diff --git "a/Patient_info_and_summary.csv" "b/Patient_info_and_summary.csv"
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+Name,Age,Date_of_Birth,Phone_Number,Email,Address,Patient Progress Summary
+Emery Rodriguez,21,2001/1/5,(669)765-9245x489,hannahdyer@example.org,37784 Ramirez Spurs Suite 713,"A 17-year-old, nonparous girl presented with a one-month history of noticeable pelvic mass and was diagnosed to have a left ovarian tumour in 2007 with a raised serum CA-125 of 350 IU/L. Other tumour markers were not performed due to financial constraint. An intraoperative frozen section revealed immature teratoma and she underwent fertility sparing surgery. A staging laparotomy with left salpingo-oophorectomy, peritoneal cytology, pelvic lymph nodes sampling, and infracolic omentectomy was performed. Postoperative histology report revealed mature teratoma with focal area of immature teratoma of the left ovary. There was no malignant cell infiltration to the omentum or lymph nodes. Histology revealed immature teratoma grade I, FIGO stage 1a. Despite being advised for close surveillance, she defaulted followup after 6 months postoperative.
+One year later, she presented with lower abdominal discomfort and resought medical advice. She developed radiological recurrence of pelvic mass with a raised serum CA-125 of 180 IU/L following which she completed 6 courses of systemic chemotherapy (carboplatin-paclitaxel). After chemotherapy, the tumour marker normalised (<35 IU/L) but the pelvic mass progressively increased in size. CT scan of the abdomen and pelvis revealed presence of bilateral large adnexal masses with infiltration into uterus and also possibly to the sigmoid colon. Growing teratoma syndrome was suspected. She underwent staging laparotomy and complete excision of the tumour. Full bilateral pelvic lymphadenectomy was done. Postoperative CT scan of the abdomen and pelvis showed no residual disease. Histology of excised mass revealed mature teratoma with no presence of immature cells. The patient remained with no recurrence at the time of this report, which is 8 months after the second operation for GTS."
+Henry King,26,1988/8/27,804.973.3503x9745,cheryl36@example.com,96232 Ashley Ways Suite 547,"A 55-year-old Vietnamese male with no significant past medical history presents to a local community hospital emergency department because of abdominal pain and distention of two-week duration. The abdominal pain was generalized, described as cramping, present throughout the day, had no association with meals, and was getting progressively worse. The patient also reported nausea and vomiting clear material. He denied any recent fever, chills, night sweats, weight loss, change in bowel habits, sick contacts, and consumption of raw food. In addition, he denied any chest pain, shortness of breath, joint swelling, and skin rash. After immigration from Vietnam 11 years ago, his only travel outside the USA was back to his homeland one year prior to this illness. The patient was not taking any prescribed or over the counter medications or herbal compounds and denied any allergies. His physical examination showed no skin rash or jaundice, cardiopulmonary examination showed no abnormality, and the abdomen was moderately distended, with active bowel sounds, diffuse tenderness without rebound, and moderate ascites. There was no hepatomegaly or abdominal mass.
+In the emergency department, a complete blood count and comprehensive metabolic panel were significant for an elevated white blood count of 15.400 with 36% eosinophils. Abdominal and pelvis computer tomography (CT) showed moderate ascites with thickening of the gastric antrum and proximal small bowel (). The patient was admitted to the general medical service and placed on bowel rest and intravenous fluid hydration. Further he underwent esophagogastroduodenoscopy (EGD), which demonstrated mild duodenitis and biopsies demonstrated mild nonspecific acute inflammation predominantly lymphocytic. Stool tests were negative for ova and parasites. In addition, a screen for Cryptosporidium, Cyclospora, Isospora, and Sarcocystis did not reveal evidence of recent infection. Over several days, the patient's abdominal pain improved, diet was advanced, and he was discharged home with an empiric trial of albendazole for a presumptive diagnosis of parasitic infection.
+Two weeks after discharge, the patient was readmitted with worsening abdominal pain. Physical examination showed increased abdomen distention. Repeated blood counts and serum biochemical tests demonstrated an increase in white cell count of 17.100/mL with 71% eosinophils (absolute eosinophil count of 12.141/弮l with normal upper limit <450) (). Liver function tests continued to be within normal limits. Serum IgE level was elevated at 548 IU/mL (normal < 180). Repeat stool tests were negative for ova and parasites. Furthermore, immunologic studies for Toxocara, Trichinella, Strongyloides, Filiaria, Schistosoma, Echinococcus, and Cysticerus were negative.
+Repeated EGD was nondiagnostic. Flow cytometry of peripheral blood revealed no myelo- or lymphoproliferative findings. Serum 帣-2-microglobulin and LDH were 2.2 mg/dL (normal: 0.8??.0) and 170 U/L (normal: 80??00), respectively. Ultrasound guided abdominal paracentesis showed WBC count of 6600/mL, 95% of which were eosinophils (), LDH 284 mg/dL, albumin 3.2 g/dL (simultaneous serum albumin 4.1 g/dL). In order to exclude small bowel lymphoma, the patient underwent diagnostic laparoscopy with full-thickness biopsy of an inflamed portion of the jejunum. This revealed skipped areas of hyperemia and discoloration involving the small intestine and to a lesser degree the colon in addition to yellow-green ascites (). Histopathological evaluation showed marked eosinophilic infiltration of the muscularis propria and serosa with concomitant mild acute inflammatory reaction (). There was no evidence of malignancy, granuloma, TB, or parasites.
+The constellation of clinical presentation and histopathological findings were suggestive of eosinophilic gastroenteritis. Subsequently, the patient was started on oral prednisone (20 mg/day). Two weeks later and with noticeable symptomatic improvement, the prednisone was tapered over a two-week period. After completion of steroids, the patient's abdominal pain and physical finding of ascites completely resolved and a peripheral blood count revealed an absolute eosinophil count of 300/弮l (nL < 450). Furthermore, IgE level dropped to 105 IU/mL and CT imaging of the abdominal and pelvis showed complete resolution of the ascites and small bowel thickening. Four months have elapsed since treatment and the patient remains asymptomatic on no medications."
+Victoria Daniels,30,1982/6/2,+1-856-413-4368x190,barbarahoward@example.org,1117 Kaiser River Suite 673,"The first case involved a 43-year-old man with a past medical history of hyperlipidemia and hypertension who presented to the hospital with chest pain. The chest pain was described as a pressure-like sensation in the center of his chest, 8/10 in severity, and radiated down his left arm. Upon presentation, vital signs were stable, cardiac biomarkers were within normal limits, and the electrocardiogram (EKG) showed no ST/T-waves changes. Transthoracic echocardiogram showed normal left ventricle function and no wall motion abnormalities. Of note, the patient had a similar presentation and ER course two weeks prior.
+Due to the fact that the patient continued to have 8/10 chest pain during his hospital stay, coronary angiogram was ultimately done. The angiogram showed normal coronary arteries without evidence of coronary vasospasm or an existing myocardial bridge. Slow flow, however, was noted in the left anterior descending artery (LAD). An intracoronary adenosine challenge was done and showed normalization of the TIMI (Thrombolysis in Myocardial Infarction) frame count (). The patient was given the diagnosis of coronary slow flow phenomenon and started on dipyridamole 50 mg three times a day and discharged home.
+On six-month followup, the patient reported that he had been chest-pain-free. Shortly after his six-month followup, the patient ran out of his medicine and again began to experience chest pain. Once the patient was placed back on his dipyridamole, he became chest-pain-free."
+Xander Santana,32,2000/6/28,362.516.5576x16185,udavenport@example.net,14752 Michael Path Suite 576,"The second case involved a 70-year-old gentleman with a past medical history of squamous cell carcinoma of the base of tongue six years prior. The patient presented with a single episode of chest pain at rest described as pressure-like and associated with shortness of breath and diaphoresis. Admission EKG revealed T-wave inversion in the anterior leads and a prolonged QT interval (). Cardiac enzymes were also noted to be elevated (CKMB 8.3 IU/l and troponin I 1.14 ng/mL). Transthoracic echocardiogram showed normal left ventricular function with no wall motion abnormalities or left ventricular hypertrophy. A diagnosis of non-ST-elevation myocardial infarction (NSTEMI) was made, and the patient was started on the appropriate acute coronary syndrome medications. Left heart catheterization was done the following day and revealed normal coronary arteries with slow flow noted in LAD. An intracoronary adenosine challenge was done that showed normalization of the TIMI frame count (). The patient was given the diagnosis of coronary slow flow and started on amlodipine 2.5 mg daily. On 6-month followup, the patient reports that he has been chest-pain-free."
+Myra Hunter,20,2003/12/11,-9773,brandon65@example.org,459 Carmen Hill Apt. 378,"An 18-year-old woman with a history of eczema during childhood presented with complaints of episodes of generalized urticaria, nasal congestion and secretion, conjunctivitis, and periorbital and labial oedema 6?? hours after coitus. There was no vaginal itching or burning.
+Total IgE was slightly elevated, 350 (0??50) KIU/L. The Phadia Immunocap and the Multiple Allergen Simultaneous Test-chemiluminescent Assay (MAST CLA) test panels were negative []. Histamine release tests for latex, the partners saliva, sweat and semen were performed. The histamine release test procedure includes histamine release from peripheral whole-blood basophils, in a glass fiber prepared microtiter plate, by challenging 25 弮L heparinised whole blood with 25 弮L buffered allergen dilutions in various concentrations for 60 minutes at 37簞C. The assay is calibrated by a two-point standard curve and a positive cell control (anti-IgE) []. The test results are given as negative or positive. Histamine release tests for latex and for the partners saliva and sweat were negative, whereas the test was positive for the partners semen. The partners sweat, saliva, and semen were also tested in blood from a healthy control person, and these tests were all negative. Furthermore, a skin prick test was performed in the patient finding a positive reaction with a diameter of 12 (positive control 5) mm for the partners semen. Skin prick tests with the partners semen were also performed in two healthy women finding negative results.
+During the first 6 months after a diagnosis of anaphylaxis to human seminal plasma was established, condom usage was not sufficient for prophylaxis. Even close body contact such as kissing and hugging would cause acute urticaria, sneezing, and conjunctivitis despite daily intake of oral antihistamines, however, life-threatening anaphylactic reactions did not occur. Sexual intercourse was only possible on prednisolone 25 mg/day; so, the couple opted for abstinence and slept in separate rooms during most of that period. Between 6 and 12 months after the diagnosis was established, gradually, body contact became possible, and some months later with the use of a condom and on premedication with oral antihistamines coitus was possible without associated symptoms. During the second and third years after diagnosis the patient would still use oral antihistamines prior to intercourse several times per week; however, the condition was challenged on a regular basis by the couple showing milder and milder symptoms. Five years after the diagnosis incidental episodes of provocation caused by condom defects and intended challenges without condom were not associated with significant symptoms. A skin prick test in the patient for the partners semen at that time found a positive reaction of a diameter of 10 (positive control 7) mm. The patient did not report any other sexual partners."
+Archer Booth,39,2003/10/31,899.766.9407x82755,gmolina@example.com,547 Kelly Groves Suite 740,"A 17-year-old man, high school student, with no relevant medical history was admitted for 10 days of intense global headache accompanied by nausea and vomiting. He was hospitalized for 4 days before admission at another institution, where imaging studies were performed with simple brain scan reported as normal and then discarded central nervous system infection. The patient was managed with analgesics and was discharged. For persistence of the headache and sensory symptoms including hypoesthesia in right hemibody with slight loss of muscle strength, he was admitted again. He was evaluated by the Neurology Department with a physical examination which showed a blood pressure of 138/76, heart rate of 88 beats per minute, and respiratory rate of 17 per minute, temperature of 37 degrees, neurological exam with fluent speech, cranial nerves normal, fundus with absence of venous pulses bilaterally, muscle strength of 3 of 5 in right hemibody, tendon reflexes of +++ numbness in right hemibody. No nuchal rigidity or other signs of meningitis were identified. A new magnetic resonance imaging study with gadolinium and venography reported cerebral sinus thrombosis of the superior longitudinal sinus with venous infarction in subacute phase (Figures and ). Given the findings, it was decided to initiate anticoagulation with unfractionated heparin and warfarin. Further investigations ruled out infectious etiology. He was studied for primary thrombophilia identifying a mutation in the prothrombin gene with the following test: ?en F2 was analyzed using quantitative chain reaction (qPCR) with amplimers and subsequent extension of thermal dissociation curve. Platform Roche Light Cycler. It confirms the presence of G20210A mutation in the prothrombin gene. The mutation was found in heterozygous state, means that the patient has copy of the mutated gene.??The patient has a total resolution of symptoms and continues with oral anticoagulation with warfarin."
+Zariyah Blanchard,35,1984/9/29,868.737.7002x36809,kvance@example.org,55908 Kirsten Orchard,"A 47-year-old man presented at our attention for fever and abdominal pain in the right lumbar region without urinary symptoms. His medical history did not reveal any diseases. An abdominal ultrasonography detected an oval mass measuring 6 cm in diameter to the right para-aortic region. A CT confirmed the presence of a solid mass (53.3 ? 48 ? 60 mm3); the involvement of adjacent viscera was unclear, in particular the kidneys, renal vessels and right psoas muscle, while the cava vein appeared displaced in an anterior-medial direction (). The mass appeared well-encapsulated and defined. No signs of von Recklinghausen? disease were identified. Liver function tests were normal and preoperative tumour markers, including carcinoembryonic antigen (CEA) and carbohydrate antigen 19.9 (CA19.9), were not elevated.
+A CT-guided fine needle biopsy (FNB) showed a benign neoplasm of peripheral nerves tissue, characterized by the presence of elongated and wavy cells positive of S-100 protein. For these symptoms, the patient underwent a surgical resection that started with a subcostal incision after right ureteral stent placement. At the intra-abdominal exploration, the lesion appeared to constrict the cava vein and displace the right kidney, the renal vein () and the right ureter. These structures were identified and preserved after a sharp dissection. The specimen was extracted with en-bloc resection. Total operative time was 177 minutes with negligible intraoperative blood loss. The postoperative hospital course was uneventful, and the patient was discharged after 6 days. Pathology examination revealed a well-circumscribed lesion composed of loosely arranged tumour cells with the typical fascicular and wavy pattern of growth, plenty of collagen fibers and myxoid areas. We evaluated the expression of calretinin in our case, showing a weak stain in less than 25% of tumour cells, confirming the diagnosis of Neurofibroma (). During a multidisciplinary meeting, a clinical and instrumental follow-up was recommended. At the 8-month follow-up, the CT scan was completely negative."
+Adler Mathis,43,1991/7/5,845-263-0963x320,alanrivera@example.com,6402 Nguyen Lodge Suite 172,"A 52-year-old female with history of hypertension, smoking, alcohol dependence, and coronary vascular disease with recent myocardial infarction was admitted due to acute change in mental status. The patient had a spontaneous intraventricular hemorrhage, and an emergency bedside ventriculostomy was performed. Her hospital course was marked by persistent fevers in spite of multiple negative blood, cerebrospinal fluid (CSF), and urinary cultures. She received empiric levofloxacin intravenously 750 mg daily and vancomycin 1 gram intravenously every 12 hours until day 9 of hospitalization. Her neurologic function steadily improved, and the ventriculostomy was discontinued on day 11. However, her CSF cultures on that day yielded coagulase-negative staphylococcal (CoNS) species. Vancomycin 1 gram and rifampin 600 mg intravenously were administered every 12 hours. On day 15, computerized tomography (CT) of the head demonstrated increased intraventricular hemorrhage requiring reinsertion of an external ventriculostomy. Repeated CSF analysis demonstrated elevated WBC (57 cells/mm3 and protein 149 mg/dL) with decreased glucose (67 mg/dL). CSF cultures yielded CoNS again. Cultures of CSF continued to yield CoNS for the next three days despite the addition of daptomycin intravenously at 10 mg/kg (dosed at actual body weight) daily. As a result, intraventricular daptomycin was added on day 18, 10 mg daily for the first two days and then every other day. Culture of CSF became sterile on day 25 following 7 days of daptomycin intravenous and intraventricular therapy in addition to continued administration of intravenous vancomycin and rifampin. The second ventriculostomy was discontinued on day 38 (as was rifampin administration). Intravenous daptomycin and vancomycin were discontinued on day 55 after 37 days of dual treatment. Mental status progressively improved during this time.
+Daptomycin peak and trough levels in the CSF were measured on day 29, and day 30, respectively (correlating to day 10 following the start of intravenous and day 11 following the start of intraventricular daptomycin). The peak CSF level (following intravenous and intraventricular administration) was 6.30 mcg/mL on day 29 and the trough CSF level was 1.39 mcg/mL on day 30. The serum trough level on day 30 was 20.15 mcg/mL, and the minimum inhibitory concentration (MIC) of CoNS to daptomycin was <1 mcg/mL.
+The remaining hospital course was complicated with respiratory failure requiring tracheostomy and ventilation support, ventilator-associated pneumonia, sacral pressure ulcer, and Clostridium difficile colitis. The patient was successfully discharged on day 65 to a rehabilitation center."
+Anne Glass,37,2000/5/2,001-733-202-7272x66215,david64@example.net,8343 Sara Causeway Apt. 566,"A 66-year-old male was seen in a USAID, Academic Model Providing Access to Healthcare (AMPATH) Partnership clinic in western Kenya, complaining of general body itchiness and skin patches on the chest for 3 months prior to contact. He had tested HIV positive three months prior to enrollment at the clinic. He complained of poor appetite and had lost 3 kg. He did not report any allergies to food or drugs, did not smoke, but reported that he takes alcohol (local brew) 2-3 times/week.
+On physical examination, he was in fair general condition with a BP of 100/60 mmHg, pulse rate of 92 beats per minute, temperature 36.1簞C, and arterial oxygen saturation of 93% while breathing ambient air. He weighed 65 kgs. His skin had 3 hypopigmented and hypoaesthetic patches on the right chest wall and right upper arm. The largest lesion measured 5 by 6 cm and the smallest 2 by 3 cm. Other systems were essentially normal. Baseline investigations revealed a CD4 cell count of 145/mL, CD4 percentage 10%, white blood cell count of 2800/uL, Hemoglobin 12.3 g/dL, and platelets count of 178,000/uL. SGPT and creatinine were within normal ranges. His chest X-ray was without evidence of pathology.
+An impression of Tinea corporis was made and the patient assigned WHO clinical stage 2 due to weight loss of <10%. He was given cotrimoxazole prophylactic therapy and clotrimazole cream. One month later, the patient was started on an ART regimen composed of stavudine, lamivudine, and nevirapine after adherence counseling. The patient's progress (CD4 counts, viral load and weight) is summarized in .
+The patient had poor adherence based upon missed clinic appointments and self report. There is documented history that the patient did not take his medications for a period of one month during the 3rd year of ART. He attributed this to social stressors. An outreach worker had to visit his home to remind him of clinic visits. After several adherence counseling sessions, his plasma viral load dropped from 1,084,798/mL at 29 months of treatment to 433,376/mL six months later. At this point, virological treatment failure was confirmed based on a plasma viral load of >5000 copies/mL. A decision was made to continue with first-line ART until perfect adherence is maintained for at least six months before initiating second-line ART. All this time the skin lesions persisted despite regular use of clotrimazole cream.
+After demonstrating good adherence, the patient was initiated on second-line ART regimen including abacavir, didanosine, and aluvia (Lopinavir/Ritonavir) 47 months after initiating first-line ART. The skin lesions persisted but did not increase in number or size. A decision to refer him to the regional center for leprosy was made where a skin smear was done and was positive for acid fast bacilli. According to Ridley-Jopling system, he was classified as having borderline tuberculoid leprosy based on having three lesions only that were well demarcated, asymmetrical, and unilateral. However, there was no enlargement of the nerve trunks and no neurological deficits other than the hypoaesthesia. According to the WHO classification, he was classified as having multibacillary leprosy based on having a positive skin smear on at least one site. Seven months after initiating second-line ART, he was put on rifampicin 600 mg monthly, clofazimine 300 mg once a month and 50 mg daily and dapsone 100 mg daily for 12 months which is the WHO recommended multidrug treatment (MDT) regimen for multibacillary leprosy. Six months later, the skin lesions had resolved, there was no neurological sequelea, and a check viral load was 188 copies/mL.
+Eighteen months since initiating MDT for leprosy, the patient remained stable without new lesions, nor neurological deficits. A follow-up skin biopsy showed mild chronic inflammation with noncaseating granulomas. Fite's Acid fast stain for leprosy was negative. Genotypic viral resistance testing performed revealed resistance mutations to nonnucleotide reverse transcriptase inhibitors (NNRTI's) and nucleoside reverse transcriptase inhibitors (NRTI's) but none to protease inhibitors (PI's)."
+Allan Martin,24,1978/2/23,453.361.7956x949,oking@example.net,770 Frye Wall Suite 349,"A 51-year-old man who lived in Trabzon, Turkey, was admitted to the hospital because of anorexia, dizziness, nausea, vomiting, diarrhea, and weight loss. During the previous few months, he had developed dark skin pigmentation noted by his family and lumbar back pain. He had knee surgery for a torn meniscus 5 months before admission; the past medical history otherwise was negative. Examination showed low blood pressure (90/50 mm Hg), severe orthostatic hypotension, and inguinal lymphadenopathy. Laboratory studies showed high erythrocyte sedimentation rate (50 mm/h), high C-reactive protein (14.5 mg/L), low-serum sodium (121 mmol/L), high-serum potassium (7.5 mmol/L), high-serum creatinine (2.2 mg/dL), and low-serum cortisol (5 弮g/dL).
+The diagnosis of acute adrenal crisis was made, and the patient was started on intravenous fluid replacement and methylprednisolone. Microscopic examination of the stool showed leukocytes and erythrocytes, and ciprofloxacin was started; however, stool cultures showed no pathologic microorganisms and the diarrhea resolved within 2 days. After 2 days of intravenous steroids, the serum sodium and creatinine levels became normal. Fludrocortisone was added because of resistant hyperkalemia.
+Further studies showed a low adrenocorticotropic hormone (ACTH) level (5.41 pg/mL) under treatment. Magnetic resonance imaging (MRI) of the upper abdomen showed asymmetrically enlarged adrenal glands (coronal diameter: right, 9 mm; left, 11 mm), consistent with bilateral adrenal hyperplasia (). Possible reasons that may cause adrenal insufficiency by infiltrating adrenal glands were sought throughly. Considering tuberculosis; the patient could not produce a sputum sample, and chest radiography was normal.
+Inguinal sonography showed multiple, enlarged (diameter, 1.5 to 2 cm), hypoechoic, nonreactive right inguinal lymph nodes with thickened cortex; excisional biopsy of an inguinal lymph node showed caseating granulomas, consistent with granulomatous lymphadenitis (). Lumbar MRI showed loss of vertebral body height and the presence of pathologic signal in L1 and L2, consistent with compression fracture, metastasis, or infection (); lumbar vertebral biopsy, performed by an open surgery, showed chronic, necrotic, caseating granulomas consistent with tuberculous osteomyelitis (). Polymerase chain reaction assays of homogenates of the lymph node and vertebral specimens were negative for Mycobacterium tuberculosis. Further evaluation was negative for other chronic diseases, diabetes mellitus, human immunodeficiency virus infection, and malignancy.
+The patient was treated with isoniazid, rifampicin, and pyrazinamide for 1 year, in addition to steroids (5 mg/day, fludrocortisone 0.1 mg/day). Two months after antituberculous therapy was completed, the glucocorticoid and mineralocorticoid drugs were stopped, and the patient was monitored closely as an inpatient. After 1 week of discontinuing steroid therapy, the morning serum cortisol was (7.3?? 弮g/dL), and ACTH was high (874??65 pg/mL). A Synacthen stimulation test was not performed as the level of ACTH was already very high. MRI of the adrenal glands showed bilateral asymmetric adrenal hyperplasia, similar to that observed 1 year earlier. The patient was begun again prednisolone (5 mg/d) and advised to increase the dosage during stressful conditions including fever, surgery, dental extraction, strenuous exercise with sweating, during extremely hot weather, and with gastrointestinal upsets such as diarrhea []."
+Mila Huynh,26,1980/5/5,8446533368,tammy22@example.org,358 Chandler Dam,"A 20-year-old man referred to surgery department of Faghihi hospital, affiliated to Shiraz University of medical science, due to painless left axillary mass for 2 months duration. His past medical history was unremarkable. On physical examination he had stable vital signs. A firm mass was palpated at the left axillary area measuring about 8 ? 7 centimeter (cm). There was no evidence of hepatosplenomegaly and generalized lymphadenopathy.
+Left axillary ultrasound examination showed a well-defined superficial mass with area of punctate calcification with no evidence of hemorrhage and necrosis, suggestive of an enlarged lymph node ().
+The patient's lab data including complete blood count with differential and biochemical tests were within normal limits. Chest X-ray and abdominal ultrasound were normal. The left axillary mass was excised. On gross inspection, there was a firm creamy brown lymph node, measuring 8 ? 7 ? 5 cm with focal areas of white discoloration and hard consistency (). Histologic examination revealed follicular pattern with large nodules of mantle cells arranged concentrically around atrophic and vascularized germinal centers (Figures and ). There was also some benign-appearing bone trabeculae interspersed with lymphoid tissue ().
+The diagnosis based on histologic examination was Castleman's disease, hyaline-vascular type with osseous metaplasia."
+Layton Cardenas,41,1984/8/7,(498)508-1250,tatetimothy@example.org,6770 David Crossing Apt. 083,"A 5-year-old boy presented to our hospital 2 days after being involved in a motor vehicle crash (MVC) with a velocity of 32 miles per hour. He was knocked down from the side while crossing the road as a pedestrian and was ejected about seven yards from the vehicle. On examination he had signs of torticollis to the right side, decreased reflexes and decreased power in his right arm (indicative of a brachial plexus injury), and decreased sensation below the clinical level of the second lumbar vertebra (L2). He also suffered decreased anal tone and lost bladder control. A Magnetic Resonance Image (MRI) demonstrated spinal cord oedema at the level of the second cervical vertebra (C2) () as well as spinal cord injury with oedema from the level of the 10th thoracic vertebra till the first lumbar vertebra (T10-L1) (). There were also facet joint fractures with disrupted ligamentum flavum and interspinous ligaments at the level of the second and third vertebrae (L2-L3). Prior to the surgical procedure the cervical spine radiographs were normal.
+After the MRI was performed, the patient underwent decompression of the spinal cord and fusion of the second and third vertebral bodies (L2-L3) (). Afterwards he was admitted to the postoperative ICU for five days, where he developed right-sided paralysis of the diaphragm and subsequent pulmonary complications as well as a urinary tract infection. Computed Tomography (CT) scanning performed postoperatively demonstrated no further abnormalities. The outcome of this boy was good; he returned to normal life."
+Raven Hayden,44,1995/10/21,477.812.9844,don97@example.com,2797 Hernandez Trail Suite 280,"A 41-year-old Caucasian female patient with a past medical history significant for NF presented for open biopsy of her left tibia. The patient detailed a one and a half year progressive weakness and pain in her left ankle. Initial plain film radiographic examination in August 2010 showed a 3 ? 1.5 ? 2 cm destructive lesion of the cortical bone in the distal tibia. MRI analysis of the lesion in September 2010 showed a larger enhancing 5.7 ? 4.6 cm lesion. At that time the patient underwent Tru-Cut soft tissue biopsy of the mass with pathology confirming a nerve sheath tumor. However, there was insufficient tissue to determine malignancy and further tests were required. After a brief loss to follow up for insurance and financial difficulties, another MRI examination in January 2011 revealed an even larger 6.5 ? 5.1 cm T2 hyperintense lesion eroding through the tibia with a 2.4 cm proximal periosteal extension. The patient's condition had also deteriorated, and she now required crutch support for ambulation. She reported decreased sensation to cold, light touch, and pinprick over the left first and second toes. Concern for malignant degeneration of her NF disease in the left ankle warranted a more extensive open biopsy for definitive diagnoses.
+Preoperative anesthetic evaluation revealed no other significant medical problems, no known drug allergies, no prior general anesthetics, and a family history of pseudo-cholinesterase deficiency. She had several previous cutaneous nodule excisions for cosmesis completed under a combination of local anesthesia and sedation at outside institutions. The patient was prescribed temazepam (Restoril, Mallinckrodt Pharmaceuticals Group, MO) orally for insomnia as necessary, as well as hydrocodone-acetaminophen (Vicodin, Abbott Laboratories, IL) and ibuprofen (Motrin, McNeil Consumer Healthcare Division, PA) orally as required for ankle related pain. On general examination, she had multiple cutaneous neurofibromas diffusely distributed throughout her body. Her BMI was 29 and her airway examination was unremarkable.
+Prior to the nerve blockade, standard monitors (noninvasive blood pressure cuff, pulse oximeter, and 3-lead ECG) were applied. Supplemental oxygen (3 L/minute) was administered via nasal cannula. Adequate sedation was achieved with intravenous midazolam 2 mg (Versed, Roche, NY), and fentanyl 150 mcg after timeout was completed. The patient was placed in supine position with left foot elevation and left knee flexion, and the skin sterilized with ChloraPrep (Cardinal Health, OH).
+The US transducer (linear, 12-3 MHz, L12-3 Phillips) was placed transversely at the inferior aspect of the popliteal fossa. Cephalad and caudad orientation of the probe demonstrated relevant anatomy including the popliteal artery, vein, sciatic nerve, and its bifurcation into the common peroneal and tibial nerves. Of specific interest, sonographic ?arget signs??[] consistent with previous descriptions of intraneural fibromas [] were demonstrated in the sciatic, common peroneal, and tibial nerves []. The lesions appeared solitary, ovoid and contiguous with the nerve, had a hypoechoic echotexture with well-defined margins, and demonstrated subtle distal acoustic enhancement (). With popliteal artery in view, we were able to demonstrate true and faux (neurofibroma) arterial structures using doppler analysis (). Tracing the path of the sciatic nerve proximally, we identified a portion of the nerve with no neurofibromatous changes on ultrasound. We also carefully selected an area of the inferior thigh void of cutaneous neurofibromas for needle insertion. The skin was infiltrated with 2 mL 2% lidocaine, and a 10 cm 22-gauge Stimuplex needle (B. Braun, PA) was utilized. A real-time view of the Stimuplex needle tip, popliteal artery, and sciatic nerve was maintained at all times during the block. A total of 30 mL 0.5% ropivacaine (APP Pharmaceuticals, IL) with 1 : 400.000 epinephrine was injected with intermittent negative aspiration for blood. The local anesthetic spread circumferentially around the sciatic nerve as noted on ultrasound examination (). The patient reported no paresthesias or discomfort during the procedure.
+Within ten minutes, the patient reported subjective numbness, warmth, and heaviness of her left calf and foot. On examination she had complete sensation loss to sharp touch and cold in the sciatic distribution of her left lower extremity. Intraoperatively, sedation was provided with midazolam 2 mg IV followed by a propofol infusion (25??0 mcg/kg/min). She maintained spontaneous ventilation via laryngeal mask airway. The patient did not respond to the incision and remained hemodynamically stable for the duration of surgery. She received ondansetron 4 mg (Zofran, GlaxoSmithKline, NC) intravenously twenty minutes prior to the completion of surgery for nausea prophylaxis.
+The patient was alert, awake, and oriented in the postanesthesia care unit. She complained of no pain (verbal pain score 0/10) and had residual sensory loss and motor weakness of 1/5 in the left lower extremity. The patient denied symptoms of nausea and was discharged home later that afternoon. On post-operative day one, the patient was contacted at home via telephone for followup. The patient stated baseline motor and sensory functions returned approximately eight hours after the operation. Her pain was adequately addressed at home with hydrocodone-acetaminophen (Vicodin, Abbot Laboratories, IL) orally every six hours as needed. Her pain at rest was 1-2/10, and with activity increased to 3-4/10. She had no hematoma or tenderness at the site of the regional blockade. The patient reported an overall favorable anesthetic and postoperative pain experience."
+Leroy Atkins,30,2002/3/16,434-989-8873x26209,gerald24@example.net,1108 Ferguson Manors Suite 954,"An 87-year-old lady who lives alone presented to the medical admissions unit with an inability to open her right eye. She has a past history of mild dementia and depression and was previous to this otherwise fit and well. She describes a 6-day history of blister formation surrounding the eye that extends to her right forehead and scalp. Her family noticed her eye was becoming increasingly droopy, red, and swollen culminating in it being permanently shut for twenty-four hours prior to admission. This visual impairment was most likely responsible for her falling before attending hospital, during which she sustained a left elbow laceration. Of note, she had been started two days previously on flucloxacillin and phenoxymethylpenicillin by her general practitioner.
+On examination she had a vesicular rash covering her right scalp, forehead, eye, and upper cheek. It was erythematous, swollen, and tender. She had a complete ophthalmoplegia, and her pupil was fixed and dilated. Her visual acuity in that eye was reduced to counting fingers. The remainder of her neurological and other systems examinations were normal. She was commenced on oral and topical acyclovir, dexamethasone, and cyclopentolate subsequent to ophthalmology review. There was no evidence of vasculitis on slit-lamp examination (see Figures and ).
+The vesicular rash resolved some two weeks later after admission, and she was discharged. She had regained some of her eye movements partially but the ptosis remained."
+Mina Cox,41,1978/1/13,(207)714-9451x84988,joshuapittman@example.org,2095 Mary Mount,"The patient was a 42-year-old female who initially presented to the ED with left buttock and left-sided back pain that was described as ??2/10.??She had previously had a left gluteal abscess incised and drained at an outside hospital. She denied any history of fever. Her other past medical history included schizophrenia and prior Caesarian sections. She had a 6-pack-year smoking history. On physical examination, the patient was afebrile with stable vitals. She was awake and alert. Her abdomen was soft, obese, and nontender without masses. Rectal examination showed good sphincter tone without any purulent drainage. A boggy swelling was palpable in the left side of the rectum at the 3 or 4 o'clock position. The rest of the physical exam was benign. A CAT (computerized axial tomography) scan was performed, showing a large right-sided abscess ()
+The patient was taken to the operating room for examination under anesthesia. Digital rectal exam showed an induration and boggy swelling 10 cm from the anal verge and at the 3 o'clock position. The examination was complemented with anoscopy, which revealed vague bulge into the lumen corresponding to the digital palpation site. Due to the difficult location of the abscess, surgical drainage was not feasible transrectally and the abscess was drained percutaneously under fluoroscopy by Interventional radiology.
+Multiple pictures were taken under fluoroscopy to characterize the abscess, shown in Figures and . The drainage catheter was left creating a fistula between the abscess and the skin. The drainage catheter had several dislodgements. Two tube-checks and adjustments were done by interventional radiology.
+However, two months after the initial procedure, the patient was again admitted with the similar symptoms. The patient was taken for surgical drainage through the previous transgluteal catheter insertion site, whereupon mucopurulent material was drained. The abscess was packed and the patient was once again discharged on trimethoprim/sulfamethoxazole and ciprofloxacin. One month after this, the patient was again admitted complaining of pain in her abdomen, groin, and vagina and drainage of purulent material from the left buttock at the surgical incision site. The patient was taken to the OR and an incision was made through her previous incision scar in the left buttock about 6 cm from the anal opening. Bimanual exam revealed a large boggy swelling. The abscess was dissected out and then opened. The serous and purulent fluid contents were drained and a size 28 Malecot and a 22 French Foley were both left in and sutured to the skin. The patient tolerated the procedure well and was sent home with daily wound and drain care as well as a 10 day course of ciprofloxacin and trimethoprim/sulfamethoxazole. She returned to the outpatient office for followup and had complete recovery of her abscess."
+Connor Dyer,31,1980/12/11,981.358.5320,lcalderon@example.net,4653 Thomas Burg Suite 964,"A 47-year-old man from Spain presented in University Hospital La Paz in Madrid, Spain, with a two-day history of intermittent fever, headache and fatigue. The patient had returned a week earlier from a four-week trip to Equatorial Guinea. He did not take anti-malarial chemoprophylaxis during the visit. He was a category A3 HIV-infected patient with a CD4 cell count of 650/弮L and HIV viral load of less than 20 copies/mL. He had been taking tenofovir, emtricitabine and efavirenz since 2008. On examination, he was febrile (38.7簞C) and had a heart rate of 120 beats/min, blood pressure of 93/64 mmHg, normal respiration rate and oxygen saturation 95% on room air. Laboratory investigations showed normal haemoglobin concentration (14.8 gr/dL), normal cell count and leukocyte formula (4.4 ? 109 cells/L, N 89.1%, L 6.9% M 1.6%), moderate thrombocytopaenia (36 ? 109 cells/L, reference range 125-350 ? 109 cells/L), normal glucose levels (110 mg/dL), bilirubin (28 弮mol/L, reference value < 20 弮mol/L), creatinine (176 弮mol/L, reference range 40-120 弮mol/L) and slightly increased aspartate transaminase (82 UI/L, normal < 37 UI/L) and an elevated C-reactive protein concentration of 157 mg/L (normal < 10 mg/L). Malaria parasites were seen on Giemsa-stained thick and thin blood films with Field's stain in 7% of erythrocytes. Parasite morphology identified P. falciparum. A rapid diagnostic test (RDT) result for histidine-rich protein 2 of P. falciparum (Now簧 Malaria Test, Binax INC, Maine, USA) was positive. Results of multiplex PCR assay, species-specific nested-PCR [] were positive for P. falciparum. The patient was admitted to the intensive care unit with several signs of severe malaria (parasitaemia of 7% of erythrocytes, haemodynamic instability, decreased level of consciousness, respiratory distress syndrome and mild renal insufficiency) for monitoring. Patient was treated with quinine and doxycycline intravenous for seven days at the recommended doses in adults. The anti-retroviral therapy with tenofovir, emtricitabine and efavirenz was not interrupted. On day 2 the parasitaemia was 1%. The parasites were cleared after six days without recrudescence. The hospital stay lasted 13 days."
+Estrella Patel,43,1988/4/4,236.652.2654x831,keith12@example.com,3953 Austin Branch,"A 38-year-old man from France presented to University Hospital La Paz, with a two-day history of fever, sweating, abdominal pain and vomiting after returning from a six-day visit to the Ivory Coast. He did not use personal vector avoidance measures (insect repellent, long-sleeved clothing, netting). He had not taken anti-malarial chemoprophylaxis. He had been diagnosed with HIV infection 10 years before. He was taking tenofovir, abacavir and darunavir/ritonavir with a CD4 cell count of 432/弮L and undetectable viral load (less than 20 copies/mL). He was admitted to the emergency department with a temperature of 39.9簞C but he was in good general condition with a normal respiratory rate, blood pressure of 147/88 mmHg, and normal oxygen saturation. The day of admission, laboratory investigations revealed: normal haemoglobin concentration (15,0 gr/dL), normal white cell count and leukocyte formula (6.3 ? 109 cells/L, N 78.3%, L 12.3%, M 8.5%), moderate thrombocytopaenia (91 ? 109 cells/L, reference range 125-350 ? 109 cells/L), normal glucose levels (104 mg/dL), bilirubin (1.6 弮mol/L, reference value < 20 弮mol/L), creatinine (135 弮mol/L, reference range 40-120 弮mol/L) and slightly increased aspartate transaminase (95 UI/L, normal < 37 UI/L) and ALT (92 UI/L, normal < 65 UI/L) and an elevated C-reactive protein concentration of 112 mg/L (normal < 10 mg/L). Malaria parasites were detected by microscopic examination in 0.5% of his erythrocytes. The RDT (Now簧 Malaria Test, Binax INC, Maine, USA) was positive for P. falciparum. The patient was treated with atovaquone/proguanil 250 mg/100 mg, every six hours for three days. On day 3, he was again febrile with P. falciparum parasitaemia nearly 8% of erytrocytes. His laboratory results showed a decreased haemoglobin concentration of 10.0 gr/dL and thrombocytopaenia more severe than 33 ? 109 cells/L. Anti-malarial treatment was changed to intravenous quinine and doxycycline for seven days and was monitored in the intensive care unit for the first 24 hours. The anti-retroviral therapy with tenofovir, abacavir and darunavir/ritonavir was stopped, after initiating the malarial treatment with quinine. On day 6 he was cleared of parasitaemia. He was discharged after 10 days. The multiplex PCR assays performed on the sample collected on the day of admission confirmed that the patient was only infected with P. falciparum. Analysis of point mutations in the cytochrome b gene, related to resistance to atovaquone, and in the dihydrofolate reductase (DHFR) gene, related to proguanil resistance, show a single mutation in the cytochrome b gene (L283I) and four point mutations for the DHFR gene (Table )."
+Parker Boyle,18,1986/11/26,707-895-1979x703,johnkirk@example.com,053 Makayla Ridges Apt. 788,"The patient, a 38 year old man, had started to drink alcohol at age 11. By the age of 18 he fulfilled the DSM-IV criteria for alcohol dependence. His first detoxification treatment was at age 15. Multiple detoxification and prolonged withdrawal therapies as well as anti-craving therapy with acamprosate had been unsuccessful. Before surgery the longest period of abstinence lasted 3 months. During these drug-free intervals the patient reported massive craving and high sensitivity to alcohol-related cues. Pre- and post-surgical assessment included Symptom Check list 90 (SCL), psychopathology, obsessive-compulsive drinking scale (OCDS), alcohol urge questionnaire (AUQ). The alcohol dependence scale (ADS) was only assessed before surgery. In addition, the patient had also been examined with a comprehensive neuropsychological test battery, which had revealed neither marked neuropsychological difficulties nor dementia. One week after implantation of the DBS electrodes (13 January, 2008) the stimulation was switched on. The patient experienced a short period of hypomania, which stopped upon changing stimulation parameters. Since then up to the submission of this report the patient has been alcohol abstinent and reports a virtually complete reduction of his sensitivity to alcohol related cues.
+Bilateral stereotactically guided implantation of quadripolar brain electrodes (model 3387, Medtronic, Minneapolis, MI, USA) was performed in general anesthesia as described by Heinze et al. . The electrode position was confirmed intraoperatively using stereotactic X-rays and finally by computed tomographic imaging (CT, see ). Postoperative CT-scans were retransferred into treatment planning MRI images. The most distal contact of the electrode was located 1?? mm rostral to the anterior commissure projecting onto the lateral border of the NAcc. This particular placement was necessary to save a prominent A1-segment of the anterior cerebral artery running through the intended target area. Settings of the impulse generator (Kinetra簧, Medtronic, Minneapolis) at time of testing were: monopolar cathodic using the most distal contact in each hemisphere (frequency: 130 Hz, pulse width: 90 繕s, amplitude: 3.5V ). The current (radius of approx. 3 mm around the active electrode contact ) affected dorsal parts of the NAcc, the BSTM and the VP (see )."
+Aliya Alfaro,38,1998/12/18,795-927-8148,odavis@example.org,908 Donna Inlet,"A 32-year-old woman with a history of psychological problems spent 1 year in an adolescent psychiatric unit and received psychotherapy for an eating disorder. Acts of DSH were carried for 7 years between the ages of 14 and 21 years, including cutting with objects such as glass, and blades and self-poisoning. All cuts were made to her left nondominant upper and lower arm alone, leaving her with numerous scars. Scar reconstruction was carried out on her left forearm."
+Xzavier Roach,26,1987/6/12,958.652.8553,laurajones@example.net,4218 Brown Trail Apt. 019,"A 20-year-old woman presented with a history of moderate depressive disorder and personality difficulties. She was taking antidepressants and had a history of DSH for 5 years, between the ages of 12 and 17 years. She had multiple lacerations that were made with razor blades to bilateral forearms. Scar reconstruction was performed on her left forearm."
+Lyanna Gordon,35,1979/9/27,001-976-405-5841x4237,imercado@example.org,18485 Webster Throughway Suite 120,"A 32-year-old Afro-Caribbean female presented, on antidepressants for depression. With a 9-year history of DSH between the ages of 14 and 23 years, razor blades were used to both arms and she presented with linear scars to both forearms, one of which had become very stretched and unsightly. Scar reconstruction was performed on her right forearm."
+Karter Parsons,23,1994/6/18,684-294-5751x624,huntercasey@example.com,908 Johnny Isle Apt. 234,A 28-year-old female presented who suffered from bipolar disorder and depression. She had a history of being in foster care as an adolescent with a number of psychosocial issues. She had a 9-year history of DSH between the ages of 13 and 22 years including overdose as well as self-cutting with razor blades and any other sharp objects found. Multiple linear scars were seen to bilateral arms with the left arm being more severe. Scar reconstruction was performed on her left forearm.
+Maia Scott,35,2000/5/28,-2869,hwalters@example.com,688 Townsend Curve Suite 621,"A 37-year-old female patient presented with a large symptomatic panniculus after open gastric bypass surgery and massive weight loss (110 lb) (Fig ). Her initial BMI was 52.67; after her weight loss, her BMI was 32.55. Chronic skin problems were confined to the lower abdomen under the large panniculus. The patient also complained of difficulty in ambulation and interference with performing ADL associated with the large panniculus. She had a strong desire to preserve her navel. She underwent a functional horizontal panniculectomy with umbilical transposition, and a total of 10.10 lb of skin and subcutaneous fat was removed. Postoperative follow-up at 6 months showed no evidence of skin problems and improved ADL, based on her SF-36 score (Fig )."
+Leo Jordan,45,2004/10/21,213.897.7399x922,landerson@example.net,44389 Stephen Manor Suite 268,"A 34-year-old female patient complained of frequent infection and rashes in the skin around the navel and under the pannus along the suprapubic region and both groins after open gastric bypass surgery and massive weight loss (122 lb). Her BMI decreased from 44.38 to 24.60. Of note, she had a large incisional ventral hernia associated with her gastric bypass surgery (Fig ). She wanted to preserve her navel. She underwent a functional horizontal panniculectomy with umbilical transposition. Concomitant hernia repair was performed. A minimal vertical skin and subcutaneous excision overlying the supraumbilical hernia was also performed because of compromised perfusion. A total of 3.6 lb of skin and subcutaneous fat was removed. Twelve-month follow-up showed resolution of her skin problems and no evidence of hernia recurrence (Fig )."
+Adalynn Hancock,32,1998/5/18,(431)652-2084,anne76@example.net,50166 Smith Ville Apt. 695,"A 45-year-old female patient presented with a large panniculus and associated chronic skin problems in the lower abdomen after massive weight loss (140 lb) following open gastric bypass surgery. This resulted in a decrease of her BMI from 58.87 to 34.84. She complained of a significant difficulty in ambulating and carrying out her ADL associated with the large panniculus (Fig ). This was supported by her preoperative SF-36 score. She was indifferent to preservation of her navel. She underwent a horizontal panniculectomy with the sacrifice of her navel. A total of 11.0 lb of skin and subcutaneous fat was removed. There was no evidence of skin problems at 9 months postoperatively. Patient also reported improved ADL, as observed in her postoperative SF-36 score (Fig )."
+Rex Curry,42,1978/9/2,-9002,kevinhill@example.org,8633 Gregory Track,"A 37-year-old female patient presented with skin problems confined to her lower abdomen and around the navel after open gastric bypass surgery and massive weight loss (130 lb). There was also skin irritation in the vertical redundant folds around the navel (Fig ). Her BMI decreased from 46.67 to 23.99. She complained of interference with her ADL. She desired to preserve her navel and thus underwent a functional horizontal panniculectomy, minimal excision of vertical excess skin and subcutaneous fat from the supraumbilical region, and umbilical transposition. A total of 3.91 lb was removed during these procedures. Postoperative follow-up showed resolution of skin problems as early as 3 months after the surgery (Fig )."
+Alison Matthews,38,1997/1/8,9073238048,tracyfranklin@example.net,285 Andrew Fort,"A 55-year-old Caucasian man was admitted to the Nephrology Department at our institution for ARF diagnosed in the emergency room along with left-sided, community-acquired pneumonia. He was on oral anti-diabetic treatment for uncomplicated type 2 diabetes and was a cigarette smoker. He reported no recent use of non-steroidal anti-inflammatory drugs or antibiotics.
+Clinical examination revealed that his temperature was 38簞C and his blood pressure was 120/60 mmHg. His urinary output was diminished and concentrated. Pulmonary examination revealed diffuse crackles of the left lung accompanied by a dry, irritative cough and exertional dyspnea. The rest of the patient's examination was normal.
+Chest X-ray revealed alveolar opacities in the left lung. No sputum could be obtained for culture, but his test for Legionella antigenuria was positive. Antibiotic therapy with erythromycin and ofloxacin was initiated.
+Blood tests revealed elevated serum creatinine (614 弮mol/L; normal range, 62 to 106 弮mol/L), blood urea nitrogen (28 mmol/L; normal range, 2.14 to 7.14 mmol/L) and C-reactive protein (360 mg/L; normal range, 0 to 3 mg/L) with leukocytosis (13 g/L; normal range, 4 to 11 g/L). No anemia or thrombocytopenia was noted, and the patient's liver function tests were normal. The patient had elevated levels of lactate dehydrogenase (408 IU/L; normal range, 135 to 225 IU/L) and creatine phosphokinase (CPK) (2000 IU/L; normal range, 47 to 171 IU/L). At room air, his arterial blood gas was pH 7.44 (normal range, 7.35 to 7.45), partial pressure of carbon dioxide was 29 mmHg (normal range, 35 to 45 mmHg) and partial pressure of oxygen was 65 mmHg (normal range, 80 to 100 mmHg) with HCO3 of 22 mmol/L (normal range, 20 to 25 mmol/L).
+Analysis of the urinary sediment revealed aseptic leukocyturia (684/mm3; normal range, < 20/mm3) and hematuria (56/mm3; normal range, 0 to 10/mm3). The patient's urinary sodium was below 20 mmol/L, urinary urea was 13 g/L and proteinuria was 2.48 g/L (normal range, 0 to 0.3 g/L) with albuminuria of 0.4 g/L (normal range, < 0.03 g/L). His renal ultrasound was normal.
+Although our patient's respiratory signs and chest X-ray revealed improvement with antibiotics, his ARF worsened despite saline solute infusion, and he became anuric. His serum creatinine level at day 3 was 1000 弮mol/L. Hemodialysis was initiated with a central jugular catheter.
+Percutaneous renal biopsy was performed at day 4, which showed acute TIN (Figures and ) with interstitial edema and inflammatory peritubular infiltrate composed of lymphocytes and plasma cells. No proliferation or deposit was noted on the 21 glomeruli examined. Under immunofluorescence, only immunoglobulin-secreting plasma cells were visible.
+The patient's blood cultures were normal, his bacterial and viral serologies were negative (leptosirosis, human immunodeficiency virus (HIV), hepatitis B virus and hepatitis C virus), the search for tuberculosis and autoimmunity was negative (normal complement level, negative anti-nuclear antibodies and anti-SSA/SSB) and his eye examination was normal. Therefore, we attributed his acute TIN to LD.
+Steroid treatment was initiated at 1 mg/kg/day. The patient's renal function rapidly improved, with appropriate diuresis allowing for withdrawal of hemodialysis after 2 days. There was no worsening of respiratory signs under steroid treatment. The patient was discharged at day 10, at which time his serum creatinine level was 110 弮mol/L. One month later, after cessation of steroids and antibiotics, his serum creatinine level was 77 弮mol/L. Investigation by Health Services did not find the source of Legionella contamination."
+Preston Peters,33,1987/8/14,(953)768-6574x655,robert10@example.com,10835 John Vista Apt. 887,"A 12-year-old Caucasian boy was referred with a presumed diagnosis of right ON glioma to our hospital. Four years earlier, his local ophthalmologist had diagnosed a 'yellow-whitish, well-demarcated papillary cyst with central retinal vessel displacement' in his right eye (oculus dexter, or OD) and documented a visual acuity of 20/30 in both eyes. He was examined twice a year, and his vision remained stable. Four years later, his ophthalmologist documented 'visual acuity of 20/80 and concentric visual field reduction to the central 10簞 isopter in OD'. Fundoscopic variation of the lesion was not noted.
+One month later, after a severe headache, visual loss progressed and no light perception with an absolute afferent pupillary defect was present in the OD. A computed tomography (CT) scan showed right ON thickening, and the boy was referred and admitted to our center.
+At admission, the described neuro-ophthalmologic findings were confirmed, and on CT, the optic disc appeared elevated and enhanced after intravenous contrast was administered. Fundoscopy revealed a well-defined whitish mass without macroscopic calcification at the ON head, dilated and tortuous retinal vessels, and small superficial retinal hemorrhages (Figure ). A complete general examination did not detect any other alterations.
+After informed consent was obtained from our patient's parents, a right transfrontal exploratory orbitotomy with canalicular unroofing was performed, and a normal chiasm, prechiasmatic and canalicular ON, and grayish infiltration in the proximal intraorbital portion were revealed. A frozen intraoperative biopsy of the tumor was diagnosed as an 'unrecognized tumoral process', and 0.8 cm of distal ON was resected. Because the eye had no light perception and the tumor was potentially malignant, the remaining ON and globe were enucleated with excision of the retrobulbar orbital fat.
+A gross examination of the eye revealed an ON with a width of 6 to 7 mm and a length of 6 mm. A sagittal section through the globe revealed a small, whitish, rounded tumor of 2 to 3 mm with a soft surface at the optic disc. No lesions of the cornea, iris, lens, or ciliary processes were detected. The tumor had areas composed of poorly differentiated neuroblastic cells with nuclear pleomorphism but no mesenchymal elements. Thus, the final histopathological diagnosis was malignant non-teratoid medulloepithelioma of the ON []. There was dense granulation tissue with giant cells, but no tumor was present in the adipose tissue surrounding the ON (Figure ).
+Systemic work-up was negative for any evidence of metastatic disease. In view of the significant mortality rate of this tumor, orbital exenteration was suggested, but our patient's parents declined [-]. Fifty gray of telegammatherapy (Co60) was applied in two fields. Our patient was closely followed with annual orbital CT and half-yearly echography for six years without evidence of recurrence. At present, he is 37 years old and has a disease-free survival of 25 years."
+Leila Phan,37,1982/11/3,647.926.8184x38380,garrettderrick@example.org,5570 Kevin Cliff Apt. 674,"A 73 year-old man was admitted to our unit with severe aortic stenosis requiring aortic valve replacement. The patient had numerous risk factors for cardiovascular disease including obesity (BMI = 40; BSA = 2,46), hypercholesterolemia, hypertriglyceridemia, Type II Diabetes Mellitus and being a cigarette smoker. The procedure was performed through a J-shaped mini-sternotomy [] with routine ascending aorta and right atrial cannulation. After opening the aorta, we carefully removed all the debris on the valvular annulus that extended to the mitro-aortic junction. A tissue valve was then implanted. The operation was completed routinely and without incident. The patient was discharged from the Intensive Care Unit on post-operative day two. There were no major complications."
+Maison Costa,37,1982/1/21,(258)480-8603x9549,ericbrown@example.net,104 Jennifer Trace Apt. 521,"A 40-year-old Caucasian man with a body mass index (BMI) of 29 was admitted to our hospital with a 5-day history of fever. His physical examination revealed anorexia and fever (temperature > 39簞C). His white blood cell count was 11,350 cells/mm3 with 5800 lymphocytes/mm3. His C-reactive protein level was 51 mg/L. His liver function test results were alanine aminotransferase 68 IU/L and aspartate aminotransferase 75 IU/L. His prothrombin and partial thromboplastin times were within normal limits. Multiple blood cultures were negative.
+The results of serological tests for human immunodeficiency virus (HIV) enzyme-linked immunosorbent assay (ELISA), hepatitis A immunoglobulin M (IgM), hepatitis B surface antigen, hepatitis C virus, Coxsackie B virus and toxoplasmosis were negative. Viral capsid antigen and Epstein-Barr nuclear antigen IgG antibodies were positive, suggesting a past infection with Epstein-Barr virus. The serological test for CMV ELISA was positive for IgM antibodies (CMV IgM > 50 U/ml). The result of a CMV pp65 antigenemia assay was also positive, suggesting acute CMV infection.
+On day 6 after admission, the patient complained of diffuse abdominal pain. An abdominal ultrasound revealed a small increase in the size of the spleen and the presence of free peritoneal fluid. During the next 24 hours, his abdominal pain worsened with the addition of rebound tenderness. Abdominal contrast-enhanced computed tomography revealed the presence of a thrombus about 7 mm in diameter located at the proximal superior mesenteric vein (Figure ).
+An emergency laparotomy was performed. The small bowel as far as the distal ileum and its associated mesentery had diffuse edema and ischemic lesions (Figure ). Furthermore, a segmental infarction of the proximal jejunum 50 cm long was present. An extensive enterectomy of about 100 cm of jejunum, including the necrotic segment, was performed, followed by an end-to-end anastomosis.
+Neither the patient nor his first-degree relatives had a history of vasculopathy or thrombosis. Anti-coagulation therapy was administered preoperatively when the diagnosis was established in the form of small-fractionated heparin (enoxaparin sodium 6000 IU twice daily) and continued for 1 month postoperatively. The patient had an uneventful recovery and was discharged on the 11th postoperative day.
+One month later the patient underwent a complete coagulation profile check, including anti-phospholipid antibody, factor VIII, protein C and protein S levels, as well as factor V Leiden and prothrombin 20210A mutations, that showed no deficiency. Six months later the patient was healthy and free of any symptoms."
+Robin Lloyd,32,1984/5/18,291-713-0090x3138,vazqueztimothy@example.org,174 Mejia Lakes Suite 010,"A 62-year-old caucasian male known for dyslipidemia and scalp psoriasis was admitted to the emergency room for right renal colic. The patients had no history of constitutional symptoms, gross hematuria or abdominal pain. Laboratory findings were unremarkable. A computerized tomography (CT) was performed, which showed a 3.3 cm heterogeneous enhancing lesion in the upper pole of the right kidney consistent with a renal carcinoma (Figure ). Patient was then scheduled for a laparoscopic partial nephrectomy. The per- and post-operative periods were uneventful. Lymph nodes were explored during surgery and none were found. Nothing in the patient's clinical history or in the thoracic and abdominal CT scan performed suggested sarcoid granulomas involvement. No lymph node nor metastasis were present at the time of the surgery and at 30 months follow-up.
+Macroscopically, the tumor lesion revealed a 3.5 cm encapsulated yellowish mass with bosselated surface with small foci of hemorrhage and necrosis.
+Histological examination showed a conventional clear cell type renal carcinoma of Fuhrman nuclear grade III, without sarcomatoid features (Figure ). There was no perinephric, renal sinus fat, or renal vessel involvement. Surgical margins were negative. Neoplastic proliferation was delineated from normal renal parenchyma by a fibrous pseudocapsule where multiple non-necrotizing granulomas with multinucleated giant cells were found (Figure ). No granuloma was seen within the tumor. These granulomas did not contain centrally located malignant cells. These granulomas were associated with mild mononuclear, lymphocytic inflammatory infiltrate. No granuloma was seen in the adjacent renal parenchyma (Figure ). Ziehl-Neelsen and Grocott stains did not detect the presence of mycobacteria or fungi."
+Zaire Lawson,32,1983/2/15,+1-533-463-1289x37939,rhonda20@example.net,28797 Cruz Summit,"A 10-year old boy presented with a painful swelling in the dorsal aspect of the left distal thigh without history of trauma. Pain started 3 weeks before, increased with time and resulted in difficulties in walking at time of presentation. No fever, night sweats or weight loss was reported. Physical examination revealed a 9 ? 4 cm palpable firm mass in the biceps femoris muscle. Magnetic resonance imaging (MRI) demonstrated a 4 ? 3 ? 9 cm ill-defining tumor within the long head of the biceps femoris muscle with vivid uptake of contrast medium (Figure ). Also, enlarged lymph nodes up to a diameter of 2 cm were detected popliteal, inguinal and iliac. Radiologically, the most probable diagnosis was a malignant soft tissue tumor, most likely a rhabdomyosarcoma. Beside slightly enlarged inguinal and popliteal lymph nodes further staging did not reveal other organ or skin involvement. Laboratory HIV 1 + 2 screening tests showed no signs for HIV infection. Histological diagnosis was achieved by incisional biopsy. After being classified as Murphy stage II [], further treatment was conducted according to the international protocol for childhood ALCL (ALCL-99-NHL-BFM). ALK-1/NPM PCR was found positive in peripheral blood. After two cycles of chemotherapy the tumor was no longer detectable clinically or by ultrasound. The patient is currently receiving further chemotherapy without experiencing major toxicity."
+Phoebe Hodge,18,1985/2/9,-10654,millerrebecca@example.net,869 Cody Square,"A 22-year-old Turkish man presented with a five-year history of intermittent daily headache centered on the left retro-orbital and orbital side. The pain was unilateral with a side shift only within the same bout. He experienced four to twenty attacks a week from the beginning of the bout, which resulted in severe social agitation. The attacks started abruptly and usually peaked within five minutes, without any aura or precipitating factors, and lasted 30 minutes to 120 minutes. He suffered from rhinorrhea, lacrimation and ptosis during the headaches, without any noted nausea, vomiting or photophobia. He had previously used several daily medications unsuccessfully, such as verapamil 160 mg thrice daily, naproxen 500 mg thrice daily, ibuprofen 600 mg thrice daily, dexketoprofen trometamol 25 mg twice daily, indomethacin 25 mg thrice daily, loratadine 5 mg daily and prednisolone 60 mg daily. Both general and neurological examinations between attacks and hematological-biochemical screenings were normal. He had neither significant past medical history nor family history of headache.
+On the day of a severe headache, an ophthalmological examination of our patient revealed lacrimation, conjunctival injection and ptosis without miosis. We measured both his pupils as 3.5 mm, with normal pupillary reactions to both light and near stimulation. As attacks occurred without significant periods of remission, we diagnosed our patient with chronic CH. We applied a cotton tip with 2 mL of lidocaine hydrochloride and epinephrine (Jetocaine, 20 mg lidocaine/0.025 mg epinephrine) into the left nostril for 10 minutes. The ptosis responded to the treatment and the intensity of his headache decreased. The magnetic resonance (MR) images of his brain and orbit and MR angiography of his brain and carotid artery were within normal limits. In 12 months of follow-up, he had six to ten attacks a week accompanied by autonomic symptoms, which resolved with intranasal lidocaine application."
+Reign Carroll,42,1995/4/9,(698)911-6158x074,fisherapril@example.net,1274 Kelsey Shoals,"A 29-year-old man with metastatic ONB presented to Virginia G. Piper Cancer Center Clinical Trials at Scottsdale Healthcare for participation in a pilot study to apply WGS on a fresh biopsy of one of his metastatic lesions to determine if identification of somatic perturbations might be useful for downstream therapy. The initial diagnosis of ONB was made after expert pathologic review at a major academic center. The tumor consisted of nests of closely packed cells with small to medium sized nuclei and scant cytoplasm. Within the nests, single cell and occasional necrosis was present. The tumor had features of epithelial differentiation confirmed by pankeratin staining, which highlights the clusters and single cells within the nests with strong cytoplasmic staining. The rest of the cells stain strongly for synaptophysin supporting the diagnosis of high grade ONB. The tumor was negative for chromogranin, neurofilament, CD45, CD20, S100, HMB45, and Melan A. Subsequently collected specimens also underwent confirmatory pathology review for the ONB diagnosis."
+Zara Petersen,22,1979/2/11,001-504-462-8999x653,jenkinssummer@example.com,06632 Michael Parkway Apt. 029,"Our case was a 15-year-old boy who had a motor vehicle accident. There was swelling, ecchymosis, severe pain, and valgus deformity, because of medial proximal fracture fragment, on the left knee. After evaluating the first radiograph (Figures and ), closed reduction and long leg splint were done, and control X-ray was taken (Figures and ). Correlation with computed tomography was performed in order to ascertain the fracture pattern (Figures and ). The patient had no neurovascular problems on his first physical examination.
+The fracture pattern was determined, and the patient underwent open reduction and internal fixation operation in emergency conditions. After a full anatomic reduction was achieved in our operation, the metaphyseal fragment was fixed to physis by two transverse cannulated screws. Fixation was also applied to the medial condyle with one cannulated screw (Figures and ). Since the patient's growth continues, we ensured that no screw passes through the physis. The patient was followed up for three weeks with long leg splint in the postoperative period. At the end of the three weeks, the splint was removed, a knee exercise program was implemented, and the patient was asked to walk on tiptoes for three weeks. At the end of the six weeks, knee extension was full, flexion was 150簞, and the patient started to walk with full weight. In his last control at the end of the one year, the knee regained full extension and 160簞 flexion."
+Samson Wilkins,24,1987/10/10,372-992-3611x160,jose83@example.com,2552 Wheeler Corners,"A 66-year-old man presented to the emergency department of University Hospital in Seoul, South Korea, complaining of severe, constant pain and bruising over the right flank for the previous 2 weeks. He had fallen, striking his right flank on the edge of the metal wastebasket approximately 4 weeks prior to presentation. At that time, he had a light abrasion on the right flank, but he did not receive any special treatment. He had a history of cardiovascular disease and poorly controlled type 2 diabetes mellitus over the past 40 years.
+On admission, the patient's mental status was alert. His vital signs were stable except for his temperature, which was 37.7簞C. Physical examination revealed intense pain on palpation, crepitus, swelling, and bruising over the right side of the abdominal wall, extending into the shoulder. No traces of the original wound remained. There were no other abnormal findings on physical examination. Laboratory tests revealed the following: white blood cell count, 8,000/mm3 with 74% neutrophils (normal, 4,500-11,000/mm3 with 40-75% neutrophils); hematocrit, 52.5% (normal, 38-52%); hemoglobin, 18.1 g/dL (normal, 13-17 g/dL); platelet count, 125,000/mm3 (normal, 150,000-400,000/mm3); and C-reactive protein, 256.43 mg/L (normal, 0-3 mg/L). Computed tomography scans of the chest and abdomen revealed soft tissue edema and stranding with gas in the chest and abdominal wall (Figure ). They did not show any abscesses in any other organs. After cultures of two blood draws and a sample obtained by direct needle aspiration were performed, treatment with cefazolin (2 g every 8 h, intravenously [i.v.]) and clindamycin (300 mg every 6 h, i.v.) was started. On hospital day 2, clindamycin was discontinued and cefazolin was changed to ceftriaxone (2 g every 24 h, i.v.) with the preliminary report of Gram-negative bacilli in the culture of the aspirated specimen. Because the patient did not show signs of systemic toxicity, elective operative drainage and debridement was performed on hospital day 3. Intraoperative findings included a foul-smelling brownish-gray exudate and subcutaneous emphysema tracking along the superficial and deep fascia from the right shoulder to the groin. On hospital day 5, the initial blood cultures were negative. The aerobic and anaerobic cultures of the needle-aspiration specimen and the necrotic tissue obtained during the operation were positive only for R. planticola, on hospital day 3 and 5 respectively, as determined biochemically by using the Vitek2 automated identification system (bioM矇rieux, Marcy l'Etoile, France; 95% probability). It demonstrated mucoid colony in both blood agar and MacConkey agar. The identity of the isolate was further confirmed using 16S rRNA sequencing []. Comparative sequence analysis showed a 100% identity with the sequence corresponding to the 16S rRNA gene of R. planticola ATCC 33531. Antibiotic susceptibility results were obtained using a Vitek2 AST-131 kit (bioM矇rieux) according to Clinical Laboratory Standards Institute methods. The isolate was found to be intermediate only to ampicillin and susceptible to the following antibiotics: amikacin, amoxicillin/clavulanic acid, aztreonam, cefepime, cefotaxime, cefoxitin, ceftazidime, cephalothin, gentamicin, imipenem, meropenem, piperacillin/tazobactam, tobramycin, levofloxacin, trimethoprim/sulfamethoxazole, and tigecycline. The isolates did not reveal extended-spectrum 帣-lactamase production.
+The patient required repetitive surgical debridements, and the wound was left open because of copious amounts of tissue fluid discharge (50-150 mL daily). Despite conversion to a negative culture on hospital day 16, ceftriaxone was changed to levofloxacin (500 mg every 24 h, i.v.) because the amount of discharge did not decrease. The patient's condition was complicated by Clostridium difficile-associated colitis on hospital day 28. Consequently, levofloxacin was discontinued, and the patient received tigecycline (initial loading dose of 100 mg, followed by 50 mg every 12 h, i.v.) for the coverage of both R. planticola and C. difficile. Over the course of 6 weeks of antibiotic therapy combined with five surgical debridements, the patient demonstrated obvious clinical improvement of both the colitis and the necrotizing fasciitis. Wound closure was performed on hospital day 37. After the 14-day administration of tigecycline, the patient had completed the treatment and was discharged without oral antibiotics. At outpatient follow-up, 4 weeks after discharge, the surgical wound was completely healed without any evidence of necrosis. The patient reported the resolution of symptoms related to the necrotizing fasciitis of the chest and abdominal wall."
+Amalia Avila,45,1999/8/28,001-281-335-7155x242,kaitlyndixon@example.org,6055 Jamie Ford,"A 55-year-old man presented a lush conjunctival hyperaemia and chemosis of the inferior bulbar conjunctiva in the left eye accompanied with dry eye symptoms, on March 2011. This lesion has been described for the first time three months earlier, and it had been the reason for five emergency hospital visits. In this period the patient has been treated with different drops and ointments, including topical steroids, anti-inflammatory, antibiotics, and eye lubricants, but none has proven any efficacy.
+On March 2011, examination of the left eye disclosed an unilateral swollen and hyperemic inferior bulbar conjunctiva extending to both canthi; this was a light-pink-coloured lesion, painless, compressible and with an underlying transparent content (Figures and ); the inferior border of the mass was not identified.
+In the patient's medical history is important to highlight a kidney transplant in 1999 by the Alport syndrome that is currently being treated with corticosteroids, cyclosporine, and azathioprine.
+On ophthalmic examination, the best corrected visual acuity was 20/25 in both eyes. The biomicroscopy of the left eye revealed a punctate keratitis and the fundoscopy was normal. Intraocular pressure was 15 mmHg and pupils' reflexes were normal. The patient had no proptosis and no limitation on the eye movements. No signs of eye alterations associated with Alport's disease were found. No other systemic symptoms were pointed out by the patient.
+A computed tomography scan of the orbits and brain described a right and left maxillary and sphenoid sinuses, suggestive of sinus inflammation, with no involvement of the orbit (Figures and ).
+On May 2011, an incisional biopsy was performed under local anaesthesia which proved to be diagnostic and therapeutic. Histology showed a lymphatic proliferation and ectasia with a network of empty bloodless channels lined by flattened endothelium with the presence of some blood vessels and inflammatory infiltrate (haematoxylin and eosin stain, ?100; ), which is consistent with the diagnosis of conjunctival lymphangioma.
+The excision of the lesion led to the resolution of the case (Figures and ). Meanwhile the upper respiratory tract infection, which is likely to have exacerbated the size of the lymphangioma was resolved.
+Ten months later the patient remains asymptomatic with no signs of recurrence of the lesion."
+Jaylen Atkins,38,1997/2/15,867.924.6689x07063,tpaul@example.org,070 Mclaughlin Throughway,"A 71-years-old female patient was presented to our burn clinic with the complaints of pain, rush, and burning in the left knee. Except of hypertension regulated with amlodipine besylate, the patient had not any systemic disease such as diabetes mellitus or asthma. The patient stated that she was on medical therapy for a long time due to osteoarthritis, but she had stopped it both because of epigastric burning and pains on her left knee not to resolve. The patient had referred to a person dealing with alternative medicine on the advice from her neighbour. That person had applied vaseline to the left knee and then scattered mustard seeds that were pulverized in a mortar on the creamed area followed by covering it with cotton and gauze. The patient stated that she had opened the dressing after 24 hours because of she felt burn in the left knee and that she had washed her knee which was slightly rushed using water and soap. However, complaints of rush, swelling, and itching in the left knee had started at the 36 hour after the application. On her physical examination, an erosion was found, surrounding the knee and compatible with second-degree burn, being more in the anterior side (). The treatment was planned as the patient to be hospitalized in the burn unit since she was elderly and the burn was surrounding the joint. First the burn area was cleansed with distilled water and debridement was made through a scalpel. Following application of the silver sulfadiazine cream, the burn area was wrapped with a gauze. This treatment was planned as once a day and the patient was discharged after one week. Topical silver sulfadiazine cream and daily dressing changes were applied over 14 days. The burn area was completely healed at the end of the first month (). No contracture developed during the 3-month follow-up period."
+Mina Hunter,39,1980/12/17,5023985852,christopherallen@example.com,61602 Briggs Motorway Suite 011,"A 40-year-old male patient reported to the Department of Conservative Dentistry and Endodontics, HiTech Dental college and Hospitals, complaint of pain in the posterior right mandibular region for the past two weeks. He gave a history of intermittent pain in the same region for the past three months since the tooth was restored. His past medical history was found to be noncontributory. Clinical examination revealed a carious right mandibular first molar (47) with tenderness on percussion. The clinical findings, radiographic findings, and vitality tests led to a diagnosis of irreversible pulpitis with acute apical periodontitis of the right mandibular first molar, necessitating endodontic therapy.
+Radiographic evaluation of the involved that tooth did not reveal any unusual anatomy (). The tooth was anesthetized using 2% Lignocaine with 1 : 80,000 adrenaline (Lignox, Indoco Remedies Ltd., India) and isolated using rubber dam. Endodontic access cavity was established. The pulp chamber frequently flushed with 5% sodium hypochlorite to remove debris and bacteria. Inspection of the pulp chamber revealed five canal orifices (2 mesial and 3 distal, ). Canal patency was checked with number 10 K-file (Mani, Inc.; Tochigi, Japan). Working length radiograph was taken () and the presence of five canals was confirmed.
+Cleaning and shaping was performed using using a crown down technique with Protaper files (Maillefer, Dentsply, Ballaigues, Switzerland) under abundant irrigation with 5% sodium hypochlorite solution in a 5 mL syringe and EDTA (Glyde, Maillefer, Dentsply, Ballaigues, Switzerland). The tooth was then temporized. In order to ascertain the presence of middle distal canal, dental imaging using a multisliced computed tomography (SCT) was planned. After obtaining the informed consent from the patient, SCT of the mandible was performed using Dentascan, Dental Software (GE healthcare, USA). The spiral computed tomographic images revealed the presence of the three distal canals (Figures and ).
+Patient was then recalled after a week. The root canals were then dried with paper points (Maillefer, Dentsply, Ballaigues, Switzerland) and obturated with cold, laterally condensed gutta-percha (Maillefer, Dentsply, Ballaigues, Switzerland) and AH plus resin sealer (Maillefer, Dentsply, Ballaigues, Switzerland, )."
+Archer Byrd,25,2002/7/31,001-858-827-5840,davidflores@example.net,311 Jones Crest,"A 23-year-old woman weighing 301 pounds and with a body mass index of 50.1 kg/m簡 presented to the bariatric surgery clinic for weight-loss surgery. She underwent a laparoscopic sleeve gastrectomy with no apparent postoperative complications. However, two weeks later, she presented with complaints of nausea, vomiting, epigastric pain and fever. She denied any hematemesis, changes in bowel movements, recent travel, or sick contacts. On examination she was febrile but had no peritoneal signs. CT abdomen revealed a 5.4 ? 3 cm fluid collection abuting the gastric body. Upper GI series revealed a leak near the GE junction (). Intravenous antibiotics and total parenteral nutrition were initiated. An upper endoscopy was done to assess the site and the size of the leak following which an 18 mm ? 125 mm fully covered wall flex stent was placed (). Gastrografin study during the procedure revealed no leak (). The patient was discharged home on total parenteral nutrition. Followup demonstrated clinical improvement, and repeat CT abdomen showed improvement in the fluid collection. The patient was started on a clear liquid diet 2 weeks after the procedure, to which protein shakes were later added. Patient was able to tolerate pureed food without any complaints at the end of the second month. Gastric sleeve stent was removed after 6 weeks. Follow-up upper GI series showed no gastric leak (). Proton pump inhibitor therapy was discontinued after 8 weeks. One year after the procedure the patient has lost 103 pounds and has been doing well."
+Giselle Lang,35,1995/12/24,501.261.6151x293,joshuawong@example.com,309 Christian Grove Apt. 405,"A 52-year-old man sought for treatment of a white plaque in the gingiva. The lesion was asymptomatic and had been noticed by the patient two years before the consultation. He reported daily tobacco and alcohol consumption. Oral examination revealed an 8 mm diameter and ill-defined white plaque on the edentulous alveolar ridge, region corresponding to the 38 tooth. Radiographs showed normal bone appearance (). The clinical diagnosis was leukoplakia.
+Under local anaesthesia, the white plaque was excised. Microscopically, the oral squamous epithelium was hyperplastic and hyperkeratotic but without dysplastic alterations (). A discrete chronic inflammatory infiltrate in the subjacent connective tissue was observed. In the deep portion of oral submucosa there were numerous islands of odontogenic epithelial cells scattered in a fibrous stroma (). Few nests were predominantly composed by polyhedric cells (). Other epithelial islands consisted of peripheral rows of palisaded hyperchromatic columnar cells and central polyhedric cells. The outer cells presented more basophilic staining than that inner ones (). In few larger islands, it was possible to see evident budding projections (). Semiserial section of the lesion exhibited epithelial islands with squamous metaplasia and incipient cystic formation (Figures and ). Another interesting microscopical feature was the presence of connective tissue surrounding the islands of odontogenic epithelial cells with looser arrangement than adjacent collagenous tissue not involved with the lesion (). The aggregate of odontogenic epithelial cells was confined to the connective tissue, without bone infiltration. The diagnosis established was early peripheral ameloblastoma subjacent to a nondysplastic leukoplakia. The patient was submitted to a long follow-up. In the nine-year follow-up, he was clinically and radiographically normal ()."
+Wells Brewer,41,1992/9/17,001-276-355-8571x4794,portereric@example.org,6429 Robertson Roads Suite 976,"A 53-year-old woman presented with subjective sensation of retroorbital pulsation. Digital subtraction angiogram demonstrated a 10 mm left supraclinoid ophthalmic artery aneurysm with a 5.5 mm neck. She underwent elective stent-assisted coiling of this aneurysm. The procedure was performed under general anesthesia. Clopidogrel 600 mg and aspirin 325 mg was given through a nasogastric tube at the beginning of the case. Femoral artery access was established with a 7 F 11 cm sheath. Heparin was given intravenously to maintain activated coagulation time between 250 and 300 seconds throughout the case. A Neuroform-3 (4 ? 20 mm) stent (Boston Scientific, Natick, MA, USA) was deployed across the aneurysm neck. The aneurysm was then embolized using two HydroFrame coils (MicroVention, Aliso Viejo, CA, USA) through an Excelsior SL 10 microcatheter (Boston Scientific, Natick, MA, USA) positioned within the aneurysm dome (Figures and ). A Hydrosoft 10 helical 4 ? 6 mm coil (MicroVention, Aliso Viejo, CA, USA) was then chosen to continue the embolization. During delivery the coil detached from the delivery system without activation of the release mechanism. A long portion of the coil was left in the cavernous internal carotid artery (ICA) proximal to the aneurysm (Figures and ). Retrieval of the displaced coil was first attempted using the Alligator 4 mm Retrieval Device (ev3 Endovascular, Inc, Plymouth, MN, USA), but this was unsuccessful. An Amplatz 4 mm GooseNeck Microsnare (ev3 Endovascular, Inc, Plymouth, MN, USA) was then used for retrieval, but this resulted in further coils prolapse (Figures and ). At this point the ICA developed significant vasospasm. Nicardipine was infused intra-arterially with radiographic improvement. Abciximab (Reopro, Centocor, Malvern, PA, USA) 0.125 mcg/kg/min was also started to prevent thromboembolic complication. A Merci V 2.5 Soft retriever (Concentric Medical Inc, Mountain View, CA, USA) was advanced to the displaced coil and engaged the coil loops. Multiple fragments of the coil were retrieved. A remaining coil fragment was jailed to the vessel wall by placement of another Neuroform 3 stent (Figures and ). A 6 French Envoy guide catheter was used in the ICA, and this was removed simultaneously with the Merci device (Codman & Shurtleff Inc, Raynham, MA, USA). Post-operative angiogram shows near complete occlusion of the aneurysm. Flow in the ICA and its branches were normal (Figures and ). Abciximab was stopped 6 hours after the procedure. The patient had an uneventful postoperative course and was discharged to home neurologically intact. On three-month followup the patient remains neurologically normal (modified Rankin score = 0); and she has 20/20 vision bilaterally. She reported significant improvement in her subjective retroorbital pulsation. Magnetic resonance angiogram 1 year after procedure shows no evidence of aneurysm recurrence or coil compaction."
+Thea Bennett,19,1986/12/18,384.237.5416,belinda91@example.org,73849 Mark Forest Suite 764,"A 75-year-old woman with atrial fibrillation presented with Hunt Hess grade four subarachnoid hemorrhage (SAH). Digital subtraction angiography revealed a 2.5 mm right posterior communicating artery (PCOM) aneurysm with irregular dome (Figures and ). She underwent emergent ventriculostomy and stent-assisted coiling of the ruptured aneurysm. Femoral artery access was established with a 7 F 11 cm sheath. Heparin was not given. A Prowler Select Plus microcatheter (Cordis Endovascular, Miami Lakes, Florida, USA) led by a Synchro 2 soft microwire (Boston Scientific, Natick, MA, USA) was advanced into the distal ICA. An Enterprise 4.5x22 mm stent (Cordis, Bridgewater Township, NJ, USA) was deployed across the neck of the aneurysm. Migration of the stent was noted during deployment, but it still covered the neck of the aneurysm. Tirofiban 0.1 microgram/kg/min was started intravenously. Two HydroCoil 10 coils (2 mm ? 4 cm) (MicroVention, Aliso Viejo, CA, USA) were initially deployed into the aneurysm through a SL-10 microcatheter (Boston Scientific). During coiling embolization several loops of the coil bulged into the parent artery (Figures and ). A decision was made to deploy an overlapping stent to hold the coil mass in the aneurysm. A Renegade Hi-Flo microcatheter (Boston Scientific, Natick, MA, USA) led by a Synchro 2 soft microwire was advanced into the vasculature. Significant migration of the previously placed stent was noted when the microcatheter and microwire passed through the Enterprise stent and the coil mass herniated out of the aneurysm (Figures and ). Attempts to engage the stent and coils using the Synchro 2 soft microwire were without success. A Merci V 3.0 firm Retriever was advanced into the ICA led by an 18 L Merci microcatheter (Concentric Medical Inc, Mountain View, CA, USA). We were able to engage the coils and stent and pulled them into the cavernous segment. A Merci V 2.5 soft Retriever was then advanced to the ICA. The Retriever engaged the coils and the stent again but attempts to pull them into the 6 F Envoy MPD guiding catheter (Codman & Shurtleff Inc, Raynham, MA, USA) were unsuccessful. At this point the coil/stent mass dislodged from the Merci device. The Merci Retriever, the 18 L Merci microcatheter, and the 6 F guiding catheter were then removed. A 7 F Envoy catheter led by a 0.038 glidewire was then used to select right carotid artery, and the tip of guiding catheter was placed at the distal cervical ICA near petrous bone. The 18 L Merci microcatheter led by a Synchro 2 soft microwire was again advanced into the distal ICA. The microwire was then removed, and a Merci V 2.0 Firm Retriever was advanced. The coils and the stent were pulled to the tip of the guiding catheter. The guiding catheter, the microcatheter, and the Retriever along with the coils and the stent were successfully removed out of the sheath. Examination of the objects on the field showed that the stent and the coils were intact without missing pieces. A postretrieval angiogram shows that the aneurysm was stable and the right ICA was patent without evidence of arterial dissection, pseudoaneurysm, or occlusion.
+A subsequent attempt at stent-assisted coiling of the aneurysm was successful using a Neuroform 4.0 mm ? 20 mm stent (Boston Scientific, Natick, MA, USA) and HydroCoils. A control angiogram after final coil deployment shows obliteration of the aneurysm (Figures and ). The stent was patent. An intracranial run showed that the distal ICA and its branches were normal in caliber without vasospasm or thromboembolism. Clopidogrel 600 mg and aspirin 325 mg was given at the end of the procedure. A repeat angiogram 3 days later showed moderate vasospasm and a secured PCOM aneurysm. Unfortunately the patient's clinical exam did not improve significantly, and the family decided on palliative care. She expired one month after the initial hemorrhage."
+Leonardo Ali,45,1986/11/5,(427)362-9748x40393,lknight@example.org,4111 Webb Stream Apt. 524,"A 68-year-old man presented in 2010 with recanalization of a previously treated anterior communicating artery (ACOM) aneurysm (). He had a history of Grade I SAH in 2004 from a ruptured 15 mm ACOM aneurysm. He was treated initially with endovascular coiling in 2004, and a repeated coil embolization was performed in 2008. A decision was made to treat this recurrent aneurysm with further coiling. Femoral artery access with a 7 F sheath was obtained. A 6 F Envoy guide catheter was introduced into the left ICA over a guidewire. Superselectively, the aneurysm was catheterized with a SL-10 microcatheter and a Synchro 10 microwire. A 3 ? 6 mm Orbit Galaxy coil (Codman & Shurtleff Inc, Raynham, MA, USA) was deployed in the aneurysm, but not detached since the coil was oversized and herniated in the parent vessel. Subsequently, a 2 ? 4 mm Galaxy Xtrasoft coil (Codman & Shurtleff Inc, Raynham, MA, USA) was deployed in the aneurysm. As soon as it was detached, the flow carried the coil from the aneurysm to the left A2 segment of the anterior cerebral artery (). A repeated injection demonstrates thrombosis of the left A2 without flow distal to the migrated coil (). At this point the SSEP signals were lost from the right leg. The decision was made to retrieve the coil with a Merci retriever, but the angle of the left A1/A2 junction was too acute to allow delivery of the Merci device from the left. An exchange maneuver was performed to replace the femoral access with an 8F sheath. An 8F Merci balloon guide catheter (Concentric Medical Inc, Mountain View, CA, USA) was also exchanged to replace the 6 F Envoy catheter and placed in the right ICA with the aim to diminish flow by inflating the balloon at the tip of the Merci guide while we are retrieving the coil. The left A2 was then catheterized through the right A1 with an 18 L Merci microcatheter. The microcatheter was advanced proximal to the migrated coil first, and 8 mg of tissue plasminogen activator was infused. The catheter was then taken distal to the coil, and a V2.0 soft Merci retriever was deployed and successfully ensnared the migrated coil (Figures and ). With the proximal balloon inflated, the coil was brought down to the tip of the guide catheter. At this point, we were unable to bring the coil inside the guide catheter, so the Merci retriever was removed, and an Alligator 2 mm Retrieval Device (ev3 Endovascular, Inc, Plymouth, MN, USA) was utilized to grab the coil and bring it inside the guide catheter. Postprocedure angiography demonstrates patency of the Left A2 (). At this point the SSEP signals returned to normal. Postoperatively the patient remains neurologically intact and was scheduled for a repeated coiling in the future."
+Zelda Sparks,40,1980/3/24,+1-648-804-2570x87737,durhammorgan@example.org,2704 Wolf Station Suite 760,"A 76-year-old Caucasian female was referred to our department due to a 6-month history of constant aching pain over her left hip region. Imaging features were very typical of a primary bone tumor and thus, as tentative diagnosis chondrosarcoma was made by the reporting radiologist (). Subsequently performed tumor staging revealed the tumor as being a primary with an otherwise clear bone scan, CT chest, and abdomen. There was no evidence of metastatic disease. However, imaging of the kidneys suggested possible renal cell carcinoma involving the right kidney.
+Biopsy specimen of the proximal left femur revealed a biphasic tumor composed of a cartilaginous component with abrupt transition into a noncartilaginous malignant mesenchymal component (). The diagnosis of a dedifferentiated chondrosarcoma was made. The dedifferentiated part was consistent with an osteosarcoma.
+The patient underwent limb salvage surgery, performed according to standardized local protocol by surgeons specialized in oncologic surgery, followed by endoprosthetic replacement. Wide surgical margins were achieved. Although the patient was reasonably fit, adjuvant chemotherapy was not given due to the patient's age.
+During the further course of treatment, the suspicious condition in the right kidney, that had already been present during initial tumor staging prior to limb salvage surgery, was diagnosed as clear-cell renal cell carcinoma () and immediately subjected to nephrectomy. There was no evidence of metastatic disease. After more than 5 years of followup the patient is still free of disease.
+Besides the current complaints described above, the patient underwent hysterectomy and cholecystectomy years ago. She could not remember the reason and there is no documentation discussing why those operations were performed. However, her medical family history () revealed that her youngest brother started suffering from invasive medium- to-low differentiated urothelial carcinoma () of the bladder when he was 67-year-old. He died at age 69 of a fibroblastic osteosarcoma () located in his left femur. Their mother presented with renal cell carcinoma as well when she was 65-year-old (specimen not available).
+To assess the hypothesized diagnosis of LFS, DNA was isolated from blood samples of the female index patient, and we analyzed the tumor suppressor gene p53 using semiquantitative, multiplex ligation-dependent probe amplification (MLPA, MRC-Holland) to rule out alterations of the TP53 gene. Moreover, the entire coding (exons 2??1) region and flanking intron regions of TP53 were sequenced. Since both MLPA and sequenciation did not reveal pathologic changes of the TP53 gene, the GAG-banding pattern derived from cell division was analyzed as well. However, chromosomal aberrations were not detected in the cytogenetic analysis neither for structural or numerical reasons. Taking into account all the results obtained, the diagnosis of LFS could not be confirmed, but there is still uncertainty regarding a definitive diagnosis in terms of a possible new genetic syndrome."
+Drake Gonzalez,33,2000/7/19,001-319-772-2952,jacksonjonathon@example.com,227 Sarah Causeway Apt. 618,"An 11-year-old male patient presented to our institution after sustaining trauma to his left lower extremity. On the day of presentation, there had been high winds in the vicinity resulting in the corrugated iron roof of a garage he had been walking nearby blowing off and landing on his left leg. The patient was trapped under the sheet of metal until freed by attending paramedics. In the emergency department, primary and secondary survey assessments of the patient revealed injuries to the knee and distal fibula only. A full formal examination of the knee was not possible due to pain and a tense haemarthrosis. Subsequent plain radiographs revealed an intra-articular avulsion fracture (), as well as fracture of the distal fibular diaphysis. A working diagnosis of displaced tibial spine avulsion fracture was made, and the patient was scheduled for surgery the following day to assess and fix the injury. Examination under anaesthesia revealed a ten-degree block to neutral extension of the knee and a positive Lachmann test with a soft end point. Arthroscopic examination of the knee revealed a lesion at odds with the preoperative diagnosis of tibial spine avulsion. A femoral end osteo-chondral avulsion fracture of the ACL was revealed (). Due to the unexpected findings and uncertainty about the optimal method of fixation in a skeletally immature patient, the fragment was reduced back into its normal position, the arthroscopic portals were closed, and the knee was splinted in extension in a plaster of Paris splint. With the benefit of hindsight, the treating team acknowledged that if a bone fragment this large had been avulsed from the tibial insertion of the ACL, this should have been reflected in the architecture of the tibial spine footprint on the preoperative X-ray. But as the appearances of this region appeared normal, this avulsion was unlikely to have occurred from the tibial end of the ACL, rather occurring from the less common femoral origin. A CT scan was subsequently obtained (), and the literature was scrutinised to aid preoperative planning of definitive fixation. Subsequent definitive fixation was perfomed nine days following the index procedure using a part arthroscopic and part open approach. Initial arthroscopic manoeuvres (including the use of a direct anterior portal in addition to the two standard portals) involved gentle curettage of the residual crater over the medial aspect of the lateral femoral condyle from where the ACL had been avulsed. Then two 2.4 mm Beath pins were passed in transosseous manner from the lateral supracondylar ridge into the centre of the defect (crossing the physis) using a posterior cruciate ligament targeting guide. 2 loops of 1 PDS suture were passed via these tunnels from the outside of the knee to the centre of the defect. Then a medial parapatellar approach to the knee joint was performed to formally expose the knee, two No. 2 Vicryl Bunnell sutures were passed across the femoral end of the ACL, and these sutures were placed into the PDS loops that had previously been passed into the knee. Pulling on the PDS sutures allowed the No. 2 Vicryl sutures to be passed through the tunnels previously drilled with the Beath pins and to be delivered to the lateral supracondylar ridge of the femur. The sutures were then tied to one another over a bone bridge thereby reducing the avulsed fragment back into its normal anatomical position (). Postoperatively, the patient was splinted in extension for the first four weeks. At this stage, the patient was placed into a range of motion knee brace (allowing up to sixty degrees of flexion) and allowed to partially weight bear with crutches. At six weeks following surgery, the patient's brace was slackened to allow a full range of motion. Radiographs performed nine weeks following definitive fixation showed union of his fracture (). He was allowed to ambulate free of his brace at this stage. At six-month follow up, the patient was able to ambulate without walking aids with a normal gait pattern and had a negative anterior drawer and Lachmann test and full restoration of knee flexion. No deformity or leg length discrepancy was noted at this follow up interval."
+Abigail Larson,45,2003/10/31,001-682-547-7541x130,oanderson@example.net,8924 Martin Locks,"A 66-year-old African American woman with osteoporosis, osteoarthritis, and impaired glucose tolerance presented to the emergency department with a 5-day history of left groin pain, nausea, vomiting, and fatigue. Five days prior to admission, she had noted an abscess on her inner left thigh that progressively ruptured and drained purulent, bloody material. On evaluation, she was tachycardic (HR: 111??36) and febrile to 103.2簞F. The left thigh wound drained a thin serous and dishwater-type fluid. Labs revealed leukocytosis and hyperglycemia (WBCs = 23.8 ? 103: 86.4% neutrophils, 5.4% lymph, 8.1% monocyte; glucose: 239 g/dL; BUN 13 mg/dL, creatinine 0.6 mg/dL, chloride 92 mmol/L, total CO2 24 mmol/dL, total creatinine kinase = 67 mg/dL). CT scan showed a 4.6 ? 1.4 ? 5 cm fluid collection proximal to the left gracilis muscles with presence of gas bubbles, edema, and fat stranding in the subcutaneous tissues. The patient was taken emergently to the operating room to undergo radical debridement, washout, packing, and subsequently admitted for IV antibiotic therapy.
+Microscopic analysis of the debrided specimen revealed areas of necrosis and acute and chronic inflammation, consistent with a diagnosis of necrotizing fasciitis. Gram stain of the initial intraoperative specimen showed ?ew gram positive cocci in pairs and chains,??and final bacterial culture showed many GBS, moderate S. lugdunensis, and moderate Corynebacterium (see ). Subsequent additional debridement grew many GBS and many S. lugdunensis. Blood cultures were negative. Blood tests for HIV 1, HIV 2, hepatitis B, and hepatitis C were negative. QuantiFERON gold tuberculosis test was negative. During the course of hospitalization, the patient was empirically treated with IV antibiotics including vancomycin, clindamycin, and aztreonam. After multiple debridements, the patient underwent plastic surgery reconstruction of her left groin. She was discharged home in stable condition after a 67-day hospital course and is doing well at followup 18 months later."
+Rafael Zimmerman,41,1984/3/13,640-466-8610x1618,kathryn74@example.org,97704 Katherine Point,"A 47 year-old-man, human immunodeficiency virus negative, with a recent diagnosis of central nervous system lymphoma presented with perianal skin lesions and nonbloody diarrhea. The skin lesions began as nodules that progressed to a roughened plaque and in the minority, ulceration. The lesions began eight weeks prior to presentation, were multiple, scattered in the perianal area and upper thigh bilaterally, and three centimeters at the widest diameter (). A more distinct lesion with irregular border was present over the sacrum consistent with a decubitus ulcer. The patient had been diagnosed with a CNS lymphoma six weeks prior to admission when he presented to another hospital with lower extremity weakness, saddle anesthesia, and fecal incontinence, and was found to have a L1-L2 intramedullary spinal mass. He had emergent surgical resection of the mass and was treated with high-dose dexamethasone and further radiation therapy. He was additionally found to have a right temporal lobe mass that was resected and pathology was consistent with a B-cell lymphoma with T-cell infiltration. He had no other significant past medical history or immunocompromising condition. The lower extremity weakness persisted and primarily confined him to bed. For ongoing fecal incontinence and the nonhealing sacral decubitus ulcer, he ultimately had a diverting colostomy. Two weeks prior to presentation, his bowel movements became more liquid in consistency and increased in frequency. He denied abdominal pain. The perianal skin lesions were not painful, but the initial loss of sensation from the compressive spinal mass had not recovered. He remained on a dexamethasone taper and was transferred to this hospital for further evaluation for chemotherapy. His complete blood count was notable for a normocytic anemia, and his liver function tests for an elevated alkaline phosphatase. An excisional biopsy of one of the skin lesions from the upper thigh was obtained and sent for pathological examination.
+Sections of the pathological specimen revealed a dense neutrophilic crust with numerous bacteria distributed in varying sized aggregates, and the underlying epidermis was acanthotic with artefactual subepidermal clefting. However, the superficial dermis demonstrated a distinct perivascular lymphocytic infiltrate, and the endothelial cells were markedly enlarged (). Some endothelial cells contained magenta-colored nuclear inclusions consistent with cytomegalovirus (CMV) infection which was confirmed by a positive CMV immunostain (). Stains with periodic acid-Schiff and for acid-fast bacilli were negative.
+The patient was treated with intravenous ganciclovir at five mg/kg every twelve hours for 21 days followed by transition to valganciclovir. A serum CMV viral load was 16,400 copies/mL at treatment initiation and was undetectable after four weeks of treatment. The diarrhea resolved within two weeks, and the skin lesions had completely healed at the time of switch to valganciclovir. Based on pathological findings and response to treatment, the diagnosis of cutaneous CMV was made. The primary mode of pathogenesis was thought to be local inoculation from fecal shedding. The diarrhea appeared to be a manifestation of CMV colitis, but given the commitment to CMV treatment and the response to therapy, no further investigation was performed. Unfortunately, the patient later died secondary to complications of an intracranial hemorrhage at the site of the temporal lobe resection."
+Ariyah McGee,34,1998/1/12,963-271-9815x25904,christopher03@example.com,9952 Cervantes Islands,"The second patient reported in this series was a 73-year-old female with a diagnosis of rectal adenocarcinoma 6 cm from the anal verge who underwent neoadjuvant therapy. In contrast to the first patient, this patient underwent a hybrid NOTES TME using a transanally inserted rigid, single port device. The single port access device has 3 channels for instrumentation, with 2 additional channels for CO2 insufflation. Using a 10 mm 45-degree laparoscopic camera, in lieu of a flexible colonoscope, the TME dissection was then carried out transanally with laparoscopic assistance as previously described. Operative time was 360 minutes. This patient also recovered uneventfully and was discharged home on postoperative day 6. Pathology revealed tumor-free margins and intact mesorectum with 2 of 11 lymph nodes positive for tumor (pT3N1)."
+Conner Weeks,32,1989/12/23,001-204-689-0781x40059,llara@example.com,57640 Craig Throughway,"The third case was reported by Tuech et al. in 2011 []. This report describes a 45-year-old woman with a reported T1sm3 rectal adenocarcinoma 3 cm above the dentate line. For this procedure a single port access device, endorec trocar (Aspide, France), was also used. This trocar consists of a rigid port with 40 mm outer diameter, three 5 mm, and one 10 mm access channel and an air inlet tube through which CO2 can be inflated. The extraperitoneal rectum was completely mobilized using this device. Once the lateral rectal attachments were divided, the rectovaginal peritoneal reflection was identified and perforated to gain access to the abdominal cavity. A second endorec trocar (Aspide, France) was then placed through the proposed ileostomy site and laparoscopic assistance with proximal colonic mobilization ensued. The procedure was performed successfully without complication. Operative time was 5 hours. The patient did well postoperatively without complication. Pathology revealed a pT1sm3N0 tumor. Fifteen lymph nodes were retrieved with the specimen.
+While the principles of NOTES transanal rectal cancer resection remain the same, the methodology, particularly with respect to transanal dissection, varies between clinical trials. The consensus is that the majority of the rectal and mesorectal dissection can be achieved transanally while laparoscopic assistance is needed for proximal colon mobilization and tissue retraction. It is the preference of our group at this time to use the rigid TEO platform for transanal endoscopic rectal dissection rather than a flexible single port device. The TEO platform comes in 2 lengths, provides rigid stabilization for instrument manipulation, and is an established cost effective, reusable platform readily available at our institution. Nonetheless, the published reports thus far demonstrate that adequate hybrid NOTES TME can be achieved using flexible or rigid platforms and highlight the importance of continued work and development in this field.
+As part of our effort to further this work, we are currently enrolling patients into an ongoing United States based Institutional Review Board (IRB) approved prospective clinical trial []. Patients selected for this approach include those with biopsy proven resectable adenocarcinoma of rectum located 4??2 cm from anal verge who are otherwise eligible to undergo standard open or laparoscopic low anterior resection with temporary diverting stoma. Tumors must be preoperatively staged as node negative, T1 (high risk features), T2 or T3 based on pelvic MRI with no evidence of metastasis on staging CT scans. For preoperatively staged T3N0 tumors, patients must have completed full-course neoadjuvant treatment. Procedures are performed following the same steps as described in cadavers, using an abdominal and perineal team working simultaneously. Transanal dissection is performed via the TEM platform with laparoscopic assistance through 1?? abdominal trocars. The right lower quadrant trocar is later used as the ileostomy site. Following transanal specimen retrieval, a handsewn coloanal anastomosis with diverting ileostomy is performed. For this protocol, a diverting ileostomy is standard given performance of a low-lying anastomosis in patients who likely will require either neoadjuvant or adjuvant chemoradiation."
+Karen Hart,33,1979/8/3,(619)452-8104x100,jonescatherine@example.org,326 Garcia Forest,"A 30-year-old pregnant Caucasian female complaining of severe anal pain and an anal bump was referred to the Colorectal Surgery Office by her primary care physician. She was 8-week pregnant. Her pain started a few days earlier and she noticed a small amount of bright red blood on the toilet paper and coating the stools. She had been constipated. She stated the pain was worse during and after defecation. Her medical history was significant for irritable bowel syndrome, recurrent oral ulcers, and anal pruritis. She denied abdominal pain, nausea, or vomiting. Her family history was significant for inflammatory bowel disease in her maternal relatives. She denied any history of anal intercourse or instrumentation.
+Upon examination there were no significant physical findings with the exception of what appeared to be an atypical fissure with heaped up skin edges and ulceration in the center in the left posterior position. A local block was placed and a steroid injection was performed. Topical lidocaine mixed with diltiazem and high fiber supplementation were prescribed.
+Her pain transiently improved but upon repeat examination two weeks later she was having recurrent pain and there was no change in the appearance of the fissure. She was admitted for pain control, an examination under anesthesia, and a flexible sigmoidoscopy. The differential diagnosis upon admission was new onset Crohn's Disease or a severe anal fissure. Upon admission, her vitals were normal and anal inspection revealed two large skin tags. A digital rectal exam could not be done secondary to severe tenderness. Labs showed normal serum electrolytes, WBC 3900, platelets 133000, Hb 11 g/dL, Hct 31.5, and MCV 91.
+She was taken to the operating room and examination demonstrated a large deep anal canal ulcer in the left posterior-lateral position (). No obvious fistula or abscess was identified. A sigmoidoscopy was performed and revealed numerous aphthous erosions involving the mucosa of the rectum and sigmoid colon, which appeared consistent with inflammatory bowel disease. The proximal colon was not evaluated endoscopically. Biopsies were taken from the anal ulcer and rectosigmoid mucosa (). An additional steroid injection was given into the ulcer bed. She was discharged home that day and was to follow up the following week.
+In the following few days, the results of the peripheral blood smear and pathology returned. The smear contained 5% blasts. The biopsy from the anal ulcer depicted squamous mucosa with ulceration and submucosal atypical hematopoietic cell infiltrates suggestive of acute leukemia. Similar findings of discrete mucosal and submucosal aggregates of atypical large and medium-sized hematopoietic cells were noted on rectal biopsies. She was immediately readmitted and a bone biopsy was performed. Her results with flow cytometry showed hypercellularity with 53% blast cells. The abnormal cells were positive for CD13 (58%), CD33 (73%), CD15 (59%), CD45, CD34, CD64, CD4, HLA DR, and MPO markers consistent with acute monocytic leukemia (FAB M5b). Refer to Figures , , and . Subsequent cerebrospinal fluid analysis also showed 30% blasts on flow cytometry. Her cytogenetic evaluation revealed an abnormal female karyotype with Inv (16) (p13q22), and Trisomy 8 and 22.
+She was diagnosed with acute myeloid leukemia and started on high-dose Idarubicin and cytarabine for induction chemotherapy. Intrathecal methotrexate was also given as there was evidence of central nervous system disease. Her pregnancy was terminated therapeutically before the chemotherapy was started. A repeat bone marrow biopsy nine months later after completing chemotherapy did not show any atypical cells. She clinically has no evidence of disease at this time."
+Joel Porter,29,2000/6/17,001-362-783-0235,george64@example.net,62790 Gibson Point,"A 61-year-old man was admitted to our hospital for a solid mass found in the right kidney during a routine checkup. Computed tomography showed that the mass was located in the superior pole. No remarkable symptoms such as flank pain or urinary irritation were reported by the patient. He also had no familial history or clinical evidences of VHL disease. Radical nephrectomy was carried out, showing a 5.3 ? 5.0 ? 5.0 cm mass. It was grey to yellowish in color and well-demarcated from the surrounding renal parenchyma. The patient had an uneventful postoperative recovery and was well at 12 months follow-up."
+Ryleigh Munoz,39,1989/3/15,(922)859-1395,tinalambert@example.com,47541 Mark Springs Apt. 391,"The patient was a boy, 4 years and 6 months old, who presented with a large intra abdominal mass. No risk factors such as prematurity, viral infection, or developmental disorders were present at the time of diagnosis. Radiological assessment suggested a multifocal epithelial tumor in both sides of the liver. Multiple bilateral lung metastases were also identified, classifying the tumor as stage Pretext IV. Serum 帢-fetoprotein (AFP) at diagnosis was 400.000 繕g/l. Treatment was initiated at this stage following the guidelines of the collaborative international center trial SIOPEL3. The high risk protocol consisted of 4? Cisplatin (CDDP, 80 mg/m2/24 h), 3? Carboplatin (CARBO, 500 mg/m2//1 h), and 3? Doxorubicin (DOXO, 60 mg/m2/48 h). After these courses, the tumor showed stable disease with slightly decreased AFP levels and tumor volume. However, lung metastases had completely disappeared. After completing chemotherapy, a local progress (tumor volume) occurred. Consecutively, the patient received high dose chemotherapy (CARBO/VP16 according to the GPOH protocol HB99) together with autologous stem cell transplantation and a transarterial chemoembolisation. This led to a partial response of tumor volume and AFP (50.000 繕g/l). With lung metastases still absent and the primary tumor being regarded as unresectable, the decision was taken to perform a living related liver transplantation (segments II and III) from the child's father. Immediately before operation, AFP rose again to a level of 153.000 繕g/l, still there were no lung metastases detectable. Hepatectomy and liver transplantation were carried out 6 months after initial diagnosis."
+Justin Cherry,41,2000/3/6,001-744-398-1385x4772,hernandezjeffrey@example.org,890 Joshua Keys Suite 871,"The patient is a 32-month-old male with a history of asthma who had been born at 36 weeks gestation via an unremarkable induced vaginal delivery secondary to oligohydramnios, with a birth weight of 5 pounds 12 ounces. The patient's asthma history is significant for multiple emergency room visits and one prior non-PICU admission for an asthma exacerbation. His maintenance medical regimen includes daily inhaled corticosteroids and albuterol as needed. The patient lives with his mother, father, an older sister who is healthy, a maternal grandmother who smokes in the house, and a cat.
+The patient presented to a nearby emergency room seven days prior to presentation with worsening respiratory distress in the context of two weeks of upper respiratory symptoms and diarrhea. On initial presentation at the nearby emergency room, he was diagnosed with bilateral pneumonia and treated as an outpatient with amoxicillin, azithromycin, oral steroids, and nebulized albuterol treatments. Four days after the initial emergency room visit, his respiratory symptoms progressed, necessitating emergency intubation and high frequency oscillatory ventilation at the outside hospital. The patient was positive for human metapneumovirus and had healthy appearing airways on bronchoscopy. After three days of progressive worsening on increased respiratory support, the patient was transferred to the JHH Pediatric Intensive Care Unit from an outside hospital and venovenous extracorporeal membrane oxygenation was initiated. Please refer to for the chest radiograph prior to ECMO initiation.
+The patient was initially treated with vancomycin, piperacillin/tazobactam, and fluconazole for presumed superinfection in addition to the HMPV pneumonia. After the blood cultures were negative for bacteria, fungi, and viruses for 48 hours, vancomycin and fluconazole were discontinued. However, due to the severity of his illness and concern for bacterial suprainfection, he completed an 11-day course of piperacillin/tazobactam for presumptive pneumonia. Due to decreasing urine output and concern for fluid overload compromising his respiratory status, the patient was started on continuous venovenous hemofiltration with a positive response, and he was subsequently transitioned to a furosemide infusion. He also required a nicardipine infusion for elevated blood pressures. Heparin anticoagulation and routine blood product transfusions were used during the ECMO run as per protocol.
+The patient progressed favorably from a respiratory perspective and was successfully decannulated on day 9 of ECMO, extubated 4 days following ECMO, and transitioned to room air 9 days following extubation.
+Given the unusual clinical course, an immunodeficiency workup to further investigate possible reasons for the development of respiratory failure in an otherwise healthy host was performed. T cell subsets were within normal limits. The remainder of his hospital course on the floor was notable for a successful diuretic wean, normalization of his work of breathing, cleared lung exam without coarseness, subglottic edema with intact vocal cords noted on bedside flexible laryngoscopy, and significant strides in physical and speech therapy."
+Nyomi Cabrera,35,2005/8/29,676-998-4027x404,yarmstrong@example.org,43243 Aguilar Club,"A 77-year-old man presented to the urology outpatient clinic with a right scrotal swelling; the patient did not report any symptoms such as pain or discomfort from the site of the swelling. However, the patient did express his concerns about the slow and gradual growth of the mass in his scrotum for months. The patient had no history of asbestos exposure or any surgical procedures.
+On examination he had a tense swelling in the right hemiscrotum, the clinical features of which were consistent with a hydrocele. The scrotal ultrasound scan reported a large 7-8 cm multiloculated hydrocele ().
+Following a thorough review, the patient underwent surgery to excise the right scrotal mass. Surgery revealed a tense multicystic mass which was completely excised and sent for histopathological assessment. The histopathology review of the scrotal cyst did report a benign multicystic mesothelioma arising from the tunica vaginalis ().
+Four months later the patient presented for post-operative followup, and on examination the right testis was hard and fixed in the hemiscrotum but the right hemiscrotum, returned to the normal size. He was asymptomatic and free of recurrence."
+Cade O’Neill,30,1986/8/4,+1-521-247-4203x2799,idavis@example.net,964 Burns Creek,"A 6-month-old female infant had presented five times to medical services since birth with a history of discharge from the umbilicus. On days 2 and 4, she presented with bleeding from the umbilical stump, which was managed with a pressure dressing. At 2 weeks of age, she attended a general practitioner surgery with discharge of watery liquid from the umbilicus, and it was treated like an umbilical granuloma with silver nitrate application. She came to the paediatric assessment unit of the local district general hospital at 3 weeks of age because of ongoing discharge. The periumbilical skin area appeared raw with features of a chemical dermatitis. An umbilical swab was taken and treatment with oral flucloxacillin commenced. The child presented again with ongoing symptoms. This time, it was diagnosed as excoriated umbilical granuloma with possible tinea corporis infection and she was treated with miconazole and neomycin. The discharge was mainly serous fluid which occasionally turned serosanguinous but did not contain pus.
+At 6 months of age, she was rereferred by the general practitioner for persistent umbilical discharge with intermittent blood-stained fluid whilst she had been on her third course of antibiotics. On this occasion a consultant paediatrician reviewed the infant. An ultrasound was requested to investigate for remnants of an omphalomesenteric duct because of the persistence of symptoms. The ultrasound showed a cystic structure of 5 mm diameter with echogenic walls situated deep to the umbilicus (see ).
+There was no communication with the bowel. A fistula extended through the anterior abdominal wall to the umbilicus. She was referred to surgeons for further management. She had a surgical excision of the cyst and sinus tract at 7 months. On macroscopic analysis, it was found to be a hard cystic lesion below the umbilicus surrounded by thick chronic inflammatory tissue. A fistula extended through the abdominal wall with no obvious communication or tract to the peritoneal cavity except for its continuation into the ligamentum teres. Histology showed skin with exudates and ulceration overlying a cystic structure lined by gastric corpus type mucosa in keeping with an umbilical cyst lined by ectopic gastric mucosa (). Her postoperative recovery was uneventful, discharge and dermatitis resolved and she was discharged from hospital care."
+Kenna Barr,29,1993/1/8,001-242-559-8814,kristenwalker@example.net,3155 Ashley Ford Apt. 408,"A 41-year-old-female had complained of headache and loss of olfactory function and underwent consultation at the Department of Otolaryngology of a general hospital. Endoscopic examination revealed a large mass involving the olfactory cleft of the left nasal cavity. Microscopic examination of a biopsy specimen indicated a diagnosis of neurogenic tumor. She was then referred to Kyoto University Hospital for further examination and treatment.
+Nasal endoscopy demonstrated a soft, whitish mass occupying the olfactory cleft and extending laterally to the middle meatus, with destruction of the middle turbinate in the left nostril. Computed tomography (CT) displayed a lesion at the olfactory cleft that extended superiorly to the olfactory groove, with a bone defect in the skull base (). The cribriform plate was elevated upward indicating that the tumor originated from the extracranial compartment. Magnetic resonance imaging (MRI) revealed a mass showing cystic changes (Figures ??, with solid portions demonstrating strong postgadolinium contrast enhancement. Our initial diagnosis based on radiographic findings was esthesioneuroblastoma. Partial resection of the tumor in the olfactory cleft was then performed using the endoscopic endonasal approach under local anesthesia, which suggested a histopathologic diagnosis of schwannoma. Based on this result, we planned subtotal resection of the tumor via an endoscopic endonasal approach.
+Under general anesthesia, the uncinate process in the left nostril was removed to expose the tumor in the middle meatus (). The tumor was attached but had not invaded the internal orbital wall. The anterior part of the middle turbinate was separated from the agger nasi and reserved into the choana as a pedicle flap. Resection of the agger nasi using a drill resulted in exposure of the entire anterior surface of the tumor. A tumor capsule was dissected from the nasal septum and then from the crista galli using a suction elevator and a 45-degree angled endoscope for visualization. During this procedure, the olfactory nerves were identified. After confirmation of their location, the anterior and lateral walls of the tumor were dissected from the posterior wall of the frontal sinus and nasofrontal duct.
+Afterward, the tumor capsule at the anterior surface was opened using an ultrasonic cutter (Harmonic scalpel, EthiconEndo-Surgery, Blue Ash, OH). The tumor contents were debulked with an ultrasonic surgical aspiration (CUSA, Tyco Healthcare Radionics, Burlington, MA) without bleeding. The tumor capsule was resected, except for the region connected to the dura matter. Following surgery, the region with the bone defect was covered with a mucoperiosteal pedicle flap that originated from the nasal septum and the middle turbinate. Pedicle flaps were fixed with fibrin glue, then covered with pieces of gelatin sponges. The operation lasted 3 h, and the volume of blood loss was less than 10 mL.
+Microscopic examination of the resected tumor demonstrated a neoplasm composed of spindle cells with eosinophilic cytoplasms and elongated or wavy nuclei with occasional symplastic changes (). The mitotic index was less than one per ten high-power fields, and there was no geographic tumor necrosis. All features were apparently compatible with schwannomas. Immunohistochemically, the spindle cells were diffusely positive for S-100 protein, neuron-specific enolase, and synaptophysin (Figures , , and ), and negative for epithelial membrane antigen (), which also supported the diagnosis of schwannoma, although Leu7 was completely negative (). The Ki-67 labeling index was 2%. These results were considered to best fit with a diagnosis of olfactory ensheathing cell tumor.
+No perioperative cerebrospinal leakage was identified. Postoperative imaging examinations confirmed subtotal extirpation of the tumor. The patient had an uneventful postoperative course, and no further recurrence was detected during the 2-year follow-up period (Figures ??."
+Harley Rosas,29,1987/11/24,664-364-1994x47584,salazarkrista@example.com,691 Alvarado Alley,"A 50-year-old, nonsmoker woman was admitted to outpatient clinic for periodic examination. She was diagnosed with lung tuberculosis at the age of six and had history of several times of hospitalisation with the diagnosis of recurrent pulmonary infections. She had two term healthy deliveries. She had no complaints.
+At the physical examination, slight ipsilateral deviation of the trachea was found. There were fine crackles and decreased breath sounds on the left side. Findings on the rest of the physical examination were unremarkable. Routine hematologic and biochemical profiles were within the normal ranges.
+Plain radiograph showed a loss of volume of her left lung, cardiac and mediastinal displacement to the left, increased density in the left lower lung zone, and hyperinflation of the lung on the right side (). Hemidiaphragm elevation with volume loss of the left lung and absence of hilar shadow were remarkable.
+Echocardiogram showed no apparent structural abnormality of the heart, and no pulmonary hypertension (pressure gradient = 20 mmHg) was detected. Pulmonary function tests showed a ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) of 80%; FEV1 of 2.47 L (61% of predicted), FVC of 2.90 L (52% of predicted), total lung capacity of 67% of predicted, and a diffusion capacity for carbon monoxide of 72% of predicted.
+Contrast-enhanced 7 mm collimator computed tomographic (CT) of the chest showed an enlargement of the pulmonary artery trunk and demonstrated the absence of the left pulmonary artery with displacement of heart and mediastinum to the left and volume loss associated with increased interstitial markings involving her left lung (Figures and ). Cardiac arteriographic study revealed no other additional cardiac abnormalities.
+We decided to follow up the patient for respiratory symptoms, such as breathlessness, hemoptysis, and pulmonary hypertension. The risk factors regarding the absence of a pulmonary artery and travelling to high altitude were explained to our patient. Her clinical status remained stable, without any symptoms, during the follow-up period."
+Joelle Hamilton,39,1989/7/23,3102354858,atkinsonkenneth@example.org,77216 Maurice Course Apt. 281,"A 59-year-old Caucasian female with past medical history of hypertension, obesity, mild osteopenia, and >20 pack years smoking history presented to the primary care physician with a more than four-month history of generalized weakness, anorexia, weight loss of more than 30 pounds, a growing subcutaneous mass in the right lower back and back pain in the lumbar region. MRI of the spine revealed confluent bulky soft tissue mass measuring approximately 14 cm anteroposterior ? 13 cm transverse in size in the retroperitoneum region and pathological compression fracture of L1 vertebrae. Further, CT scan of chest/abdomen/pelvis confirmed bulky retroperitoneal mass/adenopathy with extensive liver metastases and multiple tiny pulmonary nodules ().
+The mass at lower back was excised and immunohistochemical staining of subcutaneous mass was positive for cytokeratin 7, cytokeratin 20, mucicarmine and villin but negative for ER, mammaglobin, TTF-1, napsin A, CDX2, p63, calretinin, and hepatocyte antigen. The villin positivity in conjunction with the cytokeratin 7 positive expression is suggestive of a noncolorectal gastrointestinal origin, including pancreaticobiliary/gallbladder source. The tissue of origin assay was unable to locate the primary source and subsequently, diagnosis of poorly differentiated adenocarcinoma of unknown primary was rendered. Ten days after the biopsy, while waiting for chemotherapy to begin, patient presented to her primary care physician with severe nausea and vomiting, altered mental status and decreased urine output. Basic metabolic panel (Chem-7) was consistent with dehydration with blood urea nitrogen (BUN) and creatinine of 31 mg/dL and 1.6 mg/dL, respectively, elevated from her baseline normal values about 10 days later. Patient was given a liter of intravenous fluid and was sent back home with antiemetics.
+Four days later, after nausea and vomiting persisted with lethargy, weakness and very poor appetite, patient presented to emergency room. Chem-7 revealed BUN of 117 mg/dL with a creatinine of 7.5 mg/dL. Other pertinent lab values with normal values in parentheses showed calcium 6.5 (8.9??0.3) mg/dL, phosphorus 8.8 (2.6??.6) mg/dL, uric acid 26.5 (2.8??.6) mg/dL, and lactate dehydrogenase 1265 IU/L with normal transaminases. Obstructive uropathy was excluded by retroperitoneal ultrasound. Patient went into oliguric acute renal failure (ARF) and was treated with intravenous fluids. However, renal function did not improve over the next two days, and hemodialysis was started along with rasburicase. Lab abnormalities were consistent with TLS. Due to poor prognosis, patient was not started on chemotherapy and discharged to hospice without chemotherapy, and she died three weeks later."
+Jason McFarland,28,1991/6/25,+1-368-825-7097x9762,david42@example.net,6374 Greene Rapid Apt. 063,"The patient is a 57-year-old Hispanic man with a history of stage III moderately differentiated gastric adenocarcinoma intestinal type, diagnosed in late 2006. He was enrolled in a clinical trial for a new regimen of neoadjuvant chemotherapy consisting of oxaliplatin (85 mg/m簡 i.v. over 2 hours on days 1 and 15), docetaxel (25 mg/m簡 i.v. over 30 minutes on days 1, 8, 15), floxuridine (110 mg/kg i.v. over 24 hours on days 1, 8, 15), and leucovorin calcium (500 mg/m簡 i.v. over 24 hours on days 1, 8, 15) with treatment repeated every 4 weeks. After the second course (January 2007), he underwent resective therapy (partial gastrectomy) followed by 2 more cycles of the above-mentioned chemotherapy regimen as an adjuvant therapy.
+Five months later, recurrence of the primary tumor was found in the liver; therefore, the patient was started on a different regimen (paclitaxel 120 mg/m簡, floxuridine 150 mg/kg, leucovorin 500 mg/m簡, and cisplatin 100 mg/m簡), and liver segmentectomy was performed.
+Unfortunately, patient failed regular controls, and by 2011 a CT of the chest and abdomen revealed extensive metastatic liver nodules which ranged from 3.5 cm to sub-centimeter in size, and metastasis to the sternum were also found. Consequently, he was again included in the initial experimental chemotherapy regimen as a first line therapy for his metastatic disease (oxaliplatin, docetaxel, floxuridine, and leucovorin).
+Seven days after receiving the first chemotherapy cycle, he developed nausea, vomiting, oliguria, generalized weakness, and was referred to the emergency department by his oncologist due to abnormal laboratory data ().
+On arrival the patient was alert and appeared in poor general condition, pale, volume depleted with low blood pressure (102/63 mmHg), tachycardia (102/min), respiratory rate of 20/min, and body temperature of 36.6簞C. A firm, nontender, 2 cm below the costal margin of the right midclavicular line hepatomegaly was appreciated. There was no peripheral lymphadenopathy, and laboratory findings are shown on .
+Urinalysis determined urine pH of 5.0 (4.5??.5). The chest radiograph appeared to be normal. An EKG demonstrated atrial fibrillation with rapid ventricular response, left anterior fascicular block, and peaked T waves (). A renal ultrasound examination revealed an increased bilateral cortical echogenicity but no evidence of hydronephrosis.
+A diagnosis of chemotherapy-induced TLS with acute renal failure was made. The patient was given vigorous volume expansion, intravenous sodium bicarbonate, calcium gluconate, insulin given together with 50% dextrose, and allopurinol. His laboratory data did not improve and hemodialysis was started. The patient underwent a total of 6 hemodialysis over a course of two weeks and was discharged 18 days after with normal serum electrolyte and metabolic parameters. However, his renal function continued to be impaired with a serum creatinine of 3.86 mg/dL, blood urea nitrogen of 23 mg/dL, and eGFR of 16."
+Annika Pineda,40,2001/12/8,-817,lauravasquez@example.org,0057 Coleman Branch Suite 282,"A 28-year-old man with no past medical history presented to the emergency department with a two-week history of severe ??0-out-of-10??colicky epigastric pain with profound nausea, 15??0 episodes of vomiting daily, and decreased oral intake for fear of triggering these symptoms. He denied alcohol and tobacco use, but reported he had smoked two marijuana cigars (each containing approximately 1.5 grams marijuana bud) every day for the last ten years. As his symptoms of nausea, vomiting, and abdominal pain intensified, he self-medicated himself with increasing amounts of marijuana and his symptoms became increasingly intense. The patient reported that he initially got symptomatic relief with a hot shower, though as his symptoms intensified, he required increasingly longer bathing times that eventually progressed to the patient soaking himself in hot baths for hours each day. He stated that he had never experienced any of these symptoms in the past. In the emergency department, the patient's vital signs were within normal limits and his physical exam was significant only for minor tenderness to palpation in the epigastric region. The patient had no focal neurological deficits. The patient was admitted for intravenous fluid support, antiemetic therapy, and further evaluation.
+The patient's medical evaluation revealed a complete blood count, basic metabolic profile, and hepatic profile that were within normal limits. An abdominal computerized tomography (CT) scan was negative for pathology, an EGD with biopsies showed only mild gastritis, and a gastric emptying study showed mildly delayed gastric emptying.
+In this patient, initial symptomatic treatment with ondansetron and morphine was unable to keep the patient from having breakthrough episodes of nausea, vomiting, and epigastric pain. The patient was unable to tolerate even a clear liquid diet, and was extremely anxious about trying to increase or advance his oral intake given the painful episodes that food had triggered in the past. After administering 1 mg IV lorazepam, the patient improved at a remarkable pace; within 10 minutes of administration he no longer experienced nausea, abdominal, or food aversion. Over the next 12 hours, he transitioned to a regular diet, oral lorazepam (1 mg tablets), and was able to discontinue all other analgesic and antiemetic medications. The time from marijuana cessation to complete resolution of symptoms was approximately three weeks. The patient was discharged with a seven-day prescription for lorazepam (1 mg PO, twice daily). The patient was contacted at 3 and 6 months after discharge and he reported that, with sustained abstinence from marijuana, he had no return of his symptoms."
+Gerardo Hail,19,1986/7/25,808-378-9325x52825,sylviataylor@example.net,0784 Torres Creek,"A 77-year-old female with recurrent non-small-cell lung cancer presented to the outpatient lung clinic complaining of tremor, weakness, inability to coordinate motor movements, and confusion. Central nervous system metastases were suspected, and a CT scan of the head was ordered.
+The patient's medications were reported as oxycodone (slow release) 50 mg twice daily, oxycodone (immediate release) 5 mg when required, esomeprazole 40 mg twice daily, temazepam 10 mg at night, and docusate 100 mg with sennosides 16 mg twice daily. There was confusion as to whether this list was complete.
+A telephone conversation with the patient's community pharmacist revealed in addition to her reported medications that she had recently picked up a repeat prescription of citalopram 20 mg once a day, after not having it dispensed for several months. Diazepam had also recently been prescribed by her general practitioner for restless legs. The oxycodone had been started several months earlier (rotated from morphine) for cancer-related pain during the period that the patient was not taking her citalopram.
+Further discussion with the patient elucidated that the symptoms started shortly after recommencing the citalopram. The lung clinic pharmacist suspected a drug interaction between citalopram and oxycodone which had resulted in serotonin syndrome. Use of the Naranjo probability scale indicated a probable relationship between the combination of oxycodone and citalopram and the serotonin symptoms []. The symptoms satisfied the Sternbach diagnostic criteria for serotonin syndrome [].
+Oxycodone was changed back to morphine, and the esomeprazole was reduced to 40 mg daily (which in turn should improve citalopram clearance). The symptoms resolved within 48 hours, and the CT scan later came back clear."
+Lainey Ford,37,1986/1/10,814-775-7833x708,donnavazquez@example.com,0523 Alyssa Coves Apt. 703,"A 78-year-old female presented with asymptomatic upper abdominal mass. Computed tomography (CT) was performed and demonstrated an encapsulated solid and cystic tumour involving the right lobe of the liver, measuring 16 cm in maximum diameter (). Positron emission tomography (PET) showed intense peripheral metabolic activity with a photopenic core, suspicious for a malignant tumour with central cystic, haemorrhagic or necrotic change. There was no evidence of underlying liver disease on blood tests, and tumour markers including carcinoembryonic antigen (CEA), carbohydrate antigen (CA-19.9), alpha feto protein (AFP), and chromogranin A were within normal limits.
+At the time of surgery a large, a well-circumscribed, partially haemorrhagic cystic lesion was noted (). This was adherent to the proximal colon and omentum, however, with no clear direct invasion. A 3 cm cystic nodule was also noted in the right pelvis. A partial right hepatectomy and en bloc extended right hemicolectomy were performed as well as removal of the pelvic nodule. The patient's post-operative course was unremarkable.
+Histology of the tumour revealed variable morphology. Prominent intratumoral necrosis was seen, and there was moderate mitotic activity. The morphological and immunohistochemical profile was consistent with undifferentiated embryonal sarcoma. The tumour was comprised of densely cellular areas of rounded and pleomorphic cells and myxoid more paucicellular areas with stellate and spindled cells (). Tumour cells stained positively for AE1/AE3, alpha1-antitrypsin, vimentin, and desmin. Variably sized eosinophilic, intracytoplasmic, PAS-positive, diastase resistant globules were also noted within occasional tumour cells (). In addition, nodules of malignant hepatoid tumour were admixed with the undifferentiated areas () and stained positively for HepPar-1, polyclonal carcinomembryonic antigen, and AE1/AE3.
+The patient declined adjuvant chemotherapy. Repeat CT imaging 6 months postoperatively showed no evidence of recurrent disease."
+Luis Kerr,25,1990/2/12,704.438.5522,omacdonald@example.com,6601 Robert Fork Apt. 512,"A 17-year-old primigravida, 31 weeks of pregnancy, was refereed to our hospital presenting a fetus with a large head circumference, one chest, and two vertebral columns. Two-dimensional (2D) ultrasound scan realized with a Voluson 730 Pro machine (General Electric, Medical System, Healthcare, Zipf, Austria) equipped with a volumetric convex probe (RAB 4?? L) showed a conjoined twin-cephalothoracopagus janiceps disymmetros, one placenta, and polyhydramnios. Twins were fused from head until upper abdomen at the level of the umbilical cord; they had a single chest, a common liver, two vertebral columns, and two hearts. There was one skull with two faces (), one of them well-formed with two eyeballs, brain, and duplicates and fused thalamus (). After preterm labor at 34 weeks, twins weighed 1, 660 g and were born by Cesarean section, surviving for twenty minutes. The X-ray and postmortem analysis confirmed the prenatal diagnosis (Figures and )."
+Baylee Brennan,22,1996/12/26,(638)860-6034,latoya04@example.org,026 Kelley Trail Apt. 878,"A 62-year-old female patient presented to the Accident and Emergency Department with abdominal pain and nausea. She described a 3-week history of worsening right upper quadrant pain but denied any nausea, vomiting, or fevers. Her past medical history included coeliac disease, a hiatus hernia, and irritable bowel syndrome. Her regular medications were Mebeverine, Omeprazole, and Movicol with no known drug allergies. She worked as a cleaner, did not smoke, and drank minimal alcohol. Of note, she had not travelled recently, never had instrumentation of her abdomen, and did not have any recent antimicrobial treatments. Specifically, she denied any intentional or accidental ingestion of soil or aquatic material.
+On admission, she was apyrexial with normal observations. Significant examination findings were that of localised tenderness in the right upper abdominal quadrant, consistent with acute cholecystitis. Blood tests revealed raised inflammatory markers with mildly deranged liver function tests. (White Cell Count 24.0 ? 109/L, Erythrocyte Sedimentation Rate 98, C-Reactive protein 248, Bilirubin 12, Alkaline Phosphatase 189 U/L, Alanine aminotransferase 58 U/L, Gamma-glutamyl Transferase 141 U/L, Albumin 37 g/L). An ultrasound was performed which reported?€he gallbladder is distended, containing debris and calculi. It is thick walled, tender with some pericholecystic fluid around it. There is no drainable abscess or collections. The ultrasound appearances are consistent with an acute cholecystitis. The common bile duct is not dilated, and there are no dilated intrahepatic ducts. Normal appearances of the liver, spleen, and both kidneys.??She received 3 days of intravenous Co-amoxiclav, and her symptoms resolved. She was discharged with a 5-day course of oral Co-amoxiclav with arrangements to return for an elective laparoscopic cholecystectomy.
+Five months after her initial presentation, she reattended electively for a laparoscopic cholecystectomy. Due to adhesions throughout the epigastrium and right upper quadrant, this was converted to an open procedure. The gallbladder was buried in omentum, and there was a chronic abscess cavity due to a localised perforation of the gallbladder. Fluid from the gallbladder was sent for microbiological examination and a partial cholecystectomy performed.
+Postoperatively the patient was systemically well. Her observations were normal with no pyrexia, and she had minimal pain. The surgical team was contacted two days after the operation and informed that viable Raoultella planticola had been identified by VITEK 2 biochemical identification system with a very good probability of 99%. This was sensitive to Co-amoxiclav, Ciprofloxacin, Cefuroxime, and Tazocin. She was started on oral Co-amoxiclav following discussion with the microbiology team. She continued to make a good recovery and was discharged after a full 7-day course of Co-amoxiclav.
+She was reviewed 3 months after discharge with no new complaints."
+Curtis Pugh,21,1990/7/13,-2953,brownandrew@example.com,2633 Romero Fork Suite 191,"A 38-year-old woman with a 3-year history of cholecystolithiasis was examined at a local hospital and referred to our hospital for endoscopic gallstone removal without gallbladder excision. When she was hospitalized at our hospital, the acute right upper abdominal pain had persisted for two hours.
+On physical examination, no signs of jaundice were seen in the skin or sclera. The patient's abdomen was soft, with no sign of lumps, with tenderness other than rebound tenderness in the gallbladder area. Murphy's sign was positive. Ultrasonography revealed several movable masses of 7 ? 10 mm and 7 ? 9 mm in size, which were strongly echogenic, with acoustic shadowing in the body of the gallbladder; an immovable strongly echogenic mass of 7 ? 10 mm with acoustic shadowing in the neck of gallbladder and cystic duct; and poor sound penetration and a dense, low-light spot in the dark space of the bile. There was no thickening of the gallbladder wall. The gallbladder emptying index was 30%. No obvious abnormalities were seen in the liver, spleen or pancreas.
+The patient was diagnosed as having cholecystolithiasis complicating acute cholecystitis and incomplete biliary-tract obstruction. The patient had been given anti-inflammatory treatment after the examination for 2 weeks and the symptoms of acute cholecystitis had disappeared before the operation was schedule, and the patient was strongly in favor of preserving the gallbladder.
+Consequently, after approval by the medical ethics committee and provision of informed consent by the patient, the gallbladder was laparoscopically isolated and transected at the bottom (< 6 mm) under general anesthesia. First, the bile was drained with a sterile ventricular drainage tube to a sterile injector, and transferred to sterile tubes. Next, the gallbladder was explored with a three-channeled cholecystoscope (CHiAO; Chinese national patent number: ZL200810026985.X HAWK, China []), and the stones were collected with a stone extractor. We found only mild congestion in the gallbladder mucosa, which indicated only slight inflammation of gallbladder. Using endoscopy, we found many small, semitransparent stones (< 1 mm) adhered to the gallbladder wall (Figure ). These stones were removed with an endoscopic attachment (CHiAO absorbing box; Chinese national patent number: ZL 201110167069.X) designed to remove sludge-like gallstones combined with seven types of manipulation (pushing, squeezing, pressuring, tearing, bracing, flushing, and sucking) [], while several large stones (> 5 mm) were removed with a stone extractor (Figure ). The small stones were yellowish and semitransparent, and the large stones were polyhedron or globular in shape, and had a radial, layered arrangement in profile (Figure ). The bile was yellowish, opaque, turbid, and very viscous. After centrifugation at 1,450 g for 10 min, the bile supernatant was transferred to a clean tube, and about 0.5 mL of sediment was kept. The bile sediment was smeared onto labeled slides and viewed under a system microscope (BX51; Olympus, Tokyo, Japan). Colorless hexagonal plate crystals with high refractivity and limpid edges were seen, which were judged to be cystine crystals based on their morphology. Meanwhile, colorless, transparent crystals (in the shape of rectangles with missing corners or squares with missing corners, or glass flakes) were seen, which were judged to be cholesterol crystals from their morphology (Figure ).
+The gallbladder stones were analyzed with a Fourier transform infrared spectrometer (TENSOR27; Bruker Optics GmBH, Ettlingen, Germany) in the frequency range of 400 to 4,000 per cm at 4 per cm resolution. The results indicated that the small stones were cystine stones and that the large stones were cholesterol stones; (Figure ).
+Next, some of the small stones and a piece of a large stone were fixed onto the sample table and dried at 60簞C overnight, then sputter-coated with gold (ETD-2000, Beijing Elaborate Technology Development Ltd., China) and observed under a scanning electron microscope (EVO LS10; Carl Zeiss, Cambridge, England). The samples were photographed and analyzed with an energy spectrometer (X-Max; Oxford Instruments plc, Oxford, UK). Under scanning electron microscopy, the small stones were found to be composed of hexagonal cystine crystals (30-270 弮m), some with prominences on their edges. The energy spectrum indicated that the elemental composition was carbon, oxygen, nitrogen, and sulfur, along with gold from the coating. The large stones were composed of lamellar cholesterol crystals with a thickness of about 1 弮m. The energy spectrum indicated that the elemental composition was carbon and oxygen, with gold from the coating (Figure )."
+Landry Person,41,1992/3/23,725-249-6446x264,ortizmary@example.net,8400 Martin Village,"A 47-year-old Sri Lankan male presented in October 2006 with a 3-month history of bilateral red watery eyes with a foreign body sensation. He had RA, which was quiescent at presentation for which he was taking oral diclofenac, prednisolone (PDN), and methotrexate (MTX) with calcium and folic acid supplements.
+On examination, his best corrected visual acuity (BCVA) was 6/19 right eye (OD) and 6/9 left eye (OS). There was an inferonasal peripheral crescent-shaped area of corneal thinning (80%) forming a gutter from 3 to 6 o'clock, 1.4 mm wide in the right eye, while in the left eye there was a smaller inferonasal gutter with 20% thinning. His PDN and MTX were increased and hourly topical carmellose sodium 0.5% added. Initial reduction of ocular discomfort prompted reduction of his systemic medication, but on review within 9 days BCVA OD was reduced to 6/38 and the right anterior chamber was shallow with a small corneal perforation noted in the corneal gutter. This was plugged with iris and not actively leaking. The perforation was repaired with corneal cyanoacrylate glue and a bandage contact lens (BCL) was placed for comfort and exchanged at 6 weekly intervals thereafter. Slow tapering of his systemic medication was attempted again. On review 4 months later in February 2007, a small leak from the previous perforation was noted. After further cyanoacetate glue repair, he underwent multilayered amniotic membrane graft (AMG) to the right eye in March 2007.
+Initially his postoperative course was satisfactory but attendance at follow-up appointments was poor. In June 2009, he attended with marked discomfort and redness of both eyes and BCVA of 6/15 OD and 6/7 OS. He was systemically well with no signs of active RA. He was found to have marked bilateral inferior corneal stromal thinning with perforations in the inferotemporal mid-periphery and a small iris prolapse plugging the hole in both eyes (). Bilateral emergency tectonic penetrating keratoplasties (PKP) were performed, decentered infero-nasally in order to replace the thinned cornea (). Lamellar grafts were initially attempted but was converted to a PKP as a satisfactory lamellar plane was impossible to create due to a soft eye from the perforations. His systemic medications were again increased.
