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3917170-2

noncomm/PMC003xxxxxx/PMC3917170.xml

Anticonvulsant hypersensitivity syndrome associated with carbamazepine administration: Case series

A 41-year-old male patient had complaints of skin lesions over the trunk with shooting pain at the back, radiating to the front. He was diagnosed as having herpes zoster by a local physician and treated with tablet acyclovir 800 mg five times a day, tablet mecobalamine 500 μg thrice a day, tablet folic acid 5 mg once a day and tablet carbamazepine 300 mg once a day.\nThe lesions of herpes zoster subsided within 5 days of treatment but on the 7th day, he developed new reddish skin lesions over the trunk. He discontinued all medications and the new lesions subsided within 2 days. The patient had again consulted the doctor for persisting shooting pain and was prescribed tablet carbamazepine 300 mg once a day, tablet fexofenadine 60 mg once a day, tablet clonazepam 0.5 mg once a day and tablet aceclofenac 100 mg daily. But after 9 days, reddish-colored lesions reappeared over the trunk spreading to upper and lower limbs so he was referred to department of skin and venereal diseases of Dhiraj Hospital, Piparia, Vadodara. On examination, the lesions were flat, reddish in color with well-demarcated margin present all over the body []. Laboratory investigations were sent immediately to rule out internal organ involvement. Investigations showed hemoglobin (Hb) 13.4 gm%, total leukocyte count (TLC) 5300/mm3, neutrophils 86%, lymphocytes 09%, monocytes 02%, eosinophil 03%, basophil 00%, random blood glucose (RBS) 128 mg%, blood urea 21mg%, serum creatinine 0.9 mg%, SGPT 50 IU/L, SGOT 23 IU/L and serum bilirubin 0.6 mg%. The level of SGPT was borderline high suggesting of mild liver involvement. Carbamazepine was discontinued and he was given injection dexamethasone 8 mg and injection pheniramine maleate 4 mg intramuscularly once a day for 3 days. After 4 days of treatment, lesions subsided without any sequelae and liver enzymes came back to normal.

[[41.0, 'year']]

M

{'16641839': 1, '10612272': 1, '34067134': 1, '34959331': 1, '27730770': 1, '32455203': 1, '27999472': 2, '28127149': 1, '28638280': 2, '31085955': 1, '29564734': 1, '11072960': 1, '21986395': 1, '34621604': 2, '31982029': 2, '21428769': 1, '24554914': 2}

{'3917170-1': 2, '3917170-3': 2, '5472963-1': 1, '5153889-1': 1, '6983282-1': 1, '8463002-1': 1}

3917170-3

noncomm/PMC003xxxxxx/PMC3917170.xml

Anticonvulsant hypersensitivity syndrome associated with carbamazepine administration: Case series

A 50-year-old male patient was suffering from trigeminal neuralgia and was on tablet carbamazepine 300 mg once a day for last 1 week. He developed reddish-colored skin lesions all over the body, spreading into oral cavity with fever after 8 days of starting the treatment. He was suspected of having drug reaction and referred to department of skin and venereal diseases of Dhiraj hospital, Piparia. On clinical examination, skin lesions were present all over the body with itching and fever []. The lesion appeared first in oral cavity and spread to the trunk and extremities. He was diagnosed as having maculopapular eruptions due to carbamazepine. Blood investigations revealed WBC count 6300/mm3, neutrophils 78%, lymphocytes 15%, urine albumin 3+ and SGPT 60 IU/l, suggestive of liver and kidney involvement. Tablet carbamazepine was stopped immediately and he was given oral prednisolone 30 mg once a day for 1 week and tapered by 5 mg per week along with injection pheniramine maleate 4 mg intramuscularly. He was on regular follow-up with good improvement in his clinical condition.

[[50.0, 'year']]

M

{'16641839': 1, '10612272': 1, '34067134': 1, '34959331': 1, '27730770': 1, '32455203': 1, '27999472': 2, '28127149': 1, '28638280': 2, '31085955': 1, '29564734': 1, '11072960': 1, '21986395': 1, '34621604': 2, '31982029': 2, '21428769': 1, '24554914': 2}

{'3917170-1': 2, '3917170-2': 2, '5472963-1': 1, '5153889-1': 1, '6983282-1': 1, '8463002-1': 1}

3917171-1

noncomm/PMC003xxxxxx/PMC3917171.xml

Periodic paralysis: An unusual presentation of drug-induced hyperkalemia

A 67-year-old woman presented to emergency department with complaints of episodes of inability to walk for the past 5 days, happening 4-5 times a day. Each episode lasted for 15-20 minutes and was associated with restlessness and breathlessness. Patient was apparently alright one month before, since then she started feeling generalized weakness on and off. However, for past 5 days symptoms were exaggerated and she started feeling sudden loss of power in both the lower limbs simultaneously and inability to walk. She could walk normally after the episode subsided. This episode was not associated with pain in the limbs. Patient was totally conscious during the entire episode. Her medical history was significant for diabetes and hypertension for the past 5 years. The patient's drug therapy consisted of insulin nova mixtard 30/70 (for the past 10 years), olmesartan 20 mg per day (for past 2 years), perindopril 4 mg per day (for past 16 months), and torsemide 10 mg per day (for past 6 months).\nOn examination she was found to be alert and fully oriented. Vital signs revealed a regular pulse rate of 93 beats per minute, blood pressure of 130/80 mmHg, temperature of 36.8°C, a respiratory rate of 14/min and oxygen saturation of 100% on room air by pulse oxymetry. Cardiac auscultation revealed normal heart sounds, respiratory examination revealed bilateral vesicular breath sounds with bilateral basal crepitations. Complete neurological examination did not reveal significant finding.\nThe results of laboratory examination were as follows: 10.6 g%, Total Leukocyte Count: 10,500, Differential Leukocyte Count: N70 L26 M3 E1 B0, ESR: 12 mm/hr, Random blood sugar: 98 mg/dl, Urea: 24 mg/dl, Creatinine: 1.2 mg/dl, Total Cholesterol: 198 mg/dl, Triglyceride: 112 mg/dl, HDL: 38 mg/dl, LDL: 138 mg/dl, Serum sodium: 134 mEq/L, Serum potassium: 8.6 mEq/L, Total calcium: 11 mg/dl, Ionized calcium: 1.30 mEq/L, Serum Magnesium: 2.5 mg/dl, Serum chloride: 104 mmol/L, Serum Bicarbonate: 24 mmol/l. ECG showed normal sinus rhythm, normal axis, and tall T waves. CT scan and EMG were not done.\nDiabetic neuropathy, Gullian Barre Syndrome, metabolic cause of periodic paralysis.\nThe diagnosis of drug-induced hyperkalemia presenting as periodic paralysis was suggested by very high serum potassium concentration during the attack and also persistent hyperkalemia between attacks.\nPatient was immediately admitted and the treatment for hyperkalemia was instituted. Drugs causing potassium retention were immediately stopped. Medical measures were started to lower down the level of serum K+ which included K+ bind sachet (calcium polystyrene sulfonate) thrice daily. Lactulose syrup and magnesium sulfate was given to avoid constipation. Her K+ started decreasing progressively and within 24 h K+ got reduced from 8.4 mEq/L to 6.8 mEq/L. In the next 24 h serum K+ further lowered from 6.8 to 5.4 mEq/L.\nThere was progressive fall of blood pressure during the course of the treatment and patient was overall drowsy and disoriented. Measures were taken to maintain her blood pressure.\nPatient responded well to the treatment and was discharged in a stable state with serum K+ level of 5.1 mEq/L, and blood pressure of 120/80 mmHg on 5th day of admission.\nThe patient has been followed-up on an outpatient basis, her serum potassium has been stable with no further episodes of periodic paralysis.

[[67.0, 'year']]

F

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{}

3917172-1

noncomm/PMC003xxxxxx/PMC3917172.xml

Cholestatic presentation of yellow phosphorus poisoning

A forty three-year-old gentleman presented to us after eight days of suicidal ingestion of one tube (35 g) of rodenticide paste (Ratol, containing 3% YP). He had history of daily alcohol intake of about 50-60 grams for the past 5 years without any history suggestive of underlying chronic liver disease or cirrhosis. He had no past history of jaundice. He denied history of ingesting any other drugs or toxins in the recent past.\nAfter self-limiting nausea and vomiting on the day of ingestion, he remained asymptomatic for 4 days. He observed dark-coloured urine and generalized itching on day 5 after ingestion. Pruritus was severe and disturbing his sleep. After being detected to have jaundice, by his local physician, he was referred to our institute on day 8 for further investigation.\nExamination revealed clinical jaundice with excoriation marks all over the body secondary to severe pruritus. His liver was palpable 4 cm below the costal margin and was firm in consistency. Detailed examination failed to show any stigma of underlying chronic liver disease, splenomegaly, or ascites. Cardiovascular and nervous system examination was observed normal and there were no bleeding diathesis. He was not in hepatic encephalopathy as assessed by normal mini-mental state examination score (MMSE). He reported the pruritus as 8 on a visual analogue score of 0 to 10.[]\nEvaluation showed a normal hemogram, with bilirubin of 22 mg/dL (0.2-2.0 mg/dL) with a direct fraction of 18 mg/dL, serum alanine amino transferase (ALT) of 58 IU/L (0-40 IU/L), aspartate amino transferase (AST) level of 100 IU/L (0-40 IU/L), alkaline phosphatase (AP) value of 277 IU/L (50-150 IU/L), and gamma glutamyl transferase (GGT) of 140 IU/L (20-40 IU/L). Prothrombin time was prolonged by 4 seconds, which normalized after vitamin K injection. Electrocardiogram and renal functions were normal.\nOther causes of liver disease were ruled out by negative HbsAg, anti-HCV, IgM anti-HEV, and IgM anti-HAV serology. His serum ceruloplasmin and ferritin levels were normal. Ultrasound scan of the abdomen was unremarkable, except for a fatty liver. Upper Gastrointestinal (GI) endoscopy showed no varices. After normalization of prothrombin time, liver biopsy was done on day 14 of ingestion, which showed enlarged hepatocytes, giant cell transformation, intrahepatic cholestasis and spotty hepatocyte necrosis with infiltration by lymphocytes and few eosinophils []. Histopathology has not shown any evidence of architectural distortion of hepatic lobule, fibrosis, cirrhosis, or regenerating nodules.\nThe patient never developed any clinical signs of acute liver failure. Pruritus was controlled with emollients, ursodeoxycholic acid, cholestyramine and sertraline. Liver function tests normalized and pruritus also improved over the next 3 weeks. Patient is currently asymptomatic after 4-months of follow-up.

[[43.0, 'year']]

M

{'21713048': 2, '22209551': 1, '32655238': 1, '7273676': 1, '8583080': 1, '19210266': 1, '25848404': 1, '32039071': 2, '14755786': 1, '33052182': 1, '946251': 1, '31243985': 1, '21761550': 1, '14988373': 1, '5538680': 1, '19502664': 1, '24554916': 2}

{'3113395-1': 1, '7004260-1': 1}

3917212-1

noncomm/PMC003xxxxxx/PMC3917212.xml

Periodontal microsurgery: A case report

During periodontal examination of an 18-year-old female at the Department of Periodontics of Vasantdada Patil Dental College Sangli (M.H), it was found that there was inadequate attached gingiva on the labial aspect of mandibular right and left central incisor with the recession of 5 mm and 2 mm respectively. There was mild to moderate marginal gingival inflammation. The recession defect was classified as Class III for 41 and Class I with 31 (Miller classification) []. Patient's medical history was non-contributory and she had no complaints or discomfort. Since esthetics is of concern, it was decided to treat the site by autogenous free gingival grafting to achieve root coverage for both lower centrals and also to increase the width of attached gingiva. Patient agreed to this treatment plan and treatment was initiated with instructions for plaque control, followed by thorough scaling and root planning [].\nDuring the surgical appointment, after local anesthesia had been achieved, the exposed root was planned thoroughly with a Gracey 1-2 curette. With microsurgical approach using surgical microscope [] the area on the right and left mandibular central incisor that was to receive the gingival graft was prepared by raising of a partial-thickness flap []; graft tissue (approximately 2 mm in thickness) was obtained from the palatal side at the level of the left premolars and first molar []. After obtaining graft, donor site was protected by an acrylic stent. The graft was sutured in place by means of interrupted sutures (6-0 ethicon sutures) at the coronal and apical corners. A basting-type of suture was also used to obtain good adaptation of the graft to the recipient site []. A non-eugenol periodontal dressing was applied to recipient site after covering the graft with aluminum foil []. The patient received routine postsurgical instructions, including a 0.12% of chlorhexidine mouth rinse twice daily along with 400 mg ibuprofen 3 times a day for 7 days. 1 week after the surgical procedure, the patient reported with no major problems; wound healing of the grafted sites and donor site was assessed weekly for the first 2 weeks. At the 12-week evaluation, there was a gain in attached gingiva around the right lower anterior []. Patient had no complaints about the treatment outcome and oral hygiene was reinforced at this appointment.

[[18.0, 'year']]

F

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{}

3917213-1

noncomm/PMC003xxxxxx/PMC3917213.xml

Treating congenitally missing teeth with an interdisciplinary approach

A 23-year-old female patient reported to the Department of Periodontology and Oral Implantology, Luxmi Bai Institute of Dental Sciences and Hospital, Patiala to get a better tooth and gum esthetics. No specific past dental, family and medical history was elicited. No relevant findings were observed on extra-oral examination. Intra-oral examination revealed retained primary maxillary right and left canines. Diastema was present between maxillary central incisors and between right central incisor and primary maxillary canine. Distally tilted right maxillary second molar was present. Gingival and periodontal examination revealed healthy periodontium. Radiographic examination was done to evaluate the proposed site for implant placement, which included intra-oral periapical radiograph and orthopantomogram []. Based on the above findings, patient was diagnosed congenitally lateral missing lateral incisors and right mandibular second premolar.\nThe case was discussed with the Department of Orthodontics and treatment to be done was planned. Informed consent was obtained from the patient. Extraction of retained deciduous maxillary right and left canine was done. Simultaneous closure of midline diastema and bilateral distalization of maxillary canine was done to gain space between central incisor and canines bilaterally.\nWhen the sufficient interdental area between two teeth was gained [], the implant placement surgery was planned. Under local anesthesia, the crestal incision was given and mucoperiosteal flap was elevated. The site was initially with 2 mm pilot drill. The site was then gradually enlarged with standard color coded drills to the desired lengths at the osteotomy sites. The implant was delivered at the prepared osteotomy sites []. Primary closure of the flap was obtained with interrupted type resorbable sutures. Radiographic examination was done post-operatively []. Patient was prescribed non-steroidal anti-inflammatory drug ibuprofen 600 mg thrice a day for 5 days. Chlorhexidine gluconate 0.2% was prescribed for 2 weeks, soft diet instructions were given. After 5 months under sterile conditions, 2nd stage surgery was done using crestal exposure of implant cover screw. A healing abutment was placed with hex screw driver on each implant. At 2 weeks later impressions were made with open tray technique with impression copings placed into the implants. Shade selection was done. Healing abutments were replaced until prosthesis was manufactured. After a week, the healing abutments were removed and replaced by final abutments onto which final prosthesis was given []. Patient was happy with her new smile.

[[23.0, 'year']]

F

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{'3984204-1': 1}

3917214-1

noncomm/PMC003xxxxxx/PMC3917214.xml

Enamel pearl on an unusual location associated with localized periodontal disease: A clinical report

A 21-year-old male patient presented to the Department of Periodontics for treatment, with a chief complaint of bleeding from gums. Intra-oral clinical examination of the patient revealed generalized pale pink gingiva with reddish pink interdental papilla and marginal gingiva in mandibular central incisors []. Notably, significant deposits of plaque and calculus were also present on the lingual surface of mandibular incisors. Bleeding on probing was noted. Grade II and grade I mobility was present in mandibular right and left central incisor respectively. A sinus opening was also seen at the apex of mandibular right central incisor []. Radiographic examination of mandibular anterior teeth showed severe bone loss in mandibular central incisors along with involvement of peri-apex in mandibular right central incisor. The sinus tract on the facial surface of mandibular right central incisor could be traced up to the apex of the tooth with gutta percha point []. Vitality testing of mandibular right central incisor showed the tooth to be non-vital. Patient gave no history of trauma to mandibular right central incisor and trauma from occlusion was absent. A diagnosis of chronic localized periodontitis was made on the basis of history, clinical, and radiographic examination.\nInitial periodontal treatment consisted of oral hygiene instructions and generalized scaling. Completion of phase I therapy led to an incidental finding of enamel pearl on the lingual surface of mandibular right central incisor at a distance of approx. 2.5 mm from the CEJ and about 2 mm × 3 mm in diameter []. Subsequently, root canal treatment was done in mandibular right central incisor [] and the flap was raised in mandibular incisor region []. The area was completely debrided and odontoplasty was performed in mandibular right central incisor to remove the enamel pearl []. The flap was re-approximated and sutured []. The patient was recalled after 1 week for suture removal and showed uneventful healing []. Six month recall of the patient showed complete resolution of gingival inflammation [], reduction in mobility and significant resolution of periapical lesion [].

[[21.0, 'year']]

M

{'18460580': 1, '10760733': 1, '2717905': 1, '292719': 1, '4529437': 1, '6581220': 1, '3483374': 1, '14259659': 1, '2762508': 1, '269760': 1, '10673666': 1, '287738': 1, '4529438': 1, '1514933': 1, '20587950': 1, '2640436': 1, '14946301': 1, '9249641': 1, '8432951': 1, '7026760': 1, '2191975': 1, '24554894': 2}

{}

3917215-1

noncomm/PMC003xxxxxx/PMC3917215.xml

Lateral sliding bridge flap technique along with platelet rich fibrin and guided tissue regeneration for root coverage

A 38-year-old male patient reported to the Department of Periodontology with the chief complaint of hypersensitivity in lower front tooth region for 4 months. Clinical examination revealed Miller's Class III recession in mandibular anterior teeth measuring 2 mm each in mandibular central incisors, 1 mm in left lateral incisor, 3 mm in right lateral incisor and 4 mm each in mandibular canines []. The probing depth was recorded as 3 mm around the involved teeth. The medical history of the patient was non-significant.\nThe surgical procedure was explained to the patient and informed consent was obtained. Preparation of the patient was carried out, which included scaling and root planning of the entire dentition and oral hygiene instructions. The probing depth was recorded as 2 mm after initial preparation.\nBlood of the patient was drawn in 10 ml test tubes without an anticoagulant and centrifuged immediately. Blood was centrifuged using a table top centrifuge (REMY Laboratories) for 12 min at 2700 rpm.\nThe resultant product consisted of the following three layers:\nThe top most layer consisting of acellular platelet poor plasma PRF clot in the middle Red blood cells at the bottom [].\nPRF can be obtained in the form of a membrane by squeezing out the fluids in the fibrin clot [].\nThe PRF membrane was placed over GTR membrane (HEALIGUIDE®) [].\nIt included the bridge flap technique given by Marggraf[] and later modified by Romanos.[] Under local anesthesia, an arch shaped or semilunar incision was given in the vestibule at a distance, which was twice the amount of gingival recession plus 2 mm (2* gingival recession + 2 mm).[] This ensures a wide flap, which is necessary for a sufficient blood supply. A split thickness flap was then elevated in the apicocoronal direction [] and it was connected with the first incision so that the two flaps communicated with each other. The patency of the reflection was checked with the help of a periosteal elevator or a periodontal probe []. PRF in a collagen membrane carrier was placed over the sites with denuded root surfaces []. The entire flap was then coronally positioned to cover the membrane and sling sutures were placed []. A non-eugenol periodontal dressing (Coe-pack, GC) was given over the surgical site.\nThe patient was prescribed antibiotics (Amoxicillin, 500 mg thrice daily) and analgesics (Ibuprofen, 400 mg thrice daily) for 5 days and 0.12% chlorhexidine digluconate mouth rinse for 4 weeks. The patient was advised to follow routine post-operative periodontal mucogingival instructions, with minor modifications. He was told to avoid pulling on the lips to observe the surgical site. Both the dressing and sutures were removed 10 days after surgery. The patient was recalled after 8 weeks, and the complete root coverage was observed []. Six months follow-up showed stable results []. The patient was satisfied with the treatment.

[[38.0, 'year']]

M

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{}

3917216-1

noncomm/PMC003xxxxxx/PMC3917216.xml

Papillon-lefevre syndrome: Case series and review of literature

A 14-year-old girl, visited to outpatient Department of Periodontia, Government Dental College and Hospital, Ahmedabad, India with chief complain of premature loss of deciduous and permanent teeth and mobility in remaining teeth.\nShe was the first child born to apparently healthy non-consanguineous parents. History revealed that her deciduous teeth had erupted normally, but exfoliated gradually by the age of 4-5 years. Similarly, her permanent teeth were lost prematurely after erupting normally. Patient was having complained of mobility and bleeding gum before 2 years, visited a periodontist and undergone treatment in the form of periodontal flap surgery. After one and half year, patient was having same complain and came to Government Dental College and Hospital, Ahmedabad.\nThere was no family history of ichthyosis or hereditary or acquired palmoplanter keratodermas. The patient also gave a history of development of fissures, thickening and flaking in the skin of palms and soles that resulted in peeling off of skin leaving red thin area underneath since age of 3-4 years. She had exacerbation and remissions of the skin lesions since early childhood, visiting dermatologist regularly, but no improvement was seen. She repeatedly contracted systemic infections.\nExtra-oral examination\nOn extra-oral examination, patient presented with well-demarcated, yellowish, keratotic plaques over the skin of palms and soles extending on to the dorsal surfaces. Skin of both palms and soles was peeling off leaving underlying red shiny area suggestive of keratoderma []. Well circumscribed, psoriasiform, erythematous, scaly plaques were also present on the elbows and knees bilaterally along with dystrophy and transverse grooving of the nails. The fingers were pointed giving clawed appearance.\nIntra-oral examination\nIntra-oral examination revealed edentulous area between teeth 44 and 33 and 11, 21 and 22 were also missing. Edentulous maxillary and mandibular ridges were covered with normal mucosa. The teeth present were 12, 13,14,15,16,22, 24, 25, 26, 33, 34, 35, 36, 44, 45 and 46 covered with soft deposits and band of subgingival calculus. Gingiva was fiery red in color with inflammatory gingival enlargement Iva Ingle Classification grade II. Pathological migration was associated with 12, 14, 23, 24, 33 and 34. On assessment grade III mobility was present in relation with 14, grade II in relation with 24, 25, 33, 34, 36 and 44. Remaining teeth were present with grade I mobility. There was the presence of recession grade III in relation with 14 and 33 [Figures –].\nOrthopantogram showed extensive alveolar bone loss in all remaining teeth. The alveolar bone around the mobile teeth was devoid of definable lamina dura. An extensive alveolar bone loss was noted, giving the teeth 31, 41 and 43 a “floating in air appearance,” which were extracted afterwards [].

[[14.0, 'year']]

F

{'18714933': 1, '9585898': 1, '15491306': 1, '12861881': 1, '20881810': 1, '12509601': 1, '22141356': 1, '16460249': 1, '15728180': 1, '11140563': 1, '15840775': 1, '159254': 1, '10593994': 1, '11807457': 1, '2974049': 1, '34513733': 1, '2529483': 1, '6229622': 1, '21165748': 1, '16926422': 1, '26523234': 1, '34603725': 2, '10581027': 1, '11106356': 1, '28920035': 2, '26155583': 1, '12637913': 1, '16332247': 1, '14244097': 1, '11922261': 1, '3156430': 1, '8195982': 1, '24554896': 2}

{'5554421-1': 1, '8473953-1': 1}

3917217-1

noncomm/PMC003xxxxxx/PMC3917217.xml

Non-surgical treatment of peri-implantitis with the adjunctive use of an 810-nm diode laser

A 45-year-old male presented with pain and swelling at a mandibular implant site (Nobel Biocare, SW). Clinical examination revealed a deep pocket [7-mm pocket depth (PD)] and bleeding on probing [], with suppuration and gingival inflammatory edema at the implant site. The patient was in good general health, did not take any medications, and was an occasional smoker (4-5 cigarettes/day).\nNo occlusal trauma or parafunctional habits were detected.\nA periapical radiograph demonstrated bone loss of five fixture threads on the most distal mandibular left implant, when compared to the original radiograph [].\nThe patient was eventually scheduled for periodontal surgery to treat the inflammatory lesion, but emergency intervention was indicated to disinfect the area by removing the bacterial biofilm and alleviating pain using an 810-nm diode laser []. No local anesthesia or systemic antibiotics were administered.\nThe patient was asked to rinse with undiluted chlorhexidine 0.2% for 1 min. After insertion of the optical fiber parallel to the long axis of the implant 1 mm from the most apical portion of the pocket, the diode insert was moved in an apico-coronal and mesio-distal direction for 30 sec at each inflamed implant site. It was used at a power of 0.5 W in a continuous wave (cw) [equivalent to 1 W in pulsating mode (pw) for 30 s] in duplicate on each site, for a total time of 360 sec with a fluence of 1.96 J/cm2.\nNon-surgical periodontal instrumentation was performed with hand instrumentation using a titan curette (Roncati Implant Care, by Martin KLS) and a piezoelectric ultrasonic device with plastic fused to a metal insert (Piezon Master 700, EMS, PI insert), as needed. Finally, a 0.5% chlorhexidine gel was deposited into the sulcus with a disposable syringe and a blunt needle.\nThese procedures were repeated the following day.\nThe area was checked for plaque removal and home care compliance for the first month on a weekly basis and was followed by routine supportive periodontal therapy at 3-month intervals. The adjunctive use of the diode laser was included in the conventional periodontal maintenance every 6 months for the following 3 years.\nPeriodontal indices were documented and intraoral periapical radiographs were taken at the 1-year [], and 2-, 3-, 4-, and 5-year [Figures and ] follow-up recall appointments.\nSatisfactory results were obtained by the application of laser-assisted non-surgical peri-implant therapy. Periodontal pocket depth was reduced from 7 to 3 mm with no bleeding upon probing. Intraoral periapical radiographs, taken for up to 5 years post-non-surgical treatment, provide evidence of some improvement of the bone level. The reduction of periodontal pockets is probably due to re-epithelialization, with formation of a long junctional epithelial attachment.

[[45.0, 'year']]

M

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{}

3917218-1

noncomm/PMC003xxxxxx/PMC3917218.xml

Non-familial cherubism: A case report with its surgical management

An 11-year-old male patient of non-consanguineous parents came with the chief complaint of missing teeth in both upper and lower jaw. Patient gave a history of painless bilateral swelling in the mandibular region. Swelling arose at the age of approximately 3-4 years, which progressed rapidly until the age of 8 years. There was no history of a similar disease in any the parents or siblings. Prenatal and natal history revealed a normal full term pregnancy. There was no history of any drug therapy. Patient did not suffer from any serious illness, mental retardation or social inabilities. On clinical examination, it was noticed that swelling was more prominent on the right side, firm on palpation and non-tender. The extension of swelling was from the anterior part of ramus to mandibular premolar region on the right side and from the anterior part of ramus to mandibular molar region on the left side []. Both right and left submandibular lymph nodes were palpable. Gingiva was pink, firm, fibromatous, covering almost all the teeth []. Mandibular buccal vestibular fullness due to swelling in both right and left side was seen. Panoramic-radiograph [] showed large, multiloculated soap bubble-like cavities at the angle and ramus of the mandible as well as thin vestibular cortical bone without involving condyles. These lesions were accompanied by displacement and impaction of erupted teeth and dental follicles. Incisal one-third of mandibular incisors were visible in the oral cavity, all the other teeth were impacted.\nSerum alkaline phosphate, calcium and phosphorous levels were within the normal ranges. Histopathological evaluation of an incisional biopsy in right mandibular region showed highly vascular fibrous stroma with numerous multinucleated giant cells. The family, clinical, radiographic, laboratory and microscopic features suggested a diagnosis of non-familial cherubism. The treatment consisted of an external bevel gingivectomy in all quadrants using a scalpel and electro cautery. In between, gingivectomy was performed quadrant wise with adequate healing time [Figures and ]. Post-operatively healing was excellent with improvement in quality-of-life. Orthodontic treatment has been planned for the present case in the near future and follow-up visits are still in progress.

[[11.0, 'year']]

M

{'10364528': 1, '10364527': 1, '24421967': 1, '11381256': 1, '285398': 1, '21957392': 2, '16053841': 1, '16713807': 1, '11581066': 1, '17728954': 1, '24554898': 2}

{'3180837-1': 1}

3917219-1

noncomm/PMC003xxxxxx/PMC3917219.xml

Peripheral ossifying fibroma: A case report

A 30-year-old female patient reported with the complain of discomfort during chewing and speaking due to a growth in the left lower posterior region of the jaw, which started as a small papule approximately 8 months ago and gradually increased in size with time to attain present size. There was no associated history of bleeding or pain. Her medical history was non-significant and no h/o any medication at that time. She had a habit of chewing smokeless tobacco, since many years.\nIntraoral examination revealed an approximately 2 cm × 2 cm sessile, non-tender, firm, pale pinkish growth present on the interdental gingiva in relation to the mandibular left canine-premolar region [Figures and ]. The lesion was extending from mesial of left lateral incisor to the mesial of left first premolar and up to the level of the occlusal surface, causing occlusal interference. Pathologic migration of mandibular left canine was present as mesial and buccal migration. Radiographically, there was angular bone loss in relation to mandibular left canine and premolar with displacement of mandibular left canine [].\nThe differential diagnosis included irritation fibroma, pyogenic granuloma and POF. Based on the clinical and radiographic findings, the provisional diagnosis of irritation fibroma was made.\nThe periodontal treatment plan included patient education and motivation for oral hygiene instructions and quitting the habit, scaling and root planing, reevaluation and surgical excision of the lesion under local anesthesia. Scaling and root planing was performed for elimination of local etiological factors. After 1 week of scaling and root planing, a reevaluation and surgical excision down to the periosteum were performed [] and periodontal dressing was placed []. Patient was given post-operative instructions and was prescribed with analgesic (tablet ibuprofen-400 mg tds every 4-6 h as needed for pain) and antimicrobial rinse (0.2% chlorhexidine gluconate twice-a-day for 1 week). She was recalled, after 1 week for follow-up. The excised tissue [] was placed in 10% neutral buffered formalin and sent for the histopathologic examination.\nBiopsy specimen microscopically consisted of hyperplastic parakeratinized stratified squamous epithelium with thin, long and anastomosing rete ridges and fibrous connective tissue containing several irregularly shaped trabeculae of bone, droplets of basophilic cementum-like material and numerous plump fibroblasts []. Histopathologic diagnosis was POF.\nAt 1 week post-operative visit, patient presented for periodontal dressing removal and follow-up examination. Recovery was uneventful with a satisfactory healing []. Patient is on regular follow-up at 6 months post-operative without any recurrence [].

[[30.0, 'year']]

F

{'8708123': 1, '26604587': 2, '11495143': 1, '26556782': 1, '3864113': 1, '11447957': 1, '17220623': 1, '15735548': 1, '27795650': 2, '34691463': 1, '34153696': 1, '19000465': 1, '7776054': 1, '2926546': 1, '16001734': 1, '33489156': 2, '24554899': 2}

{'7813068-1': 1, '4632236-1': 1, '5015566-1': 1}

3917223-1

noncomm/PMC003xxxxxx/PMC3917223.xml

Necrobiosis Lipoidica Diabeticorum

The patient, a Caucasian 16-y-old girl, was born at term by non-consanguineous, healthy parents. Type 1 diabetes (T1DM) had been diagnosed at one year of age. Our patient’s medical history was otherwise unremarkable. Until the age of 12 she maintained an adequate glucose control with HbA1c < 34 mmol/mol. Thereafter her glucose control progressively worsened with a HbA1c of 86 mmol/mol. At the age of 16, during a routine diabetes follow-up visit, the patient presented with erythematous subcutaneous nodular lesions which had appeared 4 mo earlier, initially in the pretibial area and subsequently in the interscapular area. Her HbA1c was 64 mmol/mol and daily insulin requirements were 0.95 U/kg/day. In the suspect of necrobiosis lipoidica, a skin biopsy was performed (lower extremities and interscapular area) ( and ). The microscopic evaluation of the pretibial lesions was suggestive of necrobiosis lipoidica. The smaller lesions in the interscapular area showed signs of perivascular dermatitis which could be consistent with early stages of necrobiosis lipoidica (). Local treatment with tacrolimus determined a progressive improvement of the lesions. Diabetes self-management education was reinforced and her HbA1c showed a gradual reduction.

[[16.0, 'year']]

F

{'17519431': 1, '19060464': 1, '22738100': 1, '16309486': 1, '18718195': 1, '16325069': 1, '17544959': 1, '21577369': 1, '30066458': 1, '28560219': 1, '16828404': 1, '15787840': 1, '22606526': 2, '20465710': 1, '20107745': 1, '24575162': 2}

{'3350198-1': 1}

3917396-1

noncomm/PMC003xxxxxx/PMC3917396.xml

A case of subacute cutaneous lupus erythematosus as a result of ranibizumab (Lucentis) treatment

An 82-year-old female was referred to a dermatologist with a generalized, scaly, symmetric, non-palpable but very erythematous, almost hemorrhagic rash which was painful and associated with a mild itch. It was initially on the face, neck and forearms in light-exposed areas [Figs. and ]. The presence of the rash on her legs [] at that stage is uncertain as they were bandaged following surgery and subsequent ulceration. It had developed over two weeks following an injection of Lucentis as part of her treatment for neovascular AMD.\nShe had been diagnosed with “wet” AMD in 2002. Over the following two years, she was treated with seven doses of Verteporfin (Visudyne) and a single dose of Bevacizumab (Avastin). Her general health was good and, in addition to AMD, her medical history consisted of well-controlled hypothyroidism, hypertension and recently stripped varicose veins. Her medications included aspirin, thyroxine, amlodipine, and calcium and cholecalciferol supplements, all of which she had been using for a prolonged period.\nIn August 2008, she received a single 2.3-mg intravitreal injection of ranibizumab. Five days later, she developed a few “flat, brown spots” which over the next 10 days, evolved into the rash described above. Her dermatologist prescribed topical methylprednisolone ointment for the face and betamethasone ointment for the rest. None of the other medications had been changed or added in the months preceding this episode. Arthralgia and myalgia were not present.\nA biopsy [] showed a prominent lichenoid inflammatory process with some necrotic keratinocytes in keeping with a drug reaction and, considering the clinical history, consistent with the diagnosis of drug-induced, subacute cutaneous lupus erythematosus (SCLE).\nImmunofluorescence was negative but she had already been using steroids. She was commenced on oral steroids which were initially ceased by her vascular surgeon due to slow healing of her leg wounds. They were restarted and she improved markedly at 25 mg/day.\nThe dose was being weaned until it was again ceased, this time by an immunologist. The rash flared quite markedly and steroids were recommenced. In February 2009, hydroxychloroquine (Plaquenil) was introduced as a steroid-sparing agent and surprisingly, her rash flared again. A second biopsy in April was also suggestive of SCLE.\nHer standard bloods were unremarkable except for a mild anemia (111 g/L). Erythrocyte sedimentation rate (ESR) was initially elevated at 30 mm/h (normal < 20 mm/h) which decreased to 4 mm/h over several months. Antinuclear antibodies (ANA)/anti-SSA in particular SSA (Ro60) and SSB (La) were present. Anti-DNA, complement, ANCA, cardiolipin, and mitochondrial and ribosomal antibodies were all within normal limits.\nBy July 2009, she was on 15 mg of prednisolone and, excluding her upper back, the rash was much improved. Her chest, face and arms were virtually clear.

