems may be the most severely damaged and therefore critical for survival . moreover , it is important to highlight that there is no perceived unmet clinical need to appropriately risk - stratify most patients in the icu . simple clinical variables , many of which are captured in the icu scores , provide immediate and reasonable risk prediction . as cardiovascular function is the key variable in many critically ill patients , bnp and nt - probnp - as quantitative markers of hemodynamic cardiac stress and heart failure summarizing the extent of systolic and diastolic left ventricular dysfunction , valvular dysfunction , and right ventricular dysfunction - have been shown to be predictors of death in several previous studies . we are still searching how to best apply this information in the clinical care of critically ill patients . however , prognostic biomarker studies , particularly with bnp and nt - probnp , have already contributed to a better understanding of many disorders in the icu . in fact , the observation that hemodynamic cardiac stress is present in multiple conditions provided important novel insights into pathophysiology and highlighted a dominant role of the cardiovascular system of many common disorders in the icu , including septic shock and weaning failure . bnp : brain natriuretic peptide ; crp : c - reactive protein ; ed : emergency department ; icu : intensive care unit ; nt - probnp : n - terminal pro - brain natriuretic peptide . cm was supported by research grants from the swiss national science foundation , the swiss heart foundation , abbott ( abbott park , il , usa ) , biosite ( san diego , ca , usa ) , brahms ( hennigsdorf , germany ) , roche ( basel , switzerland ) , siemens ( munich , germany ) , nanosphere ( northbrook , il , usa ) , and the university of basel .

biomarkers complement other clinical information by proving quantitative data regarding a pathophysiological mechanism that can be used for the early diagnosis of a specific disease , to monitor and guide treatment , and to predict the risk of death or other adverse events . the stronger the link between the information provided by the biomarker and the immediate clinical course of action that we physicians take in response , the higher the clinical utility of the biomarker . this link is weakest for prognostic biomarkers applied in patients with a wide variety of diseases , such as in unselected intensive care unit ( icu ) patients . although the added value on top of current icu mortality scores seems to be too low to justify clinical use , the observation that hemodynamic cardiac stress and inflammation are present in multiple conditions provides important insights into the pathophysiology of common disorders in the icu .

" oxygen is vitally important in bronchiolitis and there is little evidence that any other treatment is useful . " reynolds and cook ( 1963 ) respiratory syncytial virus ( rsv ) was first identified in 1956 as the agent that causes chimpanzee coryza and subsequently isolated from children in 1957 . since then this medium - sized enveloped rna paramyxovirus has been recognised as the single most important virus causing acute respiratory tract infections in children . the virus replicates in nasopharyngeal epithelium and then spreads to lower respiratory tract one to three days later . rsv infects respiratory epithelial cells by attaching itself to the cell surface by means of an envelope glycoprotein , the g ( attachment ) protein . a second envelope glycoprotein , the f ( fusion ) protein , mediates fusion with the epithelial cell membrane along with adjacent cells , resulting in the formation of multinucleated cells the vast majority of rsv research and studies have concentrated on the lungs and the mechanics of pulmonary immunopathology . dr eisenhut 's thorough systematic review of extrapulmonary manifestations of severe rsv infection clearly demonstrates clinical consequences peripheral to the lung parenchyma . it begs the question as to whether these are direct rsv effects ( i.e. , rsv infection of that tissue ) or indirect , being secondary to parenchymal lung disease and its causative respiratory compromise or consequential of prowling inflammatory mediators ? rsv , like the other paramyxiviridae , can infect non - epithelial cells if it can gain access to the receptors on their surface , as demonstrated by the use of monkey kidney cells for rsv culture in vitro . rsv - rna has been detected by rt - pcr in whole blood but not plasma of infants and neonates , but this alone merely indicates cell - associated rsv genome . this is not necessarily viable rsv and is likely to be virus phagocytozed by neutrophils or monocytes . to escape their white cell captors rsv evidence of deposition in distant organs comes from detection in the myocardium , liver , and cerebrospinal fluid . however , strong convincing evidence of rsv - related inflammation or infection of these sites is less forthcoming unfortunately , this is not necessarily indicative of rsv - directed myocardial injury , but more likely the result of ( right ) heart strain secondary to severe lung parenchymal disease . likewise , it is highly suggestive that raised hepatic transaminases in this patient group are consequential to hepatic congestion or ischaemia due to right heart failure , itself secondary to parenchymal lung disease and/or pulmonary hypertension . proof of a rsv hepatitis would take histological verification ( i.e. , liver biopsy ) , which for ethical reasons is only ever going to occur postmortem . apnoeas and seizures undoubtedly occur in rsv infection , but presently there is more support for rsv encephalopathy than rsv encephalitis [ 12 - 15 ] . unfortunately , many of the reports fail to adequately adjust for the confounding consequence that hypoxic episodes and hypercapnoea may have on the patient 's neurological status . when not related to hypoxic or electrolyte imbalance triggers , rsv 's central influence / effect is probably related to released neurotoxic inflammatory chemokines and cytokines . endocrine impact / consequences , although interesting , appear to be the sequelae of severe rsv pulmonary disease and/or its treatment . it is likely that occurrences of hyponatraemia and hyponatraemic seizures are largely related to the use of hypotonic / electrolyte - poor intravenous solutions . further research is required to scrutinize whether the reported neuroendocrine stress response in rsv bronchiolitis is no more than an epiphenomenon reflecting severity of rsv disease . most of the extrapulmonary effects are likely to be the end result of released inflammatory mediators such as cytokines and chemokines triggered by the rsv respiratory tract infection . the antiviral and cell - mediated immune reaction to rsv infection the storm of t helper 1-type cytokines ( ifn , il-2 , il-12 ) , t helper 2-type cytokines ( il-4 , il-5 , il-6 , il-10 ) , antiviral interferons ( ifn , ifn ) and chemokines ( c , cc , cxc and cx3c subgroups ) released from respiratory epithelial cells may regulate the immune profile and reaction in outlying cells . host genetic factors may further manipulate the immune - augmented response at distant extrapulmonary sites . dr eisenhut is correct to remind clinicians of them so that they may be vigilant to their occurrence and consequences . the challenge for researchers is to discern whether these extrapulmonary effects are as a result of site - specific rsv infection or inflammatory mediators dispersed from the provoked respiratory tract . although the basic sentiments of reynolds and cook still ring true , the understanding of rsv disease and its treatment options has progressed over time .

extrapulmonary effects of severe respiratory syncytial virus ( rsv ) infection are not uncommon . dr eisenhut 's systematic review of extrapulmonary manifestations of severe rsv infection clearly demonstrates clinical consequences peripheral to the lung parenchyma . the extrapulmonary impact of rsv infection raises questions as to whether these are direct rsv effects ( i.e. , rsv infection of site - specific tissue ) , secondary to parenchymal lung disease and its causative respiratory failure , or the result of inflammatory mediators dispersed from the provoked respiratory epithelium .

tufted angioma ( ta ) is a rare vascular tumor most commonly localized to the skin and subcutaneous tissue , characterized by slow angiomatous proliferation . the term ta was coined because of the characteristic dense clumps and lobules of endothelial cells and capillaries observed on histology . it is a variant of capillary hemangioma and supported by the finding of characteristic crystalline lamellae in both of them . it may be evident at birth , but usually develops during late infancy or adolescence . a 2-year - old boy presented with coalescing , red - purple , firm plaques with irregular borders and few superimposed papules extending from the right retroauricular region to his neck and upper trunk . his mother gave a history that the child initially had a small erythematous macule behind the right ear at 9 months of his age , which gradually progressed to multiple plaques , extending on to the neck and front of the chest . on examination , the plaques were deep red in color with few areas of violaceous discoloration and telangiectasia at the margins involving approximately 7 12 cm area from right ear to right anterior chest [ figure 1 and 2 ] . routine investigations including hemogram , liver and renal function tests , and chest x - ray were within normal limits . histopathology revealed a normal epidermis with the dermis showing proliferating capillaries forming into nodules lined by endothelial cells [ figure 3 and 4 ] . red to purple colored plaque of tufted angioma over the right side of neck tufted angioma involving neck and extending on to chest photomicrograph showing lobules of proliferating capillaries ( h and e , 10 10 ) higher magnification of the proliferating capillaries ( h and e , 10 40 ) ta , also called angioplasty of nagakawa , is a very rare pattern of angioma . some cases have been reported in a familial pattern and a few in pregnancy which resolve after delivery . it usually starts as a small macule , which resembles a port wine stain and progresses to deep red to purple plaques or nodules of 210 cm size . in the present patient , the most common sites of involvement are the neck , shoulder , or upper trunk , and occasionally the proximal limbs . ta is a benign condition , pain and tenderness are common associated symptoms , and hyperhidrosis is a frequent finding that occurs in 30% of patients . in a review of 13 cases of ta , the author observed three different clinical patterns : ta without complications , ta without thrombocytopenia but with chronic coagulopathy , and ta complicated by kasabach - merritt syndrome with thrombocytopenia . when the onset is later , partial spontaneous regression of ta may occur but complete disappearance is extremely rare . pulsed dye laser has been reported as an option for treatment of ta associated with pain . our patient had classic clinical features of indurated red to purple plaques and typical histological picture of nodules of proliferation of capillaries lined by endothelial cells and no mitoses , consistent with a diagnosis of ta . this case of ta involving large areas of skin over the head , neck , and chest is reported for its rarity .

tufted angioma ( ta ) is a rare , benign , cutaneous angiomatous proliferation . it is more common in children , usually presenting as red - purple painful plaques on the trunk . we describe here a ta observed at nine months of age , appearing initially over the retroauricular area , gradually extending to involve skin of neck and trunk by two years of age . this case of a large ta ( 7 12 cm ) in an indian male child is reported here due to its rare presentation .

a 61 year old man presented to our institution with a diagnosis of stage t3a prostate cancer . his serum prostate - specific antigen level was 5.3 ng / ml , and a transrectal biopsy demonstrated a gleason score of 3 + 4=7 in 20% to 80% of the cores from both lobes . a combination of suture ligation , bipolar cautery , harmonic scalpel , and holc were successfully used at various stages of the procedure to help achieve hemostasis and for ligation of the vas deferens . holc were used specifically for control of the lateral pedicle of the prostate during ralrp . we did not use holc at the bladder neck or the site of vesicourethral anastomosis . the vesicourethral anastomosis was achieved by using a single intracorporeal knot running 2 - 0 monocryl suture . also , the patient did not undergo wide dissection of the bladder neck during ralrp . pathology showed a gleason score of 3 + 4=7 with extracapsular extension , but negative lymph nodes , negative margins , no seminal vesicle invasion , and no angiolymphatic invasion . three months after surgery , he complained of dysuria and decreased force of the urine stream . he underwent retrograde cystourethrography in the office , which revealed a bladder neck contracture on the urethra ( fig . the cystourethroscopy demonstrated a normal - looking urinary sphincter but a very tight bladder neck . the bladder neck was successfully dilated , and visualization of the bladder revealed the presence of four holc . the four holc were floating in the bladder without stone formation and had migrated from the previous ralrp ( fig . , an indwelling urethral catheter was left for 7 days . at the 3 month follow - up after this dilatation , the patient was satisfied with his voiding habits and reported having a good urinary stream . with the recent surge in minimally invasive surgery ( robotic and laparoscopic assisted surgery ) , interest in hemostatic alternatives to suturing has increased . several automated suturing devices including endostitch ( autosuture , ussc , norwalk , ct , usa ) , lapraty clips ( ethicon , endosurgery inc , piscataway , nj , usa ) , and holc have been used during laparoscopic procedures . among them , holc are a commonly used device and have been shown to be safe and reliable for vascular control in laparoscopic procedures . during ralrp , holc have been used for ligation of the vasa deferentia , seminal vesicle arteries , and prostatic pedicles to prevent excessive electrocautery and possible injury to the neurovascular bundles . however , several limitations , in addition to the concern for clip migration , have become apparent . blumenthal et al . reported the first case of migration of holc into the vesicourethral anastomosis after ralrp . there have been some reports of intravesical migration of these clips causing urethral erosion , bladder neck contractures , and subsequent calculus formation [ 2 - 6 ] . in all those cases , however , holc lodged in the bladder neck area with stone formation . in our case , the holc were floating in the bladder without stone formation . of a case in which a metal clip had migrated into the urinary bladder after retropubic radical prostatectomy . it was hypothesized that inflammation had arisen around the urinary bladder or vesicourethral anastomosis and that this also involved the metal clip , which then eroded the bladder wall and eventually migrated into the bladder . also , in our case , the mechanism of migration of holc in the bladder is unclear . according to the hypothesis described above , we can suspect that the holc migrated into the bladder during the serial course . on the basis of these findings , we recommend minimizing the use of holc on tissue immediately adjacent to the anastomosis during ralrp , specifically , the vasa and seminal vesicles , and every effort should be made to retrieve any loose clips after the procedure . these clips are prone to migration and may cause , or significantly contribute to , bladder neck contracture formation after ralrp . migration of holc into the vesicourethral anastomosis should be considered in patients with symptoms consistent with bladder neck contracture after ralrp . in addition , in these cases , noncontrast computed tomography scan might be helpful to detect clips .

hem - o - lok clips ( weck surgical instruments , teleflex medical , durham , nc , usa ) are widely used in robot - assisted laparoscopic radical prostatectomy because of their easy application and secure clamping . to date , there have been some reports of intravesical migration of these clips causing urethral erosion , bladder neck contractures , and subsequent calculus formation . we report the first case of bladder migration of hem - o - lok clips without stone formation after robot - assisted laparoscopic radical prostatectomy . the hem - o - lok clips were found during urethral dilation with a guide wire for bladder neck contracture under cystourethroscopy . the hem - o - lok clips were floating in the bladder without stone formation and were removed by a cystoscopic procedure .

sinus lift surgery is recommended in maxillary edentulous region when the remaining available bone is inadequate as consequence of maxillary sinus pneumatization . other uses have been explained for this technique for outpatient posterior maxillary segmental orthognathic surgery and orthodontic purposes . bone suture consists of creating a hole in the bone for the purpose of anchoring soft tissues to the bone . creating bone holes in lateral maxillary sinus wall above the antrostomy window for fixing torn schneiderian membrane is a known indication for bone suture technique [ figure 1 ] . elevating schneiderian membrane from the medial maxillary sinus wall and securing it to the bone hole above the antrostomy window securing the buccal fat pad ( bfp ) to the periphery of the antrostomy window for better nourishment of the grafted material in maxillary sinus and as an alternative to bone tags for fixation of collagen membrane are the other applications . a new indication for firmly anchoring the bfp to the medial maxillary sinus wall as the last resort for the management of perforated schneiderian membrane is explained in this article . the patient was 62-year - old male who had decided to replace his lost teeth in the jaws with fixed dental implants . during the lateral sinus lift surgery , a large perforation occurred that was not amenable to local application of collagen membrane . the bfp was brought out through a 1-cm incision behind the maxillary buttress and was firmly attached to the medial wall with the aid of the bone suture . the biomaterial ( dfdba : cenobone , hamanand saz baft , kish , iran ) was added beneath that , between bfp and maxillary sinus floor . six months after lateral sinus lift surgery , two dental fixtures ( biohorizons : birmengam , usa ) were inserted . ( a ) buccal fat pad ( * ) is fixed to the palate by means of bone suture ; ( b ) schematic representation ; ( c ) cone - beam computed tomography taken 1-month after the operation shows the ability of the flap to retain the biomaterial between the flap and maxillary sinus floor ; ( d ) postoperative photograph 1-year after prosthetic replacement using bfp as the last resort for managing perforated schneiderian membrane is increasing today . suturing this flap to the remaining schneiderian membrane is difficult and has the risk of suture release through the delicate thin schneiderian membrane . firmly securing the bfp to the medial maxillary sinus wall has the benefit of isolating the graft / biomaterial from maxillary sinus and participating in graft nourishment . we do every effort to complete the procedure in the first sinus lift surgery because stopping the procedure and re - entry to the surgical field in another session is associated with a great failure rate in our hands . lateral sinus lift is a modified form of caldwell - luc surgery in which the integrity of maxillary sinus membrane is preserved . when the schneiderian membrane is torn and the surgeon decide to stop the procedure and doing another attempt several month later , then the clinician is confronted with previously operated sinus with established increased risk of complications . bone suture in the medial maxillary sinus wall is a useful aid in managing large perforated schneiderian membrane , with the aid of the bfp .