+One week postoperatively, BCVA was 6/38 OD and 6/19 OS but one month later he presented with recurrent, bilateral paracentral corneal melts. Glue repair was again performed and topical cyclosporine 0.5% twice daily was added to both eyes. He subsequently underwent a further triple-layered AMG and second PKP to both eyes in September 2009.
+Infliximab (5 mg/kg intravenously) was commenced on the first postoperative day and he continued to receive cycles at the same dose at weeks 2 and 6 and then every 8 weeks, while PDN and MTX were gradually reduced. Since he was from an area of high prevalence of tuberculosis, prophylactic isoniazid was commenced. He underwent uncomplicated phacoemulsification with posterior chamber intraocular implantation in both eyes in June 2010. Eighteen months following infliximab therapy both eyes remained quiet with no signs of further corneal melting. The BCVA was 6/48 in both eyes, limited by subepithelial haze and thinning of his corneal grafts ()."
+Moses Branch,20,1998/2/21,001-451-246-6978x01170,gardnerdarryl@example.org,2069 Kelly Shores Apt. 020,"A 46-years-old woman presented to our hospital with complaining of dysuria, frequency, and recurrent urinary tract infections from one year ago. She had no hematuria, suprapubic pain, or family history of such problems. She had history of hysterectomy three years before this admission due to uterine leiomyoma. Physical examination revealed a mobile, round mass in bimanual examination. Abdominal ultrasonography revealed a round mass measuring 4 ? 5 cm (). There was no hydronephrosis in both kidneys. There was a round hyperdense intravesical mass near bladder neck in CT scan (). The mass was intramural in MR imaging and showed intermediate signal intensity on T1-weighted images (). A well defined 3 ? 4 centimeter mass was seen in superolateral part of bladder neck during cystoscopy. There was no any involvement of ureteral orifices. Due to huge size of the mass and its proximity to ureteral orifice, trans-urethral bladder resection was not planned for patient.
+She underwent exploratory laparotomy with low midline incision. The mass was identified in the posterior aspect of the bladder wall so partial cystectomy was performed for her. The pathology of mass was epithelioid leiomyoma. The postoperative period was uneventful, and the patient was discharged from hospital after 4 days.
+The patient's followup with clinical examination, abdominopelvic CT scan, and cystoscopy was normal in period of 2 years."
+Luisa Foley,39,1985/4/29,001-404-253-1063x454,natashawhite@example.org,818 Daniel Stream,"A 45-year-old man, who suffered from pain in the left posterior maxilla and a bad smell from the nose, was referred to our department. A 4 ? 6 ? 3 cm cyst was found in the left maxillary molar region on radiological examination (). After treating the acute infection, the patient underwent cyst enucleation under general anaesthesia (). Six months postoperatively, the area had a severe bony defect extending to the zygomatic buttress superiorly and hamular notch posteriorly. After computed tomography (CT) and model analysis of the defect, we decided to reconstruct it using transport distraction. Under general anaesthesia, a vestibular incision was made and a mucoperiosteal flap was raised to expose the lateral wall of the maxilla. The bone between the number 23 and the number 25 maxillary teeth was cut vertically with a saw and then connected to a horizontal bone cut 5 mm above the apex of the second premolar running posteriorly on the buccal side. The bone on the palatinal side was cut horizontally with curved osteotomes, gently to avoid damaging the palatal mucosa. Before mobilising the transport segment including number 25, the distractor was adapted to its stabilising plates with screws, and then the segment was mobilised using osteotomes (). Before suturing the surgical site, the distractor was checked to ensure that the transport segment was being moved into the proper position.
+After a 7-day healing period, the distractor was activated by 1 mm once daily for 15 days. After full activation, the distractor was left in situ for the consolidation phase. Six weeks later, the distractor was removed and two dental implants were placed in the new bone. After 3 months for osseointegration, we realised that the implants were not aligned on the proper axis and position on CT (). To correct this situation, a subapical osteotomy including the implants was performed and a block autogenous graft was taken from the mandibular symphysis and adapted to the superior border of the osteotomy line.
+Permanent prosthetic rehabilitation was started 4 months after the subapical osteotomy. Metal-supported porcelain restorations were constructed using conventional methods. The patient was followed up 3, 6, 12 and 24 months after the prosthetic rehabilitation (Figures and )."
+Mohammad Kramer,23,2002/12/25,890.907.2418x649,michaellee@example.org,34649 John Creek,"A 63-year-old woman with no past history of coagulation abnormality, recent trauma, or hormonal substitution experienced sudden onset of headache followed by installation of right hemiplegia and global aphasia. Computed tomography and subsequent brain MRI revealed massive left frontotemporal hemorrhagic infarction and thrombosis of the superior sagittal sinus, left sigmoid/transverse sinus, and cortical vein (Figures , , and ). Subsequently, chest tomography showed bilateral subsegmentary pulmonary embolism (). Doppler did not reveal any deep venous thrombosis of the lower limbs.
+The laboratory data showed severe hypochromic microcytic anemia with hemoglobin value of 3,4 g/L (normal range: 12??6). Serum iron concentration was 1 弮mol/L (N = 5??0), and ferritin concentration was 2 mg/dL (N = 11??37). No B12 vitamin or folate deficiency was found. Screening for coagulopathy was normal, including factor II, factor V (Leyden), activated protein C resistance, and antiphospholipid antibodies. Protein C, protein S, and antithrombin III were not interpretable because of early vitamin K antagonists therapy. Protein immunofixation electrophoresis demonstrated no gammopathy. Upper gastrointestinal and lower digestive endoscopies, mammography, endovaginal echography, thoracoabdominal and pelvic computed tomography were performed and failed to detect any malignant disease, source of active bleeding, or pelvic vein thrombosis.
+The patient was treated by blood transfusion and anticoagulation with intravenous heparin, followed by vitamin K antagonists (acenocoumarol) for a total duration of six months. The brain MRI performed one month after the onset showed an almost complete repermeabilisation of the cerebral venous sinuses.
+The patient's right hemiparesis gradually improved, as well as her global aphasia. The patient was discharged three months after the onset. The anemia gradually improved with a hemoglobin value of 13,0 g/L. Our assumption regarding the origin of the anemia was a vegetarian diet without a proper iron substitution."
+Hanna Stein,32,1992/2/21,+1-463-207-6792x25661,watersdaniel@example.net,132 Holland Port Apt. 676,"A 43-year-old Caucasian female with a history of nonischemic dilated cardiomyopathy with left ventricular ejection fraction (LVEF) of 10??5% status following Thoratec Heart-Mate II left ventricular assist device (LVAD) (implanted 2 years prior as a Bridge to Transplant) was transferred to our tertiary care facility for management of unresolving pseudomonas driveline infection. The patient secondary to persistent pseudomonas bacteremia despite adequate treatment with intravenous antibiotics underwent LVAD removal with reimplantation with another VAD. The patient also underwent an AICD lead extraction with generator change secondary to questionable vegetation on the defibrillator lead on transesophageal echocardiogram. The patient did well following that and remained home for 4 months while awaiting a cardiac transplant. Her past history was significant for hypertension, dyslipidemia, recurrent pulmonary embolism, history of herpes zoster infection with postherpetic neuralgia, and intracerebral hemorrhage.
+Four months later the patient was electively admitted for transplant evaluation. Her panel reactive antibody (PRA) levels were found to be low at 4% as measured by flow cytometry using HLA class I Luminex-coated beads. The patient (CMV positive) finally underwent a CMV negative, Epstein-Barr virus (EBV) positive orthotopic heart transplant without the need for desensitization. The patient's immediate postoperative course was complicated by multiple failed attempts at extubation secondary to fluid overload that required tracheostomy and acute kidney injury requiring temporary hemodialysis (with complete eventual recovery of renal function). The patient after 4 weeks, on routine surveillance endomyocardial biopsy (EMB), was found to have ISHLT grade 2R acute cellular rejection which was successfully treated with intravenous pulsed steroids and mycophenolate mofetil. The patient was eventually discharged home 2 weeks later and was followed as an outpatient. Three months subsequent to transplant the patient started to develop signs and symptoms of upper respiratory tract infections manifesting as unremitting cough. The patient admitted was found to have viral infection with positive serologies for entero, rhino, and coronaviruses, and the EMB was negative for rejection. The patient was managed conservatively without any antiviral treatment except prophylactic ganciclovir for CMV prophylaxis and discharged home. The patient did present again with similar respiratory symptoms a month later at which time it was decided to treat the patient with a course of oseltamivir (Tamiflu) for a clinical suspicion of influenza. The patient was discharged only to be readmitted 2 months later (6 months after transplant) for symptoms of exertional dyspnea, nausea, and abdominal pain. The patient was found to have low cardiac index (1.59 L/min/m2) and elevated right sided pressures on right heart catheterization while the EMB remained negative for cellular or humoral rejection. An echocardiogram at the time revealed a mildly depressed left ventricular ejection fraction at 40% with mild right ventricular dysfunction. The patient's panel reactive antibodies were undetectable. lists the trends in the available viral titres and other laboratory data (glucose and lipids). The patient was treated with intravenous methylprednisolone and plasmapheresis to treat for possible graft dysfunction. The next day the patient had a sudden cardiorespiratory arrest and died despite prolonged attempts at resuscitation.
+A postmortem analysis revealed microscopic changes of concentric intimal proliferation and inflammation resulting in near-total luminal occlusion in the epicardial and the intramyocardial coronary vessels, suggestive of graft vasculopathy (Figures ??. There was no evidence of rejection seen."
+Creed Summers,28,1998/7/10,001-302-693-2222x43904,dawn58@example.com,227 Edward Lakes Suite 061,"A 74-year-old female was referred to Emergency Unit (EU) of our hospital for an acute dyspnoea with 1-month history of progressive globus sensation; the patient was admitted to the Pneumology Department for evaluation of an important hypercapnic respiratory failure. Arterial blood gas analysis showed pH 7.35, pCO2 82.9 mmHg, pO2 52 mmHg; chest X-ray was negative for pulmonary disease. Family history was negative for remarkable diseases. Patient's past medical history included surgical excision of a cutaneous melanoma followed by chemotherapy (presently NED), carotid thromboendoarterectomy, a surgically treated CNS meningioma with implantation of ventriculo peritoneal shunt. Traumatic lesion of vocal cords, causing mild persistent dysphonia, was reported to have occurred during previous intubation for brain surgery. In the EU, the patient underwent a flexible endoscopic evaluation of the larynx that revealed a bulky mass on the left aryepiglottic fold with the involvement of the glottic space and consequent almost complete obstruction of the laryngeal respiratory space. No palpable lymph nodes were present.
+The patient was transferred to the Otolaryngology Department because of acute dyspnoea, and emergency tracheostomy was performed followed by incisional biopsy of the lesion. Intraoperatively, the mass was found to be smooth, pedunculated, and 3.5 cm in diameter. The histopathological examination of the incisional biopsy sample reported nonspecific fibrous submucosal tissue.
+CT scan demonstrated a round, heterogeneously enhancing mass, measuring 3.5 ? 3 ? 2.8 cm, which extended from the left aryepiglottic fold to the false vocal cord ().
+A second single-step surgical excision was then decided. The left false vocal cord was incised with a sickle knife, and a microflap was dissected; blunt dissection revealed an encapsulated, soft tissue mass. The tumor was completely excised. Macroscopically the surgical specimen consisted of a well encapsulated tan-coloured tumor mass, measuring 4 ? 2 cm. At microscopic examination, the tumor showed densely cellular areas with sheets of spindle cell palisading around amorphous matrix (Antoni A pattern) and less cellular areas with spindle cells in myxoid stroma and disorganized distribution (Antoni B pattern) (). Tumor cells were strongly immunoreactive for S100 protein. Cellular proliferation index evaluated with Ki67 antibody was <1%.
+Two weeks postoperatively, the patient reported that her globus sensation, chronic throat clearing, and shortness of breath had disappeared. The tracheostomy was closed. One month after surgery, she was reevaluated in the outpatient clinic by flexible fiberoptic laryngoscopy that revealed a complete healing of the vocal cord, minimal erythema, and no edema. At 18-month followup, the patient presented no endoscopic evidence of tumor recurrence and her voice had improved markedly ()."
+Frankie Stone,20,1998/8/9,515.426.0360,jorge57@example.com,397 Charles Underpass,"A 70-year-old, right-handed male developed simple motor seizures characterized by painful dystonic posturing of the right hand following left parietal meningeoma resection. Infrequently, the motor seizure spread to the right face and leg. At baseline the patient had a right hemiparesis with clasp knife rigidity of the arm, hyperreflexia, an extensor plantar response, and distal sensory loss in the right arm and leg predominantly involving proprioception. Gait was consistent with mild right-sided spastic hemiplegia. The patient's use of his right hand was limited to maintaining a grasp.
+During seizures, the strength and duration of muscle contraction appeared to be proportional to pain intensity. At the onset, sustained contraction of the right forearm and hand muscles with dystonic posturing were associated with severe pain in the right hand and wrist. The patient usually attempted to relieve pain by passively dorsiflexing the right wrist and fingers with the left hand. Pain intensity was reported as 10/10 and associated with grimacing, moaning, and tearfulness. Seizure involvement of the right face and right leg was not painful.
+Thirteen partial motor seizures were recorded during inpatient, continuous video/EEG monitoring. Most were not associated with epileptiform activity and either showed little change or irregular left central theta waves. Rarely, rhythmic low amplitude sharp waves appeared in the left central head region after the onset of arm jerking. MRI scanning indicated volume loss and increased T2 signal in the left parietal area.
+Initially, VNS plus levetiracetam resulted in a 70% reduction in seizure frequency. The VNS was turned off to allow MRI scanning, and its initial effectiveness was never reestablished. The patient received four BTX injections spaced 1 to 2 months apart using the following dosing schedule: (1) 200 units, right forearm, (2) 50 units, right deltoid; 50 units, right biceps brachii, (3) 100 units, right forearm flexor muscles, and (4) 50 units, right deltoid; 50 units, right biceps brachii; 50 units right forearm flexors; 50 units, right forearm extensors. The patient reported satisfactory pain relief during seizures and ictal facial grimacing and tearfulness resolved. Epilepsy surgery was then performed and resulted in seizure control so that further injections were not necessary.
+The patient reported less-painful seizures several hours after the first injection, suggesting an early onset of toxin-induced analgesia or placebo effect. However, he reported the same degree of sustained relief (80??0%) prior to injections two, three, and four as he did at one week after first injection. Thus, pain did not return to baseline levels between injections, so duration of effect following each injection was at least two months. Pain during seizures was easily tolerated by the patient but continued to vary directly with seizure duration and intensity. Definitive resective surgery occurred one month after the fourth injection."
+Finn Wheeler,31,1988/10/30,707.650.4806x72284,fisherkari@example.com,9121 Sanford Expressway,"A 30-year-old male presented with a 27-year history of partial motor seizures with painful muscle contractions beginning in the left foot and leg, sometimes spreading to the left thigh. The contractions occasionally extended rostrally to the thoracic paraspinal muscles. He also experienced complex partial, secondarily generalized seizures and simple partial status epilepticus. His neurological exam was normal.
+Pain Associated with Seizures. The patient reported a pain level of 10/10 during contractions of the left leg and foot at seizure onset. Muscle contractions in the left thigh, as well as in the paraspinal region, elicited a similar pain rating.
+Inpatient, continuous video/EEG monitoring recorded 10??0 partial motor seizures per day and an episode of simple partial focal motor status. Electrographic seizure onset appeared as rhythmic fast activity, C4 greater than Cz, and 2?? seconds after clinical seizure onset. The MRI did not reveal structural abnormalities. Ictal SPECT did not show perfusion abnormalities. Interictal PET revealed hypometabolism in the medial right posterior frontal and anterior parietal lobes.
+While under our care, VNS plus phenytoin, oxcarbazepine, clorazepate, and levetiracetam failed to control seizures. The patient received two BTX injections one month apart: (1) 40 units, left gastrocnemius; 30 units, left tibialis posterior; 30 units, left peroneus longus; 20 units, left peroneus brevis; 20 units, left flexor digitorum brevis; 40 units, left paraspinal muscles; 30 units, right paraspinal muscles, and (2) 300 units to the left thigh muscles, including the vastus medialis, vastus lateralis, rectus femoris, and thigh adductors. Injections were discontinued following successful palliative epilepsy surgery. Surgery included subpial transections of the superior and medial aspects of the right cerebral hemisphere and cortical resection of the medial aspect of the right cerebral hemisphere. Because some seizures persisted, the patient was subsequently enrolled by us (B. J. Fisch and M. E. Carey) in a Phase II clinical trial for the treatment of medically refractory partial seizures.
+The patient reported a 60??0% reduction in pain in his left lower leg and paraspinal muscles during seizures two to three days after his first injection. The focus of maximum pain shifted to the left foot and thigh but the highest ictal pain rating was 4/10. The second injection included left thigh muscles, and further pain relief was reported. Toxin-induced analgesia in the areas targeted by the first injection was sustained for at least two months. Epilepsy surgery occurred one month after the second injection."
+Sydney Cross,23,1991/5/7,001-648-468-4008,hjohnson@example.com,908 Riggs Overpass,"An 8-month-old girl was referred to the Department of Oral and Maxillofacial Surgery of the University Hospital San Vicente in Medell穩n, Colombia, for evaluation of multiple erythematous lesions on the tongue, cheek and floor of the mouth (). The lesions had been present for the previous four months. Physical examination revealed well-demarcated nodules measuring around 1 cm in diameter. The overlying mucosa appeared normal and nonulcerated. In order to complete a histological analysis, excisional biopsies were performed. The surgical samples were fixed in 10% buffer formalin for a minimum of 48 hours, embedded in paraffin, and cut at 5 弮m to be stained with Hematoxylin-Eosin technique. Microscopically, fusiform cell proliferation with elongated nuclei and eosinophilic cytoplasm was observed. Several blood vessels lined by a thin layer of endothelial cells were observed intercalated in the fascicules (). Immunohistochemical techniques were also applied, involving monoclonal antibodies against actin, vimentin, cytokeratin, and the S-100 protein (). The immunohistochemical study revealed the expression of vimentin, desmin, muscle specific actin (MSA), and smooth muscle actin (SMA) within the tumor cells. The other markers studied (cytokeratin, AE1/AE3, EMA, S100, and CD34) were negative. Diagnosis of vascular leiomyomas was confirmed. Computerized tomography ruled out bone association, corroborating the completely mucosal allocation of the leiomyomas. Finally, the lesions were removed under general anaesthesia (). The patient had a correct evolution without any postoperative incident. The patient returned after a 6-month period, at which time there was no evidence of recurrence."
+Fabian Dodson,22,1994/8/3,+1-295-468-1808x722,parkapril@example.org,6702 Harris Ferry Apt. 399,"A healthy 37-year-old multiparous woman, gravida two para one, presented to the birthing unit in spontaneous labour at term. Three years prior, she had an emergency lower-segment caesarean section (LSCS) for failure to progress in labour, at 8 cm cervical dilatation. She had no other history of gynaecological surgery. On presentation, she was contacting every three minutes, with membranes intact and a reassuring cardiotocograph. An amniotomy was performed two hours later, at 8 cm cervical dilatation and station 2, producing copious clear liquor. No abnormalities were noted.
+Two minutes after the amniotomy, a ten-minute foetal bradycardia occurred (to 77 bpm), and the patient was transferred to theatres for an emergency LSCS. She was not in significant pain and had only scant vaginal bleeding. Due to the urgency of the situation, neither abdominal nor vaginal examinations were performed at that time. A live female infant was delivered 15 mins later, weighing 3285 g. The baby was dusky, with blood throughout her airways, and cord pHs of 6.97 (arterial) and 7.15 (venous). Despite this, the baby resuscitated well and had Apgars of eight (at one minute), eight (five), and nine (ten).
+Until this point the LSCS was routine, with no abnormalities noted. The uterus was closed in one layer, with persistent bleeding from an extension of the left uterine incision, near the left ureter. The ureter was thought to have been clamped during the repair, so assistance was sought from urology, who reflected the ureter and bladder off the uterus. This exposed an avulsion tear of the anterior vaginal wall, extending bilaterally to the uterosacral ligaments. The intact, dilated cervix was entirely visible through the tear. (see ). There was significant bleeding from the vaginal tear as well as from the (intact but friable) posterior bladder wall. Opinion was sought from a second Obstetrician, with consensus that the degree of damage and bleeding warranted a total hysterectomy. This was performed with the assistance of a specialist gynaecological oncologist. A left ureteric stent was also placed by the urology team once the bleeding was controlled.
+The patient had a total blood loss of 2500 mL, with her haemoglobin recorded as low as 67 g/L. During the operation she received 6 U of packed red blood cells, 2 U of fresh frozen plasma, 1 L of albumin and 8 L of crystalloid. She also required a metaraminol infusion to maintain her blood pressure above 90/60 mmHg. The total anaesthetic time was seven hours. Postoperatively, the patient was transferred to the intensive care unit, where she remained intubated and ventilated until the next morning. Despite this, she recovered well and was discharged home on day eight.
+Histopathology of the patients' uterus revealed that the previous LSCS scar was close to the site of the most recent LSCS incision, that is, 5 cm superior to the site of the rupture."
+Etta Yang,34,1982/11/11,001-478-415-9677x1742,stephen93@example.org,66140 Jones Valleys,"A 17-month-old African-American girl was referred from her private dentist for evaluation of two papillomatous lesions in the anterior maxilla (). History revealed a healthy child, the product of a normal, uncomplicated full-term pregnancy. Dental history revealed that the growths first appeared 5 months ago and were slowly increasing in size. No history of dental and/or facial trauma was reported. The child was not in any pain, and no interference with feeding was reported by the mother.
+The lesion on the buccal mucosa was about 1 centimeter in size, pink in color, stippled and attached via a peduncle to the attached gingiva opposite tooth no. 51 and tooth no. 52. The lesion blanched slightly with digital pressure.
+The lesion of the palate was about 0.75 cm in size, circular, pink in color, stippled, sessile, and adjacent to the incisive papilla between tooth no. 51 and tooth no. 52. No blanching was noted with slight digital pressure.
+A radiograph of the area revealed no bony involvement ().
+Due to the age of the patient and the relative complexity of the procedure, it was decided to perform excisional biopsy of both lesions under general anesthesia. The lesions were excised utilizing a number 11 scalpel blade. The excised areas were then cauterized.
+On one-week followup both areas were healing well; no pain or discomfort and no difficulty in eating were reported by the mother ().
+includes most of the lesions that should be considered in the differential diagnosis of both lesions. An attempt is made to order the lesions ranging from the most likely to the least likely to occur in this specific patient.
+Buccal lesion?ense fibrous connective tissue surfaced by stratified squamous epithelium with a normal maturation pattern. No evidence of malignancy. Diagnosis of focal fibrous hyperplasia ().
+Palatal lesion?ense fibrous connective tissue surfaced by stratified squamous epithelium with a normal maturation pattern. Many stellate fibroblasts and long thin rete pegs are present. Diagnosis of giant cell fibroma ().
+The pathology report also suggested that since there were only subtle histological differences between the two lesions, they might have simply been in different stages of maturation. The report also advised that the child be assessed now and in the future for additional lesions and to consider and rule out fibromatosis syndrome."
+Malcolm Waters,22,1979/1/10,462-607-9525x25028,bmyers@example.org,600 Scott Points Suite 608,"A previously healthy, but obese 38-year-old Native American female, sought surgical evaluation for a left ulnar nerve entrapment syndrome. A routine preoperative laboratory assessment demonstrated a hematocrit of 30%, WBC of 3 ? 109/L (48% lymphocytes, 6% monocytes, 16% segmented polymorphonuclear cells, 25% promyelocytes, and 2% blasts) and a platelet count of 13 ? 109/L. Further blood test including a coagulation panel showed normal electrolytes and hepatic transaminases, mildly elevated serum lactate dehydrogenase at 298 U/L, prothrombin time of 14.5 seconds (normal 11??3.5), partial thromboplastin time of 35 seconds (normal 25??4), fibrinogen of 762 mg/dL (normal, 212??70), thrombin time of 13 seconds (normal, 15??9), and D-dimer 9.64 弮g/mL (normal, <0.40). Peripheral blood film showed several circulating blasts with coarse reddish-purple granules and Auer rods in the cytoplasm, convoluted nuclei, prominent nucleoli and fine open chromatin consistent with promyelocytes. Bone marrow biopsy and aspirate revealed a hypercellular marrow dominated by sheets of promyelocytic-appearing blasts. () Immunohistochemical studies showed that the blasts were positive for CD117 and myeloperoxidase, stained dimly for CD45, and did not express HLA-DR. Cytogenetic analysis demonstrated the characteristic t(15; 17) translocation and FISH analysis confirmed the presence of a PML/RARA rearrangement. She began induction chemotherapy (idarubicin 12 mg/m2/day IV, days 1?? and cytosine arabinoside [Ara-C] 100 mg/m2/day IV, days 1??) in conjunction with ATRA (45 mg/m2 daily in two divided doses PO). On day 7, she was prescribed fluconazole 400 mg daily and levofloxacin 500 mg daily for antifungal and antibacterial prophylaxis, respectively. On day 17, she reported a throbbing and persistent frontal headache which was accompanied by photosensitivity, nausea, and vomiting. Her neurologic exam was unremarkable. Ophthalmologic exam showed bilateral papilledema but no retinal hemorrhages. A lumbar puncture showed a CSF opening pressure of 300 mm of water (normal <200) with normal biochemical and cytologic findings. Magnetic resonance imaging of the brain was normal. ATRA was withheld and she received 1,000 mg of acetazolamide twice daily in conjunction with standard antiemetics and analgesics. Over the course of the next week, her neurologic and ocular symptoms improved, but they did not completely resolve until 2 days after fluconazole was also discontinued. She has since completed consolidation chemotherapy consisting of two cycles of arsenic trioxide (0.15 mg/kg/day, IV, 5 days/week for 5 weeks), followed by two cycles of ATRA (45 mg/m2/day in two divided doses, PO, days 1??) and daunorubicin (50 mg/m2 IV, days 1??) without recrudescent neurologic symptoms []. She then completed ATRA maintenance every other week for a year in conjunction with daily 6-mercaptopurine and weekly methotrexate []. She remains in clinical and molecular CR at 18 months of followup."
+Bristol Hart,33,2002/2/25,674-710-7528x06971,kristinvalencia@example.org,146 Jeffery Inlet,"Mr BA, 20-year-old, was followed for a juvenile SPA (at the age of 16) with sacroiliitis and bilateral coxitis. Besides, HLA typing was not performed. In 1999, that is, four years after the beginning of his disease, the patient's disease was active under NSAID with a BASDAI at 6. At that time, the patient also developed a sudden onset of persistent diarrhea, made of watery but not bloody stools. Colonoscopy was unremarkable. Systematic colonic biopsies had revealed a thickened subepithelial collagen layer and diffuse inflammation of the lamina propria with prominent intraepithelial lymphocytic infiltration, findings consistent with CC. The NSAIDs were stopped and SLZ was started at a dose of 3 g/day, resulting in a marked clinical improvement with a BASDAI score at 3.5 after 3 months. Since then, the patient no longer had diarrhea with a current decline of 11 years."
+Joel Rocha,40,2002/3/28,585.458.5174x517,nancy69@example.com,3663 Gallagher Mountain Apt. 451,"The patient was a 74-year-old woman who had undergone radical hysterectomy and radiation therapy for cervical cancer in 2000. She was never followed up by urologists for postoperative neurogenic bladder. In April 2009, she was referred to our hospital because of acute renal failure with bilateral hydronephrosis. Her general status improved after indwelling of stents in both ureters, which were replaced every 2-3 months. Retrograde pyelography (RP) was performed at every instance of stent replacement. RP showed atrophic bladder and stenosis of the lower part of the ureters; however, there were no signs of a tumor. She complained of gross hematuria in October 2010, and cystoscopy showed bleeding from the right ureteral orifice. Computed tomography (CT) did not reveal the source of bleeding, such as, ureteral or pelvic cancer. The bleeding resolved spontaneously after 1 month of conservative therapy. Massive bleeding suddenly recurred during a routine replacement of the stents in December 2010, and blood transfusion became necessary.
+Contrast-enhanced CT showed hematomas in the right renal pelvis and the ureter; however, there were no aneurysms or extravasations (Figures and ). Angiography was performed, but no pseudoaneurysms were found, and the source of bleeding was not identified (). Acute pyelonephritis was also observed. However, the infection and the hematuria were again resolved by conservative therapy. Massive bleeding recurred in March 2011. An immediate angiography was performed, which showed a fistula between the ureter and a pseudoaneurysm of the internal pudendal artery (). Coil embolization was performed (), which successfully controlled the bleeding. To avoid further indwelling of the ureteral stents, we recommended the creation of a urinary diversion; however, the patient refused to undergo any more open abdominal surgeries. After 3 weeks, nephrostomies were performed in both kidneys, and the ureteral stents were removed. Thereafter, hematuria did not recur up to the last followup in July 2011."
+Emmie Ramirez,33,2004/3/19,844-293-3347x1479,aanderson@example.com,6491 Baker Trail,"The patient was a 63-year-old woman with typical chest pain. she suffered from risk factors of hypertension (HTN), hyperlipidemia (HLP), diabetic mellitus (DM), and smoking. She did not have any abnormality in her physical examination. The biochemical test results, including cardiac enzymes were all within normal limits. Her baseline electrocardiogram was a normal sinus rhythm with left bundle branch block (LBBB). Transthoracic echocardiography showed a 40% ejection fraction, left ventricular dilatation with hypokinesia in the lateral walls and dyskinesia of septal and apical walls.
+She underwent Coronary angiography (CAG) that revealed a tubular lesion (95%) in the proximal left anterior descending artery (LAD), and a diffuse lesion (95%) in mid part of LAD with a good distal flow. Stenting of proximal lesion with a 3 mm x 19 mm, paclitaxel-eluting coronary stent system (EURoCOR), and mid part of lesion with a 2.5 mm x 32 mm paclitaxel-eluting coronary stent system (EURoCOR) was carried out for her with success. After stenting, coronary angiography showed good deposition of stent with a good distal flow (TIMI3) (). Afte 6 days, the patient referred with a typical chest pain without any response to medication.
+Coronary angiography was done for her and showed an optimal extent expansion without any significant residual stenosis. However, we detected the definite fracture of stent, which was implanted in the mid part of LAD 6 days before her admission ()."
+David Horton,39,1982/4/8,264.309.3030,tammywallace@example.com,8061 Dunlap Creek,"A 10 year-old girl was referred to the Prosthodontic Department, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran by her parents who were in search of a prosthesis that could prevent injuries to her oral mucosa, and improve her function and appearance. Medical history revealed that the girl was the second child of consanguineous parents whose first child was normal. When the patient was a few months old, her parents began to suspect that there was something wrong with the child since she failed to cry during painful stimuli, did not sweat and suffered from episodes of unexplained fever that decreased with physical activity. By the time she was 12 months old, deep ulcers developed in the patient? fingers, lips, tongue and oral mucosa due to bites, with premature loss of a number of teeth due to biting hard toys. At that time, the child was diagnosed with CIPA however, the parents did not seek dental management until she was 10 years old.
+Oral examination of the child showed mixed dentition. The left and right permanent canines were present in the mandible; however other teeth were lost due to biting hard items and self-tooth extraction. The remaining mandibular teeth had mild cervical caries.
+In the maxilla, both the right and left permanent first molars were in good condition and only occlusal caries were noted. The other remaining maxillary teeth and roots were primary teeth with extensive caries (). Necrotic ulcers were apparent on the left side of the tongue and buccal mucosa which resulted from the child's biting habit (). The patient had a decreased ability to open her mouth that was attributed to a fibrous band of scar tissue in the cheeks. The hands and fingers also showed signs of biting ().
+Although the patient had mild mental retardation, she was very cooperative and eager to have teeth that could improve her appearance and function. After extraction of her maxillary primary teeth and roots under anesthesia (due to the vasoconstrictor role of epinephrine), an esthetic-functional acrylic removable partial prosthesis was provided. In the mandible, the cervical caries of the canines were removed and restored with tooth-colored composite resins. After removal of the canine teeth undercuts, a mandibular overdenture was constructed ().
+The parents were instructed to remove both prostheses at night. Prophylactic daily use of fluoride gel inside the overdenture was recommended to prevent caries. During the first visit (24 hours after prosthesis insertion), the mucosa was checked carefully for any signs of tissue inflammation and ulcers due to the prosthesis. After one week, the mother reported that her daughter had managed well with artificial teeth and that she had been able to chew soft food.
+At one month recall, the patient could chew tough food with her prosthesis. An improvement in ulcerations was noted and no new lesions were seen. The prosthesis improved the patient's appearance and psychosocial adjustments. After a six month follow-up, the girl was in good condition and was satisfied with her prosthesis. There was no weight loss and she could chew well. Her oral hygiene improved due to her care and the parents??cooperation. The remaining teeth were also in good condition and no gingivitis around the canine teeth was observed."
+Aitana Moore,21,1989/12/2,(907)612-3741x498,rebeccamay@example.net,279 Tony Ranch Apt. 720,"A 75 year old female presented gradual onset of pain, redness and swelling of the left breast with 7 days duration without any history of trauma, diabetes mellitus or other chronic diseases. She did not take any medication. On examination, she was febrile and had pulse rate of 90 beats/minute and blood pressure of 110/80 mmHg. Her left breast was swollen, red, tender and warm with a necrotic lesion of 3x4 cm. Investigations revealed a hemoglobin concentration of 12 gm% with a white cell count of 18,500/cu.mm. Renal and liver function tests were within normal limits as was the chest radiograph. A diagnosis of severe mastitis with probable abscess was made. An incision was taken over the breast to drain the underlying pus collections if any but there were no localized abscess ().
+However, within 24 hours the underlying breast tissue showed necrosis with black eschar formation. An incisional biopsy revealed breast parenchymal necrosis, polymorphonuclear infiltration and several broad aseptate hyaline fungal hyphae. A simple mastectomy was done. Histopathological examination showed extensive necrosis of the breast parenchyma with polymorphonuclear infiltration, hemorrhage and thrombosed blood vessels and many broad aseptate hyaline fungal hyphae branching at 90o suggestive of mucormycosis ().
+Intravenous amphotericin-B (1 mg/kg/day in the form of infusion in 5% dextrose) was administered for 10 days followed by one month fluconazole treatment. The patient showed complete remission after one week. We grafted the wound with split thickness skin graft after one month. She was asymptomatic during her 3 months follow up."
+Levi Snyder,38,1997/7/31,+1-439-262-4691x77366,vrichardson@example.org,998 Silva Points,"A 26-year-old lady with RRMS since 11 months ago who had been treated with betaseron (8 mIU every other day) was visited in MS clinic of our hospital affiliated to Mashahd University of Medical Sciences in Mashahad, Iran because of icter and fatigue from 3 days ago. Her disease had started from 13 months ago with left optic neuritis. The first attack had improved completely with high dose intravenous prednisolone (1 gr/day for 5 consecutive days). Two months later, a second attack occurred as spastic paraparesis. The patient received another 5-day intravenous corticosteroid pulse therapy and after complete recovery, INF帣1-b was started. The patient was doing well until she visited because of fatigue and icter. At this time, neurologic examination was normal. She had received no drug other than betaseron. The patient had no history of viral infection, fauvism, blood transfusion or additional drug intake. Physical examination showed pale conjunctiva and icteric sclera without organomegaly or lymphadenopathy. La ratory tests were as follows (normal ranges are in parenthesis): Total billirubin: 8.5 mg/dl (<1.1 mg/dl), direct billirubin: 0.4 mg/dl (<0.25 mg/dl), SGOT: 24 IU/L (up to 40), SGPT: 27 IU/L (up to 40), Alkaline phosphatise: 140 U/L (64-306), LDH: 819 IU/l (up to 480), HBsAg: Negative, Anti HCV Ab (IgM and IgG): Negative, indirect coomb? test: positive, Direct coomb? test: Positive, ANA: Negative, Anti-DNA (ds): Negative, rheumatoid factor: Negative, blood iron profile: Normal, reticulocyte: 2.3% corrected (??%), serum protein and immunoelectrophoresis: Normal, U/A: Normal, WBC: 8400 (Neut: 66%, lym: 30%, Mono: 2%, Eos: 2%), RBC: 3.44 ? 10(6), Hb: 10.3 g/dl, Hct: 32.5, MCV: 94.5 fL, MCH: 29.9 pg, MCHC: 31.7 g/dl, platelet count: 275000 and erythrocyte sedimentation rate: 20 mm/h. The red blood cell morphology of the peripheral blood showed spherocytosis, mild macrocytosis, and polychromatophilia. Ultrasonography of the liver, spleen, portal vein and gall bladder was normal.
+Other causes of AHA were ruled out or the patient. Medical records of the patient were reviewed comprehensively and pre-existing AHA was ruled out. INF帣1-b was discontinued and the patient was observed carefully for 4 weeks. No additional drug was started for the treatment of patient? anemia. The patient became asymptomatic and icter disappeared about 3 weeks after drug discontinuation. Indirect coomb? test became negative, direct coomb? test titer decreased and hemoglobin level increased to 13.4 g/dl. Since that time -6 months ago- the patient is doing well without receiving any medication. Fortunately, the patient had no relapse of MS and no disease modifying treatment measure was needed."
+Callie Evans,44,1978/6/8,495-479-3488x80314,kennethflores@example.org,0517 Sandy Fords,"A 67 year old female was initially presented to the Emergency Department with a complaint of epigastric abdominal pain. She described a two weeks history of that pain. Her medical history was unremarkable. On examination, she was in discomfort, with a heart rate of 90/min, blood pressure 110/60 mmHg and respiratory rate 18/min. On palpation, epigastric tenderness was present and a pulsatile mass was detected in this region. The laboratory analysis yielded hemoglobin (Hb): 11.2 g/dl (12-16), white blood cells: 14600/mm(3) (4500-11000) with neutrophils 78%. Findings on her electrocardiography and chest radiography were interpreted as normal. The patient was admitted to the Intensive Care Unit (ICU). An urgent computed tomography scan was performed which showed an infra-renal abdominal aortic aneurysm with a transverse diameter of 7 cm () starting 3 cm distal to renal arteries and ending 1 cm above common iliac arteries. CT findings include early detection of contrast material in the inferior vena cava, suggestive of an aortocaval fistula (). The ACF was concealed by a huge mural thrombus.
+Over the next 12 hours, the jugular venous pressure (JVP) elevated gradually, the blood pressure decreased and the patient became oliguric. Cardiac assessment did not show any pathologic change, so the patient was prepared for an emergent laparotomy. At laparotomy, a large retroperitoneal hematoma was detected and the aorta was exposed and clamped proximally from the lesser sac under the diaphragm and distally at the common iliac arteries. Having opened the aneurysm sac, the aortocaval fistula was identified. The venous bleeding into the aneurysm sac was controlled by direct pressure. The fistula was over sewn from within the aneurysm sac with 3-0 prolene. Then the aneurysm was replaced with a 20 mm diameter tubular graft. The patient was returned to the ICU after completion of the operation. She recovered very soon and was discharged in seven days."
+Elias Larson,23,1991/4/12,(211)481-7751x8006,derek20@example.net,86259 Robertson Keys,"A 59 year old man with a compliant of abdominal pain was referred to our department. He described a sudden onset of palpitations and dizziness, two days before admission. His past medical history was unremarkable with no history of smoking. Abdominal examination revealed a large but non-tender pulsatile mass in the epigastric region. The laboratory analysis yielded hemoglobin (Hb): 15.8 g/dl (12-16), white blood cells: 9700/mm3 (4000-11000) with 66% neutrophils, aspartate amino transferase (AST): 28 U/L (0-40), alanine amino transferase (ALT): 17 U/L (0-40) and urea: 40. After adequate resuscitation and hemodynamic stabilization, an abdominopelvic CT scan with IV contrast showed an infrarenal aortic aneurysm, 8 cm in transverse diameter, suspicious to retroperitoneal leak. It also revealed simultaneous contrast material enhancement in the inferior vena cava. Emergent laparotomy was performed and the same procedure accomplished for repair. The patient was admitted in ICU for 5 days and was discharged 7 days later."
+Alayna Villa,40,2005/9/1,+1-514-833-6396x33446,mary22@example.org,131 Eric Cape Apt. 511,"A 31 year-old Iranian woman presented with a long history of non-pruritic verrucous lesions involving the extensor of her limbs. She had a previous history of developing scars at sites of minor trauma and suffered from hoarseness. She had a history of several episodes of respiratory tract obstruction and dysphagia for two years and aphonia for four months. The patient had no history of epilepsy or photosensitivity.
+Her older sister, aged 32, had similar but milder dermatological manifestations.
+On physical examination of these sisters, numerous flesh colored verrucous symmetric papules were observed on the elbows, knees, feet, toes and fingers. Yellow papules were found on soft palate () and multiple beaded papules along the margins of their eyelids (). Multiple acneiform (pock like) scars were noticed over their forearms and legs. The younger sister had fissured lips and her frenulum was thickened and infiltrated and was unable to protrude her tongue out of the mouth. Other systemic examinations including central nervous system were normal. The routine hematological and biochemical investigations were within normal limits. Skull radiography was normal.
+Histological examination of the skin lesions in the elbow showed deposition of a periodic acid-Schiffpositive (PAS +), pink amorphous material in the papillary dermis and around blood vessels and appendages (). All these clinical and laboratory data were consistent with lipoid proteinosis."
+Clay Ballard,31,1995/3/4,+1-244-574-6229x030,nicolejensen@example.com,9756 Michael Estates,"Our patient was a 27 years old man with intermittent nocturnal fever, abdominal pain, loss of appetite, vomiting, diarrhea and severe weight loss for 6 months. Patient was unemployed and had low socio-economic status. He had previous history of opioid use in forms of inhalation and digestion. He had been imprisoned 4 years ago. He denied alcohol drinking and any unsafe sexual contact or intravenous drug use.
+The patient was quite cachectic and had low grade fever. Other vital signs were normal. Physical exam revealed oropharyngeal candidiasis. He was not icteric,and no organomegaly was found. The results of his blood tests are depicted in . Upper GI endoscopy revealed severe esophagitis due to Candida with scattered whitish plaques on an erythematous basis. There were generalized nodularity and candidiasis lesions in duodenum. Microscopic evaluation of duodenal biopsy material showed partial blunting of the villi. Abundant macrophages containing intracytoplasmic microorganisms had infiltrated and expanded the lamina propria. High magnification view revealed Leishmania amastigotes with nuclei and kinetoplasts ( and ). Leishman bodies were also observed in bone marrow aspiration specimen (). Budding yeast cells and pseudohyphae of Candida albicans were also seen in duodenal mucosa ().
+For definite diagnosis, we checked anti-leishman antibodies in the patient? serum. Latex aglutination test and immunofluorescent antibody were positive for Leishmania infantum.
+Because of poor general condition, generalized candidiasis lesions and severe cachexia and lymphopenia, patient was suspicious for HIV infection. HIV-Ab was positive with CD4+ cell count of 80/弮l, hence diagnosis of AIDS with visceral leichmaniasis was confirmed.
+Patient was sent to the special center for AIDS treatment to receive the optimum care and unfortunately died 2 weeks later due to sepsis."
+Alejandra Yang,42,1989/2/26,761.531.1291x79104,brandondunlap@example.net,121 Alexandra Estates Apt. 499,"A 49-year-old diabetic woman referred with left flank pain. Her physical examination was unremarkable, except for high blood pressure (160/90 mmHg). Complete blood count and electrolytes were normal. The biochemistry analysis showed high triglyceride (260 mg/dl) and fasting blood sugar (180 mg/dl). Other laboratory results were normal, including renin, aldosterone and 24-hour urinary VMA and metanephrine. Abdominal sonography demonstrated an 82 mm hypoechoic mass, containing internal cystic component adjacent to superior pole of left kidney. CT scan of abdomen showed an 8.2x7.5x6 cm hypoattenuated cystic mass with calcified wall in the left adrenal gland ().
+Because of the newly diagnosed arterial hypertension, she was operated with the possible impression of pheochromocytoma. During operation a cystic mass with solid components was detected in the left adrenal measuring 8x7x6 cm, which had pushed the kidney downward. The cystic mass was successfully removed with intact wall by adrenalectomy and sent for pathologic study. Gross sectioning of the specimen showed adrenal gland with some cystic structures. These cysts had whitish friable wall, grossly in favor of hydatid cyst. Microscopic examination confirmed the gross findings and multiple cystic structures with some scolices and laminated membrane were seen. After operation, all blood pressures were about 130/80 mmHg and postoperative period was uneventful. After 2 months, she was doing well and symptom-free."
+Malcolm Watkins,29,1985/1/8,001-334-639-3920,alfred77@example.net,85583 Livingston Mountains,"An 80-year-old man presented with progressive dysphagia, weakness and weight loss since 5 months prior to admission. His past medical history was completely unremarkable. Physical examination showed a cachectic and pale old male. Heart, lung and other parts of the body were unremarkable. Laboratory findings were: WBC: 3400/ml, Hb: 7.3 gr/dl, platelet: 190000/ml. Occult blood was detected in the stool examination. Upper gastrointestinal endoscopy showed an ulcerative infiltrative mass in the lower third of esophagus. The lumen of the esophagus was narrowed by the tumor so that the tube could not be passed through stomach. A biopsy was taken with the pathologic diagnosis of well differentiated SCC.
+CT scan of the chest and abdomen did not reveal any additional finding without any evidence of metastasis. The patient underwent surgery for resection of the tumor, and distal esophagectomy (Orringer's operation) was performed. The specimen received in the pathology laboratory consisted of a segment of esophagus with an ulcerated infiltrative mass measuring 5Xx3x2.5 cm which has nearly obliterated the lumen with 2-cm distance from the distal resected margin of cardia which grossly seemed unremarkable except for mild firmness. Grossly, no overt mass was detected in the stomach.
+Microscopic analysis of the sections from the esophagus showed well differentiated SCC invading the adventitia (). The distal surgical resection margin of gastroesophageal junction showed well differentiated adenocarcinoma with focal invasion to the superficial muscularis properia (). There was normal esophageal mucosa between the two tumors, so these two tumors were completely separate. No lymph node metastasis of either SCC or adenocarcinoma was identified.
+Unfortunately after resection of the esophagus, the patient developed pneumothorax and with the diagnosis of air leak and right main bronchus rupture, emergency right postrolateral thoracotomy performed and chest tube was inserted but the patient did not tolerate and died after cardiorespiratory arrest."
+Lola George,21,1985/6/25,7768802107,melissabrown@example.com,452 Mark Place,"A 23-year-old man with mild jaundice and anemia was referred to the Hematology Research Center and Genetic and Prenatal Diagnosis of Thalassemia and Hemophilia Service of Datgheib and Nemazee Hospital (the main reference hospitals affiliated to Shiraz University of Medical Sciences in Shiraz, southern Iran) for premarital screening for thalassemia. On physical examination, he was asymptomatic and had no clinical manifestations. However, hemoglobin electrophoresis at pH 8.6 (Helena, Process-24, Beaumont, TX, USA) detected a band located between Hb A1 and Hb H (). The proportion of this unknown band was determined by capillary electrophoresis (Sebia, Capillarys 2, and Norcross, GA, USA).
+To determine the nature of the unknown Hb, chain separation by high performance liquid chromatography (HPLC) was used. The lysate was injected in a Vydac column in a Waters system (Waters, Breeze, Milford, MA, USA), and comparison of the retention times identified the unknown band as a 帣 variant (). The 帣 gene was sequenced with an ABI 310 Genetic Analyzer (Applied Biosystems, Carlsbad, CA, USA) to detect the mutation or deletion which caused the formation of this hemoglobin. By comparing sequencing graphs for normal and sample sequences, we detected a mutation in codon 77 (CAC >GAC) which caused the 帣77 His?sp substitution in the 帣 chain (Hb J-Iran) (). Molecular studies of the alpha globin gene found the homozygous form of the 3.7-kbp deletion (-帢(-3.7)/-帢(-3.7)), the probable cause of mild hypochromic microcytic anemia in the proband (diagnosed by blood smear prepared from fresh blood and stained with Wright stain). To detect long deletions in the alpha gene, gap- PCR was done, and to detect mutations or deletions, the reverse dot blot method was used according to the manufacturer? protocol for the strip assay 帢 globin gene kit (Viennalab, Vienna, Austria). Further studies were done in five of the proband? siblings and his mother (his father had died before he was referred to our center). The results are summarized in ."
+Mark Fuller,43,2003/4/27,(987)468-4872,kking@example.org,6573 Martinez Loop,"A 46-year old man presented 3 days after the sudden onset of back pain, numbness, and weakness of lower limbs after warfarin therapy for deep vein thrombosis. Clinical examination showed that the degree of motor weakness of both lower limbs was 3/5 and the level of numbness was T11 dermatome. Reflexes were depressed. Rectal examination showed normal anal tone and urinary retention was not detected. There was no neurological deficit in the upper limbs. The MRI revealed a posterior thoracolumbar epidural hematoma from the level of T10 to L2 with significant cord compression. The epidural mass was hyperintense on the T1W images ().
+The patient was admitted to our department, an emergency decompression was recommended and operation preparing was started. But he refused surgical treatment. Therefore, he was managed conservatively with cessation of warfarin therapy and beginning of low-molecular-weight heparin therapy. He was not placed on intravenous or oral steroids due to his neurological complaint started 3 days ago. His complaint of weakness in lower extremities were gradually recovered in one week and he was mobilized. After one month, he regained full power and a control MRI was performed. MRI revealed the resolution of the thoracolumbar epidural hematoma totally ()."
+Oakley Zavala,28,1994/7/23,+1-268-717-4709x1287,amandacooper@example.net,3067 Chandler Radial,"A 74-year-old man was referred to our department with recurrent sinusitis and a non-healed extraction wound was left after removal of the regional tooth about two years ago. The patient was diagnosed with acute sinusitis by a family doctor. The patient was managed by antibiotic therapy ?ithout??radiographic and histopathological examination.
+The patient? medical and familial histories were unremarkable. The clinical appearance of the lesion showed a central depressed part with superficial yellowish-white necrotized tissue surrounded by a narrow erythematic rim and mucosal hyperplasia. The lesion was not tender nor bleeding. There was a bony hard alveolar swelling in buccal aspect of premolar and molar region. No significant pus discharge was detected. Mucosal surface was normal in color and texture. Other parts of oral cavity showed normal color and texture. Oroantral fistula had been considered as an early diagnosis ().
+On panoramic view, complete loss of alveolar process in left premolar and molar region was detected. Borders of left antrum were not clearly visible. There was no remnant of bone trabequla or sequestra (). Water`s view confirmed loss of borders of maxillary sinus and lateral wall of nasal fossa in the left side. Complete haziness of the left antrum and relative haziness of left nasal fossa compared with the right one was obvious ().
+CT demonstrated a massive expansile lesion invading the entire left maxillary sinus. The lateral nasal wall and labial cortex of the maxilla as well as ethmoidal sinuses were involved. Osteomeatal complex and inferior and lateral wall of antrum in the left side were not visible ( and ).
+Regarding the size of lesion in antrum, an origin of sinus was suspected.
+The incisional biopsy revealed fragments of a benign neoplasia of odontogenic origin, characterized by the proliferation of small odontogenic epithelium islands and cords interlarded by a dense fibrous stroma, exhibiting intense collagenized areas. Follicular islands of odontogenic epithelium were bordered by columnar and palisaded ameloblastic cells with polarized hyperchromatic nuclei. Some of the stellate reticulum components of this follicular ameloblastoma showed squamous differentiation ().
+A radical left maxillectomy was performed. Multiple fragments from left middle and inferior turbinate, left maxillary sinus, left maxilla, left ethmoid tissue and left masseteric region were fixed in formalin submitted to laboratory. Sinonasal follicular ameloblastoma was reported along with mild chronic inflammation in the left ethmoid, maxilla and left middle turbinate tissue. The patient had no sign of recurrence after 4 years follow up."
+Dillon Sloan,18,1996/2/1,617-232-2487x2420,deanna02@example.com,873 Anderson Rue,"A 53 year old female without significant past medical history developed severe viral pneumonia, with rapid, progressive deterioration in her respiratory status. She developed ARDS and mechanical ventilatory management using ARDS protocol were unable to maintain adequate oxygenation. As a result, bedside VV-ECMO was planned. Transesophageal echocardiography (TEE) was performed to visualize proper positioning of the guidewire and cannula. Using the Seldinger technique, the right internal jugular vein was accessed and a guide wire was placed. Placement of the guidewire into the IVC proved difficult due to repeated migration of the guidewire into the right ventricle. After multiple attempts, the guidewire was visualized to course properly from the SVC to the IVC. After a bolus dose of 5000 units of intravenous heparin was given, the right internal jugular venous access site was dilated. Just as the final dilatation was completed and upon dilator exchange with simultaneous advancement of the 23 French Avalon cannula, TEE lost visualization of the guidewire. Multiple premature ventricular beats were noted and immediately, a new, rapidly enlarging pericardial effusion was detected (Figure ). Emergent preparations were made for bedside surgical decompression of the pericardial space. Quickly the patient lost blood pressure from acute cardiac tamponade. The Avalon cannula was immediately clamped at the end but not removed. A emergent subxiphoid pericardial window was performed, resulting in drainage of venous blood and restoration of blood pressure. Transfusion was initiated and the patient was emergently transported to the operating room for surgical exploration. The Avalon cannula was found to have perforated the apex of the right ventricle. The injury was repaired primarily and the Avalon cannula was repositioned toward the IVC again by TEE with additional direct manipulation. VV-ECMO was initiated and the oxygenation improved. Due to excessive coagulopathies, the sternum was left open but was closed on postoperative day 2. From that point, she remained free from any cardiac or infectious complications and her pulmonary condition slowly improved. She was successfully weaned from VV-ECMO on postoperative day 9 and was discharged home on postoperative day 24 without the need for home oxygen. She regained full physical functions at home and recovered normal pulmonary function by 3 months following discharge from the hospital."
+Selene Short,33,2005/6/26,(695)653-0021,kristine72@example.org,2653 Eaton Bridge,"A 37-year-old nulligravid female presented to our clinic for an annual gynecologic examination. There were no abnormal findings noted on pelvic exam and a screening Pap smear was performed. Four weeks later, the patient returned for a colposcopic examination for findings of low-grade squamous intraepithelial lesion on her Pap smear. She was without complaint at this follow-up visit. However, her cervix was obstructed from view by a new anterior vaginal wall mass. The patient was sent for voiding cystourethrogram (VCUG), which did not demonstrate a urethral diverticulum. Subsequently, the patient was sent for magnetic resonance imaging (MRI). The MRI characterized a 4.6 ? 4.2 ? 4.0 centimeter mass located within the anterior vaginal wall with mild homogeneous enhancement (). After consultation with a urogynecology specialist, the patient was taken to the operating theater for excision of the mass via the vaginal approach. A transverse incision was made along the anterior vaginal wall epithelium overlying the periurethral mass. Two solid individual masses were then carefully dissected away from the urethra. The periurethral tissues were closed in layers using a pants-over-suit technique.
+A gross inspection by the surgeons revealed two soft, tan, smooth masses with no evidence of necrosis upon cross-section. They were felt to be periurethral leiomyomas and were sent to pathology for permanent section. The dimensions of the masses were 4.3 ? 3.5 ? 3.5 centimeters and 4.0 ? 3.7 ? 2.5 centimeters. Final histopathology revealed smooth muscle tumors with diffuse moderate atypia, absent necrosis, and less than 2 mitotic figures (MFs) per 10 high powered fields (HPFs) (). The final diagnosis was STUMP. A second, independent pathologist was consulted and agreed."
+Hezekiah Herrera,24,1990/6/15,992.562.4824x159,cburke@example.com,59892 John Spring Suite 071,"A 25-year-old G2P1L1 with 25 weeks of pregnancy was referred to the emergency ward of our hospital at midnight from a peripheral rural health centre with a diagnosis of rupture uterus. Our hospital is a referral hospital attached to a government medical college which mainly caters to rural population. The lady had a previous uneventful vaginal delivery of a 2.5 kg baby 3 years back. This was her second pregnancy. She had antenatal checkups at a rural primary health centre. She went for an ultrasound examination at 25 weeks of gestation due to pain abdomen and absent fetal movements. The ultrasound examination done at the peripheral centre showed an intrauterine fetal demise of 24 weeks. In view of the fetal demise, the lady was induced with misoprostol for expulsion of the fetus. By twelve hours after induction she developed hypotension, tachycardia, and hypovolemic shock. In view of these features, a diagnosis of rupture uterus was made and the patient was referred to our hospital.
+On examination, the lady was in hypovolemic shock with severe pallor and rapid feeble pulse. Her blood pressure was not recordable. The abdomen was tense and distended and the uterine size was not made out. Pelvic examination revealed fullness in the fornices with cervical movement tenderness. There was no vaginal bleeding. As the patient was in shock, she was taken for immediate laparotomy after resuscitation. Her hemoglobin was 3 gm% at the time of laparotomy.
+At laparotomy, there was a rupture of right rudimentary noncommunicating horn of a unicornuate uterus () with the fetus and intact sac lying free in the peritoneal cavity with a hemoperitoneum of about three litres (). The fetus weighed about 600 grams (). The rudimentary horn was excised. After achieving hemostasis, abdomen was closed in layers after keeping a drain. The lady was transfused with 5 units of blood. Her postoperative recovery was good. She was later investigated for urinary tract anomalies which were found to be absent. She was discharged from the hospital on the eighth postoperative day."
+Ximena Gibbs,27,1985/1/25,7988213701,wjackson@example.com,818 Burch Forge Suite 945,"A 8-month-old girl presenting with restlessness and intermittent fever of unknown etiology was brought to the daily clinic by her parents. The parents did not complain about any problems related to urination, and there was some amount of daily urine output.
+She had been born term after an uneventful pregnancy via normal vaginal delivery. Far to the parents' knowledge the newborn examination was normal. On physical examination, she had normal vital signs. She was found to have a midline abdominal mass. The rest of the examination was normal. Initial laboratory values were unremarkable, except for a mild leukocytosis and plenty of erythrocytes in the urine. The urine culture did not reveal any pathological findings. Blood urea levels and creatinine levels were normal.
+Abdominopelvic sonography showed bilateral grade 4 hydronephrosis and a large well-circumscribed midline cystic mass including internal echoes. The cyst reached up to the umbilical level (). No bladder could be identified on control pelvic ultrasonography (US) exams until the exam was repeated after the insertion of a Foley urethral catheter (). Magnetic resonance (MR) scan of the abdomen and pelvis was obtained; it revealed hematocolpos that was causing marked distention of the uterus and cervix. The urinary bladder was significantly compressed (). The presumptive diagnosis of hydrometrocolpos secondary to an obstructing lesion was made.
+The patient underwent voiding cystourethrogram (VCUG) which demonstrated no reflux but a compressed urinary bladder with a diminished urine volume of approximately 25cc (). The diagnosis of imperforate hymen was made under sedation during the instrumentation for the procedure by the inspection of a protuberant mass on retraction of the labia. The family had not noted any perineal abnormalities prior to presentation to the clinic.
+The patient was taken into the operating room, and a simple cruciate incision was made over the hymen under general anesthesia which resulted in drainage of approximately 500 mL cloudy, yellowish, nonbloody mucosal secretions from the vagina. No acute or subacute complications occurred.
+During a period of 6-month followup, repeated ultrasound exams documented the gradual resolution of bilateral hydroureteronephrosis. The suspicion of bicornuate uterus raised by pelvic control ultrasound was verified by a postoperative MR exam (Figures , , and )."
+Deacon Best,20,1988/9/27,553.326.2072,wolfetonya@example.com,97776 Sarah Mall Suite 223,"A 66-year-old African American woman first presented with left hip pain. MRI showed a left iliac wing tumor which was determined to be a plasmacytoma on subsequent CT-guided biopsy. She developed progressive disease over the next four years including lesions in multiple ribs and vertebral bodies, pelvis, skull, humeri, and femurs. She was treated with dexamethasone, thalidomide, and numerous courses of radiation, all with variable response.
+The Patient was subsequently found to have elevated transaminases. On PET/CT, in addition to multiple bony lesions, there was an intensely FDG avid upper abdominal mass. The mass was in the region of the head and body of the pancreas with no definite pancreatic duct dilation (). Biopsy confirmed multiple myeloma (). The patient was admitted to the hospital two months later for jaundice with an elevated direct bilirubin due to the pancreatic mass compressing the distal common bile duct (). She underwent a therapeutic ERCP with distal common bile duct stent placement which caused her jaundice to resolve. She then completed a second course of radiation and chemotherapy. Follow-up CT of the abdomen and pelvis showed significant reduction in the size of the pancreatic mass.
+Findings remained stable on subsequent studies until two years later when the patient developed nausea and abdominal pain. CT demonstrated interval enlargement of the pancreatic head mass. The patient received additional palliative radiation therapy; however follow-up studies showed multiple new metastatic liver lesions as well as an infiltrative mass in the porta hepatis encasing the portal vein, common hepatic artery and gastroduodenal artery (). The porta hepatis mass appeared to extend from the pancreatic head mass. Since conventional therapy was no longer working, the patient was admitted into a clinical trial and expired four months later."
+Lexie Carpenter,28,1995/9/18,584-624-5426x4772,nwolfe@example.org,5158 Moore Stravenue Apt. 420,"A 34 year-old female, gravida 1 para 0, at 35 weeks was admitted to the hospital in preterm labor. She had been followed throughout her pregnancy by a perinatologist with concerns of preterm delivery secondary to a prominent septate uterus ().
+She was started on penicillin for GBS prophylaxis. During the second stage of labor she had nonreassuring fetal heart tones. The 5-pound-0-ounce infant was delivered by outlet forceps-assisted vaginal delivery with apgars of 4 at 1 minute and 7 at 5 minutes. A second degree midline perineal laceration was repaired in standard fashion. This was done after 10 minutes of waiting on placenta delivery and to prevent any excess bleeding from the laceration site.
+After forty minutes of cord traction, uterine massage, IV pitocin (20 units in 500 mL normal saline at 125 mL/hr), and attempted manual extraction with IV stadol 2 mg for pain, we were unable to deliver the placenta. She was taken to the operating room for manual extraction after spinal anesthesia was placed. Multiple attempts were made at manual removal under direct ultrasound visualization. We were unable to reach the placenta as the septum and the contraction of the lower uterine segment blocked our ability to reach it at its fundal location in the right horn. A sharp uterine currettage was performed, again without success, as the curette barely reached the edge of the placenta. It was clear at this point that the placenta was trapped and not accessible for delivery without general anesthesia.
+Consent was obtained after discussion with the patient and her husband to proceed with general anesthesia and one last attempt for manual removal and possible curettage; however, if unsuccessful, we would proceed with a laparotomy and hysterotomy with possible hysterectomy if there was evidence of myometrial invasion of the placenta. We understood their desire for uterine preservation for future fertility. After general anesthesia was obtained, there was appropriate uterine relaxation but we were unable to remove the placenta via manual attempt and currettage. The placenta remained trapped in the right uterine horn, and the septum continued to block appropriate access. A low transverse uterine incision was then made and we were still unable to reach the placenta that was trapped in the right uterine horn. Thus, a reversed ?-??shaped uterine incision was extended up to the fundus on the right side. The placenta was then identified and manually removed. The placenta was removed entirely intact, and there was no evidence of abnormal invasive placentation. The uterus was closed in a three-layer closure. The estimated blood loss was 1,000 mL. Her preoperative hemoglobin was 13.6 and postoperative day 1 hemoglobin was 9.8. She did not require blood product transfusion. The remainder of her postpartum course was unremarkable, and she was discharged home in stable condition on postoperative day 4. Upon discharge, she was appropriately counseled on the need for a repeat cesarean delivery given her uterine incision. We also recommended her to have an outpatient consultation by a reproductive infertility specialist regarding a metroplasty to decrease her risk of preterm delivery and recurrent retained placenta in future pregnancies."
+Jeremy Hurley,23,1987/4/18,(422)542-4718x261,anthonycarpenter@example.org,1903 Russell Mountains Suite 644,"A married 22-year-old lady presented with a chief complaint of tenderness, heat, and pain in the anterior parts of both legs of one-week duration; no pitting edema was present. The signs had gradually developed on the lower one-third of the right leg in an area 3?? cm in diameter and on the left leg in an area 4-5 cm in diameter. In the physical examination, the patient was ill without fever and erythema, and nodular lesions were seen ()."
+Rylan Ray,18,1992/8/2,817-558-5021x97149,jeremybrown@example.com,792 Foley Walks Apt. 605,"A married 22-year-old lady presented with a chief complaint of pain and tenderness on the anterior part of her right leg, which gradually increased in intensity; the same problems appeared on the left leg, too. Physical examination revealed 0.5 ? 0.5 cm nodules with 3??0 cm erythematous margins. She was ill but afebrile ().
+Both the patients reported sore throat, fever, chills, and general symptoms of a cold two weeks previously and reported taking oral contraceptives. Physical examination did not yield any abnormal findings. After 8 weeks, the conditions completely resolved. During the sickness period the patients received a single dose of penicillin 1200000 U intramuscularly and nonsteroidal anti-inflammatory drugs. After 8 weeks the conditions completely resolved."
+Arlo Mayer,20,2003/3/31,9235172569,gentrymelissa@example.org,501 Sarah Station,"A 69-year-old woman with a past medical history of hypertension presented to her primary care physician's office one day after a head-on motor vehicle accident. She had been wearing a seat-belt, and the airbag had deployed. Although paramedics had been called to the scene, the patient refused transport to the emergency room. A persistent, mild burning sensation in the chest prompted her to seek medical attention the following day. At that time, the physical examination was notable for contusion, with excoriation, swelling, and ecchymosis in the soft tissues overlying the left chest, sternum, and breast. The presentation was felt to be consistent with chest wall trauma. An EKG was not obtained. The patient was instructed to use acetaminophen and warm compresses for pain.
+Several weeks later, the patient was hospitalized for a headache and acute hearing loss. The burning chest pain had resolved, and the chest contusion had markedly improved. During the five-day hospitalization, the patient received routine subcutaneous unfractionated heparin, deep venous thrombosis prophylaxis. Routine laboratory assessment on admission disclosed mild thrombocytosis, with a platelet count of 474 K/uL. Daily laboratory results were similar; however, on the day of discharge the platelet count had fallen to 174 K/uL. Although this represented a substantial decline of more than 50%, the absolute value remained within the normal reference range, and no additional workup was pursued.
+The following day, the patient developed severe chest pain radiating to the shoulders, associated with diaphoresis, lightheadedness, and a brief episode of syncope. Paramedics were called, and the patient was transported to the emergency department. Initial examination revealed a diaphoretic woman with a pulse of 40 beats per minute and a blood pressure of 144/70 mmHg. Notable exam findings included elevated jugular venous pulsations with Cannon A waves. An EKG revealed sinus tachycardia with 3rd-degree A-V block and a slow junctional escape rhythm, inferior ST segment elevation, and lateral ST segment depression. A right-sided EKG was then obtained with similar findings along with ST segment elevation in V4r?6r suggesting right ventricular involvement (). The patient was taken emergently to the cardiac catheterization laboratory, and a temporary transvenous pacemaker wire was inserted. Coronary angiography disclosed a spiral dissection of the mid-right coronary artery (RCA) with thrombus in the posterior descending and posterolateral ventricular arteries () without evidence of ascending aortic dissection on aortography (). The extent of the right coronary dissection was further characterized with intravascular ultrasound (). The remaining coronary arteries were normal.
+Initial abnormal laboratory results included a CKMB of 23.8 ng/mL, a serum troponin T of 0.21 ng/mL, and a platelet count of 84 K/uL. Given the clinical history and the substantial thrombocytopenia, there was a high suspicion for heparin-induced thrombocytopenia; argatroban was therefore utilized for anticoagulation. Catheter-based thrombectomy was performed to alleviate thrombotic occlusion of the distal RCA branches, with restoration of TIMI-3 flow and resolution of the ST elevations and complete heart block. The RCA dissection was managed conservatively without the need for balloon angioplasty or stent placement. The patient was transferred to the cardiac intensive care unit, where follow-up transthoracic echocardiography revealed an ejection fraction of 74% without wall motion abnormalities. A heparin-PF4 antibody test was highly positive, with an optical density of 3.3, corroborating the diagnosis of heparin-induced thrombocytopenia. A comprehensive duplex assessment for vascular thrombosis disclosed thrombus in both cephalic veins. Laboratory evaluation for other hypercoagulable conditions was negative.
+The patient recovered quickly and was transitioned to warfarin therapy which was continued for three months as an outpatient. The platelet count returned to baseline. The patient has remained free from any additional cardiac or thromboembolic complications."
+Ainhoa Tucker,39,1993/10/16,892-901-0872,chris57@example.org,6579 Lewis Manor,"A 33-year-old man was admitted to our hospital because of generalized weakness, emaciation and anorexia 12 years after massive small bowel resection. Our patient underwent massive small bowel and ileocecal resection because of small bowel volvulus 12 years ago. An end-to-side anastomosis was performed between his proximal jejunum and his ascending colon, with only 40 cm of his small bowel remaining. Subsequent bowel rehabilitation therapy, which included enteral nutrition with dietary fiber, recombinant human growth hormone and glutamine, was instituted for four weeks []. Our patient was weaned from total parenteral nutrition (TPN) and had a normal diet up to the present.
+One month ago, our patient developed diarrhea and weight loss of 7 kg with no obvious predisposing cause; he felt weak, anorexic and dizzy, and became progressively cachexic. Urinary volume was reduced, while stool volume was increased. On admission, our patient's body weight was 36 kg, body mass index (BMI) 12.2 kg/m2, heart rate 80 beats per minute (bpm), blood pressure 70/50 mmHg, and respiratory rate 18 bpm. He was oriented and cognitively intact. Pitting edema appeared in his lower extremities. An abdominal examination revealed previous surgery scarring, thin skin, a scaphoid abdomen, and negative shifting dullness. A chest X-ray showed a high density shadow of a nodule outside his right upper lung, considered to be rib calcification. A lower limb X-ray and ultrasound of both kidneys and ureters were normal. An ultrasound of his gallbladder showed gallbladder atrophy. An electrocardiogram showed normal sinus rhythm with T wave changes (II/III/avF/v4-6 flat, inversion), with incomplete right bundle branch block. All laboratory values are presented in Table .
+Our patient was diagnosed with severe malnutrition and was supported by blood transfusion, parenteral nutrition (500 kcal/day), fluid, electrolyte, trace element and multi-vitamin supplementation (one ampoule each of Soluvit簧 and Addamel簧 daily), along with thiamine 100 mg intravenously prophylactically. Our patient's physical strength improved after these treatments, and pitting edema of the lower extremities decreased. Within 24 hours, our patient presented with profound fatigue and flaccid weakness of all four limbs. His heart rate was 98 bpm, respiration was normal, but biochemical investigation showed severe hypophosphatemia 0.05 mmol/L (Table ), hence a clinical diagnosis of RFS was made, and immediately the patient was transferred to the intensive care unit (ICU) for closer monitoring. Parenteral and enteral nutrition were interrupted and intravenous supplementation with phosphate polyfusor (120 mmol on the first day, then 60 mmol per day intravenously or enterally for five days) was initiated, along with enteral and parenteral multi-vitamins and trace elements (two ampoules each of Soluvit簧, Vitalipid簧 and Addamel簧 daily for two days, thereafter one ampoule of each daily). He also received a once daily intramuscular dose of Vitamin B12 0.1 mg and thiamine 100 mg. In addition, a hydrocortisone injection 100 mg was given to prevent adrenal insufficiency on the fifth day. A plasma transfusion was given to expand blood volume because blood pressure fell to 97/60 mmHg temporarily.
+On the seventh day, our patient had numbness of his limbs, diarrhea and dyspnea. At the same time, a chest X-ray indicated right middle lobe pneumonia. Respiratory muscle weakness was considered to be the reason, and an emergency tracheotomy with mechanical ventilation was done, and sputum aspiration was regularly performed. Anti-diarrhea (diphenoxylate 1 pill three times a day by mouth), anti-infection (moxifloxacin 0.4 g/day intravenously), and antacid (omeprazole 40 mg intravenously twice daily) therapy were given immediately.
+On the ninth day, when his blood chemistry became normal, enteral nutrition was resumed at 500 kcal/day and increased gradually. On the twelfth day, total enteral nutrition was well tolerated with improved pulmonary symptoms, and our patient was successfully weaned from mechanical ventilator support. Subsequently, he received recombinant human growth hormone therapy (10 u/d) and total enteral nutritional support for one month and recovered uneventfully with a weight of 45 kg (gain of 9 kg) and a BMI of 15.2 kg/m2."
+Ivan Parsons,27,1999/3/14,(722)686-2618x19290,kayla55@example.org,80238 Christopher Hill,"A 41-year-old woman presented with a history of left exophtalmos for 8 years and deterioration of visual acuity in the last 8 months. His medical and ocular histories were unremarkable. Physical examination disclosed no system abnormality except ocular findings. There was an indolor left exophtalmos, no axil with downward displacement of the globe. Abduction of the left eye was slightly restricted. Partial visual field defect was noted. Visual acuity was 8/10 in the left eye and 10/10 in the right eye. Cranial CT scan demontrated a superolaterally solid tumor, well circumscribed with homogeneous enhancement without bone erosion (Figure ). MRI showed a round mass that was extraconal, isointensity on T1-weighted imaging, slightly hyperintensity on T2-weighted imaging and enhanced after intravenous contrast administration (Figure and ). The globe was displaced anteriorly. The optic nerve was medially displaced by the intervening mass. Our preoperative diagnoses was pleomorphic adenoma and adenoid cystic carcinoma. The tumor was removed completely through lateral orbitotomy with minimal orbital rim osteotomy. At surgery the mass was extraconal, very firm, enucleated easily and schowed no invasion or adhesion to other structures, including skin, globe, extraocullar muscles, lacrimal gland, and orbital bone. The diagnosis of CS was confirmed by histopathological examination. Gross pathologic analysis revealed well-encapsulated tan tissue measuring 2 ? 3 ? 1,5 cm (Figure ). No areas of hemorrhage or necrosis were noted. Histologically, the lesion was nodular, and there was differentiation toward the adnexal ductal epithelium with chondromyxoid and adipocytic differentiation in the stroma (Figure ). Early postoperative CT image schows complete removal with good orbital reconstruction (Figure ). The postoperative course was uneventful. The patient was discharged 4 days after the operation without any complication. Eye motility, visual acuity and cosmetic appearance improved satisfactorily. No recurrence has been seen with one year of follow-up."
+Maia Escobar,22,2003/4/25,+1-640-666-7894x5792,aprilgonzales@example.net,14064 Snyder Stream Suite 258,"A 28-year-old man from East Mediterranean area admitted to hematology department with complaints of abdominal pain, diarrhea and weight loss of 25 kg in the last six months. On clinical examination, his blood pressure was 110/70 mmHg and pulse rate was 90 beats/min (regular). He was pale with cachectic appearance. He had clubbing of the fingers, edema and evidence of dehydration. There were no palpable lymph nodes or splenomegaly. The patient? hemoglobin level was 11.6 g/dl, hematocrit level 35.7%, red blood cell count 4.44?106/mm3, platelet count 361?103/mm3, mean corpuscular volume 80.4 fl mean corpuscular hemoglobin concentration 32.4%, total white blood cells count 22.5x103/mm3(lymphocyte count 12.4x103/mm3), neutrophil 9.5x103/mm3. Lymphocytosis was observed in the peripheral blood smear. Erythrocyte sedimentation rate was 90 mm/h. The multiple plasma biochemical abnormalities included albumin 2.0 g/dl, total protein 5.2 g/dl, low plasma potassium 2.9 mmol/L, serum iron was 42 弮g/dl and iron binding capacity 464 弮g/dl as well as iron saturation 9%. Serum folic acid level was low while cobalamin and zinc levels were normal. Bacteriological, virological and parasitological studies of stools revealed no evidence for specific agents. Chest x-ray was normal and abdominal x-ray showed air levels in non-dilated large bowel. Barium x-ray studies showed segmentation, dilatation of bowel loops, mucosal folds thickening and delayed intestinal transit. Endoscopic examination showed mild duodenitis. There was no abnormality in colonoscopic examination. Computed tomographic (CT) scans of the abdominal region showed multiple mesenterical lymphadenopathy and thickening of small bowel. Maximal size of lymph nodes were 3 centimetres on CT scan. The samples of duodenal biopsies revealed moderate infiltration by normal appearing plasma cells. Microscopic evaluation of the duodenal biopsy sample revealed no evidence of Helicobacter pylori. The serum IgG, IgA gliadin antibodies and IgA endomysial antibodies were negative. The examination of stool and duodenal aspiration fluid for parasites was normal. The immunological profile was normal except of elevated IgA (). The increased IgA was polyclonal and an abnormal precipitin line of IgA with no response to light chains was found on immunoelectropheresis. In order to determine the extent of disease and to obtain a diagnostic sample laparoscopy was performed. Histological examination of the excised jejunal biopsy showed subtotal villous atrophy and dense lymphoplasmacytic infiltration limited to mucosa and submucosa (). The extensive plasmacytic infiltaration was established in mesenteric lymph nodes. CD 20 were found positive in the mesenteric lymph node (). In the immunohistochemical analysis of the intestinal and lymph node biopsy material, LCA, CD-79, CD-20 and IgA were found positive while kappa and lambda heavy chain, IgD and IgM were found negative (). Bone marrow aspiration and biopsy revealed diffuse lymphoplasmacytic infiltration (). Malabsorption was confirmed by abnormal D-xylose absorption (urine excretion of D-xylose was 1.20 g/5 h; normal value >4.5 g/5 h). Patient was put on long term treatment with tetracycline regimen (500 mg PO, four time, every day). His symptoms and physical condition improved and diarrhea disappeared at the second week. The patient appeared normal with the exception of clubbing, that was still present at the third month. The lymphocytosis resolved about three months. Follow-up CT of the abdomen showed no abnormality at the sixth month. Serum IgA concentration decreased to normal levels and bone marrow examination performed on the 6th month revealed normal trilineal hematopoiesis without any evidence of lymphoplasmacytic infiltration. Tetracycline treatment continued as one year, as advised in the literature., Currently, the patient has been disease-free, in the 8th year after his treatment."
+Zachariah Rose,45,1987/9/9,228-268-6238x177,carneysamantha@example.org,307 Johnson Ridges,"A 45-year-old HIV-infected woman came to our observation in March 2010 with a 4-6-month history of fatigue, severe pain in the hip joints, rib cage, dorsal and lumbosacral spine, causing gait instability. She after 12 months of ART including TDF, complained initial gait disturbances. Her HIV-1 infection was probably due to unprotected sexual contacts prior to 1988. She also had chronic HCV-related hepatitis (genotype 1b) and borderline personality disorder. Her family history was unremarkable. In the past, she had been treated with several antiretroviral therapies, although not strictly followed because of her psychiatric disorder. Since September 2008, once admitted in a non-profit Residential Care Facility, she was receiving regular ART. At the last follow-up, HIV-1 RNA count was almost undetectable levels (<20 copies/mL) and CD4 cell count was 322/mm3, while in September 2008 HIV-1 RNA was 510 copies/mL and the CD4 cell count 298/mm3. When first visited by us (on March 2010), her treatment included zidovudine 300 mg every 12h, TDF 245 mg daily, atazanavir 300 mg daily boosted by ritonavir 100 mg daily, risperidone 3 mg b.i.d., levopromazine 100 mg t. i. d., valproate 500 mg b.i.d, clonazepam 5 mg t.i.d. Her weight was 65 Kg, height 153 cm, body mass index (BMI) 27 Kg/m2, she had proximal muscle weakness, diffuse bone tenderness and antalgic gait.
+Laboratory values at presentation and during follow up are summarized in . A DXA scan was performed in March 2010 and showed a BMD of 0.459 g/cm2 (Z-score ??.3) at the L2?4 level of the spine and of 0.549 g/cm2 (Z-score ??.1) at the femoral neck. The whole body 99mTc-methylene diphosphonate (99mTc-MDP) bone scintigraphy showed an increased uptake at the lumbar and thoracic spine, sacroiliac region and hip joints, consistent with multiple pseudo-fractures (). The dorsal and lumbosacral spine X-ray showed diffuse osteopenia, fracture deformities of D7 and L2?4 (). Because of the temporal relationship between the beginning of TDF therapy and OM-related symptoms, in the absence of other explanations and in accord with previously published similar cases,, we made a diagnosis of hypophosphatemic TDF-induced OM. TDF was stopped and the ART modified to darunavir boosted by ritonavir, emitricitabine and raltegravir. In addition, oral cholecalciferol (300,000 IU/daily for 2 days and 10,000 IU/week), calcitriol (0.25 mcg /daily) and neutral sodium-potassium phosphate containing 1500 mg of phosphorus/daily were given. Two months after discontinuation of TDF, bone pain and gait disturbances as well as laboratory data were significantly improved (). Eleven months later, the patient was free of bone and joint-related symptoms and a whole body 99mTc-MDP bone scintigraphy showed complete resolution of the OM ()."
+Magnolia Gillespie,26,1978/1/7,756-504-5024x957,jonesdonna@example.org,5582 Clark Gardens Suite 747,"A 32 years old male was admitted to our hospital with complaints of abdominal pain, diarrhea, fatigue, nausea, loss of appetite, cough, night sweats and weight loss. Lasting for 2 months except for mild diarrhea lasting for 3 days. His history was unremarkable for travelling, animal husbandry, hunting, drugs and agriculture. There were no similar symptoms in his family and neighbours. His axillary body temperature was 37.2簞C, blood pressure was 120/80 mmHg, heart rate was 82/min, and respiration rate was 22/min. Physical examination revealed urticarial lesions on his back.
+His laboratory tests were as follows: leukocytes 7800/mm3, eosinophils 3900/mm3 (%49), platelets 293000/mm3, hemoglobin 13,8 g/dL, hematocrit %42.6, C-Reactive Protein (CRP) 35 mg/dl. Peripheric blood smear revealed eosinophilia as high as 46% of white blood cells. Routine biochemical tests, urine analysis, and serum IgE were in normal range. Hepatitis B virus surface antigen (HBsAg), anti-hepatitis C virus antibodies (Anti-HCV), anti-human immunodeficiency virus antibodies (Anti-HIV), venereal disease research laboratory (VDRL), Epstein-Barr virus virus capsid antigen (EBV-VCA) IgM, cytomegalovirus (CMV) IgM, anti-rubella IgM, Rose-Bengal, Wright agglutination, and Grubel-Widal tests were negative. The chest radiogram was also normal. Nonpruritic skin lesions on his back were diagnosed as dermographic urticaria after consulting with a dermatologist (). Desloratadin and hydroxyzine were administered. The skin lesions were not resolved with these drugs. The patient was hospitalized to investigate the possible infectious causes of hypereosinophilia.
+The bacteriological cultures of urine, blood, and sputum and tuberculosis culture of the sputum were
+No bacteria were seen in Gram and Ehrlich-
+Ziehl-Neelsen stainings of the sputum. There was no parasite in stool examination performed on five consecutive days. Mebendazole 200 mg daily was given for possible helmintic infestation for five days. As well as, no clinical or laboratory response was achieved. Anti-nuclear antibody, anti-double-stranded DNA, perinuclear antineutrophil cytoplasmic antibody (p-ANCA) and cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) tests were negative. Abdominal ultrasound (US) was normal. The electrocardiogram revealed an extension in PR duration and echocardiography revealed pleural effusion in the neighbourhood of the right ventricle. Computed tomography (CT) scan of the thorax was normal. However, multipl hypodense lesions were detected in periportal areas of the liver in upper abdominal sections of the CT scan. The largest lesion? size reached 3x4 cm, the others had approximately 1??.5 cm diameters. There was no enhancement on lesions ().
+Serum of the patient was sent to The Refik Saydam Hygiene Center Presidency for serological tests of Toxacara canis and F. hepatica. Although serology for T. canis was negative, F. hepatica indirect hemagglutination (IHA) test was positive at a titer of 1/1280. His history was reviewed repeated and we figured out that he had eaten raw watercress on riverside 3 months before his hospital admission. Triclabendazole (Egaten簧) 10mg/kg single dose was started and repeated after 2 weeks. His complaints resolved in 3 weeks of treatment. The hemogram and peripheric blood smear revealed normal eosinophil count, then. CRP level in serum was reduced to normal range too."
+Forest Hodges,18,1979/1/28,646-493-5159x40592,goodmangary@example.com,11994 Robinson Land,"A previously healthy and normally developing 4-year-old girl presented to our pediatric clinic with a 2-day history of painless, gradually progressing ptosis and swollen right eyelid. Visual acuity was 20/20 in her both eyes. Ophthalmological examination of the patient was normal other than upper eyelid ptosis, proptosis, and ophthalmoplegia in the right eye. She was not able to use her left leg and left arm at admission. For this reason, cranial computed tomography (CT) was performed to check for intracranial hemorrhage or mass and turned out to be normal. Complete blood count, electrolyte levels, and sedimentation rate were in normal ranges. There was no atypical cell in peripheral blood smear. In orbital MRI examination, postgadolinium fat-saturated T1-weighted images revealed marked contrast enhancement of medial () and inferior rectus () muscles. MRI also showed enlargement of superior, inferior, and medial rectus muscles and their tendons in the right eye with minimally hyperintensity on fat-saturated T2-weighted image (). A preliminary diagnosis of IOP was made, although it is rare in a child. The child was decided to be treated with intravenous high-dose steroids before considering a biopsy. She began to show signs of clinical improvement, including reduced proptosis and ptosis within 36 hours after starting high-dose steroid treatment. She continued with intravenous high-dose steroids for 3 full days before she was discharged on a gradually tapering dose of oral prednisone. Two weeks after initial examination, follow-up orbital MRI demonstrated a reduction in the size and contrast enhancement of effected muscles in postgadolinium fat-saturated T1-weighted images ()."
+Eve Castillo,22,1990/3/13,766.719.8467,whitakerfelicia@example.net,1682 Sanford Passage Suite 869,"A 40-year-old man was referred to our department due to severe hypertriglyceridemia (TG: 1,598 mg/dl) in August 2010. His body weight was 67 kg and height 170 cm (BMI: 23.2 kg/m2). At the age of 23 he has been diagnosed as bipolar disorder, and the treatment using olanzapine started in March 2008. He has been treated by using levomepromazine (10 mg/day), lithium carbonate (800 mg/day), flunitrazepam (2 mg/day) and olanzapine (10 mg/day). After the cessation of olanzapine, he was treated by levomepromazine (10 mg/day), lithium carbonate (800 mg/day), flunitrazepam (2 mg/day) and quetiapine fumarate (50 mg/day). Cessation of taking olanzapine did not change his body, however, promptly decreased serum TG level (). To understand which TG-rich lipoprotein is important for olanzapine-induced hypertriglyceridemia, we measured each lipoprotein fraction by the newly developed anion-exchange high-performance liquid chromatography []. Serum very low-density lipoprotein cholesterol (VLDL-C) level was remarkably high during the olanzapine use, and was also promptly decreased after the cessation of olanzapine, and the decrease of VLDL-C almost paralleled the decrease of TG (). Serum levels of other TG-rich lipoproteins, intermediate-density lipoprotein (IDL)-C and chylomicron (CM)-C, decreased at one month after the cessation, however, again increased slightly at two months after the cessation (). Serum LPL levels increased at one month after the cessation, however, again decreased slightly at two months after the cessation (). Serum adiponectin level was constantly increased, and hs-CRP level was constantly and significantly decreased after the cessation of olanzapine ()."
+Kai Hail,36,2001/2/26,001-761-425-5686x899,raymondrichmond@example.org,5776 Monica Avenue,"A 58-year-old man was admitted to our hospital with sudden onset of left flank muscle strain with flank pain by moving sofa at home, followed by fever with chills for two weeks. He has a history of congenital valvular heart disease but no symptoms of heart failure. He was admitted to our hospital due to left flank pain and mild fever with chills (two episodes per day) that persisted despite treatment with analgesics and antifebrile drugs.
+On admission, his blood pressure was 124/68 mmHg, body temperature was 38 繙C, heart rate was 118 beats per minute, and respiratory rate was 18 breaths per minute without distress. His heart had a regular beat with systolic murmur (Grade 3) that was overt at the right upper side sternum and apex. A left flank knocking pain with no evident skin lesion was also recorded. His Chest-X-ray indicated clear lung field but borderline cardiomegaly, suggested left ventricle hypertrophy (LVH). Laboratory studies measured white blood cell (WBC) count (11,100/繕L (neutrophil-segment 84.3%)), hemoglobin (10.1 g/dL (MCV, 76.5 fL)), platelet count (287,000/繕L), creatinine (1.12 mg/dL), Na (133 mmol/L), K (4.7 mmol/L), C-reactive protein (CRP) (13.16 mg/dL), and erythrocyte sedimentation rate (ESR) (114 mm/h). The patient described the left flank pain as persistent, dull, and aggravated by changing of position. He denied any other discomfort, such as malaise, loss of body weight, dyspnea on exertion, chest discomfort, nausea, diarrhea, or dysuria. He also denied any history of travel, trauma, intravenous drug use, or recent dental care.
+Abdominal computed tomography (CT) was performed on suspicion that the fever and left flank pain were related to an abdominal infection. This CT indicated a 1.6 cm nodule lesion in the spleen (), compatible with site of tenderness, suggestive of spleen abscess or infarction. Empiric therapy with ceftriaxone 2 g every 12 hour was prescribed initially.
+Echocardiography was arranged under consideration of valvular heart disease and unexplained metastatic infection of spleen emboli, which indicated preserved left ventricular (LV) systolic function (ejection fraction, 62%), severe aortic regurgitation (AR) (pressure gradient, 60 mmHg), and a flail mitral valve (MV) with severe mitral regurgitation (MR) (PG, 160 mmHg). Echocardiography indicated no evidence of infective vegetation. Four days after admission, two independent blood cultures yielded Haemophilus aphrophilus.
+The findings described above fulfill the Duke criteria for infective endocarditis (one major finding: positive blood culture; three minor findings: predisposition for heart disease, fever, and vascular emboli). Thus, we diagnosed our patients with Haemophilus aphrophilus associated subacute endocarditis, with a predisposition for congenital valvular heart disease, complicated with spleen abscess which thought to be associated with hemogenous seeding by hematoma caused by flank muscle strain injury. We kept Ceftriaxone (2000 mg/12 h) by intravenous drip. The patient? fever gradually subsided and his left flank pain completely resolved within two weeks. We maintained Ceftriaxone use for a total of two weeks, at which time the patient? WBC count was 6200/繕L (neutrophil-segment, 63.8%), CRP was 0.15 mg/dL, ESR was 38 mm/h, and a liver echogram indicated no evidence of spleen abscess. The patient denied any episode of fever or left flank pain during entire course of treatment, we classified the patient as free from disease."
+Lainey Olsen,37,1997/5/28,2487848173,meghanfriedman@example.com,0664 Melissa Plain,"A 49-year-old male patient (188 cm, 98 kg) suffered from decompensated dilative cardiomyopathy. As he did not respond to conventional treatment (inotropes and insertion of an intraaortic balloon pump) a Jarvik 2000 left ventricular assist device (Jarvik Heart Inc., NYC, NY, USA) was implanted. Postoperatively, the patient developed right heart failure, necessitating the implantation of an additional temporary right ventricular assist device (Levitronix, Levitronix GmbH, Zurich, Switzerland). Severe postoperative bleeding required rethoracotomy and mass transfusion. Despite no further bleeding and faultless function of both cardiac assist devices, the patient developed a severe vasoplegic shock, requiring very high dosages of norepinephrine (4.0 mg/h) and vasopressin (6.0 I.U./h). After administration of a single dose methylene blue both norepinephrine and vasopressin dosages rapidly decreased and serum lactate concentrations normalized (). On the fourth postoperative day the patient developed pneumonia caused by pseudomonas aeruginosa with severe impairment of pulmonary function. An oxygenator was connected to the right ventricular assist device to enable sufficient oxygenation. Despite inhalative application of milrinone and iloprost, right ventricular function did not recover sufficiently. Although the patient was treated with antibiotics (piperacillin/tazobactam, ciprofloxacin, vancomycin) markers of infection did not decrease and the patient died ten days after methylene blue administration from multi-organ failure."
+Skyler Richmond,23,1997/3/31,344-604-8932,danawood@example.net,88069 Joshua Meadow,"A 46-year-old male patient (185 cm, 80 kg) with a history of myocardial infarction and limited cardiac function (LVEF 20%) underwent resection of a massive left ventricular anterior wall aneurysm combined with mitral valve annuloplasty. Despite adequate filling pressures, use of multiple inotropic agents including levosimendan and insertion of an intraaortic balloon pump, cardiogenic shock occured postoperatively. He was transferred to the operating room for venoarterial extracorporal membrane oxygenation (ECMO, Medtronic, Biomedicus, MI, USA) rescue therapy. Since weaning from ECMO remained unsuccessful for four days, a permanent left ventricular assist device (Jarvik 2000) was inserted. Postoperatively, the patient suffered from right heart failure resistant to inhalation of iloprost and milrinone, so that venoarterial ECMO had to be re-implanted. Despite good function of both cardiac assist devices the patient suffered from severe vasodilatory shock resistant to high dosages of norepinephrine (3.0 mg/h) and vasopressin (8.0 I.U./h). Administration of methylene blue resulted in a reduction of norepinephrine and vasopressin to acceptable dosages within four hours (). However, no therapeutic option was suitable for this patient: switching to a synchronized biventricular assist device was technically not possible any more. The patient died 18 hours after methylene blue administration."
+Whitney Mahoney,42,1980/10/15,741.641.4952,qdavenport@example.org,8488 Jonathan Estate,"In a 32-year-old male patient (187 cm, 114 kg) with decompensated dilative cardiomyopathy a biventricular assist device (Berlin Heart Excor, Berlin Heart GmbH, Berlin, Germany) was implanted, as a bridge to transplant. Postoperatively, severe septic shock caused by pneumonia occurred and was treated empirically with meropenem, moxifloxacin, and linezolid. Despite adequate filling pressures, 7.0 mg/h of norepinephrine and 7.0 I.U./h of vasopressin were necessary to stabilize circulatory conditions. Methylene blue was applicated and vasoconstrictor dosages could be reduced within hours (). On the fourth postoperative day the patient suddenly developed pulmonary edema. Despite therapeutical heparinization and aspirin therapy echocardiography revealed a thrombus, most probably derived from the left atrial appendage, nearly completely occluding the left ventricular inflow cannula. In an immediate re-operation the left ventricular inflow cannula was replaced from the left ventricular apex to the left atrium. During surgery, the left atrium ruptured. Surgical repair was unfeasible, so that the patient died intraoperatively from severe hemorrhage."
+Kamryn Austin,19,1990/9/17,001-809-288-9913x617,dgonzalez@example.org,75357 Frazier Pine,"A 70-year-old male patient (155 cm, 64 kg) with pre-existing coronary heart disease underwent coronary angiography with instable angina pectoris. A significant stenosis of the right coronary artery was detected. The attempt to insert the wire into the right coronary artery resulted in a complete dissection of the vessel. Emergency coronary artery bypass operation with a saphenous vein graft was performed immediately, but revascularisation was technically impossible. Accordingly, the patient developed right heart failure and received venoarterial ECMO. Postoperatively, norepinephrine (1.6 mg/h) and vasopressin (8.0 I.U. /h) resistant vasodilatory shock occurred. After a single dose of methylene blue vasoconstrictor dosages decreased within hours (). Despite maximum pharmacological support including inhalation of iloprost and milrinone right ventricular performance could not be improved during the following seven days. As the patient was considered to be too old for implantation of a definitive right ventricular assist device, therapeutic measures were terminated. The patient died 8 days after methylene blue administration."
+Alivia Dawson,39,1997/7/29,(677)415-2664,oking@example.net,177 Lopez Islands,"A 72-years-old nonsmoker woman with fever, chronic cough, purulent sputum, and dyspnea, who had previously taken medication for bronchial asthma for 16 years, was admitted because chest X-ray showed a 5 cm-sized mass-like consolidation in the right lower lung field. Chest computed tomography also noted pneumonic infiltrations in the middle lobe and right lower lobe of the right lung. We started intravenous antibiotics upon diagnosis as possible pneumonia. Bronchial washing was performed because we could not exclude malignancy, such as invasive adenocarcinoma. Washing cytology was negative for malignancy. Although symptoms were improved with antibiotics, a follow-up chest X-ray was not improved. Furthermore, chest CT scans after 4 months showed aggravated infiltrations and newly developed nodules in both of the upper lung fields (). Percutaneous transthoracic needle aspiration was performed on the patient. Finally, lepidic predominant adenocarcinoma was diagnosed (). After this diagnosis, the patient received the three courses of first-line chemotherapy with docetaxel plus carboplatin as stage IV (T4N0M1) with lung-to-lung metastasis. However, the treatment response was progressive disease (). Thus, the patient began to take gefitinib at 250 mg/day because EGFR gene analysis in this patient showed a deletion mutation in exon 19 and point mutation L858R in exon 21 by direct sequence method (). A remarkable tumor regression was found as nearly complete response was achieved after 2 months (). The tumor size of right middle lobe and lower lobe was decreasing, and the metastatic nodules of both upper lobes had nearly disappeared. This response lasted for almost 15 months (). Although gefitinib was discontinued because the disease had progressed, the patient with a good performance status received 2 courses of pemetrexed and 4 sequential courses of gemcitabine/vinorelbine chemotherapy (). Despite continued chemotherapy, the patient showed radiographic progression. Thus, we commenced re-treatment with gefitinib. Two months later, a partial response had been achieved at the primary tumor and metastatic lesions (). The response continued even after 4 months. Even after that, the repeated re-administration of gefitinib after 3 to 4 months had elapsed was shown stable disease. The patient was still alive 5 years after she was initially diagnosed with metastatic invasive adenocarcinoma."
+Iker Gibbs,44,1996/7/23,001-262-849-0612x30028,tiffanyperez@example.com,18085 Doyle Hill Apt. 266,"A 26-year-old man was diagnosed with malignant NPC, which, after treatment, metastasized to bone. At the beginning, he received full cycles of chemotherapy and radiotherapy. At his regular follow up, back pain was noted after definitive treatment for 3 months. So we further investigated the progression of his disease by bone scanning. The bone scan revealed diffuse increased tracer uptake throughout the skeleton (). Because diffuse metastases were highly suspected and superscan pattern was revealed, we also arranged MRI of the spine to confirm the presence of bone lesions. Diffuse bony metastases were detected. With disease progression, back pain was exacerbated and poorly controlled by pain killer medications. Localized radiation treatment (300 cGy in 10 fractions) to vertebrae T5, T6, T10, and the lower portion of T9, and 3 months after radiotherapy, a bone scan to detect the effects, were arranged. However, increased diffuse activity indicating diffuse metastases was still present (). Examination by 18-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) to determine the extent of metastatic spread demonstrated multiple bony metastatic lesions and enhanced uptake in the skull, entire spine, rib cage, pelvic bones, and humeral and femoral shafts. Additionally, the PET scan also revealed ?old??lesions in areas which had received radiotherapy ()."
+Carter Mejia,38,1984/2/28,421-763-2294x0825,shellywood@example.org,974 Jessica Hollow Apt. 056,"A 27-year-old young man presented to city hospital with 38 簞C fever, dyspnea, cough, wheezing and left sided chest pain. His complaints began after an episode of viral infection one week before his admission. Influenza antigen test for influenza A and Ig E antibody was positive. His skin allergy test was positive to dust mite. Chest radiography showed bronchovascular prominence (). Chest computed tomography also revealed bronchovascular prominence and pericardial minimal effusion (). He was diagnosed with asthma and acute viral bronchitis and pericarditis. He was treated by oseltamivir, bronchodilator and anti-inflammatory, but his respiratuar compliants persisted. He was referred to our hospital two weeks later. His medical history revealed that his father had Wegener Diseases, and his mother had asthma. He has had symptoms of allergic rhinitis for two years but didn? have diagnosis. He never smoked. On admission, the patient hemodynamic status was tachycardic as pulse 105 bpm and besides this, blood pressure was 110/70 mmHg, temperature 37 簞C and respiratory rate 20/min. White blood cell count, erythrocyte sedimentation rate, C-reactive protein values were 21.7?109/L, 25 mm/h and 7.9 mg/L respectively on admission. He had elevated cardiac enzymes as troponin I 0.01 弮g/L, and CPK-MB 53 UI/L. C-ANCA was negative. Blood and sputum examination were all negative. Physical examination revealed that there were remarkable wheezes in both lungs and sinus tashicardia on auscultation. Electrocardiographic findings were nonspecific. Echocardiogram showed global hypokinesia in the left ventricular and a decrease of ejection fraction as 40%. After being started on diuretic and ACE inhibiteur therapy, the patient? clinical condition significantly improved. One month later control Echocardiogram showed significantly improvement in left ventricular systolic function as 57%."
+Atticus Andrade,22,1986/7/5,689-376-8106,bowmanjohn@example.net,346 Andrew Streets,"This case represents an 84-year-old man with a known history of left anterior descending (LAD) coronary artery lesion with a mass noted on the tricuspid valve. He had previously undergone percutaneous coronary intervention with 2 stents placed in the LAD coronary artery, 6 years earlier. Subsequently, he was being closely followed by his cardiologist for the coronary artery lesion, when the right atrial mass was found on transthoracic echocardiography. This mass was observed for a 6-month period. A repeat echocardiogram revealed a rapid expansion of the mass. Specifically, the mass grew by 1 cm in that 6-month period. The mass was found to be fixated on the tricuspid valve. Also at this time, the patient had some complaints of dyspnea on exertion, which prompted a cardiac workup. The results of the workup eventually showed a lesion within the previously placed stent. The combination of in-stent thrombosis of the coronary stent with the rapid progression of the intracardiac mass incited the decision for surgical intervention. The patient was taken to the operating room for a single vessel coronary artery bypass grafting and excision of the intracardiac mass.
+The operation was performed under normothermic cardiopulmonary bypass using ascending aortic and bicaval cannulation (Video). The right atrium was opened and a solid, well-encapsulated 1-by-2-cm mass was found to be attached to the atrial side of the tricuspid valve (Fig ). It was subsequently shaved off and sent to the laboratory for histological evaluation (Fig ). The right atrium was then closed, followed by the single coronary artery bypass grafting utilizing the left internal mammary artery to the LAD. After completion of the procedure, no regurgitant flow was demonstrated at the tricuspid valve. The patient was discharged 5 days after the operation, following a postoperative pneumothorax, which resolved spontaneously. The final pathology on the right atrial mass confirmed the diagnosis of PFE.[]"
+Emmy Peralta,28,1993/9/21,258-211-9125,emily76@example.org,0157 Anderson Street,"In Nov, 2010, a 46-year-old woman was referred to Department of Ggyneco-obstetrics of Changhai Hospital due to a uterus mass and a left pelvic adnexal mass, which were palpated during a routine physical examination, but presenting no abnormal vaginal bleeding and stigmata of the tuberous sclerosus complex. Serum CA-125 and CA-19-9 levels as well as other laboratory findings were all within the normal limits. Transabdominal sonography revealed a uterus mass (diameter 3.2 cm), a left pelvic adnexal cystic mass (diameter 3.7 cm) and a left pelvic mass(diameter 4.9 cm). The initial clinical impression of the lesions was uterus leiomyoma and left ovary chocolate cyst. Then the patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Intraoperative findings included smooth surface masses arising from the posterior wall of the enlarged uterus (diameter 3 cm), right part of cervix (diameter 3 cm) and the left broad ligament (diameter 4 cm), with hypertrophic ovaries, normal fallopian tubes, without ascites. An intraoperative frozen section of the uterine mass was interpreted as leiomyoma.
+The surgical specimens were collected and fixed in 10% formalin for H-Estaining and immunohistochemical staining. The immunophenotypes of tumor cells was examined by EnVision Plus system (DAKO Corporation). The antibodies used included HMB-45 (1:50), Melan-A(1:50), smooth muscle actin (1:50), calponin (1:100), CD34 (1:50), CD10(1:100), S-100(1:200), p53(1:50), estrogen receptor (1:80), progesterone receptor (1:40) and MIB-1 (1:200). The surgical specimens included a 9 cm ? 6 cm ? 6 cm uterus with left adnexae and right cavitas pelvis masses. Grossly, two round masses were found in the uterine, with a 3 cm ? 3 cm ? 2 cm mass in the myometrium and a 3 cm ? 3 cm ? 3 cm mass in the subserosa of posterior wall; a mass measuring 5 cm ? 5 cm ? 4 cm was found in the left broad ligament, multiple masses were found in the right cavitas pelvis, with the largest diameter being 3 cm (Figure ). The masses were round or nodulose, solid, well-demarcated and partially encapsulated by thin membranous tissue. The cross section surfaces of the masses were grayish-white, without fresh, old hemorrhage or necrosis. A 3 cm ? 3 cm ? 3 cm cystic tumor was found on the left adnexa. H-E staining showed that all the PEC lesions in our case had a similar morphological feature under microscope. The tumors were mainly composed of epithelioid cells, with a few spindle-shaped cells; the tumor cells had abundant clear-to-fine eosinophilic granular cytoplasm, with round to oval nuclei, mild-to-moderate pleomorphism and a mitotic count of 1-4/50HPF. There were no necroses; the tumor cells were arranged in nests, bundles or patches; some surrounded and radiated alone the blood vessels. And there were no pathological mitoses. Proliferation of thin-walled capillary-like vessels was also noted in foci with occasional glomerulus-like vascular tuft formation. There were no mature adipose tissues, spindle-shaped smooth-muscle bundles, or abnormal thick-walled blood vessels characteristic of classic AML and necrosis. Immunohistochemically, the tumor cells were negative for CD34, CD10, S-100 and p53, and strongly positive for HMB-45 (Figure ) and Melan-A, smooth muscle actin (SMA), calponin (Figure ), ER and PR. A low proliferative fraction was detected with MIB-1 antibody(3-5% positive MIB-1 staining). PAS staining without diastase predigestion found that some tumor cells were positive, and PAS staining with diastase predigestion showed completely negative results. Masson staining of the connective tissues showed a great deal of collagen fibers in the stroma.
+Other specimens revealed chronic cervicitis, endometrium of proliferative phase, follicular cyst of left ovary, normal right ovary, and fallopian tubes. The postoperative course was uneventful, and the patient was discharged 4 days after surgery. No further treatment was needed; and no recurrence was noticed 12 months later as shown by transabdominal sonography of the abdomen and pelvis. She is currently followed up regularly by ultrasonography."
+Dangelo Kerr,27,1990/4/13,001-319-798-8094x9304,burtonjessica@example.net,678 Jessica Place,"A 31-year-old right hand dominant, African American female presented to the University of Chicago Emergency Department with swelling and progressive pain of her right thumb (first digit) that worsened with activity. She first encountered pain in her previously healthy thumb 2 weeks prior to presentation. She denied trauma and surgery to the affected digit. On physical examination, the digit was erythematous and moderately tender to palpation. Motor function was grossly intact but range of motion (ROM) at the metacarpophalangeal (MP) and interphalangeal joints was reduced because of pain. No neurovascular deficits were noted. There were no palpable masses. The patient was afebrile and a complete blood count and basic metabolic panel were within normal limits. X-rays of the digit revealed radio-opaque masses around the volar aspect of MP joint consistent with synovial chondromatosis without evidence of acute fracture (Fig ). The digit was managed conservatively and placed in a spica splint. The patient was admitted for empiric antibiotic therapy for suspected cellulitis or abscess in the setting of underlying synovial chondromatosis.
+After 24 hours, physical examination revealed moderately decreased erythema and swelling and improvement of thumb ROM. Severe thumb pain persisted. A hand surgery consult was requested, and CT scan of the hand was obtained. Consistent with the initial x-rays, foci of mineralization adjacent to the thumb MP joint were noted (Fig ). This was again suggestive of synovial chondromatosis. The thumb was placed in a spica splint and the patient was seen in hand clinic the following week. After 1 week of immobilization, swelling of the thumb had subsided but pain and tenderness at the first MP joint persisted. Total active motion of the thumb was 36簞. Surgical excision of the masses identified by radiography was subsequently recommended.
+During surgery, access to the masses was achieved by making an L-shaped incision transversely along the digital-palmar crease of the thumb and extending it distally up the radial mid-axial line. The radial and ulnar neurovascular structures were identified during subcutaneous dissection and retracted to the periphery of the incision. Approach to the MP joint was performed at the radial border and dissection was carried down between the abductor pollicis brevis and the flexor pollicis brevis. During exposure of the intermuscular plane, a thick, yellow-tinted fluid extruded into the surgical field. The fluid was aspirated and microbiological examination and gram stain revealed unidentified debris without evidence of bacteria or leukocytes. Deeper dissection revealed multiple firm, irregularly shaped masses adjacent to but not penetrating the MP joint capsule (Fig ). These masses were well-circumscribed and partially surrounded by fibrotic tissue. They were removed from the pericapsular area by simple dissection. Intraoperative fluoroscopy demonstrated complete removal of extraneous calcific material. The joint capsule surface was explored and revealed no evidence of capsule violation. Histological examination of the resected specimen confirmed that the excised masses resulted from calcium phosphate deposition (Fig ). The wound healed satisfactorily. By postoperative week 6, the thumb was pain-free and fully functional. There has not been any evidence of recurrence. Of note, no synchronous lesions were found and the patient denied a family history of tumoral calcinosis."
+Baylee Roth,45,1996/10/23,656-960-0792x77382,yadams@example.com,88095 Vargas Gardens Apt. 661,"A 3 day-old male neonate was brought to medical attention by his parents who complained of inability to see his eyes since birth, mucopurulent discharge and excessive tearing (). The baby had developed a fever 24 hours before presentation. Antenatal care had been uneventful, there was no maternal genital infection, delivery was normal vaginal and there was no report of birth trauma.
+The baby was slightly febrile (temperature, 38.5簞C) and without jaundice. Ocular examination revealed a purulent discharge, moderate conjunctival injection and massive chemosis in both eyes (). Both upper lids were everted and the eyeball could not be seen without a speculum. No systemic abnormality was detected.
+A diagnosis of bilateral congenital lid eversion with possible neonatal sepsis was made. Pediatricians were consulted and the patient was treated as a case of neonatal sepsis with intravenous cefuroxime. The eyes were treated with tobramycin ointment, padding with 5% hypertonic saline-soaked gauze dressing and frequent application of methylcellulose gel. By the eighth day of admission, the chemosis resolved (), the eyelids became well-apposed and fever subsided. Dilated funduscopy with 0.5% tropicamide eye drops revealed normal fundi in both eyes."
+Roy Salas,21,2001/4/1,+1-967-458-5435x480,tcollier@example.net,7765 Lauren Cove,"A 4 day-old boy () presented with protrusion of the left eye of 4 days??duration. The right eye did not open spontaneously, but seemed otherwise normal. No discharge was reported. Pregnancy had been uneventful and delivery was vaginal and spontaneous. There was no history of maternal genital infection or birth trauma.
+There was no history of fever or convulsions and pediatric assessment revealed no abnormalities. The left upper lid was everted with gross conjunctival injection and chemosis, but there was no discharge. Mild upper lid eversion, and mild conjunctival injection and chemosis of the right eye were also present. Both globes were otherwise normal.
+The left eye was treated with tobramycin ointment, methylcellulose gel and padding with gauze dressings soaked in 5% hypertonic saline. The right eye was treated with only tobramycin ointment. The left upper lid needed to be repositioned twice. Complete resolution was achieved by the tenth day of admission (). Dilated funduscopy with 0.5% tropicamide eye drops showed normal fundi."
+Amber Lara,29,2003/1/9,+1-628-253-4513x196,amber98@example.org,765 Poole Squares Suite 928,"A 4 hour-old male neonate was referred from a private hospital immediately after birth to the emergency room of our eye clinic with fleshy protrusion of the lids and inability to open both eyes since birth (). Pregnancy had been uneventful, labor was not prolonged, and delivery was spontaneous and vaginal. The perinatal period had also been uneventful. There was no history suggestive of genital infections in the mother. There was no eye discharge, nor had any traditional eye medication been applied.
+Pediatric assessment revealed no abnormality. Ocular examination revealed bilateral everted upper lids, exposed and chemotic conjunctiva covering the eyeballs and tense lids, but normal cornea and anterior chamber depths in both eyes.
+The parents refused admission on financial and social grounds; he was therefore treated on an outpatient basis. Treatment consisted of daily eye cleansing, application of gauze dressings soaked with 5% hypertonic saline over the chemotic conjunctiva, chloramphenicol ointment, and padding. During follow up, he developed a mild serous discharge and ciprofloxacin eye drops were commenced every two hours. Ten days later, the baby achieved complete eye opening in both eyes (). Dilated funduscopy with 0.5% tropicamide eye drops disclosed normal fundi."
+Caiden Cox,33,2001/4/23,626.542.0809,davidwilliams@example.org,65197 Andrew Falls,"A 44-year-old Caucasian man with good past health and unremarkable ophthalmic history presented with an acute-onset relative scotoma in his left eye after viewing a partial solar eclipse in Hong Kong on July 22, 2009. The duration of viewing had been brief and less than two seconds. He had not used any protective eyewear while sun gazing and denied the use of corticosteroid medications or any recent stressful event. He presented to the eye clinic two days later with best-corrected visual acuity of 20/20 and 20/18 in his right and left eyes, respectively. Anterior segment examination was unremarkable. Fundus examination revealed shallow subretinal fluid accumulation and RPE changes involving the fovea in the left eye (). FA showed progressive fluorescein leakage nasal to the fovea, without evidence of choroidal neovascularization (). Spectral domain OCT scan of the left eye demonstrated serous detachment of the neurosensory retina involving the fovea with central foveal thickness of 552弮m (). No abnormality was detected on FA and OCT in the unaffected fellow eye. A diagnosis of CSCR of the left eye was made and conservative management was adopted.
+The patient was reassessed six weeks later and he still complained of a persistent central scotoma. Nonetheless, visual acuity remained stable. Fundus examination of the left eye showed an increase in subretinal fluid. OCT demonstrated an increase in the serous neurosensory retinal detachment (). Ten weeks after the onset of symptoms, the patient no longer complained of any visual disturbances and best-corrected visual acuity was 20/20 in both eyes. OCT of the left eye showed reduction in the amount of subretinal fluid (). Considering the spontaneous improvement, conservative management was continued."
+Sadie Lang,40,1990/7/31,001-725-256-6281x17881,kylereed@example.com,705 Vincent Overpass Suite 837,"The patient presented herein is a 52-year-old woman suffering from primary open angle glaucoma (POAG) in both eyes. She has no history of systemic disorders and is not on any systemic medications. She underwent laser in situ keratomileusis (LASIK) 9 years ago for refractive error of ??.50??.00?180 in both eyes, and was diagnosed with glaucoma 7 years afterwards. Her ocular examination when I saw her for the first time two years ago was as follows.
+Best corrected visual acuity (BCVA) was 6/10 and 3/10 in the right and left eyes with ??.00??.00?30 and ??3.00??.50?180 respectively while wearing rigid gas permeable (RGP) contact lenses. Slitlamp examination revealed a LASIK flap and signs of corneal ectasia in the left eye, mild nuclear sclerosis changes were evident in both eyes and other slitlamp findings were unremarkable. Orbscan images (Orbscan II, Bausch & Lomb, Salt Lake City, USA) are shown in . Gonioscopy revealed widely open anterior chamber angles with no synechiae. Intraocular pressure (IOP) by Goldmann applanation tonometry (GAT) was 10 and 12 mmHg in the right and left eyes respectively while receiving latanoprost (once daily), timolol (twice daily) and dorzolamide (twice daily) in both eyes. Central corneal thickness (CCT) measured 431 and 322 microns in her right and left eyes respectively. Fundus examination revealed average-sized discs with vertical cup to disc ratios of 0.9 and 0.8 in the right and left eyes respectively, together with inferior rim loss; the macula, vessels and periphery were unremarkable. Baseline automated perimetry (Humphrey Field Analyzer II, Humphrey Systems, Carl Zeiss Meditec Inc., Dublin, USA) is shown in .
+Considering that target IOP had been achieved, I suggested that she be followed closely with medications. She was observed for two years, but on her last examination I noticed suspicious progression of cupping and visual field defects especially in her left eye. The follow-up visual field and Stratus OCT (Carl Zeiss Meditec, Dublin, USA) scans of the peripapillary nerve fiber layer are shown in and . At this time, IOP was measured by the ocular response analyzer (ORA) (Reichert Ophthalmic Instruments, Buffalo, USA) which reported cornea-compensated IOP (IOPcc) of 22 and 21 mmHg in the right and left eyes, respectively ().
+Herein we present the opinions of three glaucoma specialists on the diagnosis and management of this patient.
+This 52-year old lady is a case of POAG with history of prior LASIK surgery. IOP is acceptable while measured with GAT, but high with the ORA. Clinical and visual field evaluation show signs of glaucoma progression.
+The patient has a thin cornea (OD: 431 and OS: 322 microns) and IOP measured with GAT should be corrected on the basis of corneal thickness. The Goldmann tonometer is assumed to measure IOP accurately when CCT is 520 microns and many correction formulas have been introduced for thicker and thinner corneas. Although all reports agree that CCT affects IOP measurement, there is no consensus regarding a specific formula for IOP correction in routine clinical practice. The suggested formulas do not seem to be precise in patients with very thin or thick corneas, such as this patient. Moreover, it is not clear whether any specific conversion factor can be applied to patients who have undergone corneal refractive surgery. It has been shown that corneal hysteresis (CH) and corneal resistance factor (CRF) are decreased in eyes with previous keratorefractive surgery. The only available instrument that can measure these factors and correct the measured IOP accordingly is the ORA. In this patient, no data are provided about CH and CRF, but considering the significant difference between IOPcc values determined by ORA and GAT readings, they should be low. Some studies suggest using the Dynamic Contour Tonometer (Pascal tonometer) in patients with previous corneal refractive surgery, but because of mixed results, it is hard to select one instrument as the device of choice. In a recent study, IOP was measured with Goldmann and Schiotz tonometers before and after LASIK surgery in 23 eyes. Interestingly, Schiotz measurements were consistent before and after surgery while Goldmann readings were significantly lower after LASIK. With respect to the available data, I would prefer to rely on IOPs measured with the ORA in this patient.
+The baseline perimetry is reliable and shows generalized depression and typical superior arcuate visual field defects. The cause of generalized suppression can be the cataracts or refractive error (possibly, the refractive error had not been corrected while performing the visual field, because there is no data about the refraction in the printout). In the follow-up perimetry, defect depth has increased and progression of the visual field defect is obvious. In the OCT, the circle is not centered on the optic nerve and signal strengths are 2 and 0 in the right and left eyes, respectively. Currently, for most studies, the minimum acceptable signal strength is six. With respect to the cornea and cataract, it seems impossible to obtain pictures of higher quality. To me, recording the optic nerve head findings and obtaining serial visual fields are appropriate tools for following this patient.
+Due to corneal ectasia in the left eye and regression of myopia in the right eye, the patient wears RGP contact lenses. A portion of this myopia may be due to nuclear sclerosis. It has been demonstrated that prostaglandins can cause corneal thinning, and although the reported effects are not severe, I would prefer not to use this class of medications in this particular patient. The mentioned effect has been attributed to PGF2-induced up-regulation of matrix metalloproteinases with subsequent alterations of the extracellular matrix of the corneal stroma. These effects may eventually lead to corneal weakening. A suitable alternative can be brimonidine, though its efficacy is not as much as latanoprost and it entails a higher rate of ocular allergy.
+Since acceptable target IOP cannot be attained with medical therapy and the patient is already on 3 topical drugs, a laser or surgical intervention is necessary. I would try laser trabeculoplasty and if this is ineffective, the next step would be incisional surgery. The gold standard surgery for patients with primary open angle glaucoma is trabeculectomy. In this patient because of dependence on contact lenses, a blebless surgery is recommended to prevent bleb associated infections. Viscocanalostomy which is regarded as a blebless procedure leads to bleb formation in 5% of all patients, according to Stegmann et al. Moreover, in about 50% of patients who undergo viscocanalostomy, laser goniopuncture is necessary which will convert the procedure to a penetrating intervention and may produce a bleb. Post-viscocanalostomy IOPs are usually in the high teens which would not be an acceptable level in this patient. Trabectome is another option but similar to viscocanalostomy, it may not reduce IOP to the low teens. Moreover, this patient may require corneal transplantation in the future or simultaneously with glaucoma surgery. Because of the low grade post-transplant inflammation, the possibility of trabeculectomy bleb fibrosis is high. Based on the available literature, the preferred surgery in grafted patients seems to be a shunt. All in all, I prefer shunt surgery if laser trabeculoplasty is not effective. In contrast to the prior literature, IOPs in the low teens are achievable with shunts, as was attained in 62% of patients in the tube group at 3 years in the ?rabeculectomy versus Tube??trial.
+This is a 52-year old Caucasian female who was diagnosed with glaucoma, 7 years after LASIK. In the mean time, she has also developed post-LASIK ectasia with corneal thinning, more marked in the left eye along with worsening of myopia and induced astigmatism, again much worse in the left eye. Pressures have been seemingly well controlled in both eyes with the caveat that the real IOPs are actually unknown especially in the left eye where CCT is extremely thin. ORA measurements confirm a significant underestimation of IOP in both eyes with waveforms typical of keratoconus in both eyes. There is now strong suspicion of progression at the level of the visual fields in both eyes and the disc in the left eye, although no baseline images are available to compare to. Stratus OCT images obtained at final follow-up are unfortunately not helpful, given the very low signal strengths and poor segmentation of RNFL in both eyes.
+I think the first thing to establish is whether the visual field progression is real. If repeat testing confirms progression in the left eye, then the rate of progression seems fast enough to warrant aggressive treatment, given the patient? young age and her life expectancy. Nonsurgical options are limited. Brimonidine is rarely tolerated on a long-term basis and is not likely to have much of an effect as the fourth medication. The same is true with laser trabeculoplasty. Unless the patient is reluctant to have surgery, I would recommend trabeculectomy with mitomycin C, since the newer angle surgeries are unlikely to achieve the low target pressure required in this patient. Of course, it would be very difficult to titrate the endpoint in such a case postoperatively: avoiding hypotony and maculopathy in a young myopic patient and at the same time reaching a low enough target IOP. Multiple tight sutures should be placed with gradual laser suture lysis postoperatively to prevent severe hypotony. Checking the pressure postoperatively with Dynamic Contour Tonometry or ORA may also be helpful. I would aim for a target of around 5?? mmHg based on GAT readings, although I should admit that this is only a rough guess.
+For the right eye, in which progression is still not quite established, I would step up treatment by doing a selective laser trabeculoplasty and adding brimonidine to reach a target in the range of 6?? mmHg based on GAT and then, closely watch the patient for evidence of progression and results of surgery in the left eye. She may need surgery soon in the right eye as well.
+This case outlines a scenario where a post-LASIK eye exhibits keratectasia and glaucoma progression, likely due to underestimated IOP by GAT. It highlights the intricacies of glaucoma management in myopes with astigmatism and previous LASIK.
+The assessment of glaucoma in highly myopic eyes is fraught with difficulty. The optic discs are notoriously difficult to assess as they have large diameters, greater cup disc ratios, and shallower optic cups. The single unreliable (with poor signal strength) Stratus OCT scan (Fig. 4) adds little to this difficult diagnosis as the absolute values for retinal nerve fiber thickness are often globally reduced in high myopes. Visual fields are also difficult to judge, as myopic retinal degeneration and tilted discs may mimic glaucomatous visual field defects. Hence, it is possible that glaucoma may have been present and missed in this case prior to LASIK.
+Accurate IOP measurement is crucial for monitoring glaucoma in such cases. There is 5.5 D of astigmatism in the left eye and ideally, GAT should be performed in two perpendicular directions and averaged. GAT is inaccurate when there is high astigmatism or deviation from CCT of 500 弮m. Studies have shown a 2 to 7 mmHg underestimation of IOP by GAT per 100 弮m of corneal thinning. The ORA and Dynamic Contour Tonometer are purported to be independent of changes in CCT and therefore may reflect a closer measure of the actual IOP in this case. It could be advisable to continue the use of the ORA to monitor IOP in the long term for consistency.
+As the IOPcc provided by ORA is actually far above target IOP, it is likely that glaucoma progression is IOP related. With the evidence of visual field and optic disc progression in a relatively young individual, trabeculectomy with mitomycin C is the preferred option. Care is needed as the increased axial length, thinner sclera, and larger intraocular volume predispose myopic eyes to hypotony, shallow anterior chambers, and choroidal effusions after surgery.
+Difficulties with continuing RGP contact lens use after trabeculectomy are well known and the patient must be counseled that she may need to return to wearing glasses or eventually require corneal surgery for visual rehabilitation."
+Wells Russell,23,1988/9/10,950.638.3185,lhouston@example.net,64258 Wade Extensions Suite 002,"An 80-year-old male patient had been under observation for dry-type AMD in his left eye. There was history of severe vision loss in the right eye due to a disciform scar secondary to AMD since 1995. VA in his left eye had been 20/25 with confluent soft drusen in the macula. In September 2006, he noticed sudden visual loss to 20/200. Ophthalmoscopy disclosed subretinal hemorrhage in the macular region (). Fluorescein angiography showed fluorescein blockage due to submacular hemorrhage (). An intravitreal injection of 50 弮g rtPA and 0.3 ml SF6 was performed promptly, followed by prone positioning for 24 hours. Displacement of subretinal hemorrhage was apparent the next day and intravitreal injection of 1.25 mg bevacizumab was performed. Due to persistent leakage on FA, a second injection of the same dose of bevacizumab was performed one month later. Follow-up examinations were performed at six-week intervals using OCT. The patient was followed for one year; at final examination the CNV regressed and best corrected VA reached 20/30 (, , )."
+Raelynn Savage,21,1991/4/10,524.342.8997,grussell@example.com,1915 Rodney Viaduct,"A 45-year-old British Caucasian woman with a two-day history of intermittent abdominal pain which radiated to her back presented to our surgical unit. She was opening her bowels and passing flatus infrequently. On examination, her abdomen was soft and non-distended with upper abdominal tenderness and voluntary guarding. She was hemodynamically stable and afebrile. Routine investigations revealed a hemoglobin of 13.5 g/dL, white cell count of 6900 109/L, a bilirubin of 3 弮mol/L and normal liver function tests. She had a background of previous open jejunoileal bypass surgery with an ileal band in 2005 with an abdominoplasty in South America. Other co-morbidities included Mobitz type one heart block with a permanent pacemaker. She also had depression. Initially, acute cholecystitis was suspected. An ultrasound scan was unremarkable. Due to the persistence of her symptoms a computed tomography (CT) of the abdomen and pelvis was performed and demonstrated small bowel obstruction with a transition point at the proximal jejunum (Figure ). She was treated conservatively as a suspected paralytic ileus. Because her obstructive symptoms increased in severity, a gastrografin swallow study was performed that demonstrated proximal jejunal dilatation with an abrupt transition point at the jejunoileal anastomosis (Figure ). The findings were suggestive of a small bowel volvulus at the site of anastomosis. Due to a continued deterioration in her symptoms it was decided to perform an exploratory laparotomy. Intra-operatively, a proximal small bowel volvulus at the site of the side to side jejunoileal anastomosis was found. The side-to-side anastomosis was narrow, at only 3 cm in diameter (Figure ). The jejunal band had migrated into the small bowel mesentery with no damage to the bowel (Figure ). The small bowel volvulus was corrected with ease and the site of the anastomosis was broadened by simply apposing the proximal and distal small bowel loops adjacent to the anastomosis with interrupted extra-mucosal absorbable sutures. The constrictive distal jejunal band was divided and removed. The patient made an uneventful post-operative recovery with a return of normal bowel function within three days. On follow-up three months post-operatively, she was well and asymptomatic."
+Keaton Morgan,40,1987/2/19,303-591-5122,emily41@example.net,72539 Angela Inlet Apt. 053,"A 61-year-old man presented with a lesion involving the central left lower eyelid margin. He had been diagnosed with mantle cell lymphoma 6 years prior to this presentation. The patient was initially treated with rituximab and cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP). However, upon recurrence, the patient received unrelated donor stem cell transplantation, 13 months prior to appearance of the eyelid mass. His post-transplant course had been complicated by recurrent viral infections, including influenza and cytomegalovirus (CMV) reactivation. He had developed basal cell carcinoma (BCC) in his forehead and chin three years ago and was treated with surgical excision. Pertinent physical findings consisted of a central area of ulceration, with telangiectasia and crusting in the left lower eyelid. The patient was neutropenic at diagnosis (white blood cell count=4000/fL). Incisional biopsy of the mass revealed a squamous cell carcinoma (SCC) in situ. The patient underwent wide local excision of the mass with frozen section control of the margins. The defect was repaired using a tarsoconjunctival flap (Hughes procedure) from the left upper eyelid with a full thickness skin graft harvested from the left upper eyelid. The patient did well postoperatively with no evidence of local or regional recurrence at last contact, 5 months after surgery."
+Delilah Gould,30,1982/8/6,712.925.8792,cassandra63@example.com,1509 Miller Ford,"A 61-year-old woman with a history of follicular NHL presented with a lesion in her left upper eyelid. Follicular lymphoma had been diagnosed three years ago and was being treated with chemotherapy (R-CHOP) at the time of presentation. She had a biopsy of the left upper eyelid lesion two years ago confirming BCC but the margins were not clear. When the patient presented to a Mohs surgeon, it was felt that the area of previous biopsy was undetectable and hence, further excision was deferred. The patient received no further intervention for this lesion and was under therapy for lymphoma in the interim. On examination, there was a well-circumscribed lesion at the upper eyelid margin. She was scheduled for surgical excision after completion of chemotherapy. The patient remains under close follow-up and there is only mild increase in the size of the lesion three months after initial presentation."
+Blaine Daniels,28,1992/4/21,684-636-0586x23346,fitzpatrickcalvin@example.com,9814 Lowery Road Apt. 519,"A 65-year-old man with a history of transformed follicular NHL was noted to have a mass in his right lateral canthus. The patient had stage IV NHL with bone marrow involvement, initially diagnosed one year ago. He had been treated with 6 courses of R-CHOP chemotherapy and had a complete response. He had first noticed a lesion in the right lateral canthus, 11 months prior to presentation to our clinic. Tumor resection by Mohs surgery was performed and the histologic diagnosis confirmed a BCC. Over the past 4 to 5 months, the patient has noted recurrence of the mass in the same area and the lesion had apparently almost doubled in size, in the month prior to presentation to our clinic. A recent biopsy showed BCC with a morpheaform (sclerosing) pattern and perineural invasion ().
+On examination, there was an ulcerative mass in the right lateral canthus (). This mass was removed in its entirety, with 4 mm free margins. The excision included 2/3 of the lower eyelid, 1/3 of the upper eyelid and much of the soft tissue in the lateral canthus down to the orbital rim. A tissue sampling from the inner side of the orbital rim was also performed. Margin clearance was confirmed on frozen section and complex repair of the defect in the right upper eyelid was performed using a tarsoconjunctival flap (). Adjuvant postoperative radiotherapy was recommended given the extensive perineural invasion seen on the surgical specimen but this could not be carried out because the patient was simultaneously found to have recurrence of systemic lymphoma and required treatment with R-CHOP; therefore excessive dermal toxicity was expected from radiation therapy combined with Adriamycin. The patient is currently under close observation for recurrence of the carcinoma and radiation will be performed after cessation of the chemotherapy regimen for systemic lymphoma."
+Ember Rangel,20,1991/8/30,-5772,sarawallace@example.net,728 Rebecca Valley,"A 63-year-old man with a history of stage III follicular NHL, presented with a poorly differentiated SCC of the left lower eyelid and cheek one year after a diagnosis of NHL. He had received R-CHOP for NHL, achieved complete remission and was still on maintenance Rituximab therapy when he developed the eyelid carcinoma. On examination, there was a lesion in the left lower eyelid and cheek in the distribution of the infraorbital nerve. A biopsy had revealed SCC with perineural invasion. The patient underwent surgical resection of this mass and infraorbital nerve dissection. He received postoperative adjuvant radiotherapy and has had no evidence of recurrence at last contact, 6 months after completion of radiotherapy."
+Saint Colon,37,2002/4/5,726.840.2436x4600,teresaanderson@example.net,063 Brian Keys Apt. 221,"A 76-year-old man with a history of central nervous system lymphoma of large, diffuse, B-cell variety, and bilateral intraocular lymphoma, presented with a lesion in his lower eyelid and cheek that had been proven to be a BCC based on a recent biopsy. He had received systemic methotrexate and rituximab together with radiation therapy to both orbits, which had resulted in complete remission. On examination, there was an area of ulceration, with indurated margins, crusting and surrounding telangiectasia on the left lower eyelid, extending onto the cheek. Wide local excision of the lesion with frozen section control of the margins was performed. The patient has had no recurrence of eyelid carcinoma during 3 years of follow-up."
+Remy Hubbard,26,1992/5/27,4393060114,deborah81@example.net,92061 Ashley Springs,"A 20-year-old male patient, a known case of diabetes mellitus type I from 7 years before, presented to a private ophthalmology office. His blood sugar was inadequately controlled even with insulin injections. His parents were consanguineous but healthy, however his grandparents were diabetic. Best-corrected visual acuity was 1/10 in both eyes with ??.25+1.50@55 and ??.25+1.50@131 in his right and left eyes respectively. Intraocular pressure was 14 mmHg in both eyes and biomicroscopic examinations were completely normal. Fundus examination showed advanced bilateral optic atrophy but no sign of diabetic retinopathy (, ). Laboratory studies and dehydration test confirmed diabetes insipidus. An audiologic examination revealed neurosensory deafness. Magnetic resonance imaging (MRI) of the brain and lumbar spine was normal. Both kidneys were larger than normal and showed signs of moderate hydronephrosis on ultrasonographic evaluation. The bladder wall had a trabecular pattern and the urinary tract was dilated on both sides. The patient had 170 ml post-voiding bladder residue. Urologic examination and sonographic findings were consistent with a neurogenic bladder (). The patient also had polyuria and extra-residual voiding which indicated atony of the urinary tract. Urogenital examination revealed some degree of delayed sexual maturation."
+Forrest Hensley,31,2003/2/17,(395)450-6483,lisapadilla@example.net,2125 Miranda Harbors Suite 236,"A 64 year-old-man presented with abrupt, painless, and severe visual loss to counting fingers at 1 m in his left eye; best-corrected visual acuity was 20/20 in his right eye. He had noted temporary visual loss of a few seconds??duration in the same eye a few days before total visual loss. Intraocular pressure was 19 mmHg and the anterior segment was normal in both eyes, but afferent pupillary defect was present in the left eye. The right fundus was normal (), however in the left eye, ophthalmoscopy and fluorescein angiography showed narrowing of retinal arteries, boxcarring and fragmentation of blood flow in the retinal arterioles, the retina was opaque and a cherry-red spot was present (). Angiography revealed a prolonged arm-retina time, prolonged filling of retinal arteries, and a long arteriovenous time, as well as late staining of the optic nerve head with peripapillary splinter hemorrhages and disseminated retinal hemorrhages in all quadrants ().
+The following laboratory tests were raised above normal limits: fibrinogen 6.1 g/l, CRP 34 mg/l, serum glucose 6.9 mmol/l, HbA1C 7.2, uric acid 451.8 mol/l, total cholesterol 7.5 mmol/l, HDL 0.9 mmol/l, low-density lipoprotein (LDL) 5.0 mmol/l, triglycerides 2.1 mmol/l, and erythrocyte sedimentation rate 42 mm/h. Complete blood count (red blood cells, white blood cells and platelets) was normal. Prothrombine time was 85% and the activated partial thromboplastin time was 26 seconds. Rheumatic factor, antinuclear antibodies, anti-neutrophil cytoplasmic antibodies, immune complexes, and antiphospholipid antibodies were negative.
+Clinical examination revealed abdominal obesity and systemic hypertension (160/110 mmHg). A color Doppler scan of the carotid arteries showed bilateral stenosis, 45% on the right side and 64% on the left. Holter monitoring revealed normal cardiac rhythm."
+Malaya Foley,35,1992/7/13,583-312-1777x2707,pricebrian@example.com,089 Garza Mission Suite 312,"A 64-year-old diabetic lady underwent pars plana vitrectomy in her left eye for a taut posterior hyaloid face due to proliferative diabetic retinopathy (PDR). Visual acuity (VA) at baseline had been 20/120. She had previously received panretinal laser photocoagulation (PRP) and the retinopathy had been stable, but there was localized extrafoveal tractional retinal detachment in the inferonasal quadrant. After vitrectomy, she was discharged in good condition, VA of 20/400 and mild vitreous hemorrhage (VH). One month postoperatively, the density of the VH increased and VA decreased to counting fingers (CF) (). The VH was non-clearing for three months but on echography, the retina was attached (). VH density decreased one month later and the patient received additional peripheral laser therapy. Six months postoperatively, she underwent uncomplicated phacoemulsification with intraocular lens (IOL) implantation due to severe lens opacity. One month after cataract surgery, VA was 20/400, intraocular pressure (IOP) was 3 mmHg and there was fibrin deposition over the IOL. Fundus examination revealed regressed PDR. She received steroid
+and cycloplegic drops and the condition remained stable three months after cataract surgery. On final examination, about 10 months after cataract surgery, VA deteriorated to hand motions, IOP was 5 mmHg, the IOL was partially captured by iris with fibrovasular tissue behind the IOL (); the fundus was not visible. The echography is shown in .
+Based on this presentation, what is your diagnosis, what treatment modality would you recommend and do you think there has been any pitfall in the management of this patient?
+This appears to be a case of anterior hyaloidal proliferation, which is a fibrovascular response of the vitreous base to anterior ischemia. There are a number of established risk factors including traction as an indication for surgery, recurrent hemorrhage, and cataract extraction.
+Although it is stated that ?undus examination revealed regressed PDR??at six months, it is quite likely that the anterior retina remained very ischemic and continued to produce large quantities of vascular endothelial growth factor (VEGF) which diffused forward, aided by the state of pseudophakia. The low IOP is due to traction on the ciliary body. This is a very serious situation, and in retrospect might have been avoided by more aggressive trimming of the vitreous base at the time of initial surgery together with heavy peripheral panretinal photocoagulation.
+If the patient is keen on further treatment now (and without it the eye is lost), I would recommend intravitreal injection of an anti-VEGF followed by further surgery 6 days later. This surgery should remove as much of the anterior fibrous tissue as possible, and apply additional PRP as far forward as possible. The surgeon will find a dense white band of fibrous tissue over the ciliary body, and I recommend that they resist the temptation to peel this off! Finally I recommend silicone oil tamponade, as this will help counter the hypotony, as well as acting as a ?EGF insulator??to guard against furthers proliferation.
+Based on the provided information, this lady? left eye presents a diabetic anterior fibrovascular proliferation () associated with severe tractional retinal detachment (). IOP is low and the eye seems already on the way to phthisis bulbi. At this stage and despite all heroic interventions, the prognosis remains very poor. A vitrectomy with dissection of proliferations and probably anterior retinectomy, IOL removal and silicone injection could be a last chance treatment.