[[82.0, 'year']]

F

{'2179293': 1, '18490414': 1, '18797894': 1, '32960413': 1, '2671533': 1, '3873891': 1, '9498030': 1, '17195229': 1, '10326532': 1, '16015021': 1, '24212210': 2}

{}

3917399-1

noncomm/PMC003xxxxxx/PMC3917399.xml

Coexistent miliary tuberculosis of choroid and tubercular panuveitis: A report

A 27-year-old man presented with progressively worsening vision in his left eye for 1 month. He was a known case of tubercular meningitis on four drugs antitubercular medication (ATT). He had 6/6 vision in the right eye with an unremarkable anterior segment. Left eye had perception of light. Fig. and depict slit lamp evaluation of active panuveitis in the left eye. An ultrasound examination followed by [] was performed due to poor view of the fundus, which revealed vitritis, thickened retinochoroidal complex and attached retina consistent with panuveitis. shows choroidal miliary tubercles in the right eye. Fundus fluorescein angiography revealed active choroiditis lesions []. Polymerase chain reaction (PCR) performed on the aqueous aspirate from the left eye revealed MPB64 gene and nested-PCR (nPCR) detected IS6110 region specific for Mycobacterium tuberculosis (MTB) []. High resolution computerized tomography of the chest revealed tubercular miliary mottling in both lungs.\nPatient was advised to continue ATT and lensectomy with vitrectomy was performed in the left eye. Extensive choroidal tubercles were noted during surgery. Figs. and show progressive resolution of the choroiditis lesions at 1 and 2 months follow-up respectively in the right eye with vision maintained at 6/6. Left eye had best-corrected visual acuity of counting fingers with a hazy media, dense epiretinal membrane, scarring at fovea and attached retina [] at 2 months. Fig. and reveal anterior segment findings in the left eye at 1 and 2 months respectively.

[[27.0, 'year']]

M

{'33116360': 1, '21898048': 2, '18029267': 1, '24008783': 2}

{'3345054-1': 1}

3917400-1

noncomm/PMC003xxxxxx/PMC3917400.xml

A unique case of phaeohyphomycosis subretinal abscess in a patient with arthropathy and lung pathology

A 67-year-old male presented to the emergency eye centre (EEC) complaining of a painful right eye of 5-day duration. The medical history included active rheumatoid arthritis. His regular medications included sulfasalazine, prednisolone, and methotrexate for his rheumatoid disease.\nClinical examination revealed a visual acuity (VA) of 6/9 with minimal conjunctival injection, anterior chamber (AC) cells 1+ and posterior synechiae (PS). A diagnosis of anterior uveitis was made and the patient was commenced on topical prednisolone 1% and topical cyclopentolate 1%. The response to this treatment was good and the steroids were slowly tapered over 1 month; however, before cessation of treatment, the anterior segment inflammation worsened. The patient represented with VA 6/36 and AC cells 3+, extensive PS and a posterior vitritis. Immediate management included a subconjunctival injection of mydricaine No. 2, the topical treatment was increased and an urgent referral was made to the uveitis service.\nAt review, 4 weeks after presentation, the anterior and posterior segment inflammation remained and a white mass was noted in the peripheral nasal retina [ upper plate], almost at the ora serrata. A diagnosis of presumed Toxoplasma chorioretinitis was made and treatment with pyrimethamine and sulfadiazine followed by oral clindamycin was initiated. On further questioning, it was discovered that there was the possibility of a previous pulmonary tuberculosis (TB) infection. The patient's previous employment was gold-mining. A chest X-ray showed apical lung scarring on the right. He had had no previous treatment for active tuberculosis. In view of concern over possible reactivation of TB with an increase in oral steroids, further investigations were performed. HIV testing was negative. Quantiferon and induced sputum sampling were also performed (all negative) and the dose of prednisolone was increased to 60 mg daily. Blood cultures were also negative and there was no serological evidence of Toxoplasma infection (toxoplasma latex <16).\nThe patient responded to oral steroids and clindamycin, with a reduction in intraocular inflammation and improved VA of 6/18 after 2 weeks treatment. However, when the oral prednisolone was gradually reduced and the clindamycin stopped (after 5 weeks treatment), there was an increase in intraocular inflammation and VA reduced to 3/60. A diagnostic pars plana vitrectomy was therefore performed with vitreous sampling, which revealed a chronic vitritis without infectious agent or neoplasia. No herpes family viruses or toxoplasma organisms were identified on polymerase chain reaction testing.\nIn order to clinch the diagnosis, combined cataract surgery, retinal biopsy, and intraocular oil tamponade was performed. The combined procedure facilitated access to the anteriorly located subretinal mass. Surgery was performed 4 months after the patient initially presented with acute anterior uveitis. The nasal sub-retinal mass was biopsied using a 23-gauge (23G) vitrector hand piece and samples sent to histopathology and microbiology. Haematoxylin and eosin stained sections revealed an abscess with occasional granulomata. Close inspection showed brown pigmented septate branching hyphae that stained strongly with Masson Fontana melanin stain and with a Periodic Acid Schiff (PAS) and silver stain [ middle and lower plates]. The presence of a melanin containing, septate, branching, and mycelial fungus on histopathology was diagnostic of phaeohyphomycosis infection, on morphology alone. Prolonged fungal culture of the biopsy was negative and 18S ribosomal subunit polymerase chain reaction (PCR) was also negative (most likely due to the presence of PCR inhibitors in the sample). The absence of a culture and PCR result did not permit precise speciation of the phaeohyphomycosis fungus. The patient was referred to the infectious diseases department and oral voriconazole therapy initiated. The patient remained under joint care and was treated with antifungal therapy for 6 months; however, no primary source of fungal infection was identified. Following retinal biopsy the patient developed a retinal fold secondary to proliferative vitreoretinopathy (PVR), which extended from the biopsy site to the optic disc. Vitrectomy, removal of silicone oil, epiretinal membrane peel, subretinal PVR removal and retinectomy were performed with laser retinopexy and intraocular gas tamponade. Unfortunately, the patient required two further operations for rhegmatogenous retinal detachment. Currently, the retina is flat with heavy silicone oil tamponade and the VA is 2/60. Further retinal biopsy taken during vitrectomy for retinal detachment revealed no fungal elements on microscopy and intravitreal amphotericin B was also injected perioperatively.

[[67.0, 'year']]

M

{'3236148': 1, '20930077': 1, '19360381': 1, '2587052': 1, '19008596': 1, '19542933': 1, '25378901': 2, '7348844': 1, '15019330': 1, '27447296': 1, '10972493': 1, '11162996': 1, '14699452': 1, '24413827': 2}

{'4213137-1': 1}

3917403-1

noncomm/PMC003xxxxxx/PMC3917403.xml

Corneal arcus and xanthomas in homozygous familial hypercholesterolemia: First report from China

A 12-year-old male, whose father was a LDL receptor (LDL-R) mutation carrier, developed corneal arcus and multiple skin lesions with a 10-year history of xanthomas. Both his parents had elevated levels of total serum cholesterol and LDL cholesterol. His elder brother died of myocardial infarction secondary to FH at the age of 7 years. Physical examination showed the presence of subcutaneous yellow nodules at the knuckles of his fingers [], elbows [], knees [], and Achilles tendons []. They were up to 10 cm in size and partly tended to coalesce. Some other yellow nodules of varying sizes under the skin erupted over the buttocks []. This patient had no problems with his vision. Intraocular pressures were unremarkable. The ocular exam revealed a partial circumferential white-grey deposit corresponding to corneal arcus [Fig. and ]. Fundus examination was normal. B-scan revealed extensive plaques and enhanced intima-media thickness of common carotid arterial wall. Laboratory studies disclosed the following values: Total serum cholesterol, 752.1 mg/dL (normal range, 110-220 mg/dL); triglyceride, 96.6 mg/dL (normal range, 50-150 mg/dL); LDL cholesterol, 661.3 mg/dL (normal range, 80-140 mg/dL). Findings were consistent with type IIa hyperlipoproteinemia. As is shown in the figure [], there are cytosine (C)>thymine (T) heterozygous double peaks at 97 in the second exon of LDL-R gene, which is in GenBank as a known mutation of NM_001195798.1:c. 97C>T. This mutation resulted in the change from C to T 33rd codon in E2 of LDL-R gene and, thus, glutamine became the stop codon in the corresponding amino acid (NP_001182732.1:p.Gln33X). The result of genealogical analysis indicated that his father had a similar gene mutation. A diagnosis of homozygous familial hypercholesterolemia was made.\nHomozygous FH is clinically characterized by cutaneous xanthomas, enlarged Achilles tendons, atherosclerosis, and corneal arcus, usually developing from early childhood.[]\nHomozygotic patients usually manifest corneal arcus before the age of 10 years. Although no significant correlations were obtained between corneal arcus and patterns of hyperlipoproteinaemia in previous observations,[] a recent study of homozygous familial hypercholesterolemia series indicated that patients with corneal arcus had higher cholesterol-year score and was correlated with calcific atherosclerosis.[] The exact biochemical mechanisms of corneal arcus remain controversial. One explanation is the proximity to limbal vasculature that may increase endothelial permeability to lipids via active scavenging mechanisms. Another is the temperature gradient that can alter lipid deposition as the infiltrating particles pass from limbal blood vessel into the cornea. Finally, the collagen fiber gradient might filter the lipid-rich particles.[]\nEarly combination therapy with LDL apheresis, statins, and cholesterol absorption inhibitors are advised in children with homozygous FH at the highest risk.[]

[[12.0, 'year']]

M

{'17130340': 1, '12813012': 1, '6306464': 1, '18331643': 1, '12062534': 1, '6671092': 1, '24088637': 2}

{}

3917404-1

noncomm/PMC003xxxxxx/PMC3917404.xml

Susac's syndrome: First from India and youngest in the world

A two and half year old female was admitted at the emergency room suffering from gradually worsening headache followed by nausea. The child was lethargic, and had reduced level of consciousness with hypoacusis. Laboratory studies were negative for antinuclear antibodies, hepatitis, Epstein-Barr polymerase chain reaction, cardiolipin antibodies, and herpes infection. Cerebro Spinal Fluid (CSF) analysis was negative for oligoclonal bands and nonreactive for the Venereal Disease Research Laboratory (VDRL) test. However, patient's level of consciousness and age did not allow measurement of visual acuity or hearing loss. Color fundus and red free photography was performed, which showed inferotemporal retinal arteriolar branch occlusion in the right eye [Figs. and ]. Optical coherence tomography of right macula showed no significant change. Magnetic resonance imaging (MRI) revealed multiple foci of increased FLAIR T2 signal intensity in the periventricular white matter and corpus callosum [] and T1 image showed lesions with decreased intensity in corpus callosum []. She was treated with intravenous prednisolone one gram/kilogram body weight for 3 days. The response to steroid was remarkable. The symptoms of encephalopathy subsided within 48 h. She was started on oral steroid (prednisolone) 10 mg/day for 10 days, which was tapered gradually. Repeat MRI, 4 weeks later, showed almost complete disappearance of the foci [Figs. and ]. Child did not return for subsequent follow-up visits.

[[2.5, 'year']]

F

{'20920828': 1, '22446902': 1, '26715396': 1, '1595113': 1, '11097286': 1, '571975': 1, '14694047': 1, '17476496': 1, '18268443': 1, '10844072': 1, '10628717': 1, '17331544': 1, '24088634': 2}

{}

3917483-1

noncomm/PMC003xxxxxx/PMC3917483.xml

Cartilage Hair Hypoplasia: First report from Iran

An eight-year-old boy was visited in endocrinology clinic of the Kashan University of Medical Sciences. He was 15.5 kg in weight (3.5 standard deviation below mean) and his height was 92 cm (7 standard deviation below mean). Based on the available documents, he weighed 3.65 kg (50th centile) at birth, with a crown to heel length of 47 cm (10th centile). He had shown abdominal distention and vomiting in his neonatal period and eventually diagnosed asHirschsprung disease that was confirmed using biopsy.\nIn physical examination he had severe short stature, disproportionate short-limbed dwarfism, short and puffy hands, and genu varum deformity. The sternum was abnormally prominent. Hyperextensibility of the joints was not detected.\nHis scalp hairs, eyebrows, and eyelashes were fair, very fine and sparse (). While no nail dysplasia or dental abnormality was found, intellectual development was normal for his age and no clinical evidence of immunodeficiency was observed. However he developed hypothyroidism in the age of 6 years. A 3-mm kidney stone was detected when he was 3 years old that enlarged to 8mm in size at the age of 8 and treated by lithotripsy.\nSkeletal X-rays revealed typical metaphyseal dysostosis, including widening, cupping, and defective mineralization in the metaphysis of the tubular bones (). Vesicouretral reflux was detected in his voiding vesicocyctogram. Complete blood count, electrolytes, and renal function tests were normal. Sterile pyuria was found in several samples of urinalysis that may be as a result of the vesicouretral reflux or renal stone. Microscopic stool examination detected no fat globules. The patient had been assessed for celiac disease and cystic fibrosis during his infancy that was negative.

[[8.0, 'year']]

M

{'1542548': 1, '11058677': 1, '15167352': 1, '1404295': 1, '11207361': 1, '18627050': 1, '10494084': 1, '11940090': 1, '21396580': 1, '27633379': 1, '17041608': 1, '25847322': 1, '16838329': 1, '18978468': 1, '14284412': 1, '21146796': 1, '24791127': 2}

{}

3917491-1

noncomm/PMC003xxxxxx/PMC3917491.xml

An extremely large primary omental hydatid cyst: report of a rare case

The case was an 82-year-old woman, with a body weight of 61 kg , who was referred to the emergency room with complaints of severe abdominal distention and dyspnea. She was admitted in the internal medicine ward with a primary diagnosis of ascites due to cirrhosis, based on the presence of the Caput medusae sign and clinical suspicion of ascites. She had a past history of eight abortions. She also mentioned an episode of abdominal distention about 40 years ago with a slow evolution. She also complained of a loss of the ability to walk during the last 10 years. During the last 2 years, her dyspnea has worsened gradually, so that she was unable to sleep in the supine position and obliged her to rest in lateral decubitus and semi-sitting positions. She had no other significant history of digestive problems during the recent years.\npattern B. Hard and sticky debris of cyst after aspiration.\nAbdominopelvic ultrasonography showed a heterogeneous hypoechoic lesion filling the whole abdominal and pelvic cavities. Hematologic, serologic and hepatic tests were reported to be normal. After a surgery consult, an abdominal and pelvic computed tomography scan (CT) with intra-venous (IV) contrast revealed a giant hypodense cystic mass of about 30x32 x43 cm located in the entire abdominopelvic cavity. It also revealed cystic wall calcifications in several areas that were extended to the abdominal skin border (). With the differential diagnostics of ovarian cystadenoma, mesenteric cyst and omental cyst, the medical team decided to perform laparotomy in which a large cyst was revealed that had displaced the intestines to the sides of the abdomen. There was an important cyst calcification near the left abdominal wall, of about 2x4 cm. Anterior wall of the cyst was covered by the greater omentum, with manifestations of a vascular pattern (). Cyst aspiration was performed and the sample was sent for pathological analysis. About 20 liters of cystic contents were aspirated. After decompression of the cyst, atrophy of the uterus, ovaries, stomach and spleen were observed. The posterior wall of the cyst adhered intimately and extensively to the mesentery, which prohibited the complete cyst release from the surrounding structures. The debris contained within the cyst was hard and sticky; therefore, the cyst was washed using Povidone-iodine 10% and the debris inside the cyst was removed (). Finally, we performed a partial cystectomy and ensured external drainage. After five days, the patient was breathing normally and her weight was 44 kg (17 kg weight loss) (). The pathology report confirmed a hydatid cyst in the sample of cystic wall, but smear and culture of cystic contents were negative.\nThe patient was discharged home and prescribed oral Albendazol with a dose of 15 mg/kg per day. After two weeks, the drain tubes were removed and she could walk without any help after 10 years and sleep in supine position after 2 years.

[[82.0, 'year']]

F

{'16336394': 1, '10835129': 1, '29184259': 1, '18071284': 1, '17407024': 1, '19433195': 1, '17259768': 1, '19535759': 1, '17462273': 1, '17646459': 1, '15803811': 1, '12845535': 1, '23754874': 1, '11111243': 1, '17932603': 1, '24791126': 2}

{}

3917920-1

noncomm/PMC003xxxxxx/PMC3917920.xml

Disseminated intravascular coagulopathy caused by Kikuchi–Fujimoto disease resulting in death: first case report in Turkey

A 32-year-old woman was admitted to hospital complaining of fever, fatigue, as well as chest and abdominal pain of 15 days’ duration, and with no personal and family history for tuberculosis and malignant diseases. Vital signs in the emergency department revealed a temperature of 39°C, a blood pressure level of 140/80 mmHg, a heart rate of 88 bpm, and a respiratory rate of 16 breaths/minute. On physical examination, she was lethargic and maculopapular rashes were patent on her face, trunk, and upper and lower extremities. She had bilateral enlarged cervical, axillary, and inguinal lymph nodes, which were freely mobile, painless on palpation, discrete and sized in the range of 0.5–3.7 cm. In , computed tomography of the neck showed the presence of lymphadenomegalies of various sizes. Cardiovascular and respiratory examinations were unremarkable. Initial laboratory studies revealed hemoglobin levels of 10.2 g/dL, leukocytes of 17,800/mm³ with an abnormal differential count of eosinophils of 9.8%, neutrophils of 54.3%, monocytes of 14%, platelets of 205,000/mm³, lactate dehydrogenase of 578 U/L, C-reactive protein of 28.2 mg/L, and an erythrocyte sedimentation rate (ESR) of 77 mm/hour. Liver and renal tests were normal. Serologic tests for toxoplasma, Epstein–Barr virus, rubella, cytomegalovirus, herpes simplex type 1, hepatitis B, and hepatitis C were all negative. Blood, urine, and sputum cultures were negative. Sputum culture was also negative for acid-fast bacilli. Protein electrophoresis showed polyclonal gammopathy. Also, immunological and rheumatological tests, including antinuclear antibody, deoxyribonucleic acid antibody, perinuclear anti-neutrophil cytoplasmic antibodies, antineutrophil cytoplasmic antibodies, extractable nuclear antigens, and rheumatoid factor were all negative. Electrocardiogram and chest radiographs were normal.\nComputed tomography demonstrated generalized lymphadenopathy in the axillae, cervical area, paraaortic areas, inguinal area, and mediastinum.\nWe took a cervical lymph node biopsy that showed karyorrhectic debris and the cellular infiltration of histiocytes and immunoblasts in the absence of polymorphonuclear leukocytes () and activated B-cells with histiocytes (). An immunohistochemical study showed that the lymphoid cells adjacent to the necrotic foci were strongly positive for cluster of differentiation (CD)3, and the histiocytic cells at the periphery of the necrotic foci were strongly positive for CD68, so we thought that this histological pattern was suggestive of KFD.\nAfter diagnosis, the patient received corticosteroid and hydroxychloroquine therapy. During treatment, the patient’s clinical and laboratory parameters worsened. The patient’s diagnosis was revised, but new findings were unremarkable for a particular disease. The patient’s hemoglobin values decreased, and the peripheral blood smear revealed schistocytes. Blood tests showed raised D-dimer, activated partial thromboplastin time, prothrombin time, and international normalized ratio with decreased fibrinogen. The patient’s condition quickly worsened and eventually disseminated intravascular coagulopathy (DIC) developed. She remained completely unresponsive to therapy and she subsequently died.

[[32.0, 'year']]

F

{'28638624': 2, '3217625': 1, '27433383': 2, '15992668': 1, '16538388': 1, '34745628': 1, '15578393': 1, '12748557': 1, '11726124': 1, '28255545': 2, '16352644': 1, '15272543': 1, '33371072': 2, '8630396': 1, '30833818': 2, '2784712': 1, '8261853': 1, '29387087': 2, '8873511': 1, '21090519': 1, '8982035': 1, '24520206': 2}

{'7748204-1': 1, '4945722-1': 1, '5314258-1': 1, '6393831-1': 1, '5471450-1': 1, '5745701-1': 1}

3917953-1

noncomm/PMC003xxxxxx/PMC3917953.xml

Spectral-domain optical coherence tomographic and fundus autofluorescence findings in eyes with primary intraocular lymphoma

A 57-year-old man visited our clinic with blurred vision in his right eye of 3 months’ duration. He had been diagnosed with PCNSL 3 years earlier. Our initial examination showed iritis, mutton fat keratic precipitates, vitreous opacities, retinal infiltrations, and retinal vasculitis. Diagnostic vitrectomy was performed, and cytodiagnosis showed class V lymphoma cells. The IL-10/IL-6 ratio in the vitreous was 12.0. Thus, a diagnosis of PIOL was made.\nHis best-corrected visual acuity after vitrectomy was hand motion. Fundus examination revealed diffuse infiltration into the macular area and retinal vasculitis in the temporal and nasal areas (). Late phase fluorescein angiography (FA) showed hypofluorescent spots with a leopard spot-like pattern in the posterior fundus, and staining of the arteries with an avascular area in the nasal area (). SD-OCT examination showed nodular hyper-reflective infiltrations at the level of the RPE, a separation of Bruch’s membrane from the RPE, partial destruction of the RPE, disruption of the photoreceptor inner segment/outer segment (IS/OS) junction line, and hyper-reflective signals in the inner retina (). A layered structure of the retina could not be detected on the temporal side. FAF examinations were not performed in this case.\nThe patient was treated by intravitreal injection of methotrexate. After six injections, the retinal hyper-reflective infiltrations decreased in the SD-OCT images, and the level of IL-10 in the aqueous humor became undetectable. Recurrence of PCNSL was not found.

[[57.0, 'year']]

M

{'30858685': 1, '27784984': 1, '23958842': 1, '22661396': 1, '18327131': 1, '20723993': 1, '25120475': 2, '29018736': 1, '9298057': 1, '22449988': 1, '20065216': 1, '12578786': 1, '15671263': 1, '16912010': 1, '19458079': 1, '18936428': 1, '32322750': 1, '11884876': 1, '24011267': 1, '19243734': 1, '19834356': 1, '22589439': 1, '21509532': 1, '25971162': 1, '22477623': 2, '28039672': 1, '29271394': 1, '24559259': 2, '21030872': 1, '20456441': 1, '30930667': 1, '26482033': 1, '24520190': 2}

{'3917953-2': 2, '3917953-3': 2, '4127548-1': 1, '4127548-2': 1, '3944943-1': 1, '3500988-1': 1}

3917953-2

noncomm/PMC003xxxxxx/PMC3917953.xml

Spectral-domain optical coherence tomographic and fundus autofluorescence findings in eyes with primary intraocular lymphoma

A 57-year-old man visited our clinic with blurred vision in his left eye of one month’s duration. The initial examination showed diffuse vitreous opacities and retinal infiltrations. Diagnostic vitrectomy was performed, and cytodiagnosis revealed atypical class V lymphocytes with dyskaryosis and aberrant chromatin (). The IL-10/IL-6 ratio of the vitreous was 30.9. Thus, a diagnosis of PIOL was made.\nThe best-corrected visual acuity after vitrectomy was 1.0. Fundus examination revealed many small, yellow lesions with distinct boundaries resembling drusen in the posterior fundus (). A granular pattern of hypoautofluorescence and hyperautofluorescence was seen in the FAF images (). Late phase FA showed hyperfluorescence of the disc and small spots in the posterior fundus that corresponded to the hypofluorescent spots in the FAF images (). SD-OCT showed nodular hyper-reflective infiltrations at and above the level of the RPE, a separation of Bruch’s membrane from the RPE, partial destruction of the RPE and IS/OS junction, and multiple hyper-reflective signals in the inner retina (). PCNSL was not detected by magnetic resonance imaging. The patient was treated by intravitreal injection of methotrexate. After four injections, the retinal hyper-reflective infiltrations decreased in the SD-OCT images and the level of IL-10 in the aqueous humor became undetectable.

[[57.0, 'year']]

M

{'30858685': 1, '27784984': 1, '23958842': 1, '22661396': 1, '18327131': 1, '20723993': 1, '25120475': 2, '29018736': 1, '9298057': 1, '22449988': 1, '20065216': 1, '12578786': 1, '15671263': 1, '16912010': 1, '19458079': 1, '18936428': 1, '32322750': 1, '11884876': 1, '24011267': 1, '19243734': 1, '19834356': 1, '22589439': 1, '21509532': 1, '25971162': 1, '22477623': 2, '28039672': 1, '29271394': 1, '24559259': 2, '21030872': 1, '20456441': 1, '30930667': 1, '26482033': 1, '24520190': 2}

{'3917953-1': 2, '3917953-3': 2, '4127548-1': 1, '4127548-2': 1, '3944943-1': 1, '3500988-1': 1}

3917953-3

noncomm/PMC003xxxxxx/PMC3917953.xml

Spectral-domain optical coherence tomographic and fundus autofluorescence findings in eyes with primary intraocular lymphoma

A 67-year-old man visited our clinic with blurred vision in the left eye of one month’s duration. He had been diagnosed with PCNSL one year earlier. Our ophthalmoscopic examination showed diffuse vitreous opacities and retinal infiltrations in the macular area. Diagnostic vitrectomy was performed, and cytodiagnosis revealed class III lymphoma cells. The IL-10/IL-6 ratio in the vitreous was 27.4, leading to a diagnosis of PIOL.\nThe decimal best-corrected visual acuity after vitrectomy was 0.15. Fundus examination revealed many large whitish yellow spots with indistinct boundaries in the macular area (). The FAF images showed hypoautofluorescence and hyperautofluorescence surrounding the spots with a honeycomb shape in the macular area (). Late phase FA showed hyperfluorescence of the disc and a fluorescence pattern of the retina that was the reverse of the FAF pattern (). The SD-OCT images showed hyper-reflective infiltrations at the level of the RPE, separation of Bruch’s membrane from the RPE, disruption of the IS/OS junction, hyper-reflective bands above the RPE, and hyper-reflective signals in the inner retina (). Magnetic resonance imaging showed that the PCNSL had not recurred. This patient was treated by intravitreal injection of methotrexate. After six injections, the retinal hyper-reflective infiltrations decreased in the SD-OCT images and the IL-10 level in aqueous humor was undetectable.

[[67.0, 'year']]

M

{'30858685': 1, '27784984': 1, '23958842': 1, '22661396': 1, '18327131': 1, '20723993': 1, '25120475': 2, '29018736': 1, '9298057': 1, '22449988': 1, '20065216': 1, '12578786': 1, '15671263': 1, '16912010': 1, '19458079': 1, '18936428': 1, '32322750': 1, '11884876': 1, '24011267': 1, '19243734': 1, '19834356': 1, '22589439': 1, '21509532': 1, '25971162': 1, '22477623': 2, '28039672': 1, '29271394': 1, '24559259': 2, '21030872': 1, '20456441': 1, '30930667': 1, '26482033': 1, '24520190': 2}

{'3917953-1': 2, '3917953-2': 2, '4127548-1': 1, '4127548-2': 1, '3944943-1': 1, '3500988-1': 1}

3918521-1

noncomm/PMC003xxxxxx/PMC3918521.xml

Primary Follicular Lymphoma in a Male Breast: A Case Report

A 46-year-old man was diagnosed with liver cirrhosis secondary to chronic hepatitis B infection. Ten years later, a mass with 1.5 cm diameter was detected by abdominal computed tomography (CT) scan in Couinaud's segment 8 during a routine follow-up. Viral serologic tests were positive for serum hepatitis B surface antigen (HBsAg), envelope antigen (HBeAg), and antibody (HBeAb) and negative for hepatitis C virus antibody. The patient underwent segmentectomy of the liver. Histology of the resected specimen revealed 1.2 cm HCC with Edmondson grade II and peritumoral microvessel invasion (pT2). The postoperative course was uneventful.\nFive months later, the patient presented with a painless palpable mass in the right chest wall. The mass was movable and round shaped without fixation to the skin or muscle. On mammography, there was a round, homogenous, well-circumscribed mass (). Ultrasonography revealed an oval hypoechoic mass, measuring 1.6 cm in diameter, on the right chest wall without evidence of axillary involvement. Excisional biopsy was performed for histologic examination. Microscopic findings showed atypical lymphoid cells with a follicular growth pattern. Immunohistochemical staining was positive for antibodies against CD20, B cell lymphoma (Bcl)-2, and Bcl-6, and negative for CD3 (). Definite histology was diagnosed as grade 1 FL of the breast based on morphologic features and immunohistochemistry. Positron emission tomography-CT, abdominal CT, and chest CT were used to stage the disease, and there were no other suspected lesions. Aspirate and bone marrow biopsy was performed for initial staging procedure, and the results revealed normocellular marrow with no evidence of malignancy. The stage was IEA according to the Ann Arbor staging system [], and the prognostic index was low according to the Follicular Lymphoma International Prognostic Index (FL-IPI) []. The patient did not receive further adjuvant therapy, and he remains alive with complete remission at 40 months after surgery.

[[46.0, 'year']]

M

{'1835586': 1, '22823980': 2, '6548796': 1, '20959600': 1, '21179013': 1, '23006942': 1, '11815954': 1, '23008294': 1, '5121694': 1, '18380889': 1, '15126323': 1, '20688564': 1, '4555557': 1, '19570964': 1, '26759113': 1, '30814841': 1, '24520230': 2}

{'3419691-1': 1}

3918532-1

noncomm/PMC003xxxxxx/PMC3918532.xml

Adenoid Cystic Carcinoma of the Breast: A Case Series of Six Patients and Literature Review

A 70-year-old female had a mass in her left breast, which was detected on a routine screening mammogram. Mammography and breast ultrasonography (US) showed an irregular mass measuring 2.4×1.4 cm with a spiculated margin in the upper inner quadrant. Breast magnetic resonance imaging (MRI) showed an irregular enhancing mass in the left breast. Results of a subsequent diagnostic core biopsy indicated an infiltrative ductal carcinoma. The patient underwent quadrantectomy with sentinel lymph node biopsy (SLNB). The tumor was found to be an ACC measuring 2.0×1.9×1.5 cm (nuclear grade, 2), and the sentinel lymph node was negative for metastasis (pT2N0M0). Immunohistochemistry (IHC) of the tumor was negative for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) expression. The patient did not receive adjuvant radiotherapy or chemotherapy. The patient has been free of recurrence during 28 months of follow-up.

[[70.0, 'year']]

F

{'22015727': 1, '16798905': 1, '8685217': 1, '30363306': 2, '15816611': 1, '33791208': 1, '22179977': 1, '30697408': 2, '31393393': 2, '33364705': 1, '22154460': 1, '3030200': 1, '31912013': 1, '20589709': 1, '11030399': 1, '15528965': 1, '16813652': 2, '12095593': 1, '25487882': 1, '1311551': 1, '29080560': 2, '34830849': 1, '20653964': 1, '26348644': 1, '25516849': 1, '24520228': 2}

{'3918532-2': 2, '3918532-3': 2, '3918532-4': 2, '3918532-5': 2, '5660888-1': 1, '6159263-1': 1, '1526742-1': 1, '6344919-1': 1, '6708915-1': 1}

3918532-2

noncomm/PMC003xxxxxx/PMC3918532.xml

Adenoid Cystic Carcinoma of the Breast: A Case Series of Six Patients and Literature Review

A 33-year-old female presented with a mass in her right breast, which was discovered during self-examination. The patient underwent a right inner quadrantectomy with SLNB. Histopathologic examination of the tumor specimen after surgery showed an ACC of low nuclear grade measuring 1.6×1.2×2.5 cm and no metastasis to the sentinel lymph node (pT2N0M0). The tumor was negative for expression of ER, PR, and HER2. The patient subsequently received adjuvant chemotherapy with fluorouracil, doxorubicin, and cyclophosphamide (FAC), followed by adjuvant radiation therapy. After 28 disease-free months, chest computed tomography (CT) showed multiple lung nodules that were suspicious for metastatic disease. The patient underwent pulmonary metastasectomy using wedge resection of the left upper and lower lobes. Histopathology indicated metastatic ACC. The largest of eight metastases measured 0.9 cm. The patient received first-line palliative chemotherapy with docetaxel every three weeks. After six cycles, response assessment showed stable disease, and chemotherapy was discontinued. Seventeen months later, chest CT showed that the lung nodules had become larger. Because of her poor overall condition, the patient received three cycles of capecitabine without further chemotherapy. She has had stable disease for the past 12 months.

[[33.0, 'year']]

F

{'22015727': 1, '16798905': 1, '8685217': 1, '30363306': 2, '15816611': 1, '33791208': 1, '22179977': 1, '30697408': 2, '31393393': 2, '33364705': 1, '22154460': 1, '3030200': 1, '31912013': 1, '20589709': 1, '11030399': 1, '15528965': 1, '16813652': 2, '12095593': 1, '25487882': 1, '1311551': 1, '29080560': 2, '34830849': 1, '20653964': 1, '26348644': 1, '25516849': 1, '24520228': 2}

{'3918532-1': 2, '3918532-3': 2, '3918532-4': 2, '3918532-5': 2, '5660888-1': 1, '6159263-1': 1, '1526742-1': 1, '6344919-1': 1, '6708915-1': 1}

3918532-3

noncomm/PMC003xxxxxx/PMC3918532.xml

Adenoid Cystic Carcinoma of the Breast: A Case Series of Six Patients and Literature Review

A 56-year-old female was found to have a palpable mass and skin retraction involving the left breast. Mammography and breast US showed a conglomerate mass measuring 2.6 cm and a daughter nodule measuring 0.5 cm in the lower inner quadrant. Breast MRI showed two intensely enhancing round and irregular masses and skin retraction. Left quadrantectomy and axillary lymph node dissection (ALND) were performed. The tumors were ACCs with low nuclear grade, measuring 1.4×1.2×1.2 cm and 1.2×1.1×0.9 cm. No metastatic axillary lymph nodes were observed (pT1N0M0). IHC was negative for ER, PR, and HER2 expression. The patient subsequently received adjuvant radiation therapy. She has been free of recurrence for 65 months.