bone suture in lateral sinus lift has four indications . three of them depend on creating a hole in the lateral maxillary sinus wall above the antrostomy window for securing the elevated medial maxillary sinus membrane to manage perforated schneiderian membrane . covering the buccal antrostomy window with the buccal fat pad ( bfp ) for better nourishment of the inserted graft and as an alternative for bone tags in fixation of collagen membrane has been reported previously . a new indication for firmly anchoring the bfp to the medial maxillary sinus wall as the last resort for the management of perforated schneiderian membrane is explained in this article .

most babies with congenital diaphragmatic hernia ( cdh ) are now diagnosed on antenatal ultrasound , however , they may present with respiratory distress after birth . we present a rare case of right diaphragmatic hernia with hepatic torsion causing biliary obstruction and obstructive jaundice . to our knowledge , this anomaly has not been reported in the available literature . a 2-month - old baby girl was referred with jaundice , acholic stool , and highly colored urine since birth . she was admitted to another hospital with fever , cough and poor intake and treated as a case of pneumonia , right diaphragmatic hernia , and cholestatic jaundice . the total bilirubin was 12.50 mg / dl , alanine transaminase 244 u / l , aspartate transaminase 500 u / l , alkaline phosphatase 485 u / l , and albumin 3.2 g / dl . x - ray revealed marked elevation of the right dome of the diaphragm with upward migration of the liver . ultrasound , computed tomography abdomen and magnetic resonance ( mr ) cholangiogram showed cdh with a large segment of the liver herniated into the right chest and severe intra and extrahepatic bile duct dilatation . posterolateral defect , and nearly two - third of the liver was seen in the thoracic cavity . the right lobe of the liver had nearly 180 counter clock rotation causing obstruction to the biliary outflow [ figure 1 ] . the right hepatic torsion was corrected , and liver was relocated into the abdomen . after relocation , it was noticed that the hepatobiliary anatomy has been restored [ figure 2 ] . an operative cholangiogram showed that there were intra and extrahepatic biliary ducts dilatation with dilated common bile duct ( cbd ) but free flow of the contrast into the intestine . it was not possible to close the abdominal wall without significant tension , therefore , only skin closure was performed without repair of the abdominal wall muscles . in the postoperative period , the child was kept on assisted ventilation for 2 days , and then gradually weaned off the ventilator . baby was readmitted at the age of 6 months ; repair of ventral hernia was performed and later discharged home in a stable condition . the total bilirubin dropped from 12.50 mg / l into its normal values within 3 months after initial surgery . a repeat ultrasound at 6 months showed normal liver architecture with no evidence of biliary dilatation . right liver lobe having 180 torsion and pale color normal anatomy restored after correction of right hepatic torsion the association of jaundice with cdh is well - established and the common causes are herniation of the hepatobiliary apparatus in the chest , malrotation causing occlusion of cbd , neonatal hepatitis , biliary atresia , and cytomegalovirus infections to mention a few . obstructive jaundice has also been reported in other diaphragmatic defects such as hiatal and morgagni hernias . to our knowledge , chd with liver herniation in the chest and causing hepatic torsion and obstruction to the biliary outflow has not been reported in the available literature . x - ray chest picked up the diaphragmatic hernia . ultrasonography and mr cholangiogram were suggesting dilated hepatobiliary system and dilated cbd with the impression of choledochal cyst . reviewing the mr cholangiogram retrospectively , the gall bladder was seen on the medial side of the herniated right lobe but due to the distorted anatomy , it was not possible to make a diagnosis of hepatic torsion . it was only after exploration and liver reduction in the abdomen that we found there was liver torsion causing biliary obstruction . once the torsion was corrected the operative cholangiogram showed the free passage of contrast in the bowel excluding other possible causes such as choledochal cyst and extrahepatic biliary atresia . another difficulty faced after liver reduction in the abdomen was small abdominal capacity to close the abdomen without tension . with primary closure , there was high - risk of abdominal compartment syndrome , and therefore , it was decided to leave a ventral hernia for later repair . this approach definitely helped the baby , and she recovered soon , and the ventral hernia was repaired easily at the age of 6 months . the presence of liver in the chest can cause biliary obstruction and in worst - case scenario even torsion of liver . leaving a ventral hernia for later repair in large cdh with limited abdominal cavity

right sided congenital diaphragmatic hernia may cause biliary obstruction . we present a 2 months female infant who had respiratory distress and persistent jaundice since birth . investigations suggested direct hyperbilirubinemia , right - sided diaphragmatic hernia with liver herniation in the thorax , and intra- and extrahepatic biliary dilatation . laparotomy showed herniation of liver in the chest with hepatic torsion of about 180 causing obstruction of bile ducts . liver torsion was corrected and liver relocated in the abdomen . an operative cholangiogram confirmed free passage of contrast to the intestine after correction of hepatic torsion . repair of the diaphragmatic hernia was performed . only skin closure was performed leaving a ventral hernia to avoid abdominal compartment syndrome . postoperatively , the baby was kept on ventilator for 2 days and then extubated . she showed rapid recovery and was discharged in a stable condition . the ventral hernia was repaired at the age of 6 months . her total bilirubin levels dropped gradually from 12.50 mg / dl into its normal values within 3 months .

a 19-year - old male patient reported with a swelling in the posterior portion of his palate , which was present for the past 3 months . on examination , the swelling was 2 2 cm in dimension , extending anteriorly from the posterior portion of the hard palate , laterally 6 mm away from the left alveolar margin , medially 2 cm from the right alveolar margin , and posteriorly 1 cm anterior to the uvula [ figure 1 ] . the swelling was firm in consistency , nontender , and had no fixity to the overlying palatal mucosa or the underlying bone . preoperative intraoral picture of the lesion incisional biopsy was done , and the lesion was diagnosed as pleomorphic adenoma arising from the minor salivary glands in soft palate region after histopathologic examination and clinical correlation findings . reconstruction of the soft palate defect after the tumor excision was done by using bipedicle rotational and advancement of palatal pedicle flaps [ figure 2b ] , following which prefabricated surgical splint was placed . ( a ) excised tumor mass ( b ) intraoperative picture after reconstruction the postoperative recovery was uneventful . the palatal splint was removed after 1 week . on reviewing the patient after 1 month , the reconstructed surgical defect with bipedicled rotation and advancement flaps were healing uneventfully [ figure 3 ] . pleomorphic adenoma is a mixed salivary gland tumor originating from the epithelial and mesodermal elements . it consists of acini , cords , and thin strands of epithelial cells suspended in a stroma which often has a myxomatous appearance . however , some cases exhibiting rapid growth have been reported.[24 ] lopez - ce - drun et al . reported a case of pleomorphic adenoma in the palate of a 16-year - old male patient which was noted only 2 weeks before his presentation . most cases of palatal pleomorphic adenoma cause not only a bulge in the palatal mucosa , but also erosion of the palatal bone as well . in our case report , the patient presented with a painless swelling in the soft palate , which was noted 3 months before his presentation . the noninvasive diagnostic aids for salivary gland tumors include ultrasound , computerized tomography , and magnetic resonance imaging . these are useful methods in determining the size of the lesion as well as verifying any bony involvement.[68 ] overall , the prognosis for pleomorphic adenomas of minor salivary glands is generally considered to be better than that for those arising in the parotid salivary gland . we did wide excision of the tumor with clear margins , followed by reconstruction of the defect created by the surgical excision . the reconstruction technique used was bipedicled palatal rotation and advancement flap , which was used to cover the surgical defect . this technique is versatile for reconstruction of soft palatal defects created by surgical excision of the tumors . hence , we conclude that this particular case report occurring in a young adolescent is rare and the technique used for reconstruction was versatile and at the same time simple to perform .

pleomorphic adenoma generally occurs in the 4thand 5thdecade of life . the adenoma is an uncommon presentation and is exceedingly rare in children and young adolescents . this case report deals with the diagnosis and surgical management of pleomorphic adenoma in the soft palate region in a young adolescent patient .

the challenge in diagnosis is that there is no single definitive clinical symptoms or signs . initial treatment approach to the patients with suspected acute bacterial meningitis depends on rapid diagnostic evaluation and emergent antimicrobial and adjunctive therapy . once there is a suspicion , lumbar puncture should be performed immediately to determine whether the cerebrospinal fluid ( csf ) findings are consistent with clinical diagnosis . ankylosing spondylitis is a complex , potentially debilitating disease that is insidious in onset and progressing to radiological sacroiliitis over several years . in advanced stage of disease , the affected tissue is gradually replaced by fibrocartilage and then becomes ossified . in 1940 , taylor described a modified para - median lumbosacral approach through the l5-s1 space . the l5-s1 space is least likely to be obliterated by pathological processes such as degeneration and excessive scarring . here lumbar puncture was successfully performed with taylor 's approach after it failed with the conventional approach . a 42-year - old gentleman , weighing around 50 kg , presented with the history of headache , fever ( up to 102 f ) , and altered level of consciousness of 1-day duration . on examination , he was confused and neck stiffness was present . he was febrile and tachycardic . with the suspicion of bacterial meningitis , empiric antibiotic therapy with ceftriaxone 2 recent radiograph of lumbosacral spine revealed bilateral sacroiliitis , calcification of anterior and posterior longitudinal ligaments with syndesmophytes and bamboo spine [ figure 1 ] . local examination of lumbar spine revealed loss of lumbar lordosis [ figure 2 ] . multiple attempts for lumbar puncture in left lateral position at various levels ( l2 - 3 and l3 - 4 ) , with both midline and para - median approach were carried out by experienced anesthesiologists , but it failed . after eight failed attempts , lumbar puncture was successfully performed with the taylor 's approach . after infiltration with local anesthetic agent , 25 gauge quincke spinal needle was inserted at a point 1 cm medial and 1 cm caudal to the lowest prominence of posterior superior iliac spine , located immediately anterior to skin dimple [ figure 2 ] . the needle was directed in a cephalo - medial direction towards the l5-s1 space and turbid csf was obtained in first attempt . csf analysis was highly suggestive of bacterial meningitis and the culture report revealed streptococcus pneumoniae . ceftriaxone was administered 2 g 12 hourly for 14 days and dexamethasone was continued 6 hourly for 4 days at the dose of 7.5 mg . x - ray of lumbosacral spine showing bilateral sacroiliitis , calcification of anterior and posterior longitudinal ligaments with syndesmophytes and bamboo spine . needle insertion point and direction is marked by black arrows patient lying in left lateral position showing loss of lumbar lordosis . posterior superior iliac spine is marked by white arrow and the site of skin puncture for lumbar puncture by taylor 's apporach is marked by black arrow . the outcome of the patients is improved by prompt antibiotics treatment . delay in antibiotic therapy the odds for unfavorable outcome may increase by up to 30% per h of treatment delay . after administration of antibiotics , the chance of positive csf culture decreases with time , but is likely to be positive within 4 h. ankylosing spondylitis is a chronic rheumatic disease causing chronic inflammation , bone destruction and aberrant bone repair . in the late stage of disease lumbar puncture is technically challenging in these patients due to reduced articular mobility of spine , obliteration of interspinous spaces , midline ossification of interspinous ligament and difficulty in proper patient positioning . taylor 's approach can provide a reliable alternative to midline approach for lumbar puncture by targeting the l5-s1 interlaminar space , which is the lowest and widest available space , which is least affected by arthritic and degenerative changes . use of ultrasound for lumbar puncture has been shown to reduce the risk of failure as well as the number of needle insertions and redirections . ultrasound guidance has been shown to be useful in obstetric and nonobstetric population with difficult surface anatomic landmarks . however , it is operator dependent and is not routinely available in all places . in our case , lumbar puncture with taylor 's approach can be helpful for obtaining csf sample for diagnostic evaluation in patients with deformity of spine , when conventional technique for lumbar puncture fails .

meningitis and encephalitis are the neurological emergencies . as the clinical findings lack specificity , once suspected , cerebrospinal fluid ( csf ) analysis should be performed and parenteral antimicrobials should be administered without delay . lumbar puncture can be technically challenging in patients with ankylosing spondylitis due to ossification of ligaments and obliteration of interspinous spaces . here , we present a case of ankylosing spondylitis where attempts for lumbar puncture by conventional approach failed . csf sample was successfully obtained by taylor 's approach .

we performed a prospective study to determine whether asymptomatic or mild infection attributable to sars - cov was common in hcws in this outbreak at prince of wales hospital . when it had been established that an outbreak was occurring , a sars screening clinic was instituted to care for hospital staff with symptoms suggestive of or suspected to be sars . asymptomatic staff or those without compatible symptoms were also invited to participate in this study . in late march and early april 2003 , a blood sample was collected from each hcw who voluntarily participated and who wished to be tested for antibody to sars - cov ; a second blood sample was collected 46 weeks later . most of the second blood samples were collected in early may 2003 , approximately 8 weeks from the first peak and 4 weeks from the second peak of admission of hcws with sars ( figure ) . each hcw completed a questionnaire to document known direct contact with sars patients , their body fluids , secretions , or excretions ; places of duty within the hospital ; and symptoms of any illness during the period between first and second blood sample collection . additional information also included the department and the position of hcws , so that the job nature could be delineated . number of patients with severe acute respiratory syndrome ( sars ) admitted to prince of wales hospital during the first 10 weeks of the sars outbreak . a total of 160 healthcare workers and 171 non - healthcare workers were admitted ; a second peak of admission occurred the 5th week after the outbreak started . immunoglobulin ( ig ) g antibody to sars - cov was detected by an immunofluorescence assay on the basis of vero cells infected with coronavirus isolated from a patient with sars . we isolated this sars - cov and determined the complete genome sequence ( genbank accession no . this immunofluorescence assay had been successfully used for serodiagnosis of sars in patients in our hospital ; titers of > 320 developed in acutely ill sars patients 4 weeks after onset of illness . six hundred and seventy - four hcws completed the questionnaire and had a second serum sample obtained . the mean age of these hcws was 40 years ( range 2060 ) , and 75% were female . hcw jobs were categorized into five groups according to those with direct patient care , namely : doctors and nurses , 28% ( 188 ) ; healthcare and general service assistants , 15% ( 104 ) ; and allied health workers , including physiotherapists , occupational therapists , and x - ray technicians , 6% ( 43 ) . the remainder of staff , who did not have direct patient care , included the ancillary staff , 35% ( 235 ) ; pathology laboratory staff , 14% ( 95 ) ; and others , 1% ( 9 hcws ) . altogether , 43% of the hcws reported having known direct contact with patients with sars or their body fluids , secretions , or excretions . an additional proportion of hcws might have had contact with patients who subsequently were confirmed to have had sars , unknown to the hcws . a total of 36% of the staff worked in or visited adult medical or pediatric wards with sars patients30% in the accident and emergency unit and 9% in the intensive - care unit all areas at high risk for sars within the hospital during the outbreak . of the 674 hcws , 353 ( 52% ) reported mild , self - limiting illnesses during the period between the times when the first and second blood samples were collected ( table ) . all symptoms reported were mild , self - limiting , and lasted for 1 to 2 days . the current global outbreak of sars is associated with a novel coronavirus , sars - cov , which is phylogenetically distinct from other known members of the virus family ( coronaviridae ) and genus ( coronavirus ) ( 68 ) . the full clinical spectrum of this novel infection in humans has not yet been defined . among the 674 hcws that we examined it is possible that a proportion of our study participants might not have actually been exposed to sars - cov . although these participants were working in our hospital when a large number of patients with sars were staying there , vigilant infection - control measures had been in place since the outbreak was recognized ( 9 ) . all staff working in high - risk areas were required to wear a mask , gloves , eye goggles , and protective clothing . the results of this study show that our sars clinic successfully identified all staff with sars - cov infections . alternatively , our data suggest that asymptomatic or mild forms of sars - cov are rare at the current point to which the virus has evolved . from the virologic viewpoint , this finding indicates that the novel coronavirus has not yet adapted to transmit among humans through asymptomatically infected hosts . this finding has important public health implications , as the level of immunity towards sars - cov could be very low even in members of communities that had had a large outbreak of sars . if this is the case , a large proportion of the population remains susceptible , and another major outbreak may occur when the virus is introduced by highly infectious sources .