+These conditions could sometimes be prevented by early diagnosis and intervention: generous photocoagulation of all anterior ischemic areas, treatment of significant retinal detachment in particular in the anterior retina and intraocular use of anti-VEGF agents. This complication must be in mind when hypotony, especially associated with a vitreous hemorrhage, is diagnosed after any surgery for diabetic retinopathy.
+Further upstream, the risk of these complications usually justifies a reoperation if the fundus remains inaccessible for more than one month after vitrectomy for diabetic retinopathy due to vitreous hemorrhage, to check the retina and treat the cause of bleeding. In high-risk cases (in particular cases with proliferation extending forward to the equator), some surgeons systematically inject anti-VEGF agents at the end of the vitrectomy, even though its benefit has not been clearly proven.
+This is a 64-year-old woman with diabetes mellitus and history of decreased vision in the left eye, pars plana vitrectomy and PRP for management of PDR. Later on she underwent phacoemulsification with IOL implantation. Sixteen months after initial evaluation, VA was CF and IOP was 5 mmHg. Examination revealed that the IOL was partially captured, there was fibrovasular tissue behind the IOL, and the fundus was not visible. Echography demonstrated vitreous hemorrhage, tractional retinal detachment (TRD) with proliferation and a posterior closed funnel. The choroid is thickened, and the axial length of the eye seems decreased as compared to previous echographic images. It is clear that this is a case of a TRD, fibrinoid syndrome and a prephthisical eye following vitrectomy, PRP, and phacoemulsification with IOL implantation for management of severe PDR.
+At this point, I would consider surgery if this is the only eye. My approach would be to perform a 23-gauge transconjunctival sutureless vitrectomy with membrane peeling, IOL removal and silicone oil (SO) injection. My preference on a complicated case like this would be to use 5,000 centistoke (cs) SO. We have previously reported a higher rate of complications using 1,000 cs SO for complex retinal detachment repair including retinal redetachments, reproliferation, glaucoma, hypotony, keratopathy, cataract; furthermore, SO emulsification tends to occur not only more frequently but also faster with 1000 cs SO. Effective management for postoperative hypotony is problematic, revision of vitrectomy with peeling of membranes from the ciliary processes might be of value. In addition, subconjunctival injections of long-acting (depot) steroids may be given (anterior subconjunctival injections as opposed to posterior sub-Tenon injections are more likely to produce an elevation/normalization of IOP). No intravitreal bevacizumab should be used at this stage as it could induce worsening of the TRD.
+In retrospect, I would have treated the vitreous hemorrhage earlier with a fluid-air/ gas exchange to avoid fibrin development. In addition, I would have treated the fibrin deposition over the IOL with intracameral tissue plasminogen activator at a dose of 25 弮g/0.1 mL. Any fibrin appearing in the frontal plane as a result of severe inflammation may result in development of a cyclitic membrane and phthisis bulbi in severe cases. Steroids do not appear to retard healing of any of the ocular structures and should be adequately used to suppress all inflammation.
+In summary, this is a 64-year-old woman with diabetes mellitus and history of decreased vision in the left eye, pars plana vitrectomy and PRP for PDR, and phacoemulsification with IOL implantation. She developed a TRD, fibrinoid syndrome and a prephthisical eye with hypotony. Surgery is warranted if this is an only eye but the patient should be warned that the prognosis is poor.
+This is a case of vitreous hemorrhage after vitrectomy for PDR, a common complication with an incidence of 12% to 63%. The hemorrhage may appear within the first few weeks after surgery or months later. The source of early bleeding in such cases may be residual blood in the peripheral vitreous skirt, iatrogenic intraoperative injury to retinal vessels, and incomplete removal of fibrovascular tissues. The cause of late vitreous hemorrhage (one month postoperatively in this patient) can be fibrovascular proliferation from the sclerotomy sites or from the vitreous base. The vitreous hemorrhage persisted for three months after vitrectomy, during this period the retina was attached as revealed by B scan ultrasonography.
+In this case it may be difficult to differentiate the origin of vitreous hemorrhage by conventional methods of examination using an indirect ophthalmoscope or B scan ultrasonography because of poor visibility and limited scope of evaluation of anterior segment structures to detect complications at the sclerotomy sites. On the other end, ultrasound biomicroscopy (UBM) is helpful to provides images of fibrovascular ingrowth at sclerotomy sites. Postvitrectomy vitreous hemorrhage clears more rapidly in aphakic eyes (at an average of 5.3 weeks) than in phakic eyes (at an average of 16.2 weeks).
+Vitreous hemorrhage decreased four months after surgery in this case and the patient received additional peripheral laser therapy. Six months after vitrectomy the patient underwent uncomplicated phacoemulsification with IOL implantation. An important finding was ocular hypotonia one month after cataract surgery which may have been due to peripheral retinal detachment or anterior retinal displacement and ciliary body detachment secondary to fibrovascular proliferation from the sclerotomy sites or from the vitreous base. At this stage of the disease, UBM imaging is highly recommended. UBM also is helpful for early diagnosis and timely management of such complications.
+Presence of any fibrovascular proliferation at the sclerotomy site would indicate the need for more aggressive retinal ablation, especially to the periphery, with the indirect laser delivery system, transconjunctival cryopexy, or transconjunctival diopexy with diode laser. It appears that these complications could have been diagnosed and treated earlier.
+Finally about 10 months after cataract surgery there was massive fibrovasular tissue behind the IOL and IOP was 5 mmHg, the B-scan ultrasonography showed advanced TRD of the posterior and peripheral retina. These findings are consistent with anterior hyaloidal fibrovascular proliferation. It is a severe complication after vitrectomy for PDR, which, if not treated aggressively can lead to phthisis bulbi. Therefore despite the poor prognosis and visual outcome in this case, it is recommended to perform vitrectomy, remove all fibrovascular proliferation at the sclerotomy sites and peripheral retina, repair the retinal detachment, aggressively perform retinal ablation especially to the periphery of the retina with endolaser, indirect laser delivery system, cryopexy, or diopexy, and inject silicone oil. I would prefer to inject intravitreal bevacizumab and triamcinolone acetonide at the conclusion of surgery in this case."
+Mohammad Snow,44,1992/8/13,001-249-373-3594,luismiller@example.net,47498 Patrick Place Suite 602,"A 26-year-old man presented with acute loss of vision in his left eye following blunt trauma. Best-corrected visual acuity (BCVA) was 20/20 and 20/200 in the right and left eyes, respectively. Examination of the left eye showed a normal anterior segment. Fundus examination revealed abnormal yellow discoloration in the macular area with juxtapapillary subretinal hemorrhage, but the optic disc appeared normal (). All examinations of the right eye were normal. Goldmann perimetry revealed an absolute central scotoma (). Fluorescein angiography revealed blocked fluorescence in the macula (). Vertical and horizontal linear OCT Scans (OCT/SLO, OTI, Toronto, Ontario, Canada) revealed thickening of outer retinal structures and increased reflectivity in the area of the photoreceptor outer segments with preservation of inner retinal architecture; central foveal thickness was 115 弮m (). One month later, BCVA of the left eye improved to 20/20. There was no evidence of significant scarring on ophthalmoscopy. Repeat OCT showed a surprisingly normal pattern with central foveal thickness of 231 弮m ()."
+Alexia Bridges,19,1999/9/16,001-632-232-1781x345,richardburke@example.com,64099 Schwartz Views,"A 10-year-old boy presented with bilateral decreased vision since the age of three. His parents were consanguineous but normal on ophthalmic examinations. Best-corrected visual acuity (BCVA) was 20/160 and 20/800 in his right and left eyes with correction of ??2.00 and ??3.00 sphere, respectively. On slitlamp biomicroscopy, diffuse intra-epithelial microcystic changes were present within the entire corneal epithelium (). Intraocular pressure (IOP) was normal and funduscopic examination disclosed pathologic myopic changes in both eyes. The clinical diagnosis was MCD associated with amblyopia due to high myopia. To improve visual acuity and anterior corneal clarity, the patient underwent automated lamellar therapeutic keratoplasty (ALTK) with a thickness of 250 弮m in his left eye.
+The corneal button was sent in 10% formalin to the pathology laboratory. After bisecting the specimen, one half was processed and embedded in paraffin wax. Sections were prepared and stained with Hematoxylin and Eosin (H&E) for studying the general morphology and by PAS sequence with and without diastase to identify glycogen. The histopathological sections were examined by light microscopy (Olympus BX43, Olympus Co., Tokyo, Japan). The other half of the specimen was sent in 2.5% glutaraldehyde to the electron microscopy laboratory for transmission electron microscopy (EM 900, Zeiss, Germany). Histopathological examination disclosed a partial-thickness cornea with abnormal-appearing epithelium consisting of numerous intracytoplasmic cyst-like inclusions together with cellular swelling (). The cells contained moderate amounts of PAS-positive (), diastase-sensitive () material consistent with glycogen. Other corneal layers were unremarkable. Transmission electron microscopic examination disclosed numerous and variable-sized vacuoles within the cytoplasm in all epithelial layers (). Moderate numbers of electron-dense and membrane-bound intracytoplasmic bodies similar to lysosomes were also noted, some within the vacuoles (). No abnormal findings were noted elsewhere. The histopathologic and electron microscopic findings confirmed the clinical diagnosis of MCD."
+Mohammed Liu,36,1980/1/6,-2450,shepherdbrian@example.net,248 Heather Ports Suite 688,"A 17-year-old female presented with foreign body sensation and pain in both eyes since 3 years ago without any significant medical or family history. BCVA in her right and left eyes was 20/40 and 20/50, respectively with refractive error of ??.5 sphere in both eyes. On retroillumunation by slitlamp biomicroscopy, there were diffuse (limbus to limbus) intra-epithelial microcystic lesions together with regional haze in both corneas () but other corneal layers were unremarkable. IOP and funduscopic examinations were within normal limits. The clinical features were characteristic for MCD.
+After topical anesthesia, confocal scan 3.0 (Nidek Technology, Padova, Italy) was performed on both eyes using methylcellulose as a coupling agent between the front lens (40?, 0.75 objective lens) and the surface of the cornea. The automatic full thickness and epithelial modes were used to capture images from all corneal layers with particular attention to the anterior parts of the involved cornea. The manual analytic software of the confocal scan was utilized to measure the abnormal confocal findings.
+Confocal scan examination of both corneas disclosed scattered and well-defined round to oval hyporeflective intracytoplasmic areas measuring 6.8 to 41.4 弮m in their largest diameter within the superficial corneal epithelium (), diffuse hyperreflective spots in the basal epithelium (), irregular and poorly-defined high contrast areas in the sub-basal epithelial region and foci of sub-epithelial fibrosis (). A few hyperreflective lesions containing high contrast spots, corresponding to cell nuclei, were also present. The subepithelial nerve plexus was not visible because of the regional hyperreflectivity. No abnormal finding was noted in the rest of corneal stroma and the endothelium. The confocal microscopic features were consistent with the clinical diagnosis of MCD."
+Kate Harvey,34,2003/3/14,3176261611,charleswyatt@example.org,90081 Benton Circle,"The patient presented herein, is a 29-year-old man with history of unilateral alkaline chemical injury 14 years ago. Upon referral, visual acuity was 20/20 and the examination was unremarkable in the right eye. Vision was hand motions (HM) in his left eye and a small angle exotropia (10??5 Prism Diopters) was evident. Slitlamp examination revealed severe corneal opacification and vascularization (). Intraocular pressure (IOP) was 13 and 10 mmHg in the right and left eyes, respectively. B-scan ultrasonography ruled out gross posterior segment pathologies and impression cytology revealed total limbal stem cell deficiency (LSCD) in the left eye.
+The injured eye underwent cultivated autologous stem cell transplantation on amniotic membrane (AM) after punctal cauterization. The patient received a topical steroid (betamethasone 0.1%, Sina-Daru, Tehran, Iran), and an antibiotic (chloramphenicol 0.5%, Sina-Daru, Tehran, Iran). Antibiotic drops were continued for 1 to 2 weeks until complete epithelialization. Steroid drops were tapered off according to the level of ocular inflammation over 6?? weeks. A preservative-free artificial tear (Artelac, Bausch and Lomb, USA) was used for lubrication as needed. The patient received systemic prednisolone 1 mg/kg (Sina-Daru, Tehran, Iran) for 3 to 4 weeks. Visual acuity in the left eye improved to counting fingers at 75 cm along with modest decrease in corneal vascularization and opacity 3 months after the procedure ().
+Due to deep corneal stromal opacification, penetrating keratoplasty (PKP) was performed 6 months later. One month after PKP, visual acuity improved to 20/120. The patient complained of diplopia which was due to improvement in vision and the small angle exotropia. Six weeks later, IOP increased to 32 mmHg which was controlled by topical timolol 0.5% (Sina-Daru, Tehran, Iran) two times per day and systemic acetazolamide 250mg, three times per day. Cup-disc ratio was 0.3. Systemic acetazolamide was discontinued due to elevated liver enzymes and replaced by topical dorzolamide 2% (Sina-Daru, Tehran, Iran) two times per day.
+Eight weeks after corneal transplantation, the patient developed epithelial rejection, which was treated with topical steroids. Four months after surgery, IOP rose to 30 mmHg and brimonidine 0.2% (Alphagan, Allergan Inc., Irvine, USA) and latanoprost 0.005% (Xalatan, Pfizer Inc., New York, USA) were added to the regimen. Five months after PKP, visual acuity improved to 20/80 but IOP was poorly controlled (). The patient underwent Ahmed Glaucoma Valve (AGV) surgery. Two months later, a mild posterior subcapsular cataract was observed. Five month after AGV, corneal endothelial and subepithelial rejection were observed which was aggressively treated with systemic prednisolone and topical betamethasone. Overall, the patient experienced three attacks of corneal endothelial rejection 5, 9 and 16 months after AGV. There was a slightly progressive vascularization in the graft periphery 8 months after PKP.
+Considering multiple episodes of corneal endothelial rejection and progressive corneal conjunctivalization in an eye with defective ocular surface, systemic cyclosporine (Sandimmune簧, Novartis Pharma Stein AG, Stein, Switzerland) 300 mg per day was started. One month later, it was replaced by mycophenolate mofetil (Cellcept簧, Hoffmann-La Roche Inc., Nutley, USA) 2 grams per day due to elevated liver enzymes. Two weeks later liver enzymes levels improved but 2 months thereafter, rose critically again and mycophenolate was also discontinued. After that, the patient was put on fluorometholone 0.25% eye drops once daily together with topical cyclosporine 2%.
+One year after PKP, impression cytology confirmed corneal conjunctivalization in the superior and inferior temporal quadrants by the presence of goblet cells on the corneal side of the specimens. About 20 months after PKP, vascularization and conjunctivalization was continuing but did not reach the central 5 mm zone of the cornea (). At final visit, visual acuity was maintained at 20/80 and IOP was 16 mmHg without any glaucoma medications.
+Herein we present the views of two anterior segment specialists on the management of LSCD in this patient.
+To maximize the outcomes of transplantation of ex vivo cultured limbal epithelial cells (LECs), several issues need to be considered. First of all, the ocular surface should be optimized before performing any kind of limbal stem cell transplantation. Although both puncti of the recipient eye were cauterized prior to transplantation, it is unclear whether the ocular surface was actually ready for surgery. For example, it has not been mentioned whether the recipient eye had any other factor which may interfere with ocular surface health, such as surface inflammation, symblepharon, closure and blinking problems, or lid margin abnormalities.
+After any form of ex vivo culture of LECs and before transplantation of the product to the ocular surface, it is necessary to demonstrate that the product really contains viable stem cells. A number of methods have been employed for this purpose such as functional assay of colony forming ability of transplanted cells, immunohistological assays, evidence of donor cell survival, and confocal scanning. In this case report, the evaluation method for the product has not been stated. Transplantation of a product with inadequate viable stem cells can result in long-term failure, which finally developed in this patient.
+Although the surgical technique for transplantation of ex vivo cultured LECs is fairly similar in different studies, postoperative medical regimens may differ among them. The basic principles of this regimen include immediate control of inflammation, prophylaxis against infection, and mechanical protection of the graft. Application of autologous serum eye drops may further optimize the environment for stem cell survival. The early postoperative course of the patient has not been mentioned which may be a clue to final graft survival.
+The patient in this report showed improvement in visual acuity with moderate decrease in corneal vascularization and opacification 3 months after surgery (). However, these could not be considered to be absolute measures of success. There were still many areas of corneal vascularization with a clinical appearance of residual conjunctivalization (). There is no data on fluorescein staining patterns or the results of impression cytology at this postoperative time point. Due to lack of these data, there is a possibility that the patient was still suffering from residual LSCD at that time. It should be mentioned that in addition to clinical findings, a more definitive way to evaluate the success of surgery is to perform impression cytology on the corneal surface postoperatively. This test, which was not performed in the case report, is necessary before proceeding with corneal transplantation. This may explain why the patient finally developed partial LSCD.
+Performing an eccentric full-thickness graft in a vascularized cornea () should be considered as a high risk corneal graft. This is why the patient developed multiple episodes of graft rejection. In these cases, if there is no full-thickness corneal involvement, it is always preferable to perform lamellar rather than full-thickness corneal transplantation.
+The postoperative management of this immunologically high risk graft is vital in determining the outcome. The main measure to be used for prevention of rejection in high risk grafts is immunosuppression. Although corticosteroids have traditionally been used for this purpose, new agents have been available in the past years. In high risk patients, topical steroids are used frequently in the postoperative period, followed by their long-term use if there is no contraindication. Sometimes, low dose steroids need to be used indefinitely after surgery. Therefore, potential complications of steroids, such as cataracts, glaucoma, delayed wound healing, and infectious keratitis should seriously be considered. Systemic steroids can also be used as an adjunct to topical therapy, particularly in high risk cases with concomitant systemic inflammatory diseases. Recently, steroids with lower rates of complications have been introduced; examples include loteprednol etabonate and fluorometholone which can be used for keratoplasty patients who require long-term maintenance therapy.
+In addition to corticosteroids, cyclosporine A (CsA), a calcineurin inhibitor, has been used extensively in organ transplantations including high risk corneal allografts. Many studies have demonstrated the effectiveness of CsA, either topically or systemically, to reduce rejection rates in high risk keratoplasty patients. Although 0.05% CsA is commercially available, a 2% concentration has been shown to be effective for this purpose. Oral CsA may be used in very high-risk cases when topical medications may not be sufficient to prevent corneal graft rejection. However, oral CsA is associated with a number of dose-related side effects, most commonly nephrotoxicity, hypertension, and hepatotoxicity, which developed in this case. Various other systemic immunosuppressive agents have been used in patients with high risk corneal grafts such as tacrolimus, azathioprine, mycophenolate mofetil, and rapamycin, sometimes in combination. However, all of these agents may be associated with adverse effects, which developed in this case after using mycophenolate. In my personal experience, the preferable initial immunosuppressive medication is topical 2% CsA which may be used alone or in combination with topical steroids. This may be why the patient did not develop any episode of graft rejection while on topical CsA.
+This case report shows how difficult it may be to manage patients with significant ocular surface disease. A comprehensive multidisciplinary approach is necessary to deal with these grave eye conditions.
+This 29-year-old man with severe vascularization, conjunctivalization and diffuse haziness of the cornea has unilateral total LSCD. He had history of chemical injury 14 years before presentation. At this stage, any type of corneal transplantation (penetrating or lamellar) would have a short survival and may fail rapidly. Because the right eye is normal in appearance and has no history of exposure to chemical agents, limbal stem cells could be harvested for ex vivo expansion. This technique which has become available in some centers in recent years, enables patients to make benefit of their own stem cells. This technique brings hope for traditionally poor chance cases with LSCD. At this stage it is very important to optimize the status of the fornices. Severe symblepharon and foreshortening of the fornices prevents adequate tear film lubrication and lid function. Therefore, reconstruction of the fornices and release of symblepharon using amniotic membrane can be helpful.
+After limbal stem cell transplantation, it would be better to use preservative-free medications. The medications used in this case are not preservative-free and can be toxic to the transplanted tissue.
+After PKP in cases who are considered to be high risk due to previous limbal stem cell (LSC) transplantation, immunosuppressive treatment must be used. Steroids alone are not enough and can be used in the immediate post-PKP period, but systemic or topical immunosuppression with medications such as cyclosporine A (Sandimmune簧) or mycophenolate mofetil (Cellcept簧) are important preventive measures against rejection of corneal transplants. It would be better to start these medications earlier and prior to immune system activation.
+IOP rise with coticosteroids can be due to steroid responsiveness. This risk is higher with topical betamethasone than other steroids. If the use of these types of medications is mandatory, alternative medications, e.g. fluorometholone or loteprednol can be considered.
+In summary, the management of LSCD has remarkably changed over the recent years. Cultivation of LSC and application of immunosuppressive medications will help clinicians improve the final outcomes. Glaucoma is a sight-threatening complication in these cases. Manipulation of cicatrized and scarified conjunctiva, extensive use of steroids, and multiple operations are important factors predisposing to glaucoma.
+Surgical management of LSCD depends on the laterality and severity of corneal involvement. Partial LSCD can be managed using amniotic membrane transplantation (AMT) or sequential epitheliectomy. In partial or total unilateral cases, conjunctival-limbal autograft (CLAU) is a good choice. Recently, transplantation of limbal epithelial stem cells cultivated on carriers such as AM or transplantation of ex vivo cultured autologous oral mucosal epithelial cells has been considered as alternative procedures for unilateral or bilateral LSCD.
+The main objective of any kind of stem cell transplantation is to supply new corneal epithelium for a prolonged, if not indefinite, period of time so that patients can be relieved from annoying photophobia and regain useful vision. Cultivation of a small part of the limbus may provide epithelial progenitor cells, which might survive for a while on the ocular surface. In eyes with superficial corneal vascularization and pannus, a single procedure is frequently enough. However, if there is concomitant deep corneal stromal scarring, penetrating or lamellar keratoplasty is needed to restore vision. Drawback to CLAU and conjunctival-limbal allograft (CLAL) is that due to removal of fairly large segments of limbal tissue, the donor eye is at risk of surgically induced LSCD. The use of autologous cultivated limbal stem cell transplantation has been suggested to overcome this limitation. Cultivating a small amount of limbal tissue provides adequate limbal stem cells for treatment of total LSCD.
+Use of AM as a carrier medium for cultivated limbal stem cells entails the following advantages. Its stromal matrix is similar to conjunctival basement membrane and is a suitable medium for growth of limbal stem cells, it is antigen-free and resorbed gradually. AM facilitates ocular surface epithelialization, it down-regulates inflammatory cytokines, facilitates epithelial cell differentiation and may be used for ocular surface reconstruction.
+The use of ex vivo cultured limbal epithelial stem cells for treatment of corneal LSCD in humans was first described by Pellegrini et al in 1997. Since then several additional reports on the use of this technology to treat patients have been published. In addition, other studies have reported the transplantation of ex vivo cultured autologous oral mucosal epithelial cells to treat LSCD. Numerous reviews have dealt with the scientific theory and evidence behind this treatment. In almost all studies, the authors conclude that this method is a successful procedure to treat unilateral corneal stem cell deficiency. Some key questions still need to be answered. The exact proportion of stem cells present in ex vivo cultured limbal epithelial cell sheets is unclear and needs to be determined. The behavior of limbal epithelial stem cells post-transplantation also needs to be elucidated. It has been proposed that the success of this treatment relies on the re-integration of exogenous cultured limbal stem cells into the ocular surface, and that these cells function to continuously replenish the corneal epithelium. It is interesting that despite the different methodologies employed, the success rate and outcomes are remarkably similar.
+The surgeon subsequently performed optical PKP in this case. He selected fresh donor cornea with a very good coverage of epithelial cells; therefore some transient amplifying cells (TACs), which support corneal clarity have been theoretically transferred by the corneal graft. It is not possible to judge whether the cause of corneal clarity is related to TACs transferred by the corneal graft or due to transplanted epithelial progenitor cells cultivated on the AM. However, it seems that the period of corneal clarity was relatively longer than usual corneal grafts without stem cell transplantation.
+In summary, cultivated stem cell transplantation on AM might be an effective way to improve the health of the injured ocular surface. Despite uncertainties, published clinical evidence supports the continued advancement of this procedure for treatment of corneal epithelial stem cell deficiency. To date, this procedure has been regarded as experimental, but in the light of the clinical outcomes, it seems that it has the potential to become a viable option for treatment of many patients with severe limbal stem cell deficiency."
+Cayden Woodward,20,1996/7/14,+1-541-782-3584x804,patrickreynolds@example.net,3876 Jeremiah Light Suite 308,"A 54-year-old woman (PV) was admitted in 2009 to the Stroke Unit of Azienda Ospedaliera Ospedale di Circolo di Busto Arsizio, Saronno, Tradate for recurrent attacks of right temporal migraine followed by a sudden sequence of left hemiparesis, associated with a decreased level of consciousness, dysarthria, vision loss and sensory deficit alternating in limb side. The neurological examination at admission revealed a mild depression and a slight cognitive deficit with a Minimental State Examination Score (MMSE) of 27/30. No cranial nerve deficits, including dysarthria and nystagmus, were detected. A slight left hemiparesis, mild hypotonia in the four limbs and alternating arm deficit in sensation were also observed. Cerebellar tasks showed a bilateral dysmetria pattern at the nose?inger and heel?hin test and inaccuracies were observed in fast alternating hand movements (dysdiadochokinesia). Truncal ataxia and intention tremor were not detected. Stance was achievable without aid although the loss of balance and gait was ataxic, but she was able to walk without help. From early childhood she suffered from migraine with aura with a bi-monthly frequency, mainly characterised by vision loss, sensory deficit in the right limbs and sometimes, left hemiparesis. Aura usually developed over a period of 5 min and lasted less than 60 min. No triggers for symptoms onset or worsening were identified. Biochemistry, inflammatory markers, thyroid hormones, cyanocobalamin dosage and autoantibodies search (anti GAD, anti-glyadin, anti-endomysium, anti neuronal) were negative. ECG, echocardiography and epiaortic and transcranial ultrasound examination were normal too. The brain CT scan performed in the acute phase demonstrated a hypodense round lesion proximal to the left silvian fissure. The cerebral MRI confirmed the left hyperintense round lesion at T2 and FLAIR weighted images, consistent with an old small ischemic infarction and revealed a mild cerebellar atrophy (Fig. ). Electroencephalogram showed unspecific abnormalities on the left hemisphere, consistent with lesional activity. During the hospitalization, the patient? left strength deficit as well as migraine progressively improved whereas cerebellar deficits remained stable. Since the patient did not reported other hemiplegic attacks at 1 year follow-up, no therapy was administered. Familial history was not completely available given the premature death of both parents. One brother had an undocumented mental retardation. However, his neurological examination was negative except for a bradypsychia.
+Given the suspicion of sporadic hemiplegic migraine, a genetic analysis for FHM1 and FHM2 was performed after obtaining informed consent. Sequence analysis of CACNA1A gene revealed the presence of the heterozygous variant c.1748G>A, resulting in the p.Arg583Gln missense substitution in the putative protein, already described in association with hemiplegic migraine and ataxia ()."
+Drew Bailey,39,1995/8/26,-2572,jacksondominique@example.com,98563 Owen Mews Apt. 329,"A 43-year-old Caucasian female patient presented for treatment of facial pain, with complaint of severe episodic pain in right face, ear and neck, first appeared 12 years ago, worsening in the last 3 months, with crisis of sharp and severe pain. The patient was previously diagnosed with sleep bruxism, depression and insomnia.
+Physical examination revealed moderate pain upon palpation of right temporomandibular joint (TMJ), superficial masseter, occipital and sternocleidomastoid muscles. A trigger point was found in right medium masseter muscle referring pain to the ipsilateral ear and TMJ. The maximum mouth opening (MMO) with pain was 39 mm and no other significant signs were detected.
+Masticatory myofascial pain and cervicalgia were the initial diagnosis and treatment consisted of advisement of the condition, counseling to avoid clenching her teeth during the day, hot packets and the nocturnal use of an occlusal stabilization splint in the upper jaw. The patient was also referred to a psychologist, physician and physical therapist for management of depression, insomnia and cervicalgia.
+After 3 months, the patient reported a significant improvement, with no pain upon muscle palpation or function, and the MMO was 46 mm. However, she complained of a paroxysmal, short-duration pain below the right TMJ and in the temporal region, triggered by MMO and mastication. Intraoral and radiographic exams were unremarkable. Extra oral physical examination revealed that the palpation of the right auriculotemporal nerve region elicited a sharp pain familiar to the patient, which extended from below TMJ to the temporal region.
+The hypotheses diagnosis was AN. The auriculotemporal nerve was then blocked with 0.5 ml 2 % lidocaine and 0.5 ml of a suspension containing dexamethasone disodium sulfate (2 mg/ml) and dexamethasone acetate (8 mg/ml) as follows: the needle is inserted below the TMJ, in the posterior margin of the head of the mandible immediately in front of the tragus, to a depth of 1??.2 cm, at a horizontal 45繙 angle in the direction of the nose, with care taken to first perform aspiration in order to avoid intravascular injection [].
+There was full improvement of painful symptoms after a single blockade, with no recurrence after a 12-month follow-up."
+Axel Bowen,42,1997/10/1,(760)915-7053x52920,michael84@example.net,3119 Paul Roads,"This 35-year-old male was admitted 6 years ago to the neurology outpatient clinic of our hospital suffering from left periocular neuralgiform pain for the last 2 months, consisting of paroxysmal attacks of stroke-like sensations, which developed spontaneously or were triggered by innocuous stimuli in facial and intraoral areas. Several seconds after that, he felt a throbbing retro-orbital pain with unilateral autonomic symptoms such as homolateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, and palpebral fissure narrowing. This latter pain lasted less than 3 h, most often 30??0 min, and was successfully treated with subcutaneous sumatriptan injections (6 mg each) and oxygen at a rate of 10 l/min at the emergency room. With the cessation of cluster-type pain, the patient had a pain-free period which ranged from hours, at the beginning of the disease, to days or weeks, after treatment initiation. These bouts (neuralgiform and cluster types) were frequent (2??/day) at regular hours (12:00 to 16:00 h in the daytime; 03:00 to 04:00 at night) before the use of carbamazepine. Carbamazepine, initially scheduled at 600 mg bid, was ineffective, as were non-steroidal anti-inflammatory drugs. Therefore, pregabaline (600 mg bid), clonazepam (6 mg tid), and gabapentine (800 mg bid) were tried in combination and with verapamil (360 mg bid). Some, but unsatisfactory, clinical benefit was achieved with verapamil (360 mg bid), pregabaline (600 mg bid), and carbamazepine (1,400 mg bid). These three drugs combined achieved the best clinical results (one or two cluster-tic bouts every 2 weeks). Nevertheless, three lidocaine endovenous boluses (500 mg/day for five consecutive days) were administered the following year, and thermocoagulation of his left Gasser ganglion was applied three times in the same period. Pain bouts disappeared for weeks after lidocaine boluses, but they relapsed with the same violence. Each of the thermocoagulation procedures was followed by a variable attack-free period, but polytherapy was still needed since attempts at dose-lowering proved useless. Neuralgiform attacks had always been sharp, stabbing pain in the periorbital region, lasting for seconds and always followed by cluster-type pain. After the first thermocoagulation of his left Gasser ganglion, cluster-type pain mostly disappeared. Then bouts of neuralgiform pain were not followed by cluster-type pain. There was no cluster-type pain recorded without the initial, neuralgiform-type pain; bouts always occurred on his left side. Most recently, some months after the third thermocoagulation procedure, neuralgiform bouts are less frequent (1?? per month, lasting a few seconds). Even attempts at treatment simplification have not been useful. Repeated neurological exams were normal for the first 3 years, but generalized hyperreflexia, consisting of generalized brisk deep tendon reflexes and exhaustible clonus on his Achilles tendon, was progressively observed over the last 2 years. At present, other neurological symptoms and signs are absent, but fatigue has been a complaint recorded since beta-interferon was initiated. Cerebrospinal fluid (CSF) routinely performed 2 years after the initial symptoms (a spinal tap was proposed after the first MRI, but patient refused it) was normal, the oligoclonal bands being absent.
+Computed tomography (CT) scan was normal. The first MRI study, performed 2 months after the initial symptoms, showed a T2-weighted hyperintense lesion (Fig. a) in the left trigeminal main sensory nucleus and root inlet, being hypointense (black hole) on T1-weighted image (Fig. b). In a second MRI study, performed 2 years later, eight T2-weighted hyperintense lesions were observed, some of them in the left trigeminal root inlet and main sensory nucleus area (Fig. a), but also in the right side, giving a mirror image of trigeminal root inlets and main sensory nucleus, in the left median pedunculus, and in the left cerebellar hemisphere. All of these lesions were hypointense in gadolinium-enhanced T1-weighted images (Fig. b). In the same MRI study, we observed new MRI lesions (Fig. a, T2-weighted image; Fig. b, FLAIR). 6 months later, a further MRI study showed new, periventricular, and juxtacortical lesions (data not shown). Based on the MRIs a diagnosis of MS was considered, and the patient was treated accordingly.
+The first blink-reflex study, performed 2 months after the initial symptoms, showed an absence of R1 component after stimulation of both supra-orbital nerves, the R2 component being bilaterally normal (Fig. a, b, asterisks. Latencies ranged from 35.4 to 41.0 ms). Trigeminal sensory-evoked potentials showed a delay of cortical latencies after left mandibular nerve stimulation (P20 wave at 38.45 ms; data not shown). Five years later, a new and recent blink-reflex study showed the R1 component absent after left supra-orbital nerve stimulation (Fig. c), but a small and delayed R1 component could be seen after right supra-orbital nerve stimulation (Fig. d, arrow). After treatment with methylprednisolone (MTP 1 g/day for 5 days) pain bouts improved, and their regular pattern changed to random along the day. MTP was used five times throughout his illness. Some weeks after the beginning of BIF-1A (250 mcg/three times a week) injections, pain bouts temporarily disappeared. Carbamazepine was reduced to 600 mg bid and maintained today. In addition, there were normal parameters in the somatosensory evoked potentials studied at both median nerves and both lower limbs."
+Dream Levy,26,2003/8/1,671.405.5583x964,richard82@example.org,276 Natalie Fields Suite 026,"A 51-year-old woman had been healthy and denied head trauma, coffee or alcohol consumption, and contraceptive drug use history. She did not have postpartum headache in the past. However, she had suffered from monthly episodic moderate headaches since age 46 and they always occurred on the first menstrual day. Premonitory symptoms included 1 week of abdominal fullness and poor appetite.
+She always experienced sensory aura as hypoesthesia at her left hand and gradually extended to whole upper limb within 20??0 min. It disappeared also from her hand and then completely remission in another 20??0 min. The whole process did not involve face, trunk, or other limbs. She did not have visual or language auras. After remission of the sensory aura, headache ensued immediately and was described as holocranial, throbbing, and outward expanding in nature. Associated symptoms included photophobia, nausea, and occasional vomiting without phonophobia. Physical activities exacerbated the pain; therefore she was confined to bed. The headache usually lasted for 6 h despite taking 500 mg acetaminophen from local clinic. After the headache, euphoria would occur during the two menstrual days that followed. She denied having isolated aura without headache through her life.
+She began menopause half a year ago, and did not receive hormone replacement therapy. Her headache pattern then changed, with the headache still occurring regularly at intervals of once per month, but each attack lasted only for one-half to 2 h. She no longer experienced aura or premonitory symptoms. The headache remained holocranial, but became a dull pain in nature. Associated symptoms included photophobia rather than phonophobia, nausea or vomiting. Physical activities did not exacerbate her pain, so she could work or ambulate as usual.
+Due to the atypical presentation of MM, she came to visit us and further evaluations were arranged for her. General physical and neurological exams were normal. Electroencephalography, brain magnetic resonance imaging, and conventional angiography showed no abnormality. Blood tests, including anti-nuclear antibodies, were all within normal limits. She fulfilled the diagnostic criteria of PMM with typical sensory aura. As the current headache simply recurred each month and did not affect her much, 500 mg acetaminophen was still recommended for acute symptomatic relief."
+Harold Stark,28,1979/8/1,852.763.2970x50920,kristennewman@example.org,82040 Gardner Lane,"A 50-year-old woman with history of non-small cell lung carcinoma since November 2005, had been receiving chemotherapy with carboplatin, paclitaxel and systemic bevacizumab for 8 months. She was referred on February 2007, due to loss of vision, accompanied with pain and metamorphopsia in her right eye.
+Vision was 20/40 in her right and 20/20 in her left eye. Ophthalmoscopy revealed a subretinal mass, light orange in color approximately four disc diameters in size, temporal and superior to the fovea, without retinal detachment in the right eye (). Ultrasonography demonstrated a choroidal mass 8.8?7.5 mm at its base with maximal elevation of 1.74 mm in the right eye (). Fluorescein angiography showed a mottled pattern in the region of the tumor without leakage ().
+We injected 2.5 mg bevacizumab intravitreally in the right eye of the patient five times over a period of seven months. shows the date of each injection. Pain disappeared after the third injection, metamorphopsia decreased and vision improved to 20/20. Fundus examination revealed regression of the tumor (). On January 2008, a B-scan was performed with special attention to the temporal aspect of the globe and no tumor could be detected; in addition, the choroid was of normal thickness (). The angiogram showed a less hyperfluorescent plaque without leakage ()."
+Kamilah Morris,25,1989/7/16,756-680-3753x2682,mjimenez@example.com,72140 Perry Springs Apt. 316,"A seven-year-old boy presented with marked generalized hypopigmentation, reduced visual acuity, photophobia, and nystagmus (). He had always bruised easily but superficially with minor trauma, without history of internal organ bleeding (). His parents were unrelated, and he had an unaffected brother and sister. Best corrected monocular visual acuity was 20/200 in both eyes. Due to presence of nystagmus, monocular vision was measured by fogging the fellow eye with +6 D overcorrection. Binocular visual acuity was 20/160 when he maintained fusion. Refraction was +10.00-4.00?10簞 in the right and +9.00-4.00?160簞 in the left eye. He had obvious horizontal jerk nystagmus and 50 prism diopters (PD) of intermittent exotropia. His green irides were markedly transilluminable (), both fundi were hypopigmented and foveal hypoplasia was evident. The patient was found to have a platelet storage-pool defect together with prolonged bleeding time and abnormal platelet aggregation studies. His bleeding time was prolonged, however prothrombin time (PT), partial thromboplastin time (PTT) and platelet counts were normal. There was severe platelet release defect with low ADP and increased ATP/ADP ratio. A classic method of platelet aggregometry was performed. In this method, a panel of platelet agonists (collagen, ADP, and ristocetin) at a range of concentrations, triggers platelet activation and is used to detect storage-pool and secretion defects. Von Willebrand factor (vWF) activity was 76%, vWF antigen was 68%, and factor VIII activity was 55% (all values within normal limits). Tyrosinase activity was not measured.
+The patient underwent strabismus surgery considering precautions such as reserving platelet concentrates in case of a hemorrhagic event. A 10 mm recession of both lateral recti was performed. Exotropia was reduced to 35 PD postoperatively. Three months later, a 6 mm resection of both medial rectus muscles was performed. After the second operation, the eyes became nearly orthophoric (). Visual acuity increased to 20/120 and nystagmus was decreased subjectively and objectively. Although intraoperative conjunctival bleeding was more than usual, platelet transfusion was not required. After 18 months, the eyes were nearly orthophoric and the patient was happy with the results."
+Christian Gordon,41,1985/9/13,655.352.9014x020,alejandroparker@example.com,345 Willis Flats,"A 4 year-old girl was referred because of refractory amblyopia in her right eye. Cycloplegic refraction was ??.00??.00?180繙 and +1.00??.50?10繙 in the right and left eyes respectively. Best corrected visual acuity was counting fingers at 4 meters in the right eye and 20/25 in the left eye. There was right esotropia of 20 prism diopters (PD). Slitlamp examination and pupillary light responses were normal. Funduscopic examination was normal in the left eye but showed myelination of the nerve fiber layer superotemporal and inferotemporal to the macula in the right eye. The peripapillary area and the fovea were not involved. The optic disc was hypoplastic and the foveal reflex was dull. Axial length was 26.62 and 22.12 mm in the right and left eyes respectively. Optical coherence tomography (OCT) of the myelinated area revealed increased thickness of the nerve fiber layer (NFL) to nearly 50% of total retinal thickness together with atrophy of underlying retinal layers. Due to disc hypoplasia, a brain and orbital MRI was requested, which was normal."
+Taylor Conrad,18,1989/11/10,(287)805-0015x6927,floresmelanie@example.com,707 Patrick Street,"A 1 year-old girl presented with history of strabismus since birth. Refraction was +1.50??.50?180繙 and ??.00??.00?180繙 in the right and left eyes respectively. On examination, there was left exotropia of about 20 PD, localized posterior lens opacity, extensive myelination of peripapillary and macular nerve fibers, and a fibrovascular stalk arising from the superotemporal vascular arcade to the posterior lens capsule at the site of the opacity. No further investigations were conducted for this subject.
+Different theories have been proposed to explain the pathogenesis of myelinated nerve fibers. It has been suggested that a defect in the lamina cribrosa might allow myelin to be deposited in the retina or adjacent to the optic disc but such a defect has not been demonstrated in autopsied eyes. Another explanation is that heterotopic oligodendrocytes or glial cells within the retina are responsible for abnormal myelination of retinal nerve fibers. This theory has been supported by the presence of glial cells resembling oligodendrocytes which are responsible for normal myelination in the central nervous system.
+Unilateral, and rarely bilateral, retinal myelination may be associated with high axial myopia, deep amblyopia, and strabismus.??Ellis and coworkers reported 6 patients with myelinated NFL, high axial myopia and refractory amblyopia, and evaluated them with particular emphasis on sensory status. The authors suggested that low vision in these patients has an organic etiology in addition to functional amblyopia. They also suggested myelination around the macula to be the most likely cause of poor vision and proposed that glial cells or myelin impede transmission of light through the retina or impulses from the retina to the lateral geniculate body.
+Associations reported with this syndrome include anterior segment abnormalities, congenital cataracts, choroidal and optic disc colobomas, persistent hyaloid membrane or artery, macular pucker, abnormal foveal reflex and macular pigmentary changes, decrease in ganglion cells, epilepsy, dolichocephaly and Von-Recklinghausen disease.??The first case described herein had optic disc hypoplasia and the second patient had localized posterior lens opacity and a fibrovascular stalk attached to the posterior lens capsule at the site of the opacity.
+Although the amblyopia in these patients has been called refractory, it consists of two components; one is the organic defect in the retina which is not treatable, but the other is due to anisometropia which does respond to amblyopia therapy and should therefore be corrected."
+Dilan Ortiz,25,1994/8/2,(998)707-3730x279,alvarezdale@example.net,16384 Hayley Road Suite 681,"A 40 year-old woman was referred to a refractive surgery clinic complaining of blurred vision and photophobia. She had undergone myopic LASIK 8 years ago. There had been no problem one year after surgery with best corrected visual acuity (BCVA) of 20/20 at that time. Her complaints started gradually and progressed thereafter. She had no history of systemic disease including diabetes mellitus and hypertension.
+Upon presentation, BCVA in her right and left eyes were 4/10 and 5/10, with ??.00??.50?180簞 and ??.50??.50?165簞, respectively. On slitlamp examination, the LASIK flap interface was barely visible. Intraocular pressure (IOP) was 14 and 13 mmHg, in the right and left eyes respectively. Funduscopy revealed mild myopic chorioretinal degeneration but was otherwise unremarkable.
+What are the differential diagnoses and what would you suggest for further evaluation?
+Differential diagnoses include the following:
+Post-LASIK progressive keratectasia which most often occurs 6 to 24 months after LASIK. Good BCVA of 20/20 for one year and then its gradual decrease makes this diagnosis probable. At this stage, we are unaware of the preoperative refraction, pachymetry, and topography; thus we have little information about the risk factors for keratectasia. BCVA of 4/10 and 5/10 are in favor of keratectasia. On the other hand, regular with-the-rule astigmatism and the normal slitlamp examination are against such a diagnosis. We need a new topography to evaluate ectasia.
+Cataract formation is another possibility. Cataracts are more common in high myopic patients and are probably seen earlier than normal age-matched persons. The progressive myopia may be due to gradual nuclear sclerosis.
+Considering the presence of high myopia before refractive surgery, the risk of primary open-angle glaucoma is increased. IOPs are underestimated after keratorefractive procedures for myopia. To compensate for erroneous IOP measurements, 1 mmHg should be added to measured IOPs for each 14 to 17 microns of laser ablation. Alternatively, for each diopter of myopic correction, 1 to 1.5 mmHg may be added. In eyes with previous myopic refractive surgery, IOP measurement from the corneal periphery may be more accurate. The dynamic contour (Pascal) tonometer may also be more precise in such cases. The apparently normal appearance of the optic nerve head is against a diagnosis of glaucoma.
+Long-term regression is possible in eyes that have undergone LASIK surgery for high myopia. Predisposing factors include the use of certain types of excimer machines, ablation pattern (broad beam excimers have the highest, while flying spot machines have the lowest risk of regression), optical and transition zone diameters (the lower the diameter, the higher the risk), and patient age (the younger the patient, the higher the risk). In this case with gradual regression over several years, we do not know the initial refraction or the type of the excimer machine. BCVA was 20/20 after surgery, but is not better than 5/10 now. Therefore, the probability of pure regression is low.
+Flap wrinkling and epithelial ingrowth can also decrease visual acuity. Usually, decreased vision due to such factors occurs sooner. Both conditions can be identified on slitlamp examination, which has been normal in this case.
+Based on history and symptoms, the most probable diagnoses are post-LASIK keratectasia, nuclear sclerosis, and post-LASIK regression. If the lens is clear on slitlamp biomicroscopy, I would request the patient? preoperative documents, a new corneal topography, and ultrasonic pachymetry for both eyes.
+Due to good visual acuity in the first postoperative year, gradual decrease in BCVA and gradual regression of myopia and astigmatism, the first and most important differential diagnosis is ectasia. Given her complaints, other diagnoses such as decentered ablation, regression, and corneal irregularity should also be considered. Performing a normalized topography (by changing the scales and color bars) and comparing it with preoperative topographic maps (i.e. difference map) is important. It would also be helpful to request elevation topography."
+Anna McConnell,41,1983/11/2,(965)285-0869,thomasjoshua@example.org,802 Dennis Squares,"A 24-year-old man was referred to our center complaining of bilateral ocular irritation and progressive visual deterioration over the past 4 years. Past ocular history was negative for wearing contact lenses or previous ocular infections and there was no family history of ocular disorders. Previous records revealed no gross ocular abnormalities until 4 years ago. The patient reported pain, redness and swelling in the distal joints of his hands, and had been diagnosed with seropositive rheumatoid arthritis since the age of sixteen. The proximal interphalangial (PIP) and metacarpophalangial (MCP) joints in both hands were principally involved resulting in significant deformity in the fifth fingers (). At presentation, rheumatoid arthritis was well controlled with hydroxychloroquine under observation of a rheumatologist.
+On ophthalmic examination, uncorrected visual acuity (UCVA) was 20/50 bilaterally which improved to 20/20 in both eyes with ??0.25 ??4.25@48 簞 and ??0.75 ??2.00@100 簞 in the right and left eyes respectively. Keratometric readings were 47.00?140, 43.25?50; and 43.00?100, 44.75?10 in the right and left eyes, respectively.
+Slit lamp biomicroscopy revealed normal lid margins without any signs of meibomian gland dysfunction or blepharitis; the tear meniscus and tear break up time were within normal limits. The conjunctiva was slightly injected near the limbus but the sclera was normal. Marked corneal thinning and bulging was noted in the whole periphery of the cornea; this circumferential gutter was 1.5?? millimeters in width with superficial vascularization but had an intact epithelium. Circumferential lipid deposition was detected in front of the leading vascular edge. The central cornea however, was clear and free of lipid deposits and vascularization (). These features were similar to manifestations of Terrien? marginal degeneration.
+In addition to the above-mentioned findings, broad bands and vesicles were present on the corneal endothelial surface. The band-like lesions had parallel scalloped edges which did not taper toward the ends and were more prominent with retroillumination (). The appearance of the lesions was typical for posterior polymorphous corneal dystrophy.
+The anterior chamber was deep and the lens and iris were normal with no sign of current or previous inflammation. Intraocular pressure measured with Goldmann applanation tonometry was 6 and 7 mmHg in the right and left eyes, respectively. Gonioscopy was unremarkable and the angle appeared open. Posterior segment examination was also unremarkable. Ultrasonic pachymetry revealed central and mean peripheral thickness of 450 弮m and 390 弮m respectively in the right cornea. Corresponding values for the left cornea were 506 弮m and 250 弮m. Corneal thickness was most significantly attenuated in the superior corneal periphery."
+London Ortiz,43,1985/7/25,5819866130,ibrown@example.net,065 Donna Lodge Suite 754,"The single eye of a 16-year-old boy with history of scleral buckling and buckle revision developed inferior redetachment approaching the fovea. Pars plana deep vitrectomy with injection of heavy silicone oil (Densiron 68, Fluoron GmbH, Neu-Ulm, Germany) was scheduled for this large, myopic eye which also had a mild posterior subcapsular cataract.
+The procedure included pars plana lensectomy, deep vitrectomy, injection of perfluorocarbon liquid (DK Line; Bausch and Lomb Inc., Waterford, Ireland), endolaser photocoagulation, superior peripheral iridotomy, air-fluid exchange and injection of 10 milliliters of Densiron 68 into the air filled vitreous cavity; all of which were accomplished without complications.
+The retina was reattached after surgery but the postoperative course was complicated by an intense inflammatory response, early emulsification of silicone oil in the first week, and formation of macular pucker. Repeat pars plana vitrectomy along with epiretinal membrane removal and silicone oil injection was performed 4 weeks after the initial vitrectomy. Despite attempting meticulous removal of heavy silicone oil droplets, many remained in the eye and were obviously heavier than water in the early postoperative period, but became lighter with time.
+Two months after silicone oil removal, some droplets were visible in the mid-vitreous cavity, some adhered to the cornea in supine position while others still rested on the retinal surface. Along with these changes, the media became hazy and diffuse iris depigmentation developed together with pigment globules on the iris, and in the anterior chamber and vitreous cavity ().
+With time, increasing droplets were noted floating in the vitreous cavity, hindering fundus visibility and reducing corrected visual acuity from 20/100 to 20/200. Another washout surgery was performed 6 months later. , taken at the time of this operation, demonstrates the large, lighter-than-water silicone oil droplets behind the cornea.
+This surgery was successful in partially clearing the media and returning 20/100 vision to the patient."
+Anna Harris,37,1995/7/21,200.210.2595x9259,alan50@example.org,020 Mark Vista Suite 192,"A 40-year-old myopic female presented with a paracentral scotoma OS of about one week? duration. Her past ocular history revealed high bilateral myopia of 11.75 diopters (D) in the right eye (OD) and 10.0 D in the left eye (OS). She had been operated for rhegmatogenous retinal detachment in her right eye 15 years earlier and 360 degrees circumferential prophylactic argon laser treatment had been performed for both eyes. Two years before the current episode, cataract surgery had been performed followed by Nd:YAG laser capsulotomy in both eyes a few months later. To treat residual astigmatism, an arcuate corneal incision had been performed in the left eye a few months following cataract surgery.
+Upon presentation, best corrected visual acuity (BCVA) was 0.9 and 0.8 in the right and left eyes, respectively. No signs of inflammation were detected in the anterior chambers, but laser flare photometry (LFP) values were slightly elevated; up to 9.5 ph/ms OD and 13.2 ph/ms OS (normal values: 3?? ph/ms). There were no cells visible in the vitreous. Visual field testing using the Octopus Perimeter簧 (Haag-Streit, Bern, Switzerland) showed a peripapillary scotoma OS () and a normal visual field OD. Microperimetry displayed slightly diminished retinal sensitivity OS with a test score of 390/560 versus 414/560 OD.
+Fundus examination showed pale discolored dots around the optic disc and along the superior temporal arcade OS () which corresponded to faintly hyperfluorescent areas on FA (). More precise information on the diseased areas was revealed by ICGA: there was extensive peripapillary hypofluorescence extending inferiorly together with centripetal hypofluorescent dots along the superior temporal arcade (). These areas were precisely delineated by FAF, showing hyper-autofluorescence corresponding to ICGA hypofluorescent areas (). Spectral domain OCT imaging (Heidelberg Instruments, Heidelberg, Germany) clearly showed POSL damage in scans through ICGA hypofluorescent and FAF hyper-autofluorescent areas, which also corresponded to the visual field defect. The whole POSL was damaged on scans through the ICGA hypofluorescent area (), but damage was partial in bordering areas ().
+Four weeks later, discolored lesions were still visible in the fundus (), FA and FAF illustrated a few scattered new lesions ( and ), but on ICGA the hypofluorescence had regressed almost completely and this was related with visual field recovery ( and ; second column from the left).
+Four months later, fundus examination showed scars in areas where lesions had been present, a finding not typical of MEWDS (). These scars were also seen on FA frames in the form of late hyperfluorescent dots () as well as on ICGA frames in the form of hypofluorescent dots (). Along the superior temporal arcade, FA hyperfluorescent areas had disappeared () and on FAF a normal homogeneous aspect was seen ().
+Twelve months after the last follow-up (16 months after the first episode), the patient was seen again for the same subjective scotoma in her left eye accompanied by photopsias. BCVA was 1.0 OD and 0.9 OS. No inflammation was noted in the anterior chamber or in the vitreous. LFP values were 6.0 ph/ms OD and 8.9 ph/ ms OS, showing slight subclinical flare OS. Intraocular pressure was 14 mmHg bilaterally. On fundus examination peripapillary and superior nasal scars were more numerous than 12 months earlier (). Octopus簧 perimetry showed a peripapillary scotoma similar to the one seen during the prior presentation which increased 4 days later (; third and second columns from the right); the microperimetry score declined again to 338/560 as during the first episode. On FA there were less intensely hyperfluorescent zones indicating more atrophic areas than acutely involved retina (). FAF did not show the intense hyper-autofluorescence seen during the first episode (). Only ICGA accounted for the functional impairment recorded by visual field testing and microperimetry, and allowed to identify the involved areas showing hypofluorescence precisely corresponding to the scotoma (). The hypofluorescent ICGA areas also corresponded to POSL damage (). The disease pattern seen with this recurrence clearly corresponded to multifocal choroiditis, therefore a sub-Tenon injection of triamcinolone acetonide (40 mg) was performed considering progression of visual field defects after 4 days and due to the fact that unlike MEWDS, multifocal choroiditis produces scars and carries a high risk of inflammatory choroidal neovascular membranes.
+One month after the sub-Tenon? triamcinolone injection OS, the diffuse peripapillary hypofluorescence recovered on ICGA where only small hypofluorescent dots representing previous chorioretinal scars were still visible () and corresponded to POSL reconstitution () as well as visual field recovery (). In parallel, microperimetry improved from 328/560 to 424/560. Regular follow-up including ICGA was decided for the patient, as occult choriocapillaritis can occur in the absence of any signs except for ICGA hypofluorescence."
+Samuel Armstrong,34,1978/3/9,(906)591-1514,hlevine@example.net,540 English Throughway,"A 92-year-old man presented with complaints of low back pain. He had magnetic resonance imaging of the spine performed which incidentally revealed a mass in the left kidney. A CT scan confirmed this finding, demonstrating a 6 cm solid enhancing mass in the left kidney, in addition to multiple bilateral lung nodules and lesions in the spine worrisome for metastatic disease. He was presumed to have metastatic renal cell carcinoma and underwent a radical nephrectomy.
+Dissection of the radical nephrectomy specimen revealed a solitary tumor measuring 7.4 ? 5.8 ? 3.5 cm, which was well circumscribed, tan-brown, and confined to the kidney. Microscopic examination of the renal tumor revealed areas typical of an oncocytoma with an archipelaginous architectural pattern near the center of the tumor (). In addition to the oncocytic cells, a second population of cells arranged in small groups containing high nuclear/cytoplasmic ratios, nuclear hyperchromasia, occasional prominent nucleoli, and rare mitoses were noted (). The nests were restricted to the oncocytic neoplasm and were not present in several additional sections from the surrounding grossly unremarkable renal parenchyma. The second population of cells was strongly positive for PSA, PAP, cytokeratin (AE1/AE3), and EMA, confirming the diagnosis of prostatic adenocarcinoma metastatic to renal oncocytoma. The pathologic diagnosis led to testing for serum PSA (>500 ng/mL), and the subsequent prostate needle biopsy demonstrated a high-grade prostatic adenocarcinoma with a Gleason score of 9 (4 + 5) that was morphologically similar to the metastatic deposits within the renal oncocytoma."
+Presley Mills,18,1982/6/27,001-650-637-1476,toddtimothy@example.net,894 Simpson Valleys Apt. 663,"The patient is a 49-year-old Caucasian male that initially presented with a three-to-four month history of unilateral tonsillar swelling. Computer tomography of the neck revealed bilateral tonsillar enlargement, right greater than left, with a right internal jugular chain lymph node measuring 1.5 cm by 1.5 cm. The patient underwent a bilateral tonsillectomy without complications. Pathology of the left tonsil was benign, but the right tonsil contained a 2.4 cm, poorly differentiated, squamous cell carcinoma. The remainder of his staging work-up was negative, and he was staged with T2N1M0, Stage III invasive squamous cell carcinoma of the right tonsil.
+Combined modality therapy with concurrent cisplatin chemotherapy and daily radiation therapy was initiated. The tumor bed and ipsilateral neck were treated with 200 centi-Gray (cGy) fractions to 7,000 cGy, while the contralateral neck received 170 cGy fractions to 5,600 cGy. The cisplatin therapy was administered at a dose of 100 mg per meter squared on days one, twenty-two and forty-three of his six weeks of radiation. The patient was able to complete his treatment as prescribed without the need for a treatment break. He developed grade II erythema within the radiation field on bilateral necks, dysgeusia, xerostomia, and mucositis symptoms but otherwise did well.
+Following completion of his treatment, the patient was able to return to work and displayed regular improvement during his scheduled follow-up visits. The erythema that developed during his treatment had completely resolved and the patient regularly reported feeling well. Approximately nine months after his last radiation or chemotherapy treatment, the patient reported to the clinic for routine followup. He noted a twenty-four hour history of a tender, hot, confluent rash on his right neck that began at his clavicle and extended superiorly to the mandibular angle (Figures and ). He reported an oral temperature of 102 F; his temperature in the clinic was 101.2 F. He also experienced some myalgias and arthralgias but denied constitutional symptoms of nausea, vomiting, weight loss, drenching night sweats, and fatigue. He denied any respiratory symptoms, cough, hemoptysis, or bone pain. The patient had received no interval chemotherapy and had not started any new medications since his last visit. Radiation recall dermatitis was suspected in this patient given the distribution of the rash and presenting symptoms. Due to the warmth of the tissue and the fever, there was some concern for cellulitis as well, which prompted treatment with doxycycline. The patient was seen several months after this clinical encounter for routine followup and reported that his rash resolved in the five to six days following the initial presentation. He continued to report experiencing xerostomia and dysgeusia; he denied any recurrence of his rash."
+Alex Rogers,32,1988/8/2,877.984.7022x24272,kaylee50@example.com,0646 Jessica Course,"A 67-year-old man underwent low anterior resection with para-aortic lymphadenectomy for advanced rectal cancer. Neither neoadjuvant radiotherapy nor chemotherapy was performed. Early postoperative course was uneventful and the patient was discharged from hospital 10 days after the surgery. After discharge, however, abdominal distension developed and rapidly deteriorated. On the routine outpatient visit planned 21 days after surgery, the patient suffered from a severe sense of abdominal fullness and remarkable abdominal distension was noted with 92 cm of abdominal girth measured at the umbilicus. An emergency abdominal computed tomography (CT) scan proved that abdominal distension was caused by massive ascites (Fig. ). Urgent diagnostic paracentesis showed that the ascites was a white milky fluid containing high levels of triglycerides (546 mg/dl), leading to a diagnosis of massive chylous ascites. Simultaneous laboratory findings showed severe hypoproteinemia (total protein 4.5 g/dl, albumin 2.1 g/dl) and lymphopenia (white cell count 3000/弮l, lymphocyte count 150/弮l). However, neither abdominal pain nor other signs suggestive of infection were found. Based on sporadic evidence that TPN with or without octreotide was reported to be effective for eradicating chyloperitoneum occurring after abdominal surgery [?, emergency admission was offered to the patient but rejected due to social reasons. Therefore, an oral fat-free ED (30 kcal/kg/day of Elental簧, Ajinomoto Pharmaceutical Co. Ltd, Tokyo, Japan) was initiated. Elental簧 was given orally two or three times a day. Oral intake was strictly restricted to Elental簧, water, and sugar/milk-free beverage. The patient was seen weekly in the outpatient clinic. After the initiation of oral Elental簧, abdominal distension gradually improved. Most notably, the sense of abdominal fullness dramatically abated a few days after starting Elental簧. His abdominal girth decreased to 82 cm and an abdominal CT scan showed no ascitic fluid in the abdomen 42 days after surgery. At that time, hypoproteinemia and lymphopenia improved (total protein 7.2 g/dl, albumin 4.2 g/dl, white cell count 6300/弮l, lymphocyte count 2010/弮l). Accordingly, the ED was totally replaced by a normal diet the following day, after which no abdominal distension was noted. As a result, the chylous ascites was successfully treated in the outpatient clinic. Six months after rectal surgery, the patient underwent partial hepatectomy (S8 segmentectomy) for liver metastasis originating from the rectal cancer. At that time, no ascitic fluid was seen in the abdomen. The patient is doing well without evidence of cancer recurrence or chyloperitoneum at 18 months after the initial rectal surgery (Fig. )."
+Madelyn Morris,45,2004/9/12,292.850.6796x2282,john37@example.net,7528 Garcia Ways Apt. 676,"A 48-year-old gentleman presented to the emergency department with a six-hour history of confusion and dysphasia. He was a smoker of five cigars a day and consumed 40 units of alcohol per week. His past medical history was notable for an episode of pancreatitis. His son had type 1 diabetes mellitus; family history was, otherwise, unremarkable.
+His wife described two discrete episodes of bizarre behaviour in the year prior to his current admission. She reported behaviour such as shaking salt into his tea and mixing up various household utensils. The first of these episodes lasted three days and was associated with ataxia. The second, six months later, was associated with an expressive dysphasia. Investigations at that time included routine bloods, ANA, ANCA, CT brain, MRI brain, and EEG, all of which were normal. A lumbar puncture during the second episode yielded CSF with normal cytology but an elevated protein of 1 g. His work colleagues also reported some intermittent unusual behaviour and subtle personality changes in recent months. His clinical condition improved spontaneously on both of these occasions and a presumptive diagnosis of transient ischaemic attacks was made.
+When reviewed in the emergency department on this occasion, he was agitated. Vital signs were normal. He had an expressive dysphasia and appeared disorientated and confused scoring 26/30 on the minimental state score (MMSE). Cranial and peripheral nerve examinations were normal, as was fundoscopy. There was no meningism. Cardiorespiratory and abdominal examinations were normal. Initial investigations revealed normal full blood count, inflammatory markers, electrolytes, and renal function. Liver function tests, alpha-feto protein, and ammonia levels were normal. CK was mildly elevated at 211. CT brain and MRI brain using a 1.5 Tesla machine were normal. CSF analysis revealed an elevated protein of 0.81 with normal cytology and glucose. EEG revealed intermixed theta activity. Over the following days, he developed myoclonus, a marked startle reflex, diffuse rigidity, hyperreflexia, and a fine tremor. He also developed generalised seizures.
+Further laboratory tests including VDRL, TPHA, ANCA, anti-GBM, heavy metal screen, antineuronal antibodies, red cell transketolase, brucella, mycoplasma, and lyme serology were all normal. Autoimmune screen and haematinics including vitamin B12 levels were likewise normal.
+Thyroid function showed T4 10.3 and TSH 9.97 with markedly elevated anti-thyroid peroxidase antibodies at 25600 and normal antithyroglobulin antibodies. A diagnosis of Hashimoto's encephalopathy was made and high-dose steroids initiated. Within days, there was marked clinical improvement with full resolution of confusion and myoclonus. He was discharged well several days later on high-dose oral prednisolone. This was gradually reduced over six months, without relapse. One year after this hospital admission, routine thyroid function tests revealed overt hypothyroidism with T4 of 7.4 and TSH of 51. At this point, thyroxine replacement was introduced."
+Christian Alvarez,44,1999/3/27,-7434,wramos@example.net,8669 Kane Valleys Apt. 473,"A 20-year-old African male, who recently emigrated from Ghana, presented to the medical emergency room with complaints of abdominal pain and nausea for nearly 2 weeks. The patient stated that approximately 2 weeks ago he began noticing dull, intermittent, midepigastric pain which was neither alleviated nor aggravated by any factors. He also admitted having nausea over the past 10 days, and admitted having a 20-pound unintentional weight loss over the past 6 months. He denied any vomiting, hematemesis, melena, fever, chills, night sweats, and cough. The patient stated that he had previously been in good health and denied the use of any medications. He denied the use of illicit drugs, alcohol, and tobacco and had never participated in any sexual activity. Family history was noncontributory, including the absence of malignancy, or gastrointestinal disorders. Prior to his arrival in the United States 4 weeks ago, purified protein derivative (PPD) testing for tuberculosis yielded an induration of less than 1 centimeter (cm).
+Physical examination was remarkable for mild midepigastric tenderness without guarding or rigidity. Liver transaminases and total bilirubin were within normal range; however there was an increased alkaline phosphatase noted to be 200 U/L. Amylase and lipase levels were also within normal range. Chest X-ray performed was negative for any cardiopulmonary process, and lung fields were noted to be clear. Computed tomography (CT) of the abdomen performed revealed a complex cystic mass with thick-walled irregular septations in head of the pancreas and extending into the porta hepatis, suspicious for a cystic pancreatic neoplasm (). Also noted was another complex cystic lesion with an internal septation in the splenic porta lying between the tail of the pancreas and the spleen ().
+Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) of the pancreatic head mass was performed. Sonographically, there was a 3 cm irregular mass within the head of the pancreas extending into the porta hepatis. On-site cytologic and histopathologic evaluation of the biopsy specimen revealed the presence of lymphohistiocytic aggregates suggestive of granulomatous inflammation with no evidence of malignancy (). Although smears for acid fast bacilli were negative, a culture of the specimen obtained was remarkable for Mycobacterium tuberculosis.
+Given the diagnosis of pancreatic TB, testing for human immunodeficiency virus, a repeat PPD and interferon-帠 release assay for TB were performed; all yielding negative results. The patient was started on antituberculin therapy with isoniazid, rifampin, pyrazinamide, and ethambutol. The patient reported improvement of symptoms after 3 months of therapy. Repeat imaging of the abdomen performed 3 months after the initiation of antituberculin therapy revealed complete resolution of the two pancreatic masses, and antituberculin therapy was discontinued after a 6-month duration."
+Leilani Bartlett,32,2002/8/1,(683)501-0649,ykramer@example.org,2844 Darrell Track,"A previously healthy 7-year-old Caucasian female presented with a 10-day history of lethargy, fever, sore throat, and cough associated with abdominal pain, vomiting, and dark colored urine. Mild periorbital edema was accompanied by abnormal urinalysis results (protein [3+], blood [3+]). Results of investigations included the following values: serum urea nitrogen, 50.1 mg/dL (17.9 mmol/L); creatinine, 0.98 mg/dL (87 弮mol/L); hemoglobin, 10.9 g/dL (109 g/L); C-reactive protein, 77 mg/L; C3, 0.36 mg/mL (0.36 g/L; reference range, 0.75-1.65); C4, 0.29 mg/mL (0.29 g/L; reference range, 0.11-0.43); and urine protein-creatinine ratio, 5,221 mg/g. Both serum anti-streptolysin O (>200 U/mL) and anti-DNase antibody titers (360 U/mL) were elevated. Kidney ultrasound showed 8.3-cm kidneys with loss of corticomedullary differentiation.
+The patient improved after treatment with phenoxymethylpenicillin, although proteinuria and microscopic hematuria persisted. Four months later, she developed macroscopic hematuria after an upper respiratory tract infection.
+Nine months after presentation, kidney biopsy showed mesangial hypercellularity, segmental endocapillary hypercellularity, and segmental capillary wall double contours on light microscopy. Immunoperoxidase staining showed marked granular capillary wall and mesangial C3, C9, and CFHR5 deposition (A). Glomerular C1q and immunoglobulins were absent. On electron microscopy, glomerular basement membranes appeared thickened, with segmental duplication of the basement membrane and mesangial cell interposition. There were intramembranous electron-dense deposits with occasional subendothelial deposits, as well as scattered hump-like subepithelial deposits. Mesangial deposits were absent. Angiotensin receptor blockade reduced urinary protein loss and kidney function remained normal.
+Twenty months after presentation, a second kidney biopsy (A) showed persistent membranoproliferative glomerulonephritis with tubulointerstitial scarring involving ??0% of the cortex. Electron microscopy showed intramembranous electron-dense deposits and some mesangial deposits. The findings in both biopsies are consistent with C3 glomerulopathy with a membranoproliferative pattern of glomerulonephritis. Proteinuria improved with glucocorticoid therapy. Since the onset of disease, circulating C3 levels have remained low (B). She has not developed ocular drusen or lipodystrophy. C3NeF has been consistently undetectable and anti-factor H autoantibodies have not been detected.
+To determine whether there was any other serum factor enhancing C3 activation, we added purified C3 (0.5% solution; Merck, ) to serum from the index case and compared its hemolytic activity at 2 and 4 hours with that of C3-deficient human serum reconstituted with purified C3 in an identical fashion. Hemolytic activity at 2 (60% vs 57%) and 4 hours (43% vs 47%) did not differ between the test and control sera, indicating that there was no evidence of accelerated serum C3 conversion in serum of the index case.
+We performed screening for the known genetic causes of alternative pathway dysregulation. No coding mutations were detected in the complement genes CD46, complement factor H (CFH), factor B, factor I, and C3. No copy number variation within the CFH-CFHR gene locus was seen using a multiplex ligation-dependent probe amplification assay. CFHR5 gene sequencing revealed a single heterozygous nucleotide duplication in exon 4 (c.485dupA) which generates a reading frameshift at amino acid 163 and a premature stop codon at amino acid position 197 (p.Glu163Argfs*34). This variant was not detected by sequencing of 198 ethnically matched DNA samples (obtained from the UK Blood Services Collection of Common Controls) and was not present in dbSNP (, accessed October 2011). The healthy mother (I-2) and sister (II-1), but not the 2 other siblings examined (II-2 and II-4), were heterozygous for this sequence variant (C). The complement profile of the kindred is shown in . Serum CFHR5 levels in unaffected members with the gene variant were within the range seen in healthy controls (3.4-10.1 弮g/mL). However, serum CFHR5 level was decreased in the index case (2.1 弮g/mL). Notably, serum CFHR5 levels also were found to be decreased in individuals with biopsy-proven C3 glomerulonephritis (D)."
+Kace Nelson,33,1990/2/28,644-624-3715x245,tparker@example.net,467 Lynch Locks,"An 81-year-old woman with dyspnoea, tachypnea, stridor, tachycardia, one week history of progressively increasing degree of breathlessness, and a 4-year history of anterior-lateral neck swelling came to our unit. Oxygen therapy was immediately set up, and an urgent CT scan of the neck (Figure ) showed a huge multinodular goiter with retrosternal extension, producing left displacement of the trachea and its marked narrowing in laterolateral diameter. Because of rapidly worsening respiratory distress, an awake fiberoptic intubation using a small endotracheal tube, followed by induction of general anesthesia and emergency total thyroidectomy by manubriotomy were performed (Figure ). Intraoperative surgical dissection helped by loupe magnification [] revealed a mass adherent to the right common carotid artery and extending into the upper mediastinum. It also confirmed the marked left displacement of the trachea and permitted bilateral parathyroid gland and recurrent laryngeal nerve identification. Recovery showed a successfully treated atrial fibrillation and dysphonia due to a left vocal cord palsy confirmed by laryngoscopy. The patient was discharged 7 days after the operation. Microscopic examination revealed a H羹rthle cell carcinoma. Transient recurrent laryngeal nerve palsy was successfully treated by logotherapy over a period of four months. The patient currently shows a five-year disease-free follow up."
+Everly Bennett,30,1989/11/28,001-604-848-4895x6332,pattonbrittany@example.org,993 Gomez Track,"A 59-years-old woman with a large and mainly right-sided cervical mass (Figure ) came to us with severe dyspnoea, stridor and visible use of accessory respiratory muscles, and cyanosis. Computed tomography scan was performed after an awake fiberoptic intubation followed by induction of general anesthesia, revealing a thyroid mass extending into the upper mediastinum, with displacement and compression of the right jugular vein and carotid artery on the lateral side and of the trachea on the medial one, with an apparent adherence to the superior vena cava and left innominate vein. Emergency surgery was performed. At operation, performed by sternal split, the lumen of the trachea seemed to be almost completely shut by the compression of the mass, and the lower portion of this retrosternal goitre projected into the left innominate vein, with tumor floating into the lumen (Figures , ). Removal of the neoplastic thrombus through an incision in the vein was performed en bloc with the thyroid mass (Figure ). Both tumor and thrombus were completely replaced by follicular carcinoma. Recovery was uneventful and the patient was discharged ten days after the operation. After four years, and after radioiodine therapy and chemotherapy, the patient is still in follow-up without recurrence or evidence of metastases."
+Leonardo Corona,18,2004/7/25,443-500-9609x8958,huffmansherry@example.com,38555 Carlson Extensions Suite 315,"A 73-year-old man was admitted in emergency with a neck mass, sudden dyspnoea, stridor, dysphonia, and progressively worsening dysphagia. A history of multinodular goitre was noted in addition to a previous right radical nephrectomy for non-metastatic renal cell carcinoma 8 years before. The patient underwent fine-needle aspiration consistent with multinodular goitre 5 months before. Three days before admission the patient underwent a total-body CT scan showing a thyroid mass with substernal extension involving and completely obstructing the upper airways, the right vocal cord, with right jugular vein and carotid artery compression and displacement, in addition to diffuse lymphadenopathy (Figure ). Physical examination revealed a large, painful, diffuse, and predominantly rightsided thyroid swelling. A flexible laryngoscopy revealed right vocal cord palsy and left cord paresis, with an almost total reduction of the laryngeal lumen. For these reasons, emergency endotracheal intubation was performed followed by total thyroidectomy with lymph node dissection (Figure ). The operation was completed by a tracheotomy, considering the evident tracheomalacia (Figure ). Histology revealed a poorly differentiated trabecular carcinoma, consisting of mainly clear cells with scanty oxyphil ones, with large nucleolated nuclei and frequent mitoses. Immunostains with alkaline phosphatase-anti-alkaline phosphatase showed strong and diffuse membrane positivity for CD10 antigen. These patterns were consistent with a renal cell primary carcinoma. The patient had an uneventful postoperative course and was discharged 10 days after the operation. Palliative chemotherapy was started, but the disease progressed and he died 7 months after surgery."
+Marianna Frazier,38,2005/3/5,7322449256,danielsims@example.net,34442 Moore Point,"A 42-year-old woman with a previous history of no symptomatic multinodular goiter was evaluated for an emergency at our surgical department for acute, progressive dyspnea and intermittent inspiratory stridor, associated with a spontaneous and rapidly enlarging mass of the neck. Clinical examination revealed a large, firm, nonfluctuant thyroid swelling on the right side of the neck. Initial analyses of arterial blood gas, complete blood cell count, electrolyte levels, prothrombin and bleeding times, and thyroid function tests were normal. An urgent computerized tomography scan showed a hematoma within the right lobe of the thyroid, with substernal extension, and tracheal deviation with marked luminal narrowing (Figure ). The rapid progression of respiratory distress meant performing endotracheal intubation by flexible laryngoscopy revealing normal vocal cord function and an emergency total thyroidectomy. During the operation, the thyroid gland revealed a huge, edematous, nonfluctuant, rubbery, firm swelling with easy bleeding on touch, but the capsule appeared to be intact without rupture (Figure ). Microscopic examination revealed a colloid multinodular goiter with massive parenchymal hemorrhage. Recovery was uneventful, and the patient was discharged 2 days after the operation."
+Callum Valenzuela,36,1990/5/24,8508044095,qkemp@example.com,26834 Jerry Parkway Apt. 840,"An 81-year-old man with a forty-year history of substernal multinodular goiter was admitted in emergency with dysphonia and intermittent, sudden dyspnoea, and stridor. A flexible laryngoscopy revealed right vocal cord palsy, with a nearly total reduction of the laryngeal lumen, and a CT scan confirmed the compression of the trachea by a cervicomediastinal goitre. An emergency endotracheal intubation was performed followed by total thyroidectomy by manubriotomy. The thyroid gland appeared wooden in consistency, strongly adherent to the trachea, and to the pre-thyroid muscles, without signs of infiltrations, caudally extending up to the left Innominate vein (Figure ). The patient was discharged seven days after the operation without postoperative complications. Histology revealed a medullary carcinoma completely replacing the right lobe mass. A follow-up of four months showed a normal calcitonin haematic level."
+Henley Guevara,45,1993/11/19,+1-300-205-5279x28301,fcastro@example.com,9928 Joseph Lights Suite 776,"A 68-year-old woman was referred to our department in February 2008 for a second opinion regarding a metastatic urothelial carcinoma. Her history began six months prior to her visit when she presented with recurrent urinary tract infections. A cystoscopy and TUR revealed a high grade infiltrating urothelial carcinoma in the lateral right wall of the bladder (T2a). Staging CT scans were performed and showed metastatic disease mediastinal and hiliar lymph nodes, multiple and bilateral lung nodules, and metastases located in the internal iliac lymph nodes. The patient was initially treated with six cycles of chemotherapy with gemcitabine 1200 mg/m2 on day 1 and 60 mg/m2 cisplatin on days 1 and 8 every 21 days, showing a partial response after three cycles. The disease was followed up until January 2009, when imaging studies demonstrated the presence of a single metastatic lesion in the left lower lung lobe. A second line of chemotherapy using carboplatin AUC = 3 on day 1 and 1500 mg/m2 gemcitabine on day 1 every 15 days was initiated, and after eight cycles, new progression of the described lung lesion was documented. A third line of chemotherapy was proposed, and in June 2009, the patient was started on cisplatin 60 mg/m2 and pemetrexed 500 mg/m2 day 1 every 28 days. She had a partial response after two cycles, and after four cycles of chemotherapy, a slight increase in the size of the left lower lung nodule was revealed on the CT scan, although a bone scan was negative.
+With the diagnosis of a recurrence of a single lung metastatic nodule measuring 56 ? 53 ? 51 millimeters, in October 2009, a hypo-fractionated course of SBRT was delivered to the lung nodule. This patient was placed in a supine position and was immobilized using an alpha cradle device to improve the reproducibility of the setup during daily treatments. A planning CT scan was performed. A combination of three sets of CT scans obtained during free breathing, deep inspiration and deep expiration were used to generate an internal target volume (ITV) that accounts for respiratory motion. The gross tumor volume (GTV) was the lung nodule, and the clinical target volume (CTV) included the ITV with a symmetric 0.5 cm margin. Respiratory tumor movement was observed under fluoroscopy. The delimited organs at risk (OARS) and the applied constraints are listed in Figure .
+A 3D-conformal multifield technique was used with six coplanar and one non-coplanar statics beams. SBRT was delivered by a linear accelerator (Oncor, Siemens, Palo Alto, California, USA) with 6-MV photons. A total dose of 48 Gy in three fractions over six days was prescribed to the 95% of the CTV (Figure ). Patient positioning and isocenter verification were checked using cone beam CT."
+Tommy Duran,24,1998/11/13,(699)770-4999,kenneth43@example.org,7005 Deborah Isle Suite 802,"Case 1: A 60-year-old male was admitted with melena and diagnosed with differentiated-type MGC with liver metastasis and local lymph node metastasis. He was classified as level 1 and treated with S-1 plus CDDP combination for four cycles. CR was confirmed radiologically () and endoscopically. Two years later, he was informed of local lymphadenopathy but declined surgery. CR was reacquired after an additional two cycles of S-1 plus CDDP. In this case, strictly scheduled chemotherapy provided a maximum anti-tumor effect."
+Willa Moss,26,2004/2/26,-8205,seanbender@example.org,797 Eddie Garden Suite 700,"Case 2: A 70-year-old male diagnosed with differentiated-type MGC with massive liver metastasis was treated with S-1 plus CDDP combination for two cycles. Following radiological confirmation of PD, he was treated with four cycles of S-1 plus CPT-11, on the basis that even when one S-1 combination therapy is evaluated as PD, another might be effective. We therefore selected the next S-1 combination in accordance with the program for this patient, and he finally achieved partial response (PR) ()."
+Porter Carroll,45,1986/10/2,362.778.7327,christienguyen@example.org,34992 Ward Orchard Suite 555,"Case 3: A 82 year old female presented with anorexia and anemia. She had undifferentiated-type MGC and her condition was classified as level 2. She was given a blood transfusion and treatment was started with S-1 alone on November 5, 2004. She died from liver metastasis, while pathological CR was found by stomach dissection. Because she refused further chemotherapy, we stopped giving S-1 on May 9, 2005. Her tumor markers increased markedly after we stopped S-1 treatment, suggesting that S-1 should have been effective for controlling this case (). We propose that S-1 should be given continuously, unless it is toxic."
+Zara Strong,33,1991/9/6,(738)772-4149,scottbrenda@example.org,04473 Joel Summit Apt. 075,"A 36-year-old normotensive Caucasian woman was admitted to our nephrology department one year after a non-selective glomerular proteinuria of 2.1 g/day, leukocyturia (10/弮L), and microhematuria were diagnosed. Comorbidity included allergic asthma, obesity with a body mass index of 46.9 kg/m2, and gastroesophageal reflux disease. Standard laboratory tests showed normoglycemia, glomerular hyperfiltration (creatinine clearance of 157 mL/minute), and an elevated leukocyte count (12,600 cells per microliter). Erythrocyte sedimentation rate was repeatedly found to be elevated (40/43 mm/hour). Except for a borderline anti-nuclear antibody titer (1:40) and smooth muscle antibody titer (1:80), the results of laboratory vasculitis screening were negative. On serological examination, active HIV or hepatitis (A, B, or C) infections were ruled out. Serum protein electrophoresis showed prominent alpha 1 (9.3%) and alpha 2 (13.2%) fractions and a double peak of the beta fraction. FibGN was established by typical electron microscopy findings in the renal biopsy (Figure ). Upon diagnosis, an angiotensin-converting enzyme (ACE) inhibitor, diuretics, and a protein-restricted diet were initiated.
+Six months after the diagnosis of FibGN, prednisolone (60 mg/day tapered off to 10 mg every other day) was added temporarily. However, proteinuria (2.5 g/day) did not improve.
+Thirteen months later, nephrotic syndrome (proteinuria of 6.3 g/day) occurred after a respiratory infection. Estimated glomerular filtration rate (eGFR) [] was 108.6 mL/minute per 1.73 m2. Both leukocyturia and microscopic hematuria deteriorated. Anti-nuclear antibody titer was 1:160, and leukocytosis (13,300 cells per microliter) persisted. Complement C3 and C4 were within normal range, and cryoglobulinemia was ruled out. Both plasma and urinary protein immunofixations were unremarkable. Abdominal ultrasound, gynecologic, pulmologic, and urologic exams yielded normal results. Cardiac workup, including echocardiography and electrocardiography (ECG), was unrevealing except for an incomplete right bundle branch block and intraventricular conductance abnormalities in ECG leads II and aVF. A second renal biopsy confirmed FibGN. The prednisolone dose was temporarily increased (60 mg/day for three months and tapered off to 5 mg every other day) and had to be discontinued after five more months because of side effects consistent with iatrogenic Cushing's syndrome (for example, weight gain, glucose intolerance, mood changes, and typical fat distribution). After discontinuation of steroids, proteinuria remained below 3 g/day for three years. However, over the course of a total of five years without immunosuppressive therapy, proteinuria worsened (4.8 g/day) and eGFR decreased to 64 mL/minute per 1.73 m2.
+Six years after the diagnosis of FibGN, nephrotic syndrome recurred (proteinuria of 16.5 g/day) during a respiratory infection. Both steroid therapy (pulse and tapering off over the course of four weeks) and mycophenolate mofetil therapy (2 g/day for three months) were applied. During these therapies, proteinuria leveled off at 2 g/day whereas renal function remained impaired, indicative of chronic kidney disease: KDIGO (Kidney Disease: Improving Global Outcomes) stage III (eGFR of 50 mL/minute per 1.73 m2). Eight years after disease onset, our patient was readmitted for nephrotic syndrome (proteinuria of 20.8 g/day). Albumin/creatinine ratio (ACR) was 3.99 g/g. An aggravated arterial hypertension was addressed by switching the ACE inhibitor to a combination of the angiotensin receptor blocker valsartan and the direct renin antagonist aliskiren. In addition, our patient received rituximab (375 mg/m2) weekly for four weeks. In follow-up exams, proteinuria leveled off at 7 g/day (ACR of 2.98 g/g) whereas eGFR decreased to 32 mL/minute per 1.73 m2.
+One year later (or nine years after disease onset), our patient complained of fatigue. The results of ECG and transthoracic echocardiography remained unchanged, thereby rendering a cardiac involvement [] unlikely. Given the persisting gross proteinuria of 7 g/day, plasmapheresis was chosen as salvage therapy to decrease a putative plasma factor contributing to FibGN. Three cycles of five to seven plasmapheresis sessions each were performed during three hospital stays within nine months. During each session, 3 L of plasma or 71% of estimated plasma volume was replaced by a 5% human albumin solution. The treatment was well tolerated. Coagulation tests and immunoglobulin G checks were performed regularly. After the first cycle, proteinuria decreased from 7 to 2.2 g/day. After the second one, proteinuria decreased to 1.2 g/day. Finally, after the third cycle, proteinuria was below 1 g/day, indicating that nephrotic syndrome was in remission (Figure ). Likewise, ACR decreased from 3.3 g/g before the onset of plasmapheresis therapy to less than 0.2 g/g after three cycles of plasmapheresis. Renal function remained impaired (eGFR of 23 mL/minute per 1.73 m2) once steady state was reached. Leukocyturia decreased from 140 to 7/弮L and hematuria improved from 666 to 24 erythrocytes/弮L after three cycles of plasmapheresis.
+To maintain nephrotic syndrome remission, plasmapheresis sessions were scheduled to be performed every three months. In the maintenance phase, two intermittent plasmapheresis sessions were actually performed. However, the last one had to be interrupted after 45 minutes because of an allergic reaction to albumin in the exchange fluid. Thus, allergy prophylaxis will be considered in upcoming plasmapheresis sessions guided by proteinuria.
+Ten months after induction plasmapheresis therapy (or 10 years after the onset of FibGN), remission of nephrotic syndrome prevailed. Residual proteinuria (0.2 g/day) and creatinine clearance (31.7 mL/minute, KDIGO stage III) remained stable. Figure displays the course of serum creatinine and serum albumin. Following onset of plasmapheresis, our patient made a considerable recoveryin terms of quality of life, she resumed a part-time employment."
+Axl Kramer,34,1979/7/13,(318)366-5549x42592,smithheather@example.net,1172 Clark Springs,"A 50-year-old male was admitted to the hospital, with gradual onset of pain and swelling in the right shoulder since 4 days. He denied fever, chills, or rigors. His past medical history was significant for hypertension and intravenous drug abuse. His last use of heroin was 2 months ago with an unsterilized needle contaminated by saliva, in the right arm. Physical examination revealed limited range of motion of right shoulder secondary to pain. Radiograph of the right shoulder was suggestive of osteomyelitis. A computed topographic scan of the shoulder revealed multifocal, intraarticular abscess formation involving the right upper extremity. It also showed erosion of the humeral head and the glenohumeral joint, consistent with septic arthritis (). Arthrocentesis was done, and the cell count of the synovial fluid showed white blood cell count of 9.4 ? 109/L (90% neutrophils, 1% bands). Cultures of the synovial fluid grew Ewingella americana. The antimicrobial susceptibility test carried out by disk diffusion method showed susceptibility to amikacin, ampicillin, cefazolin, gentamicin, piperacillin tazobactam, tobramycin, and trimethoprim sulfamethoxazole while was resistant to ciprofloxacin.
+The patient was started on ceftriaxone 2 gm intravenous every 24 hours. He continued to improve and was discharged home to complete 6 weeks of intravenous antibiotic therapy. He was followed 4 weeks later in the outpatient clinic and showed resolution of infection which was confirmed both clinically and by imaging. The antibiotic course was completed with no complications."
+Hanna Brooks,31,1994/5/4,(437)348-3003,odonnellalison@example.net,94051 Myers Track Suite 517,"A four-year-old previously healthy girl presented with two months of abdominal pain and ten days of jaundice and acholic stools. There was no recent weight loss, no nausea or vomiting, fever, or change in mental status. There was no history of recent travel or trauma. There is no family history of pancreatic tumors in the past. The patients' mother had been exposed to radiation from Chernobyl in the former Soviet Union in 1989 and suffers from an unknown thyroid ailment. The mother takes no medication for her thyroid and has not had any surgery for a thyroid disorder.
+On physical examination the child was jaundiced and had a palpable mass in the right upper quadrant that was nontender. The rest of her physical exam was unremarkable. Her laboratory results were remarkable for elevated direct bilirubin, LDH, GGTP, and alkaline phosphatase. Her alpha-fetoprotein, CEA and CA-125, were normal, her CA19-9 was elevated (see ). All of her blood counts were within normal limits as were her coagulation tests. Fasting blood glucose analysis was normal on multiple tests.
+A CT scan revealed a 3 cm suspicious area in the head of the pancreas with dilatation of both the pancreatic and common bile ducts (Figures and ). The gallbladder was markedly distended as were the intra-hepatic biliary radicles. A CT of the chest was negative/normal. Endoscopic ultrasound (PentaxFG38) revealed a well-circumscribed 3 cm lesion. FNA biopsy was performed (), and the results were consistent with a low-grade malignant epithelial tumor, most likely a nonfunctioning pancreatic neuroendocrine tumor, based on positive synaptophysin and chromogranin stains.
+At laparotomy a large tumor in the head of the pancreas was palpated. In addition, several peripancreatic lymph nodes appeared grossly enlarged. A nonpylorus sparing Whipple procedure was performed including removal of the peripancreatic lymph nodes. The final pathology of the sample was a well-differentiated, non-functioning neuroendocrine carcinoma with 3 out of 12 lymph nodes sampled positive for tumor. There was no extension into the surrounding tissues or duodenum.
+The patient had an uneventful postoperative recovery, tolerated a regular diet on postoperative day 5, and was discharged on the 9th postoperative day.
+Pediatric oncologic consultation chose the ?ait and see??approach, with no postoperative adjuvant therapy being administered. 18 months later, the child is apparently healthy, growing well, and with no current signs of disease."
+Jordan Mullen,19,1986/7/29,332.494.8909x91238,rachel66@example.com,54752 Brett Lake,"A 27-year-old third gravida, one infant death, one living child who were born vaginally presented to us at 32 weeks gestation with history of gradual abdominal distension and vague pain abdomen since one month. On examination, blood pressure was 130/80 mm Hg, abdomen was overdistended upto xiphisternum, fetal parts were not palpable, and fetal heart sounds could not be localized. She was neither diabetic nor anemic.
+Ultrasound showed a single live fetus corresponding to 32 weeks of gestation with polyhydramnios (AFI: 28 cm). Normal amniotic fluid index ranges from 8 to 20 cm. There were no gross structural abnormalities. Placenta was on the anterior wall upper segment, grade II. A well-defined echogenic mass measuring 11.5 cm ? 12 cm different from the rest of the placenta was seen bulging on the fetal side (). Patient went into spontaneous preterm labor and delivered female baby weighing 1.6 Kg with Apgar scores 9 and 10 at 1 and 5 minutes, respectively. Placenta weighed 2 Kg. A lobular mass measuring 12 cm ? 12 cm was attached to the fetal surface of placenta with a pedicle (). Baby died of DIC on 3rd postnatal day. Histopathology of placenta was angiomatous pattern of chorioangioma ()."
+Shay Rosales,35,1998/9/20,4053199720,michaelthomas@example.org,66466 Daniels Ports Suite 402,"A 21-years-old unmarried nulliparous female presented with complaints of something coming out of vagina for 8 years associated with discharge per vaginum. Menstruation was normal. There were no urinary or bowel complaints, chronic cough, constipation, heavy weight lifting, and no family history of similar problem. General physical and systemic examination including nervous system and vertebral column examination were unremarkable. Local genital examination revealed third-degree cervical descent manifesting as a cystic swelling protruding through the introitus. External os was compressed and deviated to one side due to swelling (). Swelling was cystic and reducible. The pelvic examination revealed a normal-sized uterus and bilateral adnexa. Ultrasound showed a normal-sized uterus with normal myometrial echotexture and unremarkable endometrium with a 4.7 ? 1.8 cm anechoic cyst in cervical region.
+Patient was planned for cystectomy and sling surgery. A large 4 ? 5 cm cyst filled with white mucinous substance was removed from the cervix which was 35 grams in weight (). After the cystectomy the cervical descent became second degree, so the sling surgery was postponed, and patient was asked to come for follow-up after 6 weeks, at which time, first-degree cervical descent was noted. Histopathology examination showed cyst wall lined with cuboidal epithelium suggestive of Nabothian cyst."
+Wilder Houston,29,1991/8/2,(261)681-4712x085,jennifer36@example.com,260 Guzman Lane,"A two-year-old girl was referred to the Urology Department for the management of vesicoureteral reflux (VUR). She had initially had a urinary tract infection (UTI) before presentation at the age of two, when right hydronephrosis and VUR on the ipsilateral side (Grade IV) were noted. She was the offspring of nonconsanguineous parents and was a twin, born at 29 weeks' gestation, weighing 2,069 g. Antenatal ultrasound had not exhibited any abnormalities, and at birth she had no deformities of the limbs or anus. There was no significant past history. Her mother was not diabetic.
+On examination, she was active and alert, in satisfactory general health, and had passed normal mental milestones. She had a normal lower region and buttocks, no natal cleft, and no dimples at the hips and knees. Equinovarus deformity was slightly present, but had not been identified on previous medical checkups. She was able to walk and move her lower limbs, had sensations in the lower limbs and perineum, and had normal tendon refluxes, including the anocutaneous reflex. She had no anal stenosis or deformity. She had no constant urine leakage, but had urine dribble during emptying; however, her parents had failed to recognize this as abnormal. Other systems were clinically normal.
+Urinalysis showed pyuria without bacteria. Ultrasound revealed bilateral hydronephrosis of grade III by The Society for Fetal Urology guidelines. X-ray and CT of the lower region showed the absence of the sacral bone under S2 and distal lumbar vertebrae. The limb bones were not hypoplastic. On MRI T1- and T2-weighted sagittal images of the lumbosacral spine showed partial agenesis of the sacrum, a truncated cord and filum terminale (). A cystogram taken at another hospital showed a trabeculated bladder with fairly poor capacity and with grade IV reflux (). Urodynamic study showed sphincter-detrusor dyssynergia (DSD) with maximum bladder pressure of 80 cmH2O (). The maximum bladder capacity was 170 mL with no leakage. DMSA showed renal scarring on both kidneys, suggesting kidney damage, which was thought to have been caused by the neuropathic bladder and VUR. The diagnosis of caudal regression syndrome was made, and clean intermittent catheterization (CIC) by her parent was started."
+Lylah Sampson,23,1980/7/14,001-676-942-6348x05020,hamiltonthomas@example.net,7915 Williams Locks Suite 895,"A 54-year-old woman was referred for upper endoscopy for dysphagia. She had a history of esophagectomy with coloplasty for stenosis due to corrosive injuries 5 years ago. Physical examination was normal and laboratory results were within normal limits. Upper endoscopy showed an anastomotic esophageal-colonic stricture with a big diverticulum on the coloplasty. At this moment, our patient receives antibiotherapy for urinary infection. Three days later, there was no diverticulum and the colocolic anastomosis was without abnormalities at colonoscopy, but an erythematous and edematous bulging polypoid lesion () with purulent discharging from appendiceal orifice into the coecum () appeared. These endoscopic features were strongly suggestive of appendicitis. Antibiotherapy was stopped and laboratory results showed mild leucocytosis. The abdominal computed tomography findings were a tumefied appendix with local infiltration and a blade liquid (). Therefore, the case was referred to surgery. Surgeons conclude that there was no emergency given the normality of physical examination and laboratory results being within normal limits. Two weeks later, we performed a colonoscopic second look, the same feature of bulging polypoid lesion into the cecal lumen was found but without purulent discharging this time. To drain the pus, the appendiceal orifice was intubated and abundantly irrigated with saline solution using ERCP endoscopic retrograde cholangio-pancreatography catheter resulting in residual pus flowing (). Three months later, our patient remains asymptomatic."
+Cain Leblanc,26,1995/8/31,495.216.0335,ndavis@example.net,0948 Jason Ranch,"A 42-year-old G7P1051 presented at 39 weeks estimated gestational age for a scheduled elective repeat low transverse cesarean section with bilateral tubal ligation. Two years earlier, she had undergone a low transverse cesarean section for arrest of descent. Following that delivery, she had an episode of moderate dyspnea that spontaneously resolved without evaluation or treatment. Her medical and surgical history was otherwise unremarkable. During the current pregnancy, her antenatal course was complicated by class A1 gestational diabetes mellitus treated with diet.
+On the day of her cesarean delivery, her vital signs and physical exam were normal, and her hemoglobin was 12.6 gm/dl. Her surgical procedures were unremarkable and the estimated blood loss was 600 mL.
+Approximately twelve hours after delivery, the patient experienced the sudden onset of dyspnea. Initially, she had no other symptoms such as chest pain, cough, palpitations, or calf pain. On physical examination, she had moderate respiratory distress with tachypnea (RR 24/min) and tachycardia (HR 107 bpm). The patient's pulmonary exam revealed tachypnea with use of accessory muscles, shallow breaths, and coarse crackles bilaterally at the bases. The cardiovascular exam demonstrated tachycardia with regular rhythm and a diastolic murmur was appreciated. No S3 or S4 heart sounds were noted at the time. The patient required oxygen supplementation via nasal cannula at 2 liters per minute to maintain saturation at > than 95%. Laboratory work was sent and her hemoglobin was reassuring at 12.0 gm/dl.
+Several hours later, the patient continued to experience dyspnea with an increased demand for supplemental oxygen, requiring a high flow face mask at 10 liters per minute. Vital sign abnormalities progressed to a more concerning state of respiratory distress as her heart rate increased to over 115 bpm and her respiratory rate to > 26/min. A diagnosis of pulmonary embolism (PE) was considered and a spiral CT was ordered. The preliminary read of the CT scan demonstrated small bibasilar pleural effusions with extensive parenchymal airspace disease and multifocal areas of patchy, bilateral consolidation with relative sparing of the periphery in the upper lobes, consistent with underlying infection, hemorrhage, evolving ARDS, or progressive pulmonary edema. No evidence of a PE was noted on the preliminary reading.
+Over the next three hours, the severity of her tachycardia and tachypnea increased (HR > 120 bpm and RR > 28/min). She developed orthopnea and hemoptysis suggestive of heart failure. Administration of intravenous furosemide resulted in partial resolution of her symptoms. Cardiac echocardiogram was obtained for a tentative diagnosis of postpartum cardiomyopathy. However, rather than an enlarged heart, the echocardiogram revealed a large left atrial mass obstructing the mitral valve and resulting in functional mitral stenosis.
+The patient underwent an emergent thoracotomy approximately 48 hours after her cesarean delivery. A 5 cm, intracardiac tumor consistent with an atrial myxoma was found adherent to the inferolateral left atrium and the annulus of the mitral valve. The tumor was completely resected and sent for pathological examination. Microscopic analysis revealed a benign atrial myxoma.
+The patient was transferred to SICU postoperatively in stable condition and was monitored closely. Over the next two days, despite the patient being initially extubated and clinically stable, the patient's condition deteriorated and she developed signs of cardiogenic shock. A transesophageal echocardiogram revealed evidence of severe aortic insufficiency and the patient was emergently taken back to the operating room 48 hours after her initial cardiac surgery.
+At the time of her second open heart surgery, she was found to have disruption of the noncoronary posterior cusp of the aortic valve which had separated from its base at the aortic root likely secondary to aggressive resection of the myxoma during the initial surgery resulting in severe aortic insufficiency. The patient underwent aortic root replacement with the insertion of a bioprosthetic aortic valve.
+After surgery, the patient required initial hemodynamic support with an intra-aortic balloon pump and pressors. After a slow recovery, she was discharged to home twenty days following her second cardiac surgery. The patient did well at home requiring 20 mg of furosemide and 81 mg of aspirin daily as her only medications. At two months, a follow-up echocardiogram showed no signs of heart failure or aortic insufficiency with an estimated ejection fraction measuring 60%??5%. The patient has resumed all physical activity at the level prior to her cardiac procedures and has no long term sequelae."
+Novalee Watkins,27,1979/12/20,(972)437-3843x287,kevinlevy@example.com,63357 David Radial,"A 40-year-old Polish male with no significant medical history presented to the emergency room with complaints of dysphagia and weight loss for nearly 3 months. The patient began noticing difficulty in swallowing liquids, eventually progressing to dysphagia for both liquids and solids over the last several weeks. He described the dysphagia as difficulty passing a food bolus through his lower esophagus and denied any difficulty initiating a swallow. The patient also noticed an unintentional weight loss of nearly 30 pounds over the past 3 months. He denied any nausea, vomiting, abdominal pain, melena, hematemesis, fevers, or chills. The patient denied the use of any medications, illicit drugs, alcohol, or tobacco. Family history was noncontributory, including the absence of any malignancy, gastrointestinal, or neurologic disorders.
+Physical examination was remarkable for pallor and mild midepigastric tenderness without guarding or rigidity. Digital rectal examination did not reveal any mass lesions or evidence of gross bleeding. Laboratory evaluation was significant for hemoglobin of 8.9 gm/dL with hematocrit of 27%. Liver transaminases were within normal range; however, there was an increased alkaline phosphatase noted to be 205 U/L.
+The patient was admitted to the medical ward where he underwent an esophagogastroduodenoscopy (EGD). EGD revealed a large, ulcerated, fungating gastric cardia mass with overlying exudates suspicious for neoplasm (). Several biopsies were obtained which confirmed the presence of a moderately differentiated gastric adenocarcinoma (). Computed tomography (CT) of the head, thorax, abdomen, and pelvis was remarkable for a 9.15 cm ? 7.96 cm soft tissue mass within the cardia of the stomach involving the gastroesophageal junction and along the lesser curvature. Also noted was extension of the mass into the liver parenchyma suggestive of local tumor invasion (). There was no evidence of invasion to any other organs or distant metastases.
+Given the size and extension of the gastric mass, the patient was deemed a poor surgical candidate. After an oncology evaluation, patient underwent chemoradiation therapy with paclitaxel and carboplatin. The patient was discharged and continued to follow with the oncology service for further chemoradiation therapy.
+The patient returned to the medical emergency room 2 months later after the abrupt onset of large volume hematemesis. Emergent EGD revealed the invading gastric mass was unchanged from previous endoscopic evaluation 2 months prior. Also observed was the presence of blood clots in the fundus, with no evidence of active bleeding. Repeat CT of the abdomen was suggestive of increasing tumor invasion into the liver parenchyma compared to previous imaging done prior to chemoradiation therapy. The patient refused further diagnostic and therapeutic measures. His hospitalization was complicated by repeated massive hematemesis and multiple organ failure leading to his eventual death on hospital day 6."
+Nash Holloway,20,1994/5/6,205.302.0799x448,mbrown@example.org,12313 Davis Ranch,"In this paper we describe the case of a 25-year-old woman with 38 weeks of gestation and a symptomatic tumor of the lower abdominal wall. We supposed the tumor to be a scar endometriosis as the patient had a previous caesarian section and the tumor was located 2 cm cranial to the scar. Therefore, a preoperative diagnostic cytology has not been performed. The presurgical examination showed a dense and painful mass with a diameter of 3-4 cm. Ultrasound revealed a subfascial, intramuscular localization. The tumor did not disturb the uterus and the pregnancy. As a caesarian section has been planned, we decided to resect the tumor within the surgery. After successful child delivery and closure of the uterine tissue and the peritoneum, we found a dense, incompressible, grey tumor in the right rectus sheath with a local infiltration of the rectus muscle. A local complete resection with a macroscopically tumor-free margin was performed. The tumor size of not more than 3 cm allowed the resection without any functional limitations. A mesh reconstruction was not necessary. Surprisingly, an aggressive musculoaponeurotic fibromatosis was found in the histologic examination. The patient recovered without any complications or functional defects. We recommended clinical and sonographic controls of the tumor location. Since 2 years after surgical intervention, the patient is recurrence-free."
+Mae Corona,25,1988/4/26,+1-524-534-7944x03508,zfisher@example.net,94141 Rich Parkway,"A 20-year-old male from Mexico with no significant past medical history presented with 3 months of left facial swelling and pain associated with fevers, night sweats, unintentional weight loss, myalgias, and arthralgias.
+He had been evaluated and treated multiple times by the emergency department, an inner city hospital, and an outpatient dentist with several different antibiotic regimens, narcotic pain control, oral steroids, and drainage catheter placement for a presumed dental abscess. His symptoms improved slightly with these interventions but recurred after the completion of each course of treatment. After his fifth admission at an outside hospital, he was transferred to our university hospital for evaluation of fever of unknown origin and workup of presumed sepsis.
+He denied visual changes, symptoms of upper or lower respiratory infection, chest pain or palpitations, nausea, vomiting, diarrhea, hematochezia, dysuria, exposure to animals or insects, sick contacts, recent travel, or high-risk behaviors for substance abuse or sexually transmitted infections. He had received all of his immunizations as a child in Mexico. He denied family history of any illnesses.
+Upon transfer and admission to our institution, his vital signs were within normal limits: temperature of 98簞F, heart rate of 69 beats per minute, blood pressure of 112/72, respiratory rate of 12 breaths per minute, and oxygen saturation of 92% on room air. On exam, he was noted to have nonmobile and tender left mandibular swelling. His eye exam showed red scleral injection without exudate and a grey-brown ring around the irises. Neck exam revealed posterior left cervical lymphadenopathy that was hard, fixed, and painful. The remainder of the HEENT exam was unremarkable. Lungs were clear to auscultation bilaterally, and the cardiovascular exam was within normal limits. The abdomen was soft, nontender, and nondistended. Pulses were 2+ bilaterally, and the neurological exam was nonfocal.
+Initial laboratory evaluation was notable for hyponatremia (Na 133 mmol/L, NL 135??45 mmol/L), anemia (hemoglobin 9.5 g/dL, NL 14.0??8.0 g/dL; hematocrit 30%, NL 40.0??2.0%), leukopenia (WBC 2.0 ? 109/L, NL 4.0??0.0 ? 109/L), hypertriglyceridemia (284 mg/dL, NL 30??50 mg/dL), and transaminitis (ALT 206 U/L, NL 0??4 U/L; AST 102 U/L, NL 0??4 U/L). Infectious disease evaluation on admission included multiple blood and urine cultures that were negative. A chest X-ray and computed tomography (CT) imaging of the chest showed multiple bilateral pulmonary nodules of uncertain etiology as well as a right lower lobe consolidation, paratracheal, mediastinal, and left hilar nodes, and left axillary edema. CT of the abdomen and pelvis showed bilateral pyelonephritis with enlarged spleen, and a CT maxillofacial scan demonstrated inflammatory changes of the face without evidence of abscess ().
+The patient was started on broad-spectrum antibiotics, stress-dose steroids, and IV fluids, which resulted in hemodynamic stability but persistent fevers. Repeat infectious disease workup, including blood, urine, sputum, and fecal cultures, HIV testing, PPD, VDRL, transthoracic echocardiography, and soft tissue biopsy of the left mandible, was unremarkable.
+A more thorough laboratory investigation was initiated. Abnormalities included elevated LDH (1102 U/L, NL 118??32 U/L), ferritin (13,500 ng/mL, NL 18??70 ng/mL), C-reactive protein (64.6 mg/L, NL 0.1??.9 mg/L), and erythrocyte sedimentation rate (54 mm/hr, NL 0??0 mm/hr). Repeat CT scan revealed bilateral pleural effusions, numerous pulmonary nodules, and axillary, subpectoral, and retroperitoneal fat stranding (). A PET scan demonstrated several hypermetabolic lesions involving musculature and fat stranding throughout the body, most likely related to a systemic infectious or inflammatory process.
+A liver biopsy was suggestive of drug reaction. Lung nodule biopsy showed normal tissue in the lesions and no evidence of infection or malignancy. Left mandibular soft tissue biopsy showed necrosis and acute inflammation, but no evidence of infection or malignancy. Finally, bone marrow biopsy revealed extensive macrophage hemophagocytosis, pathognomonic for hemophagocytic syndrome ().
+The patient was recognized to have HPS and started on IVIG and high-dose IV dexamethasone before transitioning to a slow prednisone taper and cyclosporine. An extensive search for an underlying rheumatic (ANA, ds DNA, anti-MPO, anti-PR3, RF and CCF antibodies, c-ANCA, and p-ANCA) and malignant etiology (flow cytometry, T-cell receptor rearrangement study, bone marrow, soft tissue, and lung biopsies, PET scan) was unrevealing. No evidence of malignancy was evident on any of the bone marrow or soft tissue biopsy specimens. As a result, a working diagnosis of infection-associated hemophagocytic syndrome with an unknown primary infection was pursued. However, an exhaustive infectious disease workup (including viral hepatitis, EBV, Parvovirus, HSV, CMV, HHV-6, Coccidioides, Trichinella, leishmaniasis, Cryptococcus, Aspergillus, histoplasmosis, and acid-fast Bacilli) was negative.
+Despite appropriate treatment for HPS, the patient deteriorated and eventually expired from a massive GI bleed. On autopsy, he was found to have occult anaplastic large-cell lymphoma (ALCL; stage IV) involving lung, stomach, lower GI tract, mesenteric lymph nodes, and spleen."
+Darian Farmer,44,1984/3/8,804.873.7359,layala@example.net,52557 Christopher Spring,"A 41-year-old Caucasian female presented with a 2-day history of abdominal distention and generalized pain that was worsened with motion. These symptoms were accompanied by nausea, several episodes of nonbilious vomiting, and poor appetite. Her last bowel movement had been a week prior to admission. Her past medical history was significant for type 2 diabetes and vulvar lichen sclerosis, which was being treated with steroids since its diagnosis one year prior. She had a 15-pack-year history of tobacco use, as well as a distant history of intravenous heroin abuse with subsequent long-term dependence on methadone maintenance at 180 mg.
+Vital signs were noted as temperature 98.7簞F, blood pressure 121/68 mmHg, pulse 101 bpm, and respiratory rate 24. Physical examination revealed diffuse abdominal tenderness with maximal pain on the left side, as well as rebound tenderness, guarding, and hypoactive bowel sounds. A rectal exam revealed no masses, empty ampulla, and hemoccult negative stool. Laboratory studies revealed a white blood cell count of 22,200/mL with bandemia, glucose at 267 mg/dL, and lactic acid elevated at 4.7 mmol/L. Other laboratory values were all normal. A CT scan of the abdomen and pelvis with PO contrast revealed multiple foci of extraluminal air in the peritoneum, a large amount of fecal material in the colon, and extravasation of oral contrast consistent with perforation of the colon (Figures and ).
+The patient was promptly taken to the operating room for an exploratory laparotomy with a provisional diagnosis of bowel perforation with peritonitis. She was found to have a large perforation in the sigmoid colon measuring approximately 8??0 cm. The remainder of the bowel was proximally dilated and filled with hard dry fecal material, with its widest point measuring 19 cm in circumference with a very thin bowel wall. Extensive purulent material with fibrinous exudates into the small and large bowel, as well as multiple large fecaliths of varying size in the peritoneal cavity, was found. Initially, an attempt was made to salvage part of the colon by pursuing a left hemicolectomy, but further exploration revealed extensive serosal hemorrhage of the transverse colon, which prompted the decision to pursue a subtotal colectomy with end ileostomy ().
+Pathological examination of the resected colon revealed multiple ischemic mucosal ulcers consistent with sterocoral perforation. The margins of the perforation showed transmural necrosis with acute necroinflammatory changes. No other pathologies like infarction, inflammatory bowel disease, or tumors were found so fecalomas were attributed as the cause of serosal hemorrhage and colonic inflammation.
+The postoperative course was complicated by sepsis, mechanical ventilation dependence, and adult respiratory distress syndrome. She made a slow but satisfactory recovery and was subsequently discharged from the hospital 3 weeks afterwards. She returned 7 months later for reversal of ileostomy with an ileorectal anastomosis."
+Madelynn Stephens,28,1994/1/13,981.477.6428x2835,tmalone@example.com,75062 Ronald Roads,"A 52-year-old man, without any past medical illness, presented with a 12-month history of progressive proptosis of the right eye. Physical examination revealed a decreased right visual acuity, inferior displacement of the globe, severe conjunctival chemosis, and reduced corneal sensitivity (). No abnormality of the left eye was detected. An incisional biopsy was performed at a different institution, and the pathology report demonstrated a fusocellular neoplasm with hemangiopericytoma pattern, also compatible with monophasic synovial sarcoma. Computed tomography (CT) and magnetic resonance imaging (MRI) scans revealed a well-defined right intrasonic mass, measuring 5.3 ? 4.6 ? 3.6 cm, with ocular globe displacement but without involvement of the temporal fossa (). Upon admission, the patient had a Karnofsky score of 90% and was classified as grade zero according to the status of the Eastern Cooperative Oncology Group (ECOG).
+Based on this diagnosis, a right lateral orbital exenteration with excision of the mass by a craniofacial approach was performed. We found a mass that measured 7 ? 8 cm with sphenoidal fissure obliteration and destruction of the roof and lateral wall of the orbit. Based on these findings, the lesion was resected, and we performed an orbital roof plasty with cyanoacrylate (). There were no postoperative complications. Definitive histopathological examination revealed a mesenchymal chondrosarcoma located in the orbital soft tissue, with temporal muscle and zygomatic bone infiltration and a 5 mm bone margin. The posterior edge of the ocular globe, the globe itself, and the optic nerve did not show evidence of the neoplasm ().
+The patient was advised adjuvant chemotherapy and radiotherapy. He received a total of 66 Gy of external radiotherapy to the temporozygomatic region, showing no signs of toxicity or infection. He is currently on a regimen of vincristine, adriamycin, and cyclophosphamide alternating with ifosfamide and etoposide (VAC/IE), which is used in the treatment of patients with Ewing's Sarcoma. Currently, the patient is alive and without evidence of disease."
+Messiah Galvan,37,1983/1/4,(836)478-7340x421,qgarcia@example.com,615 Gabriela Mission,"A 49-year-old Iranian male with a history of IHD and arterial hypertension (AH) was admitted at the Emergency Ward of Vase?e Hospital, Sabzevar, Iran. The chief complaint of the patient was red eye and left eye bleeding since a day earlier (). The patient lived in a village. A neighbouring general physician at the nearest health centre (the first line of examination) referred the patient to the Vase?e Hospital for controlling blood hypertension and treating the eye bleeding. The general physician? diagnosis was eye bleeding due to AH. At hospital (the second line of examination), the on-duty general physician at the screening clinic admitted the patient with the detected diagnosis. Then, the on-call cardiologist (the third line of examination) requested a non urgent consult for evaluating the source of eye bleeding. On eye examination, visual acuity of both eyes was 20/20, both eyes had pterygium; and a dark mobile foreign body compatible with a blood-engorged live leech in the lower fornix of the left eye was detected, associated with visible bleeding (). The leech was removed after instillation of 0.5% tetracaine eye drops via forceps. After the removal, bleeding stopped immediately. Upon history taking, the patient disclosed that he had washed hands and faces the other day with water from an open water container without watching for its content. Later on, a parasitological examination identified the foreign body most probably as a Limnatis nilotica species."
+Dallas Hinton,24,1995/8/3,+1-761-472-8596x822,katie10@example.com,57195 Brandy Cliff Apt. 726,"Case 1 is a 63 years old male patient, under follow up in our hospital, with a grade IV glioblastoma (determined by histopathology) in the right temporal lobe. As it can be observed in , at the time of diagnosis the tumor is located very close to the cortex. This corresponds with a higher probability of seizures, symptom that led this patient to a first medical consultation. Patient-specific analysis of this glioma determined that it was characterized by a net proliferation rate of 0.107 cells/day and a net diffusion (migration) rate of 0.255 in white matter. Corresponding tumor mass velocity and invisibility index were 120.8 mm/year and 2.38 , respectively. Considering the range of values reported for high grade gliomas (velocities of 10 to 200 mm/year and invisibility index of 2 to 20 
+), those values meant that this tumor had a relatively intermediate growth velocity and low invisibility index. These parameters describe a relatively ?enign??tumor in relation with the glioblastoma spectrum. In correspondence with (but independently from) this prediction, this was a relatively rare case that was left without surgical intervention up to five months from diagnosis.
+Simulation of case 1 in a ?irtual patient??began with the localization of an initial unique tumor cell in the white matter of the superior temporal gyrus. Malignization of the tumor was predicted around 152 days (five months) after its onset and diagnosis after 267 days (nine months). The whole simulation of this case can be observed in the File Case S1 video submitted as a supporting information file. shows the real and simulated tumor at the diagnosis time for different tumor views. In simulated images ( and 1(e)), the central white area represents the concentrated tumor mass while the black surrounding area indicates tumor infiltration, with low concentration of tumor cells invading normal brain tissue.
+A good correlation between real and simulated radios of the tumor mass can be observed (8.9 vs. 9.7 mm, respectively). When the simulated image is generated with the same detection level as the MRI technique (around 400 cells/
+), there is also a fairly good correlation between real and simulated infiltrative areas (compare with 1(d), axial view). Simulated infiltrative areas detected at 1 cell/, nevertheless, indicate that they would be underestimated by current diagnostic imaging. This is something also reported by others and it is related to one of the main potential clinical utilities of this type of models.
+presents the tumor mass and infiltration 20 days after diagnosis time. At this time, real and simulated tumor mass radios are 12.1 and 12.2 , respectively. Simulated infiltrative areas also correlate well with those derived from real images when generated at the same detection level (see , axial view), but a higher level of detection indicates again that this area may be larger than that evidenced by real MRI images. These two moments (diagnosis time and 20 days after) were used to estimate the main parameters of the model (net proliferation and diffusion rates) in a patient-specific way. Tumor evolution to the next time stage (40 days after diagnosis) was then predicted by the model.
+shows the predicted tumor-mass and infiltrative areas 40 days after diagnosis, over different slices from the axial plane, given a better overview of the 3D tumor evolution. A good correspondence can be observed between real and simulated images generated at a detection level of 400 cells/mm
+2 (compare first with second row of images). Here, tumor mass radii are 14.8 and 15.8 mm, respectively. Again, a higher detection level of 1 cell/ indicates larger invasion than that observed by MRI real images (third row). These results indicate a fairly good prediction accomplished by the numerical model.
+superimposes the predicted tumor mass at different times upon the Talairach atlas, indicating the main brain structures that are being affected by tumor evolution. At diagnosis time (270 days from tumor onset, ), tumor mass affects 8.2% of the Brodmann area 41 and 12.6% of the Brodmann area 42 (references 2 and 3, respectively). These areas belong to the primary auditory cortex (Heschl? gyrus). Related main functions are basic processing of auditory stimuli (speech and non-speech) , and processing of sound intensity , .
+50 days after diagnosis (320 days from tumor onset, ), the tumor mass invades great part of transverse and superior gyrus of the temporal lobe (references 1 and 6, respectively) and 10.9% of the Brodmann area 22 (reference 4). If the dominant cerebral hemisphere were the right one, this area would be part of the Wernicke? area, fully related to auditory comprehension of language . If it was not, as in the majority of cases, this area would have also roles related with receptive language but in a subordinated way, leading to a bilateral dissociation design . This seems to be the case with functions related to lexical ambiguity resolution, where left and right Wernicke? areas function as processors of dominant and subordinated meanings of ambiguous words, respectively.
+100 days after diagnosis (370 days from tumor onset, ), the tumor has expanded to the pre-central gyrus of the frontal lobe (10) and up to the right lateral ventricle (7). It also affected 21.4% of the Brodmann area 43 (9), 10.7% of the Brodmann area 13 (8) and 3.3% of the Brodmann area 39 (5). Brodmann area 43 is associated with some motor responses to vibrotactile digit stimulation and to spoken language . Brodmann area 13 belongs to the insular cortex, that is reported to participate in somatosensory , olfaction and taste , and verbal memory functions , among others. Finally, Brodmann area 39 is also part of the Wernicke? area or its contralateral homologous. In the right hemisphere, it is generally associated to visuospatial processing and music reading . predicts that, at the time of death (survival time of 140 days after diagnosis or 410 days from tumor onset), the tumor mass has extended through the insula (11), lentiform nucleus (12) and thalamus (13).
+presents tumor status at the predicted time of death. The estimated tumor mass diameter (assuming an spherical shape) at this moment is 62.9 mm, a value slightly smaller than the lethal size parameter used (70 mm, see ). This might be attributed to the corrections added to the model in relation with tumor location. Indeed, at this time the tumor mass edge reaches the ?oramen magnum?? as is evidenced by the Talairach atlas in . This means that herniation, and consequently death, could be imminent."
+Frankie Pitts,24,1985/3/25,+1-663-430-1063x916,moorejeremy@example.com,45595 Hatfield Trafficway,"Case 2 is a 32 years old male with a histopathology of anaplastic oligodendroglioma (grade III) reported in previous literature . The whole simulation of this case can be observed in the File Case S2 video submitted as a supporting information file. compares simulations of this case at different times made with two distinct mathematical models: left column corresponds to simulations obtained with the present model, right column corresponds to simulations derived from our implementation of a model previously described in the literature (this model does not include differential migration based on topological brain structures). This figure should be compared with from that shows the real MRI images from this patient. Real tumor dimensions correspond well with those predicted by the present model. At diagnosis, real and simulated tumor mass radii are 8.9 and 8.7 mm; while tumor infiltration radii are 28.4 and 28.9 mm, respectively (compare from with axial view from ). Eighteen days after diagnosis, real and simulated tumor mass radii are 11.4 and 10.6 mm; and tumor infiltration radii are 33.1 and 31.2 mm, respectively (compare from with axial view from ). Simulations made with a previous model ( and 6(d)) also reach tumor dimensions similar to real ones.
+However, if we analyze tumor spreading the situation is different. Our model seems to be more accurate regarding tumor spreading than previous ones and these differences between models become significant 18 days after diagnosis. Real images show that tumor invasion through the corpus callosum is significantly augmented at that time ( from ). They also evidence a mass-effect that compresses the lateral ventricles. Although this kind of mathematical models do not include the mass-effect, this type of spreading through the corpus callosum can be observed in simulations made with our model (see axial view form ) but not in those derived from previous ones (axial view from ).
+This consideration is extremely important, as its consequences worsen with time: differences between both models become more evident 100 days after diagnosis, as it can be evidenced in and 6(f). At this time point, simulations made with the present model predicts a larger spreading of the tumor through the corpus callosum with tumor cells reaching the contralateral hemisphere and anterior zones of the brain. Simulations with previous models, on the contrary, do not evidence this type of spreading. Though this time stage does not have real images to correlate with, it evidences the natural evolution of the previous tumor status."
+Nala Woodward,37,1994/9/1,9495835771,gregorygarcia@example.org,99261 David Roads,"The patient is now 20 years old; she is the second child of healthy non-consanguineous parents. There was no family history of liver disease, diabetes, or hypercholesterolemia. Since birth, her general health had been good; however, hepatomegaly was noticed during a routine health care visit and therefore, at 5 years of age, the patient was referred to our hospital. At that time, her height was 100.6 cm (-2.0 SD as compared to a normal Japanese girl) and her weight was 14.1 kg (-1.8 SD as compared to a normal Japanese girl) (BMI= 14.1 kg/m2). A physical examination revealed hepatomegaly with moderate elevation of serum transaminases. Jaundice and splenomegaly were absent. She was admitted for further evaluation . Laboratory findings revealed liver dysfunction and hypercholesterolemia (AST 211 IU/L, ALT 321 IU/L, lactate dehydrogenase 914 IU/L , alkaline phosphatase 971 IU/L, leucine aminopeptidase 272 IU/L, ?-glutamyl transpeptidase 10 IU/L, total cholesterol 207 mg/dL, HDL-cholesterol 45 mg/dL, triglyceride 142 mg/dL, and total bile acid 5.5 mg/L). Serum anti-nuclear antibody, anti-smooth muscle antibody, and anti-DNA antibody were negative. Her fasting blood glucose was 91 mg/dL and within the normal range. Glucosuria was detected; however, an oral glucose tolerance test (OGTT) showed normal glucose levels and insulin responses (). Abdominal computed tomography (CT) revealed hepatomegaly with diffuse low density and no mass, suggesting fatty liver change. Ultrasonography and CT demonstrated no abnormalities in other organs. It was suspected that the patient had some degree of liver disease, and a liver biopsy was performed. Biopsy specimens showed vacuolar degeneration of individual hepatocytes and macrovesicular steatosis (). Hepatitis, drug-induced disease, and congenital metabolic diseases were excluded, and the origin of the liver disease remained unknown. As the cause of liver disease was not determined, we treated the patient for hypercholesterolemia with ethyl icosapentate, which is not hepatotoxic (). Post-treatment, her serum cholesterol level had decreased to almost within the normal range. Regarding hepatic dysfunction, the patient? serum transaminase levels were reduced but continued to fluctuate at the upper end of the normal range. A CT scan showed improvement of fatty change in the liver. When the patients was 9 years of age, it was noticed during a routine laboratory evaluation that she had elevated HbA1c (7.3%) and she was reevaluated for diabetes. At this time, her height was 127.4 cm and her body weight was 25.7 kg (these measurements correspond to -1.0 SD for a normal Japanese girl). BMI was calculated as 15.9 kg/m2. The second OGTT showed reductions in both glucose tolerance and insulinogenic index (). The peak level of serum C-peptide after glucagon stimulation remained normal (3.9 ng/mL, normal range >2.0 ng/mL). Islet cell antibodies (ICAs) and glutamic acid decarboxylase (GAD) antibody were not detected in the serum. At this time, she was suspected to have MODY3 because of liver disease and negative auto-antibodies. It has been reported that sulphonylureas are effective in the treatment of patients with MODY3 (); however, the use of sulphonylureas in children is not approved by the health insurance authorities in Japan. Since the patient had a reduced insulinogenic index, insulin treatment in a total daily dose of 9 units prior to each meal was initiated. Since that time, the patient? diabetes has been under good control and her liver dysfunction has been normalized. She is now 20 years old, and her total daily insulin requirement has increased to 36 units, while her HbA1c levels range from 6.5% to 7%. We could not obtain patient and parental consent for a second biopsy.
+Because the clinical course led to a probable diagnosis of MODY, we analyzed HNF1A, 4A and -1B by polymerase chain reaction and direct sequencing, according to a previous report (). Sequence analysis of HNF1A identified a heterozygous mutation at the consensus splice donor site of intron 9, which has been previously reported in a MODY3 family (). Neither of the patient? parents had this base change, indicating that the mutation occurred de novo. However, we could not perform an analysis of somatic mutations of HNF1A in liver tissue, which was previously biopsied, because we did not have access to the samples."
+Jeremias Baxter,27,1994/5/19,970.714.4343x993,taylor55@example.com,167 Jon Trafficway,"Patient 2: The second patient was a 2.5-month-old male infant whose blood glucose was checked because of a history of PNDM in his older brother (Patient 1, presented above). The infant was admitted to our hospital with a blood glucose level of 570 mg/dL. The parents stated that they had not observed any symptoms and reported a weight gain of 2 kg in the first 2 months of life. Physical examination, venous blood gas and electrolyte levels were all normal. HbA1c level was 8.9%. The patient was discharged with 0.4 U/kg/day insulin therapy.
+Both patients were followed and received insulin treatment until they were 15 2/12 and 10 9/12 years old, at which time their diagnosis of diabetes was established to be due to an ABCC8 gene mutation, identified by sequencing analysis in Exeter, U.K. Genetic studies revealed a novel homozygous missense mutation, p.E382K, in exon 7 of ABCC8 gene (). This G>A mutation at nucleotide 1144 (c.1144G>A) results in the substitution of lysine (basic charged polar amino acid) for glutamic acid (acidic charged polar amino acid) at codon 382 (p.Glu382Lys). The glutamic acid residue at codon 382 is conserved across species. This result was consistent with the diagnosis of recessively inherited neonatal diabetes due to the mutation in the SUR1 subunit of the KATP channel. The parents were first-degree cousins and both of them were heterozygous for the E382K missense mutation ().
+The patients were hospitalized in our clinic for a change of their therapy from insulin to SU. Prior to SU treatment, total daily insulin dose was 0.9 U/kg/day in the older patient and 1.0 U/kg/day in his younger brother. Their HbA1c levels were 8.1% and 8%, respectively. Oral glibenclamide was started in a dose of 0.1 mg/kg/day and gradually increased up to a final dose of 0.8 mg/kg/day twice daily in one week. Insulin requirements were decreased by 50% within one week. At the end of the week, C-peptide levels increased from 0.07 to 2.2 ng/mL and from 0.17 to 2 ng/mL, respectively. Insulin therapy was stopped at the end of two months. Blood glucose levels remained within normal ranges on glibenclamide therapy. HbA1c levels decreased to 6.3% and 6.4% (normal ranges 4.5-6.5%) in patient 1 and 2, respectively ().
+Currently, the patients have been on SU therapy for 3.5 years, and no side effects were reported. The older sibling has a good glycemic control (HbA1c 6.7%) with a lower dose of SU (0.4 mg/kg/day), but the younger has poor glycemic control (HbA1c 10.1% three months prior to the last visit and 7.9% at the last visit) even with a higher dose of SU (0.6 mg/kg/day) (). Both patients have low body mass indices (BMI) 16.7 kg/m2 [-2.86 standard deviation score (SDS)] and 17.5 kg/m2(-1.45 SDS), respectively. With glucagon stimulation, C-peptide level was higher in the younger sibling (1.64 vs. 2.24 ng/mL) (Table 1). The younger sibling claimed he was well compliant with the SU treatment, but he admitted not being completely compliant with his diet. The parents confirmed that their son was regularly taking the SU tablets. Before increasing the SU dose, we decided to follow the patient? compliance to the current therapy. Over the following 3 months, the patient showed an increasingly good compliance to the diet and his blood glucose control significantly improved without any increase in SU daily dose and the HbA1c level decreased below 8%."
+Lara Silva,33,1978/6/8,609-505-5863x55701,ucarter@example.com,05379 Campbell Lodge Suite 910,"During the screening programme for congenital hypothyroidism, a fifteen-day old male infant was found twice to have a thyrotropin (TSH) level exceeding 600 mU/L. The patient was referred to the neonatology unit of Erciyes University Faculty of Medicine. Medical history revealed that the mother had received methimazole therapy for 3 weeks due to multiple hyperactive nodules and that this was followed by RAI treatment (20 mCi). Subsequent to this treatment, the mother was detected to be at the 12th week of her pregnancy. It was reported that the mother remained euthyroid after the treatment and this was given as the reason why fetal thyroid functions were not measured. The baby was born spontaneously via the vaginal route at the end of a 42-week pregnancy. At birth, body weight was 3840 g, length was 52 cm and head circumference was 36.5 cm. On the 15th postnatal day, the infant was 55 cm in length, weight was 4720 g, and head circumference was 37 cm. His anterior fontanelle dimensions were 4x6 cm and those for the posterior fontanelle were 0.5x0.5 cm. Otherwise, physical examination was normal. The umbilical cord was still undetached.
+A plain knee X-ray showed findings consistent with a37-week gestation. Thyroid volume was measured as 0.1 mL(normal= 0.8) by ultrasonography. Free triiodothyronine was 1.55 pg/mL (normal= 2.99-6.66), free thyroxine 2.9 pg/mL (normal= 6.6-23.7), thyrotropin (TSH) 452 mU/L (normal= 0.70-18.10), thyroglobulin level 20.1 ng/mL (normal= 91), urine iodine level was 3 弮g/dL (normal= 10-20 弮g/dL). TSH receptor antibody level of the maternal serum was 2.4 U/L (normal= 0-10 U/L). The baby was started on L-thyroxine therapy at a dose of 15 弮g/kg and is now being followed by our team."
+Luka Huynh,38,1987/6/21,(675)289-7540x7655,nreed@example.net,5568 Sullivan Tunnel Apt. 704,"The patient is a 21 year-old Pakistani male, born to non-consanguineous parents. He was diagnosed with Hepatitis A (IgM positive) at the age of 3 years and made a full and uneventful recovery. He first developed neurological symptoms at age 14 years, with gradual onset of walking difficulties that progressed over several years to bilateral foot drops requiring orthoses. Over the same period he also developed symmetrical distal numbness and subjective coldness in both feet ascending to the knees, and more mildly in his hands. There was no significant cognitive impairment.
+Examination revealed muscle wasting of hands and distal lower limbs. He had clawed toes, but no pes cavus or nerve thickening. He walked with a slow, unsteady gait. Tone was decreased and muscle power was severely weak in a number of distal muscle groups, with no detectable power (MRC grade 0/5) in left abductor pollicis brevis, both first dorsal interossei and both anterior tibialis muscles. While proximal power was normal in the upper limbs, there was symmetrical weakness (MRC grade 4-/5) of hip flexion. All tendon reflexes were absent. Sensory examination was normal in the upper limbs, but revealed decreased perception of pin-prick and light touch distal to the knees, impaired vibration sense to the ankles and absent joint position sense at the toes. There was mild hepatomegaly.
+Liver ultrasound revealed abnormal echogenicity, serum liver enzymes were minimally abnormal (gamma GT 70 U/L, normal range <55 U/L), CT showed heterogeneous liver enhancement, and liver biopsy confirmed patchy steatosis (??0%) with early bridging fibrosis, but overall clinically there was no significant chronic liver disease. CSF analysis showed an increased protein of 1963 mg/L (normal <500 mg/L) and raised lactate of 4.3 mmol/L (normal 0.7??.0 mmol/L). Cranial MRI revealed diffuse hyperintense T2 weighted signal in the cerebral white matter () and cerebellum, but imaging of the brain stem was normal. A previous MRI head scan at age 9 years, performed because of headaches, was normal. Nerve conduction studies confirmed an axonal sensory motor polyneuropathy and sural nerve biopsy showed a severe chronic axonal neuropathy with only occasional surviving myelinated axons.
+The patient?��� sister developed a progressive, fatal hepatitis at age 9 years. Their father had suffered an episode of hepatitis as a child but made a full recovery. The patient? mother and older brother are both well and there are no other family members with either liver disease or neuropathy.
+Left quadriceps needle muscle biopsy was performed with informed consent. Histological and histochemical analyses of mitochondrial enzyme activities, including the sequential reaction for COX and succinate dehydrogenase (SDH) activities, were performed using 10 弮m serial cross-sections according to standard procedures as was electron microscopy (EM). This study had the relevant institutional ethical approval and complied with the Declaration of Helsinki.
+Total DNA was extracted from the muscle biopsy by standard procedures and screened for common mtDNA point mutations. A long-range PCR assay employing a pair of primers (L3965 (nucleotides 3965??984) and H129 (nucleotides 129??10)) amplified a ??2.7 kb product in wild-type mtDNA across the major arc of mtDNA to screen for mtDNA rearrangements (GenBank Accession No. ). The level of deleted mtDNA in individual COX-deficient and COX-positive reacting muscle fibres was determined by quantitative real-time PCR of the MTND1 and MTND4 regions of the mitochondrial genome as previously described . In addition, the assessment of mtDNA copy number in the patient? muscle sample was investigated by a real-time PCR assay, which co-amplifies a mtDNA-encoded gene (MTND1) and a nuclear housekeeping gene (18S rRNA) .
+The entire coding regions, including intron?xon boundaries, of the POLG (), DGUOK () and MPV17 () genes were amplified using intronic M13-tailed primers by standard PCR. Purified PCR products (ExoSapIT, GE Healthcare) were sequenced with BigDye Terminator cycle sequencing chemistries on an ABI3130xl Genetic Analyzer (Applied Biosystems) and analysed using Mutation Surveyor software (Softgenetics)."
+Oaklee Gomez,37,1978/8/30,001-939-889-1686,davidmarshall@example.org,72249 Webb Freeway Apt. 379,"A 20-year-old unmarried female presented a well-circumscribed mobile lump in the upper outer quadrant of her left breast. The lump had gradually increased in size over the last six months and had started to be painful in the last few days. On clinical examination, the lump measured 5.5 cm ? 4 cm, and the skin over the lump was not attached to the mass and showed no signs of inflammation. The patient presented this for the first time to the surgery outpatient department. Moreover, there was no history of trauma and no previous fine needle aspiration cytology (FNAC) had been performed. The lump was diagnosed clinically as a fibroadenoma, and the FNAC was carried out with a 5-ml syringe using a 24-gauge needle. Smears were dried, fixed, and stained with hematoxylin and eosin and then evaluated by the pathologist. The smears were highly cellular; most of the cells were scattered individually and had hyperchromatic round/oval nuclei with smudged chromatin and eosinophilic cytoplasm. There were only a few tight clusters of ductal epithelial cells with myoepithelial cells, and a few focal areas of fibromyxoid stroma ( and ). There was no evidence of any necrosis, and no inflammatory cells or red blood cells were present. A diagnosis of fibroadenoma with secondary squamous metaplasia was reported after the FNAC, and an excision biopsy was carried out. The removed tissue was fixed in 10% buffered formalin overnight. On macroscopic inspection, the specimen was found to be an encapsulated grey white mass measuring 5.2 cm ? 4 cm ? 3.5 cm. A grey brown area measuring 4 cm ? 4 cm ? 3.5 cm with small cystic areas was evident in the cross-sectional view of the specimen. The remaining part of the specimen was firm, grey white with a single small cystic area. Representative multiple sections were prepared from the grey brown areas, the cystic areas, and the firm grey white area. Tissue samples, measuring 4?? mm in size, were fixed in the 10% neutral buffered formalin, processed under standardized conditions for paraffin embedding. Sections of 3?? 繕m were cut and stained with hematoxylin and eosin using the standard procedures. On microscopic examination, sections from the grey white area indicated an intracanalicular type of fibroadenoma with cleft-like spaces. In addition, sections from grey brown areas revealed areas of ischemic hemorrhagic necrosis within the fibroadenoma. The outlines of the intracanalicular pattern were still retained along with congested small vessels and areas of haemorrhage (). The epithelium lining the cleft-like spaces was desquamated and lying as individual cells in the cleft spaces (). Few lobules showed complete disintegration of ductal and stromal cells. The ductal cells were round to polygonal in shape, and stromal cells were spindle shaped. Both these cell types were lying singly in a cystic space lined by the ductal epithelial cells (). No inflammatory cells were evident. The histological diagnosis was fibroadenoma with subtotal infarction."
+Isaiah Boyer,38,1989/4/29,534-344-8193x09354,michaelleonard@example.net,99941 Emily Ramp,"A four-month-old male infant from a rural district in Khorramabad, southwest Iran was brought to the emergency room of the Lorestan University of Medical Sciences Hospital with history of refusal of feeds, hyperactive bowel sound, vomiting, and change in stool texture. The patient also had episodes of retching and mild abdominal distension. The mother suffered abdominal pain and had history of diarrhea.
