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tardive dystonia ( td ) , a rarer side effect after longer exposure to antipsychotics , is characterized by local or general , sustained , involuntary contraction of a muscle or muscle group , with twisting movements , generally slow , which may affect the limbs , trunk , neck , or face . td has been shown to develop in about 3% of patients who have had long - term exposure to antipsychotics . . the low risk of td for atypical antipsychotics is thought to result from their weak affinity for dopamine receptors . compared with typical , atypical antipsychotic agents have a greater affinity for serotonin 5-ht2a than dopamine d2 receptors , with a low propensity to induce td . among this olanzapine is thought to have preferential action at mesolimbic over nigrostriatal dopaminergic pathways and is , therefore , associated with a very low incidence of extrapyramidal symptom ( eps ) . furthermore , a retrospective analysis of controlled multicentric trials suggested that olanzapine also improves preexisting symptoms of tardive movements . we report a case of 20-year - old male , belonging to lower socioeconomic class , educated up to 2 standard , presented with severe unilateral dystonic left sided neck movements [ figure 1 ] . careful history exploration revealed he was taking risperidone 2 mg irregularly for 2 months and then olanzapine 5 mg for another 4 months . picture of neck dystonia of patient at 19 years , the patient presented with occasional anger outbursts , getting provoked on small matters and beating family members , running away from home , screaming episodes occasionally , fearfulness , sleep disturbance for 2 days ; which was precipitated after fever . according to the mother , one friend might have threatened / made fun of him actually and after that patient stopped going out of house , and displayed above mentioned symptoms . this was interpreted as psychosis with persecutory ideas , and he was treated with risperidone 2 mg / day for 2 months and then with olanzapine 5 mg / day for 4 months . in last two follow - ups patient did not present himself , and mother reported unusual neck movements , which were taken as a part of his overall psychopathology and not taken seriously , slight intermittent neck movements reported were missed as part of adolescent behavior problems mimicking some hero in movies . as neck dystonia increased , the patient had a severe disability as patient had to keep his hands behind his head for the support . the movement would decrease when the patient was lying down and was absent during sleep . he even stopped taking food due to severe neck movements making chewing and swallowing difficult . his birth and early developmental milestones were normal . during 210 years of age patient was inattentive and mildly hyperactive . other siblings were educated with master 's degree , and patient was also sent to school , but due to inattention and restlessness , he did not pass 2 standard after three attempts . he left the schooling . with average executive functioning and life skills , he worked as an unskilled laborer in the neighborhood shops as a helping hand . , he was found to be getting over familiar , cheerful , moody , and short tempered . sometimes , the patient had inappropriate social judgment ; for which his friends made fun of him , and teased him . on mental status assessment , routine investigations , thyroid function tests , electroencephalogram , fundus examination , cervical x - ray , magnetic resonance imaging brain were normal . after consulting neurophysician , wilson 's disease and other secondary causes of dystonia were ruled out . the patient was treated with clonazepam 1 mg total dissolved solid ( tds ) , tetrabenazine 25 mg tds , trihexiphenidyl 2 mg bipolar disorder ( bd ) . after 2 months , there was some improvement of around 30% . baclofen 10 mg was added ; increased up to 20 mg , trihexyphenidyl reduced to 2 mg . with little improvement after 4 months of treatment for dystonia , levodopa + carbidopa ( 100 + 25 ) was added by neurophysician and increased up to tablet tds and baclofen omitted . after 12 months of treatment , patient has improved around 90% with tetrabenazine 75 mg , levodopa + carbidopa ( 100 + 25 ) - tablet bd , and clonazepam 1 mg bd . earlier case reports reported td developing with high - dose atypical antipsychotics such as olanzapine 20 mg or aripiprazole 15 mg with longer duration of exposure of around 1215 months in established psychiatric illness like schizophrenia or any other psychotic illness . eps in general and tardive dyskinesia , in particular , have been extensively studied in schizophrenia . even though a number of studies suggest that bipolar patients experience higher rates of eps ( parkinsonism , dystonia , akathisia ) and td compared to patients with a diagnosis of schizophrenia , research within the bd population has been limited . the risk is found to be 3 to 5 times higher in elderly patients compared to young patients . in addition to age , the risk is directly proportional to : female gender , daily and total dose of the antipsychotic drug , presence of mood disorder , the use of anticholinergics with neuroleptics , previous physical therapies ( electroconvulsive therapy ) , the presence of other physical illness such as diabetes or an organic disorder , younger age of exposure , and the presence of extrapyramidal symptoms early in treatment . this patient 's severe dystonic neck movements developed within short period of 6 months of exposure to atypical antipsychotics risperidone 2 mg and then olanzapine 5 mg only , which can cause minimal extrapyramidal side effects . in this case , risk factors for developing serious disabling td were neuroleptic exposure , borderline intellectual functioning , externalizing behavior , probable misdiagnosis , and overlooking early indicators of side effects . this case highlights dangers of casually prescribing low dose second generation antipsychotics in patient with hyperthymic temperament and borderline intellectual functioning with vague short lasting presenting complaints ; probably misdiagnosed as psychosis ; leading to such severe adverse effects because patients with organic brain damage are more prone to develop adverse effects like td . thus , judicious use of antipsychotics , with detailed and frequent assessments is important , and emergent stereotyped behavior or unexplained movements must be examined carefully and taken seriously . 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 . syncope is caused by transient diffuse cerebral hypoperfusion and is characterized by transient loss of consciousness with a rapid onset followed by spontaneous and complete recovery . clinical features of syncope may include myoclonic jerks which are often multifocal and asynchronous , convulsions , and urinary incontinence , making it difficult to differentiate from epileptic seizure by clinical features alone . significant fluctuations in cerebral perfusion pressure are prevented by autoregulation of cerebral circulation , but there may be conditions where such mechanism may not compensate adequately . cough syncope , a rare form of syncope , may be a result of transient failure of the cerebral autoregulatory mechanism to cope with sudden decrease in cerebral blood flow . we present an unusual case of recurrent cough syncope , which was initially diagnosed and treated as seizures , in the context of a left - sided glomus jugulare tumor , a benign paraganglioma . a 43-year - old right - handed woman with history of glomus jugulare tumor in the left jugular fossa with intracranial extension into the posterior cranial fossa was transferred from another hospital for recurrent seizure - like spells . she had a 90% surgical resection of the tumor done in 2011 followed by radiation therapy in september 2012 . her episodes occurred multiple times a day ( 7 per day on average ) during wakeful state . they were triggered by coughing ( usually a bout of cough ) and were characterized by staring and unresponsiveness as well as stiffening of the body with mild shaking of both upper extremities . she was diagnosed with epileptic seizures but continued to have episodes during treatment with the antiepileptic drugs ( aeds ) phenytoin , levetiracetam , and lamotrigine . escalation of aed therapy made her increasingly drowsy , and she was on all three aforementioned aeds at the time of presentation . her physical examination was remarkable for excessive drowsiness , mild dysarthria , right sixth cranial nerve palsy , mild hypertonia with hyperreflexia in the lower extremities ( left more than right ) , and bilateral ( left more than right ) ankle clonus . she had a lumbar puncture done at the outside hospital , and the opening cerebrospinal fluid ( csf ) pressure was reported to be 25 cm . blood work was also unremarkable except for mild anemia ( hemoglobin : 9.4 g / dl ) , mild hyponatremia ( 132 meq / l ) , and mild hypokalemia ( 3.1 meq / l ) . antiepileptic drug levels were within therapeutic range ( free phenytoin : 1.3 g / ml , levetiracetam : 5.9 g / ml , and lamotrigine : 2.3 g / ml ) . all started with a bout of cough when the patient was lying in bed ( in supine or in lateral position ) which was followed by brief ( less than a minute ) distal upper extremity tremor and subtle proximal upper extremity myoclonic jerks and prolonged unresponsiveness for up to 10 min . all of these episodes were associated with hypotension ( 7278/3147 mm of hg as revealed by continuous arterial pressure monitoring ) and bradycardia ( 5459 bpm ) . the eeg during the spells was characterized by generalized synchronous and asynchronous high amplitude 1- to 2-hz delta activity which progressed to generalized attenuation and then transitioned to generalized delta activity again with recovery ( fig . 1 ) . a head ct showed recurrence of the glomus jugulare tumor and communicating hydrocephalus . an external ventricular drain ( evd ) after placement of the evd , her drowsiness gradually started to improve , and episodes decreased in frequency to one per day . 3 showed an enhancing t2 hyperintense left skull base mass in the region of the left jugular foramen with extension into the posterior cranial fossa and below the base of the skull . brain imaging showed evidence of hydrocephalus that had increased compared with her previous brain imaging done 2 months back . her mental status continued to improve , and she had only one mild episode triggered by cough during the next two days before her discharge . repeat surgical resection of the tumor was recommended by the otolaryngology team , which the patient declined . based on the clinical features and eeg findings , the episodes observed in our patient are most consistent with cough syncope . the mechanism underlying cough syncope is not definitively established , but it is postulated that coughing increases intrathoracic and intraabdominal pressures leading to a transient increase in icp . increased icp , in turn , causes a decrease in cerebral perfusion pressure which , if it drops below a critical level , may result in global cerebral hypoperfusion leading to syncope . transient cerebral circulatory arrest has been demonstrated by transcranial doppler measurements during cough syncope . our patient also had a drop in blood pressure and heart rate but probably not sufficient to cause syncope by itself . cough syncope has been associated with posterior fossa mass lesions or tonsillar herniation and with hydrocephalus . it may be speculated that bouts of cough caused transient herniation of cerebellar tonsils obstructing csf flow that further contributed to the increase in icp during coughing . decrease in frequency of events following placement of evd to relieve icp lends support to this notion . paragangliomas are rare tumors of extraadrenal chromaffin cell origin that most commonly occur in the head and neck region . catecholamine - hypersecreting paraganglionomas are uncommon in the head and neck region , and most patients ( 95% ) with hypersecreting paraganglionomas have hypertension . hypotension accompanying syncope observed in our patient was not orthostasis - related ( the patient was always supine during spells ) and was most likely related to cough . identified a subset of patients with cough syncope who lacked a blood pressure overshoot ( expected response ) after the relief of straining during valsalva maneuver . the authors postulate that cough syncope in these patients might be the result of delayed recovery from hypotension that follows a paroxysm of cough , and this was likely contributing to global cerebral hypoperfusion in our patient . this case highlights the fact that cough syncope , a rare form of syncope , may be associated with intracranial mass lesions that indirectly exaggerate the increase in icp in response to cough . glomus caroticum tumor presenting as recurrent unexplained syncope and posterior fossa meningioma presenting as recurrent cough syncope have been described . recurrent cough syncope should trigger search for factors , including brain tumors , with the potential to cause transient elevation in icp . this case also illustrates an important role for ceeg monitoring with video in distinguishing syncope from seizures in cough syncope cases .

tardive dystonia ( td ) is a serious side effect of antipsychotic medications , more with typical antipsychotics , that is potentially irreversible in affected patients . studies show that newer atypical antipsychotics have a lower risk of td . as a result , many clinicians may have developed a false sense of security when prescribing these medications . we report a case of 20-year - old male with hyperthymic temperament and borderline intellectual functioning , who developed severe td after low dose short duration exposure to atypical antipsychotic risperidone and then olanzapine . the goal of this paper is to alert the reader to be judicious and cautious before using casual low dose second generation antipsychotics in patient with no core psychotic features , hyperthymic temperament , or borderline intellectual functioning suggestive of organic brain damage , who are more prone to develop adverse effects such as td and monitor the onset of td in patients taking atypical antipsychotics .

agenesis of the inferior vena cava ( ivc ) as a cause of recurrent deep vein thrombosis ( dvt ) is uncommon . a 33-year - old male with no family history of thrombophilia , who had experienced multiple recurrent episodes of dvt over a 15-year period of unknown cause , was admitted into our hospital because of cellulitis in the right leg . congenital absence of the ivc could be a rare risk factor for idiopathic dvt , especially in young individuals . venous thromboembolism ( vte ) , which includes deep vein thrombosis ( dvt ) and pulmonary embolism , has an incidence of 1 to 3 per 1000 individuals per year in western populations.1 congenital anomalies of the inferior vena cava ( ivc ) are uncommon , and have been associated with the development of venous thrombosis of the lower limbs.2 congenital anomalies of the ivc has been reported as a risk factor for dvt , especially in individuals < 30 years old , and a concomitant thrombophilic disorder has been found in such individuals.3 we report a case of recurrent dvt in a 33-year - old man with agenesis of the ivc . the patient had experienced recurring episodes of idiopathic dvt in the right leg for 15 years . a 33-year - old man was admitted to the internal medicine department , holy family hospital , nazareth , israel , because of cellulitis in the right leg . one week prior to his admission , he complained about pain and increased local heat in the left ankle and thumb of the right leg . the patient had no history of previous trauma , surgery , insect bites , dysuria , or joint symptoms , and no family history of thrombophilia . he reported that he had ( a ) rheumatic fever without any complications when he was 19 years old , which was treated with penicillin , ( b ) been hospitalized when he was 23 years old because of infected skin ulcers on the right calf , for which he was treated by parenteral antibiotics , and ( c ) recurrent episodes of idiopathic dvt for the last 15 years . he also reported that he had not been treated with warfarin , but he had been on prophylactic enoxaparin therapy for dvt some years ago which has since been stopped and that he had been recently treated with allopurinol and colchicine for a presumed diagnosis of gout . he had been investigated several times for a primary hypercoagulability state , and the results were negative . on examination , the most outstanding clinical findings were swelling of ankles , mild edema , redness , and increased temperature of the right ankle and calf with trophic skin changes ( skin discoloration with ulcers ) , and superficial varicose veins in the lower abdomen ( figure 1 ) . the clinical laboratory findings ( erythrocyte sedimentation rate , leukocyte and platelet counts , and plasma hemoglobulin , plasma protein c , plasma protein s , fibrinogen , and antithrombin iii levels ) , the results of the kidney and liver function tests , and resistance to activated protein c were all normal . polymorphisms of the genes that encode for methylenetetrahydrofolate reductase were not detected , and the factor v leiden and prothrombin mutations g20210a were absent . the results of the clinical immunological studies for complement c3 and c4 and rheumatoid factor were negative , and no circulating titers for antinuclear antibody , antineutrophil cytoplasmic antibody , and cardiolipin antibody were found . cultures from the infected skin ulcers of the right leg were positive for methicillin - resistant staphylococcus aureus ( mrsa ) . ultrasound imaging of the leg veins showed a previous dvt in the right common femoral vein , and dilated superficial inguinal veins . computer tomography with contrast of the abdomen showed agenesis of the infrarenal segment of the ivc ( figure 2 ) with dilated azygos and hemiazygos veins ( figure 3 ) . there were also varicose veins in the abdominal wall and right groin , which were associated with dilated superficial and collateral veins ( figure 4 ) . transthoracic echocardiography of the patient s heart revealed mild atrial enlargement and good systolic function of the left ventricle , and no pathological valvular flows . the patient was diagnosed as having agenesis of the infrarenal segment of the ivc and dvt of the right leg without concomitant risk factors for vte . since we attributed the agenesis of the ivc to be the underlying cause of the recurrent episodes of the dvts , the patient was started on anticoagulant therapy ( subcutaneous enoxaparin 160 mg / day ) for dvt , antibiotic therapy ( intravenous vancomycin 1.5 g / day for mrsa skin infection ) , and referred to a vascular surgeon specialist but the patient refused . at follow - up in the internal medicine clinic , the most outstanding clinical findings were swelling of left ankle , redness , with trophic skin changes , and a mild improvement of the skin ulcers . despite several phone calls for follow - up the normal ivc is composed of 4 segments : hepatic , suprarenal , renal , and infrarenal . since many transformations can occur during the formation of the ivc such anomalies occur in 0.3% of otherwise healthy individuals , and in 0.6% to 2% of patients with other cardiovascular anomalies.4 ruggeri et al reported 10 years ago 4 cases of congenital absence of the ivc in 75 young patients with idiopathic dvt over a 5-year period , and estimated that 5% of young patients with dvt had an anomaly of the ivc.5 venous thrombosis is caused by the presence of isolated or combined risk factors . almost 150 years ago , the nineteenth century pathologist rudolf virchow described 3 critically important causes of venous thrombosis : venous damage , coagulation defect(s ) , and venous stasis.6 individuals with a congenital anomaly of the ivc are typically asymptomatic , and the anomaly is usually detected incidentally during radiological or abdominal procedures . congenital absence of the ivc is infrequently associated with thromboembolic events.5 patients who suffer from congenital anomalies of the ivc usually develop a compensatory circulation through the azygos veins or collateral abdominal veins in order to keep the venous return near normal levels.7 most reported cases of congenital anomalies of ivc cases have been linked to thrombophilia disorders.3,5,7 however , the true prevalence of thrombophilia in congenital anomalies of the ivc is unknown because the screening for thrombophilia in patients with an ivc anomaly was usually incomplete.3 anticoagulants , but not thrombolytic therapy , are usually prescribed for venous thrombosis , but the duration of the anticoagulant therapy is not well established . hence , anticoagulant therapy for an indefinite duration will probably be prescribed , unless vascular reconstructive surgery is done on the anomalous ivc . such surgery has been rarely reported , and its long - term outcome is undetermined.8 congenital anomalies of the ivc may cause recurrent dvt , especially in young individuals .

background : agenesis of the inferior vena cava ( ivc ) as a cause of recurrent deep vein thrombosis ( dvt ) is uncommon.case:a 33-year - old male with no family history of thrombophilia , who had experienced multiple recurrent episodes of dvt over a 15-year period of unknown cause , was admitted into our hospital because of cellulitis in the right leg . computer tomography with contrast of the abdomen showed an absence of ivc.conclusion:congenital absence of the ivc could be a rare risk factor for idiopathic dvt , especially in young individuals .