[[56.0, 'year']]

F

{'22015727': 1, '16798905': 1, '8685217': 1, '30363306': 2, '15816611': 1, '33791208': 1, '22179977': 1, '30697408': 2, '31393393': 2, '33364705': 1, '22154460': 1, '3030200': 1, '31912013': 1, '20589709': 1, '11030399': 1, '15528965': 1, '16813652': 2, '12095593': 1, '25487882': 1, '1311551': 1, '29080560': 2, '34830849': 1, '20653964': 1, '26348644': 1, '25516849': 1, '24520228': 2}

{'3918532-1': 2, '3918532-2': 2, '3918532-4': 2, '3918532-5': 2, '5660888-1': 1, '6159263-1': 1, '1526742-1': 1, '6344919-1': 1, '6708915-1': 1}

3918532-4

noncomm/PMC003xxxxxx/PMC3918532.xml

Adenoid Cystic Carcinoma of the Breast: A Case Series of Six Patients and Literature Review

A 47-year-old female presented with a palpable mass in her left breast, which she had discovered three years before being seen by us. Mammography and breast US showed multiple masses in the left upper breast. Breast MRI showed an enhancing lobulated mass measuring 1.1×1.2 cm in the left upper breast and multiple small adjacent and posterior nodules. Results of a subsequent diagnostic core biopsy revealed an infiltrative ductal carcinoma with features of ACC. The patient underwent a modified radical mastectomy (MRM) with SLNB. Histopathologic examination of the resected specimen showed multiple ACCs measuring a total of 4.2×2.3×3 cm. There were no metastatic lymph nodes (pT2N0M0). IHC was negative for ER, PR, and HER2 expression. The patient underwent six cycles of adjuvant chemotherapy using cyclophosphamide, methotrexate, and 5-fluorouracil. She has been free of recurrence for 48 months.

[[47.0, 'year']]

F

{'22015727': 1, '16798905': 1, '8685217': 1, '30363306': 2, '15816611': 1, '33791208': 1, '22179977': 1, '30697408': 2, '31393393': 2, '33364705': 1, '22154460': 1, '3030200': 1, '31912013': 1, '20589709': 1, '11030399': 1, '15528965': 1, '16813652': 2, '12095593': 1, '25487882': 1, '1311551': 1, '29080560': 2, '34830849': 1, '20653964': 1, '26348644': 1, '25516849': 1, '24520228': 2}

{'3918532-1': 2, '3918532-2': 2, '3918532-3': 2, '3918532-5': 2, '5660888-1': 1, '6159263-1': 1, '1526742-1': 1, '6344919-1': 1, '6708915-1': 1}

3918532-5

noncomm/PMC003xxxxxx/PMC3918532.xml

Adenoid Cystic Carcinoma of the Breast: A Case Series of Six Patients and Literature Review

A 49-year-old female presented with a palpable mass in her right breast, which she had discovered one year earlier. Mammography and breast US showed a poorly defined mass measuring 3.0×2.5 cm in the right upper breast and thickening of the overlying skin. The patient underwent MRM and ALND. Histopathologic examination revealed an ACC measuring 4.5×3.7×2.5 cm and no metastatic lymph nodes (pT2N0M0). The tumor consisted of 50% solid component in addition to necrosis and infiltrative invasion. IHC was negative for expression of ER, PR, and HER2. The patient underwent six cycles of adjuvant chemotherapy using FAC. She was free of disease for 45 months, and was then seen with thickened, reddish skin at the previous surgical site. Results of a skin biopsy indicated recurrent ACC. Local excision was performed, followed by a wide excision and postoperative radiotherapy, because the posterior and lateral resection margins were involved with the tumor. No recurrence has been detected during 52 months of follow-up.

[[49.0, 'year']]

F

{'22015727': 1, '16798905': 1, '8685217': 1, '30363306': 2, '15816611': 1, '33791208': 1, '22179977': 1, '30697408': 2, '31393393': 2, '33364705': 1, '22154460': 1, '3030200': 1, '31912013': 1, '20589709': 1, '11030399': 1, '15528965': 1, '16813652': 2, '12095593': 1, '25487882': 1, '1311551': 1, '29080560': 2, '34830849': 1, '20653964': 1, '26348644': 1, '25516849': 1, '24520228': 2}

{'3918532-1': 2, '3918532-2': 2, '3918532-3': 2, '3918532-4': 2, '5660888-1': 1, '6159263-1': 1, '1526742-1': 1, '6344919-1': 1, '6708915-1': 1}

3918533-1

noncomm/PMC003xxxxxx/PMC3918533.xml

Pseudocirrhosis of Breast Cancer Metastases to the Liver Treated by Chemotherapy

A 47-year-old woman visited our hospital in January 2003 because of a painful right breast mass with skin dimpling. On initial evaluation, chest CT revealed the presence of a heterogeneous enhancing breast mass measuring 9 cm with skin invasion and multiple conglomerated lymph nodes in the right axillary area. In addition, multiple metastatic pleural masses with malignant pleural effusion and mediastinal lymph node enlargement were also observed. A bone scan showed increased uptake in the sternum and right sixth anterior rib. There was no evidence of liver metastases on the initial CT scan (). Fine-needle aspiration cytology of the breast mass showed atypical malignant cells. Accordingly, she was diagnosed with stage IV right breast cancer with multiple pleural and bone metastases. She subsequently received palliative chemotherapy with docetaxel and epirubicin. Follow-up CT scan performed after four cycles of chemotherapy showed partial regression of the breast mass and multiple metastatic masses in the pleura and axillary area. She then underwent palliative total mastectomy of her right breast because of an ulcerated skin lesion. Pathological examination showed invasive ductal carcinoma with nuclear grade 2 and lymphatic and perineural invasion. Immunohistochemistry studies showed positive staining for the estrogen receptor (ER) protein, progesterone receptor protein, and human epidermal growth factor receptor 2 (HER2) (score 3). She received two additional cycles of chemotherapy with docetaxel and epirubicin. A follow-up CT scan showed stable disease and she then started taking tamoxifen (20 mg daily) in July 2003.\nTwo years later, in November 2005, a surveillance breast ultrasound showed an irregular circumscribed mass measuring 1 cm on theright mastectomy site. The patient underwent a wide local excision and pathology confirmed an invasive ductal carcinoma. Although previous metastatic lesions showed stable disease, a new chest wall lesion had developed; therefore, her treatment was switched from tamoxifen to the non-steroidal aromatase inhibitor anastrozole. At that time, she was postmenopausal, based on her serum follicle-stimulating hormone levels. In January 2007, a bone scan showed new increased uptake in the right second rib, the third anterior rib, and the right acetabulum. She had progressive disease of the bone; therefore, capecitabine (an oral prodrug of 5-fluorouracil; 2,500 mg/m2/day) was started (two weeks on, one week off). After nine cycles of chemotherapy, she had stable disease and was off chemotherapy for approximately four years with no evidence of progression.\nHowever, follow-up CT scan performed in June 2011 showed multiple newly developed peripheral enhancing nodules in the liver (). She received six cycles of chemotherapy until November 2011, and CT scan showed that her metastatic hepatic lesions were stable. Since then, her chemotherapy has been discontinued because of grade 4 neutropenia and osteomyelitis of the mandible. Four months later, follow-up CT scan showed ill-defined heterogeneous enhancing lesions in the entire liver with surface nodularity. The liver had a nodular contour consistent with cirrhosis, as well as moderate ascites (). F18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET-CT) also showed disseminated and innumerable lesions throughout almost the entire liver with increased FDG uptake (maximum standardized uptake value [SUVmax], 7.3), suggesting diffuse liver metastasis (). Palliative chemotherapy with docetaxel and epirubicin was started again. Endoscopy showed grade 3 large esophageal varices with a red color sign. She denied a history of liver disease, alcohol use, and risk factors for viral hepatitis. Serologies for viral or autoimmune etiologies of cirrhosis were negative and the serum level of alpha-fetoprotein was normal. An ultrasound-guided liver biopsy was performed in order to confirm the cause of the cirrhotic changes. Pathological examination showed that the hepatic parenchyma was diffusely infiltrated by poorly differentiated carcinoma cells. Hepatocytes were almost replaced by carcinoma cells and extensive fibrosis between clusters of cancer cells was observed (). Immunohistochemical staining was positive for gross cystic disease fluid protein-15, MOC 31, ER, and HER2 (score 3), but negative for hepatocytes (). Follow-up PET-CT showed progression of liver metastases with increased FDG uptake (SUVmax, 9.0) since the scan performed in June 2011. Therefore, we concluded that the hepatic metastases from breast cancer had progressed and led to cirrhotic changes in the liver.\nSubsequently, her chemotherapy regimen was changed to trastuzumab and docetaxel. However, bleeding of esophageal varices occurred on the sixth day after initiation of chemotherapy, and hepatic failure progressed gradually. Therefore, the patient decided to discontinue chemotherapy.

[[47.0, 'year']]

F

{'30899627': 2, '26443452': 1, '26567115': 1, '20375937': 1, '27721722': 2, '21447980': 1, '17265127': 1, '18330959': 1, '11568328': 1, '21418309': 1, '31175499': 1, '14975965': 1, '27293396': 2, '34277423': 1, '27686493': 1, '34881031': 1, '17189839': 1, '7992734': 1, '20308502': 1, '28123730': 1, '22328846': 1, '22692285': 1, '24520229': 2}

{'4899638-1': 1, '5043255-1': 1, '5043255-2': 1, '5043255-3': 1, '5043255-4': 1, '5043255-5': 1, '5043255-6': 1, '6420322-1': 1}

3919427-1

noncomm/PMC003xxxxxx/PMC3919427.xml

Adverse Skin Reactions due to Ribavirin in Hepatitis C Combination Therapy with Pegylated Interferon-α2a

We describe a 59-year-old Japanese woman with a chronic hepatitis C infection who developed erythema during PEG-IFN-α2a and ribavirin therapy. There was a faint erythema on her trunk and her arms after 8 weeks of treatment (week 8). Administration of bepotastine besilate had no effect. However, the erythema improved with the application of crotamiton cream and alclometasone dipropionate ointment. Fluvastatin sodium was added for her hypercholesterolemia at week 12. The HCV RNA virus had decreased from 6.6 logIU/ml to negative at week 16. Subcutaneous injection of PEG-IFN-α2a was postponed due to recurrent erythema at week 20. Eruption at the injection site of IFN occurred after each injection, and then, eruption on her head, face and neck (exposed skin) was observed (fig. ). Twenty milligrams of prednisolone was administered. After each administration of prednisolone and ribavirin, the eruption recurred. The eruption consisted of red papules fused to an erythematous plaque. After PEG-IFN-α2a subcutaneous injection in her right arm, the eruptions became worse and she had a consultation in our department. At that time, she had infiltrative erythema without any mucosal symptoms on her whole body (fig. ). It seemed to be an erythema multiforme type drug eruption of PEG-IFN-α2a, ribavirin and/or fluvastatin sodium from the clinical course. Although administration of all drugs was stopped, the eruption expanded after administering 40 mg prednisolone and a topical steroid. Since prednisolone was suspected to have been the cause of the drug eruption, the eruption improved after it was changed to 6 mg of betamethasone.\nThe HCV RNA virus was negative at week 17. However, it had increased to 6.8 logIU/ml at week 28.\nThe lymphocyte transformation test (LTT) was carried out for PEG-IFN-α2a, ribavirin and fluvastatin sodium. Only ribavirin was positive.

[[59.0, 'year']]

F

{'12590246': 1, '15857485': 1, '15206691': 1, '17983378': 1, '15230812': 1, '17683392': 1, '32404434': 1, '16225644': 1, '24516409': 2}

{}

3919486-1

noncomm/PMC003xxxxxx/PMC3919486.xml

Spontaneous Cutaneous Endometriosis of the Umbilicus

In December 2012, a 31-year-old Caucasian woman presented to the dermatology outpatient clinic with a 1-month history of a persistent, raised lesion in the umbilicus. The patient had noted swelling and one episode of spontaneous frank bleeding from the lesion. There was no associated cyclical pain at the lesion site.\nAt the time of examination, a single firm 0.5-cm black-coloured papule was seen within the umbilicus at the 3 o'clock position. The lesion was tender to palpation with intact overlying skin. No discharge or underlying umbilical hernia was noted.\nThe patient had a history of 2 previous melanomas: the first in 2003 on the left abdomen and the second on the right buttock in 2006. Both tumours were excised with clear margins. There was no history of previous abdominal or laparoscopic procedures. She had no previous diagnosis of endometriosis and no catamenial complaints.\nGiven the anatomical location, a skin punch biopsy of the umbilical lesion was performed. During dermatology review, 1 month later, it was noted that 3 distinct skin-coloured papules had appeared next to the initial lesion (fig. ).\nHistological examination of the punch biopsy revealed a lesion in the superficial dermis comprising a single dilated glandular structure, surrounded by cellular endometrial-type stroma (fig. ). The gland was lined by a single layer of columnar cells, a few of which had apical cilia. The overlying epidermis was unremarkable. No malignancy was identified. A diagnosis of cutaneous endometriosis was determined.\nThe patient was referred for surgical excision of the umbilical papules. Subsequent gynaecological evaluation revealed a 3-year history of dysmenorrhoea. A provisional diagnosis of coexistent pelvic endometriosis was made. Abdominal and transvaginal ultrasonography were unremarkable. A diagnostic and therapeutic laparoscopic examination was advised if the patient remained unable to conceive over the following 6 months.

[[31.0, 'year']]

F

{'28966521': 2, '19970197': 1, '25770141': 2, '17954799': 1, '21170542': 1, '15106631': 1, '34939402': 2, '19475890': 1, '12780722': 1, '34547012': 1, '16046431': 1, '27747115': 2, '32307951': 2, '13057992': 1, '20422419': 1, '21810390': 1, '24516408': 2}

{'8694163-1': 1, '7160592-1': 1, '5055931-1': 1, '4357830-1': 1, '5597658-1': 1}

3919519-1

noncomm/PMC003xxxxxx/PMC3919519.xml

Emergency Superficial Temporal Artery to Middle Cerebral Artery Bypass after Intravenous Recombinant Tissue Plasminogen Activator Administration for Acute Cerebral Ischemia in a Patient with Moyamoya Disease

A 33-year-old healthy male with no known previous medical history developed right hemiparesis and motor aphasia and was referred to our hospital. The patient's National Institutes of Health Stroke Scale (NIHSS) score was 20 points at the time of admission. A computed tomography (CT) scan was performed immediately and showed no acute lesion. According to the treatment protocol for acute cerebral ischemia, the patient received emergency intravenous rt-PA administration (0.6 mg/kg) by a neurologist at our hospital 2 h and 50 min after the onset of the event. After completion of rt-PA administration, symptoms progressed to complete right hemiplegia. During this treatment, the mean blood pressure was stable at 120–130 mm Hg, oxygen saturation was maintained at >99% by oxygen inhalation (2 l/min), and blood glucose level was stable (109–113 mg/dl). Emergency magnetic resonance imaging (MRI) showed an acute ischemic lesion in the left basal ganglia to corona radiata (fig. ). MR angiography (MRA) showed severe stenosis of the bilateral terminal portion of the internal carotid artery (ICA) and occlusion at the origin of the left MCA (fig. ). Perfusion MRI showed marked prolongation of the mean transit time (MTT) in a broad area of the left MCA territory, including Broca's area, indicating the existence of a large area of hypoperfusion (fig. ). Obvious diffusion-perfusion mismatch was detected. Blood pressure values measured just before and after MRI were 129 and 144 mm Hg, respectively.\nThe patient was referred to our department for consideration of endovascular revascularization. We performed digital subtraction angiography, which showed mild stenosis of the terminal portion of the right ICA, severe stenosis of the A1 portion of the right anterior cerebral artery, and severe stenosis of the terminal portion of the left ICA and M1 portion of the left MCA, with poor peripheral circulation when compared with the right (fig. ). Based on these data, acute cerebral ischemia induced by moyamoya disease or moyamoya-like angiopathy was diagnosed, because the patient had no remarkable past medical history or risk factors for arteriosclerosis. We first considered emergency endovascular revascularization because of clinical progression despite best medical treatment, but in a second stage, we considered the STA-MCA bypass was a better option than endovascular ballooning or stenting for this case on the premise of underlying moyamoya disease and progressive angiopathy. Since the patient showed no significant improvement during the examination, we finally decided to perform emergency STA-MCA bypass to prevent further progression of cerebral ischemia.\nDetailed informed consent was obtained from the patient's family, and the operation began 7 h after the administration of rt-PA. A successful single bypass using the parietal branch of the STA with a small craniotomy was achieved, as demonstrated by intraoperative indocyanine green videoangiography (data not shown). Revascularization was accomplished 9.5 h after the administration of rt-PA. Symptoms stabilized and subsequently improved postoperatively. The free radical scavenger edaravone (60 mg/day) [] was given postoperatively to minimize ischemic damage. Follow-up CT was performed on postoperative day 2 and confirmed the patency of the bypass, absence of postoperative hemorrhage, and no apparent progression of infarction. The phosphodiesterase inhibitor and antiplatelet and vasodilating agent cilostazol (200 mg/day) [] was started by oral administration on postoperative day 2 to improve peripheral cerebral blood flow and to reduce edema formation. MRI was performed on postoperative day 4 and confirmed the patency of the bypass with persistent stenosis of the terminal portion of bilateral ICA (fig. ) and new small lesions when compared with those seen on preoperative diffusion-weighted imaging (DWI) (fig. ). Perfusion MRI showed complete recovery of MTT in the left cerebral hemisphere (fig. ). Most areas of preoperative hypoperfusion seen after rt-PA administration were rescued by the emergency operation and additional medical treatment. Blood pressure values measured just before and after MRI were 113 and 108 mm Hg, respectively.\nHyperperfusion syndrome and hemorrhage into an area of ischemia did not occur. Four months after surgery, the patient resumed his previous full-time employment (Department of Statistical Analysis) and continued to take cilostazol (200 mg/day). He remains well at the 1.5-year follow-up visit.

[[33.0, 'year']]

M

{'19499983': 1, '22463811': 1, '17957395': 1, '19321945': 1, '8789652': 1, '21990810': 1, '21135550': 1, '20833591': 1, '24516411': 2}

{}

3919962-1

noncomm/PMC003xxxxxx/PMC3919962.xml

The First Korean Case of Nontuberculous Mycobacterial Lung Disease Caused by Mycobacterium abscessus Subspecies bolletii in a Patient with Bronchiectasis

A 66-year-old male was referred to our hospital for management of probable NTM lung disease. He was an ex-smoker and had a history of previous treatment for pulmonary tuberculosis 10 years prior. Six months before his visit to our hospital, the patient reported chronic cough and sputum. He was initially diagnosed with acid-fast bacilli (AFB) smear-positive pulmonary tuberculosis and received isoniazid, rifampin, ethambutol, and pyrazinamide for 6 months. However, AFB smears were persistently positive, and NTM were cultured from his sputum specimens. He was then referred to our hospital.\nPhysical examination showed that the patient was 172.3 cm tall and weighed 56.1 kg. Laboratory tests results were unremarkable. A human immunodeficiency virus antibody test was negative. The chest radiograph and computed tomography (CT) scan revealed multifocal bronchiectasis and bronchiolitis in both lungs that suggested the nodular bronchiectatic form of NTM lung disease ().\nThe patient's sputum was positive for AFB staining, and NTM were isolated more than three times in a liquid culture system (Bactec MGIT 960 system; BD Diagnostics, Sparks, MD, USA). To identify the etiological agent, bacteria were initially propagated in 7H9 broth (Difco Laboratories, Detroit, MI, USA) supplemented with 10% (vol/vol) oleic acid-albumin-dextrose-catalase (BD Diagnostics) for 7 days at 37℃, sub-cultured in egg-based 3% Ogawa solid media (Shinyang, Seoul, Korea), and genomic DNA was extracted from the cultured bacteria. Initial species identification using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method based on the rpoB gene (Myco-ID; M&D Inc., Wonju, Korea) was M. abscessus complex.\nTo speciate the isolates, sequencing analysis of the nearly complete 16S rRNA gene, partial hsp65, and rpoB sequences were performed using GenBank () with the BLAST algorithm. The 16S rRNA sequences showed 100% identity with M. abscessus subsp. abscessus (GenBank accession no. NR074427), M. abscessus subsp. massiliense (GenBank accession no. NR074421), M. chelonae (GenBank accession no. AY457082), and M. abscessus subsp. bolletii (GenBank accession no. NR043236). The hsp65 and rpoB sequences were 100% identical to those of the M. abscessus subsp. bolletii type strain (GenBank accession nos. FJ607778 and AY859692). Phylogenetic analysis based on the rpoB sequences from the isolate SMC-bol-002 and from those of closely related species within the RGM showed that this strain belonged to M. abscessus subsp. bolletii ().\nDrug susceptibility testing was performed using a broth microdilution method (). At the genetic level, the isolate was genotyped for erm(41) polymorphism and for rrl mutations; these are known as the two main mechanisms of macrolide resistance. The isolate had the erm(41) gene with a T28 sequevar and no rrl mutation acquisition.\nThe patient received oral clarithromycin and moxifloxacin, along with an initial 4-week course of intravenous amikacin and cefoxitin. During 4 weeks of initial antibiotic treatment, his symptoms and CT lesions were improved and sputum culture results were negative after 2, 3, and 4 weeks after treatment. Although he took oral clarithromycin and moxifloxacin for a total duration of 24 months, follow-up sputum cultures were persistently positive after 2 months after antibiotic treatment.

[[66.0, 'year']]

M

{'21106786': 1, '13035193': 1, '17277290': 1, '20833823': 1, '32339194': 1, '23541540': 1, '19193279': 1, '29791556': 1, '19661243': 1, '25114696': 1, '10921960': 1, '16478850': 1, '19675221': 1, '16014496': 1, '19732795': 1, '16403878': 1, '21135185': 1, '24523815': 2}

{}

3919963-1

noncomm/PMC003xxxxxx/PMC3919963.xml

Two Cases of Glomus Tumor Arising in Large Airway: Well Organized Radiologic, Macroscopic and Microscopic Findings

A 64-year old man, who had no clinical respiratory symptom and previous medical problem except hypertension, visited our hospital due to incidentally found tracheal mass on the examination of health care program using computed tomography (CT). CT revealed a highly enhanced 2.6 cm-sized, iceberg shaped mid-tracheal tumor involving the right-side posterolateral wall, suggesting the impression of tracheal paraganglioma (most likely), sclerosing hemangioma and leiomyoma (). On the bronchoscopic examination, a 1 cm-sized, vascular mass was noted 7 cm below the vocal cord (). However, pulmonary function test (PFT) showed no abnormal findings: forced vital capacity (FVC), 3.6 L; forced expiratory volume in 1 second (FEV1), 3.13 L; and FEV1/FVC, 87%. Tracheal resection and anastomosis was done. He is well without evidence of local recurrence or complication two years after operation.

[[64.0, 'year']]

M

{'25344687': 1, '31189773': 1, '23050181': 2, '11859201': 1, '29221350': 1, '2153371': 1, '14080348': 1, '11734464': 1, '17905464': 1, '11603225': 1, '9891244': 1, '21104079': 1, '27621844': 1, '29642190': 1, '25544269': 1, '16632723': 1, '24523816': 2}

{'3459257-1': 1}

3919964-1

noncomm/PMC003xxxxxx/PMC3919964.xml

A Case of Immunoglobulin G4-Related Disease Presenting as a Pleural Mass

A 66-year-old male was referred from a local clinic with one-week history of cough and sputum, and abnormal chest X-ray findings. He was a current smoker (one pack per day for 40 years) and had been diagnosed as Alzheimer type dementia. Medications for the dementia included donepezil, sodium valproate and quetiapine. He had no history of diabetes, hypertension and tuberculosis. He denied body weight loss or night sweating. He had no pleuritic chest pain or dyspnea.\nOn admission, he was acutely ill-looking. Blood pressure was 120/80 mm Hg, body temperature was 37.5℃, pulse rate was 66/min, and respiratory rate was 20/min. The lymph node in the neck was not palpated. Physical examination of the chest revealed crackle on right lower lung field but heart sound was normal without murmur. Complete blood count results were hemoglobin 12.7 g/dL, white blood cell (WBC) count 11,750/µL (neutrophils 76%, lymphocytes 21%, monocytes 2%, and eosinophils 1%), and platelet count 309,000/µL. C-reactive protein (CRP) was 34.5 mg/L (reference, 0.00-5.0 mg/L). Liver function test, blood urea nitrogen and glucose were normal. Urine analysis showed no abnormalities. Gram staining with culture, acid fast bacilli (AFB) smear and polymerase chain reaction for AFB of sputum were all negative. The urine pneumococcus antigen was also negative.\nChest X-ray revealed a pneumonic infiltration at right lower lobe (RLL) and a pleura-based mass at right upper hemithorax (). Chest computed tomography (CT) scan showed a consolidation in RLL and a 3.0×1.3 cm-sized ovoid shaped pleural mass with contrast enhancement surrounding normal lung parenchyma with clear margin ().\nWe started antibiotic therapy with a third-generation cephalosporin and macrolide considering the consolidation at RLL as pneumonia. After the treatment the respiratory symptoms and the consolidation on chest X-ray gradually improved. WBC count and CRP level also normalized. However, the pleural mass remained unchanged. We then performed video-assisted thoracoscopic surgery for the lesion. Grossly, the mass consisted of oval-shaped soft tissues 3.0×2.0×1.5 cm in size. Histopathologic examination revealed dense and diffuse lymphoplasmacytic infiltration, storiform fibrosis and some eosinophilic infiltration (). Immunohistochemical staining revealed numerous IgG and IgG4 positive cells (>50 per high power field) (). With the final diagnosis of IgG4-related disease, we then examined the serum IgG4 level, which was increased to 148.0 mg/dL (reference, 6.1-121.4 mg/dL). To identify possible synchronous lesions, we performed otolaryngologic examination and abdominal CT scan and no extrathoracic lesions were evident. The patient was discharged without further treatment at hospital day 14 and has been followed-up at an outpatient clinic without evidence of recurrence.

[[66.0, 'year']]

M

{'21124093': 1, '19398440': 1, '33825979': 2, '22316447': 1, '19757521': 1, '14614606': 1, '22596100': 1, '15316319': 1, '18223321': 1, '11236777': 1, '18239323': 1, '27433179': 2, '18580683': 1, '15897744': 1, '19898222': 1, '19221056': 1, '25237380': 2, '18043395': 1, '27207156': 1, '24523817': 2}

{'4943903-1': 1, '4165665-1': 1, '8026788-1': 1}

3919965-1

noncomm/PMC003xxxxxx/PMC3919965.xml

A Case Report of IgG4-Related Disease Clinically Mimicking Pleural Mesothelioma

A 74-year-old male patient had been followed-up for 4 years after radical prostatectomy due to adenocarcinoma of prostate. He was experienced smoker with 30 pack-years and had history of medication for diabetes mellitus and hypertension, but no history of drug, allergy or autoimmune disease and occupational or environmental exposure to asbestos. On the follow-up examinations, the right pleural effusion on chest X-ray (, one year ago) and the patchy lesions of the right lung on computed tomography (, 6 months ago) were found. However, serum prostate-specific antigen level was within normal limit, and repeated cytological evaluations for pleural effusion showed no evidence of malignancy. Multiple nodules and diffuse pleural thickening in the left lower lung field were newly developed 3 months ago (). Positron emission tomography also disclosed hot uptake on these new nodules (, arrows) and no identifiable lesions on the other organs including pancreas, thyroid and salivary gland. Under the impression of mesothelioma, wedge resection was done. Microscopically, visceral pleura and alveolar interstitium were thickened with dense cellular infiltration and fibrosis (). Infiltrates were mainly composed of lymphoplasma cells without cytological atypia (). Many multinucleated giant cells of foreign-body type were noted near the degenerated elastic layer of the visceral pleura on the inflammatory and fibrotic background (). Some blood vessels showed angiocentric infiltration of lymphoplasma cells, but there was no evidence of destructive changes such as neutrophilic infiltration and fibrinoid necrosis in the vessel walls (). All special stains for acid fast bacilli, Grocott-Gomori methenamine silver, periodic acid-Schiff, and mucicarmine failed to demonstrate any organism. The results of immunohistochemical stain with IgG (1:1,000, Dako, Glostrup, Denmark) and IgG4 (1:2,000, Binding Site, Bermingham, UK) revealed increased proportion of IgG4-positive plasma cells, estimated at about 40% (). Based on the histological and immunohistochemical findings, IgG4-related disease was confirmed, and increased serum level of IgG4 (over than 201 mg/dL) were subsequently checked. The patient showed excellent response to treatment with steroid (prednisolone) and followed-up over 20 months without any evidence of recurrence.

[[74.0, 'year']]

M

{'21498344': 1, '33825979': 2, '1609154': 1, '22187229': 1, '19550328': 1, '17571078': 1, '27433179': 2, '25237380': 2, '19898222': 1, '29707337': 1, '31666048': 2, '20733352': 1, '19718789': 1, '27207156': 1, '18753944': 1, '24523818': 2}

{'4943903-1': 1, '4165665-1': 1, '6822466-1': 1, '8026788-1': 1}

3920364-1

noncomm/PMC003xxxxxx/PMC3920364.xml

Bilateral pneumothorax following a blunt trachea trauma

This is an unusual report of a 13-year old boy suffering from bilateral pneumothorax and pneumomediastinum after a trauma. The boy had not been hospitalised before the accident and did not suffer from any lung disease. While riding a bike he crashed in an unknown manner. The arriving emergency doctors found an unconscious boy with laboured breathing. The exact accident mechanism could not be reported from any pedestrians at that point of time. First, a Quincke-oedema or allergic reaction was suspected due to a severe facial swelling. Due to this assumption, glucocorticoids were injected intravenously. On the way to the hospital, the patient developed respiratory insufficiency and was intubated. In the clinic, extended physical examinations, performed in order to identify the reason for respiratory failure showed a bounce mark located below the thyroid gland as well as a severe skin emphysema. Reconstruction of the accident revealed that the origin of the bounce mark was due to a collision with a bollard.

[[13.0, 'year']]

M

{'14759406': 1, '18442616': 1, '20586564': 1, '15919275': 1, '19211582': 1, '16485190': 1, '16899839': 1, '11932162': 1, '33489509': 2, '9315814': 1, '26029515': 2}

{'7805511-1': 1}

3920414-1

noncomm/PMC003xxxxxx/PMC3920414.xml

A case report of tuberculous abscess of the chest wall accompanied with pulmonary carcinoma

A 66-year-old man with no past history of pulmonary TB or immunocompromised status presented at the National Hospital Organization Shikoku Cancer Center with a chief complaint of a painless mass in his left chest wall. Computed tomography (CT) revealed an 8-cm tumor and peripherally enhancing fluid collection in the chest wall adjacent to the seventh and eighth ribs, without osteolytic change (A). A pulmonary nodule demonstrating a mixed ground glass opacity (GGO) measuring 19 × 15 mm in segment 4 of the left lung (B) was detected incidentary. Blood tests revealed that white blood cell count was within the normal range. Levels of C-reactive protein, carcinoembryonic antigen, and cytokeratin 19 fragments in the serum were 0.82 mg/dl, 2.2 ng/ml, and 1.4 ng/ml, respectively. Results of acid-fast staining from the sputum culture and the aspiration specimen were negative. The aspirated specimen from the chest wall tumor was positive for Mycobacterium tuberculosis (polymerase chain reaction). The tumor was therefore diagnosed as TACW. Pulmonary nodule was clinically diagnosed as lung cancer T1aN0M0 stage IA. Surgery was performed at the regional TB ward of the National Hospital Organization Ehime Medical Center.\nLingulectomy and lymph node dissection (levels 10 and 11) were performed. Video-assisted procedure was performed through a 6-cm access thoracotomy over the mid-axillary line in the fourth intercostal space, 1-cm access ports in the mid-axillary line in the sixth intercostal space and posterior axillary line in the fifth intercostal space. No penetration of the parietal pleura by the abscess was evident. Slight adhesion was found in the pleural cavity but not between the lower lobe and the parietal pleura adjacent to the abscess. For the abscess, debridement without rib resection was performed. Debridement of the necrotic tissue and the abscess wall was performed through another 5-cm incision right over the abscess. Chest wall cavity and the pleural cavity were drained with silicon drains. These were removed on postoperative day 5 and postoperative day 7 respectively. The postoperative course was uneventful. Antituberculous chemotherapy consisting of isoniazid (300 mg), rifampicin (600 mg), ethambutol (750 mg), and pyrazynamide (1.5 g) per day was initiated on postoperative day 14. The patient was discharged on postoperative day 17.\nHistologically, GGO consisted of an adenocarcinoma mixed subtype (bronchioloalveolar carcinoma + papillary adenocarcinoma) without lymph node metastasis. Pathologically, the tumor was diagnosed as T1aN0M0 stage IA. Caseation necrosis surrounded by Langhans-type giant cells was seen in the specimen from the chest wall abscess, was compatible with tuberculoid granuloma. M. tuberculosis was identified in an 8-week culture of the pus from the abscess.