+The complete blood count showed a leukocyte count of 7800 弮L with eosinophilia of 7%. The results of biochemistry tests were as follows: Na (130.0 mEq/L), Ca (10.4 mg/dL), and total protein (4.6 g/dL) (). The urine analysis and culture were normal and negative, respectively. Direct examination of fresh fecal samples using Lugol's iodine solution and the concentration technique showed E. histolytica cysts and trophozoites with red blood cells (occult blood) and many leukocytes (). The infant was given metronidazole syrups (35??0 mg/kg/BW/day) and oral rehydration salt (ORS), which he took for 5 days with improvement. Subsequently, the infant was feeding normally with breast milk. On the seventh day after treatment, the results of the laboratory tests such as CBC and chemistry all were negative. Repeat wet mount prepared on slides from fresh stool samples and stained using iron hematoxylin technique, showed no parasites after examination of many fields of the slides. He was discharged in stable condition 7 days after admission."
+Chaya Villanueva,30,1995/9/29,(908)778-3853,christopher01@example.org,921 Tara Mountain Apt. 711,"A quadriplegic edentulous 30-year-old male with a history of head trauma caused by a car accident 3 years ago was referred for replacement of missing teeth. He had extracted all his teeth because of severe caries due to a 10-month coma and the jaw ankylosis resulting from the trauma. His chief complaint was inability of chewing, and mouth opening range was normal. After meticulous diagnostic survey, maxillary and mandibular overdentures were selected as the treatment plan. He had type 3, divisions A, D, C in different part of maxillary arch and type 1 division A in mandibular arch [].
+Eight implants (4.1 ? 12 mm; ITI Dental Implant System, Straumann AG, Basel, Switzerland) were inserted in the maxilla and mandible according to surgical stents (). A bar- (ITI Dental Implant System) retained maxillary overdenture and ball- (Rhein 83, Bologna, Italy) retained mandibular overdenture were processed using conventional procedures [].
+The patient's general condition improved after a year, and his speech therapist requested palatal lift prosthesis to correct the patient's hypernasal speech and also emphasized that his soft palate muscle activities may be corrected after a period of using palatal lift prosthesis.
+To construct a new maxillary prosthesis with palatal lift, preliminary impression was made with irreversible hydrocolloid (Jeltrate, Alginate, Fast set, Dentsply Philadelphia, PA, USA) and a custom tray was fabricated with light cured resin (Triad VLC, Dentsply). Border molding in vestibules was performed by impression compound (Kerr, Orange, NJ, USA) and completed with the Iso Functional compound (GC Dental Corp., Tokyo, Japan) in the soft palate site. Final impression was made by polyether material, (Impergum F, 3M ESPE, St. Paul, MN, USA, ). An overimpression of the placed mandibular overdenture with irreversible hydrocolloid was also obtained. The impressions were poured with type III stone (Fujirock, GC Dental). After obtaining the maxillomandibular records with a record base and occlusion rim, the casts were transferred to a semiadjustable articulator (ARH type, Dentatus AB, Stockholm, Sweden) using a face-bow transfer (AEB face-bow, Dentatus AB). A protrusive record was made to set the articulator's condylar elements, and a lingualized occlusal schema was achieved. Denture teeth were arranged on the record base with an index to duplicate the same position of the first overdenture teeth. The trial arrangement was evaluated intraorally, for esthetics, occlusal vertical dimension, and centric relation. The 1 mm thickness vacuum heat-pressed polyethylene was adapted around the bar portion of maxillary cast as a spacer, and the prosthesis was processed using heat cure acrylic resin material (Triplex hot, Ivoclar Vivadent, Schaan, Liechtenstein). The 1 mm thick spacer was removed from the intaglio surface of the denture, and this area was lined with autopolymerizing resilient material (Mollosil, Detax, GmbH, Ettlingen, Germany). The denture was placed on the cast until the resilient material setting was completed (). After delivery, denture care instructions were given to the patient. Patient was told to clean the tissue surface using soft cloth. Recall appointments were scheduled at 1 day, 1 week, 1 month, and every 6 months. The soft liner replacement was scheduled every 6 months, but the soft liner maintained its resiliency after a year, so it was replaced only once in 2 years. In this period the dentures were well maintained, and the patient was comfortable using them (). His hypernasal speech was improved, and the patient returned to use his old denture."
+Huxley Simpson,33,1995/4/19,(479)395-3078,erikwest@example.org,2717 Kimberly Lock,"A twenty-five-year-old second gravida at 36 weeks of gestation was referred to our institution as a case of encephalocele with preeclampsia complicating pregnancy, for further management. The patient had regular antenatal visits and was diagnosed to have preeclampsia at 32 weeks of gestation. She was not on any medication. A target scan done at 19 weeks was said to be normal. On examination, her blood pressure was 140/90 mmHg. Systemic examination was normal. Obstetric examination revealed a single live fetus corresponding to thirty-six weeks in breech presentation. On ultrasound examination (Toshiba Nemio 10, curvilinear, 5 MHz probe), there was a fetus corresponding to 36 weeks in breech presentation with an amniotic fluid index of 14. There were two echogenic masses of 4 cm ? 5 cm and 3 cm ? 4 cm, arising from the placenta in close proximity with the occiput of the fetus (). One was cystic, and the other showed lobulation/septation. As there was no defect in the skull, encephalocele was considered to be less likely. Their attachment to other structures could not be traced. Gross fetal intracranial anatomy was normal. On Doppler ultrasound examination, there was minimal vascularity on the surface of the mass. Although magnetic resonance imagining (MRI) is the investigation of choice when an encephalocele is suspected, this investigation could not be done due to patients financial constraints. At thirty-eight weeks of gestation, the patient was posted for cesarean section for breech presentation, and a live male baby of 2.8 kg was delivered. There were no gross external deformities or anomalies in the neonate. The placenta measured 15 cm ? 12 cm ? 4 cm and weighed 250 grams. Maternal and fetal surfaces of the placenta were unremarkable. There were two masses attached to the membranes measuring 5.5 cm ? 5 cm and 4 cm ? 3 cm, respectively (). The first mass appeared lobulated. The second mass appeared cystic. Histopathological examination of the placenta was unremarkable. Histopathological examination of the masses showed lining of epidermis with attached adnexa of varying maturity. There were lobules of adipose tissue, stromal myxoid changes and islands of osteoid, and cartilage and smooth muscles tissues. The above findings were suggestive of benign teratoma of the placenta. The patient had uneventful postoperative period and was discharged on the seventh postoperative day. Neonate also did not have any problems."
+Anastasia English,21,1998/2/18,340-649-7544x2457,christopher60@example.org,363 Christina Via,"A 23-year-old woman presented with complaints of secondary infertility and postmenstrual spotting for one year. She gave a history of missed abortion of ten-week period of gestation for which she underwent dilatation and curettage for retained products after two months of abortion. Her menstrual cycles were regular with normal flow. General physical and pelvic examination was normal.
+Transvaginal ultrasonography revealed a linear hyperechogenic endometrial shadow, suggestive of calcified lesions (). Diagnostic hysteroscopy revealed a pale endometrium with white, bone-like, and spicules occupying almost whole of the cavity till the internal os and extending into the posterior uterine wall (). The cervix was dilated, and the bony spicules were removed from the uterine cavity by curettage (). Histopathologic examination confirmed multiple bony pieces suggestive of retained product of conception.
+Following this report, the history was reviewed again in which the patient confessed of having a premarital second trimester medical termination of pregnancy three years back. Three weeks after surgery although the patient had a normal menstrual period, ultrasound showed persistence of calcifications. She was posted for a repeat hysteroscopic removal of bony spicules. This time her evacuation was complete, and her follow-up scan after two weeks was normal. On followup, the patient's hormonal profile and her husband's semen analysis are within normal limits, and she has been advised a hysterosalpingogram for tubal patency."
+Junior Rios,42,1999/11/19,001-598-354-7634x708,wbird@example.org,01399 Maldonado Mission Suite 573,"The patient was an 82-year-old male with recurrent nodal marginal zone B-cell stage 4 lymphoma, mostly involving abdominal lymph nodes. His past medical history included IgG kappa monoclonal gammopathy, congestive heart failure, sick sinus syndrome, and hypertension. The patient presented to the hospital complaining of chills, fever, and dyspnea for two days, 4 days after receiving his first infusion of rituximab therapy (375 mg/m2) with a premedication including acetaminophen and diphenhydramine but not steroids. No history of recent upper respiratory infection, chest pain, acute blood loss, or new medications was reported. The patient was admitted to the hospital and started on broad-spectrum antibiotics. His routine blood counts, liver function test, renal function test, and D-dimer were normal. His shortness of breath progressively worsened over the course of 3 days. The patient developed hypoxic respiratory failure. On physical examination, he was tachypneic and tachycardic. Lung auscultation revealed bibasilar inspiratory crackles. Oxygen saturation was 90% on nonrebreather mask and arterial blood gas revealed a PO2 of 54 mmHg on 100% FiO2. CT of the chest showed bilateral diffuse patchy infiltrates involving 3/4 of the lung parenchyma (). The patient had a previous PET CT one month ago which showed mild bilateral fibrous changes in the periphery of the lungs.
+The patient was intubated and placed on mechanical ventilation. A two-dimensional echocardiogram (2D-Echo) showed left ventricular ejection fraction (EF) of 55%, stage 1-diastolic function and no valvular disease. BNP level was 95 pg/mL. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsies was performed. Bacterial, viral, and fungal cultures were negative. BAL was negative for Pneumocystis jirovecii and malignant cells. Biopsy showed pulmonary parenchyma with patchy fibroblastic proliferation, suggestive of BOOP with no malignant or atypical cells ().
+Antibiotics were discontinued and the patient was extubated, but continued to require high oxygen flow. Methylprednisolone 40 mg IV every 8 hours was started with a gradual improvement in his oxygen saturation over the next few days. Follow-up CT scan of the chest two weeks after starting steroids showed improvement in the bilateral pulmonary infiltrates. He was switched to oral prednisone at a dose 60 mg daily with a weaning plan over the next few months. After discharge to home, he no longer required oxygen."
+Brooke Compton,21,1998/11/30,802.643.0942x8557,rebeccacampbell@example.org,962 Ralph Mall,"A 25-year-old pregnant lady was referred to our antenatal clinic at 24 weeks of gestation for investigations. She had a history of focal seizure, carpopedal spasm, and lip smacking movement since 6 years of age, for which she did not seek any medical advice. This was her second pregnancy which she had conceived spontaneously. Previously she had spontaneous abortion in first trimester. So far she had been supervised at a primary health centre and was apparently uncomplicated. There was no seizure activity during this pregnancy. She achieved menarche at 14 years of age, and her menstrual cycles were regular with scanty flow. At the age of 16 years, she had recurrent seizures for which she was prescribed oral phenytoin with some relief in symptoms. She stopped medication after 3 years without medical consultation.
+Her general physical examination revealed height of 145 cm (<3rd centile), round facies, and short right 4th metacarpal. Further detailed examination showed signs of latent tetany in the form of positive Chvostek's sign and Trousseau's sign. Abdominal examination revealed uterus of approximately 24 weeks of gestation. Blood investigation showed low serum calcium (7.8 mg/dL) with high serum phosphate (5.8 mg/dL). The blood parathormone (PTH) level was raised (196 pg/mL) together with high alkaline phosphatase (200 U/L) and high 25(OH) vitamin D (29.77) level. The blood thyroxin level was below normal range and was associated with high thyroid stimulating hormone level. EEG revealed generalized epileptiform discharge. Computerized tomographic examination of brain showed multiple calcifications in bilateral globus pallidus, caudate nucleus, thalamus, frontal region, parietal lobes, and cerebellar hemispheres. Ultrasonographic parameters for fetal growth were found adequate. She was diagnosed with pseudohypoparathyroidism 1a and prescribed oral calcium (2.5 gm/day) and active vitamin D (1 弮g/day) together with levothyroxine 125 弮g daily in empty stomach. She had spontaneous onset of labor at 40 weeks of gestation. Her serum calcium was found very low (1.52 mg/dL) but without any seizures or tetany. She was managed with calcium infusion. Augmentation of labour with oxytocin failed to progress, and emergency cesarean section was done under regional anesthesia for nonprogress of labour. She delivered a healthy baby with a birth weight of 3.2 kg with good Apgar score. Her intraoperative and postoperative course was uneventful. She was discharged in satisfactory condition on fourth postpartum day."
+Abner Bell,22,1988/6/20,001-696-656-4264x6626,marisamills@example.net,770 Diana Harbors Suite 674,"A 40-year-old African gravid 3/para 3 woman was admitted to the intensive care unit (ICU) following a caesarian section for placental abruption and fetal distress. She was booked for antenatal care at approximately 34 weeks of pregnancy with antenatal care prior to that done in Africa for this pregnancy. Her initial assessment was satisfactory (Tables and ), but in the background history, it was noted that she was suffering from constipation and gestational diabetes mellitus in her last pregnancy () and was poorly compliant with insulin therapy.
+She underwent emergency C-section after she presented with antepartum haemorrhage, and intraoperative findings were a low-lying placenta with large retroplacental clot with abruption. Postoperatively, she continued to bleed per vagina in ICU and received 7 units of red cell concentrate (RCC), 4 units of plasma, 4 pools of platelets, and an oxytocin infusion. Despite treatment, she continued to bleed and was transferred back to theatre, where a uterine tamponade balloon was successfully inserted. Her total blood loss was estimated in excess of 3 litres.
+On the same evening, she began to complain of abdominal pain. On examination, her vital signs were within the normal range. Abdominal examination revealed a distended abdomen with tenderness in the epigastrium and left upper quadrant and was tympanic to percussion over the epigastric region. There was no guarding or rigidity noted. An abdominal X-ray showed significant gastric distension with diffusely noted gas pattern consistent with gastric emphysema (). CT confirmed air in the stomach wall, with moderate abdominal and pelvic fluid, which was attributed to her earlier C-section (). An urgent upper GI endoscopy was arranged which revealed a normal oesophagus, food in the stomach, and, on washing, revealed an oedematous beefy red, friable mucous-coated stomach mucosa extending over greater curvature from midstomach towards the fundus (). Following consultation with the upper GI unit in a tertiary referral centre, this patient was managed conservatively with gastric drainage via nasogastric tube, broad-spectrum antibiotic cover, oral sucralfate, and total parenteral nutrition with close monitoring in ICU.
+Her further clinical course was uneventful, and she responded very well to conservative management. A repeat CT, one week later, showed absence of gastric wall gas or free air (). The large and small bowel loops appeared normal, and she was discharged home."
+Melody Combs,22,1978/1/30,2249469749,jenniferhampton@example.net,134 Watkins Meadow,"A 48 years-old white man was followed for a 20-years history of severe chronic plaque psoriasis. In 1990 HCV infection was demonstrated with raised liver enzymes and ongoing viral replication. The patient presented to us with persistently elevated aminotransferase levels (ALT; three times normal), HCV infection with genotype 2a-2c (Simmonds Classification) and HCV-RNA titer (measured by the quantitative-chain-reaction assay, detection limit, 50 IU/mL) of 2,050,000 IU/mL []. A liver biopsy showed moderate to severe fibrosis with moderate to severe portal, per-portal and globular mononuclear infiltrate (metavir A3, F3) []. The patient denied his consensus for interferon IFN-帢/ribavirin therapy because of the possible worsening of psoriasis during IFN therapy. In the past, the patient received numerous topical courses of corticosteroids, vitamin D derivates, tar derivates and salicylic acid with partial improvement. Ultraviolet B phototherapy was introduced for 4 months with only slight response. At baseline, the patient presented with a Psoriasis Area and Severity Index (PASI) of 19. 8 (), a Body Surface Area of 19, with a severe palmo-plantar involvement that impaired his quality of life (QOL), measured by the Dermatology Life Quality Index (DLQI) questionnaire, with a score of 19 (range 0 to 30, being 30 the worse QOL). Because of the severity, extension and QOL impairment, systemic therapy was essential and cyclosporine was chosen in the HCV setting, considering the contraindication for methotrexate and the scarce response after two months of acitretin. Cyclosporine was introduced at 5 mg/kg/day with progressive tapering of the dose by 50 mg/weekly after PASI-90 achievement (90 % of PASI improvement; ). During cyclosporine therapy, liver function tests (transaminases and gamma glutamil transferase) were measured every and HCV viral load was measured every six months using the same quantitative polymerase-chain reaction assay (detection limit, 50 IU/mL). A total of five courses (duration range: three - six months) of cyclosporine (5 mg/kg/day) were followed by the patient during a 38-month period. The viral load diminished during the 38 months of intermittent cyclosporine therapy to the lowest level measured at month-36 (6.5 x 105 IU/mL). The transaminases levels diminished during the whole therapy, with a 42 % of improvement from baseline to 38th month (). Blood pressure, triglycerides, total or LDL-cholesterol levels and renal function remained on the normal range during the whole cyclosporine intake period."
+Ahmad McIntyre,36,1982/4/5,857-814-2939,mark97@example.com,172 Lara Wall Apt. 020,"A 19-year-old female patient was referred to the Department of Endodontics, Ragas Dental College and Hospital, with the chief complaint of intermittent pain in the lower right back teeth for the past three months. Her past medical history was found to be noncontributory. Clinical examination revealed a deep carious lesion in right mandibular first molar no. 46. The clinical and radiographic findings led to a diagnosis of chronic irreversible pulpitis of the right mandibular first molar no. 46, necessitating endodontic therapy. Radiographic evaluation of the involved tooth indicated a deep, carious lesion approximating the pulp and a normal canal configuration of two canals in the mesial root and one canal in the distal root (). The right inferior alveolar nerve was anesthetized using 2% Lignocaine with 1 : 80,000 adrenaline (Lignox, Indoco Remedies Ltd, India). The tooth was isolated using rubber dam, and an endodontic access cavity was established. Investigation of the root canal system was initially performed with the aid of an endodontic explorer, and the canals were explored with a no. 10 K-file (Mani, Inc; Tochigi, Japan), two canals mesially and single canal distally were located initially. In order to enhance the visualisation, we observed the pulp chamber with the aid of an magnifying loupes (Seiler loupes, 2.5? magnification). Examining the fissure connecting the two mesial canals revealed an additional orifice in between the two mesial canals (mesiobuccal, middle mesial, and mesiolingual). The additional canal was explored with a no. 10 K-file (Mani, Inc; Tochigi, Japan).
+Multiple working length radiographs were taken at different angulations with one file placed in each of the 3 mesial and single distal orifice to confirm the independent presence of 4 distinct canals (). Individual canal instrumentation was performed using a crown down preparation with Protaper nickel-titanium rotary instruments (Maillefer, Dentsply, Ballaigues, Switzerland). Copious chemical irrigation was performed with 5.25% sodium hypochlorite solution and EDTA (Glyde, Maillefer, Dentsply, Ballaigues, Switzerland). The root canals were dried with paper points (Maillefer, Dentsply, Ballaigues, Switzerland), and the pulp chamber was examined again under the magnifying loupes (Seiler loupes, 2.5? magnification) (). Obturation was performed after two weeks with resin sealer (AH plus-Dentsply, DeTrey Konstanz, Germany) and cold laterally condensed with gutta-percha (Mailllefer, Dentsply, Tulsa, OK) and sealed with IRM cement. Postobturation radiograph was taken to confirm the completeness and the extension of the root filling, which revealed three distinct orifices with three separate apical terminations of mesial canals with thin dentinal separation between three canals till apical third. With regard to Pomeranz's classification this case is classified as independent middle mesial canal and type VIII root canal morphology according to Vertucci's classification ()."
+Rebekah Brown,39,1987/4/15,-10276,uhayes@example.net,168 Anderson Lake,"A 35-year-old female patient reported with spontaneous pain in lower right back tooth indicative of chronic irreversible pulpitis no. 46 (). After anesthesia and rubber dam placement, access cavity was prepared and the coronal pulp tissue was removed. Totally 5 distinct orifices-3 located mesially (mesiobuccal, middle mesial and mesiolingual) and 2 distally (distobuccal and distolingual) (). The canals were explored with no. 10 K-file (Mani, Inc; Tochigi, Japan). The working length radiograph confirmed the presence of 5 distinct orifices and 4 apical terminations. Chemomechanical preparation was performed using the step back technique and the root canals were obturated with cold, laterally condensed gutta-percha (Maillefer, Dentsply, Ballaigues, Switzerland), and resin sealer (AH plus sealer-Maillefer, Dentsply, Ballaigues, Switzerland). Postobturation radiograph () revealed the presence of confluent middle mesial canal originated as a separate orifice but joined in the apical third of the mesiobuccal canal."
+Elijah Buck,23,2005/4/3,(409)277-2468x30230,riley88@example.com,28830 Lisa Summit,"A 28-year-old female patient reported with spontaneous pain in lower right back tooth no. 46. Endodontic treatment was indicated because of apical periodontitis. After anesthesia and rubber dam placement, access cavity was prepared and pulp tissue was removed. Totally 5 distinct orifices-3 located mesially (mesiobuccal, middle mesial, and mesiolingual) and 2 distally (distobuccal and distolingual) () were detected on inspection using operating microscope. The working length radiograph confirmed the presence of 5 distinct orifices, and 4 apical terminations confluent middle mesial canal originated as a separate orifice but joined in the apical third of the mesio buccal canal (). Chemomechanical preparation was performed using the step back technique and obturated with cold, laterally condensed gutta-percha (Maillefer, Dentsply, Ballaigues, Switzerland) and resin sealer (AH plus -Maillefer, Dentsply, Ballaigues, Switzerland). Postobturation radiograph revealed confluent middle mesial canal and (additional type 3-2) ()."
+Livia O’Neill,31,1997/8/5,(434)241-1271x222,deannamartin@example.net,316 Gallegos Neck Suite 748,"A 24-year-old female patient was referred for root canal treatment of lower left mandibular first molar owing to irreversible pulpitis no. 36. Access preparation was performed and pulp tissue extirpated under local anesthesia. One distal and 2 mesial canal orifices were revealed on inspection using operating microscope under 12.8? magnifications (). After probing with a Hu-Friedy (Chicago, IL) DG 16 endodontic explorer, a small hemorrhagic point was noticed in between two mesial canal orifices. A working length radiograph was taken that confirmed the presence of 4 canals (). Cleaning and shaping were done and filled with cold, laterally condensed gutta-percha and AH plus resin sealer. Postobturation radiograph () reveals 1 distal (vertucci type 1) 3 mesial canals where the middle mesial canal is joined with mesiobuccal canal (confluent), (additional types 3-2)."
+Marcel Bravo,28,1985/9/9,(483)757-5347x67980,robertkramer@example.com,4418 Jones Rest Suite 482,"A 13-year-old female patient reported complaining of missing teeth in the lower anterior region. (). Patient mother gave a history of presence of milk teeth in the lower arch, but, after their exfoliation, permanent teeth did not erupt. There was no history of any infection or trauma to the anterior region. Patient was healthy with no relevant medical and family history and was born to nonconsanguineous parents. She was normal in her facial appearance and did not show any physical or skeletal abnormality (). Radiological examinations of the clavicles, vertebral skeleton, skull, and chest were found to be normal. Ophthalmological and neurological examination of the patient revealed no pathological symptoms and showed no signs of mental retardation. Hematological and biochemical findings were found within normal limits.
+Intraoral examination revealed midline diastema and presence of permanent teeth like 11, 16, 21, and 26 in the maxillary arch, 34, 35, 36, 44, 45, 46, and, 47 in the mandibular arch. Primary teeth like 53, 55, 63, 65, and 73 were retained (). The remaining permanent teeth were missing clinically. On radiographic examination, congenital absence of 12, 13, 15, 17, 22, 23, 24, 27, 31, 32, 33, 37, 41, and 42 (14 teeth) was confirmed (). All third molar teeth buds were also missing. Permanent mandibular right canine was impacted mesioangularly with crown transmigrated to contralateral side crossing the midline and was rotated. Other anomalies also noticed on the radiograph like, taurodontism in mandibular right first and second molars and left first molar, pyramidal or conical shaped, fused roots in maxillary both primary and permanent molars and generalized microdontia.
+In view of the oligodontia of permanent teeth, a detailed examination was done to rule out syndromes or systemic diseases associated with oligodontia and found negative. Finally, a diagnosis of nonsyndromic occurrence of multiple dental anomalies was made. As patient was mainly concerned with missing lower anterior teeth, removable partial denture fabrication was done to restore esthetics and masticatory function."
+Amoura Tate,23,1998/2/14,692.324.4371,angela09@example.com,625 Natasha Overpass,"A 55-year-old male patient presented to our emergency with abdominal pain, distension, and absolute constipation for two days. The patient had three similar episodes in the past, which responded to conservative management. There was no history of abdominal surgery or trauma. The abdominal examination revealed distension with rebound tenderness and hurried intestinal peristaltic sounds. On digital rectal examination, rectum was empty with ballooning.
+Hematological investigations demonstrated neutrophilic leucocytosis. Abdominal X-ray on erect posture revealed multiple air fluid levels with presence of valvulae conniventes. Ultrasonography demonstrated dilated bowel loops without any ascites.
+The patient underwent exploratory laparotomy for acute intestinal obstruction. On exploration, almost entire small gut was found to be in the left paraduodenal area enclosed in a hernial sac (). The inferior mesenteric vein was situated on the right free margin of hernia sac and at the region of ileocecal junction, it passed onto the anterior aspect of terminal ileum (). The small gut, within the sac, was distended and congested. The peritoneal attachment along the right free margin of inferior mesenteric vein was excised, and the herniated small gut was reduced beneath the inferior mesenteric vein to its normal position on the left side of the base of the mesentery of small intestine. The peritoneal attachment at the neck of the hernia sac was sutured with the retroperitoneum; thus closing the neck of the hernial orifice. The postoperative recovery was uneventful. On followup, for next one year, the patient has been free from any further abdominal problems."
+Dalton Stevens,33,1984/7/20,001-986-493-3624x120,justinwalsh@example.com,26553 Mccarty Motorway Suite 600,"A 49-year-old female patient described an episode of sudden dyspnoea that required digital maneuvers to clear the airway. She described that during the maneuver a smooth mass was detached from the pharynx and swallowed. Similar episodes were repeated in two occasions. During examination a progressive dysphagia to solids was noted. No history of loss weight, cough, or hematemesis was noted. She had no comorbidity of interest.
+A CT scan was performed revealing a soft tissue mass in the esophagus, extending from the level of the cervical esophagus to the lower esophagus with no clear relation to the esophagus wall.
+The upper endoscopy showed a sausage-shaped mass obstructing the esophageal lumen, arising from the upper esophageal sphincter and ending 13 cm below ()."
+Katherine Sawyer,35,1980/9/23,542-247-4106x66213,petersonrobert@example.net,394 John Point,"A 27-year-old female reported with the chief complaint of a ?ractured filling??in her left lower back tooth. History revealed intermittent pain localized to the same tooth during mastication. The tooth was previously restored with a silver amalgam restoration 7 years back. Clinical examination revealed a silver amalgam restoration with secondary caries in the left mandibular first molar (tooth 19) which was tender to percussion. Vitality tests elicited no response. Preoperative radiographs showed widening of periodontal ligament space in relation to the mesial root apex. In addition, radiographic apical contour of the tooth suggested that there might be two distal and two mesial roots (). From the clinical and radiographic findings a diagnosis of pulpal necrosis with symptomatic apical periodontitis was made and endodontic treatment was initiated.
+Following endodontic access cavity preparation, two mesial and one buccally placed distal canal orifice was identified. Upon visual inspection of the floor of the pulp chamber using a dental operating microscope, a dark line was observed extending from the distal canal orifice towards the distolingual corner. At this corner, the overlying dentin was removed and a second distal canal orifice was detected. The conventional access was modified to improve access to the additional canals (). Root canal orifices were named as per the nomenclature proposed by Albuquerque et al. []. Working length was confirmed () and the canals were instrumented. Calcium hydroxide was placed as an intracanal medicament with a lentulospiral and the access cavity was sealed with Cavit G. The patient was asymptomatic at the next appointment, a week later, which allowed for root canal obturation and a coronal composite restoration ()."
+Jefferson Weiss,28,2003/3/10,+1-953-979-3639x03458,wwright@example.com,18126 Griffin Forges,"A 32-year-old unmarried male, smoker, and beef eater from rural Kashmir, India presented to the surgical emergency department of a tertiary care hospital in Srinagar with features of acute abdomen. He had a three-day history of upper abdominal pain of increasing severity, nausea, and bilious vomiting with fever and chills. Previous history was suggestive of chronic acid peptic disorder. Physical examination revealed anicterus, tachycardia, temperature of 38.5簞C, tenderness, and guarding in the epigastrium and right hypochondrium. The total leukocyte count was 13.5 ? 109/L with a differential count depicting polymorphs77, lymphocytes20, monocytes02, and eosinophils01. The total bilirubin was 12.7 弮mol/L, ALP was 197 IU/L, AST was 68 IU/L and ALT was 42 IU/L. Chest and abdominal radiographs (standing/supine) were normal. USG abdomen reported free fluid in Morrison's pouch. The patient was operated with an impression of a perforated duodenal ulcer. Operative findings showed a severely inflamed gall bladder with patchy necrosis and a perforation in fundus with pericholecystic pus collection. Further exploration was interesting, and to our surprise we extricated an adult tape worm of approximately 1.7 m in length from the gall bladder which was devoid of stones ().
+Peritoneal mopping, closure of perforation, and cholecystostomy were done. Cholecystectomy was avoided in view of severe inflammation around the Calot's triangle. Rest of the viscera were normal. The specimen sent to the department of pathology/parasitology was confirmed to be Taenia saginata. In the postoperative period, patient had mild respiratory tract infection. Bile started draining with pus flakes from cholecystostomy tube on 5th post operative day. Cholangiogram on 9th postoperative day showed a normal anatomy and free drainage into the duodenum. Liquid orals were started on 2nd postoperative day with full orals resuming by 4th postoperative day. The cholecystostomy tube was removed on 14th postoperative day. Retrospective history was negative for jaundice or passage of worm segments. The patient was given a single dose of praziquantel: 15 mg/kg body weight. Parasitological controls (two series of three fecal samples each), performed two months later, were negative for Taenia eggs. The patient was followed up regularly, and an interval cholecystectomy was done after 6 weeks."
+Lennox Vo,21,1979/7/5,402-786-6615x650,jessicagarner@example.org,96158 Jose Path Apt. 415,"A 71-year-old woman, who underwent a total hysterectomy and oophorectomy 8 years ago for endometrial cancer, was admitted for recurrent abdominal mass detected during a routine control thoracoabdominal computerized tomography (CT) scan. CT scan revealed a 5 ? 6 cm sized cystic mass located in the left para-aortic area, at the level of the renal artery orifice of the abdominal aorta. No other metastasis had been demonstrated. In the blood chemistry, only mild elevation of CA 125 was present. The rest was unremarkable.
+A 6 ? 6 ? 5 cm sized tumoral mass, located between the abdominal aorta and the left renal artery, was revealed at the laparotomy. In addition, about 10 cm proximal to the ileocecal valve, a nodular soft and freely mobile mass of 3 cm diameter was observed on mesentery. A surgical resection of the para-aortic mass and an excisional biopsy of the mesenteric mass were performed. The histological evaluation of the para-aortic cystic mass revealed the metastasis of the primary endometrial serous papillary carcinoma. The histological features of the mesenteric mass were consistent with breast tissue, including lobular and ductal structures in a fibrovascular tissue (Figures and ). Immunohistochemistry with milk fat globulin protein 1 antibodies (MFGP 1) were positive for epithelial and acinar cells, consistent with mammary epithelial differentiation ()."
+Gordon Felix,30,1997/9/14,+1-545-542-3845x6904,gcastaneda@example.org,095 Linda Islands,"A 55-year-old man, lawyer, was admitted to the hospital because of abdominal pain located in the epigastrium and right hypochondrium, intermittent night sweats, and 3 kg involuntary weight loss over the preceding 8 months. Approximately 5 years earlier severe aortic valve stenosis, with left ventricular hypertrophy, paroxysmal atrial fibrillation, and heart failure (class III NYHA) were diagnosed, and aortic valve replacement was performed using a biological prosthetic valve. Furthermore, the patient was an alcohol user (70 g/day) and had endoscopically diagnosed chronic antral gastritis. He lived in an urban area but, approximately 18 months before admission, he traveled to Nepal living in settings with poor hygienic standards. Daily medications included omeprazole 20 mg.
+Approximately one year before admission, the patient began to have intermittent, profuse night sweats associated with abdominal pain located in the epigastrium, and right hypochondrium. He reported no fever or chills. No remarks on routine physical examination performed by his attending physician were made, and summarizes the results of prescribed laboratory tests. Serologies for human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and VDRL were negative. Serologies for cytomegalovirus (CMV) and Epstein Barr virus (EBV) showed past infections. Two blood cultures were negative. A transthoracic echocardiography detected hemodynamically well-functioning aortic valve prosthesis, ascendant aortic dilatation, and no valve vegetations. An abdominal ultrasound revealed a biliary cyst of the liver. His physician eventually decided to prescribe sertraline for depression.
+Four months before admission, the patient was still complaining of abdominal pain, with the same characteristics and was referred to our out-patient clinic. Laboratory tests were repeated (), protein electrophoresis was performed, and results were within normal range.
+Meanwhile, during a work trip to Brazil, the patient developed lower limbs leukocytoclastic vasculitis ().
+Due to worsening of intermittent night sweats, persistence of abdominal pain, and 3 kg involuntary weight loss over the preceding 8 months with no fever, the patient was admitted to the hospital.
+On examination, the patient was in good condition, the temperature was 37.1簞C, the pulse rate 75 beats per minute, the blood pressure was 130/75 mmHg, and respiratory rate was 15 per minute. The oxygen saturation in ambient air was 98%, good oral and dental health. There was no superficial lymphadenopathy. There was no jugular venous distension. Auscultation of the heart revealed a mechanical second heart sound, a grade II/VI systolic murmur in the aortic area. No chest rales were detected. There were no conjunctival hemorrhages, Osler's nodes, Janeway's lesions, Roth's spots, splinter hemorrhages, or peripheral edema.
+The electrocardiogram showed a normal sinus rhythm with nonspecific repolarization abnormalities.
+Routine laboratory tests () were performed and revealed hemoglobin 12.8 g/L [13.5??7.5], platelet count 139,000 per mm3 [150,000??50,000], aspartate aminotransferase (AST) 61 U/L [<50 U/L], alanine aminotransferase (ALT) 73 [<50 U/L], alkaline phosphatase (ALP) 110 [<120 U/L], ferritin 418 ng/mL [24??36], C-reactive protein (CRP) 4.1 [<5.0 mg/L], erythrocyte sedimentation rate (ESR) 15 mm/hr [<20], and rheumatoid factor (RF) 318 U/mL [<14]. Electrolyte panel and urinalyses were normal. Serologies for HIV, HBV, HCV, Schistosoma, Borrelia, Rickettsia, Leishmania, and VDRL were negative. Serologies for CMV, EBV, and Toxoplasmose showed past infections. Widal and Huddlesson reactions and research of Plasmodium sppwere negative as well. Two sets of blood culture specimens exhibited no growth. Protein electrophoresis showed IgG-K/弇 monoclonal hypergammaglobulinemia. Abdominal ultrasound detected mild hepatosplenomegaly. Thoracic-abdominal-pelvic computer tomography disclosed gastric wall calcification and confirmed hepatosplenomegaly. To rule out endocarditis, transesophageal echocardiography was performed. Two very small echodense images suggestive of surgery-related alterations versus fibrosis were detected on the aortic cups (Figures and ). Fundus examination showed no retinal abnormalities.
+Liver biopsy revealed infectious hepatitis without pathognomonic features () and with no fibrin ring granulomas described in Q fever.
+EDTA-whole blood and paraffin-included liver biopsy were then sent to CEVDI/INSA for C. burnetii laboratory diagnosis. The serologic evaluation was performed by Indirect Immunofluorescence Assay (IFA) using the commercial C. burnetii I+II IgG/A/M Immunofluorescence kit (Vircell Microbiologists, Granada, Spain). It revealed a high anti-phase I IgG with an end-point titer of 204,800 suggestive of chronic Q fever (anti-phase I IgG ??00 was the reference cut-off, for results). C. burnetii active infection was also confirmed by molecular testing. For this purpose, genomic DNA was extracted from buffy coat and liver tissue using DNeasy blood & tissue kit (Qiagen GmbH, Hilden, Germany). The presence of C. burnetii DNA was screened by polymerase chain reaction (PCR) in a nested reaction using the primers pairs Trans1-Trans2 and Trans3-Trans4 that target a transposon-like repetitive region in the agents genome []. Specific DNA was detected in liver tissue but not in blood, and C. burnetii identity was confirmed by amplicon sequencing. The quality of DNA in both samples was previously verified by amplification of human 帣-actin gene as internal control. Moreover, the absence of bacteria in blood sample was reinforced by a negative result also obtained for the isolation attempt. In fact, an additional buffy coat aliquot was inoculated in DH82 cells, routinely used in CEVDI for C. burnetii isolation, and after a standard 60-day incubation at 37簞C and 5% CO2 atmosphere in BSL3 condition, no bacteria growth could be detected. The paraffin processing of the liver sample limited its utility for agents isolation.
+Final diagnosis of chronic Q fever was made, with histologically documented infectious hepatitis and endocarditis by modified Duke's criteria []. Our patient met one of the major criterion of Q fever endocarditis (C. burnetii serology with anti-phase I IgG titer >800) and three minor criteria (predisposing heart condition with biological prosthetic aortic valve, immunological phenomena with RF positive, vascular phenomena with leukocytoclastic vasculitis). Furthermore, we probably may consider the valvular alterations detected by transesophageal echocardiography as a minor criterion (echocardiographic findings not meeting a major criterion).
+Antimicrobial therapy with doxycycline 100 mg bid, and hydroxychloroquine 200 mg tid was started and the patient became asymptomatic within 8 days.
+The patient is still being followed in our out-patient clinic and he is adhering to treatment. He remains well and his weight gradually returned to normal (75 kg-Bode Mass Index 23,1), 8 months after the diagnosis. The titers of antibodies to C. burnetii have been falling in response to therapy. Results of the periodical serological tests are summarized in , together with results of the laboratory tests ()."
+Paisleigh Hardy,23,1997/12/23,387-603-5208x109,taylorphillips@example.net,9279 Williams Mill Suite 450,"A 70-year-old male presented to our outpatient department with anorexia and weight loss during the last three months. He was diagnosed with myelodysplastic syndrome a year ago and was treated accordingly by a hematologist. The physical examination was noncontributory. The medical history of the patient revealed right nephrectomy 22 years ago owing to renal cell carcinoma; grade 2 (according to Fuhrmann grading system) and T1b (TNM staging system for kidney cancer, 7th edition). His blood glucose was elevated. Liver function tests, serum amylase, bilirubin; CEA and CA 19-9 were within the normal limits. Ultrasound examination of the abdomen revealed a large mass at the region of the pancreatic head. Contrast-enhanced computed tomography of the abdomen was performed, which confirmed a 9 ? 5 cm lesion at the head of the pancreas (). Due to his medical history of a right nephrectomy 22 years ago owing to renal cell carcinoma, a CT scan of the brain and the thorax was performed, which was negative for metastases.
+The patient underwent a pancreatoduodenectomy with pylorus preserving (Longmire-Traverso) in order to remove the tumor. The postoperative period was uneventful, and the patient was released from our department 7 days after his operation. Histopathological evaluation showed a 9 ? 5 ? 4 cm solid lesion with areas of hemorrhage and necrosis (). The lesion was composed of solid sheets of cells divided by bands of fibrovascular tissue into large nests and alveoli. The cells showed moderate clear-to-granular eosinophilic cytoplasm with well-defined cell borders. The nuclei were central and pleomorphic with conspicuous nucleoli. The lesion was surrounded by a thick collagenous capsule and completely separated from the pancreatic tissue with no infiltration. The morphology was identical to that of the primary renal tumor which was reviewed. A final diagnosis of metastatic clear cell renal cell carcinoma of the head of the pancreas was reached (Figures and ). The surgical margins were free of tumor. The followup of the patient was every 6 months for the first 2 years and then annually. The patient remains free of symptoms and without recurrence of the primary tumor three years after his treatment."
+Jayceon Willis,43,1997/11/21,2137444539,sawyersamantha@example.net,563 Solomon Greens,"A 27-year-old, otherwise healthy normal male presented to the reconstructive surgery clinic of Hazrat Fateme hospital. His problem first appeared about 11 years ago, as a small pink lesion on the hard palate and a simultaneous scaly papule on the anterior chest. Several hospital admissions and therapies including antibiotics did not have any effect on the disease. The lesions grew gradually interfering with oral function and finally the diagnosis was confirmed through pathologic and mycological studies. The biopsy results are discussed later. All other test results including blood biochemistry, hematology, sexually transmitted disease (STD) serology, urine analysis and microbiology, and stool exam were within normal limits. Moreover, intact cell mediated immunity was revealed. Imaging studies showed the extent of mass growth and the involvement of surrounding bone. The mass was resected sacrificing the involved soft tissue and bone, and the palatal defect was covered by means of local tissue, only to fail. The patient received Amphotericin B and Itraconazole according to a protocol provided by clinical mycologists of the department of infectious diseases (, ). Finally, after confirming the disease free margins of the defect, the decision to employ free tissue transfer was made. To cover this 38 by 42 mm three-dimensional defect in the palate, a well vascularized thin tissue providing viable skin was needed. Along the length of the pedicle was an issue to facilitate microsurgical transplantation. Thus, a free radial forearm fasciocutaneous flap was chosen ().
+The patient underwent surgery once the necessary tests were run and the patency of the ulnar artery and deep palmar arch was confirmed preoperatively. The flap was dissected on the nondominant limb in a distal to proximal direction on its radial artery pedicle and venae comitantes. After preparation of the Facial vessels as the recipient vessels, the flap was harvested and transplanted. The nasal lining was restored by split thickness skin graft. The patient received postoperative care and was discharged after the donor site dressing and immobilizing splint were removed, and scheduled for several office visits.
+The histological finding in the biopsy specimen was that of a granulomatous reaction characterized by formation of pseudotubercles containing giant cells, and a focal round cell infiltration in the superficial portions of the specimen. The fungi appeared in clusters of brown, spherical cells with thick, dark cell walls and coarsely granular pigmented protoplasm. The cultural characteristics were also studied. The colonies produced black, slow growing, heaped-up colonies and the Cladosporium type of sporulation was noted.
+The last specimens obtained before the final reconstructive procedure showed eosinophil rich acute inflammation without any fungal infection. Cultures obtained as the reference method were all negative."
+Alexa Kerr,26,1990/9/24,(771)384-2382x0558,leonardschwartz@example.org,26712 Michael Glen,"A 38-year-old man reported with a swelling in the medial aspect of the right thigh for the past 10 months. The swelling was gradually increasing in size. There was no history of trauma or fever. The history of pain was present in the thigh. On the examination, a non-tender swelling felt in the subcutaneous area of the right medial aspect of the thigh. Swelling was firm in consistency, which was free from the underlying structures. Blood tests were within normal limits.
+Ultrasonography (USG) revealed a cystic lesion of a size of approximately 5 x 7 cm in the subcutaneous area of the right thigh ().
+There was evidence of multiple daughter cysts within the cystic lesion along with few floating membranes. Probable diagnosis of subcutaneous hydatid cyst was made. The rest of the organs were normal. On the computed tomography (CT) of the thigh, there was a well-defined cystic mass in the antero-medial subcutaneous area of the left thigh. Bones and muscles of the rest of the thigh were normal. The patient underwent surgery with a probable diagnosis of hydatid cyst.
+On exploration, a cystic mass was revealed in the subcutaneous area of the right thigh. On cut section of the cyst, its color was white. The skin was closed primarily after thorough wash. On histopathological examination, diagnosis was made as hydatid cyst. The postoperative period was uneventful and the patient was discharged on albendazole at a dose of 400 mg. In follow-up of 8 months, the patient was asymptomatic without any recurrence."
+Louie McGuire,19,2005/5/8,325-984-9682,joshualeonard@example.com,32408 Coleman Brook Suite 248,"A 10-year-old boy presented with a 2-weeks history of tenderness and induration in the medial aspect of the right knee, after a fall on his leg. Physical examination revealed a 5 cm round, mobile mass, well circumscribed, without localized pain to palpation. The patient had no symptomatology before the traumatism.
+An X-ray of the right knee and its laboratory values including VSH, CRP, HLG, serum calcium, alkaline phosphatase, phosphorus, magnesium, were normal ().
+The IRM of the right knee revealed an oval soft tissue mass (6,5/3,5/1,5cm) on the medial side of the right knee. The lesion exhibited hypointense signal on MR T1-weighted images, isointense signal on MR T2-weighted images and moderate enhancement after injection of gadolinium ().
+The incisional biopsy revealed multiple reddish nodules, well circumscribed. The first histopathology examination established the diagnostic of villonodular synovitis. The second look, in the other department established the diagnostic of glomangyoma.
+In the meantime, the tumor developed outside the skin and became mushroom-like, painless (). After 2 months, we performed a surgical excision, followed by another histopathological examination. A histopathological diagnosis of glomus tumor was made. The postoperative evolution was very good, without local recurrence after complete excision."
+April Becker,45,1981/8/13,(234)234-9526x956,lorithompson@example.org,097 Kelli Points Suite 338,"A 34-year-old HIV-1-infected woman was admitted for dyspnea and acute bilateral pneumonia. HIV-1 infection had been diagnosed 8 years earlier during pregnancy, when she received only mother-to-child antiviral infection prevention. When her virus load (VL) reached 100000 copies/ml and CD4-cell count fell to 270/mm3 HAART with efavirenz, tenofovir and emcitrabine was started on 16 July 2008. Eight days later, she complained of fever and a persistent cough. Because no clinical improvement was obtained after 5 days of self-administered amoxicillin?lavulanate and ofloxacin, she was admitted; her chest X-ray showed bilateral interstitial pneumonia. Her diagnostic work-up found polypnea, cough and fever at 41簞C, and a biologically severe inflammatory syndrome (C-reactive protein: 190 g/dL) without eosinophilia. Arterial blood-gas determination showed severe hypoxemia PO2 45.6 mm Hg. The thoracic computed tomography (CT) scan revealed multifocal areas of branched centrilobular nodules and patchy ground-glass opacities with few lobular reticulates (Fi), without cavitation, pleural involvement or mediastinal lymphadenopathy. Bronchoalveolar lavage (BAL) cytology showed 950,000 cells/ml: 33% macrophages, 16% neutrophils, 8% eosinophils, no mast cells and 43% lymphocytes, with a CD4/CD8 ratio of 0.6. Direct BAL microscopy was negative for Pneumocystis jiroveci cysts, Mycobacterium species, Candida and viral inclusions. Histological examination of bronchial biopsies showed aspecific chronic inflammatory infiltrates. At this time, her HIV-1 VL was 5,322 copies/ml and CD4 T-lymphocyte count had reached 510/mm3 (25%).
+Because of the worsening of the pulmonary function, the patient was transferred to the ICU and improved rapidly, when HAART was interrupted, under cotrimoxazole and steroids (1mg/kg/day) initiated for suspected IRIS, unmasking of PJP, which was subsequently confirmed, after the elimination of other possible diagnoses, by both BAL positive Pneumocystis-DNA polymerase chain reaction amplification and careful microscopic reanalysis showing a few parasitic cysts."
+Lawson Gonzales,27,1993/1/29,641.383.9152x9050,pamelawoodward@example.com,47558 Mendez Rapids Apt. 491,"A 90 days old female patient, according to information given by the mother, had shown progressive signs of difficulty in swallowing and breathing, together with repeated incidences of cough and vomiting. The constant refusal to suck the pacifier and to be breastfed, meant that it took a long time to feed the baby. The medical report informed that there was a delay in weight gain. At the first medical examination, a voluminous and mobile tumoral alteration was noticed on the dorsum of the tongue, resting anteriorly, but it wasn? possible to stipulate whether it extended to the oropharyngeal area.
+A new exam was set and when the computer images were obtained ??for which the patient was sedated under spontaneous breathing ??a pediculated mass with a cylindrical body could be seen (phallic). It was located longitudinally on the dorsum of the tongue, with its base placed in the median furrow, at an almost equal distance between the apex of the tongue and the foramen cecum. The lesion was mobile to any direction, composed of a soft consistency, yielding to traction and with color and texture similar to those of the oral mucous membranes (Figure ).
+Computed topography images were obtained. Through the use of a non ionic oral radiocontrastant a polipoid lesion was clearly distinguishable on the dorsum of the tongue, measuring 2,1cm x 0,8cm. The use of an oral radiocontrast allowed not only for the delimitation of the lesion's contours, but also, its dynamics, demonstrating its movement from the dorsum of the tongue to the oropharyngeal area, suspending the soft palate (Figure ).
+Surgery was performed under general anesthetic, using nasotracheal intubation. A complete resection of the pedicle was performed, involving, in depth, the fibers of the superior longitudinal muscle of the tongue. After the hemostasis, the procedure was concluded with layer sutures to isolated points. The surgical specimen was stored in a 10% buffered formaldehyde solution and sent for anatomopathological analysis (Figure ).
+On the macroscopic examination a polypoid fragment of light brown tissue covered by a grayish and wrinkled mucous membrane was observed, measuring 0,8 x 0,9 x 0,8 cm. At the sections, in turn, it shows a bright light brown color.
+The microscopic examination revealed a polipoid lesion lined with keratinizing squamous epithelium, containing stroma, besides connective and adipose tissue, smooth and striated muscle and salivary glands (Figure - a,b,c,d).
+The postoperative period evolved without complications. In the five-month follow up there wasn? any recurrence and the patient, therefore, was considered free from the lesion."
+Hadley Reed,43,1980/10/3,375-425-0321x017,nkennedy@example.com,5324 Janice Park,"ZM, a 37 year old multiparous woman from Northern Tanzania, presented with complaints of generalized body swelling associated with progressive weight gain for ten years. The onset coincided with her last child birth which was complicated by mild post-partum haemorrhage following which she failed to lactate. She also experienced cold intolerance, loss of libido and a complete cessation of her menses. Four years prior admission she had had a serious febrile illness following which she experienced a brief period of altered level of consciousness and transient aphasia; since then she noted slowing of speech. As part of her systems review, she reported an anterior neck swelling which increased during her last pregnancy then gradually subsided a few months later. She also reported headaches of moderate intensity but no gross visual changes; she suffered from occasional rashes in sunlight exposed areas but no mucosal ulceration. Her past medical history revealed no previously diagnosed chronic illnesses; she was sero-negative for HIV and syphilis. Her obstetric history revealed she had a parity of five with four living children (one still birth at term with no obvious congenital malformations noted). Since she had received no formal antenatal care, there were no records of blood pressure measurements during pregnancy. All were home deliveries in the absence of a qualified birth attendant.
+Vitals: Pulse: 70/min; BP: 102/68 mm Hg; Temp: 36.2 degrees C; Respiratory rate 14/min. Orthostatics: Supine BP 110/80 mm Hg, standing BP 95/60 mm Hg. General/ endocrine: overweight woman (BMI 29. 1 kg/m2), looking younger than her stated age. She was pale with generalized, non-pitting edema involving face and extremities. Of note she had no oral ulcers and her thyroid gland was not palpable. She had ?labaster??skin with patchy hair loss over scalp; sparse axillary and pubic hair. Cardiovascular: Regular rate and rhythm with distant heart sounds. Respiratory/Abdominal exams were unremarkable. Neurologic Exam:Higher centres: Fully oriented to time, place and person but with marked slowing of speech and mentation. Cranial nerves: Optic nerve- Visual acuity 20/30 both eyes; gross visual fields normal at bedside. Fundoscopy: no papilledema noted. Extra-ocular movements were intact. Motor: Limbs hypotonic; power reduced to grade 4/5 MRC (Medical Research Council grade) with proximal weaker than distal muscle groups. Reflexes: Ankle jerks were delayed and plantar responses flexor. Sensation was normal for all modalities tested.
+Please see Table .
+Minor field defects were noted in both temporal fields.
+Chest X-ray: cardiomegaly, small left sided pleural effusion; Echo: 15 mm pericardial effusion, normal left ventricular function; X-ray of Sella: no evidence of mass lesion, symmetric floor (Figure ); Non-contrast axial head CT scan: possible asymmetric density within the sella turcica (but no ?mpty sella??sign); dorsum sellae poorly visualized (Figure ).
+The patient was started on hormone replacement therapy including thyroxine 50 mcg daily, prednisone 5 mg AM and 2.5 mg PM and a combined oral contraceptive. During her stay in the wards the patient? condition deteriorated abruptly due to an adrenal crisis probably precipitated by the vigorous thyroid hormone replacement. The dose of thyroxine was lowered to 25 mcg daily and the patient kept on normal saline and IV hydrocortisone 100 mg 6hourly. In addition, severe hyponatremia should be managed with water restriction and hypertonic saline infusion; the latter was avoided because of the difficulty monitoring Na+ levels and the associated risk of osmotic demyelination syndrome. Upon discharge three weeks later her rate of speech, mentation and exercise tolerance was significantly better compared to admission. On a two-month follow-up visit, there was a marked reduction in the generalised edema. The thyroxine dosage was subsequently increased gradually to 100 mcg daily. Her hair pattern had normalized in three months. At her five-month follow up visit, it was noted that she had developed livedo reticularis over her lower extremities bilaterally. (Figure ) She was subsequently started on anti platelet therapy (junior aspirin 75 mg daily) and the oral contraceptive stopped. The livedo reticularis had disappeared on a subsequent visit. At 16 months, the patient was in good general health except for a headache and occasional palpitations. At this juncture, the thyroxine dose was lowered to 75 mcg daily.
+This patient has anterior pituitary insufficiency beginning in the post partum period. Neurohypophyseal involvement is unlikely given the persistently elevated urine specific gravity even post steroid therapy which essentially rules out diabetes insipidus. The most likely differentials are lymphocytic hypophysitis (LyHy) and Sheehan? syndrome. An underlying co-morbid auto-immune condition such as systemic lupus erythematosus (SLE) or anti-phospholipid syndrome is a relevant clinical consideration but is made less likely given her negative antibody screens. Neoplasms and other granulomatous disorders of the hypophysis (tuberculosis, syphilis, sarcoidosis and histiocytosis X) are also possibilities but would be lower on the list of differentials in the absence of appropriate clinical and laboratory evidence."
+Easton Hebert,40,1982/3/10,001-871-481-0146,steven65@example.org,819 Kevin Drive Suite 020,"A 45-year-old woman was presented at the emergency department because of respiratory insufficiency. Her past history revealed allergic asthma with recurrent bronchitis. Five days before presentation, she developed a fever and diarrhea. The day before admission, she was seen by her general practitioner who prescribed Augmentin for a respiratory tract infection. Her chest X-ray showed complete opacification of the left lung (Figure ) with a differential diagnosis of pleural effusion, pneumonia, or complete left lung atelectasis. Because of progressive respiratory failure, she had to be intubated. Bedside ultrasound with a 5-MHz probe (GE FPA 2B 5 Mhz microconvex ultrasound probe, GE Healthcare Diagnostic Imaging, Hoevelaken, The Netherlands) parallel to the ribs in the anterior lower and upper thorax was conducted (Figure ). This revealed no pleural effusion but an irregular hypoechogenic area with air bronchograms and many hyperechogenic spots. The CT scan performed afterwards showed a practically complete consolidated left lung compatible with pneumonia."
+Kyleigh Barron,28,1994/7/23,001-526-932-3601x19663,yarnold@example.com,17361 Campbell Gardens Apt. 608,"A 16-year-old man was transferred from another hospital in cardiogenic shock which resulted from idiopathic dilated cardiomyopathy. He was supported with venous-arterial extracorporeal life support (ECLS). He required therapeutic anticoagulation because of the ECLS. There were intermittent problems with oxygenation that recovered spontaneously. After a few days, he continued to have low saturation with diminished breath sounds at the left side of the chest. A chest X-ray (Figure ) showed opacification of the whole left lung with the differential diagnosis of pleural effusion or total atelectasis of the left lung. Bedside ultrasound with a 5-MHz probe (GE FPA 2B 5 Mhz microconvex ultrasound probe) parallel to the ribs of the anterior lower and upper thorax revealed total left lung collapse and a surrounding hypoechogenic area suggestive of pleural effusion (Figure ). The pleural line was not visible in the collapsed lung. This patient was treated with bronchial suction by bronchoscopy and nursing in the right-sided position. A rigid sputum plug was removed from the left main bronchus. After this, the chest X-ray appeared nearly normal, indicating that the therapy had been effective."
+Dustin Dodson,43,1986/3/2,604-434-9553,michaelryan@example.com,866 Avery Lock Suite 865,"A 60-year-old female presented with 4-week history initially of dry cough and night sweats with subsequent nausea and weight loss. Her past medical history, social and occupational history, and systematic questioning did not reveal further relevant information; neither headache nor visual disturbance was noted. Her drug history included Rosuvastatin 10 mg daily, Glucosamine 500 mg thrice daily, Ibuprofen, and Salbutamol inhaler as required.
+She had a temperature of 39簞C and physical examination was unremarkable. There was no temporal tenderness and no limb girdle tenderness or weakness. Fundoscopy showed normal vessels.
+Initial laboratory tests showed raised CRP 335 mg/L and ESR 62 mm/hr with elevated liver enzymes showing a mixed picture with total Bilirubin 8 弮mol/L, ALP 589 U/L, GGT514 U/L, ALT 112 U/L, AST 47 U/L, and albumin 36 g/L. Chest X-ray was reported as normal.
+Ultrasound scan (USS) of abdomen showed a stone in the gall bladder with a normal common bile duct. Magnetic resonance cholangiopancreatography (MRCP) confirmed USS findings and showed a normal biliary tree. Her atypical infective screen was negative including blood cultures, and a serologic screen for viruses, atypical bacteria, and fungi. Her liver screen including hepatitis serology and autoantibody screen was negative.
+CT scan of chest, abdomen, and pelvis showed a spiculated nodule in the posterior region of the apex in the left upper lobe of the lung. Bronchoscopy was unremarkable and the washings of left upper lobe lesion were negative. The lesion was considered to be longstanding and related to previous resolved inflammation.
+She continued to be pyrexic with worsening liver functions. She then underwent liver biopsy which showed lobular granulomatous inflammation with no significant Kupfer activity or inclusions ().
+A whole body positron emission tomogram (PET) showed increased metabolic activity within central large vessels; thoracic and abdominal aorta; proximal carotids and subclavian arteries (). These findings were strongly suspicious of a large vessel vasculitis. Temporal artery biopsy confirmed giant cell arteritis ().
+Treatment with steroids resulted in prompt resolution of her symptoms and normalizing of CRP, ESR, and liver functions. A followup PET scan in 2 months showed complete resolution of previous abnormalities confirming a positive response to treatment."
+Etta Lawrence,25,1989/10/14,(215)235-0831,shannonweaver@example.net,9036 Mendez Forest Suite 260,"A 62-year-old female with ulcerative colitis in remission was found to have a 20 mm submucosal protuberance at the appendiceal orifice during surveillance colonoscopy (). EUS (12 MHz TTS mini probe, Olympus America, Center Valley, PA) demonstrated a hypoechoic lesion with an anechoic heterogeneous center in the appendix (), suggestive of mucocele. Patient underwent a successful laparoscopic appendectomy. Histology revealed mucinous cystadenoma of proximal appendix."
+Kaleb Marks,25,1982/6/25,001-920-430-5378x58573,sarah63@example.net,7769 Brown Bridge,"A 34-year-old female undergoing colonoscopy for evaluation of bloody diarrhea was found to have mild pan colitis (biopsy revealed ulcerative colitis) with an incidental finding of a bulging appendiceal orifice (). EUS revealed an anechoic and homogeneous lesion measuring 20 mm in thickness with well-defined borders and lack of invasion to nearby structures (). The mass was suspicious for appendiceal mucocele. Patient underwent appendectomy without any complications. Histological examination of the resected appendix revealed adenomatous changes with nuclear hyperchromasia and elongation, best seen at crypt bases with abundant mucin (Figures and ). In addition, there is depletion of the normal underlying population of lymphocytes. This set of findings is consistent with the diagnosis of appendiceal mucinous cystadenoma."
+Monica Greene,26,1981/8/30,521-625-2355,susanwagner@example.com,98082 Williams Points,"A 15-year-old boy without any medical history was referred to our hospital for osteomyelitis of the sternum and a subcutaneous abscess extending over half of the anterior chest wall. The patient's chest had been elbowed by an opponent during a basketball game 19 days earlier. He stated that there were no abrasions or lacerations at the time of injury, but 10 days later, he developed chest wall swelling () and fever. He consulted a local orthopedist and underwent chest computed tomography (CT), leading to provisional diagnosis. The chest mass was punctured, and the pus was drained. Subsequently, the patient was sent to our hospital. Chest CT revealed a sternal fracture and extensive fluid collection in the chest wall (). Increased density of the region behind the sternum was also observed, but we concluded that inflammation had not affected the anterior mediastinum. Because the patient did not appear severely ill, we performed pus drainage from a minimal incision and subcutaneously applied a 19 Fr silicone drain connected to a closed drainage system (BLAKE drain and J-VAC Reservoir; Johnson and Johnson Medical, Tokyo) under general anesthesia. The drained material yielded a Staphylococcus aureus isolate on microbiological culture; this culture was sensitive to all antibiotics tested. The patient was treated by intravenous administration of sulbacillin for 2 weeks, followed by oral administration of tosufloxacin for 10 days. The drain was removed on postoperative day 14. The patient was discharged on postoperative day 26, and antibiotic therapy was discontinued. While infectious granulation was observed at the drain tube-penetrating site for a few months after discharge, complete epithelialization of the site was confirmed 4 months after the surgery. Follow-up CT performed 4 months after surgery showed disappearance of fluid collection and ossification of the fracture site (). The patient did not show any symptoms and signs of recurrence 6 months after the surgery."
+Griffin Phillips,31,1990/6/14,7234822846,stephen55@example.org,415 Alexander Parks Apt. 634,"A 39 y/o male patient presented with a 2-month history of decreased vision, halos, pain, and photophobia of the left eye. The patient was diagnosed with keratoconus at age 16, for which he used rigid contact lens in the left eye, with a best corrected visual acuity (VA) of 20/60. The patient's past medical history revealed that he had a complicated vaginal delivery with the use of obstetrical forceps.
+Clinical examination showed a VA of 20/400 in the left eye with a refraction of ??.00 + 5.00 ? 095 and a stable VA of 20/20 in the right eye with a refraction of ??.00 + 0.50 ? 180. Slit lamp biomicroscopy displayed corneal stromal and epithelial edema associated with centrally located parallel vertical opaque lines at the level of Descemet's membrane (). The right eye had no corneal changes and the intraocular pressure and the posterior segment examination was unremarkable in both eyes. Further studies included a corneal topography (Orbscan) that ruled out keratoconus and showed regular astigmatism of 5.7 D at an axis (097簞) that correlated with the location of the striae on slit lamp, and an anterior segment OCT that showed hypereflective linear structures protruding into the anterior chamber at the level of the posterior cornea.
+A diagnosis of corneal edema secondary to endothelial decompensation in the left eye secondary to forceps injury and history of Descemet's membrane break was made. The patient underwent a Descemet's stripping automated endothelial keratoplasty (DSAEK) in order to replace the diseased posterior corneal lamella that included a Descemet's membrane previously traumatized by the obstetrical forceps, and an endothelium that had undergone gradual decompensation. The stripped Descemet's membrane was submitted for histopathological evaluation. The patient had good visual outcome after DSAEK with BCVA of 20/80. Slit lamp examination revealed a well appositioned graft, and a clear cornea with minimal superficial scarring (). Mild superficial corneal scarring and preexisting amblyopia limited final visual acuity.
+Histological examination of the stripped Descemet's membrane revealed endothelial attenuation and a thickened PAS-positive membrane with areas of nodular thickening at the edge of the initial break composed of concentric deposits of PAS-positive material ()."
+Naomi Vance,38,1985/2/15,+1-335-805-7222x811,freemanchristopher@example.com,260 George Squares,"A 54-year-old man presented with small seropurulent discharging lesion located at the junction of upper one-third and lower two-thirds of the anterior border of the sternocleidomastoid muscle (). The lesion started as a small nodule three months back which busted after two weeks and resulted in a small ulcer with seropurulent discharge. Patient did not have previous history of swelling in the neck. Examination of the oral cavity was normal. Clinically, the possibility of brachial fistula or tubercular sinus was considered. Biopsy was taken from the fistula, which revealed chronic inflammation and no evidence of tuberculosis. A fistulogram showed that the fistulous tract was communicating with the submandibular duct (Wharton's duct) (). No stone was detected on the X-ray.
+The diagnosis of orocutaneous fistula with communication with the submandibular duct was hence made. Excision of the submandibular gland and the fistulous tract was carried out. The tract was found to be communicating with the submandibular duct and a small stone was present in the duct just distal to the point of communication between the fistulous tract and the submandibular duct. Postoperative recovery of the patient was uneventful."
+Casen French,39,2002/10/1,383-526-7763x218,cooksamantha@example.com,14439 Betty Locks,"A 23-month-old girl presented to our facility with one week of worsening fevers, productive cough, and increased work of breathing. Over the previous 3 months, she was treated for presumed upper respiratory tract infections with inhaled beta-agonists, inhaled steroids, oral steroids, and several different oral antibiotics. Relevant medical history was significant for prematurity and severe anemia necessitating intrauterine blood transfusions, CDA diagnosed at 20 months by bone marrow biopsy and aspiration that was morphologically consistent with type II, and surgical placement of a Port-a-Cath for chronic blood transfusions.
+Initial vital signs were temperature 37.9 degrees Celsius, heart rate 156 bpm, respiratory rate 50/min with oxygen saturation 83% on room air and 98% on 1 LPM oxygen by nasal cannula, and blood pressure 115/61 mm Hg. She appeared in mild distress with increased work of breathing. She had moderate frontal bossing with open anterior fontanelle. Heart examination was significant for a II/IV systolic ejection murmur. Lung exam revealed diffuse rales bilaterally but no wheezing. Abdomen was not distended. The liver was palpated 4 cm below the costal margin, and the spleen palpated to the level of the umbilicus. She had no clubbing, cyanosis, or peripheral edema.
+Chest radiograph showed diffuse ground glass alveolar infiltrates which were chronic in nature when compared to a chest X-ray from one year prior (). Blood, urine, and respiratory cultures were sent, and the patient was started empirically on oral azithromycin and parenteral ceftriaxone.
+On day 3, a transthoracic echocardiogram revealed a patent foramen ovale but no cardiomyopathic process. An abdominal ultrasound confirmed hepatosplenomegaly. Repeat chest X-ray showed no changes, and chest CT was offered but the parents refused.
+Despite 4 days of antibiotics, the patient continued to spike intermittent fevers and was still on oxygen treatment, and there still were no changes on chest radiograph. Bronchoscopy was performed and was anatomically normal. The bronchoalveolar lavage (BAL) fluid was cloudy in appearance and revealed no evidence of aspiration or malignant cells. Grocott's methenamine silver (GMS) stain was negative for Pneumocystis jirovecii. Ziehl-Neelsen stain was negative for acid-fast bacilli (AFB). Fungal, bacterial, AFB, RSV, and influenza cultures of BAL fluid revealed no growth. Differential of the WBCs indicated 68% macrophages, 12% PMNs, and 10% lymphocytes. Light microscopic examination of BAL fluid using Periodic acid-Schiff (PAS) stain was positive for abundant amorphous material within the pulmonary macrophages and also in larger extracellular aggregates suggesting pulmonary alveolar proteinosis (). The lipid-laden macrophage (LLM) index was 120 [].
+On day 5, the patient's work of breathing improved, lung sounds improved, and the supplemental oxygen was decreased to 0.5 LPM by nasal cannula. Antibacterials were discontinued. On day 7, BAL fluid was positive for cytomegalovirus (CMV) by indirect fluorescent antibody testing and serum CMV IgG and IgM antibodies were detected by immunoassay, while CMV DNA of the blood remained negative. Ophthalmologic examination revealed no signs of CMV retinitis. The patient was started on parenteral ganciclovir. On day 9, the patient was weaned off supplemental oxygen to room air. She continued IV ganciclovir and was discharged from the hospital.
+After completion of two weeks of ganciclovir, the patient presented to her hematologist's office for scheduled followup and blood transfusion. Chest X-ray was repeated and showed minimal interval improvement in the diffuse coarse reticular opacities noted on X-ray from her most recent hospitalization. Again, the parents refused CT scan. The patient was subsequently lost to followup. Several months later she was admitted to a hospital in another state in respiratory failure. Per report, she required intubation and BAL was performed, which confirmed PAP."
+Lorelai Duke,20,1985/4/5,813.572.8372x99775,ericreyes@example.com,54234 Waters Mills,"The patient is a 55-year-old female with known stage III b serous ovarian cancer. She had undergone an abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy, followed by 6 cycles of carbo/taxol chemotherapy with complete clinical response. She was free of disease for 2 years until her disease recurred and was treated with Carboplatin and Taxol. The carboplatin was eventually switched to Doxil. However, the repeat positron emission tomography (PET) scan at that time showed progression of her disease. Thus she underwent exploratory laparotomy with removal of a splenic mass. She was noted to have peritoneal carcinomatosis at that time and was then treated with Gemzar. The patient had stable disease after this treatment. Five years after the initial diagnosis, the patient was admitted to the hospital with anemia, hemoglobin of 7.0 gm/dl, fatigue, and melena. Computerized Tomography (CT) of the abdomen without IV contrast was obtained on admission, which revealed calcified, heterogeneous, mixed intermediate and high-density deposits worrisome for peritoneal carcinomatosis (, arrows). No IV contrast was administered due to her poor kidney function. She was referred for an EGD, which showed a 7 mm erythematous lesion at the gastroesophageal junction and a 1.5 to 2 cm subepithelial mass () with a superficial overlying erosion in the antrum, but no obvious source for any active bleeding. Initial endoscopic biopsies of the gastroesophageal junction lesion showed granulation tissue polyp with foveolar hyperplasia, and the antral biopsies were normal. Due to the presence of a subepithelial lesion in the antrum, the patient was referred for EUS. Two subepithelial lesions were discovered by EUS, one in the antrum measuring 3.4 ? 3.7 cm () and one in the body of the stomach 1.2 ? 0.8 cm (). The lesion in the body of the stomach was not appreciated during the EGD. The lesions were hypoechoic masses emanating from the muscularis propria and had the typical appearance of gastrointestinal stromal tumors. FNA was performed of both masses. Both sites revealed papillary adenocarcinoma from an ovarian papillary serous adenocarcinoma primary (). Immunostains for progesterone receptor, estrogen receptor and p 53 were focally positive and confirmatory. The patient was treated with Taxol and is undergoing surveillance imaging."
+Kalel Copeland,18,1979/3/8,913.587.9767x677,tonirogers@example.net,2805 Kurt Gateway,"A twenty-year-old Cameroonian woman, gravida 1 para 0 presented at 35 weeks gestation to the antenatal consultation unit of our hospital with an unusually distended abdomen, for her first antenatal care visit. Her past medical history revealed a herniorrhaphy three years prior to this consultation, for a congenital umbilical hernia.
+On physical examination, the patient's general condition was satisfactory. She was afebrile with a pulse rate of 70 beats per minute and a blood pressure of 100/60 mmHg. She had moderately colored conjunctivae and her cardiopulmonary examination was normal. Her abdomen was unduly distended around the central area, with a hyperpigmented necrotic scar overlying the paraumbilical area. Abdominal palpation revealed complete absence of abdominal wall around the paraumbilical area overlying the uterus. This hernia orifice was about 15 cm by 10 cm. Most of the gravid uterus protruded via this orifice in a standing position (). The fundal height was estimated at 32 cm. The foetal lie was longitudinal, and foetal parts could easily be palpated across the herniated gravid uterus. Foetal heart sounds were regular and there was no evidence of uterine contractions. The skin around the hernial sac was hyperpigmented, necrotic, and very tense. Vaginal examination revealed a firm, long, median, and closed cervix; the rest of the clinical examination was unremarkable.
+Blood and urine analysis were within normal limits. Our hospital did not dispose of an ultrasound machine for further foetal evaluation.
+We discussed the possibility of hospitalisation and an elective caesarean section but the patient declined the proposal due to financial constraints and chose to return home against medical advice. Topical antiseptics were given to the patient to apply on the abdominal skin, and the next visit scheduled in one week.
+She however presented three weeks later at the maternity in active labour. Clinical evaluation revealed foetal bradycardia with a foetal heart rate at 90 beats per minute. An emergency transverse lower segment caesarean section was performed under general anaesthesia (for acute foetal distress). The incision was paramedian, avoiding the necrotic zones. Just beneath the skin was a large round umbilical hernial sac containing the gravid uterus. We found remnants of the chromic catgut sutures used to repair the umbilical hernia three years ago. We did a transverse lower segment incision on the uterus extracting a live male foetus weighing 3400 g. The APGAR scores were 5 and 7 at the first and fifth minutes, respectively. The placenta was anterior corporeal. Following satisfactory haemostasis on the uterus, we concomitantly repaired the hernial orifice. This was done by excision of all zones of necrotic tissue, reduction of the hernia sac, end-to-end approximation of the orifice borders, and reinforcement of the rectus abdominis muscles. Excess and necrotic skin was removed before closure of the skin. The surgery lasted close to two hours. The postoperatory period was uneventful; the wound healed by primary intention, and the patient was discharged on the eighth day postoperation. She was seen six weeks later during her postpartum visit. She was enjoying relatively good health, her scar was well healed, and her baby was doing well."
+Dayana Robinson,32,1993/6/24,001-867-258-7571x21877,morganerickson@example.com,626 Bates Mews,"A 23-year-old woman in her first pregnancy with an ordinary follow-up and no previous medical history attended our ultrasound unit for a 20-week scan. The sonographic findings (levorotation of the cardiac axis, pericardial effusion, large overriding aorta, perimembranous ventricular septal defect, and narrow pulmonary artery) (Figures and ) diagnosed tetralogy of Fallot. The right atrium was slightly enlarged, and the fetus presented dysplastic (multicystic) kidneys with oligohydramnios (). Due to the dreadful prognosis, the parents decided to terminate the pregnancy. The postmortem study confirmed the sonographic findings; however, it showed a right-sided aortic arch and an abnormal cloacal septation (imperforate anus with a sigmoid colon opening in the posterior side of the bladder) (Figures and ), which was not seen prenatally. Although the FISH showed only two copies of the X chromosome probe, with absence of a SRY marker, an external male genitalia with hypospadias was present (). Internally, the uterus and fallopian tubes were missing and only two small streak ovaries with oogonia at both sides of the bladder were seen. Genetic test was also performed to rule out microdeletions in the chromosome 22 and mutations in the genes causing 21-hydroxylase-deficiency. All with negative results."
+Matthew Bass,23,1991/6/25,001-250-985-5637x645,katherinemorgan@example.net,326 Patrick Club Apt. 452,"A 51-year-old female patient was attended at the Otorhinolaryngology Clinic of the University of Campinas Teaching Hospital (Campinas, Brazil) on November, 2009, for an oral cavity verrucous lesions evaluation (). Patient reported that she had the lesions since birth and they were presenting a painless progressive slow growth in the left hemiplate and bilateral superior labiogingival sulcus. Physical examination showed nasal columella involvement, extending throughout the upper lip, soft and hard palate, and oropharynx with total preservation of the facial midline.
+At the age of 16, patient had a left parotid gland myxoid tumor, being submitted to a partial parotidectomy surgery. After two years, the tumor returned, and she had another surgery. During the new operation, the left facial nerve was injured, resulting in an ipsilateral peripheral facial paralysis. After the procedure, patient received adjuvant radiotherapy.
+There are no data regarding the palate lesion pattern before or after these treatments. However, the patient and her family did not reported any lesion change during the subsequently years.
+After 11 years since the first procedure, the patient attended at the Otorhinolaryngology Clinic for a palate lesion evaluation. An incisional biopsy was made and the histopathological result reported presence of both gingival e palate tissues with stratified and cornified epithelium, severe hyperplasia, and mild chronic inflammatory infiltration (Figures and ). The analysis showed no signs of malignancy or external agent infections (e.g., Candida spp, HPV). The final diagnosis was oral linearepidermalnevus.
+The follow-up decision was to do lesions evaluations every six months. During the first period, the lesions remained the same. Patient is currently under the Otorhinolaryngology Clinic care."
+Zahra Maynard,44,2002/5/8,(886)618-0572x2652,cherrydaniel@example.com,309 Eileen Course Apt. 827,"A 26-year-old male patient was diagnosed as AML-M2 in 1995. Following an induction regimen he achieved complete remission (CR) and received an allogeneic peripheral blood stem cell transplantation from his 37-year-old HLA identical brother in 1997. The conditioning regimen consisted of busulfan and cyclophosphamide, and the GVHD prophylaxis was done with cyclosporin and short-term methotrexate. He did not develop any acute or chronic GVHD and remained in CR with complete donor-type chimerism until 2008 when he was admitted to the neurosurgery clinic with back pain. The vertebral MRI revealed a tumor invading the 6th thoracic vertebrae causing pathological fracture. The tumor was completely excised, and the pathological evaluation was consistent with CD38++ and CD117+ atypical plasma cell infiltration with kappa monoclonality. He had IgG kappa monoclonal gammopathy on immune electrophoresis and an elevated erythrocyte sedimentation rate along with a mild anemia and normal renal function tests. Bone marrow (BM) examination revealed 9% plasma cells with CD38+CD138+CD19?D56?D44+CD28?D20??immunophenotype and kappa predominance. The cytogenetic study did not detect any abnormality. Bone marrow chimerism analysis was consistent with 100% donor type in both T-and non-T-cell lineages. Chimerism study was also done with the DNA extracted from the plasmacytoma and revealed 18% donor and 82% recipient cells (). The presence of EBV could not be demonstrated in BM or plasmacytoma by in-situ hybridization for EBV early RNA as well as PCR analysis of EBV DNA. The donor was also found to be negative for signs of secretory paraproteinemia. The patient received 3000 cGy local radiotherapy to T5?7 level of the spine and high-dose oral dexamethasone. After attaining a CR, it was decided to perform an allogeneic HCT without immunosuppression, instead of the general approach of autologous transplantation, since he had complete donor type of chimerism. Following a nonmyeloablative conditioning with fludarabine and melphalan a hematologic engraftment was achieved. The BM and blood examinations revealed CR for myeloma and a continued complete donor-type chimerism. The patient developed a grade 2 acute GVHD of skin which was controlled with steroids, but acute grade 3 gastrointestinal GVHD required the addition of cyclosporin. Later immunosuppression could be tapered off completely without causing rebound GVHD. He continued in CR until one year after transplantation when he developed progressive mucor sinusitis and infectious meningitis and eventually died."
+Landry Pugh,36,1988/9/26,(504)329-2421x7527,pdalton@example.com,381 Thomas Islands,"A 39-year-old Japanese woman with a history of one miscarriage at 6 weeks' gestation had become pregnant under anticoagulation treatment of 2500 U danaparoid sodium because of her osteoporosis and osteonecrosis of femoral head and 100 mg aspirin per day from 4 weeks' gestation at Nagoya City University Hospital. She has had a 22-year history of SLE, which had been in remission for more than 4 years under a treatment of 5 mg prednisolone daily.
+At this point, our case was not diagnosed with APS, because she suffered from only one miscarriage. However, we planed to do anticoagulant treatment during pregnancy, because her lupus anticoagulant (LA) [] was ascertained to be strongly positive by diluted activated partial thromboplastin time (aPTT) methods and diluted Russel's viper venom time (RVVT) before pregnancy. Prednisolone therapy was interrupted before this pregnancy because the patient thought it affected infertility.
+Her edema and protein urea appeared at 17 weeks' gestation (). Her blood pressure was 121/78 mmHg and laboratory studies showed anti-帣2-glycoprotein I (帣2GPI) 9.4 U/mL (normal range < 1.9), aPTT 30%, LA by aPTT 30 seconds, LA by RVVT 1.47, and urinary protein 2.0 g/day at 17 weeks of gestation. At 21 weeks of gestation, she had body edema and protein urea (8.1 g/24 h). Laboratory studies were shown in . At 21 weeks of gestation she was hospitalized because of severe edema and acute renal dysfunction, and treatment of 40 mg prednisolone daily started at 22 weeks of gestation.
+She had developed epigastralgia and vomiting. Thrombocytopenia and hemolytic anemia together with liver and renal dysfunction and an elevated level of C-reactive protein were observed (). At 22 weeks and 6 days of gestation, emergency cesarean section was performed because of fetal distress with loss of variability and severe late deceleration, abnormal Doppler flow velocimetry waveform analysis suggestive of fetal hypoxemia, and the HELLP syndrome. The baby was weighting 414 g, and the clinical manifestations were morphologically normal. Four days after birth the baby died of pulmonary hemorrhage. Placental infarction was pathologically found.
+Her laboratory examinations showed liver dysfunction, and the data from coagulation studies indicated the diagnostic criteria for DIC. Intravascular infusion of nafamostat methylate together with antibiotics, gamma-globulin 15 g, and platelet transfusion gradually improved the clinical symptoms and laboratory abnormalities. The patient had no fever or persistent epigastralgia. Her blood pressure was 140/92 mmHg and pulse was 118 per min under antihypertensive therapy. Her renal biopsy showed lupus nephritis INS/RPS class IV with mesangial interposition, massive subendothelial, subepithelial and mesangial deposit, fibrinoid necrosis, karyorrhexis, swelling of endothelial cells, and foam cells. The patient was diagnosed MAPS. Then multitarget therapy (prednisolone, cyclosporine, and mizoribine) was started.
+Presently, the patient is now being treated as an outpatient who is asymptomatic, while continuing treatment with cyclosporine A (75 mg/day), mizoribine (100 mg/day), and prednisolone (25 mg/day). Anticoagulation with warfarin (2 mg/day) was started to a target international normalized ratio (INR) of 2-3."
+Landry Cain,29,1996/9/3,782.573.4663x08385,donald07@example.org,2521 Ayala Trail,"A 45-year-old male was transferred to our facility from an outside institution with the diagnosis of TEF and the presence of a possible foreign body seen on CT scan of his chest. The patient gave a history of recurrent pneumonia and cough in the last few months. Prior to presentation to the hospital, the patient had finished a course of antibiotics. Despite this, he complained of increasing cough over the prior week but no history of dysphagia, hemoptysis, hematemesis, or chest pain. The physical exam was unremarkable except for inspiratory crackles and diminished breath sounds heard at the lung bases. Axial CT images of the chest both with and without intravenous contrast were obtained. A small, linear, walled air collection was noted just above the carina tracking towards the esophagus, a finding suspicious for a tracheoesophageal fistula ().
+Under sedation and spontaneous ventilation, bronchoscopic and endoscopic examinations were performed. A hard, disc-shaped foreign body was impacted in the esophagus and was also protruding into the lumen of the distal trachea (see ). Gentle attempts to remove the FB were unsuccessful and aborted. Two days later the patient underwent a thoracotomy for foreign body removal and TEF repair. Mask ventilation was easy with low positive inspiratory pressures. A left double lumen tube was placed via direct laryngoscopy. With fiberoptic bronchoscope (FOB) allowing for direct vision, the bronchial lumen was advanced into the left main stem bronchus with subsequent deflation of the right lung. With the double lumen ETT in position, ventilation of only the left lung avoided any air insufflations through the fistula into the esophagus (due to the anatomical location of the fistula 1 cm above the carina). The patient was placed in the left lateral decubitus position and the ETT placement again confirmed with the FOB. Surgical approach was via right thoracotomy, with removal of the foreign body and primary repair of both the trachea and the esophagus. After the surgery the patient resumed spontaneous ventilation and was extubated prior to transfer to the ICU. Pathology confirmed that the foreign body was a dental plate. Later, the patient revealed that after an appendectomy 5 years ago, he could not find his partial dental plate."
+Benson Tang,30,1979/12/22,858-879-9608x698,campbellryan@example.net,886 Lisa Forge,"A 37-year-old man developed alopecia totalis, loss of eyebrows and eyelashes and widespread thinning of the hair since 31-years-old with no personal or family history of vitiligo. He had been treated with corticosteroid with diagnosis of AA with good response to the treatment but due to adverse effects, the treatment was discontinued and DPCP 0.5% for 4 months (once a week) in hair loss regions was commenced following washing the areas 5 hours later with no prior sensitization that resulted in the first sign of hair regrowth in early fourth week and nearly total hair of head with regrowth of eyebrows, eyelashes and beard at the third month. Some vitiligo patches were revealed on his scalp and arm distant from the location of DPCP application and they preceded by contact dermatitis of the scalp (Figures and ). Then dark hair in the depigmented patch was gradually replaced on the scalp with white hair. Complete blood count and biochemical profile were normal and antinuclear antibody test was negative but antithyroid peroxidase was in high range (29.7; normal ranges up to 16) in this case."
+Belle Bowman,24,1977/11/12,+1-827-754-6966x2300,melissabaird@example.net,3420 Christopher Square,"A 42-year-old woman with 25 years history of hair loss and a mean duration of 3 months DPCP therapy before the onset of vitiligo is the second case. The first presentation of the disease was generalized hair loss. She had been treated with corticosteroid with the diagnosis of AA for several years but due to low effectiveness, the treatment failed. She complained of coin shape hair loss in her scalp and body since 17-years-old. In physical examination rounded irregular patches varying from 1 to 2 cm mostly in occipital and parietal regions were observed. She had no personal or familial history of vitiligo. In our center, the patient was treated with intralesional corticosteroid and topical minoxidil but due to the remain of hair loss patches, topical DPCP 0.5% was prescribed once a week without prior sensitization. The treatment resulted in the first sign of white hair regrowth at the 6th week, and some vitiligo patches appeared on the scalp with even white and dark hair, as well as on her face, after 5 months distant to the site of application. A marked reaction with macular erythema was obvious on her scalp after the first time application of DPCP but it subsided a few days later. There has been no relapse of alopecia in several months followup after discontinuing of DCP therapy and the depigmented areas remained unchanged.
+A growth of dark hair within the vitiliginous patch on both patients was probably due to activation of follicular melanocytes by a nonspecific effect of contact dermatitis. Vitiliginous patches at the sites of contact with DPCP may be the consequence of postinflammatory hypopigmentation."
+Francisco Evans,32,1998/7/9,+1-852-319-8583x425,jennifermcdonald@example.net,52480 Joseph Corners Apt. 925,"A 24-year-old man presented at our clinic with a four-year history of a painful nodule in his left cheek that reoccurred after two attempted excisions in the last four months by different specialists. No biopsy result or other histological information was available. Otherwise healthy, the patient complained of pain and local tenderness. Clinical examination revealed a well-defined, round, firm nodule in the middle of the left cheek, approximately 1 ? 1 cm in size that appeared to be subdermic with no apparent fixation to the underlying tissues. The overlying skin was normal and the nodule was extremely painful on palpation. Examination of the oral cavity was normal and no neck lymph nodes could be palpated. Complete head and neck examination and laboratory tests were also unremarkable. Contrast enhanced CT (puffed cheek method) revealed a well-defined, contrast-enhanced, round soft-tissue mass of the left cheek over the buccinator muscle measuring 13.8 ? 9 mm, with no apparent relations to the surrounding tissues (). Attached to it a very small satellite lesion was noted. In the operating room under local anesthesia, a relatively wide excision in order to remove both the masses was performed. Though we were not able to demarcate the main and satellite nodules macroscopically, no evidence of residual disease was apparent. Special care was taken regarding the protection of facial nerve branches and the cosmetic result. Histological examination of the specimen was consistent with the diagnosis of glomus tumor of the solid type, with no mention of potential residual disease (). The patient reported relief of his symptoms after surgery, but at 2-month followup he complained of gradual recurrence of local tenderness at the site of the excision. Three months later, the patient had a small palpable nodule and complete recurrence of his symptoms. Under local anesthesia, a very wide excision including the previous scar (with approximately 1 cm margin around the scar) was performed. Histological examination revealed glomus tumor with solid, angiomatoid, and angiomyomatous features (). The margins of the excision were reported as free of lesion. The patient remains without any symptoms nine months after surgery."
+Eliana Avalos,30,2001/7/4,734-239-2066,harrisdebbie@example.com,305 Mccormick Rue Suite 514,"A 65-year-old woman presented with a mass 6 cm in diameter located on her right frontoparietal region. The mass had appeared approximately three months earlier and had grown rapidly. The patient's history included resected colorectal adenocarcinoma followed by general surgery and was disease-free for five years. She was referred to us because the swelling and pain indicated a sebaceous cyst or a benign soft tissue tumor (). The mass was indurated, round, and adherent to the deep planes. Mild alopecia and skin expansion due to the mass were observed on her anterior scalp. The patient complained of tenderness and mild pain when the mass was palpated. Our clinical differential diagnoses included sebaceous cyst, lipoma, or localized soft tissue tumors. But the plain radiographs and the computerized tomography demonstrated a destructive mass which was eroding the bone over the right frontoparietal region ().
+A transverse incision and a meticulous blunt dissection that were performed under local anesthesia exposed a rubbery soft tissue mass extending to the outer table of the skull. The mass was dissected with care. However, we noticed calvarial bone destruction with an exposed duramater and lytic lesions 2 ? 3 cm in size around the calvarial defect. The mass was completely resected. The mass was measured to be 5.5 ? 5.0 ? 2.0 cm (). The damaged bone sites were resected with a 1 cm security margin. A section of the duramater measuring 2 ? 3 cm was removed and the defect was reconstructed using a tensor fascia graft by the brain surgeons. Hemostasis was achieved using electrocautery and bone wax. A bolster dressing was applied following the primary closure of the skin incision. The specimen was sent for histopathological analysis. The patient was monitored closely for one day and was discharged the next day.
+Histopathologic findings revealed many low differentiated adenoid, and apoptotic and necrotic spaces lined with atypical epithelial islands with vesicular nuclei. At high-power magnification, the specimens showed cytologic atypia with pleomorphic and hyperchromatic nuclei. Immunohistochemical analysis was positive for carcinoembryonic antigen (CEA), villin, and cytokeratins 7 and 20. The specimens were negative for vimentin, chromogranin, thyroglobulin, thyroid transcription factor 1 (TTF-1), and CDX2. The final diagnosis was metastatic low-differentiated adenocarcinoma compatible with the immunophenotype of colorectal adenocarcinoma (Figures , , and ). After the histopathological evaluation revealed metastatic adenocarcinoma, the patient was referred to the medical oncology department."
+Coen Carlson,30,2005/8/25,473.344.9274,williamfloyd@example.org,34942 Robert Roads Suite 651,"A 48-year-old woman presented with epigastric discomfort. Upper gastrointestinal (GI) endoscopy revealed severe mucosal atrophy in the gastric corpus. Magnifying endoscopy of the corpus revealed closely arranged small round and oval pits with a surrounding network of capillaries. In the antrum, both conventional and magnifying endoscopy demonstrated no abnormal features, and the patient was tentatively diagnosed as having autoimmune gastritis [?. Biopsy specimens were taken from both the antrum and the corpus. The histology of the antral mucosa was normal, whereas that of the corpus exhibited severe atrophy. The serum gastrin level was 4440 pg/mL (reference range: <200 pg/mL), and the level of antiparietal cell antibody was ?160 positive. The patient was negative for anti-intrinsic factor antibody and anti-H. pylori antibody IgG, and the urea breast test gave a result of 2.2??(reference range: <2.5??. The diagnosis of autoimmune gastritis was therefore confirmed."
+Kali Adkins,32,1992/6/14,+1-868-265-8822x726,dillonstone@example.com,6673 Robert Lane,"A 72-year-old woman presented for a routine health check. Upper GI endoscopy identified severe atrophy of the mucosa in the gastric corpus (), and magnifying endoscopy showed a pattern of closely spaced small round and oval pits (). Conventional endoscopy of the antrum demonstrated no abnormality, suggesting a diagnosis of autoimmune gastritis. As this endoscopic examination was part of a routine health check, no biopsy was performed. However, serum samples revealed a gastrin level of 1800 pg/mL (reference range: <200 pg/mL) and antiparietal cell antibody ?40 positive, with negativity for anti-intrinsic factor antibody and anti-H. pylori antibody IgG. Autoimmune gastritis was therefore confirmed."
+Kylo Stafford,37,2002/2/22,+1-861-844-4669x7855,manuel77@example.org,528 Reilly Loop Suite 202,"A 58-year-old man had been found to have gastric nodules by X-ray and endoscopic examinations at another hospital. During the endoscopic examination, three nodules were biopsied and one was suspected to be a carcinoid tumor. The other two were diagnosed as atrophic gastric mucosa. A conventional endoscopic reexamination at our hospital revealed multiple nodules on the greater curvature of the corpus (), one of which was reddish ( yellow arrow). Magnifying endoscopy showed that this reddish nodule had a gyriform-like structure with an irregular vascular pattern (). Based on the magnifying endoscopy findings, the reddish nodule was diagnosed as a carcinoid tumor, and this was subsequently confirmed by histological examination of a biopsy sample. Conventional endoscopic examination of the corpus demonstrated severe atrophic gastritis (). Magnifying endoscopic examination of the other nodules revealed closely arranged small round pits () and a pattern of closely arranged small round and oval pits was also observed in the mucosa surrounding these nodules (Figures and ). Thus, magnifying endoscopy was able to show that this characteristic pit pattern was present even in the atrophic mucosa of the corpus, leading to a diagnosis of autoimmune gastritis associated with a carcinoid tumor. Analysis of the patient's serum showed a gastrin level of 2700 pg/mL (reference range: <200 pg/mL), antiparietal cell antibody ?80 positive, positivity for anti-intrinsic factor antibody, and negativity for anti-H. pylori antibody IgG. The reddish nodule and some of the surrounding nodules that showed closely arranged small round pits were treated by endoscopic mucosal dissection (ESD). The reddish nodule was 3 mm in diameter and histological examination confirmed that it was a carcinoid tumor. The other small nodules showed remnants of fundic glands within the atrophic mucosa ()."
+Bridget Huber,39,1988/12/20,(579)355-8943x6502,dgordon@example.net,4539 Joseph Bypass Apt. 951,"A 58-year-old female had lumbar pain and shortness of breath at the time of admission. Medical history revealed the patient being under medical treatment for chronic obstructive lung disease. A slight limitation in lumbar movements was determined by physical examination. Routine laboratory tests were normal. Further radiological evaluation included ultrasonography (US), color Doppler ultrasonography (CDUS), thoracoabdominal magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP). The balanced turbo field echo (BTFE-BH SENSE) sequence on MRI (Figures and ) revealed following findings: the aorta, aortic arc, and apex of the heart were located on the right-hand side, and the inferior vena cava, stomach, and spleen were located on the left-hand side according to the midline. The liver was located in the midline, but it was left-dominant liver. The position of the gallbladder was right-hand sided under the liver. The pancreas was located on its normal position in the midline. The spleen had three foci (polysplenia) and was in a settled position on the left-hand side under the liver. The right renal vein which was retroaortic has passed posterior to the aorta and drained into the inferior vena cava. The small and large intestines seemed to have some degree of malrotation. It was observed that the large and small intestines were predominantly settled in lower right region and upper left region of the abdomen, respectively. Color Doppler ultrasonography showed that the inferior vena cava and aorta flows were on the opposite side of the normal location (). On MRCP, the liver was observed to be left dominant located, and common bile duct was lying towards the inferomedial from the left-hand side."
+Mac Potts,36,2005/3/19,(393)832-6135x70628,danielhodges@example.com,20009 Chase Square Suite 279,"43-year-old female, previously healthy, presented with episodic severe pain affecting her right 4th finger for many years. The involved area is specific to the extent that the patient can pinpoint the exact area. The condition provoked by pressing on that area and by cold exposure. The attack manifests with pain followed by a color change of the finger (blue then red), only at the distal phalanx, and attacks last about 10 to 20 minutes. She is a housewife with no history of trauma or paraesthesia. She is not on long-term medications and has no symptoms suggestive of connective tissue disease. On examination, skin examination was normal with no localized tenderness or swelling. Tinnel and phalen tests were negative. MRI () showed a small lesion measuring 0.6 cm ? 0.6 cm subjacent to the nail bed of the fourth finger. On T1-weighted images, the lesion appears of low signal. On T2 sequences, the lesion appears of bright signal. After i.v. gadolinium administration, the lesion appears intensely enhanced. The MRI findings were going with the diagnosis of glomus tumor. The patient referred to a hand surgeon and surgical excision, and histopathology confirmed glomus tumor. Patient recovered well, and, within 10 days, pain subsided, and Raynaud's phenomenon resolved."
+Ellison McIntyre,37,1994/9/12,543-635-3116,alexander96@example.com,1768 Cochran Junction Apt. 165,"A catheter was inserted for intravenous hyperalimentation into the right femoral vein of a 77-year-old man with a cerebral hemorrhage. Hyperalimentation was started after the position of the catheter was confirmed by a plain radiograph (). Antibiotics (PAPM/BP) had been used for the laryngitis by the otolaryngologist for 9 days and stopped. The patient developed fever, subcutaneous swelling, and redness in right lower quadrant of the abdomen 11 days later (). An axial abdominal computed tomographic (CT) scan for suspected phlebitis and cellulitis revealed that the catheter was located in the right inferior epigastric vein. Swelling of the adjacent right lower rectus abdominal muscle and subcutaneous tissue was also evident (). Intravenous hyperalimentation was stopped and the catheter was removed. Subsequently, the subcutaneous swelling and clinical redness disappeared within a few days. We did not use any antibiotics for the cellulitis."
+Eliseo Hall,29,2004/6/14,265.710.3746,cynthia42@example.com,8933 Bean Island,"A 53-year-old woman without significant past medical history developed an asymptomatic left-sided supraclavicular mass. A core needle biopsy showed sheets of large neoplastic cells that were positive for CD15 and CD30 and negative for CD45, consistent with classical Hodgkin Lymphoma, nodular sclerosis, grade 2. Imaging also revealed nonbulky disease in the anterior mediastinum, and no bone marrow biopsy was performed (). The patient declined conventional therapy, instead seeking 5 months of alternative treatments without response. Her disease remained stable, and thus she continued to decline therapy.
+Five years later, she developed pruritus, night sweats, and dysphagia. One year later, she developed progressively severe dysphagia with a 12 kg weight loss, significant dyspnea, productive cough, and was admitted to the hospital to receive intravenous antibiotics for pneumonia. Imaging revealed significant adenopathy in the neck, mediastinum, and abdomen, groin as well as hepatosplenomegaly (). In addition, she had partial compression of the superior vena cava and trachea by the mediastinal mass, cavitary lesion in the upper lobe of the right lung, and evidence of tracheoesophageal and tracheomediastinal fistulae (arrow in lower ). Excisional biopsy of a supraclavicular lymph node showed sheets of Reed-Sternberg cells with focal necrosis and dense but limited fibrosis. The large neoplastic cells were positive for CD15 and CD30 but negative for CD20 and CD45, consistent with classical Hodgkin lymphoma, nodular sclerosis subtype. Bone marrow examination was without disease. A bronchoscopy and barium swallow () identified fistulous tracts connecting the trachea with the esophagus and the mediastinum. A gastrostomy tube and tracheal stent (covered and self-expanding, Microinvasive, Boston Scientific, Natick, MA) were placed to minimize the risk of recurrent aspiration pneumonia.
+Despite requiring supplemental oxygen and weighing only 39 kilograms, therapy was initiated 73 months after her initial diagnosis with doxorubicin, vinblastine, and dacarbazine (AVD). Bleomycin was not given due to lung disease and oxygen requirement. She had minimal therapy-related toxicities which responded well to supportive care. After 2 cycles of therapy, restaging studies showed a 75% decrease of her mediastinal mass, but the fistulae remained unchanged. Her cough significantly improved and oxygen requirement normalized. She continued on therapy, completing 8 cycles and gaining over 5 kilograms. Restaging CT scans demonstrated a near complete resolution of her mediastinal disease and fistulae, and no other disease was noted. A posttreatment PET/CT demonstrated a non-FDG avid residual mediastinal mass. At restaging imaging 3 months later, the mass persisted unchanged and the patient declined biopsy or further intervention.
+Approximately two years after completing therapy, she remained without disease but had frequent upper respiratory infections. Her stent was exchanged, and eventually removed. After removal, her frequent infections disappeared. She remains without evidence of disease six years removed from initiation of therapy and eleven years from diagnosis."
+Leah Leon,36,1998/3/13,001-328-676-1604x3915,christine60@example.com,860 Chapman Center,"A 71-year-old female with multiple myeloma (MM) IgG/lambda stage III A (II ISS) presented to routine follow-up seven years after 3 cycles of VAD (vincristine, adriamycin, dexamethasone) induction, ciclophosphamide and stem cell harvest followed by autologous stem cell transplantation (ASCT) conditioned with melphalan 200 mg/m2, complaining of a moderate pain in her right ribs and pelvis. Radiographs showed multiple stable osteolytic lesions in her spine, pelvis, ribs, and skull, when compared to those obtained 18-month before. An MRI of her spine confirmed the stability of bone lesions compared to the previous one done one year before. Bone marrow biopsy showed 10% of monoclonal plasma cells. Serum monoclonal component was stable (IgG 0.8 g/L). CT/PET using 18F labelled with Fluorodeoxyglucose (18F-FDG) as positron-emitting radionuclide () showed three hypermetabolic focal lesions in the fifth right rib (thick white arrows), D10 vertebral body (thin white arrow), and right ischium (black arrow), with standardized uptake value (SUV) of 14.8 (normal cut off 2.5), 3.3, and 9.3, respectively. Considering the moderate pain and in order to test unique lenalidomide efficacy in bone lesions, after signed written informed consent, the patient was treated uniquely by lenalidomide (25 mg/day, 1 to 21 every 28 days, for a total of 6 cycles). We avoided dexamethasone use on purpose, as well as bisphosphonates to show drug efficacy. Six-month follow-up PET-CT showed a complete disappearance of the lesions (), that was confirmed one year later."
+Marshall Enriquez,27,2000/8/13,796-704-6152x1632,randy45@example.net,5045 Kristen Station,"In February 2010 a 48-year-old man was admitted to our hospital for fever and jaundice appeared few hours after the twelfth BCG bladder instillation because of urothelial carcinoma of the bladder diagnosed two years earlier. The patient was known to our department for a diagnosis of follicular lymphoma made ten years before, and treated with six cycles of CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine, prednisone) plus Rituximab (Mabthera簧-Roche), an anti CD20 antibody.
+At admission the patient was in fair general conditions but feverish (38,5簞C); physical examination revealed scleral and skin jaundice, painful hepatomegaly on palpation, while pulmonary examination was unremarkable and the patient had no peripheral lymphoadenopathy. Complete blood count revealed only a mild hypocromic microcytic anemia with normal platelet and WBC count. Blood chemical assays showed abnormal liver function tests (ALT 265 UI/L, ASL 406 UI/L, serum alkaline phosphatase 785 UI/L, gamma-glutamyl-transferase 370 UI/L, total bilirubin 4,71 mg/dL), elevated LDH (639 UI/L), beta2-microglobulin (6,6 mg/L) and C-reactive protein (92.4 mg/L). Tumor markers were within normal range. Routine blood and urine cultures did not yield any common pathogens and the results of serologic tests in order to assess virus and bacteria exposures were negative. An abdominal ultrasonography confirmed mild hepatomegaly in association with splenomegaly (diameter 13 cm). Chest X-ray showed diffuse bronchial walls thickening and a focal opacity with air bronchogram in the left lower lobe, expression of a possible exacerbation of a concomitant chronic obstructive pulmonary disease. Despite empirical broad-spectrum antibiotic therapy with piperacillin/tazobactam, the patient? clinical conditions progressively deteriorated and he experienced worsening of fever (40簞C), thorax pain and worsening dyspnoea requiring oxygen supply. A high-resolution chest CT-scan was carried out, that confirmed a diffuse and bilateral hazy increase of lung density (?round glass??opacity), especially in the bases, and the presence of diffuse and bilateral multiple micronodules with random distribution, with thickening of the interlobular septa and a left lower lobe consolidation (). A bronchoscopy was carried out and samples of broncho-alveolar lavage were sent for microscopy and culture. To exclude a relapse of his hematological disease, the patient underwent bone marrow trephine biopsy: no evidence of lymphoma relapse was found in his bone marrow specimen, which instead documented multiple aggregates of epithelioid histiocytes setting up for a granulomatous myelitis (); finally, because of a continue and gradual increment of liver function tests, particularly of serum alkaline phosphatase (1124 UI/L), and gamma-glutamyl-transferase (481 UI/L), a liver biopsy was performed, whose histological examination documented the presence of several non-caseating epithelioid granulomas with Langhans giant cells revealing a granulomatous hepatitis ().
+Because of the concomitant radiological findings documented at CT chest scan, suggestive for miliary lung involvement (), a systemic infection caused by BCG was suspected on the basis of the recent intravesical administration of BCG and the worsening patient conditions, despite several days of antibiotic treatment. An accurate research of acid-fast bacilli was performed in blood, bone marrow, urine, feces, sputum, biopsy specimens, and broncho-alveolar lavage (BAL) by cultures, PCR analysis and Ziehl-Neelsen staining, with no evidence of Mycobacterium spp. Of note a high CD4/CD8 ratio was found in BAL samples (22.73, normal value 1??); the tuberculin skin test using 2 UI of purified protein derivative (PPD) and the interferon-gamma release assay (Quantiferon) were negative.
+So that, although acid-fast bacilli were not elsewhere isolated and blood and bone marrow taken at the same time were PCR negative, ten days after admission an antituberculous treatment was started with isoniazid, rifampicin, and ethambutol, to which ciprofloxacin and corticosteroids were added. After 15 days of antituberculous therapy, fever and dyspnoea subsided and liver-function tests markedly improved along with the patient general well-being. The patient discharged home for the full six-month course of his treatment, at the end of which he was healthy, with complete normalization of inflammation signs and liver function tests, and disappearance of pulmonary nodules and parenchymal abnormalities and of bone marrow granulomatosis, documented at radiologic and histological exams."
+Nellie Willis,31,1989/9/1,(475)798-7335,wmaxwell@example.com,02598 Henderson Locks Suite 701,"A 54-year-old male patient was admitted complaining of fever, coughing, headache and sputum during the previous month. He had a two-week history of oral amoxicillin clavulanate (1 gr, twice daily) and ciprofloxacin (500 mg, twice daily) use. He was diagnosed with stage two chronic lymphocytic leukemia (CLL) one year prior to admission. Chemotherapy or any immunosuppressive treatment including steroids had not been administered to the patient during his follow-ups. He did not have any CLL complications.
+A physical examination was performed, and he had a body temperature of 38.5 繙C, a blood pressure of 135/80 mmHg and a regular pulse rate of 100 beats per minute. The pathological findings of the examination included cervical lymphadenopathy and right basal crackles upon auscultation of the lung. A neurological examination revealed a normal, oriented man without neurologic deficits. Laboratory tests revealed a hemoglobin level of 9, 3 g/dl, a white blood cell count of 58.900/mm3 (86% lymphocytes) and a platelet count of 159.000 cells/mm3. Serum glucose, electrolyte and kidney function tests were normal. A peripheral blood examination demonstrated lymphocyte predominance and the presence of basket cells. Urinalysis and urine and blood cultures were negative for any microorganism.
+Cefepime (2 grams, three times daily) was administered intravenous to the patient in addition to oral clarithromycin (500 mg, twice daily). Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) rapidly increased, and we decided to cease clarithromycin on the first day of treatment. The patient? fever remained on the fourth day of treatment, and we replaced cefepime with vancomycin and carbapenem. Thoracic computed tomography (CT) exhibited parenchymal infiltration. A brain CT scan revealed normal findings. Due to an on-going disturbance in the liver function tests, vancomycin treatment was ceased on the second day. The patient? condition did not improve with these treatments, and he continued to have temperatures up to 39 C. In the meantime, the patient? condition was complicated with Coombs positive hemolytic anemia, and daily prednisolone was administered for two weeks (60 mg on the first three days, followed by 30mg/day).
+The patient? headache did not resolve during his hospitalization, and on the 21st day after admission, the patient lost consciousness. While blood cultures from the early period of hospitalization were negative, a blood culture obtained on the 18th day of hospitalization revealed mucoid yeast colonies on the 3rd day following collection. A lumbar puncture sample contained 20 leukocytes/mm3 and, 100 erythrocytes/mm3, and the protein and glucose levels were 36,2 mg/dl and 26 mg/dl respectively. Encapsulated budding yeast cells resembling Cryptococcus were observed using an India ink preparation. The blood cultures were continuously monitored using an automated blood culture system (BACTEC 9000/BD), and Sabouraud dextrose agar (SDA; 4%) and inhibitory mould agar (IMA) were used for CSF culture. Inoculated culture media were evaluated after 72 hours and morphology results from cornmeal?ween 80 agar and the API ID 32C system (bioMerieux-USA) were used for identification. Cryptococcus neoformans was identified as the offending pathogen, and it was separated from Cryptococcus gattii by growth features on canavanine-glycine-bromothymol blue (CGB) agar. Amphotericin B was started at a dose of 0,8 mg/kg. However, the patient? condition did not improve, and he died one day after treatment initiation due to respiratory failure and septic shock."
+Remington Woodard,36,1986/8/2,274-298-4588x96125,robert63@example.org,7679 Ashley Mountains,"Here, we describe a rare occurrence of PML, with a rapidly fatal outcome, in 59-year-old woman who underwent UCBT for Follicular Non Hodgkin Lymphoma in January 2011; she was in complete remission (CR) confirmed by the PET scan after 5 lines of treatment. At transplantation, no organ dysfunction was present.
+The reduced intensity conditioning (RIC) regimen consisted of total body irradiation (2 Gys in 1 fraction), Fludarabine at 40 mg/m2/day for 5 days, and Cyclophosphamide at 50mg/Kg/day. A total nucleated cell dose of 3.3 107/kg body weight was infused on day 0. The cord blood unit and the patient were HLA matched 4/6 with mismatch of locus A and B. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine A at 3 mg/kg/day, and Mycophenolate Mofetyl (MMF) at 500mgx 4/day, beginning on day -3. Neutrophil engraftment (>0.5 ? 109/L) occurred on day 26.
+On day 35, the patient presented a skin grade 2 acute GVHD reaction, without other organ dysfunction, and 2 mg/kg methyl-prednisolone was started; a rapid clinically response was observed. On day 51, the patient developed CMV reactivation detected by quantitative polymerase chain reaction (PCR) in the peripheral blood with 1359 copies; and an antiviral treatment with Gancyclovir (Cymevan) 2.5 mg/kg/day was administrated after adaptation with her renal function.
+On day 68, at the time of her outpatient visit, she developed confusion, short-term memory dysfunction, and altered mental status, with focal signs and abnormal Babinsky reflexes on the left, and lack of the force on the thighs lower limbs. A brain computed tomography (CT) scan demonstrated no specific findings. The patient was described as cachectic, alert, awake, and oriented to person, time, and place. Her speech was fluent; comprehension, naming, and repetition were intact. Examination of the cranial nerves showed mild drooping of the left angle of the mouth; all other cranial nerves were intact. Motor strength was 4+/5 on the left symmetrically in the upper and lower extremities and 5-/5 in the right extremities. Deep tendon reflexes were hyperactive, but no extensor plantar responses were recorded. The complete blood count and chemistry levels were normal, except for positive schizocytes. Blood urea nitrogen and serum creatinine levels were 15.9 mmol/L and 179 弮mol/L, respectively. The diagnosis of thrombotic microangiopathy was made in the presence of haemolytic anemia, thrombocytopenia, renal failure and presence of schizocytes in biological assessment. The patient received corticotherapy at 1mg/kg/day, and 5 plasma exchanges were made. The cyclosporine was discontinued and MMF treatment was continued. We assisted rapidly to a response of her haemolytic anemia, improved thrombocytopenia but without improvement of her neurological troubles. With worsening mental status on day 83, a magnetic resonance imaging (MRI) of the brain after gadolinium injection showed a non-enhancing hypo-intensity Image in (T1- sequence) beyond the white matter.
+However, after gadolinium injection showed an image in the axial (FLAIR sequence) showing hyper-intensity lesions in the white matter of the frontal lobes. There is no signal abnormality of the cortex. Note that there is no mass effect on the ventricular cavities or midline structures.
+Furthermore the MRI in B1000 diffusion sequence showed a restriction of diffusion in the damage areas of the white matter.
+On day 84, the patient? mental status was stable, and a lumbar cerebrospinal fluid (CSF) examination revealed a white blood cell (WBC) count of 1 cells/L, a normal Glucose level of 3.89 mmol/L and a normal protein level of 389mg/L. the mycological (aspergillosis, Cryptococcus), and Gram staining and culture were negative. A specimen was sent for polymerase chain reaction (PCR) analysis for JC virus was positive in the CSF and the serum (negative for CMV, VZV, HHV-6, EBV and herpes simplex virus by PCR). A treatment with 5 mg/kg/week of Vistid (Cidofovir) was initiated on day 86 associated with Mefloquine (Lariam簧) and Mirtazapine (Norset簧). It was around this time that the patient? general condition began to worsen. Acute deterioration of cognitive function occurred with confusion and autism. Because of CR of her GVHD; steroids were tapered and ultimately discontinued on day 97. An electroencephalogram demonstrated mild bi-frontal slowing, with diffuse brain damage, more prominent on the left than the right.
+Re-examination of CSF on day 93 revealed a WBC count of 3 cells/mL, a protein level of 323 mg/L, Glucose level of 5.08 mmol/L. JCV was positive in CSF by PCR. HHV- 6, CMV, HSV, VZV, EBV, enterovirus were negatives by qualitative PCR assay. PCR of the CSF for JCV conducted in the same laboratory as previously was positive, establishing the diagnosis.
+Throughout her hospital stay, the patient? neurologic condition continued to deteriorate. Her course was marked by an episode of altered mental status, progressive dementia, motor weakness, declining visual acuity and worsening performance status. In the light of clinical deterioration no further exams was performed in respect to the family? wish for no further intervention. She was continued to a skilled nursing facility in our unit, where she died one month after the diagnosis of PML, on day 110 after UCBT.
+Unfortunately we did not perform a neuropathologic examination of the brain by autopsy in respect to the family? wish."
+Aubrie Waller,40,1993/3/13,325.478.5053x308,fischertimothy@example.net,4098 Amanda Forest Suite 668,"A 25-year-old British male dived into hotel swimming pool in 1989 and sustained a C-6 fracture. Anterior fusion of the cervical spine was performed with a bone graft taken from the right iliac crest. This patient required tracheostomy for clearance of secretions. Neurological examination revealed tetraplegia at C-6 (American Spinal Injury Association Grade A). He has been managing his bladder by an indwelling urethral catheter. The catheter was changed every 4 weeks by a health professional. This patient could not recollect developing autonomic dysreflexia in the past.
+This patient rang the Spinal Injuries Centre on a Sunday in 2010 and informed the staff that his catheter was blocked. This patient was advised to come to the Spinal Injuries Centre immediately. This patient's brother brought him to the Spinal Unit within half an hour and he was attended to promptly. This patient looked well; he did not have sweating, headache, goose pimples or flushing of the face. He was alert and made the usual conversation about going to his favourite public houses for drinks. He was not breathless. He did not have increased spasms. This patient did not have to wait for any time. This patient's brother lifted him, put him on the bed and undressed him. The blocked catheter was removed. The external urethral meatus was cleaned with chlorhexidine prior to catheterisation. Then this patient, who was lying on the bed, said that the ceiling lights were very bright and glaring. Five milligrams of Nifedipine was given sublingually. This patient started having fits involving his head, face, neck and shoulders with loss of consciousness. A 14-French silicone Foley catheter was inserted per urethra without any delay and 300 ml of clear urine was drained. After this patient received Nifedipine, his blood pressure was 84/51 mmHg. A Venflon was inserted in his foot. Blood tests revealed: haemoglobin, 14.4 g/dl; white cell count, 11.3 ? 109/l; urea, 2.5 mmol/l; creatinine, 49 umol/l; glucose, 5.4 mmol/l.
+This patient recovered consciousness within 5 min. Two hundred forty milligrams of Gentamicin was administered intravenously, as spinal cord injury patients with blocked catheters are susceptible to developing urine infections. This patient recovered well and he was able to take his tea. This patient was admitted to the Spinal Injuries Centre for observation.
+A request was made for a brain scan for this patient. A blocked catheter and distended bladder led to autonomic dysreflexia and the patient developed convulsions. Computed tomography of the brain would show whether this patient had developed an intracranial bleed as a result of a transient hypertensive episode due to autonomic dysreflexia. CT of the brain revealed no focal cerebral or cerebellar abnormality. There was no intra-cranial haemorrhage.
+In order to prevent recurrence of autonomic dysreflexia due to a blocked catheter, it was decided to take possible measures to prevent blockage of the urinary catheter. He was advised to drink plenty of fluids. This patient was requested to get his catheter changed more frequently. In case of blockage of the catheter, this patient was instructed to take Nifedipine 5 mg sublingually in order to prevent a rise in blood pressure due to autonomic dysreflexia. This patient was advised to carry Nifedipine capsules with him at all times. His carers were trained how to administer Nifedipine sublingually.
+At present this patient was taking Oxybutynin 5 mg once a day. After discussing with him, this patient was prescribed 10 mg of modified-release Oxybutynin once a day. He was also prescribed an alpha-adrenoceptor blocking drug, Doxazosin modified-release 4 mg once a day. Doxazosin is likely to reduce the frequency and severity of autonomic dysreflexia. This patient was informed of the side effects of long-term indwelling catheter drainage. For example, long-term indwelling urinary catheters are often associated with problems such as urinary infection, blocked catheters and stones in the bladder. Intermittent catheterisation was preferable to long-term indwelling catheters. Unfortunately, this patient did not have carers who could perform intermittent catheterisations."
+Marley Goodwin,43,2005/2/15,+1-707-749-7664x6359,elizabeth31@example.org,607 Allen Fall,"A 51-year-old 75-kg man with a background history of ischaemic heart disease, chronic back pain, and depression ingested amitriptyline in excess of 43 mg/kg (> 65 ? 50-mg tablets) and unknown quantities of quetiapine, citalopram, metoprolol, quinapril, and aspirin in a deliberate act of self-poisoning. At ambulance arrival (time approximately 40 min after ingestion) he was agitated and poorly co-operative, with a heart rate of 160 bpm and blood pressure 100/70. En route to hospital he became unresponsive and then suffered a generalised seizure, which was terminated with 4 mg intravenous midazolam. On arrival to our tertiary care facility (time 60 min following ingestion), the Glasgow Coma Scale (GCS) score was three, temperature was 37.6簞C, pupils were dilated (4 mm), heart rate was 150 beats per minute, blood pressure was 112/82 mmHg, and serum glucose 14.0 mmoll-1. A 12-lead electrocardiogram (ECG; Figure ) revealed a wide complex tachycardia with QRS duration of 180 ms and a prominent R wave in aVR, supporting a clinical diagnosis of tricyclic antidepressant cardiotoxicity.
+One-litre 0.9% saline and 50 ml 8.4% sodium bicarbonate were administered intravenously. He subsequently underwent endotracheal intubation following administration of midazolam 5 mg and suxamethonium 100 mg. Mechanical ventilation was initiated and titrated to an end-tidal CO2 of 30 mmHg. A gastric tube was placed and 50 g activated charcoal instilled. A further 1-l 0.9% saline was administered intravenously and an additional 300 ml 8.4% sodium bicarbonate injected in divided aliquots (50 ml) to an arterial pH of 7.51 (serum bicarbonate 35.6 mmol/l, sodium 141 mmol/l, potassium 3.4 mmol/l).
+ECG QRS duration narrowed to 96 ms. However, despite 8 mg metaraminol delivered in 2-mg increments, the blood pressure deteriorated to 70/58 mmHg (pulse rate 130 beats per minute; Figure ) at time 115 min. Given the ongoing haemodynamic instability, a decision was made to undertake lipid rescue treatment while preparations were made for central line insertion and anticipated vasopressor infusion.
+At 115 min after drug ingestion, 100 ml 20% lipid emulsion (Intralipid簧, Fresenius Kabi) was injected over 1 min followed by a further 400 ml over 30 min. Following administration ECG QRS duration narrowed further to 80 ms, the heart rate was 120 beats per minute, and BP 140/80 mmHg. Serial ECG parameters (QRS duration, QTc) to 205 min are presented in Table . Thereafter the patient remained haemodynamically stable. He required no further inotropic/vasoactive medications at any point during his Emergency Department or ICU admission.
+Blood was drawn immediately prior to ILE administration, and at 5, 15, 35, and 90 min post ILE commencement (corresponding to 110, 115, 125, 145, and 205 min after initial ingestion) for later determination of plasma amitriptyline and triglyceride concentration. All samples were centrifuged at 3 000 g for 10 min effecting partial visual separation of more lipaemic plasma above from more aqueous plasma below. Blood was then frozen in an upright position to -15簞C before undergoing manual cleavage of separated plasma from the buffy coat and red cell mass. The upper 50% of centrifuged plasma (nominally top) was then separated from the lower 50% (nominally bottom) in an attempt to obtain contemporaneous samples exhibiting a gradient of lipaemia. All samples then underwent assay for plasma amitriptyline by high-performance gas chromatography with the mass selection method and plasma triglyceride estimation by a commercial laboratory. Plasma amitriptyline and triglyceride concentrations are presented in Table .
+The patient was subsequently transferred to the ICU with ongoing bicarbonate infusion. Serum lipase was 18 U/l (normal range 13-60 U/l) 24 h after lipid infusion. Electrocardiogram QRS duration was noted to have normalised completely on day 2. Extubation occurred on day 3 with ICU discharge on the same day following development of aspiration pneumonia requiring antibiotic therapy. He was discharged neurologically intact to the psychiatry service on day 7."
+Shiloh Hall,20,1993/6/10,001-278-442-4948x61671,across@example.net,245 Christina Oval Apt. 473,"The patient was a 76-year-old man whose chief complaint was difficulty in walking and pain in his right loin. His coexisting disorders included diabetes mellitus, hypertension, and alcoholic liver cirrhosis. He also had a history of gastrectomy for gastric cancer, subarachnoid hemorrhage, normal pressure hydrocephalus, and cerebral infarction. On admission, his body temperature was 35.9簞C; blood pressure, 113/80 mmHg; and pulse rate, 95 beats/min. He reported tenderness in his right loin, but there were no reddish areas or swelling. His laboratory data on admission were as follows: white blood cell count, 460 ? 102/弮l (neutrophils: 98.5%); hemoglobin, 7.5 g/dl; creatine, 3.5 mg/dl and C-reactive protein, 25.7 mg/dl. Abdominal computed tomography (CT) showed gas and fluid collection extending from the subcutaneous layer of his right loin to his retroperitoneal cavity (Fig. ). Based on these findings, we diagnosed necrotizing fasciitis. No connection was found between the necrotizing fasciitis and the gut and his appendix was not swollen. Therefore, a 10-cm incision was made in his right loin. Pus and foul-smelling gas were released, and the subcutaneous fat was debrided. Bacterial culture of the pus grew Peptostreptococcus micros, Peptostreptococcus sp., Prevotella disiens, and Escherichia coli. Antibiotic sensitivity tests for meropenem hydrate and clindamycin hydrochloride were positive. We irrigated the incised tissue and gave systematic antibiotic therapy (meropenem hydrate: 1 g/day, clindamycin hydrochloride: 1.2 g/day) for 10 days. His inflammatory response improved; however, the underlying cause of his condition could not be investigated effectively because he suffered epileptic seizures. About 3 months after his admission, sordes were discharged from the affected body part. Subsequently, an appendicocutaneous fistula was revealed by fluoroscopy-aided colonoscopy (Fig. ). An open laparotomy revealed strong adhesions between the terminal ileum and retroperitoneum. We found that the distal end of the vermiform appendix had adhered to the retroperitoneum and a fistula had formed. Thus, we performed appendectomy and fistulectomy. The pathohistological diagnosis was chronic acute phlegmonous appendicitis.
+His postoperative course was uneventful; however, on postoperative day 35, a urinary tract infection developed and methicillin-resistant staphylococcus aureus sepsis ensued, resulting in the death of multiple organ failure on postoperative day 48."
+Thomas Richardson,44,1985/7/7,227.739.7230,taylor89@example.net,076 Christine Mill Suite 844,"A 65-year-old man presented to the hospital in March 2006 with a rectal syndrome with minimal rectal bleeding, which had appeared two months earlier, and with an overall deterioration of health. The patient had a history of cholecystectomy. A complete proctologic examination revealed a left lateral mass 4 cm from the anal margin, with a good sphincter tone. A biopsy was performed. The anatomopathological study showed morphological and immunohistochemical aspects, suggesting a spindle cell GIST (). X-ray computed tomography (CT) of the abdomen and pelvis revealed the presence of a rectal tumour mass of 6 cm in diameter, pre-sacral and well encapsulated. Proctectomy and coloanal anastomosis were performed. After a histopathologic examination of the resected specimen, the diagnosis of malignant stromal tumour was made (intense expression of the anti-c-kit antibody; size > 5 cm; high mitotic index; mitosis > 5/50 fields). The postoperative course was uneventful. Eight months after surgery, the patient presented with multifocal, unresectable liver metastases, for which he was treated with imatinib. The hepatic lesions remained stable 12 months after treatment onset. Treatment was then suspended due to the patient's general health deterioration and tumour progression."
+Allison Trujillo,19,1986/7/25,(245)778-5498,schneiderrobert@example.org,350 Martin Crescent Apt. 644,"A 77-year-old woman without significant medical history presented to the hospital in October 2008 with rectal tenesmus and bleeding of medium abundance, which had appeared two months earlier. Digital rectal examination revealed a deep indurate sessile mass located 3 cm from the anal margin and leading up into the lower rectum. A proctoscopy revealed a tumour process extending from the dentate line and 10 cm from the anal margin. A biopsy was performed. The histopathologic study showed morphological and immunohistochemical aspects, suggesting a GIST. A colonoscopy did not reveal abnormalities in other parts of the colon. Thoracoabdominal and pelvic CT scans were then performed for staging. This examination provided an objective view of the lesion, showing a rectal tissue tumour of 8 cm in diameter, located on the posterior wall and showing an infiltration of presacral fat, but without bone involvement (). No lymph node, liver or lung injury was detected. An abdominoperineal resection was performed. The histopathologic study revealed a submucosal, ulcerated tumour, measuring 8 x 5 x 5 cm, and consisting of a rather dense fuso-cellular proliferation with fascicular architecture, a high risk of malignancy (mitosis > 5/50 fields, tumour size > 5 cm), and a complete resection. The immunohistochemical study showed a diffuse and intense c-kit and CD34 expression, confirming the stromal tumour type, whereas the other differentiation markers were negative (desmin and actin). The postoperative course was uneventful. The patient received adjuvant treatment with imatinib for a year, given the potential malignant aspect of the tumour. The evolution was good 13 months later."
+Apollo Hall,22,1994/4/14,988.789.2589,romerodanielle@example.net,111 Vang Fall Suite 340,"An 85-year-old woman with a past medical history of severe peripheral vascular disease and right below knee amputation presented to the emergency department with a 1-day history of non-positional dizziness and weakness. She denied any headache, neck pain, chest pain, trauma, or fever. Her ED vital signs were normal, and her ECG showed normal sinus rhythm with a heart rate of 91 bpm. Her physical examination was normal including a right below knee stump that was clean and dry. An MRI/MRA of the head and neck showed no new changes. The patient required intravenous access to work up her dizziness and weakness. The patient had multiple failed blind ED peripheral IV attempts performed in the past.
+An ED bedside ultrasound guided antecubital brachial vein was cannulated on the first attempt using the long-axis approach (see video clips in Additional files , , and .). After applying an elastic tourniquet to the patients non-dominant left arm and applying ultrasound gel, a high frequency linear array probe was used to identify an antecubital vein that was the largest in diameter, at least 3 mm or greater in diameter and a vein as close as possible to the skin surface. An augmentation procedure was performed by squeezing the patient's forearm while sampling the vessel with color Doppler and pulse Doppler. The augmentation procedure with increased Doppler flow verified the selected vessel was a vein, since an arterial vessel would produce a pulsatile Doppler flow pattern (see video clip in Additional file .). The skin was prepped with alcohol swabs, the vein verified with augmentation again, and the probe, now covered with a thin sterile plastic film dressing, was placed in the nine o'clock position to view the antecubital brachial vein in short-axis, then the ultrasound probe was turned counter clockwise to the six o'clock position to position the vein in the long-axis position (Figure ). The ED physician held the vascular ultrasound probe while resting on the patient's bed to provide stability. A 20-gauge 2-in. catheter was placed under the long-axis of the probe and vein so that direct visualization of the needle tip and catheter inside the vessel could occur (Figures and ). The catheter was flushed with saline and secured."
+Leah Good,28,1981/4/21,620-390-4851x21136,everettelizabeth@example.org,7386 Gomez Cove,"A 27-year-old man presents to the emergency department with a 1-day history of severe right upper extremity pain and swelling. The patient's status is post open reduction internal fixation for a left tibial plateau fracture, which was complicated by methicillin-sensitive Staphylococcus aureus osteomyelitis. A peripherally inserted central catheter (PICC) line was subsequently placed for intravenous antibiotic therapy. He denied any other past medical history. Aside from the pain and swelling to his right arm, the patient reports no associated shortness of breath, chest pain, or fever. His emergency department (ED) vital signs were as follows: temperature 97.1簞F, blood pressure 135/74 mmHg, heart rate 82 bpm, respiratory rate 14 bpm, and oxygen saturation 100% on room air. Physical examination result was normal except for the right upper extremity that showed surrounding edema and mild erythema by the PICC line site (Figure ). The arm had tenderness to palpation, but no significant increase in warmth was noted.
+On initial assessment, the triage nurse suspecting a possible upper extremity deep vein thrombosis notified the ED physician to facilitate a rapid bedside ultrasound of the right upper extremity. This ultrasound was performed (Additional files , , , and , available in the online version of this paper). Both short-axis and long-axis views of the brachial vein are shown (Figures and and Additional files , ). The short-axis view of the right axillary vein revealed a non-compressible deep venous thrombosis (Figure and Additional file ). Long-axis ultrasonographic evaluation of the axillary and subclavian veins near the PICC line tip revealed deep venous thrombosis of both the axillary and subclavian veins (Figure and Additional file ).
+Comprehensive radiology ultrasonography of the right upper extremity showed no flow and/or compressibility in the right subclavian vein or the right axillary vein adjacent to the PICC line, consistent with complete thrombosis. The right internal jugular vein and right brachial vein were patent and compressible, and the right innominate vein demonstrated patent flow. The patient was admitted to the hospital, and he was treated with oral antibiotics and subcutaneous enoxaparin injections."
+Davian Farley,26,1982/5/9,840.302.1270,sosawalter@example.net,211 Mcbride Burg Apt. 327,"A 58-year-old Malay woman had ulcerative colitis that was diagnosed 21 years ago when she presented with recurrent diarrhea. Five years ago, she started to develop peripheral polyarthritis. There were no other extra-articular manifestations such as uveitis or pyoderma gangrenosum. She had multiple relapses of colitis with polyarthritis and therefore had received multiple courses of tapering-dose oral prednisolone with maintenance of 1 g of mesalazine three times a day and subsequently 100 mg of azathioprine once daily. Finally, two years later, with the above treatment, the primary disease managed to be brought to remission.
+In spite of the clinical and histological remission of the IBD, the left knee arthritis seems to be persistent, but other peripheral joints mentioned above were in remission without any permanent deformity. A clinical assessment revealed that the left knee was swollen, warm, and tender. The inflammatory marker C-reactive protein was increased to 1.14 mg/dL (normal is less than 0.5 mg/dL). A knee aspirate revealed clear synovial fluid and did not yield any growth. She received two courses of 500 mg of intravenous methylprednisolone daily for three days followed by a tapering dose of oral prednisolone for one year for active and persistent left knee arthritis, but the effects were temporary. Mesalazine was changed to 1 g of sulfasalazine twice a day, and the azathioprine dose was subsequently increased to 150 mg once daily. Unfortunately, she developed leukopenia; therefore, the azathioprine dose had to be reduced back to 100 mg daily. Despite aggressive treatment with multiple courses of high-dose systemic and local steroid with the maximum tolerated doses of sulfasalazine and azathioprine, she still had recurrent left knee effusion and synovitis. Indeed, the disease had caused significant pain and restriction of mobility. Also, after almost two years of corticosteroid therapy, our patient has endured significant iatrogenic morbidity, including Cushingoid habitus, impaired fasting glucose, hypertension, and bilateral cataract with increased intraocular pressure.
+In view of persistent unbearable pain and swelling of the left knee with severe secondary osteoarthritis, a total left knee replacement was done in the same year. During the operation, there was active synovitis of the left knee, and a histopathological examination of the synovial tissue revealed 'rice bodies', which are fibrocollagenous connective tissue stroma admixed with fibrinous exudates and abundant foci of vascular proliferation, suggestive of inflammatory arthritis (Figure ). One month after the operation, the left knee effusion recurred and there was persistent elevation of the inflammatory markers. Subsequently, a left knee arthroscopic debridement and near-total synovectomy were performed five years ago. Ten milligrams of oral methotrexate weekly was added one month after the operation, on top of 1 g of sulfasalazine twice a day, 10 mg of prednisolone once daily, and 100 mg of azathioprine once daily. Unfortunately, despite the above treatment for four months, our patient continued to show poor response and persistent recurrence of knee effusion. Subsequently, 25 mg of subcutaneous etanercept twice weekly, together with the other DMARDs and azathioprine, was initiated after three months.
+Eventually, the joint showed resolution of knee joint swelling and synovitis at the fifth week of treatment, visual analogue scale score improved from 70 to 20 mm, and the C-reactive protein level decreased to 0.8 mg/dL. After six months of treatment with etanercept, azathioprine was stopped and sulfasalazine was changed to 1 g of mesalazine three times a day as our patient had a mild flare of ulcerative colitis with community-acquired pneumonia. The steroid was also tapered off after six months of treatment.
+Twenty-five milligrams of subcutaneous etanercept biweekly and 10 mg of methotrexate weekly were continued, and after 12 months of follow-up, the colitis or arthritis was in remission and no serious side effects were noted."
+Wrenley Avila,34,2000/6/5,(724)909-3373,lparker@example.net,453 Thomas Station Apt. 126,"An 83-year-old diabetic man of African descent presented with a four week history of constipation and a two week history of obstipation to our emergency department. He noticed painless increasing abdominal distension with concomitant leg edema. He denied any history of vomiting, fever or anorexia. He used several laxative concoctions with no relief. He revealed a long standing history of incontinence at night with hesitancy and poor stream but denied frequency and strangury. He had been diabetic and on treatment for 25 years with a history of diabetic retinopathy.
+On admission, he was tachycardic (pulse 102 beats per minute) with a blood pressure of 160/85 mm Hg and random blood glucose of 511 mg/dL (28.39 mmol/L). He had bilateral pitting edema up to mid leg. A large abdominal mass extended out of the pelvis just below the xiphisternum (Figure ). The mass was dull to percussion and tender on palpation. His bowel sounds were hyperactive. A symmetrically enlarged, smooth, rubbery prostate was felt on palpation with a bulge above the prostate. All other examinations were normal. Blood test results revealed a normochromic normocytic anemia (hemoglobin 10.4 g/dL, MCV 90.9 fL) with renal impairment (blood urea nitrogen (BUN) 30 mg/dL, creatinine 1.8 mg/dL) and a normal prostate-specific antigen (PSA) level (4 ng/mL). Computed tomography (CT) of the abdomen was ordered with a working diagnosis of bowel obstruction likely secondary to a tumor in mind. The results showed gross distension of the urinary bladder above the level of the umbilicus with marked bilateral hydronephrosis and hydroureter (Figures and ).
+A Foley catheter was inserted which yielded 5000 ml of clear urine. On the following day the patient passed flatus and his leg edema had decreased markedly. He passed stool on the third day with the aid of a suppository. The catheter was removed at the patient's request and he was sent home passing urine freely. His renal impairment resolved (creatinine (Cr) 1.5 mg/dL) on discharge. He was non-compliant with follow up.
+One week later, he returned to the emergency department with constipation and bilateral pedal edema. A Foley catheter was re-inserted and 3100 ml of clear urine was drained. The edema completely resolved thereafter and the patient was sent home with the catheter in situ."
+Jaylen Swanson,23,1998/7/5,213-452-8728x124,elizabethsmith@example.net,9725 Willie Mews Apt. 508,"In 2005, a 42-year-old Brazilian woman presented to an eye doctor with a visual impairment, and pappiledema. Upon neurological examination, she was diagnosed with communicating hydrocephalus. A ventriculo-peritoneal shunt was implanted and the hydrocephalus improved. Neuroendoscopic surgery showed multiple cysts in the subarachnoidal space, and histopathological examination indicated cestode-derived tissue. Serology for cysticercosis was strongly positive, but copro-multiplex PCR was negative for taeniasis. The patient was treated with praziquantel at first and then with albendazole. Post-treatment serology remained positive."
+Helen Doyle,38,2002/4/29,(530)690-9009,ohubbard@example.com,64981 Crawford Points Apt. 739,"A 38-year-old Japanese man expelled a single tapeworm in 2000. He was treated with pyrantel pamoate, a drug used primarily for nematode parasites. In 2004, he complained of headaches and multiple cystic lesions were found on brain computed tomography (CT). However, at this time, no medical or surgical treatment was initiated because all of the cysts were deemed dead based on the CT image and the patient's normal eosinophil value. In 2009, he complained of a narrowing field of vision. Serology showed strong positive responses, but copro-LAMP was negative. The patient was treated with albendazole in 2010, and follow-up is ongoing."
+Kashton Cantrell,18,2002/12/25,(377)884-2296,brent33@example.org,2925 Sanchez Isle,"A 31-year-old Japanese man noticed a subcutaneous nodule on his neck in December 2009. When the number of nodules increased by May 2010, brain CT and magnetic resonance imaging (MRI) showed multiple cystic lesions in the brain and serology showed strong positive responses. Tapeworm proglottids were expelled in his stools at the beginning of July 2010 and were identified as T. solium by multiplex PCR. He remembered he had found a similar white noodle-like substance in 2009, but he did not care about it. Taeniasis was treated using Gastrografin (diatrizoate meglumine and diatrizoate sodium) at Mie University hospital in Mie, Japan on 14 July, but no worms were expelled. However, T. solium infection was confirmed by copro-LAMP and Taenia eggs were identified microscopically. On July 28th 2010, the patient expelled additional worms. Then he was treated with Gastrografin and albendazole in August 2010, but tapeworm(s) were not expelled. However, it was considered that the patient became free from T. solium tapeworm after he found the worm by himself on 28th July, as copro-LAMP was negative until December 2010. In contrast, the subcutaneous and intracranial nodules disappeared within 4 weeks after the treatment.