whether severe acute respiratory syndrome associated coronavirus ( sars - cov ) infection can be asymptomatic is unclear . we examined the seroprevalence of sars - cov among 674 healthcare workers from a hospital in which a sars outbreak had occurred . a total of 353 ( 52% ) experienced mild self - limiting illnesses , and 321 ( 48% ) were asymptomatic throughout the course of these observations . none of these healthcare workers had antibody to sars cov , indicating that subclinical or mild infection attributable to sars cov in adults is rare .

in this issue of critical care , textoris and colleagues report that high levels of central venous oxygen saturation ( scvo2 ) are associated with mortality in patients with septic shock . scvo2 is easily measured in most icu patients and thus represents a convenient therapeutic marker in the resuscitation of the critically ill patient . low scvo2 is a valid therapeutic target in early septic shock and a diagnostic marker for low cardiac output . scvo2 itself is a surrogate marker of mixed venous oxygen saturation , which in theory reflects the balance between global oxygen delivery and consumption , so that low scvo2 is a marker of inadequate oxygen delivery . so far , the focus has mostly been on low levels of scvo2 , but textoris and co - workers have focused on higher levels of scvo2 in septic shock patients . they hypothesise that levels of scvo2 above 80% correlate with increased mortality and that this correlation is likely due to impaired ability to extract oxygen . in a retrospective design , they identified all adult icu patients with septic shock in a 2-year period and registered lowest and highest scvo2 measurements during the first 3 days in the icu . they found that the maximum scvo2 was significantly higher in the patients that died in hospital than in those who survived ( 85% versus 79% , p = 0.009 ) . the association between maximum scvo2 and mortality persisted in a multivariate analysis adjusting for other variables that differed between the survivors and non - survivors . this is of obvious interest , but the study has several limitations , as the authors point out . the retrospective design carries an inherent risk of selection bias since patients with mild disease or early death might not have had any scvo2 measurements and were then excluded from the study . furthermore , scvo2 might have been measured more frequently in the most severely ill patients , increasing the chance for a high scvo2 measurement , especially as scvo2 varies over time . scvo2 depends on arterial oxygen saturation , cardiac output , oxygen consumption , haemoglobin levels and shunting . the ability of scvo2 to reflect systemic oxygen delivery / consumption is not constant in time as it depends on many conditions , including sedation , ventilator treatment , redistribution of blood as seen in shock and thus shock severity , the position of the catheter tip , which depends on the body position , and so on . textoris and co - workers hypothesise that the high scvo2 in the non - survivor group is likely due to impaired oxygen extraction , but there may be other explanations . it is likely that very aggressive resuscitation with high doses of fluid , vasopressors , inotropes and blood resulting in supranormal oxygen delivery , and thus high scvo2 , negatively impacts on survival . alternatively , impaired regulation of the microcirculation might have resulted in shunting and thus high scvo2 . the current data can not distinguish between these alternative hypotheses as discussed by the authors . if high scvo2 associates with increased mortality in sepsis , it may have clinical implications . but the hypothesis should be evaluated in a prospective , multicentre study with protocolized scvo2 measurements and detailed registration of potentially confounding factors , including use of fluid , vasopressors , inotropes and blood , to reduce the risk of bias . results from such a study have the potential to influence the design of further clinical trials evaluating scvo2 as a target for shock therapy .

shock therapy aims at increasing central venous oxygen saturation ( scvo2 ) , which is a marker of inadequate oxygen delivery . in this issue of critical care , textoris and colleagues challenge this notion by reporting that high levels of scvo2 are associated with mortality in patients with septic shock . this is of obvious interest , but as their retrospective design has inherent limitations , the association should be confirmed in a prospective , multicenter study with protocolized scvo2 measurements and detailed registration of potentially confounding factors .

splenic artery aneurysm is the third most common location of intraabdominal aneurysms following the abdominal aorta and iliac arteries . a 35-year - old woman presented with three episodes of passage of black tarry stools . there was no history suggestive of any systemic infections , trauma , family history of aneurysm , and connective tissue disorders . the patient had an anxious look , pallor , pulse rate of 120/min . and b.p of 90/70 mm hg . an emergency upper gastrointestinal endoscopy was done which revealed grade ii - iii oesophageal varices for which sclerotherapy was done . doppler study was suggestive of extrahepatic portal vein obstruction ( ehpvo ) with splenic artery aneurysm and multiple perisplenic , gastric , and perioesophageal collaterals and documenting portal cavernoma with hepatofugal flow ( figure 1 ) . on digital subtraction angiography a selective angiogram confirmed a huge saccular aneurysm arising from splenic artery . on laparotomy a normal appearing liver , no ascites , and a 8 10 centimeters aneurysm arising from splenic artery , involving middle and distal two - thirds of an artery and an enlarged spleen were observed ( figure 2 ) . splenic aneurysm biopsy revealed true aneurysm , splenic biopsy showed congestion with small areas of infarction , and liver biopsy was normal . this patient had an uneventful postoperative period and was discharged on the 10th postoperative day . splenic artery aneurysms larger than 3 centimeters are rare , but giant aneurysms measuring 10 cm or more have been reported . splenic artery aneurysm has a female predominance , can be diagnosed at any age , but is more commonly seen in the fifth and sixth decades with a mean age of presentation of 52 years . these are generally located in the middle and distal segment of the artery and are mostly of saccular form . specific causes of splenic artery aneurysms remain unknown , although suspected etiological factors are thought to be atherosclerosis , focal arterial inflammation , pancreatitis , hypersplenism , portal hypertension , trauma , and hormonal and hemodynamic changes due to pregnancy , liver transplant , and splenomegaly . these aneurysms can be asymptomatic and in up to 20% may present with epigastric or left upper quadrant abdominal pain . occasionally , the aneurysm can erode into an adjacent viscus or into the pancreatic duct and presents as gastrointestinal hemorrhage . contrast - enhanced ct scans and ct angiogram are important in the evaluation of this condition . doppler ultrasound represents a fast and noninvasive strategy and is considered modality very reliable in diagnosis and has great potential as follow - up tools . once the diagnosis has been confirmed , a therapeutic strategy needs to be determined . treatment is recommended for all patients with symptomatic aneurysms , those with aneurysm larger than 2 centimeters in a diameter , growing aneurysms , and for all pregnant women and women of childbearing age who may subsequently become pregnant . the choice is governed by the condition of the patient , the exact morphology of the aneurysm , and the availability of the endovascular procedure facility . open surgery is reserved mostly for the treatment of complications or if the endovascular procedures fail or are lack of availability of endovascular procedures or allergic to contrast medium . surgical procedure for splenic artery aneurysm may involve splenic artery ligation , aneurysmectomy , or splenectomy is the option . if the aneurysm is located in the distal third of the artery and the aneurysm has to be resected , the patient may ultimately require a splenectomy . if the aneurysm is located in the proximal third of the artery , splenic conservation should be attempted .

splenic artery aneurysm is the third most common location of intra - abdominal aneurysms . giant splenic artery aneurysm is rarely seen and is at a high risk of rupture . location and size of the splenic artery aneurysm determine the likelihood of rupture . a case of giant splenic artery aneurysm in a 35-year - old woman is reported . she presented with upper gastrointestinal bleeding . she had splenomegaly and extrahepatic hepatic portal hypertension . angiography confirmed a giant splenic artery aneurysm measuring 8 10 centimeters , located in middle and distal two - thirds of the splenic artery . surgical treatment in the form of in toto excision of aneurysm with splenectomy and devascularization was performed .

allergic contact dermatitis ( acd ) is one of the two types of contact dermatitis , that is , it represents the manifestations of an allergic response caused by contact with a substance , the other type being irritant contact dermatitis . it represents an eczematous pathology , wherein a specific exogenous allergen triggers an inflammatory response through the mechanism of delayed hypersensitivity . acd occurs due a milieu of allergens and involves different anatomical sites , including the eyelids and periorbital areas . a 40-year - old female patient came to us with swelling and redness over the eyelids and the periorbital area . these complaints were associated with severe itching and a burning sensation around the affected areas . a few ill - defined , erythematous papules and plaques were also seen over the left upper eyelid and along the lower eyelid margins [ figure 1 ] . erythema and edema over the eyelids and periorbital area on detailed questioning , the patient revealed the instillation of two eye - drop ( e / d ) preparations , occupol - d ( containing polymyxin b sulfate , chloramphenicol and dexamethasone ) and occurest - ah ( containing phenylephrine hcl , naphazoline hcl , menthol , camphor , chlorpheniramine maleate ) for some ophthalmic complaint . the patient had experienced intense itching around the eyes within a few hours after the instillation of the e / d and the lesions were noticed on the next day . the patient also gave history of swelling of her left ear , around 2 years back , following the use of some ear drops . once the lesions resolved , after 2 weeks the patient was subjected to patch testing ( after informed consent ) with occupol - d e / d and ocurest - ah e / d with normal saline as control . the test was performed on the back of the patient using the commercial undiluted preparation of these medications . the test drops and the control were applied to the skin and retained using strips of wartman 's filter paper . these strips were then covered with adhesive tape and proper labeling was done [ figure 2 ] . the test was read at 48 h and then at 96 h and it revealed a 1 + positivity for occupol - d e / d [ figure 3 ] . the test revealed a low positivity , probably due to the presence of dexamethasone in the e / ds . patch testing with two eye - drop preparations and normal saline as control 1 + positive patch test reaction with occupol - d eye drops it occurs in response to a variety of allergens , including topically applied ophthalmic drugs . the notable classes include beta - blockers such as timolol and levobunolol , antibiotics , parasympathomimetics like pilocarpine , sympathomimetics like apraclonidine , brimonidine and dipivefrine , carbonic anhydrase inhibitors like dorzolamide , and prostaglandins like latanoprost . it is important to identify the causative agent and the pharmacologically related agents ( with which there can be cross - sensitization ) , so that the susceptible patient can avoid preparations containing them in the future . phenylephrine has been seen to be responsible for causing acd ( dermatoconjunctivitis ) in patients in whom e / ds were used for cycloplegic refraction . chloramphenicol is a very common ingredient of commercial e / ds and ointments , routinely used for ocular and periorbital infections due to its wide antibacterial activity . literature reports chloramphenicol as the incriminating agent of contact conjunctivitis and dermatitis of the lids after application of the drug as e / ds or ointment . in another study conducted by gossens a , antibiotics such as neomycin and related aminoglycosides particularly chloramphenicol , polymyxin b , oxytetracycline and rifampicin ; antiseptics ( mostly mercurials ) ; corticosteroids , mydriatic agents ( phenylephrine , atropine , homatropine , tropicamide ) , and beta - blocking agents ( betaxolol , metaprolol , timolol ) ; as vehicle components , lanolin components , cetyl alcohol , sorbitan sesquioleate , and propylene glycol ; as preservatives , thiomersal , and benzalkonium chloride and as antioxidants , sodium metabisulfite , and ethylene diamine hcl were also found to be responsible for causing acd . however , as e / d are the most commonly prescribed medication by any ophthalmologist and form the mainstay of treatment of ophthalmic patients , their use can not be stopped . however , caution can be exercised while prescribing them , especially in patients who have some history of acd or any other form of allergy . in our patient , acd could have been due to any one of the ingredients of the e / ds . since the patient revealed a positive patch test to occupol d eye - drops only , so any one of its three main ingredients ( polymyxin b , chloramphenicol , and dexamethasone ) may be causative . comparing with previous literature , polymyxin and chloramphenicol seem to be most likely agents . allergic contact dermatitis to eye drop preparations can be one of the most important causes of periorbital dermatitis .

allergic contact dermatitis ( acd ) occurs due to a milieu of allergens and involves different anatomical sites , including eyelids , and periorbital areas . topically applied ophthalmic drugs are a potential cause of acd of the periorbital region . here we describe the report of a patient who developed acd to eye drop preparations .

acquired abnormalities of platelets may be quantitative or qualitative , although some patients have both types of defects . quantitative defects may be a result of the failure of production , shortened survival , or sequestration . the latter is an important cause of thrombocytopenia and usually involves the sequestration of platelets in an enlarged spleen from any cause ( portal hypertension , sarcoidosis , lymphoma , or gaucher s disease ) . the total body platelet mass is essentially normal in patients with hypersplenism ; however , a much larger fraction of the platelets than normal are in the enlarged spleen , in which case splenectomy is indicated to correct the thrombocytopenia . ( except in thrombocytopenia caused by portal hypertension).1 , 2 the presence of concomitant severe aortic valve stenosis with splenomegaly - induced thrombocytopenia , which necessitates aortic valve replacement , is rare . no clear guideline exists for the pre- and post - operative management of patients undergoing cardiac surgery in the hematological and surgical literature , and this condition has profound implications in patients undergoing cardiac surgery with the aid of cardiopulmonary bypass , where heparin is used for anti - coagulation.35 this dilemma is further complicated in the setting of a young patient undergoing aortic valve replacement , in which the insertion of a mechanical prosthesis would be the procedure of choice . this requires life - long anticoagulation with warfarin , which can predispose the patient to catastrophic bleeding ; using a tissue valve will subject the patient to multiple redo operations in the patient s lifetime . a 22-year - old woman was referred to our cardiac center for the consideration of aortic valve replacement . the aortic valve was bicuspid , and there was no significant associated left ventricular hypertrophy . the patient s complaint was fatigue , dyspnea , and palpitation , and auscultation revealed systolic murmur . biochemical findings were anemia ( hb = 8) and thrombocytopenia ( platelet count = 50,000 ) . echocardiography revealed that the aorta was dilated , the aortic valve was calcified , the bicuspid leaflets had moderate aortic stenosis , and there was moderate to severe aortic regurgitation . the diameters of the annulus , sino - tubular junction , and the proximal ascending aorta were19 , 30 , and 32 mm , respectively , and the dilated part of the aorta was 40 mm . after median sternotomy and pericardiectomy , cardiopulmonary bypass was initiated and the severely calcified stenotic bicuspid aortic valve was replaced with a number 23 homograft using the mini root technique . at the end of cardiopulmonary bypass , the median sternotomy incision was extended to the above umbilicus ; and the layers were closed anatomically after splenectomy . we believe that open heart surgery valve replacement and splenectomy can be successfully performed simultaneously in a patient with thrombocytopenia and severe aortic valve stenosis . in our patient , splenectomy was performed at the end of cardiopulmonary bypass for aortic valve replacement with good results . there was no post - operative complication , and the patient had ordinary convalescence with a normalized platelet count . the decision to choose a mechanical versus tissue prosthesis in young thrombocytopenia patients with aortic valve stenosis is not an easy one . laboratory investigations and/or markers can determine whether a patient is more prone to bleeding or to thrombosis , so clinical strategy needs to be tailored on the basis of the clinical presentation of thrombocytopenia and the risks and benefits of the treatment options available.4 , 5 it is advisable that splenomegaly be addressed at the time of open heart valve surgery and not during staged operation inasmuch as it can avert secondary operation , eliminate the cause of thrombocytopenia , return normal platelet count immediately after surgery , and confer liberal decision to choose the prosthesis without the fear of thrombocytopenia complications . meanwhile , it is possible to decrease the disadvantage of bleeding complications of one - stage operation by meticulous dissection , proper hemostasis , reversing heparin at the end of the procedure , and justifying the use of coagulating factors .