[[66.0, 'year']]

M

{'7424882': 1, '22708086': 1, '18154822': 1, '7065721': 1, '16572076': 1, '22241003': 1, '12089737': 1, '5440805': 1, '23272861': 1, '6427232': 1, '11752984': 1, '26029508': 2}

{}

3920440-1

noncomm/PMC003xxxxxx/PMC3920440.xml

Pneumocystis pneumonia in everolimus therapy: An indistinguishable case from drug induced interstitial lung disease

A 66-year-old Japanese male with advanced renal cell carcinoma (RCC) visited our respiratory outpatient clinic complaining of progressive exertional dyspnea for 1 month after administration of everolimus. He had suffered from unresectable RCC with multiple bone metastases for 2 years (clear cell carcinoma. cT3cN0M1. stage IV). Previous therapy included sunitinib for 1 year, followed by axitinib for 2 months. This regimen failed to prevent disease progression. Thereafter, third-line therapy with everolimus was initiated. The patient was an exsmoker and had stopped smoking 35 years back. Annual check-ups had revealed that he was asymptomatic for any breathing problems, with no abnormalities in the pulmonary function tests or chest computed tomography (CT) scans. On his first visit to our clinic, he was afebrile but presented with general malaise and tachypnea accompanied by hypoxemia (SpO2, 96% after inhaling oxygen by mask at 4 L/min). He had slight systemic edema, probably caused by renal insufficiency and/or hypoalbuminemia. Cardiac pulmonary edema was excluded by echocardiography. On chest auscultation, no wheeze or crackle was audible. Chest radiograph revealed bilateral infiltration on both lungs, while chest CT revealed diffuse ground glass opacities in both lung fields (A and B). The laboratory findings on admission are presented in . In brief, we observed mild lymphocytosis, mild anemia, thrombocytopenia, slight liver dysfunction, and renal insufficiency. Lactate dehydrogenase (LDH) and CRP were elevated at 583 IU/L and 16.7 mg/dl, respectively. The serum level of Krebs von den Lungen-6 (KL-6): a sensitive marker for interstitial pneumonia, was also elevated at 735 U/mL (normal range; <500 U/mL), excluding the possibility of atypical pneumonia. On the basis of these findings, we suspected that the patient had everolimus-induced ILD. On the first hospital day, a bronchoalveolar lavage (BAL) was performed to determine the cellular fractionation in the BAL fluid (BALF) as well as to exclude respiratory infections. BALF recovered from right B3b revealed an increased total cell number (3.10 × 105 cells/mL) with lymphocytosis (macrophages, 65.4%; lymphocytes, 29.0%; neutrophils, 4.2%; eosinophils, 1.4%). The CD4/CD8 ratio was 0.9 (normal range in nonsmokers, 0.4−1.0). BALF cultures were negative for bacteria, acid-fast bacilli, and fungi. Unfortunately, we could not perform a transbronchial lung biopsy (TBLB) because of the patient's frequent cough and oxygen desaturation during the bronchoscopic procedure.\nBecause drug allergy for everolimus was strongly suspected, we performed a drug-induced lymphocyte stimulation test (DLST) using serum and BALF. Although DLST with serum revealed a negative reaction, the test with BALF was positive with a stimulation index of 204% compared with that in the control (368 cpm for everolimus and 179 cpm for control). Taken together, these clinical findings confirmed the diagnosis of everolimus-induced ILD. Therefore, everolimus therapy was discontinued, and intravenous methylprednisolone administration (1000 mg/day for 3 consecutive days) was initiated immediately after BAL. Oral prednisolone administration (50 mg/day) was followed by steroid pulse therapy. Despite this vigorous therapy, his respiratory distress and radiographic findings rapidly exacerbated day by day (). On the fifth hospital day, the presence of PCR for Pneumocystis jirovecii DNA in BALF was established. Moreover, serum (1–3) – β−D-glucan levels were markedly increased at 137.5 pg/mL (normal range; <20 pg/mL). Cytomegalovirus (CMV) pp65 antigenemia in the serum and CMV-DNA in BALF were negative. Therefore, a diagnosis of PCP was confirmed. Intravenous trimethoprim-sulfamethoxazole administration was initiated immediately, and his respiratory symptoms improved dramatically within a week, along with dissolution of the interstitial shadow on radiographs. Unfortunately, everolimus was discontinued even after recovery from PCP owing to intolerable adverse gastrointestinal effects, including nausea and anorexia. The patient was referred to the palliative care unit and died of cancer 5 months later.

[[66.0, 'year']]

M

{'24590692': 1, '23423809': 1, '23615698': 1, '22333263': 1, '23461041': 1, '23433101': 1, '12695843': 1, '19265086': 1, '20194812': 1, '15062594': 1, '17426225': 1, '25379397': 1, '2785902': 1, '15230812': 1, '19745764': 1, '15190141': 1, '22438405': 1, '23312829': 1, '26029507': 2}

{}

3920448-1

noncomm/PMC003xxxxxx/PMC3920448.xml

Rheumatoid pleural effusion presenting as pseudochylothorax in a patient without previous diagnosis of rheumatoid arthritis

A 50-year-old man, a truck driver and current smoker, was first found to have an asymptomatic right pleural effusion on chest radiography at a medical examination in September 2011. There had been no abnormal signs at the previous year's exam. His past medical history and family history were non-contributory.\nTwo rounds of thoracocentesis were performed without definitive diagnosis (September and November 2011). The patient remained asymptomatic and was followed with no treatment, but the pleural effusion gradually increased and he was referred to our hospital in October 2012. The chest radiograph on admission confirmed a moderate right-sided pleural effusion (). Blood tests revealed slight abnormalities of C-reactive protein (CRP) level (0.4 mg/dl), erythrocyte sedimentation rate (ESR) (39 mm/h), and triglyceride and total cholesterol levels (244 mg/dl, 238 mg/dl, respectively). There was a slight pleural thickening on the CT scan with pleural phase contrast enhancement, but there was no evidence of pulmonary tuberculosis, interstitial pneumonia, or other disease in the lung field ().\nWe performed medical thoracoscopy under local anesthesia for definitive diagnosis. The pleural fluid was turbid and the pleura was slightly thickened with a scattered granular appearance. A soft yellow material was found on the visceral and parietal pleura and fibrin deposition was recognized in the thoracic cavity ().\nThe pleural fluid was confirmed as pseudochylothorax because it had high cholesterol and low triglyceride concentrations (248 mg/dL and 12 mg/dL, respectively). And low glucose (6.0 mg/dl), high lactate dehydrogenase (LDH) (2438U/l), a slight elevation in adenosine deaminase (ADA) (57.7 μg/ml), and low complement C3 and C4 levels (13 mg/dl, 2.9 mg/dl, respectively) were noted. No malignant cells were found in the cytologic examination of the pleural fluid. There were sparse macrophages and neutrophils dispersed in the granular materials and no mesothelial cells were found. Microbiologic smears and cultures of pleural fluid showed no growth. Biopsy of the parietal pleura showed infiltration with inflammatory cells including lymphocytes and plasma cells and a lack of normal mesothelial cells, which was highly suspicious for rheumatoid pleurisy, although an obvious rheumatoid nodule was not observed.\nThe slight elevation in the ADA level of the pleural fluid may have also been consistent with tuberculous pleurisy, but this was ruled out by culture and biopsy findings. Additional laboratory data showed elevated levels of rheumatoid factor (RF) (72 units/mL, normal <15) and anti-cyclic citrullinated peptide (anti-CCP) antibody (6.8 units/mL, normal <4.4).\nThe discharge diagnosis of highly suspected rheumatoid pleurisy was based on the clinical features and the results of the above-stated studies, although the high pH and absence of RF in the pleural effusion were atypical. The patient's right lung was well expanded and decortication was not necessary.\nAt about 30 days after discharge, the patient presented with polyarthralgia and we were able to confirm the diagnosis of RA according to the 2010 RA classification criteria .

[[50.0, 'year']]

M

{'14558078': 1, '4023991': 1, '19118434': 1, '10352651': 1, '11908862': 1, '27621864': 1, '5923534': 1, '19809057': 1, '1117726': 1, '5727884': 1, '7387017': 1, '20872595': 1, '18477860': 1, '26029510': 2}

{}

3921025-1

noncomm/PMC003xxxxxx/PMC3921025.xml

Donor cornea preparation in partial big bubble deep anterior lamellar keratoplasty

The patient was a 20-year-old Indian male with bilateral advanced keratoconus and previous hydrops in the right eye resulting in corneal scarring (). DALK was performed in the right eye and subsequently performed 1 year later in the left eye following intolerance of contact lens wear. Intraoperatively, an Anwar big bubble was attempted in both eyes after initial manual lamellar dissection, but only a partial central bubble was obtained in both eyes. In the right eye especially, the full-thickness corneal scar due to previous hydrops prevented full extension of the big bubble to the trephination edge. Therefore, the donor cornea was prepared with a tapered edge to facilitate graft-host apposition as described above. The postoperative recovery was uneventful (see for visual outcome). The postoperative result shows excellent graft-host apposition on anterior segment ocular computed tomography (Visante, Zeiss, Munich, Germany; and ) The graft with the tapered ends matches the recipient bed with the peripheral rim of residual corneal stroma from incomplete corneal stroma removal.

[[20.0, 'year']]

M

{'20693553': 1, '16876513': 1, '9135380': 1, '12140020': 1, '10365042': 1, '17895417': 1, '9850251': 1, '15350322': 1, '19589495': 1, '15877089': 1, '11973386': 1, '11973083': 1, '10090362': 1, '24523576': 2}

{}

3921079-1

noncomm/PMC003xxxxxx/PMC3921079.xml

Choroidal atrophy in a patient with paraneoplastic retinopathy and anti-TRPM1 antibody

A 69-year-old man visited our clinic in July 2010 with complaints of blurred vision and night blindness in both eyes. Our initial examination found that his best-corrected visual acuity in decimal units was 1.0 in the right eye and 0.6 in the left eye. His refractive error was +3.0 D and +3.5 D for the right eye and left eye, respectively. Full-field rod ERGs were absent and cone-rod mixed responses were the negative type, indicating ON bipolar cell dysfunction (). From the symptoms and ophthalmic examination, he was suspected of having PR.\nA general physical examination revealed small cell carcinoma of the lung and Western blot of the patient’s serum showed autoantibodies against TRPM1. We diagnosed this patient with melanoma-associated retinopathy and retinal ON bipolar dysfunction due to TRPM1 autoantibody and have reported his findings in more detail elsewhere. After diagnosis, chemotherapy was started using cisplatin and etoposide combined with radiation for the lung cancer in August 2010. The patient achieved a complete remission, but underwent cranial irradiation in March 2011 to prevent brain metastasis.\nWe have followed this patient ophthalmologically for more than 2 years since his initial visit and his symptoms have not changed. His best-corrected visual acuity decreased slightly to 0.8 in the right eye and 0.5 in the left eye due to progression of cataracts. His visual field has not constricted and his ERGs have not changed (see ). Rod responses were nonrecordable in 2010 and 2012. The amplitudes for a-wave of cone-rod mixed maximum response were 240 μV and 220 μV in 2010 and 2012, respectively, and those for b-wave were 150 μV and 120 μV, respectively. The amplitudes of cone response were about 25 μV for the a-wave and 50 μV for the b-wave at both times in 2010 and 2012. The amplitudes of the 30 Hz flicker ERGs were 14 μV in 2010 and 11 μV in 2012. The difference in the ERGs was most likely within the error of measurement and not due to differences in retinal function. However, fundus photographs taken in October 2012 showed diffuse choroidal hypopigmentation in both eyes (). We also found that the choroidal vessels were more visible than those obtained at the initial examination ().\nSpectral domain optical coherence tomography (Heidelberg Engineering, Heidelberg, Germany) showed a slight reduction in retinal thickness during the 2 years of follow-up, but the morphological architecture of the retina appeared almost normal at both times (). Consistent with the choroidal hypopigmentation of the fundus, spectral domain optical coherence tomography showed a marked decrease in choroidal thickness over the 2-year period (, arrowhead). Subfoveal choroidal thickness in the right eye measured manually was 250 μm in 2010, 180 μm in 2011, and 110 μm in 2012, and for the left eye was 380 μm in 2010, 230 μm in 2011, and 100 μm in 2012.

[[69.0, 'year']]

M

{'1544774': 1, '9537257': 1, '19232559': 1, '31117125': 1, '3488053': 1, '19436059': 1, '11725182': 1, '26818117': 1, '23410821': 1, '32930896': 1, '26605361': 1, '8038126': 1, '2971322': 1, '23794161': 1, '8425845': 1, '20846719': 1, '19878917': 1, '19587221': 1, '23769333': 1, '21674222': 1, '21411639': 1, '19343091': 1, '21708378': 1, '22487582': 1, '19861548': 1, '23095726': 1, '20948460': 1, '21611200': 2, '22240936': 1, '18660533': 1, '19966281': 1, '32324760': 2, '23452348': 1, '24523577': 2}

{'3096646-1': 1, '7179873-1': 1, '7179873-2': 1}

3921092-1

noncomm/PMC003xxxxxx/PMC3921092.xml

Two grams of sarcosine in schizophrenia – is it too much? A potential role of glutamate-serotonin interaction

The patient was a 23-year-old male suffering from schizophrenia for 5 years (diagnosed according to the International Classification of Diseases-Tenth Revision), who had undergone psychiatric hospitalization four times in the past, most recently 3 years earlier. The first episode involved a picture of typical paranoid syndrome and was induced by amphetamines. Subsequent psychotic episodes were not related to drug use. During a stable period, the patient presented mild severity of negative (blunted and inappropriate affect, social withdrawal) and depressive symptoms and moderate cognitive problems (memory and attention), which were the main indication for administration of sarcosine. Among positive symptomatology, the patient described only periodic mild racing thoughts without typical delusions or hallucinations. Both parents were diagnosed with schizophrenia. After receiving information about sarcosine, the patient signed an informed consent form and started receiving the amino acid. Basic laboratory tests were performed (complete blood count, electrolytes, liver and renal parameters, lipids, prolactin, and thyroid stimulating hormone), which showed no deviations from reference values. The patient had no neurological, endocrine, or other chronic comorbidities at the time of treatment. We excluded ongoing alcohol and drug dependence or use in the previous 6 months (using a panel drug testing), but the patient smoked about 15 cigarettes per day. He was unemployed at that time and on a disability living allowance. Before addition of sarcosine, the patient has been receiving quetiapine 500 mg per day for 2 years and citalopram 10 mg per day for several months. Citalopram was prescribed due to panic attacks and negative symptoms.\nDuring the first 2 weeks of sarcosine administration at 2 g per day, the patient reported improvement in overall activity, concentration, and mood. After a further 2 weeks, he reported moderate inner tension with mildly increased drive, excessive activity and irritability, and a significant increase in sexual tension. Further examination ruled out a diagnosis of hypomania. The patient found these symptoms to be very unpleasant and asked for modification of his treatment. The overall impact of sarcosine he described as positive, and therefore it was decided to maintain the sarcosine supplementation but to reduce the dose by half to 1 g per day. After lowering the dose of sarcosine without changes in the dosage of his concomitant medications, the intensity of his excitation and irritability decreased, and the patient subjectively described his overall mental state as better in comparison with the period before sarcosine and treatment with 2 g of the amino acid (see ). There were no external circumstances to explain the observed intensity of psychomotor agitation symptoms.

[[23.0, 'year']]

M

{'16780811': 1, '19887019': 1, '23027421': 1, '23562005': 1, '10628529': 1, '23455590': 1, '21936588': 1, '34658976': 1, '18348597': 1, '24946468': 1, '8932891': 1, '16275807': 1, '11281957': 1, '25784808': 2, '28245819': 1, '22297716': 1, '10719161': 1, '18164691': 1, '21586917': 1, '20807960': 1, '11870017': 1, '20679587': 1, '31960362': 1, '23179966': 1, '18540918': 1, '21536064': 1, '15023571': 1, '17504103': 1, '22138164': 1, '19909229': 1, '17545748': 1, '16625590': 1, '22387855': 1, '17659263': 1, '34977503': 1, '9384954': 1, '22860161': 1, '24523591': 2}

{'4356443-1': 1}

3921274-1

noncomm/PMC003xxxxxx/PMC3921274.xml

Internal Carotid Artery Reconstruction Using Multiple Fenestrated Clips for Complete Occlusion of Large Paraclinoid Aneurysms

A 27-year-old female presented with sudden loss of vision on the left side. Her vision had gradually deteriorated for the past two months. On neuro-ophthalmologic examination, visual acuity measured as 0.1 on the right eye by Snellen's chart, but there was total blindness on the left. There were no defects in visual fields and no limitations in extraocular movement. An aneurysm was measured just over 60 mm in diameter in its greatest dimension (). Preoperative routine BTO was performed during preoperative DSA. Exposure of cervical ICA, intradural and extradural clinoidectomy with resection of DDR was performed routinely via OZA. The non-thrombosed giant aneurysm was directly clipped and the entire length of the supraclinoid ICA was reconstructed with eight different types of fenestrated aneurysm clips. The distal flow through the anterior cerebral artery and middle cerebral artery was nicely preserved (). Postoperatively, the patient experienced right transient hemiparesis two days after surgery. However, it resolved two days later with hypervolemic and hypertensive therapy. Postoperatively, her right eye vision had not changed, but her left eye vision improved to a level that she could perceive hand movement 30 cm in front of her.

[[27.0, 'year']]

F

{'3989589': 1, '15876985': 1, '8186963': 1, '15912157': 1, '16955039': 1, '10719864': 1, '21135716': 1, '11152364': 1, '12943569': 1, '21126877': 1, '12924695': 1, '11136984': 1, '20860951': 1, '19240558': 1, '22898891': 1, '11565882': 1, '16060237': 1, '654969': 1, '18091231': 1, '23087381': 1, '2913220': 1, '8151343': 1, '12234448': 1, '17041495': 1, '21082045': 1, '19760439': 1, '17038952': 1, '12823885': 1, '15361819': 1, '22361473': 1, '10321876': 1, '19240577': 1, '15926728': 1, '6835497': 1, '3404229': 1, '18518728': 1, '12699558': 1, '1111150': 1, '24527189': 2}

{'3921274-2': 2}

3921274-2

noncomm/PMC003xxxxxx/PMC3921274.xml

Internal Carotid Artery Reconstruction Using Multiple Fenestrated Clips for Complete Occlusion of Large Paraclinoid Aneurysms

A 57-year-old woman presented with a one month history of blurred vision in her left eye. She had a 14-year history of hypertension for which she had been prescribed antihypertensive medication. On neuro-ophthalmologic examination, visual acuity measured as 0.9 on both sides by Snellen's chart, and no defects in visual fields or extraocular movements were noted. An unruptured left carotid cave aneurysm measuring 12×10 mm was found (). Prior to planning surgical clipping, collateral circulation tolerance was confirmed with BTO during the preoperative DSA. The cervical ICA was exposed for proximal control and OZA with anterior clinoidectomy, and resection of the DDR was performed as part of a routine procedure to expose the proximal neck of the aneurysm. The intraoperative MEP and VEP were also monitored. During the tandem clipping and reconstruction of the aneurysm, an intraoperative rupture occurred. Ten minutes after proximal temporary occlusion of the cervical ICA, the amplitude of the MEP had completely dissipated. However, ten more minutes of proximal cervical ICA temporary occlusion was needed for complete occlusion of the broad aneurysm neck. Four differently shaped fenestrated and two standard clips were used to reconstruct the ICA with preservation of the ophthalmic and posterior communicating arteries (). After re-opening the proximal cervical ICA temporary occlusion, the MEP amplitude had recovered to one-third of normal at the end of surgery. The patient displayed right hemiparesis (grade III) immediately after the operation, but her motor weakness gradually recovered and normalized within six hours after surgery. No other complications were noted in her last follow-up visit.

[[57.0, 'year']]

F

{'3989589': 1, '15876985': 1, '8186963': 1, '15912157': 1, '16955039': 1, '10719864': 1, '21135716': 1, '11152364': 1, '12943569': 1, '21126877': 1, '12924695': 1, '11136984': 1, '20860951': 1, '19240558': 1, '22898891': 1, '11565882': 1, '16060237': 1, '654969': 1, '18091231': 1, '23087381': 1, '2913220': 1, '8151343': 1, '12234448': 1, '17041495': 1, '21082045': 1, '19760439': 1, '17038952': 1, '12823885': 1, '15361819': 1, '22361473': 1, '10321876': 1, '19240577': 1, '15926728': 1, '6835497': 1, '3404229': 1, '18518728': 1, '12699558': 1, '1111150': 1, '24527189': 2}

{'3921274-1': 2}

3921280-1

noncomm/PMC003xxxxxx/PMC3921280.xml

Revascularization for Symptomatic Occlusion of the Anterior Cerebral Artery Using Superficial Temporal Artery

A 69-year-old man, with hypertension and past history as heavy smoker and chronic alcoholic for 40 years, presented with several episodes of transient weakness involving left lower extremity that lasted for 6 months. Each episode occurred once a week, and lasted approximately for 10-20 seconds. The initial magnetic resonance imaging (MRI) from another hospital revealed multifocal stenosis of cerebral artery including left proximal internal carotid artery (ICA), right proximal external carotid artery (ECA), right middle cerebral artery (MCA) at the M1 segment, and occlusion of right ACA at the A2 segment without any evidence of cerebral infarct in the diffusion weighted imaging. Despite the medical treatment with warfarin for one month, there was an increase in the frequency of transient ischemic attack (TIA) in the left leg. Follow-up MRI revealed acute focal infarct in the right frontal periventricular white matter corresponding to the territory of right ACA (). The rate of occurrence of TIA was once or twice a day despite combined medical treatment with warfarin and aspirin.\nThe patient visited our hospital one month after the first experience of infarct. On presentation, no apparent neurological deficit was found. Cardiac evaluation did not reveal any remarkable findings. Cerebral angiography revealed multifocal atherosclerotic luminal irregularity in both the ICA, especially moderate stenosis of the right supraclinoid ICA segment. Right ACA was occluded at the A2 segment, but collateral flow from right MCA and posterior cerebral artery (PCA) was minimal (). Basal and acetazolamide-stressed brain perfusion single photon emission computerized tomography (SPECT) with 99mTc-hexamethylpropyleneamin oxime was performed to evaluate the patient's hemodynamic status. Brain SPECT showed decreased perfusion and decreased vascular reserve in the right frontal lobe ().\nOral anticoagulant and antiplatelet agent were discontinued 1 week prior to surgery. After 2 months from experience of cerebral infarct, revascularization surgery was performed. After confirmation of sufficient length and integrity of parietal branch of the STA in preoperative ECA angiography, we planned end-to-side anastomosis between ipsilateral STA and distal ACA. Under general anesthesia, curvelinear skin incision was made along the parietal branch of the superficial temporal artery (STA), and then extended to the contralateral frontal just behind the hairline. The parietal branch of the STA were saved and prepared for anastomosis to the distal ACA. The frontal branch of the STA with galeal flap was saved as well during the preparation in case of adverse events, such as graft failure (). The length of parietal branch of the STA was 11 cm from the bifurcation of the STA. After right paramedian craniotomy and opening of the dura, the cortical branches of the right ACA were observed. We chose one of the cortical branches as a recipient artery, in which no flow was detected on the intraoperative Doppler. After confirmation of sufficient length and good pulsation of the parietal branch of the STA, end-to-side anastomosis between STA and ACA was performed (). Anterograde flow from the STA and flow diversion to the recipient artery was confirmed on the intraoperative Doppler.\nThe TIA of the left leg disappeared immediately after surgery. Oral antiplatelet agent (aspirin) was resumed on the first postoperative day with a dose of 100 mg/day. The patient was discharged with no apparent neurological deficit. Six months after the operation, follow-up cerebral angiography showed obvious flow through right STA to the territory of the right ACA and decreased leptomeningeal collateral flow from right PCA (). Brain SPECT revealed improved perfusion and vascular reserve when compared with preoperative imaging (). The patient received follow-up care for 30 months after surgery without occurrence of any remarkable events.

[[69.0, 'year']]

M

{'6171745': 1, '12453077': 1, '19589132': 1, '3393069': 1, '6827332': 1, '19955742': 1, '6659000': 1, '30397592': 2, '9242243': 1, '3973733': 1, '24527195': 2}

{'6199401-1': 1}

3921281-1

noncomm/PMC003xxxxxx/PMC3921281.xml

Spinal Subdural Hematoma Following Cranial Subdural Hematoma : A Case Report with a Literature Review

A 47-year-old female patient was referred to our hospital due to sudden onset of headache (visual analog scale; VAS 8) and backaches (VAS 6) following a slip and fall two weeks prior to admission, resulting in periorbital swelling, bruising and a headache. The pain was aggravated by standing and walking and partially relieved by sitting. The patient showed no sensory and motor deficits in lower limbs and there were neither bladder nor bowel dysfunction. She was alert and well oriented, and her spine was aligned normally in the coronal plane with mild loss of lumbar lordosis. Lumbar spine movements in the sagittal plane were restricted by pain. Upon straight leg-raise testing, the patient's leg was able to be raised 60° while lying down, with no neurological deficits noted in the limbs. The cervical spine was normal. There was no evidence of cranial nerve palsy or lateralizing neurological deficits. She had no previous history of anticoagulant therapy and hematological coagulopathy. Her coagulation profiles including platelet count, prothrombin time, and activated partial thromboplastin time were all within the normal ranges. Cranial imaging studies revealed a small amount of acute SDH along the tentorium (). Magnetic resonance imaging of the patient's lumbosacral spine revealed spinal SDH at the anterior portion of the caudal thecal sac at the levels of L5-S2 with marked neural compression (). No definite contrast enhancement at the lesion site was observed. The remaining intracranial structures and cervicothoracic spine were normal. Based on radiologic findings, traumatic intracranial SDH at the tentorium with subsequent spinal SDH was diagnosed. Seven-day course of conservative management was uneventful, and the patient experienced no neurological deficits, without notable event. Her complaints of headache and back pain were nearly resolved, and the patient returned to normal daily activities. At one-year follow-up, the patient was free of leg pain, but complained of a sustained mild headache. Follow-up imaging studies showed no definite abnormalities in the cranium or spine.

[[47.0, 'year']]

F

{'10090608': 1, '15070147': 1, '9322857': 1, '16377954': 1, '12886137': 1, '18301828': 1, '10199259': 1, '8837111': 1, '10419371': 1, '12765819': 1, '8421539': 1, '24891866': 2, '27169053': 2, '20505298': 1, '16540860': 1, '8614052': 1, '3421458': 1, '24527196': 2}

{'4040635-1': 1, '4852623-1': 1}

3921282-1

noncomm/PMC003xxxxxx/PMC3921282.xml

Pure Intramuscular Osteolipoma

A 51-year-old female presented with a 5-year history of a painless, progressively enlarging mass on the posterior neck. She reported neck stiffness without associated neurological symptoms. Physical examination revealed a soft, non-tender, uniform mass without surface abnormalities. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a circumscribed mass involving the posterior neck muscles in the midline between the C2 and C6 spinous processes with a large calcified component (). The ovoid mass was measured 4 cm in width, 6 cm in length, and 3 cm in height, without infiltration of the cervical spine. Subsequently, the patient underwent a whole body bone scan, which revealed an amorphous calcification of the posterior neck without metastasis ().\nWe performed tumor resection under general anaesthesia. The mass had a well-demarcated margin and the outer wall was very firm without adhesion to ligaments or paravertebral muscles. Gross examination revealed a well-circumscribed mass composed of adipose and bony tissue, with red bone marrow visible on the cut surface (). Histological study showed a lipomatous lesion with large foci of osseous metaplasia at the periphery of the mass; the bony portion was surrounded by mature adipose tissue (). Microscopic examination of the red bone marrow showed a meshwork of bone trabeculae and hematopoietic marrow elements ().\nThe patient was diagnosed with an intramuscular osteolipoma of the posterior neck and no recurrence was observed at the 6-month follow-up.

[[51.0, 'year']]

F

{'20224717': 1, '22052147': 1, '21822651': 1, '20192646': 1, '21654449': 1, '14975977': 1, '25656666': 1, '18628326': 1, '18952409': 1, '17416808': 1, '25901244': 2, '26713137': 1, '21247817': 1, '19767701': 1, '14433447': 1, '28018060': 1, '11147847': 1, '16098751': 1, '19008584': 1, '21860148': 1, '32092692': 2, '30425872': 2, '19918398': 2, '31640774': 1, '24527197': 2}

{'6217886-1': 1, '2769468-1': 1, '4404547-1': 1, '7036695-1': 1}

3921283-1

noncomm/PMC003xxxxxx/PMC3921283.xml

Multiple Spinal Cord Recurrences of an Intracranial Ependymoma after 14 Years

33-year-old male visited with the complaint of sudden dysuria, difficulty in defecation, and progressive paraparesis. He also had a thoraco-lumbar back pain for two months. Bilateral weakness in the leg muscles (grade 4) and hypesthesia/numbness below T12 dermatome were found in the neurological examinations. Micturition was not possible. There were no specific abnormalities in the cranial nerves and upper extremities.\nFourteen years prior, the patient was diagnosed with a fourth ventricle low grade ependymoma. A gross total resection of the tumor with a ventriculoperitoneal shunt procedure was performed. Postoperative radiation therapy was also performed delivering 45 Gy to the posterior fossa and 10 Gy boost to the tumor bed. At initial surgery, the evaluation for spinal metastasis was not considered and prophylactic spinal irradiation was not performed because the intracranial ependymoma was low grade. Follow up was continued for three years, without any sign of tumor recurrences. All the previous medical records were meticulously reviewed.\nThe thoracolumbar MR image taken at a different hospital demonstrated an intradural-extramedullary mass involving T12 and L1 (). The tumor was 5.7 cm in size, dorsal in location, and was compressing the spinal cord. Emergency operation with a routine laminectomy of T12-L1 was performed. A gray-red intradural extramedullary mass was noted and was easily separated from the spinal arachnoid and completely removed without complication. Weakness and voiding difficulties experienced by the patient improved immediately after surgery.\nThe histologic findings of the lesion were consistent with an ependymal tumor with a high Ki-67 mitotic index (up to 60%), moderate nuclear pleomorphism, and tumor necrosis. Based upon the histology, a diagnosis of World Health Organization (WHO) grade III anaplastic ependymoma was made (). A postoperative whole spine MR study revealed multiple small enhancing lesions from C6 to L5 (). A brain MR showed no evidence of residual tumor or tumor recurrence (). No other ventriculoperitoneal shunt pathway-related metastases were found.\nThe patient received a radiation therapy to the whole spine of 36 Gy in 1.5 Gy fractions and with an additional boost of 9 Gy in 1.8 Gy fractions to the thoraco-lumbar tumor site using a 6 MV photon. During radiation therapy, RTOG/EORTC grade 2 hematologic toxicity was observed and resolved without specific treatment. Chemotherapy was reserved for disease progression. The patient's neurologic and clinical status improved and remained stable. Follow up images showed disappearance or a decrease in size of the spinal residual mass after radiation therapy and there was no evidence of tumor progression for three years ().

[[33.0, 'year']]

M

{'6886786': 1, '1876243': 1, '19629395': 1, '11147894': 1, '9474274': 1, '9531369': 1, '8814165': 1, '11763427': 1, '21107192': 1, '16462515': 1, '9210062': 1, '1831193': 1, '2013772': 1, '11817702': 1, '21142463': 1, '21142461': 1, '17882342': 1, '20484442': 1, '24527198': 2}

{}

3921284-1

noncomm/PMC003xxxxxx/PMC3921284.xml

Migration and Coiling of Peritoneal Catheter into the Subgaleal Space: A Very Rare Complication of Subgaleoperitoneal Shunt

A 32-year-old male patient underwent a craniectomy and duraplasty with artificial dura due to an infected compound depressed skull fracture at another hospital. Eighteen months later, the patient underwent cranioplasty using methylmetacrylate for the skull defect which crossed the sagittal suture line. After the cranioplasty, the scalp progressively grew due to leakage of the cerebrospinal fluid (CSF) into the subgaleal space (). Conservative treatments such as direct aspiration of the CSF followed by compression with elastic bandage and continuous lumbar drainage were not effective. The patient underwent SP shunting for persistent cranial pseudomeningocele. Two short catheters were placed into the subgaleal space and connected to a distal catheter using a Y-shaped rigid connector without any valve systems (). The cranial shunt catheter was anchored at the level of the connector. Following the SP shunt, the pseudomeningocele were relieved. Six months later, the patient again presented with scalp swelling and headaches. Simple X-ray of the skull revealed a migrated and coiled shunt catheter under the scalp (). The peritoneal catheter was seen by an abdominal radiography. The patient was treated by removing the entire shunt catheter and the dura was covered with a subgaleal flap to prevent CSF leak. After the operation, the subgaleal CSF collection disappeared () and the patient is currently doing well without further complications.

[[32.0, 'year']]

M

{'21808520': 1, '23466843': 1, '23248689': 2, '28553395': 2, '22648078': 1, '7444744': 1, '12235495': 1, '7671271': 1, '15164137': 1, '6211525': 1, '4710656': 1, '34667670': 1, '10398996': 1, '24527199': 2}

{'5437804-1': 1, '3519067-1': 1}

3921285-1

noncomm/PMC003xxxxxx/PMC3921285.xml

Successful Treatment of Infantile Fibrosarcoma Spinal Metastasis by Chemotherapy and Stereotactic Hypofractionated Radiotherapy

A previously healthy 8-month-old boy presented with a 3×3 cm mass in the right lower leg, which was surgically excised. Pathological analysis confirmed the diagnosis of infantile fibrosarcoma and the surgical margin was not clear. His parents refused reexcision but accepted monitoring by regular imaging. However, a mass was detected again in the same area two years after surgery. Therefore, the patient then underwent complete excision, and recurrent sarcoma was confirmed histologically. After the second resection, the patient had monthly follow-up and no evidence of disease was observed on an ongoing one year.\nA surveillance whole-body fludeoxyglucose positron emission tomography scan conducted 3 years after the initial presentation demonstrated a recurrent mass in the right lower leg, one micrometastatic lesions at the left proximal fibula and another macrometastasis in the 4th lumbar vertebral column, respectively. Lumbar spine magnetic resonance imaging (MRI) revealed a contrast-enhancing lesion of 1.6 cm in the posterior aspect of the 4th lumbar vertebral column without spinal canal compression (). To preserve right lower leg, debulking surgery of the recurrent lesion was performed, and the histological features were found to be consistent with recurrent sarcoma with rhabomyosarcomatous differentiation. Two weeks after the surgery, the patient started to receive chemotherapy with a VAC regimen composed of vincristine (1.5 mg/m2), dactinomycin (0.045 mg/kg), and cyclophosphamide (2.2 g/m2) for a total of 44 weeks treatment course.\nGiven the potential risk of spinal pathologic fracture and myelopathy, radiotherapy was chosen to treat the 4th lumbar vertebral metastatic lesion. Cyberknife® hypofractionated radiotherapy was decided due to the solitary nature of the metastasis and fewer sessions are needed, which would decrease the frequency of general anesthesia for radiotherapy. The patient was immobilized in a vacuum mattress. Fused enhanced computed tomography (CT) (Accuray) and MRI scans were used in the treatment planning. The delineation of the gross tumor volume (GTV) and the organs at risk was carried out on the planning CT. Given the potential risk of kyphosis and scoliosis by asymmetric irradiation of the spine, the whole involved vertebra was contoured as the GTV. Clinical target volume was equal to the GTV and no margin was added to obtain the planning target volume (PTV), which was 8.84 mL. No fiducial or other markers were implanted to localize the irradiated area. A total of 26 Gy was prescribed to the 75% isodose line, covering 92.64% of the PTV with a maximal spinal cord dose of 744.26 cGy (). Cyberknife® stereotactic body radiotherapy was performed on the 15th, 16th, 19th, and 20th of October 2009 with a mean procedure time of 83 min (range 56 min to 128 min). The radiotherapy course was conducted in a manner concomitant with the first cycle of chemotherapy. During the radiotherapy, immobilization was aided by general anesthesia, and X-sight spine tracking (Accuray Inc.) was used to minimize setup error.\nThe patient tolerated the anesthesia and immobilization well and remained still during the radiotherapy. Up to the date of this report, i.e., 33 months after radiotherapy, the patient remains neurologically stable and 23% reduction in tumor volume was achieved on the surveillance MRI scans (). No acute radiation toxicity was found.