a review of the literature and an extensive medline search revealed that this is the first case report of the use of guaifenesin to increase sperm motility . he reported an inability to conceive with his wife after 18 months of unprotected intercourse . a semen analysis was performed that included spermatozoa count , liquefaction , morphology , motility , viscosity and volume . two months after guaifenesin therapy the semen analysis was repeated that demonstrated marked improvement in both total sperm count and motility . evidence for the effectiveness of guaifenesin is almost entirely anecdotal . given the mechanism of action of guaifenesin , it is not clear from this case why the patient demonstrated such a large improvement in both sperm count and motility . additional studies of the effects of guaifenesin on male fertility could yield information of the medication s effect on men with normal or decreased total sperm counts . there are currently anecdotal reports and popular news media stories on the use of guaifenesin , particularly the brand name product robitussin ( pfizer , inc . , new york , ny ) , for use in treating both male and female infertility.14 guaifenesin is an expectorant medication sold over the counter and usually taken by mouth to assist expectoration of phlegm from the airways in acute respiratory tract infections . its mode of action in treating infertility is not well understood , but it appears to decrease mucus viscosity . a 32-year - old male patient presented to his primary care provider for an infertility evaluation . the patient is a nonsmoker , who consumes little or no alcohol with no known allergies . a recent screening exam for pulmonary tuberculosis was negative and the patient had recently undergone a required military service physical exam . he reported an inability to conceive with his wife after 18 months of unprotected , regular intercourse . as part of a routine infertility evaluation a semen analysis was performed that included spermatozoa count , liquefaction , morphology , motility , viscosity and volume ( cpt code 89320 ) . initial results of the semen analysis demonstrated low sperm count and motility ( table 1 ) . this sample , as well as the follow - up sample , were obtained through masturbation and provided to the lab within 30 minutes of collection . the patient s primary care provider offered treatment with guaifenesin 600 mg extended release tablets twice daily . the repeat semen analysis demonstrated marked improvement in both total sperm count and motility ( table 1 ) . the patient made no other significant lifestyle changes during the treatment course with guaifenesin . at the time of writing this case report describes the semen analysis laboratory results in a male patient who was given guaifenesin . guaifenesin is a mucolytic agent usually taken orally to assist the expectoration of phlegm from the airways in acute respiratory tract infections . scientific evidence for the effectiveness of guaifenesin is almost entirely anecdotal ; a review of medical literature revealed very limited data on use of guaifenesin for infertility.5,6 there appeared to be some improvement in a small study without controls of female infertility related to hostile cervical mucus.5 check regards guaifenesin as the simplest but least effective method of improving cervical mucus.7 given the proposed mechanism of action of guaifenesin , it is not clear from this case why the patient demonstrated such a large improvement in both sperm count and motility . additional study of the effects of guaifenesin on male fertility suggests the need to conduct a more rigorous placebo - controlled clinical trial that could yield information of the medication s effects on men with normal or decreased total sperm counts . primary diffuse leptomeningeal gliomatosis ( pdlg ) is a rare neoplasm with a short survival time of a few months . we report on a 53-year - old male patient who presented with epileptic seizures , gait disturbance , paraparesis and sensory deficits in the dermatomes t8 - 10 . magnetic resonance imaging ( mri ) revealing numerous spinal and cranial gadolinium - enhancing nodules in the meninges and histopathology led us to diagnose primary diffuse leptomeningeal gliomatosis with who grade iii astrocytic cells . consecutively , the patient underwent craniospinal radiotherapy ( 30 gy ) and 11 sequential cycles of temozolomide . thirteen months later , spinal mri revealed tumor progression . second - line chemotherapy with 5 cycles of irinotecan and bevacizumab did not prevent further clinical deterioration . the patient died twenty - two months after diagnosis , being the longest survival time described thus far with respect to pdlg consisting of astrocytic tumor cells . radiochemotherapy including temozolomide , as established standard therapy for brain malignant astrocytomas , might be valid as a basic therapeutic strategy for this pdlg subtype . primary diffuse leptomeningeal gliomatosis ( pdlg ) is diagnosed when a glioma is located in the subarachnoid space , while intraparenchymal tumor lesions are absent . pdlg must be distinguished from secondary meningeal gliomatosis resulting from a primary gliomatous cns tumor . pdlg , especially when caused by malignant astrocytic cells , is associated with very poor survival . we describe a patient with pdlg consisting of malignant astrocytic cells who underwent combined radio- and chemotherapy leading to the longest survival time described in the literature thus far . a 53-year - old man was referred to the dept . of neurology due to a generalized epileptic seizure and five months later he presented with bilateral sensory deficits at dermatome levels t8 - 10 , paraparesis and gait disturbance . cerebrospinal fluid ( csf ) analysis revealed a high cell count ( 300/3 cells/l ; reference range : 5/3 cells/l ) with atypical cells that could not be further characterized . t1-weighted images ( t1-wi ) revealed spinal and cranial gd - enhancing nodules in the leptomeninges ( figures 1a - e ) and on t2-weighted images ( t2-wi ) an intramedullary edema ( figure 1c ) . note gd - enhanced supra- and in - fratentorial meningeal thickenings of the brain in sagittal t1-w image ( a ) . prior to ra - diochemotherapy , t1-wi reveals lep - tomeningeal gd - enhancement ( b ) and t2-wi shows edema of the myelon on levels c7 , t1 - 2 and t5 - 6 due to minor tumor extensions in the adjacent spinal cord ( c ) . following radiochemotherapy , t1-wi displays reduced leptomeningeal gd - enhancement ( d ) while t2-wi shows less myelon spinal edema on those levels ( e ) . three weeks later , intradural biopsy from a gd - enhancing nodule at l2 - 3 level revealed fibrously - thickened meninges infiltrated by malignant astrocytic tumor cells ( figures 2a - c ) . the tumor was categorized as primary diffuse leptomeningeal gliomatosis ( pdlg ) confirmed by the reference center for brain tumors in dsseldorf , germany . intradural lumbar biopsy displays fibrously - thickened lep - tomeninges infiltrated by pleomorphic neoplastic astrocytic cells ( a ) . the astrocytic tumor cells reveal intensive intracytoplasmic staining with anti - glial fibrillary astrocytic protein . ki67 ( mib-1 ) staining reveals a high proliferation index of up to 20% ( c ) . prior to radiotherapy of the craniospinal axis ( 4 2.5 gy / week , total dose : 30 gy ) , the patient underwent 3 cycles of temozolomide ( tmz ) ( cycle 1 : 150 - 200 mg / mtzm , d1 - 5 , q28d ) . on re - staging , spinal t1-weighted images showed tumor - lesion regression on l5 and spinal t2-wi images demonstrated spinal - edema regression ( compare figures 1c - d with figures 1a - b ) . three weeks after the completion of radiotherapy the patient received eight additional cycles of tmz ( 200 mg / mtzm , d1 - 5 , q28d ) , during which meningeal thickening of the brain regressed . however , spinal mri thirteen months after starting tmz therapy revealed meningeal tumor progression at the lesions on spinal levels c1 - 2 , c7-t2 and t5 - 8 . five cycles of second - line chemotherapy with irinotecan and bevacizumab failed to halt further clinical deterioration . the patient died twenty - two months after the diagnosis of pdlg and exhibited until dead an encouraging karnovsky performance status of 60% . the diagnosis of pdlg is usually established by autopsy but rarely diagnosed prior to death . pdlg of the oligodendroglial and that of the well - differentiated astrocytic tumor type are associated with a considerably longer median survival time than that of the malignant astrocytic tumor type . pdlg was diagnosed in the aforementioned case , as we observed on histopathology leptomeningeally - encapsulated malignant astrocytic cells without primary attachment to the spinal cord or brain parenchyma and gd - enhancing leptomeningeal thickening at the base of the brain and spinal level in mri . various treatment modalities were used for 14 patients suffering from pdlg with malignant astrocytic cells reported in the literature so far ( cf . table 1 ) , demonstrating the lack of a standardized treatment regimen of pdlg with malignant astrocytic cells . although the number of cases is small , the data on their survival times ( cf . table 2 ) might suggest that radiotherapy and temozolomide ( tmz ) as established treatment for newly diagnosed recurrent anaplastic astrocytomas also seem to be valid for pdlg with malignant astrocytic cells . this concept is supported by the observation that radiotherapy alone can prolong the median survival time of five months for patients without any specific therapy to a median survival of 12 months and that integration of tmz in the chemotherapy alone may lead to a prolonged median survival of 15 months . the importance of tmz in the chemotherapy treatment of pdlg is supported by the observation that the median survival time fell to 3 months when the integration of tmz was omitted . clinico - pathological characteristics and treatment of adult patients suffering from pdlg with malignant astrocytic cells including our case 5-fu = 5-fluouracil , adr = adriamycin , auc 5 = carboplatine , bcnu = carmustine , brs = brainstem , bvz = bevacizumab , c = cycle , ca = cytarabine , ccnu = lomustine , cr = cranial , cyc = cyclophosphamide , ddp = cisplatin , eto = etoposide , inn = topotecan , int = irinotecan , irp = raised intracranial pressure , it = intrathecally , mcnu = ramustine , mtx = methotrexate , sc = spinal cord , tmz = temozolomide , top = thiotepa , vincristine , prednison summary of the literature : pdlg with malignant astrocytic cells the prolonged survival of our patient may be due to the addition of tmz to radiation therapy as it resulted in an extent of the median survival time for high grade glioma patients . in addition , the hypofractionated radiotherapy regimen used is supposed to be more effective than conventional fractionated irradiation . additionally , the patient 's good karnofsky performance status may have contributed to our patient 's prolonged survival . in conclusion , we report on partial regression and long survival in a patient with pdlg of the malignant astrocytic type following hypofractionated radiotherapy and tmz . an immediate radiochemotherapy seems crucial for a prolonged survival of pdlg patients in good general condition . the authors disclose no or potential conflict of interest including any financial , personal or other relationships with other people or organizations within the three years of beginning the submitted work that could inappropriately influence or be perceived to influence their work .

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

a 60-year - old woman ( height , 162 cm ; weight , 61 kg ) visited pain clinic with tactile allodynia and electric shock - like pain in the left dorsal scapular area around the t3 dermatome , which had been diagnosed as phn about 1 month previously and attack of the herpes zoster was 1 year ago . the 100-mm visual analogue scale ( vas ) of allodynia and electric shock - like pain was rated between 70 and 80 mm on a scale from 0 ( no pain ) to 100 ( worst pain imaginable ) . the interlaminar epidural block was performed at the t3 - 4 space by the paramedian approach with 5 ml of 0.2% ropivacaine and 20 mg of triamcinolone acetate . pregabalin and morphine at doses of 150 mg and 10 mg , respectively , twice a day , amitriptyline at a dose of 10 mg before sleep and topical lidocaine patches were prescribed . dosages of all drugs were adjusted depending on the side effects during the follow - up period . epidural blocks were repeated twice with a 1-week interval and the continuous intravenous infusion of ketamine ( 60 mg ) was performed over a period of 1 hour twice a week under careful monitoring . after 1 month elapsed , electric shock - like pain was reduced to a vas score of 30/100 , but allodynia was not diminished ( vas score of 70/100 ) . after 4 months elapsed , we decided to administer magnesium sulfate via the intravenous route . and it was done with continuous intravenous infusion of 1,000 mg of magnesium sulfate in 50 ml of normal saline for 1 hour . before and after infusion , the serum magnesium levels were checked . after magnesium therapy , she felt very good about her pain and the vas of allodynia was reduced to 40 - 50 . at 1-week follow - up , she was very satisfied with the treatment and reported the reduction of allodynia on the dorsal scapular area of up to 50% ( vas 25 - 30/100 ) . however , the serum magnesium level had increased above normal range ( 2.3 meq / l to 2.9 although it was below the serum level reveals of the adverse effect , we decided to stop intravenous infusion of magnesium sulfate . for more accurate and safe delivery of magnesium to the target site , we applied magnesium using the transforaminal epidural injection technique . with the patient 's informed consent , left t3 tfemi identification of the t3 nerve root sheath and epidural space was performed using contrast media ( fig . 1 ) . then , 100 mg of magnesium sulphate and 1 ml of 0.2% ropivacaine ( total volume , 2 ml ) was carefully injected . tfemi was repeated twice with a 1-week interval ( total of three times ) and the degree of pain decreased gradually during the follow - up period . one week after the last procedure , the vas score of allodynia decreased to 15/100 and all medications except pregabalin were discontinued . the vas was 10/100 throughout 1-month follow - up , and pregabalin had also been tapered . to our knowledge , no previous report has described about the magnesium administration by the transforaminal epidural route in patients with neuropathic pain . here , in our report of phn patient , this treatment resulted in effective pain relief . previous studies have demonstrated the anti - allodynic effects of nmda receptor antagonists in neuropathic pain disorders . among the currently available nmda receptor antagonists , ketamine is the most widely used one for the treatment of neuropathic pain . however , ketamine is not always effective and psychomimetic side effects are frequent . magnesium can antagonize nmda receptor channels by blocking calcium influx in a voltage - gated manner . intravenous administration of magnesium is efficacious in the management of various conditions associated with neuropathic pain , including phn . demirkaya and colleagues revealed 1 g i.v . mg sulfate is effective in the treatment of migraine attacks and collins and colleagues reported that 70 mg / kg magnesium sulphate infusions in 4 hours for 5 days reduced pain in patients with complex regional pain syndrome . whether intravenous administration of magnesium can achieve a sufficient concentration in the cerebrospinal fluid to block nmda receptors is unclear and studies have reported on the limited efficacy of magnesium when administered via the intravenous route . furthermore , even if the dose of intravenously administered magnesium is not sufficient to present toxicity , patients are still at risk of magnesium overdose . neuraxial administration of magnesium is an " off - label " use , and the safety of this technique in human subjects is still undetermined . however , animal studies showed that intrathecally administered magnesium was free of neurotoxicity , and recent studies have demonstrated the safety of magnesium administration via the epidural or intrathecal route in humans . in fact , the exact site of action of epidurally administered magnesium ( i.e. , spinal or supraspinal ) remains unclear . however , comparison with previous reports regarding intravenous magnesium administration suggested that the low dose epidural magnesium used in our patient was unlikely to result in systemic effects . in conclusion , tfemi showed a favourable result in the treatment of intractable allodynia associated with phn . this study was performed in only a single case , and further investigations are required to determine the efficacy of tfemi in the management of allodynia in patients with phn .

because of rampant concern that estrogenic chemicals in the environment may be adversely affecting the health of humans and wildlife , reliable methods for detecting and characterizing estrogenic chemicals are needed . it is important that general agreement be reached on which tests to use and that these tests then be applied to the testing of both man - made and naturally occurring chemicals . as a step toward developing a comprehensive approach to screening chemicals for estrogenic activity , three assays for detecting estrogenicity were conducted on 10 chemicals with known or suspected estrogenic activity . the assays were 1 ) competitive binding with the mouse uterine estrogen receptor , 2 ) transcriptional activation in hela cells transfected with plasmids containing an estrogen receptor and a response element , and 3 ) the uterotropic assay in mice . the chemicals studied were 17 beta - estradiol , diethylstilbestrol , tamoxifen , 4-hydroxytamoxifen , methoxychlor , the methoxychlor metabolite 2,2-bis(p - hydroxyphenyl)-1,1,1-trichloroethane ( hpte ) , endosulfan , nonylphenol , o , p'-ddt , and kepone . these studies were conducted to assess the utility of this three - assay combination in the routine screening of chemicals , or combinations of chemicals , for estrogenic activity . results were consistent among the three assays with respect to what is known about the estrogenic activities of the chemicals tested and their requirements for metabolic activation . by providing information on three levels of hormonal activity ( receptor binding , transcriptional activation , and an in vivo effect in an estrogen - responsive tissue ) , an informative profile of estrogenic activity is obtained with a reasonable investment of resources.imagesp1296-afigure 1.figure 2.figure 3.figure 4.figure 5 .