splenomegaly - induced thrombocytopenia is fully described in hematological and surgical literature , but its association with severe aortic stenosis is rare . we present a case of severe aortic valve stenosis with severe splenomegaly - induced thrombocytopenia in which aortic valve replacement was done with a number 23 homograft and splenectomy was performed after the end of cardiopulmonary bypass . platelet count turned to normal value post - operatively , and the patient spent an ordinary convalescence period and was discharged from the hospital without any complications .

torsion of the vermiform appendix , though rare , also presents in a similar fashion , and it is detectable only at operation . a 52-year - old female presented with pain in the right iliac fossa , since 8 days and fever since 3 days . clinically , the patient was febrile ( 101 ) , with tachycardia and guarding in the right iliac fossa with rebound tenderness . intra - operatively , there was evidence of torsion of the vermiform appendix with a counter - clockwise rotation of 180 , around 1.5 cm from the base of the appendix [ figure 1 ] . the length of the appendix was approximately 8 cm and it appeared to be inflamed . appendicular torsion first described by payne in 1918 , occurs along with the long axis of the appendix and is located at least 1 cm from its base . the degree of torsion is usually between 180 and 1080. the direction is most commonly anti - clockwise . the torsion causes luminal obstruction , compromising the blood supply leading to strangulation , and infarction that presents clinically as an acute abdomen . it can be primary or subsequent to other pathological conditions like faecolith , mucocele , carcinoid tumor or lipoma a fan - shaped mesoappendix with a narrow base , long appendix can cause primary torsion . the site of torsion is variable and could be at the base or about 1 cm or more distal to the base . uroz - tristan et al . have mentioned a case in which ultrasonography detected torsion of the appendix along with inflammation . once the torsion has started , venous obstruction and , later arterial occlusion combine to jeopardize the life of their supplied structure , the presence of bacterial life in a twisted organ might be expected to be especially severe and productive of symptoms and signs , easily distinguished , and of rapidly increasing severity . preoperative diagnosis is difficult . this entities could be included in the differential diagnosis of pain in right iliac fossa .

torsion of the vermiform appendix is a rare condition detectable only at operation . it can be primary or secondary . this is a case report of 52-year - old female with 180 anti - clockwise rotation of the appendix . torsion can further leads to strangulation and infarction of the organ . appendicular torsion could be included in the differential diagnosis of pain in right iliac fossa .

tracheal bronchus is a rare congenital anomaly with a published incidence of between 0.1% and 3% first described by sandifort in 1785 and includes a variety of bronchial anomalies arising from the trachea and main bronchus supplying the upper lobes . malignant neoplasms arising in these bronchi are rare and may pose a diagnostic and management dilemma . 2 presentation of case a 56 year old male presented with a history of a dry cough , shortness of breath and a headache , he had no previous illness . the jugular venous pressure ( jvp ) was markedly elevated and on auscultation of the chest there was decreased air entry on the right side . the chest x - ray showed a large right sided intra - thoracic mass ( fig . a computerized tomogram ( ct ) of the chest showed a large mass arising from an anomalous tracheal bronchus with compression of the right main bronchus and obliteration of the right middle lobe bronchus . a bronchoscopy was performed confirming a tracheal bronchus arising above the carina on the right side of the trachea . echocardiography was used to exclude thrombi in the heart as a result of svc occlusion . a right thoracotomy was performed and a large mass was encountered occupying most of the intra - thoracic space with compression of the lung ( fig . it was intimately involved with the mediastinum , overlying the superior vena cava ( svc ) which could not be visualised . the pericardium was opened anteriorly to gain access to the svc and blood supply . as this mass had involved and occluded the svc , a clamp was applied at the atrial level and the svc transected . the mass was then lifted superiorly and the svc clamped at the confluence of the two brachiocephalic vessels . this allowed the main pulmonary artery trunk to be exposed and the pulmonary vessels to the upper lobe identified and transected . the superior pulmonary vein supplying the right upper lobe was oversewn and transected intra - pericardial . the abnormal bronchus which supplied the right upper lobe could then be transected close to the trachea and the entire mass with the upper lobe removed and sent for histology . an 18 mm dacron was sewn into position with 4/0 prolene replacing the svc and re - establishing flow . the resected svc was encased in tissue accounting for its occlusion but was not invaded by the tumour . the patient has been followed up for 18 months and is asymptomatic with no evidence of tumour recurrence . the embryological development of the tracheobronchial tree begins at twenty four days as a ventral bud in the laryngo - tracheal groove . at twenty eight days it is thought that the anomalous bronchi develop around this stage although , the precise mechanism is controversial . there is a spectrum of anomalous bronchi and in a large series , 56% arose from the trachea , 4.8% from the carina and 38% from the bronchial tree . they are seven times more common on the right side and are further classified as displaced when a branch of the upper lobe is missing or supernumerary when the upper lobe has its normal anatomical branching . a true tracheal bronchus known as a pig bronchus , is where the right upper lobe bronchus is absent and is replaced by the abnormal bronchus ( fig.5 ) . it may be associated with other congenital anomalies and the importance of knowing and understanding this anomaly is for diagnostic and therapeutic purposes especially in fields of chest surgery , radiology and anaesthetic management [ 13 ] . the majority of patients with anomalous bronchi are thought to remain asymptomatic but numerous reports have been published with complications such as recurrent infections , bronchiectasis , haemoptysis , malignancy , chronic cough as well as acute respiratory distress and stridor in the paediatric population . reports of malignant tumours arising from tracheal bronchi have been published and this patient appears to be the third documented case of a squamous carcinoma arising in a true management of these cases is surgical removal and pre - operative evaluation is critical in assessing operability . the complications following svc replacement should also be stressed which may include stenotic anastomotic lines , kinking , thrombosis and or infection which is a serious complication . in cases of thrombosis contraindications to svc replacement is essentially unresectable tumours that have involved the svc . in our case there was no necessity for a bypass graft as the svc was already occluded . in non - occlusive cases clamping of the svc may result in haemodynamic changes which may include hypotension , cerebral oedema , intra - cranial bleed and transient cerebral dysfunction . malignant change in abnormal bronchi have been reported in the literature from time to time but squamous tumours appear to be very rare . to our knowledge , presentation with such a large tumour and a svc syndrome has never been previously reported . although these anomalous bronchi are rare they may result in major difficulties if undiagnosed pre - operatively especially when using double lumen endotracheal tubes in thoracic surgery . if found incidentally patients should be informed of this anomaly in case there is need for future surgical management . dr n. nicolaou : participated in the conceptions and design of the paper . drafted the manuscript and did literature review . dr a. du plessis : was the diagonistic radiologist and participated in drafting the manuscript .

highlightsmalignant neoplasms in tracheal bronchi are rare and may pose a diagnostic and management dilemma.this appears to be the third documented case of squamous carcinoma arising in a true tracheal bronchus.the diagnostic and surgical management of this complex case may serve as a learning point .

lightning injury is a global mortality of 1000 deaths per year , and is the second most common cause of weather - related deaths in the united states . injuries to the lungs and mediastinum after a lightning strike rarely have been described as hemo / pneumothorax and pneumomediastinum . review of the lightning - induced injury literature revealed several neurological complications such as polyneuropathy , myelopathy , spinal cord injury , motor neuron disease . we describe the case of a patient with a history of lightning strike at childhood period , prior the onset of isolated , diaphragmatic paralysis , unilaterally . a healthy 67-year - old male presented to the thorax surgery department of our faculty with intermittent dyspnea , hyperhidrosis and painless right epigastric swelling . he had a history of lightning strike at the age of 12 which yield to burn and deterioration of consciousness lasted 1 day . following this injury , throughout 10 years period , he had tinnitus every day , beginning just at the time of the lightning strike and lasting 5 min . effort dyspnea that increased with bending and lying down was added to his complaints at the ages of 1718 years . he did not present to any clinic since february 2009 , which he showed up to thorax surgery department of our hospital . after a detailed examination , a chest x - ray and a thorax computed tomography ( ct ) was performed to the patient . both chest x - ray and thorax ct revealed elevation at the right diaphragm and the pre - diagnosis was paralysis of the phrenic nerve and congenital eventration ( figures 1 and 2 ) . despite there was no reciprocal movement diaphragm , neurological assessment was demanded to determine possible phrenic nerve paralysis . he was well nourished and had no muscle wasting with normal strength and deep tendon reflexes . he had a subjective hypoesthesia at the right lower extremity , which may be due to the lymphangitis that he experienced 5 years ago . to assess the phrenic nerve function , nerve conduction study for phrenic nerve we performed electrical stimulation with surface bipolar electrodes applied over the phrenic nerve at the neck . stimulation was given just above the clavicle , between the sternal and clavicular heads of the sternocleidomastoid muscles , and the responses to electrical stimulation were recorded with surface electrodes attached over the lateral chest . there was no electrophysiological response in the right phrenic nerve ( figure 3a ) , the left phrenic nerve was normal according to the referance normal values ( figure 3b ) . b ) left phrenic nerve motor conduction study revealing normal electrophysiological response . a ) right phrenic nerve motor conduction study revealing no electrophysiological response . category i consists of signs and symptoms that are temporary and usually benign . category ii conditions are prolonged or permanent produced by central nervous system lesions such as encephalopathy , myelopathy . category iv encompasses neurologic lesions that are not directly activated by the lightning strike but are the result of trauma secondary to falls or blasts effects . despite the acute ( hypoxic encephalopathy due to cardiac arrest , isolated facial nerve palsy , transient amnesia , paresthesia , paralysis , dysfunction of the 8 cranial nerve ) and chronic ( cerebral edema , occlusive or hemoragic lesions , seizures , myelopathy , polyneuropathy , extrapyramidal syndrome ) neurological complications following the lightning strike were reported in the literature , there was no diaphragm paralysis found . however , review of the literature revealed many neurological complications following electrical injuries such as loss of consciousness , acute and/or delayed peripheral neuropathies , memory problems , paresthesia , chronic pain , weakness . whereas our patient presented with unilateral diaphragm paralysis following a lightning strike , we had to exclude other reasons which could cause diaphragm paralysis . unilateral or bilateral diaphragmatic paralysis can occur in the course of several diseases , being usually a serious condition . chronic diaphragmatic failure is usually due to muscle fatigue in patients with pulmonary disease or to muscle denervation in patients with amyotrophic lateral sclerosis . occasionally , sub - acute or chronic diaphragmatic failure is the first manifestation of motor neuron disease , hereditary neuropathies , lambert - eaton syndrome , or myopathies . acute respiratory failure occurs typically in patients with the guillain - barr syndrome in whom phrenic nerve or nerve root demyelination lead to ineffective contraction of the diaphragm , requiring assisted ventilation until recovery . all these entities were reasonably excluded in our patient , who had no other clinical or electrophysiological manifestation of neurological disease except for his unilateral phrenic nerve lesion . this clinically and electrophysiologically proven unilateral , isolated diaphragmatic paralysis was described in order to emphasize a rare complication of lightning strike .

lightning injury is the second most common cause of weather - related deaths in the united states . despite the several neurological complications such as polyneuropathy , myelopathy , spinal cord injury , motor neuron disease due to the lightning - induced injury , there is no documented case of unilateral diaphragmatic paralysis . we describe the case of a patient with a history of lightning strike at childhood period , prior the onset of isolated , diaphragmatic paralysis , unilaterally . clinical and electrophysiological findings suggest an injury restricted to the phrenic nerve , unilaterally .

intracranial air is common after head injury or craniofacial surgery and is known as pneumocephalus . usually , it does not require surgical treatment ; however , tension pneumocephalus results from intracranial air under pressure as a rare complication . in exceptional cases , a 58-year - old man underwent ethmoid sinus surgery and subsequently developed rapidly progressive global headache , restlessness , and diplegia with sensory loss . he was admitted to the intensive care unit due to deterioration of the conscious level . a ct scan of the head demonstrated an extensive pneumocephalus with intracranial air causing a mass effect and gross compression of the brain ( fig . 1a ) due to presumed dural air leak from a defect in the cribriform plate ( arrow ) . this was surgically revised with release of intracranial tension and a duraplastic procedure , followed by rapid improvement and full clinical resolution within 36 h. both mechanisms that have been proposed for the development of pneumocephalus may have taken place in our patient : the ball - valve and the inverted pop bottle effect . it has been postulated that air passes through the dural tear by elevated upper airway pressure that occurs during coughing or sneezing the ball - valve effect . the other mechanism operates when cerebrospinal fluid leaves the intracranial space through the dural leak and the resulting negative pressure causes air to rush in , similar to an inverted pop bottle . in our case , the frontal retention of air caused widening of the interhemispheric fissure leading to a peaked appearance of the frontal poles commonly referred to as the mount fuji sign ( fig . generally , the most common symptoms of tension pneumocephalus are altered consciousness , headache , generalized convulsions , or restlessness , but even cardiac arrest caused by tension pneumocephalus has been reported . besides the typical symptoms , our patient developed marked weakness of both legs with inability to walk after a few hours , most likely due to air compression of the interhemispheric leg motor cortex area . the present case report underlines that early diagnosis of tension pneumocephalus and emergent surgical treatment are crucial to prevent life - threatening deterioration .

tension pneumocephalus results from intracranial air under pressure as a rare complication after head injury or craniofacial surgery . a 58-year - old man underwent ethmoid sinus surgery and subsequently developed rapidly progressive global headache , restlessness , diplegia with sensory loss , and deterioration of the conscious level . a head ct demonstrated extensive pneumocephalus with gross compression of the brain . the frontal retention of air caused widening of the interhemispheric fissure leading to a peaked appearance of the frontal poles , referred to as the mount fuji sign. surgical revision of a dural air leak resulted in rapid improvement and full clinical resolution . early diagnosis of tension pneumocephalus and emergent surgical treatment are crucial to prevent life - threatening deterioration .