[[8.0, 'month']]

M

{'27602180': 1, '19917847': 1, '29176539': 1, '15558704': 1, '21853519': 1, '20588196': 1, '15458600': 1, '22312536': 1, '8420891': 1, '22812410': 1, '1148990': 1, '20062569': 1, '19165076': 1, '9194784': 1, '17224814': 1, '19386434': 1, '9614899': 1, '21319143': 1, '24527200': 2}

{}

3921286-1

noncomm/PMC003xxxxxx/PMC3921286.xml

Charcot Spine Treated Using a Single Staged Posterolateral Costotransversectomy Approach in a Patient with Traumatic Spinal Cord Injury

The patient was a 57-year-old man with a 26 year history of complete T8 paraplegia. He suffered a T7, 8 burst fracture in a motor vehicle accident. At that time, he was treated at another institution. In 2010, 26 years after the injury, the patient presented to our institution because of a crunching noise inside his back when transferring from the wheelchair to the bed. He was unable to maintain the sitting posture.\nPhysical examination showed a kyphotic deformity of the thoracolumbar junction. He had flaccid, areflexic lower extremities. He had no significant contractures at the hips and knees. Laboratory analysis revealed no signs of infectious spondylitis or urinary tract infection.\nOn thoracolumbar spine radiographs, there was old fracture of T7, 8 by trauma, and deformity at the T11, 12 segments : right ward translation of T11 with respect to the distal segments; marked destruction of the T11, 12 vertebral body; productive bony changes including sclerosis and bulky osteophytes; and destruction of the posterior elements ().\nCT scan confirmed the radiographic findings of an extensive destructive. Additionally, CT revealed a large complex paraspinal soft tissue process with areas of fluid attenuation, ossifications, and peripheral bony debris extending as far as the posterior paraspinal soft tissues ().\nMRI further demonstrated the complexity of the vertebral destruction and paraspinal mass with associated fluid collections. The mass was intermediate signal intensity on T1 weighted images, complex with mildly hyperintense areas on T2 weighted images, and demonstrated peripheral enhancement ().\nIn view of this radiological evidence, the possibility of a chronic infection or a cancerous process was nevertheless envisaged and prompted us to perform a surgical exploration and biopsy for ruling out these differential diagnoses. Cultures of liquid samples were negative. Histological examination revealed the presence of fibrous tissue with sequestered bone but no signs of malignancy (). The findings were typical of Charcot spine. Therefore, the authors could make a diagnosis Charcot spine.\nOne week after a surgical exploration and biopsy, the authors performed a circumferential arthrodesis via a single staged posterolateral costotransversectomy approach for correction T11, 12 severe deformities. The thoracolumbar spine was exposed and pedicle screws were inserted into T8-T10 and L1-L3. Because of gross instability and collapse across the Charcot segment, a unilateral rod was used for temporary stability and distraction. Laminectomy was performed at T10 and L1 to gain access to the normal epidural space above and below. Next, the scar and hypertrophic reactive tissue around the left T11, 12 roots and the residual T11, 12 posterior elements was removed. The left T11, 12 roots were then ligated and divided to give access to the lateral and anterior aspects of the destroyed vertebral bodies (). Bony resection of the residual T11, 12 bodies and adjacent disc was then carried out, taking care to keep within the confines of the anterior pseudocapsule of the Charcot joint. The end plates of T10 and L1 were then prepared. A mesh case with auto-iliac bone graft, placed within the concavity of the endplates. The lateral posterior elements of T10 (inferior facet) and L1 (superior facet) were decorticated and packed with morselized local bone and allograft. The patient tolerated the surgical procedure well, there were no intraoperative complications, and estimated blood loss was 500 mL. After surgery, the patient was mobilized as tolerated without brace. A prophylactic antibiotic was used for 48 hours after surgery. There were no postoperative complications.\nTwo year after surgery, the patient returned to independent life including driving to work. And the fusion appeared solid without evidence of hardware loosening or change in spinal alignment on the plain radiographs (). However, the follow-up CT imagies revealed inadequate preparation of T10 lower and L1 upper end plate, and incorrect placement of a mesh cage. A floating mesh cage (not placed within the concavity of the endplates) generally cannot guarant solid fusion. We thought that causes of inadequate endplate preparation were limited visualization of posterior approach and vague boundary between bone and disc by the scar and hypertrophic reactive tissue around the Charcot segment. Instead of getting fusion between T10 and L1, we luckily got solid fusion between the residual T11, 12 bodies by a mesh cage with auto-iliac bone graft ().

[[57.0, 'year']]

M

{'16688025': 1, '15928542': 1, '18976172': 1, '20338837': 1, '30014254': 1, '22938550': 1, '9041906': 1, '20494808': 1, '7939982': 1, '2326701': 1, '1997897': 1, '17554573': 1, '28053724': 1, '29755231': 1, '33414850': 1, '20505559': 1, '32600397': 2, '25212444': 1, '8222448': 1, '3128083': 1, '1802163': 1, '10715032': 1, '15672097': 1, '17863764': 1, '24527201': 2}

{'7325221-1': 1}

3921287-1

noncomm/PMC003xxxxxx/PMC3921287.xml

Charcot Arthropathy of the Lumbosacral Spine Mimicking a Vertebral Tumor after Spinal Cord Injury

A 38-year-old man was admitted to our department with a one-month history of back pain radiating from the right flank and abdomen that had recently worsened. He had developed quadriplegia after spinal cord injury at C5-6 (). For last twenty years previously, he had been in bed ridden state. He had also experienced intermittent back pain for 10 years. The patient presented at our institute to check a lumbosacral osteolytic mass found by computed tomography (CT) at another institute during an investigation of growing back pain. Clinical examination showed a complete, flaccid, and areflexic paralysis of both lower limbs, with no sensation below T2. The patient had limitations of motion with no significant contractures at the right hip, and no palpable masses, fluid collections, or appreciable lymphadenopathy. Laboratory analysis revealed no signs of a spinal infection.\nPlain radiography revealed erosion and destruction of L5 and the sacral vertebral body and the presence of paravertebral hypertrophic ossification with a pseudotumoral appearance around the L5-S1 joint (). A three dimensional CT scan highlighted the severity of the intervertebral dislocation in the lying position (), and magnetic resonance imaging (MRI) showed peripheral and paravertebral gadolinium uptake by the osteolytic lesion at L5 and S1 vertebrae ().\nIn view of these radiological features, the possibility of a chronic infection or a cancerous process was envisaged, and this prompted us to perform a vertebral needle biopsy. Cultures of central/disc liquid samples were negative, and histological findings revealed extensive fibrotic change but no evidence of an infective or neoplastic process. Based on clinical history, laboratory finding, and histologic features the lesion was consistent with CSA.\nIn terms of therapeutic options, the extensive spinal ankylosis and widespread para-osteoarthropathy around hips meant that stabilization surgery would probably have resulted in a poor functional outcome. Moreover, the patient refused a surgery because of the absence of malignancy. An external support with a body jacket molded for sitting was also suggested but the patient refused. Hence, we were only able to implement regular clinical and radiological monitoring. During follow-up no specific changes were observed after discharge.

[[38.0, 'year']]

M

{'16688025': 1, '32600397': 2, '19504271': 1, '34755208': 1, '20338837': 1, '22361621': 1, '17285059': 1, '28053724': 1, '20505559': 1, '29755231': 1, '24527202': 2}

{'7325221-1': 1}

3921288-1

noncomm/PMC003xxxxxx/PMC3921288.xml

Glomus Tumor in the Femoral Nerve

A 56-year-old man presented with severe lancinating pain at left anterior thigh for nine years, one year after accidentally bumping his left thigh to a tree. The pain worsened over time and he eventually limped for five years. He initially visited the other medical center where he was diagnosed with a mass lesion in the left thigh. Surgical exploration was performed, which was unsuccessful, and the pain persisted. The effect of direct lidocaine injection was temporary and unsatisfactory. He was referred to the neurosurgery department for evaluation and surgical management.\nOn physical examination, severe direct tenderness in the left anterior thigh was observed. His left thigh was rather atrophic compared to the right side. The range of motion in the extremities was full, but pain was provoked by physical irritation or by knee extension. The pain graded by the Visual Analog Scale was 10. Motor weakness or radiating pain in the leg was not distinct. Electromyography (EMG) and nerve conduction velocity were consistent with left femoral neuropathy of moderate degree and chronic partial axonotmesis state. The defect was most severe at the branch leading to the vastus lateralis.\nThe magnetic resonance images showed a well-defined, enhancing mass of 2.5 cm in diameter at left mid-thigh level, in between the rectus femoris, vastus laterlis, and vastus intermedius muscles (). The mass was formed along a muscular branch of the femoral nerve, and thus resembled a neurogenic tumor of femoral nerve branch, such as schwannoma. The initial differential diagnoses before operation were schwannoma or post-traumatic painful neuroma.\nThe patient underwent surgical exploration and gross total resection was done under spinal anesthesia. Intraoperative ultrasonography was used to localize the mass (). The tan, pinkish white tumor was oval in shape with moderate vascularity, and well demarcated with the nerve tissue ().\nThe pathological findings were compatible with benign glomus tumor. The tumor cells were basophilic, round and fairly uniformed. They had rich cytoplasm and centrally placed nuclei. The cellular borders were sharply defined and angulated, and dilated vessels were surrounded by the tumor cells. The immunohistochemical staining showed positive for smooth muscle antigen (SMA) and negative for S-100 protein, and the Ki-67 proliferative index was less than 1.0% ().\nPostoperatively, the patient's symptom improved dramatically. The sharp pain was completely resolved and new neurological deficit was not observed. No evidence of recurrence or pain was noted at 24 months after resection.

[[56.0, 'year']]

M

{'16148414': 1, '11145243': 1, '31624656': 1, '8600806': 1, '11355180': 1, '18788860': 1, '14080348': 1, '1321179': 1, '28303299': 1, '20856673': 1, '2153724': 1, '14007480': 1, '1721776': 1, '11105311': 1, '17041200': 1, '18240933': 1, '24527203': 2}

{}

3921297-1

noncomm/PMC003xxxxxx/PMC3921297.xml

Nutritional Intervention for a Patient with Diabetic Nephropathy

The patient was a 52-year-old woman who was diagnosed with type 2 diabetes mellitus approximately 6 years ago. The patient had been taking oral hypoglycemic agents (Glimepiride) and insulin (Glargine 18-20 IU before breakfast and 4 IU before bed) to control blood glucose level. The patient's 2 hrs postprandial blood level was normally maintained between 280-300 mg/dL, however, the level increased to 300-400 mg/dL, in recent 2-3 weeks and the patient was hospitalized to control high glucose level. In addition to that, the patient had been receiving medical treatment for hypertension and dyslipidemia, and regular blood tests and urine tests were performed to monitor significant changes. The patient had been diagnosed with renal failure and proteinuria one year ago, and at the time of this hospitalization, the patient was diagnosed with stage 4 chronic kidney disease, and was consulted for nutrition education of diabetic nephropathy.\nThe patient's height and weight were 158 cm and 81.4 kg, respectively, percent of ideal body weight was 155.5%, indicating she was severely obese. Biochemical values of the patient are shown in .\nThe patient preferred a salty soup and stew, and the actual amount of intake exceeded the recommendation. When eating out once a week, the patient often ate a hamburger or a noodle meal. The patient's diet history was analyzed by the 24-hr recall method using Can Pro 3.0 software (The Korean Nutrition Society, Seoul, South Korea) (). The patient consumed approximately 1,840 kcal/d with a protein intake of 67.5 g, and the energy ratio from carbohydrate, protein, and fat was 61.7%: 14.4%: 23.9%, respectively. The patient did not take any nutritional supplements, and did not drink alcohol, or smoke. The patient's physical activity was rated to mild level of a homemaker; she participated in weight training or bowling for 2 hrs (3 times a week). The patient had never received nutrition education.\nThe patient was prescribed the nutritional regimen as follows.\n- Energy: 1,600 kcal (30 kcal/kg x 52.4 kg ideal body weight [IBW]) - Protein: 40 g/d (0.8 g/kg × 52.4 kg [IBW]) - Sodium: 2,000 mg/d - Potassium: 2,000 mg/d\nThis patient revealed problematic dietary habits including excessive carbohydrate intake, excessive protein intake, and excessive potassium intake (). After analysing etiology, lack of knowledge and absence of education experience were selected as main causes. Therefore nutrition education for diabetic nephropathy was conducted.\nThe nutritional problems of "excessive carbohydrate intake" and "excessive protein intake" were managed by establishing adequate nutrition through a diet comprising 1,600 kcal of energy, and below 60 percent of energy from carbohydrate and 40 g of protein per day. Food models and a food exchange list were configured to provide nutritional training for the proper dietary intake. Compliance issues were also discussed during the education period.\nThe association of carbohydrate intake and blood glucose control was discussed in relation to the nutritional problem of "excessive carbohydrate intake". Also, recommended amount of rice intake was 2/3-3/4 bowls (2.3 exchanges), which is reduced from one bowl (3 exchanges) a meal. Usually, it was necessary to take a proper amount of fat for preventing malnutrition and lack of caloric intake arise when protein and carbohydrates were restricted. However the patient had dyslipidemia and limited intake of animal fat was recommended. In addition, the patient was provided with information on the importance of eating the low-salt diet and tips for how to eat the low-salt diet easily. The tips for how to eat the low-salt diet are as follows. 1) Apply of spicy and sour flavor seasoning like pepper or vinegar, instead of salt or fermented soybean paste. 2) Limit the intake of high-salt-containing foods, such as kimchi, and other salted and pickled foods, 3) Consume side dishes during meals without the addition of salt, 4) Grilled food rather than boiled was recommended and use the food's own flavor effectively when cooking, 5) When salting, focus on one kind of food.\nThe patient was instructed to limit their intake of high potassium-containing foods (grains, potatoes, sweet potatoes, corn, soybean, green vegetables, nuts, tomatoes, kiwi, banana, melon etc.). To reduce potassium intake, the intake of raw vegetables was recommended. It was also recommended to remove the shell before cooking, to use leaves rather than stem and to boil vegetables in water 4-5 times of their volumes.\nThe results of nutrition education after 3 months are shown in -. The patient's diet history during last 3 months was analyzed by the 24-hr recall method using Can Pro 3.0 software (The Korean Nutrition Society, Seoul, South Korea). The patient consumed approximately 1,300 kcal/d with a protein intake of 37.6 g, and the energy supply from carbohydrate, protein, and fat was 71.3%, 11.6%, and 17.1%, respectively.\nAfter receiving the nutrition education for three months, the patient's energy intake was reduced by 500 kcal compared to three months ago. Protein intake was about 30 g less compared to three months ago. Limited intake of high-potassium foods was relatively well kept.

[[52.0, 'year']]

F

{'9080995': 1, '31781571': 1, '32742960': 1, '29849886': 1, '25695027': 1, '30679960': 1, '33888647': 1, '23264422': 1, '15616252': 1, '34654871': 1, '24527422': 2}

{}

3921299-1

noncomm/PMC003xxxxxx/PMC3921299.xml

Basophil Activation Test with Food Additives in Chronic Urticaria Patients

A 37-year-old woman visited the outpatient allergy clinic because of urticaria. She suffered from recurrent generalized urticaria, rash, and facial angioedema. She complained that the urticarial aggravation occurred particularly when eating high-seasoned, spicy, or Chinese foods. Previously, she had been treated for allergic rhinitis and also had experienced severe urticaria with a generalized rash after taking non-steroidal anti-inflammatory drugs (NSAIDs). Peripheral eosinophil counts and serum total IgE in her blood were 97.2/µL and 97 kU/L, respectively. T4 and thyroid stimulating hormone were also within normal range. A skin prick test showed weakly positive reactions (wheal size ≥3 mm but allergen/histamine ratio <1) to silk worm pupa, herring, cabbage, celery and walnut; however, none of them provoked urticaria in the history. In the BAT, a total of 18.7% of basophils were activated after stimulation with MSG (); however, the other 14 additives did not induce significant basophil activation, compared to the negative control (1.3%).

[[37.0, 'year']]

F

{'1626990': 1, '20084843': 1, '10452764': 1, '19796222': 1, '19348919': 1, '16634880': 1, '16751009': 1, '8651031': 1, '16918509': 1, '15668987': 1, '15316492': 1, '26468368': 1, '12209108': 1, '2861222': 1, '19549026': 1, '12752589': 1, '19240377': 1, '14982518': 1, '21530870': 1, '16215324': 1, '20106580': 1, '7985255': 1, '20608919': 1, '3060514': 1, '16400887': 1, '1993134': 1, '10359874': 1, '30018635': 1, '20042231': 1, '10719307': 1, '34068047': 1, '23404176': 2, '7236502': 1, '24260732': 1, '12542996': 1, '18551832': 1, '2876337': 1, '16599242': 1, '19772519': 1, '19014398': 1, '20447080': 1, '8982428': 1, '19772512': 1, '11929494': 1, '18325576': 1, '16670519': 1, '18445192': 1, '18564624': 1, '20592921': 2, '8120272': 1, '15347380': 1, '24527415': 2}

{'3921299-2': 2, '3563024-1': 1, '2892054-1': 1}

3921299-2

noncomm/PMC003xxxxxx/PMC3921299.xml

Basophil Activation Test with Food Additives in Chronic Urticaria Patients

A 19 year-old female high school student with recurrent urticaria visited the allergy clinic. She complained of recurrent episodes of localized urticaria and erythematous rashes on face. She had been experiencing urticarial symptoms that had developed after eating a school meal. Her past medical history or family history was unremarkable for allergic diseases. Laboratory findings including peripheral eosinophil count and serum total IgE were within the normal range. The result of an autologous serum skin test was also negative. There were no food allergens which positively reacted to the skin prick test. In BAT, only sodium benzoate activated basophils significantly (37.5% activation; ). After she abstained from the food additives by avoiding the relevant processed foods, her urticarial symptoms were resolved dramatically without further anti-histamine medications.

[[19.0, 'year']]

F

{'1626990': 1, '20084843': 1, '10452764': 1, '19796222': 1, '19348919': 1, '16634880': 1, '16751009': 1, '8651031': 1, '16918509': 1, '15668987': 1, '15316492': 1, '26468368': 1, '12209108': 1, '2861222': 1, '19549026': 1, '12752589': 1, '19240377': 1, '14982518': 1, '21530870': 1, '16215324': 1, '20106580': 1, '7985255': 1, '20608919': 1, '3060514': 1, '16400887': 1, '1993134': 1, '10359874': 1, '30018635': 1, '20042231': 1, '10719307': 1, '34068047': 1, '23404176': 2, '7236502': 1, '24260732': 1, '12542996': 1, '18551832': 1, '2876337': 1, '16599242': 1, '19772519': 1, '19014398': 1, '20447080': 1, '8982428': 1, '19772512': 1, '11929494': 1, '18325576': 1, '16670519': 1, '18445192': 1, '18564624': 1, '20592921': 2, '8120272': 1, '15347380': 1, '24527415': 2}

{'3921299-1': 2, '3563024-1': 1, '2892054-1': 1}

3921642-1

noncomm/PMC003xxxxxx/PMC3921642.xml

Oversized pseudocysts of the spleen: Report of two cases

Patient A was a 36 years old male with a history of abdominal injury in the past. He came to the emergency room with symptoms of abdominal pain and dyspepsia. The basic laboratory tests were non specific. The ultrasound examination showed a large, solitary, cystic mass of the spleen. The serological tests were negative for antiechinococcal antibodies. The patient was scheduled for CT control of the upper abdomen which revealed a solitary, smooth outlined splenic cyst, with signs of calcification. The cyst was occupying almost the entire splenic parenchyma, and particularly the splenic hilum, and it was 10.31 cm × 8.79 cm in size (). All data, so far, including the history of a past injury, supported the diagnosis of a SP.\nPatient A underwent a laparotomy and total splenectomy. The histologic examination showed a splenic pseudocyst with a thick, fibrotic wall, and sparse calcifications within the cystic wall, but lacking any epithelial elements. The liquid contained in the cyst was sent for a cytologic examination, which was negative for malignant cells or parasites. The patient underwent a full vaccination protocol, for avoidance of postoperative infections. Six months after the surgical procedure, no infections or other complications have been observed.

[[36.0, 'year']]

M

{'21121158': 1, '11194923': 1, '28267665': 1, '20148140': 2, '11782581': 1, '15599294': 1, '32685077': 1, '6502717': 1, '23879417': 1, '19172349': 1, '29794364': 2, '19886050': 1, '18022436': 1, '13559574': 1, '17560933': 1, '34418805': 1, '11893134': 1, '12403089': 1, '29435376': 2, '23500751': 1, '9114689': 1, '11569516': 1, '7356115': 1, '17990026': 1, '31528311': 2, '10645063': 1, '24463562': 2}

{'3921642-2': 2, '6293666-1': 1, '5757091-1': 1, '6668769-1': 1, '2820005-1': 1}

3921642-2

noncomm/PMC003xxxxxx/PMC3921642.xml

Oversized pseudocysts of the spleen: Report of two cases

Patient B was a 39 years old female with a history of ulcerative colitis. She came to the emergency room complaining for a painful mass in her left upper abdomen. The basic laboratory tests were in this case not specific as well. The ultrasound examination showed a solitary, cystic mass of the spleen of great size (). The serological tests were negative for antiechinococcal antibodies. The findings of the CT control revealed a solitary, smooth outlined cyst, with signs of calcification, occupying most of the splenic parenchyma (). The cyst was measured 7 cm × 7 cm. The possible diagnosis, so far, was a SP of unknown origin, since there was no obvious history of infarction, infection or injury in the past.\nPatient B underwent a laparotomy with a total splenectomy, as well. The histologic examination described a splenic cyst with a thick, fibrotic wall, but without epithelial elements. Calcifications were also observed within the cystic wall, but in a lower density compared to patient A. The cytologic examination of the cystic liquid was negative for malignant cells or parasites. Full vaccination was performed according to protocol. One year after surgery, no adverse events such as infection or other complications have been observed.

[[39.0, 'year']]

F

{'21121158': 1, '11194923': 1, '28267665': 1, '20148140': 2, '11782581': 1, '15599294': 1, '32685077': 1, '6502717': 1, '23879417': 1, '19172349': 1, '29794364': 2, '19886050': 1, '18022436': 1, '13559574': 1, '17560933': 1, '34418805': 1, '11893134': 1, '12403089': 1, '29435376': 2, '23500751': 1, '9114689': 1, '11569516': 1, '7356115': 1, '17990026': 1, '31528311': 2, '10645063': 1, '24463562': 2}

{'3921642-1': 2, '6293666-1': 1, '5757091-1': 1, '6668769-1': 1, '2820005-1': 1}

3921651-1

noncomm/PMC003xxxxxx/PMC3921651.xml

Adrenal gunshot wound: Laparoscopic approach. Report of a case

29-years-old man comes to the emergency room, in good general clinical condition (heart rate 78/min; blood pressure 120/65 mmHg), with a penetrating wound in left lumbar region without signs of peritonitis (). We perform routine blood tests (Hb 14.8 g/dl, WBC 11,000), chest X-ray and abdominal CT. The chest X-ray shows, in left subfrenic space, the presence of foreign metallic body (diameter 9 mm). The abdominal CT was performed with triphasic technique for the study of the urinary tract. The metallic bullet (diameter 1 cm) was found in retroperitoneum associated with cortical lesion of the upper pole of left kidney with perirenal subcapsular hematoma (transverse diameter 5.2 cm, sagittal 6.5 cm, coronal 11 cm). The excretory phase of both kidneys is regular and there are not lesions of the other abdominal organs (). Given the hemodynamic stability and the absence of hemoperitoneum we decide to take a NOM. Control blood test is repeated after 3 and 6 h with evidence of significant decline in hemoglobin (Hb 10.8 g/dl vs 14.8 g/dl); heart rate and blood pressure are normal. The rapid anemia and the CT report (renal cortical lesion with retroperitoneal hematoma) encourage us to carry out an exploratory diagnostic laparoscopy. The patient is placed in right lateral recumbency with an inclination of 50–60° relative to the operating table which is broken to extend the space between the last rib and the iliac crest. We used Veress needle to induce pneumoperitoneum and three trocars in the left subcostal region. In contrast to retroperitoneal approach, we chose a transperitoneal laparoscopic procedure because allows for a larger working space, adequate maneuverability and the presence of familiar anatomic landmarks. Careful exploration of the peritoneal cavity did not show lesions of the peritoneal organs. Considering CT results, the spleno-pancreatic block is medially mobilized to access the retroperitoneum and reach the adrenal and renal space. We opened Gerota on the upper pole of the kidney with identification of peri-renal hematoma, without any signs of active bleeding. We decide to carry out intraoperative radiological control using an image intensifier. Only a careful and accurate comparison of these X-ray images and laparoscopic vision allows us to identify and extract the bullet out of the adrenal parenchyma (a and b). Accurate hemostasis is made through a bipolar forceps and further application of fibrin glue in the renal and adrenal loggia for the purpose of a correct repositioning of the spleno-pancreatic block. We settle a tubular drainage in renal region. In postoperative period hemoglobin values were stable and were not required transfusion. The abdominal drain is removed during the fourth postoperative day and the patient is discharged without complications.

[[29.0, 'year']]

M

{'23093462': 1, '26490773': 1, '31110726': 1, '33039342': 1, '18266578': 1, '27381696': 1, '33208280': 1, '17544428': 1, '15028199': 1, '33191192': 1, '23140925': 1, '7457711': 1, '19374761': 1, '23052797': 1, '15554270': 1, '26468756': 1, '33191193': 1, '32972888': 1, '32832189': 2, '12075838': 1, '20476676': 1, '31074390': 1, '29254254': 1, '30947065': 2, '33862411': 1, '18701009': 1, '32193139': 1, '27734794': 1, '29707111': 1, '33191191': 1, '24441440': 2}

{'7422010-1': 1, '6446056-1': 1}

3921654-1

noncomm/PMC003xxxxxx/PMC3921654.xml

Hyperamylasaemia and ischaemic colitis

A 66-year-old gentleman was brought to A&E as a blue light call with an immediate preceding history of sudden onset severe central and lower abdominal pain, associated with nausea and vomiting. He also reported several episodes of fresh bleeding per rectum (PR) on the same day of admission, prior to which he reported a 2-week history of intermittent constipation and loss of appetite. He reported no recent fevers or other associated symptoms or illnesses.\nThe patient had a known extensive vasculopathic history comprised of hypertension, ischaemic heart disease, a previous stroke, atrial fibrillation and an abdominal aortic aneurysm (AAA) of 4.3 cm. He had undergone a colonic polypectomy 2 years ago, with otherwise normal colonoscopy and there was no family history of bowel cancers. Drug history included Acenocoumarin (Sintrom), a new coumarin anticoagulant.\nAt paramedics’ arrival he was hypotensive at 68/38 mmHg and tachycardic at 140 bpm, but responded to initial fluid resuscitation, BP 89/52 mmHg, pulse 120 bpm in A&E. Abdominal examination elicited lower abdominal tenderness and a palpable AAA. Rectal examination showed fresh blood.\nAmylase (3776 U/l), lactate dehydrogenase (492 IU/l), urea (11.8 mmol/l) and creatinine (149 μmol/l) were all raised. Arterial blood gas (ABG) analysis revealed a metabolic acidosis of pH 7.33 and a raised lactate of 3.49 mmol/l with an accompanying base excess of -5.3 mmol/l. His Modified Glasgow Score for pancreatitis was 1, indicating a low suspicion for this diagnosis.\nConservative management was started, consisting of intravenous fluid resuscitation, antibiotics, nil-by-mouth, nasogastric-tube insertion, urinary catheterization and close observation. Chest X-ray did not show any sign of perforation (). An urgent CT scan reported circumferential bowel wall thickening in the descending and sigmoid colon and pneumatosis, indicative of possible transmural infarction (). Flexible sigmoidoscopy and subsequent colonoscopy () found ischaemic colitis of the sigmoid colon characterised by sloughy mucosa and ulceration.\nThere was negligible clinical improvement with conservative management; therefore, on day 3 of admission, it was decided to proceed with laparotomy + Hartmann's procedure. Pre-operatively, haemoglobin was 10.2 g/dl, platelets 162 × 109/l and INR 2.0, therefore 2 units of fresh frozen plasma were given.\nMacroscopically, the excised colonic sample was 360 mm × 35 mm, with areas of bowel wall measuring up to 8 mm thick and ischaemia extending to one margin of the sample. Microscopically, histology showed extensive partial thickness infarction characterised by mucosal ischaemia and submucosal oedema. There was also a focal area of full thickness ischaemia. A stricture was noted on histology, but no malignancy was present and the lymph nodes identified were reactive.\nIntensive therapy unit (ITU) care was required in the immediate post-operative period and the patient made an uneventful recovery, albeit a minor wound infection around the 7th post-operative day, which was successfully treated. The patient was discharged home and has made good progress since. By 6 months post-operatively he had gained 1 stone in weight and has since had a successful reversal of the colostomy.

[[66.0, 'year']]

M

{'16168242': 1, '15056090': 1, '21056146': 1, '19570972': 1, '5766043': 1, '21960763': 1, '12816826': 1, '14696300': 1, '19109863': 1, '5906128': 1, '24441438': 2}

{}

3921658-1

noncomm/PMC003xxxxxx/PMC3921658.xml

Tibial baseplate fracture associated with polyethylene wear and osteolysis after total knee arthroplasty

A 69-year-old woman had undergone total knee arthroplasty eleven prior due to a diagnosis of primary gonarthrosis. She had a history of hypertension and goiter and was 98 kg and 164 cm tall with a calculated body mass index of 36.43 kg/cm2. Her height and weight were approximately the same when the primary total knee arthroplasty was performed. After this initial procedure, she underwent regular follow-ups every year for five years; her last follow-up was conducted six years prior to presentation, and she was not informed of the need for continued follow-up. Her control radiograph revealed varus malalignment of the tibia three year after the primary surgery (). Approximately a one and a half years prior to presentation, she experienced a slight pain in her operated left knee, which increased over the subsequent six months. When she was admitted to the local hospital, an analgesic drug was prescribed to her.\nAs her pain continued to increase over time, she presented to our central hospital; radiographs taken at that time revealed significant osteolysis in the medial condyle of the tibia (). Physical examination revealed a healthy-appearing obese woman in no acute distress and normal examination of the lower extremities. There was a well-healed anterior incision over the left knee without any evidence of skin infection. Active and passive motion of the knee caused pain in the medial part of knee. C-reactive protein, erythrocyte sedimentation rate, thyroid function tests and all other laboratory values were in the normal range. Loosening of the tibial component without any infection was reported on the bone scintigraphy.\nThe patient underwent a revision knee arthroplasty, and the previous incision site was used. There was a medial tibial baseplate fracture in the sagittal and coronal planes and a heavily worn polyethylene insert (A and B). There was no loosening in the lateral part of the tibial baseplate and no evidence of infection. Revision knee arthroplasty was performed after removal of the implants (). There were no post-operative complications, and the patient was ambulating with partial weight-bearing on the second day after the surgery. Significant pain relief and functional improvement was achieved based on early follow-ups.

[[69.0, 'year']]

F

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{'5448053-1': 1}

3921659-1

noncomm/PMC003xxxxxx/PMC3921659.xml

Endovascular reconstruction of an interrupted inferior vena cava

A 65-year old female was referred to our institution with an infected painful chronic right lower limb venous ulcer. The ulcer had been present for 8 months, with periods of infective exacerbations, where no complete healing was achieved despite appropriate limb compression and wound therapies. The right lower limb revealed typical chronic venous changes with near circumferential ulceration just proximal to the ankle. She had a past history of left-sided deep venous thrombosis and recurrent pulmonary embolism post partum in her late twenties, for which she received an IVC plication clip as an open surgical procedure. She went on to develop bilateral lower limb venous insufficiency and had presented 3 years prior with left leg venous ulceration. At this time venography demonstrated a left common iliac vein (CIV) occlusion, presumed to be due to May Thurner's syndrome, but the plicated IVC was not noticed. At that time she was successfully managed with a Cook Zilver stent (Cook, Bloomingdale, IN, USA) to revascularise the occluded iliac vein along with the adjuncts of split skin grafting to the ulcer and long term bilateral compression therapy.\nA CT venogram (A) demonstrated in stent stenosis of the Zilver stent and a narrowing of the proximal right CIV. The plication clip appeared to be reducing the IVC lumen to 2–3 mm in diameter. Digital Subtraction Venography (B and C) confirmed a severe stenosis of the right CIV ostium with a large filling defect in the proximal portion of the CIV stent. Lateral projections revealed a pin hole stenosis of the IVC, approximately 4 cm proximal to the iliocaval confluence, presumably due to the encircling clip.\nThe patient was taken to theatre where bilateral antegrade 7 FG (Cordis Corp, Johnson and Johnson, Bridgewater, NJ, USA) common femoral venous sheaths were placed. The stenoses were crossed with a Van Schie 2 (Cook Medical, Bloomington, IN, USA) catheter and an .035 Terumo angled stiff glidewire (Terumo Medical, Somerset, NJ, USA), which was then exchanged for a stiff type Amplatz wire (Cook Medical, Bloomington, IN, USA). The caval stenosis was predilated using two kissing 10 mm × 40 mm Fox PTA balloons (Abbott Vascular, Illinois, USA). The right Amplatz wire was pulled back into the iliac vein and the left sheath exchanged for a short 12 FG sheath (Cordis Corp, Johnson and Johnson, Bridgewater, NJ, USA). A Palmaz balloon expandable stent (Cordis Corp, Johnson and Johnson, Bridgewater, NJ, USA) was placed on a 20 mm balloon into the stenosed IVC and inflated, ensuring enough distal clearance from the iliocaval confluence. The right amplatz wire was then placed through the Palmaz stent and bilateral 14 mm × 140 mm Vena Zilver stents (Cook Medical, Bloomington, IN, USA) were ‘kissed’ into the Palmaz stent. These were post dilated with 14 mm × 40 mm Fox PTA balloon (Abbott Vascular, Illinois, USA). Final venography did not demonstrate any residual stenosis of the iliocaval confluence, nor of the cava itself ().\nThe patient made an uneventful post-operative recovery, with significant improvement in her lower limb pain. She was later taken back to theatre to place a split skin graft over the venous ulceration. Oral anticoagulation was continued and she was discharged home after a 4-week stay in hospital with all wounds healed. Follow up duplex ultrasound at 4 weeks post discharge demonstrated patency of the stents with no evidence of restenosis.