the following section describes the treatment procedure for patients with deep infection following tka using modified static spacers . the original prosthesis was removed , followed by intensive irrigation and wide debridement of the infected soft tissue . a 36 fr - diameter straight thoracic catheter ( mallinckrodt medical , athlone , ireland ) and a steinmann pin measuring 3.0 mm in diameter and 22 cm in length vancomycin ( 2 g ) was then added to the gentamicin bone cement ( depuy , warsaw , in , usa ) . at the late liquid stage of the cement , the steinmann pin was inserted into the tube , and the prepared cement was delivered through the tube . during this procedure , the tube was removed from the cement rod using a surgical knife . finally , a cement rod measuring 9 mm in diameter and 22 cm in length was formed ( fig . an entry hole was created at the center of the distal femur and proximal tibia for the insertion of the cement rod . the rod was then inserted into the femur and tibia through this hole . during insertion , it was important to place the center of the cement rod on an imaginary joint line . the proximal medullary canal of the tibia was filled with antibiotic - impregnated cement up to the surface of the proximal tibia , while the surgical assistant maintained proper anatomic alignment and joint space . the space between the cement of the distal femur and the proximal tibia was filled with more antibiotic - impregnated cement . finally , the suprapatellar pouch and medial and lateral gutter space were filled with antibiotic - impregnated cement to reduce soft tissue adhesion ( fig . cylinder splint immobilization was required for three days after the operation , after which a fixed - angle knee brace was used and toe - touching ambulation was allowed until the reimplantation surgery . from april to november 2007 , the authors performed the static technique in four patients using the novel antibiotic - impregnated cement rod for the treatment of infected tka ( culture : staphylococcus in three cases and no bacteria in one case ) . follow - up laboratory studies , including erythrocyte sedimentation rate and c - reactive protein , culture study via knee aspiration and a frozen biopsy from the second - stage operation ( < 5 polymorpho - leukocytes / high power field ) were performed to confirm successful eradication of the infection . the second - stage reimplantation was performed when all the criteria for the validation of infection control were met ( fig . the second - stage reimplantation was performed using the rectus snipping approach , and more than 90 of flexion was obtained intra - operatively . in all four patients , no re - infection was evident after two and a half years of follow - up . the range of motion of the knee joints were respectively improved from 50 to 80 , 95 , and 100 , and the knee society scores were 70 , 86 , 65 , and 84 , respectively , in the last follow - up evaluation . fehring et al.8 ) emphasized the importance of resting the joint in septic joint conditions . others also reported that the static spacer technique provides more stability than the mobile spacer technique in patients with severe bone loss.5,8 ) the main advantage of this technique is the maintenance of a normally aligned lower limb during the interval period . this maintains knee stability in combination with early muscle strengthening exercises , including quadriceps setting exercise , and enables the patient to comfortably dress and manage him / herself during the intervening period . the cement rod and static spacer provide a stable gap between the femur and tibia , thereby minimizing soft tissue contracture and shortening of the lower limb . in addition , symmetric maintenance of the soft tissue of both medial and lateral gutters requires no additional soft tissue balancing at the second - stage reimplantation . the additional cost of a metal nail , however , and the difficulty in infection control due to biofilm formation around the metal nail can be troublesome . in addition , a metal nail can not be removed easily at the second stage reimplantation due to its hardness , and soft tissue adhesion of the femoral or tibial medullary canals . on the other hand , an antibiotic - impregnated cement rod enjoys advantages , such as inexpensive antibiotic delivery to the marrow spaces and easy removal by using a hercules cutter . in addition , a static spacer is anchored to the cement rod , which can prevent spacer migration and bone erosion . this feature is believed to generate less cement wear debris than with the conventional static spacer or mobile articulating spacer technique . during the conduct of the antibiotic - impregnated cement rod technique , antibiotic - impregnated cement was applied to the proximal tibia , distal femur , joint gap space , suprapatellar pouch , and both gutters in a stepwise manner . this technique enables easy removal of the cement and reduced soft tissue adhesion at second - stage reimplantation . ankle dorsiflexion passive range of motion ( df prom ) measurements are performed in the field of physical therapy to estimate ankle motion during functional activities1 and to prevent lower extremity injuries2 . although in the clinical setting , ankle df prom is frequently measured under non - weight - bearing ( non - wb ) conditions1 , 3 , 4 , many researchers have stated that the wb position is more appropriate for estimating the amount of ankle df motion during functional activities5 , 6 . therefore , wb ankle df prom should be measured during interventions focused on increasing ankle df prom . limited ankle df prom with knee extended may result from gastrocnemius tightness and insufficient posterior talar glide7 . thus , gastrocnemius stretching and talocrural joint mobilization have been performed as intervention strategies to increase ankle df prom3 , 8 , 9 . previous studies have reported a significant increase in ankle df prom after these interventions3 , 8 , 9 ; however , to our knowledge , no study has demonstrated the combined effect of both interventions on wb ankle df prom . therefore , the aim of the present study was to examine the influence of gastrocnemius stretching combined with joint mobilization on wb ankle df prom . in total , 11 male subjects with bilateral limited non - wb ankle df prom with knee extended ( mean age , 22.82 3.09 years ; mean height , 175.91 3.39 cm ; mean weight , 69.55 3.78 kg ; mean non - wb ankle df prom , 4.17 2.48 ) participated in this study . inclusion criteria were 1 ) ankle df prom with knee extension < 10 ; 2 ) ankle df prom with knee flexion > 10 ; and 3 ) > 5 difference in ankle df prom between knee extension and knee flexion conditions on bilateral sides in non - wb positions3 . subjects with a history of surgery on the lower extremity , fracture , or neurological diseases were excluded from this study . all participants signed an informed consent form approved by the institutional research review committee of inje university prior to participation in this study . the study protocol of this study complies with the ethical standard of the declaration of helsinki . wb ankle df prom with knee extended was measured following the procedures suggested by munteanu et al10 . subjects stood in front of a wall and placed the leg being tested behind the contralateral leg in a lunge posture . subjects were asked to place both hands on the wall and then lean forward without heel - off and knee flexion until maximum stretch was felt in the gastrocnemius on the tested leg . the force applied to the tested leg was maintained at 60 5% of the subject s weight using scales11 . an examiner determined the maximum tibial inclination using an inclinometer to measure the wb ankle df prom with knee extended . measurements of wb ankle df prom were repeated 3 times for each ankle under pre- and post - intervention conditions . the mean value of 3 trials was used for data analysis . for gastrocnemius stretching combined with joint mobilization , subjects leaned forward against the wall in the same lunge posture as that during measurement of wb ankle df prom with knee extended until the maximum gastrocnemius stretch was felt . subjects held the end - range posture while an examiner provided the talus of the tested leg with sustained anterior - to - posterior gliding force . an intervention trial was performed for 30 s , and 10 trials were repeated with 30-s rest periods for each ankle . the difference in wb ankle df prom with knee extended between pre- and post - intervention conditions was analyzed using a paired t - test . wb ankle df prom with knee extended was significantly increased in post - intervention compared with pre - intervention conditions ( 42.60 5.49 versus 38.24 4.69 , p < 0.001 ) . our findings demonstrate that gastrocnemius stretching combined with joint mobilization significantly increases wb ankle df prom with knee extended . stretching exercises increase tolerance , resulting in increased rom12 . additionally , increased displacement of the myotendinous junction ( mtj ) after gastrocnemius stretching for 5 min was found in a previous study13 . therefore , the change in tolerance and/or increase in mtj displacement might have influenced our findings . the addition of talocrural joint mobilization to gastrocnemius stretching is another possible explanation for our findings . previous research by dinh et al.3 showed a 4.25 increase in wb ankle df prom with knee extended after gastrocnemius stretching alone for 3 weeks . although gastrocnemius stretching combined with joint mobilization was applied for 5 min in the present study , the amount of increase in wb ankle df prom after intervention ( i.e. , 4.36 ) was similar to that found previously . considering this outcome , despite the relatively short period of intervention in the present study , it may be inferred that the addition of talocrural joint mobilization might maximize the effects of general gastrocnemius stretching . thus , we conclude that gastrocnemius stretching combined with joint mobilization might decrease gastrocnemius tightness and increase posterior talar gliding movement , which effectively increases wb ankle df prom with the knee extended . first , although non - wb ankle df prom was used as an inclusion criterion , changes in non - wb ankle df prom after intervention were not measured . however , we believe that wb ankle df prom is clinically more important because most functional activities are performed under the wb condition . second , our study included only male subjects , and the results can not be generalized to women .

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

an estimated 170 million people worldwide have hepatitis c virus ( hcv ) infection and over 20,000 new cases emerge every year . hcv infection frequently persists and may cause cirrhosis and hepatocellular carcinoma . in the us and most developed nations , where the prevalence of infection is 1%2% , hcv is the leading cause of chronic liver disease.1 hcv infection is a serious public health problem in egypt , and is the country with the highest hcv prevalence , where 10%20% of the general population is infected.2 interferons are a group of glycoproteins that modulate the activity of the immune system . recombinant alpha - interferon ( ifn ) has recently been approved as a therapy for chronic hepatitis c , for its antiviral effects and inhibition of cell proliferation.3 although interferon - based therapy is widely used for the treatment of chronic hcv , it is not without its disadvantages . treatment duration lasts for months , and is often fraught with potentially dangerous side effects . some of these side effects , such as influenza - like illness , myalgias , depression , and cytopenias can be intolerable resulting in premature treatment cessation , but have no lasting effects . ocular complications are among the complications of interferon therapy and include retinal hemorrhages , cotton wool spots , loss of color vision , cataracts , glaucoma , and occasionally retinal artery or vein obstruction . although the incidence of ophthalmological disorders while on interferon therapy is low , this can result in loss of vision.411 in this prospective case series study , one hundred patients with chronic hepatitis - c under interferon ( inf ) therapy were consecutively recruited from patients attending the outpatient ophthalmic clinic at the university hospital , faculty of medicine , al - azhar university , assuit . the study protocol was approved by the ethics committee at al - azhar university hospital . written informed consent was obtained from all patients included in the study , and then in addition to the medical and laboratory examination , all patients were subjected to full ophthalmological assessment to evaluate the retinopathy associated interferon therapy . inclusion criteria were : ( 1 ) seropositivity for anti - hcv antibodies determined using elisa ; ( 2 ) first use of interferon therapy . exclusion criteria were : ( 1 ) previous interferon therapy ; ( 2 ) patients with hepatitis b ; ( 3 ) patients with decompensated liver ; ( 4 ) patients with renal failure ; ( 5 ) patients with cardiovascular disorders such as coronary insufficiency , congestive heart failure , and ischemic stroke ; ( 6 ) patients with a dense cataract , visual field abnormality , glaucoma , or any other ocular abnormalities . evaluation before treatment : history of visual loss , hazy vision , and ocular disease or ocular surgeries ophthalmological examination : ( 1 ) best corrected visual acuity ( bcva ) measured using landolt s broken rings ; ( 2 ) pupillary reaction ( direct and consensual ) and if there is afferent pupillary defect ; ( 3 ) full slit - lamp examination ; ( 4 ) intraocular pressure ( iop ) measured by goldmann s applanation tonometer ; ( 5 ) fundus biomicroscopy ( carried out after maximum pupillary dilation by a combination of tropicamide 1% eye drops and phenylephrine 2.5% eye drops using both slit - lamp biomicroscopy with noncontact + 90 d volk lens and/or goldmann contact lens ) ; ( 6 ) examination of the retinal periphery using an indirect ophthalmoscope . medical examinations and abdominal ultrasonography investigations : ( 1 ) ocular , both colored fundus photography and fundus fluorescein angiography ( ffa ) ; ( 2 ) laboratory ( including enzyme - linked immunosorbent assay ( ellsa ) test for hepatitis surface ag and ab ; polymerase chain reaction ( pcr ) for hepatitis c virus rna ; full blood count ; prothrombin time ; direct and indirect bilirubin ; fasting blood sugar ; serum creatinine ; liver enzymes ( serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase ) ; alanine aminotransferase . patients were treated with pegylated interferon -2a at a dose of 180 mcg injected subcutaneously once weekly for 48 weeks . all patients underwent clinical and laboratory assessments , ophthalmic examination , at 15 days , 1 month , 2 months , 3 months , 6 months , 8 months , and 9 months after the start of ifn treatment . patients were treated with pegylated interferon -2a at a dose of 180 mcg injected subcutaneously once weekly for 48 weeks . all patients underwent clinical and laboratory assessments , ophthalmic examination , at 15 days , 1 month , 2 months , 3 months , 6 months , 8 months , and 9 months after the start of ifn treatment . initially , 120 patients fulfilled the criteria for ifn therapy , but 20 of them were excluded due to non - compliance with the follow - up visits and due to the presence of diabetic or hypertensive retinopathy . also , two patients died during the study time , due to a disease not related to hepatitis , so these patients are not included . therefore , a total of 100 patients ( 68 male and 32 female ) , with chronic hcv were selected . after the start of interferon therapy , 16 out of 100 patients ( 16% ) developed retinopathy which was bilateral in 12 ( 75% ) patients and unilateral in 4 ( 25% ) patients . retinopathy was initially diagnosed by the appearance of a cotton wool spot in 14 patients . in four of the 14 patients , retinal hemorrhage two of the 16 patients who developed retinopathy were diagnosed by retinal hemorrhage without cotton wool spots . one patient ( not diabetic or hypertensive ) had cystoid macular edema , this was the only patient who complained of the visual disturbance due to interferon . all patients had bcva of ( 6/6 ) during ifn treatment except for three patients : the one who had cystoid macular edema ( bcva was 6/12 and returned to 6/6 after cessation of treatment ) and two patients with ametropic amblyopia . in addition , we confirmed that all patients with hypertension had no retinopathy using the standard classification . to exclude the possibility of the development of diabetic or hypertension retinopathy after ifn treatment , we deleted the data obtained from patients who had diabetes or hypertension and any retinopathy 2 months after the cessation of ifn treatment . retinopathy was first diagnosed 214 weeks after the start of treatment and disappeared in 11 of the 16 patients despite the continuation of therapy . a few cotton wool spots , retinal hemorrhages , or both were observed in the remaining five patients at the end of treatment but resolved within 1 month after treatment was stopped . no other ocular complications ( ie , cataracts , glaucoma , retinal artery , or vein obstruction ) were observed . the mean hemoglobin values , white blood cell , red blood cell , and platelet counts decreased significantly ( p < 0.0001 ) during ifn treatment . the clinical profiles and laboratory data of the patients are shown in tables 1 and 2 , respectively . interferon - associated retinopathy was first recognized in 1990 when ikebe and associates reported a 39-year - old patient who developed retinal hemorrhages and cotton wool spots following intravenous administration of interferon.12 the underlying mechanisms of interferon - induced retinopathy are not completely understood . guyer et al13 had proposed an immune complex deposition causing occlusion of retinal capillaries leading to cotton wool spot formation . on the other hand , an ischemic insult , similar to that seen in hypertensive and diabetic patients could be another potential mechanism by which these changes develop.14 some studies15,16 have shown a relatively higher incidence of retinopathy ( symptomatic or asymptomatic ) ranging from 19% to 64% during treatment with interferon . panetta and gilani17 and cuthbertson et al14 show relatively lower incidences of retinopathy ( 3.8% and 6.25% , respectively ) . similar to other studies,4,5,9 our study also shows that retinal changes usually develop within the first 3 months of interferon treatment , a fact that may favor an immune etiology rather than a cumulative effect of interferon leading to the development of retinopathy . retinopathy developed by week 14 in most of the patients ( 13/16 , 81.25% ) after the start of therapy and disappeared in the majority of the patients ( 11/16 , 68.75% ) during the 48 week period in which the patients were receiving the treatment . this suggests that treatment can be continued despite the development of retinopathy in many patients . however , two patients who developed cotton wool spots early in the therapy ( 2 weeks ) thereafter suffered from retinal hemorrhage in a prolonged manner . therefore , patients who develop cotton wool spots early on during therapy should be carefully monitored . however , as reported in previous studies,4,13,14 most of the patients with retinopathy in this study were asymptomatic . this study confirms previous reports that retinopathy is a temporary and asymptomatic complication of interferon therapy . therefore there is no rule for suspending the use of interferon in patients who develop retinopathy or any other ocular side effects . it s commonly agreed among authors that careful monitoring should be performed in the presence of any ocular sign , even without symptoms.18

we have prepared two new diastereoisomeric 2-aza-5-phosphabicyclo[2.2.1]heptanes from naturally occurring trans-4-hydroxy - l - proline in six chemical operations . these syntheses are concise and highly efficient , with straightforward purification . when we used these chiral phosphines as catalysts for reactions of -substituted allenoates with imines , we obtained enantiomerically enriched pyrrolines in good yields with excellent enantioselectivities . these two diastereoisomeric phosphines functioned as pseudoenantiomers , providing their chiral pyrrolines with opposite absolute configurations .

nathan , as an oncology fellow , knew well that white blood cells fought infections . this was an experiment repeated in front of us all the time , he says : chemotherapy lowered his patients ' white blood cells and increased their risk of infections . mackaness had shown that macrophage activation did not depend on direct contact with t cells ( 1 ) , suggesting the possibility of a secreted factor . when nathan tested the supernatant from activated t cells , he saw that it did indeed induce macrophage activation ( 2 ) . nathan got a rough idea of the molecular weight ( 3 ) , but that was the best anyone could do , he says . protein separation methods were primitive , and cloned proteins and monoclonal antibodies would only become available a decade later . henry murray , one of nathan 's collaborators , sums up the feeling of frustration : we were all nibbling at the edges of the same problem . nathan therefore changed tack to take a closer look at the activated macrophages . short - lived neutrophils were known to produce hydrogen peroxide , and nathan found the same was true of longer - lived activated macrophages ( 4 ) . unlike previous signs of macrophage activation increased spreading , phagocytosis , and glucose metabolism this so - called respiratory burst ifn had been on the cover of time magazine , and recombinant murine ifn was found to induce macrophages to kill tumor cells ( 5 ) . nathan , now a faculty member in zanvil cohn 's macrophage factory at rockefeller university ( new york , ny ) , thought ifn might also activate macrophages to kill intracellular parasites . consistent with this idea , ifn was made by antigen - stimulated t cells and was associated with defense from infection . now the respiratory burst gave nathan an assay , berish rubin ( down the street at the new york blood center ) supplied an ifn monoclonal antibody , and a phone call to genentech yielded recombinant ifn. in a seminal paper published in the journal of experimental medicine in 1983 , nathan was thus able to show that depleting ifn from unpurified t cell supernatants decreased the respiratory burst activity and the killing of intracellular protozoa in human macrophages . adding back recombinant ifn into this mix restored macrophage activation ( 6 ) . i had an assay , a hunch , a history of purifying proteins that did this , and the serendipity of meeting with people nearby who had the antibody . nathan next showed that ifn worked in people . injecting recombinant ifn directly into cutaneous lesions of lepromatous leprosy patients induced macrophage infiltration , hydrogen peroxide production , and killing of the causative pathogen , mycobacterium leprae ( 7 ) . in the 1990s , the macrophages of children with ifn receptor deficiencies were shown to be defective in killing mycobacteria ( 8) . tracing the pathway from t cells to macrophages to bacteria started , for nathan , in 1967 , and he says we still haven't finished making the molecular links . a glomangioma is a benign vascular tumor derived from the glomus body , a specialized neuromyoarterial structure involved in thermal regulation . it is a subtype of the more generalized category of glomus tumors and should not be confused with the head and neck paragangliomas , such as the glomus tympanicum or glomus jugulare . it should also be distinguished from the glomangiopericytoma , the sinonasal type hemangiopericytoma , which displays different ultrastructural and histochemical characteristics.1 glomangiomas are most commonly found subungually and are exceedingly rare in the head and neck.2 they account for only 0.6% of all nonepithelial tumors of the nasal cavity , nasopharynx , and paranasal sinuses.3 glomangiomas that induce paraneoplastic osteomalacia are even more uncommon , with only one case reported to date.4 while there are several documented cases of oncogenic osteomalacia ( oo ) caused by glomangiopericytomas,5 we present the second reported case of glomangioma - induced osteomalacia and the first case documented in english . a 42-year - old man with a history of unexplained hip , rib , scapula , and metatarsal fractures ; left foot pain with exercise ; and weakness presented to our clinic for evaluation of a paranasal sinus tumor . the endocrinology service initially diagnosed him with tumor - induced osteomalacia caused by fibroblast growth factor 23 ( fgf23 ) , which prompted an octreotide scan revealing a questionable area of enhancement in the pituitary . a subsequent magnetic resonance imaging ( mri ) showed an ethmoid mass extending through the cribriform intracranially , measuring 3.9 1.9 2.4 cm at its largest dimensions ( fig . the patient reported occasional sinus congestion , decreased sense of smell during the preceding 2 to 3 years and occasional blurry vision in the morning . his laboratory workup revealed a significantly decreased 1,25-vitamin d level of less than 8 ng / ml , a decreased phosphate level to 1.6 mg / dl , a low to normal calcium level of 8.7 mg / dl , and a significantly elevated alkaline phosphatase level at 65.3 g / l . preoperative mri , t1 with contrast , showing an ethmoid mass extending through the cribriform intracranially . the patient underwent a combined endoscopic endonasal approach to the anterior skull base with tumor resection . the cribriform defect and intraoperative cerebrospinal fluid ( csf ) leak pathology revealed a vascular neoplasm with a uniform cluster of ovoid cells arranged around the vessels and moderate focal nuclear enlargement ( fig . tumor cells stained positive for cd31 and smooth muscle actin ( sma ) but negative for cd34 , s100 , and pan - cytokeratin on immunohistochemistry ( fig . the patient reported near - complete resolution of bone pain and improvement in smell , and he had normalization of phosphate , alkaline phosphatase , vitamin d , and other laboratory values . repeat mri showed gross total resection of the mass and no detectable recurrence ( fig . 4 ) . postoperative mri , t1 with contrast , showing gross total resection of the mass with nasoseptal flap reconstruction of the skull base . osteomalacia is a disease of the bone characterized by defective mineralization of osteoid from decreased levels of available phosphate and calcium or increased bone resorption . it often presents with diffuse joint and bone pain , easy fracturing , difficulty walking , weakness , and other nonspecific symptoms . oo is a rare , disabling , and curable form of osteomalacia that affects both sexes equally and usually presents around 40 years of age.6 it is not well described in glomangiomas but has been detailed several times in relation to glomangiopericytomas and other soft tissue and bone tumors , with more than 300 reported cases7 since its debut in 1947.8 it predominantly occurs in the context of mesenchymal tumors and is thought to be due to neoplastic overexpression of fgf23 . this protein inactivates the sodium - phosphate pump in the proximal tubule ( prohibiting phosphate reabsorption and inducing renal phosphate wasting ) and reduces 1-hydroxylation of 25-hydroxy vitamin d.9 accordingly , common oo laboratory abnormalities include hypophosphatemia , normal or decreased calcium , decreased 1,25-dihydroxy vitamin d3 with resistance to vitamin d supplementation , and elevated alkaline phosphatase , which our patient exhibited . tumors causing oo tend to be small , occult , and slow growing , making diagnosis remarkably difficult . when other causes of osteomalacia have been ruled out and oo is suspected , clinicians should consider measuring a serum fgf23 level . elevated fgf23 in this setting should then prompt full body imaging ( including hands and feet ) to expose the lesion . the current imaging standard for investigation of oo is whole - body mri short tau inversion recovery ( stir).10 another commonly used modality is octreotide scintigraphy ( octreoscan ) , which utilizes a radiotracer that binds to somatostatin receptors overexpressed on the causative tumor.11 once the neoplasm is localized , surgical resection with wide margins is the definitive treatment . it is curative in essentially all cases and typically leads to rapid normalization of laboratory values and reversal of most clinical symptoms . the nonspecific presentation of osteomalacia , the obscure nature of the tumors that cause oo , and the rarity of glomangiomas in the head and neck make this patient 's diagnosis challenging . we believe this to be the second reported case of paranasal sinus glomangioma - induced osteomalacia and the first reported in english . many head and neck surgeons may not be aware of its existence or consider it in their differential diagnoses of sinus tumors . this report serves to increase the awareness of this uncommon pathology so that it may be considered and treated in future cases .