+The patient's travel history indicated that he had worked for one month in a rural area 150 km from Delhi, India on 3 separate occasions. The first, second and third visits were March-April 2008, October-November 2008 and March-April 2010, respectively. Based on this information, it was suspected that he acquired the parasite during his first or second stay in India. A mtDNA gene (chromosome c oxidase subunit 1) of the obtained proglottids was sequenced according to previous research [], and was determined to be identical to the Indian haplotype of T. solium (GenBank Accession Number: ). Due to the risk of the patient contaminating his living environment with parasite eggs while infected with the intestinal form of T. solium, his wife and 4 year old son were tested serologically for cysticercosis. In addition, 41 colleagues who had also travelled to India since 2007 were tested serologically for cysticercosis, with 39 of these individuals also tested for taeniasis using copro-LAMP. To date, none of these individuals have tested positive for either cysticercosis or taeniasis. This case is notable as a rare imported case of T. solium taeniasis/cysticercosis in Japan."
+Yamileth Vang,20,1983/1/31,375.576.2421,michaelhampton@example.net,443 Mendoza Rapids,"Patient 1 is a 51-year-old Caucasian woman with acromegaly, treated with pegvisomant (Somavert, Pfizer, NY, USA) after three unsuccessful transsphenoidal endoscopic tumor resections and ineffective somatostatin analog treatment. This patient presented to the outpatient clinic of Endocrinology of Modena with the clinical suspicion of acromegaly. A hormonal analysis demonstrated raised serum levels of IGF-1 (666 ng/mL; normal range: 94 ng/mL to 267 ng/mL) and basal GH (22.1 ng/mL) and a pituitary magnetic resonance imaging (MRI) scan disclosed a pituitary macroadenoma with a diameter of 12 mm, which extended to her right cavernous sinus. Our patient underwent three transsphenoidal endoscopic pituitary tumor resections, which did not lead to complete tumor resection because of residual tissue within the right cavernous sinus. She was treated with the somatostatin analog, octreotide long-acting release (LAR) (Sandostatin LAR, Novartis Pharma AG, Basel, Switzerland), at the dosage of 20 mg intramuscularly every 28 days for three months followed by 30 mg every 20 days but this did not lower her IGF-1 serum levels (821.3 ng/dL and 741.3 ng/mL, respectively). Thus, she was started on pegvisomant treatment 13 months after the initial diagnosis of acromegaly, at a dosage of 10 mg/day delivered subcutaneously, which rapidly decreased her IGF-1 serum level (251.3 ng/mL after two months of treatment). In July 2008, our patient underwent pituitary-directed Gamma-Knife stereotaxic radiosurgery. She is still under pegvisomant treatment at a dosage of 10 mg subcutaneously, daily resulting in a good control of her serum IGF-1 (206 ng/mL)."
+Jimmy Correa,34,1991/12/25,495-416-0272x3369,sford@example.org,6790 Jordan Islands,"Patient 2 is a 71-year-old Caucasian woman with acromegaly, treated with surgery 23 years before the initiation of pegvisomant treatment; the latter was administered because all previous pharmacological treatments failed. This patient came to our attention with IGF-1 serum levels higher than normal (280.1 ng/mL; normal range: 20 ng/mL to 182 ng/mL) during cabergoline treatment (Dostinex, Pfizer) at a dose of 0.1 mg twice weekly. Our patient reported a previous long history of acromegaly treated with surgery by means of a conventional transnasal transsphenoidal approach. A pituitary MRI showed a small piece of residual adenomatous tissue. Previous pharmacological treatments included bromocriptine, octreotide (Sandostatin, Novartis Pharma AG), octreotide LAR, and lanreotide (Ipstyl, Ipsen, Milan, Italy) but our patient had discontinued somatostatin and SSAs due to intolerance to the drugs; notwithstanding, they were effective in controlling the disease. As the control of the disease was suboptimal (her serum IGF-1 was constantly higher than the upper limit of the normal range) with cabergoline treatment, our patient was switched to pegvisomant therapy at a dose of 10 mg/day subcutaneously. The latter was effective in normalizing her IGF-1 serum levels (150 ng/mL after two months of treatment).
+After starting pegvisomant therapy, both women developed a rapid, progressive increase in subcutaneous fat depots at the site of injection in the abdominal periumbilical region. Both patients reported abdominal fat accumulation, and physical examinations performed four and two months after starting pegvisomant treatment for patient 1 and patient 2, respectively, revealed a soft, painless anterior abdominal wall swelling, consisting with a thickening of subcutaneous fat tissue.
+Both patients underwent detailed clinical and radiological investigations at baseline (Phase 1), after at least eight months of pegvisomant treatment (10 mg once a day) at the abdominal site, when abdominal lipohypertrophy had just started developing. Soon after the baseline evaluation, both patients switched the injection site from the abdomen to the anterior surface of both thighs. The dose of pegvisomant was not changed. A radiological evaluation was repeated after four months (Phase 2). A hormonal evaluation and study of their body composition by means of a physical evaluation, MRI of the abdomen and thighs and dual energy X-ray absorptiometry (DXA), were performed in Phase 1 and Phase 2 with the aim of detecting and quantifying changes in their subcutaneous adipose tissue.
+At physical examination, the abdominal wall swelling decreased progressively in both patients after switching the site of injection to the thighs. Swelling, however, developed at these new sites of pegvisomant injection in both patients within four months.
+The MRI images and evaluation of fat mass content with DXA (Table ) confirmed a reduction in abdominal subcutaneous fat thickness in patient 1 (Figure ) and patient 2 (Figure ), together with a concomitant increase in the subcutaneous fat at the anterior surface of both thighs in patient 1 (Figure ) and patient 2 (Figure ). Body fat thickness also increased in the flanks and back areas (only in patient 2; Figure ) and the posterior surface of the thighs in both patients (Figures and ).
+A tendency for a reduction in IGF-1 and IGF-binding protein 3 and a better control of the disease was documented, especially in patient 2 (Table ). Neither patient experienced other side effects; in particular, no enlargement of the pituitary residual tumor was recorded. Notwithstanding advice by us about the benefits of the treatment and the importance of continuing pegvisomant administration, patient 2 decided to stop pegvisomant because of the discomfort related to lipohypertrophy. In patient 2, pegvisomant withdrawal resulted in a progressive disappearance of the lipohypertrophy. Patient 1 was asked to rotate the site of injection over several districts (thighs, abdomen, arms and buttocks). As a consequence, a minimal swelling developed at these sites, without affecting self-image and patient's compliance to the treatment."
+Valery Brown,20,1986/10/24,(572)385-4725,destinyaguilar@example.org,06893 Jackson Divide,"EB is a lively and cooperative 58 year-old, right-handed woman. Two years previous to testing she suffered a large ischemic stroke involving the insular, frontal and temporal regions of the right hemisphere (see Figure ). Sensory and motor functions were briefly assessed through the standardized neurological examination by Bisiach et al. (). With this test both functions are examined according to a three-point scale ranging from score 0 (absence of deficit) to score 3 (maximum deficit). At the time of testing EB presented with left spastic hemiparesis (score 2 for the lower and 3 for the upper limb) and left hemianopia (score 3 for both quadrants). She also presented with USN and tactile extinction, as described below.
+Tactile sensation and extinction were tested in the baseline assessment and in the experimental evaluations by computer-controlled devices (Foreman & Co., UK) producing single silent and invisible touches of 100 ms duration. The stimulators were taped on the distal pad of the forefinger of each hand while EB rested the hands on her lap and fixated a central mark placed on the table in front of her. Each testing session comprised the following stimulus types: 12 unilateral left, 12 unilateral right and 24 bilateral, plus 12 catch trials (no stimulation), for a total of 60 trials, delivered in random order within a single session. After each trial the examiner verbally prompted the patient to report the presence and the side of any perceived stimulus, recorded EB's response and started the following trial.
+USN was formally tested in the baseline assessment and the experimental sessions, through common standardized tests, namely letter cancellation (Diller and Weinberg, ), star cancellation (Wilson et al., ), figure and shape copying test (Wilson et al., ), and sentence reading test (Pizzamiglio et al., )."
+Elijah Giles,42,1985/3/22,(430)856-9272x13233,patrick28@example.org,17400 Michael Springs,"A 48 year-old woman with several discrete granular corneal deposits visited our clinic with her daughter for evaluation of corneal dystrophy. Her 23 year-old daughter, determined to be a GCD2 R124H heterozygote, had best corrected visual acuity (BCVA) 20/20 in both eyes and showed no corneal deposit (). The patient had no history of glasses or contact lens wear. Upon reexamination six months later, the daughter showed one small corneal deposit in the right eye (white arrow, ) and none in the left ()."
+Bailee Bowman,21,2005/6/29,-3254,hernandezolivia@example.org,7246 Angela Manor Apt. 983,"A 28 year-old man was evaluated for corneal dystrophy because his older sister was diagnosed as being a GCD2 homozygote. He had used glasses for eight years. Upon initial examination, granular deposits or diffuse haziness were not observed in either eye (data not shown). Upon reexamination two years later, due to DNA analysis that showed him to be a GCD2 heterozygote, a newly developed, faint granular deposit was observed in each eye (data not shown)."
+Francisco Ford,24,1981/6/1,(621)250-3649,tammy73@example.org,4170 Tran Keys,"A 45-year-old man sustained blunt compression injury to his abdomen while working under a van. He was immediately extricated and presented at a referring hospital 24 hours later with mild abdominal fullness and pain. Upon transfer to our hospital, he had developed worsening abdominal pain and one episode of nonbilious emesis. He was tachycardic (120 beats/min) with mildly elevated blood pressure (140/80). His abdomen was distended, diffusely tender; and without signs of external trauma. Abnormal laboratory studies included WBC 19?103/弮L, ALT 86 units/L, alkaline phosphatase 136 units/L, and total bilirubin 3.7 mg/dL. Contrast-enhanced computed tomography (CT) of the chest/abdomen/pelvis revealed free fluid around the liver and right pericolic gutter () without evidence of extraluminal air or solid organ injury. Clips from a laparoscopic cholecystectomy (performed three years earlier for acute cholecystitis) were visualized in the hepatic fossa. Given the high suspicion for bowel and/or bile duct injury, he was taken to the operating room for exploratory laparotomy.
+Exploration revealed bilious fluid that tracked into the right pericolic gutter and retroperitoneum. No injuries were detected in any solid organs or hollow viscera. Medial rotation of the right colon and duodenum did not reveal injuries in the lesser sac or retroperitoneum. The hepatic hilum was bile stained and dissection of the hepatoduodenal ligament demonstrated complete avulsion of the hepatic duct at the confluence. The left hepatic duct and the right posterior and anterior duct junctions were visualized (). The common hepatic duct stump was oversewn and a single-layer hepaticojejunostomy was created using a retrocolic Roux-en-Y limb (). A stapled side-to-side jejunojejunostomy was performed and two closed suction drains were placed at the biliary-enteric anastomosis. The patient was discharged home with a single closed suction drain that was removed six weeks postoperatively. He has continued to do well at over three months after injury."
+Alexandra Bullock,45,1987/5/2,289.246.7760x97863,brianstone@example.net,35176 Hartman Oval,"A 77-years-old female was referred to our clinic for evaluation of worsening heart failure. She had no history of international travel. During etiological evaluation of heart failure, echocardiography revealed an ejection fraction of 40% with a multilobular cystic structure localized to intramyocardial left ventricular apex (). Computed tomography confirmed the diagnosis () and screening of other organ involvement including brain, lung, and liver were negative for cystic echinococcosis. Serum indirect hemagglutination assay test for Echinococcus granulasus was positive. Thus, diagnosis of isolated cardiac apical cystic echinococcosis was confirmed. The patient was recommended surgery, however, patient refused the surgical operation."
+Ben Edwards,37,1989/4/30,2945978421,leonjeff@example.com,04445 Kenneth Mews,"A 28-month-old girl was admitted to the Pediatric Department with a five-day history of pain in the left hip, limpness, and fever. The girl had a pelvic trauma one day before the onset of the symptoms. Examination showed an irritable girl with temperature of 39簞C. A general examination was normal. Although the girl kept antalgic position (semiflexed of the left leg) with pain in left groin, hyperextension of the hip, forced abduction, and external rotation of the left hip were limited and painful. Plain radiograph of the pelvis and ultrasonography of the hips were normal. Laboratory findings on admission showed a white blood cell count of 11600/弮L, erythrocyte sedimentation rate (ESR) of 110 mm/1st hour, and C reactive protein (CRP) of 69 mg/L. A bone scan (99 mT-MDP) performed two days after admission revealed increased uptake in the left sacroiliac joint. A CT scan performed four days after admission showed pinching of the left sacroiliac joint without effusion in this joint and thickening of the left iliacus muscles. The sacral and iliac cortices were regular along the sacroiliac joint. The left hip joint was normal without effusion. The diagnosis of pyogenic sacroiliitis was suspected, and intravenous treatment with oxacillin and gentamycin was started. MRI of the pelvis performed ten days after admission revealed on T2-weighted images an increase of the signal intensities of the left sacroiliac joint and increase of the signal of the iliacus and gluteal muscles. Also there was a little effusion in the left sacroiliac joint (). All radiologic findings (bone scan, CT scan, and MRI) suggested a left sided sacroiliitis. Blood cultures were negative. On intravenous antibiotherapy, pain decreased, and mobility improved after three weeks. The girl was discharged after three weeks of intravenous oxacillin and continued oral oxacillin for three weeks. Followed up six months later, the girl improved well without sequelae."
+Ivy Conley,37,2004/5/8,+1-246-528-5844x53896,davidhess@example.com,2149 Jensen Spring Apt. 398,"A previously healthy 13-year-old girl was admitted to the Pediatric Department presenting with fever and inability to walk. Sudden right hip and buttock pain with fever up to 40簞C had developed in the patient three days before admission to the hospital. The pain had gradually progressed to the point that she was unable to walk. The patient had no history of prior trauma but she had a skin infection in her right foot secondary to tattooing. On admission to the hospital, the patient had a temperature of 39簞C and marked pain on motion of the right hip with limitation of right hip movement. Physical examination revealed exquisite tenderness on palpation of the right hip and the right sacroiliac joint.
+Laboratory findings on admission included a white blood cell count of 31200/弮L with 80% polymorphonuclear leukocytes, ESR of 110 mm/1st hour, and CRP of 213 mg/L. A roentgenogram of the pelvis showed no abnormalities, and ultrasono-graphic of the hips was normal. The admitting diagnosis was septic arthritis of the right hip or right pyogenic sacroiliitis. Empiric intravenous antibiotherapy (oxacillin gentamycin) was started. On the second day of admission, CT of the pelvis was performed; it revealed apparent widening of the right sacroiliac joint with infiltration, edema of the soft tissue surrounding the joint, and presence of microabscess in the right iliacus muscle. All these findings suggested right pyogenic sacroiliitis joint (). An isotope bone scan was performed two days after admission, showed increased uptake in the right sacroiliac joint. Three days after the onset of antibiotherapy, the patient did not respond to treatment, continued to have fever, groin pain, and since blood cultures have identified Proteus mirabilis, than antibiotherapy was switched to the association of Cefotaxime with fosfomycin intravenously. Over the next 48 hours, apyrexia was obtained and symptoms gradually improved. CT of the pelvis was performed fifteen days after the first CT; it showed signs of right sacroiliitis with infiltration and microabscess of the soft tissue, surrounding the joint with erosions of the subchondral iliac bone (). The patient responded promptly to 25 days of intravenous antibiotherapy followed by an additional two weeks of oral antibiotherapy (ofloxacin). Followed up six months later the girl improved well without sequelae."
+Marvin Cochran,32,1983/3/15,808-282-7935,oliverkathleen@example.com,8299 Wade Falls Suite 297,"The clinical history of an Italian female patient of 43 years old with a height of 1,50 cm, begins at two years when after a normal postnatal development, was admitted the first time to a children's hospital because of a delay in growth and difficulty walking but with no mental retardation. At the age of 7 years, she had the second admittance to the hospital for a diagnostic setup, because the growth retardation was apparent, and she referred joints stiffness; physical examination showed muscular weakness, pectus carinatum, stubby neck, genu valgum, joints out of proportion to her age, and globose abdomen. The urine test was positive for the presence of keratan sulfate and fibroblasts cultures obtained from skin biopsies showed a deficiency of beta galactosidase activity confirming the diagnosis of type IVB Morquio syndrome. At the age of 11 years, she underwent tibial varus osteotomy of the left knee, while at 29 years she underwent arthroscopy of the left knee for a medial meniscus regularization procedures, cartilage debridement, and removal of an osteochondral fragment. At 35 years, she underwent surgery for uterine fibromyoma. The patient did not follow any supportive measures or rehabilitation protocol to treat the skeletal manifestations of her disease.
+At the age of 40 years till now, the physical conditions of the patient have worsened for a further deterioration of her joints, with difficulty walking and recurrent pain. The neurological examination revealed hyporeflexia either at superior or at inferior limbs, paresthesias, and muscles fasciculations. With the aim to evaluate the locomotor system conditions of the patient, a full skeletal radiographic survey has been obtained (standing anterior posterior (AP) and lateral views of the entire spine, standing pelvis view, PA view of the chest, standing AP views of the knees). MR study with a 1,5 T superconducting system (Magneton Symphony, Siemens AG, Erlangen, Germany) of the entire column, hip, knees, and ankles was also performed, including coronal, sagittal and axial views. The radiographic and MRI assessment refers to a patient who did not undergo any other surgical procedures except for those carried out at 11 and 29 years. The AP radiographic view of the spine showed a mild thoraco-lumbar right scoliosis; the lateral view demonstrated a slight thoraco-lumbar kyphosis with irregular, flat and antero-posteriorly enlarged vertebral bodies particularly in mid-thoracic region, thoraco-lumbar junction and distal lumbar spine, produced by partial ossification of cartilaginous vertebral body (Figures , , and ). The cervical tract showed wedge shape of the vertebral bodies and an hypoplasia of the odontoid process (). Roentgenographic findings of the chest included a relatively small size of her chest with oar-shaped ribs, (widening ribs anteriorly and narrowing posteriorly). The iliac wings of the pelvis were flared, with short femoral necks, flattered femoral epiphysis, and marked degenerative changes of the hip joints (). In the lower extremity, the lower ends of the femur and the upper ends of the tibia were large with an evident genu valgus deformity. Severe degenerative changes of the knee joints were present with the signs of the previous left tibial osteotomy (). MRI due to its multiplanar features confirmed radiographics findings adding further information on the degenerative alterations of the joints. Sagittal view of cervical and thoracic spine showed either the morphological alterations of the vertebral bodies or the hypoplasia of the odontoid process with a mild narrowing of the spinal canal and cord compression at the level of C2-C3 (Figures and ). On dorsal tract platyspondyly, end plate irregularity, and anterior beaking of the vertebral bodies characteristics of dysostosis multiplex, were present. MRI of the pelvis in coronal view showed multiple abnormalities including oblique acetabular roof with, flattening of the femoral heads, and severe degenerative changes in the hip joints confirmed by axial views (Figures and ). In addition to a genu valgus deformity, widening of the metaphysis and epiphyses, severe bilateral involvement of knees articular cartilage with multiple osteoarthritic changes were also detected. (Figures , , and ) Similar findings were also carried out on ankle joints, in particular at the level of tibial epiphysis and talar dome ()."
+Alma Barajas,33,1991/9/19,+1-400-955-7721x617,kristen41@example.com,698 Herrera Alley Suite 607,"An 8-year-old boy presented to the Department of Pedodontics of Dr. HSJIDS with the chief complaint of swelling and pain in the lower right posterior region since 3-4 days. Intraoral examination revealed a fractured filling, grade 1 mobility of the tooth, tenderness on percussion, and abscess in relation to tooth 85. An intraoral periapical radiograph was advised; it revealed the presence of a sharp radiopaque material present in relation to the external surface of the mesial root ().
+Extraction of the involved tooth was done, and the foreign object was removed that was found out to be a sharp tip of the metallic compass (). On further questioning, it was told by the patient's parents that the child frequently used to use a metallic compass to take out the impacted food from the fractured filling."
+Brennan Huff,34,1981/5/28,(922)637-5875,jessica17@example.net,998 Anderson Village,"An 11-year-old boy was brought to the Department of Pediatric Dentistry with the chief complaint of pain and swelling in the maxillary anterior region. He had suffered dental trauma a year back. Intraoral examination revealed fractured 11 with the slit-like opening involving the pulp chamber of tooth 11 (). The tooth exhibited the following clinical features: swelling in the labial vestibule, grade 1 mobility, and tenderness on percussion. An intraoral periapical X-ray of the region was advised. The radiograph revealed a stapler pin in the pulp chamber of 11 (). History revealed that the child had the habit of playing with the stapler; the pin got stuck in his tooth. Attempts by him to remove it were futile. The incident was concealed from his parents as he feared a reprimand or admonishment. A tetanus vaccine booster dose was administered to the patient in the very first appointment. The timing of presentation enabled us to solve the problem by removing of the stapler pin from the tooth () by making a conventional access cavity followed by copious irrigation of the pulp chamber to remove the debris present; routine endodontic procedure was followed by placement of dressing of nonsetting calcium hydroxide. Once the tooth was asymptomatic, it was obturated."
+Karsyn Cisneros,18,1988/9/18,001-595-624-9870,christopher75@example.org,17252 Casey Dam,"An 28-year-old male patient reported to the Department of Oral Medicine and Radiology with a complaint of dull pain in upper right back region. The patient was an air conditioner mechanic and had met with an accident two months back; while repairing the air conditioner, it suddenly burst and he got severe injuries on his face and one of the fragments of the air conditioner got embedded in oral cavity. On examination, there was a fibrous swelling palpable in the vestibular area of the upper right premolars. An OPG radiograph was advised (). The radiograph revealed a rectangular radiopacity in the premolar region. The area was explored under local anesthesia, and a rectangular copper strip approximately 0.7 ? 1 cm was removed ()."
+Alden Terry,36,1998/1/16,655-590-5542x188,diana00@example.com,75237 Knight Greens Apt. 277,"An 20-year-old male patient reported to the department with a history of breaking a sewing needle in upper right back area two days back while trying to remove the food debris (). An IOPA radiograph was advised, and it revealed a radiopaque object that was the broken needle on both sides of 17. Under local anesthesia, the two fragments were removed ()."
+Wren Wiggins,21,1994/7/1,(312)411-2734,hammondamanda@example.com,62052 Walter Ville,"A 19-year-old male patient was referred to the Department of Oral Medicine and Radiology for treatment. Patient gave a one-month history of a mild pain and swelling in the right posterior mandible. Pain is intermediate and usually seen on mastication. Initially, the swelling was small in size and showed a gradual increase to its present dimensions. Clinical examination revealed a firm, non-tender swelling expanding the buccal and lingual cortices of the mandible, extending from right first premolar region to third molar region, and it obliterated the buccal vestibule. The skin over the swelling was normal, and there was no history of paresthesia (Figures and ).
+The panoramic radiograph showed a large well-defined, sclerotic margined, multilocular radiolucent lesion with ?oap bubble??appearance extending from the lower right canine to 1 cm distal to the third molar and also showed first molar mesial root resorption (). The right mandibular lateral occlusal radiograph showed multilocular radiolucent lesion with expansions of buccal and lingual cortices (). Fine needle aspiration was performed to rule out odontogenic cysts, and results were negative. Benign odontogenic tumors were considered, and incisional biopsy was made and a histopathological examination of the tissue sample exhibited rounded, stellate, and spindle-shaped mesenchymal cells arranged in a loose, myxoid stroma with few collagen fibrils (). These results were suggestive of OM. Segmental resection of the right side mandible was performed under general anesthesia (). Reconstruction was done by microvascular iliac bone grafting, and fixation was achieved with titanium plates (). Postoperative complications included iliac bone graft rejection, and sequestrated bone graft was removed 3 months later. 30 months after the surgical procedure, there were no radiographic or clinical signs of recurrence and patient was not interested for rehabilitation."
+Azariah Hawkins,45,1999/2/27,7564449986,kylecollins@example.org,461 Nelson Mount,"A 29-year old male living in a rural area of Southern Sudan has been maintained on continuous ambulatory peritoneal dialysis for two years. He presented to our center in May 2010 complaining of fever, dry cough, shortness of breath, and abdominal discomfort of four days duration. He was very ill, pale, and dehydrated. His temperature was 38.4簞C, respiratory rate 30 per min, pulse rate 120 beats per minute, and blood pressure 70/50 mmHg. There were enlarged tender submandibular lymph nodes, but no mouth ulcers or other palpable lymph nodes. Chest and precordium examination was unremarkable. Abdominal examination revealed bilateral loins tenderness but no guarding. There was no palpable organomegaly, and the peritoneal catheter exit site showed no signs of inflammation. The skin was intact and there was no arthritis. Neurological examination revealed no abnormality.
+The patient was admitted and rehydrated. The peritoneal effluent was inspected and found to be clear. Investigations revealed WBCs count of 13,100/弮L with 90% polymorphonuclear cells, hemoglobin 5.6 g/dL, platelets 160,000/弮L, ESR > 150 mm/hr, serum albumin 1.9 mg/dL, blood urea 168 mg/dL, serum creatinine 9.2 mg/dL, and normal liver enzymes and electrolyte levels. Peritoneal effluent contained 50 WBC/弮L. Blood film for malaria was negative as were serological tests for Brucella and Salmonella.
+We sent blood and peritoneal effluent samples for culture and started empiric antibiotic treatment with ceftriaxone, and ciprofloxacin. He also received 4 units of blood to correct his anemia.
+Peritoneal effluent cultures remained negative after three days of incubation. Blood samples were cultured in Brain heart infusion (BHI) broth and Thioglycollate broth. After five days of incubation, the aerobic BHI broth showed increased turbidity and gram stain revealed tiny gram negative pleomorphic bacilli. Subcultures were performed in three solid media; blood agar, chocolate agar, and McConkey agar. Forty eight hours later the subcultures showed non hemolytic mucoid gray white colonies on the chocolate agar, very faint growth was detected on the blood agar, and no growth noticed on the McConkey agar plate.
+Giemsa stain smear revealed a bipolar organism. The isolated organism tested negative for oxidase, urease, motility and fermentation of lactose, and other sugars. A battery of chemical tests was performed utilizing two analytical profile index kits (API, bioMerieux) for identification of gram-negative rods; API-20E and API-20NE. Both failed to identify the organism but confirmed that it did not belong to hemophilus, actinobacillus, cardiobacterium, ekinella or kingella species. Thus, the organism was identified as Francisella tularensis. Further investigations to determine antimicrobial sensitivity were not done due to inadequate lab safety facilities.
+The patient's condition was generally better but he was still running on and off fever. We started him on a ten-days course of gentamicin. The patient improved dramatically after receiving gentamicin and was discharged in good condition. He remained asymptomatic two weeks later when he presented for followup. No similar condition emerged in his family or contacts including the medical and laboratory personnel. To the best of our knowledge, this is the first reported case of Francisella septicemia in our area and, may be, in Africa."
+Ariel Hartman,45,1989/8/17,001-364-502-1252x527,brittany34@example.net,1346 Webster Plain Suite 995,"A 63-year-old man was referred to the Department of Prosthodontics in the Faculty of Dentistry at Isfahan University of Medical Sciences, Iran, for prosthodontic treatment. The patient's chief complaint was the restoration of worn teeth, in addition to the replacement of unacceptable restorations and missing teeth. An initial evaluation of the patient indicated a history of depression, and also, parafunctional habits of bruxism and clenching. Oral hygiene was fair, and there was no periodontal problem. Clinical and radiographic examinations and diagnostic casts revealed severe attrition, especially on anterior teeth and an uneven occlusal plane (). The causes of the severe wear were parafunctional habits, unsuitable restorations, and a lack of stable posterior occlusion.
+After oral hygiene instructions, making impressions and diagnostic workup, removable provisional prostheses were fabricated with correct occlusal plane and adjusted clinically for achieving good aesthetics, phonetics, and OVD. This removable prosthesis was used to evaluate the OVD and patient tolerance ().
+An ITI implant (4.8 ? 10) (Straumann, Basel, Switzerland) was inserted in right first lower molar region after precise clinical and radiographic evaluation and diagnostic waxup using surgical stent. Root canal therapy (RCT) of anterior worn teeth and retreatment of teeth with unacceptable RCTs were performed, and casted posts and cores were fabricated (). Fixed and removable provisional restorations were inserted and adjusted until patient acceptance achieved. These restorations were fabricated according to the diagnostic waxup (), for which the Broadrick flag analyzer was used to determine the curve of occlusal plane. Impressions were made from provisional restorations, and casts were transferred to the Denar Mark II articulator (Teledyne Water pik, Fort Collins, CO, USA) using the Denar Slidematic facebow (Teledyne Water pik, Fort Collins, CO, USA). Then, an anterior guide table was customized by pattern resin (Duralay, Reliance Dental MFG Co., Worth, CO, USA). After completion of teeth preparations, the final impressions were made with silicon impression material (Speedex, Coltene AG, Alstatten, Switzerland/impergum, 3 M ESPE), and metal-ceramic restorations were fabricated. In the maxillary restorations, rest seats, guide planes, and retentive undercuts were formed in the RPD abutments. A Kennedy class II mode 1 maxillary RPD was fabricated and delivered (). Finally, the occlusion of restorations was adjusted so that equal-intensity centric contacts were established on all teeth (), and anterior guidance discluded all posterior teeth in eccentric jaw movements. A maxillary occlusal splint was fabricated for protecting the restorations from patient's parafunction. The smile view of patient after treatment is shown in . One-year followup showed no problem in teeth, restorations and temporomandibular joints and show the panoramic image after this period."
+Baker Crosby,33,1985/7/6,397-241-2653x1017,larsontodd@example.net,94875 Brandon Throughway,"A 75-year-old male referred to the eye clinic of Erciyes University Medical Faculty with the complaint of vision loss and conjunctival hyperemia of the left eye. He had a history of trauma to his left eye four days ago. Magnetic resonance imaging (MRI) of the orbits showed bilateral proptosis which was significant on the left as well as edema and inflammation at the anteroinferior part of the left bulbus oculi. He was referred to our clinic to investigate the etiology of the proptosis. His past medical history included hypertension which was regulated with an oral antihypertensive agent. Visual acuity was counting fingers on the right eye and 5/10 Snellen lines on the left. He had nuclear cataract, and minimal proptosis on the right eye, conjunctival hyperemia, chemosis, nuclear cataract and moderate proptosis on the left eye. The intraocular pressure and fundus examinations were within normal limits for both eyes. Hertel exophthalmometer measurements were 21 mm on the right and 24 mm on the left. Ocular ultrasonographic (USG) examination of both eyes were normal. The patient was hospitalized for the differential diagnosis of orbital pseudotumor, orbital cellulitis, retrobulbar tumor, intraorbital foreign body, thyroid ophthalmopathy, and carotid-cavernous fistula. The patient received oral flurbiprofen (100 mg, t.i.d) and ciprofloxacin (750 mg, b.i.d), topical moxifloxacine and dexamethasone 6 times daily and cold compresses as an initial treatment. Orbital computerized tomography showed no foreign body, and there was no murmur on auscultation of the glob. The proptosis was not pulsatile. The visual acuity on the left eye decreased to 4/10 Snellen lines one day after the hospitalization although the other ocular signs remained the same. After the consultations with the departments of infectious diseases and endocrinology, the diagnosis of orbital cellulitis and/or thyroid ophthalmopathy was not considered. An oral steroid (fluocortolone 1 mg/kg,) and preventive treatment for the gastric mucosa (ranitidine HCL, b.i.d) were added to the treatment because of the possible diagnosis of orbital pseudotumor.
+On the second day of the hospitalization, vesicular and pustular lesions occurred around the left eyelid and forehead, and the diagnosis of HZO was made (). The visual acuity of the left eye rapidly decreased to counting fingers from 3 meters, and a punctate keratopathy was detected on slit-lamp examination. After the consultation with the department of dermatology, oral corticosteroid treatment was stopped, and the patient was commenced on a treatment of oral valacyclovir (1 g, t.i.d. for 7 days), vitamin B1 (250 mg, b.i.d), vitamin B6 (250 mg, b.i.d), and dressing with ethacridine lactate for the skin lesions. The visual acuity of the left eye decreased to hand motions one day after the initialization of this treatment. Total ophthalmoplegia and ptosis of the left eye were detected (). There were dendritic lesions on the cornea (). Since a brief period of disorientation and a syncope was developed, a diagnosis of OAS and a probable cranial involvement was considered and the patient was referred to the department of infectious diseases. The patient was commenced on intravenous ampicillin sulbactam (2 gr, t.i.d.) and acyclovir (750 mg, t.i.d.) for 14 days, topical acyclovir ointment 5 times, moxifloxacin and polyacrylic acid 6 times, and a fixed combination of dorzolamide HCL and timolol maleate 2 times per day. Two days later uveitis with cyclitic membrane and hemorrhage in the anterior chamber were developed (). Topical cycloplegic drops and hot eye compresses were added to the treatment 5 times per day. Topical steroids were not considered because of the diffuse corneal epithelial defects. MRI examination showed an enlargement of the extraocular muscles and an increase in the amount of the soft tissues around the preseptal area; both of the cavernous sinuses were normal. Both of the superior orbital veins were dilated, which were more significant on the left. There was a choroidal detachment and an intraocular hemorrhage on the left eye. Diffusion MRI showed a deficiency of the diffusion on the right frontal and frontoparietal regions.
+When the acute clinical signs of HZO were regressed, the patient was commenced on a tapering dose of oral prednisolone (1 mg/kg per day) to accelerate the recovery of the total ophthalmoplegia, proptosis, and ptosis. Topical cortisone treatment (dexamethasone) 8 times was added after the recovery of the corneal epithelial defects.
+At the end of 5-month follow-up period, the visual acuity of the left eye was counting fingers from 1.5 meters. Anterior segment examination showed an epithelial defect at the inferior half of the cornea, posterior synechiae at the pupillary area, fibrinoid reaction in the anterior chamber and mature cataract. The intraocular pressure of the left eye was 4 mmHg (applanation). The USG examination of the left eye revealed a choroidal detachment. The corneal sensation, ocular motility, and the ptosis showed partial improvement at the end of five months ()."
+Keily Potts,24,1980/10/21,-3236,jennifermeyer@example.net,38499 Blevins Garden Apt. 690,"A nineteen-year-old female patient who had severe facial trauma was referred for dental rehabilitation after a series of esthetic surgery operations. The patient's history revealed a blow to her face after falling off a cliff during mountain biking. Her initial evaluation in Emergency Service reported that her general condition was poor, and her hemoglobin value was 6 mg/dL with severe maxillofacial trauma and bleeding. The patient had an emergency consultation at the Department of Plastic and Reconstructive Surgery after a rapid hemodynamic stabilization and CT scans. According to the medical records obtained from her physician, she had a severe soft tissue injury and accompanying comminuted bone fractures on bilateral maxilla, zygoma, periorbital area, mandible, and nasal bones. Bone fragments were fixed with titanium plates and screws without bone grafting. There was also a posterior vertical split fracture on the hard palate extending anteriorly to both sides creating a mobile free bone fragment on the anterior maxilla. Those fractures were also fixed after reconstruction and then soft tissue repair was done. Complications were not seen in the early postoperative period; however, followup of the patient indicated bone necrosis on the anterior maxilla including the alveolar process extending to the palate. After debridement of the necrosis process, the defect was reconstructed with mucosal flaps and bony reconstruction was postponed. The patient refused the bone graft surgery planned for the repair of the defect on the anterior maxilla and had been consulted for prosthetic treatment.
+Her clinical examination showed soft tissue defects on the face particularly eye area and dysmorphic appearance (). The panoramic radiograph demonstrated mini plates and screws used for fixing fractured zygomatic arch, orbital, and maxillary sinus walls. Intraoral examination revealed the absence of the anterior maxillary alveolar ridge and bone until the apex line; both maxillary central and lateral incisors and right canine teeth were lost as a result of traumatic injury ().
+The patient had an Angle Class I occlusion with an acceptable vertical and horizontal overlap prior to the accident. Because of the loss of premaxillary segment, the patient experienced speech problems and had difficulty in biting and swallowing (). In addition, the maxillary lip had lost support and was depressed into the defect area. The mandible was overclosed, resulting in a decrease of the vertical facial height. The temporomandibular joints were asymptomatic and jaw movement was in normal limits. The patient has complained of her inability to communicate, emotional disturbance of her appearance, and anxiety about the restoration of her teeth. After her extensive surgical procedures, initially temporary acrylic prosthetic rehabilitation was applied approximately one year later after trauma in order to restore her oral and dental function ().
+As a treatment method, the zirconia-based crown bridge prosthesis had been planned and applied between right first molar teeth through left second premolar teeth for the replacement of the missing teeth (). A new centric relation was made to transfer the articulator and shade was selected. This prosthesis was combined with gingiva-colored porcelain (Noritake Super Porcelain; Noritake, Nagoya, Japan) to compensate for the loss of hard and soft tissue on the anterior maxillary area and lip support. The zirconia framework was veneered by feldspathic porcelain and occlusion balance was checked. Definitive zirconia_crown bridge prosthesis was fabricated using computer aided design/computer-assisted manufacturing (CAD/CAM) system (Procera, Nobel Biocare). The patient was given home oral health care instructions, including use of dental floss, interproximal brushes, and an oral mouth rinse.
+The advantages of combined prosthesis included esthetic and biocompatible restoration with zirconia prosthesis. A satisfactory esthetic and functional result was achieved after fixed denture adjustments (). After the 1st, 3rd, 6th, and 12th months recall visit, the patient was satisfied with her new appearance and had no functional difficulties during eating, chewing, or swallowing. Speech impairment was eliminated considerably and the patient's profile was improved to a certain degree. In a followup of 5 years period, the prosthesis was stable and there was no evidence for relapse or dysmorphology was found."
+Alfred Bell,43,1978/11/12,(896)232-7339x8427,pmoore@example.org,653 Cox Route Suite 122,"A 21-year-old, 31-week pregnant, gravida 1, para 0 case was confused with a moderately poor general condition and was admitted to the obstetric clinic. When the patient came to the hospital, her arterial blood pressure was 210/130 mmHg, and anamnesis from her relatives revealed that she had a generalized seizure 1 hour prior to admission. On bed-side ultrasound, normal amniotic fluid volume and one viable fetus with a body size consistent with 29 weeks were found. The patient had 4+ proteinuria and was diagnosed as eclamptic and given a loading dose of magnesium sulphate (4 grams). Three minutes after magnesium sulphate was administered, the patient had another generalized convulsion and was given diazepam (10 mg i.v.). The patient had respiratory distress and was intubated orotracheally and taken to the operating room for an emergency Cesarean section. Thiopental sodium (250 mg, Pental) and cisatracurium (4 mg, Nimbex) was administered for induction of anesthesia followed by 50% O2 + 50% N2O and 0.75% MAC isoflurane. One viable female baby in breech presentation was delivered by Cesarean section. The baby's birth weight was 1100 gr and height was 36 cm with a 1-minute APGAR score of 7. After the operation, the patient, still entubated, was taken to the intensive care unit, and mechanical ventilation was initiated (SIMV, f: 12/min, FiO2: 60, TV: 500 mL, I : E = 1 : 2). In the intensive care unit, her blood pressure tended to increase (180/110 mmHg) so nitroglycerin (10 弮g/kg/h) and magnesium sulfate (2 gr/h) infusion was continued. The patient was administered dexamethasone (32 mg/day) and an oral antihypertensive amlodipine (Norvasc 10 mg/day). As she regained consciousness and spontaneous breathing, the patient was extubated. But 15 min after extubation, the patient had another convulsion and was reintubated. Biochemical values of the case were as follow: Hb: 13.5 gr/dL, Htc: %37, WBC: 16590/mm3, PLT: 50.000/mm3, AST: 375 U/L, and ALT: 183 U/L, LDH: 1213 U/L, and her coagulation parameters were Prothrombin time (PT): 52,1 secs, activated prothrombin time (APTT): 25,2 secs, INR: 1,44. With these findings, the patient was diagnosed as having HELLP syndrome and eclampsia, and neurologic examination showed no lateralization. The patient was administered Thiopental sodium (100 mg bolus followed by a continuous infusion of 250 mg/h i.v.), and her convulsions were reduced considerably. Therefore, first day after surgery thiopental sodium was stopped, and after approximately 6 hours, the patient was extubated. Magnesium sulfate infusion was continued. The patients, postoperative first-day MRI showed increased intensity lesions on sequences T2, FLAIR, DAG, and ADC in bilateral basal ganglia, at the level of centrum semiovale on the frontal areas, bilateral parietotemporal, occipital regions, and left cerebellum (). The patient was diagnosed as having PRES. The patient was treated with magnesium sulfate for 48 hours, and her platelet counts were 44,000/mm3 on the first day after the operation. Her liver enzyme and LDH levels were elevated. As her general condition improved, the patient was taken to the obstetric clinic on the second postoperative day. Her liver enzyme and LDH levels started to decrease starting from the second postoperative day. Her platelet counts were 97,000/mm3 on the second day after surgery. Her drains were removed on the third day after the surgery and sutures were removed on the 7th postpartum day. The patient was discharged with suggestions after that. Her MRI was taken after a month and was totally normal ()."
+Melody Rios,27,2004/9/24,+1-934-953-1770x37549,emartinez@example.net,9922 Calvin Union Suite 762,"A 45-year-old female presented to the emergency department with a 1-day history of new onset abdominal pain. The abdominal pain was described as severe and sharp. It localized to the epigastric, right upper, and right lower quadrants as well as radiated posteriorly. She had nausea, as well as multiple episodes of nonbilious vomiting. The past medical history was significant for breast cancer, and the past surgical history was significant for a c-section, bilateral mastectomy, and bilateral tubal ligation.
+On admission, her temperature was 97.8簞F and hemodynamically stable. Her exam was significant for epigastric tenderness, as well as a positive Murphy's sign, and tenderness over McBurney's point. She had no peritoneal signs, and a negative psoas, obturator, and Rovsing's sign. Clinically, her general appearance was not consistent with sepsis or bacteremia. Her white blood cell count was 8 K/弮L with a hematocrit of 37.8%. Her admission chemistry was normal, but her hepatic profile revealed an elevated total bilirubin of 1.4 mg/dL, a direct bilirubin of 0.5 mg/dL, and normal transaminases and alkaline phosphatase. The urinalysis revealed 3+ occult blood.
+CT abdomen and pelvis with contrast revealed cholelithiasis with the possibility of cholecystitis, as well as a dilated (9 mm) fluid filled appendix suggesting the possibility of early appendicitis (). An abdominal sonogram was performed, which confirmed the acute cholecystitis with cholelithiasis with the common bile duct size of 4 mm but did not visualize the appendix.
+The patient was brought to the operating room where a laparoscopic cholecystectomy and appendectomy was performed. The appendix intraoperatively appeared to be an early appendicitis, nonperforated. The abdomen was accessed via a single 12 mm port and five additional 5 mm ports (). The surgery time was 2 hours and 3 minutes. The final pathology revealed both acute and chronic cholecystitis with cholelithiasis, as well as nonperforated acute appendicitis with periappendicitis. The patient was discharged home on postoperative day 2 and made an uneventful and full recovery."
+Israel Franklin,38,1986/8/13,5385247140,julie36@example.net,14023 Johnson Forest Apt. 754,"A 51-year-old type II diabetic gentleman had been under our care for one year with recurrent high-grade superficial transitional cell carcinoma (TCC) of the bladder. This had been treated with TURBTs and subsequent six instillation courses of intravesical mitomycin-C and BCG. He had, on three occasions, tumour in the prostatic urethra which was resected and then treated with three instillations, at three-week intervals, of mitomycin-C gel (20 mg Mitomycin-C in 5 mL water for injections and 5 mL Instillagel, that is, 2 mg繚mL??). Treatment was given for one hour, and the gel was retained with the assistance of a penile clamp. After the first treatment, the patient complained of severe dysuria, but after three weeks, continued with treatment. When readmitted for a check cystoscopy, he complained of continuing dysuria and deterioration in urinary flow. At cystoscopy he was found to have a very dense, almost impassable, distal urethral stricture which was eventually dilated using S-curve dilators over a guide wire up to 20 French to allow passage of the cystoscope. Cystoscopy demonstrated the stricture to be approximately 2.5 cm long and corresponded to the site and size of the penile clamp. There was no further stricturing and no evidence of urethral tumour recurrence proximally. Following a period of one month with an indwelling urethral catheter, his catheter was removed and he voided satisfactorily. He awaits further cystoscopic surveillance."
+Angela Huerta,44,1990/3/6,(523)349-6862x131,dillonpamela@example.org,436 Rodgers Route,"A 28-year-old female was referred to our practice complaining with recurrent urinary symptoms such as dysuria, burning, pollakiuria, and urinary urgency. Neither personal nor familiar medical history of interest was reported. Periodical urocultures resulted negative. Yeasts and Koch's bacillus were also excluded. Intravenous urography (IVU) revealed a left double excretory system, without any other relevant findings. A CT scan showed an unspecific bladder wall thickening. A subsequent cystoscopy revealed a whitish thin plaque covering the whole bladder surface with the exception of the trigone area. Underneath this whitish plaque, the mucosa appeared erythematous and bled easily during the examination (). Random biopsies reported a keratinizing squamous metaplasia of the bladder (). Due to the age and mild symptoms of the patient, we agreed on a conservative management and proposed annual cystoscopy with random biopsies combined with annual upper urinary tract imaging (CT scan or IVU). After a two-year followup, the patient is felling generally well with occasional urinary symptoms but no evidence of disease progression."
+Douglas Aguirre,44,1984/12/22,3403205506,rachel93@example.net,5191 Jones Drive,"A 68-year-old Caucasian male with a history of multiple myeloma on lenalidomide/dexamethasone, diabetes, and end-stage renal disease on hemodialysis was admitted to the hospital for severe diarrhea and dehydration. On physical examination, he was found to be afebrile with benign abdominal exam. His white blood cell count (WBC) was normal. Fecal leukocytes were detected. Stool ova and parasites and bacterial stool cultures were negative. A computed tomography (CT) of the abdomen and pelvis showed diffuse thickening of the colon wall involving the entire colon and rectum consistent with infectious colitis. With the high suspicion of Clostridium difficile associated colitis, metronidazole 500 mg orally every 8 hours was empirically started. The cytomegalovirus serum polymerase chain reaction (PCR), enzyme immunoassay (EIA) for C. difficile toxin A/B and C. diffile PCR were all negative. Despite metronidazole treatment, his diarrhea persisted and on the 7th hospital day, he had a temperature of 101.8簞F and rifaximin 550 mg orally twice daily was added. He responded rapidly to the combination treatment and the diarrhea and fever resolved by the 14th hospital day and he was discharged on metronidazole for 14 days. However, a week later the patient was readmitted to the hospital with diarrhea, nausea and abdominal pain. On physical examination, he was afebrile and appeared to be in mild distress with right-lower quadrant and suprapubic tenderness on palpation. His leukocyte count was 6,200 cells/弮L and a repeat abdominal CT showed changes of pancolitis consistent with an infectious process. Metronidazole was continued and cefepime 1 gram intravenously every 24 hours was added. Stool culture showed only normal fecal flora and blood cultures were negative, however; the EIA C. difficile toxin stool assay was positive. His therapy was changed from metronidazole and cefepime to vancomycin 250 mg orally every 6 hours, as his symptoms restarted within 5 days of receiving rifaximin and while on metronidazole. Over the following nine days, the patient showed little response to therapy, averaging six loose bowel movements a day along with persistent abdominal tenderness and distention. He had a WBC count of 5,000 cells/弮L with 32% bands, and a lactate level was elevated at 4 mmol/L. An abdominal X-ray showed no bowel distention. By the 10th hospital day, the patient developed leukocytosis with a WBC count of 17,200 cells/弮L and was now considered to have failed vancomycin treatment. Tigecycline 100 mg intravenously once, followed by 50 mg every 12 hours and rifaximin 550 mg orally every 12 hours, was added to the vancomycin. Though the patient's leukocyte count peaked at 19,900 cells/弮L (during 2nd day of modified therapy), he responded well with a gradual decrease in leukocytosis, diarrhea, and abdominal pain. He was discharged on the 16th hospital day with resolution of symptoms after 4 days of tigecycline, rifaximin, and vancomycin treatment. He was continued on this antibiotic regimen for an additional ten days. One month after finishing antibiotics, the patient was free of symptoms."
+Ariah Warren,41,1984/3/18,-5861,jasonlin@example.net,904 Henson Islands,"A 34-year-old female, without a familial history of neurofibromatosis, presented with left hearing disturbance. Magnetic resonance imaging (MRI) in 2004 showed VS at left cerebellopontine angle. Two times of left retrosigmoid approach with partial tumor removal were done during 2004. Pathological report was schwannoma WHO grade I. At 1 year after the second surgery, SRT, hypofraction was given due to regrowth of the tumor. Linear accelerator base system (6 MV dedicated Linac, Varian; with X-knife planning system version 3&4, Radionics) was used for SRT treatment. Four isocenters with total average dose of 30 Gray in 6 fractions prescribed at 80% isodose line were given to the patient during 2 weeks period. The tumor volume was 4.8 cc. The tumor had been well controlled for 6 years after SRT. revealed the MRI Axial and Coronal showing a left VS at the time before SRT.
+The patient presented with left facial palsy, dysphagia, and right hemiparesis 6 years after SRT. Computer tomography revealed marked progression in size with cystic and hemorrhagic changes of the preexisting tumor at left CPA with new obstructive hydrocephalus (). Craniotomy with tumor removal was done immediately. MRI was performed at 3 weeks after operation, and the study shows small residual tumor at the left internal auditory canal with the cluster lesions at the superior aspect of the surgical site that is compatible with the resolving hematomas (). The patient had improvement of her neurological symptom after surgery. The pathological report was malignant peripheral nerve sheath tumor arising on schwannoma, with heterogenous mesenchymal rhabdomyoblastic and chondroblastic differentiation, WHO grade IV.
+Because of malignant histology and small residual tumor, the patient underwent postoperative radiation therapy with 3-dimensional conformal radiation therapy (3D-CRT). A total dose of 54 Gray in 27 fractions was planned for the patient. After 20 Gray in 10 fractions of 3D-CRT, the patient developed deterioration of consciousness. CT emergency was done and showed progression of residual tumor with internal bleeding (). Obstructive hydrocephalus was more severe. Ventriculoperitoneal shunt was performed immediately. After VP shunt, the patient still had no cooperation and showed no response to deep pain. Because the prognosis of the patient was poor, we discussed with her husband about the end of life care. Finally, the patient was discharged home for best supportive care 1 month later.
+The two pathological specimens were examined in two occasions as shown in . The first specimen reveals low cellularity spindle cell tumor with minimal nuclear atypia and fibrillary cytoplasm that are compatible with schwannoma ().
+The second specimen was performed after irradiation and composed of markedly hypercellularity and hyperchromatic spindle cells growing in fasciculated pattern. The cytoplasm is typically light staining and indistinct (). A few areas of markedly pleomorphic nuclei, brisk mitotic activity, and round cells epithelioid appearance are also seen (Figures and ).
+The capacity of MPNST to undergo focal mesenchymal differentiation is well known. Rhabdomyosarcoma is most frequent. The other sarcomatous component may be present such as chondrosarcoma and osteosarcoma. In this case, pluridirectional differentiations are observed as chondrosarcomatous component () and rhabdomyoblastic component ().
+Immunohistochemically, S-100 is negative () and confirms rhabdoid/skeletal muscle differentiation with positive staining with sarcomeric actin (). The high proliferative index (Ki 67) is also seen supporting malignant behavior ()."
+Abel Enriquez,39,1997/8/28,(825)777-6488,dicksontiffany@example.org,5370 Coleman Plains,"The patient is a 68-year-old male with history of untreated hypothyroidism, untreated hypertension, and no medical care for over the last 10 years who presented to hospital with complaints of nausea, vomiting, and lower extremity weakness. Patient had called 911 two weeks prior for an episode of chest pain that felt like he was having a heart attack. When emergency medical service (EMS) arrived, chest pain had resolved and patient refused to come to hospital. A similar episode of severe chest pain occurred the following week, for which he called 911, but again refused transfer. On the day of admission patient called 911 again, but this time for nausea, vomiting, and weakness. When EMS arrived, they noticed he had slurred speech, a left-sided facial droop, and, therefore, transferred him to the hospital with concerns for stroke.
+In the emergency room, physical exam was most remarkable for all the classic signs of hypothyroidism including hypothermia at 35.8簞C, periorbital edema, puffy facies, macroglossia, hoarse voice, and delayed relaxation of deep tendon reflexes. His electrocardiogram (EKG) showed low voltage and sinus bradycardia with a rate in the 40 s. He did have left-sided facial droop and dysarthria, which was found to have been present for many years according to his family, and strength was 5/5 throughout his upper and lower extremities. No other focal neurological deficits were appreciated. Head CT without contrast indicated there was no acute intracranial pathology, brain MRI without contrast showed extensive chronic microvascular ischemic disease, as well as remote microhemorrhages in the right occipital and left cerebellar hemisphere. Lumbar spine MRI without contrast showed multilevel degenerative changes, most pronounced at the L5-S1 with a diffuse disc bulge, moderate-to-severe left and right neural foraminal stenosis, but no central canal stenosis.
+Initial laboratory data was significant for a TSH of 63.4 IU/mL, creatinine of 1.9 mg/dL, hemoglobin of 7.3 gm/dL, and a normal white blood cell count. Patient was given two units of packed red blood cells, which improved his anemia to 9.7 gm/dL. He was admitted to general medicine service for further management of his severe hypothyroidism and workup for his anemia of unknown etiology.
+The following morning repeat labs showed further decline in his kidney function, with a creatinine of 3.1 mg/dL, and potassium of 5.1 mMol/L. There also was new leukocytosis of 15 (?109/L) with a 94% left shift, a new thrombocytopenia of 131 (?109/L), down from 225 (?109/L) at admission, and an elevated creatine phosphokinase (CPK) of 500 IU/L. A portable chest X-ray did not show any obvious sings of widened mediastinum but did show a left lower lobe consolidation consistent with a pneumonia for which he was started on IV azithromycin and ampicillin/sulbactam.
+Nursing staff noted stool incontinence, for which a rectal exam was performed showing good rectal tone, and a positive guaiac. In addition, despite receiving aggressive fluid resuscitation, patient continued to be in auric renal failure. Patient then received 3 more liters of fluid throughout the day, a Foley was placed, and bladder scans showed a total of 48 cc of urine, enough to send urine studies. Urinalysis was negative for any signs of infection, and urine electrolytes indicated a fractional excretion of sodium (FeNa) of 0.96% looking initially like a prerenal process.
+Labs were again repeated that evening, with a rising creatinine to 4.1 mg/dL, a lactate of 3.7 mMol/L, and patient still had no urinary output. Nephrology and endocrinology specialists were consulted, and the thought process was that his renal failure was likely stemming from his severe hypothyroidism causing a low flow state. He was started on levothyroxine (T4) and liothyronine (T3) and continued to get intravenous fluids.
+The third day after admission morning laboratory data showed further increase in his creatinine to 6.1 mg/dL, a worsening leukocytosis to 16.7 (?109/L), an improved lactate of 2.2 mMol/L, and a worsening thrombocytopenia of 92 (?109/L). Thrombotic thrombocytopenia purpura (TTP) and HUS were also considered on the differential, given the anemia, and high LDH of 1014 IU/L. However, the smear did not have significant amounts of schistocytes, and the haptoglobin was normal; thus making it less likely.
+Patient began complaining of abdominal pain and in the setting of an increasing leukocytosis and diarrhea, an abdominal CT without contrast was performed. This showed colitis, which looked either infectious or ischemic, as well as, a possible aortic dissection. A CT angiogram of the chest, abdomen, and pelvis was subsequently performed STAT, which showed a large type B dissection starting in the descending thoracic aorta just past the origin of the subclavian artery, extending into the abdominal aorta, with near complete collapse of the true lumen at the level of the renal arteries, with extension of the dissection into the common iliac arteries bilaterally, and ending at the level of iliac bifurcation (see Figures ??.
+Following is a discussion on the presentation of this case of severe hypothyroidism and long-standing hypertension who presented with anuria/renal failure. Through the case, we highlight the importance of having aortic dissection as an important differential in patients presenting with anuria who have a long-standing history of uncontrolled hypertension."
+Nellie Duarte,26,2001/1/30,292-331-4231,wilsontaylor@example.com,1316 Ruiz Garden Suite 219,"In March 2011, a 35-year-old man was admitted to the Institute of Infectious Diseases, ?aolo Giaccone??University Polyclinic in Palermo, because of intermittent fever, arthralgias, and sweating for two months. He also reported a one-week history of intermittent pain in his left arm. He was employed at a slaughterhouse and regularly ate unpasteurized cheese. On admission, physical examination showed hepatosplenomegaly and on cardiac auscultation a 3/6 systolic murmur was heard all over the precordium. Laboratory test results revealed an increase in aspartate aminotransferase (98 U/L, upper normal limit 37 U/L), alanine aminotransferase (200 U/L, upper normal limit 41 U/L), and C-reactive protein (1.6 mg/dL, upper normal limit 1 mg/dL). Electrocardiogram (ECG) showed normal sinus rhythm. A transthoracic echocardiogram was performed and showed mild aortic and mitral insufficiency. A rapid agglutination test (Rosa Bengala Test) and Wright's serum agglutination were performed and they were both positive.
+Brucella melitensis was isolated from blood culture. The patient was treated with oral doxycycline (100 mg twice a day for 6 weeks) and intravenously (IV) rifampin (450 mg twice a day for 3 weeks). Oral rifampin at the same dose was administered for a further three weeks after hospital discharge. Fifteen days after the end of treatment, the patient had a recurrence of fever, asthenia, and hiporexia. The physical examination did not show remarkable changes. Echocardiogram showed an aortic valve vegetation (1.4 ? 0.9 in diameter) with eccentric jet of insufficiency, mitral valve with minimal prolapse of the anterior flap, mild mitral, and tricuspid insufficiency. Laboratory test results revealed a total white blood count of 3830 cells/mm3, haemoglobin 11.8 g/dL (normal range 13??7 g/dL), platelet 163000 cells/mm3 (normal range 150??00 ? 103/mm3), erythrocyte sedimentation rate 6 mm/h (upper normal limit 15), C-reactive protein 4.68 mg/dL, and lactate dehydrogenase 634 U/L (normal range 240??80 U/L).
+Brucella melitensis was isolated from blood culture. PCR assay on blood for detection of Brucella was positive. A treatment with IV rifampin (450 mg twice a day) and oral doxycycline (100 mg twice a day) was resumed and IV amikacin (1 gr once a day) was started. Nine days after admission, the patient experienced acute left upper limb pain. Decreased pulses and decreased skin temperature of the arm were noticed. Echo Doppler showed thrombosis of the left subclavian artery. The CT scan showed axillary artery filling defect with side calcification. Heparin (25000 U/24 h) was administered for ten days and the patient underwent an aortic valve replacement surgery with prosthesis implantation. The treatment with IV rifampin (450 mg twice a day), IV amikacin (1 gr once a day), and oral doxycycline (100 mg twice a day) was stopped after 45 days. Oral rifampin and doxycycline, at the same dose, were administered for further 45 days with complete resolution of symptoms. Blood cultures became negative after ten days of triple therapy."
+Abdullah Simmons,31,1977/11/25,001-612-780-3318,richardsonkimberly@example.net,8026 Tina Crest,"A 28-year-old male patient reported to the department of oral and maxillofacial surgery at people's dental academy complaining of asymmetry of the face and scar in the mandibular angle region on the left side since 3 years. The patient gave a history that he had tripped and fallen down 3 years back and he had a laceration on the left side of the face that developed in to a scar. The patient's chief complaint was left side facial growth without pain. The patient had no history of systemic diseases. Extraoral examination showed an obvious unilateral swelling centered over the mandibular angle. Palpation indicated that the swollen tissue was normal in tone and nontender. Mandibular movements were in the normal range. When the patient was asked to clench, the swelling became more prominent and firm. The patient said that he uses the left side of the jaw more while chewing food. There was no history of temporomandibular joint clicking, and no family history of masseter hypertrophy. Physical examination revealed that the patient had unilateral masseter muscle bulging, with a prominent mandibular angle at the lower border. Intraoral examination revealed distoangularly impacted 38 and 48. OPG showed a prominent mandibular angle. Data from clinical and radiographic examination led to the diagnosis of unilateral masseter muscle hypertrophy (Figures , , , , , and ). Nonsurgical options such as botox therapy and the advantages and disadvantages of both surgery and botox treatment were discussed with the patient. The patient opted for surgical option as he wanted to get rid of the scar immediately and we told him that we can do the correction of masseter hypertrophy and scar revision through one incisional approach only. A combined reduction of the mandibular angle and shaving of the masseter muscle was planned. The surgery was done under general anesthesia with nasotracheal intubation. Xylocaine 2% with adrenalin was infiltrated in the angle of the mandible. An elliptical incision was placed around the hypertrophic scar and the scar was removed (). The marginal mandibular nerve was identified and protected. Debulking of the masseter muscle was performed as the patient was very worried about the asymmetry of the face (). The muscle was incised approximately 5 mm above the mandibular basilar. The entire ascending portion of the masseter muscle was detached, and a vertical internal muscle band equivalent to two third of the thickness of the muscle was resected. After the muscle was resected, the remaining external third was sutured to its site of origin onto the muscle stump inserted in the mandibular basilar. The bony deformity was trimmed and removed in the angle of the mandible with surgical bur (). Sharp margins were trimmed with a bone file. The shaved masseter muscle and the resected excess mandibular angle was sent to oral pathology department in 10% formalin (Figures and ). Primary closure was done with 5-0 prolene suture (). After 1 week, the prolene sutures were removed and the wound healed uneventfully."
+Reagan Franco,35,1983/4/29,+1-289-510-1020x6482,tinamoore@example.com,4198 Davis Haven,"A 9-year-old girl was referred for neurological examination due to sudden onset of diplopia. The patient affirmed that after waking up on that morning, she started to feel visual impairment in which an object was seen as two while having both eyes open. She also said that the distance between the two objects enlarged when looking to the left. Her past medical and familial history was unremarkable for any degenerative or neurological disorder. General clinical assessment of the patient was found within normal limits. Neurological examination revealed convergent strabismus and no movement of the left lateral rectus muscle. The remainder of the exam was essentially normal, including visual fields and routine ophthalmoscopy. Blood laboratory exams and electrocardiogram were found to be normal. Magnetic resonance imaging (MRI) of the brain showed multiple lesions affecting the periventricular, juxtacortical and infratentorial regions (Figures , , and ). Brain MRI also showed gadolinium-enhancing and nonenhancing lesions (). A cerebrospinal fluid analysis was unremarkable. As no other structural abnormalities were identified, a diagnosis of multiple sclerosis (MS) was made and the neurological symptom was attributed to it. Based on this diagnosis, we started pulse corticosteroid therapy with methylprednisolone during three days. The girl did not recover after 6 months of the diplopia and is currently being followed on outpatient appointments."
+Gage Frost,27,1995/6/28,(337)426-6055x682,jillstone@example.org,89205 Chapman Ford,"A 60-year-old white male presented to hematology/oncology clinic for a routine followup visit. The patient was complaining of mild shortness of breath on exertion. His past medical history consisted of hypertension and a left upper extremity necrotic mass, 4.4 ? 3 ? 3 cm, that was resected 5 weeks ago (). Pathology revealed high-grade soft tissue undifferentiated sarcoma/pleomorphic malignant fibrous histiocytoma with clear resection margins tumor cells restricted to the dermis () without evidence of lymphovascular invasion. Giant malignant cells on an inflammatory background were identified on H&E stain (.) Immunohistochemistry of the pathology specimen was positive for CD 68 and CD 99 (Figures and ) and negative for S-100, HMB-45, SMA, pan-keratin, factor 13-A, and desmin. At the time, a chest X-ray was negative for metastatic disease (). A chest X-ray and CT scan of the thorax both revealed numerous bilateral pulmonary nodules (Figures and ) suspicious for metastasis with left axillary and left superior diaphragmatic lymphadenopathy with splenomegaly and bilateral adrenal nodules. Routine blood work revealed a white blood cell count of 109.4 K/mm3 with absolute bands of 25 K/mm3 and an absolute neutrophil count of 64 K/mm3 (). C-reactive protein was 14.8 mg/dL. A peripheral blood smear showed presence of mature granulocytes with toxic granulations and vacuolizations and a significant left shift with excess of bands and occasional metamyelocytes and myelocytes. PCR for BCR-ABL fusion transcript was negative. His vital signs were as follows: pulse 123, BP 119/60, temp. 99.1簞F, and RR 26??0. The patient was in mild respiratory distress. Head and neck examinations were unremarkable. Bilateral crackles were heard on lung auscultation. On cardiovascular exam, the patient was tachycardic, S1 and S2 were noted. The abdomen was soft, distended with mild diffuse tenderness, and present bowel sounds. Splenomegaly was noted on palpation. Blood cultures were drawn, which remain negative. Based on physical examination and data mentioned above, the patient was diagnosed with metastatic cutaneous IMFH associated with a leukemoid reaction. The patient was treated with supportive measures and broad spectrum antibiotics. Unfortunately, his breathing became increasingly labored, he failed several trials of BiPAP and was intubated. He remained tachypnic and became hypotensive. The patient did not receive vasopressors as per the family's wishes. The following day, the patient went into asystole and expired. Death occurred less than 45 days after initial diagnosis."
+Paula Kline,18,1998/6/20,871-614-3672x6846,jesserogers@example.net,66382 Mcintosh Plains Apt. 630,"A 42-year-old man appeared with melena and underwent several examinations, including esophagogastroduodenoscopy (EGD), colonoscopy, and abdominal CT with a contrast agent. Abdominal CT scan revealed a wall thickness in the small intestine (Figures and ). The patient was referred to our hospital.
+His hemoglobin level was 11.8 g/dl (normal range 11.3??5.5 g/dl). We conducted a capsule endoscopy and found part of a tumor in the small intestine, suggesting small bowel tumor (). In particular, the mucosal contrast of the tumor was enhanced by the effect of the spectral specification of flexible spectral imaging color enhancement (FICE) settings 1 and 2 (Figures and ). In order to investigate the small bowel tumor, antegrade spiral enteroscopy (SE) was conducted []. SE showed a multinodular polyp (type Ip) 20 ? 15 mm in diameter located about two meters distal to the ligament of Treitz (). Biopsy specimen revealed an atypical epithelium. We considered that the lesion was located within the mucosa and decided to perform EMR. We used a DBE (EN-450T5/W, FUJIFILM Medical Co., Ltd., Japan)with an overtube (TS-13140, FUJIFILM Medical Co., Ltd., Japan) and a transparent cap (D-201-11304 Olympus Co., Ltd., Japan) attached to the endoscope tip, which is useful in the colon by pushing draped folds aside or helping luminal orientation at bends by keeping appropriate distance between lens and mucosa []. In order to reduce intraluminal gas, a CO2 insufflation pump was used during the procedure.It took 12 min to approach the jejunum polyp. Hyaluronic acid at 0.12% (MucoUp, Johnson & Johnson K.K., Japan) was injected into the submucosal layer to lift the surrounding mucosa using a 25-gauge needle (TOP Corp., Japan). A 15 mm electrosurgicaldiameter snare (Snare-Master, Olympus Medical Systems Corp., Japan) was placed around the lifted area. The lesion was strangulated and resected en bloc using blended electric current (Endocut 2 mode ICC200, ERBE, Germany). The electric current output was increased from 60 to 100 W for final resection. Histological examination showed adenocarcinoma (). The invasion depth of the carcinoma was limited to the mucosal layer. There was no lymphovascular invasion of carcinoma cells. The lateral and vertical margins of the specimen were negative. The patient was discharged seven days after EMR without any complications, such as perforation and bleeding. Follow-up endoscopy and abdominal CT scan four months after EMR showed no local or remote recurrences."
+Ramon Zamora,21,1996/5/15,7675841002,shahshelley@example.org,5351 Kathryn Roads Suite 331,"A 30-year-old, gravida 1 lady, of 39 weeks' gestation, presented to an outside hospital with acute severe epigastric pain, shoulder-tip pain, and severe intravascular volume depletion. An emergency lower section caesarian section was performed, and a healthy female was delivered. During the procedure, the blood was noted to be of ?trawberry milkshake??consistency. Blood drawn for analysis precipitated into two layers. The upper two-thirds of the sample, constituting the plasma component, was lipid in nature. The laboratory was initially unable to process the sample, although an amylase of 900 U/L was obtained (reference range: 28??00 U/L). The patient had no significant medical or family history, and her pregnancy was previously uncomplicated. A clinical diagnosis of acute pancreatitis was made based on the revised Atlanta Classification of Acute Pancreatitis [], most likely secondary to extreme gestational HTG, and the patient was transferred to our institution one day after caesarian section.
+Initial examination following transfer revealed a markedly unwell and tachycardic (140BPM) patient with gross abdominal distension and a rigid, tender abdomen. Further investigations demonstrated a leukocytosis (20.5 ? 109/L, reference: 3.5??1 ? 109/L), elevated random cholesterol (Chol, 20.3 mmol/L, reference: desirable <5.2 mmol/L) and triglyceride (TG, 45.29 mmol/L, reference: 0.15??.8 mmol/L) levels, and a prothrombin time (PT) of 20 seconds. Lipase (148 U/L, reference: 13??0 U/L), amylase (495 U/L), and C-reactive protein (CRP, 420.0 mg/L, reference: 0??.0 mg/L) were all elevated. Given the high lipid content of the patient's blood at initial presentation, neither the Ranson or Glasgow scoring systems could be utilised. A contrast-enhanced CT abdomen and pelvis was performed, which found moderate volumes of ascites, small bowel dilatation consistent with ileus, and bilateral pleural effusions with associated atelectasis. There was no radiological evidence of any pancreatic pathology at this stage. As a result, mild acute pancreatitis was predicted as per the Modified CT Severity Index [].
+Despite aggressive resuscitation, the patient remained haemodynamically unstable after transfer (tachycardic and hypotensive), requiring significant vasopressor support. As a result of the associated pulmonary oedema and inotropic dependent cardiac failure, she developed type 1 respiratory failure necessitating intubation and ventilation. In addition, a persistent oliguria secondary to acute renal failure was noted with concomitant metabolic acidosis, and it was felt that dialysis would be appropriate. As a result of this multiorgan failure, the patient was transferred to the intensive care unit. In spite of this, she demonstrated persistent organ failure during her ICU stay [].
+Three sessions of plasmapheresis were performed during a progressive deterioration in the patient's condition, using 5% human albumin solution as replacement fluid. She rapidly improved, both clinically and biochemically (random Chol: 3.1 mmol/L, TG: 6.4 mmol/L), was extubated and maintained on supportive care (gastric decompression, jejunal feeding tube, total parenteral nutrition, and haemodialysis), returning to the ward nine days after admission.
+Once the patient was stabilised, she continued to experience intermittent temperature spikes. Blood cultures were positive for Staphylococcal and Candida spp. Interval imaging over four weeks showed an evolving ascites () and loculation. No evidence of pancreatic or peripancreatic collections or necrosis was noted during this period. Samples of the ascitic fluid obtained under ultrasound guidance grew Escherichia coli. After detailed discussion with the microbiology service, appropriate parenteral antibiotics and antifungals were commenced. The ascitic collections were not amenable to radiological drainage due to their highly loculated nature. A decision was made not to proceed to laparotomy and surgical drainage, as the ascites promptly resolved, and her inflammatory markers quickly fell with the commencement of targeted antimicrobial therapy. The patient's clinical condition continued to improve until the time of her discharge."
+Sierra Barker,45,1987/5/15,(889)402-0139x3340,katherinelong@example.org,395 Gloria Curve Apt. 626,"A 43-year-old man was referred to our department complaining of a mass in the right preauricular region, which had been developing painlessly over 1 year. The physical examination revealed a hard mass approximately 2 cm diameter in the right preauricular region. Otoscopy showed swelling of the anterior wall in the right external acoustic meatus, covered by normal skin. There was no temporomandibular joint (TMJ) pain, trismus, or hearing loss, and there was no history of facial trauma. The general physical examination did not disclose any abnormalities.
+Magnetic resonance imaging (MRI) revealed a solid lobulated lesion in the right preauricular region, which was proximate to the capsule of the right TMJ (). The lesion was isointense relative to muscle on T1-weighted images, hyperintense on T2-weighted images, and partially enhanced after gadolinium injection.
+A benign tumor in the right TMJ was suspected clinically. The lesion was removed surgically via a preauricular incision under general anesthesia to determine the histopathological diagnosis. The lesion was independent of the parotid gland and was not in contact with either the TMJ or the cartilage of the acoustic meatus (). Although the lesion was attached to the surface of the temporal bone, there was no invasion of the temporal bone, and the lesion was removed easily by en bloc excision.
+The specimen was a 2.5 ? 2 ? 1.5 cm, well-circumscribed, nodular, white-grey, hard, elastic mass. Histopathologically, the tumor was well circumscribed and encapsulated by thin fibrous connective tissue. The tumor comprised mainly of hyaline cartilage, which contained chondrocyte with chondrocytic lacunae, with collagenous fibrous tissue in the center of lesion (). The tumor had low cellularity, with no evidence of atypia or mitotic figures. Immunohistochemically, the chondrocytes expressed S-100 protein and vimentin, but were negative for epithelial cell markers. These histopathological findings revealed the diagnosis of chondroma.
+The postoperative period was uneventful, and there was no evidence of recurrence at the 2-year followup."
+Kade Jenkins,42,1987/9/12,(301)479-9255x36034,christinemcfarland@example.net,194 Holly Mission,"A 9-year-old boy was admitted to the emergency department with abdominal pain from 3 days ago. The pain was colicky in nature and 3 episodes of biliary vomiting were reported. Simple abdominal radiography indicated loop distention in the small intestine with air-fluid levels (). The child was submitted to laparotomy: we found severely distended intestinal loops in jejunum and ileum, with the distension proceeding as far as a Meckel's diverticulum (). A hard mass was palpated at some 5 cm after the Meckel's diverticulum, suggesting that obstruction originated at some point after the diverticulum. Enterotomy produced a round mass measuring 4 ? 5 cm and brown in color. Sectioning the mass demonstrated lumps of meat, forming bezoar (). Histopathologic studies of the diverticulum reported ectopic gastric tissue. A history obtained after surgery indicated that the child had consumed meat a week ago."
+Rylee Hicks,44,2002/10/30,(930)227-3964,lwilliams@example.com,2668 John Oval Apt. 529,"A 5-year-old boy referred to the pediatric gastroenterology clinic, complaining of colicky abdominal pain and 5 episodes of vomiting from yesterday. No history of surgery or disease was mentioned. Simple abdominal radiography depicted signs of intestinal obstruction. The patient was admitted to the operating room with a diagnosis of acute appendicitis. The appendix was found to be normal. Severe loop distention was observed as far as 3-4 cm after a Meckel's diverticulum. Enterotomy revealed a quantity of orange impacted at the diverticulum, extending as far as 5 cm after the diverticulum and causing obstruction at this point (). Histopathology reported no ectopic tissue. After the surgery, the parents mentioned that the child had eaten large quantities of orange 2 days ago.
+In both cases there were no preexisting motility disorders or predisposing factors. Except Meckel's diverticulum any histopathologic problems such as changes in number of ganglions or neuromotor units were not seen."
+Maddox Cantu,18,1989/7/25,001-661-511-4538,xalexander@example.net,7535 Carpenter Green,"The patient is a Caucasian female (Fig. ), who was born to a 32-year-old mother and 34-year-old father after a third full term uneventful pregnancy. Her birth weight was 2700g, length 40 cm, head circumference 35 cm. The patient has two healthy half-siblings from the mother? first marriage. Analysis of the family history did not reveal previous bone disorders in the other family members. Bone dysplasia was considered as a diagnosis due to the short stature of the newborn, however, no radiographs were taken at that time. The patient? motor development was delayed; she started to walk at the age of 2 years. At the age of 3 years she was referred to the Ambulant Centre for Defects of Locomotor Apparatus in Prague. At that time her height was 62 cm (-8.8 SD), upper segment/lower segment = 39.7 cm (-.5 SD)/22.3 cm (-10.1 SD), arm span 63 cm, head circumference 48.6 cm (between 25-50 centile) and her weight was 8 kg. The patient had a genu valgum deformity and a waddling gait was observed. Her hands and feet were relatively long.
+At the age of 4 years, patient was able to walk only for short distances. At that time she developed recurrent paroxysmal attacks of impaired consciousness with succession of muscular spasms. The cause of her seizures was hypertension secondary to a right dysplastic kidney. After right nefrectomy, her seizures disappeared and the blood pressure returned to normal. Bracing was used as a treatment for patient? severe scoliosis at the age of 4 years.
+Radiographs taken between 2 and 6.5 years documented lack of ossification of the capital femoral epiphyses, severe metaphyseal changes, scoliosis convex to the left, and delayed carpal/tarsal bone age (Fig. ).
+At 6.5 years her height was 72 cm (-9.2 SD) and her weight was 11 kg. The patient? thickness of skin folds was normal and her muscle development correlated with the length of her extremities. Her mental development, vision and hearing were normal.
+At the age of 9 years the patient? height was 78.8 cm (-9.2 SD), the upper segment/lower segment ratio was 47 cm(-10.2 SD)/31.8 cm(-9.4 SD), span 86 cm, weight 13.3 kg and the head circumference 51.6 cm (33rd centile).
+At 10 years her height was 80 cm (-10 SD) and her weight was 14.5 kg (Fig. ). There was an increase of her spinal deformity (dextro-convex scoliosis of the thoracic spine and sinistro-convex scoliosis of the thoraco-lumbar spine with marked hyperextension), (Fig. ). Her mobility was limited; she was walking by taking short steps.
+Radiographs taken between 6.5 and 11 years of age documented progress of spinal scoliosis and increased genu valgum deformity. Ossification of the capital femoral epiphyses was absent and the carpal/tarsal bone age was delayed (Fig. ). Bilateral release of tractus iliotibialis and osteotomy of the left fibula, with corrective osteotomy of proximal metaphyses of the left tibia, were performed at the age of 8.5 years. At 9.5 years of age bilateral partial medial epiphyseodesis of distal femora was performed. Valgus deformity of the knees decreased after these surgeries."
+Galilea Cisneros,36,1984/1/8,(312)487-7624x8215,richelizabeth@example.com,1643 Nicole Fall Suite 043,"A twenty-seven-year-old woman presented with intermittent hematuria and a mass coming out from the vagina. On examination, she was found to have a fleshy mass at the urethral meatus (). She did not have any voiding symptoms or perineal pain. On urethroscopy, the mass was occupying the mid and distal urethra from 10 o?淆lock to 6 o?淆lock position. Cystoscopy was normal. The urethra could be calibrated up to 18 Fr. The mass was excised and the proximal urethral mucosa was mobilized and approximated with the distal edge. After excision of the tumor, the urethra could admit a 30 Fr dilator. Patient was catheterized for 48 hours and voided well on catheter removal. Histopathological examination revealed an encapsulated tumor composed of spindle-shaped smooth muscle fibers arranged in a whorling pattern. On immunohistochemical examination tumor was positive for vimentin and smooth muscle actin. A diagnosis of leiomyoma was made ()."
+Alden Rowe,28,2004/7/2,001-492-878-0899x163,wrightsarah@example.org,124 Jennifer Forge Suite 185,"A 27-year-old G11 P2262 female with no significant past medical history had a routine prenatal ultrasound at 35 weeks gestation. The ultrasound showed a 4.0 cm cystic lesion in the right ovary of the fetus. The remainder of the pregnancy was uneventful. The female neonate was delivered vaginally without any complications.
+A pelvic ultrasound was performed one day after birth to follow up on the ovarian cyst seen in utero. Ultrasound showed a 5.8 ? 4.0 ? 4.3 cm cystic mass with internal hemorrhage. There was a smaller cyst internally measuring 0.8 ? 0.9 ? 1.0 cm (). An MRI was recommended for further characterization, which was performed on the same day. MRI showed a 4.5 ? 5.6 ? 4.5 cm cystic mass with layering hemorrhage or proteinaceous elements. A 1.0 cm nodular cyst was present against the inner wall of the larger cyst (). The size of the ovarian cyst had increased in size with morphologic changes since the prenatal ultrasound. Suspicion for ovarian torsion was high and the female newborn underwent oopherectomy on the seventh day of life. Imaging findings of ovarian torsion with internal hemorrhage were confirmed in the surgical pathology report."
+Matilda Wu,37,1983/6/19,001-407-529-8628x53647,elizabethtodd@example.org,888 Torres Road,"A 45-year-old male Moroccan patient presented to the emergency department with gross rectal bleeding and hematuria secondary to a stab wound to the perianal area. The patient was admitted four hours after his knife stabbing. On physical examination, the patient looked well and was stable hemodynamically. He had mild suprapubic tenderness and the rectal examination revealed evidence of rectal bleeding together with a 2 cm wound, located 1 cm laterally to the anal opening (). A proctosigmoidoscopy performed on the patient revealed two defects of the posterior and the anterior walls of the rectum. An emergency cystogram CT was done through a urethral catheter under screening, and the rectum was also filled with the contrast in order to improve its evaluation. This clearly showed an extraperitoneal contrast extravasation associated with an anterior rectal wall defect () and two bladder wall defects located in the posterior wall and the dome of the urinary bladder (). The CT showed no abnormalities in the nearby organs. The rectal injury treatment consisted of distal rectal washout, transanal rectal wound repair that was protected by a diverting colostomy and the bladder injury was managed by a urethral catheter drainage. Three months later, the colostomy was reversed without other sequela. The urethral catheter was left in place for 30 days, and the patient was put on oral broad spectrum prophylactic antibiotics.
+A retrograde cystogram was done 30 days later and showed no further evidence of extravasation. After a one-year followup, the patient is healthy and totally asymptomatic."
+Kyson Hawkins,33,1997/7/12,(557)353-4184,patrickjoseph@example.com,72807 Wade Ford Suite 224,"A 61-year-old male presented with a history of hypertension and years of hyperuricemia and gouty arthropathy. He consulted for 4 small lesions present on a raised, irregular, erythematous penis that caused him pain during erection. The lesions were not adherent to deep planes, and the largest lesion was 2.5 cm, suggestive of gouty tophi.
+The patient also exhibited similar lesions of various sizes on his hands, feet, and elbows, which did not cause symptoms. He was treated with allopurinol and NSAIDs, but despite treatment, the lesions did not disappear.
+The patient's analytical findings showed only a mild renal insufficiency (creatinine of 1.5 mg/dL) and hyperuricemia of 9 mg/dL.
+We performed a surgical excision of the tophi from the penis, without incident (Figures and ). The excised fragments were sent to pathology, confirming the gouty tophi (based on monosodium urate levels). The patient was asymptomatic for 9 months after surgery."
+Ariel Owen,19,2000/11/23,001-568-693-5687x2251,gcarter@example.org,15335 Barnes Club,"At April 2008, an 18-year-old man was referred by a neurologist to our department with 6-day history of progressive deteriorating neurologic symptoms and an abnormal brain magnetic resonance imaging (MRI). His problem has begun with weakness and paresthesia in the right upper extremity with gradual extension to left arm and both lower limbs. On the third day, he felt haziness of vision in his right eye and pain on lateral gaze. In the same day, he also experienced few attacks of grand mal seizure. On neurological evaluation upon admission, he was well-oriented gentleman looking apprehensive and concerning about his symptoms. He was afebrile with normal general physical examination. Positive findings in neurological evaluation included visual acuity of 20/200 in right eye, with central scotoma and signs of papillitis on fundoscopy, jerk nystagmus on lateral gaze, decreased power in extremities (3/5 in right and 4/5 in left), +1 deep tendon reflexes, bilateral Babinski sign, and mild ataxic gait with normal superficial and deep sensations.
+While patient was started on Valproate- (Depakine Chrono 500 mg twice per day) obtained lab data revealed below results: CBC, blood sugar (BS), serum electrolytes, liver and kidney function tests, and urine analysis all were normal and ESR was 15 mm. Serology for HIV, HCV, EBV, HZV, borrelia, and toxoplasma was negative so was a tuberculosis skin test and collagen vasculitis work up. Chest X-ray was normal. Cerebrospinal fluid (CSF) analysis showed 2 RBC, 0 WBC, protein of 125 mg/dL, sugar 50 mg/dL (BS: 110), LDH: 43 U/mL, and positive oligoclonal band (OCB). Visual-evoked potentials (VEP) test was prolonged in right eye so was the left-sided sensory-evoked potentials (SEPs).
+Brain MRI revealed multiple large round-shaped lesions with central low T1, high T2 signal high-intensity signals and marginal low T2, iso T1 signals in right centrum semiovale, and perileft occipital horn white matter extending to splenium of corpus callosum, which were associated with sever peripheral vasogenic edema but no mass effect and no midline structural shift (Figures ??. In postcontrast T1W images, heterogeneous enhancement was noted in lesions (Figures ??. Result of cervical MRI was normal.
+These findings brought several differential diagnoses such as acute disseminated encephalomyelitis, multifocal glioma, metastasis, vasculitis, lymphoma, lymphoproliferative diseases, and TMS under consideration. At this stage for proper management of the patient, a biopsy was suggested which was refused by the patient and his parents, so we decided to treat the patient empirically with the diagnosis of TMS in spite of clinical (seizure) and MRI red flag signs []. This decision was made on the basis of the presence of papillitis, normal blood tests, prolonged VEP and SEP, presence of OCB, and no shift in midline structure in spite of large lesions.
+He received a 7-day course of 1 gr daily intravenous methylprednisolone (IVMP). This was followed by further 2 weeks of 75 mg daily oral prednisolone (OPN) with tapering and discontinuation of the drug in the third week. From the third day of IVMP, he begun improving and discharged by the end of OPN therapy with mild right-sided weakness.
+Thirteen months later he was returned with left optic neuritis, received 5-day course of IVMP, and with respect to 2nd MRI done at August 2008, he was discharged on weekly intramuscular injection of Interferon beta1a (Avonex). So far, he has been stable and no further relapse has been reported.
+Two further MRI studies were performed at August 2008 (Figures ?? and August 2011 (Figures ??. They demonstrated sequelae of previous lesions as high T2 signal intensities with resolution of their peripheral vasogenic edema. The lower row is postcontrast axial T1W images (g and h), which show no enhancement in lesions and no abnormal signal intensity can be detected in cervical cord."
+Cannon David,43,2004/9/23,383.375.3681,rayyoung@example.com,546 Turner Shore,"We present herein the case of a 34-year-old Caucasian patient G1P0 that was referred to our department for ?locked atrial bigeminy with pseudobradycardia??detected elsewhere at 33 of weeks of gestation. Furthermore, a placenta previa was diagnosed.
+The patient was scanned at our department at 37 weeks of gestation. An echocardiography showed during all the examination an arrhythmia that in M-mode resulted in being a blocked atrial trigeminy with a mean fetal heart rate (FHR) of 100 bpm (Figures and ).
+A female neonate of 2770 gr and Apgar score 9/10 at 1/5簞 minutes, respectively, was born by cesarean section at 38 weeks because of the placenta previa.
+An ECG performed at birth revealed blocked supraventricular extrasystoles (). Instead, successively at cardiomonitoring, no extrasystoles were registered.
+An ECG the day after did not register any extrasystole.
+On day 3, an ECG showed no atrial extrasystoles and a normal QTc interval at upper limits. An echocardiography performed the same day showed a small patent FO with moderate left-to-right shunt and a trivial tricuspid regurgitation with an indirect estimate of pulmonary artery pressure of 35 mmHg.
+To our surprise, on day 11, ECG revealed supraventricular trigeminy and episodes of paroxystic supraventricular tachycardia (). A treatment with Lanoxin syrup 0.25 mL twice a day was started. A control on day 17 showed a paroxystic supraventricular tachycardia interrupted by some sinusal beats (). Digoxinemia level was at 1.4 ng/mL, and therapy with Sotalol hydrochloride 2 mg/kg twice a day was started.
+On day 18, an episode of PSVT that needed a ?iving reflex??maneuver was registered. The same day, a cardiomonitoring showed extrasystoles and episodes of bradycardia with a heart rate of 80 bpm.
+A 24 hr ECG/Holter monitoring on day 20 recorded a sinusal rhythm with a mean heart rate at lower limits for age, some blocked supraventricular extrasystoles, and 3 isolated and monomorphic ventricular extrasystoles. During sleep, some episodes of 2nd-degree AV block Mobitz type I and Mobitz type II were recorded. Interventricular conduction was regular. There were no significant alterations of the ventricular repolarization.
+After consulting 24 hr ECG monitoring, we decided to gradually suspend Lanoxin. Currently, the little girl is administered Sotalol hydrochloride 2 mg/kg twice a day and she is doing well."
+Haylee Blankenship,40,1992/4/3,(600)734-5993,michael40@example.com,857 Rojas Run,"A 49-year-old Iraqi male presented in February 2011 to the American University of Beirut Medical Center (AUB-MC) with fever, chills, chest pain, anorexia, and weight loss after being operated on for a presumed malignant thymoma in India. His initial history goes back to May 2010 when he was diagnosed with myasthenia gravis in Iraq and was started on prednisone 60 mg orally and mestinon 60 mg orally three times per day. A computed tomography (CT) of the chest done in Iraq showed a cystic mediastinal mass abutting the right ventricle described as thymoma (images not available) but very similar to the CT done at our institution later. No interventions were undertaken in Iraq. He was then referred for right lateral thoracotomy in India in November 2010. Pathology revealed malignant thymoma. The patient remained hospitalized in India for 3 weeks where he reported chills, weight loss, and sweating without any documented fever. He was started on chemotherapy (unknown regimen) and was discharged home on levofloxacin 500 mg orally daily for ten days. No microbiological work-up was initiated in India to try to detect an underlying infectious process. The period from December 2010 until February 2011 in Iraq was characterized by recurrent chest pain, fever, chills, sweating, cough, and greenish sputum production. Blood tests at that time showed a WBC of 26,000/弮L. Repeated CT of the chest showed multiple cystic masses impinging on the right ventricle and left atrium described as metastasis in concordance with his history of malignant thymoma (). At a local hospital, he received blood transfusion, fluconazole, and cefotaxime both at unknown frequency and dosage without improvement. He then had a PET scan in Lebanon showing cystic masses in the chest with necrosis and invasion of the pericardium described as metastasis. He presented to our institution where echocardiography showed two large anterior fluid collections one of which was compressing the right ventricle with a third cyst behind the left atrium (). Pericardiocentesis was performed and yielded 90 mL of greenish yellow purulent fluid. The Gram stain showed Gram-positive branching rods, and the recovered Nocardia spp. was identified in Laboratories Cerba France as N. asiatica (). The susceptibility testing (Cerba, France) revealed susceptibility to all tested antimicrobials except macrolides, clindamycin, colistin, and aztreonam. A median sternotomy was performed and debridement of the abscesses in the anterior mediastinum as well as biopsy of suspicious tissue was performed. The pathology did not reveal any malignancy. The posterior abscess could not be drained without instituting cardiopulmonary bypass and so was left to be drained with the help of endoscopic ultrasound via the esophagus.
+CT scan of brain showed multiple cystic lesions so the patient was diagnosed as having disseminated Nocardia asiatica infection and was started on imipenem, amikacin, and trimethoprim sulfamethoxazole (TMP-SMX) to be given for at least 9??2 months. At five months of followup, the patient is doing well clinically and radiographically."
+Ernesto Dorsey,44,1987/11/29,+1-986-402-6816x1943,davissteven@example.com,45332 Warren Causeway Suite 875,"A male 32-year-old patient, who lives in Campinas, S瓊o Paulo, Brazil, was admitted to a private hospital in his city. He had traveled on vacation to the state of Bahia, (Northeastern Brazil) Barra Grande city, on New Year's Eve 2008. After approximately one month of return, the patient reported a sudden onset of symptoms and the clinical pattern at admission to hospital included fever (39簞C), fatigue, malaise, persistent and nonproductive cough, and diarrhea. The patient was examined by a physician and, after a chest radiography, the putative diagnosis at that time was pneumonia and antibiotic treatment was started at home. One week after the treatment the patient remained with continuous lassitude and diarrhea with some blood and persistent cough and was examined by other physicians that reported the same symptoms. Routine laboratory examinations were performed: complete blood count (n = 3) in alternate days for one week and one stool parasitological examination for screening intestinal parasites. The only alteration detected in the blood count was eosinophilia, which showed a gradual increase once every two days: 816, 1,232, and 1,408 cells/弮L percentage corresponding to 8.0%, 14.0%, and 16.0%, respectively, of total leukocytes (normal range 0??.0% or ??00 cells/弮L). The parasitological investigation?resh stool examination?evealed trophozoites of Entamoeba 
+histolytica/Entamoeba 
+dispar. The patient was treated with secnidazole, 2,000 mg at that moment and 2,000 mg after 14 days. About two weeks after the treatment, the patient remained with the same signs and symptoms exhibited before the diagnosis of pneumonia and amebiasis and his clinical pattern worsened: very strong cough, progressing to dyspnea, generalized rash, and marked weight loss (about 8 pounds since the onset of symptoms). One week later, a new routine laboratory investigation showed leukocytosis, presence of atypical lymphocytes, normocytic-normochromic anemia, and high eosinophilia: 4,560 cells/弮L??0.0% of total leukocytes. The patient was hospitalized and submitted to infectious diseases screening, which revealed positive serology to Epstein-Barr virus (EBV), cytomegalovirus (CMV) and hepatitis A virus (IgG-ELISA) for all viruses, data consistent with past infections. Serology for hepatitis B and C viruses, HIV types I and II, Toxoplasma gondii, and Toxocara 
+canis was all negative. The stool parasitological examination evidenced the presence of Entamoeba coli and Endolimax 
+nana, and hemocultures were negative. After the inconclusive diagnosis and a suspicion of infection with helminths, the patient was referred to the Department of Animal Biology, Sector of Parasitology, of Biology Institute in State University of Campinas. The patient showed all the exams and was interviewed about his signs and symptoms and about information regarding travel history. Important epidemiological data and clinical pattern were obtained from that holiday: the patient had gone through a small dam to get to a beach (Taipus de Fora) rarely explored by tourists and often frequented by autochthonous population; the exposure time was approximately five minutes. The patient also recalled that he had a localized pruritic rash in both legs?ercarial dermatitis?fter crossing the weir. Prior parasitological stool testing was negative on prior days until the one done at 70 days. The Kato-Katz method [] as well as the flotation procedure of Willis and spontaneous sedimentation method was applied in the Sector Parasitology in the State University of Campinas to search for helminthes. The coproparasitological analysis showed many Charcot Leyden crystals, and the Kato-Katz method showed the presence of Schistosoma mansoni eggs with typical lateral spine (). The quantitative analysis revealed the presence of 240 eggs per gram of stool. The patient was treated with Oxamniquine (Mansil)?ingle dose of four tablets of 250 mg, according to the weight of the patient. The control of cure was performed for four successive months after the treatment using the Kato-Katz method to search for eggs. All stool samples were exposed to light for about 2 hours to stimulate eclosion of the miracidia. The monitoring of the control of cure to search for eggs or larvae was all negative for Schistosoma 
+mansoni, and the result of the treatment was favorable."
+Addyson Phan,36,2005/8/30,596-552-5665x1677,leonalan@example.net,163 Hurst Haven Suite 321,"We present a case of a 64-year-old caucasian female who presented to the emergency department with bilateral foot pain, erythema, and redness more prominent in the right foot (). The pain was excruciating, 10/10, burning in quality and worsened with ambulation as well as being placed in a dependent position. Her medical history was significant for hypertension, myelodysplastic syndrome disorder in remission, and stroke two years ago. She was placed on aspirin after that for secondary prevention of stroke. Two weeks prior to this presentation, she was found to have right iliac artery thrombosis and anticoagulation with coumadin was initiated with discontinuation of the aspirin. One week prior to this presentation, she presented to another hospital where she was treated for provisional diagnosis of cellulitis and patient was sent home on antibiotics, although she returned, since the symptoms were not improving. There was no history of trauma. Other medications included gabapentin, omeprazole, and atenolol. On examination, she was hemodynamically stable and afebrile, distal pulses were intact, and there was blanchable erythema in the bilateral lower extremities. The erythema worsened on changing the position of the legs from supine to dependent position. One peculiar thing was that she complained of more severe pain and redness when she wore socks or putting the blanket on her legs and felt some relief with a cooling fan by her legs or pouring cold water down her legs. There were no sensory deficits to light touch and pin prick. Monofilament testing was normal. Laboratory studies showed normal white blood cell and platelet count with an elevated international normalized ratio (INR). Initial differential diagnosis including cellulitis and arterial or venous insufficiency were systematically excluded. A presumptive diagnosis of erythromelalgia was made taking into account that she fulfills all of the Thompsons's criteria. Aspirin 325 mg was initiated. The patient showed significant improvement in her symptoms within 24 hours of initiation of aspirin therapy (), her pain and redness came down significantly from 10/10 to 3/10, both upon ambulation and with rise in room temperature, she was able to walk pain-free for the first time in 2 weeks. However, the erythema and redness persisted for some time. After a followup of two weeks, her symptoms completely resolved and she was advised to continue taking the aspirin."
+Maison Mills,22,1988/8/22,529.495.2977x483,kelliclayton@example.org,237 Samuel Plains,"A 48-year-old Caucasian woman visited the outpatient clinic, complaining of pain and swelling in left knee and small joints in her hands. Laboratory findings showed a slightly elevation of erythrocyte sedimentation rate (ESR; 40 mm/h) and C-reactive protein (CRP; 28 mg/L). Rheumatoid factor (RF) level was <20 IU/mL, and anticyclic citrullinated peptide (anti-CCP) level was 94 IU/mL. Subsequent radiography showed bone atrophy around the wrist, suggesting RA. She was diagnosed as having seropositive rheumatoid arthritis. Treatment was started with prednisolone (15 mg/day) and methotrexate (15 mg/week), which improved her clinical symptoms and laboratory findings. Leflunomide (diseasemodifying antirheumatic drug (DMARD)) at 20 mg was additionally administered but was discontinued because of oral ulcerations. After a 6-month period, she remained stable on 7.5 mg prednisolone a day and 15 mg methotrexate a week.
+However, a year later, she presented with fatigue and pain in both upper extremities. She did not experience weight loss or low-grade fever. The RA remained stable with the aforementioned therapy. Upon physical examination, a blood pressure difference between the left and the right arm was noted, respectively, 109/71 mmHg and 93/71 mmHg. Furthermore, a murmur was noticed over the left carotid artery. Pulsations of both radial arteries were reduced. Laboratory tests showed a slight leukocytosis (15 ? 109/L), CRP 14 mg/L, and ESR 14 mm/h.
+Subsequent MRA and angiography demonstrated extensive vascular stenotic lesions (). In the right truncus brachiocephalicus, an occlusion at its origin from the aortic arch was found. The right subclavian artery showed two important constrictions with a significant stenotic lesion of the proximal branch and distal a complete occlusion. The left subclavian artery was constricted in its proximal part. There was also occlusion of the left common carotid artery at its origin as well in its distal part. Furthermore, both left common iliac artery and right external iliac artery showed stenotic lesions. Positron emission tomography (PET) scan demonstrated increased fluorodeoxyglucose (FDG) uptake along both brachial arteries, suggestive of active vasculitis. Despite the late onset, the diagnosis TA was made according to the Sharma modified diagnostic criteria, approximately a year after the patient was diagnosed with RA. We started therapy with a higher-dose prednisolone (40 mg/day). Despite our treatment, the patient's condition deteriorated with intermittent claudication of both legs. Subsequently Bosentan (Tracleer, 250 mg/day) was added, and she underwent a percutaneous transluminal angioplasty (PTA) with placement of a stent across the stenotic segment of the left common iliac artery and right external iliac artery. After placement of the stents, her clinical symptoms were markedly relieved. Subclavian stenting has been scheduled in due time. Due to the development of hypotension of 77/74 mmHg on Bosentan therapy, the dose was adjusted. Lately she has been stable on 125 mg a day. Antitumor necrosis factor (TNF)-帢 therapy as a next step in the treatment will be considered."
+June Blevins,45,1996/6/29,2519204655,melanie09@example.org,5274 Carlson Drives Suite 747,"A 60-year-old female was referred to us for the treatment of PMP. She had undergone palliative resection and HIPEC for PMP one year before. Histological diagnosis was low-grade appendiceal mucinous neoplasm with peritoneal dissemination, classified as disseminated adenomucinosis (DPAM) according to the criteria by Ronnett. At the time of referral, tumor was diffusely spread in the peritoneal cavity and single nodule was observed in the right lower lung (). CRS and HIPEC were performed, and complete cytoreduction was achieved. The lung nodule was removed by wedge resection. Histological findings of the lung nodule were similar with those of appendiceal tumor, showing that low-grade mucinous neoplasm invaded pulmonary parenchyma (). CT examination two months after CRS showed multiple lung nodules, and they progressed rapidly (). She underwent laparotomy for intestinal obstruction caused by diffuse abdominal recurrence five months later. The histological type of recurrent lesions was the same as that of previously resected specimens. Serum levels of CEA and CA19-9 were 10.6 ng/mL and 62.3 U/mL before CRS, and returned to normal ranges after CRS, respectively. They still remained in the normal range at the time of CT examination, and increased again to 6.8 and 105.5 at the time of laparotomy. She died of the disease one year after CRS."
+Avi Horn,33,1981/8/14,(770)721-2155x775,bradleychristopher@example.com,469 Christopher Fall,"A 53-year-old white female with the past medical history of type II diabetes mellitus, hypertension, hyperlipidemia, depression, coronary artery disease after RCA stent, and peripheral vascular disease after bilateral stents to the common iliac arteries was transferred to our hospital after being diagnosed to have osteomyelitis of right great toe and methicillin-sensitive staphylococcus aureus bacteremia from an outside hospital. She was started on ertapenem for bacteremia before getting transferred to our hospital. The baseline laboratory values done on an outpatient evaluation basis just 10 days prior to the admission were WBC 12.5, hemoglobin 13.4, haematocrit 39, platelets 564, BUN 22, creatinine 1.5, glucose 222, sodium 138 meq/L, potassium 4.2 meq/L, chloride 101 meq/L, bicarbonate 25 meq/L, bilirubin total-0.3 mg/dL, bilirubin direct 0.1 mg/dL, alanine transaminase (ALT)-8 IU/L, aspartate transaminase (AST) 9 IU/L, alkaline phosphatase (ALP) 78 IU/L, direct albumin, 3.8 gm/dL, protein total 7.80 gm/dL, PT-10.2 s, INR 1.0, PTT 28 s, and sedimentation rate 72 h; blood culture showed no growth even after 5 days. On admission, physical examination findings were unremarkable except for her right great toe which was swollen and oozing; pedal pulses were not palpable. Laboratory showed an increase in leukocytes 16,300/uL; reference range (4500??500), platelets 775 thousand/cu繚mm reference (140??40), glucose 300 mg/dL (70??05), creatinine 2 mg/dL (0.6??.1), low glomerular filtration rate (gfr) 26 mL/min, normal PT 16.4 s (9.0??2.0), PTT 42 s (25??5), and INR 1.6. Blood culture done two times showed no growth even after 5 days. X-ray right foot showed osteomyelitis of right great toe; ertapenem was discontinued and was started on nafcillin 12 gram/day. The day nafcillin started was considered as day 1. Surgery was done under general anesthesia on day 4 for the amputation of right great toe. Abdominal aortogram was performed on day 10 and was found to have mild narrowing at the level of tibioperoneal trunk with areas of stenosis the dorsalis pedis artery was occluded. The patient underwent right second toe amputation and percutaneous angioplasty for worsening of her osteomyelitis. On day 15, she was found to be jaundiced with mild disorientation; her liver function showed elevated total and direct bilirubin, alkaline phosphatase (ALP), and gamma glutamyl transpeptidase (GGTP) levels (bilirubin total (T)-9.6; direct (D)-7.3; ALP-388 IU/L; AST-67 IU/L; ALT-24 IU/L; GGTP-878 IU/L, with decreased creatinine clearance 30 mL/min/24 hr reference range (72??41 mL/min/24 hr). Pharmacy was consulted for drug-related hepatic injury, and nafcillin was discontinued immediately. A mild, transient drop in the levels of AST, ALT, ALP, and GGTP was noted immediately after stopping nafcillin. Further workup for hepatitis and jaundice was done to rule out other causes of hepatotoxicity. Workup included a negative direct coombs, and antibody screening, negative ANCA test for MPO and PR3 antibodies, rheumatoid factor, antismooth muscle antibody, antinuclear antibody, and HLA B27 were also negative. Levels of C3 and C4 complements were normal; liver-kidney microsomal antibody, alpha fetoprotein, and antithyroid peroxidase were also normal. Abdominal ultrasound showed a heterogenous appearance of liver parenchyma, and MRI abdomen was normal. The patient had an elevated GGTP, ALP, and bilirubin, mostly direct bilirubin () before being discharged to transitional care unit for rehabilitation.
+On day 36, her jaundice worsened, and she was admitted at a liver transplant center for further evaluation. Her workup included elevated AST 152 IU/L, ALT 85 IU/L, ALP >1800 IU/L, GGT >1500 IU/L, and total bilirubin 11.5 mg/dL, repeat ultrasound abdomen showed no intra- and extrahepatic biliary obstruction; MRCP was unremarkable; liver biopsy showed diffuse hepatocanalicular cholestasis with focal centrizonal bile infarct, periportal hepatocellular swelling and mild nodular hyperplasia like changes. Diagnosis of cholestatic jaundice secondary to nafcillin was made and Ursodiol 10 mg/kg was started. There was no evidence of fulminant hepatic failure, coagulopathy, or encephalopathy. The patient was discharged to home. The patient was followed as an outpatient with regular blood tests for LFT. The GGTP and ALP both remained elevated >1500 IU/L.
+On day 54, she was readmitted to the ER for abdominal pain and hematuria. Her workup revealed bilirubin (T-28.7 mg/dL, D-21.3 mg/dL), ALP >1884 IU/L, ALT 24 IU/L, ammonia 45 ug/dL (reference 31??23), creatinine 1.6, INR 5.4, PT 58.5, haemoglobin 7.5 gm/dL (reference 11.5??6.0), and haematocrit 21% (reference 37??7); urinalysis showed blood in urine, and blood culture remained negative. She was transfused two units of blood and was hemodynamically stabilized. She was monitored closely in the hospital. On day 84, she redeveloped an abdominal pain and was shifted to the liver transplant centre for further evaluation, where she went into respiratory arrest and succumbed to her underlying disease conditions."
+Avah Rowe,18,2000/11/1,(669)645-9816x3374,kellyday@example.org,47276 Weiss Path Apt. 583,"A 34 year old previously well lady from urban Sri Lanka presented to the Institute of Neurology at the National Hospital of Sri Lanka with a one month history of numbness of the right side of her face and difficulty chewing from the right side of her mouth. She described the onset of the symptoms as sudden as it was present on awakening from an uninterrupted sleep the previous night. The symptoms had persisted over a month without much progression. She had received treatment from a general practitioner but her symptoms had not improved. She did not have any diplopia or blurred vision, painful eye movements, hearing impairment, dysphagia or dysarthria. She did not complain of limb weakness or unsteadiness with tendency to fall. She did not complain of shooting pain on the right side of the face triggered by touch and has had no previous facial rashes. She denied sexual promiscuity. She had lived in Sri Lanka all her life and has not had any foreign travel.
+Neurological examination revealed an alert lady who was oriented to time, place and person. There was no facial asymmetry or drooling of saliva and no obvious facial rashes. On asking the patient to open her mouth there was slight jaw deviation to the right side (Figure ). Palpation of the Temporalis and Masseters did not reveal any wasting. Sensory examination revealed impaired pain sensation on the right side of the face involving the Ophthalmic, Maxillary and Mandibular divisions of the trigeminal nerve conforming to the characteristic onion skin distribution. The corneal reflex on the right side was also absent. All other cranial nerve examination was normal including the adjacent nerves. Opthalmoscopic examination did no reveal optic atrophy or papillitis. There was no limb involvement with normal Corticospinal, Spinothalamic and Posterior column pathway examination including preserved reflexes and there were no demonstrable Cerebellar signs.
+Magnetic Resonance Imaging (MRI) of the brain and spinal cord was subsequently performed and it revealed multiple, hyperintense (Both T2WI and T2 FLAIR), periventricular lesions in the deep white matter conforming to the characteristic Dawson? Finger appearance which is highly suggestive of multiple sclerosis (Figures -). There were also similar lesions in the right cerebellar peduncle. The spinal cord was free of lesions. Cerebrospinal fluid analysis revealed normal protein levels with no cells. The presence of oligoclonal bands could not be analyzed as this facility is unavailable at our institution and was unaffordable to the patient to be done in the private sector. Visual and Brainstem evoked potential studies were carried out and revealed normal results. All other basic biochemistry results were normal including normal inflammatory markers.
+She was treated with intravenous Methylprednisalone 1 g daily for 3 days followed by oral Prednisalone 50 mg daily (1 mg/kg/day) with plans to gradually taper off the treatment later. She was advised on the possibility of further neurological deficits in the future and asked to adhere to the follow up programme."
+Kamden Banks,32,1994/3/24,+1-571-657-5075x946,michaelsmith@example.com,08387 Alyssa Stravenue,"A 29-years-old unidentified male suffered multiple blunt trauma in a severe motor vehicle collision. On suspicion of intracranial injury due to left sided globe rupture, FAST exam was skipped and the patient was rushed to CT. After intravenous administration of contrast, axial CT (Figure ) demonstrated bilateral pneumothoraces, periaortic hematoma and pulmonary contusion. Coronal view (Figure ) showed mild right sided deviation of the trachea, pseudoaneurysm of the descending aorta and hemopericardium. Remarkable contrast reflux was seen into the inferior vena cava (IVC) and hepatic veins. This phenomenon was presumably caused by equalization of cardiac chamber pressures typical of tamponade. Even though emergent thoracotomy following blunt trauma carries an overall survival rate of only 1-2% [], after the loss of vital signs, emergent thoracotomy was performed and 2.5 liters of pericardial blood was found originating from a right atrial tear. This case shows that the use of contrast in CT can reveal changes in cardiac chamber pressures possibly indicating traumatic cardiac tamponade.
+Several studies have described the relationship between IVC contrast reflux and several morbidities (pulmonary hypertension, tricuspid regurgitation and right ventricular systolic dysfunction) [-]. Dusaj et al. [] demonstrated the hemodynamic potential of Coronary CT angiography (CTCA). Quantification of IVC and SVC contrast characteristics during CTCA provides a quick, feasible and accurate method of estimating right atrial and ventricular response. Their findings correlated with echocardiographic estimations of right atrial and right ventricular pressures. Similarly, we have found that contrast reflux in the IVC, SVC and hepatic veins correlates with acute hemodynamic changes associated with cardiac tamponade."
+Cali Delacruz,30,1992/1/19,(696)967-8889x2074,april50@example.org,0826 Flores Station Suite 983,"A 71-year-old female was referred to our Unit for anterior thoracic pain associated with a mass of the anterior mediastinum. The CT-scan detected a calcified shadow measuring 10 ? 7 cm that suggested a thymoma (Figure ). The lesion was immediately adjacent to the posterior sternal profile without any erosion of the cortex; on the contrary, one of the calcifications appeared to fusion to the left posterior sternal margin. The PET-scan was silent except for a small focal spot between the mediastinal mass and the right posterior sternal margin, corresponding approximately to the referred pain. The clinical examinations for myasthenia gravis (physical examination, antibodies against the acetylcholine receptor and single fiber electromyography) were negative. We avoided a biopsy of the lesion, considering that the tumors of the anterior mediastinum suspected for thymoma are directly referred to surgery. Keeping in mind the local fusion of the ?hymoma??with the sternum and the PET spot suspected for a focal malignancy, cryopreserved allograft sternum and costal cartilage were prepared by the Regional Bank for Muscle and Bone Tissue (Banca Regionale di Tessuto Muscolo-Scheletrico, Istituto Ortopedico G. Pini, Milano, trapianti@gpini.it) in the case of sternal resection.
+The firm adhesion of the tumor with the sternal body became evident at the sternotomy. A frozen section suspected a tumor of cartilage; consequently, the mediastinal mass, the sternal body and the costal cartilages were resected en bloc. For reconstruction we used the cryopreserved allograft properly tailored and fixed to the sternal manubrium and to the ribs. Titanium plates bended on site were used to fix the graft (Synthes, Oberdorf, Switzerland). The chest wall stability was excellent and the postoperative course was uneventful (Figure ). Final histology was positive for chondrosarcoma. The residual native sternum stumps received adjuvant radiotherapy. Twelve months after surgery the patient is in good clinical condition, without any sign of tumor relapse; in addition, the thoracic wall is stable with normal respiratory movements."
+Memphis Rasmussen,31,2005/4/3,(868)348-7675x0965,ismall@example.com,98450 Mark Dale Suite 536,"An 81-year old, American Society of Anesesthesiolgists (ASA) physical status III, female with past medical history significant for hypertension, hypercholesterolemia, prolonged history of depression with previous psychiatric admissions, osteoporosis, gastro-esophageal reflux disease and constipation, was admitted to psychiatry for major depression as her family noted gradual cognitive decline for 2?? weeks prior to presentation, resulting in a near-catatonic state. Patient reportedly had increasing sadness and started to withdraw, eating and hydrating less and less, and was minimally ambulating secondary to major depression. On admission, she was on buspirone, mitrazapine, bupropion, zolpidem, nortriptyline, lorazepam, pantoprazole, lubiprostone, amlodipine and rosuvastatin ??all of which have been tapered off prior to initiation of ECT. Patient had no drug or food allergies. She never smoked cigarettes or consumed alcohol, lived with her husband of forty years. Family history was significant for hypertension and father having a myocardial infarction. She was scheduled to have an ECT as her depression was resistant to pharmacotherapy.
+Pre-procedure testing showed a normal echocardiogram (ejection fraction of 75%, normal right ventricular systolic function), normal complete blood count and chemistry panel. Electrocardiogram (ECG) showed normal sinus rhythm and chest X-ray ruled out any acute pathology. Routine cardiology clearance was obtained and the patient was recommended to be started on aspirin 81 mg once daily. One week after admission, the patient was scheduled to have an ECT, once all medications were tapered off.
+Pre-anaesthetic evaluation revealed an elderly female who was alert, not oriented to place or time but oriented to person, with a heart rate of 78 beats per minute and a blood pressure of 118/76 mm of Hg. She was 5????and weighed 140 lb with a BMI of 24. Physical examination was otherwise unremarkable.
+On the day of the procedure, the patient was alert and ambulatory and was escorted to the ECT room. A total intravenous anaesthesia was planned for the right unilateral ECT. In the operating room the patient? ECG leads II and V5, non invasive blood pressure (NIBP) and SaO2, were monitored. A tourniquet was inflated over the left leg and methohexital 100 mg followed by succinylcholine 80 mg was used for general anesthesia and neuromuscular blockade respectively. After the fifth escalating (0.5 seconds doubling up to 8 seconds duration, 20 Hz, 800 mA, 0.3 ms) electric stimulations, a seizure was witnessed in the left lower extremity and immediately after, the patient desaturated and became bradycardic (heart rate in 50?), with no palpable pulse. A diagnosis of pulseless electrical activity was made and advanced cardiac life support (ACLS簧) protocol for cardiac arrest was initiated. Patient was successfully resuscitated with in 3 min after being intubated and receiving 1 mg of intravenous atropine and 1 mg of intravenous epinephrine. A right femoral venous catheter was also placed during resuscitation. The initial arterial blood gases during the arrest on 100% FiO2 were: pH = 7.44, pCO2 = 31, pO2 = 209 and HCO3 = 21.3. She was later transferred to the medical intensive care unit, where she was uneventfully extubated a day after the cardiac arrest. An echocardiogram done immediately after cardiac arrest could not visualize the right ventricle wall and the left ventricle had an ejection fraction of 65% with akinesis of the entire inferoseptal wall. ECG and troponins were negative for myocardial infarction.
+Further investigations revealed the presence of a DVT in the left popliteal and superficial femoral veins, with no evidence of DVT in the right lower extremity. A computerized tomography (CT) of the chest with IV contrast revealed a large embolus completely occluding the right lower lobe pulmonary artery along with small filling defects in the left lower lobe pulmonary artery (Figure ). There was an associated area of pulmonary infarction (Hampton hump) measuring 2.5 ? 4.5 cm involving the base of the right upper lobe (Figure ).
+The pulmonary embolus thus diagnosed, was treated with enoxaparin and the patient was later bridged to warfarin with a target INR of 2.0-3.0. Subsequently, an inferior vena cava (IVC) filter was placed to preclude further embolization into the pulmonary artery. At the time of discharge to sub-acute rehabilitation center, 7 days after cardiac arrest, patient was able to communicate verbally, her mental status has not only not suffered, but was significantly improved, compared to pre-admission level. Catatonia or near-catatonia, as in this case, are known to resolve as quickly as with single treatment, requiring no consequent treatments, now even months after the initial procedure. Patient has since returned to fully independent living in the community."
+Esperanza Colon,35,1983/12/21,(365)505-3224,arnoldjoy@example.org,3461 Hughes Mill Suite 599,"Previously well 60years old Sri Lankan Tamil male had dark urine for 3weeks which he ignored attributing it to change in the weather. He later developed purplish discoloration of fingers and toes associated with pain in extremities 10days prior to admission. He was admitted to the local hospital with progressively worsening shortness of breath even on mild exertion for seven days. On admission he had dry black discoloration of fingers and toes suggestive of dry gangrene. He did not recall any recent febrile illness or sore throat. There was no history of skin rashes, arthralgia or oral ulcers. There were no previous similar episodes.
+He had never smoked and took alcohol only occasionally. Nor he did take any prescribed or recreational drugs. There was no history of viral hepatitis. He had not received any blood transfusions and nor there was any sexual promiscuity. He was a daily paid manual worker and had 3 children.
+On further questioning he mentioned that they were displaced from their home due to floods and unusually cold weather and had to live in a temporary shelter one month prior to presentation. He was involved in carrying their belongings to dry land knee deep in cold rainwater. His urine colour turned dark about one week later.
+On examination he was febrile and sweaty. He appeared ill but was not in pain. He had severe pallor and was mildly icteric. There was no finger clubbing. Fingers, toes and forefoot were discolored, shrunken and appeared lifeless (Figures and ). Pulse rate was 92bpm, regular with good volume. Jugular venous pressure was not elevated. Blood pressure was 110/70mmHg. On auscultation heart was in dual rhythm with an ejection systolic murmur in aortic area. All peripheral pulses were palpable. Respiratory system examination was normal. No palpable liver, spleen or other masses were detected on abdominal examination. Patient was conscious and rational. No neurological deficits were detected except absent sensation on peripheries which were discoloured.
+Laboratory investigations revealed, Hb-2.7g/dl, platelets-432000/l, WBC-15810/l (N 64, L- 19, E- 7, M 9) MCV-106.3fl, MCH-65pg, MCHC-61.1g/dl and reticulocyte count 14%. Total bilirubin 26.8mol/l, Indirect bilirubin 14.6mol/l, Direct bilirubin 12.2mol/l, AST-62u/l, ALT-16u/l, ALP-212u/l,Serum creatinine 89mol/l, Serum sodium 143mmol/l, Serum potassium 3.8mmol/l. Fasting blood sugar 4.7mmol/l erythrocyte sedimentation rate 30mm/Hr. Urine for haemoglobin was positive.
+Hepatitis B surface antigen and Hepatitis C antibody were negative. Anti nuclear antibody and HIV serology were also negative. Mycoplasma IgM was negative. Epstein Barr virus IgM was positive with a titre of 1 in 1600. VDRL was non reactive. Blood picture revealed normochromic normocytic red cells, spherocytes, polychromatic cells, nucleated RBC and red cell clumps suggestive of acute haemolysis. White cells showed neutrophil leucocytosis with left shift. Platelets were normal in number with many platelet clumps. Direct antiglobulin test was positive with IgM and anti C3d specificity with strong auto-agglutination at 4C and room temperature and no auto-agglutination at 37C. Cold agglutinin titre was 1 in 2048.
+Blood film findings were compatible with severe cold auto-agglutinin mediated peripheral haemolysis with C3d specificity. Serum protein electrophoresis showed polyclonal increase in Gamma globulin region. Cryoglubulins were not detected.
+Upper gastrointestinal endoscopy showed multiple small antral ulcers and multiple small duodenal ulcers with no active bleeding.
+Vascular surgeon decided no active intervention needed as patient had demarcated dry gangrene. Provisional diagnosis was cold autoimmune haemolysis associated with Epstein Barr virus IgM.
+Patient was transfused seven units of O positive red cells over a period of one week. He was started on folic acid 5mg daily. After the blood transfusions he improved symptomatically. Repeat blood film two weeks after admission showed resolution of haemolysis. Patient was advised to avoid cold and to wear gloves and stockings in cold weather. He was discharged home after arranging follow up for occupational therapy. Due to the loss of fingers and toes he was markedly disabled and had to stop working as a labourer."
+Bruce Myers,24,1990/1/2,(485)682-8882,laralawrence@example.com,430 Stokes Stream Suite 222,"A 5-year-old castrated male Labrador Retriever was presented to a referring veterinarian for a swelling in the neck region. On physical examination a hard, painless, not retractable spherical mass, the size of a golf ball (+/ 55cm), was palpated just caudally of the left mandibula, in the region of the mandibular lymph node. A fine needle aspiration was performed and the dog was placed on antibiotics pending the outcome. As cytology results were inconclusive, mainly consisting of necrotic cell debris, antibiotic therapy was stopped and it was decided to remove the mass for histopathological examination. During surgical exploration a second, more oval, 154cm mass, located caudally from the first one, was noticed. This caudal mass was left in place and no biopsy samples were taken from it.
+On histopathological examination, the first cranial spherical mass noticed, turned out to consist of a reactive lymph node with metastasis of an anaplastic carcinoma. The metastatis consisted of small nests composed of large pleiomorphic polygonal or oval cells with a large round nucleus with coarse chromatin and inconspicuous nucleoli, and a variable amount of granular, slightly basophilic cytoplasm. Anisocytosis, anisokaryosis and karyomegaly was prominent (Figure ). Mitotic figures were numerous, ranging from 58 mitotic figures/high power field (HPF). The neoplastic nests were surrounded by a fine fibrovascular stroma. Randomly distributed, there were small foci with necrosis. Immunohistochemical evaluation with a panel of commercially available mouse and rabbit anti-human primary monoclonal antibodies (DAKO Corp.; Heverlee, Belgium) remained negative for pan cytokeratin (clone AE1/AE3), Melan A (clone A103), CD20 (polyclonal), CD3 (polyclonal) and a mouse monoclonal anti canine CD18 (clone CA16.3C10; P. Moore; University of California, Davis, USA) antibody remained negative. Positive immunohistochemical staining was detected with human mouse monoclonal anti-vimentin (V9) and Chromogranin A (polyclonal) antibodies (Figure ). Based on morphology of the tumor and immunoreactivity the diagnosis of neuroendocrine tumor, more specific paraganglioma was made. Because of the anatomical location, a paraganglioma of the carotid body was suspected."
+Lydia Gates,23,1985/10/23,546-646-2120x5447,millertheresa@example.com,299 Horne Court Apt. 298,"An 87-year-old woman with a history of pseudophakic bullous keratopathy and multiple failed corneal transplants received a type I Boston keratoprosthesis in the left eye, which served to improve her vision from count fingers at 1 foot to 20/70. She was maintained on vancomycin, fluoroquinolone, corticosteroid, and glaucoma drops, and opted against bandage contact lens use. At 8 months postoperatively, a thin transparent tissue was observed covering the periphery of the anterior surface of the front plate (Figs. ) and this involvement was further detailed by HD-OCT. This tissue was removed several times for the purpose of histopathologic and immunocytopathologic analysis and typically regrew within 1 month (Fig. ). Initially, visual acuity was not affected but was later reduced to 20/150 by encroachment of the tissue onto the visual axis. Visual acuity was restored to 20/70 by mechanical debridement of the central epithelium. The tissue has not approached the visual axis since and vision has remained stable for 5 months."
+Ermias Bradford,35,1992/3/3,3884327333,travisbaldwin@example.org,285 Collier Forge,"A monocular 71-year-old man with congenital glaucoma and a history of multiple failed corneal transplants underwent type I Boston keratoprosthesis placement in the left eye, which served to improve his vision from hand motion to 20/60. He was maintained on daily vancomycin, fluoroquinolone, and glaucoma drops and intermittently wore a bandage contact lens. Thin transparent tissue was observed over the front plate, covering the periphery of the device, but sparing the visual axis by both slit-lamp and HD-OCT examination, 9 months after placement of the device. Debridement of this tissue for histopathologic and immunocytopathologic analysis did not alter his visual acuity; the tissue regrew within 1 month."
+Rhea Watts,44,2000/8/21,(977)729-7075,kimberly09@example.net,400 Hernandez Row Apt. 865,"Two months after placement of a type I Boston keratoprosthesis in the left eye, a 69-year-old man with a history of pseudophakic bullous keratopathy, multiple failed corneal transplants, and retinal detachment surgery displayed a clear tissue covering the carrier corneal tissue-device junction, but sparing the visual axis by both slit-lamp and HD-OCT examination. He was on vancomycin, fluoroquinolone, corticosteroid, and glaucoma drops, and was using a bandage contact lens. His vision fluctuated but remained in the range of hand motions, unchanged from before the surgery, due to a retinal detachment that had proved inoperable. Since the visual axis was not affected, the tissue was not debrided."
+Dakota Pugh,27,2001/4/18,770-661-1350x170,noblecorey@example.com,8772 Adam Street,"A monocular 81-year-old woman with chronic angle closure glaucoma and multiple failed corneal transplants underwent placement of a type I Boston keratoprosthesis in the left eye. This served to improve her vision from light perception to 20/50. The patient was lost to follow-up and presented 6 months later exhibiting a transparent tissue over the front plate of the keratoprosthesis. This tissue spared the visual axis by both slit-lamp and HD-OCT examination. The patient had been maintained on a daily regimen of vancomycin, fluoroquinolone, corticosteroid, and glaucoma drops, and a bandage contact lens was in place. The tissue was not debrided since it did not encroach on the visual axis."
+Landry Decker,28,1985/6/18,001-292-420-3464,courtneymiller@example.net,240 Jonathan Garden,"A sixteen-year old male adolescent was brought to our department with complaints of ?rritability, regressive behavior, apathy, crying and truancy?? Upon questioning of his parents it was learned that the complaints have been present for the past year. The patient had started to display anxiety during separation from his mother, wept frequently and complained of vague pains, lethargy, forgetfulness and reduced concentration alternating with racing thoughts, irritability, anhedonia, distractibility, reduced sleep and appetite. Speech was reduced and he became progressively isolated from his peers. He refused to go to school and when sent became truant frequently. His parents reported that he was frequently agitated, spent his free time in front of his computer and that he ran excessive debts on their credit cards buying items on-line. There was no previous history of compulsive shopping or buying sprees. Premorbid personality of the adolescent was described as extrovert, euthymic and active. He was well liked by his friends although the academic staff reported problems in attention starting from the second grade. His teachers also reported fidgetiness and impulsivity which was especially prominent in mathematics lessons.
+In the mental status examination, impaired attention, concentration, as well as insomnia, reduced working and short-term memory, elementary auditory (i.e. knocking and ringing), olfactory (i.e. burnt rubber, perfumes and tobacco), and visual hallucinations (i.e. a white, man-like shape, especially present in the evenings), as well as passive suicidal ideation were noted. Judgment, abstract thought and reality testing were impaired. Speech was hypo-phonic, thought process was sluggish. Thought content was found to be impoverished and dominated by somatic complaints, delusions of reference, guilt and thought broadcasting. Mood was blunted and the affect was restricted in range. Psychomotor activity and appetite were reduced.
+The patient reported that those complaints arose in the past year and that hallucinations were added in the past three months. Within the last month, delusions of reference (i.e. thinking that others were looking at and talking about him), delusions of guilt (i.e. that he had sinned and would be punished) arose and the patient reported that his thoughts were broadcast so that others can read and understand his thoughts. No history of psychoactive substance use, encephalitis, use of antipsychotics/antiemetics, exposure to carbon-monoxide or organophosphate compounds or stressors was present. The patient was not vegetarian. Past medical history and family history was unremarkable for both psychopathology and chronic medical disorders. Physical and neurological examination revealed glossitis, ataxia, rigidity in both shoulders, cog-wheel rigidity in the left elbow, bilateral problems of coordination in cerebellar examination, reduced swinging of the arms and masked face. Romberg? sign was present although no signs or symptoms of peripheral neuropathy could be observed. Evaluation with The Extrapyramidal Symptom Rating Scale (ESRS) yielded a score of 19, with items of bradykinesia and parkinsonism being positive [].
+Electroencephalography, electromyography, somatosensorial evoked potentials, cerebrospinal fluid analysis, cranial MRI, thyroid and liver function tests, pancreatic enzymes, electrolytes, parathormone, ceruloplasmin and whole blood count were within normal limits. HIV (ELISA) was negative. Twenty-four hour urine copper level was within normal ranges. An ophthalmologic examination ruled out the presence of a Kayser Fleischer ring. A peripheral blood smear with Wright? stain was found to be normal. Endoscopy revealed atrophy of the gastric mucosa while a biopsy sample taken during endoscopy revealed colonization with Helicobacter Pylori. A Schilling test was administered to determine the etiology of Vitamin B12 deficiency and it was observed that radiolabeled Vitamin B12 levels were low both for Stage I and II of the test which was thought to reflect malabsorbtion [].
+Psychometric testing with the Beck Depression (BDI) and Anxiety Inventories (BAI) revealed scores of 35 (Cut-off score = 17, Severe Depressive Symptoms) and 36 (Without a clinically defined cut-off score albeit denoting severe anxiety), respectively [,]. An evaluation with the Turkish version of the Young Mania Rating Scale (YMRS), which does not have clinically designated cut-off score, yielded a score of 13 []. Psychotic symptoms were evaluated with Positive and Negative Syndrome Scale and the patient scored 20, 23 and 56 for the Positive, Negative and General Psychopathology subscales (Total 99) []. Vitamin B 12 levels were found to be 166 ng/mL in two subsequent tests after 6?? hours of fasting with immunoassay method via Advia Centaur XTTM (Normal 197??00 ng/mL) while folate and transcobalamine levels were normal. Hemoglobin was found to be 10 g/dL (Normal 14??8 g/dL) and MCV was 98 fL (Normal 80- 100 fL) []. Bone marrow examination did not reveal megaloblastic changes.
+As a result of the history and evaluations and noting that the psychotic symptoms were superimposed on affective-anxious symptoms, the patient was diagnosed as having Mood disorder with Mixed, Psychotic Features due to Vitamin B12 Deficiency according to DSM-IV-TR criteria and risperidone 0.5 mg/day and intramuscular vitamin B12 500 mcg/day were started for treatment []. Risperidone was chosen because of it being one of the most commonly used atypical antipsychotics for management of psychosis, pervasive developmental disorders, mental retardation, mood disorders and disruptive behavior disorders in children and adolescents and having no known interaction with vitamin B12. The usual dose range of risperidone for acute psychosis and mood disorder is reported to be 2?? mg/day while we have started risperidon at 0.5 mg/day to help stabilize the patient while the medical work-up and treatments were being completed []. Vitamin B12 was the only vitamin supplement started.
+At the same time the patient was referred for treatment of Helicobacter pylori and was prescribed clarithromycin 1000 mg/day, lansoprazole 60 mg/day and amoxicillin 2000 mg/day. A follow-up visit on the second week revealed that no psychotic features were present, Romberg? sign was negative and that cerebellar tests were within normal limits. Extrapyramidal symptoms were reduced. Both the patient and his mother reported that apathy, crying, regressive behavior and truancy were reduced. An evaluation with BDI and BAI revealed scores of 9 and 15, respectively while Evaluation with ESRS and YMRS yielded a score of 3 for both. PANSS scores for positive, negative and general psychopathology subscales were 13, 15 and 36 respectively (Total 64). Vitamin B12 levels were measured at this visit as 595 ng/mL. At the scond week, risperidone was stopped and parenteral Vitamin B12 treatment was continued with monthly injections for 3 months. The time course of changes in BDI, BAI, PANSS and its subscales, YMRS and ESRS according to Vitamin B12 levels is illustrated in Figure .
+A follow-up endoscopy and biopsy at the first month revealed that H. pylori were eradicated from the gastric mucosa. The patient was followed for another 6 months at monthly intervals and the psychiatric symptoms did not recur at the time of last evaluation.
+This study reports a case of vitamin B12 deficiency in an adolescent who presented with mixed mood disorder symptoms with psychotic features as well as extra-pyramidal symptoms and its response to Vitamin B12 treatment. Although concurrent administration of risperidone in our patient may be considered as a limitation in light of reports of improvement in psychotic symptoms as early as the first week, the fact that the administered dose of 0.5 mg/day was lower than doses recommended for controlling acute psychosis and mood disorders may support the beneficial effect of treatment with Vitamin B12 []. The course of improvement in psychometric measures with changes in Vitamin B12 levels may also support this hypothesis (Figure ).
+Up to now, there was only one case report of psychotic disorder, again concomitant with extrapyramidal symptoms associated with Vitamin B12 and folate deficiency in a 12-year old male adolescent and this case was also reported from Turkey []. The time course and response to treatment as well as the content of the symptoms of the patient reported by Dogan and colleagues [] seems to be similar to our patient and although the folate levels in our patient were within normal limits it may be argued that vitamin B12 deficiency may have masked concurrent folate deficiency in our patient.
+It is also unclear why Vitamin B12 deficiency leads to prominent neuro-psychological symptoms in some patients and not others. C677T polymorphism of the methylene-tetrahydro folate reductase (MTHFR) gene, which has an elevated prevalence in Mediterranean countries, may protect patients defective for Vitamin B12 levels against the emergence of hematological symptoms and homozygosity for this gene may be elevated in Turkish populations, especially from Eastern Turkey [,,].
+Another interesting feature of both our patient and that reported by Dogan and colleagues seem to be the prominence of extra-pyramidal symptoms in presentation []. This may be due to the dissociation between neurological and hematological symptoms, presumably due to MTHFR polymorphism or alternatively it may be due to changes in basal ganglia, especially globus pallidus as observed in Methly-malonic academia []. It may also be posited that patients with less severe mutations of methyl-malonyl coA mutase may be asymptomatic initially and reduced activity of the enzyme, perhaps in situations of vitamin B12 deficiency may lead to changes in basal ganglia []. It may also be striking that both our patient and the other, two cases of vitamin B12 deficiency with extra-pyramidal symptoms are males [,]. Although the lack of evaluation of volumes of basal ganglia in our patient may also be a limitation of our study, it may be said that future studies evaluating volumes of basal ganglia in patients with Vitamin B12 deficiency are needed.
+The pathophysiology of extrapyramidal symptoms in patients with Vitamin B12 deficiency is far from clear, although some indirect evidence exists. Firstly, S-Adenosylmethionine (SAM) in carbon transfer metabolism is the only methyl donor in the Central Nervous System and knockout mice for the MTHFR enzyme have been reported to have reduced SAM, global DNA hypomethlyation and cerebellar pathology []. Secondly, cysteine which is a precursor for the major intracellular redox buffer glutathione is a breakdown product of homocysteine and therefore the carbon transfer metabolism. Neurons lack this pathway and are dependent on glia for production, thereby rendering them more susceptible to oxidative damage []. The facts that MDA (malondialdehyde) is a measure of membrane lipid peroxidation and that MMA (methyl malonic academia) is an inborn error of metabolism usually presenting with acute extrapyramidal symptoms in infants sometimes responds to vitamin B12 treatment also support the importance of vitamin B12 in preventing oxidative damage, perhaps especially for dopaminergic neurons [,,]. Thirdly, MTHFR is also involved in the metabolism of tetrahydrobiopterin and the latter is required for synthesis of dopamine and serotonin. It also acts directly on specific membrane receptors to release monoamine neurotransmitters as well as having specific protective antioxidant effects on dopamine neurons []. Dopamine also stimulates methylation of phospholipids in the neuronal membrane and this reaction depends on single carbon folate pathway, thereby underlining the importance of the relationship between dopaminergic neurotransmission and single carbon metabolism []. Lastly, the cholinergic synapses may also be involved in the pathophysiology because of the dependence of choline synthesis on SAM []. Globus pallidus among the basal ganglia may be expecially vulnerable to these pathophysiological mechanisms []. Regardless of the pathophysiological mechanism involved, further studies involving larger samples are needed to determine the prevalence of extrapyramidal symptoms in vitamin B 12 deficient patients from varying age cohorts."
+Taylor Mosley,32,1988/6/28,-8773,olivia10@example.com,01524 Christina Wall,"A 49-year old male patient presented with flank pain and hematuria. The CT scan showed a large pelvic tumor 18 cm in diameter (Figure ). A biopsy was performed and the pathologic examination revealed a spindle cell tumor with co-expression of CD117 and S100 protein, as well as a point mutation in c-kit exon 11, consistent with the diagnosis GIST. Due to the large tumor size, neoadjuvant therapy with imatinib 400 mg daily was initiated. After 6 months of treatment, the patient developed grade 3 hepatotoxicity with ALT and AST elevations from normal values to 882 U/l and 383 U/l, and an elevated bilirubin of 25 umol/l. Imatinib was paused for two weeks and parameters rapidly declined to normal limits. Treatment was then continued at 400 mg OD and sustained tumor shrinkage was seen in subsequent CT scans. After 16 months of neoadjuvant therapy tumor shrinkage ceased and tumor size was reduced from 18 cm to 14 cm (22% reduction). A complete tumor resection was performed at that time. Consistent with the clinical response, the pathological examination revealed a tumor regression of 20% (Figure ) with low expression of proliferation markers (MIB <1%). Due to the high risk of recurrence, adjuvant therapy with imatinib 400 mg OD was initiated. After 7 months of adjuvant treatment, grade 4 hepatotoxicity developed with an ALT 1837 U/l and AST 1022 U/l (Figure ) and an elevated bilirubin of 90 umol/l. Imatinib was paused for a total duration of 8 weeks, and subsequently the elevated transaminases declined to values within normal limits. Subsequent re-challenge of imatinib was associated with another episode of hepatotoxicity after 14 days of re-exposure. A corresponding MRI showed the development of cirrhotic changes of the liver (Figure ), which had been absent at the previous MRI 3 months before. Other possible causes of liver damage, including metastasis, alcoholic liver disease, hepatitis A, B, C, and E, autoimmune hepatitis and metabolic disorders were excluded. Imatinib was discontinued permanently and the transaminases returned to normal values within 6 months. Fifteen months after discontinuation of imatinib the patient is still without relapse, but cirrhotic changes of the liver remained sustained on MRI."
+Zaniyah Carson,33,1981/6/9,(710)417-2382,zmurphy@example.org,5623 Allen Villages Apt. 165,"The patient is a 63-year-old Caucasian man. He is 1.61 meters tall and weighs 66 kilograms. After working as a car mechanic for 36 years, he had been receiving disability benefits for 11 years. He was working part-time as a caretaker averaging 10 hours per week until two and a half years ago. At the age of 35, the patient began having bouts of severe back pain approximately twice a year. When these episodes occurred, he took non-steroidal anti-inflammatory drugs for three to four weeks for pain relief. At the age of 40, lumbar spondylolisthesis was diagnosed by radiography. At the age of 50, he suddenly developed severe right hip pain. He suffered from substantial arthrosis on the right side, which was treated with a total hip replacement one year later.