[[65.0, 'year']]

F

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{'7333087-1': 1}

3921868-1

noncomm/PMC003xxxxxx/PMC3921868.xml

Rapid onset of Stevens-Johnson syndrome and toxic epidermal necrolysis after ingestion of acetaminophen

A 43-year-old woman visited our hospital with an erythematous skin rash involving bullae throughout the body. Oropharyngeal ulceration and conjunctivitis developed within just two days after medication with acetaminophen to treat an infection of the upper respiratory tract (). The patient had a history of asthma, which had been controlled for five years by inhalation of a corticosteroid or long-acting beta-2 agonist, and had reported an incident of immediate drug hypersensitivity, urticaria to acetaminophen one year earlier. On examination, the patient was alert and appeared acutely ill. Her body temperature was 39.4℃, blood pressure was 115/90 mmHg, pulse rate was 140 beats per minute, and respiratory rate was 24 breaths per minute. Macular rash and epidermal detachment was evident on approximately 20% of the body surface. Nikolsky's sign was positive. Tenderness was evident, especially in parts of the skin affected by the rash. The white blood cell count was 2.900/mm3, the hemoglobin concentration was 13.2 g/dL, and the platelet count was 160,000/mm3. Her C-reactive protein was increased to 16.64 mg/dL, and the level of procalcitonin was 0.34 ng/mL. The level of total protein was 5.9 g/dL, the level of albumin was 3.1 g/dL, the level of blood urea nitrogen was 8 mg/dL, and the level of serum creatinine was 0.6 mg/dL. The level of aspartate aminotransferase was 102 IU/L, and the level of alanine aminotransferase was 40 IU/L. Levels of sodium, potassium and calcium levels were slight decreased. There was no eosinophilia.\nThe skin lesions rapidly progressed to bullous skin lesions covering the whole body, with epidermal detachment apparent over more than 30% of the body surface with time in spite of administration of high dose systemic corticosteroid (). After diagnosis of TEN, we administered intravenous immunoglobulin G (IVIG) at 2 g/kg/day for 3 days. After the treatment with IVIG, the epidermal detachment of the skin ceased and the severity of the skin lesions decreased. Empirical antibiotic use was continued for three weeks. The patient was discharged from the hospital 33 days after admission.\nWe thoroughly investigated other causes of the pathology, including viral infection. Nonetheless, there was no evidence of other causes besides ingestion of acetominophen.

[[43.0, 'year']]

F

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{'3921868-2': 2, '4731484-1': 1, '7180430-1': 1}

3921868-2

noncomm/PMC003xxxxxx/PMC3921868.xml

Rapid onset of Stevens-Johnson syndrome and toxic epidermal necrolysis after ingestion of acetaminophen

A 60-year-old man with a five-year history of diabetes mellitus and hypertension was treated with acetaminophen for three days owing to infection of the upper respiratory tract. He had no history of allergic responses. A erythematous rash throughout the body was evident 3 days after initial exposure to acetominophen. The rash spread and became generalized within a few days, with the appearance of bullae. He was admitted to another hospital 7 days after initial exposure to acetaminophen (day 7) and treated with IVIG delivered at a rate of 1 g/kg/day for 3 days. Skin lesions were accompanied by a fever, with a body temperature > 39℃. A skin biopsy performed on day 8 indicated an early phase of toxic epidermal necrolysis. On day 14 he was referred to our hospital with multiple exfoliations, extensive bullae throughout his body, oral mucositis and ocular involvement (). On examination, the patient was alert and appeared chronically ill. His body temperature was 38.4℃, blood pressure was 144/70 mmHg, pulse rate was 90 beats per minute, and respiratory rate was 20 breaths per minute. Nikolsky's sign was positive. Tenderness was evident, especially in parts of the skin affected by the rash.\nThe patient's white blood cell count was 1.700/mm3, the hemoglobin concentration was 11.9 g/dL, and the platelet count was 183,000/mm3. His C-reactive protein was increased to 6.55 mg/dL and the level of procalcitonin was 0.1 ng/mL. The level of total protein was 4.7 g/dL, the level of albumin was 1.5 g/dL, the level of blood urea nitrogen was 10 mg/dL, and the level of serum creatinine was 0.6 mg/dL. The sodium, potassium, phosphate, calcium and uric acid levels were slightly decreased. There was no evidence of eosinophilia and levels of liver enzymes were within the normal range.\nThe patient was isolated to reduce the risk of secondary infection, and received fluid therapy and parenteral nutrition with high protein content. After treatment of skin lesions by the topical application of mupirocin, 0.9% NaCl and 0.5% AgNO3 three times a day for 7 days, the skin condition gradually improved. The patient was discharged from the hospital on day 30. We are confident that the reaction was caused by acetaminophen, because it appears to be the only drug to which the patient was exposed to within a 30-day period prior to his initial admission.

[[60.0, 'year']]

M

{'21057748': 1, '29978260': 1, '26844223': 2, '27574505': 1, '27571915': 1, '27119002': 1, '19875224': 1, '16504917': 1, '9357376': 1, '10724193': 1, '7477195': 1, '17919775': 1, '12271299': 1, '24527403': 1, '28963996': 1, '10669183': 1, '22014021': 1, '16394480': 1, '7794310': 1, '32351742': 2, '12220477': 1, '28291796': 1, '21654132': 1, '21162721': 1, '25352860': 1, '19153164': 1, '24527413': 2}

{'3921868-1': 2, '4731484-1': 1, '7180430-1': 1}

3924013-1

noncomm/PMC003xxxxxx/PMC3924013.xml

Acute Myocardial Infarction after Radiofrequency Catheter Ablation of Typical Atrial Flutter

A 53-yr-old man with persistent atrial flutter () was admitted on August 20th 2012, to undergo radiofrequency catheter ablation. He was given intravenous heparin continuously until 6 hr before the procedure. Transesophageal echocardiogram did not show evidence of intracardiac thrombus two days before the procedure. After obtaining informed consent, he was brought to our electrophysiology laboratory after fasting for 8 hr. Under local anesthesia using lidocaine after sterile draping, two quadripolar electrode catheters (St. Jude Medical, Inc., St. Paul, MN, USA) were positioned to record the activity of the bundle of His and the right ventricular apex. The high right atrium (RA), mid RA, and coronary sinus (CS) were mapped with a deflectable duo-decapolar catheter (St. Jude Medical) (). Intracardiac electrograms were recorded using a Prucka CardioLab™ electrophysiology system (General Electric Health Care System, Inc., Milwaukee, WI, USA). His baseline intracardiac electrogram showed typical counterclockwise atrial flutter (). A 7Fr, 4mm-tip irrigation ablation catheter (St. Jude Medical, Inc., St. Paul, MN, USA) was inserted through an 8Fr, 60 cm-long RAMP sheath (St. Jude Medical, Inc., St. Paul, MN, USA). Radiofrequency current was applied to the posteroseptal side of the cavotricuspid isthmus, with temperature limit of 35℃ and power of 30-35 W (). As atrial flutter persisted after enough ablation, we started making ablation lines at the posterolateral side of the isthmus. Atrial flutter was suddenly terminated while making the first ablation line at the posterolateral side. To ensure successful ablation, radiofrequency energy was delivered six more times. Bidirectional isthmus block was confirmed. During the procedure, the patient complained of chest pain, but we considered it to be related to the ablation itself, because there was no change in the electrocardiogram and because the pain was not severe.\nWhen he returned to the ward, he reported worsening chest pain. We obtained a 12-lead electrocardiogram, which showed ST-segment elevation in leads II, III, aVF, and V5-6 and ST depression in leads I, aVL, and V1-4, suggesting acute myocardial in farction of the inferior wall (). He was immediately brought to the catheterization laboratory. Coronary angiography showed total occlusion at the distal portion of the right coronary artery, which was close to the area of ablation (). We aspirated red thrombi from the artery. After intracoronary injection of abciximab, balloon dilatation with a 3.0×20 mm balloon with a maximum pressure of 10 ATM was done with 20% residual stenosis. His chest pain was immediately relieved. After an hour, the elevated ST segments in leads II, III, aVF, and V5-6 returned to baseline. Cardiac troponin I peaked at 145.92 ng/mL 10 hr later.\nThe patient did not experience chest pain up to the time of discharge. However, approximately 21 hr after the completion of radiofrequency ablation, atrial flutter recurred. As it did not return to sinus rhythm with intravenous amiodarone, and because he developed hypotension 2 hr later, we performed electrical cardioversion with 70 J to achieve sinus conversion. To maintain the sinus rhythm, oral amiodarone 200 mg once daily was prescribed. Five days later, he was discharged without any symptoms as sinus rhythm persisted. After a year, he is still in sinus rhythm and has not experienced any kind of chest pain.

[[53.0, 'year']]

M

{'32983496': 2, '1518977': 1, '12049382': 1, '8301848': 1, '20663073': 1, '20132383': 1, '15185908': 1, '25485779': 1, '29062708': 1, '26039980': 1, '12693503': 1, '17941197': 1, '27206630': 1, '9124165': 1, '33024490': 1, '28948152': 1, '30279875': 1, '11232993': 1, '12435195': 1, '20345628': 1, '1565886': 1, '24550661': 2}

{'7495811-1': 1}

3924014-1

noncomm/PMC003xxxxxx/PMC3924014.xml

Iliocaval Fistula Presenting with Paradoxical Pulmonary Embolism Combined with High-Output Heart Failure Successfully Treated by Endovascular Stent-Graft Repair: Case Report

A 51-yr-old male was admitted on April 4, 2012, with palpitation and exertional dyspnea gradually deteriorated for a week. He visited other hospital a week ago, because anorexia, nausea, vomiting and abdominal discomfort developed and continued for three weeks without any improvement. In that hospital, right iliac artery aneurysm (4.5 cm in diameter) with iliocaval shunt combined with thrombus was found incidentally by contrast-enhanced computed tomography (CT) (). He was referred to our hospital for proper management of iliocaval fistula. His risk factor of iliac aneurysm was hypertension. However, he have not underwent any abdominal trauma or surgery.\nOn admission to our hospital, his vital sign were blood pressure of 137/82 mmHg, heart rate of 103 beats/min, respiratory rate of 20/min, body temperature of 36.5℃, and oxygen saturation of 96%. His heart sound was regular and rapid. Rale was auscultated on both lower lung field. Bruit detected by auscultation of right inguinal area and palpable mass was not identified. There was no leg edema and normal peripheral arterial pulse was detected in both lower extremities.\nLaboratory test showed a slight elevated C-reactive protein of 0.95 mg/dL (normal range < 0.3 mg/dL) without leukocytosis, creatinine level of 1.45 mg/dL (normal range: 0.5-1.3 mg/dL), aspartate transaminase of 56 IU/L (normal range: 12-33 IU/L) and alanine transaminase of 119 IU/L (normal range: 5-35 IU/L). Platelet, bilirubin, and international normalized ratio was within normal range and electrolyte or acid-base imbalance was not found. CK-MB and Troponin T was within normal range, but NT pro-BNP was elevated to 2,404 pg/mL (normal range: 5-125 pg/mL). Electrocardiogram showed sinus tachycardia without abnormal ST segment or T wave change. Cardiomegaly with pulmonary edema and bilateral pleural effusion in simple chest x-ray was detected. We considered possibility of heart failure, and examined echocardiogram. Ejection fraction was 63% and regional wall motion abnormalities was not observed. These findings suggested high-output heart failure. Right atrial and ventricular dilatation, D-shaped left ventricle, and the dilatation of inferior vena cava was identified incidentally. Contrast-enhanced chest CT was performed and showed pulmonary thromboembolism involved right lower lobe base segmental pulmonary artery (). We checked doppler sonography of lower extremities, tumor markers, and upper and lower endoscopy for evaluate origin of emboli. There were no evidence of deep vein thrombosis or malignancy. Therefore, we concluded that pulmonary emboli was originated from thrombus in iliac aneurysmal sac.\nWe decided to treat his iliocaval shunt by endovascular stent graft implantation for restoring heart function and preventing recurrent pulmonary embolism. For a start embolization of right common iliac artery was performed with PLUG 10mm (Amplatzer vascluar plug, Aga Medical Corp) (). Angiogram showed aneurysmal dilatation of right common iliac artery and iliocaval shunt. Some filling defects near the aneurysm, suggesting of thrombi (). Then two graft stents (Excluder contralateral leg 12/100 mm, 12/120 mm, W.L Gore and Associates) are placed at right common iliac artery. Post-stenting balloon angioplasties were performed (EverCross 12/40 mm, EV3 Inc). After the procedure, aortogram showed well implanted graft stents and no visible of IVC and endoleak (). After the implantation of graft stents, dyspnea was improved and follow up creatinine level and liver enzymes were normalized. Simple chest x-ray showed no pulmonary edema or pleural effusion at discharge. Coumadization was started for resolution and prevention of pulmonary embolism.\nAt routine follow up 6 months after the procedure, the patient was in good clinical condition. Echocardiogram showed that D-shaped left ventricle was completely resolved and right atrial and ventricular size was normalized. CT demonstrated that the stent-graft was patent and well-postioned, without evidence of graft migration, aortacaval communication or endoleak (). Pulmonary embolism was mostly regressed ().

[[51.0, 'year']]

M

{'12432197': 1, '2032099': 1, '10819393': 1, '7494369': 1, '16884429': 1, '7825158': 1, '22197523': 1, '3694759': 1, '1990167': 1, '21638254': 1, '19702345': 1, '24550662': 2}

{}

3924015-1

noncomm/PMC003xxxxxx/PMC3924015.xml

Successful Pregnancy in a Patient with Autosomal Dominant Polycystic Kidney Disease on Long-Term Hemodialysis

A 38-yr-old primigravida female on HD presented with amenorrhea in May 2011. She had been diagnosed with ADPKD 6 yr ago. She started HD 3 times a week after 3 yr of her initial diagnosis. At the time of presentation, she was normotensive and had been prescribed aspirin (100 mg daily), multivitamins, calcium-based phosphate binders, and erythropoietin (1,000 units every HD session). Her dry weight was 53.3 kg and interdialytic weight gain was 1.5-2.5 kg. Her mother had ADPKD and was also on HD.\nShe was confirmed to be 8 weeks pregnant by pelvic ultrasound and beta-hCG test. The physical examination revealed a blood pressure (BP) of 137/85 mm Hg and a regular heart rate of 107 beats per minute. Laboratory findings at presentation were as follows: hemoglobin (Hb) of 10.4 g/dL; hematocrit (Hct) 31.5%; blood urea nitrogen (BUN) 56.9 mg/dL; serum creatinine (Cr) 9.0 mg/dL; total protein 5.9 g/dL; serum albumin 3.7 g/dL; serum calcium 9.3 mg/dL; serum phosphorus 3.3 mg/dL; potassium 5.5 mM/L; and normal liver function. Her 24-hr urine volume was about 1 liter. The computed tomography scan taken 2 yr ago showed bilaterally enlarged kidneys filled with numerous renal cysts along with only a few liver cysts (). Total kidney volume was measured to be 5,970 mL.\nShe was managed by a multidisciplinary team approach to optimize the patient and fetal outcomes. Firstly, the risk of pregnancy in a dialysis patient and the need for intensive dialysis were discussed with her family. Secondly, our team evaluated the risk of stunted intrauterine fetal growth by her massively enlarged kidneys. We considered a unilateral nephrectomy at the second trimester to secure the intraabdominal space, but the risk was determined to outweigh the benefits in this case. Finally, genetic counseling about the fetus's risk of inheriting ADPKD and prenatal genetic diagnosis was provided but declined by the patient.\nAt 10 weeks gestation, HD prescription was changed to 4-hr treatments 4-5 times a week, and a predialysis BUN less than 50 mg/dL was targeted. Throughout pregnancy, predialysis BUN was maintained at 25.1-51.3 mg/dL. Standard unfractionated heparin was used for anticoagulation. Her BP was well controlled without any antihypertensive medication: systolic BP remained at 110-140 mmHg and diastolic was consistently at 60-80 mmHg. Anemia was managed with recombinant human erythropoietin and intravenous iron without transfusion. Erythropoietin doses were adjusted to target a maternal Hb between 10-11 g/dL. The median dose was 18,000 IU/week (range, 5,000-26,000 IU/week) during gestational weeks 12-36. In addition, 100 mg intravenous iron sucrose was administered every session during gestational weeks 19-22. The hemoglobin level was maintained above 9.5 g/dL in the third trimester. However, urine volume gradually decreased to less than 100 mL per day. The follow-up data of dry weight, predialysis BUN and Hb level are shown in .\nFetal growth was appropriate for gestational age. Routine fetal karyotyping was performed at 16 gestational weeks, but mutation screening was not performed. At 34.5 weeks of gestation, the membrane ruptured during HD, and vaginal delivery was performed without any complications. She delivered a healthy female weighing 2,100 g. One week after delivery, the patient was hospitalized for 5 days because of postpartum cardiomyopathy.

[[38.0, 'year']]

F

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{'7688026-1': 1}

3924016-1

noncomm/PMC003xxxxxx/PMC3924016.xml

A Case of Nonisland Pedicled Foot Fillet Flap for Below-Knee Amputation Stump Wound: Treatment Option for Compartment Syndrome after Fibular Free Flap Surgery

A 66-yr-old man, who had developed compartment syndrome after a fibular osseous free flap transfer from the left leg to the mandible on April 24, 2013, was referred to our department on postoperative day 26. The donor site, which had been closed primarily, was opened on postoperative day 7. Evaluation showed a 20-cm fibular defect, a residual 8-cm proximal fibular segment, an intact tibia, and extensive necrosis in all compartments of the leg. The foot was well vascularized through the posterior tibial vessels but was insensate. Treatment included several debridements with irrigation in the operation room for 3 weeks. A suction pressure wound therapy system was applied on the wound and changed every 3 days.\nAfter the wound improved, 3 treatment options were considered including above-knee amputation, below-knee amputation, or flap reconstruction without amputation. Considering the patient's age, his general condition, and the wound condition, we selected a below-knee amputation to preserve knee joint function. A foot fillet flap was considered to reduce donor site morbidity, but dissection of the posterior tibial vessels was not possible because of inflammation, scar formation, and adhesion to surrounding tissue. Therefore, a nonisland pedicled flap including skin and soft tissue in the pedicle was planned.\nAt 47 days after the initial fibular free flap transfer, below-knee amputation and coverage of the stump were performed under general anesthesia with loupe magnification, a pneumatic thigh tourniquet without limb exsanguinations. After devitalized tissue in the wound was debrided completely, the tibia was cut 13.5 cm distal to the tibial tuberosity. The dorsum of the foot was incised from the distal margin of the wound near the lateral ankle to the wound at the dorsum of the foot (). The toes were amputated through the metatarsophalangeal joints. The remaining skin and soft tissue, including the vascular pedicle, were elevated at the subperiosteal level. The distal tibial and fibular segments and all tarsal and metatarsal bones were removed. Dense fibrous tissue at the plantar surface of the foot, large tendons, and volar plates of the metatarsophalangeal joints were excised. The intrinsic muscles of the foot were preserved, and the posterior tibial neurovascular bundle was not debulked (). The flap was rotated 180° and folded, and the posterior plantar part of the flap was placed at the weight bearing aspect of the distal tibia. The anterior plantar part of the flap was placed in the soft tissue defect at the posterior calf, and the calf part of the flap was placed at the soft tissue defect of the anterior calf below the patella. After insertion of suction drainage tubes, the flap was sutured to the wound and remaining flap margins (). Complete survival of the flap was achieved and the knee joint was mobilized early.\nAt 84 days after below-knee amputation and flap coverage, a debulking procedure was performed to reduce the excess volume of the healed flap. The posterior tibial neurovascular pedicle was inevitably transected and immediate neurorrhaphy of the posterior tibial nerve was performed. At 2 months after the debulking procedure, the patient noted tingling sensation at the flap. Follow-up at 7 months after below-knee amputation and nonisland pedicled foot fillet flap showed that the flap was well healed with improving sensation to the skin flap and the patient was satisfied with the result ().

[[66.0, 'year']]

M

{'16184523': 1, '12794465': 1, '7638302': 1, '3782218': 1, '9771370': 1, '11115284': 1, '22949008': 1, '20471850': 1, '11823938': 1, '33564573': 1, '21112184': 1, '22821839': 1, '11786790': 1, '8863975': 1, '3295912': 1, '11800433': 1, '19836708': 1, '7053496': 1, '24550664': 2}

{}

3924710-1

noncomm/PMC003xxxxxx/PMC3924710.xml

Glomerulopathy with Homozygous Apolipoprotein E2: A Report of Three Cases and Review of the Literature

A 66-year-old male was referred to our center by his primary care physician because of the increase of proteinuria. He was diagnosed with diabetes at the age of 50 years but remained untreated. At the age of 60 years, he started voglibose at the diabetes center of our hospital. At the age of 66 years, urinary abnormality of protein 3+ and occult blood 1+ was pointed out, combined with simple diabetic retinopathy and a serum creatinine level of 0.96 mg/dl. He was referred to our center for further investigation, and a renal biopsy was performed. One of 11 glomeruli showed global sclerosis, and the other glomeruli showed massive foam cell infiltration in the glomerular capillaries and mildly expanded mesangium (fig. ). These foam cells immunohistochemically stained positive for cluster differentiation 68 (CD68) (not shown). Transmission electron microscope images also revealed foam cell infiltration mainly located in the capillaries containing scattered lipid droplets and lamellar bodies in their cytoplasm (fig. ). The glomerular basement membrane (GBM) showed mild thickening, and nodular lesions were formed in some glomeruli. The interstitium and tubules showed mild fibrosis and atrophy (25% of the cortical region), and a moderate degree of arteriolar hyalinosis was also found. No interstitial foamy cells or foamy tubular degeneration was found. Immunofluorescence study revealed no significant glomerular deposits. The patient's lipid profile showed type III HLP (table ). Apolipoprotein phenotype analysis showed a homozygosity of apoE2. A further DNA sequence analysis was performed as described previously [] and showed a nucleotide substitution of cysteine for arginine at codon 158 (Arg158Cys) of the apoE gene and no other mutations. Eicosapentaenoic acid was added to his statin therapy, but he progressed to end-stage renal failure and was started on dialysis 8 years after the diagnosis.

[[66.0, 'year']]

M

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{'3924710-2': 2, '3924710-3': 2, '4777904-1': 1, '6287602-1': 1, '5903162-1': 1}

3924710-2

noncomm/PMC003xxxxxx/PMC3924710.xml

Glomerulopathy with Homozygous Apolipoprotein E2: A Report of Three Cases and Review of the Literature

A 58-year-old male was referred to our center by his primary care physician due to nephrotic syndrome. He had massive proteinuria (7.38 g/day) and hypoalbuminemia (1.9 g/dl). He had been treated for diabetes since the age of 50 years and had been started on insulin therapy at the age of 55 years. He had been well-managed (HbA1c, 5.3%), although a pre-proliferative retinopathy and mild renal dysfunction (sCr, 1.38 mg/dl) became evident. His renal biopsy revealed 5 of 22 glomeruli with global sclerosis. The residual glomeruli showed massive foam cell infiltration in the glomerular capillaries and severely widened mesangium (fig. ). These foam cells stained positive for CD68 (not shown). Transmission electron microscope images also revealed foam cell infiltration mainly located in the capillaries containing scattered lipid droplets and lamellar bodies in their cytoplasm (fig. ). The glomerular tufts were enlarged with hyalinosis, mesangiolysis and microaneurysmal formation, which were consistent with diabetic glomerulosclerosis. The interstitium and tubules showed moderate fibrosis and atrophy (50% of the cortical region). The foamy change was seen in some tubular epithelial cells, but no interstitial foamy cells were found. The interlobular arteries showed a moderate degree of fibrous intimal thickening, and the arterioles also showed a moderate degree of subendothelial hyalinosis. Immunofluorescence studies revealed nonspecific linear IgG deposits along the GBM; however, no significant deposit was found by electron microscopy. The patient's lipid profile showed type III HLP (table ). He had an apoE2 homozygote phenotype and the Arg158Cys genotype with no other mutations. Three years after the diagnosis, he progressed to renal failure and was started on hemodialysis.

[[58.0, 'year']]

M

{'29692990': 2, '16431249': 1, '30701487': 1, '30309894': 1, '12882872': 1, '25887903': 1, '22508733': 1, '8052351': 1, '9342484': 1, '5783631': 1, '18045818': 1, '11318963': 1, '20534298': 1, '10552997': 1, '30542638': 2, '1756519': 1, '28578625': 1, '2310424': 1, '26955632': 2, '4829776': 1, '8862125': 1, '29740794': 1, '19034316': 1, '8589283': 1, '12121348': 1, '24570682': 2}

{'3924710-1': 2, '3924710-3': 2, '4777904-1': 1, '6287602-1': 1, '5903162-1': 1}

3924710-3

noncomm/PMC003xxxxxx/PMC3924710.xml

Glomerulopathy with Homozygous Apolipoprotein E2: A Report of Three Cases and Review of the Literature

A 78-year-old male with nephrotic syndrome was referred to our center by his primary care physician. The patient had a history of hypertension since the age of 45 years, hypothyroidism since the age of 68 years and diabetes mellitus since the age of 70 years. He also had a history of percutaneous coronary intervention for coronary artery disease and femoropopliteal bypass surgery for peripheral arterial disease at the age of 74 years, and a history of Wallenberg syndrome since the age of 77 years. He was being treated with an angiotensin II receptor blocker, a calcium-channel blocker, pitavastatin, aspirin and levothyroxine sodium hydrate. Diabetic control by diet and an oral α-glucosidase inhibitor were sufficient. There was no evidence of retinopathy or albuminuria before the episode of nephrosis. His urinalysis on admission was positive for proteinuria (2.5 g/day) and red blood cells (1–4/hpf). His blood chemistry findings were as follows: albumin 3.2 g/dl, creatinine 1.11 mg/dl and HbA1c 6.1%. A kidney biopsy revealed 21 glomeruli, of which 2 were globally sclerotic. The glomeruli showed increased mesangial matrices and mild GBM thickening. Massive foam cells had infiltrated into the glomerular capillaries and mesangial region (fig. ). These foam cells stained positive with Oil Red O (fig. ) and immunohistochemically stained positive for CD68 (fig. ). Transmission electron microscope images also revealed foam cell infiltration mainly located in the capillaries, and some mesangial cells showed scattered lipid droplets in their cytoplasm (fig. ). Mild interstitial fibrosis and tubular atrophy (20% of the cortical region) as well as moderate arteriosclerosis and arteriolar hyalinosis were found. The foamy change was seen in some tubular epithelial cells but no interstitial foamy cells were found. Immunofluorescence studies revealed segmental deposits of IgM and C3 in the mesangial area and slightly peripheral IgG deposits in the glomeruli; however, no significant deposit was found by electron microscopy. He had an apoE2 homozygote phenotype and the Arg158Cys genotype with no other mutations. After the diagnosis, ezetimibe was added to his statin therapy. The patient's most recent serum creatinine was increased to 2.1 mg/dl after 2 years.

[[78.0, 'year']]

M

{'29692990': 2, '16431249': 1, '30701487': 1, '30309894': 1, '12882872': 1, '25887903': 1, '22508733': 1, '8052351': 1, '9342484': 1, '5783631': 1, '18045818': 1, '11318963': 1, '20534298': 1, '10552997': 1, '30542638': 2, '1756519': 1, '28578625': 1, '2310424': 1, '26955632': 2, '4829776': 1, '8862125': 1, '29740794': 1, '19034316': 1, '8589283': 1, '12121348': 1, '24570682': 2}

{'3924710-1': 2, '3924710-2': 2, '4777904-1': 1, '6287602-1': 1, '5903162-1': 1}

3924711-1

noncomm/PMC003xxxxxx/PMC3924711.xml

A Case of Atypical Hemolytic Uremic Syndrome Successfully Treated with Eculizumab

A 51-year-old Caucasian man was brought into the Emergency Department following a mechanical fall. His past medical history was significant for rheumatic heart disease, mechanical mitral valve replacement at the age of 29 years, repeat replacement at the age of 33 years, and left-sided stroke. He was on warfarin for anticoagulation (mechanical valve). His social history was significant for smoking (2–3 cigarettes/day) and occasional use of alcohol, while family history was significant only for diabetes mellitus.\nOn physical examination, his vitals were stable with a temperature 98° F, blood pressure 113/79 mm Hg, pulse rate 88 beats/min, and respiratory rate 18 breaths/min. There was no rash except for mild ecchymosis over the right eye and helix of the right ear. His conjunctiva was pale but anicteric. There was mild pedal edema. A cardiac examination demonstrated a mechanical heart valve click, normal second heart sound, absent murmur, and no pericardial rub. His neurological exam revealed mild confusion and right-sided weakness. The rest of the examination was unremarkable.\nA computed tomography of the head without contrast, performed in the Emergency Department, showed a right subdural hematoma. He was subsequently transferred to the Intensive Care Unit for observation and neurological monitoring. Laboratory tests showed a very high prothrombin time. Serum creatinine on the day of admission (day 1) was 70.72 μmol/l (normal range: 53.04–97.24 μmol/l). He received 4-factor (II, VII, IX, and X) prothrombin complex concentrate for reversal of the high international normalized ratio in view of his subdural hematoma. By the next morning (day 2), he had become oliguric, and serum creatinine increased to 247.52 μmol/l. Other laboratory results on day 2 are shown in table . Urine sediment showed granular casts. There were no dysmorphic red blood cells or cellular casts.\nIn view of the drop in hemoglobin and platelets, elevated lactate dehydrogenase (LDH), indirect hyperbilirubinemia, and acute kidney injury, the possibility of TMA secondary to hemolytic uremic syndrome/thrombotic thrombocytopenic purpura was considered. Complement studies showed C3 0.70 g/l (normal range: 0.82–1.85 g/l) and C4 0.19 g/l (normal range: 0.15–0.53 g/l). ANA, anti-dsDNA, hepatitis panel, HIV, anti-scl-70, ANCA and anticardiolipin antibody were all negative.\nA peripheral smear demonstrated the presence of schistocytes consistent with microangiopathic hemolytic anemia. A renal ultrasound was unremarkable. A Tc-99m MAG3 scan demonstrated decreased perfusion to both kidneys and severely decreased cortical uptake. Renal Doppler study of the right kidney showed a resistive index of 0.69. Blood flow to the left kidney could not be assessed completely due to abdominal gas.\nOn day 4, a renal biopsy was performed which conformed TMA. The findings are outlined below (fig. , fig. , fig. ).\nA diagnosis of aHUS was made based on biopsy findings, serological data, and clinical history. A normal ADAMTS 13 and an equivocal antibody test to ADAMTS 13 ruled out thrombotic thrombocytopenic purpura. On day 3, hemodialysis was initiated due to anuria and hyperkalemia. Plasma exchange with fresh frozen plasma was initiated on day 5 for treatment of aHUS (60 ml/kg of fresh frozen plasma for restitution). Fresh frozen plasma was selected as the restitution fluid in view of the initial concern about genetic or inherited complement defects. Subsequent quantitative assays looking for genetic or inherited complement defects [factor B 239.7 μg/ml (127.6–278 μg/ml), MCP CD46 positive, factor H 253 μg/ml (160–412 μg/ml) and factor I 33.5 μg/ml (29.3–58.5 μg/ml)] were within normal limits. Factor H antibody was negative. A genetic mutational analysis for the above described complement factors was unable to be performed due to denial from the patient's insurance company. Plasma exchange was discontinued after 2 days, and eculizumab was started after administration of a meningococcal vaccine (day 7). By day 8, the patient's platelets improved to 142 × 10/l and LDH decreased to 945 U/l. Hemoglobin also stabilized. Eculizumab was continued at 900 mg every week for a total of 5 weeks and then transitioned to 1,200 mg every 2 weeks. Urine output gradually improved and hemodialysis was terminated after 2.5 months. His estimated glomerular filtration rate at 6 months was 41 ml/min/1.73 m2 as determined by the MDRD formula. The trends in LDH and platelets over time are represented in fig. . A computed tomography scan of the chest/abdomen/pelvis was also done to rule out infection or malignancy as precipitants for aHUS.\nInformed consent was obtained from the patient for the publishing of this work.

[[51.0, 'year']]

M

{'19846853': 1, '20595690': 1, '22802338': 1, '26288712': 1, '27110144': 1, '22517061': 1, '33678802': 1, '26251715': 1, '19556379': 1, '19025115': 1, '29043138': 1, '16621965': 1, '30262558': 1, '25400666': 1, '22287852': 1, '21902819': 1, '24570684': 2}

{}

3924712-1

noncomm/PMC003xxxxxx/PMC3924712.xml

A Case of Water Intoxication with Prolonged Hyponatremia Caused by Excessive Water Drinking and Secondary SIADH

A 22-year-old man who was an inmate in a detention facility joined a game of ‘rock/paper/scissors’ with his roommates at 8:00 p.m. They made a rule that the loser of each game must drink a cup of water as a penalty by using a plastic cup with a capacity of 300 ml. That night, he lost the game again and again, and had to drink 20–22 cups of water during 25–28 games in total for the 3-hour game, indicating that he must have drunk at least 6 liters of water in 3 h. At 11:30 p.m., 3.5 h after beginning the penalty drinking, he showed restlessness and peculiar behavior, including speaking meaningless words. Because he also started vomiting and having convulsions soon thereafter, he was seen by a doctor in a clinic at the facility at midnight, and he was administered 100 mg phenobarbital intramuscularly.\nHowever, his condition was not improved by the treatment, and it progressively worsened, showing more serious signs such as incontinence of urine and feces, tonic convulsions, and consciousness disturbance. He was finally transferred to our hospital at 2:00 p.m., 18 h after the beginning of the penalty drinking. Clinical episodes which can cause SIADH, such as epilepsy, brain surgery history, head injury or a history of meningoencephalitis, were not seen in his past history.\nWhen he was hospitalized, he was in a coma (Japan Coma Scale; III-100). His height, body weight, blood pressure, pulse rate and body temperature were 167 cm, 49 kg, 140/90 mm Hg, 60 beats/min and 36.8°C, respectively. Edema was not present in his face or legs. The neurological examination showed no abnormality including enhanced or pathological tendon reflex. Muscle rigidity was slightly enhanced in the proximal portion of his extremities. The results of the laboratory tests on admission are summarized in table , and significant hyponatremia (120 mmol/l) was assumed to be the principle cause of the coma and/or other neurological abnormalities. A brain magnetic resonance imaging (MRI) study showed high-intensity signals in the perilateral ventricular region and brain white matter consistent with the development of brain edema, as shown in fig. . A chest X-ray showed no abnormalities, including alveolar shadow, pleural effusion, cardiomegaly and congestion (X-ray not shown).\nAlthough excess water drinking in the detention facility would have triggered the dilution of the patient's body fluid, it was not concluded that the temporal massive water drinking caused the prolonged dilution of body fluid until 15 h after the discontinuation of the water drinking. Indeed, his laboratory tests showed hypertonic urine (305 mosm/kg H2O), indicating the disturbance of free water excretion in response to the remarkable hyponatremia. This finding, taken together with the patient's decreased free water clearance, inhibition of the renin-aldosterone system and hypouricemia with elevated uric acid clearance led us to make a tentative diagnosis as secondary SIADH, and the diagnosis was confirmed later by the detection of an inappropriate elevation of the plasma ADH concentration.\nThe patient's clinical course and the changes in the laboratory findings are summarized in fig. . As an initial therapy for the severe hyponatremia, physiological saline was infused in combination with 40 mg furosemide twice a day. In addition, 6.6 mg dexamethasone was also administered for the reduction of the patient's brain edema. Because he showed systemic convulsions again on the 2nd day, an electroencephalogram was performed and showed a spike and wave pattern, suggesting the diagnosis of epilepsy. The convulsions disappeared after an administration of phenytoin.\nOn the 3rd day, his consciousness disturbance had almost disappeared, with an elevation of the serum sodium concentration (138 mmol/l). On admission, he showed elevated serum creatine phosphokinase (2,386 IU/l) and urine myoglobin (372.1 ng/ml) as well as muscle pain, which were consistent with rhabdomyolysis resulting from the recurrent convulsions and hyponatremia. Following the improvement of the hyponatremia, those abnormalities also disappeared by the 5th day. After confirmation of the disappearance of the brain high-intensity signals by MRI and the normalization of the disturbed free water clearance on the 5th day, the patient was discharged and he returned to the detention facility with no significant clinical signs on the 6th day.