sporotrichosis is a subacute or chronic mycosis caused by fungi of the genus sporothrix , whose natural reservoir is the soil . it is transmitted through inoculation of the traumatic agent in the skin [ 1 , 2 ] . the peculiar epidemiological situation of the city of rio de janeiro , where an epidemic of cases transmitted by cats is observed , must serve as a warning for the risk of professionals in contact with these animals to acquire the disease . the patient was a 48-year - old caucasian female veterinarian who lived in rio de janeiro . whilst working on the medication of a cat with sporotrichosis , her left hand was scratched . it evolved after 4 weeks with the formation of an erythematous papule on the left thumb . after using various antibiotics without improvement upon examination , she presented edema and significant erythema in the distal phalanx of the left thumb , with a distal crusted ulcer area causing detachment of the nail plate ( fig . 1 , fig . her ipsilateral forearm showed small nodules , slightly erythematous , painful on palpation , following the lymphatic path , more palpable than visible . bacterioscopy was negative and the culture for common germs showed growth of escherichia coli , considered as a contaminant . bacilloscopy and culture for mycobacteria were negative , whilst fungal culture showed growth of sporothrix schenckii . due to the location of the lesion , the degree of involvement of the phalanx and intense pain , plain radiography revealed involvement of the distal phalanx , with the appearance of osteomyelitis ( fig . 3 ) , subsequently confirmed by computed tomography . there were no signs of joint involvement . bone biopsy was performed on the involved phalanx , with the bone fragments sent for culture , and there was recurrent growth of s. schenckii . the conclusion , therefore , was sporotrichosis with bone involvement , and itraconazole 400 mg / day was started for 12 months . the patient progressed well , with complete healing of the lesion and pain relief , remaining in ward attendance . sporotrichosis , whose agent is a fungus of the genus sporothrix , is transmitted especially through traumatic inoculation of its agent into the skin . classically , the transmission occurs after minor trauma with twigs , branches , thorns and other vegetals . the incubation period varies from 3 days to 3 months [ 1 , 2 , 3 ] . since 1998 , the city of rio de janeiro has been undergoing a peculiar situation , an epidemic of zoonotic sporotrichosis due to infected cats , which is considered rare in other regions of brazil and the world [ 4 , 5 ] . the increased incidence of sporotrichosis in rio de janeiro has been observed for over a decade . from 1998 to 2004 , 759 humans and 1,503 cats were diagnosed with sporotrichosis at ipec - fiocruz , a reference institution of rio de janeiro . in the previous period , from 1986 to 1998 , the situation worsened between 2005 and 2008 , when 804 new cases were reported , already being considered the greatest epidemic by zoonotic transmission . the infection can occur by contiguity or hematogenous diffusion , which may manifest from small granulomas to large lytic lesions , similar to osteomyelitis . only a small number of patients present general symptoms and leukocytosis , whilst the vast majority present increased hemosedimentation rate . sporotrichosis was always considered as an occupational disease [ 1 , 2 , 3 ] . in 1926 , foerster drew attention to the fact that the majority of sporotrichosis cases were acquired at work , and that many of them could generate sequels that would compromise labor activities and therefore must have their occupational nature emphasized . gardener 's disease and to be primarily related to rose planters , but a range of professionals , especially in rural areas , is subject to acquiring the infection , such as farmers , miners , lumberjacks and others [ 1 , 2 ] . the new epidemiology profile of the disease in the city of rio de janeiro , however , should be a warning to the risk of contamination of other professionals that could acquire the disease , especially veterinarians . it is believed that it is not necessary for a cat to scratch or bite in order to transmit the disease ; thus , professionals should be informed about the risks and the use of personal protective equipment , such as gloves , to manipulate cats that are sick or under suspicion of sporotrichosis .

sporotrichosis is a subacute or chronic mycosis caused by a fungus of the genus sporothrix , which is found in soil . it can be acquired by trauma to the skin . bone and joint lesions are very rare . the city of rio de janeiro is undergoing an epidemic transmitted by cats , and this should be an alert for the risk to professionals in contact with these animals . the patient was a veterinarian who developed occupational sporotrichosis with osteoarticular involvement transmitted by a cat during a consultation .

in a study that was published in a recent issue of critical care and that was conducted in a cohort of 50 patients with severe sepsis at intensive care unit ( icu ) admission , andaluz - ojeda and colleagues reported that absolute counts and relative concentrations of natural killer ( nk ) cells were significantly higher in patients who died . in an earlier study , also published in critical care , we characterized the abnormalities of lymphocytes in 52 patients with septic shock during the first 28 days in the icu . the study design was approved by the university hospital ethics committee , and all participants or their next of kin provided written informed consent . table 1 shows the significant differences found in the counts and percentages of lymphocyte subpopulations during the first week of follow - up . like previous investigators , we have found a reduced count of circulating nk cells in patients with septic shock , independently of their outcome . although patients who did not survive exhibited less nk cell depletion than survivors at icu admission , there were no differences in cd56cd3cell counts in blood between survivors and non - survivors . these data are slightly in agreement with those reported by andaluz - ojeda and colleagues , who found that patients with the highest nk cell number had the lowest probability to survive . however , unlike giamarellos - bourboulis and colleagues , we did not find higher percentages of nk cells in patients who did not survive . counts and percentages of lymphocytes and their main subpopulations during the first week of follow - up in patients with septic shock and in healthy controls using cd69 and cd57 surface antigens , we determined the counts and distributions of the activation stage of nk cells ( cd3cd56 ) by flow cytometry . we obtained a significant increase in the counts and percentages of the cd3cd56cd69cells in non - survivors at icu admission and on day 3 ( figure 1 ) . the mean fluorescence intensity for cd56cd3cd69cells was also significantly higher in non - survival patients than in survivors or controls ( 30.6 4.2 versus 20.3 2.6 and 18.3 0.9 , respectively ; p < 0.05 for both ) . cd69 is rapidly induced in nk cells after activation and its role in nk cytotoxicity has been demonstrated in humans . kinetics of circulating blood percentage of total natural killer ( nk ) cells ( a ) and counts ( b ) of cd3cd56cd69nk subset in patients with septic shock during their stay in the intensive care unit . values are expressed as the mean percentage standard deviation ( a ) or as the mean of cells per microliter standard deviation ( b ) . data from non - survival patients , survivors , and healthy control subjects are shown in red , green , and blue , respectively . the mann - whitney u test for non - parametric data was used to analyze differences between the groups , and analysis of variance followed by wilcoxon signed - rank tests were used for within - group analyses . * p < 0.05 for survivors or non - survivors versus controls ; p < 0.05 for survivors versus non - survivors ; p < 0.05 for each follow - up time versus intensive care unit admission . we further found a significantly higher percentage of cd3cd56cd57nk cells in non - survival patients than in survivors and controls at icu admission ( 70.8% 3.3% versus 57.3% 9.2% and 53.6% 3.7% , respectively ; p < 0.05 ) . non - survivors had a strong but not significant trend toward an increase of cd3cd56cd57nk cell count ( 94.8 7.3 versus 56.9 12.4 cells per cubic millimeter ) . the expression of cd57 , a long - lived marker and highly differentiated effector of nk cells , is increased in septic shock patients who died . these data demonstrate an important role of nk cells as key participants in the early inflammatory response during septic shock . patients who did not survive exhibited less nk cell depletion than survivors and these cells were very early activated and rapidly differentiated . we propose to asses nk cell phenotype and functions for a better understanding of the physiopathology of sepsis in order to apply new therapies at an early stage . count ' values are presented as cells per cubic millimeter , and ' percentage ' values are presented as percentages . the mann - whitney u test for non - parametric

recently , several studies about the role of natural killer ( nk ) cells in sepsis have been highlighted . in an earlier study , we characterized the abnormalities of circulating lymphocytes in 52 patients with septic shock during the first 28 days in the intensive care unit . our results confirm and expand some previous reports . we found that patients who did not survive exhibited less nk cell ( cd3cd56 + ) depletion than survivors and that these nk cells expressed cd69 + and cd57 + . these data demonstrate that nk cells are key participants in septic shock because patients who survived have more depletion and expressed less early activation and differentiation .

the considerable number of non - coding rnas ( ncrnas ) that has been detected in the past few years was largely unexpected ( 13 ) . although the functions of the many recently identified ncrnas remain mostly unknown , increasing evidence stands in support of the notion that ncrnas represent a diverse and important functional output of most genomes ( 4 ) . all ncrnas in noncode were filtered automatically from genbank ( 5 ) and the literature , and were then later manually curated . with the exception of rrnas and trnas , all classes of reported ncrnas the aim of the database is to provide a platform that will facilitate both bioinformatic as well as experimental research . in addition to containing sequence data , noncode provides a user - friendly interface , a visualization platform and a convenient search option , allowing efficient recovery of sequences , regulatory elements in the flanking sequences , related publications and other information . data collection and annotation for noncode v2.0 was carried out in a similar fashion as for version 1.0 and can be briefly described as follows : genbank entries constituted the major source of noncode . we searched pubmed ( 6 ) with a list of ncrna keywords , such as ncrna , grna , etc . , and thereafter consulted the literature matched with them and extracted more ncrna keywords . the downloaded genbank files ( gbfiles ) were then filtered using these keywords , and the filtered entries were subsequently confirmed by manual curation . for all obtained ncrna records , basic information related to sequence , name , alias , length , ncrna class , organism , references and accession number in genbank were extracted and entered into the noncode database . each ncrna sequence was checked for redundancies using perl scripts , and each cluster of redundant sequences was given a non - redundant noncode accession number ( uniqid , i.e. unique ncrna i.d . ) . process function class ( pfclass) system based on the biological processes or functions in which an ncrna is involved , and one or more of the 26 pfclasses were also assigned to all ncrnas in noncode v2.0 . moreover , a subset of ncrnas has been divided into nine additional categories according to whether they are gender- or tissue - specific or associated with tumors and diseases , etc . where possible , noncode also provides additional annotations , such as information on function , cellular role , cellular location , chromosomal localization and splicing . the annotations and the genomic mapping information of the sequences rely on data provided in the original genbank records , the fantom3 database ( 2 ) , the ucsc genome browser database ( 7 ) , or directly from the reference literature . the purpose of the database is to serve the research community by organizing information concerning all types of ncrnas ( except trnas and rrnas ) from all groups of organisms . as of august 2007 , the significant growth in the amount of data , compared with the 5339 non - redundant sequences in the previous edition published in 2005 , is primarily due to systematic identification of mrna - like ncrna transcripts ( 2 ) and the discovery of piwi - interacting rnas ( pirnas ) through large - scale cdna sequencing ( 1,3,8 ) . other novel ncrnas , such as stem - bulge rnas ( sbrnas ) ( 9 ) , snrna - like rnas ( snlrnas ) ( 9 ) and a number of unclassified ncrna transcripts were mainly obtained from our laboratory and other published literature ( 1012 ) . according to the traditional classification system , noncode v2.0 contains three novel classes of ncrnas , the sbrnas , the snlrnas and the pirnas , whereas the number of pfclasses is the same as in noncode v1.0 ( i.e. 26 ) , with sbrnas and snlrnas corresponding to the miscfunction_snm and pirnas to rna - processing_cleavage pfclass . sequences can be searched using accession numbers found in genbank , name , traditional class , pfclass , organism and uniqid in noncode . in addition to access to noncode database records , search results are also linked to full genbank entries ( figure 1 ) . in the current version of the database , we also included the online blast service ( ncbi wwwblast version 2.2.17 ) which allows sequence similarity searches against the entire noncode v2.0 database . ( d ) the link from genome browser to noncode . in this updated version of noncode , a ucsc genome browser for noncode was constructed for saccharomyces cerevisiae , caenorhabditis elegans and homo sapiens . ncrna loci of these species may be viewed through the noncode track in the genome browser . other common tracks concerning basic information on these species , such as mrna genes , ests and so on , have also been retrieved from the ucsc genome browser database . for the above three species , ncrna entries in the noncode database can be directly linked to the genome browser ; similarly , noncode ncrna annotations may be accessed through the genome browser ( figure 1 ) . as new ncrnas are being progressively discovered , we will continue to update the noncode database . submissions of new ncrnas are invited , and should be sent to [email protected] . within the coming year , we will continue to add genome browser services for other model organisms , such as mouse and fly . given the increasing amount of ncrna data and the emergence of ncrna prediction software [ e.g. qrna ( 13 ) , rnaz ( 14 ) ] , we will attempt to establish a service for ncrna prediction based on the mentioned softwares and the information in the noncode database .

the noncode database is an integrated knowledge database designed for the analysis of non - coding rnas ( ncrnas ) . since noncode was first released 3 years ago , the number of known ncrnas has grown rapidly , and there is growing recognition that ncrnas play important regulatory roles in most organisms . in the updated version of noncode ( noncode v2.0 ) , the number of collected ncrnas has reached 206 226 , including a wide range of micrornas , piwi - interacting rnas and mrna - like ncrnas . the improvements brought to the database include not only new and updated ncrna data sets , but also an incorporation of blast alignment search service and access through our custom ucsc genome browser . noncode can be found under http://www.noncode.org or http://noncode.bioinfo.org.cn .

it appears that the potentially fatal pathogen burkholderia cepacia has taken hold of another reservoir for transmission in the form of moisturizing body milk . b. cepacia , a gram - negative rod bacterium known for its affinity towards and its virulence in moist environments , presents a clinical challenge in the treatment and management of susceptible populations and in the subsequent identification of causative sources during nosocomial outbreaks . capable of person - to - person transmission and transmission through contact with surfaces such as medical devices and medicines , b. cepacia is an opportunistic pathogen highly resistant to most antimicrobial agents and it possesses a 42% mortality rate . the need for all clinicians to examine more closely their environments in an effort to halt the spread of b. cepacia is therefore critical . alvarez - lerma and colleagues observed over an 18-day period that five critically ill patients admitted to a multidisciplinary 18-bed intensive care unit contracted the nosocomial infection b. cepacia . microbiologic analysis was performed on the collected oropharyngeal mucosa , urine , and bronchial aspirates from all patients in the intensive care unit and on samples of antiseptics , eau de cologne , and moisturizing body milk used in routine nursing care . it was determined that the strains of b. cepacia isolated from the patients and from the moisturizing body milk were of the same clone , indicating the lotion was the source of the outbreak . upon this discovery , the hospital immediately withdrew the product from routine nursing care hospital wide and notified the manufacturing company about the b. cepacia contamination . alvarez - lerma and colleagues strongly recommend cosmetic products that do not guarantee sterilization during the manufacturing process should not be used in critical care settings . from an all or nothing perspective and within the context that b. cepacia only survived in moisturizing body milk , this approach would appear practical and the right thing to do in an effort to promote quality and safe patient care . removing nonsterile cosmetic products such as lotion from the critical care setting , however , would not completely eradicate or protect patients from b. cepacia infecting humans in the hospital setting . the fact remains that b. cepacia has the potential to find its way into reservoirs that have undergone sterile manufacture because of its affinity for moist environments . several recent studies illustrate that strains of the b. cepacia complex were found in antiseptics , ultrasound gel , enteral feedings , and albuterol and nasal sprays products manufactured in sterile environments [ 3 - 6 ] . in an effort to first do no harm , the clinician must carefully weigh the risks and benefits of all interventions for every patient . the critically ill patient in a state of imbalance is more susceptible and vulnerable to pathogens in their environment ; therefore , a greater need for enhanced analysis of the benefits and risks inherently exists . it is feasible to ban the use of lotions in critically ill patients if it is known that b. cepacia clinically demonstrates higher colonization rates within moisturizing body milks than any other products , sterilized or nonsterilized , used in the hospital . without such evidence that lotions possess a higher colonization rate for b. cepacia , from a nursing perspective the potential benefits of the use of nonsterilized lotion for the patient might be overlooked . lotion , commonly applied to patients with dry , itchy skin , helps to decrease scratching , which can lead to skin excoriation and can leave the body open to infection . lotion may also be utilized in patients who are bed - ridden and who present with red areas on bony prominences . here , the lotion helps to create a gentle friction on the reddened areas of the body , which helps to stimulate blood flow to the surrounding tissue in an effort to ward off potential development of pressure ulcers . additionally , the use of lotions can assist in the donning of latex - free compression stockings commonly used in a multitude of medical conditions such as lymphedema and venous insufficiency . from a holistic perspective the use of aids in the bonding process of parents of babies in the neonatal intensive care unit by helping to facilitate infant massages , and helps facilitate sensory integration therapies in children with autism and sensory processing disorders . there is no doubt of the tragic magnitude that would ensue if a widespread deadly outbreak of b. cepacia was to occur from the use of moisturizing body lotions , especially if those greatly affected were infants , children , and adults concurrently battling critical or chronic illnesses . halting the spread of b. cepacia infection can not occur only through the discontinuation of nonsterilized cosmetic products , and neither can it be guaranteed only with the use of sterilized products . a tried and true way to take hold of b. cepacia therefore appears to be through the continued and regimented practice of adequate hand washing .