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

gestational trophoblastic disease describes a number of gynecologic tumors that originate in trophoblastic layer including hydatidiform mole ( complete or partial ) , invasive mole , choriocarcinoma , placental site trophoblastic tumor and epitheloid trophoblastic tumor . invasive mole may arise from any pregnancy event although in most cases is diagnosed after molar pregnancy . overall cure rate in low risk patients is nearly 100% and in high - risk patient 90% . in rare cases , molar tissue traverses thickness of myometrium and leads to perforation and acute abdomen and invasive mole infrequently metastasis . the best treatment option is chemotherapy ( according to stage and score with single or multiple agent ) and in patients that fertility is not the matter , hysterectomy can be done . a 41 years old g3p2ab1 woman referred to firouzgar hospital 2 months after curettage of molar pregnancy with vaginal bleeding and acute abdomen . in workup , hcg 224000 miu / ml and evidence of metastasis was detected . chemotherapy due to stage 3 and score 9 and surgery due to acute abdomen was done . this case reported about ovarian metastasis and uterine rupture with acute abdomen and involvement of omentum in metastatic invasive mole . management of this patient was successful . in follow up , she was free of disease without sequel of any kind for five years now . invasive mole is penetration of molar tissue ( complete or partial mole ) into myometrium or uterine vasculature ( 1 , 16 , 19 ) . pathologists mention the existence of villi in trophoblastic tissue ( 8 , 12 ) . locally invasive gestational trophoblastic neoplasia develops in 15% of patients and metastatic form in 4% of patients after evacuation of complete mole and infrequently after partial mole ( 2 ) . hcg level ( > 100000 miu / ml ) , excessive uterine enlargement , theca lutein cyst size 6 cm are considered as high risks for developing post molar tumors ( high risk mole ) ( 3 ) . the most common symptom of invasive mole is persistent vaginal bleeding after evacuation of molar pregnancy ( sub involution of uterus and persistent theca lutein cyst is another symptom ) . the rise in hcg titer is a laboratory test for diagnosis of invasive mole in follow up of molar pregnancy . although definite diagnosis of invasive mole is based on pathology ( 8) , with hcg or radiologic diagnosis ( 9 ) , invasive mole is diagnosed as well . in rare cases , metastasis occurred and the most common sites were lungs ( 80% ) ( 4 ) , vagina ( 30% ) , pelvis ( 20% ) , liver ( 10% ) , brain ( 10% ) , bowel and kidney and spleen ( < 5% ) were other metastatic sites . metastasis can occur from direct extension of another pelvic neoplasm or by hematogenous or lymphatic spread or by transcelomic dissemination . possibility of metastasis to ovary is extremely rare which is even much lower than that of nongestational primary ovary choriocarcinoma with an incidence of 1 in 3.710 ( 5 ) . invasive mole is curable with chemotherapy but hysterectomy decreases the need for multiple courses of chemotherapy and in patients with heavy bleeding or sepsis for control of complication and stabilization , chemotherapy is needed ( 6 , 11 ) . here a case with invasive mole after evacuation of molar pregnancy , presented with acute abdomen and in surgery metastasis to ovary and omentum and parametrium was detected . a 41- year- old housewife woman , gravid 3 para 2 live child 2 ( all nvd ) with a last 10 years old child referred to firouzgar hospital on 24 august 2010 with a history of a dilation and curettage and 2 months of cough . on examination , she was febrile ( 38c . , tachycardia , leukocytosis ( 16000 ) and uterus was tender and enlarged . vaginal bleeding persisted and second curettage was done in another hospital . at that time , chest x - ray was normal . in our hospital , report of sample pathology given from first and second curettage was complete mole . after molar evacuation , the patient was not monitored for weekly determination of hcg level . she received antibiotics ( due to fever ) and work up for malignant trophoblastic disease or persistent gtn was done because of high hcg level ( 224000 miu / ml ) and much too enlarged uterus and involvement of the whole uterine parenchyma , which was detected on sonography ( largest tumor size in uterus was 6 cm ) . thyroid function test demonstrated hyperthyroidism . in the metastatic work up , ct scan of chest and abdomen and brain was carried out . ct scan of the abdomen and pelvis showed involvement of the left adnexa and pelvic lymphadenopathy . the patient s chest ct scan showed multiple bilateral round pulmonary metastatic lesions that were 2 cm in diameter , illustrated in figure 1 . pulmonary metastasis in invasive mole once the disease was diagnosed , the patient chemotherapy with ema started ( table 1 ) . because of acute abdomen and severe abdominal pain and unstable vital signs with diagnosis of perforative peritonitis , the patient was taken up for emergency laparotomy . due to hyperthyroid state , in induction of anesthesia , blocker agent was administered . in this patient , subtotal hysterectomy and left salpingo oophorectomy and resection of omentum were done . in gross uterus , uterine wall was perforated by tumoral invasion on the left side of posterior wall ( figure 2 ) . enlarged uterus , ovarian metastasis , perforation of uterus , and myometrium invasion the patient was iii:9 according to figo staging and who scoring ( 7 ) the bilateral uterine parameters , the external surface of the endocervical canal and the omentum were invaded by tumors . villous formation in myometrium villosity with necrosis in invasive mole this patient was treated with 4 courses of chemotherapy with ema - co . after negative hcg ( < 5 ) , she received an additional 3 courses of chemotherapy to reduce the relapse . hcg titer was later tested monthly for1 year . when the first year of testing hcg terminated , hcg testing on a bimonthly basis for 2 years was done . the patient was followed up to 5 years and after that the patient was free of tumor and the hcg was negative . invasive mole with rupture of uterus and metastasis to ovary and omentum and manifestation of acute abdomen was rare ( 5 ) . according to epidemiological retrospective survey , invasive mole secondary to hydatidiform mole occurred in six months after evacuation ( 5 , 3 ) . partial and complete hydatidiform mole are distinct disease processes with characteristic cytogenetic , histologic , and clinical features ( 8) . ( 13 ) reported a case of invasive mole presenting as acute hemoperitoneum that was similar to the present case . molar tissue can penetrate myometrium ( 9 ) and lead to uterine perforation ( 13 ) and cause vaginal bleeding due to erosion of uterine vessels ( 14 , 15 ) . similar to atala et al.s case report in 1991(14 ) , in our case , uterine perforation with acute intra peritoneal hemorrhage was seen . due to ease of entry of molar tissue into large venous lake present in myometrium and pelvis in pregnancy or trophoblastic disease metastasis of invasive mole commonly in lungs and after lungs in vagina , cervix , broad ligament ( 16 , 19 ) , in our case metastasis to lung and ovary and omentum although theca lutein cysts in high - risk mole due to high serum hcg level are seen normally , they regress spontaneously within 24 months ( 17 ) . non gestational choriocarcinoma of ovary is differential diagnosis ( 5 ) but due to occurrence of metastasis to ovary in our case after molar pregnancy , this differential diagnosis was not a matter . as in a report of invasive mole in fallopian tube ( 21 ) , the first misdiagnosis of our case in another hospital , repeat curettage was done , although the first diagnosis could be persistent gtn . in another case report ( 15 ) from bruner , similarity with our case was seen . combination chemotherapy should be continued in such cases as far as toxicity permits until the patient achieves 3 consecutive normal hcg levels ( 9 , 18 ) . as normal hcg levels are attained , 3 additional courses of chemotherapy are administered to reduce the risk of relapse . in low risk patients , one or two courses are adequate ( 19 ) . in our case , 3 courses of chemotherapy after normalization of hcg were done . hysterectomy may be required in invasive mole in order to control vaginal bleeding and in unstable patient or in sepsis ( 6 , 20 ) . hysterectomy is a reasonable option for patients who do not wish to preserve their fertility , but it does not prevent metastasis ( 20 ) . furthermore , in patients with extensive uterine tumor , hysterectomy may substantially reduce the trophoblastic tumor burden ( 20 ) and thereby limit the need for multiple courses of chemotherapy . in our case , due to unstable and uterine rupture , hysterectomy was done but the need for chemotherapy courses was not removed and after several courses of chemotherapy with ema - co courses , it was cured . however , final diagnosis of our patient was invasive mole with metastasis to ovary and omentum and lung ( stage 3 ) and uterine rupture . the patient responded to the treatment well and in follow up this patient was still fine for 5 years after definite care for metastasis invasive mole with surgery and chemotherapy . an invasive mole in uterus with ovarian and omental metastasis was diagnosed and the patient was successfully treated by hysterectomy and chemotherapy and she was fine for 5 years in follow up . temporary henna tattoos or pseudotattoo have become increasingly widespread among children and adolescent , as a safe and economic alternative to permanent tattoos . it is well - known that allergic skin reactions to natural henna are rare , due to its extremely low rate of sensitization . in india , north of africa , china , and egypt , it is used in weddings and religious ceremonies ; in occident , it is used to dye hair and cosmetics . paraphenylenediamine ( ppd ) , a powerful allergen , is added to the henna tattoo mixtures ( black henna tattoo ) to decrease application time and intensify the color . we describe the case of a 7-year - old boy who reported erythematous papular bulls - eye shaped lesions and consolidated edema primarily in the upper and lower extremities [ figure 1 ] . he also showed an erythematous - eczematous lesion on his leg , shaped like a dolphin [ figure 2 ] , and lesions compatible with erythema multiforme - like reaction . erythematous papular lesions contact eczema in the tattoo area dolphin shaped patch tests were performed , and we observed a high sensitivity after 48 h and moderate after 96 h. we reported a positive reaction to ppd . henna has been used to paint the skin for adornment and religious reasons for 9000 years and in over 60 countries . christians , jews , muslims , hindus , and buddhists have used henna as part of their religious customs . the henna is a flowering plant native to northern africa , western and southern asia in semi - arid zones , used since antiquity to dye skin . it has a great affinity for keratinocytes , and it is used to create temporary tattoos , without it being necessary to puncture the skin . black henna contains an ingredient in addition to pure henna to achieve its ebony color . in most cases , this added ingredient is ppd , a powerful sensitizer that should not be directly applied to the skin as it may cause mild contact dermatitis . one of the most dangerous applications of this chemical is when it is added to henna because the dye is applied while the ppd is in its oxidation process , and its potential as allergen is increased . when added to henna , the concentration of ppd is often much higher than what is approved for use in hair dyes . the cause of the sensitivity to ppd is unknown ; it is believed that the mechanism involved in the pathogenesis may be a reaction mediated by type iii immune complexes and associated with type iv retarded hypersensitivity . various topicals allergens cause erythema multiforme , including topical drugs such as corticosteroids , nonsteroidal anti - inflammatory drugs , iodine povidone , imiquimod ; rubber gloves ; nickel and herbicides . three possible causes of the residual hypopigmentation have been described : a reduction in melanin synthesis , selective destruction of the melanocytes , or photoleukomelanodermitis due to pigment blocking . as henna tattoos are becoming increasingly popular , prevention requires the provision of information to consumers , especially young people and their parents . it is important for the population to be aware of this circumstance and the risk entailed by sensitization to ppd . to conclude , we believe that temporary black henna tattooing should be controlled by health authority legislation to minimize the appearance of new cases of reaction to ppd and the serious and permanent consequences we have presented . it is important for the population to be aware of the risk entailed by sensitization to ppd due to popular henna tattoos .

background : invasive mole is responsible for most cases of localized gestational trophoblastic neoplasia . gestational trophoblastic disease describes a number of gynecologic tumors that originate in trophoblastic layer including hydatidiform mole ( complete or partial ) , invasive mole , choriocarcinoma , placental site trophoblastic tumor and epitheloid trophoblastic tumor . invasive mole may arise from any pregnancy event although in most cases is diagnosed after molar pregnancy . overall cure rate in low risk patients is nearly 100% and in high - risk patient 90% . in rare cases , molar tissue traverses thickness of myometrium and leads to perforation and acute abdomen and invasive mole infrequently metastasis . the best treatment option is chemotherapy ( according to stage and score with single or multiple agent ) and in patients that fertility is not the matter , hysterectomy can be done.case presentation : a 41 years old g3p2ab1 woman referred to firouzgar hospital 2 months after curettage of molar pregnancy with vaginal bleeding and acute abdomen . in workup , hcg 224000 miu / ml and evidence of metastasis was detected . chemotherapy due to stage 3 and score 9 and surgery due to acute abdomen was done . this case was reported for its rarity.discussion:this case reported about ovarian metastasis and uterine rupture with acute abdomen and involvement of omentum in metastatic invasive mole . lack of surveillance led to extensive morbidity . management of this patient was successful . in follow up , she was free of disease without sequel of any kind for five years now .

a 55 year - old man visited our emergency department because of increasing frequency of chest pain . he had undergone off - pump coronary artery bypass grafting ( cabg ) 10 years ago because of unstable angina associated with three vessel coronary artery disease . at the initial operation , the in situ right internal thoracic artery ( ita ) , in situ left ita and in situ right gastroepiploic artery ( rgea ) grafts were used to revascularize the left anterior descending coronary artery , two obtuse marginal coronary branches , and posterior descending coronary artery , respectively . an excess segment of the distal right ita was connected to the side of left ita as a y - composite graft and anastomosed to the first diagonal coronary artery . coronary angiography and myocardial single photon emission computed tomography ( spect ) were performed at 5 years after surgery as a follow - up study . the 5-year angiography showed all patent grafts and the myocardial spect demonstrated no perfusion decrease . exertional chest pain recurred at 7 years after surgery , and a repeated coronary angiography showed patent previous grafts including faint visualization of the in situ rgea graft associated with significant stenosis at the os of the celiac axis . the computed tomographic angiogram also demonstrated a 90% stenosis at the celiac os , which had been without stenosis on abdominal angiography taken before the surgery ( fig . redo off - pump cabg was performed 10 years after the initial surgery because of an increasing frequency of angina and an aggravated finding of the follow - up myocardial spect , which was a newly developed reversible perfusion decrease in the inferior wall ( fig . , the great saphenous vein was harvested from the lower leg and interposed between the middle part of in situ right ita and distal part of in situ rgea grafts used previously , to supply blood flow from the right ita graft to the posterior descending coronary artery . one year after redo surgery , the patient had no symptoms of angina and coronary angiogram was performed and revealed patent grafts , including an interposed saphenous vein graft ( fig . 3a ) . the myocardial spect test was also performed and demonstrated that there was no perfusion decrease including the inferior wall ( fig . reoperations for coronary artery disease have been increased due to the increased number of isolated cabg . the society of thoracic surgeons statistics indicated that nearly 5% of the current cabg procedures done in the us were repeat surgical revascularization . angiographic indications for reoperation are progression of native coronary atherosclerosis , previous graft failure or a combination of both . one previous study demonstrated that 4 out of 400 patients who underwent cabg using the rgea graft needed percutaneous interventions due to the rgea graft failure during postoperative follow - up of 2211 months . one of those 4 patients required an angioplasty for a newly developed stenosis of the celiac trunk . in the present case , an indication for reoperation the patient had been free of angina , and the angiographic and myocardial spect follow - up studies revealed no abnormal findings at postoperative 5 years . when the patient suffered from recurred angina at postoperative 7 years , coronary angiography showed a faint visualization of the in situ rgea graft associated with significant stenosis at the os of the celiac axis . the 10-year follow - up myocardial spect test demonstrated a newly developed reversible perfusion decrease in the inferior wall . the prevalence of celiac axis stenosis was 7.3% in a korean population although it was lower than the previously reported incidence of celiac axis stenosis in western populations ranged from 12.5% to 24% . in the present case , celiac artery stenting could be an alternative option in such a case . however , we performed a redo operation because celiac axis stenting was associated with a high incidence of late restenosis . the aorta or another in situ arterial graft could be chosen as a blood source . alternatively , patent in situ grafts used previously may be re - used as an inflow conduit . with regards to our patient , the 3 in situ arterial grafts had already been used . the saphenous vein graft was interposed between the middle part of right ita and distal part of in situ rgea grafts used previously . autosomal - dominant polycystic kidney disease ( adpkd ) is characterized by cyst formation and occurs primarily in the kidneys . due to the replacement of the normal renal parenchyma , adpkd results in end - stage renal failure in 45% of patients . approximately 711% of patients receiving renal replacement therapy in the western world are doing so due to adpkd . the underlying cause of adpkd is a mutation in the polycystin-1 and -2 plasma proteins , located in the primary cilia . this mutation leads to abnormal function of renal tubular epithelia and inadequate calcium influx followed by cyst formation . cardiovascular disease is the most frequent cause ( 36% ) of mortality in patients with adpkd . patients with adpkd often develop hypertension at an earlier age than the general population before any impairment of kidney function . it is hypothesized that the renin - aldosterone system and endothelial dysfunction caused by impaired nitric oxide release are the important factors in the development of hypertension in adpkd patients . we describe an uncommon case of a middle - aged man with a spontaneous coronary artery dissection ( cad ) and adpkd . a 41-year - old caucasian man presented at an emergency department with acute chest pain . the chest pain began 2 h before presentation . medical history recorded a subdural haematoma , as a result of trauma . according to the family history , our patient was a non - smoker , with no history of hypertension , diabetes mellitus or hypercholesterolaemia . on physical examination , the blood pressure was 155/102 mmhg and the pulse 72 beats / minute ; other vital parameters were normal . electrocardiography showed a sinus rhythm of 65 beats / minute and st elevation in the precordial leads ( figure 1 ) . / l , creatine kinase mb was 17.4 u / l and troponin t was 0.21 ng / ml . the other laboratory test results were normal . echocardiography revealed a hypokinetic septum and a slightly impaired left ventricular function with an ejection fraction of 4560% . electrocardiography on presentation shows a sinus rhythm of 65 beats / minute and st elevation in v3 , ii and iii . based on these results , a presumptive diagnosis of acute septal myocardial infarction was made . coronary artery angiography ( cag ) revealed a transient occlusion of the left anterior descending ( lad ) coronary artery , most probably as a result of myocardial bridging ( figure 2a ) . the cag ( a ) shows the compression of the lad coronary artery during the systole resulting in narrowing and ( b ) performed after the second chest pain attack demonstrating a dissection in the distal left anterior descending coronary artery . however , the chest pain returned 3 days after the presentation . a second electrocardiography showed persistent inverted t waves in the precordial leads without st elevation . it disclosed an open lad with a dissection in the distal part and a double lumen , which was not observed during the first angiography ( figure 2b ) . the definitive diagnosis of non - q - wave anterior infarct as a result of a spontaneous lad dissection was made . based on the cysts in both kidneys combined with a family history of adpkd , the diagnosis of adpkd was made ( ravine s criteria ) . since cerebral aneurysms are one of the extrarenal manifestations of adpkd , a computerized tomography angiography of the brain was performed , with a negative result for vascular anomalies . an exercise stress test , performed 16 days after the onset of chest pain , was normal . the lad was patent without a significant infarction , but still with a double lumen appearance . at 2-year follow - up by a nephrologist , our patient , a relatively young man with a negative cardiovascular profile and a history of subdural haematoma , developed a myocardial infarction secondary to dissection of the lad . the cad was not recognized during the first cag because the relevant coronary artery can obturate the dissection in the acute phase . this condition is found when the segmental coronary artery has an intramyocardial course , being compressed during systole and restored during diastole . therefore , one would require a difference in coronary artery contraction in the systolic and diastolic phase which was not observed on the first cag . four cases were reported on the occurrence of a spontaneous cad in middle - aged adpkd patients . predisposing factors for cad in adpkd patients are still undetermined , especially in the absence of traditional cardiovascular risk factors . furthermore , it is not known if arterial dissection is an extrarenal manifestation of adpkd or if is just secondary to hypertension . the estimated prevalence of spontaneous cad is 0.7% , and it is in 2% of cases , the cause of acute coronary syndrome . the lad is affected in 80% of the patients with cad [ 8 , 9 ] . the majority of patients with a cad often lack classical risk factors for cardiovascular disease and are female . de maio et al . identified three groups of patients with cad : ( i ) patients with atherosclerotic cardiovascular disease , ( ii ) women in the postpartum period and ( iii ) an idiopathic group . several underlying conditions in the idiopathic group are suggested , such as polyarteritis nodosa , lupus erythematosus , marfan s syndrome , ehlers danlos syndrome , intense physical exercise , the use of cocaine , cyclosporin and oral contraceptives . the tunica media , the middle layer of elastic arteries , include smooth muscles with interposing layers of elastic lamellae . the connection between the intracellular contractile filaments and extracellular elastic fibres is provided by dense plaque sites . localization in the dense plaques assigns a significant function to polycystins in maintaining vascular integrity . furthermore , qian et al . suggested that abnormal intracellular calcium concentration in the vascular smooth muscle cells is linked to vascular phenotype in the case of inactivation of polycystin-2 protein . literature also confirms the observation of intracranial aneurysms and myocardial infarction secondary to coronary aneurysms in certain families and the occurrence of vascular rupture and haemorrhage in homozygous polycystic kidney disease ( pkd)-1 knockout mice [ 4 , 11 ] . considering these results , and the high plasma renin activity and impaired nitric oxide release in adpkd patients , we speculate that the vascular abnormalities are most likely a direct result of pkd mutations rather than a secondary cause of hypertension . in conclusion , polycystins seem to play a main role in the stability of the arterial vasculature . therefore , a spontaneous cad should be considered as an extrarenal manifestation of adpkd . the clinician should be aware of cad if adpkd patients present with chest pain or discomfort . cag can be inconclusive in respect to the mechanism of coronary occlusion in the acute phase and should be repeated , especially when the complaints persist .