[[22.0, 'year']]

M

{'10353946': 1, '760555': 1, '9132693': 1, '21539169': 1, '1742879': 1, '3285701': 1, '10954875': 1, '7801741': 1, '8481936': 1, '9083241': 1, '34722083': 2, '13641402': 1, '30843112': 1, '11370203': 1, '26994458': 1, '6486156': 1, '24570685': 2}

{'8549404-1': 1}

3924734-1

noncomm/PMC003xxxxxx/PMC3924734.xml

Incidental diagnosis of vaginal schwannoma in a patient with thigh pain

A 43-year-old Korean woman (gravid 2, para 2) presented to an orthopedist with thigh pain and burning and tingling sensations in the medial aspect of the left thigh. The pain reported to be exacerbated by dorsiflexion of the ankle or prolonged activity. The patient's medical history was otherwise unremarkable, and her physical examination was normal. Ankle and toes had full range of motion and deep tendon reflexes were intact. Straight leg raising test was negative, but caused vague discomfort in the thigh. Plain radiograph AP and lateral views of the left thigh were normal. The patient was referred for MRI of the left thigh and images revealed a mass lesion of heterogeneous intensity 5.2×5.7 cm in the left vaginal wall (). During subsequent physical examination, a cystic, non-tender, swelling was palpated in the left vaginal wall.\nThe patient referred to a gynecologist and it was decided to excise the mass via per-vaginal approach. The solid mass was removed without any perioperative complications, and the patient made an uneventful recovery. Patient's thigh pain disappeared after surgery.\nMacroscopically, the tumor was a well-circumscribed, soft, solid mass measuring 5.3×4.3 cm. Tumor section revealed a yellow/gray heterogeneous appearance without apparent necrosis ().\nMicroscopic examination showed a fascicular arrangement of spindle cells without nuclear atypia. Mitosis was not observed in high-power fields. Immunohistochemically, tumor cells showed a positive reaction for S-100 protein. All of these features were in keeping with a diagnosis of schwannoma ().\nThe patient has been followed for 8 months since surgery without evidence of recurrence.

[[43.0, 'year']]

F

{'1634131': 1, '19155938': 1, '33360976': 1, '1503512': 1, '17506381': 1, '29181168': 1, '20227020': 1, '15566462': 1, '24596825': 2}

{}

3924737-1

noncomm/PMC003xxxxxx/PMC3924737.xml

Unusual presentation of retroperitoneal leiomyosarcoma mimicking an adnexal tumor with highly elevated serum CA-19-9

A 77-year-old woman was admitted with vague lower abdominal fullness and pain over six months. Tingling sensation on her right lower extremity has been developed since two months ago. Her menopause occurred at age of 45 years and she has never taken any hormone replacement therapy.\nA hard, fixed, and non-tender mass as large as a man's fist was palpated in right lower abdomen on pelvic examination. Contrast-enhanced abdominal computerized tomography (CT) showed 9.4 × 6.3 × 5.1 cm sized lobulated mass in right pelvic cavity (). It was seen relatively high enhanced and heterogenic mass on CT and causing hydronephroureterosis as a result of direct invasion of the ureter. The liver and renal function tests, and tumor markers such as CA-125, carcinoembryonic antigen, and alpha-fetoprotein were normal except the highly elevated level of CA-19-9 (70,000 U/mL).\nUnder the general anesthesia, surgical exploration was performed on suspicion of an ovary-origin tumor. The uterus and both adnexa showed normal appearance, however a 9 × 6 × 5 cm sized spherical mass with clear margin was found around right internal iliac artery in right retroperitoneal space (). No enlargement of lymph nodes around the mass and metastasis were found. Intraoperative frozen section analysis suggested of a leiomyosarcoma. Radical surgical resection was done including total hysterectomy, both adnexectomy, and right pelvic lymph node sampling. Surgical excision was attempted in order to completely remove the tumor after dissecting mesenteric adhesion. However, the tumor was firmly adhered to the ureter as well as right internal iliac artery and the tissue of tumor crumbled very easily. Tearing of internal iliac vein that occurred during dissection the mass from the ureter and internal iliac vessels was repaired by vascular surgeon. Most of the prominent mass was removed and the operation was finished with inserting an internal ureteral stent in the right ureter to prevent leakage or stricture due to undiagnosed latent ureteral injury.\nPathologic examination revealed a high-grade leiomyosarcoma with spindle-shaped tumor cells arranged in fascicles with intermediate dysplasia and also rich mitotic cell division (). On immunohistochemical staining, the sample showed positive results for vimentin, smooth muscle actin, and desmin; on the contrary, the sample was negative for CD31, CD34, and S-100 protein test (). The tumor was surgically staged as stage IIB (T2b2 N0 M0) leiomyosarcoma.\nThe patient started late oral diet after 7 days of operation due to a mild paralytic ileus, and then exercised well and showed no symptoms or signs of postoperative complication until 20 days when she could discharge after the operation. We had scheduled postoperative radiation therapy considering the patient's general condition 4 weeks later after surgery. The radiation treatment with 3 dimensional conformal radiotherapy using a 10 MV photon beam (Varian, Palo Alto, CA, USA) was applied to the tumor bed and total dose of 5,040 cGy was administered with a fractionated daily dose of 180 cGy, five days a week. Serum CA-19-9 returned to normal level (25.85 U/mL) in the end of radiation therapy. She is currently alive 12 months after treatment without recurrence or metastasis.

[[77.0, 'year']]

F

{'18514700': 1, '2540348': 1, '8751554': 1, '15160351': 1, '2511339': 1, '6266775': 1, '7998525': 1, '3750612': 1, '19829841': 2, '9742918': 1, '8522250': 1, '8299085': 1, '16926564': 1, '9457038': 1, '3366953': 1, '34392834': 1, '24596823': 2}

{'2740064-1': 1}

3924738-1

noncomm/PMC003xxxxxx/PMC3924738.xml

An unusual prenatal manifestation of a huge congenital cystic adenomatoid malformation with favorable perinatal outcome

A 33-year-old primi gravida was referred to our tertiary center at 21+3 weeks of gestation because of a suspected large thoracic mass with ascites. Ultrasonography was performed using the Accuvix A30 (Samsung Medison Co. Ltd., Seoul, Korea) with a 2 to 6 MHz transabdominal probe. The initial ultrasonography revealed a huge hyperechoic and well-defined mass in the right lung, occupying approximately three-quarters of the thoracic volume (). A cystic lesion of 25 mm in diameter was located centrally within the mass and this mass was supplied by the pulmonary artery (). The fetus was diagnosed with mixed CCAM. The heart was forced to the left side of the thoracic cavity, which made the left lung nearly invisible on the ultrasonography. The fetus was hydrophic, with massive ascites and scalp edema, and left cardiac function was decreased. No other abnormalities were found.\nFollowing extensive counseling on the prognosis and the possibility of intrauterine death, the parents chose to continue the pregnancy. The parents also did not wish to perform fetal karyotyping. Because of massive ascites, we decided to perform the abdomino-amniotic shunting immediately. The patient was admitted at 21+3 weeks of gestation and abdomino-amniotic shunting was performed. After successful shunting, the ascites disappeared () and the fetal hydrops was also resolved two weeks following the shunting. Serial ultrasonographs showed an alleviation of the mediastinal shifting, a decrease in mass size, and the appearance of the left lung (). Cardiac function also improved.\nA follow-up ultrasound at 36+1 weeks of gestation demonstrated retarded fetal growth with oligohydramnios, and therefore we decided to deliver the baby. The mother delivered an 1,890 g female fetus by Cesarean section at 36+3 weeks of gestation. Initial crying was good and the Apgar score were 7 and 8 at 1 and 5 minutes, respectively. However the baby developed respiratory distress soon after birth and was placed on a mechanical ventilator. Chest computed tomography (CT) showed a large solid mass with an internal cystic lesion in the right middle to lower lung, suggestive of CCAM (). On postnatal day 5, a lobectomy of the right middle and lower lung was performed. A pathology report confirmed the diagnosis of mixed CCAM. The baby was doing well without any respiratory symptoms at one month of follow-up.

[[33.0, 'year']]

F

{'20105595': 1, '9730204': 1, '8783108': 1, '19159718': 1, '9790364': 1, '21618254': 1, '15912480': 1, '18753764': 1, '19540178': 1, '12632377': 1, '22990987': 1, '17556826': 1, '24596822': 2}

{}

3924740-1

noncomm/PMC003xxxxxx/PMC3924740.xml

Vaginal adhesions in a woman with the history of dystocia

A 32-year-old woman (gravida 4, para 2) visited our institution due to dyspareunia lasting for 5 months after her second delivery. Seven years before her visit, she delivered her first baby by Cesarean section due to progression failure. However, she succeeded in vaginal birth after a Cesarean delivery (VBAC) for her second delivery at another institution. She reported that during her second labor, she underwent numerous pelvic examinations because her labor did not progress smoothly. Finally, she underwent a vaginal delivery of a female infant weighing 3,580 g without applying vacuum or forceps. She did not visit at her scheduled postpartum examination after her second delivery, therefore, her perineal area was not explored after her vaginal birth.\nAfter her second birth, she experienced dyspareunia and her husband could not resume his sexual activity due to inability to achieve full penile insertion. Also, she reported the immediate leakage of semen after intercourse. In addition, her menstruation did not resume, but she attributed this phenomenon to breastfeeding. There was no abnormal finding in her vital signs and laboratory tests. However, it was hard to insert the speculum fully into her vagina because of her blind vagina canal. Also, her cervix could not be visualized by speculum examination. As a result of a thick transverse vaginal septum blocking her vaginal cavity, we could insert a speculum only 2 to 3 cm into her vagina (). Transvaginal ultrasonography (Voluson 730 Expert, GE Medical Systems, Zipf, Austria) showed a transverse vaginal septum measuring 0.94 cm thick and a fluid-filled cavity beyond it (). Vaginal adhesion was diagnosed and she was admitted for treatment of this rare condition.\nAfter hospitalization, prophylactic intravenous antibiotics (3rd-generation cephalosporin with metronidazole) were administered first. After the day of admission, the fluid in the obstructed vaginal cavity was aspirated and examined. This fluid was turbid and had a foul odor but no bacteria were found upon culture examination. With this aspiration, we excised the vaginal septum and sutured the remained edge of this septum to the vaginal wall using 2-0 Vicryl (Ethicon Inc., Somerville, NJ, USA) (). After the operation, we inserted Vaseline gauze into the vaginal cavity to prevent re-adhesion and hemorrhage. This packed gauze was maintained during the whole hospitalization period and changed every day. Antibiotics were administered intravenously for 5 days and she was discharged on day 5 after the operation. Three months following surgery, she noticed an improvement in her dyspareunia and resumed sexual activity. Pelvic examination revealed a well-maintained vaginal cavity.

[[32.0, 'year']]

F

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{}

3924744-1

noncomm/PMC003xxxxxx/PMC3924744.xml

Successful pregnancy by direct intraperitoneal insemination in an infertile patient with failure of recanalization of isthmic stenosis after laparoscopic radical trachelectomy

On July 2006, a 32-year-old nulligravida had a laparoscopic radical trachelectomy with pelvic and paraaortic lymph node dissection due to cervical cancer IB1. The tumor size was less than 3.3 cm and pathology was confirmed as poorly differentiated squamous cell carcinoma with clear resection margin (). There were no postoperative complications and any adjuvant treatment was not given after operation.\nIn 2009, she visited our hospital due to amenorrhea for 6 months. Her serum follicle-stimulating hormone and estradiol concentrations were within the normal ranges with 8.1 mIU/mL and 210 pg/mL, respectively. Ultrasonography (USG)-guided sounding was performed for estimating isthmic patency and isthmic stenosis was confirmed. She wished to be pregnant and therefore she was referred to our infertility clinic. Routine work-up for infertility was performed. All laboratory tests including semen analysis showed normal results. We performed an USG-guided dilatation of isthmovaginal opening, nonetheless isthmovaginal recanalization failed. On August 2009, reconstruction of isthmovaginal opening and isthmovaginal anastomosis were performed again to solve this problem under general anesthesia. On the next month, intrauterine insemination (IUI) was performed during controlled ovarian stimulation (COS) cycle using gonadotropin releasing hormone (GnRH) antagonist multiple dose protocol (MDP) but she failed to become pregnant.\nOn January 2010, patient visited our infertility clinic for second cycle of IUI. Unfortunately, we found isthmic restenosis and decided to try DIPI after consultation with patient. On Feburary 2010, DIPI was performed under transvaginal (TV) USG guidance during COS cycle using GnRH antagonist MDP but patient failed to become pregnant. Although we performed second cycle of intraperitoneal insemination (IPI) during COS cycle using GnRH antagonist MDP on July 2010, patient also failed to get pregnant. On October 2010, DIPI in natural ovulatory cycle was performed again. When dominant follicle reached a mean diameter of 18 mm, a recombinant human chorionic gonadotropin (rhCG, Ovidrel, Merck Serono SA, Geneva, Switzerland) of 250 µg was administered subcutaneously to trigger follicular maturation. DIPI was performed 36 hours after rhCG injection. For DIPI, partner's semen was obtained by masturbation and liquefied at room temperature and then its amount, sperm concentration, and sperm motility were evaluated. Partner's sperm concentration was 214×106/mL and percentages of motile sperm and sperm with normal morphology were 61% and 23%, respectively. Semen was layered upon a dual-density gradient (Ception, Sage international, Trumbull, CT, USA) and centrifuged at 300 g for 20 minutes and then washed again with Quinn's sperm washing media (Sage international) by centrifugation at 300 g for 10 minutes. The vagina was cleansed and TV USG was performed to identify the fluid in the posterior cul-de-sac (PCDS) and ovaries. A 30 cm long 17 gauge disposable needle (Cook, Bloomington, IN, USA) was placed in a needle guide attached to the vaginal probe. The needle was put into the PCDS along the biopsy guide. The syringe containing the prepared semen sample is attached to the needle and the semen sample of 2 mL was injected directly into the PCDS (). Intravenous sedation was not carried out during DIPI. Luteal support was provided by administering 90 mg of vaginal progesterone gel (Crinone gel 8%, Merck Serono SA) once daily from the day of DIPI. Pregnancies were confirmed by rising serum β-human chorionic gonadotropin (β-hCG) concentrations and transvaginal ultrasonographic evidence of a gestational sac. Luteal support was commenced with 400 mg/day transvaginal progesterone insertion from the day of IPI. A serum β-hCG measured 20 days after DIPI was 2,660 mIU/mL and on the same day, a gestational sac with a mean diameter of 2.4 mm was visualized in TV USG. The intrapartum course was uncomplicated though whole pregnancy period. An amniocentesis for fetal karyotyping which was performed at 15 weeks of gestation showed normal results. Classical Ceasarean section was performed due to previous laparoscopic radical trachelectomy and T-lie presentation at 37 weeks of gestation and 3,330 g female baby was born and her Apgar score at 1 and 3 minutes after birth were 7 and 9. Both uterine artery embolization was performed after Cesarean section due to postpartum heavy uterine bleeding and then emergency transabdominal hysterectomy was performed due to persistent bleeding despite uterine artery embolization. On postoperative 15th day, she was discharged in good health.

[[32.0, 'year']]

F

{'9359638': 1, '10975559': 1, '14634572': 1, '9478296': 1, '16709216': 1, '25872891': 1, '16140367': 1, '15870565': 1, '8419221': 1, '15950660': 1, '7711381': 1, '24596824': 2}

{}

3924747-1

noncomm/PMC003xxxxxx/PMC3924747.xml

Laparoscopic management of pelvic splenosis

A 49-year-old Korean menopausal woman was referred to our hospital for lower abdominal pain and incidentally detected ovarian mass. She had undergone a laparotomy because of a traffic accident 25 years previously, and at that time a splenectomy had been performed to remove a ruptured spleen.\nOn physical examination, the patient had left lower abdominal tenderness without specific signs of peritoneal irritation or pelvic symptoms. A gynecological ultrasonogram showed a normal uterus and right ovary in terms of size and shape. However, a 45 × 30 mm homogeneous cystic mass adhered to the left ovary without ascites. Hematological values and serum levels of CA-125 and CA-19-9 were within the normal ranges. Abdominal pelvic computerized tomography, pelvic magnetic resonance imaging and chest computerized tomography scans revealed a 50 mm cystic mass in the left pelvic cavity and several small pleural nodules in the left lower lobe of the lung. We performed laparoscopic surgery to confirm the final diagnosis and relieve the patient's persistent abdominal pain. Adhesions of the greater omentum and the anterior wall of the abdominal cavity were found along the ligamentum teres. Adhesiolysis was performed using a harmonic scalpel (Ultracision Harmonic Scalpel, Ethicon Endo Surgery, Cincinnati, OH, USA). The lesions varied in size, were a purplish color, and were lobulated and hypervascularized along the mesocolon of the bowel from the sigmoid colon to the rectum (). The splenic nodules were entirely removed after dissecting them from the bowel. Rectum tearing was observed in the serosal layer, and primary closure was performed using 3-0 polyglactin 910 sutures (Vicryl, Ethicon Inc., Somerville, NJ, USA). In the pelvic cavity, 50×30 mm splenic nodules were seen on the upper side of the left uterosacral ligament, ureter, and lower lateral side of the left ovary (). The left pelvic wall peritoneum was carefully dissected and the splenic nodules were removed after locating the ureter in the retroperitoneal area. The largest mass adhered to the mesocolon, and was sent for frozen section examination and confirmation as normal splenic tissue (). The nodules were placed in an endo-bag (Lap-bag, Sejong Medical, Paju, Korea) and retrieved via a 12 mm trocar. The patient recovered without any complications and was discharged on the eighth postoperative day. The patient is currently being followed up without any other complications or specific symptoms.

[[49.0, 'year']]

F

{'16804467': 1, '15586507': 1, '12171856': 1, '17653553': 1, '9479721': 1, '19997810': 1, '30363257': 1, '7738925': 1, '16254119': 1, '15449073': 1, '17591312': 1, '19838993': 1, '11395829': 1, '24596826': 2}

{}

3927003-1

noncomm/PMC003xxxxxx/PMC3927003.xml

Endobronchial hemorrhage after intubation with double-lumen endotracheal tube in a patient with idiopathic thrombocytopenic purpura for minimally invasive cardiac surgery: a case report

A 62-year-old man (169 cm in height and 69 kg in weight) was admitted to hospital with dizziness and paresthesia of both hands. He was diagnosed with cerebral infarction, and while doing additional examination, cerebral infarction was assumed to be due to infective endocarditis. Transthoracic echocardiography showed large and hypermobile vegetations on anterior mitral leaflet. He was scheduled to have mitral valve replacement using MICS due to tremendous risk of systemic embolism.\nTwo months back, he was admitted to the Department of Neurosurgery in our hospital because of subarachnoid hemorrhage in left central sulcus and precentral sulcus, and blood spots on the lower limbs and thrombocytopenia (33,000 /mm3) were incidentally detected. Although in a bone marrow aspiration, pathologic finding was not observed and the platelet associated immunoglobulins was negative, ITP was clinically diagnosed. However, steroid therapy was not started immediately and his platelet count was examined as needed.\nHis platelet count was 40,000 /mm3 the day before surgery. Because MICS needed the use of heparin prior to cardiopulmonary bypass (CPB), we decided to transfuse platelets after surgery. For premedication, 0.2 mg of glycopyrrolate was injected intramuscularly 30 minutes before the surgery. Vital signs at the time of arrival at the operation room were blood pressure at 125/75 mmHg, heart rate at 98 beats/min, and oxygen saturation (SpO2) as 99%.\nFor the induction of anesthesia, while 0.1 µg/kg/min of remifentanil was infused for three minutes, 10 mg of etomidate and 10 mg of cisatracurium were also injected. Then a left-sided 35-french DLT was intubated with a stylet. The stylet was removed immediately after the tip of DLT passed through the vocal cords. When the tube was inserted at a depth of 29 cm to lips, resistance was felt. Tracheal cuff and the bronchial cuff were inflated with 6 ml and 2 ml of air, respectively. After making a judgment that the location of tube was appropriate by using bronchoscope, the bronchial cuff was deflated in order to prevent bronchial injury from postural changes, and there was no bleeding. Anesthesia was maintained with sevoflurane 1.5 vol%, oxygen 1.0 L/min, medical air 1.5 L/min and remifentanil 0.12 µg/kg/min were continuously infused intravenously. The patient underwent DLT change when we detected leakage of endotracheal balloon. After the exchange of DLT using tube exchange catheter, we confirmed the location of the DLT by using bronchoscope, and there was no bleeding. Insertion of superior vena cava (SVC) drainage catheter and central venous pressure catheter were performed via right internal jugular vein. Heparin 2,100 IU was administered to prevent clot formation of SVC drainage catheter. There was no sign of bleeding during those procedures. At the end of the procedure, we detected bleeding from the left side of DLT. The appearance of the bleeding was blood-tinged or frothy pink like pulmonary edema. The bleeding was sucked via suction catheter and the amount of the bleeding was about 150-200 ml. Due to the bleeding via the left side of DLT, we carried out lung separation immediately and decided to check the location of the bleeding with a fiberoptic bronchoscope. The carinal region and the left and the right bronchus were examined with a fiberoptic bronchoscope, but the focus of the bleeding in the traveling direction from the left mainstem bronchus was not detected. Because fiberoptic bronchoscopic view had poor visibility due to blood, we could not detect the focus of the bleeding and active bleeding from bronchus. Also, there was no bleeding via right side of DLT. Because we could not find the evidence of tracheobronchial laceration or rupture and the patient did not have any subcutaneous emphysema, and pneumomediastium, we excluded the possibility of mechanical injury of airway.\nBlood loss was estimated to be 150-200 ml over 30 min. Therefore, we suspected bronchial arterial injury; MICS was immediately stopped and bronchial artery embolization was scheduled in the angiographic room. Vital signs at that time, were blood pressure (BP) at 105/50 mmHg, heart rate (HR) at 115 beats/min, and SpO2 89%. During the transportation of the patient to the angiographic room, gradual decrease in the bleeding was noted, and the patient's vital signs in the angiographic room were stable (BP at 110-120/50-80 mmHg, HR 100 beats/min, and SpO2 99-100%). Angiography of the bronchial artery was performed, but focus of the bleeding was not found (). With reference to the risk of re-bleeding from the injured bronchial artery and the possibility of uncontrolled bleeding in patient with ITP, we decided to embolize the contributing bronchial arteries. After finishing the embolization of bilateral bronchial arteries, the chest X-ray was checked, and total atelectasis of left lung was observed (). There was no evidence of active bleeding, but blood clot was detected and removed using bronchoscope. After the removal of blood clot, an improvement in lung collapse was noted.\nThe patient was scheduled for MICS 6 days later. Due to lowered platelet count (54,000 /mm3), a high-dose IVIG therapy (35 g/day, 0.5 g/kg) for 2 days was started. Platelet count was increased to 87,000 /mm3 after 6 days. We intubated with single lumen endotracheal tube and lung isolation was achieved with intermittent total lung deflation. The surgery was done safely, and the outcome was favorable for the patient without any postsurgical decrease in platelet count or bleeding. He was extubated on the postoperative day (POD) 2, and transferred from the intensive care unit to the ward on POD 5. The patient left the hospital after making a full recovery on POD 28.

[[62.0, 'year']]

M

{'31080648': 1, '15111197': 1, '10800836': 1, '27162650': 1, '21881359': 1, '17018424': 1, '1712769': 1, '15073718': 1, '9354527': 1, '6187102': 1, '22361820': 1, '11887052': 1, '24567815': 2}

{}

3927004-1

noncomm/PMC003xxxxxx/PMC3927004.xml

The effect of ketamine as an additive in epidural block on the intractable herpetic neuralgia: a case report

A 35-year-old, 162 cm, 61 kg female patient was referred to our pain clinic due to severe painful rashes in the right lower extremity (L3 to L5 dermatome). Her past medical history included acute myeloid leukemia for 15 months and peripheral blood stem cell transplantation had been carried out eleven months previously. The rash had developed 25 days ago and clinical evaluation confirmed acute herpes zoster neuropathy. The viral skin lesions resolved successfully with intravenous acyclovir during the acute phase. However, the leg pain remained severe and significantly increased despite treatment with pregabalin, opioids, tricyclic antidepressants, corticosteroids, benzodiazepines and non-steroidal anti-inflammatory drugs. She suffered from continuous burning pain (8 points on verbal rating scale [VRS], 0 = no pain, 10 = worst pain imaginable) with intermittent electrical shock-like painful sensation (10 VRS) occurring approximately every 30 min, each lasting several seconds. The affected area was sensitive to touch and she felt numbness and tingling. She also reported intermittent discoloration on her affected dermatomes from red to dark red. She had been treated with pregabalin 450 mg, oxycodone 320 mg, tramadol 300 mg, fentanyl patch 100 µg, amitriptyline 10 mg, fluoxetine 20 mg in a day and morphine intravenous patient-controlled analgesia (PCA) with a basal rate of 4 mg/h and a bolus dose of 2 mg to control the pain. Despite escalating doses of medication and intravenous PCA infusion, her pain remained at 8 VRS. We considered lumbar epidural PCA infusion for pain relief. With patient approval, an epidural catheter was inserted into the L2-3 interlaminar epidural space and was confirmed on fluoroscopy. A sensory block below the L3 dermatome was established. However, continuous epidural PCA infusion of 0.375% ropivacaine and morphine sulfate 0.4 mg/h did not alleviate pain sufficiently (7 VRS). Approximately one week after epidural PCA administration, we tried single-shot ketamine (Ketomine®, Dai Han Pharmaceutical, Seoul, Korea) 5 mg, which was diluted in normal saline to 3 ml, through the lumbar epidural catheter. Within a few hours, she reported substantial pain relief without significant adverse effect (5 VRS). After three days, she received a second single-shot of ketamine 5 mg via the epidural route. The pain area was gradually reduced in size and allodynia was improved (3 VRS). Epidurally administered ketamine, in addition to ropivacaine and morphine, provided sufficient and prolonged analgesia. Five days later, the epidural PCA could be stopped and she was discharged in a stable condition with a VRS below 3. She has been followed in a VRS 2 to 3 by our pain clinic for the past four months and is undergoing tapering of her medications including pregabalin 75 mg and oxycodone 10 mg a day without further nerve block.

[[35.0, 'year']]

F

{'8424543': 1, '9414063': 1, '17006081': 1, '12950855': 1, '12966258': 1, '8838194': 1, '28298208': 1, '11020749': 1, '20526188': 1, '15136679': 1, '10707998': 1, '8942324': 1, '11973202': 1, '14742331': 1, '21846679': 1, '24567816': 2}

{}

3927005-1

noncomm/PMC003xxxxxx/PMC3927005.xml

The anesthetic experience of implantable left ventricular assist device insertion: a case report

A 75-year-old man (height, 165 cm; weight, 49.5 kg) was admitted for the medically-untreatable congestive heart failure. At 63 years of age, he underwent the aortic valve replacement with Medtronic Hall valve (Medtronic, Inc, Minneapolis, MN, USA) due to severe aortic regurgitation of rheumatic origin. A year after the operation, congestive heart failure was induced by tachycardia. Acute renal failure was wax and wane, according to his condition. He was taking warfarin and platelet aggregation inhibitor. His prothrombin time was 1.52 INR and platelet count was 7,5000/µl. Implantable LVAD insertion was decided as a better therapeutic option than cardiac transplantation because of his old age.\nDobutamine (3 µg/kg/min) had been continuously administered to stabilize vital sign from the ward. On arrival at the operating room, his blood pressure (BP) was 87/55 mmHg and the heart rate was 55 beats/min with atrial fibrillation. An invasive arterial catheter was placed in a radial artery with local anesthetic infiltration. Anesthesia was induced with 20 mg of etomidate, 50 mg of rocuronium, 50 µg of sufentanil and maintained with 1-2% isoflurane-medical air-O2 (fraction of inspired oxygen, 50%). BP immediate after the tracheal intubation () was 70/40 mmHg, but overcame within 3 min after using 20 mg of ephedrine, 20 µg of epinephrine and increasing in dose of continuous dobutamine infusion up to 10 µg/kg/min. Tidal volume was set at 8-10 ml/kg of ideal body weight and respiratory rate was adjusted 6-14/min to maintain arterial carbon dioxide tension at 35-45 mmHg. Mechanical ventilation was continued at 5 cycles/min with tidal volume of 5ml/kg of ideal body weight during cardiopulmonary bypass (CPB) for preventing atelectasis and ischemia reperfusion injury to the lung []. A pulmonary arterial catheter was inserted through the right internal jugular vein to monitor pulmonary artery pressure and obtain hemodynamic profiles, such as cardiac output and mixed venous O2 saturation, and placement of a TEE probe was performed.\nHis left ventricular (LV) ejection fraction was 20% by Simpson's method and the prosthetic valve was well-functioning on TEE. Severely dilated LV internal diameter was 69 mm at the end of contraction and mitral valve tethering with mitral regurgitation was observed. Before initiating CPB, atrial septal defect or patent foramen ovale was evaluated by TEE using agitated saline injection. Agitated saline test was done with pulmonary artery squeezing and confirmed absence of the right to the left shunt.\nRedosternotomy was extended into the upper abdomen. Blood pump pocket was secured below the diaphragm within the abdominal muscles. Outflow graft was anastomosed to the side of the proximal ascending aorta with partial clamping. Activated clotting time (ACT) was 688 sec after 150 mg of heparin administration and CPB flow rate was maintained with 4.2 L/min. Maze operation for atrial fibrillation was also implemented and the mechanical aortic valve was closed by over-sewing both sides of the valve with dacron patches. Using circular blade, LV apex was perforated parallel to the septum, and apical ring was completely inserted into the LV apex after apical muscle resection. Inflow conduit was put into the apical ring and prepared purse string suture enabled the ring tightened.\nAfter implantation, TEE showed the correct placement of inflow cannula near the LV apex () and no evidence of mitral regurgitation or right ventricular (RV) dysfunction. Twenty parts per million (PPM) of inhaled nitric oxide, 0.38 µg/kg/min of milrinone, and 2 µg/kg/min of isoproterenol were started to use before CPB weaning for preventing RV dysfunction after LVAD placement. In addition, 5 µg/kg/min of dobutamine, 0.2 mcg/kg/min of norepinephrine and 6 IU/h of vasopressin were used to manage hypotension and to prevent vasoplegia. After weaning from CPB, protamine 120 mg was slowly injected and ACT was checked 117 sec. Surgeons, anesthesiologists and perfusionists closely communicated volume status to maintain sufficient LVAD flow because of massive bleeding. Volume status was evaluated overall by a visual inspection of the heart, TEE and mixed venous O2 saturation. Estimated bleeding was 5000 ml and 7 units (U) of red blood cell (RBC), 5 U of fresh frozen plasma, 23 U of cryoprecipitate, and 2 U of plateletpheresis concentrate were transfused. A total of 4 gm of tranxaminic acid was injected.\nAfter surgery, he was transferred to the intensive care unit, and ongoing bleeding from the chest tube was 2 L during the first 3hours of admission. Coagulation studies identified no severe coagulopathy showing INR 1.42, ACT 135 sec, fibrinogen 236 mg/dl and platelet count 74,000/µl. Reoperation was immediately performed and LV apical site bleeding was successfully controlled. Extubation was done at 15 hours after the reoperation and he was moved to the general ward on postoperative day 10, without significant complications.