alvarez - lerma and colleagues observed over an 18-day period that five critically ill patients admitted to a multidisciplinary 18-bed intensive care unit contracted burkholderia cepacia from unopened containers of moisturizing body milk , calling into question the use in critical care settings of cosmetic products that do not guarantee sterilization during the manufacturing process . is this the answer to the problem , however , or should the use of lotions in such settings be re - examined ?

angiotensin converting enzyme ( ace ) inhibitors are commonly used in children for treatment of hypertension and congestive cardiac failure due to their cardiac and renoprotective properties . captopril and enalapril are off - patent ace inhibitors and hence are considered more economical . side effects including hyperkalemia , cough , angioedema , and hypoglycemia have been reported with the use of several ace inhibitors , including enalapril . a 5-year - old boy presented to our institution with headache and vomiting since three days . there was no fever , visual complaints , drug intake , trauma , tuberculosis contact , oliguria , dysuria , or bowel complaints . it was a home delivery conducted at his native place by a trained dai . he was apparently well till present without any significant complaints . on admission , he was afebrile with a heart rate of 106/min , respiratory rate of 24/min , and blood pressure of 160/110 mmhg ( > 95 percentile for age and sex ) . his height was 94 cm and weight was 13.4 kg ( both below the fifth percentile for age ) . investigations revealed : hemoglobin 7.6 g / dl , total leucocyte count 7600/cumm , and platelet count 4.5 lac / cumm . blood urea nitrogen was 34 mg / dl , and serum creatinine was 1.4 mg / dl . arterial blood gas analysis revealed : ph 7.28 , pco2 25 mmhg , and hco3 12.3 mmol / l . serum calcium was 7.2 mg / dl , alkaline phosphatase 872 iu / l , and phosphorous 5.1 mg / dl . / kg / day ) , nifedepine ( 0.5 mg / kg / dose ) , and enalapril 0.5 his blood pressure was well controlled with above medications . on day 4 of admission , he developed altered sensorium . his repeat serum sodium was 109 meq / l . as the patient was not on any diuretics , had no gastrointestinal losses and his hypertension was under control , a diagnosis of enalapril induced severe hyponatremia leading to altered sensorium was made . enalapril was omitted , and subsequently hydrallazine ( 2 mg / kg / day ) was added for hypertension . intravenous hyponatremic correction was started and his serum sodium gradually became normal within 3 days . repeat investigations are shown in table 1 . as per the world health organization collaborating centre for international drug monitoring and naranjo algorithm , the adverse event was probably / likely related to enalapril . dimercaptosuccinic acid ( dmsa ) scan , micturating cystourethrogram , and renal biopsy were planned and he was discharged after 10 days . enalapril is a derivative of proline but unlike captopril does not contain a sulfydryl group . as a prodrug , enalapril is metabolised to the active form enalaprilat by various esterases in the liver . it has a half - life of 35 h and is still detectable in the plasma after 96 h. the maximum inhibition of ace activity occurs with peak plasma concentrations of enalaprilat and is sustained for 10 h and reverses gradually . excretion is primarily by glomerular filtration , and hence the drug will accumulate in patients who have advanced renal failure . renin is the rate - limiting enzyme that cleaves four amino acids from the renin substrate , angiotensinogen , produced by the liver to form angiotensin i. angiotensin i is further cleaved of two amino acids by ace , which is present in plasma and in the walls of small blood vessels in the lungs , kidneys , and other organs , to form the octapeptide angiotensin ll . it is the primary effector molecule of the ras and acts through stimulation of specific cell - surface receptors ( i.e. , at1 and at2 ) in the arteries and various target tissues . it occurs by potentiation of plasma renin activity due to decrease in the level of angiotensin ii . the antidiuretic effects of vasopressin can play a key role in the development of hyponatremia . johnson et al . found that the systemic administration of angiotensin ii or its precursors directly stimulates the thirst center , with the resulting polydipsia having the potential of further lowering the serum sodium concentration . described a 60-year - old man with idiopathic dilated cardiomyopathy who developed hyponatremia on enalapril therapy . the authors concluded that severe symptomatic hyponatremia induced by the syndrome of inappropriate secretion of antidiuretic hormone should be considered a rare but possible complication associated with ace inhibitor therapy . we could not estimate serum renin and vasopressin in our patient due to financial constraints . it has also been found that administration of ace inhibitors is associated with decrease tubular reabsorption of sodium . furthermore , enalapril therapy results in the sustained increase in effective renal plasma flow due to a pronounced fall of vascular resistance . the combination of these factors could result in an increased natriuretic effect in patients receiving enalapril therapy . this case demonstrates the probable association between the development of severe hyponatremia and the administration of enalapril .

enalapril is an angiotensin converting enzyme inhibitor widely used in children for treatment of hypertension and congestive cardiac failure . we report a 5-year - old boy who developed severe hyponatremia and altered sensorium on enalapril therapy . the serum sodium gradually became normal within 3 days . the patient 's sensorium improved significantly on correction of hyponatremia . through this case , we highlight the importance of monitoring serum sodium in patients on enalapril therapy .

leukodystrophies are congenital demyelinating disorders causing damage to the myelin sheath , an insulating membrane that surrounds nerve cells in the brain . there are forty different types and adrenoleukodystrophy ( ald ) is an x - linked inherited disorder with a prevalence of 1 in 20,000 - 50,000 individuals worldwide . people with x - linked adrenoleukodystrophy ( x - ald ) accumulate high levels of saturated , very long chain fatty acids ( vlcfa ) in the brain and adrenal cortex . the loss of myelin and the progressive dysfunction of the adrenal gland are the primary characteristics of x - ald . while nearly all patients with x - ald suffer from adrenal insufficiency , also known as addison 's disease , the neurological symptoms can begin either in childhood or in adulthood . the childhood cerebral form is the most severe , with onset between ages 4 and 10 . the most common symptoms are usually behavioral changes such as abnormal withdrawal or aggression , poor memory , and poor school performance . other symptoms include visual loss , learning disabilities , seizures , poorly articulated speech , difficulty swallowing , deafness , disturbances of gait and coordination , fatigue , intermittent vomiting , increased skin pigmentation and progressive dementia . there are a couple of case reports in india on this disorder , but none relating the symptoms to attention deficit hyperactivity disorder ( adhd ) . we are presenting this interesting case of x - ald , childhood onset , initially presenting to psychiatric outpatients department with features of adhd . a 7-year - old boy was brought to the psychiatry outpatient department by his mother . no concerns noted in the school or at home until 5 years of age . when he progressed to year one in school , problems started . teachers complained that he had been inattentive , does nt sit at one place and disruptive in the class . his scholastic performance declined , and mother started having difficult time at home as well . he showed no interest in homework , could nt remember what has been taught , more importantly started to forget what he has learnt in the past 2 years . the teachers have advised consulting a psychiatrist and that he may need a special school for further education as his behavior was unmanageable . she however tried changing the schools twice before bringing him for consultation , but his behavior problems got worse . during the assessment the boy was very impatient , constantly trying to leave the interview room , running up and down the stairs , distractible , and uncooperative . the assessment was done on two occasions , and neuropsychologist was involved who administered rating scales to screen and assess the severity of behavioral problems . the boy had hyper - pigmented lesions in his face , but it was overlooked at that point . he was started on methylphenidate 5 mg initially and titrated to 10 mg . as his behavior was very disruptive , putting himself at risk of accidental harm , he was started on risperidone 0.5 mg . two weeks later he presented with fever and an episode of generalized tonic clonic seizures . he presented again the following week with another episode of generalized tonic - clonic seizures with fever and altered consciousness . brain was done which revealed symmetrical t2-hyperintense white matter changes mainly in the posterior periventricular area . pediatric neurologist and endocrinologist were involved , plasma assay of vlcfa done and a diagnosis of ald was made . probing family history revealed similar problems in his cousin who died at the age of ten . literature search has shown a couple of case reports from united states where ald was misdiagnosed as adhd . this is the first time we hear about this rare neurological condition presenting as adhd in india . it never struck in our mind that symptoms of adhd could be secondary to another neurological disorder in this boy given the typical nature and onset of the presentation . furthermore , we overlooked the hyperpigmentation in the face initially until he was seen by endocrinologist after the mri helped with the diagnosis . the presence of facial hyperpigmentation and occurrence of tonic clonic seizures during the course of the illness should alert the clinicians look for these rare but important genetic cause . we explained the course and prognosis of the condition to the parents and given appropriate psychological support . the boy was also referred to special education and occupational therapy as part of the treatment plan .

x - linked adrenoleukodystrophy ( x - ald ) is one the leukodystrophies causing a progressive decline in neurological function mainly affecting the children . the most common symptoms are changes in behavior , including social withdrawal or aggression , poor memory or poor scholastic performance . here , we present a 7-year - old boy who presented with symptoms of inattention and hyperactivity and later turned out to be a case of x - ald .

a 35-year - old female patient presented with recent - onset of pain , redness , and lid swelling in the right eye . four years earlier she had undergone bone marrow transplantation ( bmt ) for aml , with successful remission . she was under treatment with oral steroids for graft - versus - host - reaction ( gvh ) . her best - corrected vision in the right eye was counting fingers and in the left eye was 20/20 . the right eye showed lid edema , conjunctival and ciliary congestion , chemosis , a paracentral corneal epithelial defect , 3 + cells in the anterior chamber ( ac ) with fibrin strands and hypopyon and a posterior subcapsular cataract . applanation intraocular pressure ( iop ) was 34 mmhg in the right eye and 30 mmhg in the left eye . right fundus could not be seen clearly due to media opacities produced by a combination of corneal epithelial defect , ac reaction , and cataract . initial diagnosis of a corneal epithelial defect in the right eye , and bilateral glaucoma was made . she was started on topical antibiotics ( gatifloxacin ) , ocular lubricants ( carboxy - methylcellulose ) , and mydriatic - cycloplegics ( 1% atropine ) for the right eye and topical glaucoma medications ( 0.5% timolol ) bilaterally . on follow - up , the epithelial defect had healed and the lid edema , redness , and iop had reduced . she was prescribed topical steroids ( 1% prednisolone acetate ) and was reviewed at close intervals . nevertheless , the hypopyon was not responsive even after a week of treatment [ fig . 1 ] . lid edema and congestion have reduced after treating glaucoma and ocular surface disease due to graft - versus - host disease ( gvh ) due to failure of conventional treatment , masquerade syndrome was suspected and investigated . b - scan ultrasonography showed a few intravitreal echoes , choroidal thickening , and exudative retinal detachment [ fig . 2 ] . b - scan shows choroidal thickening and elevated retina inferiorly suggestive of choroidal infiltration and exudative retinal detachment aspiration of the ac infiltrate was performed under aseptic conditions . cytology of anterior chamber ( ac ) aspirate shows malignant cells confirming the rare location of ocular relapse in acute myeloid leukemia ( aml ) based upon the cytology and ultrasonography , we arrived at a diagnosis of relapse of aml involving the ac and choroid . it is extremely rare for relapse of aml to present with anterior segment manifestations . in a prospective 2-year study of 53 patients undergoing treatment of aml , no patient presented with hypopyon uveitis . our patient presented with multiple possible causes for visual loss and pain including corneal epithelial defect , ac reaction , and posterior subcapsular cataract and glaucoma . the patient was taking oral steroids for gvh , which confounded her initial clinical picture . in leukemic patients who have undergone bmt , the occurrence of gvh can further mask a classic presentation of masquerade syndrome by causing a congested , painful eye . increase in iop can to be due to the presence of tumor cells in the ac . however , in this patient , iop was high in both eyes at initial presentation . the secondary glaucoma was possibly due to a combination of tumor infiltration affecting the right eye and systemic steroid therapy affecting both eyes . posterior segment infiltration could not be visualized due to a combination of corneal , lenticular , and ac pathology . a high index of suspicion is necessary in patients with leukemia who are in remission . in such patients , mumps uveitis and chemical reiter 's syndrome may further complicate the diagnosis . in patients with a malignant cause of masquerade syndrome , cytologic analysis of intraocular fluids has been reported to be an essential diagnostic procedure with positive yield in 64% of cases . although cd56 expression of tumor cells is believed to be associated with cns involvement , immunophenotyping could not be done in our case . since there are few references of immunophenotyping of hypopyon cells in aml , this association with cd56 is yet to be confirmed . it is postulated that the blood - ocular barrier may be responsible for creating a pharmacological sanctuary , resulting in suppression , but not eradication of malignant cells by chemotherapeutic agents . patients with aml treated with radiotherapy and chemotherapy developed leukemic hypopyon 3 months to 9 years after initial diagnosis . all reviewed patients in this report died within 1 year of developing leukemic hypopyon . although the treatment of aml has changed since , their conclusion that leukemic hypopyon is associated with systemic leukemic relapse even if systemic examination reveals no leukemia , except for that in the ac , remains valid today . patients with hypopyon uveitis may present with or without the classical clinical signs of masquerade syndrome depending upon coexisting ocular pathology . judicious use of cytology was useful in differentiating it from true inflammation and confirming this rare complication of aml . timely diagnosis is essential , particularly if the suspicion of ocular or systemic malignancy needs to be validated .

anterior segment infiltration in acute myeloid leukemia ( aml ) presenting as hypopyon uveitis is very rare . we report this case as an uncommon presentation in a patient on remission after bone marrow transplant for aml . in addition to the hypopyon , the patient presented with red eye caused by ocular surface disease due to concurrent graft - versus - host disease and glaucoma . the classical manifestations of masquerade syndrome due to aml were altered by concurrent pathologies . media opacities further confounded the differential diagnosis . we highlight the investigations used to arrive at a definitive diagnosis . in uveitis , there is a need to maintain a high index of clinical suspicion , as early diagnosis in ocular malignancy can save sight and life .