+Three years ago, he began to develop neurological symptoms in both hands. Pain and loss of function of his fingers prevented him from working as a caretaker. The pain radiated from his neck bilaterally down to his fingers and was described as parasthesia-like in nature. He also complained of weakness in his hands. Left hand digit flexion was classified as J1 and right hand as J4. Digit extension was classified as J4 on the left and J2 on the right and abduction on the left was classified as J0 and on the right as J1. The patient also had difficulty walking (Nurick 4, EMS 10/18) as he had to support himself using his surroundings in order to stand upright and was unable to walk unassisted. He was referred to a neurologist by his general practitioner who in turn referred him to a neurosurgeon. Radiographs (Figure ) magnetic resonance imaging (Figure ) and computed tomography (CT) revealed a spondylolisthesis between C7 and T1. Using the Meyerding classification [], which was initially developed for grading the degree of lumbar spondylolisthesis, the patient would have been diagnosed with a cervico-thoracic spondylolisthesis of the second or third degree. The spondylolisthesis, measured using the method developed by Kawasaki et al. [], was 13 mm. In view of the special nature of the case, a collaborative treatment between neurosurgeons and orthopedic surgeons was favored and subsequently implemented.
+The surgical management was performed as follows:
+The patient was placed in the supine position. The intervertebral disk at C7-T1 was exposed using blunt dissection. The disk was then removed to the point of the ligamentum flavum. A subsequent resection of the lateral parts of the intervertebral discs significantly mobilized the spondylolisthesis.
+The wound was closed and the patient was rotated to the prone position. First, the dislocation between vertebras C7 and T1 was reduced while positioning the head.
+Subsequently, the lateral masses were prepared from a dorsal approach between C5 and T3. Then, lateral mass-screws were inserted into C5 and C6. We had noticed considerable laxity between C6 and C7. In addition, C5 and C6 were naturally fused and we decided to include them in the instrumentation. There was also a rigid displacement between C7 and T1.
+Bicortical screws were then inserted into the transverse processes of T2 and T3. These were inserted into at least two segments from both sides in divergent directions. The length of these screws was 10 to 12 mm, with a diameter of 3.2 mm.
+This was followed by a laminectomy. Since the roots of C7 and C8 were exposed, the lateral masses of C7 and C8 had to be resected. Longitudinal rods were placed. Proper reduction in lordosis and the preservation of a 5 mm intervertebral space between C7 and T1 were confirmed by radiograph. Set screws were used to fix the instrumentation in the desired position. Chips of cortical and cancellous bone were placed lateral to the longitudinal rods.
+The dorsal wound was then closed. The patient was again rotated to the supine position to reopen the ventral wound. Now, instead of the previously seen displacement, a large gap was visible between C7 and T1. The endplates between C7 and T1 were milled and the ligamentum flavum was resected using punches. Then, the spinal canal was exposed completely, using a Caspar opener.
+Subsequently, a Harms basket, filled with autograft bone chips, was inserted into the intervertebral space. Three drains were placed and the wound was closed. For prophylactic infection control, the patient was perioperatively given intravenous 1.5 g cefuroxime twice a day for the next four days. Intraoperative and postoperative radiographs (Figure and ) were taken to confirm correct placement of the instrumentation.
+Following the operation, the patient was transferred to the intensive care unit. His vital signs were stable enough for him to be transferred to the general postoperative recovery ward on the fourth postoperative day. Eleven days after surgery, the patient left the hospital and entered an orthopedic and neurologic rehabilitation program.
+The pain and parasthesias in his fingers resolved after the operation. Two months postoperatively, his ability to walk had noticeably improved after completing his rehabilitation program (Nurick 3).
+Today, two years postoperatively, the patient is able to walk without assistance (Nurick 2). Flexion of the fingers on his left hand was graded as J3 and as J5 on the right hand. Extension of the fingers on his left hand was graded as J4 and as J2 on the right. Abduction was graded as J4 for his left hand and as J2 for his right hand (EMS 14/18)."
+Ares Cardenas,26,1984/7/2,001-320-948-8460x5649,colewendy@example.org,0672 Ramirez Cape Suite 832,"Case 1 was an eight-month-old Caucasian male reported to have deficient GALC enzyme activity. Sequence analysis with 30-kb deletion analysis identified one copy of a five-bp deletion in exon 16 of the GALC gene. A second mutation was not identified. After the affected individual passed away, samples from the parents were sent to EGL for testing. The individual? mother was found to carry the five-bp deletion. Array-CGH deletion/duplication testing of the individual? father detected a 6.9-kb deletion of exon 8 (see figure )."
+Raven Dougherty,44,2002/7/15,(392)820-6091,gabriellebrown@example.org,606 Robert Heights,"Case 2 was a one-year-old Caucasian female reported to have deficient GALC enzyme activity by blood assay and by fibroblast assay, and clinical features consistent with Krabbe disease. Sequence analysis with 30-kb deletion analysis identified one copy of the 30-kb deletion in this individual. A second mutation was not identified. Testing of the parents indicated that the child? mother was the carrier of the 30-kb deletion. Array-CGH deletion/duplication analysis of the individual? father revealed a novel 11-kb duplication encompassing exons 11 through 14. Subsequent deletion/duplication testing of the affected individual revealed a complex copy number pattern in the GALC gene resulting from the overlapping combination of the 30-kb deletion, which extends from exons 11 through the end of the gene, and a duplication of exons 11 through 14 (see figure ). In this individual, the combination of a deletion and a duplication resulted in an array result with normal copy number for exons 11 through 14, while exons 15 through the end of the gene were deleted. In the absence of parental testing, this combined set of copy number changes would have been difficult to detect and interpret. This individual was confirmed to be the same individual reported in [] and is the only report of a large duplication in the GALC gene to date."
+Brett Schmitt,26,1984/11/12,+1-825-636-9666x3140,harrisaaron@example.org,820 Hernandez Stravenue,"Case 3 was a 17-month-old East Indian female. Testing in another laboratory indicated deficient GALC activity and a homozygous single base pair deletion in exon 1 of the GALC gene. Testing of this individual? parents indicated that the mother was a carrier of the single base pair deletion, but testing for the mutation in the father was negative. Samples were submitted to EGL for array-CGH deletion/duplication testing for the affected individual and her father. This testing revealed a deletion of exons 1 through 6 in both individuals (see figure ). The deletion that the affected individual inherited from her father caused the mutation inherited from her mother to appear homozygous by sequence analysis."
+Queen Macias,41,1998/6/5,257.238.7944,davenportlisa@example.com,305 Burnett Walk Suite 349,"Our patient was a three-year-old Arabic boy who presented to a peripheral medical center with a two-month history of lower back pain followed by progressive paraparesis. He had no symptomatology related to posterior fossa syndrome or increased intracranial pressure. Six weeks after the start of his symptoms, he developed urinary and bowel incontinence. During the physical examination, the boy was fully awake and cooperative. All cranial nerves were intact. His pupils were 2 mm, bilaterally equal and normally reacting to light. He had full extra-ocular movement with no nystagmus. There was no papilloedema. An examination of the upper extremities was normal. He had symmetrical lower limb weakness with muscle group power grade 1/5 distally and 3/5 proximally associated with hypotonia, absent reflexes and diminished sensations up to the L1 dermatome. His anal tone was reduced. Cauda equina syndrome was suspected, for which he underwent a magnetic resonance imaging (MRI) scan of the spine that revealed spinal canal filling and lesions in the thoracic and lumbar regions. At that stage, he was referred to our institution as a patient with a spinal tumor.
+Upon reviewing his spinal MRI, drop metastasis was suspected. A cranio-spinal MRI scan was performed, which showed a posterior fossa tumor associated with radiographic features of intracranial and spinal metastasis, (Figures A, B and A). This MRI feature was suggestive of medulloblastoma. Given the fact that the thoracolumbar pathology is mainly a diffuse process affecting cauda equina roots, which is probably not amenable to surgical removal, we decided to direct the surgical treatment to the primary posterior fossa tumor only. Therefore, he underwent a suboccipital craniotomy and subtotal resection of the posterior fossa tumor. Neuropathological examination of the resected specimen revealed features of classic medulloblastoma. The cells had primitive nuclei, which were packed without signs of differentiation (Figure A). Also, the tumor lacked any anaplastic or large cell features. The tumor cells were uniformly expressing synaptophysin (Novocastra?? clone 27 G12, 1:100, Newcastle, UK) (Figure B). Since our patient was young and the clinical course was atypical, immunostaining for integrase interactor 1 (INI-1) protein (BAF47; BD Biosciences, clone 25, 1:200) was also performed and the neoplastic cells were uniformly immunoreactive to it (Figure C). This practically excludes atypical teratoid/rhabdoid tumor as a diagnostic possibility. Subsequently, our patient received cranio-spinal axis radiotherapy (36 Gy) and 18 Gy boost to the posterior fossa. Adjunctive chemotherapy was given, which consisted of vincristine, cisplatin, and CCNU (lomustine).
+During his treatment course he received rehabilitation therapy. Three months after his initial treatment, he had substantial improvement in his overall neurological functions. He started to walk without assistance and was able to control his bladder and bowel functions. A neuroaxis follow-up MRI after one year showed regression of his cranial and spinal disease (Figures C, D and B). At the time of writing this report, he has retained good neurological function."
+Moshe Castro,34,1999/5/22,764.213.9814x3889,kristierodgers@example.org,13612 Campbell Court,"A two-day-old term baby girl of Arab origin was the first child for young non-consanguineous parents. The pregnancy was uneventful without any history of maternal illness, fever or rash. The baby was delivered by normal spontaneous vaginal delivery outside our hospital. The family pedigree is negative for congenital malformation.
+The baby was referred to the neonatal intensive care unit of the Suez Canal University Hospital, Egypt, when she was two days old due to malformed upper extremities, multiple purpuric eruptions and bilateral corneal opacities (Figures A, B).
+Physical examination at presentation revealed a baby with stable vital signs who was alert, pink and active, with a length of 49 cm, a weight of 2,800 g, and a head circumference of 34 cm (all on the 50th percentile), bilateral corneal opacities without any facial dysmorphic features, multiple purpuric eruptions mostly on the anterior aspect of the lower limbs and abdomen. She had bilaterally absent radii and radial deviation of both upper limbs with no thumb deformity. There were no deformities in the lower limbs. Abdominal examination revealed no organomegaly, there was no clinical evidence of congenital heart disease and the other systems were normal.
+Initial laboratory investigations gave the following results: complete blood count: hemoglobin, 10 g/dL; mean corpuscular volume, 105 fl; mean corpuscular hemoglobin, 34 pg; reticulocytic count, 6%; TLC: 49,000/uL, 60% s. neutrophils, 5% myelocytes, 5% metamyelocyte, 10% normoblasts; platelet count, 20,000/uL; prothrombin time, 12.8 seconds (cont 12); partial thromboplastin time, 28.0 seconds (cont 28). Liver function tests had the following results: bilirubin (total), 6.14 mg/dL; (direct), 0.24 mg/dL; glutamic pyruvic transaminase, 28 U/L; and glutamic oxaloacetic transaminase, 34 U/L. Electrolytes and kidney function were: Na, 136 mmol/L; K, 4.8 mmol/L; serum creatinine, 0.9 mg/dL. TORCH screens were normal with rubella IgG antibodies, 12 Eu (0??0) and Rubella IgM antibodies, 0.20 Eu (0??0). Radiography of the forearm showed bilateral absence of radii (Figure C). Her abdominal and cranial ultrasonography were normal. Based on these physical findings, thrombocytopenia, and X-ray results, the diagnosis of TAR syndrome was made. At this time she received two platelet transfusions and had a post transfusion platelet count of 55,000/uL. Bone marrow aspiration performed when she was seven days old revealed previously undetected megakaryocytes in the examined smears. It also showed that the myeloid cell line was mildly hyperactive with preservation of normal sequential maturation, the myeloid/erythroid ratio was slightly decreased, the erythroid cell line had mild hyperplasia with dysplastic changes and an increase in the early stages. Ophthalmology consultation revealed irregular red reflex with bilateral nuclear congenital cataract, both eyes were equal and normal in size.
+She is now on prophylactic platelet transfusion twice weekly and is scheduled for cataract surgery by the age of six weeks to prevent irreversible amblyopia and sensory nystagmus, starting with the right eye as it is denser. The parents refused to do genetic studies for their baby."
+Eloise King,44,1978/7/19,(215)272-0764,loganmoreno@example.com,32182 Jack Path Apt. 268,"A 27-year-old male Caucasian professional football player had recurrent pain and swelling of his left knee. Seven years ago at another center, our patient underwent arthroscopic reconstruction of his left anterior cruciate ligament with a bone-patellar tendon autograft and partial lateral meniscectomy. His present complaints began one year after the initial surgery, and a large chondral lesion was detected on his lateral femoral condyle. On two occasions our patient had undergone microfracture procedures, but had been unable to return to the professional sport due to constant pain and swelling of his knee. On examination, our patient had full extension and 130簞 of flexion, and elicited pain on the lateral side of his knee after 60簞 of flexion. He had an effusion and loose bodies were palpated in the lateral recess. Anterior drawer, Lachman and McMurray tests were negative. Tegner-Lysholm and Brittberg-Peterson scores were 64 and 58, respectively. Neurologic and vascular examinations were normal.
+Magnetic resonance imaging (MRI) demonstrated a grade 4 large chondral lesion at the weight-bearing area of the lateral femoral condyle of his left knee (Figure , b).
+Informed consent was obtained from our patient and approval was obtained from the local ethics committee. An arthroscopic examination revealed a large chondral defect with a rough surface measuring 3 cm ? 3 cm (Outerbridge grade 4, Noyes grade 3B) on the lateral femoral condyle (Figure ). Loose bodies were removed, and autologous cartilage biopsies were obtained from the superomedial edge of the femoral trochlea and sent to a commercial cell culturing facility.
+Two months later, a MACI procedure was performed. With our patient under general anesthesia, the lesion was approached via a lateral 10 cm parapatellar incision. Osteophytes were excised, the cartilage defect was debrided to the subchondral bone with a 90簞 angled rougine, and the surface was smoothened with a low-speed burr. The defect size was measured as 3 cm ? 3 cm (9 cm2) and MACI implant was resized over a template to match the defect size. A fibrin-containing tissue glue (Tisseel, Baxter Inc., Seoul, Republic of Korea) was used to fix the scaffold containing the cultured autologous chondrocyte within the defect. After five minutes in full extension, flexion and extension movements were performed to check for implant fixation. The wound was then closed layer by layer.
+Our patient remained non-weight-bearing for six weeks postoperatively, began partial weight-bearing from the seventh postoperative week, and gradually progressed to full weight-bearing at 12 weeks. Range of motion exercises from 0簞 to 40簞 were started on the second day after the procedure, using continuous passive motion for four to six hours daily. After one week, the range of motion was increased by 5簞 per day. During this period, a quadriceps strengthening exercise and stretching of the hamstrings and calf were continued. Six months after the procedure our patient was allowed to jog and to initiate low velocity running. The physical therapy and fitness program were continued for nine months. Our patient was on the football field with full activity at the end of the first year.
+At his last follow-up, two years after the index procedure, our patient had a full range of motion with no lateral knee pain or swelling. Tegner-Lysholm and Brittberg-Peterson scores were 91 and 6, respectively. He was playing in a professional football league and had a good performance within full season matches.
+MRI was performed (Philips, Achieva 3 T, Amsterdam, Netherlands) every six months. An MRI evaluation two years after the MACI confirmed that our patient maintained an excellent repair of the defect under the high demands of professional soccer (Figure , b).
+Our patient had no complaints, but a second-look arthroscopy was performed to evaluate the outcomes of the MACI procedure at two years. Informed consent was taken. The cartilage defect was totally healed with the same margin to the normal cartilage and as robust as healthy cartilage (Figure ). Our patient did not give permission for a biopsy."
+Julian Church,29,2005/5/20,632.400.5185,gloriahughes@example.com,42336 Ellis Neck,"A 38-year-old Asian man presented with macroscopic hematuria and left back pain. He underwent computed tomography of his abdomen and a large enhancing left renal mass and renal hilar lymph node swelling were noted (Figure ). The tumor was located in the middle-inferior portion of his left kidney. He had no previous history of chemotherapy. All his blood test results were unremarkable. A radical left nephrectomy was performed and the lymph nodes were simultaneously removed.
+An ill-demarcated tumor measuring 6 ? 6 ? 7.5cm was observed in the middle-inferior pole of his left kidney. The cut surface was yellow or white in color. There was hemorrhage and necrosis present.
+On microscopy, the tumor consisted of a combined epithelial and sarcomatous component. The epithelial component comprised neoplastic cells with clear or eosinophilic cytoplasm (Figure a). Regarding the architectural aspects, the epithelial component had a solid growth pattern or a papillary growth pattern with delicate fibrovascular cores. The neoplastic epithelial cells had enlarged nuclei with an irregular nuclear membrane and distinct nucleoli. This nuclear atypia corresponded to Fuhrman Grade 3. The sarcomatous component consisted of spindle cells with fibroconnective stroma. The neoplastic sarcomatous cells had enlarged irregular nuclei with distinct nucleoli. This nuclear atypia corresponded to Fuhrman Grade 3 to 4. These findings were consistent with sarcomatoid change.
+Immunohistochemistry revealed that the nuclei of many tumor cells were positive for transcription factor E3 (TFE3) (Figure b). In addition, the neoplastic epithelial cells were diffusely positive for alpha-methylacyl-coenzyme A racemase, CAM5.2 and EMA, and focally positive for cluster of differentiation 10 and vimentin. The neoplastic sarcomatous cells were focally positive for alpha-methylacyl-coenzyme A racemase, EMA and vimentin. The tumor cells, however, were negative for cytokeratin 7, Melan A and human melanoma black-45. Therefore, the tumor was finally diagnosed as RCC associated with Xp11.2 translocation/TFE3 gene fusion. Renal vein involvement was demonstrated, but lymph node metastasis and distant metastasis were absent. Accordingly, the tumor was classified as pT2pN0M0, Stage II.
+Alpha-interferon was administered as adjuvant therapy after the surgery. A recurrent mass was found in his left lung by computed tomography three months after surgery, in spite of the adjuvant therapy. The tumor enlarged despite treatment with interleukin-2. Tyrosine kinase inhibitors sunitinib and sorafenib and the mammalian target of rapamycin inhibitor everolimus were sequentially administered, but the tumor showed no response. Metastatic tumors developed in our patient? brain, liver and bone and he died 16 months after the nephrectomy."
+Ayleen Watson,29,1980/12/26,303.347.9849x98573,harrellkevin@example.org,6970 Benjamin Spurs Apt. 476,"A 76-year-old woman underwent elective endoscopic resection of a papillary adenoma. During this procedure, which included biliary sphincterotomy for removal of common bile duct stones, no particular problems were encountered. Immediately after the procedure the patient developed severe dyspnoea and massive subcutaneous emphysema of the thorax, neck, face and lower extremities. Chest X-ray and CT revealed left-sided pneumothorax, right-sided tension pneumothorax, pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum (Figs. and ). CT with oral contrast showed a minimal amount of contrast leakage in the second part of the duodenum (Fig. ). The patient was treated with oxygen, bilateral chest tube placement, antibiotics, and a nil per mouth regime. After 1 day she was transferred from the intensive care unit to the normal ward. She gradually improved and was discharged from the hospital 10 days after the procedure."
+Greyson McGuire,33,1989/6/25,001-372-681-6695x36593,matthew96@example.com,41332 Mcdowell Springs Apt. 416,"A 77-year-old man was admitted with obstructive jaundice. Imaging studies suggested a pancreatic head tumour. Endoscopic cholangiography showed a severe stenosis of the distal common bile duct. For selective cannulation pre-cut sphincterotomy was performed followed by placement of a plastic endoprosthesis. During this procedure retroperitoneal air was noticed. The patient became hypotensive and developed extensive subcutaneous air of the neck and head. Further imaging showed mediastinal air and bilateral pneumothorax. Conservative treatment was started, including antibiotic treatment for 5 days, intravenous fluids, nil per mouth and gastric drainage. The clinical course was uneventful and the patient made a rapid recovery within 1 week."
+April May,30,1999/4/29,775-364-0551x92524,maryrhodes@example.com,02587 Kevin Fields Apt. 620,"An 88-year-old woman with complaints of intermittent abdominal pain was scheduled for ERCP for removal of biliary stones. The papilla was situated in a large duodenal diverticulum. Following guidewire-assisted sphincterotomy there was immediate suspicion of an abnormal route with retroperitoneal leakage. Furthermore, there was active bleeding at the site of the sphincterotomy. Haemostasis was achieved with adrenalin injections. The patient developed gradually progressive subcutaneous emphysema, chest pain and dyspnoea. Additional imaging showed pneumomediastinum and right-sided pneumothorax. Initial treatment included insertion of a nasobiliary drain and administration of oxygen. She was transported to the intensive care unit where a chest tube was inserted and antibiotic treatment was started. The following day there was marked clinical improvement and she could return to the normal ward. The further clinical course was uneventful."
+Finley Arnold,29,2003/10/26,001-698-261-0230x59772,kelsey65@example.com,725 Williams Falls,"A 58-year-old woman underwent ERCP for further evaluation and treatment of jaundice and biliary pain. Biliary cannulation was unsuccessful and pre-cut sphincterotomy was performed. After successful cannulation, cholangiography failed to show clear biliary abnormalities. At this stage the presence of retroperitoneal and mediastinal air was noted, accompanied by right-sided pneumothorax. Conservative treatment was initiated and consisted of nil per mouth, nasobiliary drainage and antibiotics. The further clinical course was uncomplicated and the patient fully recovered."
+Finley Rhodes,42,2003/4/22,(418)924-0842x1170,cruzhayley@example.net,4609 Shawn Viaduct,"A 14-year-old girl presented with a 6-week history of fatigue, persistent rhinorrhea, and intermittent epistaxis. Her history was also significant for recurrent sinusitis, rash, decreased urine output, and myalgias. The patient was seen by her pediatrician with concerns that her nose was ?ollapsing.??Past medical history includes atopic dermatitis as a child and allergic rhinitis.
+On admission to our hospital, the patient? physical exam was remarkable for pallor, saddle nose, dried nasal secretions, oral ulcers, synovial swelling around multiple joints, and palpable purpura on her distal extremities. Initial laboratory tests showed that the patient was in acute renal failure with a BUN of 131 mg/dL and creatinine of 11.14 mg/dL. She also had elevated inflammatory markers (ESR 82 mm/hr, CRP 19.2 mg/dL), normocytic anemia (hemoglobin 8.7 g/dL, MCV 79.7 fL), leukocytosis (white blood cells 29 ? 103/mm3, absolute eosinophil count 615/uL), thrombocytosis (platelets 661 ? 103/mm3), and proteinuria and hematuria on urinalysis (specific gravity 1.015, pH 6.0, large occult blood, RBC 21??0/hpf, protein 100 mg/dL, trace leukocytes, WBC 0??/hpf, epithelial cells 6??0/hpf; negative nitrite, bilirubin, ketones, and glucose). Initial imaging studies showed a left lower lobe infiltrate via chest x-ray and renal ultrasound demonstrated large, echogenic kidneys with absent corticomedullary junction differentiation.
+Given her vasculitic rash, nasal cartilage destruction, and apparent sinusitis?igns consistent with GPA?he patient was started on methylprednisolone (30 mg/kg/day) and cyclophosphamide (1 mg/kg/day) with decreased dosing secondary to renal failure. Additional laboratory results showed a positive ANCA with a cytoplasmic pattern by indirect immunofluorescence screening and an anti-proteinase 3 greater than 148 EIA/U by rapid enzyme immunoassay. On hospital day two, the patient became anuric and was started on hemodialysis. She was transferred to our intensive care unit due to hypoxia and dyspnea where she received positive pressure ventilation. In addition to hemodialysis, she underwent seven sessions of plasmapheresis. Due to worsening pulmonary symptoms, a bronchoscopy was performed which showed tracheal and bronchial ulcerations as well as pulmonary hemorrhage with the presence of bloody lavage fluid. Additionally, nasal endoscopy revealed nasal perforations with necrotic mucosa. A biopsy of her nasal mucosa demonstrated acute inflammation and necrosis without evidence of granulomatous vasculitis. A kidney biopsy found diffuse pauci-immune necrotizing and crescentic glomerulonephritis with necrotizing arteriolitis and thrombotic microangiopathy. Surprisingly, an echocardiogram done pre-operatively and prior to the previous procedures was significant for a large ovoid, homogeneous mass in the apex of the left ventricle (Figure ). At the same time, she was noted to have decreased systolic function with an ejection fraction of 40% and was incidentally found to have a bicuspid aortic valve. Due to concern over her decreased cardiac function, the patient was started on milrinone for inotropic support.
+Cardiovascular Surgery was consulted for removal of the intracardiac mass since its location and pedunculated character placed the patient at significant risk for embolic complications. Prior to surgery, anticoagulation with aspirin (325 mg/day) was initiated, and a cardiac MRI was obtained to further analyze the mass and evaluate for other cardiac changes. MRI showed a pedunculated left ventricle mass (1.45 cm ? 0.95 cm), global hypokinesis, and depressed left ventricular function. Cardiovascular Surgery performed a sternotomy followed by resection of the mass via a trans-aortic approach. Intra-operative findings were notable for a 1.1 cm ? 0.8 cm ? 0.5 cm soft, tan-white, tissue mass adherent to ventricle trebeculations. An endomyocardial biopsy was also obtained. Pathology of the left ventricular mass showed necrotic tissue with acute inflammation consisting of neutrophils and eosinophils with absence of granulomas (Figure ).
+Following the operation, the patient had an episode of non-sustained ventricular tachycardia with manipulation of pacer wires that remained post-operatively. A follow-up echocardiogram on post-operative day two demonstrated low-normal left ventricular systolic function (shortening fraction 32%) and mild aortic and mitral valve regurgitation.
+Cyclophosphamide was continued at 1 mg/kg/day and methylprednisolone at 2 mg/kg/day. Trimethoprim/sulfamethoxazole was also added for Pneumocystis prophylaxis. Prior to discharge, the patient had no further cardiac issues and started to produce small amounts of urine but remained in clinical renal failure. After twenty-one days in the hospital, she was discharged home with plans for hemodialysis three days per week."
+Titus Padilla,45,1994/3/28,689.326.8881x57581,melissa85@example.org,653 Hernandez Circle Apt. 735,"We present a 37-year-old woman with previous history of arterial hypertension and terminal chronic renal failure of unknown origin on hemodialysis program for 1 year, who received a cadaveric kidney transplant in the right iliac fossa in 2002. The patient started immunosuppressive treatment with tacrolimus, mycophenolate, and prednisone. Four years after the transplant, a sonographic control revealed a 4.5 cm multilocular cystic mass in the lower pole of the renal allograph that suggested renal cell carcinoma (). A subsequent CT scan and arteriography confirmed the diagnosis (), and the extension study resulted uneventful. The functioning renal allograph showed basal creatinine levels of 1.7 mg/dL. Because of the size and eccentric location of the tumor, transperitoneal partial nephrectomy of the allograph was performed and ischemia was not necessary. The postoperative course was uneventful. Anatomopathological study revealed a clear-cell renal carcinoma with a 2.5 cm tubular and cystic growth pattern and Furhman nuclear grade II, with no signs of neoplastic infiltration either in peritumoral tissue, hilar or perirenal fat. Six years after surgery, there is no evidence of recurrent disease; renal function is similar to that found before surgery (creatinine 1.7 mg/dL), and modifications in the immunosuppressive treatment were not necessary."
+Maggie Cervantes,18,1985/11/3,474-536-6137,davidharris@example.com,217 Medina Plains Suite 963,"A 57-year-old male presented on June 29, 2011 with a five-day history of fever, headache, nausea, rash, and fatigue. The patient had no history of immunosuppression. He reported exposure to multiple ticks and mosquitoes while riding horses in South Dakota in early June 2011. On examination, the patient was afebrile, diaphoretic, and had left upper quadrant tenderness. Except for documented tinea versicolor on his trunk, no other rashes were present. The remainder of the physical examination was unremarkable. Laboratory results from serum collected at the time of presentation showed a mild leukopenia, acute renal failure, elevated liver transaminases, and elevated anti-SFGR immunoglobulin (Ig)G; initial testing for Q fever was negative (). The patient was treated with doxycycline for 14 days for the presumptive diagnosis of RMSF and subsequently recovered. However, convalescent testing on July 12 revealed that the patient experienced no subsequent increase in anti-SFGR antibody, while a significant increase in phase I and II anti-C. burnetii IgG occurred (). The patient was judged unlikely to have been a case of RMSF as there was no demonstrable anti-SFGR IgM and no change in IgG titers. However, the patient was laboratory confirmed as infected with C. burnetii as demonstrated by a four-fold rise in phase II IgG-specific antibody titer between acute and convalescent specimens."
+Kamari Knox,21,1999/2/10,580-373-6661,scottderek@example.net,569 Hull Ramp Suite 293,"A 26-year-old woman was diagnosed with breast cancer from biopsy of an axillary lymph node. An ultrasound () followed by an MRI of the breasts (Figures and ) were subsequently performed.
+The patient underwent annual breast ultrasound because of a family history of breast cancer. In addition, she had a history of multinodular goiter. By physical examination, it was also apparent that she had a relatively large head in relation to her length (length 170 cm and head circumference 61 cm, i.e., above 97th percentile). According to the patient, macrocephaly is a common feature in her family. Family history also revealed that the patient's mother had breast cancer at the age of 45. The patient's identical twin is known to have breast fibrocystic disease ().
+In , the ultrasound shows multiple, ill-defined hypoechoic areas with acoustic shadowing, indicating multiple coarse calcifications within the right breast. In , transverse T2-weighted magnetic resonance images show multiple coarse calcifications in both breasts and a large, lobulated mass in the lower lateral quadrant of the right breast. Contrast-enhanced subtraction MR images () and T1-weighted images () show a large, macrolobulated enhancing mass with irregular margins in the lower lateral quadrant of the right breast. Finally, her sister's mammography (mediolateral oblique direction shown) showed massive calcifications in multiple, well-defined masses, some of them with adipose tissue, diagnostic of hamartomas.
+Biopsy results showed that the patient had a locally advanced, invasive, well-differentiated ductal carcinoma in the right breast which was obscured on annual ultrasound due to massive calcifications by hamartomas.
+The radiological images, together with the thyroid pathology and macrocephaly, suggested Cowden syndrome (CS) as most likely underlying cause, which was later confirmed by identification of a germline splice-site mutation: c.634 + 2T > C in intron 6 of the PTEN gene. The mutation was inherited from the patient's mother.
+The patient was treated with neoadjuvant chemotherapy with a partial response, followed by a modified radical mastectomy and preventive contralateral mastectomy, and by locoregional radiotherapy (because of 5 positive axillary lymph nodes) plus adjuvant endocrine therapy."
+Kallie Jefferson,24,1986/11/4,001-549-269-1339,jsnyder@example.com,69381 Bell Ways,"A 38-year-old man with chronic lymphocytic leukemia and recently treated with four courses of chemotherapy, including rituximab, was hospitalized with fever and respiratory symptoms. Five days before admission, he developed fever (39簞C), odynophagia, chills, dyspnoea with wheezing, cough and sputum. The total immoglobulin G level in blood was low at 2.74 g/L (normal range, 6.06??3.18 g/L), as were the IgM (0.1 g/L; normal range, 0.29??.25) and IgA (0.17 g/L; normal range, 0.66??.99) levels. Despite intravenous wide-spectrum antibiotic and antifungal treatment, fever persisted together with diarrhea. The appearance of meningeal signs prompted a lumbar puncture that revealed a slight inflammation with six white blood cells/mm3, but normal protein and glucose levels. Microbiological investigations revealed a positive enterovirus RT-PCR signal in the lower respiratory specimens (BAL), plasma, cerebrospinal fluid (CSF), and stools. Viral culture was positive for enterovirus in the respiratory tract and stools. Additional extensive microbiological investigations were all negative for any other bacterial, fungal, or viral infections. Disseminated enteroviral disease was diagnosed and the clinical condition improved rapidly after immunoglobulins were infused. This infusion was followed by a clearance of the infection in blood as shown by a negative RT-PCR assay at day 7 after infusion without relapse or evidence of persisting enteroviral infection."
+Raylan Montes,34,1986/11/25,+1-962-657-6430x69427,smithdavid@example.net,5082 Lauren Rapids Suite 757,"A 15-year-old female with idiopathic scoliosis underwent an MRI of the cervical, thoracic and lumbar spine to rule out neural axis abnormalities. An ovarian cyst was identified together with an incidental non-specific cystic structure. Kidneys were unremarkable on Doppler ultrasonography, and the non-specific cystic structure seen adjacent to the descending colon with an overall benign appearance was interpreted as a duplication cyst of the small bowel. At this stage, the initial MRI was reviewed. Retrospectively, on this review, a left adrenal mass was detected, measuring 3 ? 2 ? 4 cm. A high-resolution CT scan was ordered that showed washout properties inconsistent with a benign mass but without evidence of cystic change or hemorrhage. Differential radiological diagnosis included ganglioneuroma, ganglioneuroblastoma, neuroblastoma or pheochromocytoma. Clinical investigation included hormonal studies to evaluate catecholamine excess by the assessment of plasma metanephrines and urinary catecholamines and a metaiodobenzylguanidine (MIBG) scintiscan, which were negative, ruling out pheochromocytoma. Urinary free cortisol and demonstration of a normal diurinal rhythm of cortisol secretion by the administration of the dexamethasone suppression test were also negative ruling out subclinical cortical functional tumors. A laparoscopic left adrenalectomy was carried out. Her recovery was uneventful, and she was discharged 48 h later.
+The left adrenal tumor was firm, tan, non-encapsulated and measured 3.5 ? 2.2 ? 2.4 cm in maximum dimension. On cross-sectioning, the mass was well demarcated with a stretched rim of normal-appearing adrenal tissue on either side (Figure ). On microscopic examination, the growth appeared to have expanded the medulla, causing compression of normal cortical and medullary tissue. The lesional cells were composed of Schwannian-like spindle cells with benign-looking nuclei and long stretched cytoplasm admixed with mature ganglion cells with well delineated cell borders, abundant eosinophilic cytoplasm and a large nucleus and nucleolus (Figure ). Some of the ganglion cells were multinucleated. Collections of benign lymphocytes were seen in neurotropic patterns of distribution along the clusters of the ganglion cells (Figure ). Scattered plasma cells with occasional mast cells were also seen. Evidence of hemorrhage, necrosis, mitotic activity and an immature embryonal component were not identified. Immunohistochemistry showed lesional cells to be strongly positive to S100 (Figure ), vimentin and neurofilament (Figure ). Though chromogranin was not expressed in the lesional cells, there was good internal control with positive staining in the medullary component of the residual adrenal gland. The final diagnosis was ganglioneuroma, with a Schwannian-stroma dominant mature subtype."
+Roselyn Short,38,1996/10/25,-6588,jason61@example.org,25675 Hernandez Throughway Suite 828,"A 28-year-old female who smoked half a pack of cigarettes a day with no significant medical history was being investigated for abdominal pain. A CT scan was ordered, which revealed a large left adrenal mass adherent to the kidney. Preoperative investigations including hormonal studies to evaluate catecholamine excess by the assessment of plasma metanephrines, urinary catecholamines and a MIBG scintiscan were negative, ruling out pheochromocytoma. Urinary free cortisol and demonstration of a normal diurinal rhythm of cortisol secretion by the administration of the dexamethasone suppression test were also negative ruling out subclinical cortical functional tumors. The larger size of the mass was highly suspicious for malignancy; therefore an open surgical intervention was planned. At surgery, via a left thoracoabdominal incision an en-bloc resection of the left adrenal mass was carried out including left nephrectomy, partial diaphragmatic resection with reconstruction and placement of a left thoracostomy. Postoperatively, the only significant complication was an asymptomatic left-sided pneumothorax that resolved spontaneously upon removal of the chest tube. She was discharged with an outpatient referral to the Cancer Center in 6 weeks. No further postoperative information is available for review in the current health record system.
+The gross specimen weighing 1,492 g consisted of the left kidney and adrenal gland, with portions of the diaphragm. A large 16.5 ? 13.5 ? 12.5 cm ragged, irregular, pale-tan rubbery multinodular mass with hemorrhage and necrosis was seen completely replacing the left adrenal gland with no residual normal tissue being identified. On microscopic examination, the tumor was surrounded by a pseudocapsule distinct from the adjacent renal parenchyma (Figure ) and composed of groups of pleomorphic cells (Figure ) with areas of necrosis, hemorrhage and perineural invasion (Figure ). Heterogeneity of the tumor was seen including tumor cells being arranged in sheets and storiform patterns with extensive fibrous spindled stroma in some areas (Figure ) and others with a myxoid background (Figure ). Proliferating cells varied from bland to highly pleomorphic with histiocytoid appearance to multinucleated giant cells with a wide range of cytological atypia including large bizarre cells, irregular nuclear contours, multiple prominent eosinophilic nucleoli, nuclear grooves and folds, rare atypical mitoses, and hyperchromatic cells with eosinophilic cytoplasm (Figure ). Typical features of benign smooth muscle tumors such as bland spindled neoplastic cells with cigar-shaped nuclei arranged in fascicles were not observed. The tumor was well demarcated from the adjacent renal parenchyma by a thick fibrous pseudocapsule as seen in Figure .
+Immunohistochemical examination showed the neoplastic cells to be strongly positive for vimentin and smooth muscle actin (SMA) (Figure ) with negative staining to Pan-Keratin, cytokeratin (CK)7, CK20 and high-molecular-weight keratin (HMWK) confirming a sarcomatous lineage. Rhabdomyosarcoma was excluded by negative staining to myogenin and desmin. S100 and other melanoma markers were also negative. P53 and Ki67 were moderately expressed in the lesional cells. In situ hybridization for Epstein-Barr virus was negative. A diagnosis of primary pleomorphic leiomyosarcoma was suggested due to the cells being strongly positive to SMA. The final diagnosis of high-grade primary pleomorphic leiomyosarcoma of the adrenal gland was confirmed with corroborative external consultation due to the rarity of this lesion."
+Hezekiah Jones,40,1988/8/24,2368645098,rhall@example.net,90626 Curry Mission,"The patient was a 27-year-old Japanese woman who had right hypochondrial pain and low-grade fever. She consulted a local doctor when these symptoms aggravated. Computed tomography (CT) and ultrasonography showed a large hepatic tumor, and she was referred to our hospital for further examination and treatment. She was healthy and had no remarkable family history. Laboratory studies showed a normal serum bilirubin level and elevated levels of aspartate aminotransferase (AST) (42 U/L), alanine transaminase (ALT) (48 U/L), alkaline phosphatase (ALP) (660 U/L), lactate dehydrogenase (LDH) (398 U/L), and 帠-glutamyl transpeptidase 帠-(GPT) (204 U/L). Tests for serum viral hepatitis markers for hepatitis B and C yielded negative results. The levels of tumor markers, including 帢-fetoprotein (AFP), protein induced by vitamin K absence-II (PIVKA-II), carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19??, and cancer antigen 125 (CA125), were within normal limits. Abdominal CT (Figure ) revealed a well-defined low-density large heterogenous mass (21 ? 19 ? 14 cm) in the right liver segments. Enhanced CT revealed vessels, septa, and variable degrees of cystic change in the tumor and the absence of a solid compartment and enhanced-effect around the tumor. These findings indicated the possibility of UESL or mesenchymal hamartoma. Since her right hypochondrial pain worsened and the tumor enlarged rapidly, we considered that it was most likely UESL on the basis of the clinical symptoms, laboratory data, and CT findings. Considering the rapid progressive nature of UESL, right trisectionectomy was performed for both diagnosis and treatment on the day after admission. The tumor weighed 3,370 g. The cut surface revealed a grayish-red soft mass with cystic degeneration and areas of hemorrhage and necrosis (Figure ). On microscopic examination, the tumor showed viscous, cystic, and grayish solid areas. The viscous area was composed of pleomorphic and polynuclear dyskaryotic cells in a myxoid stroma with focal eosinophilic globules (Figure ). The lumen in the cystic area had no epithelium. The grayish area was composed of myxoid stroma and atypical bile ducts and hepatic cord. Immunohistochemical analysis showed that the tumor did not express 帢-smooth-muscle actin (帢-SMA), desmin, myoglobin, human hematopoietic progenitor cell marker (CD34), cytokeratin 19 antibody (AE-1/AE-3), hepatocyte paraffin 1 (HEP-PAR 1), and AFP, but it showed focal expression of Ki-67 (index 35 %) and mostly expressed p53. The differentiation to muscle was not clear in hematoxylin-eosin staining and other immunohistochemical analyses. The surgical margin was free. On the basis of these findings, a pathological diagnosis of UESL was made. After surgery, the patient received two courses of vincristine, adriamycin, cyclophosphamide, and actinomycin D (VADRCA) + cisplatin (CDDP) in accordance with the findings of The Third Intergroup Rhabdomyosarcoma study IRS-III [] (Table ). After the first course, the patient underwent a high-dose etoposide regimen for extraction of peripheral blood stem cells [] (Table ). During the second course, she received additional radiation therapy to remnant liver (Table ). After the second course, she received ranimustine, carboplatin, etoposide, cyclophosphamide (MCVC) therapy and underwent peripheral blood stem cell transplantation [] (Table ). Follow-up imaging studies, including a whole-body CT scan and positron emission tomography (PET), showed no evidence of recurrence of the disease. She was healthy at the follow-up examination conducted 60 months after the surgical treatment."
+Sophia Cisneros,42,1993/12/9,-3576,charlesholloway@example.org,877 Brianna Mission Apt. 111,"A 69-year-old Latino man was seen for urgent consultation in the outpatient Hepatology Clinic for evaluation of new onset jaundice and substantially elevated liver enzymes associated with nausea and extreme malaise that developed three weeks prior to presentation. The patient? past medical history was notable for type 2 diabetes mellitus, hypertension and tobacco abuse. He had no known diagnosis of chronic liver disease prior to the onset this illness. The patient was a widower and retired foreman of a starch plant who endorsed a greater than 25 pack-year smoking history and an alcohol history of 1?? cans of beer per week, on average. His last drink was one month prior to the onset of the current illness. He had a history of tattooing as a teenager, but denied history of recreational drug use and denied any non-prescription or herbal supplement use. His family history was significant for both diabetes and coronary artery disease; there was no known family history of liver disease.
+The patient was in his usual state of health and feeling quite well when he presented to his primary care provider for a routine health maintenance check-up approximately 3 weeks prior to presentation in Hepatology Clinic. At that time, the patient was counseled regarding the health benefits of smoking cessation, particularly given his known history of diabetes and hypertension. The patient was receptive to smoking cessation intervention and was prescribed varenicline 0.5 mg orally once daily, which he began taking four weeks prior to his presentation in Hepatology Clinic. The patient also continued on his long-term chronic medications that included: metformin 850 mg orally twice daily, aspirin 81 mg orally daily, valsartan 80 mg orally daily, and sildenafil 50 mg orally daily as needed. Five days after starting the varenicline, the patient developed new onset nausea, vomiting, decreased appetite, weight loss and extreme malaise. The patient? son noticed yellowing of his father? eyes and prompted him to seek immediate medical attention. Given these symptoms, the patient discontinued the varenicline on his own at day 5. The patient was seen by his primary care provider approximately two-and-a-half weeks after starting the varenicline. Liver chemistries performed at that time revealed the following: aspartate aminotransferase (AST) = 1191 U/L, alanine aminotransferase (ALT) = 1592 U/L, alkaline phosphatase (Alk Phos) = 254 U/L, total bilirubin (TBili) = 12.0 mg/dL, INR = 1.3, platelets = 289 x 106 cells/mL and serum creatinine = 1.0 mg/dL. His INR was mildly elevated at 1.3 and serum albumin was normal at 4.0 g/dL. Hemoglobin and white blood cell counts were within normal limits. No peripheral eosinophilia was noted. Acetaminophen and alcohol levels were undetectable. Viral hepatitis serologies were negative for hepatitis A (HAV) IgM, hepatitis B (HBV) sAg, and HBc IgM. Hepatitis C (HCV) Ab was noted to be positive. As the patient had no known antecedent history of abnormal liver enzymes, he had never previously been tested for HCV. A CT scan of the abdomen revealed a normal appearing liver without any evidence for cirrhosis or biliary ductal dilation or hepatic masses. Hepatic artery, hepatic veins and portal veins were all patent. Magnetic resonance cholangiopancreatography (MRCP) was also performed and was negative.
+Due to the significant hepatitis and hyperbilirubinemia, the patient was seen urgently in our Outpatient Hepatology Clinic, marking approximately three weeks after the onset of symptoms. At the time of the visit, the patient continued to complain of significant nausea, vomiting, poor appetite, 10-pound weight loss, dark urine and persistent jaundice. He continued to abstain from the use of varenicline. On physical examination, the patient was 5????tall and weighed 125 pounds. He had prominent bilateral scleral icterus and jaundiced skin. No skin rashes or lymphadenopathy were noted. Abdominal exam was unremarkable, without distention, tenderness or hepatosplenomegaly. There were no classical stigmata of chronic liver disease. Repeat laboratory studies were performed at the time of the Hepatology consultation and revealed the following: AST = 334 U/L, ALT = 515 U/L, T Bili = 18.1 mg/dL, INR = 1.2, Albumin = 3.3 g/dL and Alk Phos = 137 U/L. HCV genotype was 1a with HCV RNA level of 55,100 IU/mL. HIV testing was negative. Further laboratory testing demonstrated that the patient was negative for HBV DNA, anti-nuclear antibody, anti-smooth muscle antibody and anti-mitochrondrial antibody. Immunoglobulin and thyroid stimulating hormone levels were normal and alpha-1-antitrypsin phenotype was MM. Testing for hemochromatosis and celiac sprue were negative. Evaluation for other acute viral infections, including herpes simplex (HSV)-1 and ??, Epstein Barr virus (EBV) and Cytomegalovirus (CMV) were negative.
+Approximately two months after stopping the varenicline, the patient? AST, ALT and Alk Phos had normalized with near-normalization of the T Bili. (Figures and ) He reported a substantial improvement in his health status and normalization of his activity levels with resolution of the nausea, vomiting, fatigue and jaundice, and a return of his appetite. A percutaneous liver biopsy was performed at this point with the goal of grading and staging the patient? HCV and demonstrated changes consistent with chronic HCV, grade 2, stage 2 disease. Also noted, however, were focal lobular aggregates of pigmented Kupffer cells suggestive of more recent and significant hepatocyte injury, correlating well with the patient? clinical history. The patient was instructed never to rechallenge himself with varenicline and to report it as a medication adverse reaction in the future."
+Alden Clark,26,1990/7/31,-3231,joseph87@example.org,8007 Brooks Burgs,"Patient 1: A 13 year old girl was seen by her primary care physician because she was feeling cold and tired. She had a total T4 of 14.2 nmol/L and a TSH of 468 mIU/L. Endocrinology was not consulted because the mother refused to have her started on treatment until the tests were repeated, which was done 6 weeks later. At this time, her T4 had increased to 86.4 nmol/L and her TSH had decreased to 17.8 mIU/L(Table ). The author was then consulted and the mother insisted she had not taken any thyroid hormone. As the thyroid tests had improved considerably, it was decided to hold off on treatment until they were repeated. It is of note that the non-identical twin sister had also been diagnosed with hypothyroidism 7 months earlier when she had a goiter but no obvious symptoms of hypothyroidism, a free T4 of 0.65 pmol/L and a TSH of 915 mIU/L.
+When seen 2 months after initial testing, the patient reported that her energy level had improved, and her exam was normal except for a small goiter. There was no history of exposure to high levels of iodide or any goitrogen. She now had a normal free T4 of 15.5 pmol/L, a somewhat low TSH of 0.21 mIU/L, and positive thyroid peroxidase (TPO) antibodies. She was seen back 7 months later at which time her total T4 was 73.5 nmol/L, TSH had increased to 4.3 mIU/L, and the gland was no longer obviously enlarged. At follow-up 9 翻 months later, she had no reported symptoms of hypothyroidism but her gland had enlarged and her low T4 of <6.5 nmol/L with TSH 262 mIU/L indicated that she was again hypothyroid. The patient and mother insisted that she had not taken any of her sister? l-thyroxine during the 1.5 years she was euthyroid.
+Since one sister? severe hypothyroidism had resolved, the mother requested that her non-identical twin sister be given a trial off thyroid hormone after she had been on treatment for 18 months. After 1 month, the free T4 was low at 5.2 pmol/L (11.6-20.6), TSH 77 mIU/L, and TPO antibodies were 528 units/ml. Compared to her initial tests, this indicated only a partial recovery of thyroid function, so she was restarted on l-thyroxine."
+Chloe Sanchez,22,1989/7/5,360.801.1840x768,ashleygallagher@example.com,3620 Tiffany Spring,"A 4-year-old boy, suffering from recently developed multiple spontaneous bone fractures referred to Nemazee Hospital, Pediatric Center, for a precise diagnosis of the causes and management. The patient had developed a spontaneous right tibial fracture, proceeding by right femoral, nasal and finger fractures in a 1.5-month period (). In addition, a generalized osteoporosis was obvious in X-rays of ribs, humerous and vertebral bones, also the X-rays revealed tibial fracture (in the right side) and femoral bone fracture in the same side, in addition right iliac fracture was observed.
+Also the patient had a history of anorexia, nausea, pallor, disseminated bone pain, abdominal distention and severe generalized edema since 7 days prior to this admission. Pallor, generalized petechial lesions all over his body and face, huge peripheral lymphadenopathies (each one 4*3 cm ), a mild splenomegally, and a grade 4/6 systolic heart murmur with radiation to the left side of his chest wall were the remarkable points in physical examination. Growth percentiles of the patient were all in normal ranges.
+Complete blood count (CBC) showed, white blood cells (WBC) 1.8?103/繕l with 80% lymphocyte and 20% neutrophil, red blood cells (RBC) 2.7?106/ 繕l, platelet count (Plt) 90?103/繕l, hemoglobin (Hb) 6.4 gr/dl and erythrocyte sedimentation rate (ESR) 146 mm/hr. Other abnormal tests were urine calcium level 18.1 mg/dl, Ca 9.3 mg/dl, P 4.1 mg/dl and Alk-ph 1500 IU/L.
+Bone marrow aspiration was done and showed a hypocellular marrow containing more than 90% lymphoblasts and immunophenotyping showed B-cell ALL.
+B-cell ALL induction chemotherapy was started as follows: Prednisolone, vincristine, asparginase, daunorubicin, methotroxate and cytosin arabnoside. The patient developed complete remission. Then it has been a maintenance therapy as well as two courses of consolidation therapy. According to type of fractures (green stick) any workups for management of fractures not done for him. In follow up X-rays, callus formation was seen."
+Joseph Adams,28,1998/12/31,862-339-1816,sherryhicks@example.com,2704 Hart Creek Suite 320,"A 50-year-old female patient presented with complaints of urinary frequency and dysuria. She also complained of occasional episodes of suprapubic pain. There was no history of hematuria, graveluria, or fever. Past history of the patient revealed that she had undergone dilatation and curettage after her last pregnancy at her native place followed by insertion of an intrauterine copper T device. This was 18 years back. She had no symptoms related to the reproductive system thereafter. The patient had completely forgotten about the intrauterine device since insertion.
+Abdominal examination revealed tenderness on deep palpation over the suprapubic region. Per vaginal examination was normal and did not reveal any abnormality. Per rectal digital and proctoscopic examination did not reveal any abnormality. Hematological investigations were within the normal limits. Urine examination revealed abundant pus cells and microscopic hematuria. Plain X-ray revealed a calculus in the region of the bladder, measuring approximately 3 cms in length and 1.5 cms in breadth. At one end of the calculus, the horizontal limb of the device was seen connected to the vertical limb around which the calculus had formed (). USG examination confirmed the presence of the calculus in the bladder which was fixed as it did not exhibit any mobility within the bladder. The patient was given a course of urinary antibiotics to control the infection and then subjected to surgery. A preliminary cystoscopic examination was performed. It was observed that the stone was firmly fixed to the postero superior wall of the bladder. In view of the fixity of the stone, an open suprapubic cystolithotomy was performed. The stone was partially impregnated into the bladder musculature by virtue of the horizontal limb of the device (). The stone along with the projecting horizontal limb was carefully removed (). The partial breach in bladder musculature caused by the impalement of the foreign body (device) was sutured with an absorbable suture material. The bladder was closed with absorbable suture material. Postoperative recovery was uneventful."
+Stella Cabrera,41,1978/9/2,-6175,roylin@example.com,6905 Taylor Rest Suite 671,"We present a case diagnosed with ruptured subcapsular liver hematoma and Purtscher-like retinopathy in a patient with postpartum HELLP syndrome.
+A multiparous (pregnancies 8 and deliveries 3) pregnant woman aged 44 is admitted at 34 weeks of gestation in the emergency room at a city hospital for lack of fetal movements, painful uterine contractions, and headache. Obstetrical examination reveals a dead fetus. The patient presents 180/125 mmHg blood pressure, proteinuria (4 g/dL), and bilateral leg edema and is diagnosed with severe preeclampsia. The patient is given intensive antihypertensive treatment, but blood pressure remains elevated (160/110 mmHg).
+A few hours later, the patient spontaneously gives birth to an 1100 g dead male fetus. Postpartum, despite intensive antihypertensive treatment, blood pressure remains elevated (160/120 mmHg) with a heart rate of 130 beats/min and general pallor. Shortly after fetal expulsion, the patient begins to experience acute pain in the right upper quadrant irradiated towards the right shoulder as well as signs of severe anemia. Lab analysis confirms severe anemia (Hb = 7.63 g/dL, Ht = 23%), elevated liver enzymes (AST = 418 U/l, ALT = 596 U/l), and thrombocytopenia (Plt = 110.000/mm3). The patient is sent to a higher degree hospital with the clinical suspicion of HELLP syndrome and hepatic subcapsular hematoma for further investigation and appropriate therapeutic conduct.
+Patient's condition worsens, with intense pallor, severe anemia (Hb = 5.3 g/dL, Ht = 16%), decreasing platelets (Plt = 90.000/mm3), increased liver enzymes (AST = 578 U/l, ALT = 732 U/l), elevated lactate dehydrogenase (600 U/l), and total bilirubin (BT = 3.5 mg/dL). Clinical examination reveals a distended and painful abdomen, with signs of peritoneal irritation and positive Mandel sign.
+Emergency abdominal ultrasound examination identifies heterogeneous liver structure with a 9/5 cm hypoechoic lesion in the right lobe, suggestive for a subcapsular hematoma and moderate quantity of perihepatic fluid in the Morrison宎s space and Douglas宎s pouch (). The next examination performed after 15 minutes describes enlargement of the subcapsular hematoma image (12/7 cm) as well as the volume of the Morrison宎s and Douglas宎s space fluid ().
+Along with the alteration of the patient condition, she accuses loss of visual acuity and, consequently, an eye examination is performed. Eye examination reveals diminished visual acuity in both eyes: 0.05?ight eye and 0.1?eft eye. Intraocular pressure: 17 mmHg?ight eye and 18 mmHg?eft eye. Pupillary light reflexes are present bilaterally with a normal anterior pole. Fundus examination describes similar changes bilaterally: papillar edema with blurred papillar contour, various sizes of peripapillar cotton wool exudates along the vascular temporal arcades, mild retinal edema, and normal peripheral retina (). The diagnosis is Purtscher-like retinopathy.
+Patient's general condition continued to worsen, and she has clinical signs of hemorrhagic shock: dizziness, intense pallor, cold extremities, low blood pressure (80/55 mmHg), sinus tachycardia (HR = 130/min), weak peripheral pulse, and vomiting. Emergency exploratory laparotomy is consequently performed, finding an important amount of blood in the peritoneal cavity (1500 mL) and a large ruptured liver hematoma occupying the entire diaphragmatic surface of the right liver lobe, which is evacuated (1000 mL blood clots) followed by surgical haemostasis with collagen patches and perihepatic drainage associated with intensive fluid replacement, as well as blood and fresh-frozen plasma transfusions.
+Postoperatively, the patient's condition gradually improved, with no further complications. She was discharged after 16 days of follow up. Ultrasound control at discharge showed a normal-sized liver with homogenous structure without pathologic processes. Patient's visual acuity progressively improved during hospitalization (0.2?ight eye and 0.3?eft eye at discharge), and the eye examination before discharge revealed diminished papillar edema and exudates bilaterally."
+Cade Shields,42,1981/10/24,001-964-833-1717,daisymiller@example.org,276 Johns Mews,"A 27-year-old male patient presented with a swelling on the right side of the back of two week duration. The mass was 4 ? 4.5 cm in size, soft in consistency, and was in the subcutaneous plane. It was not associated with pain. The clinical diagnosis was that of a lipoma. FNAC was done using 22 G needle and 10 mL syringe. Aspiration yielded straw colored clear fluid. The smears were air dried as well as wet fixed in 95% ethyl alcohol and stained with May Grunwald Giemsa, haematoxylin, and eosin and Papinicolaou stains.
+On cytology, fragments of bluish fibrillary material with interspersed small nuclei were seen (). Thick blue spherules within the substance of the fibrillary material gave a honeycomb appearance. Mixed inflammatory cells consisting of neutrophils, eosinophils, lymphocytes, and histiocytes were seen surrounding the fibrillary material. A diagnosis of parasitic material was offered on cytology. This material was excised and sent for histopathological examination. The parasite cysticercus cellulose was seen in the tissue section with extensive mixed inflammatory cell infiltrate in the surrounding tissue (). A final diagnosis of subcutaneous cysticercosis was made. The patient also received oral antihelminthic therapy and is doing well."
+Analia Fleming,39,2000/3/11,267-268-8672x3615,brianandersen@example.net,9158 Collins Parkways Suite 530,"A 74-year-old woman presented initially to a hospital with a 3-week history of abdominal pain, anorexia, and weight loss of 5 kg over 3 months. As abdominal computed tomography (CT) scan showed a cystic lesion in the pancreatic head, she was referred to our university hospital with the diagnosis of pancreatic head carcinoma. She denied fever, chills, nausea, vomiting, and diarrhea. On admission she was afebrile. On physical examination she had mild tenderness in the right lower quadrant. Her medical history was unremarkable. She had an uncle who had been treated for TB. Laboratory tests showed an elevated erythrocyte sedimentation rate (111 mm/hr, 2 < normal value < 16 mm/hr), serum CA125 level (83 U/mL, normal value < 35 U/mL), and serum sIL-2R level (1706 U/mL, 127 < normal value < 582 U/mL). She had a positive tuberculin skin test and a positive QuantiFERON-TB-2 Gold (Cellestis) result. Though chest X-ray was unremarkable, chest CT scan revealed a swollen hilar lymph node (8 mm). Abdominal CT scan showed multiple enlarged peripancreatic lymph nodes (arrows), concentric thickening of the ileocecal wall, and several segmental lesions of the ileum (), but pancreatic mass was absent. Esophagogastroduodenoscopy was unremarkable. Colonoscopy demonstrated deformed and edematous ileocecal valve with erythema () and a tiny erosive nodule near the appendiceal orifice (). Histopathological examination of the nodule disclosed epithelioid granulomas (). Though polymerase chain reaction (PCR) of the biopsied specimen was negative, culture was positive for Mycobacterium tuberculosis.
+Laparoscopic biopsy of the abdominal lymph nodes was performed to exclude other diseases, including pancreatic neoplasm and malignant lymphoma. Laparoscopy revealed numerous white tubercles diffusely covering the parietal peritoneum (). Biopsies from the ligamentum teres hepatis and peripancreatic enlarged lymph nodes were obtained. Histopathological images of the former specimen revealed multiple epithelioid granulomas around fatty tissue. The latter contained liquefied necrotic material, and histopathological examination demonstrated large multiple caseating granulomas surrounded by Langhans' giant cells and epithelioid cells with infiltration of inflammatory cells (). PCR and culture of the specimen were positive for M. tuberculosis. The organism was susceptible to isoniazid, rifampin, pyrazinamide, and ethambutol. On the basis of these findings, tuberculous lymphadenopathy, colitis, and peritonitis were finally diagnosed. Her symptoms improved after a few days of a four-drug regimen of antitubercular treatment. She remains well after six months of the treatment."
+Fernando Drake,42,1991/4/19,(633)370-8998x96481,sjohnson@example.org,20646 Larry View,"A 62-year old woman with 14 years of primary progressive MS has been wheelchair-bound for eight years and suffered from severe neuropathic pain in the upper arms and in the left foot. The pain was characterized by pricking, tingling, numbness, and sometimes electric shocks. The average pain score, 8 on the 11-point numerical rating scale (NRS), was reduced to 6 after the usage of oral pregabalin 450 mg daily. On previously prescribed oral amitriptyline 40 mg daily she experienced intolerable adverse events, such as continuous drowsiness and tiredness. Her other complaints, such as urine retention, constipation, and spasms were successfully treated with solifenacin, polyethylene glycol, and baclofen, respectively. In May 2010, while on pregabalin treatment, the patient developed a severe burning pain in her left foot, scoring 9 on NRS. The patient also experienced electric shocks and could not bear the contact with bed sheets (allodynia).
+We prescribed topical amitriptyline 5% cream to apply 3 mL once daily to the painful foot. Thirty minutes after application the patient did not experience allodynia anymore. However, when the initial pain score was higher than 5 on NRS, the burning pain was only partially reduced. Therefore, we prescribed amitriptyline 10% cream, which relieved the burning pain completely (from 9 to 0 on the NRS) already 10 minutes after each application. The relief lasted the entire day. The patient reported tiredness, as the only adverse event of the topical amitriptyline 10% cream, but even this symptom disappeared in two weeks.
+In order to determine whether pain alleviation was due to topical or to systemic effect, we suggested distant application. After application to the nonpainful foot, analgesia could also be observed in the painful foot, although 15 minutes later. Due to her physical impairments the patient was not able to apply the topical amitriptyline to her painful foot. Therefore, we advised her to apply topical amitriptyline cream to her inner forearms, which turned out to have the same effect as direct application to the nonpainful foot. Also the pricking and tingling neuropathic pain in her upper arms and her left leg responded to the topical amitriptyline 5% cream, though only partially. Then however, direct application of amitriptyline 5% cream, once a day on her upper arms and her left foots reduced this pricking and tingling pain from 8 to 0 on NRS during the second day.
+To further inquire into the magnitude of the placebo response, we designed a double blind placebo controlled crossover n-of-1 study, comparing topical placebo cream to amitriptyline 5%. The compounding pharmacist blinded the two creams in two separate tubes, and named the creams A and B, respectively. Successful treatment was defined based on the following criteria:relevant clinical pain reduction measured on NRS, successfully unblinding the treatment, no or minimal need to use escape medication.
+The instruction was to apply once daily 3 mL cream to the arm from one tube during one week, with an escape possibility of amitriptyline 10%, and to alternate the tubes every week following the pattern ABAB. The result was that the pain disappeared after application of cream B, while most of the time cream A did not reduce the pain. The patient could correctly unblind both creams, determining B as active. She noted that in the week of using the active cream no allodynia was present, with a carryover effect of one day. She did not need to use the escape medication in the week of using the active cream, though she used frequently escape medication in the placebo weeks, especially when the pain scores were above 4 on NRS. As a matter of fact, the patient could correctly identify the active cream as 5%, based on her previous experiences with both 5% and 10% creams. Furthermore, the patient did not experience any adverse events."
+Jayleen Newton,30,1982/3/5,(402)469-7967x8663,randall33@example.org,1356 Trujillo Branch,"A 38-year-old male patient presented with left testicular pain and swelling. His past medical history was unremarkable. However, he had similar complaints which also included intermittent swelling for almost 1.5 years, and during this period he received many medications for recurrent epididymitis.
+Previous imaging findings and serum tumor marker values obtained elsewhere were within normal limits. Physical examination was completely normal on his initial visit in our department, upon which he was recommended to present while he has the scrotal swelling again. The patient represented 1 month later with a significant, soft, noninfectious swelling on the left hemiscrotum, suggesting reactive hydrocele formation. Left epididymis was minimally dilated and sensitive upon palpation.
+Scrotal ultrasonography demonstrated findings related to hydrocele and left epididymitis. Testicular parenchyma was devoid of any ultrasonographic abnormality. Blood and urine tests, including serum tumor markers, were again within normal limits.
+Based on these findings, he was scheduled for left hemiscrotal exploration, during which, inflammatory tunical layers together with caput epididymis, which seemed dilated and inflamed, were excised and sent to pathology. Postoperative course was uneventful. He was discharged the following day. Histopathological examination of the excised specimen revealed normal findings for epididymis but epitheloid-type paratesticular mesothelioma () originating from tunica vaginalis to everybody's surprise. Neoplastic mesothelial cells were characterized by higher nucleus/cytoplasm ratio than normal cells, prominent nucleoli and eosinophilic cytoplasm (). Diffuse expression of cytokeratin 5/6 and calretinin () by the tumor cells as well as the muscle infiltrative properties of the neoplastic mesothelial cells in deep submesothelial lamina propria confirmed our diagnosis of malignant mesothelioma, which measured 3 mm on its maximum diameter.
+After consulting the case with medical oncology and radiation oncology departments, we decided to perform left radical orchiectomy and hemiscrotectomy as a complementary procedure. Chest and abdominal computed tomographies (CT) as well as positron-emission tomography (PET) scans were all negative. After the second operation, he was hospitalized for 6 days due to the development of left hemiscrotal hematoma, which was managed conservatively. Pathological examination of the specimens removed during the second operation confirmed the diagnosis of malignant paratesticular mesothelioma originating from the tunica vaginalis.
+Although he was offered active surveillance, he asked for a second consultation in an urooncology center elsewhere, at which he was recommended to have a diagnostic laparoscopy to exclude any lymphatic spread after having confirmed the histopathologic diagnosis of paratesticular malignant mesothelioma by second opinion. He had the procedure where all biopsies taken from pelvic lymph nodes were found to be negative. He was then given no additional treatment.
+The patient is still under our close followup, and he is disease-free for 26 months."
+Santino Watkins,37,1997/1/13,669.244.7463,kathyrodriguez@example.net,73153 Tracy Summit,"A 32-year-old married female, educated up to intermediate of arts, employed as a primary school teacher, presented to psychiatry outpatient clinic of a teaching hospital with complaint of frequent unresponsive spells for last 7 years. The first attack occurred during the third trimester of her first pregnancy and subsequently had 3-4 episodes in 2-3 days. The unresponsive spells were characterized by stretching and twisting of bilateral upper and lower limbs for 10??5 minutes, associated with extension of neck, closing of eyes and spontaneous gain of consciousness. The spells occurred only in presence of family members, not during sleep. There was no history of physical injury, tongue bite, and incontinence. With Phenytoin 300 mg started from a private practitioner, the spells were still occurring 2-3 times in 6 months and hence, she stopped medicine by herself. Surprisingly, no such spells were noticed for next 2 years. She had similar 3-4 episodes again during the third trimester of the second pregnancy 5 years back. She did not receive any treatment then. During both the first and second pregnancies/deliveries, she did not have constitutional symptoms or infections, antenatal checkups were done with routine investigations which were reported verbally by patient/family to be normal and deliveries were uneventful. There were no such episodes for next 4 years.
+Since the last year, the unresponsive spells were occurring again but were different in presentation and characteristics from previous spells. These spells lasted for 3?? minutes and occurred also during sleep. Her husband noticed that patient did not get up even on vigorous shaking during such a spell whereas she would be easily arousable from normal sleep. During these spells, she would remain unresponsive and her body would be lax without movement of any type, unlike before. She would feel weak or experience heaviness of head on subsequent day for variable hours. There was no history of other sleep-related problems. Such episodes were occurring more frequently in last 3-4 months. With medical consultation and video EEG, an impression of ?eneralized epileptiform discharges??was made, and she was advised Levetiracetam 750 mg/day in a seizure specialty hospital of a private setup. It was gradually increased up to the dose of 2250 mg over a period of 3 weeks (with the target dose 3000 mg).
+After about 24 hours of consumption of 2250 mg in the 3rd week of initiation of Levetiracetam, the patient started hearing the sound of saw cutting wooden blocks which other people nearby did not hear. The sound was high-volume, continuous, and distressing. It was so intolerable to the patient that she would be restless and felt as if her head was tearing apart. She tried to cover her ears but it did not decrease the intensity of the sound and the sound would begin or terminate for a while in between, with no control of her over it. The sounds were heard equally in both ears in a full conscious state. Besides this hallucination, no other psychotic or mood symptoms were noticed. After 3 days of such a continuous distressing experience, the same treating physician was consulted who instructed to decrease Levetiracetam to 1500 mg. The hallucination disappeared but the seizure continued with same frequency. Because of such a distressing experience and continuing seizure spells, the patient was brought to psychiatry outpatient clinic of B P Koirala Institute of Health Sciences, a teaching hospital in eastern Nepal.
+There was no report of perceived stressor preceding current exacerbations. She did not have past history of any significant head injury, CNS infection, or psychiatric including psychotic disorder including problematic substance use. They did not remember any close blood relatives suffering from similar illness or other mental disorders. General and systemic examination then, including neurological examination revealed no abnormality. Her weight was 55 kg and height 5???聆€? The MRI scan of brain (done in the private hospital and the repeat assessment) revealed normal finding. After a detail assessment, an impression of ?eizure disorder with history suggestive of Levetiracetam-induced hallucination??was made. Sodium valproate was advised with the target dose of 1000 mg with which she was seizure free till the latest followups of its 9 month treatment."
+Lola Beard,42,2004/12/3,+1-986-604-3959x835,susan10@example.com,655 Linda Mission Apt. 787,"A 27-year-old Greek male patient was presented to the outpatient clinic of the Pulmonary Medicine Department of our hospital due to relapsing episodes of fever spikes (up to 38.7簞C) accompanied by general fatigue and discomfort. He was initially treated with a course of oral antibiotics (b lactam plus macrolide) with poor clinical response. He was then transferred to our department for further evaluation. He reported a hospitalization 2 years ago due to fever of unknown origin, which subsided after a short course of high doses of corticosteroids. Nonetheless, he failed to recall any further details regarding the etiology of his hospitalization. He was a current light smoker (5 pack-years) and reported no exposure to illicit drugs, environmental, and occupational allergens or toxic fumes, chemicals, and dust. On physical examination, he was febrile with general fatigue and discomfort; however, he reported no dyspnea, tachypnea (respiratory rate 12 breaths/min), or palpitations (heart rate within normal range-70 bpm). He had no hypoxaemia (partial pressure ofoxygen 84 mm Hg) on arterial blood gas analysis. He had no clubbing, skin lesions, cervical lymphadenopathy, or joint swelling. Auscultation of the lungs mild end-inspiratory crackles in both lower lung zones. Cardiovascular, abdominal, and neurological system examinations were unremarkable.
+Laboratory tests were performed and divulged microcytic iron deficiency anaemia (Hct: 35.9%, Hgb: 11.9 g/dL, MCV: 69.7, Fe: 19 mg/dL). Ferritin, B12, and folic acid levels were within normal range. The erythrocyte sedimentation rate was 65 mm繚h??. The rest of the physical examination and routine laboratory tests, including white blood cell count and differential, red blood cell count, liver and renal function, and serum C-reactive protein, were normal. Gross and microscopic urinary analysis revealed neither hematuria nor renal red blood cell casts, while his 24-hour urine protein levels were within normal range (60 mg/dl). His chest X-ray showed alveolar infiltrates in both lower lobes. Patient was then commenced on intravenous course of broad spectrum of antibiotics (piperacillin/tazobactam plus moxifloxacin) coupled with oseltamivir 75 mgr twice daily, which was discontinued three days after the sputum smear was negative for H1N1.
+Laboratory tests for collagen vascular disease and vasculitis, including antinuclear (ANA), antiextractable nuclear antigens (ENA), antineutrophil cytoplasm (ANCA), and antiglomerular basement membrane antibodies, were also negative. The tuberculin skin test was negative. His HIV test was also negative, while his hepatitis B and C antibody titers were within normal range. The patient had a positive Mayer stool test for erythrocytes raising a suspicion for inflammatory bowel disease, but his further gastrointestinal workup (gastroscopy and colonoscopy) excluded any source of bleeding. In particular, gastroduodenal biopsies were performed and findings were inconsistent with both inflammatory bowel disease and malignancy as well as celiac disease. Regarding the latter specific antibodies against transglutaminase (ATA), both IgA and IgG isoforms were also negative.
+Pulmonary function tests (PFTs) were performed and showed normal FVC (91%), FEV1 (92%), and FEV1/FVC ratio (84.1%) and a strikingly elevated DLCO (120% of the predicted normal value) indicative of alveolar hemorrhage.
+Patient was then subjected to high-resolution computed tomography (HRCT) showing diffuse bibasilar ground-glass opacities consistent with alveolar hemorrhage (). Diagnosis of DAH was confirmed by BAL demonstrating increased numbers of hemosiderin-laden macrophages (>40% of total number of macrophages). BAL fluid specimens were negative for routine bacterial, mycobacterial, fungal, and viral as well as Pneumocystis stains and cultures. Due to the patient's continuously worsening clinical condition (onset of dyspnoea, ESR and CRP increase to 187 mm/h and 15.91 mg/L, constant decrease of haemoglobin levels), a VATS biopsy from the right middle lobe was employed to address the cause of the alveolar haemorrhage. Extensive pathologic evaluation of the lung specimen divulged hemosiderin-laden alveolar macrophages and absence of any specific pathology such as granulomas or evidence of vasculitis/capillaritis. Immunofluorescence microscopy of frozen tissue samples, using a panel of antibodies against complement and immunoglobulins was without notice of immune complexes that would drive a diagnosis towards a specific cause. Taking into consideration the above data, we came up with the diagnosis of IPH.
+Treatment with high doses of oral prednisone (0.75 mg/kg of weight) as a monotherapy was adopted for 6 weeks and gradually tapered to 0.5 mg/kr for another 6 weeks and 20 mgr for another 6 weeks leading to a profound improvement of symptoms (dyspnoea) as well as imaging and laboratory findings including complete resolution of bilateral areas of ground-glass opacities () as well as a significant incline of his haemoglobin levels and decrease of his CRP and ESR titers, respectively. The patient is now followed for almost 3 months, on an outpatient basis, in good clinical condition, free of disease relapses, afebrile, and hemodynamically stable on 10 mgr/day of oral corticosteroids. Due to high incidence of relapses, the patient is under close monitoring."
+Nathanael Carroll,34,1987/7/29,849.440.1380,wallison@example.com,9806 Deborah Island,"A 62-year-old Hispanic man with no prior history of gastrointestinal problems presented for a routine endoscopic examination. He had no family history of colorectal cancer or polyps. He had a polyp 30 cm from the anal margin that was removed through open polypectomy and rectoscopy.
+Macroscopically, the specimen was a 5 ? 3.5 ? 2 cm sessile polyp with a reddish, villous surface and a 4.5 ? 2 cm implantation base. The tissue was fixed in 10% formol, embedded in paraffin, cut at 4 弮m, and subsequently stained with hematoxylin and eosin.
+Microscopically, at low power the specimen was a traditional serrated adenoma (TSA) of colonic mucosa (sigmoid) with exuberant, villiform growth pattern and complex serration. High power examination disclosed eosinophilic pencillate cells, numerous ectopic crypts and low-grade epithelial dysplasia. (Figures and ) The fibrovascular axes showed numerous lymphangiectasias. In one of the axes a single small focus of stromal osseous metaplasia consisting of normal-looking osseous trabeculae with peripheral retraction and hemorrhage was detected. No characteristic was identified (chronic or active inflammation, ulceration, hyalinization or mucin extravasation) that would suggest a traumatic or ischemic process (Figure )."
+Zara Lloyd,34,1982/7/2,332.598.0754,belindakim@example.net,303 Cruz Point Suite 974,"A 75-year-old Caucasian woman reported a three-month period of general constitutional decline with the onset of vertiginous symptoms and vomiting one week prior to attending our emergency department. She had been living independently. Her medical history included paroxysmal atrial fibrillation treated with amiodarone and warfarin, hypertension controlled with metoprolol and irbesartan/hydrochlorothiazide, and right knee osteoarthritis. She does not have diabetes mellitus. Her initial neurological examination results were unremarkable. She received a putative diagnosis of viral labyrinthitis and was admitted for intravenous fluid replacement. Over the next week she experienced troublesome vertigo but was able to be mobile with use of a Zimmer frame. Her course was complicated one week after admission by a fracture of the lateral mass of C2 after falling whilst mobilizing to the toilet. This required hard-collar immobilization, which made further investigation problematic. At this stage she manifested a clinical rapidly progressive cerebellar syndrome with nystagmus, past-pointing, dysdiadochokinesis, dysarthria, truncal ataxia and titubation. Her functional status deteriorated to a modified Rankin score of 5.
+A brain MRI scan revealed no structural abnormalities. Anti-Yo antibodies were found to be present in serum and CSF, as were anti-GAD antibodies (Table ). The CSF showed 0 leukocytes/弮L and 50 erythrocytes/弮L, gave negative results on Gram stain and negative results on culture, her protein level was 0.44 g/L and glucose level 3.2 mmol/L (concurrent blood glucose level 5.6 mmol/L), and cytology results were negative for malignant cells. Oligoclonal bands were not detected. Her CSF was also positive for protein 14-3-3, with a single band identified on western blot immunodetection. Ca 15?? and Ca 125 titers were also mildly elevated in her blood.
+A positron emission tomography (PET) scan revealed a fludeoxyglucose-avid bulky lower uterus evident with diffuse cerebellar hypo-activity. Pelvic ultrasound revealed a 4 ? 3 cm uterine cyst. A hysterectomy and bilateral salpingoophorectomy confirmed a clear cell carcinoma of the endometrium. A diagnosis of stage II endometrial carcinoma involving and extending into the stroma of the cervix with vascular invasion and histological grade 3 was made. She received five cycles of intravenous immunoglobulin (Ig) prior to surgery. The original C2 spinal injury and multiple infective complications including aspiration pneumonia, line sepsis, percutaneous endoscopic gastrostomy (PEG) site infection and T8/9 discitis made her management difficult. Five months elapsed from presentation to diagnosis of her neoplasm. She was too frail for adjuvant chemotherapy. She was discharged to nursing home care in April 2009, where she remains to the present day.
+She was assessed in December 2009 in her nursing home where she was found to be bright and alert. She was dysarthric. She was able to engage in light-hearted conversation in relation to the performance of Australian Rules football teams in English and Macedonian. She was mostly feeding by mouth. The PEG feed was rarely used. She required a hoist for transfers. She was able to place both hands against gravity under command. There was mild tremor of her outstretched hands. There was impaired finger-to-nose testing that had improved from the examination of 21 April 2009. She was able to raise both legs against gravity. There was marked dysmetria in both lower limbs, again much less than as an in-patient. Deep tendon reflexes were 1+. There was no clonus. She had nystagmus in lateral gaze without gaze paresis. There was some limitation in her upward gaze. Convergence and accommodation reaction were normal. The cranial nerve examination was otherwise normal.
+When reassessed in August 2011 she remained bed bound without changes in the neurological examination. She remains alive to this day, dependent on staff for all acts of daily living and requiring feeding assistance. Her weight ranges from 52.8 kg to 61.8 kg."
+Zaire Quintana,24,2003/1/20,230.675.4447,josephwood@example.org,7591 Newton Meadow Apt. 065,"A 24-year-old Caucasian man presented to our facility with a six-month history of post-prandial nausea, flatulence, bloating, abdominal discomfort and associated diarrhea. He had associated episodes of fatigue, sweating, anxiety, confusion and craving for sweet foods which when taken ameliorated these symptoms. There was no significant family history, he was a non-smoker who drank less than 10 units of alcohol per week and did not take regular medications. The results of a physical examination were unremarkable and there was no evidence of an autonomic neuropathy. Routine laboratory tests including tests for thyroid function and hemoglobin A1c (HbA1c) were normal. Duodenal biopsies, a computed tomography (CT) scan of the abdomen and pelvis, a short Synacthen test, 24-hour urinary 5-hydroxy-indole-acetic acid (5-HIAA) and vanillyl-mandelic acid (VMA) test results were all normal. A scintigraphic solid phase gastric emptying study using 99mTc-tin colloid-labeled solid egg meal [] revealed accelerated gastric emptying (Figure ) and an extended glucose tolerance test with a standard 50 g glucose load indicated an appropriate rise in glucose and return to baseline in 90 minutes but a subsequent fall to 2.5 mmol/L at 180 minutes (Figure ). A diagnosis of idiopathic accelerated gastric emptying was made, and he responded well to a ?razing diet??diet (eating regular small meals rather than the usual two or three large meals per day, with a reduction in refined carbohydrates). His symptoms have remained settled after 18 months of follow-up."
+Kenia Spears,37,2005/9/9,5188799654,solson@example.com,969 John Key Apt. 314,"A 52-year-old Caucasian woman presented to our facility with a 15-year history of post-prandial bloating, abdominal pain and diarrhea. This was often associated with nausea, severe sweating, fatigue and ?ight headedness?? She did not take regular medication, was a non-smoker, drank less than 10 units of alcohol per week and had no family history of gastrointestinal or endocrine disease. The results of a physical examination were unremarkable and there were no signs of autonomic neuropathy. Routine laboratory blood tests including thyroid function were normal, and duodenal and colonic biopsies, a short Synacthen test, and a 23-seleno-25-homo-tauro-cholate (SeHCAT) retention study were also normal. A scintigraphic solid phase gastric emptying [] study revealed accelerated gastric emptying (Figure ) and an extended glucose tolerance test with a standard 50 g glucose load indicated an appropriate rise in glucose and return to baseline in 30 minutes but a subsequent fall to 2.8 mmol/L at 60 minutes, a partial recovery, but a second fall to 2.8 mmol/L at 150 minutes before return to a steady normal baseline level at 210 minutes (Figure ). A diagnosis of primary accelerated gastric emptying was made and she was advised to take up a ?razing diet?? She remains well on this treatment at four-year follow-up."
+Ameer Ho,39,1985/6/18,001-916-879-5338x47356,brianlong@example.net,0644 Hunt Junction,"An 18-year-old Caucasian woman presented to our facility with a nine-year history of post-prandial diarrhea, abdominal bloating and pain. There was associated nausea, tremor, lethargy, hunger and craving for sweet foods. She was not taking regular medication, was a non-smoker, drank less than 10 units of alcohol per week and had no family history of gastrointestinal or endocrine disease. The results of a physical examination were normal and there was no clinical evidence of autonomic neuropathy. Routine laboratory blood test results including thyroid function were normal, and duodenal biopsies, a short Synacthen test, and small bowel barium study were normal. A scintigraphic solid phase gastric emptying [] study revealed accelerated gastric emptying (Figure ) and an extended glucose tolerance test with a standard 50 g glucose load indicated an appropriate rise in glucose, but a subsequent fall to 2.6 mmol/L at 300 minutes (Figure ). A diagnosis of idiopathic accelerated gastric emptying was made and she was advised to take up a ?razing diet?? Her symptoms have remained settled at three-year follow-up."
+Calliope Richardson,27,1991/1/30,791.360.5196,jonathanwilliams@example.org,6155 Torres Mall,"A 77-year-old Caucasian woman presented to our facility with a four-month history of epigastric distension and pain soon after eating associated with a change in bowel habit. She experienced intermittent diarrhea, which on occasions was severe. She also reported marked fatigue and intermittent nausea and sweating. Her medical history included a hysterectomy, ovarian cancer and mild hypertension for which she received flecainide as her only medication. She drank about 14 units of alcohol per week and did not smoke. Her brother died of colorectal carcinoma. The results of a physical examination were unremarkable; there were surgical scars on the abdominal wall, and there was no evidence of autonomic neuropathy. Routine laboratory blood test results including thyroid function and HbA1c were normal. Duodenal and colonic biopsies, a short Synacthen test, SeHCAT retention study, glucose hydrogen breath test, and fasting serum insulin level results were normal. A scintigraphic solid phase gastric emptying [] study revealed accelerated gastric emptying (Figure ). An extended glucose tolerance test with a standard 50 g oral glucose load revealed a normal fasting glucose level, an appropriate rise in glucose and return to normal levels at 120 minutes. Insulin and C-peptide levels rose and remained elevated at 150 minutes after which serum glucose fell to 2.2 mmol/L at 150 minutes (Figure ). A diagnosis of idiopathic accelerated gastric emptying associated with reactive hypoglycemia was made. Our patient was treated with a ?razing diet?? She had a very good response to treatment, and her gastrointestinal symptoms settled. Her symptoms continued to be well controlled with simple dietary measures at 15-month follow-up. No evidence of recurrent ovarian cancer was found on review by her gynecologist and no other diseases became manifest over this period."
+Robert Whitehead,32,2004/6/18,(873)551-0210,andersonjohnathan@example.net,2222 Danielle Freeway,"A 23-year-old Caucasian woman presented to our facility with a two-year history of early satiety, diarrhea about 30 minutes after eating and intermittent weight loss. She also complained of feeling faint and weak between meals, when she became cold and clammy, very fatigued and lost consciousness during these episodes on several occasions. These episodes could often be terminated by taking sweet foods or fluids. She was not taking regular medication, was a non-smoker, drank less than 10 units of alcohol per week and had no family history of gastrointestinal or endocrine disease. The results of a physical examination were normal and there was no clinical evidence of autonomic neuropathy. Routine laboratory test results including thyroid function, coeliac screen, HbA1c, and a short Synacthen test were normal. Further, her fasting gut hormone profile, urinary 5-HIAA and 24-hour urinary VMA, SeHCAT retention study, colonoscopy, gastroscopy and mucosal biopsies, and 24-hour electrocardiogram monitoring results were normal. Rapid gastric emptying was demonstrated on a scintigraphic gastric emptying study (Figure ); serum glucose fell to 2.5 mmol/L at 150 minutes during an extended 50 g glucose tolerance test (Figure ). She was advised to take up a ?razing diet??and had a very good response remaining well at 18-month follow-up."
+Sylvie Foley,26,2005/5/25,(653)726-6943,fadams@example.com,65513 Jason Harbors,"A 64-year-old Caucasian woman presented to our facility with a 10-year history of nausea, early satiety and profound bloating followed by diarrhea. All symptoms predominantly occurred in the first three hours after eating, when she often felt faint and lethargic, and had a craving for sweet foods. She often developed a fine tremor during this period associated with nausea and sweating, which would improve if she consumed sweet foods or drink. She had well controlled rheumatoid arthritis, and was otherwise well. There was no significant family history, she drank less than five units of alcohol per week. She did not take any medications that might alter her gastrointestinal motility or glucose control. The results of a physical examination revealed features of mild rheumatoid arthritis, but no other abnormalities. She did not have any evidence of autonomic neuropathy. All routine blood test results including thyroid function and HbA1c were normal. Mucosal biopsies from the duodenum and colon, a short Synacthen test, fecal elastase and a CT scan of the abdomen and pelvis were all normal.
+A scintigraphic solid phase gastric emptying study [] revealed accelerated gastric emptying (Figure ) and an extended glucose tolerance test was performed with a 50 g oral glucose load after a 12-hour overnight fast. Insulin and C-peptide levels rose after ingestion of the glucose load and remained high at 120 minutes, serum glucose returned to baseline values of 5.9 mmol/L and then fell to 2.8 mmol/L at 150 minutes (Figure ). Our patient? symptoms resolved with dietary advice and taking up of a ?razing diet?? Her symptoms continued to be well controlled with simple dietary measures at two-year follow-up."
+Mohammad Mercado,29,1996/12/11,+1-823-812-6283x671,shanepierce@example.net,474 Colleen Trail,"A 19-year-old Caucasian man was admitted to our emergency department with a critical ischemia of his right ring finger due to a crushing injury. His finger had been caught between a car and a car-jack while he was working as a mechanic. The first physical examination of the ring finger revealed an open wound of 3 cm on the dorsal side of the middle phalanx. Edges of the wound reached the ulnar and radial digital neurovascular bundle. The patient reported decreased sensibility of the end phalanx including painful range of motion (ROM) but without loss of function of all tendons. We found a restricted finger blood flow detected by nail bed compression in comparison with the uninjured fingers. An X-ray showed an undislocated transverse fracture of the middle phalanx (Figure ). The patient was immediately transferred to the operating room (OR) where the wound was examined. Severe damage of the surrounding soft tissue was seen. Microscopic examination revealed no defect of the crushed vessels, the radial digital nerve was intact, but an epineural lesion was apparent for the ulnar digital nerve. A minimal osteosynthesis with two Kirschner-wires (K-wires) was performed. X-ray imaging showed an anatomical retention and fixation of the fracture (Figure ). The dorsal wound of the ring finger was cut out and sutured. The patient was discharged from the hospital on the fourth day without any sign of wound healing disturbance. The ring finger was immobilized with a finger splint including the proximal interphalangeal joint (PIP) and distal interphalangeal joint (DIP).
+The patient was seen five months after initial treatment in our Out-Patient Clinic and reported painful moving of the right ring finger. The examination showed an instability of the middle phalanx with a passive lateral movement. Twenty degrees ulnar deviation of the ring finger with decreased ROM of the PIP joint (E/F 0-0-60?) was apparent. In addition, the ring finger tended to cross over and overlap the adjacent finger when making a fist. The patient reported that ulna deviation of the ring finger started when K-wires had been removed by an office-based orthopedic surgeon two months after the initial surgery.
+Since that time the finger was fixed again with a splint. He also complained about tingling, coolness and numbness of the injured finger. Since the X-ray showed a nonunion (Figure ) we started treatment with a LIPUS device (Fa. Melmak GmbH, Munich, Germany) three times daily for 20 minutes including the following parameter configuration:
+Average intensity I = 30 mW/cm簡 (SATA), ultrasound frequency F = 1.5 MHz, signal impulse duration 200 microseconds, repetition rate 1 kHz, effective radiating area 3.88 cm2, temporal average power 117 mW.
+The ring finger was immobilized with a fitted personalized thermoplastic splint (Figure ) for six weeks. Six weeks after LIPUS treatment the patient reported to be without pain when moving his ring finger and clinical examination revealed a slight persistent ulna deviation of five degrees. The clinical examination showed a stable middle phalanx compared to the result six weeks previously. After four weeks of physiotherapy the ROM of the PIP joint was E/F 0-0-85簞 and the fist closure was full (Figure ), except for the pre-existent limited ROM of the DIP-Joint (E/F 0-0-15?). An X-ray confirmed fracture healing and calcification of the soft callus was clearly evident (Figure )."
+Mckinley Kirby,41,2004/2/11,623.596.7538,juangeorge@example.org,001 Barnes Lane Suite 527,"We report the case of a 38-year-old Caucasian man, with dual citizenship in the USA and Switzerland, who has been in treatment at the outpatient service of the Psychiatric University Hospital for the last four years. During childhood and adolescence, his family frequently relocated from Switzerland to the USA, and vice versa. His father, an entrepreneur, described the patient as being an ?neasy??child who was different from his siblings, and he had sought professional help for his son from a child psychiatrist in the USA. This psychiatrist diagnosed the patient, who was then nine years old, with ADHD, and over the course of the next five years, the patient received up to 10 mg of immediate-release MPH (Ritalin簧). Later on, his dosage was increased to 20 mg of sustained-release MPH (Ritalin SR簧) daily, which initially improved the patient? symptoms of hyperactivity and inattention.
+Twenty-five years ago, while he was still living in the USA, the patient? medication was changed?or the same indication?o desipramine (Norpramin簧), and MPH (Ritalin簧) was discontinued. Nevertheless, most of his difficulties persisted throughout elementary- and middle school. Between ages 14 and 16, the patient was therefore sent to a school that specialized in the instruction of students with learning disabilities such as dyslexia. At age 18, he developed obsessive-compulsive traits and received counselling; his medication was also changed at that time to clomipramine (Anafranil簧) 75 mg/daily.
+Soon afterward, the family again relocated from the USA to Switzerland, where the patient attended high school?ollowed, in 1993, by college in the USA. Still suffering from symptoms of inattention and hyperactivity, he did not finish his studies at this college, and failed in several other attempts to obtain a secondary degree in the USA, Great Britain, and Switzerland. The patient recalled that he never seemed able to ?ocus.??For unknown reasons, he did not receive further stimulant medication until six years ago, when a Swiss psychiatrist prescribed immediate-release MPH (Ritalin簧) 60 mg/daily to reduce the patient? distractibility at his newfound job as a sales clerk. The patient experienced MPH as highly effective, but not sustainable throughout the course of a day. During the following 14 months, he therefore began to use Ritalin簧 excessively, both orally and rectally, in dosages up to 4800-6000 mg/daily, by applying to thirty different doctors in three different cantons of Switzerland. He thereby fulfilled the criteria for stimulant dependence, although he never used any substance other than MPH.
+Four years ago, the patient was referred to our outpatient service for treatment. He received clinical diagnostic interviewing (SCID I, SCID II) and his ADHD was re-evaluated using recommended practice parameters []. In addition, his plasma levels of methylphenidate were obtained, a routine medical workup was performed, and information on his past medical history was collected.
+Physical examination revealed chronic back pain, and a local rheumatologist diagnosed ankylosing spondylitis (Bekhterev's disease). No other pathology was found, nor did the patient have any history of palpitations, tachycardia and dyspnea, or other adverse cardiovascular effects commonly associated with stimulant use. His blood pressure and heart rate were within the normal range, and an ECG showed no abnormalities.
+The diagnostic (SCID) testing confirmed the presence of an obsessive-compulsive disorder and revealed a combined personality disorder. There was no further history of substance misuse or dependency; the patient reported only a recreational use of cannabis. The patient first received immediate-release MPH 200 mg. This was later changed to 240 mg, and finally to 270 mg MPH per day. We repeatedly checked the plasma levels of MPH in the blood under all these dosages and found them to be within the reference range. Moreover, when the patient received extended-release MPH at a dosage of 378 mg/day, his blood plasma remained within reference range. The reference range is 43-257 nmol, and we found his plasma levels to be between 60 nmol-187 nmol/l.
+Using a combined psychosocial (CBT) and pharmacotherapeutic treatment approach, the patient? daily Ritalin簧 dosage could initially be reduced to 200 mg/daily orally. However, the patient still experienced pronounced symptoms of ADHD at this dosage, and these symptoms were also reported by his family members. He exhibited high levels of distractibility both within the clinical setting (e.g., during group therapy), and at home, where he was unable to help around the house or contribute to the care of his newborn child.
+While his signs of OCD diminished with fluoxetine 40 mg/daily, his ADHD symptoms only improved dramatically after his dosage was increased to 378 mg of extended-release MPH (Concerta簧). This was reflected in an increase of his score on the Global Assessment of Functioning scale from 43 to 68; and at home, the patient was able to care for his child several days a week and re-establish interpersonal relationships. No further excessive use of methylphenidate has been recorded for the past 24 months."
+Tony Stone,20,1984/6/28,925.525.8165,mathewharris@example.com,384 Scott Views Suite 442,"A 59-year-old Japanese man presented with a six-month history of numbness of his right hand and dull pain in his nuchal region. He had no history of cervical trauma. Three months before the first visit to our hospital, numbness had spread over all four of his limbs. No muscle weakness was observed; however, our patient showed gait ataxia because of the spasticity of his lower extremities. In a physical examination, bilateral hypesthesia (soft touch and pin prick) and a marked increase of the deep tendon reflexes in his upper and lower limbs were observed.
+Lateral X-ray films showed the absence of the posterior arch of the atlas along with atlantoaxial instability (Figure ). The atlantodental interval was 9.62 mm in a flexion position (Figure ) while no interval was observed in an extension position (Figure ). Sagittal magnetic resonance imaging revealed atrophy of his spinal cord and myelomalacia that was observed as a T2-high signal intensity area (Figure ) at the C1 level. Computed tomography (CT) showed the complete absence of the C1 posterior arch (Figure ) and an os odontoideum (Figure ). A cleft in the C1 anterior arch was also observed (Figure ): the two lateral masses were completely separated on both sides. A real model of his cervical spine was produced based on data from three-dimensional CT with contrast dye for the evaluation of the vertebral artery (Figure : produced by LEXI Co., Tokyo, Japan). Figure shows the view from the posterior direction and Figure shows the view from the lateral direction. Complete absence of the C1 posterior arch and hypertrophy of the spinous process of the axis were observed.
+Our patient underwent posterior occipito-C4 fixation with pedicle screws. Our patient was placed in a prone position in a Mayfield head clamp. At the beginning of the operation, his neck was slightly flexed in order to expose the surface of the laminae. A midline incision was made with subperiosteal exposure of his occiput and cervical spine. His neck position was then changed to a neutral position. We did not observe any bony elements between his occipital bone and C2 lamina. His occipital plate was fixed with two bicortical screws. Pedicle screws were inserted bilaterally into the C3 and the C4 vertebrae and unilaterally into the right pedicle of C2. Since his left vertebral artery ran through the pedicle of C2 (high-riding transverse foramen), screws were not inserted into the left C2 pedicle in order to avoid vertebral artery injury. Then his neck position was changed to a moderate extension position under control of fluoroscopy to achieve a good atlantodental interval. Rod fixation was performed between his occipital plate and the C4 screws. Rigid fixation was achieved by this procedure. A corticocancellous graft harvested from his posterior iliac crest was placed on the decorticated occipital bone and C2 lamina and fixed to his occipital bone with a biodegradable poly-L-lactate screw (Fixsorb-MX; Takiron, Osaka, Japan). Residual bone chips were grafted on the surface of the decorticated lamina (C2 to C4) and fixed with fibrin glue.
+Our patient? posture was managed using a cervical orthosis (Ortho collar, ARIZONO Orthopedic supplies co., Ltd., Kita-Kyusyu, Japan) for three months after surgery. Anteroposterior and lateral cervical radiographs were performed two, four and six weeks after the operation to check for loosening or dislocation of the implants and grafted bone. Three months after the operation, fusion between his occipital bone and C4 was assessed using lateral radiographs of his neck in flexion and extension position. Solid fusion was likely attained at this time (Figure ). The pedicle screws were positioned properly at C3 (Figure ) and C4 (Figure ). After the operation, the pain in his nuchal region disappeared and symptoms of his myelopathy improved. Only slight numbness of his upper limbs remained. Complete bony union of the grafted bone was observed in a CT scan performed six months after the operation. No recurrence of symptoms was observed during three years of follow-up after the operation."
+Catalina Noble,21,1989/10/18,575.906.8398x9566,bestpeter@example.com,2137 Harris Summit Suite 116,"A 78-year-old Japanese man was referred for sudden, asymptomatic gross hematuria with pyuria and clot retention that had occurred six days prior to his visit. Upon presentation at our hospital, he was afebrile and denied chills, pain, or weight change. Physical examination revealed no palpable mass or enlarged lymph nodes. The patient had undergone transurethral resection of the prostate for benign prostatic hyperplasia and transurethral lithotripsy for bladder calculi 11 years previously. He had also been diagnosed with pancreatic cancer (non-functional malignant endocrine tumor, pT2N3M1) seven years previously. Following resection of the pancreatic tumor, he had received chemotherapy for liver and lymph node metastases. Five cycles of gemcitabine therapy proved ineffective; however, stable disease was achieved by second-line chemotherapy (administered until 17 months prior to his being seen for urinary symptoms) using tegafur, gimeracil, oteracil potassium and octreotide. Because of severe adverse events (nausea, appetite loss), monotherapy using octreotide and best supportive care had been provided.
+Cystoscopy revealed a solitary non-papillary, pedunculated mass measuring approximately 1.2 cm located lateral to the left ureteral orifice (Figure ). The surface of the mass appeared reddish and highly vascular. Distended vessels were observed at the base of the mass originating from the surrounding mucosa, indicating that they were feeding vessels (Figure ). Transurethral resection of the mass was performed and the tissue was submitted for histopathological examination. Magnetic resonance imaging and cystoscopy four months after surgery did not reveal any residual tumor. The pedunculated lesion had an eroded surface and was composed of a lobular proliferation of capillary-sized vessels with large dilated vessels, possibly feeding vessels, at the base of the lesion (Figure , B). Variable anastomosing small blood vessels admixed with dilated and sinusoidal vessels were lined with plump endothelial cells (Figure ). The endothelial cells were positive for CD31, CD34, and factor VIII-related antigen, but negative for podoplanin (antibody D2-40) (data not shown). While mitoses were occasionally observed, the endothelial cells were without atypia (Figure ). Edematous and/or fibromyxoid changes were observed in the stroma. Mild lymphoplasmacytic infiltration with intermingled neutrophils was seen. Therefore, the histopathologic findings were consistent with a capillary hemangioma with eroded surface. Because of the acute symptoms together with the cystoscopic and histologic findings, we believe that the lesion should be considered a pyogenic granuloma of the bladder."
+Idris Reed,33,1990/5/8,567-556-7830,matthew39@example.com,6848 Tara Canyon,"A 17-year-old Sardinian young woman underwent an initial examination at the dentist? office during a routine checkup in 2010. After obtaining informed consent from her parents, clinical evaluation was performed, during which some caries were detected and also the need for an orthodontic consultation. The presence of an atrophy of filiform papillae with circinate erythematous ulcer-like lesions of the dorsum and the lateral border of the tongue was observed.
+During the anamnesis, neither the patient nor her parents reported any history of systemic disease or, in particular, any gastrointestinal symptoms. Talking with the patient and her parents, it was possible to verify that the tongue affection had started when she was five years old with no other symptoms and with intermittence. During her past medical history, no one had ever investigated these tongue lesions.
+With these elements, the clinician identified the tongue condition as an AG and started with a more detailed analysis of systemic and local conditions related to this pathology. The patient, as highlighted by the anamnesis, did not show any other symptoms or signs related to pathologies typically linked to an AG, apart from her short stature []. She was only 145 cm tall but this condition had previously gone unnoticed because her parents were also short. Considering the presence of short stature with an AG, the problems could be related to a nutritional dysfunction such as vitamin B12 deficiency. Given that Sardinia is an area with a high frequency of CD, gluten enteropathy became the first suspect as a possible cause for the eventual vitamin B12 deficiency.
+As a first step, a blood sample was requested to determine the vitamin deficiency and to perform AGA and tTG antibody tests and the EmA test. Hematologic tests showed a vitamin deficiency with positive results for antibody tests (Table ) so a small intestine biopsy was performed during a gastroenterological consultation [].
+A diagnosis of CD was made based on the findings from the biopsy sample; such as: the characteristic changes in intraepithelial lymphocytosis, crypt hyperplasia and a Marsh type IIIc villous atrophy. She was treated by excluding gluten-based-food from her diet (gluten-free diet). After five months she repeated the intraoral examination where it was possible to verify remission of the AG."
+Valentina Proctor,29,1995/8/6,(574)626-0820,hernandezmegan@example.com,53251 Christie Landing,"The patient was 58-year-old Japanese male with no significant medical history. He was found to have increased white blood cell count (WBC) at a medical checkup at his workplace and referred to our hospital. The laboratory data on admission showed that his WBC was 19.1 ? 109/L, with a differential of 67.5 % neutrophils, 5.5 % myelocytes, 3.0 % metamyelocytes, 6.0 % basophils, 1.5 % eosinophils, 3.0 % monocytes, 13.5 % lymphocytes. Hemoglobin concentration of 13.0 g/dL was within a normal range and platelet count of 390 ? 109/L was slightly elevated. Neutrophil alkaline phosphatase (NAP) score was decreased to 79 (control score, 170??85). Bone marrow aspirate showed marked hypercellularity. Reverse-transcription polymerase chain reaction (RT-PCR) of RNA from his bone marrow cells amplified major BCR/ABL chimeric transcript (b3a2 type). He was diagnosed as having CML in the chronic phase, then received treatment with orally imatinib at daily of 400 mg. He obtained a complete cytogenetic response as well as a major molecular response (MMR), as BCR/ABL transcripts have not been detected by quantitative RT-PCR analysis after thirteen months treatment. The MMR status has been maintained for 44 months.
+G-banding chromosomal analysis of the bone marrow cells presented 46,XY,t(7;11;9)(q22;q13;q34),t(9;22)(q34;q11.2) [20/20] (Figure ). After imatinib treatment, karyotype of the patient? bone marrow cells showed 46,XY [20/20].
+To confirm these cytogenetic aberrations, we performed Spectral karyotyping (SKY) analysis with a SkyPaint kit (Applied Spectral Imaging, Migdal Ha?mek, Israel). As shown in Figure , SKY confirmed four derivative chromosomes, der(9)t(9;11)(q34;q13), der(9)t(9;22)(q34;q11), der(11)t(7;11)(q22;q13), and der(22)t(9;22)(q34;q11). SKY could not visualize the small segment 9q34-9qter on the der(7)t(7;9)(q22;q34). The size of this segment was supposed to be smaller than a minimum genomic alteration that SKY could detect.
+For further characterization of these translocations, we next performed fluorescence in situ hybridization (FISH) analyses. In order to detect the BCR/ABL rearrangement and determine the 9q34 breakpoints, the LSI BCR/ABL ES Dual Color Translocation Probe Set (Vysis, Inc.) was used (assay 1). This probe set is a mixture of an ABL probe, which covers not only the ABL but also the centromeric located ASS gene (Spectrum Orange) and a BCR probe (Spectrum Green). In assay 1, one yellow (red-green) signal, showing the BCR/ABL fusion, one BCR (green), one ASS-ABL (larger red), and one ASS (smaller red) signal were detected (Figure ). This finding indicated that the two der(9) chromosomes had different 9q34 breakpoints, one within the ABL, generating the BCR/ABL fusion gene, the other within or centromeric to the ASS.
+Additionally, we used two types of probe. One is the CEP7 (Vysis, Inc.) (Spectrum Green) that hybridizes to the centromere of chromosome 7 (assay 2). The other is the mixture consisted of 11p (Spectrum Green), 11q (Spectrum Orange), 18p (Spectrum Green and Spectrum Orange) and 18 centromeric (Spectrum Aqua) probes (Vysis, Inc. ) (assay 3). Assay 2 indicate that the ASS-ABL segment (larger red signal) from the chromosome 9 was on der(7) with CEP7 signal. The fusion BCR/ABL signal was on der(22), and the smaller red signal, ASS, was retained on the other chromosome 9 (Figure ). In assay 3, the larger red signal, 11q, was on one of der(9) which retained the smaller red signal ASS (Figure ), indicating that the 11q segment was translocated to a chromosome 9 with rearrangement within the ABL, but not to the other from which ASS-ABL was translocated to der(7).
+The results from G-banding, SKY and FISH analyses finally revised the karyotype as 46,XY,t(7;11;9;22;9)(q22;q13;q34;q11.2;q34) (Figure ). We found nine other CML cases with five-way translocation, two of which were treated by imatinib [-] (Table ). However, to our knowledge, this combination has not reported so far [].
+Two possible mechanisms have been postulated for formation of variant translocations. One is a single-event rearrangement via simultaneous breakage of several chromosomes followed by mismatched joining []. The other is a multi-step mechanism in which a classical Ph translocation is followed by further translocation events involving chromosomes 9 and 22 and other chromosomes []. These mechanisms may have prognostic importance in that a single genomic rearrangement may confer a similar prognosis to the classical Ph translocation, whereas a multi-step mechanism represents clonal evolutions associated with a worse prognosis [].
+Conflicting data were reported on clinical relevance of variant Ph translocation to tyrosine kinase inhibitor treatment [-] and its clinical significance has not been determined yet. Our case had achieved a MMR by imatinib therapy, suggesting that a single-event rearrangement was involved in the chromosomal change. However, careful follow-up will be needed, as complex translocations might be associated with a higher degree of genomic instability."
+Vance Tran,26,1977/11/4,481.713.4028,oconnelljordan@example.net,5079 Sherry Shoal,"A 69-year-old Japanese man was admitted to our hospital for elective ileostomy closure. Ten months earlier, after chemoradiation therapy, he had undergone a low anterior resection and creation of a diverting ileostomy for rectal carcinoma, which was complicated with postoperative leakage. Histopathological study revealed stage III rectal carcinoma (T3N1M0). He had a past medical history of hypertension, cerebral hemorrhage and gastric ulcer and was taking a proton-pump inhibitor.
+On the day before the elective surgery, he received oral kanamycin and metronidazole as a chemical preparation. Additionally, immediately before the surgery, one dose of parenteral cefmetazole was given. Ileostomy closure was completed in 31 minutes without any intraoperative complications.
+His postoperative course was uneventful until the third postoperative day, when his body temperature rose to 37.8簞C. His bowel movement became frequent at 15 times a day. However, because he had no other signs or symptoms suggestive of infection, and because frequent bowel movement is not uncommon after low anterior resections, especially after those complicated with postoperative leakage, careful observation was continued without further examination or additional treatment.
+On the fourth postoperative day, in addition to the aforementioned symptoms, he presented with epigastric and left lower abdominal pain. A computed tomography (CT) scan (Figure ) revealed that subcutaneous fluid had collected adjacent to the surgical wound. CT also demonstrated a slightly distended colon without wall thickening. We immediately opened the surgical wound and drained the fluid, which was sanguineous. After the drainage, his body temperature returned to within the normal range (36.7簞C). That night, at 10:30 p.m., his blood pressure fell to 77/59mmHg and intravenous infusion was started.
+Nevertheless, in the early morning of the fifth postoperative day, his blood pressure continued to drop, thus requiring vasopressor treatment to maintain his blood pressure. Again, a CT was done, which indicated severe colonic dilation (Figure ). Laboratory data were normal except for mild liver dysfunction (aspartate transaminase, 68mU/mL; alanine transaminase, 45mU/mL) and leukocytosis (9,460 cells/弮L). Even though CT demonstrated severe dilatation of the colon, the thickening of the colonic wall that is the typical finding associated with fulminant pseudomembranous colitis was not evident. Emergent colonoscopy up to the transverse colon revealed pseudomembranes associated with severe inflammation (Figure ). Pseudomembranous colitis was thus diagnosed, and oral vancomycin was administered. Until this time, no antibiotics had been given postoperatively. In our institute, the enzyme-linked immunosorbent assay (ELISA) for C. difficile toxin is not available on weekends (the fifth postoperative days was a Saturday).
+The condition of our patient rapidly deteriorated so he was transferred to the intensive care unit at 10:30 a.m. After resuscitation, which included tracheal intubation and massive intravenous infusion along with multiple vasopressors, an emergent operation was done. The time interval between the drop of blood pressure and emergency surgery was 18 hours.
+During the laparotomy, a small amount of bloody ascites was observed and the large intestine was severely dilated, part of which was necrotic. The serosa of the small intestine was slightly inflamed but there was no sign of ischemia. Total colectomy with creation of an end ileostomy was then performed, after which our patient was returned to the intensive care unit. However, he did not recover from the shock and died 26 hours after the surgery.
+A histopathological examination (Figures and ) revealed inflamed mucosa from the cecum to the rectum which was covered with a necrotic exudate, indicating pseudomembranous colitis. A postmortem autopsy was not carried out, because consent could not be obtained from the family."
+Kylie Marsh,21,2004/8/23,001-568-643-4820x13910,emily65@example.net,718 Chapman Streets Suite 319,"A 45-year-old Thai male presented with a six-month history of right buttock and hip pain. The patient could not recall any injuries or incidents that may have caused the pain. He had no medical problems nor was he taking any medication. The MRI of the lumbosacral spine from the initial consultation at another hospital was unremarkable. He was treated unsuccessfully with a non-steroid anti-inflammatory drug and acetaminophen. He was referred to our institution for consultation. Physical examination revealed a healthy-appearing adult with an ill-defined 12 cm ? 20 cm nontender firm mass at frank and groin area. There was no overlying skin change. Both hips had a full range of movement. The neurovascular function in the field of lower extremity was found to be intact, except the power of extensor hallucis longus on the right side was grade 4/5. He had no palpable lymphadenopathy. Laboratory studies were within normal limits.
+A plain radiograph of the pelvis revealed a well-defined mineralized mass extending from the right pubic and periacetabular area that also extended to the left pubic bone. The right obturator foramen was obliterated by the tumor mass. There was a popcorn-like chondroid matrix at the soft-tissue part of the tumor, which also extended into the pelvic cavity (Figure ). Bone scintigraphy and computed tomography (CT) of the chest showed no distant metastasis except the abnormal uptake of the right pelvic and hip area. The CT scan of the pelvis showed a huge tumor mass in the pelvic cavity that involved the right sacroiliac joint and anterior border of the sacrum (Figure ). The initial diagnosis was a chondrosarcoma involving both pubic areas, the right periacetabulum and ilium.
+Incisional biopsy was performed over the right pubic area. Microscopic examination revealed small chondrocytes with dark nuclei and scant cytoplasm. They were arranged in clones and binucleated cells were present. No mitotic figures were found. The diagnosis was consistent with chondrosarcoma. The tumor was classified as Grade I (well-differentiated) (Figure ) according to the musculoskeletal tumor society staging system []. In this patient, the tumor resection was at PI-II-III, according to the Ennecking and Dunham classification [] for the resection of primary tumor involving the pelvic bone. An internal hemipelvectomy with wide margin tumor removal was performed in this patient using the modified technique described by Eilber et al. []. The incision was made from left inguinal area to right pubis and anterior superior iliac spine, then curved superoposterior to iliac crest. The previous biopsy scar was ellipsed out from the incision. The external iliac vessels, femoral and sciatic nerves were preserved and mobilized from the tumor. The muscles attached to the pelvic bone were dissected out from the affected pelvis such as rectus abdominis, abdominal muscles, iliacus, gluteal muscles, rectus femoris, adductors and hamstrings. Osteotomies were made through the sacral ala just lateral to the neural foramina and contralateral pubic rami and ischium. A polypropylene mesh (Parietene, Sofradim, Trevoux, France) was used as an anchoring mesh to maintain all dissected muscle from the pelvis and soft-tissue reconstruction (Figure ). All muscles were sutured along with mesh by prolene no. 0. They were kept attached with mesh at their optimal anatomical length to gain maximal muscle strength. Gluteal, lumbosacral and hamstrings were firstly sutured behind the mesh. Then, abdominal muscles, rectus abdominis, rectus femoris and adductor were sutured respectively by their anatomical layers. The final pathological report confirmed a well-differentiated chondrosarcoma with free margin. The radiograph of the pelvis following an internal hemipelvectomy showed upward migration of the head of the right femur (Figure ).
+Patient was placed in balanced skeletal traction at the tibial tuberosity with a weight of fifteen pounds for three weeks after surgery. Rehabilitation was uneventful. Progressive partial weight-bearing with axillary crutches was allowed after six to eight weeks. Regular strengthening exercises of the psoas, gluteus, quadriceps, and hamstring muscles were started and maintained to the highest level of tolerance during this period. At 7.5-year follow-up, the patient remained disease-free without local or distant relapse of the disease. No infection or wound complication occurred in this patient. Partial peroneal nerve palsy occurred, but was improved at the last visit. The patient had regained a range of motion of hip abduction of 15簞 and a range of hip flexion of 15簞. The functional analysis at the final follow-up according to the Musculoskeletal Tumor Society system [] was 66.7 %. He had a 3 cm leg-length discrepancy, which could be compensated by simple shoe lifts. He was able to perform most activities of daily living without any assistance. He could resume his employment as an electrical engineer by using one Canadian crutch during walking and could participate in sports exercise such as swimming or bicycling (Figure )."
+Bo Patel,25,1996/7/17,001-991-327-6397,alecbraun@example.net,9368 Johnson Road Suite 843,"A radiographic examination of the left wrist was performed in a 17-year-old Colombian man as a result of a direct incidental trauma. No fracture was seen, but an osteolytic area was found in the ulnar meta-epiphysis. The initial diagnosis was ?uvenile bone cyst?? The patient presented with a painful swelling at the wrist dorsal ulnar side, about 2.5 cm, in the absence of any epidermal dyschromias. The skin was elastic and smooth. Wrist examination showed a range of motion (ROM) of 45 簞 of extension, 70 簞 of flexion, 15 簞 of radial deviation and 10 簞 of ulnar deviation; pronation, supination and circumduction were painful. Contralateral wrist ROM was normal. The diagnosis of ?uvenile bone cyst??did not seem right and a second radiographic examination was performed. At this time, a multilocular osteolytic area inducing an expansion of the distal ulna was seen. A cortical bone interruption was also visible. Although the patient had been the victim of a trauma, this was a poor prognostic sign. Therefore an Magnetic resonance imaging examination was performed. It showed a hypointense signal in the T1 sequences and a hyperintense signal in the short TI inversion recovery (STIR) sequences, characterized by enhancement after contrast administration, due to the presence of newly formed tissue (Figure ).
+After an incisional biopsy, the diagnosis of GCT was finally made, although it was in an atypical site.
+The lesion was classified as a grade II with fracture (Figure ), according to the Campanacci Classification and as a stage II according to the Enneking Classification for benign bone tumors (Figure ).
+Subsequently, the patient was surgically treated with intralesional curettage, adjuvant therapy with 5% phenol and a synthetic bone graft reconstruction.
+A cortical bone rawplug was removed through a skin incision at the dorsomedial side of the deformity. Accessing the cystic cavity revealed a gelatinous ?hocolate brown??material, with many areas of darker color.
+The cavity was carefully emptied and curetted (Figure ), and then 5% phenol was applied in three cycles (Figure ), with subsequent neutralization by hydrogen peroxide.
+Then, using synthetic cancellous bone substitutes, a bone defect fill was performed (Figure ) and the bone rawplug was synthesized using a cannulated screw (Figure , Figure ).
+A clinical and radiographic follow-up was performed one, three, six, 12, 24 and 48 months post-operatively to evaluate the bone consolidation. Chest radiographs were performed every six months. Within the first post-operative month, the patient completely recovered the wrist ROM. After 3 years, there have been no signs of recurrence."
+Madeline Pacheco,43,1986/6/5,+1-299-453-3477x5480,jfuentes@example.org,825 Mckenzie Keys,"A 45-year-old Caucasian woman was admitted to our hospital for surgical correction of progressive right convex scoliosis. The patient had suffered from an unbalanced adolescent idiopathic thoracolumbar right scoliosis with improvement in adulthood. A pre-operative physical examination revealed painful, rigid right thoracolumbar scoliosis and unsupported sitting. A radiograph showed right convex thoracolumbar scoliosis of 68簞 with a type IV pelvic obliquity graded according to the classification of King et al. []. Her medical history revealed chronic urinary tract infections. She was treated with single-stage scoliosis correction involving posterior instrumentation (Euros spinal system; Euros, La Ciotat, France) from T4 to L5. The spondylodesis was completed by applying allograft bone chips (Etablissement Fran癟ais du Sang Alpes-M矇diterrann矇e, Tissue Bank, Marseille, France) over the laminae in the thoracolumbar region. Prophylactic cefazolin (1000 mg) was administered intravenously at the induction of anesthesia. At day 8 after the operation, the wound produced negligible clear fluid without any sign of infection and our patient was discharged to a rehabilitation center. At day 16 after the operation, she developed a fever (38.6簞C) and was readmitted to our hospital. A physical examination found an enlarged distal wound dehiscence with increased fluid production. Remarkable laboratory parameters included an increased level of C-reactive protein (65 mg/L; normal is less than 10 mg/L), a white blood cell count of 10.9 cells?109/L (normal is 4 to 10 cells?109/L), and an erythrocyte sedimentation rate of 150 mm (normal is less than 8 mm). A thorough debridement of necrotic tissue and the removal of the bone grafts were performed with the instrumentation left in place. Samples were collected from various deep areas by fluid aspiration and from the applied bone graft. Therapy with three grams of amoxicillin/clavulanate daily was initiated immediately after appropriate intra-operative cultures were obtained.
+Three intra-operative specimens were received in the laboratory; direct Gram staining was negative. Samples were inoculated on blood agar and chocolate agar (bioM矇rieux, Marcy l?toile, France) and incubated at 37簞C both aerobically with 5% carbon dioxide and anaerobically. All specimens incubated under anaerobic atmosphere yielded positive cultures with tiny, non-hemolytic colonies of Gram-positive rod-shaped bacilli. In vitro susceptibility testing using the disk diffusion method was interpreted in accordance with the guidelines of the Clinical and Laboratory Standards Institute []. It indicated susceptibility to amoxicillin/clavulanate, rifampicin, imipenem, metronidazole, clindamycin, and vancomycin and resistance to penicillin G. An attempt was made to identify the isolate by using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS) (Bruker Daltonics, Bremen, Germany). Non-inoculted alpha-cyano-hydroxycinnamic acid matrix was used as a negative control, and positive control consisted of 1.5弮L of Bruker Bacterial Test Standard, a protein extract of Escherichia coli DH5alpha. The two negative control spots remained negative, and the two positive control spots identified E. coli with score values of 2.281 and 2.363, thus validating the MALDI-TOF-MS manipulation. The isolate yielded a non-identifying spectrum with identification score values of greater than 1.699. PCR amplification and sequencing yielded a 1466-base pair (bp) 16 S rRNA gene sequence differing at only 10 nucleotide positions from that of reference R. peoriensis (GenBank AF445285; 99.3% sequence similarity) []. In parallel, a 951-bp 16 S rRNA gene sequence obtained from two patients??specimens as previously reported [] differed at only three nucleotide positions (similarity of 99.6%) from that of R. peoriensis reference (GenBank AF445285). Amoxicillin/clavulanate was replaced by a combination of rifampicin (300 mg) and clindamycin (600 mg) administered orally at eight-hour intervals for six months. Our patient was discharged five days after surgery. Wound healing and temperature were monitored at regular intervals at the out-patient clinic. At three-month follow-up, our patient was afebrile, the wound had healed, and there was no longer biological inflammation. At one-year follow-up, radiographs showed a complete correction of the scoliotic deformity and no instrumentation failure."
+Erik Bryant,45,1979/10/10,627-456-0214x688,watersjohn@example.net,082 Barron Summit,"A 48-year-old Asian woman presented to an ear, nose and throat (ENT) surgeon at our facility with complaints of headache and bleeding from the right nasal cavity for 15 days. She was known to be hypertensive and was taking amlodipine and enalapril.
+Anterior rhinoscopy revealed a mildly deviated nasal septum and a right nasal polyp. A physical examination did not reveal any other abnormalities. There was no hepatosplenomegaly or lymphadenopathy.
+The results of a computed tomography (CT) scan showed a low-density lesion with a few areas of soft tissue density completely filling the right maxillary sinus extending to the middle meatus and posterior nasal cavity, with a widened antrum. There was no bony lesion. The radiological diagnosis was antrochoanal polyp.
+The results of all laboratory tests were normal. Subsequently, endoscopic polypectomy and middle meatal antrostomy were performed. Multiple irregular grey to dark brown soft tissue fragments measuring up to 3 ? 2 ? 1.5cm were sent to our histopathology laboratory. The culture from the surgical specimen was negative for fungus. A histological examination revealed mature adipose tissue mixed with hemopoietic cells (Figure ). Hemopoietic cells are made up of trilineage elements: myeloid, erythroid and megakaryocytic cells (Figures and ).
+Based on this histomorphology, a hematological investigation including bone marrow aspiration and trephine biopsy were performed to rule out any underlying hematological disorders. Bone marrow aspirate and trephine biopsy were normocellular without fibrosis. Based on these findings, extra-adrenal myelolipoma was diagnosed. Our patient had an uneventful post-operative course and has remained disease-free at 36-month follow-up."
+Parker Mack,38,1981/5/16,479.833.1144x19250,jeromebrooks@example.org,294 Lisa Knolls,"A 39-year-old Sri Lankan woman presented with a two-week history of nausea, vomiting, severe headache, progressive drowsiness associated with high-grade intermittent fever, and confusion. SLE had been diagnosed five years before. At that time, she had had signs and symptoms of arthralgia, malar rash, alopecia, and anti-nuclear antibody and anti-double-stranded deoxyribonucleic acid antibody positivity on serum. Hypertension was diagnosed at the same time and was later treated as essential hypertension. The initial presentation of SLE was treated with high-dose prednisolone and mycophenolate mofetil (MMF). The prednisolone dose had been tapered off over the years, but MMF had been continued at high doses (1 g/day). Our patient had been poorly compliant to follow-up and had self-medicated at times with repeat prescriptions of steroids. Although the SLE activity was in remission, she was on inappropriately high doses of immunosuppressants (the indication to start MMF was unclear in the records). Apart from hypertension, her medical history was unremarkable, and she was not on any other immunosuppressants. No relevant sexual history, recent travel history, or contact with animals was reported.
+On admission, she was drowsy, febrile, and confused. Her Glasgow Coma Scale score was 12 out of 15. She had no neck stiffness. The results of a cranial nerve examination, including funduscopy, were normal. Bilateral exaggerated tendon reflexes in her limbs and bilateral extensor plantar responses were noted during a neurological examination. She had no lymphadenopathy or peripheral manifestations of active SLE. Her cardiovascular system was normal apart from a blood pressure of 150/90 mmHg. She had a non-tender, firm hepatomegaly extending 3 cm below her costal margin. The results of the rest of the abdominal examination and the respiratory system were normal. Her hemoglobin level was 9.8 mg/dL, her total leukocyte count was 21.5?109/L with 88% neutrophils, her platelet count was 324?109/L, and her blood picture showed a normochromic normocytic anemia with a left shift of leukocytes. Her erythrocyte sedimentation rate was 90 mm/hour, and her C-reactive protein was 46 mg/L (the reference value was less than 6), but her serum complement levels were within normal limits. Her blood and urine cultures were sterile, and her chest X-ray was normal. Transthoracic and transesophageal echocardiograms were normal. An ultrasound scan of her abdomen did not show focal lesions in her liver, which was enlarged, or any other foci of sepsis. Her serum electrolytes, including calcium and magnesium levels, blood glucose, and liver and renal function tests, were also within normal limits.
+Gadolinium-enhanced magnetic resonance imaging (MRI) of her brain showed multiple ring-enhancing lesions that were of varying sizes, up to 1 cm in diameter, and that were surrounded by marked perilesional edema involving her cortex, basal ganglia, brain stem, and cerebellum (Figure ). There was meningeal enhancement as well.
+A cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis, an elevated protein level of 108 mg/dL, and a low CSF-to-serum glucose ratio of 1.8:5.8. There were no atypical cells on CSF cytology, and bacterial, fungal, and tuberculous cultures of CSF were negative. The toxoplasma antibody titers were negative for immunoglobulin M but positive for immunoglobulin G (1:150). The fungal cultures were sterile. The results of the human immunodeficiency virus antibody test were negative. The serum lactate dehydrogenase level was normal. Our patient was initially treated with broad-spectrum intravenous antibiotics with both aerobic and anaerobic cover (meropenem and metronidazole) combined with steroids ??dexamethasone 4 mg three times a day (t.i.d.) ??to reduce perilesional edema. Owing to the minute size of the lesions, a biopsy for histology was not possible. However, given the poor response to antibiotics and given the likelihood of central nervous system (CNS) tuberculosis (TB) as evidenced by the clinical presentation and context, MRI characteristics, CSF analysis, and elevated inflammatory markers, anti-tuberculous chemotherapy (ATT) was empirically commenced and the steroids (dexamethasone 4 mg t.i.d.) were continued. The treatment doses of ATT were isoniazid 300 mg daily, rifampicin 450 mg daily, ethambutol 800 mg daily, and pyrazinamide 1.5 g daily for the first two months and then isoniazid and rifampicin were continued at the same doses for the rest of the duration. Antibiotics were omitted. The high-grade intermittent fever gradually subsided, but after one month of ATT, our patient became increasingly drowsy with pressure headaches and intractable vomiting, which corresponded to an increase in the size of the brain lesions and perilesional edema seen on MRI (paradoxical reaction). The dose of steroids was increased (dexamethasone 8 mg t.i.d.), and ATT was continued. From the third month of ATT, our patient showed steady improvement in clinical status, including improvement of level of consciousness with resolution of pressure headaches and intractable vomiting, improved appetite, and independent ambulation. A follow-up MRI at the end of the third month showed a significant (approximately 60%) reduction in the number of lesions (Figure ). The dexamethasone dose was reduced (by reducing both dose and frequency and by titrating dose according to symptoms) and later converted to prednisolone. Our patient was discharged on ATT to be continued for 18 months. At discharge, she was also on 20 mg of prednisolone and 75 mg of azathioprine. On review six months later, she had further improved and was independent in most activities of daily living without any remission of SLE. She was off steroids by this time."
+Esteban Skinner,40,1998/6/11,001-465-546-8946x91298,esingh@example.net,7552 Mckinney Avenue Suite 023,"A 19-year-old female Caucasian patient was diagnosed with acute lymphoblastic leukemia at the age of 15. Treatment was initiated according to the acute lymphoblastic leukemia (ALL)-10 protocol. A venous access port for intravenous infusion of chemotherapy was surgically placed with the tip of the catheter in her superior vena cava via her left subclavian vein. Treatment was continued for two years.
+Ten months after her final treatment with chemotherapy, our patient relapsed and induction chemotherapy was administered according to the ALL-R3 protocol. This was complicated by renal failure and encephalopathy and therefore mechanical ventilation and dialysis were initiated. After clinical recovery, her treatment was switched to an alternative re-induction regimen.
+During follow up treatment with 6-mercaptopurine, methotrexate, cytarabine, idarubicin, etoposide and cyclophosphamide, our patient presented to the outpatient clinic with a fever and general malaise. Blood work revealed a C-reactive protein level of 462 mg/L. The differential diagnosis included sinusitis, deep neck infection and line infection. Blood cultures were negative. A CT scan of her neck was ordered, which revealed a submental abscess extending into the submandibular space. Her skin was incised and the underlying abscess was drained.
+Our patient? fever persisted, and as the central venous catheter was still in situ it was seen as the only possible remaining cause of infection. The catheter was surgically removed without any problems, three and a half years after placement. Cultures of the catheter tip were negative, however her fever persisted and she still showed signs of ongoing infection. This inflammatory response, possibly caused by immune reconstitution, was treated with colchicine and Indomethacin. Her fever subsided and the colchicine and Indomethacin were subsequently stopped, even though her C-reactive protein level remained high (169 mg/L). Three months after removal of the indwelling central venous catheter, she underwent a stem cell transplantation.
+During stem cell transplantation, clinical suspicion arose for deep venous thrombosis of her left arm. A CT scan revealed a hyperdense structure in her left innominate vein, with thrombosis (Figure ). After a conferral with the radiologist and clinicians, it was concluded that this hyperdense lesion was a foreign body, most likely the tip of the central venous catheter which had previously been (incompletely) removed. However, on conventional chest radiographs no foreign body was visible. Due to this inconsistency, three-dimensional reconstructions were done; it became clear that this ?yperdense line??was of variable density, had an irregular surface and the continuity was interrupted at certain points (Figure ). It was now concluded that these hyperdense structures were calcifications that had developed after line removal in an old (infected) thrombus in her left innominate vein, which resembled a foreign body. She was treated with low molecular weight heparin and antibiotics, after which her fever subsided."
+Mara Villegas,18,1984/8/18,001-302-917-5428x2371,timothypeterson@example.net,25533 Michelle Expressway,"A 71-year-old Asian Japanese woman was admitted to our hospital complaining of cough, dyspnea and peripheral edema that had lasted for several weeks. On physical examination, she had a low-grade fever, an irregular heartbeat and hypertension, and an oxygen saturation of 92% with 2L/min via a nasal cannula. Peripheral lymphadenopathy and hepatosplenomegaly were absent.
+Our patient? white blood cell count was 9.4 ? 109/L, with 92.0% neutrophils, 3.5% lymphocytes, 4.0% monocytes and 0.5% basophils. She had elevated levels of C-reactive protein (11.6mg/dL; normal range <0.2 mg/dL), soluble interleukin-2 receptor (2,220U/mL, normal range: 145 to 519U/mL) and N-terminal pro-B-type natriuretic peptide (2,795.0pg/mL; normal range <125.0pg/mL).
+Virological tests related to myocarditis were negative and her angiotensin-converting enzyme level, associated with sarcoidosis, was normal. Electrocardiography showed atrial fibrillation but no evidence of any ischemic changes. Furthermore, echocardiography showed normal systolic function of her left ventricle (ejection fraction of 65%) though the diastolic function was moderately impaired (pseudonormal) due to an impairment of myocardial relaxation []: the ratio of the peak early diastolic filling velocity to the peak atrial filling velocity (E/A ratio) was increased to 1.6 in spite of the advanced age of our patient. The deceleration time did not decrease (174msec). The peak early diastolic velocity (e?? did decrease to 8.2cm/s, while the ratio of the peak early diastolic filling velocity to the peak early diastolic velocity (E/e??ratio) increased to 11.0. In addition, echocardiography revealed a diffuse and high echoic mass outside of the ventricular wall with pericardial effusion, which was originally thought to be a fibrin clot (Figure , arrow head).
+Chest X-rays showed bilateral pleural effusion with mediastinal widening. A CT scan of her body trunk was performed to better characterize the lesion anatomically, and this revealed a mediastinal mass and pericardial nodules, as well as pericardial and pleural effusion (Figure , C). Additionally, three-dimensional CT reconstruction (Figure ) showed the presence of a rough surface over the whole epicardium. These CT imaging findings showed no mass-like lesions on bilateral lung fields or within the thoracic wall.
+We next performed gallium-67-citrate (67Ga) scintigraphy to test for the existence of lymph nodes in order to make a tissue diagnosis. The 67Ga uptake was observed in the mediastinal lymph nodes, but not in other lymph nodes. Interestingly, 67Ga uptake was diffusely seen in the heart (Figure ).
+Pericardial and bilateral pleural effusions were drawn and found to be bloody, with an exudate pattern and no malignant findings on cytology. A bacterial culture revealed no microorganisms. Additionally, a flow cytometric analysis of both types of effusions showed predominant lymphocytes (B-cell to T-cell ratio of 1:4); however, there was no monoclonal pattern.
+A surgical biopsy of the mediastinal mass was considered to achieve a pathological diagnosis. However, because our patient? respiratory condition was extremely poor, neither the surgical biopsy, including thoracoscopy, nor the transarterial catheter biopsy could be performed. The most probable diagnosis was a malignant lymphoma because of the presence of a mediastinal mass and an elevated soluble interlukin-2 receptor level, which is elevated in patients with non-Hodgkin lymphoma []. Furthermore, differential diagnoses, such as myocarditis, tuberculosis and other malignant tumors, bronchogenic carcinoma, mesothelioma and melanoma were extremely unlikely based on the results of the laboratory and imaging tests. Our patient was treated with only 25mg of prednisolone, which is one of the antitumor medicines for a malignant lymphoma, due to her poor performance status and undiagnosed condition. However, the corticosteroid therapy failed to reduce the tumor size at least until day 16, when our patient? condition gradually deteriorated and she subsequently died of cardiac failure. An autopsy was performed after permission was obtained from her family. The macroscopic evaluation during the autopsy revealed that the mediastinal mass consisted of a cluster of enlarged lymph nodes. A number of disseminated masses were found on the pericardial membrane. These involvements had encircled the ventricle walls and penetrated through the cardiac layers to her endocardium (Figure , C).
+On microscopy, the mediastinal lymph nodes demonstrated a complete effacement of the normal architecture because of the dense proliferation of large blastoid cells. These cells resembled normal centroblasts, and showed large and non-cleaved cells with vesicular chromatin (Figure ). The immunohistochemical staining showed that the tumor cells were positive for cluster of differentiation (CD)20, CD79a, paired box 5 and B-cell lymphoma 2, and negative for CD3, CD4, CD5, CD8, CD45RO, CD56, multiple myeloma oncogene 1 and cyclin D1. Accordingly, the final diagnosis was established as mediastinal diffuse large B-cell lymphoma. The presumed cause of death was the impairment of cardiac function due to such lymphomatous involvement of the heart."
+Clyde Hartman,42,1996/3/4,001-223-246-1805x714,tammy53@example.net,3522 Stephenson Road Apt. 970,"A 39-year-old Thai man was referred to our institute for a pericardiectomy. He initially presented with progressive exertional dyspnea, increased abdominal girth and leg edema for nine months. He denied having cough, fever, chills, night sweats or weight loss. He was diagnosed as having HIV infection and pulmonary tuberculosis six years previously, which was complicated by pericarditis and cardiac tamponade. He was subsequently treated with antituberculosis therapy, which resulted in a cure, and he was started on a combination of stavudine, lamivudine and nevirapine.
+On physical examination, he was afebrile with the presence of marked edema in the lower extremities. His jugular veins were distended up to the mandible. He was found to have decreased breath sounds in the left lower lung area. The results of an abdominal examination were remarkable for ascites as evidenced by shifting dullness.
+The results of a sputum examination were negative for Mycobacterium tuberculosis. The chest radiograph revealed minimal fibroreticular infiltration in the right upper lung, a left-sided pleural effusion and a calcified pericardium (Figure ). Transthoracic echocardiography demonstrated normal left ventricular size with preserved left ventricular systolic function and bi-atrial enlargement. The Doppler findings were consistent with the diagnosis of constrictive pericarditis.
+Thoracocentesis yielded a milky fluid (Figure ) with a total protein level of 1.6g/dL, albumin 0.9g/dL, glucose 130mg/dL, lactate dehydrogenase (LDH) 128U/L, triglyceride 475mg/dL, cholesterol 39mg/dL and an adenosine deaminase (ADA) level of 40.6U/L (normal <45U/L). The cell count of the pleural fluid was 78 cells/mm3 with 55% lymphocytes and 29% neutrophils. Abdominal paracentesis also revealed a milky fluid and showed a total protein level of 1.7g/dL, albumin 0.9g/dL, triglyceride 535mg/dL and a cell count of 160 cells/mm3 with 79% lymphocytes and 16% neutrophils. All tests for M. tuberculosis, bacteria, and fungi from the pleural and peritoneal fluids and blood cultures were negative. In addition, a cytological examination was negative for malignant cells.
+Computed tomography (CT) of the chest showed a left-sided pleural effusion and multiple lymphadenopathies at the right hilar, right paratracheal and precarinal region (Figure ). An abdominal CT scan showed multiple small intra-abdominal lymphadenopathies. A left adrenal gland mass 3.4?1.5cm in size was noted, and a small nodule at the right adrenal gland was also detected. A percutaneous CT-guided biopsy of the left adrenal mass was performed. A histopathological examination revealed a granulomatous inflammation containing a monomorphic yeast-like organism, which was morphologically suggestive of a Histoplasma species.
+A bone marrow aspiration demonstrated no tumor or granuloma; cultures for bacteria, fungi and mycobacteria were negative.
+A lymphoscintigraphy with combined single-photon emission computed tomography/CT (SPECT/CT) imaging revealed an absence of radioactive accumulation within the pleural or peritoneal cavity in the early phase, thus excluding significant leaks from the main lymphatic tracts. On delayed images, there was radioactive accumulation in the abdomen that suggested an increased abdominal lymphatic production and a restriction of lymphatic drainage at the left subclavian vein.
+Our patient underwent a pericardiectomy and intra-operative findings demonstrated a calcified, thickened pericardium with adhesion to the heart. Histopathological findings showed pericardial fibrosis with focal calcification and no granulomas. The mediastinal lymph nodes showed a reactive change and pericardial tissue cultures for bacteria, fungi, and mycobacteria were negative.
+He was given a high-protein, low-fat diet with medium-chain triglycerides, and amphotericin B was administered to treat the disseminated histoplasmosis with adrenal involvement. Our patient was discharged home one month after the operation with resolution of his ascites and pleural effusion."