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

optimal treatment of cancers in children often requires combined - modality therapy , including : chemotherapy , surgery , and/or radiotherapy . chemotherapy is not always sufficient to achieve the cure of solid tumors in children ; either resection or radiation may be needed for local tumor control as well ( 1 ) . children with radiosensitive malignant tumors typically require radiation therapy for a number of sessions over a period of several weeks . although the procedure is painless , young children need to be sedated or anesthetised in order to provide a motionless state during the procedure . a short period of sedation , analgesia or general anaesthesia the patient and anaesthesia equipment are observed continuously by closed - circuit television , and monitors are mirrored to the remote observation site outside the treatment room . different anesthesia methods and anesthetics have been recommended to provide a safe and optimal situation of motionless with a short recovery period in children undergoing general anaesthesia or sedation for external beam irradiation ( 37 ) . this report describes the accidental detection of a missed complication by the anesthetist at the time of radiotherapy , from the previous chemotherapy , which was preliminarily and unduly attributed to anesthesia . a 2.5 year - old , 13-kg boy , asa ( american society of anesthesiologists ) class ii , with acute lymphoblastic leukaemia ( all ) , was scheduled for radiotherapy . anesthesia was planned by the anesthetist , and the physical examination was normal before radiotherapy . routine monitoring was established , and for peripheral pulse monitoring , the distal portion of the right upper limb of the child was rested out of the covers . after about 5 minutes , when the anesthetic effect of ketamine began , we noticed a lack of right radial pulse . anesthesia - related hemodynamic instability was expected , however no other manifestation of hypoxia or hypo - perfusion was detected . furthermore , carotid pulsation was normal , and examination of the left radial pulse and other peripheral pulses showed normal pulsation . the patient showed a scar and swelling on the right antecubital area . a more detailed history taken from the child s parents showed his history of chemotherapy during which extravasation of the chemotherapy drug had resulted in severe inflammation and edema at the site of injection . a colour doppler ultrasound of the antecubital area showed deep edema and chronic compression on the antecubital tissue and confirmed the diagnosis . permission was obtained from the patient s parents to use the patient s reports , however the patient s information was to remain confidential . the incidence range of extravasations of cytostatic drugs in cancer patients has been reported from 0.2 to 1.4% in a five - year study ( 8) . extravasations in cytostatic treatment may cause a wide range of symptoms , from patients discomfort to severe complications such as necrosis and amputation . ( 9 ) eccrine squamous syringometaplasia , while rare , has also occurred in patients who have received chemotherapy treatment ( 10 ) . yeung et al described a case of metastatic ovarian carcinoma with repeated thrombosis of the femoral arteries following intravenous carboplatin - based combination chemotherapy . persistent withdrawal occlusion ( pwo ) is frequently caused by fibrin sheath formation around venous access devices . small doses of thrombolytic drugs ( such as urokinase ) could manage pwo , but could also serious complicate chemotherapy drug extravasation ( 12 ) . keratolytic ointment was applied for old lesions , whereas in new lesions , multiple subcutaneous injections of hydrocortisone solution were used before the application of betamethasone ointment . application of conservative agents in radiotherapy - induced extravasation areas may avoid tissue necrosis and consequently , reconstructive surgery ( 13 ) . management of cytotoxic drug extravasation in humans is based on the experimental evidences and available case reports because of lack of randomized trials . for instance , topical dimethylsulfoxide ( dmso ) and cooling for extravasation of anthracyclines or mitomycin , local injection of hyaluronidase for extravasation of vinca alkaloids , and local injection of sodium thiosulfate ( sodium hyposulfite ) for extravasation of chlormethine ( mechlorethamine ; mustine ) should be empirically recommended . in the case of failed conservative treatment , history and physical examination before injection of anesthetic agents could be useful in preventing patient mismanagement . a weak pulse in a child can be a significant problem for the anesthesiologist and in this case , it was shown to be a critically misleading factor . increased emphasis is on clinical evaluation and pulse checking is necessary , especially in children with a history of chemotherapy . providing thorough pulse evaluation when we work on children and avoiding immediate aggressive intervention before being certain about the cause of weak pulse are additional issues of importance shown by this case report . care coordination is an important aspect of nursing care especially for elderly patients admitted to an acute care setting . in singapore care coordination and transitional care nursing is a new concept of care nevertheless important but unexplored . the objective of this paper is to explore the characteristics of elderly patients receiving care coordination , determine care gaps and intervention during home visit and telephonic review . a designed questionnaire was used to collect information on the patient s demography , social and clinical profile and determine post discharge activities using eric coleman s four pillars tool . the retrospective data from the patient s index admission from the last six months ( nov 08april 09 ) was analyzed using spss version 16 . majority , 69% were above 70 years old of which 57% female and 76% lives with their children . clinical information demonstrates that 53% had 36 co - morbidities and 58% were taking more than five medications . the abbreviated mental test score were 6.2 , 6% were depressed and delirium was present in 14% of patients . only 65 patients ( 0.1% ) had home visits and telephonic review done whilst 97% of the remaining had only telephonic review done . those who had both telephonic and home visit review , medications advice and compliance were checked only in 0.8% ( at one week ) and 1.6% ( at one month ) whilst during home visit this was done in 12.2% of patients as medication discrepancy were apparent at home . as for appointment compliance and compilation were done in 0.8% at one week and 51% at four weeks of telephonic review compared to during home visit only 4.8% . caregivers education was emphasized in 14% of patients at home visit , 2% at one week and 4% at one month of telephonic review . the result showed that home visit is effective in exploring medication compliance , advice and emphasizing caregiver education , managing appointments can be effectively done through telephone review . this study demonstrates the vital role of home visit for elderly patient to safely transit between hospitals to home .

treatment of cancer in children often requires a combination of chemotherapy , surgery , and/or radiotherapy . radiotherapy and chemotherapy are not painful processes , but children undergoing these procedures must be made motionless through anesthesia or sedation . there are a few reports of complications during these procedures in relation to the procedures themselves or to the anesthesia given . this report describes an unexpected pulseless radial artery which was preliminarily and unduly attributed to anesthesia . a 2.5 year - old male pediatric patient with an acute lymphoblastic leukaemia was scheduled for radiotherapy . anesthesia with intramuscular ketamine was induced before starting radiotherapy . about 5 minutes after injection of ketamine we found the right radial pulse undetectable . there was no other manifestation of hypoxia or hypo - perfusion . carotid pulsation was normal . examination of the left radial pulse and other peripheral pulses showed normal pulsation . the procedure was continued uneventfully . the next follow - up after radiotherapy , showed a scar and swelling on the right antecubital area , caused by extravasation of chemotherapeutic agent in the prior period of chemotherapy . doppler ultrasonography of the antecubital vein confirmed the diagnosis . this case study therefore demonstrates that proper intravenous cannula establishment before chemotherapy is of great importance . furthermore , accurate history and physical examination before induction of anesthesia or sedation may be useful in preventing mismanagement in pediatric cancer procedures .

since the introduction of extra - oral implants in reconstruction of craniofacial defects , achieving proper prosthesis retention has become more promising . these problems include ulceration of hard and/or soft tissues used for retention , lack of retention due to prosthesis movement , and tissue irritation caused by adhesives . the ideal position and number of implants for restoring orbital defects would be three non - linear implants in lateral , supraorbital , and infra - orbital rims . however , such implant arrangement is not always conceivable considering the extension of the defect , and bone quality and quantity of defect s walls . two of the most common retention systems used in reconstruction of orbital defects include freestanding abutments with magnetic retention and bar - clip retention . magnetic abutments are more common because they resolve the potential problems associated with bar - clip attachment including difficulty in insertion and removal of prosthesis by the patient , difficulty in regular hygiene measurements , and rigidity of the attachment resulting in implant overloading . however , magnetic attachment might not provide sufficient retention if implants have been placed adjacently . the presence of implant in the defective area might complicate the usual impression - taking procedures used in fabrication of conventional craniofacial prostheses . accuracy of the impression is affected by defect shape , retention system , number , and divergence of the implants . moreover , anatomical undercuts in the defect , and proximity or remoteness of the implants could complicate the impression - taking procedure . use of multiple trays , elastomeric impression materials , and dual impression technique have been suggested to overcome such problems [ 2,1214 ] . the purpose of this article was to present a case treated with an implant - supported prosthesis to reconstruct a relatively large orbital defect using three adjacent implants in the lateral orbital rim . a 60-year - old woman with a left orbital defect due to removal of periocular basal cell tumor was referred to the implant department of tehran university of medical sciences , school of dentistry , for prosthetic reconstruction of the eye . three implants ( superline , dentium , seoul , south korea ) , 8 mm in length and 3.6 mm in diameter were placed in the lateral rim of the orbit . although the most suitable sites for orbital implants are the superior and lateral rims , in the present case the implants have been placed adjacently , due to insufficient bone thickness in superior and inferior orbital rims . the defect was relatively deep with undercuts in the medial wall which could complicate impression making . the preferred prosthesis design was an implant - supported prosthesis with a custom bar containing properly distributed magnetic components . the healing abutments were unscrewed and three hexed direct - casting abutments ( implantium , dentium , seoul , south korea ) with 4.5 mm diameter were directly secured to the implants . the medial undercuts were blocked out , using a gauze pack to avoid the penetration of acrylic resin . an auto - polymerizing acrylic resin ( pattern resin , gc , tokyo , japan ) pattern was formed directly on the abutments in a manner that cobalt samarium ( co5sm ) magnets ( implantium , dentium , seoul , south korea ) , with 5.5 mm diameter and retention force of 700 gram could be placed at proper distances in the superior , inferior and lateral segments of the acrylic bar ( fig . the acrylic resin bar was casted using base metal alloy ( aalba dent inc . ; cordelia , c.a , usa ) and the magnet keepers were cemented in corresponding sites with panavia f 2.0 resin cement ( kurary medical inc , japan ) . acrylic resin pattern of bar containing indentations for magnets ( a ) , try - in of metal bar on the implants with magnet keepers in place ( b ) . the space beneath the superstructure and also the undercuts in defect walls were blocked out with gauze packs . the final impression was made in order to pick up the magnets and simultaneously record the rest of the orbital defect . light viscosity addition silicone ( panasil , kettenbach , germany ) was used as the first layer to cover the entire defect as well as the intact side of the midface . afterwards , regular viscosity addition silicone ( panasil , kettenbach , germany ) was used over the light viscosity material to create mechanical retention projections for the gypsum layer ( herostone vigodent inc . the wax pattern of the orbit was formed containing an ocular prosthesis which simulated the properties of a healthy eye . the pattern was tried on the patient and some modifications were made to improve its esthetic and adaptation . the prosthesis was made of a combination of heat - cured acrylic resin for holding the magnets , and high - temperature vulcanizing silicone with internal / external staining and other characterizations of the skin , such as wrinkles , eye brow and eye lashes . the final prosthesis was delivered to the patient and necessary home care instructions were provided such as removing the prosthesis during night , cleaning the eye defect with damp gauze , and the need for regular biannual follow - ups [ 69 ] . tissue side of the prosthesis with three magnets ( a ) , delivery of the prosthesis ( b ) the patient presented here has been treated with an implant - supported orbital prosthesis with bar - magnetic attachment . this retention mechanism might minimize the risk of mechanical overload on the implants compared to a conventional bar - clip attachment with cantilever arms . despite the proximity of implants , the mentioned distribution of magnetic attachments has increased the retention through creating a tripod . furthermore , since the acrylic resin pattern of the bar was made directly in the defective area , no implant or abutment analogues were used in final impression procedure . prolonged chair - side time is a disadvantage of the stated method which could be justified considering the mentioned advantages . the national tb prevalence survey in eritrea was conducted from february through october 2005 ( 6 ) . in 40 selected villages , a census ( which included information about sex and age ) was taken of 875 persons in each village . all persons > 15 years of age were asked to provide a morning and a spot sputum sample . persons who had 2 positive sputum samples were informed about the test results and referred for treatment . those who had 1 positive sputum sample were referred to a nearby healthcare facility for further smear examination . if results of smear examination were negative , thoracic radiographs were taken and evaluated by 2 experienced radiologists . the case definition for a sputum smear positive case was at least 2 sputum specimens positive for acid - fast bacilli by ziehl - neelsen staining and microscopy or at least 1 sputum specimen positive for acid - fast bacilli and radiographic abnormalities consistent with active pulmonary tb ( classification of the national tuberculosis control program in eritrea ) . using the prevalence estimate obtained from the survey and 2 different models , we calculated the cdr for 2004 . in model 1 , described by styblo , cdr = ( notification rate / prevalence rate ) / ( 0.5 + 0.83 [ notification rate / prevalence rate ] ) ( 7,8 ) . in model 2 , described by dye et al . , cdr = ( notification rate / prevalence rate ) / ( [ notification rate / prevalence rate ] + 0.5 ) ( 9,10 ) . we then compared the calculated cdr with the cdr estimated by the world health organization ( who ) to evaluate whether comparable conclusions about tb case detection would be obtained . a total of 38,047 persons were included in the prevalence survey . of those > 15 years of age , 18,152 ( 94.6% ) provided at least 1 sputum sample ( figure ) . the prevalence of new smear - positive tb was estimated at 90/100,000 ( 95% confidence interval [ ci ] 35145/100,000 ) in persons > 15 years of age . in 2005 , 44.7% of the eritrean population was < 15 years of age ( 11 ) , which resulted in an overall new smear - positive tb prevalence of 50/100,000 ( 95% ci 1980/100,000 ) under the assumption of no cases in persons < 15 years of age . summary of tuberculosis prevalence survey in eritrea , 2005 . in 2004 , 17/100,000 new smear - positive cases were reported ( 2 ) . for eritrea , the cdr provided by who is considerably lower than that calculated from the results of the national tb prevalence survey . both estimates indicate that eritrea has not reached the 70% target for case detection . however , the who estimate suggests that the program needs to improve case detection by a factor of 5 , whereas the survey estimate suggests that case detection needs to be improved by a factor of 1.6 . two explanations may account for the large difference : 1 ) the cdr derived from the tb prevalence survey is too high because of an underestimation of the prevalence of smear - positive tb , or 2 ) the cdr estimate published by who is too low because of an overestimation of the incidence of smear - positive tb . in the national tb prevalence survey , measures were taken to ensure high quality of the results ; e.g. , training of data collectors , repeat census taking , reexamination of all slides found positive on fluorescence microscopy , and reexamination of a 5% random sample of the negative slides . persons who had smear - positive tb may have been missed because they did not provide a specimen ; however , because only 5% of eligible persons did not provide a specimen , this can explain only a slight underestimation . furthermore , recorded reasons for not providing a specimen seem to be unrelated to a higher chance of having tb . the quality of the provided specimens may have been suboptimal because instructing and motivating persons to provide a sputum sample is challenging . for diagnosis of tb , microscopic examination of saliva is less sensitive than examination of sputum ; however , in 50% of saliva samples from patients with a positive sputum sample , bacilli can be demonstrated ( 12,13 ) . for 27,647 samples that appeared to be saliva , smear assuming that only 50% were detected , a maximum of 12 smear - positive tb patients may have been undetected . taking this into account results in a prevalence of 87/100,000 . using this estimate , model 1 provides a cdr of 30% and model 2 a cdr of 28% the possibility that persons who provided a saliva sample were not able to produce a sputum sample because they did not have pathologic pulmonary changes should also be taken into consideration . estimation of the incidence of smear - positive tb in eritrea is complicated by the fact that no data from tuberculin or prevalence surveys were available . the only data available for eritrea were reporting data , which experts assessed as being of low quality ( 14 ) . use of this limited information will result in an uncertain incidence estimate , which may result in an unreliable cdr . for most countries in africa , little information is available for estimating the prevalence of disease and progress towards the millennium development goals ( http://unstats.un.org/unsd/mi/mi_goals.asp , accessed 2006 aug 30 ) . on the basis of case reporting , tb was rightly declared an emergency by african health ministers at the who africa regional committee in maputo in 2005 ( 15 ) . to be able to fight this emergency , more reliable information about the prevalence of tb in africa is needed . furthermore , for global tb control , reliable information about the tb epidemic in africa is needed because 28% of the incident smear - positive cases occurred in the who african region in 2004 ( 2 ) . in conclusion , the example of eritrea shows that a large gap may exist between available estimates of tb prevalence and actual tb prevalence in africa . national tb prevalence surveys in africa would help provide better information on tb prevalence and case detection .