advances in oncological and supportive care have led to improved prognoses and extension of survival time in cancer patients . consequently , increasing numbers of patients with cancer require admission to intensive care units ( icus ) . in the last issue of critical care , dr taccone and coworkers reported that patients with cancer represent a large proportion of icu patients . in their substudy from the sepsis occurrence in acutely ill patients ( soap ) study conducted in 198 european icus , 15% of patients had a malignancy , mostly solid tumors but also hematological malignancies . these findings are in accordance with results from the saps-3 study , performed in 2002 in an international population comprising almost 20,000 icu patients ; these results showed that 3% of these patients had metastatic cancer , 6% had non - metastatic cancer and 2% had hematological cancer . less than 10 years ago , in guidelines for icu admission , a taskforce of the american college of critical care medicine concluded that patients with hematological or metastasized solid malignancies were poor candidates for icu admission . these patients were considered to have a very high risk ( up to 90% ) of mortality . at that time , in contrast with the very poor prognosis reported in the literature , taccone and coauthors reported much lower hospital mortality of 58% in icu patients with hematological cancer and 27% in patients with solid malignancies , compared with 23% in icu patients without cancer . others have also reported the improvement in prognosis after icu admission for patients with hematological cancer . in hematopoietic stem cell transplant recipients who received invasive mechanical ventilation , mortality was uniformly higher than 90% in studies before 1993 , but gradually decreased to 52% in 2000 . in addition to advances in stem cell transplantations , improvements in critical care may have contributed to this improvement in prognosis for these patients . clearly , patients should no longer be refused admission to icus only because they have hematological cancer . a relapsed / refractory state of leukemia and a poor sequential organ failure assessment ( sofa ) score were found to be the independent risk factors associated with mortality in patients with acute leukemia and should be considered when decisions regarding icu admission are made about patients with hematological cancer . in the study by dr taccone and colleagues , it should be noted that patients with solid cancers form a very heterogeneous population , with many different forms of cancer , different oncological treatments and different reasons for admission to the icu . most icu patients with cancer are admitted after surgery , often as primary treatment for their cancers , and the short - term prognosis of these patients is mostly good . in patients after transhiatal esophageal resection for esophageal cancer , hospital mortality may be as low as 3.5% . likewise , mortality after pancreatico - duodenectomy in patients with pancreatic cancer may be less than 5% in experienced centers . the outcome after major oncological surgery may be mostly related to the surgical procedure , more than to the critical care on the icu . only limited data are available about patients with cancer admitted to icus for other reasons than post - operative care after oncological surgery . azoulay and coauthors reported 30-day mortality of 58% in patients admitted for medical reasons . in a brazilian study involving 1,090 patients with cancer requiring icu admission for reasons other than routine postoperative care , most of these patients had non - metastasized solid cancer , and most patients required mechanical ventilation . in patients with a prolonged icu length of stay , mortality was independently associated with the number of failing organs , age and performance scale score . clearly , icu treatment is not futile for all patients with cancer . despite these recent data , rates of refusal of icu admission in cancer patients remain high and the criteria on which triage decisions are based differ between oncologists and intensivists . decisions to withhold life - sustaining treatments are more often made for patients with cancer than patients with other terminal diseases , even when these other diseases have at least the same poor prognosis . this has been demonstrated clearly for patients dying from chronic heart failure compared to patients with metastatic cancer . over the past years the prognosis of cancer patients has improved significantly , even when icu admission is necessary . refusal of icu admission should not be based on the diagnosis of cancer as the underlying condition . in contrast , these decisions should be based on the availability of treatment options , and on patients ' own preferences . unfortunately , current prognostic models for icu patients , all based on data from the first 24 hours after icu admission , such as apache ( acute physiology and chronic health evaluation ) ii and saps ( simplified acute physiology score ) ii , can not reliably predict whether cancer patients will survive icu admission . when in doubt , it may be a very good option to start full unlimited treatment for a few days . discontinuation of treatment should be considered if progressive organ failure is seen after 3 to 5 days .

a recent paper by taccone and coworkers showed that 15% of patients from 198 european intensive care units ( icus ) had a malignancy , mostly solid tumors but also hematological malignancies . over the past years , the prognosis of cancer patients has improved significantly , even when icu admission is necessary . refusal of icu admission should not be based on a diagnosis of cancer as the underlying condition . in contrast , these decisions should be based on the availability of treatment options , and on patients ' own preferences .

a 73 year old female patient presented in may 2005 with lower abdominal pain , abdominal bloating and increased frequency of bowel habits . subsequent colonoscopy detected a neoplastic lesion at the splenic flexure confirmed at biopsy to be adenocarcinoma . however , at laparotomy , the primary arising from the splenic flexure was found to be advanced with diffuse intra abdominal metastases . post - operatively , the patient received palliative chemotherapy with good response indicated by tumour shrinkage in serial ct scans and falling carcinoembryonic antigen ( cea ) . she later presented to the emergency department in august 2007 with abdominal pain and marked abdominal distension . abdominal x - ray showing colonic dilatation at laparotomy , the ascending and transverse colon was dilated to 12 cm with features of a giant mucocele which yielded 3.5 litres of clear mucus . this was found to be due to closed loop obstruction between the terminal ileum adherent to the pelvis as a result of peritoneal disease and local relapse at the splenic flexure resulting in accumulation of mucus and formation of a mucocele . a loop ileostomy was fashioned and the transverse colon was drained with a 24 french 2 way catheter brought out at the top end of the wound . post operatively , about 1600 ml of mucus was drained from the catheter in the initial few days and this subsequently reduced to 125 ml daily . appendiceal mucocele is a well recognized entity and occurs due to appendiceal obstruction followed by luminal accumulation of mucus and dilatation of the obstructed appendix ( 1 ) . it may be associated with concomitant colon cancer and hence thorough investigation of the colorectal tract is recommended after diagnosis of an appendiceal mucocele ( 2 ) . rarely an appendiceal mucocele can become very large and can present as an abdominal mass ( 3,4 ) . it has been reported as an unusual complication after diversion transverse loop colostomy in a patient with long - standing ulcerative colitis resulting from distal stomal and rectal stenosis and accumulation of mucus in the closed loop over many years 5 ) . mucocele following sequestration of a segment of bowel wall at the site of colo - colic anastomosis after resection of sigmoid carcinoma has been reported . in this case , the patient had rising carcino - embryonic antigen levels ( cea ) with increased uptake on positron emission tomography ( pet ) scan at the site of original anastomosis raising the suspicion of a recurrence . following excision of the mucocele perforation of a colonic mucocele has been reported 22 years after formation of ileostomy in a patient with crohn s disease . this occurred due to stenosis of the distal colonic segment and subsequent development of a mucocele ( 7 ) . in this case , a closed loop of the right colon and transverse colon was formed by distal obstruction at the splenic flexure by tumour relapse and proximal obstruction at the ileo - caecal valve by peritoneal metastasis . the continued secretion and accumulation of mucus led to distension of the closed colonic loop . a similar presentation has been reported in a patient with carcinomatosis peritonei from recurrent squamous cell carcinoma of the cervix , eight months after palliative bypass of obstructed ascending colon ( 8) . colonic mucoceles mostly present with abdominal distension which usually evolve slowly and insidiously over a period of 2 - 6 years ( 5 ) . it may cause obstructive symptoms if it is large enough to compress adjacent bowel segments . in patients with loop colostomies or mucous fistulas , the cessation of mucous drainage from either the rectum or the mucous fistula should alert the surgeon to the possibility of a closed loop obstruction ( 9 ) . imaging modalities such as ultrasound and ct can be used to aid diagnosis and this requires a high index of suspicion . in a majority of cases , the diagnosis is confirmed at exploratory laparotomy . in this case , a ct scan done five months before the acute presentation revealed colonic dilatation and local relapse at the splenic flexure along with liver metastasis and peritoneal disease ( figure 2 ) . a diagnosis of colonic mucocele was not made and the air fluid level in the closed loop was thought to be due to competent ileocaecal valve . on hindsight , the absence of intestinal obstruction in spite of impressive colonic dilatation in the ct scan should have raised the suspicion of an evolving colonic mucocele . this reinforces the need for a high index of suspicion so that the diagnosis can be made pre - operatively and the patient managed conservatively . ct abdomen showing dilatation of ascending and transverse colon upto splenic flexure with air fluid levels . in a case where diagnosis has been confirmed on imaging , treatment can be undertaken by ct guided drainage ( 8) . other treatment options include excision of the mucocele and this should usually be undertaken in low - risk surgical patients who have a good prognosis ( 5 ) . in cases where there is a high chance of mucocele recurrence , a permanent catheter or a sump drainage tube can be placed and the patient can be taught self irrigation ( 5 ) . colonic mucocele is an extremely rare entity and requires a high index of suspicion for diagnosis . the treatment depends on the underlying disease process and the overall prognosis of the patient . we believe this to be the first reported case in literature of a colonic mucocele following palliative bypass surgery for advanced colonic cancer .

we report an unusual case of a giant colonic mucocele following ileo - sigmoid bypass surgery in a patient with advanced adenocarcinoma of the splenic flexure . the formation of a giant colonic mucocele resulted from distal splenic flexure obstruction due to tumour relapse and proximal caecal obstruction due to peritoneal disease with subsequent accumulation of mucus in the closed loop .

congenital atrichia refers to total absence of hair from birth . it may occur as an isolated defect or in association with a wide range of anomalies . congenital atrichia without associated ectodermal abnormalities is very rare and is inherited as an autosomal recessive trait . we report a rare case of congenital atrichia associated with situs inversus of the viscera and mesocardia which has not been earlier reported in the literature . a 2-year - old male child born of consanguineous marriage presented to pediatric dermatology opd for evaluation of the complete absence of hairs on scalp , eyebrows , and eyelashes since birth . there was history of sparse hair erupting after birth which eventually was shed in 2 months . there was no history suggestive of abnormalities in hearing , dentition , epilepsy , and mental retardation , intolerance to heat , or immunodeficiency . child 's maternal aunt had alopecia of scalp and was diagnosed as having keratosis follicularis spinulosa decalvans . past history was remarkable for bronchopneumonia and congenital lobar emphysema . cutaneous examination revealed total alopecia of the scalp , eyebrows , and eyelashes and all over the body [ figure 1 ] . situs inversus of the viscera with mesocardia in the child had been confirmed by chest x ray and computed tomography of chest and abdomen [ figure 2 ] . based on clinical presentation and histological findings , two - year - old male child with total alopecia of scalp , eyebrows , and eyelashes ct - scan of chest and abdomen showing mesocardia with liver on left side and spleen on the right side it can be inherited as an autosomal recessive or autosomal dominant or x linked pattern . the cases inherited as autosomal recessive are generally the most severe form and are present since birth . congenital atrichia presents as total alopecia at birth , but sometimes scalp hair can be present at birth which is later shed between the first few months , after which no further regrowth occurs . congenital atrichia may be associated with papular lesions which is a rare form of autosomal recessive syndrome characterized by numerous , small , horny papules on the face , neck , limbs , and trunk . other syndromes associated with congenital alopecia are moynahan 's syndrome ( mental retardation , epilepsy ) , hidrotic ectodermal dysplasia ( palmoplantar keratoderma , thickened nails ) and aging syndromes . skin histology shows the total absence of hair follicles or a few scattered miniaturized follicles . alopecia universalis and vitamin d - dependent rickets type ii a induced alopecia should be considered in the differential diagnosis . the prevalence of situs inversus varies among different populations , but is less than 1 in 10,000 people . it is a congenital condition usually inherited as an autosomal recessive or x linked in which the major visceral organs are reversed or mirrored from their normal position . cardiac malpositions refer to heart that are located abnormally within the thoracic cavity or that are located outside the thoracic cavity . three major cardiac malpositions occur in the presence of right / left asymmetry : visceroatrial situs inversus with dextrocardia , visceroatrial situs solitus with dextrocardia and visceroatrial situs inversus with levocardia . the association of situs inversus and mesocardia with congenital atrichia has not been reported in literature . it is currently not known whether there is underlying genetic cause for the co - existence of these two condition in our patient or it constitutes a coincidence .

congenital alopecia includes a broad differential diagnosis and presents a diagnostic and therapeutic challenge for the physician . congenital atrichia is a rare form of irreversible alopecia that is usually inherited as an autosomal recessive pattern . we report a 2-year - old male child presenting with total alopecia of scalp , eyebrows , eyelashes , and body hair since birth . the child had cardiac malposition with situs inversus of the viscera . computed tomography of the chest and abdomen revealed median position of the heart with transposition of abdominal viscera . to our knowledge , this is the first case of congenital atrichia associated with situs inversus and mesocardia .

it was an honor for the editors of electronic physician , in its 8th anniversary , to organize the first edition of international conference on health sciences and medical technologies ichsmt16 . the proposed motto of the events was:leveraging / synergizing on the strength of technology written by professor dr . syed tajuddin syed hassan ( associate editor of electronic physician journal , universiti putra malaysia ) , which fully captured the essence of the whole conference which was focused on technology for serving the most crucial scientific domain - medicine . it is with great pride that i can report that this conference had contributors representing fourteen different nations , namely : algeria , germany , iran , switzerland , netherlands , malaysia , canada , france , morocco , spain , kingdom of saudi arabia , pakistan , tunisia and united states of america . author s affiliations were from several departments such as medicine , biology , physics , chemistry , computer sciences , environment , pharmacy , electrical and electronic engineering and mechanical engineering . an exceptional inaugural session , which contained three plenary speeches , commenced on the first day before the parallel sessions . the three speeches presented in this session were ; ( 1 ) , presented by professor dr . wolfgang seger , and was an introduction to the importance of social health and clarification of the international classification of functioning , disability and health ( icf ) . mehrdad jalalian , and explained how to publish scientific articles in journals , with the highest standards , and the most common mistakes made by researchers . this presentation also covered the ethics of publishing medical research , and ( 3 ) , by professor dr . kaouel meguenni , which highlighted cancer disease and the importance of the algerian cancer registry in several studies . three editorials ( 1 , 4 ) and five original articles ( 510 ) were selected as the best submissions to the conferences . as an award , a free advanced version of all selected papers are planned for publication in the journal electronic physician . the program committee redefined , after the reviewing step , ten sessions for international participants according to the contributed domains . the platinum sponsor of the conference was the university of tlemcen with medicine faculty and sciences faculty and research laboratories . the gold sponsors were mehr publishing group , mehrafarin scientific publishing , electronic physician journal , and acta healthmedica journal . several models , courses , communication / group process issues , and international perspectives are reviewed within it ( 11 ) . although there are some limits such as cultural bias , language difficulties and technical problems which can decrease the efficiency of these initiatives , international interdisciplinary education participates in the construction of the future of professionals and researchers , and adds to enrich innovation and scientific realizations . the conferences in general are excellent places to evaluate scientific findings and to prepare for future projects and much more ( 12 ) . ichsmt16 was an exceptional model of international interdisciplinary education and research , in which several technological innovations and medical findings were presented reviewed and commented . an exceptional deal in international medical education between germany and algeria began its first steps at the conference . the success of the conference was measured and inferred by the collected feedback forms , and a considerable amount of advice was collected from the contributors of these conferences . to ameliorate the quality of the next edition , we plan several additional improvements .

the international conference on health sciences and medical technologies ( ichsmt16 ) was held in tlemcen , algeria from 2729 september 2016 . the conference was organized by the university of tlemcen , in partnership with electronic physician journal , mehr publishing , and mehrafarin scientific publishing . there were participants from 14 nations who presented their research in poster or oral presentations . there were also some keynote speakers who gave talks on topics such as community health , ethics of publishing medical research , and scientific writing .