+Kennedi Fields,26,1995/6/27,478.462.6518x64482,uwang@example.com,03678 Irwin Valleys,"An 82-year-old male was referred to us after CT scanning showed a 160 mm diameter mass in the left lobe of the liver (Figure ). The mass compressed the stomach and displaced the gallbladder laterally. He was diagnosed with HCC, arising in the absence of cirrhosis or viral hepatitis.
+In 2007, he underwent his first CT scan, which showed hepatic steatosis and a normal-sized liver without focal lesions. In 2009, he was diagnosed with non-Hodgkin? lymphoma which was treated with allopurinol, pyridoxine, and folinic acid.
+In March 2009, he underwent the CT scan, which showed the hepatic mass and resulted in his referral to us. Magnetic resonance imaging was performed in April 2009, and showed an enlarged liver with a 168 mm mass in segments 2 and 3. He was diagnosed with HCC, and surgery was scheduled. He was in good nutritional condition, with no ascites or coagulopathy. Preoperative serum bilirubin and albumin levels were normal, and AFP level was 21 ng/mL (normal 0 to 7.22 ng/mL). He underwent open resection in April 2009. The tumor occupied all of liver segments 2 and 3, and was adherent to the stomach. The right lobe of the liver was normal in appearance. A left hepatic lobectomy was performed. Histological examination of the surgical specimen showed hepatocellular carcinoma with a solid trabecular pattern, and thick fibrotic septa which extended into the normal hepatic tissue at the resection margin (Figure ). There was diffuse steatosis of the surrounding liver parenchyma (Figure ).
+In August 2009, at the first postoperative follow-up, his serum AFP level was 16 ng/mL. Abdominal CT and positron emission tomography (PET) scans showed no evidence of tumor recurrence. Serum AFP levels were 15.7 ng/mL in November 2009 and 8.6 ng/mL in February 2010. A CT scan in March 2010 and PET scan in April 2010 did not show any evidence of recurrence. AFP levels were 17.2 ng/mL in May 2010; 18.4 ng/mL in September 2010; 15.4 ng/mL in December 2010; 16.2 ng/mL in March 2011; 3.69 ng/mL in June 2011; 3.58 ng/mL in September 2011; and 3.4 ng/ml in December 2011 (Figure ). The patient was investigated for other conditions that might cause elevated AFP levels. Testicular, gastric, pancreatic, biliary and lung cancer, and spherocytosis and tyrosinemia, were excluded."
+Clayton Bryan,42,1988/4/2,827.609.1432x2400,charlesramirez@example.com,7864 Amy Stream,"A Caucasian 18-month-old girl, born to an Italian family and raised in Italy, with a high-risk acute lymphoblastic leukemia (ALL) was being treated according to the AIEOP-BFM ALL 2000 protocol. After the third dose of VCR (1.5 mg/m2) she developed isolated hoarseness, but stridor appeared soon after the fourth dose of VCR (last dose of induction phase). A flexible fiber-optic endoscope study showed a bilateral VCP (Figure ). Electromyography revealed a predominantly axonal motor neuropathy involving above the lower extremities. A nerve conduction study of the larynx was not performed because the association of VCR administration with significant respiratory symptoms and immobility of the vocal folds, clearly shown by the fiber-optic endoscope, allowed us to make a definite diagnosis. No side effects of VCR other than VCP were found. Her stridor started to improve within the first seven days and both stridor and hoarseness completely resolved 28 days after the onset of palsy: a repeat laryngoscopy study showed normal vocal cord mobility.
+Following two consolidation blocks it was decided to administer VCR at full dose (1.5 mg/m2) first, and completely omit the second dose (scheduled just five days later): no side effect was noted. The first reinduction protocol II started 22 days after completion of consolidation block therapy and the four weekly doses of VCR were uneventfully administered with a one-third reduction (1 mg/m2).
+After four weeks of interim maintenance the second reinduction protocol II was scheduled and the first weekly dose of VCR was again administered at 1 mg/m2 without any problems; then our patient received glutamic acid 1.5 g daily orally in three divided doses and, one week later, a bolus injection of VCR was administered at full dose. Three days later she developed an intermittent hoarse voice lasting about 72 hours. Moreover, she manifested reduction of deep tendon reflexes, neuritic calf pain (treated with oral acetaminophen) and foot drop; the pain and foot drop resolved after about 24 hours. The following weekly VCR was omitted and glutamic acid was stopped after 10 days of overall treatment. The fourth and last dose of VCR was administered again at 1 mg/m2 and was well tolerated. She is now in complete remission and on maintenance therapy."
+Meredith Cook,33,1993/12/5,(544)748-2735x8578,fostercristina@example.com,2413 Veronica Green Suite 683,"A 54-year-old Caucasian male patient with no previous history of any disease was referred to our clinic on January 2001 with rectal bleeding. A colonoscopy showed an ulcerated polypoid mass in his rectum that was 12 cm distant from the anal verge. A pathological examination of the biopsied specimens revealed a GIST. Surgery was performed and the mass was excised by en bloc resection technique. A computed tomography (CT) scan of his thorax demonstrated no pathological finding. Multiple and non-resectable bilobar liver metastases were found on abdominal magnetic resonance imaging (MRI). Our patient was started on imatinib 400 mg daily in 2001. After an event-free follow-up period, our patient was readmitted in 2010 with complaints of right shoulder pain and limitation of shoulder movement. His liver metastases were seen to be stable on the abdominal and pelvic MRI. No local recurrence was found during a colonoscopic examination.
+MRI showed a 13 cm ? 10 cm ? 7 cm mass with partial contrast-enhancement that was T1- and T2-hyperintense and heterogeneous. The mass was destroying the body of his right scapula and had widespread involvement in the infraspinatus muscle. A fluorodeoxyglucose positron emission tomography (PET)-CT showed a hypermetabolic mass in his posterior right shoulder (Figure ). The mass was resected (Figure ). On microscopy, the tumor was composed of an interlacing pattern of spindle cells that stained negative for smooth muscle actin, and positive for CD117 (c-kit) and CD34 (Figure ). Pathologic findings were compatible with metastasis of GIST to the scapula. Following resection, his imatinib therapy was changed to sunitinib. At the time this report was written, our patient was still taking sunitinib 50 mg daily."
+Ezekiel Craig,37,1997/12/3,8443922517,wjones@example.org,03125 Jones Trace Suite 540,"A 74-year-old woman underwent computed tomography (CT) as a follow-up procedure following rectal cancer. In the findings, we detected a left supraclavicular lymph node suspected of metastasis (Figure ). The patient? past medical history includes the following: 7 years earlier she underwent rectal cancer treatment with low anterior resection and postoperative chemotherapy; 4 years earlier she underwent a total hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy for a stage IIIc endometrial adenocarcinoma (pT1cN1M0). Figure shows the changes of tumor markers (CA19-9, CA125, and CEA) from the time of diagnosis to the present. Subsequent to the operation, the patient received adjuvant chemotherapy. Approximately 1 year later, the patient underwent para-aortic lymphadenectomy and additional chemotherapy for the recurrence in the para-aortic lymph node of endometrial adenocarcinoma. There was no clinical evidence of local or distant recurrence from either of the two malignancies at follow-up.
+Fine needle aspiration biopsy of the left supraclavicular lymph node showed adenocarcinoma metastasis. Positron emission tomography-computed tomography (PET-CT) revealed high uptake (SUVmax 6.0) in the left supraclavicular lymph node but no other metastatic lesions elsewhere (Figure ). Middle and lower jugular neck dissection was performed in 2011 on the grounds that volume reduction would contribute to the improvement of prognosis, and residual metastasis was only identified in the left supraclavicular lymph node. A skin incision was made 2 cm above the left clavicle. Some solid lymph nodes could be palpated between the left sternocleidomastoid muscle? sternal head and clavicular head. The thoracic duct was also resected with the supraclavicular metastatic lymph nodes (Figure ). There was no lymphorrhea from the juglosubclavian angle. To prevent chyle fistula, the inferior belly of the omohyoid muscle was cut distally and tightly sutured on the venous angle (Figure ). The sternocleidomastoid muscle? sternal head was obliterated into the dead space of the venous angle with absorbable sutures. A continuous suction drainage tube was inserted into the supraclavicular space. Surgical time was 49 min and blood loss during surgery was 10 mL. Following the operation the amount of drainage was slight and the drainage tube was removed on the second postoperative day. The patient left hospital on the fifth postoperative day without any complications such as dysfunction of the upper limbs or shoulders.
+A histological examination showed that there was no metastasis among the six dissected lymph nodes at level III, and only one metastasis was detected among the 11 dissected lymph nodes at level IV. An immunohistochemical staining examination using cytokeratin 7 and cytokeratin 20 was performed in order to diagnose the primary disease and determine whether it was rectal cancer or endometrial cancer. The immunohistochemical staining examination indicated that the neck metastasis originated from endometrial adenocarcinoma [,] (Figure ).
+Extracapsular spread was not detected pathologically and consequently the patient received no additional adjuvant treatment. The patient now lives a normal life without recurrence."
+Brynn Baldwin,26,1982/7/25,894-767-4934,lancebrown@example.com,532 Richard Port,"The case involves a 58-year-old Caucasian man who presented to a regional hospital with a 24-hour history of severe PR bleeding. Our patient described the bleeding as being acute in onset, bright red with clots and associated with mild left iliac fossa pain. He had no other gastrointestinal symptoms prior to the bleed and had no history of colorectal disease. Of note, he had undergone a THA 31 days prior to his transfer from the regional hospital to our tertiary referral center and was taking oral rivaroxaban as a prophylactic anticoagulant in the postoperative period at a dose of 10 mg once daily. He was on no other medications and had no history of renal disease.
+On arrival at the regional center, our patient had hemodynamic stability but his PR bleeding continued with multiple episodes involving an average of 250 to 500 mL in volume. His hemoglobin (Hb) level dropped from 12.0 g/dL on admission to 10.3 g/dL and subsequently to 7.4 g/dL over a 24-hour period. His coagulation profile and platelet levels were normal as was his renal function. An abdominal computed tomography scan revealed uncomplicated diverticular disease but no other abnormalities. Upper gastrointestinal endoscopy was also performed, which showed very mild gastritis but no source of hemorrhage. In the 24 hours between admission and transfer to our tertiary referral center, he received a total of nine units of packed red blood cells (PRBCs) in order to maintain hemodynamic stability.
+Following transfer to our tertiary referral center, our patient had ongoing bleeding but remained hemodynamically stable. His vitals were as follows: heart rate, 98 beats/minute; blood pressure (BP), 134/71 mmHg; respiratory rate, 20 breaths/minute; oxygen saturation level, 98% on room air; and temperature, 36.0簞C. On examination, he was pale but alert and chatty. His abdomen was soft with some mild tenderness in the left iliac fossa and there were no palpable masses, no evidence of organomegaly and bowel sounds were present. A PR examination was positive for fresh blood. His respiratory and cardiovascular examinations were both normal. His Hb level on admission was 8.3 g/dl (as shown in Table ). Our patient was kept strictly nil by mouth and commenced on eight hourly intravenous fluids. A group and cross-match was taken with four units of PRBCs on standby. He was to have repeat Hb levels taken if further hemorrhage occurred and his hemodynamic parameters were observed every two hours. After a further bleed overnight, he received one unit of PRBCs.
+During the next 15 hours, our patient had a further two episodes of fresh blood PR whilst receiving three units of PRBCs. After the second episode his Hb level was 8.5 g/dL and he was prescribed a further two units of PRBCs as well as being commenced on an intravenous proton pump inhibitor. His BP subsequently dropped to 90/57 mmHg and his intravenous fluid regime was increased to 1 L every four hours with orders that he also receive Gelofusine (a succinylated gelatin solution) if his BP dropped again. He had four further episodes of bleeding over the following six hours and received two more units of PRBCs during this period. This was a total of eight units since his arrival to our tertiary referral center 24 hours earlier and 17 units in total since his presentation.
+Due to the increasing frequency of these hemorrhagic episodes, our patient underwent emergency computed tomography mesenteric angiography. A consultant interventional radiologist could identify no obvious source of bleeding but ordered that our patient be returned immediately to the interventional radiology suite for embolization if further episodes of fresh blood PR occurred. His Hb level at this time was 11.4 g/dL and our patient was hemodynamically stable.
+Over the next four days, our patient improved significantly with no further episodes of PR bleeding. He resumed a normal diet after three days and was discharged home well with a Hb level on discharge of 10.4 g/dL. His renal function remained within normal limits throughout his hospital stay.
+Our patient returned six days later, having experienced no further symptoms, and underwent a colonoscopy that was entirely normal. When he was seen again six weeks later in the outpatient clinic; he was asymptomatic and reported feeling great. He was subsequently discharged from our service."
+Jaiden Simmons,19,1982/3/6,+1-883-803-5599x484,weaverjose@example.com,338 Evans Highway,"In 2007, a 58-year-old white male with no history of tobacco use, hypertension, diabetes, or hypercholesterolemia, and no family history of coronary artery disease, was found to have a large solid right renal mass and associated tumor thrombus of the inferior vena cava and right atrium. He underwent right radical nephrectomy and tumor thrombectomy performed under extracorporeal circulation. Cardiac function was investigated, including coronary angiography and transthoracic and transesophageal echocardiography. These studies documented normal cardiac function and normal morphology of the coronary arteries. Pathological examination of the surgical specimens demonstrated pT3cN0Mx conventional (clear cell) renal carcinoma, Fuhrman Grade 3 with negative surgical margins. A regular follow-up program was started. A few months later, hepatic and contralateral renal metastases were detected. The patient started treatment with the tyrosine kinase inhibitor (TKI) sorafenib on a dose-escalation protocol. Treatment led to an initial partial response followed by stable disease for 6 months. During December 2008, in a setting of stable disease, he underwent hepatic resection and enucleation of the left renal mass. The hepatic and renal masses were confirmed to be metastases. Early radiological assessment after surgery showed no residual hepatic or renal disease, but possible involvement of the mesenteric lymph nodes. Sorafenib treatment was therefore restarted at a standard dose of 800 mg/day. Treatment led to complete disease response within a few months, and was very well tolerated by the patient, who did not experience any of the typical adverse effects of the drug.
+During February 2011, after 30 months of sorafenib treatment (6 months at 1600 mg/day and 24 months at 800 mg/day), the patient started to complain of worsening chest pain precipitated by normal physical exercise. A cardiac stress test showed exercise-induced ischemia. Coronary angiography showed critical sub-occlusion of the common trunk of the left coronary artery and the circumflex artery (Figure ). The patient subsequently underwent triple coronary artery bypass surgery and is now recovering and in good clinical condition. Sorafenib treatment has been discontinued."
+Reagan Costa,30,1993/9/6,(430)301-7840,christophercook@example.net,8265 Garrett Ports,"A 2.4 kg female infant was born at 38 weeks gestation to a 28-year-old primigravida via elective cesarean section. Birth weight was 2401 grams (2nd percentile), length was 48 cm (29th percentile), and head circumference was 34 cm (32nd percentile). The baby was diagnosed with a left sided CDH at 14 weeks gestation by routine prenatal ultrasound. Due to the prenatally diagnosed CDH, the baby was intubated at birth, made nothing per os, and placed on intravenous hyperalimentation providing a glucose infusion rate (GIR) of 8 mg/kg/min. Although her blood glucose concentration was normal at birth (103 mg/dl), she developed marked hyperglycemia (493 mg/dl) at 9 hours of life.
+Family history was notable for neonatal diabetes in the paternal grandmother that resolved within 2 months. She developed adult-onset diabetes in the 4th decade of life despite a lean body habitus.
+Pertinent physical findings in our patient included shallow supraorbital ridges, relatively prominent eyes, a mildly protruding tongue with micrognathia, mild pectus excavatum, and bilateral accessory nipples. She had a normal cranial shape, no central forehead nevus flammeus, normal ears without pits, and no evidence of limb asymmetry. She had normally developed female genitalia and an otherwise normal skin exam (See Additional file ).
+Initial laboratory evaluation revealed negative urine ketones, undetectable serum insulin concentration (< 0.5 mcIU/ml), and a low serum C-peptide concentration (0.2 ng/mL). Arterial blood gas and electrolyte measurements demonstrated a non-anion gap metabolic acidosis with an elevated serum lactate (2.47 mmol/L). A thoracoabdominal ultrasound performed on day of life 2 revealed a pancreas without definite abnormality, but bowel gas prevented optimal delineation of the organ.
+Initial management included decreasing the GIR, but a concomitant decrease in blood glucose was not observed. Over the next 6 hours, she was treated with 3 subcutaneous injections of 0.5 units rapid-acting insulin analog, which failed to normalize her blood glucose concentration. A continuous intravenous infusion of regular insulin was started with an initial rate 0.04 units/kg/hour. Six hours after initiating the insulin infusion, her blood glucose concentration fell below 200 mg/dl and insulin was briefly discontinued. Her blood glucose concentration gradually increased to 230 mg/dl over the next 6 hours, and a simultaneous serum insulin level was <0.5 mcIU/ml. Therapy with continuous intravenous insulin was resumed at 0.03 units/kg/hour. The rate of the infusion was then titrated to achieve blood glucose concentrations between 200??00 mg/dl. The maximum rate of insulin administration was 0.12 units/kg/hour.
+On day of life 4, blood glucose concentrations were stable on 0.02-0.05 units of insulin per kg per hour and our patient underwent surgical repair of her CDH. At repair she had a moderately severe hernia with small bowel, colon, stomach, and spleen in the left chest. Her CDH was associated with a 50% loss of normal diaphragm and was repaired with a patch. Her left lung was approximately 30% of normal size. She transitioned to oral feeds approximately one week after the operation.
+In preparation for discharge home, our patient was transitioned to continuous subcutaneous insulin infusion (SCII) therapy with rapid-acting analog diluted 10-fold. A single basal rate of 0.5 units/hr of U-10 insulin was programmed in the pump (total daily dose 1.2 units). Blood glucose was monitored every 3 hours (typically before breastfeeding) and a correction bolus of insulin was given for blood glucose values greater than 350 mg/dL. Use of a continuous glucose monitoring system was considered, but our patient had so little subcutaneous fat that sensor placement was deemed impossible. Upon discharge, her insulin requirement quickly waned, and the insulin was discontinued at 7 weeks of age.
+At her three-month visit, she was thriving, with a weight of 4004 grams, and a hemoglobin A1c of 4.7%. Comparative genomic hybridization microarray analysis using a 180 K oligonucleotide array platform revealed a 389 K micro-duplication in region 6q24.2, which includes the paternally expressed PLAGL1 (pleomorphic adenoma of the salivary gland gene like 1) and HYMAI (hydatidiform mole associated and imprinted [non-protein coding]) genes known to be associated with TNDM. An additional gene, PHACTR2 (phosphatase and actin regulator 2), also maps within the same deletion boundary, though presumably it is not related to the problems in our patient. The same duplication was found in her father, who did not have neonatal diabetes and who does not have considerable hyperglycemia, as evidenced by a normal HbA1c (personal communication, MJ Haller).
+The same micro-duplication in region 6q24.2 was discovered in our patient? paternal uncle and his unborn child. Amniocentesis demonstrated the presence of the mutation in our patient? first cousin. At birth, the baby boy followed a very similar course to our patient. He was small at birth, weighing 1710 grams at 34 weeks gestation (5th percentile). Hyperglycemia developed in the first 24 hours of life, and insulin therapy was required for 6 weeks before resolution occurred."
+Kenji Jacobs,41,2001/4/23,958.888.9406,ihill@example.net,754 Green Cliffs Apt. 876,"The 11 years and 2 months old girl presented to the pediatric endocrinology department for evaluation of short stature . After normal longitudinal growth in infancy, the patient? height SDS dropped from ??,67 SDS to ??.23 SDS between the ages of 2.5 and 4.5 years. Subsequently, she resumed normal height velocity, and height SDS at 10.5 years was preserved at ??.96. At presentation, height SDS was ??.10, weight SDS ??.38 (Figure ) and documented height velocity was SDS ??.2. The midparental height SDS was 0.59.
+Central hypothyroidism had been diagnosed 4 months before presentation. The girl is of normal intelligence, her school achievement is above average.
+As far as we can determine retrospectively, there was no clinical suspicion of hypoglycemia during the newborn period. There was no history of severe illness. Febrile infections were tolerated well and could all be treated at home.
+The patient had a history of a congenital right-sided facial hemangioma of plaque-morphology (Figure ). This was treated in infancy with interferone- followed by laser therapy. The clinical examination revealed a prepubertal stage (Tanner PH1, B1).
+Because of the described empty sella on MRI, comprehensive endocrine function testing was performed. Reference ranges are given in parentheses.
+繚 The GnRH test showed central hypogonadism (Table ). Estradiol was undetectable (<5 ng/l) until treatment with estradiolvalerate was initiated.
+繚 A diurnal profile of cortisol incretion was not obtainable, but repeated measurements of ACTH and serum cortisol after an overnight fast showed persistently low levels for both parameters, with a peak cortisol level of 2.7 弮g/dl (6.2-19.4), and a peak ACTH level of 12 pg/ml (7.2-63.3). 24 h urinary cortisol excretion was low with 4,4 弮g/d (36.0-137.0), and DHEAS was low with 18.1 弮g/dl (33.9-280.0).
+繚 Thyroid stimulating hormone (TSH) levels never exceeded 0.024 mIU/l (reference range 0.51-4.3), supporting the diagnosis of central hypothyroidism. Free thyroid hormone (fT4) levels were normal on levothyroxine supplementation.
+繚 Arginine stimulation test, performed twice on separate days, revealed absolute growth hormone deficiency (see Table ). IGF-1 and IGFBP-3 were normal initially, but decreased before starting GH therapy 9 months after the initial presentation to 25 ng/ml (122??55) and 2460 ng/ml (2600??100) respectively.
+In summary, our patient suffered from hypogonadotropic hypogonadism, secondary adrenal insufficiency, central hypothyroidism and absolute growth hormone deficiency.
+MRI of the brain confirmed the findings of complex structural cerebral- and cerebrovascular arterial anomalies with cerebellar dysplasia on the right side, deformation and dislocation of the brain stem, and aplasia of the right carotid (Figure ). The empty sella (Figure ) appeared to be caused by dorsal displacement of the infundibulum by arachnoidal cysts, which were stable in size over the course of one year. Cranial of the neurohypophysis a structure that appears to be a considerably reduced adenohypophysis was identified.
+To rule out further organ involvement, an echocardiography and electrocardiography, as well as an abdominal ultrasound were performed and were unremarkable.
+The radiologic bone age of the left hand was 4 years delayed according to the standards of Greulich and Pyle.
+We initiated substitution of hydrocortisone at 10 mg/m2/d p.o. immediately and GH treatment with 25 弮g/kg/d s.c. after 9 months (Patient aged 11 years and 11 months). The delay in starting GH treatment was due to the patient's intense fear of injections and therefore reluctance of the family to start treatment. In the absence of spontaneous pubertal development, Estradiolvalerate 0,3 mg/d was started at the age of 13 years and increased to 0,6 mg/d after 6 months at pubertal stage B2, PH2. The treatment with thyroxine was continued.
+The patient is now 13 years and 6 months old. Her height has reached the 3. Percentile (??,5 SDS)(Figure ) and stage of puberty is Tanner B2, PH2."
+Camilla Tanner,20,1987/12/10,+1-347-930-9891x571,padillavincent@example.net,72108 Fisher Port,"A 21-year-old Chinese man presented to our hospital with fatigue and wordlessness lasting for one year along with elevated transaminase levels for one month. One year before presentation, suffering from work and love problems, our patient had begun to complain of fatigue accompanied by wordlessness, low mood, occasional vomiting and anorexia. Subsequently, he had been diagnosed with depression disorder and had received anti-depression therapy in his native hospital several times, but to little effect. He turned to a native witch and ingested living earthworms and geckos for 10 days at her suggestion. One month before his admission to our hospital, a laboratory evaluation revealed that his transaminase level was elevated. He denied fever, jaundice, abdominal pain, melena, changes in bowel habits, chest pain, respiratory symptoms or visual changes. Furthermore, in the previous year he had unintentionally lost 25kg in weight. Nothing notable was found in his medical history or previous drug therapy.
+His physical examination demonstrated malnutrition, scythropasmus and low voice. No skin eruption was observed. His heart, lung and abdominal examination showed no sign of any abnormality. A neurologic examination did not reveal any focal deficits.
+Laboratory examination showed a white blood cell count (WBC) of 16.5 ? 109/L, with 75.6% eosinophils, alanine transaminase (ALT) 143U/L, aspartate transaminase (AST) 112U/L, gamma-glutamyltransferase (GGT) 176U/L, total bilirubin (TB) 33.1弮mol/L, direct bilirubin (DB) 19.0弮mol/L and indirect bilirubin (IB) 14.1弮mol/L. Multiple stool examinations detected Trichuris trichiura ova but no other parasite ova or larvae. A positive reaction in his serum to common parasite antigens was only detected against Paragonimus. An abdominal ultrasound (US) detected multiple small and hypoechoic nodular lesions (Figure A). A bone marrow biopsy revealed obvious eosinophilia. An US-guided liver biopsy was performed and revealed marked edema of hepatocytes, local necrosis, sinusoidal hemorrhage and heavy eosinophil leukocyte infiltration of portal areas (Figure A). No microorganisms were observed.
+According to these findings, parasitic infection accompanied by VLM was suspected, combined with depression disorder. A course of albendazole was administrated at a dosage of 400mg once daily for 14 days. One month later, a laboratory examination was conducted and showed WBC 10.4 ? 109/L, with 18.14% eosinophils, ALT 88U/L, AST 65U/L, GGT 95U/L, TB 31.2弮mol/L, DB 16.0弮mol/L and IB 15.2弮mol/L. Abdominal US revealed the disappearance of the previous multiple hypoechoic nodular lesions (Figure B). A repeated liver biopsy showed spot necrosis and partial cholestasis with some neutrophil and eosinophil leucocytes infiltration in the portal space (Figure B).
+A second course of anthelmintic treatment (albendazole, 400mg/day) was given for another 14 days. Six months after the second course, a laboratory evaluation showed: WBC 9.3 ? 109/L with 10.6% eosinophils, ALT 45U/L, AST 42U/L, GGT 68U/L, TB 28.5弮mol/L, DB 13.0弮mol/L and IB 15.5弮mol/L. No parasite ova or larvae were detected in a repeated stool examination. A repeated abdominal US and bone marrow biopsy were normal. A third liver biopsy showed hepatocyte edema accompanied by mild neutrophil and eosinophil leukocyte infiltration in the portal space, but no necrosis was observed (Figure C).
+A third course of anthelmintic therapy (albendazole, 400mg/day) was administrated for an additional seven days. Two weeks later, praziquantel was prescribed at a dosage of 1g twice daily for three days (120mg/kg, the fourth course). Two weeks after the fourth course, the laboratory examination results were almost normal except for slightly elevated eosinophil percentage (6.6%). Three months later, our patient presented with increased physical activities and his laboratory data all returned to a normal range (WBC 6.5 ? 109/L with 4.0% eosinophils, ALT 27U/L and AST 25U/L)."
+Bruno Cantrell,20,1987/7/26,454.685.4089x201,savannahgarza@example.net,58435 White Trail Apt. 294,"A 36-year-old immunocompetent male with history of gastroesophageal reflux presented with a 5-year history of dyspnea on exertion, chest tightness, shortness of breath, palpitations, and back pain. Physical exam revealed a heart murmur, ECG showed a Mobitz I AV block, RBBB, and right axis deviation, and chest radiograph demonstrated an enlarged heart. Laboratory studies were normal.
+Transthoracic echocardiography revealed heterogeneous infiltration involving the aortic root and four chambers with marked biventricular wall thickening and moderate pericardial effusion (Figure ). The infiltrated myocardium stiffened the heart and significantly impaired systolic and diastolic functions. Computed tomography (CT) revealed a diffuse soft tissue density wrapping around the great vessels.
+The patient was admitted and subsequently underwent endomyocardial biopsy prior to initiating treatment. Immunohistopathology showed infiltration of the myocardial fibers by atypical intermediate to large-sized lymphoid cell (Figure ) that were positive for CD20, CD10, CD79, CD19, and LCA. Bone marrow biopsy revealed normocellular bone marrow, without evidence of lymphoma infiltrate. The final diagnosis was primary diffuse cardiac large B-cell lymphoma.
+The patient subsequently received chemotherapy. The 1st cycle consisted of cyclophosphamide/vincristine/prednisolone (COP), omitting doxorubicin due to concern of heart toxicity given the heart block. Doxorubicin was added for the 2nd cycle (CHOP), and rituximab was added for the 3rd through 7th cycles (R-CHOP). CT showed diminished cardiac size after the first cycle. After the 2nd cycle, the patient developed ventricular tachycardia and received synchronized cardioversion with resultant 1st degree AV block. He then experienced paroxysmal ventricular tachycardia after the 4th cycle that responded to cardioversion.
+The patient responded well to chemotherapy. ECG 6 months after treatment showed normal sinus rhythm. Follow-up echocardiogram demonstrated adequate global systolic and diastolic functions, with significant reduction of myocardial thickness and resolution of pericardial effusion (Figure )."
+Yamileth Rosales,34,1987/7/14,+1-610-242-0666x07321,corey53@example.org,39672 Shelia Rapid,"A 33-year-old man presented to us with rashes on the scrotum of 2 years duration. The rashes have been painless, gradually increasing in size and number to the current state. There was no preceding history suggestive of sexually transmitted disease (STD), trauma, inflammation to the scrotum. He is not a known diabetic, and not on any immunosuppressive drugs. There are no features suggestive of hypercalcaemia.
+On physical examination, he was fit looking with Athletic physique. Review of systems was normal. The main finding was on scrotal examination, which revealed multiple nodular lesions involving the ventral surface of the scrotum, sparing other part of the scrotum and the penis. The largest nodule measured about 6 mm by 5 mm (). The lesions were not ulcerated or tender. Scrotal X-ray revealed multiple opacities in area of the lesions (). Serum calcium, phosphate and albumin were within reference value. Diabetes and retroviral screening were negative.
+Histology of the incisional biopsy showed calcium deposits in the dermis of scrotum surrounded by pseudocapsule and histiocytic inflammation. No evidence of cyst wall or keratin. He requested for excision on cosmetic ground. Wide local excision of lesion with direct closure was done with good postoperative outcome. The intraoperative and postoperative findings were shown in Figures , , and . Histology of the excised lesion remained the same. He was seen 16 months postoperatively, with no evidence of recurrence."
+Wilder Coffey,34,2002/8/25,+1-262-478-9746x842,shawn22@example.com,31530 Wright Fields,"A 6-year-old male child had reported with the chief complaint of dental decay. The patient's medical history and family history were noncontributory.
+Intraoral examination showed missing right primary central incisor and presence of mesiodens erupting into the oral cavity in the same place (Figures and ).
+Intraoral periapical radiograph revealed deviation of 11 slightly due to presence of mesiodens and overlapping of 11 over 12 was observed ().
+Also primary central incisor was exfoliated due to presence of mesiodens and mesiodens was not completely erupted. Only 2??.5 mm of crown of mesiodens was visible intraorally. The mesiodens was responsible for deviation of permanent central incisor but was not extracted. Patient was kept under observation till the eruption of permanent right central incisor."
+Paola Roberson,41,1988/7/20,6954594378,hbrown@example.org,69248 Tony Coves,"A 6-years-old male child was reported for dental check up. On intraoral examination, mesiodens was seen ().
+Intraoral periapical radiograph of the patient showed that presence of mesiodens did not affect the position of permanent central incisors. Mesiodens was conical in shape with long root. Considering that the presence of mesiodens will be responsible for noneruption of permanent central incisors, as a precautionary measure, it was extracted. (Figures and ).
+Patient was kept under observation till the successful eruption of permanent central incisors."
+Shepherd Conway,42,1979/3/26,833-212-7395x22664,hlloyd@example.net,0558 Michelle Overpass Apt. 605,"A 5-year-old male patient was reported for the dental checkup. On examination mesiodens was seen in upper arch ().
+Patient was very uncooperative. Radiographically, it was rotated and only crown portion was formed. It was conical in shape ().
+Considering that the presence of mesiodens may be responsible for noneruption of permanent central incisors, thus, as a precautionary measure, it was kept on regular followup so that preventive or interceptive measures can be applied at right time."
+Ryann Walton,28,1993/5/11,557-685-1915x8561,james30@example.org,44021 Tina Isle,"A 4-year-old female patient reported with the chief complaint of unerupted lower front teeth. Patient's medical history revealed that patient was a postoperated case of complete midline cleft palate, treated at the age of one year. Family history of the child was noncontributory.
+Oral examination showed missing mandibular incisors and canines with an embedded supernumerary tooth in the midline ().
+Anterior occlusal radiograph showed missing permanent mandibular tooth buds of 31, 32, 33, 41, 42, and 43 in lower anterior region with an embedded and obliquely placed supernumerary tooth which was parallel to the contour of the alveolar ridge with conical crown facing towards left side and long root facing towards right side of the mandibular arch ().
+The treatment was aimed at addressing the patient's need for improved speech and aesthetics. So the embedded supernumerary tooth was extracted."
+Dominick Bishop,35,1997/11/25,252-851-0370x9479,pughlisa@example.com,5579 Glass Key Suite 849,"Three 3-months-old male red-legged partridges (Alectoris rufa, Linnaeus 1758), suddenly died in October 2010, were sent to the Department of Veterinary Public Health, Unit of Pathology, for clinical and pathological investigations. The birds were part of a group of 100 animals belonging to the same species reared in a private farm located on a hill in the district of Messina. No other animal species were present in the farm. The owner bought the young birds from a private farm located in the northern Italy and grew them up without producing eggs by himself. The farm extended on a half hectare of land, exclusively deep litter system type. The owner built a circular box, about 10 m in diameter, enclosed with a metal net, about 2 m in height laterally and 3.5 m centrally, with no natural and artificial lairs; within this aviary, the owner put in a bedding of mixed straw and wood shaving directly on soil and rarely replaced it, feed box with low edge and iron poultry drinkers; subjects were introduced and subdivided in different classes of age. For three months-aged animals, food mainly consisted of commercial mixed pellet based on cereals, leguminous and minerals without any antimicrobials and coccidiostats. No vaccination protocols were applied. Anamnestic data collected from the owner referred of a sudden isolation of the diseased animals, with apathy, diarrhea and ruffled plumage; moreover, close to a diseased bird, respiratory rattles were be heard. When the first three birds died, early during the outbreak, suspecting zoonosis, the owner required necropsy. The farmer administered by himself the remaining partridges antibiotic therapy (enrofloxacin); over a three weeks??period all the remaining birds died. Post mortem radiographic exam was performed prior to necropsy on the three dead subjects. Written informed consent was obtained from the owner for publication of this report and any accompanying images. Necropsy was performed following the method proposed by Taccini et al. []. Cytological imprinting smears, obtained from lungs, liver and kidneys were stained with May Grunwald Giemsa (Bio-Optica SpA, Milano, 20134, Italy). Tissue samples obtained from the following organs, lungs, liver, esophagus, crop, proventriculus, gizzard, spleen, intestine, brain and skin were collected and fixed in 10% buffered formalin and embedded in paraffin wax. Microbiological exams for anaerobic and aerobic bacteria, virus isolation for paramyxovirus and other viral agents [], as well as parasitological examinations for intestinal protozoa and nematodes were performed to rule out other primary diseases. For the histopathological exam, 5 弮m thick histological sections were obtained and stained with Haematoxylin and Eosin (Carlo Erba Reagenti Spa, Rodano, 20090, MI, Italy), as well as with two other histochemical tests helpful to identify fungal elements, Periodic Acid Schiff (PAS) (Bio-Optica SpA, Milano, 20134, Italy) and Grocott (Bio-Optica SpA, Milano, 20134, Italy). On the basis of microscopic examination of paraffin embedded tissues, molecular tests for fungal pathogens were performed by a ribosomal internal transcribed spacer targeted amplification reaction.
+For this purpose the samples were pre-treated with mineral oil at 95 簞C for 5 min for three times [] to eliminate the paraffin embedding tissues. This pre-treatment is necessary to avoid PCR inhibition and permits the amplification of target DNA sequences as long as 611 nts.
+Successively total DNA was extracted from lung and gizzard paraffin embedded tissue sampled from three birds by using a QIAmp DNA mini kit (QIAGEN, Hilden, 40724, Germany). The contaminations were escluded during the DNA extraction, amplification or elution steps by application of the good laboratory practice. Moreover the extraction took place in a controlled area, in sterile mode, by using disposable and filtered equipments. The DNA was specthrophotometrically quantized and employed in PCR test targeted to the ribosomal regions. The DNA sequences, known as ITS, were amplified by primers annealing at the end of 18 S and 5.8 S ribosomal genes. This approach permits the use a couple of fungal universal primers to amplify a species specific DNA sequence. Species was after revealed by application of sequencing protocol on the PCR product. Amplification of the ITS1 and ITS2 regions was performed with universal fungal primers ITS1 (5??TCCGTAGGTGAACCTGCGG-3?? and ITS4 (5??TCCTCCGCTTATTGATATG-3?? []. The full ITS region was amplified by PCR in a final reaction volume of 50 弮l. Each reaction mixture contained approximately 10 ng of template DNA; 0.4 pmol (each) forward (ITS1) and reverse (ITS4) primers; 10 弮M (each) dATP, dCTP, dGTP, and dTTP; 10X reaction buffer containing 1.5 mM MgCl2 (AB) and 2 U of Taq Gold (AB). The amplification was performed in a 9700 thermal cycler (Applied Biosystems Inc., Foster City, California, 94404, USA). An initial denaturation step (94 簞C for 5 min) was followed by 35 cycles (with each cycle consisting of DNA denaturation at 94 簞C for 30 s, primer annealing at 55 簞C for 30 s, and elongation at 72 簞C for 1 min) and a final extension step at 72 簞C for 7 min. A no-template negative control was included in each PCR run. The PCR products were purified with a Spin PCR purification kit (QIAGEN, Hilden, 40724, Germany), following of the manufacturer? protocol. The DNA was eluted in 25 弮l of double-distilled H2O. The purified PCR products were sequenced with the primers ITS1 and ITS4 in two different reactions using BigDye Terminator cycle sequencing 1.1 kit (Applied Biosystems Inc., Foster City, California, 94404, USA). Sequencing was performed on an ABI Prism 310 DNA sequencer (Applied Biosystems Inc., Foster City, California, 94404, USA). The obtained data were analised by Wu Blast 2 sequence allignment software, considering 97% identitiy as the stringent parameter for strain identification.
+Total body lateral projection radiograph showed an increased perihilar interstitial pattern and air bronchogram signs due to lung edema (Figure ). At necropsy carcasses showed similar features. Birds were cachectic (70/80gr 簣 in weight); the pericloacal region was soiled by diarrheic fecal material. Opening the mouth, a little amount of mucous fluid finely distributed on a slightly reddish mucosa was seen; opening the abdominal cavity, similar features were detected on the esophagus, crop, proventriculus and gizzard. The intestine was dilated and filled by a yellow fluid content. Liver, lungs, kidneys and heart showed slight increase in volume when compared to normal size and were dark red in colour, suggesting a congestion; a serum haematic fluid oozed out on cut section. At microscope, cytological smears revealed several hyphae, pseudohyphae and blastospores. No further pathogens were detected or isolated. Histopathological exam of the lung, showed slight edema and congestion of the blood vessels, with different fungal elements, free in the tissue and within vessels, referable to blastospores, hyphae and pseudohyphae; similar bodies were detected in all organs and tissues; moreover very few macrophages were identified. In the esophagus, crop, proventriculus and gizzard, numerous vesicles surrounded by a thin fibro-connective wall, containing blastospores and pseudohyphae, were detected in the sub mucosa and sometimes in the muscularis mucosa. Some of these vesicles opened towards the mucosal epithelium. Fungi were Grocott (Figure ) and PAS positive. Neither further tissue changes nor pathogens were detected in the remaining organs. The PCR revealed an amplified product of the expected size. The sequence was analyzed and assembled by Sequencing Analysis Software (Applied Biosystem) which collect the registered data at the genetic analyzer (GenBank, NCBI, Bethesda, Maryland, 20894, USA) for the alligneament by Wu Blast 2 software (NCBI, Bethesda, Maryland, 20894, USA). The comparison with all the published sequences on GeneBank, demonstrated a major alligneament, with a 98% identify and minus penalty score for Leucosporidium scottii internal transcribed spacer (ITS), corresponding to the accession number GenBank: AF444496 []. The tests were repeated two times starting from two different DNA extraction to confirm the results and twice the obtained sequence was identified as belonging to L. scottii with a 100%-98% identity level. There are other very closely related sequences such as L. creatinovora with a 97% sequence similarity. To our sequence was assigned the accession number JX014242 indicating a 596 bp long L. scottii ITS region."
+Brooklynn McMahon,27,2001/3/20,(750)684-6032x812,tabitha94@example.org,830 Lee Cliff,"This 58 years-old man presented with a 6-month history of progressively worsening low back pain. The intensity of pain, assessed by using the visual analogue scale (VAS), was scored at 8/10. His pain was radiating to legs and impairing deambulation. His medical history was significant for hypertension. In 2008, the patient underwent microsurgical decompressive undercutting and implantation of an interspinous/interlaminar Coflex device because of L4-L5 stenosis (as documented by MRI).Postoperative and 45-day follow-up radiographic images ensured proper device position and maintenance of the range of motion. On postoperative and 45-day follow-up examination, the patient showed a quite total resolution of the prior clinic (VAS 3/10). In 2011, the patient came to our attention for recurrence of motor weakness with the L5 myotome affected, decreased Achilles and patellar reflexes, and neurogenic claudication. The X-rays, CT scan with bone windows (), and MR images revealed a mature ossification of the device with relevant restenosis. Because of the patient's disabling neurological symptoms, it was felt appropriate to treat it surgically.
+The patient was placed in a knee-chest position. A midline incision was then made and soft tissue was accordingly dissected free from the bone in a subperiosteal fashion down to the laminae, on both sides. An abnormal osseous tuberosity was subsequently detected surrounding the L4 and L5 spinous processes. The interspinous/interlaminar Coflex device implanted at that level was not detectable, as also visible in . Hence, we started to resect the new bone formation with a chisel. The ?-shaped??part of the device was completely filled by bone. Therefore, we proceeded the resection till the device was free to be removed. In addition, the dura mater was all covered by interlaminar bone which was consequently removed by using Kerrison rongeurs. Finally, gross-total resection of the new bone formation was achieved. Moreover, L4-L5 laminectomy with facet joints preservation and L3, S1 undercutting were performed. Then, secure haemostasis was obtained, and the wound was extensively irrigated and closed in layers.
+Resection of the pathologic bone formation resulted in a rapid neurological recovery (VAS 3/10), and the patient could then walk independently. Nonsteroidal antiinflammatory drugs were used for few weeks in the postoperative period. At the 2-month followup, the patient had a great reduction in pain and disability."
+Jakob Davenport,28,2001/8/25,001-804-842-7297x689,robertskayla@example.org,65749 Espinoza Burg,"A 70-year-old female patient was referred to department of Oral Medicine and Radiology with a chief complaint of a swelling in left side of neck since 12 days and pain in swelling since 10 days. Pain was increased in intensity while swallowing. Patient gives no history of fever and difficulty in eating and speaking. Patient noticed that initially swelling was initially small in size and gradually increase to present size of 4-3 cm. The patient's medical history was unremarkable.
+Clinical examination revealed that spherical shape swelling was present and that measured 4-3 cm in diameter. Swelling extending from 1 cm below lower border of mandible to upper border of thyroid cartilage. Swelling has well-defined and regular border, surface was smooth and skin over the swelling was red and shiny. It was tender on palpation but temperature was not raised. Consistency of swelling was soft and rubbery and fluctuation was present but it was not fixed to overlying skin. Other intraoral findings were grossly carious lower left second molar and fracture crown with right and left first molar. Considerable deposition of sub- and supragingival calculus and stains was noticed. Missing teeth were upper right and left molars.
+When swelling is seen at the side of neck, it is important to formulate the differential diagnosis since this would help further evaluation of the condition and management of the patient. After considering all clinical findings following entities were considered in differential diagnosis?cute submandibular sialadenitis and benign swelling of neck ().
+After that patient was advised for drainage of abscess. The investigatory work up included complete hemogram, intra oral radiographs, orthopantomograph and ultrasonography. Routine hematological investigations were within normal limit. Orthopantomograph shows carious root fracture with lower left second molar and advanced mesial caries with periapical radiolucency with lower left third molar. Ultrasonographic findings of swelling were lobular in shape, ill-defined hypoechoic lesion with heterogenous ultrasound architecture of lesion. Posterior echoes were unchanged, ultrasound characteristic of tissues were solid and no any calcification was observed. Ultrasonographic impression was enlarged submandibular gland with focal abscess suggestive of submandibular abscess or sialadenitis (Figures and ). Incision and drainage was performed. Adequate hydration should be ensured and electrolyte imbalances corrected with the administration of a single dose of parenteral antibiotics, followed by oral antibiotics for a period of 5?? days. Amoxycillin clavulanic acid (625 mg) is an excellent choice and provides good coverage against typical organisms. Patient was called for follow-up visit of 3 days from the first visit and then 1 week later. (with improvement). After that lower left first and second molar and right first molar were extracted (because patient was not willing for conservative approach) as it can cause recurrence of infection. Specimen sent for histopathological examination. The biopsy report was interpreted as an acute submandibular sialadenitis as H&E section revealed vasodilatation and increasing numbers of neutrophils in the submandibular vessels, emigrating into the parenchyma and filling ducts. Colonies of bacteria may also be seen particularly in the ducts. The ducts become dilated and filled with neutrophils; duct epithelium and then acini are progressively destroyed, leading to formation of microabscesses and destruction of large areas of the gland (). Thus, a final diagnosis of acute submandibular sialadenitis was given. There is no residual or recurrent, swelling apparent in the area of biopsy after a follow-up period of 6 months."
+Adrianna Huynh,23,1988/9/17,(854)260-1117,walkermark@example.net,944 Delacruz Hollow,"Thirteen months ago a 76 year-old man with previous history of osteoarthritis presented to his family physician with gait instability, right foot drop, and falls. His symptoms were thought to be from osteoarthritis and he was referred to an orthopaedic surgeon who found some tenderness at his knees without any malalignment or effusion. Radiographs of his knees showed mild chondrocalcinosis. He was diagnosed with calcium pyrophosphate deposition disease and was treated with intraarticular corticosteroid injections without any improvement. A podiatrist noted high steppage gait eight months ago and recommended shoe orthotics and a walker. Three months ago the orthopedic surgeon noted bilateral quadriceps atrophy and thought it to be secondary to deconditioning from chondrocalcinosis. Patient saw his primary physician one month ago for inability to walk and difficulty transferring from bed to wheelchair, again thought to be from progressive chondrocalcinosis. Two weeks ago the patient went to urgent care for urinary tract infection. A different family physician saw him and requested a neurology consultation. Patient told the neurologist about progressive leg weakness, numbness and tingling ascending up to mid back over the last year and urinary retention over the last three weeks. Neurological examination revealed decreased pin prick sixth thoracic vertebra down, complete plegia on right leg, severe weakness in the left leg, and bilateral positive Babinski? sign. Serum potassium was normal. Contrast enhanced spinal magnetic resonance imaging (MRI) suggested thoracic meningioma causing spinal cord compression (). Patient was referred to Mayo Clinic and underwent surgical resection of his tumor. Pathology came back positive for World Health Organization (WHO) grade 1 meningioma (meningothelial and psammomatous type). Two days after surgery motor strength had started to improve in both legs."
+Layton Washington,35,1978/1/22,-4246,jjenkins@example.org,4096 Davis Expressway Suite 658,"A 68-year-old male patient was admitted to our department with a diagnosis of idiopathic dilated cardiomyopathy (normal coronary arteries) associated with left bundle branch block (QRS duration of 140 msec) and reduced ejection fraction (EF, 35%).
+In February 2004, a biventricular defibrillator was implanted in primary prevention. The patient responded well to treatment, showing significant clinical improvement (EF 45%) without experiencing arrhythmia episodes.
+In May 2009, the generator was replaced because of battery depletion. Six months later, displacement of the pulse generator to the subclavian vein and tunneling of the leads with subsequent pocket infection were observed. After a first attempt of percutaneous removal of the system with unsuccessful lead extraction, in February 2011 the patient underwent surgical lead removal () and associated De Vega tricuspid annuloplasty. On that occasion, we decided not to implant a left ventricular epicardial lead in order to attempt transvenous lead placement at a later stage.
+Unfortunately, the postoperative course was complicated by a ?uperior vena cava syndrome??with massive thrombosis of the innominate, internal jugular and subclavian veins. After a short stay in the hospital Rehabilitation Unit, the patient? hemodynamic status deteriorated (NYHA class IV, EF 28%) and subsequent CRT was necessary. We considered the possibility of implanting a biventricular pacemaker to avoid epicardial lead placement because of the previous cardiac surgery procedure. However, phlebography showed complete occlusion of the upper extremity venous access and the femoral vein approach was used.
+For easier lead placement and the likelihood that an optimal defibrillation vector could not be achieved at the level of the femoral vein, a biventricular pacemaker rather than a defibrillator was implanted. In addition, the patient was electrically stable and, in the past, responded well to CRT with a marked improvement in EF (> 35%).
+During the procedure of biventricular pacemaker implantation via the femoral approach, three femoral venous accesses were obtained. The first catheter was placed into the left ventricle. A quadripolar Josephson catheter (TORQR series) was inserted into the coronary sinus (CS).
+First, a peel-away delivery sheath (Attain Command 6250-MB2X, 50 cm in length) was introduced into the electrophysiology catheter. Owing to difficulties in cannulating the CS, it was replaced with a straight sheath (model 6257S, 57 cm in length), resulting in successful access to CS and good support.
+Postero-lateral tributaries were visualized with non-occlusive CS venography (). A Medtronic Attain StarFix lead (model 4195, 103 cm in length) was inserted using the standard over-the-wire technique. The Attain StarFix lead is a 5 Fr, steroid-eluting, transvenous, unipolar, left ventricular, over the wire, cardiac vein pacing lead with three deployable lobes. During the implant procedure, the lobes can be undeployed by withdrawing the push tubing. Radiopaque markers assist in full lobe deployment. A threshold voltage of 2.5 V x 1.5 msec and a sensing threshold of 12 mV with good lead impedance were obtained. No diaphragmatic stimulation was noted at maximum output (10 V).
+The active fixation mechanism of the Attain StarFix lead contributed to the success of the procedure, enabling easy removal of the delivery system.
+The right ventricular lead was positioned in the high right ventricular septum, and the atrial lead was implanted in the right atrial septum. These locations allowed for an easier lead placement (). Both leads had active fixation (model 4076-80, 80 cm in length), with good voltage and sensing thresholds. The leads were tunneled through the rectus abdominis fascia and connected to the pulse generator in the abdominal pocket.
+The patient was discharged after 4 days without complications. At pre-discharge follow-up, the left ventricular device had a voltage and sensing threshold of 2.5 V x 1.5 msec and 10 mV, respectively.
+At one-month follow-up, the electrical measurements were stable with a voltage and sensing threshold of 1.0 V x 1.0 msec and 11.2 mV, respectively. The patient showed clinical improvement, also confirmed at echocardiography (EF 40%), suggesting a positive response to CRT.
+At 1-year follow-up, the clinical and instrumental data remained stable with marked improvement in EF (45%)."
+Valerie McDonald,28,1997/10/18,(308)695-3205x983,richard24@example.org,13624 Cooper Mills,"A 76 year-old female patient presented with 1 week history of intermittent, sharp, left flank pain, rated 8/10 in intensity. She denied nausea, vomiting, diarrhea, constipation, fever, trauma, or bleeding. She reported a similar painful episode 4 weeks prior.
+Her medical history is significant for a 10-year history of diabetes mellitus, hypertension, hyperlipidemia, and thyroidectomy for a thyroid nodule over 25 years ago. On physical examination, the patient was afebrile with an elevated BP of 160/80 and a pulse of 90 beats per minute. Her abdominal exam was remarkable for tenderness in left mid quadrant with deep palpation, without any appreciable organomegaly or masses. There were no pulsations or bruits, and her abdomen was soft and non-distended. Her rectal exam was remarkable for hemorrhoids and a skin tag, with no bright red blood in the vault.
+The Abdominal US was unremarkable. Her laboratory investigations were within normal limits except for glucose 377 and HgbA1C: 9.6%.
+Her diabetic medication regimen history included treatment with Metformin and Glyburide. Januvia was started December, 15, 2009. Thereafter Glyburide was stopped and Novolog Mix was started. Due to uncontrolled blood glucose, the regimen was changed to Lantus and Humalog on December 29, 2009 with an endocrinology follow-up. Patient had some confusion with the recently changed regimen, and when she had returned after two weeks she was requested to take Levemir 10 units daily and continue Humalog 6 units TID with meals. She was on the Levemir and Humalog combination when she was seen for abdominal pain.
+After 1 week, she reported an exacerbation of the abdominal pain, which prompted her to seek care in the ER where a CT of the abdomen was done. The CT was showed a mass in the head of the pancreas, highly suggestive of a malignant neoplasm.
+The patient was underwent an ERCP with cytology which was remarkable for mild dilation of the pancreatic and bile ducts at the level of the ampula with a negative cytology for malignant cells. The patient was discharged for outpatient follow-up with surgery and GI consults, where an endoscopic ultrasound guided FNA aspiration biopsy was positive for adenocarcinoma. The mass was inoperable and the patient was given consultation for oncology/chemotheraphy. The patient declined chemotherapy andwas discharged to hospice care as per her wishes."
+Calvin Hammond,20,1985/8/8,+1-527-232-3232x464,kevinperry@example.org,6571 Heather Via Apt. 910,"A 68 year-old-male, who had suffered from liver cirrhosis due to hepatic C virus infection, was referred to Teikyo University hospital (Tokyo, Japan) in August 2004, because of continuous fever rising. He had several hospitalization episodes for the treatment of hepatocellular carcinoma including transarterial chemo-embolization therapy, and recurrent hepatic encephalopathy in recent five years. On admission, the body temperature reached up to 39.7 簞C, the blood pressure was 105/72 mmHg, the heart rate was 95 beats/minutes, and inflammatory change and marked hepatic dysfunction was seen in the blood tests ().
+Abdominal computed tomography with contrast medium suggested the presence of liver abscess at the right lobe of the liver (, ). Blood culture showed Klebsiella pneumonia and Clostridium perfringens, then imipenem and clindamycin was administered at first. Since the inflammatory change continued, clindamycin was changed to MNZ 1500 mg/day. Infection began to be improved after initiation of MNZ, however, speech and gait difficulty with mental disturbance suddenly appeared on the 19th day after MNZ administration. Although hepatic encephalopathy was suspected at first, the serum ammonia level did not show higher value than ever (56 mg/dL) and neurological findings were not compatible with the disease. Brain MRI showed hyperintense lesion of the bilateral basal dendric nuclei which was specific for those of metronidazole-associated encephalopathy (, ), as well as hyperintensity of basal nuclei showing chronic hepatic encephalopathy (). After MNZ was ceased, the neurological abnormalities were improved gradually. MR image showed disappearance of hyperintensity of the dendric nuclei one month later (). The patient was discharged by walking alone three months later."
+Holly Berg,20,1986/2/6,456-902-2143x075,mitchellrobert@example.org,9459 John Square,"A lactating 30-year-old woman developed back pain 4 weeks after her first delivery following a normal pregnancy. She went to a local clinic for treatment, but the pain did not lessen, and she was transferred to our out-patient clinic with back pain for 3 months. She was previously healthy and did not take any medicine such as corticosteroids or thyroid hormones. Physical examinations demonstrated only tenderness of the back. Vertebral fractures of the 8th, 10th, and 12th thoracic (T) and 1st lumbar (L) vertebrae were seen on plain radiographs and MRI. BMD of the lumbar spine (L2??: 0.714 g/cm2, T-score: ??.9 SD) and proximal femur (0.589 g/cm2, T-score: ??.8 SD) confirmed the presence of associated osteoporosis. On laboratory examinations, NTX in urine was high (151.4 nmolBCE/L, normal range 9.3??4.3 nmolBCE/L). However, other laboratory examinations including serum BAP, serum PTH, and serum Ca were within normal ranges. Because she was instructed to wear a corset by a previous doctor, we advised against breast-feeding and prescribed a daily intake of 45 mg of vitamin K2 and 1,200 mg of calcium carbonate. One year after the initial consultation, her back pain had completely disappeared, and she did not have any recurrence. NTX in urine improved (14.0 nmolBCE/L). BMD at 2 years after the initial visit showed improvement (L2??: 0.749 g/cm2, T-score: ??.4 SD; and proximal femur: 0.674 g/cm2, T-score: ??.7 SD)."
+Cayson Hahn,41,1988/10/28,001-475-386-9885x135,schambers@example.org,781 Harold Tunnel,"A 31-year-old woman with back pain was admitted 3 months after her first delivery. Her back pain had started 2 weeks after delivery, and she went to a local clinic for treatment. However, the pain did not lessen, and she was transferred to our out-patient clinic. She had a past history of eating disorder and left femoral neck fracture 2 years before. Physical examinations demonstrated only tenderness of her back. Vertebral fractures of the T8, 9, 11, and 12, and L1 and 4 vertebrae were seen on plain radiographs and MRI ( and ). BMD of the lumbar spine (L2??: 0.698 g/cm2, T-score: ??.8 SD) and proximal femur (0.585 g/cm2, T-score: ??.3 SD) confirmed the presence of associated osteoporosis. Serum NTX and BAP were 25 nmolBCE/L (normal range 7.5??6.5 nmolBCE/L) and 46 U/L (normal range 9.6??5.4 U/L), respectively. There was no abnormal value on laboratory examinations of other parameters. Breast-feeding had been advised against 1 month before, so we instructed her to wear a corset and prescribed a daily intake of 45 mg of vitamin K2. Six months after the initial consultation, her back pain had decreased significantly, and she did not experience any recurrence. The bone metabolic markers both of serum NTX and BAP were suppressed to 18 nmolBCE/L and 13 U/L, respectively, after 10 months of treatment."
+Fallon Guerrero,41,1981/3/20,604.926.7934x56630,johnsonangela@example.org,275 Leslie Inlet Apt. 898,"A 31-year-old woman in her second pregnancy was transferred to our out-patient clinic due to pregnancy-associated osteoporosis. She developed back pain 2 months after her first delivery following a normal pregnancy 7 years earlier. She went to a local clinic for treatment, and compression fractures of the T7, 12, and L1 vertebrae were seen on plain radiographs and MRI. She was previously healthy and did not take any medicine. There were no abnormal values on laboratory examinations. She was instructed to wear a corset only, and not to continue breast-feeding. Because BMD showed the presence of associated osteoporosis (L2??: 0.750 g/cm2, T-score: ??.66 SD; and proximal femur: 0.539 g/cm2, T-score: ??.55 SD), she was transferred to our out-patient clinic. We prescribed a daily intake of 45 mg of vitamin K2, and her back pain completely disappeared. BMD at 2 years and 1 month after first pregnancy still showed associated osteoporosis (L2??: 0.775 g/cm2, T-score: ??.46 SD; and proximal femur: 0.569 g/cm2, T-score: ??.43 SD), and she continued to take vitamin K2 for osteoporosis treatment at her own request.
+We advised against breast-feeding on her second pregnancy and prescribed a daily intake of 45 mg of vitamin K2 2 weeks after delivery. We continued to prescribe vitamin K2 until 6 months after delivery, and no back pain appeared. BMD at 6 months after delivery showed no change (L2??: 0.778 g/cm2, T-score: ??.1 SD; and proximal femur: 0.564 g/cm2, T-score: ??.7 SD)."
+Bryce Richard,40,1991/12/15,5702133660,lblair@example.net,886 Wyatt Bypass,"A 34-year-old woman developed back pain 1 week after her first delivery following a normal pregnancy. She went to a local clinic for treatment, and compression fractures of the T6, 8, and 12 vertebrae were seen on plain radiographs and MRI ( and ). BMD showed a mild decline (L2??: 0.901 g/cm2, T-score: ??.0 SD; and proximal femur: 0.749 g/cm2, T-score: ??.0 SD). On laboratory examinations, serum NTX (30.8 nmolBCE/L) and serum Ca (10.9 mg/dL, normal range 7.8??0.1 mg/dL) were elevated, and serum intact PTH showed a decrease (7 pg/mL, normal range 10??5 pg/mL). However, other laboratory examinations including serum BAP were within the normal ranges. She was instructed to wear a corset and avoid breast-feeding, and prescribed a daily intake of non-steroidal anti-inflammatory drugs (NSAIDs). However, her back pain did not lessen, and compression changes of the thoracic vertebrae worsened on plain radiographs. So she was transferred to our out-patient clinic with back pain for 3 months.
+Physical examinations demonstrated only tenderness of her back. She was previously healthy without any other disease. We prescribed a daily intake of 45 mg of vitamin K2, and her back pain decreased gradually. At 5 months after prescribing vitamin K2, her back pain had completely disappeared. MRI after 7 months of treatment showed no signal intensities on T1- and T2-weighted images (). BMD after 12 months of treatment was 0.92 g/cm2 (T-score: ??.8 SD) of L2?? and 0.78 g/cm2 (T-score: ??.7 SD) of the proximal femur. Although we finished prescribing vitamin K2 at this time, she did not experience any recurrence."
+Davina Blackburn,41,1984/9/22,(652)749-2446,samantha86@example.net,26283 Steele Point Apt. 405,"In June 2004, a 30-year-old Japanese female initially consulted a local physician with a 6-month history of right knee pain and was treated with a non-steroidal anti-inflammatory drug. In December 2005, she consulted another local clinic since the knee pain had increased and was referred to our out-patient clinic.
+On physical examinations, redness and swelling of the anterior aspect of the knee were noted, and flexion of the knee joint was restricted to 120簞. She could not raise her lower leg against gravity because of muscle atrophy around the right thigh. On radiographs, the right patella was enlarged, and the cortical shell was irregularly discontinuous. Osteolytic and osteoblastic lesions were irregularly distributed in the patella (). Computed tomography showed an intraosseous osteolytic lesion and soft tissue extension at the anterior part to the patella (). Magnetic resonance imagings also demonstrated an intraosseous lesion extending into the anterior subcutaneous tissue. The lesion showed low signal intensity on T1-weighted images. On T2-weighted images, the proximal part of the lesion showed low signal intensity with partial high-signal areas, and the distal part showed high signal intensity with focal low-signal areas (). Incisional biopsy demonstrated a proliferation of spindle-shaped atypical cells with condensation of chromatin and abundant osteoid formation (). The histological diagnosis was fibroblastic osteosarcoma.
+The patient underwent chemotherapy including high-dose ifosfamide, adriamycin, and cisplatin. However, these were not clinically effective, and the response was estimated as progressive disease. Furthermore, she developed a pathological fracture of the patella during chemotherapy. Therefore, we performed above-the-knee amputation in April 2006. The surgical specimen showed extensive remnant of tumor cells, and the effect of the chemotherapy was evaluated as ?oor?? High-dose methotrexate, adriamycin, and cisplatin were administrated postoperatively. In December 2007, she developed multiple metastases in the thoracic vertebrae. She again underwent chemotherapy including high-dose ifosfamide, adriamycin, and cisplatin. At the most recent examination in 2010, she remains alive with metastatic disease in the thoracic spine without paralysis."
+Zahir Strong,24,2005/4/15,(255)548-7510x76988,sandranguyen@example.net,301 Garza Via Suite 721,"An 89-year-old man with a 20-year history of type 2 diabetes mellitus was hospitalized because of a hypoglycemic attack. He had regularly attended the Department of Geriatric Internal Medicine because of hypertension and dyslipidemia. He had a previous history of cerebral infarction of the right corona radiata, bleeding gastric ulcer, hyperuricemia, chronic kidney disease (stage 3), benign prostatic hypertrophy, and stable angina. His medication included metformin 500 mg/day, glimepiride 4 mg/day, aspirin 100 mg/day, omeprazole 10 mg/day, allopurinol 100 mg/day, pravastatin sodium 10 mg/day, and naftopidil 50 mg/day. He had been smoking half a pack a day for 70 years. On his last regular visit in July 2010, glycated hemoglobin (HbA1c) was 6.9%, and his usual medications were prescribed. In September 2010 he reported that his physical condition had been poor, and he had been eating only a small lunch but taking his regular medications. When he called his family, dysarthria was noticed. Because right hemiparesis developed the next morning, he was brought to our emergency room with his daughter.
+On physical examination, he had intact cranial nerves except for dysarthria, a shallow right nasolabial fossa, tongue deviation to the right, and muscle weakness of the right arm with symmetrical, not brisk reflexes. He had no ataxia or numbness, but had decreased vibration sense at both ankles. Body mass index was 21.4, blood pressure was 123/54 mmHg, and heart rate was regular and 64 beats per minute. Body temperature was 36.7簞C, and Glasgow coma scale was 14 (E4V4M6). He could say his name but not ?en??or ?lasses?? There were no other remarkable findings on physical examination including conjunctivae, oral mucosa, cervical lymph nodes, thyroid, heart, respiratory sounds, abdomen, and skin.
+Laboratory findings showed hypoglycemia (casual glucose value 1.8 mmol/L), worsening of renal dysfunction (urea nitrogen 12 mmol/L, creatinine 0.22 mmol/L), anemia (hemoglobin 9.8 g/dL, hematocrit 29.2%), hyperkalemia (5.8 mmol/L), and decreased high-density lipoprotein cholesterol (0.62 mmol/L). The rest of the findings were normal, including complete blood cell count, coagulation tests, serum transferases, sodium, calcium, phosphate, and C-reactive protein. Glycated hemoglobin (HbA1c) was 6.9%, and glycated albumin was 21.6% on admission.
+Because of the laboratory findings, 40 mL of 40% dextrose solution was given intravenously. Blood glucose level rose to 9.6 mmol/L, his signs resolved quickly, and hypoglycemic hemiparesis was diagnosed. Glimepiride, metformin, and valsartan were discontinued. As the neurological signs disappeared quickly on improvement of blood glucose, it was easy to exclude an ischemic stroke. Emergency head imaging was not done. After 48 hours' observation, he was discharged, and no relapse of hypoglycemic attack has been documented to date. The 24-hour urine collection showed no microalbuminuria, and creatinine clearance was calculated as 29 mL/min. He had no diabetic retinopathy. One month after discharge, head magnetic resonance imaging showed only old multiple cerebral infarcts, which did not differ from the previous imaging findings."
+Margo Robles,18,1988/10/24,001-521-430-4967x6732,lewisgregory@example.com,11022 Anderson Key Suite 931,"We report the case of central vein stenosis in a 60-year-old male Caucasian German dialysis patient. Our patient became dialysis-dependent in the 1970s because of postinfectious glomerulonephritis. During a 40-year history of end-stage renal disease he underwent renal transplantation three times with several years of dialysis in-between. In the meantime, and after the failure of his last renal transplant, the insertion of numerous central vein catheters from both his internal jugular veins was necessary to provide temporary dialysis access during recurrent arteriovenous fistula problems. After the final failure of an autogenous left arm access, a transposed brachial-basilic access was created in his right arm.
+Three years later, our patient reported swelling of his right arm and dry cough. In additional, a clinical investigation showed facial edema and jugular vein engorgement. Color Doppler sonography revealed a reversed flow in his jugular vein, in a cranial direction (Figure ) and a turbulent flow in his brachiocephalic vein without clear delineation of a stenosis. Computed tomography venography coronal views of his neck and upper chest revealed subtotal stenosis of his right brachiocephalic vein (Figure ) with collateral circulation from his internal jugular vein over the external jugular veins, sinus cavernosus, paravertrebral veins and the veins of the mediastinal cavity. Conventional catheter phlebography via a venous transfemoral access showed subtotal stenosis of his right brachiocephalic vein over a length of nearly 4cm (Figure ). Subsequently, the stenosis was dilated by balloon angioplasty (MAXI balloon 12/40mm, Cordis簧, Bridgewtaer, NJ, USA, and Atlas balloon 16/40mm, Bard簧, Murray Hill, NJ, USA). Because of the acute elastic recoil of the vein, a self-expanding stent (Sinus XL Stent 22/60mm, Optimed簧,Ettlingen, Germany) was placed with a good post interventional result (Figure ).
+Four weeks after stent implantation, our patient? facial edema and jugular vein engorgement were resolved, and color Doppler sonography showed normal jugular vein flow. The shunt volume measurement by Doppler sonography showed a flow volume of 2.5L/min."
+Otto Montes,30,2003/12/3,880-608-0166,marquezmadison@example.com,39249 Tonya Falls Suite 682,"A 67-year-old Spanish man with unremarkable ocular and systemic history, except for a depressive syndrome, was referred to our hospital. He presented with decreased vision in his right eye and a history of metamorphopsia for approximately 11 months. He did not report any trauma. His best-corrected visual acuity (BCVA) was 0.5 in the right eye and 1.0 in the left eye.
+Anterior segment examination revealed a bilateral nuclear sclerosis with no further abnormalities. Fundoscopy revealed an image of a full-thickness macular hole. Optical coherence tomography (OCT) examination (Figure ) showed a stage IV FTMH according to its size (more than 400 弮) and according to the posterior vitreous detachment, the latter only visible on fundoscopy examination.
+We also appreciated some cystic spaces on both edges of the hole, and a small epiretinal membrane (ERM). We observed clear irregularity of the junction of inner and outer segments of photoreceptors (IS/OS).
+Three months later, his BCVA had not improved. OCT scans revealed a closed macular hole. We observed an elevation of the photoreceptor layer and of the external limiting membrane (ELM) over a cystic space, and a defect in the continuity of the photoreceptor layer (Figure ).
+Seven months later, his BCVA remained the same. An OCT examination showed the disappearance of the cystic space, and a normal foveal contour (Figure ).
+At 13 months later, his BCVA improved to 0.7. An OCT scan showed no changes (Figure ).
+Two years later, his BCVA remained unchanged but on OCT scan we surprisingly observed a lamellar macular hole (Figure ), according to the Haouchine [] criteria: irregular thinning of foveal base, break in the inner fovea, intra-retinal split (dehiscence of the inner foveal retina from the outer retina), normal perifoveal retinal thickness and absence of a full-thickness foveal defect."
+Roselyn Rios,28,1996/2/4,(567)292-9795,sherylbanks@example.org,657 Torres Trafficway,"A 27-year-old Caucasian man who had been suffering from a nasal obstruction for eight years was admitted to the Department of Otolaryngology and Head and Neck Surgery, the Ministry of Health Izmir Tepecik Training and Research Hospital in January 2008. His past medical and family history did not include any abnormal or notable features. A mass with smooth surface, arising from the left posterior side of the nasal septum and filling the whole nasopharyngeal cavity, was seen on his endoscopic nasal examination. Other systemic examinations were normal. Complete blood count (CBC), activated partial thromboplastin time (APTT), and partial thromboplastin time (PTT) were normal. A soft tissue mass with lobulated margins was seen on computed tomography (CT) scan. Calcification was present in the septa. The mass extended from the posterior nasal septum to the pharyngeal space on the right and the nasal turbine on the left (Figure A and 1B). A punch biopsy was performed and the biopsy specimen was reported as sinonasal papilloma.
+The nasopharyngeal mass, approximately 4cmx3cm in size, was completely resected under local anesthesia via an endoscopic approach within our clinic (Figure ). No complications were seen during the early postoperative period.
+Histopathological examination with hematoxylin and eosin staining revealed a semi-cystic nasal teratoma consisting of mature epithelial and mesenchymal components (Figure A and 3B).
+The patient was followed up by periodic examinations for eight months and no recurrence was seen during this postoperative period."
+Israel Lopez,20,1996/11/12,(732)512-0145,bakermargaret@example.com,13616 Knox Mountain,"A 43-year-old Caucasian woman was treated for chronic menorrhagia with a Mirena簧 coil and traxenamic acid with no success. Her gynecologist started her on triptorelin. Three days after the first dose, she attended our eye centre casualty with progressively worsening headaches accompanied by visual disturbances. She had no past medical history of note, and was on no other medications at the time of presentation.
+She had unaided Snellen acuity of 6/36 improving to 6/18 with pinhole in either eye. Her color vision, pupils and anterior segments were normal but she had bilateral papilledema (Figure ) and enlarged blind spots on her visual fields (Figure ). She was overweight (not obese) with a body mass index of 28. She did not report any recent-onset weight gain. The rest of her physical examination was unremarkable. MRI showed no intracranial mass or ventricular dilatation but she had capacious cerebral spinal fluid (CSF) spaces around her optic nerves (Figure ). A simultaneous magnetic resonance venogram (MRV) displayed normal cerebral venous sinuses.
+She was urgently referred to our neurology team for a lumbar puncture. Her CSF opening pressure was significantly high at 43 cm but a CSF analysis was normal. A diagnosis of BIH was made and she had further therapeutic CSF drainage done at the same time. She was advised to discontinue triptorelin and start oral acetazolamide 250 mg four times a day, although this was only given for seven days and stopped, as our patient could not tolerate it.
+Within the next three days, her headaches ceased and her visual acuity began improving gradually over the next three weeks to 6/5 in both eyes. At the same time, the papilledema settled with near normal appearance of the discs (Figure ). A month later, she had a normal CSF opening pressure on a lumbar puncture. Her visual fields showed remarkable improvement with normalization of the blind spots over the next three months."
+Gianna Rubio,33,1987/10/27,(348)703-9025x57349,dominguezmandy@example.com,7924 Robert Shoal,"A previously healthy 39-year-old man who was an officer in a city hospital presented with a 10-day history of fever, chills, fatigue, sweats, and muscle aches. He noted no complaints of cough and sputum but dyspnea and jaundice which began three days ago before presentation and gradually worsening over 24??8 hrs. He had no history of exposure to an animal and travel to rural areas. His temperature was 390C (102.20F), his pulse was 96 beats/min, his respiration rate was 24 breaths/min, his systolic blood pressure was 110 mmHg, and his oxygen saturation was 96% on room air. The patient seemed icteric and lung auscultation showed bibasilar crackling. Findings of additional examination were unremarkable. Arterial blood gas analysis revealed a marked respiratory alkalosis (elevated pH and marked decline in pCO2) and mild hypoxemia (pO2, 75 mm Hg).
+The hemoglobin concentration was 4.4 g/dL, WBC count was 24 X 103cells/弮L and platelet count was normal. Blood film examination showed 90% of neutrophils with toxic granulations and erythrocyte morphology with hypochromia, anisocytosis and spherocytosis. The levels of blood urea nitrogen (BUN), creatinine, electrolytes, vitamin B12, folate and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were normal. The serum lactate dehydrogenase (LDH) level was 414 U/L (normal range, 125??40 U/L) and total bilirubin was 5.8 mg/dL (normal range, 0.3-1.2 mg/dL) with a rate of 3.0 mg/dL indirect bilirubin. The corrected reticulocyte count was 4% (normal range, 0.5-2.5%). A routine urinalysis was normal and the fecal occult blood test was negative. The erythrocyte sedimentation rate (ESR) was 100 mm/h, and the C-reactive protein (CRP) level was 272 mg/L (normal value, <8 mg/L). Chest radiography showed multiple pulmonary infiltrates and an additional CT of thorax widespread patchy ground-glass opacities throughout both lungs suggesting acute interstitial or viral pneumonia and bilateral pleural effusion (Figure a and Figureb). The direct Coombs??test (antiglobulin test) for explaining of hemolysis was positive. The patient was admitted to the intensive care room, and he began receiving intravenous fluids, empirical ampicillin/sulbactam intravenously plus oral clarithromycin for clinical diagnosis of community acquired pneumonia, and methylprednisolon intravenously (1 mg/Kg daily) for controlling hemolytic process.
+A total of 4 unites of erythrocyte suspension were administered in 24 hours and the hemoglobin concentration increased to 8.0 g/dL. Despite the clinical situation of him was good, the patient's laboratory values worsened on the second day of admittance. The BUN rose to the level of 43 mg/dL (normal range, 5??5 mg/dL) and the creatinine rose to the level of 3.4 mg/dL (normal range, 0.7-1.2 mg/dL). The AST level was 1388 U/L (normal range, 5??0 U/L) and the ALT level was 832 U/L (normal range, 5??4 mg/dL). Total bilirubin level increased to 9.4 mg/dL (indirect content, 4.1 mg/dL), and the LDH level to 4822 IU/L. The total creatine kinase level was 1515 U/L (normal range, 38??76 U/L). Performed sequential electrocardiograms and echocardiography test showed no cardiac pathology. Thyroid function tests were within normal values. A serum sample for diagnosing of Hantavirus infection, Crimean-Congo hemorrhagic fever virus (CCHFV) infection, and acute Q fever and a throat swab specimen for diagnosing of H1N1 influenza were sent to the Refik Saydam Hifzissihha Institute, Ankara, Turkey. Serological markers indicating acute infection with Epstein-Barr virus, cytomegalovirus, herpes simplex virus, parvovirus, varicella zoster virus, mumps virus, measles virus, and rubella virus were all negative. The detailed viral hepatitis markers andBrucella-specific Wright tube agglutination test were also negative. The blood and urine cultures for bacteria yielded no growth.
+His blood hemoglobin concentration decreased again to 5 gr/dL on the 3rd day and cold agglutinin test was found to be negative on the same day. The blood creatinine rose to the level of 8.4 mg/dL on the day 4th, and anuria developed. After evaluation, it was decided to take the patient in hemodialysis treatment 3 times a week. A percutaneous renal biopsy on the day 12th demonstrated acute tubulointerstitial nephritis (TIN, Figure ). Serologic and virologic analyses with ELISA and real time-PCR method for Hantavirus infection, CCHFV and PCR method for H1N1 influenza were negative. Serum sample was found to be positive against C. burnetii by immunofluorescence assay (IFA) and indicated an acute Q fever infection with the titer of 1:512 for IgG, 1:64 for IgM against phase II and a negative serology against phase I antigen. The patient continued receiving antibiotics and hemodialysis treatment for 14 days. He became afebrile after 5 days of antibiotic and steroid treatment, his clinical condition improved in 10 days, AST and ALT returned to normal levels within 15 days. The blood creatinine returned to normal levels 16 days after hemodialysis started and then hemodialysis treatment no longer needed. A total of 18 units of erythrocyte suspension were administered during the hospitalization period and the blood hemoglobin concentration was 10.9 g/dL on the 16th day of admission. Total bilirubin returned to normal levels after 21 days of admission. The pulmonary infiltrates improved after 21 days of antibiotic therapy. Steroid therapy was continued for 3 months and discontinued by reducing the dose over time. The patient improved without any complications and he was uneventful after 6 months of follow up."
+Titan Reyes,35,2003/1/23,730-885-9648x44342,ralph10@example.net,34826 Michael Dam,"A 67-year-old Japanese woman complained of acute-onset abdominal pain and vomiting (Glasgow Coma Scale score = 14). Her vital signs were largely stable, apart from tachycardia with atrial fibrillation (Af) that had never been treated. The laboratory data revealed acidosis, inflammation, and elevated lactate and creatine phosphokinase (CPK) levels. The contrast-enhanced computed tomography (CT) imaging revealed that the SMA was occluded by a thromboembolism. Because of her pre-existing Af, she was diagnosed with embolic occlusion of the SMA and intestinal necrosis. She was treated with an emergency enterectomy (Figure ). The pulse of the SMA disappeared, and a relatively fresh thrombus was observed in the stump of the resected intestines. Anticoagulation therapy with heparin was initiated after the laparotomy.
+Post-operatively, she developed methicillin-resistant Staphylococcus aureus (MRSA) colitis and sepsis. Due to her respiratory insufficiency and shock conditions, she was treated with ventilator support. Although antibiotics resolved her MRSA colitis within 3 weeks of the laparotomy, she began to gradually develop gangrene in her right hand.
+The three-dimensional CT images showed that her right brachial artery was occluded 5 cm proximal to the elbow joint (Figure B); however, we could detect arterial pulsation 15 cm proximal to the elbow joint. We diagnosed her with an acute brachial arterial occlusion associated with an SMA embolism, and 6 weeks after the emergency laparotomy, an amputation was performed 15 cm proximal to the elbow joint. We did not observe any severe atherosclerotic changes in the brachial artery. The pulsation of the brachial artery disappeared at the level of the bone transection, and the arterial lumen was filled with an organized embolus (Figure B).
+An abdominal CT scan revealed multiple infarctions of the spleen, indicating a shower embolism. Anticoagulation therapy was re-started after the amputation to prevent recurrent or new emboli. She was able to ambulate independently 2 months after the amputation. She used a prosthetic upper limb for 12 months after the amputation, at which time she died of malnutrition resulting from the enterectomy."
+Audrey Bass,25,1998/3/12,841.747.9763x6991,amytran@example.org,09393 Brandon Mount Suite 111,"A 32-year-old male, previously fit and healthy, presented with epigastric pain and was found to have an abdominal mass on abdominal ultrasound. He was referred to the First Affiliated Hospital, School of Medicine, Zhejiang University for further investigation and treatment in October 2010. There were no signs of neurofibromatosis type 1(NF-1). Physical examination revealed a firm, ill-defined, fixed mass in the upper abdomen. Laboratory findings, including leukocyte and platelet counts, hemoglobin, serum creatinine, liver function, alpha-fetoprotein, carcinoembryonic antigen and cancer antigen 19??, were all within normal limits.
+Contrast-enhanced computed tomography (CT) of the chest and abdomen showed a heterogeneous tissue retroperitoneal mass, approximately 16 cm in diameter (Figure ). Following contrast, heterogeneous enhancement of the mass was noted. Adjacent vessels, such as the common hepatic artery, the portal vein and the inferior vena cava, were compressed. There was no evidence of associated lymphadenopathy or distant metastases. Biopsy of the tumor suggested a soft tissue sarcoma composed of pleomorphic spindle cells.
+All imaging studies and serology examinations indicated that surgery was feasible. At surgery, a huge, soft, whitish, solid and cystic tumor was found, which occupied the entire abdomen. The tumor appeared to involve the distal stomach, the diaphragm, the hepatoduodenal ligament, the gastrohepatic ligament, the left lobe of the liver and the celiac trunk. It was also compressing the walls of the abdominal aorta and the inferior vena cava. Massive varicose veins were noted in the abdominal cavity. Part of the left lobe of the liver was resected due to tumor infiltration. A distal gastrectomy with a Billroth II anastomosis was simultaneously performed due to tumor involvement of the stomach. In addition, we suspected that the common bile duct had also been invaded by tumor, which was not evident on preoperative imaging, and we therefore performed a resection of the common bile duct, a cholecystectomy and T-tube drainage. Intraoperative histological examination of a frozen section suggested the presence of a soft tissue sarcoma.
+On gross examination, the tumor measured 16 ? 15.5 ? 8.2 cm. The cut surface appeared firm and yellowish in the peripheral portion with foci of hemorrhage and excessive necrosis in the center. The margins appeared macroscopically clear.
+On further histopathological examination, the neoplastic tissue displayed interlacing fascicles of spindle cells with wavy, elongated hyperchromatic nuclei. There was pronounced pleomorphism, an increased mitotic index (>50 mitoses per 10 high-power fields) and hypercellularity. Rhabdomyosarcomatous differentiation was evidenced by foci of scattered, round cells with a prominent eosinophilic cytoplasm and atypical nuclei, which were identified as rhabdomyoblasts (Figure ). Microscopically, the margins were confirmed to be clear of residual tumor.
+Immunohistochemistry demonstrated positive staining of the rhabdomyoblastic cells for desmin (Figure ) and vimentin. Nerve sheath differentiation of the spindle cells was confirmed by S-100 protein (Figure ) positivity. Tumor tissue was negative for smooth muscle actin, HMB-45, CD34 and CD117. Based on these findings, the diagnosis of a MTT was confirmed.
+According to the F矇d矇ration Nationale des Centres de Lutte Contre le Cancer (FNCLCC) grading system [], the tumor was classified as grade 3 (a total score of 7: 3 for malignant triton tumor, 3 for >50 mitoses per 10 high-power fields and 1 for <50% tumor necrosis). The surgical margins were estimated as wide []. As no macroscopic or microscopic tumor remained, surgical resection was judged complete.
+Following surgery, the patient made a good recovery and was discharged two weeks later. However, during his first follow-up assessment one month after surgery, CT imaging revealed multiple lesions in the liver, which were considered a recurrence of the tumor. Clinical deterioration occurred rapidly, and no subsequent treatment was undertaken. The patient died two and a half months after the operation."
+Landen Gaines,31,1983/1/21,232.307.2676x6234,christina52@example.net,57875 Thomas Drive Suite 345,"An 18-year-old male presented to the emergency department (ED) with several episodes of vomiting bright red blood and abdominal pain. He reported drinking tequila to the point of losing consciousness the previous night but denied daily drinking or the use of other recreational drugs. The symptoms began that morning when he awoke, about 1 h prior to presentation. He had blood-tinged emesis on his face and clothing and was noted to be pale and weak. The patient was born in Guatemala and denied any contributory medical, surgical, or medication history. On review of systems, the patient denied any recent trauma or falls. He denied fever, chills, diarrhea, blood in the stool, or history of gastrointestinal bleeding.
+At triage the vital signs were as follows: blood pressure, 106/63 mmHg; heart rate, 116 beats/min; respiratory rate, 22 breaths/min; and temperature (oral), 98.2簞F. The patient was ill-appearing, grimacing in pain, and clutching his abdomen. No scleral icterus was appreciated. There was no obvious abdominal deformity or sign of trauma. Hypoactive bowel sounds were appreciated on auscultation. The abdomen was diffusely tender to palpation and more focally in the epigastrium and suprapubic areas. There was mild distension and tympany in the suprapubic area. The patient had no guarding, no rebound tenderness, and no tenderness at the costovertebral angles. No blood was appreciated at the urethral meatus. The genitourinary examination was otherwise unremarkable. Examination of the skin revealed no hematomas, abrasions, or lacerations.
+An intravenous line was placed, normal saline fluid was given, and blood was sent for laboratory analysis. The patient had a white blood cell count of 20.4 ? 103/弮L (normal 4.5-10.8 ? 103/弮L) with neutrophils 90.3% (normal 36% to 66%), hemoglobin 12.1 g/dL (normal 13.5-17.5 g/dL), hematocrit 36% (normal 41% to 53%), BUN 32 mg/dL (normal 9??0 mg/dL), creatinine 2.50 mg/dL (normal 0.66-1.25 mg/dL), potassium 4.3 mmoL/L (normal 3.5-5.1 mmoL/L), and CO2 13 mmoL/L with an anion gap of 26 mmoL/L. Urinalysis demonstrated large blood and protein, and positive nitrites. An 18 French nonweighted nasogastric tube was passed without difficulty, and gastric lavage revealed a small amount of blood clots before running clear aspirates that smelled of alcohol. At this time, the patient began to complain of increased lower abdominal distension and the inability to void. A 14 French Foley catheter was inserted without difficulty and yielded 400 cc of bright red bloody urine.
+An emergent bedside ultrasound was performed by the EP using a Sonosite M-turbo ultrasound machine with a P21x/5-1 MHz phased array probe (Sonosite, Inc., Bothell, WA, 98021, USA). The right upper quadrant Morison's pouch view revealed free fluid between the liver and the right kidney (Figure ). The left upper quadrant view revealed fluid between the left kidney and spleen. At the lower pole of the kidney, echogenic material was found to be floating in anechoic fluid (Figure ). The pelvic view revealed a Foley catheter balloon with loss of anatomic landmarks to determine its exact location. There was anechoic free fluid in the rectovesicular pouch. The bladder walls could not be clearly delineated, and a large complex mass of heterogeneous echogenicity was seen posteriorly, thought to represent clotted blood (Figure ). The patient continued to complain of pain despite narcotic pain medication. On repeat abdominal examination, the patient had developed rebound tenderness and guarding.
+The urology service was emergently consulted, and computerized tomography (CT) scan of the abdomen and pelvis was immediately performed without contrast given patient's elevated serum creatinine. The CT scan confirmed extensive abdominal free fluid (Figure ), and a large high-density collection in the inferior abdomen compatible with a hematoma measuring 11.2 ? 9 ? 7.6 cm (Figure ). The urinary bladder was collapsed around a Foley catheter with high-density fluid within the bladder compatible with blood products (Figure ). These findings were consistent with rupture of the urinary bladder.
+The patient was taken emergently to the operating room. Antibiotics were administered and blood was typed and crossed. Laparotomy confirmed the diagnosis and revealed a 3.5-cm burst-type laceration at the bladder dome with actively bleeding edges and clot in the bladder. The edges were trimmed, and the defect was repaired with two layers of sutures. The following morning, laboratory analysis revealed a white blood cell count of 7.6 ? 103/弮L, hemoglobin 8.3 g/dL, hematocrit 23.5, BUN 11, and creatinine 0.60 mg/dL. The recovery was unremarkable, and the patient was discharged on postoperative day 3."
+Aya Herrera,35,1983/6/6,(334)500-6485,paula46@example.org,645 Christina Ports Apt. 097,Sixty-years-old man without any symptom was diagnosed as squamous cell carcinoma of lung detected by sputum cytology. He had smoked with 1.5 packs for 45 years. Tumor located at the spur of right B6 and intermediate bronchus. ILBT was performed with 20 Gy in 4 fractions followed by EBRT of 40 Gy in 18 fractions. CT based dose distribution showed that 95% of the clinical target volume receives more than 90% of the prescribed dose (Figure ). No remarkable acute toxicity and no recurrence were observed for a year.
+River Hoover,25,1984/2/17,5954255120,jessica64@example.net,24186 Wilson Crescent,"A 35-year-old Japanese woman presented to our facility with low back pain and weakness of her lower extremities. Her past history was non-contributory. No previous abnormalities had been noted during the course of her pregnancy. Her low back pain occurred without any immediate cause in gestational week 29. When weakness of her lower extremities occurred on day three of gestational week 29, causing difficulties with walking and urination, our patient consulted a local orthopedist. Blood tests revealed impaired liver function and a low platelet count, so she was brought to our emergency center.
+On her initial examination, tactile and pain sensations were both reduced to 2 out of 10 (sensation graded on a 10-point scale) from the mid-thoracic level down. Manual muscle testing (MMT) for muscles below the level of the iliopsoas showed a marked decrease in strength, with a Medical Research Council scale score of 1. Her deep tendon reflexes were slightly diminished in both extremities. Complete urinary retention was noted and rectal sphincter tone was flaccid. According to the Standard Neurological Classification of Spinal Cord Injury developed by the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS), this case was defined as grade B. On hematological testing, her platelet count was markedly reduced to 1.7 ? 104 cells/弮L. Liver function impairment was also detected (glutamic-oxaloacetic transaminase, 537U/L; glutamic-pyruvic transaminase, 294U/L; total bilirubin, 8.1 mg), while her lactate dehydrogenase and cytokeratin levels were elevated to 3766U/L and 1206U/L, respectively.
+After admission, HELLP syndrome was diagnosed in the obstetrics department based on the above laboratory test findings []. An emergency Cesarean section was successfully performed to bring the pregnancy to an end on the same day. Post-operatively, an MRI scan was performed to assess her bilateral lower limb paralysis (Figure ). Because a space-occupying lesion was detected in her thoracic spinal canal, she was referred to our department. The lesion was diagnosed as an epidural hematoma based on the MRI findings at this time, and emergency decompression was performed the same day.
+Hemilaminectomy was performed for the second to ninth thoracic vertebrae, but the epidural hematoma could not be confirmed, so the procedure was switched to a total laminectomy to allow full assessment. The dura mater was tense and swollen, and the intradural hematoma could be seen through the transparent dura. A subarachnoid hematoma was confirmed on incision of the dura and arachnoid mater, with part of the hematoma extending as far as the ventral side (Figure ). The hematoma was removed and, after thorough washing, a drain was placed. The operation was completed with suturing of artificial dura mater.
+Because pulmonary edema was also present, the drain was withdrawn on the third post-operative day. Use of a wheelchair became possible on post-operative day 10. After eight months, her lower extremity sensation had improved to a score of 8 out of 10, although her muscular strength remained limited to a slight improvement to MMT 3 in her bilateral tibialis anterior, and extensor hallucis longus and extensor digitorum longus muscles. The ASIA/ISCoS classification was grade C. MRI performed two months post-operatively revealed signal hyperintensity within her spinal cord, suggestive of myelomalacia (Figure )."
+Virginia Cantu,38,1992/5/19,962-639-2250,paulferguson@example.org,750 Torres Track Suite 298,"A 35-year-old Caucasian man was evaluated at our facility for neck pain radiating to his left arm and left leg. He had numbness in his left leg and foot, which was accompanied by weakness in the left leg. His pain was intermittent and was worse when he was supine or sitting. The pain was alleviated with walking. Our patient had tried physical therapy and chiropractic care to no avail. He denied loss of bladder or bowel control. He denied any significant past medical and surgical history except for hypertension. His family history was unremarkable except for heart failure and myocardial infarction. He denied the use of alcohol, cigarettes, or recreational drugs. A general review was negative except for occasional headaches, difficulty sleeping, and tiredness. On physical examination our patient exhibited hyperreflexia and intermittent twitching in the lower extremities. He had no footdrop or saddle anesthesia. Motor strength and sensation of his upper and lower extremities were all normal.
+Routine magnetic resonance imaging (MRI) examination of the cervical spine was performed in the sagittal and axial planes using T1, T2, and short T1-inversion recovery (STIR). MRI without addition of intravenous contrast showed that there was a loss of disc height with right-sided disc herniation at the C5 to C6 level (Figures and ). All other cervical levels were normal without central canal stenosis or neural foraminal stenosis. The cervical cord was posteriorly displaced at the level of the C5 to C6 disc space. The moderately large herniation was prominent in the right paramedian aspect. The cervical cord was of normal signal. There was extension of the herniated disc in the right C6 neural foramen that compromised the exiting nerve root. The results of MRI scans of the brain and the lumbar spine were negative.
+An anterior cervical discectomy was performed at the C5 to C6 level and an inter-body graft and plate were placed. The surgery was without complications.
+At 12-day follow-up our patient reported no residual pain from the surgery and resolution of left-sided symptoms. He reported resolution of all the symptoms that he had prior to his surgery, including his neck pain. X-ray imaging was completed and showed stable hardware (Figure ).
+Our patient was followed up for two years after his surgery. He was unable to attend the clinic, so instead he was questioned over the telephone about his symptoms. Our patient reported that the neck and left arm pain present before surgery were now completely resolved. He reported some residual left leg pain that was however vastly improved from before the surgery. The weakness in his left leg was also vastly improved compared to before surgery."
+Anakin Rollins,23,1979/3/9,(991)575-7603x06410,zdelacruz@example.com,2775 Moreno Views,"A right-handed 64 year-old man suffered an ischemic stroke affecting the left subinsular region and the claustrum 62 months prior to study onset (Figure ), which resulted in a right-sided brachiofacial hemiparesis. Handedness was measured with the Edinburgh Handedness Inventory. The patient scored 10/10, indicating right-handedness. A review of the patient? clinical record revealed a score of 3/5 for right shoulder and 2/5 for right hand strength (OMSS, Oxford Muscle Strength Scale, scored between 0 for complete paralysis, and 5 for normal strength) when he was first admitted to hospital after stroke. The clinical record also documented a mild paresis of the right lower limb (4/5). In addition, the neurologist on-duty observed a right-sided supranuclear facial paresis. Sensory function was spared and no sensory abnormalities or impairments were reported or documented in any bodily region. Deep tendon-reflexes were found to be more pronounced and brisk on the right lower limb than in the left. There was a plantar extensor reflex (Babinski sign present) only in the right lower limb. Concurrently, the patient presented with insulin-dependent diabetes and moderate elevation of liver enzymes. He was enrolled in a clinical trial evaluating motor responses. In a neurological examination prior to his participation in the evaluations performed for this study, strength in his right shoulder, right hand and right inferior were judged to be normal, with a OMSS score of 5/5. No other changes were reported. A detailed examination of the patient? medical records did not reveal any event of epileptic seizures prior or after the stroke, nor antiepileptic medication, which could have interfered with TMS-evoked activity. At the time of the evaluation, the patient was however taking ?lopidogrel??(75 mg/day), which is an oral thienopyridine class antiplatelet agent used to inhibit blood clots in coronary artery disease and cerebrovascular disease. Nonetheless, no relation between this medication and changes in cortical excitability has ever been reported. In addition, prior to the advent of the stroke the patient was taking ?nalapril??(5 mg/day), an angiotensine converting enzyme inhibitor. Enalapril has never been related to changes in cortical excitability. As it was removed from the patient? treatment after the stroke, it is very unlikely that it could have interfered TMS evoked electrophysiological recordings. Three months after the stroke, and prior to his participation in our study, the patient was enrolled in a conventional rehabilitation program for 5 months. During this period, he attended 5 days per week rehabilitation sessions at Hospital Universitari de Bellvitge. Each session lasted around 45 min. The patient? neurological status was characterized by means of extensive motor evaluations, neuropsychological testing, fMRI during motor activity, whole brain DTI, and TMS.
+The assessment of motor function comprised clinical motor assessments and computerised tests. Clinical assessments, presented in the following order, included the Action Research Arm Test (ARAT) [], Arm Paresis Score (APS) [], the Box and Block Test (BBT) [], and the Nine Hole Pegboard Test (9HPT) [,]. A computerised 3D movement analysis procedure (CMS 30 P, Zebris, Isny, Germany) was used to assess the spatial trajectories of tiny ultrasound markers attached to the moving body parts. Three diadochokinetic hand movements were tested with this device: alternate forearm pronation and supination, whole-hand tapping and index finger tapping []. Two ultrasonic markers were used for each task, and the spatial coordinates of both markers were sampled at 66 Hz, each at a spatial resolution of 0.1 mm. Continuous calculation of the three-dimensional positions of each sender was performed with commercially available software (WinData 2.19.3x, Zebris). Recording and analysis procedures were performed according to previously published methods []. First, the examiner demonstrated each movement. Then the subject performed four short trials, each lasting 4 to 5 seconds, with a short break of approximately 5 seconds in between. In all tests, the first trial was considered to be a practice trial, and the following three trials were recorded and used for analysis. For both affected and unaffected hands, the order of the examination was fixed, starting with finger tapping, followed by hand tapping, with forearm pronation and supination performed last. The patient was instructed to move as fast as possible.
+Data analysis (Software ??DA-Version 1.2?? C. Marquardt, Munich, Germany) was performed on five series of movement cycles. Two parameters were used for each diadochokinetic task: frequency (FR), defined as the number of cycles per second, and the number of inversions of the velocity profile (NIV) per movement segment. The latter was considered as a measure of smoothness. Values of NIV close to 1 were considered optimal, whereas inversions with amplitudes less than 3% of the maximal velocity were excluded.
+As an outcome measure we compared scores between the affected (right) and the unaffected (left) upper limb. Clinical motor scores used for such comparisons are presented in absolute values. In addition, the patient? clinical motor function scores were compared to normative values from a population of healthy subjects at similar ages age to the case reported in this study []. Results of the computerised movement analysis are presented as mean 簣 standard deviation.
+Single-pulse TMS was performed using a standard 70 mm figure-of-eight coil (9 cm diameter per wing) attached to a Magstim Rapid2 Stimulator (Magstim Company, Carmathenshire, Wales UK). MEPs were recorded with surface Ag/AgCl disk electrodes in a belly-tendon montage from both left and right first dorsal interossei (FDI). This muscle was selected due to its essential involvement in skillful finger movements. Such movements were impaired in this patient as a result of his stroke. For this reason the left and right first dorsal interossei (FDI) were chosen as sites for electrophysiological recordings. In addition, both flexor carpi radiali (FCR) and both biceps brachii (BB) were examined to explore differential recovery processes for muscles proximal to the FDI. In order to record any ipsilateral activation, EMG traces from left/right FDI and left/right MBB were recorded from both sides at the same time. For each pulse, we collected EMG activity for a total of 700 ms including a 100 ms pre-stimulus window (Medelec Synergy, Oxford Instruments, Pleasantville, NY, USA). EMG activity was sampled at a 5 Khz and filtered with a band-pass of 1??000 Hz. Data was stored and exported for off-line analysis using specialised software (Matlab 穢, Mathworks, Natick, Massachusetts, USA).
+An elastic lycra cap was fitted to the patient's head, on which a 10 x 10 cm grid centred on the vertex (Cz position of the international 10/20 EEG positioning system) was drawn to allow simple identification of stimulation coordinates, each of which had a 1 cm gap on all four sides to any other stimulation point. Midline points of the grid were distributed 7 cm anterior and 3 cm posterior to the vertex. From each point on the midline, 10 points separated by one cm were distributed laterally for each hemisphere. The TMS coil was placed tangential to each site, with the handle pointing backwards (in a lateral to medial and caudal to rostral position) ~45簞 lateral to the interhemispheric midline. Both, the damaged and the spared hemisphere were tested. For each hemisphere we determined the resting motor threshold (RMT) and the active motor threshold (AMT) for FDI and FCR. MEP latencies were calculated for FDI, FCR and BB. Intracortical inhibition was assessed by using the cortical silent period (CSP) for contralateral FDI and FCR muscles. We determined the centre of gravity (CoG) of the motor mapping representation for the FDI hotspot in the unaffected hemisphere. We recorded the length of the absolute cortical silent period (CSP) registered at the contralateral FDI for both hemispheres, and its topographical distribution.
+For FDI and FCR of either arm, the motor hot spot was defined as the location where the highest MEP amplitude could be elicited. The RMT was measured as the minimum stimulus intensity inducing an MEP of at least 50 弮V in 50% of 10 trials at rest at the motor hot spot []. The AMT was defined as the minimum stimulus intensity leading to a MEP of at least ~200 弮V in 5 of 10 trials during an isometric muscle activation at about 10% of maximum voluntary contraction, measured using a pressure gauge (Baseline Evaluation Systems, WA, U S A). For the CSP study, stimuli were delivered at maximum stimulation output, while the patient performed a unilateral isometric activation of the target muscle at about 10% of maximum voluntary contraction. Fifteen consecutive motor responses were recorded at variable intervals of at least 7 to 10 seconds between pulses. The CSP duration was estimated as the interval from the TMS stimulus to the time at which the post-MEP EMG activity (high-pass filtered and squared) reached 25% of the average pre-stimulus level []. MEP latencies were calculated for each muscle as the interval between the pulse artefact and the first MEP deflation after stimuli delivered at the hot spot at 120% of the RMT. Five consecutive motor responses were recorded at rest, recorded at variable intervals 7 to 10 seconds. Maps were generated by plotting the peak-to-peak MEP amplitude as a function of the stimulated scalp sites. Sites were located from the grid using a latitude/longitude-based coordinate system []. In the original grid, locations spaced 2 cm in latitude and 2 cm in longitude were stimulated. During mapping, consecutive series of 5 stimuli spaced 7 to 10 seconds apart were delivered at each scalp site, with the muscle in a relaxed state. Pulses were delivered up to 100% of the maximal stimulator output, and no MEP was ever evoked in the affected hemisphere. Pulses were delivered to the unlesioned hemisphere at 120% of RMT. CoG was determined as the amplitude-weighted centre of the MEP amplitude map (see [] for further details).
+The lack of any observable MEP after maximal TMS stimulation of the affected hemisphere prompted us to explore potential cortical sites related to modifications of the FDI cortical silent period. Locations of the grid as considered for motor mapping were explored. Five TMS stimuli 7??0 seconds apart were delivered at each scalp site, while the patient performed a voluntary contraction of the FDI muscle at 10% of the maximal voluntary contraction. Pulses were delivered at 100% of the stimulator output for the affected hemisphere and at 120% of the RMT for the unaffected hemisphere. In these maps, a CoG was determined as the weighted center of the CSP length map throughout sites, by using similar procedures as the above described MEP amplitude mapping.
+Values for cortical silent period and MEP latencies are presented as average 簣 standard deviation across different blocks of testing, whereas the rest of electrophysiological tests are presented as absolute threshold values. CoG coordinates for each hemisphere were presented as latitude/longitude location on the scalp.
+In order to evaluate the integrity of the peripheral nerve conduction (which may have explained the lack of cortically evoked MEPs from the affected (left) right motor cortex in this patient) transcutaneous electrical stimulation was used to record the latency and amplitude of the supramaximal compound muscle action potential (CMAP) of the right and left extensor carpi ulnaris muscles. We then estimated peripheral nerve conduction time (i.e., the spinal motor neuron-to muscle latency) by recording the antidromic F-wave of the ulnar nerve and applying the following formula: (F + M-1)/2, where F and M were the shortest F- and and M-wave latencies obtained by supramaximal anodal stimulation of the ulnar nerve at the wrist level. Finally, we calculated the central motor conduction time (CMCT) for the unaffected (right) hemisphere using the formula CMCT = LC-(F + M-1)/2 [], where LC is the latency of the onset of the MEP in right FDI muscle after magnetic stimulation.
+We acquired EMG signals during unilateral finger-to-thumb pinch and grasping movements to assess in a more objective manner if the engagement of the healthy unaffected (left) hand in voluntary activity could induce coupled EMG activity in the affected (right) hand and forearm and vice-versa. We attached Ag/AgCl electrodes to the left (unaffected) and right (affected) FDI and FCR muscles in a belly-tendon montage. We first asked the patient to perform with the unaffected (left) hand a set of 10 pinch movements. Right after this, the patient performed a set of 10 grasping movements. The same procedure was used thereafter with the affected (right) hand. In order to regularly pace the motor activity of the patient and equate as much as possible such rhythms to the motor activity patterns tested in other sections of the manuscript we asked him to emulate the performance of an investigator placed in front on him at a constant pace of one movement each 3?? seconds. The EMG recordings corresponding to 1 second of the 10 individual movement cycles for pinching and grasping were automatically time-locked at the time point in which the EMG traces showed muscle activity in the commanding hand of at least 200 弮V, and once aligned in time, the 10 recordings were averaged through. The whole session was videotaped to document potential macroscopic evidence of coupled mirror motor activity
+The fMRI session comprised two motor tasks using a block design. The Grasping task required a grasping movement with the right or left hand alternating with blocks of rest (4 blocks, 20 seconds per block, per active condition in a single run of approximately 6 minutes). The Tapping task required tapping movements with the index finger of the right or left hand interleaved with blocks of rest (3 active blocks, 20 seconds per block, three runs of approximately 3 minutes each).
+Images were obtained with a 3 T whole-body MRI scanner (Siemens Magnetom Trio located at Clinic Hospital, Barcelona) equipped with a non-ferromagnetic response box. Conventional high-resolution structural images [magnetization-prepared, rapid-acquired gradient echoes (MPRAGE) sequence, 240 slices sagittal, TR = 2300 ms, TE = 3 ms, 1 mm thickness (isotropic voxels)] were followed by functional images sensitive to blood oxygenation level-dependent contrast (echo planar T2*-weighted gradient echo sequence, TR = 2000 ms, TE = 29 ms, slice thickness = 4 mm). Each functional run consisted of 176 sequential whole-brain volumes for the grasping task and 96 volumes for the tapping task. Each volume comprised 32 axial slices aligned to the plane intersecting the anterior and posterior commissures, 3.5 mm in-plane resolution, 4 mm thickness, no gap, positioned to cover all but the most superior region of the brain and the cerebellum.
+FMRI data were analyzed using standard procedures implemented in the Statistical Parameter Mapping software (SPM2, ). The preprocessing included slice-timing, realignment, normalization and smoothing. First, functional volumes were phase shifted in time with reference to the first slice to minimize purely acquisition-dependent signal-variations across slices. Head-movement artifacts were corrected based on an affine rigid body transformation, where the reference volume was the first image of the first run (e.g. []). Functional data were then averaged and the mean functional image was normalized to a standard stereotaxic space using the EPI derived MNI template (ICBM 152, Montreal Neurological Institute) provided by SPM2, after an initial 12-parameter affine transformation. The resulting normalization parameters derived for the mean image were applied to the whole functional set. Finally, functional EPI volumes were re-sampled into 2 mm voxels and then spatially smoothed with an 8 mm full-width half-maximum (FWHM) isotropic Gaussian Kernel to minimize effects of inter-subject anatomical differences.
+The statistical evaluation was based on a least-square estimation using the general linear model by modelling the different conditions with a box-car regressor waveform convolved with a canonical hemodynamic response function []. Thus, a block-related design matrix was created including the conditions of interest (Grasping task: Right grasping, Left grasping and Rest; Tapping task: Right tapping, Left tapping and Rest). Eight regions of interest (ROIs) were defined on the anatomical images of the patient in order to quantify the numbers of voxels that were activated in response to the motor tasks. The following ROIs for each hemisphere were generated using WFU pickatlas toolbox [] for SPM: (1) Primary motor cortex (M1); (2) Supplementary Motor Area (SMA) and Premotor Cortex (PMC); (3) Anterior Cingulate cortex; (4) Cerebellum; (5) Superior Parietal Cortex; (6) Inferior Parietal Cortex; (7) Pons and (8) Midbrain.
+DTI data were collected in the same scanner by an eight-channel phased array head coil with parallel imaging (GRAPPA) and an acceleration factor of 2. Diffusion weighting was conducted using the standard twice-refocused spin echo sequence. Images were measured using the following parameters: 2-mm-thick slices; no gap; TR = 9100 ms; TE = 92 ms; 128 x 128 acquisition matrix; field of view, 240 x 240 mm; 64 axial slices. To obtain diffusion tensors, diffusion was measured along 20 non-collinear directions, chosen according to the standard Siemens DTI acquisition scheme using a single b value of 1000 s/mm2. Two runs of the DTI data were recorded. Data was processed as follows. The images were first skull-stripped using FSL's BET []. The two runs of diffusion data were first concatenated, and then Eddy-current- and motion-corrected using FSL's FDT (). The b-vectors were then rotated in order to take into account the corrections made at the previous stage.
+The diffusion tensors were then reconstructed using Diffusion Toolkit's least-square estimation algorithm for each voxel (Ruopeng Wang, Van J. Wedeen, TrackVis.org, Martinos Center for Biomedical Imaging, Massachusetts General Hospital). The whole brain tractography used an interpolated-streamline algorithm with an angular threshold of 35 degrees and an FA threshold of 0.2. The tensor was spectrally decomposed in order to obtain its eigenvalues and eigenvectors. The fiber direction is assumed to correspond to the principal eigenvector (the eigenvector with the largest eigenvalue). This vector was colour coded (green for anterior-posterior, blue for superior-inferior and red for left-right) to generate a colour FA map. An FA map was also generated from these eigenvalues using Diffusion Toolkit. The motor fibers were selected using three ROIs. The first two ROIs were placed in the cerebral peduncle and the posterior limb of the internal capsule, using the color-coded FA map to guide the placement. The third ROI encompassed the pre-central cortex and its underlying white matter, and was drawn on the diffusion-weighted image (DWI), with the patient's anatomical T1-weighted image (attained with the MPRAGE sequence) used as a reference. Any artifactual fibers were removed using an exclusion ROI."
+Araceli Sanchez,18,1981/7/25,001-973-950-1835x534,aevans@example.com,824 John Rue Apt. 367,"A 14-year-old Egyptian boy was referred to our institution for evaluation of recurrent hypoglycemic attacks which occurred especially in the mornings during the preceding two months. He had been diagnosed with T1DM at the age of five years and was treated with insulin in a dose of 0.7 to 1U/kg since that time. Recently, he started to develop recurrent attacks of hypoglycemia for which his insulin dose was decreased to 0.3U/kg. He had lost 2.5kg of weight and developed a craving for salt. He suffered from fatigue and dizziness. He was born and resided in a small village in Upper Egypt to unrelated Egyptian parents. He was the sixth child in his family with no history of diabetes or other auto immune diseases among family members. He had frequent hospital admissions for control of blood sugar. He was born at term with a birth weight of 3550 grams. Apart from post circumcision bleeding that was done at the age of two years by a barber, there was nothing significant in his past medical history. On physical examination, his body temperature was 36.1C, pulse rate was 92/min, blood pressure was 80/45mmHg, his height was in the 10th percentile while his weight was in the 25th percentile. He had no pallor, jaundice, or hyperpigmentation of either the skin or mucous membranes. His thyroid gland was not enlarged either on inspection or palpation. He was prepubertal: pubic and axillary hair Tanner stage 1 and testicular volume 3ml. He had slight abdominal distension, his liver and spleen were not enlarged and there was no evidence of ascities. Skin examination revealed vitiligo in the form of multiple hypopigmented areas located over the chest and abdomen. Serum biochemistry on admission showed an average blood glucose level of 77mg/dL (normal range: 82 to 110mg/dL), hemoglobin A1c 7.5% (normal range: 3.0 to 6.1), potassium: 5.9mmol/L (normal range 3.5 to 5), sodium 121mmol/L (normal range: 130 to 145) and calcium 9.7mg/dL (normal range: 8 to 10.5). Levels of blood urea nitrogen and creatinine were within the normal range. Liver function tests revealed bilirubin 11umol/L (normal <20umol/L), alanine aminotransferase (ALT) 186IU/L (normal <50IU/L), aspartate aminotransferase (AST) 123IUL (normal <50IU/L), alkaline phosphatase 108IU/L, (normal <350IU/L), and albumin 38g/L (normal range: 35 to 45g/L). Complete blood count, serum folate and vitamin B12 levels were normal. Viral hepatitis screens (HAV IgM, HBsAg, HBsIgM and IgG, Epstein-Barr virus, cytomegalovirus and herpes simplex virus) were negative. Anti-HCV and hepatitis C virus?olymerase chain reaction (HCV?CR) were positive, with a viral load of 88,440IU/mL. Anti-endomysial antibodies were not detected. There were no serological features of autoimmune hepatitis (anti-smooth muscle antibody, antinuclear antibody, anti-liver/kidney microsomal antibody, and anti-parietal cell antibody were negative), anti-adrenal antibodies were positive and serum immunoglobulins were normal. Hormonal assays revealed cortisol <1.0ug/dL (normal range: 6 to 24), adrenocorticotropic hormone (ACTH) > 1250pg/mL (normal range: 20 to 100), a peak cortisol level below 0.2mcg/dL after intravenous ACTH stimulation test (250mcg). Thyroid stimulating hormone (TSH) was 6.11uIU/mL (normal range: 0.4 to 5.0). Anti-thyroglobulin (Tg autoantibodies) were 217.8IU/mL (normal: <120), anti-thyroid peroxidase (TPO autoantibodies) 5176IU/mL (normal 60), and free thyroxine 1.4ng/dL (normal range: 0.7 to 2.0). The serum luteinizing hormone was 0.1mIU/ml (normal range: 2.9 to 21.7), follicle-stimulating hormone 0.2mIU/ml (normal range: 5 to 30), testosterone 0.02ng/mL (normal range: 9.0 to 40.0), prolactin 13ng/mL (normal range: 3 to 30). Insulin C-peptide was <0.50ng/mL (normal range: 1.5 to 3.5). Parathormone (PTH) was 33.4pg/mL (normal range: 2 to 72). Thyroid ultrasonography revealed heterogeneous echogenicity without any nodules, while ultrasonography of the abdomen was normal. His immunogenetic study demonstrated that human leukocyte antigen (HLA) typing was HLA-DR3. Based on combinations of 1DM, subclinical hypothyroidism due to Hashimoto? thyroiditis, adrenal insufficiency, vililligo and HLA-DR3, a diagnosis of APS2 was made. The presence of positivity for both anti-HCV and HCV-RNA with elevated ALT and AST levels even in the absence of hepatomegaly confirmed the diagnosis of chronic hepatitis C infection. His general condition improved gradually following the administration of hydrocortisone (10mg twice daily) and fludrocortisone (0.1mg twice daily). His diabetes was controlled with intensive multiple daily insulin injections. He was referred to the regional hepatology unit for further assessment including liver biopsy and consideration of hepatitis C eradication therapy but his father preferred to delay the treatment because he was worried about the side effects of the treatment."
+Joseph Fowler,20,1984/1/15,562-392-3315x626,vprice@example.net,15578 Martinez Street Suite 667,"The patient was a 66-year-old Caucasian man, who presented for a neuropsychological evaluation performed at the Centre of Alzheimer? Evaluation Unit (AEU), with a Mini-Mental State Examination (MMSE) value of 18/30. The neuropsychological final report, as authentically quoted and faithfully pursuant to the description of the AEU doctor, related the following: ?he present condition offers a picture of poor collaboration on the part of the patient who shows attention loss while performing the test and needs to be reminded about the given indications. Remarkable language worsening with reduced capacity of expression and comprehension that limit his autonomy. Worsening of executive functions with difficulty in planning and performing even simple activities, difficulty in solving problems. This picture defines a significant loss in instrumental activities for which assistance is needed. Treatment with anticholinesterasics and antioxidants must be continued??(Table ). For the evaluation of occlusal muscle activity, bilateral electromyography (EMG) of the masseter muscle was recorded using surface Ag/AgCl electrodes. In accordance with dental diagnostic protocols [,], a preliminary evaluation of the patient? myoelectric activity in habitual dental occlusion was performed via electromyography of the muscles in order to assess their functional balance, as the patient showed a bilateral lack of all molars, second premolars and the right medial incisor. Registered values showed a remarkable functional asymmetry of the masseter muscles: 10 mV for the left masseter and 111 mV for the right masseter, respectively (Figure ). According to the expressed electromyographic values, muscular activity was symmetrized by applying a 15-min transcutaneous stimulation of the trigeminal motor branches at low frequency for the masseter muscles and at medium frequency for the submandibular antagonist muscles. This method allowed detection of the functional trajectory of the occlusal elevator muscles and the recording of a symmetric craniomandibular relation by positioning a self-hardening material between the dental arches. The same material has been used successively to make a cusp bite modeled on the inferior dental arch, named the orthotic-syntropic bite for its particular use of electrostimulation. When the orthotic was applied, electromyographic control was repeated to verify the occlusal myoelectric balance. Substantially equal values were shown: 55 mV for the left masseter muscle and 60 mV for the right muscle (Figure ).
+Immediately after, saccadic, pupillometric and functional MRI (fMRI) examinations were performed, in habitual occlusion first and with the orthotic soon after; then, after a few days the patient was submitted again for neuropsychological evaluation. The saccadic video-oculography system used (Figure ) is made up of a computerized eye-tracking system with eye tracking acquisition times of under 100 milliseconds. It is able to measure on a space-time diagram the distance between the point at which the patient is being observed and the point at which the target is situated in that exact moment. The system can evaluate the target/eye coherence for 16 points, showing hypometric and hypermetric mistakes with drifts of different extension and the total visual attentive incoherence of the patient with rectangles. The saccadic test calculates variable target routes that do not allow mnemonic effects. Indeed, in the occlusal un-balance condition, the video-oculographic program recorded complete target/eye inconsistency for 12 of the 16 detection points (Figure ), while in the re-balance condition there were only two reported mistakes (Figure ). Pupil diameter evaluations were measured with a corneal topographer made up of a survey section with a Placido disk (24 loops), charge-coupled device (CCD)1/3 camera sensor with 56mm working distance, and constant light and a chin support. The cognitive task given was a perceptive motor practognosic test, named TanGram, made up of a puzzle of triangular, square and parallelogram-shaped geometric forms (Figure ). The patient, who had previously had how to perform the test explained to him, had to reposition in its specific place, without visual support, an element of the puzzle taken out and put in his right hand by the operator. The adopted protocol provided the pupillary diameter measurements (first basal and then during the cognitive task) just two seconds after the beginning of site exploration in the box. Pupillometric recordings were more interesting because when the patient performed the TanGram test, his basal pupillary diameter (2.65 mm) (Figure ), which is physiologically inclined to extension, reduced by ??.21 mm (2.44 mm) (Figure ), while in the occlusal re-balance condition a pupillometric increase of +0.58 mm (3.14 mm) (Figures and ) was registered, in line with what has been previously reported in the literature (Table ). The results of fMRI performed in un-balance and re-balance conditions have been reported jointly and they precisely refer to: ?ype of performed exam: direct cerebral RM. Poorly collaborative patient. No significant areas of diffusion restriction. Some foci with gliotic signs related to old vascular problems can be detected in periventricular and subcortical areas. Insignificant signal alterations in the subtentorial area. Increase of ventricular cavities width, especially of the left occipital horn and of the subarachnoid spaces with an atrophic basis. It was not possible to perform a functional study with the activation of motor areas through right hand finger tapping due to the patient? inability to perform the task correctly. After trigeminal stimulation and dental bite application, the functional study was made possible by an improved collaboration on the part of the patient, even if a correct activation of the pertinent motor area was not possible because the given orders were not performed at the same time as the acquisitions??
+Finally, a neuropsychological report, undertaken after orthotic-syntropic bite application, related the following: ?he neuropsychological evaluation evidences a higher collaboration of the patient, he is well oriented in space and shows light temporal disorientation. Minor difficulty in the comprehension of simple orders while the impediment to perform more complex tasks remains. The patient has improved short and medium term verbal memory span and his autonomy in performing instrumental activities of daily living, needing assistance only for more complex activities. Ideational slowdown remains. Improvement in executive functions capacities is evidenced, especially in planning, organization and problem solving abilities?? while the MMSE values in re-balance occlusion showed significant improvement (23/30), five points higher than the previous study (18/30) in the habitual condition (Table )."
+Lennon Reynolds,25,1996/12/25,+1-710-939-9156x18968,judith12@example.org,63654 Ashley Lane Suite 913,"A 22-year-old female was admitted with acute kidney failure following abruptio placentae causing severe vaginal haemorrhage in gestation week 33, resulting in stillbirth. The patient had a history of abortions in gestation weeks 9 and 28. Placental infarction at the second miscarriage resulted in heparin treatment during the actual pregnancy, which had been normotensive without proteinuria 2 days before admission.
+She presented with haemolytic anaemia, thrombocytopenia, schistocytes, uraemia, hypertension, oliguria and proteinuria (Table ). Treatment included plasmapheresis, haemodialysis and glucocorticoids. Anti-cardiolipin immunoglobulins, anti-Scl-70 and anti-double stranded DNA were negative. Anti-GBM and ANCA titers were not examined at disease onset, but were negative when examined 14 years later. Renal biopsy showed necrotic glomeruli with thrombi, platelet deposits and fibrin, vascular changes with luminal narrowing and intimal thickening, but no deposits. The diagnosis was TMA (pathologist Thomas Horn, MD, DMSc, Herlev Hospital, Denmark) (Figure ). A grand mal seizure occurred during hospitalization (no simultaneous metabolic derangements or severe hypertension). The clinical diagnosis was pregnancy-induced TMA with components of aHUS and TTP. After 6 months, kidney function improved and the patient was temporarily dialysis-independent for three years. She was never transplanted.
+A 69-year-old female was admitted with anuria and acute kidney failure. The patient had a 6-year hypertension history, hypothyroidism for 30 years and a minor stroke 4 months earlier treated by carotid thrombendarterectomy. At that time p-creatinine was normal. Blood tests showed severe uraemia and anaemia, but no haemolysis (Table ). The anti-GBM titer was positive, 95 U/mL (ELISA-kit, Wieslab, Sweden; ELISA-reader TECAN, Switzerland) and myeloperoxidase anti-neutrophil cytoplasmic antibodies titer (MPO ANCA) was 25 U/mL. Proteinase-3 ANCA was negative (ELISA-reader TECAN, Switzerland) and chest X-ray normal. Treatment included methylprednisolone, cyclophosphamide, plasmapheresis and haemodialysis. Renal biopsy showed diffuse extracapillary glomerulonephritis with predominantly fresh crescentic formations, focal and segmental necrosis and linear deposition of IgG along the glomerular basement membrane, consistent with anti-GBMGN (pathologist Claus B. Andersen MD, DMSc, Rigshospitalet, Denmark) (Figure ). The anti-GBM and MPO ANCA titres normalised after 16 days. There were no signs of TMA at any time. Kidney function was not regained."
+Vincent Valentine,25,2003/5/14,333.467.1821x03394,elizabethrogers@example.org,094 Jesse Cliffs Apt. 869,"A 25-year-old pregnant lady, gravida 2 and para 1, presented to the emergency room with 6 days history of lower abdominal pain, abdominal distension, bilious vomiting and constipation. She had no significant past medical or surgical history and her menstrual and antenatal history were uneventful. She was being managed conservatively for these complaints at a local hospital before presenting to us in the emergency. On examination, she was dehydrated, tachycardiac with a heart rate of 136 beats per minute and tachypneic with a respiratory rate of 28 per minute. Her initial blood pressure was 102/69 mmHg and she was drowsy. Her abdomen was distended and tense, with generalized tenderness and a tympanitic note on percussion. The uterine size was of 30 weeks gestation. Rectal examination revealed no stool and cervical os was closed on per vaginal examination. She was clinically suspected to have peritonitis with evidence of septic shock. She was resuscitated with intravenous fluids and antibiotics.
+Plain radiographs of the chest and abdomen showed pneumoperitoneum, a single fetus and a distended gas filled transverse colon. Ultrasound scan of the abdomen revealed moderate amount of free fluid with mobile internal echoes representing bowel content and intra-uterine death of the fetus. Her laboratory workup revealed severe electrolyte imbalance with serum potassium of 6.3 mmol/L (normal 3.5-5) and blood glucose level of 39 mg/dL (normal 80??60). She had evidence of severe metabolic acidosis with serum pH of 7.18 (normal 7.36-7.44), hypoxia with pO2 of 39 mmHg (normal 85??05) and deranged coagulation. The surgical and obstetric teams in the emergency room evaluated the patient. While being resuscitated in the emergency room, the conscious level of the patient dropped further and she was intubated and put on the mechanical ventilator.
+With the clinical diagnosis of bowel perforation and peritonitis, the patient was taken up for emergency laparotomy. Intra-operatively findings were of sigmoid volvulus resulting in closed loop obstruction leading to distension and ischemia of whole large bowel. The whole of the colon was dilated, friable, and gangrenous. Multiple perforations were identified in the colon with around 800 ml of feculent material aspirated on opening the abdomen. Whole colon was mobilized & resected and diverting ileostomy with a Hartman? procedure was done. A lower segment caesarean section was done for delivering the dead fetus and modified B-lynch sutures applied to the uterus. Post-operatively, she was continued on broad-spectrum antibiotics and shifted to the intensive care unit. She had an initial period of recovery for a couple of days, but subsequently, her pulmonary function deteriorated with development of pneumonia and adult respiratory distress syndrome. In addition to high ventilator support, she also needed increasing dose of inotropes and eventually expired on the 8th post-operative day due to overwhelming sepsis and organ dysfunction."
+August Preston,23,1983/7/15,214.401.4054,peckmary@example.com,2804 Michael Trafficway,"A 23-year-old woman was admitted to our hospital due to the development of a non-healing postoperative wound for approximately 4 months. In January 2011, she found a slightly painful subcutaneous mass that measured 1 ? 1.5 cm in the left buttock and underwent local excision at a local hospital. On postoperative day 2, she developed bleeding from the wound and received hemostatic interventions. However, the wound remained unhealed and continued to produce purulent exudates, with no obvious improvement after repeated dressing changes. On March 26th, 2011, the patient was referred to another hospital, where she underwent surgical debridement. Postoperatively, the wound deteriorated rapidly and developed a cauliflower-like growth. Meanwhile, she developed pitting edema of the lower extremities. Her general condition worsened.
+On April 21st, 2011, she was referred to our hospital. At the time of presentation, her general condition was poor and she had severe pallor. Her body posture was constrained and she could only sleep on the right side. There was obvious pitting edema of the bilateral lower extremities (especially the left side) and the lower abdomen. A T-shaped incision was noted on her left buttock. The cauliflower-like lesion measured 15 ? 20 cm and was sufficiently deep to reach the ischial tuberosity, with a large amount of purulent discharge (Figure ). Multiple inguinal lymph nodes were enlarged, hard, painful palpable, and fused together. Laboratory investigations revealed a red blood cell count of 1.39 ? 1012/L, hemoglobin was 31 g/L, white blood cell count was 16.54 ? 109/L, neutrophil percentage was 83.6%, platelet count was 322 ? 109/L, and the albumin level was 14.3 g/L.
+A magnetic resonance imaging (MRI) scan was performed, which revealed a large heterogeneous, irregular mass in the buttocks, buttock ulceration, and multiple enlarged pelvic and inguinal lymph nodes that were fused together (Figure ). An initial diagnosis of soft tissue sarcoma with lymph node metastasis was made. Small biopsy specimens were then taken and subjected to pathological examination, which revealed focal necrosis and tumor components. Numerous small round cells, with mostly oval nuclei and scarce cytoplasm, were seen (Figure ). Immunohistochemically, the tumor cells were strongly positive for vimentin and calretinin (Figure A,B), moderately positive for CD99 and epithelial membrane antigen (EMA) (Figure C,D), partially positive for cytokeratin and Ki67 (Figure E,F), but negative for actin, S-100, desmin, and HMB45. Based on these results, a poorly differentiated synovial sarcoma was diagnosed.
+As the patient developed severe anemia, hypoproteinemia and severe edema, she was treated with a blood transfusion, fluid infusion, supplementation with albumin and plasma, and regular dressing changes to maintain stable vital signs. However, her condition deteriorated dramatically and she rapidly developed systemic edema. As a result, she developed dyspnea, anorexia and anuria (<100 mL/d). The patient died of respiratory failure within a week after admission."
+Vincenzo Manning,24,1979/10/30,(763)673-7663,moorejason@example.net,0357 April Knolls Apt. 893,"A 59-year-old man sought medical attention in 2005 for vague abdominal discomfort, nausea and belching that had started 6 months earlier. The patient did not have any previous history of cancer in his family or any history of asbestos exposure. He denied any other gastrointestinal or constitutional symptoms. A physical examination was unremarkable except for a slightly distended abdomen. Initial investigations included routine laboratory investigations, an upper gastrointestinal tract endoscopy and a colonoscopy, all within normal limits. However, an abdominal computed tomography (CT) scan revealed omental caking, perihepatic ascites and neoplastic seeding in Morrison? pouch and the perihepatic space (Figure ). There was no evident lymphadenopathy present. A single hepatic lesion was further investigated by magnetic resonance imaging (MRI), which was compatible with a benign hemangioma. A staging investigation was negative for extra-abdominal metastases. The patient underwent diagnostic laparoscopy. Intraoperative findings revealed an omental thickening with nodules on the omentum and diffuse involvement of the peritoneal surface with relative sparing of the liver, spleen, stomach, and small and large intestine. Peritoneal biopsies results were compatible with DMPM of the epithelial subtype. He was then referred to our institution for definitive treatment. At 3 months after diagnostic laparoscopy, our team performed a complete CRS and HIPEC. Total right diaphragmatic, partial left diaphragmatic (2/3), total pelvic and parietal anterior peritonectomies were performed. The CRS procedure also included cholecystectomy, splenectomy, omentectomy, mesenteric implant fulguration and removal of laparoscopic surgery trocar sites that were invaded with tumor nodules. The peritoneal cancer index (PCI) was 21 (maximal possible score: 39). This index takes into account the number of invaded areas from a total of 13, and the maximal size of tumors nodules within 3 possible groups (<5 mm, 5 mm to 5 cm, >5 cm) []. After CRS, there was no residual tumor (completeness of cytoreduction (CCR) score = 0). HIPEC was performed with oxaliplatin 460 mg/m2 for 30 minutes and systemic 5-FU was simultaneously infused. The findings on the final pathological report were as follows: multifocal and multinodular tumor with numerous psammomatous calcifications, tumor made with polygonal cells showing a tubulopapillary proliferation pattern, cells present on the peritoneal surface and invading the underlying tissue inducing desmoplasia, tumor cells of intermediate size with a moderately abundant eosinophilic cytoplasm, round and slightly irregular nuclei with prominent nucleoli, weak mitotic activity, no intracytoplasmic mucin on periodic acid-Schiff diastase (PAS-D) staining. Immunohistochemical studies have been performed for vimentin, keratin 5/6, calretinin, Wilms' tumor 1 (WT1), carcinoembryonic antigen (CEA), CD15, E cadherin, Ber-EP4 and CD141. Tumor cells were extremely positive for calretinin, keratin 5/6 and focally positive for CD141. In conclusion, the histological aspect and the immunohistochemistry confirmed the diagnosis of DMPM of epithelial subtype.
+Our patient? postoperative course was complicated by respiratory failure episodes (secondary to pleural effusions and pulmonary edema), a right subphrenic abscess and a lower limb deep venous thrombosis. Recovery was slow but complete and our patient was discharged after 6 weeks. He was then followed with a positron emission tomography-computed tomography (PET-CT) scan every 4 months for 1 year and then every 6 months. At 36 months after treatment (June 2009), a PET-CT scan showed no evidence of recurrence.
+In November 2009 (41 months after CRS and HIPEC), the patient complained of blurred vision in his left eye and was referred to an ophthalmologist. Fundoscopic examination of the left eye revealed a solid pigmented choroidal mass above the macula measuring 6.9 ? 9.2 mm in base and 2.5 mm in height. The patient was then referred to a medical oncology service for systemic staging. MRI of the brain, and a CT scan of the thorax, abdomen and pelvis did not show any evidence of metastatic disease. The medical oncology team assumed that the left eye tumor was metastatic disease from DMPM and external beam radiotherapy of a total dose of 40 Gy (20 fractions of 2 Gy) was administered. Further ophthalmologic assessment showed no treatment response, the size of the tumor increased to 8.1 ? 11.3 mm in base and 2.9 mm in height. Two fine needle biopsies were performed but the results were deemed inconclusive. A second ophthalmologic evaluation by a specialized group of ocular oncologists was obtained. On fundus examination, a choroidal melanocytic lesion superior to the macular area was found. The lesion showed different grades of pigmentation, orange pigment on its surface and the presence of subretinal fluid (Figure ). B-scan ultrasound revealed an acoustically hollow dome-shaped lesion (Figure ), which on A-scan demonstrated a medium to low reflectivity, and a maximum height of 3.15 mm. Based on the clinical appearance and ancillary testing, a diagnosis of ocular melanoma was supported.
+In November 2010, brachytherapy with an iodine-125 plaque at a total dose of 80 Gy to the apex of the tumor was performed. In October 2011 the tumor reduced in size to 2.9 mm in height and there was no sign of recurrence of DMPM or OM on PET-CT."
+Jennifer Barber,44,1985/5/8,(713)563-5596x4785,jeffrey52@example.com,15773 Matthews Stravenue,"A 65-year-old-male presented to the surgical outpatient clinic of Medical Park Gaziantep Hospital with abdominal pain and distention, anorexia, weight loss and pyrexia. Abdominal pain was of recent onset and mainly in the central part of abdomen, but he had had a low-grade fever for at least 6 months. His pyrexia was intermittent, and most common at night and early in the morning. He had a medical history of abdominal surgery for peptic ulcer perforation 32 years ago. Clinical examination revealed a firm, vaguely defined, tender mass in the abdomen from the epigastrium to the pelvis. Blood results showed persistently high ESR (>50), high CRP (>200), leukocytosis, mildly raised alkaline phosphatase levels and anemia (normochromic, normocytic). There was no obvious source of infection that could cause the fever. Repeated blood cultures did not yield any bacterial growth. There was no improvement of the pyrexia after treating the patient with broad-spectrum antibiotics.
+Ultrasound and CT scan of the abdomen was performed, which showed multiple heterogeneous masses in one large cystic cavity almost completely filling the abdomen (Figure A and B). After the patienthad been consented for surgery, the thick cyst wall was opened, and 3 L of a clear fluid was aspirated, whose subsequent cytological examination determined class I. Surprisingly, a RSG was found at the bottom of the cavity and retrieved immediately (Figure A). Then the tumor was excised totally along with visceral peritoneum and mesorectum (Figure B). There was no major vascular or adjacent tissue invasion. The mesentery, including the tumor, was well circumscribed by the surrounding organs. Therefore, the origin of this tumor was thought to be the mesentery and visceral peritoneum in conjunction with the foreign body. The liver, spleen and pelvis had no local lesions. The patient had an uneventful postoperative recovery, and the pyrexia resolved completely following surgery.
+A histopathological examination revealed proliferation of pleomorphic cells in a storiform pattern. Mitotic figures were also frequently observed. Immunohistochemical analyses indicated that many of the tumor cells were positive for vimentin, while they were negative for cytokeratins, desmin, S-100 protein, actins, c-kit and CD34. These features are compatible with MFH of a storiform-pleomorphic subtype.
+Fourteen months following resection of the tumor, the patient was re-admitted with abdominal pain, weight loss and anemia. On CT scanning, he was found to have local recurrence of the tumor as well as liver metastases. At this stage, the patient was referred to the oncology department, but unfortunately, despite treatment, the patient died of progressive disease 2 months later."
+Solomon Washington,28,1990/9/30,553-251-0200x9510,brendavaldez@example.com,968 Randy Walks,"The proband was a 15-year-old boy born to non-consanguineous parents. He was born at 40 weeks gestation by spontaneous labor after an uneventful pregnancy. Birth parameters were as follows: weight, +0.78 SD; length, +3.1 SD; and head circumference; ??.2 SD. Long and wide great toes were already present at birth. His height remained above +2 SD (). His psychomotor development was normal for his age. Fractures at the age of 11 and 12 years led to his referral to our unit. At that time, his height was 177.0 cm (+2.7 SD). His weight and arm span were in the normal range, +0.8 SD and 99.7% of height, respectively, and his stature was proportional. Blood pressure was normal. Physical examination showed tall stature, scoliosis, and long hands and feet with arachnodactyly of all the fingers and toes, the great toes being markedly long and wide. In addition, the fifth distal phalanx of the hands exhibited minor clinodactyly (). He had no history of cardiac diseases, hypotension, ophthalmic disease, deafness, or digestive system disease. Hematological, biochemical and endocrinological values including insulin-like growth factor-I (IGF-I) were normal. However, bone formation and resorption markers were increased (serum bone-specific alkaline phosphatase, 270 U/l [normal range, 13??3.9]; osteocalcin, 12.5 ng/ml [normal range, 2.9??2.3]; cross-linked C-terminal telopeptide of type I collagen, 14.3 ng/ml [normal range, <4.5]; urinary cross-linked N-telopeptide of type I collagen, 524 nmolBCE/l [normal range, <55]). The bone mineral density (BMD) Z-score of the lumbar spine for L2??, determined with dual-energy x-ray absorptiometry (Discovery A, Hologic), was ??.2, and ??.9 when corrected for his height. Bone age was 11.0 years. Radiological examination of the skeleton showed mild scoliosis, markedly long and wide great toes, and minor clinodactyly in the fifth digit of the hands (). At the age of 15, his height reached 191.2 cm (+3.89 SD), and penile Tanner? stage was IV.
+The family tree () illustrates that the proband [III-1] has no siblings, and that his mother [II-5] and maternal grandmother [I-3] have the same phenotype (). Clinical manifestations of II-5 were as follows: age, 46 years; height, 176 cm (+3.8 SD for her age); blood pressure, 140/70 mmHg. Her great toes were surgically shortened at 15 years of age. She was given no medication, including antihypertensive drugs. Her menstrual cycles are regular. Radiological examination of II-5 showed severe scoliosis and lumbar vertebra fractures as well as markedly long and wide great toes, and minor clinodactyly in the fifth digit of the hands, like the proband (). The BMD of the lumbar spine for L2?? could not be evaluated due to compressed fractures of the lumbar vertebrae. Clinical manifestations of I-3 were as follows: age, 63 years; height, 166 cm (+3.0 SD for her age); blood pressure, 134/70 mmHg. She underwent right hip replacement arthroplasty at 50 years of age because of degenerative hip disease. She developed hypertension up to 210/110 mmHg at 59 years of age, when antihypertensive therapy was initiated. Her great toes were large in early life and shortened due to arthrogryposis with aging."