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

student perception of their dental school experience is an essential measure of the success of dental education . undergraduates ' feedback and suggestions are very important for improving the curriculum and learning process . this information also helps determine the students ' preferences regarding different elements of their educational experience . endodontics teaching can be considered complex , difficult , and stressful because of the complex anatomy of the root canal system , responsibility toward patients , and low self - confidence . however , teaching endodontics in recent years has improved as a result of the development of knowledge , techniques , and materials . dental students at taibah university , saudi arabia , take a preclinical full - year endodontic course in the 3 year of their 6-year bachelor of dental surgery degree . the course consists of 28 h of theoretical lectures and 28 3-h laboratory sessions , during which they perform technical aspects of root canal treatment on extracted single- and multi - rooted teeth . there is a one - semester clinical endodontic course in the 4 year that consists of 14 theoretical lectures and fourteen 3-h clinical sessions during which students treat single- and multi - rooted teeth . in the 5 year , endodontic treatments are performed as part of a comprehensive dentistry care course under the supervision of specialists . this study examined the endodontic experiences , perceptions of endodontic practice , and self - rated confidence of dental students enrolled in taibah university , saudi arabia . study approval was obtained from the research ethics committee of the college of dentistry , taibah university ( reference number : tucdrec/20160107/alrahabi ) . this study enrolled 41 undergraduate dental students registered in endodontic courses in the 2015 academic year at the college of dentistry , taibah university , saudi arabia . participation was voluntary , and students were informed that they could refuse participation . a questionnaire was distributed to 19 4-year and 25 5-year students in the final month of the academic year after they had had the maximum amount of training . the questions evaluated self - confidence at performing nonsurgical root canal treatment and experiences in this discipline . the level of confidence was classified using a 5-point scale as very confident , confident , neutral , not very confident , or not at all confident . to compare results , the chi - square test and mann whitney u - test were used . statistical analyses were carried out using spss version 20.0 ( spss , chicago , il , usa ) . statistical significance was set at p < 0.05 . the overall response rate was 93% , with 18 of the 19 4-year students and 23 of the 25 final - year students returning questionnaires . table 1 shows the results for the first three questions ( first endodontic case treated , level of case difficulty , and number of endodontic treatments performed by the student ) . first endodontic case treated , level of case difficulty , and number of endodontic treatments performed self - confidence of 4th- and 5th - year dental students regarding the steps of nonsurgical root canal treatment levels of confidence in the different steps of root canal treatment confidence levels differed significantly between 4- and 5-year students in the following steps of root canal treatment : determining the working length , taking and interpreting radiographs during root canal treatment , evaluating the quality of root canal obturation , and recalling the patients periodically in the correct manner . table 3 summarizes the results of the last question regarding suggestions to improve the teaching of endodontic courses . in dentistry , evaluating competence is an important step toward validating the quality of graduating dentists , although the relationship between the self - confidence and clinical competence of medical students is not fully understood . increasing the confidence of medical students should increase their competence in clinical practice . one way to standardize education is to poll students using questionnaires to help in the assessment , evaluation , and improvement of education . this study obtained information about the confidence of undergraduate dental students at taibah university , saudi arabia regarding endodontics . it revealed that an upper incisor 78% was the most common tooth first treated by students . upper incisor root canal treatment is relatively easy , and this should encourage students . in another study , most of our students described the experience with the first case as okay 78% , while 7.4% described it as easy and 14.6% described the first case as difficult , possibly because the first case for those students involved a molar or premolar . in other studies , students considered molars to be the most difficult tooth to treat . in our study , the maximum number of teeth treated in the 4 year was four cases , by 66.7% of the students , while the maximum number of teeth treated in 5 year was 11 cases , by 8.8% of the students . the number of teeth treated by students in the 4 and 5 year did not meet the recommendations of the european society of endodontology 2001 guidelines , which advised that for adequate competency a student should complete root canal treatments in 20 teeth . although the european society of endodontology published new undergraduate curriculum guidelines for endodontology in 2013 , these focused on the quality and consistency of student performance more than simply the quantity of clinical exposure . however , one study reported that 81% of the students in 48 dental schools in the european union achieved the minimum number of root canal treatments required for their graduation : the number of treated cases ranged between 3 and 80 canals , and the average was 17 canals . in our study , we observed that confidence varied according to both the year the student was in and the practical steps of nonsurgical root canal treatment . both groups reported relatively good confidence , although there were significant differences between 4 and 5 year students regarding some steps . fourth - year students were more confident than 5-year students in the following : determining the working length , dealing with x - rays during root canal treatment , evaluating root canal obturation , and recalling patient at the correct time . this might be because there were fewer 4-year students in the sample , there are fewer requirements in 4 year , and strict supervision by supervisors helped 4-year students more than 5-year students . confidence regarding working length determination was low in both 4- and 5-year students . this might be the result of the root canal anatomy , which many dental students find difficult to learn because of its variation among individuals . the reduction in confidence regarding endodontic radiology , the evaluation of root canal obturation , and determining the correct recall period probably results from insufficient clinical exposure . murray et al . wrote that a lack of clinical exposure in the undergraduate curriculum reduces the confidence that develops with clinical practice . students ' suggestions for improving the teaching of endodontics focused on two major issues : using rotary nickel - titanium ( niti ) files during treatment and increasing credit hours for the endodontic course . introducing advances in endodontics into undergraduate training , such as niti rotary instruments , may improve the clinical experience of students and their self - confidence because it will help increase the numbers of cases treated . believe that introducing niti rotary instruments into the undergraduate dental curriculum would be safe and improve endodontics teaching because inexperienced operators can learn to use rotary instruments adequately with brief training . nevertheless , another study found that intensive preclinical training is a prerequisite for using niti rotary instruments . changing the methods of teaching endodontics so that students can complete root canal treatment more easily and quickly , with minimal procedural accidents , will improve clinical outcomes . low self - confidence can be ameliorated by increasing clinical exposure , which will help students to obtain the necessary skills through experience . fourth- and fifth - year dental students at taibah university , saudi arabia , are confident regarding root canal treatment , although they report lower confidence in some steps of the root canal treatment process . endodontics education should be improved by increasing preclinical and clinical sessions and using new teaching methods that introduce recent advances in endodontics in the undergraduate curriculum . a 36-year - old woman complained of an insidious onset of generalized myoclonus that first became apparent at age 27 years . she had no perinatal problems and her development was normal in childhood and juvenile periods . adult - onset myoclonus had worsened progressively from right hand to four extremities , tremulous voice and gait disturbance developed after 3 years from disease onset , and she could not continue working as a nurse . she had no history of febrile convulsions or seizure , infectious disease in the central nervous system , exposure to toxic materials , or intake of herbal drugs . her younger brother aged 40 years old also had progressive generalized myoclonus , which was detected 6 years ago at age 34 years ( figure 1 ) . the patient was alert and oriented , and her mini - mental state examination score was 30 . she did not have gaze palsy , and her vision and hearing were normal ; however , her voice was tremulous and generalized positive myoclonus was observed at four extremities and body . negative myoclonus , dystonia , tremor , and rigidity were not detected , and both motor and sensory functions were intact . there was no evidence of cerebellar dysfunction , and she did not have an ataxic or parkinsonian gait , although she staggered slightly because of myoclonus . examination of the eyes revealed cherry - red spots ( figure 2 ) , but her electroencephalogram was normal . no white matter lesion or cerebellar atrophy was detected in an mri of her brain ( figure 3 ) . neuraminidase , hexosaminidase a , and -galactosidase activities in the leukocytes and cultured fibroblasts in patient and younger brother were normal . the cherry - red spot is a pale perifoveal ring that develops when large deposits of lipid , sphingolipid , or oligosaccharide material accumulate in the ganglionic cells at the macula.2 this is a characteristic finding in storage diseases , including the sialidoses , gm1 and gm2 gangliosidoses , neuronal ceroid lipofuscinosis , niemann - pick disease ( groups a through d ) , farber s lipogranulomatosis , and metachromatic leukodystrophy . interestingly , niemann - pick disease , farber s lipogranulomatosis , and metachromatic leukodystrophy are not associated with myoclonus . moreover , the patient in this report did not have typical findings of these 3 diseases such as the organomegaly , cognitive impairment , and gaze palsy seen in niemann - pick disease4 ; the hoarseness , arthritis , and subcutaneous nodules seen in farber s lipogranulomatosis ; or the abnormal brain mri findings in metachromatic leukodystrophy . in ceroid lipofuscinosis , sialidosis , gm1 and gm2 gangliosidoses , myoclonus , and maculopathy ( e.g. a cherry - red spot ) may coexist . although they are quite similar in appearance , the macular abnormality seen in patients with neuronal ceroid lipofuscinosis ( which has been described as bulls - eye maculopathy ) can be distinguished from the cherry - red spot by color and shape , as well as by the decreased visual acuity and visual - field restriction that are common in neuronal ceroid lipofuscinosis.5 moreover , adult - onset lipofuscinosis has an autosomal dominant inheritance , rather than the autosomal recessive pattern seen in this patient.6 gm1 gangliosidosis results from a deficiency of -galatosidase ; the adult form ( type 3 ) presents as a slowly progressive dementia with prominent parkinsonian features and extra - pyramidal dysfunction , particularly dystonia.7 gm2 gangliosidosis results from a deficiency of hexosaminidase a ; the late form ( with an onset during adolescence and young adulthood ) may be characterized by cognitive dysfunction , cerebellar dysfunction , upper and lower motor neuron involvement , and extrapyramidal dysfunction.8 because -galatosidase and hexosaminidase activity was normal in this patient , because she has a normal level of intelligence , and because no other prominent pyramidal or extrapyramidal dysfunction was detected , we might not diagnose this patient as gm1 and gm2 gangliosidoses . sialidosis is an inherited , autosomal recessive disease associated with a neuraminidase deficiency.9 it has 2 major clinical manifestations : type i ( late , adult onset ) and type ii ( early , infantile onset ) . type i sialidosis is typically found in patients aged 8 to 25 years and is characterized by cherry - red spot myoclonus , seizure , neuropathy , corneal clouding , and difficulty walking , but with normal vision and intelligence ( obrien , 1978 ) . type ii sialidosis is characterized by dysmorphism , myoclonus , mental retardation , ocular cherry - red spots , and hepatosplenomegaly . the patient in this report may present clinical evidence of type i sialidosis , but her laboratory findings do not support this diagnosis ; activities of the neuraminidase were normal . a similar case of progressive myoclonic epilepsy has been reported.10 differences from the previous report which described a patient with progressive myoclonic epilepsy , cherry - red spots and negative enzyme deficiency were theses ; 1 ) the onset - age was older than the previous report ( 27 versus 13 years , adult versus juvenile - onset ) ; 2 ) the patient had a sibling with same disease , which indicated she had inherited disease , but the patient in previous report did not have familial history ; 3 ) the patient in our report did not have a history of seizure , and it is different from the patient with myoclonic epilepsy . although the cause of cherry - red spot myoclonus is not clear , to our knowledge , this is the first report of adult - onset familial cherry - red spot myoclonus caused by an unknown type of lysosomal storage disease in korea .

objective : this study examined the endodontic experience , perceptions of endodontic practice , and self - rated confidence of dental students enrolled in taibah university , saudi arabia.materials and methods : a questionnaire was distributed to 41 undergraduate dental students registered in endodontic courses in the 2015 academic year . the questionnaire evaluated their confidence performing nonsurgical root canal treatment . the level of confidence was classified using a 5-point scale as very confident , confident , neutral , not very confident , or not at all confident . the data were analyzed using spss version 20.0 ( spss , chicago , il , usa).results : the participation rate was 93% . the maxillary incisor was the most common first tooth treated . the students were relatively confident , but their confidence levels were lower regarding endodontic radiology , evaluation of root canal obturation , and determining the correct recall period for the patient.conclusion:the confidence of undergraduates in endodontics must be enhanced to increase their clinical competence when performing root canal treatment .

septic internal jugular vein - sigmoid sinus thrombosis is a rare condition that complicates local and regional infectious inflammatory processes occurring in the head and neck . these include deep neck infections , lemierre syndrome , and central venous catheterization ( cvc ) or cannulation17 ) . this is a life - threatening condition and prompt management is essential to decrease the potential for thrombosis - related morbidity and mortality . we report a case of internal jugular vein - sigmoid sinus thrombosis due to a misplaced central venous catheter . a 52-year - old woman presented with a severe bursting headache , vomiting , and a drowsy mentality . brain computed tomography ( ct ) scan revealed subarachnoid hemorrhage in the basal cistern with a small amount of hematoma at the left sylvian fissure ( fig . we identified an aneurysmal rupture of the middle cerebral artery on the left side by cerebral catheter angiography ( fig . postoperative chest x - ray was normal except for malposition of the central venous catheter in the right internal jugular vein ( fig . ten days later , the patient developed a fever , elevated white blood cell count to 227000 , and elevated c - reactive protein to 33.6 . the central venous catheter was removed , and antibiotics were administrated through a different intravenous route . despite these managements , the patient was stupor the next day . brain ct scan revealed cerebral infarction with hemorrhagic transformation in the right temporal lobe , and ct angiography did not identify vasospasm ( fig . retrospective analysis of the contrast - enhanced ct scan and ct angiography showed an " empty delta sign " and absence of venous flow within the right internal jugular vein - sigmoid sinus that was sufficient for diagnosis of sinus thrombosis ( fig . results of central venous catheter tip and blood culture was reported staphylococcus epidermidis and methicillin - resistant staphylococcus aureus , respectively . we could not start systemic heparinization due to hemorrhagic transformation of the cerebral infarction in the right temporal lobe . we administrated mannitol and steroids to manage increased intracranial pressure ; however , the patient died from severe pneumonia due to septic emboli after one week ( fig . 2c ) . indications for a cvc are the intravenous administration of drugs , parenteral nutrition , hemodialysis , and hemodynamic monitoring13 ) . at many institutions , cvc is routinely inserted before undergoing major surgery or treating patients with critical illnesses or cancer . the most frequently available anatomical sites for cvc are the subclavian and internal jugular veins . these procedures carry a substantial risk of mechanical lesions , such as arterial puncture , pneumothorax , cardiac tamponade , nerve lesions , or thrombotic or septic complications13 ) . malpositioning of the catheter tip may happen more often in the subclavian vein than the internal jugular vein . the reported incidence of primary misplacement of the catheter tip after infraclavicular subclavian vein catheterization varies from 5% to 24% even when inserted by experienced clinicians7 ) . inadvertent catheterization of the ipsilateral internal jugular vein is one of the most common misplacements , with a reported incidence of around 7%15 ) . the positioning of catheter tips within the cardiac silhouette is associated with increased risk of cardiac tamponade6 ) . also , positioning of the catheter tip in the subclavian vein is associated with a high risk of thrombus formation and vessel occlusion2 ) . the risk of thrombosis may increase when hyperosmolar parenteral nutrition fluid is administered through a misplaced central venous catheter into a internal jugular vein3,15 ) . moreover , malpositioned catheter tips can damage the endothelium and precipitate the formation of thrombi17 ) . when a cvc causes thrombosis , the risk of catheter - related sepsis may increase . in patients with a cvc , the risk of catheter - related infection was reported to range between 1% and 10%1 ) . contamination of a thrombus from the skin puncture site may result in septic endophlebitis , and occasional blood - borne infections may also contaminate the thrombus . embolic septic thrombi may involve the lungs and , less frequently , the joints , viscera , and brain17 ) . subclavian or internal jugular vein thrombosis associated with indwelling catheters will propagate into other vessels , but extension into the intracranial sinuses and veins is rare . three reports describe an association between cerebral venous sinus thrombosis and central venous hyperalimentation due to placement of the catheter tip in the internal jugular vein3,15,16 ) . the authors warn of the potential for thrombosis due to retrograde infusion into the valveless internal jugular - dural sinus system but also suggest that the small caliber of the vein may predispose to thrombosis . in our case , we found the malpositioned catheter tip in the internal jugular vein on follow - up chest x - ray , but it was ignored . all intravenous fluids ( e.g. , total parenteral nutrition , mannitol , antibiotics ) were administered through the misplaced catheter . the patient 's condition worsened , leading to thrombosis of the internal jugular vein secondary to sigmoid sinus thrombosis . since the advent of antibiotics fever , chills , otalgia , tenderness to percussion over the mastoid emissary vein , headache and vomiting are common but not pathognomonic features8,18 ) . occasionally , neurologic symptoms are related to increased intracranial pressure or infarct and present as deteriorating mental status , lethargy , seizures , hemiplegia , and coma , and may lead to death . rarely , remote septic conditions such as pneumonia are the presenting symptoms9 ) . because of the nonspecific signs and symptoms of disease and the masking effects of antibiotics , diagnosis is difficult . the diagnosis of sigmoid sinus thrombosis can be confirmed by ct , magnetic resonance imaging , or angiography . contrast - enhanced ct scans demonstrate multiple intraluminal filling defects and nonvisualization of the sinus18 ) . in addition , low density lumen , sharply defined dense vessel wall , or distension of the thrombosed vein , such as the " empty delta sign " , are positive signs for sinus thrombosis19 ) . vascular imaging with cerebral angiography is highly specific for the recognition of sinus thrombosis because it can detect the lack of blood flow in thrombosed cerebral veins and dural sinuses . chest x - rays may also demonstrate septic embolic pleura - pulmonary complications , which are often bilateral , by revealing nodular infiltrates with pleural effusion17 ) . retrospectively , we confirmed that contrast - enhanced brain ct scans revealed a low density lumen surrounding a sharply enhanced dense vessel wall at the sigmoid sinus on the right side . also , the right internal jugular vein and sigmoid sinus were not visualized on ct angiography . treatment consists of aggressive antimicrobial therapy , heparinization , anticoagulation , and decreasing intracranial pressure . antibiotic selections is directed toward the causative pathogen cultured at the initial site of infection . recent studies have shown heparinization to be safe and beneficial , despite the possibility of an increased risk of hemorrhage4,10,16 ) . currently , heparin is recommended as the initial drug of choice for cerebral venous sinus thrombosis followed by long - term anticoagulation with warfarin5,10,12 ) . although these procedures allow for rapid clot removal and reduction of venous hypertension , hemorrhagic complications can occur , leading to be high morbidity and mortality14 ) . occlusion of the cerebral veins due to thrombosis may induce localized brain edema and venous infarction resulting in elevated intracranial pressure . finally , death frequently results from increased intracranial pressure caused by obstruction of venous and cerebrospinal outflow11 ) . in our case culture results of the subclavian catheter tip and blood were confirmed as staphylococcus epidermidis and methicillin - resistant staphylococcus aureus , respectively , and we switched from broad - spectrum antibiotics to vancomycin . unfortunately , we could not start heparinization due to concurrent cerebral hemorrhage of being transformed from cerebral infarction . severe pneumonia due to septic emboli eventually developed in both lung fields , and the patient died . diagnosis of internal jugular vein - sigmoid sinus thrombosis is challenging due to vague clinical features . therefore , if patients with malpositioned cvcs present with symptoms of fever , chills , headache , vomiting , increased intracranial pressure , mental deterioration , and focal neurologic deficits , intracranial sinus thrombosis should be considered . even vague symptoms may need to be investigated radiologically to discover a thrombosis early , when it can be treated . supported by nci 2p50 ca09825806 , nci u01 ca168394 , stand up to cancer / aacr dream team translational cancer research grant su2c - aacr - dt0209 , tcga gdac grant ( nih / nci u24 ca143883 ) to gbm ; mdacc uterine spore career development award ( nci p50ca098258 ) to lwt .