[[75.0, 'year']]

M

{'1951739': 1, '21603338': 1, '17258029': 1, '17717209': 1, '19920051': 1, '12595851': 1, '20884019': 1, '22907611': 1, '21822483': 1, '19875309': 1, '16146463': 1, '22910088': 1, '18344554': 1, '18154801': 1, '20346326': 1, '24567817': 2}

{}

3927006-1

noncomm/PMC003xxxxxx/PMC3927006.xml

Isolated central venous pressure elevation caused by hematoma formation compressing the superior vena cava following a Bentall operation: a case report

A 70-year-old male patient underwent a Bentall operation due to annulo-aortic ectasia, which was combined with severe aortic valvular insufficiency. The patient's height and weight were 165 cm and 50.9 kg, respectively and he had no co-morbid diseases except for hypertension, which was treated with a calcium channel blocker and an angiotensin converting enzyme inhibitor. The patient had a normal sinus rhythm, and the preoperative transthoracic echocardiography (TTE) revealed a left ventricular ejection fraction of 58% with no other intracardiac pathologies. Coronary angiography also revealed normal coronary arteries. After anesthetic induction, the patient's hemodynamic variables were as follows; systemic blood pressure 113/38 mmHg, heart rate 83 beats/min, central venous pressure 9 mmHg, and pulmonary arterial pressure 33/15 mmHg. A Bentall procedure was uneventfully performed and the patient was weaned off from cardiopulmonary bypass (CPB) without difficulty. The total aorta cross clamp time was 95 minutes and the total CPB time was 115 minutes. Before leaving the operating room, there was no evidence of fluid collection in the pericardial and pleural space in the transesophageal echocardiography (TEE), with the estimated left ventricular ejection fraction being 50%. Receiving norepinephrine 0.08 µg/kg/min, milrinone 0.25 µg/kg/min, and vasopressin 0.8 IU/hr, the hemodynamic parameters were as follows: heart rate of 80 beats/min, blood pressure of 87/48 mmHg, CVP of 10 mmHg, pulmonary arterial pressure of 24/15 mmHg, cardiac index of 3.4 L/min/m2, mixed venous oxygen saturation of 90%, right ventricular ejection fraction of 39%, and right ventricular end diastolic volume index of 141 mm/m2. The patient was transported to the intensive care unit (ICU) without any further events. In the ICU, as in the operating room, the patient's lungs were ventilated with a tidal volume of 500 ml at a rate of 12 breaths/min, with a fraction of inspired oxygen of 40% medical air, along with 5 cmH2O of positive end-expiratory pressure. The corresponding peak airway pressure and plateau airway pressure were 19 cmH2O and 17 cmH2O, respectively. The arterial blood gas analysis revealed pH 7.419, PaO2 123.8 mmHg, and PaCO2 34.7 mmHg. Over a period of 30 minutes in the ICU, the CVP increased from 10 to 23 mmHg, and the pulmonary artery diastolic pressure increased from 14 to 17 mmHg. The blood pressure was 90/49 mmHg, and the cardiac index was maintained at 2.7 L/m/m2 without increasing doses of norepinephrine, milrinone, and vasopressin. The electrocardiogram (ECG) revealed nonspecific ST wave changes without any changes in the height of the QRS waves, and the chest X-ray showed partial atelectasis of the right lung and moderate cardiomegaly. The patient's respiratory mechanics and follow-up arterial blood gas analysis showed no significant changes. His hemoglobin was 8.7 g/dl which is near the former value measured in the operating room of 9.0 g/dl. The platelet count was 82 × 109/L and the International Normalized Ratio of the prothrombin time was slightly elevated at 1.54. During the first 15 minutes after the surgery, 100 ml of blood were drained from his mediastinal and chest drains. Because, there was no further chest tube drainage, 100 ml of 6% hydroxyethyl starch 130/0.4 solution was infused without any transfusions.\nA TEE examination was immediately performed to confirm the cause of the CVP elevation, which revealed minimal pericardial fluid collection and preserved biventricular function in the midesophageal four-chamber view and the transgastric short axis view. The midesophageal bicaval view showed the right atrium (RA) being pushed anteriorly and laterally by a large mass measuring 6.06 cm × 8.78 cm (). The mass contained echogenic materials with some echo-free areas, which is consistent with hematoma, and as a result the SVC was almost completely obliterated by it. In the midesophageal aortic valve long axis view, the hematoma occupied the transverse sinus as well (). The patient was immediately transferred to the operating room for re-exploration. A loculated hematoma around the valved graft was found to compress the entire SVC and extended to the RA. After evacuation of the hematoma, the CVP decreased immediately from 23 to 11 mmHg. The cardiac index and the blood pressure remained stable despite the discontinuation of the vasopressor and inotropic agents. However, the patient's postoperative course deteriorated, with the development of acute renal failure and adult respiratory distress syndrome, which resulted in the prolongation of ICU stay. The patient was then transferred to the general ward at postoperative day (POD) 52 for rehabilitation, and discharged at POD 109.

[[70.0, 'year']]

M

{'17138107': 1, '18490312': 1, '7585756': 1, '3597984': 1, '3974274': 1, '10516545': 1, '8325120': 1, '19049749': 1, '18704767': 1, '2373832': 1, '11359740': 1, '24567818': 2}

{}

3927007-1

noncomm/PMC003xxxxxx/PMC3927007.xml

Usefulness of intraoperative real-time three-dimensional transesophageal echocardiography for pre-procedural evaluation of mitral valve cleft: a case report

A 38-year-old woman planned to undergo open heart surgery to surgically correct a known severe MR. She had a history of undergoing percutaneous balloon valvuloplasty due to rheumatic mitral stenosis (MS) during a previous pregnancy 10 years before. At the preoperative evaluation employing 2D TTE, a tearing of the tip of a mid part of the thickened anterior mitral valve leaflet (AML) was suggested to be the main reason for a coaptation defect producing severe MR; two-chambered views using color Doppler showed a severe central MR jet projecting into an enlarged left atrium (, and ). MVR to install a bioprosthetic valve was planned preoperatively considering the technical difficulties and worse outcome of a patch repair of a large defect on the free margin of the AML.\nAfter induction of anesthesia, a 3D-TEE probe (X7-2t transducer; Philips Healthcare, Andover, MA, USA) was placed and connected to a TEE console (iE33™, Philips Healthcare, Andover, MA, USA) and intraoperative 2D and 3D TEE examinations were performed. The 2D TEE images in the midesophageal commissural and long axis views also supported the preoperative diagnosis regarding a severe MR and systolic coaptation defect between the AML and posterior mitral leaflet (PML) (, and ). However, intraoperative real time 3D TEE provided more detailed spatial information on the MR pathology, which was entirely different from that suggested by the preoperative TTE; the "en face view" in the left atrial perspective showed a cleft in the middle of the PML, a ruptured chordae attached to the P3 scallop moving toward the left atrium during systole, and fusion of both ends of the MV commissures producing mild MS (, ). Interestingly, the defect or cleft in the AML, which had been suggested, was not observed.\nThe feasibility of MVRep was reevaluated considering this new and different intraoperative diagnosis. Finally, after confirming a cleft in the P2 scallop by direct observation through atriotomy, MVRep, consisting of posterior mitral valvuloplasty with patch closure and lifting posterior annuloplasty, was successfully performed.\nPost-procedural TEE evaluation including the RT 3D TEE view and post-operative TTE showed a satisfactory surgical outcome with sufficient diastolic opening greater than 3.5 cm2 without any residual MR (, ).

[[38.0, 'year']]

M

{'25378966': 1, '19922602': 1, '11568022': 1, '16928491': 1, '18848134': 1, '26083781': 2, '8186582': 1, '16581480': 1, '22537396': 1, '11568021': 1, '20553320': 1, '19931098': 1, '11330754': 1, '12221412': 1, '26495063': 2, '24567819': 2}

{'4610932-1': 1, '4495461-1': 1}

3927008-1

noncomm/PMC003xxxxxx/PMC3927008.xml

Torsade de pointes in liver transplantation recipient after induction of general anesthesia: a case report

A 53-year old male (height 173.6 cm, weight 75.6 kg) was scheduled for emergency cadaveric donor liver transplantation due to hepatitis B virus-related liver cirrhosis and hepatocellular carcinoma. Microvascular angina was diagnosed 2 years earlier with atypical chest pain. Coronary angiography at that time showed no significant stenotic findings. The patient was diagnosed with atrial fibrillation at the same time, and he was started on nicorandile, molsidomine, isosorbide dinitrate, digoxin, furosemide, and spironolactone. An anticoagulant was excluded due to bleeding tendencies. Furthermore, the patient had liver cirrhosis-related diabetes mellitus, portal hypertensive gastropathy, and esophageal varix.\nECG was performed just before surgery and showed atrial fibrillation with a normal heart rate (). The calculated QTc interval was 455 ms. The patient had mild mitral regurgitation and tricuspid regurgitation, but no regional wall motion abnormality was seen on preoperative echocardiography. The calculated left ventricular ejection fraction was 68%, and the mean pulmonary arterial pressure was 24 mmHg. The PT INR was 1.38, total bilirubin was 2.2 mg/dl, platelet count was 48,000 /µl, and albumin was 2.5 g/dl. Other blood test findings were within normal limits.\nWithout preoperative medication, the patient entered the operating room and his vital signs were measured immediately. His blood pressure (BP) was 117/73 mmHg, heart rate (HR) was 80 beats/min, and his pulse oximetry oxygen saturation (SpO2) was 99%. After preoxygenation with a mask by applying 100% O2 at 6 L/min for a few minutes, palonsetron 0.075 mg, lidocaine 40 mg, and propofol 120 mg were administered intravenously. After the patient lost consciousness, manual assisted ventilation was performed with 100% O2 at 6 L/min and 5 vol% sevoflurane; in addition, rocuronium 50 mg was injected. With full relaxation, the patient's trachea was intubated using a cuffed 7.5 mm endotracheal tube without difficulty. The radial and femoral arteries were cannulated, followed by continuous arterial blood pressure monitoring. A central venous catheter (AVA HF; Edwards Lifesciences, Irvine, CA, USA) was placed at the right internal jugular vein with no resistance or difficulty. A pulmonary artery catheter (Swan-Ganz CCOmbo; Edwards Lifesciences, Irvine, CA, USA) was inserted and pulmonary artery pressure monitoring was started. By ECG, no clinically significant change occurred during insertion of the pulmonary artery catheter. The catheter's position was checked with a chest X-ray. Anesthesia was maintained with 0.7 L/min O2, 1.3 L/min air, and 1.5-4.0 vol% sevoflurane. Initial arterial blood gas analysis (ABGA) revealed normal electrolyte levels and adequate oxygenation. ECG showed atrial fibrillation, but no clinically significant abnormal change was observed.\nAt 50 minutes after the patient's arrival, the surgeon started to prepare for surgery. At that time, sudden-onset large QRS tachycardia () appeared, and the femoral and radial arterial waves became flat. The end tidal CO2 (ETCO2) pressure dropped rapidly, from 35 to 13 mmHg. Epinephrine 100 µg and calcium chloride 300 mg were administered twice. One of the surgeons started cardiac compression immediately, and mechanical ventilation was continued with 100% O2. Epinephrine 1 mg was injected intravenously. During CPR, defibrillation was performed four times using 150-200 J, and epinephrine 1 mg was administered intravenously every 3-5 minutes. Amiodarone 300 mg mixed with 100 ml of normal saline was administered. Additionally, magnesium sulfate 2 g and lidocaine 70 mg were injected intravenously. Calcium chloride, regular insulin, and sodium bicarbonate were also administered after checking ABGA (). During CPR, a bloody secretion started to come out of the endotracheal tube, and the peak inspiratory pressure increased. We repeatedly suctioned the endotracheal tube, and alveolar recruitment via manual bagging was attempted a few times.\nAfter 30 minutes of CPR and the last defibrillation, large QRS tachycardia disappeared and ECG revealed a normal sinus rhythm. Simultaneously, the femoral and radial arterial waves recovered to normal wave forms. The patient's systolic BP was 80-85 mmHg, his HR was 40-45 beats/min, and ETCO2 was 17-19 mmHg. After the return of spontaneous circulation, we loaded 50 µg/kg milrinone intravenously and started continuous infusion of milrinone at 0.5 µg/kg/min and epinephrine at 0.1 µg/kg/min. Regular insulin, sodium bicarbonate, and vasopressin were also administered. The patient's temperature was 34.7℃, and both pupils were dilated without a light reflex.\nA few minutes later, the patient's SpO2 increased to 100%, and ETCO2 increased to 28 mmHg. The patient's vital signs stabilized at a HR of 80-85 beats/min, systolic BP over 100 mmHg, and mean BP over 80 mmHg. Without proceeding with the operation, the patient was transferred to the intensive care unit (ICU). The total exposure time to anesthesia was about 110 minutes. 1 L of crystalloid and 400 ml of colloid were infused, and the patient's urine output was 30 ml during anesthesia. On arrival at the ICU, the patient's BP was 98/62/76 mmHg, his SpO2 was 100%, and ECG showed atrial fibrillation with a HR of 80 beats/min. The patient's pupil reflex returned to a normal response. Electrolytes and cardiac enzymes were evaluated. Neither hypokalemia nor hypocalcemia was detected, and all electrolyte values were within normal levels. The patient's CK was 106 IU/L, CK-MB was 2.6 ng/ml, and Troponin I was slightly elevated to 0.10 ng/ml. Bedside echocardiography revealed no regional wall motion abnormality or evidence of myocardial ischemia.\nOn the second day of ICU admission, pulse-less large QRS tachycardia appeared twice. Both events were terminated after applying defibrillation using 150 J and cardiac compression for 2 minutes. Metabolic acidosis, intravascular volume loss, and pulmonary edema were aggravated and the patient's BP and SpO2 continued to decrease. On the fourth day in the ICU, the patient expired. ECG showed a marked prolonged QTc interval (). Nevertheless, cardiac echocardiography performed on the day of the patient's expiry showed normal findings. No regional wall motion abnormality was observed, and the left ventricular wall thickness was normal with a calculated ejection fraction of 56%. The patient's systolic pulmonary arterial pressure was 33 mmHg.

[[53.0, 'year']]

M

{'14579055': 1, '1898684': 1, '15618804': 1, '15915019': 1, '9792266': 1, '10624970': 1, '12895263': 1, '8067651': 1, '16510203': 1, '25866603': 1, '17495272': 1, '16306750': 1, '27601752': 1, '28367281': 1, '3047813': 1, '9425913': 1, '15318470': 1, '22499746': 1, '24567820': 2}

{}

3927077-1

noncomm/PMC003xxxxxx/PMC3927077.xml

Clear cell variant of solid pseudopapillary neoplasm of pancreas diagnosed by fine needle aspiration: A case report and review of the literature

A 22-year-old woman was admitted to the hospital for abdominal pain. Ultrasonogram showed a solid/cystic mass, 2.6 cm in diameter, in the tail of the pancreas. Percutaneous ultrasound-guided fine needle aspiration biopsy (FNAB) was performed using a 22-gauge needle. Rapid onsite evaluation was performed using Diff-Quik-stained smears. Additional smears were fixed in ethanol and stained by the Papanicolaou method. The excess material was fixed in an alcohol-formalin solution for cell block preparation and paraffin sections were stained by hematoxylin and eosin. Immunocytochemical stains were performed on cell block sections.\nThe material was highly cellular and consisted of a monotonous population of loosely cohesive small to medium-sized, round to cuboidal epithelioid cells exhibiting high nuclear/cytoplasmic ratio, finely granular “salt and pepper” chromatin and nuclear grooves. Pseudopapillary structures with arborizing capillaries and metachromic core on Diff-Quik-stained smears were lined by epithelioid cells. Acinar and rosette-like formations, as well as single neoplastic cells were observed []. The background was clean, but scattered foamy histiocytes were present. Many tumor cells exhibited single or multiple clear cytoplasmic vacuoles, displacing the nucleus [Figures and ]. The vacuoles were well-defined and variable in size, producing coin-shaped empty spaces in the cytoplasm [Figures and ]. Necrosis and mitosis were not seen. Coin-shaped vacuoles were mimicking signet-ring appearance on the cell-block [Figures and ]. Periodic acid-schiff (PAS) and mucicarmine stains were negative on the cell block sections.\nTumor cells showed strong nuclear staining for β-catenin and cytoplasmic staining for vimentin and CD10 [Figures –]. The stains were negative for chromogranin A, synaptophysin and cytokeratin.

[[22.0, 'year']]

F

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{'2964857-1': 1, '8289679-1': 1, '4637475-1': 1, '4637475-2': 1}

3927081-1

noncomm/PMC003xxxxxx/PMC3927081.xml

Ruptured venous aneurysm of cervicomedullary junction

A 52-year-old male with no known previous comorbidities presented with sudden onset headache, vomiting, and transient loss of consciousness. Patient was conscious but disoriented with no focal motor/sensory deficit. Computed tomography (CT) head revealed subarachnoid hemorrhage (SAH) with intraventricular hemorrhage (IVH) [].\nComputerized tomography angiography (CTA) [Figure –] and digital substraction angiography (DSA) [Figure and ] revealed a saccular contrast filling pouch in the left lateral aspect of CMJ. The filling was seen in early venous phase on DSA. No arterial feeder could be demonstrated. There was no AVM in the vicinity of the lesion suggesting a diagnosis of solitary alone venous aneurysm.\nPatient was operated through a midline suboccipital craniectomy with excision of posterior arch of atlas. Dura was opened in Y shape. There was no apparent dural AVM. There was evidence of old subarachnoid blood with presence of thick subarachnoid adhesions. A saccular pliable structure approx. 1.5 × 1cm was found in the subarachnoid space. Its color was indicative of venous blood. Careful dissection revealed the attachment/neck of the aneurysm with a vein. There were no arterial feeders, or evidence of surrounding AVM or dilated perimedullary vein. This aneurysm was clipped and excised [Figure –]. Gross examination revealed a thin walled vascular structure with no arterial ostia. There was a thrombus present. HPR revealed a single layer of fibromuscular tissue lined [] by a flat endothelium. There were no signs of sclerosis or inflammation. There was no muscle layer [Figure and ]. Patient was discharged on 5th postoperative day. Postoperative DSA did not show any aneurysm/AVM. On the last follow up at 5 months after surgery, the patient has no focal deficits and has joined work.

[[52.0, 'year']]

M

{'31440718': 1, '31315589': 1, '712396': 1, '23176338': 1, '20587229': 1, '24575317': 2}

{}

3927087-1

noncomm/PMC003xxxxxx/PMC3927087.xml

Convexity meningiomas enhanced by sodium fluorescein

A 72-year-old male with recurrence of an atypical meningioma, involving both frontal convexity and superior sagittal sinus (SSP). A partial removal of the bifrontal mass with residual tumor in the SSP, with transoperative SF administration, showed strong evidence of dural and tumoral dye enhancement [Figures and ]. Dural removal at the surrounding meningioma site was also enhanced by SF; there was evidence of meningioma presence in the histological analysis []. Cytogenetic analysis showed sexual chromosome Y deletion. The patient had a good neurological outcome.

[[72.0, 'year']]

M

{'21125008': 1, '11117842': 1, '8413869': 1, '22559847': 1, '23061394': 1, '15309910': 1, '23372974': 1, '16398473': 1, '10048072': 1, '26623234': 1, '20380529': 1, '13406590': 1, '18210365': 1, '27800481': 1, '18872412': 1, '23430234': 1, '30519770': 1, '9657492': 1, '23346330': 2, '24575318': 2}

{'3927087-2': 2, '3927087-3': 2, '3927087-4': 2, '3550426-1': 1}

3927087-2

noncomm/PMC003xxxxxx/PMC3927087.xml

Convexity meningiomas enhanced by sodium fluorescein

A 62-year-old male with headache and seizures, presenting a large left frontal cystic meningioma on magnetic resonance imaging (MRI) went through a radical removal, with SF transoperative tumor and surrounding dura enhancement. Histological analysis showed evidence of meningothelial meningioma and the dural surrounding area was negative, even with SF irregular enhancement. The patient was discharged without neurological abnormalities.

[[62.0, 'year']]

M

{'21125008': 1, '11117842': 1, '8413869': 1, '22559847': 1, '23061394': 1, '15309910': 1, '23372974': 1, '16398473': 1, '10048072': 1, '26623234': 1, '20380529': 1, '13406590': 1, '18210365': 1, '27800481': 1, '18872412': 1, '23430234': 1, '30519770': 1, '9657492': 1, '23346330': 2, '24575318': 2}

{'3927087-1': 2, '3927087-3': 2, '3927087-4': 2, '3550426-1': 1}

3927087-3

noncomm/PMC003xxxxxx/PMC3927087.xml

Convexity meningiomas enhanced by sodium fluorescein

A 60-year-old female with headaches showing a meningioma in the left motor area on MRI. Transoperative SF administration was used, as described below, with positive tumor and a surrounding dura enhancement []. On histological examination evidence a psamommatous meningioma was seen []. The dural tail surrounding the meningioma area was equally tumoral.

[[60.0, 'year']]

F

{'21125008': 1, '11117842': 1, '8413869': 1, '22559847': 1, '23061394': 1, '15309910': 1, '23372974': 1, '16398473': 1, '10048072': 1, '26623234': 1, '20380529': 1, '13406590': 1, '18210365': 1, '27800481': 1, '18872412': 1, '23430234': 1, '30519770': 1, '9657492': 1, '23346330': 2, '24575318': 2}

{'3927087-1': 2, '3927087-2': 2, '3927087-4': 2, '3550426-1': 1}

3927087-4

noncomm/PMC003xxxxxx/PMC3927087.xml

Convexity meningiomas enhanced by sodium fluorescein

A 37-year-old female with headaches showing a meningioma in the right frontal lobe on MRI. Transoperative SF administration enhanced tumor and a surrounding dura [Figures and ]. On histological examination a transitional meningioma was seen. The dural tail surrounding the meningioma area was involved by the disease. Cytogenetic analysis showed a 22 monosomy.

[[37.0, 'year']]

F

{'21125008': 1, '11117842': 1, '8413869': 1, '22559847': 1, '23061394': 1, '15309910': 1, '23372974': 1, '16398473': 1, '10048072': 1, '26623234': 1, '20380529': 1, '13406590': 1, '18210365': 1, '27800481': 1, '18872412': 1, '23430234': 1, '30519770': 1, '9657492': 1, '23346330': 2, '24575318': 2}

{'3927087-1': 2, '3927087-2': 2, '3927087-3': 2, '3550426-1': 1}

3927088-1

noncomm/PMC003xxxxxx/PMC3927088.xml

Noninvasive diagnosis and management of spontaneous intracranial hypotension in patients with marfan syndrome: Case Report and Review of the Literature

A 58-year-old, right-handed female with a history of Marfan syndrome, mechanical aortic valve replacement on warfarin anticoagulation, and hypertension presented to NYU Medical Center complaining of a severe, sudden-onset headache after straining at stool. She described her headache as diffuse, with radiation to the neck, dizziness, and light-headedness. She had experienced a single episode of severe nausea with vomiting. The headache worsened in the upright position.\nOn neurologic examination, the patient was awake, alert, and fully oriented. Her cranial nerves were grossly intact. She had no focal motor, sensory, or cerebellar deficits. Fundoscopic examination revealed no papilledema. Physical exam findings consistent with Marfan syndrome included dolichostenomelia and arachnodactyly, and her cardiovascular examination confirmed a mechanical aortic valve. The remainder of her exam was noncontributory. The patient's INR was 4.2, consistent with warfarin anticoagulation. All other laboratory tests were within normal limits.\nImaging of the brain demonstrated mild dilatation of the lateral ventricles with crowding of the gyri, and inferior displacement of the posterior fossa structures, with the cerebellar tonsils extended below the level of the foramen magnum []. An atrial diverticulum was noted as a medial out-pouching of the trigone of the left lateral ventricle [].\nNeurosurgery was consulted to evaluate the patient. She was admitted to the neurosurgical intensive care unit for monitoring and repeat imaging to rule out worsening ventriculomegaly. The suspicion of SIH due to tonsillar herniation in the setting of diagnosed Marfan syndrome prompted empiric treatment with intravenous hydration and keeping the patient flat for 48 hours. Warfarin anticoagulation was stopped to prepare for the possibility of an urgent intervention and an intravenous heparin drip was started the following day. Repeat CT was stable, the patient's symptoms declined steadily, and gradual elevation of the head of the bed was tolerated.\nAs the patient was anticoagulated for a mechanical aortic valve, she was considered ineligible for LP to evaluate opening pressure or administer contrast for conventional myelography. Correspondingly, definitive evaluation was completed via noninvasive MR myelography and spinal MRI [Figure and ]. Multiple sacral and thoracic root sleeve cysts and paraspinal thin bands of CSF were observed in the left thoracic region, consistent with CSF extravasation [Figure and ]. DE was noted at multiple levels from L3-S2, with positive findings by Oosterhof's, Ahn's, and Söylen's criteria []. Of note, the patient also had a significant scoliotic deformity, which may have introduced a degree of error into applying these metrics.\nGiven the resolution of the patient's symptoms under conservative management, no further interventions were required. During her hospital course the patient suffered a silent myocardial infarction, but she was ultimately discharged home without additional complications. She has remained free of orthostatic headaches for 15 months since this event.

[[58.0, 'year']]

F

{'3189335': 1, '11256662': 1, '19963654': 1, '19159394': 1, '11883832': 1, '27843325': 1, '20376739': 1, '17502658': 1, '10560599': 1, '11889250': 1, '20662850': 1, '8151355': 1, '16596670': 1, '11723293': 1, '26692704': 2, '17233313': 1, '11134370': 1, '9452231': 1, '19225772': 1, '10489939': 1, '10602862': 1, '32754800': 2, '15682009': 1, '22929030': 1, '8613851': 1, '10489951': 1, '19949036': 1, '14683542': 1, '16928994': 1, '27278058': 1, '17018311': 1, '12034948': 1, '19461064': 1, '20591885': 1, '21220378': 1, '16859269': 1, '15616116': 1, '8723076': 1, '11477262': 1, '10974720': 1, '24575323': 2}

{'7403223-1': 1, '4660503-1': 1}

3927089-1

noncomm/PMC003xxxxxx/PMC3927089.xml

Optic nerve glioma: A great mimicker

A 27-year-old male presented with progressive, painless loss of vision in right eye, associated with vomiting and headache for one and a half months, without accompanying loss of consciousness or fever. He had a history of seizures 4 years back, for which he was on antiepileptic drugs. On clinical examination, there was no perception of light in the right eye while left eye vision was normal. Computed tomography (CT) scan revealed a contrast enhancing mass arising from planum sphenoidale with mass effect []. The adjacent pituitary fossa and cavernous sinus were normal.\nPerioperative findings showed a grayish pink, nonsuckable tumor firmly adherent to the right optic nerve and expanding it. The tumor was also attached to basal dura and falx. Debulking surgery was performed. A clinical impression of an intradural, optic nerve sheath meningioma was made.\nHistopathological examination of the excised tumor revealed a moderately cellular glial tumor intermixed with extensive reactive proliferation of arachnoid cells. The tumor cells were present in a fibrillary background and exhibited minimal nuclear pleomorphism. No mitosis, necrosis or micro-vascular proliferation was noted. Adjacent to the tumor, there was marked fibroblastic and arachnoid cell proliferation with chondroid as well as chordoid differentiation along with myxoid change and dense collagenisation. The sharply outlined tumor was reticulin poor while the adjacent reactive areas were rich in reticulin fibers. On immunohistochemistry using Dako antibody kit, the tumor cells expressed glial fibrillary acid protein (GFAP). [] Epithelial membrane antigen (EMA) highlighted the reactive arachnoid cells. The chondroid areas were positive for S-100. A final diagnosis of optic glioma displaying exuberant arachnoid proliferation with cartilaginous metaplasia was made.\nPostoperatively, there was no improvement in the vision. Recurrence of tumor was noted after a period of four months and debulking surgery was repeated. Histopathological examination confirmed the presence of glioma (grade I) having similar morphology as the previous tumor displaying extensive fibro-mesenchymal proliferation of the meninges. The patient is on regular follow-up, however, there is still no improvement in the vision.

[[27.0, 'year']]

M

{'16628460': 1, '12955759': 1, '486377': 1, '19155759': 1, '9429946': 1, '8009427': 1, '15534587': 1, '4202807': 1, '27648262': 2, '24575324': 2}

{'5018588-1': 1}

3927090-1

noncomm/PMC003xxxxxx/PMC3927090.xml

Temporary clamping of bilateral external carotid arteries for surgical excision of a complex dural arteriovenous fistula

A 52-year-old male presented with head heaviness and headache, which he had for 3 weeks. He was sent to our emergency room due to his syncope and seizure. Computed tomography (CT) angiography of the brain revealed no intracranial hemorrhage but did show numerous engorged vessels in bilateral cerebral hemisphere and superficial scalp. However, digital subtraction angiography (DSA) showed numerous arterial feeders from the bilateral parietal-occipital scalp and dura, which shunted into superior saggital sinus with cerebral venous reflux, compatible with DAVFs, Cognard type IIb [Figure and ]. Urgent surgical intervention for excision of fistulas and skeletonization of the diseased sinus was performed after temporary clamping of bilateral ECAs. Intraoperative angiogram showed complete obliteration of fistula and normal venous return [Figure and ]. Eventually, the patient had good recovery without any morbidity. The modified Rankin scale (mRS) was also zero at discharge.

[[52.0, 'year']]

M

{'4813431': 1, '8814191': 1, '22107862': 1, '20979438': 1, '17881955': 1, '23259821': 1, '22274970': 1, '22610384': 1, '7815143': 1, '7862961': 1, '8609567': 1, '31692910': 1, '6864280': 1, '16340491': 1, '24575325': 2}

{'3927090-2': 2}

3927090-2

noncomm/PMC003xxxxxx/PMC3927090.xml

Temporary clamping of bilateral external carotid arteries for surgical excision of a complex dural arteriovenous fistula

A 48-year-old male presented with chronic headache, which he had suffered for several years, with pulsatile bruit sound over the bilateral ears. Neurological examination revealed no specific neurological deficit. CT angiography of the brain revealed no intracranial hemorrhage but did show numerous engorged vessels in bilateral cerebral hemisphere and superficial scalp. DSA showed DAVFs, Cognard type IIb, in sagittal-torcular region with numerous arterial feeders from bilateral ECAs with cerebral venous reflux [Figure and ]. It is risky to excise fistulas involving torcular region so surgical excision of arterial feeders and skeletonization of diseased sinus as possible was planned. The purpose of surgery is to reduce abnormal shunting flow and to prepare for further endovascular embolization or radiosurgery while identifying the exact fistula well. Using temporary clamping of bilateral ECAs, the partial excision of the complex DAVFs became easy [Figure and ]. Later, transarterial embolization (TAE) with Onyx (ev3, Irvine, California) was performed to obliterate the residual DAVFs successfully. The mRS was also zero at discharge.

[[48.0, 'year']]

M

{'4813431': 1, '8814191': 1, '22107862': 1, '20979438': 1, '17881955': 1, '23259821': 1, '22274970': 1, '22610384': 1, '7815143': 1, '7862961': 1, '8609567': 1, '31692910': 1, '6864280': 1, '16340491': 1, '24575325': 2}

{'3927090-1': 2}

3927091-1

noncomm/PMC003xxxxxx/PMC3927091.xml

C7 intralaminar screw placement, an alternative to lateral mass or pedicle fixation for treatment of cervical spondylytic myelopathy, kyphotic deformity, and trauma: A case report and technical note

A 67-year-old female who fell from standing approximately 2 weeks prior to transferring to our institution is presented. Over the 2-week period, the patient complained of worsening upper extremity function and decreased ability to ambulate.\nThe patient was diffusely weak in all muscle groups (4/5) distal to her triceps. Brisk reflexes were present in her bilateral lower extremities but clonus and Babinski were absent. Computed tomography (CT) of the cervical spine showed advanced spondylosis C4-7 with central canal and foraminal stenoisis. Of note, the lateral masses of C7 were small (8 mm) compared with adjacent lateral masses (8 mm) [Figures and ]. Also concerning were the size of the C7 pedicle, 4 mm []. The C7 lamina was large (6 mm thick and 30 mm in length) [].\nThe patient underwent a C3-6 laminectomy with C3-6 lateral mass and C7 intralaminar internal fixation (Mountaineer, Depuy Spine, Johnson and Johnson, Raynham, MA). Lateral mass screws were placed in standard fashion and each of the C3-6 lateral masses held either a 12 or 14 × 3.5 mm screw. C7 intralaminar fixation was achieved by drilling two pilot holes (Midas Rex, Medtronic) with a 3 mm matchstick at the spinolaminar junction []. The first pilot hole was drilled at the caudal aspect of the spinolaminar junction, 4 mm from the caudal laminar edge. The second pilot hole was drilled at the rostral aspect of the spinolaminar junction on the opposite operative side as the initial pilot hole, 4 mm from the rostral laminar edge. The hand drill was then used to extend the hole at 2 mm increments parallel to the angle of the lamina while checking for breaches with a ball trip probe. Two 3.5 × 24 mm intralaminar screws were then placed and attached to a rod with offset connectors. No intraoperative fluoroscopy was used.\nThe patient slowly regained strength and continues to improve in a rehabilitation facility. Postoperative imaging reveals good screw placement with a good construct. Neural elements are well decompressed.

[[67.0, 'year']]

F

{'22339053': 1, '32309663': 1, '29354732': 1, '30443487': 1, '21325933': 1, '11012049': 1, '26949456': 1, '19769494': 1, '24575319': 2}

{}

3927094-1

noncomm/PMC003xxxxxx/PMC3927094.xml

Subarachnoid hemorrhage due to nonbranching aneurysm of the middle cerebral artery in a young adult with a history of Kawasaki disease

A 20-year-old male experienced a sudden onset of headache, nausea, and vomiting. He was brought to a nearby hospital, where a head computed tomographic (CT) scan revealed SAH. He was immediately transferred to our hospital for emergency treatment. He had a history of Kawasaki disease, which was believed to be cured. He had severe atopic dermatitis and was allergic to pollen, dogs, cats, and soba. There was no relevant family medical history and no previous history of forceps delivery, major head injury, and infectious or valvular disease. On arrival at our hospital, his Glasgow Coma Scale score was 14 points (E3V5M6). Physical and neurological examination revealed no specific abnormal deficits. Laboratory blood tests also revealed no abnormalities. Plain CT of the brain showed SAH, localized in the right sylvian fissure, and evidence of skull fracture []. Subsequent CT angiography indicated an aneurysm of the right M2, which was not at a bifurcation site []. Magentic resonance (MR) angiography revealed that the aneurysm had a stalk-like narrow neck. A pseudoaneurysm was suspected on the basis of the atypical location and shape of the aneurysm, his age, and his medical history of Kawasaki disease. Preoperative echocardiography rejected the presence of bacterial endocarditis and other heart abnormalities. As far as we could examine, there were no other vascular abnormal findings other than the aneurysm described here including aneurysms of other locations.\nThe sylvian fissure was identified and opened to expose the two parallel M2 branches. The M1 and the parental artery were then subsequently secured. A thin-walled, pseudo-looking aneurysm was found buried in the frontal lobe, but it appeared to be clippable []. A 5-mm bayonet-type clip (Sugita 2, Mizuho) was chosen and several attempts were made to close the ruptured hole without narrowing the parental artery []. A doppler study confirmed good flow through the artery, and the aneurysm appeared to be completely obliterated. The thin aneurysm wall was partially trimmed for pathological analysis and Neoveil™ was wrapped around the neck. The aneurysm wall appeared extremely thin and fragile and was surrounded by some clots.\nHistopathological examination revealed that the aneurysm wall primarily consisted of thinkened tunica intima. Granulation tissue presented with edematous chronic inflammatory cell invasion and intermediate invasion of macrophages, fibroblasts, myofibroblasts, and vascular endothelial cells. There was mild invasion of lymphocytes and plasmacytes, but no neutrophils []. Lack of black Elastica van Gieson (EVG) staining demonstrated complete absence of elastic lamina. EVG staining, Masson's trichrome staining, and smooth muscle actin (SMA) immunohistochemistry also demonstrated the lack of smooth muscle cells in the tunica media. There was no atherosclerotic change in the tunica intima, which is usually observed in cerebral aneurysms [].\nAfter surgery, the patient regained consciousness and exhibited a full postoperative recovery. Two weeks later, CT angiography showed complete amelioration of the aneurysm and normal flow of the parent artery []. Plain CT after sugery also confirmed an intact brain []. His postoperative course was uneventful without any neurological deficits, and he was discharged 2 weeks after admission.

[[20.0, 'year']]

M

{'15695145': 1, '31484231': 1, '17143642': 1, '5921326': 1, '15574639': 1, '15200066': 1, '15834727': 1, '18703893': 1, '31105641': 1, '20578798': 1, '7187577': 1, '20672936': 1, '8890993': 1, '16133271': 1, '10449069': 1, '31096739': 1, '30803189': 1, '18448971': 1, '31346934': 1, '24575320': 2}

{}