wilson and jungner have defined 10 criteria for screening of chronic diseases such as dm and dr . the reported prevalence of dr in india ranges from 17.6% to 28.2% . with this prevalence , the number of people with dm is likely to increase to 79.4 million and people with dr is likely to increase to 22.4 million by the year 2030 . both dm and dr are relatively less , between 10% and 12% , in rural india compared to urban india but not small enough to ignore . considering that prevalence of dr at a moderate level of 20% in urban india and at a lower level of 10% in rural india and assuming that 70% of indians live in rural areas , the incidence of dr in rural india could rise to 10.97 million by the year 2030 . in addition , there is an acute shortage of skilled manpower to screen dr in rural india . traditionally , the two popular methods of dr screening are either ophthalmologist led or optometrist led . both methods are effective and are used both in india and globally . however , with the large emerging burden , it may no longer be the cost effective method of dr screening . hence , a cost - effective dr screening is required in rural india , and this is possible with the existing and emerging technology of telemedicine . the american telemedicine association has described four categories of dr screening from identification of mild npdr ( category 1 ) to the one that exceeds the ability of early treatment diabetic retinopathy study photographs ( category 4 ) [ table 2 ] . american telemedicine association diabetic retinopathy telescreening categories dr screening is done by direct and indirect ophthalmoscopy and fundus photography . it is also convenient because it does not need the ophthalmologist to be always present in the screening site ; the stored photographs could be examined later , and when in doubt , could be confirmed with another expert . the technological improvements in fundus photography from analog to digital , from 30 to 45 to 60 field in most digital cameras , and from mydriatic to nonmydriatic retinal cameras have made the fundus photography as the most accepted form and standard of care in dr telescreening . in past , satellite connection has been used for transmission of the fundus photographs for teleconsultation . with improvement in internet and wire - free connection , the current generation of cameras is capable of transmitting the fundus images at fraction of cost incurred in the past . we have established such a system of receiving the fundus photographs obtained in a hand - held nonmydriatic fundus camera placed at centers managing diabetes , and the images are both qualified and quantified for dr in the image reading center , l. v. prasad eye institute imaging laboratory and analysis center ( lilac ) . certified technicians grade the images and the specialist 's opinion is sought in difficult ones . this has further reduced the ophthalmologist 's time required to screen these patients . in a pilot study , the lilac received fundus photographs of 229 diabetic subjects over 6 months ; images of 32 subjects were ungradable ( small pupil , lens opacities , etc . , ) and 94 were diagnosed to having treatable dr ( unpublished data ) . with increasing and powerful internet services planned in india , this method could be the most cost - effective method of dr telescreening in rural areas . a few indian studies have confirmed the superiority of fundus photography in teleophthalmology of dr care and good patient satisfaction . some indian investigators have used the services of the indian space research organization designed teleophthalmology vehicles to transmit images from outreach locations to the dr reading and grading center at the base eye care facilities . while this facility may not be available to everyone and everywhere , the internet or cloud - based facility will be cost effective that delivers equally reliable information . the current lacunae in telescreening of dr in india are lack of enough broadband capacity in india . as india is progressing in digital technology , we hope that this deficiency will be effectively addressed . we foresee two important future developments ; one , further miniaturization of fundus camera , superior picture quality , and reduced cost of the cameras ; two , autodetection of fundus lesions in dr . this will empower and enable the patients for informed decision - making . there are many attempts currently made for autodetection of retinal lesions . while we are on the threshold of witnessing a revolution in dr screening , the knowledge , attitude , and practice ( kap ) toward diabetes and retinopathy needs considerable improvement ( authors unpublished data ) . we are less likely to benefit from these disruptive technological unless the kap also improves . prevalence of dr in rural india ( or the world ) is not too different than the urban people . however , the rural population is disadvantaged for not having a similar access to skilled personnel , particularly a specialist ophthalmologist similar to their urban counterpart . the modern technology of digital nonmydriatic photography , particularly the smartphones , fast expanding broadband transmission of these fundus pictures , and smarter autodetection of the retinal lesions will make the rural diabetic patients no more remain disadvantaged . the success of these new developments partly rests on similar improvement in the kap of the rural folk .

diabetic retinopathy ( dr ) is a growing concern in india . the first step in management of dr is timely screening . with 10% prevalence in rural india , 11 million people are likely to have dr by the year 2030 . with limited resources and skilled manpower , it will not be possible to have routine eye examination to identify and treat these patients on a regular basis . telemedicine is a possible answer in these situations where patients could be remotely screened and appropriately advised . with the advent of several technological advances such as low cost hand - held nonmydriatic camera , increased capabilities of the smartphones to take external eye and retinal photographs coupled with improving broadband connectivity ; teleophthalmology in the management of dr could be a reality in the not too distant future .

infectious endophthalmitis is a devastating vision - threatening condition consisting of inflammation of the entire globe and its intraocular contents . surgical intervention , such as pars plana vitrectomy ( ppv ) , has been used for cases with infectious endophthalmitis whose visual acuity is worse than light perception after cataract surgery . ppv for infectious endophthalmitis is challenging given the severe inflammation in the anterior chamber which creates significant media opacity and limits visualization of the posterior pole . limbal based anterior vitrectomy is sometimes used by our anterior segment colleagues in cases of posterior capsule rupture and vitreous prolapse . additionally , pediatric vitreoretinal cases involving vitreous hemorrhages , retina detachment , and opacified vitreous with uveitis benefit from iimbal vitrectomy . this surgical technique shows good efficacy and safety that is designed to avoid disruption of the vitreous base and the anterior retina . here , we describe a surgical technique combining limbal based vitrectomy and ppv to manage infectious endophthalmitis . the limbal based vitrectomy is used to initially remove infectious and inflammatory material from the anterior chamber . it is an ideal technique for visualization of the posterior pole for more complete ppv as an early intervention for infectious endophthalmitis . our surgical technique includes a five - trocar setup using 3 standard 25-gauge pars plana trocar / cannulas and 2 limbal anterior trocar / cannulas . undiluted aqueous and vitreous biopsy can be obtained prior to turning the infusion on , given the multiple trocar availability . the anterior infusion is initially turned on once it is verified in the anterior chamber via the corneal limbus . the second anterior corneal limbus cannula is used for anterior chamber washout and removal of the fibrin and inflammatory membranes . both the vitreous cutter and retinal forceps can be used to remove fibrin membranes from the pupil margins in aphakic cases and over the intraocular lens in pseudophakic cases . after all anterior chamber material is cleared and media clarity optimized the infusion line of a balanced saline solution is moved to the pars plana cannula and a complete posterior vitrectomy is performed . in cases where the media opacity remains significant , the posterior vitrectomy can be performed with the anterior infusion line . at the conclusion of the case , the small gauge limbus wounds can be hydrated or closed with single interrupted 100-nylon sutures . any leaking sclerotomies should be closed in a similar manner with 70-vicryl suture ( online suppl . patients with infectious endophthalmitis who undergo early vitrectomy might have superior outcomes with fewer complications [ 3 , 4 , 5 , 6 ] . however , early vitrectomy for infectious endophthalmitis might be challenging due to difficult visualization secondary to media opacity secondary to severe inflammation in the anterior chamber . our surgical technique of five - port combined limbal and ppv for infectious endophthalmitis allows for removal of infectious and inflammatory material from both the anterior chamber and vitreous cavity in a safe and efficient manner . the limbal based approach greatly aids visualization and potentially improves the efficacy of the ppv in cases where media opacity precludes securing a posterior segment infusion . this is significantly beneficial at removing infectious material and vitreous debris , which is paramount to accelerating infection clearance and optimizing visual outcomes . the 25-gauge trocar / cannula limbal system provides a small - gauge easy access port in the anterior chamber with good efficacy and safety . similar to the 23-gauge limbal approach , no intraoperative or postoperative complications were observed , such as corneal wound dehiscence , descemet membrane tears , iris incarceration , epithelial downgrowth , or corneal dellen , retinal tear or dialysis , retinal detachment , suprachoroidal hemorrhage or effusion . the smaller gauge cannulas ( with or without valves ) often allow for the entire procedure to be sutureless . if the cornea / limbal wounds are not water tight at the end of the case , they can be hydrated with a balanced saline solution on a blunt cannula . in cases where a pars plana infusion still can not be visualized and verified to be in the vitreous cavity , posterior vitrectomy can be performed with the limbal ( anterior ) infusion cannula . the anterior infusion line provides adequate intraocular pressure control regardless of lens status ; however , it may cause corneal striae that could degrade the view of the posterior pole . this can be minimized by ensuring that the infusion line is taped in a radial manner ( i.e. perpendicular to the circumferential cornea ) . when the view is sufficient posteriorly , we elect to move the infusion source to the pars plana cannula as soon as able . collectively , this surgical technique allows for safe , efficient , and complete anterior and posterior vitrectomy for infectious endophthalmitis . this case report was in full adherence to the declaration of helsinki and all federal and state laws .

pars plana vitrectomy for acute infectious endophthalmitis can be challenging due to severe inflammation in the anterior chamber creating significant media opacity . we describe a surgical technique combining limbal based vitrectomy and pars plana vitrectomy to manage acute infectious endophthalmitis . limbal based vitrectomy facilitates removal of anterior chamber fibrin and inflammatory membranes for safe and optimal posterior pars plana vitrectomy .

this condition of abnormal visceral rotation was known in animals since the days of aristotle . it is associated with a number of other conditions such as kartagener 's ( bronchiectasis , sinusitis , situs inversus ) and cardiac anomalies . there is no current evidence showing increased incidence of cholelithiasis in patients with situs inversus totalis . after mouret performed first laparoscopic cholecystectomy in 1987 , it has become a gold standard in treatment of cholelithiasis . the first known laparoscopic cholecystectomy in situs inversus has been reported by campos and sipes in 1991 . due to the very nature of reversed anatomy and possibility of associated anomalies a 47-year - old female presented with pain since 15 days in left hypochondrium and left iliac fossa region . ultrasonogrphy of abdomen revealed cholelithiasis with probe tenderness at left mcburney 's point with situs inversus . she was posted for laparoscopic cholecystectomy and appendicectomy . or arrangement - mirror image of routine laparoscopic cholecystectomy . anaesthetist was at the head end , monitor was placed on the patient 's left side and surgeon with camera assistant was on the right side of the patient . a 10 mm camera port was placed at supraumbilical region , epigastric 10 mm port to the surgeon 's left and right hand as and when necessary . a 5 mm mid clavicular port to the surgeon 's right hand occasionally to be hold by assistant . a 5 mm port was placed in the anterior axillary line at the level of umbilicus for gall bladder retraction . x - ray chest showing dextro cardia ct scan showing left sided liver operating instruments , hook with diathermy was passed from epigastric port and managed with right / left hand of surgeon while traction at infundibulum was exerted by the assistant . dissection at fossa was done by surgeon 's right hand at mid clavicular port and gall bladder manipulated by surgeon 's left hand through epigastric port . intra operative picture showing gall bladder on left of ligamentum teres dissection of cystic duct for simultaneous appendicectomy , same ports were used even though the positions were cumbersome . anterior axillary port was used for surgeon 's right hand , while for left hand ; mid - clavicular port was used . appendix with cecum was visualised in the left iliac fossa region somewhat high up in position . this entity is considered to have a genetic predisposition that is autosomal recessive with the defect being localised on the long arm of chromosome 14 . there is no evidence that situs inversus predisposes to cholelithiasis , but it may be a cause of diagnostic confusion . delay in the diagnosis was due to the left upper abdominal pain and unknown situs inversus . internet search has revealed 36 reported cases of cholecystectomy in situs inversus including our case [ table 1 ] . of these , 11 are males and 25 are females . the age group is from 20 to 80 years . of the reported cases , 26 are situs inversus totalis , while in 4 cases ; the condition has not been specified . the procedure becomes difficult because of the fact that the anatomy is mirror image of that of routinely seen and most surgeons are right handed . this needs alteration in technique of cholecystectomy . when chances of about 25% biliary anatomical variations are considered , the chances of iatrogenic injuries increases . publications on situs inversus and laparoscopic cholecystectomy the dissection is difficult , as commonly used right hand has to be used for retraction and left for dissection . if this anatomical variation makes the picture confusing , then early conversion should be thought . in our patient , a number of papers have suggested different port positions , but we used mirror image of standard laparoscopic cholecystectomy ports . the pubmed search has revealed the use of laparoscopy for various procedures in cases of situs inversus . the difficulties faced by all the surgeons are mainly because of the mirror image anatomy and change in the use of the dominant hand while dissecting . in conclusion , it needs modification in technique , proper planning and with cautious dissection ; the procedure can be safely completed .

situs nversus totalis is a rare condition which presents difficulty in clinical diagnosis as well as laparoscopic surgery for cholelithiasis . the mirror image anatomy makes the laparoscopic intervention difficult even for an experienced surgeon . presenting here is a case report and review of literature .

in this issue of critical care , camporota and colleagues report interesting observations on the relationship between the initial gas exchange response to high - frequency oscillatory ventilation ( hfov ) and clinical outcomes . hfov seems ideally suited to protecting the lung during mechanical ventilation in patients with acute respiratory distress syndrome ( ards ) . by delivering very small tidal volumes and allowing higher mean airway pressures however , the recently published oscillate ( oscillation in ards treated early ) and oscar ( high - frequency oscillation in ards ) trials - both of which postdate the article by camporota and colleagues - found that hfov failed to reduce mortality . in particular , oscillate raised questions of potential harm from hfov . in the face of these disappointing results , trialists and clinicians alike are left wondering how to reconcile theory to practice . a number of potential mechanisms for harm have been postulated , including ( a ) the deleterious effects of increased sedation , ( b ) hemodynamic embarrassment due to reduced right ventricular preload or increased right ventricular afterload , or ( c ) an increase in mechanical alveolar stress and strain within the baby lung . a critical factor influencing the importance of these various mechanisms may be the response of the individual patient to the application of high mean airway pressures . imaging studies have demonstrated profound heterogeneity in the extent of alveolar recruitment in response to increases in airway pressure . in patients with ' recruitable lung ' , higher airway pressures increase the size of the functional ' baby lung ' , reduce alveolar stress and strain , and may even reduce right ventricular afterload without significantly compromising right ventricular filling . in patients lacking ' recruitable lung ' , higher mean airway pressures achieve the opposite : worsened alveolar stress and strain and increased right ventricular afterload . consequently , the potential for benefit or harm may depend critically on the degree of lung recruitment in response to increasing mean airway pressure . enter the interesting observations of camporota and colleagues , who found that in patients with moderate or severe ards who were placed on hfov by their attending physicians , the change in arterial partial pressure of oxygen / fraction of inspired oxygen ( pao2/fio2 ) ratio 6 hours after hfov initiation was associated with 30-day survival . improvements in oxygenation were also associated with reductions in arterial partial pressure of carbon dioxide ( paco2 ) , particularly in patients with more severe respiratory failure , contradicting the widely held belief that hfov inevitably worsens respiratory acidosis . the oxygenation response to increased positive end - expiratory pressure ( peep ) is the product of a complex interplay between alveolar recruitment and cardiac output . classic physiological studies by dantzker and colleagues and lynch and colleagues demonstrated that increased peep reduces intrapulmonary shunt both by re - opening collapsed lung units and by reducing cardiac output . in the latter case , non - ventilated lung units are preferentially affected by reduced blood flow , possibly because of the effects of hypoxic pulmonary vasoconstriction . in the present study , camporoto and colleagues reported that cardiac output was unchanged ; thus , the short - term oxygenation response likely signifies lung recruitment . the authors speculate that the gas exchange response may be a useful predictor of the utility of hfov in the difficult - to - oxygenate patient and further propose that failure to demonstrate improved oxygenation after a 6-hour trial of hfov should prompt a consideration of alternative rescue modalities such as extracorporeal life support . it is difficult , however , to do anything more than speculate on the basis of these data . first , it is difficult to be certain whether the association between early improvements in oxygenation and reduced mortality arises from the effects of hfov - induced lung recruitment or simply represents the natural history of survivors ( whose oxygenation will tend to improve with time ) in contrast to non - survivors ( whose oxygenation will tend to worsen with time ) . second , even if the improvements in oxygenation were directly related to lung recruitment , it is impossible to discern whether oxygenation ' responders ' have lower mortality than ' non - responders ' because ' responders ' have a less fatal form of ards or because they accrue greater benefit from hfov . finally , from these data in which all patients received hfov , it is impossible to know whether increases in mean airway pressure on conventional ventilation would have been equally effective . such issues can be resolved only by a carefully designed randomized trial of an open - lung ventilation strategy that stratifies patients by oxygenation response prior to random assignment . in the meantime , in light of the available evidence , hfov should usually be reserved for patients with refractory hypoxemia . when applying hfov , clinicians should consider monitoring lung recruitment ( by oxygenation response or other means available ) and right ventricular function ( by echocardiography or other hemodynamic monitoring ) to ensure that this unique mode of ventilation is achieving appropriate physiological goals in the individual patient . hfov : high - frequency oscillatory ventilation ; peep : positive end - expiratory pressure .

high - frequency oscillatory ventilation ( hfov ) seems ideal for lung protection in acute respiratory distress syndrome , but randomized trials have not shown a mortality reduction . the initial oxygenation response to hfov appears to be associated with survival . here , we discuss the mechanisms of oxygenation response to increases in airway pressure and the interpretation of the oxygenation response observed in the present study .