septic internal jugular vein - sigmoid sinus thrombosis ( ijv - sst ) associated with a malpositioned central venous catheter is a rare condition . it is potentially life - threatening and necessitates early diagnosis and rapid administration of appropriate medications . unfortunately , it is difficult to diagnose due to vague clinical presentations . several studies such as ct , mri , and cerebral angiography should be performed and carefully examined to help make the diagnosis . we report a case of septic ijv - sst due to a malpositioned central venous catheter .

the function of sensory receptors ( nrec ) in the movement control , muscle coordination and perception of the space position of temporo - mandibular joint ( tmj ) is fundamental although the presence of nrec in the tmj is still debated : some authors have reported on the lack of nervous fibers in the articular disk 1,2 , while florid innervation of tmj has been reported in several studies on animal models and in human 3 - 6 which suggested that 6 the concentration of sensory receptors within tmj is higher in the areas supporting higher strong tensions during articular movements ( chewing , biting , speaking ) . in discordance , other authors disclosed the presence of mechanical nrec in the articular disk of human tmj 7,8 also distinguishing receptors in capsulated and uncapsulated on the bases of morphological features . the aim of this study is to ascertain the presence and the distribution of nrec in human tmj by using of immunohistochemical investigations in healthy and pathological tmj such as arthritis and arthrosis . the study was approved by the bioethics committee of the department of odontology and surgery of university of bari . 10 samples of capsular and pericapsular soft tissues with the disk were obtained from healthy patients ( six men and four women with a mean age of 39 years ) who suffered surgery of tmj because of accidental trauma of the temporo - mandibular region ; the remaining 7 cases ( four men and three women with a mean age of 57 years ) were patients surgically treated for severe degenerative lesions of tmj ( chronic arthritis and arthrosis ) . all specimens were immediately fixed in neutral buffered formalin and embedded in paraffin ; 5 micron thick sections were cut and stained with haematoxylin - eosin , pas , gomori 's reticulin and azan - mallory trichrome ; consecutive sections were used for the immunohistochemical detection of the antigens listed in table 1 . all the antibodies used are commercially avalaible from dako italia spa , milan , italy ( glial fibrillary acidic protein = gfap ; myelin basic protein = mbp ; neurofilaments = nf ; neuron specific enolase = nse ; synaptophysin ; s-100 protein = s-100 ) and from becton dickinson , burlingame , usa ( leu-7 ) . in all cases the immunohistochemical alkaline phosphatase - anti - alkaline phosphatase ( apaap ) method was performed 9 while some sections for anti - neurofilaments antibodies were treated for 10 minutes with 1% saponin in phosphate buffered saline ( pbs ) , ph 7.2 , before the application of primary antibodies . with histochemical techniques and h&e stain , nrec were not easily detectable ( figures 1 - 8 ) ; however , these were used to identify the corresponding tissue in immunostained slides . in all specimens , such types of nrec have been detected by immmunohistochemistry ( table 2 ) : a ) globular receptors with a thin capsule closely resembling ruffini 's ones ; they exhibited strong immunoreactivity in their core for s-100 , nse and leu-7 and were abundant in the superficial peri - articular muscles and in the peri - articular fibrous capsule ; b ) elongated , onion - like receptors with a thick capsule mimicking pacini 's receptors , positive for mbp , s-100 , nse and leu-7 , particularly abundant in deep muscle fibres and in peri - articular dense fibrous tissues ; c ) fusiform capsulated receptors , morphologically similar to golgi 's receptors , located within peri - articular fibrous tissues and ligament and fibromuscolar resections , strongly positive for s-100 , mbp and leu-7 and weaker gfap reactivity . in all these types of nrec ( a+b+c ) and especially in the core , punctate reactivity for synaptophysin and for neurofilaments was also evident ; d ) free and thin nervous endings in high density within subsynovial connective tissues , in intra- and periarticular fibrous tissues and along the perimisial , endomisial sarcolemma of striated muscle fibres were detected , showing immunoreactive for neurofilaments , nse , synaptophysin and to s-100 antibodies . in the articular fibrous cartilage ( articular disk ) any previously described nrec was identified ; only s-100 protein seemed to react with chondrocytes both in normal and diseased tissues . furthermore , chondrocytes of healthy individuals appeared round - shaped , with distinct cell borders and central nuclei with an evident s-100 reactivity both in nucleus and in cytoplasm . in diseased tmj , instead , chondrocytes showed a different morphoology , especially after s-100 immunostaining : they had an elongated cytoplasm with one or more thick dendritiform processes of variable length but with a strong reactivity only for s-100 protein . the number of dendritiform chondrocytes was higher in specimens of diseased patients than in healthy patients and seems undergo a reactive reparative proliferation of discal and peridiscal tissues . few studies are reported in literature on the precise identification and distribution of nrec in articular and peri - articular tissues of tmj . in the past , some authors 3 - 6 identified ruffini's - like , pacini 's like and golgi 's like receptors both in articular and periarticular tissues , using conventional or histochemical methods usually performed to identify nerve fibres and receptors 7,8 . by using immunofluorescent techniques , other authors 3 demonstrated the presence of nervous fibers in the periarticular fibrous tissues , which seemed to run along the blood vessels reaching the fibrous cartilage of tmj and ending to the inside . our study confirmed the results of other preceding reports on the presence of several different types of nrec in periarticular soft tissues of tmj , allowing additionally a precise immunohistochemical identification of ruffini's - like , pacini's- like and golgi's - like receptors in skeletal muscles and tendons , in periartcular dense fibrous connective tissues and in subsynovial tissues . in fact , nrec appeared nse , s-100 and mbp immunoreactive showing gfap and and leu-7 immunoreactivity to lower degrees . free nervous endings , immunohistochemically positive for neurofilaments , nse , and s100 protein , have been detected only in periarticular soft tissues ( higher density in muscles and in the vascular venous plexus in the posterior part of discal ligaments and in the trilaminar zone ) and not in cartilagineous disk . the latter , besides , appeared constituted by s100 immunoreactive chondrocytes both in healthy individuals and in patients with chronic degenerative tmj lesions . in pathological patients with severe disk damage number and morphology of chondrocytes were severely different in comparison to normal tissues 11 ; chondrocytes , in fact , were more numerous with a rough and thick elongated cytoplasmic processes conferring a dendritic - like appearance . in some instances , dendritic processes were extremely long and consequently their cytoplasm of origin could not be detected in a single section but only on consecutive sections of the same specimen . in no instances this cellular component and their prolongments in cartilagineous disks showed neurofilaments , nse or synaptophysin immunoreactivity . morphological changes of chondrocytes in patients with chronic arthritic disease of tmj we observed , conferring them the appearance of neural cells and their axons , have been previously described in literature 10 . this misleading feature is further emphasized by the occurence of s-100 immunoreactivity in dendritic chondrocytes , as well as in normal chondrocytes . nevertheless , s-100 positive cells in the articular cartilage of tmj bear rare , thick and coarse cytoplasmic processes in which no one of the antigens commonly found in peripheral nerve fibres ( e.g. leu-7 , mbp , neurofilaments , nse and synaptophysin ) , except for s-100 , could be detected . in contrast , peripheral nerve fibres usually exhibit long , thin and varicose cytoplamic prolongments in which a variable combination of the above mentioned antigens is usually detectable in conjunction with s-100 reactivity . the results of our study indicate that free nervous endings described by other authors 3 - 8 are definitely proven to be nrec , and it appears likely to stress that , especially in pathological conditions , chondrocytes and their prolongments might morphologically resemble nrec in the articular disk , although their immunophenotype is rather different with the lack of expression of typical neural antigens . although immunochemistry can be easily used to study distribution and location of nrec in articular tissues , we also suggest that ultrastuctural and immuno - ultrastructural studies should be performed in order to definitely assess if chondrocytes is the exclusive cell type of articular cartilage or if also nrec could be present in tmj . brown - squard syndrome ( bss ) , which occurs due to dysfunction of the spinothalamic tract , typically reflects the hemisection of the spinal cord at the cervical or thoracic level . the syndrome mainly occurs as a result of penetrating trauma , syringomyelia , hematomyelia , tumor , severe discs , or blunt trauma . among the multiple etiologies , the most common cause is penetrating trauma , such as a gunshot7,8 ) . therefore , most management guidelines focus on penetrating cervical injuries and/or vertebral artery ( va ) injury12 ) . non - missile penetrating spinal cord and va injuries are rare because of the bony structures that protect the spinal cord and va14 ) . thus , the treatment approach for wounds caused in non - missile penetrating spinal injuries such as a knife , a power drill bit , or even a pen could be different from common missile penetrating injuries5,6,13,17).to our knowledge , there are few reports in the literature of complete obstruction of the va due to penetration of a foreign body through the neural foramen into the spinal canal . herein , the authors report on va dissection and bss caused by penetration of an electric screw driver bit . a 25-year - old machine operator was involved in a violent episode and was stabbed in his right neck with an electric screw driver bit that was thrown by the opponent . on arrival at the emergency department , the electric screw driver bit was placed in the right lateral aspect of the neck at zone i ( fig . the tip of the electric screw driver bit was located at the center of the vertebral canal of c3 ( fig . he was given high - dose methylprednisolone ( bolus dose of 30mg / kg followed by 5.4mg / kg / hour for 23 hours ) according to the protocol for spinal cord injury . an immediate interventional angiography was undertaken without general anesthesia due to the nature of the emergency . the angiography revealed a total occlusion with dissection of the right va at the level of c3 . immediate coil embolization at both proximal and distal ends of the injury site was performed ( fig . an attempt at manual extraction of the electric screw driver bit failed with great resistance . after the patient was moved to the operating room , the electric screw driver bit was removed manually with muscle dissection under general anesthesia . venous blood spilled out and was controlled easily by application of several pieces of gelatin sponge . no postoperative complications such as wound dehiscence , cerebrospinal fluid ( csf ) leakage , or infection were observed . the neurological motor function of the right upper and lower extremities recovered to 3/5 and 4/5 , respectively , with persistent decreased sensory function after one year . fortunately , the patient experienced no neck swelling , auscultation of a neck bruit , or delayed ischemic complications . penetrating injury is the third most frequent cause of spinal cord injury in adults , surpassed only by traffic accidents and falls3,18 ) . stab wounds are associated with lesser surrounding tissue injury than gunshot wounds because the former delivers less energy than missile injuries9 ) . although vascular injury is the most common sequel of penetrating neck trauma , va injury is rare because it is well protected by the transverse foramen4,10 ) . therefore , penetrating injury of the va is mostly caused by gunshot wounds which deliver large kinetic energy , depending upon the bullet 's mass and speed12 ) . in this article , we report a rare case of va penetration by an electric screw driver bit with spinal cord insult , consequently presenting as bss . moreover , surgical exploration of the va can cause additional damage to the spine and surrounding tissues . therefore , it may be reasonable to embolize an occluded artery , because the unilateral ligation of the va rarely results in brainstem ischemia11,16 ) . there are a few reports regarding the treatment of traumatic va injury such as the arteriovenous fistulas and pseudoaneurysms2 ) . emergent surgical exploration is necessary for patients with hard signs of vascular injury , such as hemodynamic instability , hemorrhage exsanguinations , or expanding hematoma15 ) . patients that are hemodynamically stable and who are without respiratory compromise should undergo further diagnostic imaging evaluation15 ) . as presented in this case , endovascular techniques were a safe and effective method of treatment and were not associated with significant morbidity or mortality1 ) . airway management , intubation methods , and surgical positions can be points of debate between anesthesiologists and surgeons9 ) . if a lacerated va can be successfully obliterated , a penetrating electric screw driver bit may be extracted without general anesthesia . nevertheless , the authors recommend that surgeons should be prepared for conversion to open surgery and extraction should be performed with the support of a surgical team . we initially tried to extract the electric screw driver bit manually without general anesthesia in the intervention theater after va embolization . however , the electric screw driver bit was positioned firmly in the neural foramen , and the patient complained of severe pain when the electric screw driver bit was being pulled out . in addition , there was more important rationale that justified surgical exploration for extraction of the electric screw driver bit . on extraction of the electric screw driver bit , the authors describe a rare case of penetrating cervical injury caused by an electric screw driver bit with accompanying va penetration and bss .

aim : a study was performed on the articular disk and periarticular tissues of the temporo - mandibular joint ( tmj ) with immunohistochemical techniques to give evidence to the presence of neuroreceptors ( nrec ) in these sites . methods : the study was carried out on tissue samples obtained from 10 subjects without tmj disease and from 7 patients with severe tmj arthritis and arthrosis . we use antibodies directed against following antigens : gliofibrillary acidic protein ( gfap ) , leu-7 , myelin basic protein ( mbp ) , neurofilaments 68 kd ( nf ) , neuron specific enolase ( nse ) , s-100 protein ( s-100 ) and synaptophysin ( syn ) . results : this study revealed that ruffini's - like , pacini's - like and golgi's - like receptors can be demonstrated in tmj periarticular tissues and that free nervous endings are present in the subsynovial tissues but not within the articular disk . we observed elongated cytoplamic processes of chondrocytes that demonstrated strong s-100 immunoreactivity but they were unreactive with all other antibodies . these cytoplamic processes were more abundant and thicker in the samples obtained from patients with disease tmj . conclusion : the results of this study confirm that different nrec are detectable in tmj periarticular tissues but they are absent within the articular disk . in the latter site , only condrocytic processes are evident , especially in diseased tmj , and they might have been confused with nervous endings in previous morphological studies . nevertheless the absence of immunoreactivity for nf , nse and syn proves that they are not of neural origin .

primary intracystic squamous cell carcinoma ( scc ) in the breast is an extremely rare neoplasm . primary sccs in the breast are quite rare , although scc mixed with ductal carcinoma is more common . it can arise from metaplastic epithelium associated with other primary malignancy of the breast , metastasis from primary elsewhere in the body or an extension of malignancy from the skin covering . a 45-year - old female presented with a lump in the right breast , which she had noticed since three weeks . her menstrual cycles were regular and she had two children . clinical examination revealed a firm cystic lump of 12 10 cm in the upper inner and central quadrant of the right breast . the skin over the right breast appeared stretched , with a slight retraction of the nipple . pre - operatively , the patient was relegated to clinical stage iii ( t3n0m0 ) . ultrasonographic examination of the right breast showed an irregular - shaped hypoechoic lesion measuring 12 6 cm with an internal anechoic area measuring 6 3 cm , suggesting a cystic malignant tumor . fine needle aspiration from the lump in the right breast yielded 10 ml of pale yellow serous fluid . wet - fixed and air - dried smears were prepared from the centrifuged aspirated fluid and were stained with papanicolaou ( pap ) stain and may - grnwald - giemsa ( mgg ) stain , respectively . the smears studied were cellular and showed malignant squamous cells predominantly in singles and occasional syncytial groups , and some cells were spindle shaped . the malignant squamous cells had rounded borders with hyperchromatic enlarged nucleus and coarse irregular granular chromatin . cytoplasm of the squamous cells showed a variable degree of keratinisation [ figure 2 ] . cytology smears showing malignant squamous cells in singles with numerous cyst macrophages ( mgg , 400 ) cytology smear showing malignant squamous cells in singles , demonstrating cytoplasmic keratinisation ( pap , 400 ) to exclude metastatic scc , a search for remote primary scc included chest radiograph , cystoscopy , colposcopy , oesophagogastroscopy , laryngoscopy and cervical pap smear , which did not reveal any extramammary cancer . the criteria include : ( 1 ) no other neoplastic element , such as ductal or mesenchymal ones , are present in the tumor , ( 2 ) the tumor is independent of adjacent cutaneous structures and ( 3 ) no other distant epidermoid tumor exists in the patient . later , simple mastectomy with axillary clearance was performed and the specimen was sent for histological examination . the cut - section of the mastectomy specimen showed a large cystic tumor measuring 8 3 cm , containing yellow serous fluid . the cystic cavity was lined by dysplastic squamous epithelium with an infiltrating tumor , showing malignant squamous cells in broad sheets , groups and whorls , with keratin - pearl formation and intercellular bridges . immunostaining for estrogen / progesterone receptor and her-2/neu oncoprotein were negative and that for cytokeratin was positive . the smears studied were cellular and showed malignant squamous cells predominantly in singles and occasional syncytial groups , and some cells were spindle shaped . the malignant squamous cells had rounded borders with hyperchromatic enlarged nucleus and coarse irregular granular chromatin . cytoplasm of the squamous cells showed a variable degree of keratinisation [ figure 2 ] . cytology smears showing malignant squamous cells in singles with numerous cyst macrophages ( mgg , 400 ) cytology smear showing malignant squamous cells in singles , demonstrating cytoplasmic keratinisation ( pap , 400 ) to exclude metastatic scc , a search for remote primary scc included chest radiograph , cystoscopy , colposcopy , oesophagogastroscopy , laryngoscopy and cervical pap smear , which did not reveal any extramammary cancer . the criteria include : ( 1 ) no other neoplastic element , such as ductal or mesenchymal ones , are present in the tumor , ( 2 ) the tumor is independent of adjacent cutaneous structures and ( 3 ) no other distant epidermoid tumor exists in the patient . later , simple mastectomy with axillary clearance was performed and the specimen was sent for histological examination . the cut - section of the mastectomy specimen showed a large cystic tumor measuring 8 3 cm , containing yellow serous fluid . multiple sections studied showed cystic breast tumor . the cystic cavity was lined by dysplastic squamous epithelium with an infiltrating tumor , showing malignant squamous cells in broad sheets , groups and whorls , with keratin - pearl formation and intercellular bridges . immunostaining for estrogen / progesterone receptor and her-2/neu oncoprotein were negative and that for cytokeratin was positive . pure scc and adenosquamous carcinoma have been listed under metaplastic breast carcinomas in the world health organization classification . the japanese breast cancer society has defined scc of the breast as a special type of cancer , in which malignant cells are arranged in broad sheets and whorls with keratin formation or intercellular bridge . the incidence of scc reported in the western countries is 0.13.6% and in japan , it is 0.17% . the age group affected is between 32 and 65 years , with an increased tendency of left - sided involvement . the characteristics of scc of the breast generally reported are a large - sized tumor , rapidly growing with a central cyst formed by necrosis . this is unlikely in our case because there was little necrosis elsewhere in the tumor . the possible mode of origin of scc is epidermoid cyst of the breast , chronic abscess and complete metaplasia of glandular breast tissue . lymph node involvement is reported to be less frequent than might be expected , given the larger tumor size . the tumor cells are negative for vimentin , estrogen and progesterone and are diffusely positive for high molecular weight cytokeratin and c - erbb-2 . squamous cells in fine needle aspiration cytology ( fnac ) of breast lesions can be found in various benign lesions , like epidermoid cyst , subareolar abscess , fibroadenoma , infracted papillomas , spindle cell metaplasia , cystic sarcoma phyllodes , pseudosarcoma and malignant breast tumors or metastatic malignancy . the benign breast conditions with abundant squamous cells may sometimes mimic malignant squamous lesion and vice versa . in general benign squamous cells are bland looking and are often associated with anucleated squames , and no tumor , cell cannibalism . the malignant squamous cells are more pleomorphic , mitotically active and dyskeratotic and , sometimes , bizarre - shaped cells can be seen . the differential diagnosis of malignant squamous cells in fnac of the breast includes primary scc and metastatic scc of the breast . careful assessment of cytological features of squamous cells and the background appearance appears to be critical for arriving at a correct diagnosis . however , in the case of intracystic scc , numerous foamy macrophages coexist with malignant squamous cells . hormonal therapy is not indicated as most cases of scc are negative for hormonal receptors . scc of the breast is reported to be resistant to both radiotherapy and standard chemotherapy performed for invasive ductal carcinoma . in our case , radical mastectomy with axillary clearance was performed with postoperative adjuvant therapy , as given for common types of breast cancers . there was no evidence of recurrence of the tumor after four years of treatment . in conclusion , the presence of malignant squamous cells in fine needle aspiration of the breast suggests primary scc or metastatic scc . the finding of a pure scc necessitates more accurate work - up to exclude skin lesion or metastasis . the primary scc should not be confused with a much more largely manifested metaplastic change in other usual breast cancers . although the presence of numerous cyst macrophages in the background of breast fnac smears suggests a benign lesion , when present with malignant squamous cells , they suggest intracystic scc . despite advancements in modern medical science and the health management industry , the incidence of cerebral palsy ( cp ) continues to rise1 . the most common features of cp are decreased muscle strength and abnormal muscle tone2 . cp sufferers lack theability to generate enough force to maintain antigravity postural control , which result in abnormal postures3 . the development of movement and posture may be altered by non - progressive damage to the brain and subsequent neurological impairments ( spasticity , muscle weakness , co - contractions and visual impairment)5 . studies indicate that children and adults with both mild and severe forms of cp have postural impairments6,7,8 . the emergence of sitting postural control in early infancy changes the way infants interact with the world . from the sitting position , looking , reaching , and interacting become functional and allow exploration that supports learning and further development of motor skills . therefore , independent sitting , defined as not needing support from a caregiver or pillow while sitting , is one of the first developmental goals for every child . individual differences are present between children , and characteristic signs of developmental disorders during infancy are relatively unspecific . therefore , why a specific child is not able to achieve sitting postural control is not always clear . one method of examining postural control in adults and children is to measure the center of pressure ( cop ) at the base of support using a force platform during the task of remaining upright . cop has frequently been used to investigate postural control during standing by young children who are healthy or have cp9 , 10 . the purpose of this study was to investigate the differences of the pressure distributions of the sitting postures of typical developmental ( td ) children and children with cp . twelve cp childrens were recruited from an outpatient rehabilitation clinic . they were hemiparetic , had an mmse - k score above 2411 , could maintain an independent sitting posture without support . two of the cp children were subsequently excluded because they refused to participate in this experiment . all parents of the enrolled participants provided their written informed consent to their children s participation prior to this experiment , in accordance with the ethical principles established in the declaration of helsinki . as a result of the exclusion , this study used two school chairs mounted on a force platform to assess the quiet - sitting pressure distribution of the subjects . fsa seating assessment ( canada ) the acquisition frequency was set at 5 hz . the stated working range of the device is 0200 mmhg , with a resolution of 1 mmhg . the system was also calibrated to assign absolute pressure values to the digital output from an a / d converter connected to the sensing pad . this was done by applying a pressure distribution as similar to actual conditions as possible . then thus subjects sat on one of two school chairs according to their height . the chairs were those generally used in school . for research purposes , this study used two basic school chair because students spend a long time of day - to - day sitting on them . one chair had a 40 cm floor to seat height , a 35 cm seat depth , and a 32 cm seat width and is designed for 122.4133.5 cm height of subjects . the another had a 35 cm floor to seat height , a 38 cm seat depth , and a 35 cm seat width , and is designed for 133.6152.7 cm height of subjects . it has been used for the posture symmetry in other study13 statistical analyses were performed using pasw 18.0 . descriptive statistics were calculated ( frequency , mean , standard deviation , range ) . the mann - whitney u - tests and wilcoxon s signed rank tests were used to analyze differences between the groups and differences in lesion side , respectively . the si of the age matched td group was employed as the normal criteria . table 1table 1.general characteristics of the subjectscerebral palsygroup ( n=10)typicaldevelopmentalgroup ( n=10)age ( years)8.040.827.840.94gender ( male / female)5/54/6lesion side ( right / left)4/6symmetry index ( meansd)5.041.342.302.76 shows the general characteristics of the participants . the si of the td group was significantly closer to zero than that of the cp group of children . cp and right hemiparetic cp were respectively 4.96 ( 2.24 ) and 5.12 ( 0.83 ) with no significant difference between the hemiparetic sides . the purpose of the present study was to investigate the differences in sitting posture of children with cp while they sat on school chairs . it is known that dynamic postural control during sitting can be reliably assessed using cop data of infants who are developing typically or infants with or at risk of cp14 . the principal finding of this study is that cp children s sitting posture is asymmetrical , leaning to the less - paretic side . we thought that infants who are developing typically develop the ability to sit by exhibiting an optimal range of movement variability , whereas cp may present either too much or too little variability leading to a very rigid and narrow or unpredictable set of movement solutions to achieve independent sitting . the finding of this study is agreement with previous studies that have the dissimilarities of the cop patterns of infants with cp and td have been obviously demonstrated14 . the results can not be generalized to all cp children because the sample was limited to ten children and they were at the one stage of the developmental process . future studies should assess the relationship between symmetry of sitting posture and functional activities .

primary intracystic squamous cell carcinoma ( scc ) of the breast is an extremely rare entity and has a low incidence in comparison with other breast cancers . we report a rare case of primary intracystic scc in a 45-year - old woman who presented with a cystic lump in the right breast . cytological smears of the fluid aspirated from the breast tumor revealed malignant squamous cells dispersed in single and occasional groups along with numerous cyst macrophages , suggesting cystic scc . histological study of the mastectomy specimen confirmed the diagnosis of primary intracystic scc . although the presence of abundant foamy macrophages in the background of fine needle aspiration cytology smears of the breast suggest benign breast lesion , when associated with malignant squamous cells , these suggest cystic primary scc or metastatic scc . the primary scc should not be confused with metaplastic change in other breast carcinomas .

ectopic kidney is a relatively rare renal anomaly however , an endourologist does encounter stone disease in an ectopic kidney occasionally . factors such as anomalous blood vessels and tortuous ureter with high insertion can lead to poor drainage and predisposition to the formation of renal calculi in these patients . the common management option for such stones is laparoscopy or ultrasound guided percutaneous nephrolithotomy ( pcnl ) . we report our experience with the use the recently described micro - pcnl or microperc for two such cases . two male patients , aged 57 and 60 years respectively , presented to us with calculi in ectopic pelvic kidneys . the first patient had undergone a flexible ureterorenoscopy elsewhere during which the stone could not be reached due to difficult angulation and inflamed tissue leading to poor vision . computed tomography urogram revealed an ectopic malrotated left kidney lying over the sacrum . there was a 13 mm 11 mm sized calculus in the renal pelvis [ figure 1a and b ] . in the second patient , computed tomography urogram revealed a normal right kidney and an ectopic malrotated left kidney lying over the sacrum . there was an 18 mm 17 mm sized calculus ( 1232 hu ) in the pelvis and a 5 mm 4 mm sized calculus ( 423 hu ) in the lower calyx of the ectopic kidney [ figure 1c and d ] . ( a ) x - ray kub showing renal calculus in pelvis of pelvic ectopic kidney with double j stent in situ , ( b ) computed tomography urogram showing the pelvicalyceal system anatomy , ( c ) x - ray kub showing renal calculus ( yellow arrow ) in ectopic kidney , ( d ) computed tomography urogram showing the pelvicalyceal system anatomy ( location of pelvic stone - yellow arrow ; location of lower calyceal stone - red arrow ) both procedures were performed under general anesthesia . in lithotomy position , ureteric catheterization was carried out under cystoscopic guidance using 7 fr ureteric catheters over a 0.035 inch glidewire ( terumo , tokyo , japan ) . the position was changed to supine - oblique with a sandbag under the ipsilateral hemipelvis to move the overlying bowel away from the kidney . an ultrasound probe was pressed against the anterior abdominal wall to displace the bowel away from the line of access . further , colour doppler was used to rule out any significant blood vessel in the path of needle puncture . three - way connector was attached to the needle , allowing saline irrigation , passage of a 0.9 mm flexible microperc telescope , and a 272 m holmium : yttrium aluminum garnet ( ho : yag ) laser fiber [ figure 2 ] . the stones were completely fragmented to dust with the laser . an x - ray and ultrasound was obtained on the first post - operative day to document stone clearance and to rule out any fluid collection . the urethral catheter was removed on the first post - operative day and the patient was discharged . ( a ) surface view of patient position and ultrasound guided percutaneous renal access , ( b ) intraoperative ultrasonography picture showing entry of puncture needle ( yellow arrows ) into lower calyx containing calculus ( red arrow ) , ( c ) confirmation of access into lower calyx by antegrade contrast study to delineate pelvicalyceal system , ( d ) intraoperative surface view showing microperc instruments , ( e ) puncture site at the end of the procedure ( yellow arrow ) , ( f ) post - operative x - ray kub showing complete clearance operating times were 30 and 35 min respectively . in the first patient , ureteric catheter was left in situ for 1 day . in the second patient , ureteric catheter was replaced by a double - j stent at the end of the procedure . visual analog pain scores ( 1 - 10 scale ) on first post - operative day were two and three respectively . first post - operative day and 1 month follow - up x - ray and ultrasound kub revealed complete stone clearance and no evidence of fluid collection in the abdomen . options for managing small renal calculi in pelvic ectopic kidney are shock wave lithotripsy ( swl ) , retrograde intrarenal surgery ( rirs ) , ultrasound or laparoscopy guided pcnl . since these kidneys are surrounded by bowel and bone , moreover , the clearance of fragmented stones is also impaired due to high insertion of ureter and impaired pyeloureteral motility due to surrounding fibrous bands . rirs can be technically demanding due to abnormal and tortuous course of the ureter of a pelvic kidney . this was exemplified by our first patient in whom the stone could not be reached with flexible ureteroscope and the procedure had to be abandoned . the potential hazards in percutaneous access in an ectopic kidney are : ( 1 ) risk of injury to surrounding bowel , particularly if track dilatation is carried out through the bowel , ( 2 ) abnormal vasculature resulting in bleeding from tract dilatation and ( 3 ) spillage of fluid into peritoneal cavity . microperc is a minimally invasive form of pcnl in which percutaneous renal access and stone fragmentation are achieved in a single - step using a 16 g needle . since dilatation is not performed , potential hazards associated with it are avoided . fluid collection is less likely during puncture and at the end of the procedure since the needle puncture site closes quickly . both our patients had rapid post - operative recovery , probably due to lack of fluid spillage and hence no paralytic ileus . though laparoscopic guidance has been advocated for percutaneous access of an ectopic kidney , in experienced hands , ultrasound guidance can provide a safe entry into the appropriate calyx . appropriate patient positioning to move bowel away from the kidney , placing a sand bag to push the kidney towards the anterior abdominal wall and compression with the ultrasound transducer allow safe access into the kidney . further , the use of colour doppler rules out any significant blood vessel along the path of needle puncture . the hemoglobin drop in both of our patients was minimal , supporting the safety of this procedure . in laparoscopy guided pcnl , an abdominal drain may need to be left in situ for a prolonged period because of persistent urinary leakage . the average hospital stay in a series of 15 patients who underwent laparoscopy guided pcnl was 4.8 days ( 4 - 11 days ) . the patients in that series had sequential removal of nephrostomy tube , urethral catheter and abdominal drain , which lead to the prolonged post - operative stay . thus , ultrasound guided microperc is a safe and efficient technique in the management of small renal calculi in ectopic kidneys and it is a minimally invasive procedure with short hospital stay . the laparoscopic removal of a cervical stump following a supra cervical ( subtotal ) hysterectomy was first described by nezhat et al , and they concluded that the cervical stump could be removed laparoscopically by an experienced surgeon . the advantages of the laparoscopic approach included possible stump adhesiolysis , providing adequate postoperative vault support , and assessment of the pelvic lymph nodes . the 43-year - old , presented with a history of persistent p v discharge and occasional post - coital bleeding . she had undergone subtotal hysterectomy in 1994 , due to postpartum hemorrhage following a normal delivery . a colposcopic biopsy done in january 2009 , reported severe dysplasia of the cervix , with a human papillomavirus ( hpv ) effect and crypt extension . there was a strong family history of cancer of the cervix , as her mother had succumbed to the disease . on general examination she was in fair general condition , well - built and well - nourished , with adequate hydration . the hemoglobin was 13.3 g / dl , blood sugar was 5.3 mmols / l , urea and electrolytes were normal . an initial diagnosis of abnormal pap smear was entertained and the patient opted for a laparoscopic trachelectomy , with the option of a laparotomy , after discussing all her options . there were dense adhesions in the pouch of douglas involving the bowel and the cervical stump . the pelvic lymph nodes were clearly visualized ( after intracervical methylene blue injection ) and did not appear to be enlarged . gentle adhesiolysis was undertaken using sharp dissection , bipolar cautery , and a harmonic scalpel . the vaginal vault was subsequently opened over the ceramic cup of a clermont ferrand elevator . a cystoscopy with retrograde ureteral catheterization , to confirm the integrity of the bladder and ureters , was undertaken . the cervical stump after laparoscopic trachelectomy at one week of follow - up the patient was well . a postoperative intravenous urogram ( ivu ) confirmed that both the ureters and bladder were intact . subtotal hysterectomy was developed as a procedure in the 1990s , and is regarded as a safe option to total abdominal hysterectomy in the management of benign uterine conditions and in obstetrics , due to severe postpartum hemorrhage . okaro et al , in an assessment of the long - term outcomes of laparoscopic supracervical hysterectomy analyzed the case records of 70 consecutive women undergoing the procedure . of these , 24.3% ( 17 cases ) reported symptoms related to the cervical stump , within 14 months of the original surgery . in his series 14 of these patients underwent laparoscopic trachelectomy , one had only laparoscopic adhesiolysis and two underwent a laparotomy with trachelectomy due to dense bowel adhesions on the cervical stump . histologically the stumps showed endometriosis ( 23.5% ) and mild dysplasia in 7.6% of the patients . in this case our patient presented with persistent p v discharge and occasional post - coital bleeding . the subsequent pap smears were abnormal . in a retrospective of 41 patients undergoing laparoscopic subtotal hysterectomy , van der stege et al , noted that 98% of the patients were satisfied with their procedure , with 10% of them having monthly spotting . they concluded that although laparoscopic hysterectomy for benign diseases was a satisfactory procedure , special attention should be paid to careful management of the cervical stump . hilger et al , reviewed the indications of 310 trachelectomies performed at the mayo clinic from 1974 to 2003 . they included stump prolapse ( 4% ) , fibroid mass ( 1% ) , cervical dysplasia ( 6% ) , carcinoma in situ ( 5% ) , irregular bleeding ( 2% ) , and cervicitis ( 53% ) . the complications following vaginal trachelectomies were encountered in 80% of the procedures against 37% in the abdominal procedure . in our report the cervical stump confirmed carcinoma in situ .

management of stone disease in an ectopic kidney is challenging . laparoscopy or ultrasound guided percutaneous nephrolithotomy and retrograde intra - renal surgery are the preferred techniques for these stones . we performed ultrasound guided microperc using a 16 g needle for the management of renal calculi in pelvic ectopic kidneys in two patients . there was no intraoperative or post - operative complication . both patients had complete stone clearance and were discharged on the first post - operative day . ultrasound guided microperc is a safe and effective option for the management of small renal calculi in pelvic ectopic kidneys .