+Valerie Manning,23,2000/5/11,(411)528-1221,sherri14@example.com,60922 Elliott Expressway,"A five-month-old male infant presented with the history of fever and eye gaze from 3 days ago. Fever was mild to moderate without any associated chills.
+His birth history as well as developmental history was uneventful. The child was immunized up to date. The mother had no signs of mastitis. The child was apparently asymptomatic until two days before admission.
+There was no evidence of other focal deficit, altered sensorium, or seizures. Patient neither swam nor recently took a bath in pond, pool, or lake. All relevant history for tuberculosis was negative.
+CBC showed WBC 20,500 /mm3 (PMN 65%, lymphocytes 30%, monocytes 1%, eosinophils 1%, band cell 3%), hemoglobin 10.5 g/dL, hematocrit 31.9%, platelet count 731,000 /mm3. Serum electrolyte showed Na = 138, K = 5.7. ESR and CRP were 92 mm/h and 11.3 mg/L, respectively. Stool exam and urine analysis were normal; blood, urine, and stool culture were negative.
+A plain and contrast CT revealed communicated hydrocephalus. Following CT, lumbar puncture was done and CSF sent for microbiological and cytological analysis which revealed milky color, 2500 WBC cells/mm3 (PMN = 75%, Lymph = 25%) without any RBC with 391 mg/dL protein and 3 mg/dL of sugar. No bacteria or fungal elements were seen on gram stain. Bacterial culture was negative. Provisional diagnosis of acute bacterial meningitis was made, and the child was treated empirically by intravenous ceftriaxone 100 mg/kg/day and vancomycin 15 mg/kg/dose.
+Smear and PCR of CSF for tuberculosis was negative. Four days after starting of vancomycin and ceftriaxone, fever has not decreased so CSF examination was repeated. Second CSF analysis revealed 150 WBC cells/mm3 (PMN = 70%, Lymph = 30%), RBC 500 cells/mm3 with 121 mg/dL protein and 16 mg/dL of sugar. Naegleria Fowleri was seen on microscopic examination of wet preparation of CSF.
+Following the demonstration of amoebae in CSF, clinical diagnosis of primary amoebic meningoencephalitis (PAM) was made. Rifampin was started in a dose of 10 mg/kg orally per day and Amphotericin B in a dose of 1 mg/kg/day. CSF culture for Naegleria was also positive.
+Three days after beginning of treatment with Amphotericin B and Rifampin, there was improvement in clinical signs and symptoms but fever has not decreased yet, so brain MRI was performed that revealed just hydrocephalus (). The patient was referred to the Postgraduate Institute for the insertion of a ventriculoperitoneal shunt. Fever discontinued after surgery. After complete treatment, the patient was discharged. On followup, two months later the patient was totally asymptomatic."
+Seth Berg,19,2001/11/30,(208)522-3667,jeanpace@example.net,2337 Wood Neck Suite 525,"The subject was a 34 years old female. She was known case of hepatic hemangioma from two years ago. Also, she had fatty liver and had come to our clinic for following up her problem by Fibroscan. The body mass index of patient was 23.7. In her first Fibroscan, median fibrosis score of her liver was 17.1 kilo Pascale (Kpa) which was compatible with F4 on Metavir histological index (). Her cap score for liver steatosis was 201. The finding was unexpected; the patient was referred for liver sonography. Sonography confirmed her mild fatty liver, hepatic hemangioma (7.5?5.5 mm) in right lobe of liver, but there was no other abnormal finding. Liver function tests were normal. We tested autoimmune diseases and viral hepatitis markers for finding the reason; but all of them were normal. Based on our previously literature review, we thought hepatic hemangioma might leads to overestimation of liver fibrosis. So, we repeated Fibroscan (Echosens 502 device, France) from other sides; upper and lower to the hemangioma. Also, from her left lobe of liver by forth fold increasing of probe shuts. The findings was interesting, median fibrosis score was 4.4 that was compatible with F0 () but cap score of liver steatosis was near to our previous finding (210 dbl/m). We confirmed our guess, but more evidences were required. In the second Fibroscan we attend more to liver echogenicity and we excluded the mixed echogenicity parts for shutting.
+Interestingly, another patient came to our office for her fatty liver treatment follow up. We reviewed her medical documents for our new decision. We found that she is a known case of hepatic hemangioma. We demanded her to accept Fibroscan test. There was no problem for Fibroscan performance and patient? BMI was 24.1. Then, Fibroscan was done. Her fibrosis assessment by standard approach (right lobe) was normal and stiffness score of her liver was 5.6 Kpa which was equal with F0-F1 (). Also, her cap score for liver steatosis was 323 dbl/m. For evaluation of hepatic hemangioma effect in Fibroscan results, we repeated the procedure by forth fold increasing of probe shuts in left lobe of liver that the hemangioma was exist. Interestingly, result of Fibroscan was the same as cirrhotic patients; Fibroscan score was 11.8 Kpa (F3-F4) (). But, the cap score for liver steatosis did not change much more and was 335 dbl/m. Sonography and CT scan () have confirmed hepatic hemangioma (50-60 mm) in left lobe of patient? liver. Also, cavernous hemangioma has been reported in her liver biopsy."
+Emmalyn Travis,31,2003/5/2,-8882,charlesroberts@example.org,0282 Parker Roads Apt. 117,"A 61-year-old male presented with chronic cough and breathlessness. Chest CT revealed a well enhanced giant mass, approximately 18 cm in diameter in the right thoracic cavity (Figure ). FDG-PET showed that the SUVmax of the tumor was 5.0 in the center and almost 2.5 in the surrounding areas (Figure ). A trans-bronchial biopsy was performed and atypical cells were detected from the giant tumor. An intrathoracic malignant tumor was suspected, therefore surgical resection was performed. The CT findings suggested that the mass had not invaded surrounding organs, but had some adhesion to the right lung and superior vena cava. Surgical access to the mass was accomplished through a median sternotomy with a 4th intercostal thoracotomy of the right chest wall. A well-defined giant mass measuring 18 ? 14.5 ? 11 cm was found in the right thoracic cavity. The feeding vessels of the tumor were branching from internal thoracic vessels and collateral blood vessels were extensive surrounding the giant tumor. The tumor was completely resected without combined resection of the other organs. The weight of the tumor was 1350 g. The cut surface of tumor revealed a light brown color, an internal lobulated structure with a portion of capsulation invasion (Figure ). A microscopic examination showed the tumor to contain spindle shaped cells with a lymphocyte rich component (Figure ). Immunohistochemistry showed predominantly lymphocytes expressing CD1a, TdT and CD5. The spindle cells of the tumor were all negative for EMA, cytokeratin, CAM5.2,帢SMA, S100, CD5, TTF-1 and CD34. These histopathological findings indicated that the tumor was a type AB thymoma according to the World Health Organization classification and Masaoka stage IIB. The postoperative course was uneventful, and there has been no evidence of recurrence 6 months after the surgery."
+Willie Fields,27,1990/7/12,354-343-0830x8592,cory12@example.com,846 Martin Land,"A 70-year-old female with a history of primary angle closure glaucoma (PACG) status post laser peripheral iridotomy (PI) of both eyes (OU) presented for further management. She complained of discomfort and redness of the right eye (OD). Past medical history was significant for hypertension, gastroesophageal reflux disease and a cerebrovascular accident 15 years prior. Medications included atenolol, alprazolam, omeprazole, aspirin and topical prednisolone four times a day OD. The duration of topical prednisolone treatment was approximately 1 week prior to her presentation to our institution. The treatment was deemed necessary by the referring physician for her complaint of discomfort and redness. No other topical medications were given. Intraocular pressure (IOP) was 22 OD and 16 of the left eye (OS). Exam showed mild injection OD, shallow anterior chambers, patent PIs and cataracts OU. Gonioscopy demonstrated narrow angles with extensive peripheral anterior synechiae OU. Dilated fundus exam showed increased vessel tortuosity OU.
+Given the significant narrow angles despite patent PIs OU, cataract extraction with intraocular lens implantation OU was performed. She was treated postoperatively with topical moxifloxacin, nepafenac and prednisolone for a month. She did not receive dorzolamide or other sulfa derivatives. Postoperatively, the anterior chambers deepened and the angles opened significantly. IOP was noted to be 19 OD and 18 OS. No hypotony was detected throughout the entire course.
+Two months after cataract surgery, she developed 4 mm of proptosis, resistance to retropulsion, tortuous corkscrew blood vessels and an orbital bruit OD. Gonioscopy revealed the recurrence of narrow angles OD.
+A CCF was suspected and both computed tomography (CT) of the orbits with and without contrast and computed tomography angiography (CTA) of the head were performed. The CT orbits showed possible asymmetry of the superior ophthalmic veins (SOV). The CTA head showed atherosclerotic disease within the distal cavernous segments of the internal carotid arteries. As neither imaging modality was completely diagnostic and high suspicion for a CCF remained (based on the clinical examination findings), a six vessel cerebral angiogram was performed. The diagnostic cerebral angiogram showed a small indirect Barrow type D right carotid cavernous fistula with retrograde drainage into the right SOV (Figure ). Early filling of the right SOV was seen on right internal carotid artery injection; however, there were no feeders large enough to be actually visualized. On injection of the right external carotid artery, there was filling of the cavernous sinus via small branches of the right accessory meningeal artery. Our patient did not have a suitable endovascular corridor to the CCF via the petrosal sinuses, therefore transfemoral venous embolization did not appear possible. The plan was for transarterial embolization and if satisfactory occlusion could not be achieved from embolization of the right accessory meningeal artery feeder, then an alternative approach through the right SOV was to be considered. When diagnostic cerebral angiography was repeated prior to the planed embolization procedure, it was noted that she had undergone spontaneous partial closure of her CCF and the procedure was aborted.
+One month later, our patient developed worsening vision and was noted to have a choroidal detachment OD (Figures A and B). She declined further angiographic testing and was thus started on self-administered manual carotid jugular compressions. One month later, she was noted to have progressive worsening of her choroidal detachments and angle closure (Figure C and D).
+She eventually opted for repeat surgical intervention but when diagnostic cerebral angiography was performed prior to the embolization procedure, significant thrombosis of the CCF was noted. There was virtually no filling of the SOV on angiography and no intervention was warranted. Examination two months later showed complete resolution of her choroidal detachments and open angles OU."
+Annie Holland,37,1987/7/18,(803)235-6024,rebecca84@example.com,300 Ruiz Keys Apt. 128,"A 77-year-old Japanese woman presented to our emergency department with hematemesis. As given on the report from her nursing home, she had experienced a sudden onset of vomiting dark red fluid at least four or five times over the prior 12 hours. Her medical history included hypertension for six years, and cerebral hemorrhage three years previously with left-sided paresis and decreased mentation. Her medications included a calcium-channel blocker, an atypical anti-psychotic (sulpiride), and sodium valproate.
+On physical examination, she was afebrile, had a pulse rate of 117 beats per minute, and a blood pressure of 111/62mmHg. The differential diagnosis included ulcer, gastrointestinal (GI) tumor, angiodysplasia and diverticulitis of the small intestine, enteroaortic fistula associated with dissection or aneurysm, and small bowel ischemia with necrosis. However, no GI bleeding or evidence of ulcer was detected on emergent gastroendoscopy. A primary pulmonary source was also considered, and a chest X-ray revealed a 40mm mass in the inferior lobe of the right lung; our patient? symptoms were initially ascribed to swallowed and regurgitated blood from lung tumor-associated hemoptysis. However, subsequent serial physical examinations of the abdomen revealed signs of continuing, severe abdominal pain, with our patient grimacing during the examination, though without significant rigidity or guarding. Full characterization of the pain was limited by our patient? low level of consciousness due to past cerebrovascular accident. In addition to abdominal pain, our patient continued to have decreased urine output despite aggressive hydration, leading us to search for a possibly severe, occult abdominal pathology.
+Laboratory test results revealed a white blood cell count of 18,000 cells/弮L, C-reactive protein level of 9.03mg/dL, lactate dehydrogenase level of 342IU/L, and creatine kinase level of 1324IU/L. With an increasing likelihood of abdominal pathology, emergent CT imaging was ordered. Abdominal helical CT revealed ascites and dilated small bowel. On coronal views, a membranous structure was visualized in the center of the upper abdomen between the diaphragm and the left lobe of the liver; dilated, edematous intestine was seen on the right side of it, while air-dilated intestine was seen on the left side and in the lower abdomen (Figure ). We suspected that air introduced by prior gastroendoscopy may have been the cause of this dilation. On horizontal views, a closed loop of intestine was identified against the liver (S4 and S5); the membranous structure was identified as the falciform ligament in the center of the abdomen. On the left side, dilation of proximal intestines and collapse of distal intestine was seen (Figure ). Another cephalic horizontal view showed strangulated distal intestine through a hilar defect in the falciform ligament (Figure ). Based on the radiographic assessment, a pre-operative diagnosis of strangulated internal hernia through a defect in the falciform ligament was made.
+In addition to ascites, CT demonstrated strangulated intestine with decreased contrast enhancement. We suspected necrosis of the strangulated intestines through the falciform ligament defect. Our patient was therefore taken to the operating room urgently. Abdominal exploration revealed bloody ascites and a gangrenous bowel. Approximately 50cm of small intestine, 2m distal to Treitz??ligament, was looped over a defect in the falciform ligament. Prolonged strangulation had resulted in massive necrosis of tissue. The round ligament of the liver was cut, opening the falciform ligament and releasing the herniated bowel loop. The necrotic bowel was resected and primary anastomosis was performed. Our patient had a stable post-operative course with no gastrointestinal complications and was subsequently transferred five days after surgery for investigation of lung cancer."
+Brady Guzman,24,1992/12/28,550-249-6272,benjamin30@example.com,17400 Yolanda Stravenue Apt. 742,"A 22-year-old man was referred to a physician complaining of severe pain for 6 months from a progressively growing mass in the left arm. Medical history was unremarkable and the patient was not receiving any medication. He denied weight loss, night sweats and other unusual symptoms. Physical examination identified a fusiform palpable mass extending from the middle of the left arm to the elbow, combined with muscle weakness and numbness on forced flexion and supination. The laboratory results of kidney and liver functional tests, as well as the white blood cell counts and serum lactate dehydrogenase (LDH) levels, were within the normal range. The cerebrospinal fluid immunocytochemical analysis, bone marrow aspiration and biopsy showed negative for any malignancy. In addition, no positive symptoms were found on chest radiography or abdominal ultrasound (US).
+Magnetic resonance imaging (MRI) revealed a well-defined mass located in the medial compartment of the left arm, with homogeneous and intermediate signal intensity on the axial T2-weighted image (Figure A) and isointense to skeletal muscle on the axial T1-weighted image (Figure B). The unusual thickened median nerve was completely encased by the lesion. The axial enhanced T1-weighted image (Figure C) and axial fat-saturated enhanced T1-weighted image (Figure D) mainly showed mainly uniform enhancement in accordance with the median nerve. The coronal fat-suppression proton-density fast spin echo image showed the mass longitudinally extended along the neurovascular bundle in extension to the median nerve with measures of 10 ? 2 ? 2 cm (Figure E). Well-defined margins were noticed on the coronal blade fat-suppression proton-density image (Figure F).
+High-resolution US established a marked hypoechoic lesion on the left distal arm. The hypoechoic lesion showed a clear round halo which was completely and concentrically encased in the median nerve in transverse sonograms. The median nerve was much larger than normal and was characterized by swollen fascicles (Figure A). Longitudinal sonograms revealed the well-defined lesion extending along the median nerve (Figure B). Color Doppler sonography demonstrated avascular flow signals in the lesion (Figure C). The margin of the biceps brachii muscle slightly abutting the mass showed some hyervascularization on the color Doppler image (Figure D), while the basilic vein and ulnar nerve were normal.
+Through surgery, a well-defined and fusiform mass was found on the left arm. The tumor extending along the neurovascular bundle and in continuity with the median nerve seemed to originate from the median nerve. After resection of the fragile fleshy mass, the marked swollen median nerve was also noticed (Figure ). The median nerve was completely encased by the mass.
+Histologic examination revealed a diffuse dense monomorphic infiltration from small to intermediate-sized lymphoblasts (Figure A) showing scant cytoplasm and irregular nuclei with a high mitotic rate (Figure B), infiltrating among the fibro-fatty tissue (Figure C). Based on the immunohistochemical analysis, most of the lymphocytes stained positively for CD20, TDT, CD45, CD99, CD34, CD43, and negatively for CD3. Immunostaining for Ki-67 showed positive immunostaining of more than 90% of the lymphocytes. A diagnosis of precursor B-cell lymphoblastic lymphoma (PBLL) was rendered.
+Clinical symptoms including severe pain and numbness were relieved soon after the surgical procedure of decompression. Local radiotherapy was applied to his left arm. PET and Gallium scintigraphy were not performed at diagnosis under cost constraints. He received two cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy in the following 2 months. The patient was readmitted to our hospital due to persistent headache for a week before initiation of further chemotherapy. Cerebrospinal fluid (CSF) examination showed glucose 2.90 mmol/L, increased protein at 0.60 g/L, 90% mononuclear cells, 10% polykaryocytes, karyocyte count 90 ? 106/L, and no red blood cells (RBCs). The diagnosis of central nervous system (CNS) involvement was established. MRI of the brain was unremarkable. Neck, chest, and abdomino-pelvic sonography revealed no other involvement site except for a few axillary lymph nodes less than 10 mm in size. The patient died of multiple organ failure early in the course of high-dose methylprednisolone treatment shortly after being readmitted. Request for autopsy was denied."
+Ashley Foley,36,1979/3/16,916.311.6376,ashley27@example.com,546 King Heights Suite 860,"A 15-year-old Caucasian girl with Crohn? disease, who was on immunosuppressive therapy with oral 6-mercaptopurine, presented with fevers and sore throat, six months after her diagnosis of inflammatory bowel disease. On examination, she had bilateral tonsillar hypertrophy with basilar exudate. Epstein-Barr virus (EBV) serologies showed the presence of viral capsid antigen immunoglobulin M, immunoglobulin G and positivity for EBV nuclear antigen suggesting reactivation of the infection (Table ). She went on to develop significant jaundice and liver function tests revealed elevated transaminases and direct hyperbilirubinemia (Table ). An ultrasound of her liver did not show any obstructive pathology. The patient was hospitalized because of her persistent fevers along with jaundice, with the admitting diagnosis of EBV-induced cholestatic hepatitis. Serologies for hepatitis A, B and C, cytomegalovirus and human immunodeficiency virus (HIV) were negative. EBV copies continued to rise throughout the course of her illness, from 1,500 to 20,000 copies/mL. She continued to be febrile and developed severe respiratory distress and hypoxemia, requiring transfer to the pediatric Intensive Care Unit.
+A bone marrow biopsy and a diagnostic lumbar puncture were performed. Her cerebrospinal fluid showed evidence of pleocytosis. The bone marrow biopsy showed pancytopenia and increased lymphohistiocytic infiltrates with prominent hemophagocytosis (Figure ). The significant inflammatory response with high fevers and pancytopenia was attributed to her being infected with EBV. A decision was made to administer one dose of rituximab and high dose immunoglobulins to control the exaggerated immune response.
+There was laboratory evidence of cytopenia, with results notable for falling neutrophil count, severe anemia and thrombocytopenia (Table ). There was moderate elevation of ferritin and triglycerides. Her soluble CD25 (soluble interleukin-2 receptor) level was elevated at 39,322U/mL. (this information was not available at initial presentation). There was complete absence of CD16 and CD56 positive NK cells. NK cytotoxicity, porphyrin and granzyme testing could not be done with the initial presentation due to the absence of NK cells. Fibrinogen and coagulation studies remained within normal limits. Our patient was diagnosed with EBV-driven HLH as she fulfilled five of the eight required criteria for diagnosis, and she was started on chemotherapy with etoposide, dexamethasone and ciclosporin based on HLH 2004 protocol.
+Testing was also done to rule out HIV and other immune deficiencies. Genetic testing was carried out to rule out PRF 1, UNC13D, STX11 and STXBP2 mutations as well as signaling lymphocytic activation molecule-associated protein expression (SLAM) on cytotoxic lymphocytes.
+Our patient had moderate cervical lymphadenopathy (2cm), which was attributed to her EBV viremia at the time of diagnosis of HLH. There was moderate splenomegaly on a computed tomography scan of her abdomen but no other significant lymphadenopathy was noted, hence the diagnosis of lymphoma was not strongly considered. No further doses of rituximab were administered once HLH therapy was started. Her chemotherapeutic regimen included dexamethasone, etoposide and ciclosporin. Our patient received eight weeks of therapy on this protocol. She responded to therapy and improved clinically.
+Due to progressive enlargement of the lymph nodes in her cervical region two months after the initiation of therapy, an excisional biopsy of the cervical mass was performed (Figure ). Pathology results were consistent with EBV-positive diffuse large B-cell lymphoma. EBV viremia at the time of diagnosis of lymphoma was reported at 1,500 copies in the blood (Table ). Immunohistochemistry results were positive for CD20, CD19 and CD79a. A positron emission tomography scan showed extensive involvement of her supraclavicular and cervical lymph nodes as well as some involvement of her liver (Figure ). A bone marrow biopsy showed no evidence of involvement of lymphoma or hemophagocytosis. Treatment for lymphoma was given with six cycles of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) based on our institutional standard of care for patients sixteen years of age and older. Treatment related complications included prolonged fever and neutropenia. Restaging with positron emission tomography at the end of her R-CHOP therapy showed complete resolution. Our patient is now disease-free after completion of therapy. She has been off immunosuppressives for her Crohn? disease since her recovery from lymphoma, and has also been in remission for over 24 months now."
+Mohammad Leal,18,2000/9/7,658.802.7585x223,ajones@example.net,94212 Robert Path,"A now 38-year-old female patient was born as the third of four daughters of healthy parents. Her oldest sister remains healthy, while her second oldest sister suffers from idiopathic focal epilepsy and her youngest sister from Prader-Willi-Syndrome caused by a maternal parental disomy on chromosome 15. Following a regular pregnancy our patient first presented with a pyelonephritis at the age of four months. Right kidney aplasia and a significantly impaired renal function (serum creatinine 1.9 mg/dl, urea 83 mg/dl) were then noted, already indicating dysplasia of the left kidney. Her female external genitalia showed no anomalies and cystoscopy documented the presence of bilateral ureters. Over the following years chronic renal failure progressed as recurrent urinary tract infections occurred. Finally, she was referred to a pediatric nephrology unit at the age of 10 years and started hemodialysis six years later with a serum creatinine of 6 mg/dl. Aged 19 she received her first kidney transplant without any complications. As primary amenorrhea had persisted while pubertal development was commensurate with age, a diagnostic laparoscopy was undertaken and revealed a rudimentary uterus and regular ovaries. On the basis of a normal 46/XX karyotype the diagnosis of atypical Mayer-Rokitansky-Kuester-Hauser-Syndrome (i.e. MRKH Type II) was made. Aged 28 her first kidney transplant was lost due to consuming nephrotic syndrome caused by biopsy-proven de novo MN. At the age of 36 a second kidney transplantation was performed. Despite thymoglobulin induction and an intensified triple immunosuppressive therapy (tacrolimus, mycophenolate mofetil, prednisolone), under which she developed new onset diabetes mellitus after transplantation (NODAT), MN reoccurred within only four weeks after transplantation. Testing for secondary causes of MN such as hepatitis, HIV and antibodies against the phospholipase-A2 receptor (PLA2R) was negative []. All attempts to reverse MN including high dose steroids, immunoglobulin, plasma- and immunoabsorption, anti-CD20-antibodies (Rituximab) and proteasome inhibitor (Bortezomib) failed. Finally, the transplant had to be explanted despite remaining renal function (creatinine 2.4 mg/dl) due to the severity of nephrotic syndrome (albuminuria ??15 g/g creatinine; Figure ).
+In addition to her urogenital anomalies our patient is affected by a hyperelasticity syndrome with congenital joint laxity, kyphoscoliosis, and bilateral hip dysplasia. She shows persistent hypermobility of both elbows and knees and is easily able to place her feet behind her head, all of which are very unusual findings in a longstanding dialysis patient (Figure a-c). Her Beighton score is currently 8/9. As a result of dilating hyperelastic vascular walls arterio-venous fistulas on both arms rapidly developed hyperdynamic flows. Repeated surgical banding of the fistulas accomplished only a temporary improvement, so that vascular access was ligated shortly after transplantation to control right heart failure with tricuspid valve insufficiency (Figure d).
+In summary, this clinical picture resembles a mixture between a hypermobile (EDS3) and a vascular (EDS4) form of Ehlers-Danlos-Syndrome (EDS). Mutation analysis of the collagen type 3 alpha 1 gene (COL3A1), which is mutated in EDS4 and rarely in EDS3, was negative. We did not analyze tenascin-X (TNXB), another rare cause of EDS3, because characteristic hyperelastic skin changes were missing in our case. Mutations in the FBN1 gene, which is mutated in Marfan syndrome, had been excluded previously. As a next step a skin biopsy was taken for electron microscopy. It revealed a soft tissue disorder with loosely packed collagen fibres. The picture resembled findings in EDS4, without meeting the obligatory criteria of this disease, and was not suggestive of any other form of EDS.
+We therefore performed an array-based comparative genomic hybridisation (CGH) and detected a heterozygous 1.43 Mb deletion on chromosome 17q12 (Figure ). This deletion contained sixteen RefSeq genes and was absent in both the father and the mother of our patient, consistent with a de novo copy number variant (CNV)."
+Murphy Green,28,1998/8/22,969-567-4361,samuel26@example.net,615 Tara Mount Suite 864,"A 23-year-old woman was brought to the psychiatric department by her mother because of a change in behavior that appeared four weeks before the submission. At submission day (sixth week of sibutramine treatment at the recommended dosage of 10 mg/day), she presented elevated and expansive mood, increased energy and explosive reactions, was talkative and reported racing thoughts. Her mother stated that daughter had not slept for the past 4 weeks but felt rested, and stayed up all night cleaning the house. Daughter speech was rapid and loud, and it was hard to interrupt her. Mother said that daughter was out of home overnight on two occasions in the past month, being picked up by police for public alcohol drinking. It was behavior very unlikely her usual self. The patient stated that she just wanted to get out of the house to visit her friends and meet new interesting people. Following sibutramine withdrawal and introduction of valproic acid (2000 mg/day), the patient experienced a remission of manic episode in approximately 2 weeks.
+Six weeks later, she was admitted to the psychiatric department again with complaints of a depressed mood, loss of interest and pleasure, and marked psychomotor retardation. She said that for more than the past 2 weeks she often stayed in bed all day because of fatigue and lack of motivation. She felt guilty about the irresponsibility and excesses of the previous manic episode. She could not sleep and woke up early morning, stopped eating and bathing, her ability to think and concentrate diminished markedly. Before the manic episode, there was no significant past medical, psychiatric or substance abuse history. The results of the patient? physical and neurological examination, laboratory tests (including function of thyroid, liver and kidney), magnetic resonance imaging (MRI) of her brain, and ECG did not reveal any significant abnormalities. She had a positive family history for depression in her grandmother and bipolar disorder in her aunt. She was diagnosed as having a bipolar disorder, most recent episode depressed. In the psychiatric department, valproic acid treatment was maintained at the dose of 1500 mg/day, and sertraline 100 mg/day was started, with good results. In view of significant improvement, the patient was discharged after one month of hospitalization. There were no symptoms of mood disorder during 1 year of follow-up."
+Anthony Wilkins,39,1995/5/19,407.823.2315x07134,debbiepatel@example.net,275 David Street,"A 33 year old HIV-infected woman with a CD4 count of 32 cells/mm3 weighing 52 kg, presented with 3 months of watery diarrhoea. No cause was found despite investigations including multiple stool samples examined with modified acid-fast staining. Stavudine, lamivudine and efavirenz were started 2 months later, with efavirenz being switched to lopinavir/ritonavir following a hepatitis B flare at 3 months. Despite ART, profuse watery diarrhoea continued and after 4 months she was admitted to hospital for rehydration, weighing 44 kg. Isospora belli oocytes were observed in stool and treatment with co-trimoxazole at 1920 mg b.i.d was successful. She gained weight to 48 kg although her symptoms returned 3 months later, when oocytes were again identified in stool, despite secondary prophylaxis with co-trimoxazole 960 mg daily. At this time, her CD4 count had risen to 174 cells/mm3 and HIV viral load was 1000 copies/ml. Repeat episodes of severe diarrhoea with electrolyte disturbance continued despite secondary prophylaxis; 1 year after starting ART she weighed 38 kg. She required inpatient treatment for diarrhoea and dehydration on 18 occasions over 4 years. Each time, she improved on treatment, which included the use of single drug therapy or combinations of oral or intravenous co-trimoxazole, ciprofloxacin, albendazole and nitazoxanide. She relapsed on each occasion, despite secondary prophylaxis with co-trimoxazole 960 mg b.i.d with or without ciprofloxacin 500 mg b.i.d. She was supported with intravenous fluids, electrolyte supplementation and required total parenteral nutrition on several occasions. Diarrhoea was unlikely to be a side-effect of lopinavir/ritonavir as she remained asymptomatic between acute episodes while continuing this medication. Her CD4 was consistently >150 cells/mm3, peaking at 237 cells/mm3 after 20 months of ART. HIV viral load was consistently <50 copies/ml from 12 months of ART. She died from complications of chronic diarrhoea 4 years after starting treatment for isosporiasis."
+Amalia Foley,39,1997/8/10,+1-964-904-5802x7412,hmann@example.net,25703 John Camp Suite 865,"A 33 year old HIV-infected woman with a CD4 count of 210 cell/mm3 was treated with co-trimoxazole for microbiologically-proven Isospora belli in stool and started on secondary prophylaxis. Stavudine, lamivudine and nevirapine was started, but her gastro-intestinal symptoms never completely settled despite secondary prophylaxis with co-timoxazole at doses between 960 mg o.d. and 1920 mg b.i.d. CD4 count rose to 729 cells/mm3 and HIV viral replication was suppressed after 6 months of ART. After 2 years of intermittent symptoms, when her weight was 43 kg she was referred for gastroscopy and Isospora belli was observed in duodenal biopsy. She deteriorated and diarrhoea became more continuous; over the following 30 months she was admitted to hospital with increasing frequency. Isospora belli was observed in duodenal biopsies on 2 further occasions, but was absent from multiple stool samples taken at the same time. Co-trimoxazole, ciprofloxacin, paromomycin, pyrimethamine and nitazoxanide were all tried for relapses, with good initial response, but subsequent relapse on a combination of high dose co-trimoxazole and ciprofloxacin 500 mg b.i.d. secondary prophylaxis. Her weight dropped to 32 kg and she required 6 admissions in a 4 month period. Her clinical course was complicated by a deep vein thrombosis, major depressive episode, and hypocalcaemia-induced tetany requiring intubation and ICU admission. ART was continued throughout. HIV viral load recordings were consistently <50 copies/ml and her CD4 count peaked at 1013 cells/mm3, 5 years after starting ART. Five years after her first presentation, she died at home having declined hospital admission for a further episode of severe diarrhoea."
+Mohammad Davis,38,1992/12/3,(222)534-8513x5710,grantpatty@example.net,2701 Melissa Prairie,"A 23-year-old Caucasian woman first presented to our department 15 years ago with a palpable mass in her left breast three months after the delivery of her third child. At the time, she was breast-feeding. She had no family history of breast or ovarian cancer, and no personal history of breast disease. Menarche occurred at age thirteen, and she was nineteen when she delivered her first child. In view of her young age and Ashkenazi Jewish heritage, she subsequently underwent genetic testing, which was negative for BRCA1 and BRCA2 mutations. At the time of her initial presentation, an ultrasound of her left breast revealed a 1.7 cm mass in the area of palpable abnormality, and ultrasound guided fine needle aspiration (FNA) was suspicious for carcinoma. Extensive microcalcifications in her left breast were demonstrated on mammography. A left breast lumpectomy showed extensive intraductal and invasive ductal carcinoma with multifocally involved margins. The largest single focus of invasive cancer measured 1.5 cm. The cancer was 38 % estrogen receptor positive and 35 % progesterone receptor positive. Our patient then underwent a left total mastectomy with axillary lymph node dissection and transverse rectus abdominis myocutaneous flap reconstruction. The pathology at the time revealed additional extensive intraductal carcinoma, and axillary nodes showed no evidence of disease. Postoperatively, she received chemotherapy with cyclophosphamide, doxorubicin (Adriamycin) and 5-fluorouracil and was maintained on tamoxifen and leuprolide for three years. She was monitored closely and was without evidence of recurrence for approximately 10 years.
+Five years ago, our patient was evaluated with mammography, ultrasound and magnetic resonance imaging, which showed no evidence of malignancy in the contralateral breast. Our patient returned six months later, 20 weeks pregnant, at which time her clinical exam was unremarkable. One month later, our patient presented in the 24th week of pregnancy with a palpable mass in the upper-outer portion of her reconstructed left breast. On examination, a subcutaneous mass was appreciated, associated with the native skin of her reconstructed left breast. FNA of the mass identified malignant cells. Our patient underwent wide local excision of the mass. Histology confirmed poorly differentiated breast carcinoma invading into adipose tissue. The tumor, measuring 0.4 cm in its widest dimension, was noted to be estrogen receptor negative, but highly progesterone receptor positive (95 %) with overexpression of human epidermal growth factor receptor 2/Neu. After delivery of a healthy male child at term, our patient was treated with tamoxifen and trastuzumab and underwent radiation therapy to her left chest wall. At present, she remains on tamoxifen and is doing well without recurrent disease."
+Mia Lane,39,1999/10/21,(803)490-0024x362,diamondsosa@example.com,630 Cassandra Loaf Apt. 149,"A 4-year-old boy was admitted to our institution because of vomiting and persistent headaches. One month before admission, he had been admitted to another hospital with fever and difficulty walking. Brucellosis is endemic in the region, and Wright agglutination test is routinely performed among other examinations for the differential diagnosis of fever combined with limb dysfunction. The test was positive and the patient was treated by intramuscular gentamicin, oral doxycycline, and rifampicin. Poor compliance to oral antibiotics secondary to vomiting resulted in readmission to our hospital. CBC showed lymphocytic pleocytosis (WBC count 7.400/mL, polymorphonuclear cells 42%, and lymphocytes 48%). Erythrocyte sedimentation rate, liver and renal function tests were normal. The Wright agglutination test for brucellosis in the serum was positive at a titer of 1 : 320. Fundoscopy showed obliteration of the left optic disc margin. An antibiotic regimen of cotrimoxazole and rifampicin was initiated.
+During the first week of admission, headaches worsened. Serial fundoscopy showed frank left side papilledema. Ocular movements revealed left abducens palsy and horizontal diplopia. Papillary light reflexes were bilateral normal and no afferent papillary defect was present. Meningeal or other focal neurological features were absent. Brain magnetic resonance imaging (MRI) was normal, and bone scanning did not reveal any focal involvement.
+Lumbar puncture revealed clear cerebrospinal fluid (CSF) with high opening pressure (48 mmHg), and white blood cell count of 162 cells/mL (neutrophils 86%, monocytes 14%), glucose 32 mg/dL, and protein 60 mg/dL. CSF cultures were negative, but CSF polymerase chain reaction (PCR) examination was positive for brucellosis. Hence, the diagnosis of neurobrucellosis associated with intracranial hypertension was confirmed. Ciprofloxacin was added to the initial antibiotic regimen, and acetazolamide was administrated for intracranial hypertension.
+Repeat fundoscopy ten days later showed improvement of the left-sided papilledema. A second measurement of intracranial pressure two weeks later showed an improvement at 33 mmHg, which was further reduced to 26 mmHg after removal of 10 mL of CSF fluid. Headache regressed gradually. One month after admission, fundoscopy showed residual blurring of the temporal margin of the left optic disc. Ciprofloxacin was substituted by moxifloxacine. Acetazolamide was well tolerated and was gradually withdrawn, based on clinical improvement and normal opening pressure measurement on the last lumbar puncture which was performed before discharge.
+After two months in the hospital, the patient was discharged on a regimen of cotrimoxazole, rifampicin, and moxifloxacine for one month, followed by a period of four months with cotrimoxazole and rifampicin, with no residual deficits."
+Matias Juarez,45,1998/3/10,579-695-9541,james76@example.net,559 Villanueva Knoll,"A previously healthy 53-year-old woman, who had been complaining of respiratory tract symptoms and fever for 3 days, was diagnosed with a S. pyogenes necrotizing pneumonia with TSS and transferred to our institution. Upon admission, she was found to have multiorgan failure with acute respiratory distress syndrome and immediately required intubation and vasopressors. She also received IV penicillin, clindamycin, immunoglobulins, activated C-protein, and three days of corticosteroids at physiological dose. Over the following week, the shock resolved and her respiratory parameters improved.
+However, on day 10 her condition critically deteriorated, vasopressors were resumed and piperacillin-tazobactam was administered. On physical examination, proctorrhagia and abdominal distension were noted, and she developed leukopenia (). Abdominal CT scan revealed a pneumoperitoneum near the hypogastric region () with parietal pneumatosis of the caecum and sigmoid, compatible with acute ischemia (). An emergency laparotomy revealed intestinal and colonic necrosis which necessitated a 100 cm resection of the terminal ileum and subtotal colectomy with terminal ileostomy (). An abundant quantity of nonpurulent but foul-smelling fluid was recovered during the surgery but without any frank fecal peritonitis (). Peritoneal fluid cultures were made, and parts of the necrotic small and large bowel were sent to pathology. During the first postoperative day, the septic shock resolved, and blood cultures grew Bacteroides distasonis. The following day, a second-look laparotomy confirmed the absence of additional necrosis or ischemia and the wound was closed. The patient remained clinically stable and afebrile, but the leukocytosis progressed. Preliminary results of the peritoneal fluid cultures showed gram-negative rods and hyphae compatible with those of the Mucorales, the latter being initially considered a probable laboratory contaminant given the favorable clinical evolution of the patient at this point.
+On day 15 (five days postoperatively), the patient became unstable again, with a concomitant rise in lactate and white cell count. With the ileostomy tip and wound borders blackish, a diagnosis of intestinal mucormycosis was suspected. Liposomal amphotericin B was started at 5 mg/kg daily. An abdominal CT scan documented a lack of enhancement of the distal portion of the small bowel, including the ileostomy, compatible with ischemia (). Numerous splenic, hepatic, and renal infarcts were visible (). Ischemia was suspected on most parts of the residual small bowel. Pathological material sent during the first surgery (appendix, colon, omentum, and intra-abdominal fibrin) all showed broad nonseptate hyphae with irregular branching typical of mucormycosis invading blood vessels (). Furthermore, diffuse ischemic necrosis of most parts of the small bowel and colon secondary to the fungus vascular invasion was seen.
+A culture of peritoneal fluid on Sabouraud dextrose agar revealed a rapidly growing grayish cottony colony following incubation at 30簞C for 3 days. The organism was thermophilic, displaying good growth at 45簞C. Microscopic examination revealed large and mostly nonseptate hyphae, rhizoids, short unbranched and brown sporangiophores up to 500 弮m in length, spherical sporangia, ovoidal sporangiospores 4?? 弮m long, occasional chlamydospores, and numerous pale to dark brown azygospores (). From these features the fungus was identified as Rhizopus microsporus var. azygosporus. An DNA sequence obtained for the complete ITS1-5.8S-ITS 2 region revealed 100% homology with numerous R. microsporus strains in GenBank, including R. azygosporus strains CBS 357.93 and CBS 357.92 (GenBank accession numbers DQ119008 and AB097391). R. azygosporus is now considered a variety within R. microsporus. However, the ITS sequence does not allow discrimination of the varieties which are still assigned by morphology. The isolate was deposited at the Laboratoire de sant矇 publique du Qu矇bec under accession number LSPQ-00966. The in vitro susceptibility of the isolate to antifungal drugs was determined using the Clinical and Laboratory Standards Institute's broth microdilution method M38-A2 []. The results were as follows: amphotericin B, 1 mg/L; 5-fluorocytosine >64 mg/L, itraconazole, 1 mg/L; posaconazole, 0.5 mg/L; voriconazole, >8 mg/L; anidulafungin, >8 mg/L; caspofungin, >8 mg/L; micafungin, >8 mg/L.
+Micafungin was added to the therapeutic regimen because of a possible synergistic effect with amphotericin B against mucoraceous fungi. Daily laparotomies with broad resections of the necrotic tissues were performed. An immunology consultation did not establish an immune deficit, but immunoglobulins and interferon-gamma were administered nonetheless to optimize the phagocytic function of leucocytes.
+Unfortunately, even after eight interventions (including multiple liver segment resections, partial gastrectomy, splenectomy, multiple intestinal resections, salpingectomy, left radical nephrectomy, distal pancreatectomy, and left diaphragm resection), mucormycosis continued to progress relentlessly over surgical margins. On day 27, it was decided to cease treatments. The patient died a few hours later."
+Juliet Parrish,35,1986/5/1,995-831-3184x8320,ikelly@example.net,972 Bates Lodge Apt. 679,"In August 2009, a 60-year-old man with cryptogenetic cirrhosis was referred to our centre. His history revealed splenomegaly from the age of 16, with secondary thrombocytopenia. No clinical signs of decompensation of the liver disease were present: MELD score was 13 and Child-Pugh-Turcotte score B7. Physical examination showed splenomegaly and the presence of a pulsing voluminous mass, and vascular murmur in the middle and left upper abdominal quadrants was noted. Platelet count was 26.000/microL (normal values: 150.000??80.000/microL), and small esophageal varices were documented at endoscopy. The patient underwent a computed tomography (CT) of the abdomen which showed liver cirrhosis with signs of portal hypertension, a tortuous and ectasic splenic artery with some widely dilated sections (max 24 mm caliber), and massive aneurysmal dilation in the middle tract (90 mm of maximum diameter) with partly calcified walls, inducing a cranial displacement of the tail and the body of the pancreas ().
+Because of the severe portal hypertension, the patient was not considered eligible for the surgical treatment of SAA. We therefore decided to proceed with an angiographic approach.
+The angiographic study, performed via femoral artery approach, confirmed a voluminous wide-necked aneurysm located in the proximal third of the splenic artery, at 40 mm from the ostium, and revealed the presence of a second smaller SAA communicating with the former. The placement of a covered stent to straddle the aneurysms failed because of the extremely tortuous efferent splenic artery. A different approach was therefore attempted. The splenic artery blood flow was controlled by the inflation of a balloon catheter via occlusion of the proximal artery of the aneurysms to reduce the risk of aneurysm rupture and migration of the coils. This allowed the placing of 11 guidewires (???Curved Moveable Core, Boston Scientific, Natick, MA, USA) and 75 coils of different shape, dimensions (diameter range 10??6 mm; length range 120??00 mm) and companies (Boston Scientific, Natick, MA, USA; Cook, Bloomington, IN, USA; Balt, Montmorency, France) within the aneurysmal sac. The exclusion of the SAAs with complete preservation of distal flow to the spleen was thus obtained (), as confirmed by abdominal ultrasound ().
+A broad-spectrum antibiotic was given intravenously before, during and after the procedure. The patient was discharged from the hospital 7 days later in a good clinical condition.
+One month after the embolization, the patient developed high-moderate grade fever (>38簞C). Although large-spectrum antibiotic therapy was rapidly started, the fever worsened and the patient was again hospitalized in our unit. Abdominal ultrasound and CT scans excluded strokes/spleen abscesses, while a Tc-99m labelled white cells scintigraphy showed a progressive accumulation of circular leucocytes (90 ? 90 mm) with a sonolucent halo surrounding the aneurysm wall (). A blood culture was positive for Propionibacterium bacterium acnes, sensitive only to aminoglycosides, vancomycin, and clindamycin. Diagnosis of suprainfection of vascular devices was therefore suspected.
+Despite adequate antibiotic therapy, the clinical conditions worsened and liver failure developed (MELD 22, Child-Pugh-Turcotte C11). Because of the low pathogenicity and virulence of the causative bacteria, and the fact that infection was confined within the aneurysmatic sac, we decided to place the patient on the waiting list for a liver transplantation.
+The transplantation was performed in March 2010. During the operation, an en bloc removal of 2/3 of the distal stomach, spleen, tail and body of the pancreas and aneurysmatic bags was required because the pancreas and the transverse colon were tenaciously adherent to aneurysms. Furthermore, a partial resection of the transverse colon followed by a laterolateral anastomosis was performed due to the presence of extensive intestinal injury.
+The postoperative period was complicated by the development of a pancreatic fistula, which was drained through the laparotomic wound and in which was resolved gradually over the following weeks, and by a partial thrombosis of the superior mesenteric vein, which was resolved through an oral anticoagulant therapy.
+The patients was discharged 27 days after liver transplantation and, after two years, he is asymptomatic and in good clinical condition."
+Karsyn Dorsey,23,1999/9/30,-2138,pguerra@example.net,2429 Katherine Extensions,"A dark 60-year-old male patient visited the Department of Oral Medicine and Radiology with a chief complain of recurrent growth in the lower front region since 20 days. The patient gave a history of excision of similar growth about eight months back. The treatment details and the histopathology reports were not available. The patient gave a history of smoking and alcohol use. Medical history was noncontributory.
+Extra-oral examination revealed no apparent lymph node enlargement. Intraoral examination showed an exophytic growth of 2.5 ? 4 cm approximately on the lingual aspect of mandibular anterior region, extending from the mandibular right lateral incisor upto the left second premolar. The growth was pedunculated, arising from the marginal and attached gingiva of mandibular left incisors and canine. It is well defined, firm, nontender and covered with white pseudomembrane (). Removal of the pseudomembrane revealed blackish underlying surface. Mandibular marginal and attached gingiva was black in color especially on the labial/buccal aspect (). Multiple satellite lesions could be seen on the floor of the mouth. Correlating all the clinical features a diagnosis of malignant melanoma was made.
+Orthopantomogram showed horizontal bone loss and loss of lamina dura in relation to mandibular incisors. There was generalized rarefaction in the adjoining bone altering the normal trabecular pattern ().
+Computed tomogram (CT) showed 2.3 ? 4.4 cm sized enhancing lesion extending from right mandibular lateral incisor upto the left second premolar lingually (). There was erosion of the anterior cortex of the left body of mandible to the symphyseal region (). Enlarged, enhancing bilateral level I and II lymph nodes were seen."
+Addyson Beard,42,1987/3/4,958.248.8853x971,jeremiah31@example.net,07233 Sherry Mill,"A 50-year-old male patient with pain in the maxillary right first molar and a blackish growth on the right side of hard palate since 12 days visited the Department of Oral Medicine and Radiology. The patient did not report taking medications for any other illnesses. Habitual history was negative. Extra-oral examination revealed enlargement of bilateral submandibular lymph nodes, which were oval in shape, mobile, and nontender. On intraoral examination, a black exophytic growth was seen on the right side of the hard palate (). The lesion extended onto the buccal aspect involving the gingiva between the maxillary right first and second molars (). It was soft in consistency and nontender. Small satellite lesions were seen on the palate surrounding the lesion. A clinical diagnosis of malignant melanoma was made. Radiographs were taken and incisional biopsy performed.
+Orthopantomogram showed carious maxillary right first and second molars with destruction of the interdental bone between them. The continuity of the floor of the maxillary sinus was disrupted in the maxillary right first molar region. The periodontal ligament space in relation to all the right maxillary molars and second premolar was widened (). CT scan showed an ill-defined enhancing soft tissue mass on right side of hard palate, extending posteriorly upto the soft palate. There was no evidence of erosion or sclerosis of bone due to the soft tissue mass (Figures and ). Bilaterally enlarged level I, II, V lymph nodes were seen.
+Incisional biopsies were taken from both the lesions. Histopathological studies revealed numerous atypical melanocytes within the epithelium and also invasion into the connective tissue. These cells were epitheloid to spindle in shape, with vesicular, hyperchromatic nuclei, and prominent nucleoli. Few mitotic figures were also seen (). Thus, the pathological examination confirmed the diagnosis of malignant melanoma. The patients were then referred to the Regional Cancer Institute for further treatment. Both patients underwent excision of the primary lesion along with radical neck dissection and postoperative radiotherapy."
+Nathanael Johnson,35,1981/2/17,4906028453,owoods@example.net,09177 Lee Bypass,"A 55-year old Caucasian female with a past medical history significant for hypertension and a lumbar laminectomy for spinal stenosis 5 years prior to the current presentation underwent a uncemented metal-on-polyethylene total hip arthroplasty 2 years prior to the current presentation using a Converge acetabular cup and APR (proximally hydroxyapatite porous-coated) stem (Zimmer, Warsaw, IN) for right hip osteoarthritis. She had no pain and functioned well in terms of ambulation and activities of daily living for the first two years. After two years, she began to notice enlargement of a mass over her right hip which began to make it increasingly difficult for her to sit or lie on the right side. She ambulated at this time with a Trendelenberg gait to the right side. Her posterolateral incision was well-healed and there was no warmth or erythema. She had a large palpable mass overlying the surgical incision. She had a painless range of motion of the hip and was neurovascularly intact distally with good distal pulses. Plain radiographs did not demonstrate radiolucencies at the implant-bone interface or eccentric polyethylene wear (Figure a,b). Stem position was unchanged from postoperative radiographs. Osteolysis was noted beneath the collar of the stem. A circular soft-tissue density was seen surrounding the hip joint (Figure a,b). Three- phase technetium bone scanning demonstrated increased blood pooling involving the soft tissue lateral to the prosthesis suggesting soft tissue injury, but no evidence of prosthetic loosening. There were no other areas of activity noted. Magnetic resonance imaging demonstrated a massive collection lateral to the hip joint with extension into the ilopsoas bursa. A thin capsule-type wall surrounded the mass (Figure c). The mass demonstrated intermediate signal on T1-weighted images and increased signal on T2-weighted images.
+Because of the patient? persistent symptoms, the patient underwent surgical excision of the lesion through a posterior approach to the hip joint. After division of the tensor fascia lata and the gluteus maximus musculature, a large cystic structure protruded from the wound measuring 14 ? 10 ? 4 19 centimeters (Figure a). The cyst was noted to be compressing the sciatic nerve, although the patient did not demonstrate evidence of sciatic neuropathy. An attempt to aspirate the mass was unsuccessful. Therefore, a small incision was made in the capsular lining of the cyst to send a small quantity of the content for frozen section. Intraoperative frozen section revealed synovial hyperplasia with lymphocytic and neutrophilic infiltrate. Aggregates of organized fibrin (rice bodies) were noted. There was no evidence of infection. There was no evidence of malignancy, which would have required capsule closure, extraarticular resection of the hip joint and femoral prosthesis, and hip reconstruction. The cyst was then fully opened to reveal numerous granules of identical size and shape (Figure b). There was no gross necrotic tissue or hemorrhage. The contents of the cyst were emptied and the capsular lining was traced into the hip joint. The hip was dislocated and the capsular lining of the cyst was completely excised. There was no evidence of prosthetic loosening, polyethylene wear or metal debris. The wound was copiously irrigated and closed in layers over a drain. All cultures taken from the operating room, including aerobic, anaerobic, fungal, and acid fast bacilli, were negative for infection. Final histologic analysis confirmed the intraoperative frozen section report. Polyethylene or metallic wear debris were not identified. Following removal of the mass, the patient obtained immediate pain relief. An inpatient rheumatology workup failed to identify the presence of abnormal inflammatory markers such as rheumatoid factor or antinuclear antibody. On follow-up examination the patient was ambulating comfortably, and could sit and lie on her right side 2 months after excision of the cyst. These good results persisted to the latest follow-up 1 year after surgical excision."
+Emma Spence,41,1983/3/30,662-269-5674,clarkchristopher@example.com,29083 Davis Plains Suite 179,"Our patient was an 83-year-old African-American man, who was referred to our institution after originally presenting with difficult Foley placement at a local hospital. His medical history was relevant for benign prostatic hyperplasia, chronic renal insufficiency, arthritis and hypertension. His social history included tobacco use in the remote past. His vital signs and results of a review of systems were unremarkable. Results of a blood investigation showed a significant left shift with 82% segmented neutrophils. Urine analysis revealed cloudy urine, positive for leukocyte esterase, nitrites, small amount of blood and ketones. Microscopic examination of his urine showed 10 to 20 red blood cells (RBC) per high power field (HPF) and a field full of white blood cells (WBC) and bacteria. Our patient underwent cytoscopy after blood oozed out during initial catheter insertion. A complete investigation for hematuria including a computed tomography (CT) scan was performed that revealed a bladder mass. A TUR was undertaken, and histopathology confirmed the mass as being a high-grade bladder carcinoma. A follow-up metastatic investigation including a CT scan of the chest, abdomen, pelvis and bone were negative. Our patient developed increasing pelvic pain and significant hematuria. A radical cystoprostatectomy was subsequently performed revealing a multi-centric, ill-defined urothelial carcinoma (9 ? 7 cm) infiltrating the right pericystic soft tissue and encompassing the right ureteral orifice. Our patient tolerated the surgical procedure well. His post-operative course was complicated by right deep venous thrombosis occluding the right common femoral vein. A histopathological examination of the bladder tumor revealed a high-grade papillary urothelial carcinoma (Figure ) completely involving the dome and posterior wall, and partially involving the anterior and right lateral walls. The tumor extended into the perivascular soft tissue and metastatic urothelial carcinoma was identified in a left pelvic lymph node (staging: pT3; pN2; pMx). Additionally, histopathological examination of the prostate revealed a bilateral, multi-centric adenocarcinoma, Gleason 4 + 4 (Figure ) with perineural and lymphatic/vascular invasion. Metastatic prostatic adenocarcinoma was also identified involving the left and right pelvic lymph nodes (staging: pT3a; pN1; pMx). Interestingly, the left pelvic lymph node revealed a focus of both metastatic urothelial and prostatic carcinomas (Figures , ). The presence of two tumor types colliding in the same lymph node was confirmed using immunohistochemical stains, including CK7 and CK20, pan-CK and PSA. Additionally, both the primary tumors were stained with the same panel as an internal control. The focus of metastatic urothelial carcinoma was positive for CK7 (Figure ), pan-CK, and negative for CK20, while prostatic carcinoma was negative for CK7 (Figure ), CK20, and positive for pan-CK. In addition, the metastatic urothelial carcinoma stained negative for PSA (Figure ), while the prostatic carcinoma was positive (Figure )."
+Cillian Mann,36,1980/2/4,(649)365-5372,canderson@example.org,1095 William Row Suite 957,"A 46-year-old Caucasian female presented with a one-month history of tender brownish lump on the pinna. The patient reported that the lump was rapidly increasing in size and its surface was ulcerating. The patient? medical history was unremarkable.
+Examination revealed a 1.4 by 1.0 cm tender, firm, non-fluctuant, ulcerated lesion; initially it was thought to represent a pyogenic granuloma (Figure ). There was no palpable lymphadenopathy.
+The lesion was treated by wide circular excision with a 4-6 mm margin followed by reconstruction of the defect with a split skin graft. Histopathological evaluation of the resected tissue reported a benign calcifying epithelioma of Malherbe (Figures , and ). The patient remains well after five years."
+Paislee Cordova,25,2004/2/9,(423)221-3770x54021,ritasullivan@example.org,27756 Kathy Causeway Suite 442,"The patient was a woman in her 56 years old who had initially consulted our hospital in November 1996, at the onset of leukoplakia. The patient? major complaint was the appearance of leukoplakic lesions corresponding to left side first and second molar equivalent to palate gingiva. The patient had been previously diagnosed with uterine polyps. Her family history was unremarkable. The patient was examined at our department in late November 1996, following a referral from her local dentist, who detected white lesions on the left palate during dental treatment in mid-November of the same year. The patient was diagnosed with leukoplakia, and the palatal leukoplakia was resected through an excisional biopsy in December of the same year. The patient was subsequently followed up on an outpatient basis. In May 2006, white lesions were observed on the left buccal mucosa and the patient was diagnosed with dysplasia. The condition was treated with another surgical resection, and the patient was followed up as an outpatient. In December 2008, a leukoplakic superficial tumor appeared at left side lower canine, the first premolar equivalency department buccal marginal gingiva.
+The patient had moderate physique and was well-nourished, and no swelling of the cervical lymph nodes was observed. Leukoderma and erosion were observed at left side lower canine, the first premolar equivalency department buccal marginal gingiva. (Figure upper).
+Panoramic radiography findings did not reveal any resorption of the lower jaw. Computed tomography (CT) findings did not indicate any clear destruction of the lower left jaw or lymph node enlargement, which could be suggestive of metastasis to the neck.
+The clinical diagnosis for the patient was tumor of lower left gingiva. In January 2009, the patient underwent an excisional biopsy, with resection of the lower left gingiva tumor. Pathological analysis revealed well-differentiated SCC of more than 20 mm (pT2). No swelling of the cervical lymph nodes was observed. Hemorrhagic leukoderma and erosion were observed at left side lower canine, the first premolar equivalent to palate gingiva. (Figure lower). Panoramic radiography revealed resorption of the lower jaw (Figure ), and CT showed clear destruction of the lower left jaw, but without lymph node enlargement, which could be suggestive of metastasis to the neck (Figure ).
+On relapse, the patient was clinically diagnosed with a lower left gingiva tumor. The tumor recurred in the lower left gingiva (rT4aN0M0) in July 2009. Systemic chemotherapy was performed with 15 mg bleomycin (BLM). Beginning in August 2009, the patient underwent selective arterial injection chemotherapy, combined with radiotherapy. The chemotherapy regimen consisted of 100 mg cisplatin (CDDP), administered in 4 doses: 30 mg to the lingual artery, 40 mg to the facial artery, 10 mg to the inferior alveolar artery, and 20 mg to the occipital artery. The radiotherapy regimen using Linac consisted of a total of 64 Gray (Gy) irradiation, administered bilaterally in 32 fractions, including levels I and IIa. The patient then complained of pain in the left femur. An imaging study indicated that the tumor had metastasized to the left femur (Figure and ); therefore, 300 mg/day of tegafur-uracil (UFT) in combination with radiotherapy, consisting of bilateral irradiation of 45 Gy in 15 fractions, was applied to the metastasis. At the beginning of November 2009, the patient underwent systemic chemotherapy with 135 mg nedaplatin (CDGP) and 90 mg docetaxel (DTX), followed by 300 mg/day UFT at the end of the same month. At the beginning of December 2009, the patient underwent segmental resection of the lower left jaw, left supraomohyoid neck dissection, and lower jaw reconstruction using titanium plates. At the end of December in the same year, the femoral tumor was surgically removed and a total knee replacement was performed. CT performed 1 month after surgery revealed multiple metastases to the lungs (Figure ), liver, spine, mediastinal lymph nodes, and abdominal subcutaneous tissue (Figure ). The patient simultaneously exhibited fever and a sudden increase in her WBC count and C-reactive protein (CRP), which failed to abate, despite treatment with the antibacterial drug imipenem hydrate-cilastatin sodium. A G-CSF-producing tumor was suspected; the serum G-CSF level was high at 250 pg/ml (Figure ). The patient's WBC count eventually increased to 32 ? 103/ml. Her general condition suddenly worsened, resulting in death due to multiple organ failure in February 2010; a month since the G-CSF producing tumor was diagnosed. Patient survived for 13 months from her time of tumor diagnosis till her death and her period of survival was uneventful.
+Pathological examination on relapse revealed well-differentiated SCC. Immunostaining of the resected specimen in January 2009 confirmed the presence of G-CSF-positive tumor cells. Staining of biopsy tissue in July of the same year revealed the G-CSF-positive tumor cells to be more pronounced (Figure )."
+Vicente Deleon,33,1994/11/25,275.857.5783x91322,washingtonrobin@example.com,036 Alicia Flats Suite 362,"A 78-year-old man presented with a 6-month history of recurrent otorrhoea in the right ear. He reported no pain, hearing loss, tinnitus or vertigo. He had no history of trauma, surgery or of wearing a hearing aid. Physical examination showed a pink, smooth mass measuring 0.5??? ??.7 cm on the outer part of the right EAC. Palpation of the mass revealed no tenderness. A computed tomography (CT) examination showed a soft lesion measuring 0.5 ? 0.5 cm in the right EAC with no sign of bone destruction, but the radiologist made a diagnosis of infection and did not suspect a tumour (Figure ). Surgery was performed by the transmeatal approach with total removal of the mass. Histopathology revealed that the tumour cells were arranged in a glandular nest, similar to normal ceruminous glands. The cells were growing actively, and a diagnosis of adenoma of the ceruminous gland was made. Immunohistochemical analyses for the expression of vimentin, cytokeratin (CK), alpha-smooth muscle actin (帢-SMA), desmin, S-100 protein, Glut-1, HIF-1帢, PI3K and p-Akt were performed in the tissue sample using an EliVision plus IHC Kit (Maixin Biological, Fuzhou, China). The tumour cells were positive for CK, S-100 protein, Glut-1, HIF-1帢, PI3K and p-Akt (Figure ), but negative for all other markers examined.
+At final follow-up, 27 months after the operation, there was no evidence of recurrence."
+Gabrielle Mann,26,1979/11/1,525-262-2739x63826,kim32@example.org,2578 Nathaniel Trafficway,"Between the ages of 4 and 16 months, a 20-month-old nonatopic Pakistani boy had experienced four separate bouts of profuse vomiting approximately two hours after he had consumed rice. The quantity of rice inducing these reactions varied between 10 g with the first reaction to a few grains of rice with the most recent reaction. None of these reactions had been associated with diarrhea, skin rash or angioedema. With three of the reactions, the child had become limp and with one he had briefly stopped breathing. Neither stridor nor wheezing had been evident with the latter reaction. Investigations confirmed a total IgE of 130kU/L (ImmunoCAP; Thermo-Fisher) with negative specific IgE to rice, wheat, oats, soya, cod, egg, potatoes, peas, cauliflower, apple or a nut mix, all giving values <0.1kUA/L (ImmunoCAP; Thermo-Fisher, Horsham, UK). Skin prick testing was negative to rice, milk, egg and banana. A graded rice challenge is planned for when the child is four years of age."
+Nehemiah Rodriguez,30,1986/12/26,(869)945-9445,perkinsjoseph@example.com,535 Harris Locks,"From the age of nine months, a 16-month-old Caucasian boy with mild eczema and asthma had experienced three bouts of profuse vomiting approximately two hours after the consumption of cod. The quantity of cod inducing these reactions varied between 5 g with the first reaction to a little less than a quarter of a gram with the most recent reaction. None of these reactions had been associated with diarrhea, skin rash or angioedema. With one of the reactions, the child had become limp but none had been accompanied by dyspnea. Investigations confirmed a total IgE of 371kU/L with mildly positive specific IgE to cod at 0.98kUA/L and haddock at 0.83kUA/L (ImmunoCAP; Thermo-Fisher). The result was minimally positive to shrimp at 0.27kUA/L and significantly positive to wheat at 36kUA/L, oats at 18kUA/L and corn at 15kUA/L. The child had tolerated these cereals without reactivity on numerous previous exposures. Skin prick testing to cod, salmon, shrimp was, however, completely negative. A graded cod challenge is planned for when the child is four years of age."
+Evelyn Meadows,44,1985/12/28,(306)912-8619x207,rebeccaosborn@example.net,8040 Vanessa Canyon Suite 948,"A four-year-old Egyptian girl was referred to our pediatric endocrinology unit for evaluation of bilateral breast budding and growth of pubic hair of four months duration followed by two episodes of vaginal spotting, initially noticed two weeks prior to her presentation. Her previous medical history and birth history were unremarkable; there was no family history of endocrinological disorders or precocious puberty. At presentation, our patient was an alert, irritable child. Her height was 115 cm (>97th percentile) and weight 20 kg (90th percentile). Her vital signs were normal. She had normal ocular, thyroid and cardiorespiratory examinations and no lymphadenopathy. Her breast tissue was palpable and the contour of her nipples and areolae was equivalent to Tanner stage III breast development. Her pubic hair was coarse, pigmented and distributed over her labia majora, equivalent to Tanner stage III []. Inspection of her external genitalia revealed estrogenized vulval mucosa with a clear viscous discharge, and the clitoris was slightly enlarged. An abdominal mass was palpable in her suprapubic area, firm in consistency, not tender, with ill-defined borders. There was no obvious ascities.
+An initial ultrasonographic study of her abdomen and pelvis revealed an enlarged uterus with prominent endometrium and 7.8 cm ? 5.2 cm irregular, inhomogeneous mass in the right adnexal region lying above her uterus and crossing the midline. Her left ovary, adrenals, liver, spleen and kidneys were normal. Computed tomography imaging of her abdomen and pelvis confirmed the above mentioned findings (Figure ). Subsequent testing of her brain by magnetic resonance imaging revealed a normal-sized pituitary and infundibulum with a normal posterior pituitary bright spot. An X-ray of her left hand and wrist revealed a bone age of 5 years according to female standards [].
+Laboratory values of a complete blood count and thyroid function tests were within the normal limits. Serum concentrations of estradiol were in the range of 280 to 375 pmol/L (normal <73 for prepubertal child); progesterone, 5.3 nmol/L (normal 0 to 1.3 nmol/L); testosterone, 38.9 pg/mL (reference value 1 to 5.2 pg/mL); androstenedione, 4.1 ng/mL (normal, 0.3 to 3.1 ng/mL); and prolactin, 233 mIU/L (normal < 460 mIU/L). Basal levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were low (0.4 and 0.7 IU/L, respectively), with no change in response to stimulation by 100 mg of LH-releasing hormone intravenously. Regarding tumor markers, the total inhibin level was 1,069 U/L (normal <100 U/L for prepubertal child) and the alpha fetoprotein levelwas 987 弮g/L (normal 1 to 200 弮g/L) while B human chorionic gonadotropin, lactic dehydrogenase and alkaline phosphatase were negative. Her chromosomes were normal (46XX). Our patient underwent explorative laparotomy one week after her initial presentation to our department; a solid tumor localized to her right ovary was identified. A right salpingo-oophorectomy was performed. Gross examination showed that the tumor mass measured about 10 ? 7 cm in diameter. The mass was capsulated and its outer surface was nodular with dilated congested blood vessels. The cut section was solid and with multiple cysts containing transparent thick material. The mass was firm in consistency with friable areas. Its color was yellow grayish with small dark areas of necrosis (Figure ). The histopathological report was an MGCCST with a yolk sac tumor. The histological picture showed the presence of the yolk sac tumor and a Sertoli-Leydig cell tumor with intermediate differentiation (Figures , ). An immunohistochemical study of the tumor cells showed diffuse positive staining for alpha-fetoprotein (Figure ) and focal areas of positive staining for inhibin (Figure ).
+Our patient? postoperative period course was unremarkable, although a short period of vaginal bleeding was noted a few days after surgery. Pubic hair was lost and her breasts became less prominent over the four weeks following surgery. One month after surgery, she was started on chemotherapy treatment with bleomycin, etoposide and cisplatin (BEP regimen) every three weeks for four cycles. Eight months after surgery and chemotherapy, she was tumor free on clinical examination and radiography; her estradiol and testosterone levels had decreased to 61 pmol/L and 3.1 pg/mL, respectively. Our plan is to follow her up every three months for two years then every six months for five years."
+Wayne Riley,33,1997/1/25,001-992-479-0976x70411,cruzkimberly@example.com,19500 William Garden Suite 504,"A 70-year-old woman was referred to our clinic, complaining of rapid anterior swelling at the neck. A diffuse firm goiter was observed and the patient indicated feeling oppression of the neck. No lymph node swelling was observed. The patient has a past history of hypothyroidism and enlargement 10 years earlier and takes 50 弮g levothyroxinesodiumdaily. Laboratory examination indicated almost normal thyroid function (free T4 1.3 ng/dL, free T3 3.6 ng/dL, thyroid-stimulating hormone (TSH) 0.04 m unit/mL, thyroglobulin 600 ng/mL) with anti-microsome antibodies and anti-thyroglobulin antibodies. The s-IL-2 Receptor antibody measured as high as 970 U/ml.
+However, thyroxine-supplementation could not decrease the size of the thyroid. The thyroid gland continued to enlarge and diffuse, and was approximately 5 cm thick at the isthmus portion on the ultrasonographic examination. A computed tomography (CT) scan showed a huge thyroid enlargement with decreased internal density (Figure ). There was no obvious mass lesion in the thyroid. The enlarged thyroid gland was well demarcated.
+On FDG-PET (18 F-fluorodeoxy glucose-Positron Emission Tomography) examination, the FDG accumulation was detected in the enlarged thyroid region, suggestive of Hashimoto? thyroiditis and/or lymphoma. Serological examinations were negative for human T-cell lymphoma virus type 1 (HTLV-1). Fine needle aspiration cytology suggested the case was consistent with Hashimoto? thyroiditis. Although we suspected possible malignant lymphoma associated with Hashimoto? thyroiditis from the large thyroid size and a rapid growth rate, the diagnosis was not confirmed. Therefore, the right hemithyroidectomy was performed to obtain a definite diagnosis and relief of the local symptoms caused by an enlarged goiter (Figure ). Histological examination revealed diffuse small lymphocytic infiltration in the thyroid gland associated with Hashimoto? thyroiditis. However, Southern blot analysis of tumor specimens revealed only a monoclonal T-cell receptor gene rearrangement. The final diagnosis was peripheral T cell lymphoma. Therefore, a left hemithyroidectomy was also performed one month later. No adjuvant therapy was performed because of the tumor stage and its subtype. The patient has been well with no recurrence or no metastasis. Furthermore, no additional medication has been required for 22 months since the surgery.
+Macroscopically, the resected thyroid gland was diffusely enlarged, but the thyroid tumor was firmly encapsulated without extracapsular spread. The cut surface of the thyroid had pale white medullary components.
+Histologically, severe and diffuse infiltration of the lymphoid cells was found in the medullary region. Lymph follicle formation with germinal centers was noted in the periphery of the medullary region. Atypical lymphoid infiltrations were also located among the atrophic thyroid follicles.
+In the medullary area, infiltrated lymphoid cells were relatively uniform, small-to-medium sized, round cells with a high nuclear to cytoplasmic (N/C) ratio. These cells had round nuclei with increased coarse chromatin and small nucleoli. Mitotic figures were often seen as high as 60% in high-power fields (Figure ). These findings suggested small lymphocytic lymphoma. The atrophic thyroid epithelia showed enlarged and eosinophilic granular cytoplasm with large nuclei, so-called H羹rthle cell metaplasia. Around these H羹rthle cells there were many plasma cells, lymph follicles with germinal centers and a few eosinophils (Figure ). These findings suggested complication of Hashimoto? thyroiditis.
+Immunohistochemical examinations were performed on formalin-fixed, paraffin-embedded specimens, using an autostaining system according to the manufacturer? protocol. From these results, diffusely infiltrated lymphocytes were positive for T-cell markers (CD3 and CD45RO) and positive for B-cell markers (CD20). However, infiltrated atypical T cells showed CD3 dominancy (Figures and ). In contrast, lymphoid cells of the peripheral area with lymph follicles showed an admixture of T and B cells, mimicking lymph follicles.
+Surface marker analysis of the freshly resected tumor showed T-cell dominancy (CD2+, CD3+, CD4+, CD5+,CD45+). There was also a small population of B-cell lineage, with no dissociation of surface membranous immunoglobulin light chain kappa or lambda. These data suggest the polyclonal nature of infiltrated B lymphocytes associated with Hashimoto? thyroiditis.
+Polymerase chain reactions (PCR) for detection of rearrangement of immunoglobulin heavy chain (IgH) hypervariable region and T-cell receptor (TCR) were performed using fresh specimens as described previously []. PCR showed a polyclonal pattern for both IgH and TCR. Southern blot analysis produced a rearrangement band of TCR-帠 by Hind III digestion and TCR-帣 by BamH I digestion (Figure ). There was no rearrangement of the TCR-帤 chain or IgH."
+Kayla Levy,29,2003/12/6,(564)250-9447x3481,kenneth41@example.com,469 Sharon Manor Apt. 813,"A 62-year-old male with a history of hypertension, COPD, GERD and recently diagnosed poorly differentiated adenocarcinoma of the left lung with invasion of his left pulmonary vein and left atrium presented to the emergency department (ED) with intermittent aphasia, complaining of left flank pain and bilateral lower extremity pain and numbness. The patient was on anticoagulation therapy and scheduled to have combined cardiothoracic surgery for resection of the left lung and left atrial masses.
+On initial evaluation, he was in obvious distress, writhing in bed, with a blood pressure of 141/52 mmHg, a heart rate of 60/min, a respiratory rate of 16/min, a peripheral O2 saturation of 99% on room air, and a temperature of 37.4 簞C. He exhibited intermittent fluent aphasia. Cranial nerves II - XII were intact. Upper extremity examination revealed normal circulation, motor and sensation bilaterally. Lower extremities were pallorous and cold, the left greater than the right. There were palpable bilateral femoral pulses, nonpalpable bilateral popliteal pulses, and nonpalpable and non-dopplerable bilateral dorsalis pedis, and posterior tibial pulses. Strength was noted to be 0/5 on the right and 2/5 on the left. Sensation was decreased to light touch and pinprick, with the left greater than the right. Deep tendon reflexes were symmetrical.
+His white blood cell count (16,700/弮l) was mildly elevated, and his PTT (41.7 s) was prolonged. An EKG showed a sinus rhythm with a right bundle branch block that was unchanged from a prior EKG. A por chest X-ray (Figure ) showed a large left upper lobe mass. A brain CT demonstrated a small subacute cortical infarct in the left frontal lobe (Figure ). A CT angiogram of the aorta w ith runoff revealed occlusion of the left external iliac artery without collateral or distal reperfusion, and occlusion of the right popliteal artery (Figure ) without collateral or distal reperfusion. It also showed bilateral renal infarcts and a splenic infarct (Figure ).
+Since the patient was on Lovenox, he was not heparinized in the emergency department. He was evaluated by neurology and vascular surgery, and emergently taken to the operating room for bilateral thromboembolectomies and bilateral four-compartment fasciotomies. Improvement in lower extremity circulation was immediate upon re-establishment of blood flow with return of distal pulses. A histological examination of the emboli confirmed metastatic carcinoma consistent with poorly differentiated adenocarcinoma.
+Postoperatively, given the patient? condition on admission, he was no longer deemed a surgical candidate for mass excision. Hematology/oncology and radiation oncology were consulted, and they suggested palliative chemotherapy and radiation after his fasciotomy incisions healed. On postoperative day 3, the patient developed atrial fibrillation and was placed on diltiazem. On postoperative day 8, he was discharged home."
+Harold Patton,19,1986/8/11,001-306-753-9979x028,brittanypatton@example.com,399 Deanna Rapid Apt. 485,"A 25-year-old man suffering from severe right knee pain presented at our institution. He had received steroid-pulse therapy several times for nephrotic syndrome and was subsequently diagnosed with steroid-induced osteonecrosis of the lateral femoral condyle. The preoperative X-ray and MRI showed an osteochondral defect of the lateral femoral condyle (Figure A-C). Arthroscopic findings showed his cartilage defect was classified as International Cartilage Repair Society Grade IV lesion. Osteochondral autograft transplantation was performed using the Arthrex osteochondral autograft transfer system (Arthrex, Naples, Fla.). Bone plugs 9 mm in diameter and 15 mm in depth were removed from the lesion (recipient site). Then two osteochondral plugs 1.0 mm oversized in diameter and of the same length were harvested from the lateral patello-femoral joint surface of the ipsilateral knee and transplanted into the recipient site measuring 20 ? 10 mm using the press-fit technique (Figure A-B). Postoperatively, the patient received continuous passive motion (CPM), but remained non-weight bearing for 4 weeks. Quadriceps and hamstring strengthening exercises were encouraged. The patient had to keep taking steroid after the operation in order to control primary disease. Postoperatively, no further clinical symptoms occurred after surgery and his Lysholm score had improved from 67 to 100 four year after surgery. X-rays and MRIs one year after surgery showed the restoration of the articular cartilage surface and good engraftment of the graft (Figure C-E). We did not find any abnormality in the donor site condition."
+Lorelei Sellers,36,2005/4/25,613.370.7106x797,uramsey@example.com,1706 Adriana Spurs,"An 18-year-old man suffering from severe left knee pain had received a renal transplant because of focal segmental glomerulosclerosis and was subsequently diagnosed with steroid-induced osteonecrosis of the medial femoral condyle. The preoperative X-ray and MRI showed an osteochondral defect of the medial femoral condyle (Figure A-C). Preoperatively, the cartilage defect was predicted to be classified as an International Cartilage Repair Society Grade IV lesion and arthroscopic evaluation demonstrated the same grade lesion of the femoral medial condyle (Figure A). Osteochondral graft transplantation was performed utilizing the Arthrex osteochondral autograft transfer system (Arthrex, Naples, Fla.). A bone plug 9 mm in diameter and 13 mm in depth was removed from the lesion (recipient site). Then an osteochondral plug 1.0 mm oversized in diameter and of the same length was harvested from the lateral patello-femoral joint surface of the ipsilateral knee and transplanted into the recipient site measuring 10 ? 15 mm using the press-fit technique. However, the extended lesion partially to the non-weight bearing deep area from the transplanted site made it difficult to perform grafting even during deep knee flexion. Thus we only stimulated the bone marrow by using the microfracture technique at the lesion (Figure B). Postoperative managements were performed in the same manner as in Case 1. The patient had to keep taking steroid after the operation in order to control primary disease. X-rays and MRIs taken two years after surgery showed the restoration of the articular cartilage surface and good engraftment of the graft (Figure C-E). A second-look arthroscopy performed two years after surgery showed that the lesion was covered with cartilageous tissue even though a part of the non-grafting site at the posterior aspect of the defect exhibited only fibrous tissue coverage (Figure F). The surface of the articular cartilage was smooth both at the recipient and donor sites. We did not find any abnormality in the donor site condition. The patient had no pain and no restriction in daily activities and the Lysholm score had improved from 68 to 100 five years after surgery."
+Madden Rivers,21,1980/3/7,301-942-5692x48536,deannamoreno@example.com,5649 Matthew Road,"A 24-year-old man suffering from severe right knee pain had received a renal transplant because of focal segmental glomerulosclerosis and was subsequently diagnosed with steroid-induced osteonecrosis of the medial femoral condyle. The preoperative X-ray and MRI showed an osteochondral defect of the medial femoral condyle (Figure A-C). Following the arthroscopic confirmation of International Cartilage Repair Society Grade IV lesion, osteochondral graft transplantation was performed utilizing the Arthrex osteochondral autograft transfer system (Arthrex, Naples, Fla.). Bone plugs 9 mm in diameter and 13 mm in depth were removed from the lesion (recipient site). Then osteochondral plugs 1.0 mm oversized in diameter and of the same length were harvested from the lateral patello-femoral joint surface of the ipsilateral knee and transplanted into the recipient site measuring 30 ? 20 mm using the press-fit technique. However, similar to Case 2, the lesion in the deep posterior site partially extended to the non-weight-bearing area from the transplanted site made it difficult to perform fully coverage with grafting. Thus we only performed bone marrow stimulation using the microfracture technique (Figure A-B). Postoperative management was performed in the same way as Case 1 and 2. The patient had to keep taking steroid after the operation in order to control primary disease. X-rays and MRIs six months after surgery showed the restoration of the articular cartilage surface and the good engraftment of the graft (Figure C-E). We did not find any abnormality in the donor site condition. The patient had no pain and no restriction in daily activities and the Lysholm score had improved from 64 to 100 six months after surgery."
+Kiana Flynn,35,1994/10/25,001-588-250-5719x874,ahall@example.org,2624 Lindsey Extension Suite 724,"A 40-year-old Japanese woman presented with severe right-sided cervical radicular pain, which had resisted medication and rehabilitation. Magnetic resonance imaging of her cervical spine revealed a cervical herniated disc on the right side at the level of the C5-C6 and C6-C7 vertebrae. She was scheduled to undergo a right-sided C6 SCNRB for diagnostic and therapeutic purposes. She had no relevant medical history. Magnetic resonance imaging revealed no abnormal findings, such as a perineural cyst or an ectatic nerve root sleeve, at the right C5-C6 intervertebral foramen. Her heart rate was 71 beats per minute, her blood pressure (BP) 110/65 mmHg and her oxygen saturation (SpO2) level was 100%.
+The procedure was performed with our patient in the supine position. Our patient? head was turned to the left and secured. An anterior oblique view of the C5-C6 intervertebral foramen was obtained, and a 23-gauge spinal needle, connected to the normal extension tube with a syringe filled with contrast medium, was introduced into the posterior-caudal aspect of the C5-C6 intervertebral foramen on the right side under fluoroscopic guidance. In the anteroposterior view, the placement of the needle was considered satisfactory when it was placed no more medial than halfway across the width of the articular pillar. Because careful aspiration with a 2 mL syringe did not show any blood or cerebrospinal fluid, 1.0 mL of contrast medium was injected. Although the spread of the contrast medium along the C6 nerve root was observed, subdural flow of the contrast medium was not observed very well with real-time fluoroscopy. The extension tube used for the radiculography was removed from the spinal needle and a normal extension tube with a syringe filled with lidocaine connected in its place. We performed a negative aspiration test and then injected 1.5 mL of 1.0% lidocaine slowly around the C6 nerve root. The microbore extension tubing (pigtail) was not used in the procedure.
+Immediately after the injection of the local anesthetic, our patient developed acute flaccid paralysis, complained of breathing difficulties and became unresponsive. Her BP and SpO2 changed to 65/46 mmHg and 83%, respectively, and her respiratory pattern was uncoordinated. Her SpO2 improved to 98% after oxygen was supplied at 5 L/min by a Hudson mask, and her BP improved after the intravenous administration of a total of 0.5 mg of epinephrine. Thereafter, her cardiorespiratory status remained stable. A CT scan of her brain performed at this time revealed the presence of air gases, which suggested that a subdural injection of air occurred due to the clumsy method of attaching the extension tube filled with local anesthetic (Figure ). After 20 minutes, she regained consciousness and became alert. Her muscle strength in all four limbs returned to normal without sensory deficits. Our patient was transferred to a recovery room, kept under close observation and discharged the next day as she had no persisting neurological deficits or other impairments."
+Kannon Mejia,36,2000/6/12,+1-482-523-4910x6608,mendozatheodore@example.org,13367 Kimberly Course,"We report the case of a 70-year-old North African man who, two months prior to medical examination, presented with mild laryngeal respiratory distress that worsened until he ultimately required a tracheotomy. A direct laryngoscopy had been performed, revealing a subglottic, submucosal lump. A biopsy revealed a mantle cell type B NHL with the following antigen constellation: cluster of differentiation (CD)5+, CD20+, CD23-, cyclin D1+. Importantly, a physical examination and computed tomography (CT) scans showed a lack of lymph node involvement, establishing the larynx as the primary site of the neoplastic lesion.
+The patient? history and physical examination found no comorbidities. The patient did not present any B symptoms and had a performance status 3 as measured using the World Health Organization performance scale. During a follow-up four weeks after his initial admission, a physical examination found laterocervical lymph nodes. An investigation into possible tumoral extension by cervical, thoracoabdominal and pelvic CT scans showed a subglottic tumor (Figures and ) and cervical lymph nodes.
+A bone marrow biopsy did not show any anomalies. A blood workup showed he had normal red blood cell sedimentation rate and lactate dehydrogenase levels.
+The patient, who has been staged IIEAa (Ann Arbor Classification), received one course of rituximab-cyclophosphamide, doxorubicin, vincristine and prednisone but unfortunately died of unknown causes. No autopsy was performed in compliance with the family? wish."
+Saylor Barry,41,1994/8/6,001-290-537-3061x80768,jessica61@example.net,778 Kevin Park Apt. 735,"Mr BL, 45 years old male, lecturer, married, consulted for swelling and pain left middle finger x 3/52 The patient is a known diabetic and hypertensive diagnosed 3years ago but poorly controlled. He noticed a swelling of his left middle finger which gradually increased in size extending to the palm. There was associated pain in the affected finger which was severe, continuous, throbbing and non-radiating, relieved by elevating the hand and analgesics, no known aggravating factors. There was no antecedent history of trauma. The finger gradually became black in colour with foul-smelling discharge and no sensation at the tip. He smokes cigarettes and drinks alcohol regularly. General physical examination revealed a healthy young man, not in any obvious distress, not pale, anicteric. Examination of the left hand showed a dark coloured middle finger, with swelling extending to the palm, tenderness and sensation was found to be absent. Investigations conducted included fasting Blood Sugar which was 15.6mmol/L; urinalysis showed presence of sugar, no ketone bodies; electrolytes, urea and creatinine were within normal range; X-ray showed no bony lesions; Wound swab culture yielded mixed growth of Staphylococcus aureus, coliforms and enterobacteria. The diagnosis of Left Diabetic Hand syndrome was made. The patient had ray amputation of the left middle finger with debridement of the palm. About 50 ml of pus was drained from the hand. Post operative treatment included antibiotics and wound dressings. Secondary closure of the wound was later carried out. Patient recovered satisfactorily and was discharged to the outpatient clinic for follow up. He was also counselled on appropriate care of his hands-prevention of hand injury including the need for use of protective hand devices, seeking prompt and appropriate medical care should any form of hand injury, no matter how minor, occur and care during manicure."
+Emery Craig,39,1995/1/16,693.959.9590x930,kennethgreen@example.com,6450 Matthews Courts,"Madam ME, 60 years old female, married, trader, condulted for painful swelling of the right hand x1/12. Patient noticed a painful swelling on her right index finger which was initially treated as Whitlow. There was no history of trauma. The swelling later progressed to involve other fingers and the dorsum of the hand. There was associated fever and pain which was relieved by analgesics and elevation. She became unconscious 10hours before presentation in hospital. She was not a known hypertensive. General Physical Examination revealed an ill-looking woman, afebrile, not pale. Examination of the right hand revealed a swollen and tender with discharge from the palmar surface, herbal dressings over the wound, fluctuant, differential warmth+, black index finger, sensation was equivocal. Radial pulse was palpable (). Urinalysis revealed sugar and ketone bodies in urine; Fasting blood sugar = 17 mmol/L; X-ray showed no bony lesions, Wound swab for culture yielded Coliforms. The diagnoses of diabetic ketoacidosis (DKA) and right diabetic hand syndrome were made. The DKA was appropriately treated by the medical team and recovered consciousness. Then incision and drainage of the abscess and ray amputation of the index finger were done. She was scheduled for skin cover by the Plastic and Reconstructive Surgeon."
+Brynn Chang,30,1979/8/31,505.798.7036,wrogers@example.net,71788 Jimenez Loop,"A 42-year-old female patient, presented to our gynaecology outpatient department with complaints of lower abdominal pelvic pain and backache, dyspareunia, and difficulty in passing urine for the last 6 months. She had suprapubic pain with constant backache and heaviness in the perineum. Patient took medication from local practitioners for symptomatic relief. She presented to us when already catheterised with self-retaining Foley's catheter from outside for retention of urine for one day. There was history of similar episodes of retention of urine 4-5 times in the last 6 months for which she had to be catheterised once and again for about 5?? days each time. The catheter was removed after toning of bladder.
+Patient was para one with one live issue 20 years old conceived spontaneously and delivered by normal vaginal delivery and had three spontaneous first trimester abortions, thereafter. Menarche was attained at the age of 13 years. Patient had irregular menstrual cycles occurring at every 15??0 days with bleeding lasting for 4-5 days; the amount of blood flow was normal. There was no previous illness or surgical intervention. Patient was a vegetarian, nonsmoker, nonalcoholic with normal bowel habits. She was moderately built and nourished. General condition of the patient was stable with mild pallor. Vitals were normal. Abdominal examination revealed a firm mass of 16-week size arising from the pelvis deviated more towards the left side. The mass had smooth surface with restricted mobility. On pelvic examination, cervix was hitched below the pubic symphysis, bleeding was present through the cervical os. Foleys catheter was in situ. Uterus was acutely retroverted; a mass of about 16-week size, irregular, firm in consistency was felt through posterior and the left lateral fornix. The uterus could not be differentiated from the mass. Base line investigations and renal function tests of the patient were normal. Ultrasonography revealed a large uterine fibroid of size 14 ? 9 ? 8 cm, which was subserous with normal bilateral adnexae. Right-sided hydroureteronephrosis was also reported for which IVP was done showing right-sided ureteric obliteration with bladder neck compression. Considering the above clinical findings and investigations, provisional diagnosis of subserous fibroid was made and abdominal hysterectomy was planned. A vertical midline infraumbilical incision was employed. Intraoperatively, uterus was found to be just bulky. A large retroperitoneal firm mass of size 10 cm ? 8 cm was found arising from the posterior surface at the level of internal os (). Total abdominal hysterectomy was carried out along with removal of the large retroperitoneal mass (). Complete haemostasis was achieved and abdomen closure was done in layers. Cut section of the hysterectomy specimen showed a few small intramural fibroids on the anterior and the posterior wall of the uterus. The retroperitoneal mass depicted whorled appearance with no apparent degeneration or calcification. The hysterectomy specimen and the retroperitoneal mass were sent for histopathological examination.
+The postoperative period of the patient was uneventful. The stitch removal was done on the seventh postoperative day. The stitch line was healthy with good healing. Histopathological examination confirmed the smooth muscle cell origin of the retroperitoneal mass consistent with diagnosis of retroperitoneal leiomyoma ()."
+Ari Adkins,24,2001/3/18,(990)250-4090x1240,wrightnichole@example.net,42006 Karen Landing Apt. 620,"A 20-year old female presented with a chief complaint of spontaneous, severe and a nocturnal pain in her mandibular right posterior teeth. There was no significant medical history. Extraoral examination revealed no abnormalities. Intraoral examination revealed slight cuspal anomaly in the mandibular right second premolar. This tooth had 3 cups, a small buccal cusp, a small mesiolingual, and a large distolingual cusp but retaining the Y-shaped groove (). The tooth was sensitive to vertical and horizontal percussion. There was also horizontal mobility and depressibility. The adjacent gingiva was normal. Extraction of right lower first molar was done before 2 months due to periapical involvement from caries.
+The panoramic radiographic examination showed the normal complement of mandibular teeth. The mandibular right 2nd premolar revealed an invagination into the pulpal chamber of the tooth from the radicular portion and periapical radiolucency with an ill-defined border was present around the apex on lateral aspect of the root (). The tooth was classified as radicular dens in dente. The pulp extended from the apical foramen to the cervical region of the tooth then split just below the cemento-enamel junction (). Because of difficulties in accessing the canals, the tooth was extracted. After the removal of the tooth, the gross findings were noted down. The radicular portion was completely covered circumferentially by a mineralized structure which is yellowish in colour resembling cementum."
+Emelia Barrera,38,1996/4/2,730-979-0535x601,elizabeth18@example.net,54142 Jennifer Crest,"A 20-year-old male patient presented to the department of conservative dentistry and endodontics with pain to hot and cold food in the left mandibular posterior region. On clinical examination, the mandibular first molar exhibited caries on the distoocclusal aspect and second molar exhibited abnormal crown morphology with 2 large extra cusps on the buccal aspect of the tooth (). Distinct developmental occlusogingival grooves between the supernumerary tooth and its normal counterpart were noticed. Despite the presence of the grooves, there was no discernible separation between the 2 teeth. Caries in the developmental groove on the mesial side of the tooth was evident.
+There was no previous history of trauma or any hereditary conditions. Medical history was noncontributory. All vital signs were found to be within normal limits. Oral examination revealed a normal set of dentition. The teeth 20 and 21 were not sensitive to palpation or percussion. The tooth responded to an electric pulp tester (Parkell Electronics, Farmingdale, NY, USA) and showed early response to the cold test (R C Ice, Prime Dental products, India). On radiographic examination, tooth 21 showed resorption with the distal root and the exact anatomy of tooth 20 that could not be clearly identified, but it was possible to recognize the complex structure of the pulp (). Therefore, to ascertain the complex root canal anatomy of the tooth in a 3-dimensional (3D) manner, dental imaging with the help of spiral computed tomography (SCT) was therefore planned. Informed consent from the patient was obtained, and a multislice SCT of the mandible was performed using the dental software Dentascan (GE Healthcare, Milwaukee, WI, USA). A 3D image of the mandible was obtained. The involved tooth was focused and the morphology was obtained in transverse, axial, and sagittal sections of 0.5 mm thickness ().
+The images revealed that the mandibular left second molar had 3 root canals and that there was connection between the paramolar and second molar in the pulpal chamber. The paramolar exhibited a type II canal (according to Wiene's classification)."
+Makai Pratt,30,1979/5/8,535-786-5160x4132,kenneth53@example.com,326 Moore Village Apt. 230,"A 23-year-old lady presented to our hospital complaining of dysphagia for more than one year. Radiographic and manometric evidence supported the diagnosis of achalasia. After obtaining the institutional review board approval and informed consent, peroral endoscopic myotomy (POEM) was performed by an experienced endoscopist (Dr. Zhou, P.H.) with HybridKnife (T-type, ERBE, Germany).
+The patient was under general anaesthesia with intubation. The equipment and settings were presented in detail in supplementary data in supplementary material available online at doi:10.1155/2012/325479. The POEM procedure was carried out as previously described []. Briefly, it consisted of four steps: mucosal incision, submucosal tunnelling, myotomy, and mucosal closure (, Videos 1??). The main difference between Hybrid POEM and standard POEM was the use of the water-jet system. The water-jet allows for the rapid submucosal infusion of saline solution while tunnelling avoiding repeated changes of equipment. The tip of the knife was used to catch circular muscle bundles first and then to lift them up towards the tunnel for cutting. The length of myotomy was 13 cm (10 cm above the gastroesophageal junction (GEJ) to 3 cm below the GEJ). After careful hemostasis, metallic clips were applied to close the mucosal incision site. The whole procedure took 39 minutes.
+The patient was on proton pump inhibitor for the prevention of reflux symptom. She was given full liquid diet on postoperative day 1. Discharged on postoperative day 2, the patient expressed an experience of ? great relief??in sternum area. During follow-up time, there was improvement in dysphagia symptom score and manometric findings ()."
+Ailani Maddox,41,1980/2/21,565.348.2392x0030,claytonjason@example.com,332 Jones Wall,"The index patient was a 50-year-old female who presented with history of vague right upper abdominal pain and was found to have a firm palpable mass in right hypochondrium. With a provisional diagnosis of gallbladder cancer, she was subjected to routine investigations including radiological investigations. She had normal haemogram and liver function tests. Ultrasound of the abdomen revealed 9 ? 8 cm mass in gallbladder fossa with interface with liver not delineated and cholelithiasis. Biphasic CT abdomen showed gallbladder grossly distended: soft tissue mass in gallbladder with multiple large intraluminal projections and features suggestive of cholelithasis with polypoidal gallbladder malignancy (). A provisional diagnosis of carcinoma gallbladder was made. She was subjected to extended cholecystectomy where gallbladder, along with 4b, 5 segments of the liver were resected, and lymph node clearance was done. Intraoperative findings showed patient did not have ascites, liver metastasis, peritoneal, or omental deposits. Porta was free and there was no colonic or duodenal infiltration and no enlarged pericholedochal, paraaortic, or aortocaval lymph nodes. Grossly gallbladder was found to be distended measuring 10 ? 6.5 ? 4 cm and the lumen was filled with a fleshy friable mass measuring 5 ? 4 ? 3 cm arising from fundus and body of gallbladder (on cut-section of gallbladder). The tumor was seen extending through the wall of the gallbladder involving the serosa. Rest of the gallbladder mucosa was congested and remaining portions of the body and neck region were thickened. Liver tissue attached measured 6 ? 3 ? 4 cm. Tiny cystic and pericholedochal lymph nodes were also sampled. Microscopy of the tumor showed spindle to oval to round cells arranged in interlacing fascicles with ulceration of the gallbladder mucosa. Tumor was seen infiltrating transmurally. Tumor cells are moderately pleomorphic with hyperchromasia, occasional bizarre nuclei, multinucleated giant cells, and numerous atypical mitosis (). Serosal, cystic duct and liver resection limits were free of tumor. Sections from liver showed focal fatty changes but no tumor deposits. Lymph nodes showed reactive lymphoid hyperplasia. A panel of immunohistochemical markers performed showed strong positivity for antismooth muscle actin (SMA, monoclonal, Dako, Denmark, dilution 1 : 200) (), favouring smooth muscle differentiation, negative for pan cytokeratin. Stains performed for CD-117, CD-34, vimentin, and S-100 were noncontributory."
+Lyric Sheppard,23,1996/3/9,001-440-631-1084x096,brownnatalie@example.org,50042 James Spring Suite 377,"A 39-year-old Hispanic female presented with complaints of generalized body itching and difficulty in swallowing to both solids and liquids for the past two years. Dysphagia was progressively worsening in severity for the past few weeks and was associated with nausea and vomiting. Patient denied any weight loss, diarrhea, hematochezia, melena, odynophagia, hematemesis, and abdominal pain. Past medical history included asthma and hypereosinophilic syndrome. She also denied any tobacco, alcohol, or illicit drug use. On physical examination, elbows, hands, and the soles of the feet were hyperkeratinized. Laboratory findings showed Hb/Hct of 13.3/39.5, WBC of 8.1, absolute neutrophilic count of 800/弮L (normal reference value: 1500??000/弮L), and absolute eosinophil count was increased to 4000/弮L (normal: 0??50/弮L). Liver-related tests and connective tissue disorder tests were unremarkable.
+Esophagogastroduodenoscopy (EGD) revealed whitish exudates noted in the esophagus () with normal stomach and duodenum. Brushings were negative for Candida species, and antral biopsy was negative for Helicobacter pylori. A Double Contrast Esophagram examination revealed abnormal peristalsis/motility with the presence of a questionable mild stricture in distal esophagus. The patient was started on diflucan and protonix 40 mg daily but returned to GI clinic four weeks later with persistent dysphagia.
+EGD was repeated, and it revealed persistent whitish pin-point exudates in the mid and lower esophagus. Then, patient's protonix was increased to 40 mg twice daily and was told to followup in GI clinic in two weeks. On followup visit, her brushings showed no Candida and midesophagus biopsy showed eosinophilic infiltrate () and findings were consistent with acute eosinophilic esophagitis and microabscesses with eosinophil count of 65/HPF. Subsequently, she was started on fluticasone 40 mcg twice, daily and on a follow-up visit, she reported marked improvement in her dysphagia."
+Veda Meyer,18,1985/1/11,-9650,zmckinney@example.org,2329 Yolanda Inlet Apt. 513,"An 73-year-old female patient presented to our hospital with a chief complaint of painless macroscopic hematuria. She had a past medical history of follicular thyroid cancer status after thyroidectomy 5 months ago, breast cancer status after right mastectomy 17 years ago, hypertension, and osteoporosis. She was taking thyroxine 100 mg, omeprazole 20 mg, domperidone 20 mg, and perindopril/amlodipine 5 mg/5 mg each in once daily dose.
+The patient reported no prior episodes of gross hematuria. She had no history of smoking or occupational/chemical exposure. She denied any history of nephrolithiasis or urinary tract infections. On physical examination she had no flank pain or fever and she voided wine-colored urine. Blood tests including hemoglobin, hematocrit, liver function tests; and coagulation studies were within normal limits. Her urinalysis revealed RBCs >200 and no WBCs. An ultrasound was obtained and revealed a suspicious mass along the right lateral wall of the bladder. The kidneys were normal in appearance.
+Differential diagnosis included primary transitional cell carcinoma. However, her previous thyroid and breast cancer history could make this an unusual presentation of metastatic carcinoma to the bladder. We decided to proceed with cystoscopy, and transurethral resection of the bladder mass. During cystoscopy we found a solid mass approximately 3 cm in size along the right lateral wall of the bladder. Bilateral orifices had clear efflux of urine and there were no other noted lesions. We proceeded with transurethral resection of the mass and histopathologic examination. The hematoxylin and eosin stain revealed neoplastic cells with focal presence of hemosiderin deposition (). By immune histochemistry the cancer cells were strongly positive for thyroglobulin (), TTF-1 factor, p53 oncoprotein, Leu-7 antigen, E-cadherin and cytokeratins (7, 8/18, 19). Moderate staining was noted for synaptophysin, chromogranin, vimentin, and low expression for epithelial membrane antigen, S-100 protein and cytokeratin 34BE12. There was a negative reaction to calcitonin, CDFP-15, P63, CEA, HMB-45, HHF-35, RCC, CD10, CA-125, SMA, desmin, and hormone receptors for estrogen and progesterone. The above characteristics were more consistent with metastatic follicular thyroid cancer with neuroendocrine differentiation.
+The patient's gross hematuria resolved and treatment continued with a course of chemotherapy. Cystoscopy three months postoperatively revealed no recurrence or residual mass."
+Tristan Roy,31,2003/2/9,615-524-2846x19650,pjames@example.org,2602 Peter Lodge Suite 012,"A 24-year-old African-American female with perinatally acquired HIV and AIDS (CD4 = 27, VL 16, 164) with nonadherence to highly active antiretroviral therapy (HAART), presented to her primary HIV provider with sore throat, fever, and weakness for two weeks, and URI symptoms for one week. She reported difficulty with swallowing solids and liquids including all HAART pills due to throat pain. Three days prior to presentation, she was seen at an outside emergency department and had a positive rapid streptococcal antigen test for which she was prescribed amoxicillinclavulanic acid for strep pharyngitis; she did not fill the prescription. On exam, there was a 6-kilogram weight loss since two months prior to presentation. She was febrile and was noted to have a muffled voice. There were thick white plaques on the left tonsil, tonsillar pillar, and tongue mucosa that did not scrape off. Due to the degree of discomfort and persistent fevers up to 102 degrees Fahrenheit, there was concern for a severe infection of the parapharyngeal or retropharyngeal spaces (i.e., Lemierre's syndrome, abscess), and a CT scan of the neck was obtained. It revealed bilateral palatine tonsillitis with evidence of a possible early abscess in the left glossopalatine recess, but no obvious areas of fluid collections. Clindamycin was added to the antibiotic regimen at that time.
+Her past medical history was significant for a CD4 nadir of 14 cells/mm3, recurrent skin infections and abscesses, chronic purulent otitis media requiring tympanostomy tubes, trichomonas, and Grade 1 cervical intraepithelial neoplasia. She was notably nonadherent to her HAART regimen of daily atazanavir, lamivudine, abacavir, and ritonavir. She was also on monthly aerosolized pentamidine for pneumocystis prophylaxis, but was not taking prophylaxis for mycobacterium avium intracellulare.
+Three days later, the throat pain had worsened with extension to the right side. The patient remained febrile and was unable to take any solids or liquids orally due to pain. She also reported the development of a painful genital ulcer during the past week. She had vaginal intercourse with an asymptomatic male partner one week prior to the onset of symptoms and reported intermittent condom use. She denied any new sexual partners for the last 2 months and adamantly denied orogenital sexual contact.
+The patient denied headaches, visual changes, vomiting, seizures, or other focal neurologic symptoms on review of systems.
+Physical exam at this time revealed an ill-appearing young woman who was alert, and oriented with new enlargement of the right tonsil with erythema, new white plaques on the posterior pharynx without improvement of the left tonsil or the left side of the tongue. The patient demonstrated pain when opening her mouth for exam. On the genitourinary exam, there was labial swelling and a 1 cm large open ulcer with cream-colored discharge centrally over the ulcer. There was also a creamy film covering the vaginal introitus. She was unable to tolerate a speculum and one-finger manual exam due to significant swelling and pain.
+The patient was admitted to the hospital for worsening tonsillitis and pharyngitis not responding to dual oral antibiotic coverage, dehydration, and persistent fevers. She was started on intravenous ampicillin sulbactam, fluconazole, and acyclovir. Subsequent viral cultures from the throat, mouth, and genital ulcer became positive for HSV-2 at two days. Two years prior to the current presentation, qualitative determination of antibody status for specific IgG to both HSV-1 and HSV-2 using indirect chemiluminescence immunoassays was negative during the patient's pregnancy. Repeated evaluation using the same method for specific IgG to both HSV-1 and HSV-2 remained negative with the current illness at approximately two and a half weeks from onset of symptoms. Antibody status of HSV IgM was also negative. She was known to have had appropriate antibody responses to Hepatitis A and B vaccines. Other admission labs included a white blood cell count of 8600 per cubic millimeter with an absolute neutrophil count of 7040 per cubic millimeter, and normal complete metabolic panel with normal liver function markers.
+The patient's condition improved with treatment and once she was able to tolerate oral intake, she was discharged on hospital day 5 on oral valacyclovir 1000 mg twice daily, fluconazole 200 mg daily, and amoxicillin clavulanic acid extended-release 1 gram twice daily."
+Savanna Lyons,38,1997/7/25,(448)286-7118,millerbrent@example.org,26533 Williams Common,"Patient 1 was an 8 1/12-year-old female (); part of a non-identical twin and a product of full term uneventful gestation. Her small head was noted at birth with a head circumference of 26.7 cm (??.5 SD) while weight and height were 2.2 kg (??.1 SD) and 45.5 cm (??.1 SD), respectively. All development milestones were profoundly delayed. No history of seizures was recorded but she had recurrent attacks of fainting associated with cyanosis and extreme bradychardia that required resuscitation and admission to the ICU. At the time of examination, the patient had growth failure and microcephaly; weight of 19.9 kg (?? SD), height of 96 cm (?? SD) and head circumference of 36.8 cm (??1 SD). She was able to sit supported, could not follow or grasp objects, failed to develop language skills and had no sphincteric or bowel control. Autistic behavior and dystonic-like movements of the head and limbs were evident.
+The patient had specific facial features including broad forehead, thin long eyebrows, upslanting palpebral fissures, prominent nose, long philtrum, thin vermillion of the upper lip, prominent lower lip, and large ears with prominent antihelix. Hands and feet showed long fusiform fingers with bilateral campto-clinodactly of fifth fingers and crowded toes. General examination revealed bradychardia with normal cardiac rhythm (48 bp) and obvious vasomotor instability with prolonged capillary refill, skin mottling, and acrocyanosis. Neurological examination showed hypotonia, brisk reflexes, and intact sensation. In addition to the frequent dystonic movements, there were cerebellar signs manifested with intention tremors and truncal ataxia.
+Investigations included normal chromosomal analysis, extended metabolic screening, fundus examination, visual and brain stem auditory evoked potentials, EEG, nerve conduction velocity, and electromyography. Normal creatine kinase, liver and kidney function tests, and thyroid profile were also recorded. Intellectual quotient (IQ) using Stanford?inet test showed profound mental retardation (score 15). Assessment of cardiac function and anatomy was normal by echocardiography while ECG verified a persistent but intermittent 2:1 AV heart block confirmed by Holter examination. Repeat ECG uncovered a Mobitz I heart block, with successive prolongation of the PR interval ().
+Brain MRI () showed cerebellum hypoplasia without severe brain stem involvement. The vermis was particularly affected with prominent cerebellar folia suggestive of mild atrophic changes. Simplified gyral pattern and thin corpus callosum were noted. High signal intensities were seen bilaterally in the deep white matter on T2-weighted and FLAIR sequences impressive of defective myelination.
+Upon follow-up at the age of 8 8/12, we learned that this patient became severely dehydrated and was subsequently diagnosed with type I insulin-dependent diabetes mellitus."
+Cyrus Goodwin,21,1979/3/29,+1-420-878-3292x142,brandonmorris@example.com,2063 Nancy Cliff Suite 529,"A female patient, 14 years old (), was the first child in this family, born by normal spontaneous vaginal delivery after a full-term pregnancy. At birth, weight was 2.5 kg (??.57 SD), length was 46 cm (??.8 SD), and head circumference was 27.8 cm (??.8 SD). Neonatal history was uneventful while infancy and childhood histories showed failure to thrive, notable small head, and severe developmental delay. No history of seizures or fainting attacks was recorded. On examination, the patient could sit alone, respond to sounds, and follow objects but was unable to grasp objects, feed herself, speak or attain sphincteric or bowel control. Physically, her weight was 29 kg (??.5 SD), height 115 cm (??.5 SD), head circumference 40 cm (??1.5 SD), and there were no signs of puberty (B1, P1, A1). Facial features showed upslanting palpebral fissures, prominent nose and columella, long philtrum, V-shaped long upper lip, prominent lower lip, and large ears with prominent antihelix. Long tapered fingers, bilateral clinodactyly of fifth fingers, and mal-alignment of toes were noted. Vasomotor instability was obvious especially in lower limbs. General examination was irrelevant except for bradycardia (64 bp) with regular irregularities every three beats. Neurological examination revealed hypotonia, brisk reflexes, normal sensation, and ataxic movements. Dystonic movements of upper and lower limbs were infrequently noted.
+Similar testing to patient V-4 was conducted and results were normal. ECG showed second-degree heart blockage (), IQ score was 20 (profound mental retardation) using Stanford?inet test, hormonal profile including LH, FSH, estrogen, and progesterone were prepubertal, and glucose tolerance test showed high normal limit. Brain MRI () revealed similar forebrain and hindbrain as Patient V-4 in the form cerebellar hypoplasia/atrophy with prominent vermian involvement, similar corpus callosum, gyral pattern, and white matter."
+Shiloh Mathews,40,1999/11/10,(232)541-8831x22910,michael69@example.net,372 Bennett Corner,"An 11-year-old male patient (), second affected child in branch II, delivered vaginally after uneventful full term pregnancy. Small head (OFC: 28 cm (??.2 SD)) was noted at birth while weight and height were 2.4 kg (??.07 SD) and 46.2 cm (?? SD), respectively. No history of epilepsy, cyanosis, or fainting attacks was recorded. Similarly, patient had severe development delay, he was able to sit alone, had autistic behavior, unable to follow or grasp objects and no language skills acquired. Physical examination reported his weight of 21 kg (?? SD), height of 107 cm (??.8 SD), and head circumference of 38.5 cm (??0 SD). Facial features were similar to his affected sib (V-6) showing thin long eyebrows, upslanting palpebral fissures, prominent nose and columella, long philtrum, V-shaped thin vermillion of the upper lip, prominent lower lip, large ears with prominent antihelix. Long fusiform fingers, bilateral fifth finger campto-clinodactyly, crowded toes, and vasomotor instability were detected. The heart exam was normal except for bradycardia (55 bp) with normal cardiac rhythm. Genitalia was normal with prepubertal size testes and no signs of puberty. Neurologically, there were hypotonia, brisk reflexes, frequent dystonic movements of limbs, and truncal ataxia. All investigations were insignificant except that IQ evaluation using Stanford?inet test was 15 (profound mental retardation), ECG showed second-degree heart block (), and glucose tolerance test showed higher normal limit. Brain MRI was nearly identical forebrain and hindbrain structures as patient V-4 and V-6 ()."
+Jamir Shah,23,1986/3/19,501.504.2218,michael10@example.org,14127 Pierce Harbor Suite 527,"A 57-year old man of Swedish descent presented at Karo-linska University Hospital, on June 29, 2011, with a one-day history of fever, chills, headache and loose stool, two weeks after returning from Tanzania where he had been working intermittently for a few years. He had discontinued atovaquone-proguanil chemoprophylaxis one month before leaving endemic area. He reported being previously healthy except an episode of necrotizing fasciitis in the left thigh six months earlier.
+On examination, the patient had prominent chills without any other clinical findings and C-reactive protein (CRP) was 166 mg/l, haemoglobin 171 g/l, platelet 72x109/l, bilirubin 33 弮mol/l. He was started on intravenous cefotaxime and fluids for a suspected bacteremia, and artemether-lumefantrine (20 mg/120 mg Riamet簧; 4 tablets per dose at 0, 8, 24, 36, 48 and 60 hours) was prescribed after microscopy had shown 0.1% P. falciparum infected erythrocytes. The first dose was however delayed and parasitaemia peaked at 1.3% before decreasing promptly during treatment (Figure ). Due to persistent fever and high CRP (369 mg/l) on the second day, cefotaxime was changed to ceftazidime and a single dose gentamicin for treatment of a potential concurrent bacteraemia. The patient was discharged free of symptom after five days and prescribed one week oral ciprofloxacin. Cultures from blood, urine and stool taken at and during admission were all negative. Malaria microscopy was negative at discharge as well as two days later.
+On July 23 (24 days after treatment start), the patient presented at the emergency room with high fever since two-three days, jaundice, hypotension (systolic blood pressure 80) and slightly impaired consciousness. He responded promptly to intravenous fluids. CRP was 64 mg/l, hemoglobin 115 g/l, platelet count 116x109/l, bilirubin 49 弮mol/l, arterial blood gas and other tests were normal. Blood films were again positive for P. falciparum and oral mefloquine was started based on 0.4% parasitaemia estimated by the physician on call. The initial parasitaemia was reevaluated to 2.6% by the microbiology department the following day. The patient recovered promptly and the mefloquine course was completed. He was discharged three days after admission. On follow up one month later, the patient reported no symptoms since discharge and microscopy of blood films was negative for malaria parasites.
+In order to elucidate the cause of treatment failure, frozen EDTA plasma and blood, sampled as part of a malaria immunology study, were assessed with the patient? consent. Species-specific PCR of the ssRNA gene confirmed the presence of only P. falciparum. Genotyping of the polymorphic merozoite surface protein 2 gene (msp2) [] detected the same two alleles (336 bp FC27 and 487 bp IC-1 fragments) at both episodes.
+Drug concentrations were measured by liquid chromatography coupled to tandem mass-spectrometry (LC-MS/MS) in plasma collected on day 6 and 25 after initiating artemether-lumefantrine (Figure ). Both artemether and dihydroartemisinin concentrations were below the limit of detection (0.5 ng/ml) in all samples as expected because of their very short half-lives (2?? hrs) []. The lumefantrine concentrations were 498 ng/ml on day 6 and 39.5 ng/ml on day 25, while the metabolite desbutyl lumefantrine was 2.94 ng/ml and below detection (0.25 ng/ml), respectively.
+Genotyping of drug resistance markers [] revealed the same profiles at both episodes; the P. falciparum chloroquine resistance (pfcrt) 76 K allele, the multidrug resistance 1 (pfmdr1) 86 N allele, and single copies of the pfmdr1 gene."
+Angelica Salgado,20,1996/2/17,343-314-8332,ortegaadrian@example.org,6908 Victor Ways,"A 1-year-old girl was born uneventfully and at term. At 1 month of age, she experienced brief tonic seizures of the upper limbs with eye deviation several times a day. At 2 months of age, she developed spasms in clusters following a series of three or four brief tonic seizures a day. The patient was admitted to our hospital at the age of 4 months. At this point, zonisamide and clonazepam treatments were initiated. However, the spasms that occurred in clusters were refractory to these treatments and increased to approximately 10 times a day. Typically, each spasm episode was accompanied by the following: slightly tonic limb contraction, head adverse motion, and eye deviation to the right. These seizures lasted around 1 min. The periodic spasms that occurred in clusters consisted of a brief symmetrical contraction of the axial muscles that was associated with intense head nodding. At this point, she could gaze and track subjects. However, after the onset of this type of seizure, her development arrested. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain revealed a calcified lesion in the right frontal lobe and similar small calcified lesions in the left frontal lobe and subventricular regions. This massive tuber seemed to overlap the rolandic area (Figure a). DNA that was isolated from the patient? blood revealed a heterozygous mutation, IVS29 + 1 G > A, which has been reported as a splicing mutation of intron 29. On the basis of these radiological findings and the genetic analysis, the patient was diagnosed with tuberous sclerosis (TS). Single-photon emission computed tomography (SPECT) revealed increased blood flow in the right frontal lobe (Figure b). We performed magnetoencephalography (MEG) while the patient was in sedated sleep with Triclofos Sodium. We used a whole-head neuromagnetometer (NeuromagSystem, Elekta Neuromag Oy, Helsinki, Finland) that consisted of 102 identical sensors, each of which contained two planar gradiometers that were positioned at right angles to each other and one magnetometer. We analyzed the spikes using equivalent current dipole modeling and superimposed MEG spike sources (MEGSSs) on the patient? MRI. We used local sensors to place the MEGSSs with a goodness of fit of more than 80%. MEG showed dipole sources that were distributed in the right parietotemporal areas and that were concordant with the peritubular region (Figure c). There was no spike source in the left hemisphere. The patient had no clinical seizures during the MEG recording. We recorded the scalp EEG with a digital sampling frequency of 500 Hz for 8 h using a Nihon Kohden Neurofax (EEG-1200) (Nihon Kohden Corporation, Tokyo, Japan) using the international 10??0 scalp electrode system. The interictal paroxysmal discharges showed repeated high-voltage polyspikes and spike and wave complexes that occurred every 10??0 s over the right centroparietotemporal areas. The adverse head motions and eye deviations to the right that were followed by spasms were recorded thrice, and the seizures involving tonic limb contractions that were not followed by spasms were recorded twice. On the ictal EEG, theta bursts preceded the adverse head motions and eye deviations. At the beginning of the periodic spasms, the recordings showed no preceding spikes but showed slow waves that were superimposed with low-amplitude fast activity over the right parietotemporal region (Figure a). During the periodic spasms, the EEG showed independent high-amplitude slow waves from the right and left hemispheres. We exported the scalp EEG video data sections that were recorded from around the time of the seizures with spasms and performed an MBFA using Short Spectrum Eye software (Gram Corporation, Saitama, Japan) in order to analyze the frequency and distribution of FOs. We analyzed the power spectrograms of the frequency bands between 5.7 (time constant, 0.03 s) and 120 Hz with a frequency resolution of 2 Hz and a temporal resolution of 10 ms and measured the amplitude of each frequency in order to calculate the power in 弮V2 in 26 episodes of spasms []. As a result, in 14 spasm episodes, the analysis showed FOs of 60??0 Hz with high spectral power that were predominantly over the right centroparietotemporal areas 100??00 ms before each spasm (Figures b). In nine spasms, the records were contaminated with movement artifacts and/or muscle activity, and their interpretation was difficult. The remaining three spasms lacked clear gamma activity despite minimal artifacts and occurred mostly in the ending part of a series. This region was approximately concordant with the area around the cortical tuber that was seen on MRI, the area of high blood perfusion observed on ictal SPECT, and the cluster of spike sources observed on MEG. None of the FOs appeared at the beginning of the subsequent tonic motion (data not shown). We were not able to detect interictal high gamma activity, although we analyzed the 20 min of interictal EEG. At the age of 5 months, tuber resection was performed. Three months postoperatively, the periodic spasms had completely disappeared, and another type of brief tonic or partial myoclonus seizure that occurred once a day remained. In the analysis of the ictal EEG performed at this time, high gamma activity was not detected over the right lobes, but other high gamma activity appeared in the left central and parietal areas. One year postoperatively, the brief tonic seizures decreased to monthly, and she could sit with support. One year and seven months postoperatively, the brief tonic seizures disappeared, and she has been seizure-free."
+Trace Sweeney,18,1980/11/11,(829)916-9630x237,michellejohnson@example.net,66755 Cain Path Apt. 021,"A 78-year-old Caucasian man was admitted because of acute kidney injury to our hospital. His medical history was remarkable for acromegaly diagnosed 25 years ago that was first treated with radiotherapy. Due to a residual secretion of growth hormone he was then treated with octreotide for 10 years (10 mg every six weeks) with an adequate control of his insulin-like growth factor ?? (IGF-1) level. His medical history also revealed weight loss of 15 kg in the last four months without fever, dysuria, diarrhea or other symptoms.
+Several months prior to admission, he was treated with sulfamethoxazole-trimethoprim and ciprofloxacin for a urinary tract infection. This treatment was followed by a partially regressive acute kidney injury that was attributed to immuno-allergic nephritis. No further investigations were undertaken at that time. His residual renal function was estimated to be 50 ml/minute/1.73 m2 according to the MRDR4 system.
+During the weeks preceding admission a urinary culture yielded a multiresistant Enterobacteria which resulted in multiple successive antibiotic treatments (penicillin and two cephalosporins) over a period of five weeks. A rise in creatinine level was noted following these treatments. He was hospitalized for investigation of an acute kidney injury.
+Upon hospital admission he was afebrile. His blood pressure was 120/70 mmHg and pulse rate was 72 per minute. His physical examination was unremarkable and there was no skin rash or lymphadenopathy
+Laboratory studies were notable for a creatinine level of 4.9 mg/dL with conserved diuresis, resulting in stage F acute kidney injury according to the RIFLE (risk, injury, failure, loss, and end stage kidney disease (>three months))classification, a HCO3 level of 18.9 mM (22 to 29 mM), a phosphorus level of 6.59 mg/dL (normal 2.5 to 8.5 mg/dL) and a calcium level of 8.8 mg/dL (normal 8.5 to 10.5 mg/dL). He also had mild anemia. His leukocyte count was normal without eosinophilia. Urine dipstick showed traces of protein and hemoglobin. Immunologic tests were unremarkable and viral serologies were negative. Microscopic urine examination displayed four red cells M/L and 123 white cells with 3% of eosinophils. Urine cultures were positive for penicillin resistant citrobacter koseri. Abdominal ultrasound showed multiple cortical cysts of the left kidney, no pyelocaliceal dilatation and the presence of multiple gallstones.
+A renal biopsy was performed. Glomeruli displayed no abnormalities. Examination of the tubulointerstitial space revealed diffuse tubular atrophy with epithelial cell desquamation and necrosis as well as the presence of numerous intratubular and intracytoplasmic oxalate crystals presenting birefringrence under polarized light (Figure a, b). Chronic interstitial nephritis characterized by an infiltration of lymphocytes and histiocytes was also seen. Immunofluoresence studies were negative. Infrared analysis of the biopsy confirmed the presence of whewellite, a rare form of crystallization of monohydrated calcium oxalate.
+When asked again, the patient reported no history of vitamin C supplementation or excessive oxalate intake, no history of urinary tract stones and no relevant familial disease. During his hospital stay, no diarrhea was noted.
+A complete urinary collection displayed elevated urinary oxalate excretion, with a low citrate level (Table ). Primary hyperoxaluria was excluded as the urinary dosage of glycolate and l-glyceric acid were negative.
+A diagnosis of oxalate nephropathy with tubulointerstitial fibrosis secondary to enteric hyperoxaluria caused by octretotide and multiple antibiotic therapies was made.
+Hydration was undertaken and octreotide therapy was stopped. Oral calcium and citrate supplementation were prescribed. Creatinine levels slowly decreased and he was discharged with a nephrologic follow up. The evolution of his condition was slowly favorable (Figure .c). A new urinary collection performed 10 months after withdrawal of octreotide therapy (Table ) showed normal urinary oxalate excretion."
+Yara Gordon,45,1996/1/31,379.685.3793,jonescaroline@example.com,1952 Lopez Avenue Suite 277,"We report the case of a 44-year-old Japanese man without any noteworthy medical history (including food poisoning) except for a right tibial fracture due to a traffic accident 30 years ago. His most recent foreign travel to an endemic area (Hong Kong) was 19 years ago, and he had not noticed any gastrointestinal symptoms during that trip. He is an office worker and has no contact with livestock animals. In June 2011, he suddenly developed left knee pain that gradually worsened and therefore visited our hospital. X-rays showed no apparent bone fractures, but an MRI revealed a high-intensity area on T2-weighted images that was suggestive of a femoral bone abscess (Figure ). Approximately 60mL of cloudy yellowish joint fluid was collected, and Salmonella (O:7 positive) was isolated. In vitro susceptibility testing by the broth microdilutionmethod using the MicroScan WalkAway 96SI system (Siemens, Germany) revealed susceptibility to ampicillin (minimal inhibitory concentration, <4弮g/mL), amoxicillin?lavulanic acid (<8弮g/mL), cefotaxime (<8弮g/mL), imipenem (<1弮g/mL), minocycline (2弮g/mL), levofloxacin (<1弮g/mL), and sulfamethoxazole?rimethoprim (<1弮g/mL). The strain also was susceptible to nalidixic acid (30弮g), according to the disc method (Becton Dickinson, Cockyesville, MD, US). Blood cultures and an HIV test were both negative. Full-body computed tomography (CT) ruled out an aortic aneurysm. In light of the diagnosis of femoral abscess with septic arthritis and the results of in vitro susceptibility testing, therapy with a third-generation cephalosporin (intravenous ceftriaxone 1g, once daily) was started.
+On day 22 after presentation, he underwent arthrotomy and necrotic tissue resection. The synovium of his left knee joint was inflamed, and the distal end of his left femur contained multiple loculations that were filled with necrotic tissue. The necrotic tissue was debrided and the cavities filled with imipenem-loaded bone cement. Cultures of the necrotic tissue obtained during surgery grew O:7-positive Salmonella, as seen previously. To characterize the organism, we sent it to the Yokohama City Institute of Public Health for further analysis. The organism was classified as Salmonella enterica subspecies enterica serovar Ohio according to the serotype (6,7: b: l,w) assigned by using the Kauffmann?hite scheme [] based on agglutination with Salmonella O and H antigens (Denkaseiken, Tokyo, Japan). After postoperative rehabilitation, he was discharged on day 55 after presentation and received oral amoxicillin (500mg, four times daily) for six months in place of intravenous ceftriaxone."
+Karter Moore,28,1985/2/5,280-446-0445x985,james35@example.org,1620 Robert Parks Apt. 045,"A 43-year-old Pakistani woman presented for gynecologic surgery for an ovarian mass. Seventeen years prior, she had an emergency TV replacement with a St Jude bileaflet tilting disc prosthetic valve for bacterial endocarditis of her TV. The reasons for choosing a mechanical valve at that time are not known. Anticoagulation with warfarin without an antiplatelet agent was maintained and managed largely by our patient along with her primary care doctor. After her TV replacement she had three episodes of TV thrombosis, for which she received thrombolytics. Two of these episodes occurred during the discontinuation of warfarin and initiation of heparin or low molecular weight heparin for pregnancy, necessitating the termination of her pregnancies. Her international normalized ratio on admission was at a therapeutic level of 2.5; heparin was initiated with a goal prothrombin time of 80 seconds and warfarin discontinued for the gynecologic surgery. A preoperative echocardiogram showed a mean gradient across the TV of 5 mmHg.
+Our patient underwent an exploratory laparotomy, oophorectomy, removal of an ovarian mass and a cystotomy repair. The surgery was four hours long and she had 400 cm3 of blood loss. Heparin was off for a total of 13 hours. On postoperative day one, our patient complained that she could not hear the click of her mechanical valve. She was hemodynamically stable with a heart rate of 105 beats per minute. Doppler echocardiography showed a mean TV gradient of 18 mmHg (Figure ). A transesophageal echo showed the St Jude valve to be stuck in the open position. This was confirmed by fluoroscopy (Figure and ).
+Thrombolytics were not an option as she was in a recent postoperative state. She was maintained under close observation and serial echocardiograms showed that the gradients across her TV remained stable. Limited blood testing did not show any disorders in blood coagulation. Ten days after her initial surgery, when it was deemed safe to be placed on bypass, her St Jude TV was removed and a bioprosthetic valve was placed in the TV position. The explanted prosthesis showed fibrin and pannus that involved both discs (Figure ). Our patient tolerated the procedure well and went home in stable condition."
+Emily Rocha,24,1997/1/19,555.221.4625,mcooper@example.com,8327 Yvette Overpass,"A 26-year-old Caucasian woman who had mild lung disease presented to our facility. Her pre-partum forced expiratory volume in one second (FEV) was 2.62 L (87% predicted). Her pre-partum body mass index (BMI) was 24. She was chronically infected with Pseudomonas aeruginosa. In addition, she was pancreatically insufficient and had CF-related diabetes treated with insulin. Her glycemic control was acceptable with a hemoglobin A1C (HbA1C) level of 6.1%. She did not have microalbuminuria as estimated by a spot albumin:creatinine ratio. Eight years previously she had delivered a healthy child via a normal vaginal delivery after spontaneous rupture of membranes at 36 weeks??gestation. The pregnancy had been uncomplicated.
+Her second pregnancy was unplanned and she had conceived with a new partner. Following confirmation of the pregnancy, she was referred to a high-risk pregnancy clinic where she was reviewed regularly by a multidisciplinary team supervised by an obstetrician, a respiratory physician and an endocrinologist. The first two trimesters proceeded without significant medical complication. During the 26th week of pregnancy, a routine out-patient review revealed a fall in her lung function (FEV1 2.13 L, approximately 71% predicted) accompanied by increased respiratory symptoms. Her blood pressure was noted to be slightly elevated at 118/87. A hospital admission for treatment of her fall in lung function was declined and she was given a two-week course of oral ciprofloxacin at a dose of 750 mg twice a day. This was tolerated poorly due to nausea.
+Two weeks later, in the 28th week of pregnancy, she developed worsening nausea and further exacerbation of her respiratory symptoms with some accompanying left upper quadrant discomfort. Her blood pressure was 123/90. The results of a urinary test strip screening for proteinuria were negative. A hospital admission was again declined and treatment with oral ciprofloxacin for a presumed mild pulmonary exacerbation was continued, and she was prescribed oral metoclopramide, with outpatient follow up arranged in one week. She was advised to present to hospital sooner in the event of clinical deterioration.
+Our patient re-presented one week later with increasing nausea and a persistent impairment of lung function (FEV1 2.09; 69% predicted). She was admitted to hospital. At this time, her blood pressure was 153/89. Laboratory investigation results revealed hemoglobin of 12.3 g/dL, platelet count of 101 ? 109 cells/ml (normal range 150 to 400 ? 109 cells/ml), serum alanine transaminase (ALT) of 179 mmol/L (normal range <65 mmol/L), lactate dehydrogenase (LDH) of 279 mmol/L (normal range <240 mmol/L) and urate of 523 mmol/L (normal range 150 to 400 mmol/L). There was no significant proteinuria as assessed by a urinary protein/creatinine ratio and this remained unchanged throughout the admission. Similarly, serial assessment of her coagulation and renal function failed to reveal any abnormality. On admission, a fetal ultrasound was within normal limits.
+A diagnosis of pre-eclampsia with some features of HELLP syndrome was made, in the setting of a respiratory exacerbation. In addition to her regular medications, she was put on intravenous aztreonam at a dose of 2 g every six hours. She was given two 11.4 mg doses of intramuscular betamethasone at 12-hour intervals to assist with fetal lung maturation. Aminoglycosides were not given to avoid any potential harm to the fetal kidneys. Over the next five days she remained hypertensive with a systolic blood pressure ranging from 150 to 190 mmHg, but her platelet count increased to 239 ? 109 cells/ml and the results of liver function tests (LFTs) progressively normalized. However, on the fifth day there was a precipitous drop in platelet count to 62 ? 109 cells/ml and an increase in ALT to 118 mmol/L, accompanied by a fall in hemoglobin to 8.8 g/dL with red cell fragments observed on blood films taken at this time. A diagnosis of HELLP syndrome was made and a semi-elective caesarean section was performed 10 hours later under spinal anesthesia. HELLP-specific treatment, in particular magnesium sulfate was not administered. A healthy baby girl was delivered. Her APGAR scores were 9 and 9 at one and five minutes, respectively. All of our patient? blood parameters normalized the day following birth of her child. Our patient recovered without further medical complication. Four years later, our patient? lung function remains stable, although she continues to have intermittent exacerbations of her bronchiectasis. Our patient? child has reached normal age-specific milestones."
+Onyx Juarez,30,2000/1/18,(338)218-0086,nicholas18@example.com,13825 Jay Meadows,"The second patient was a 24-year-old man with intermediate type I/II Crigler-Najjar syndrome, which did not respond to phenobarbital. The diagnosis was established 1 month after birth and confirmed by DNA analysis, indicating a mutation on the UDP-glucuronosyltransferase 1A1 gene with the presence of the homozygous state for the L443P mutation. The patient received 2.2 billion hALPCs administered in seven infusions over 2 days. Prior to the placement of the portal catheter, the patient was administered premedication, including cefazolin (1 gr). The catheter was under ultrasound control in the portal system. Solumedrol (80 mg) was injected before the infusion. The immunosuppression treatment consisted of tacrolimus (Prograft簧, Astellas Pharma), which targeted blood levels of 6?? ng/ml. A specific coagulation prophylaxis was prescribed, with cells being suspended in albumin 5% and heparin at a concentration of 10 UI/ml. During cell infusion, the subject received bivalirudin (1.75 mg/kg) intraveinously by continuous infusion, while between consecutive cell infusions, he was given bivalirudin (0.25 mg/kg) for 2 to 4 hours depending on the thromboelastometry test. Coagulation tests including thromboelastometry (CT), platelet counts (normal values: 150??50 10exp3/繕l), D-dimer levels (normal values: <500 ng/ml), thrombin time (TT, normal values: 15??4 sec), prothrombin time (PT, normal values: 9??4 sec), and partial thromboplastin time (PTT, normal values: 20??3 sec) were repetitively performed before each infusion, 20 min after the beginning, and at the end. A liver Doppler ultra-sound was conducted after each infusion to assess portal flow. The signification of coagulation tests was summarised in ."
+Juliet Reynolds,21,1977/11/21,001-934-983-0196x574,david17@example.net,19995 Elizabeth Path Suite 384,"The third patient was a 17-years-old suffering from glycogenosis type 1a, as documented by genetic analysis (G188R mutation and 380insC insertion) and the absence of glucose-6 phosphatase activity on a liver biopsy. The patient also received antibiotic prophylaxis prior to the placement of the portal catheter as well as steroids before the infusion. The same immunosuppressor regimen as patient 2 was administered. The patient received 3 billion progenitor cells administered in seven infusions over 3 days aimed at controlling recurrent hypoglycemia. The same anticoagulation protocol and coagulation, including liver Doppler ultrasound follow-up, was applied."
+Vincent O’Connor,40,1989/2/23,6659576249,kathywalter@example.com,6368 Jack Villages,"The patient is a 55-year-old man with significant sternal keloids secondary to a previous history of severe acne. The patient desires removal of the keloids. Hence, a decision was made to excise the keloids, followed by immediate reconstruction with a propeller flap (Figs ??.
+Intraoperative excision of the keloids and undermining of adjacent subcutaneous tissue revealed chest muscle fibers fitting the description of the sternalis muscle (Fig ). The left parasternal muscle measures about 5 to 6 cm and appears to originate from the intraclavicular region (further dissection was not indicated) with insertion in the region where the left abdominal rectus sheath, left external oblique aponeurosis, and lower ribs margin converge. Tendon at the origin appears to be contiguous with tendon of the sternocleidomastoid muscle.
+The patient tolerated the procedure without any complications (Fig ). He also underwent postoperative therapeutic radiation to help prevent keloid recurrence. Peripostoperative follow-up visit revealed a well-healed scar with mile erythema along the wound-edge union (Fig ). There were no signs or symptoms of infection."
+Charli Shannon,35,1985/12/20,3562632863,valeriefarley@example.net,951 Debra Path,"A 6-month-old male infant presented to emergency room with abdominal distension, bilious vomiting and constipation for two days. There was a history of repeated episodes of such events since birth. On clinical examination the patient was febrile, with temperature of 100F, pulse 120/min and respiratory rate 28/min. Abdomen was distended with visible bowel loops. Bowel sounds were absent. Digital rectal examination revealed empty rectum. Abdominal radiograph showed air fluid levels (Fig. ). Nasogastric tube was passed and intravenous fluids and antibiotics started and surgery planned.
+At laparotomy dilated sigmoid colon found. On tracing it further distally a narrowed segment reached (Fig. ). On longitudinal enterotomy over the narrowed area, a web found which had an opening in its center. The margins of the colon over the web and few centimeters of colon around the stenosed area were inflammed and tear easily. This portion of colon was resected and an end to oblique primary colo-colic anastomosis performed.
+The post operative recovery was uneventful. Naso-gastric tube was removed on 4th post operative day and patient started orally. On 7th post-operative day patient was discharged. The histopathology of the specimen revealed inflammation and presence of ganglion cells. Patient remained well at 6 months follow up."
+Eliel Huynh,45,2003/8/12,663.311.4422,sheilahansen@example.org,3613 Rivera Brooks Suite 458,"A two-day-old male baby was referred to our institution with complaints of vomiting after every feed since birth. The referral letter revealed that the baby was born through spontaneous vaginal delivery in a private hospital; and during newborn resuscitation, the silicone suction catheter was accidentally detached from the suction machine piping and baby swallowed it.
+Since then the patient started vomiting after every feed.
+The baby was vitally stable. A radiograph of chest and upper abdomen showed a tube curled up in stomach and esophagus. Patient was taken to the operation theatre and with direct laryngoscopy under general anesthesia a soft silicon suction catheter was retrieved from the upper esophagus (Fig. , ).
+Patient showed uneventful recovery and was symptoms free at 3 months follow up."
+Oaklee Jacobs,42,1994/6/29,576-230-9464x755,callen@example.org,2298 James Lakes Suite 561,"A 24-hour-old female baby, product of spontaneous vaginal delivery, at term, in a village, weighing 2kg presented to emergency room with evisceration of intestine from abdomen. The patient was hypothermic and cyanosed. On examination baby had temperature of 96F, respiratory rate 45/min and pulse 80/min. Patient was placed under infant warmer and oxygen inhalation given via mask. Warm IV fluids infused and antibiotics started. After stabilization, the patient was shifted to the operation theatre.
+The abdominal defect was about 7cm in diameter and on right side of the umbilical cord. It was extending down to the perineum. The entire GIT was eviscerated along with liver, gallbladder and urinary bladder. Spleen, ovaries and uterus were lying inside the abdominal cavity. The intestine, gallbladder and urinary bladder were matted together and a thick peel covered them in toto. Anus was absent. There was a labial prominence on right side of the defect in perineum while on left side an abnormal vestibule harbouring two openings, found. From one opening meconium was coming and from other urine passed out. There was another labial prominence lateral to the vestibule. There was no bladder or cloacal exstrophy (Fig. ).
+It was not possible to close the defect primarily because of very limited abdominal capacity, much increased size of abdominal viscera and unusual defect. We tried spring loaded silastic silo, but it was not technically compatible with the size and shape of the defect, a sterilized blood bag was then used as silo. Post operative course remained stormy. Later baby developed septic shock and died."
+Bryan Hopkins,38,2001/8/18,518-421-4074x42060,bushkaren@example.com,7162 Alicia Unions Apt. 157,"A 4-day-old term male baby was born through cesarean section, to an otherwise healthy primigravida, at a peripheral private clinic. No prenatal problem was detected on routine antenatal visits.
+The baby did not pass meconium till 4th day when he developed marked abdominal distension along with other features of intestinal obstruction. At the time of admission to our hospital along with distension mild dehydration was also present. There was no other apparent associated anomaly. Rectal stimulation was inconclusive.
+Plain x-ray of the abdomen in erect posture showed multiple air fluid levels suggestive of distal small bowel obstruction. A diagnosis of distal small bowel atresia was made. Baby was optimized by fluid and electrolytes replacement. Parenteral antibiotics along with vitamin K were administered.
+Laparotomy was performed through a right upper transverse incision. Operative finding was type I atresia of the ascending colon just distal to hugely distended cecum (Fig. 1, 2). A ceco-colic anastomosis was performed by opening the lumens of dilated cecum and micro ascending colon through a longitudinal incision on their anterior walls. Intervening mucosal septum was excised and the defect closed transversely with covering ileostomy.
+The recovery was smooth and patient discharged on 7th postoperative day. After 3 weeks a contrast radiograph through ileostomy was performed to confirm the distal patency before ileostomy reversal (Fig. 3)."
+Gabriela McCormick,23,1988/9/14,344-776-6363x7678,donaldlutz@example.net,3923 Sandra Common,"A six years old female child weighing 12 kg, admitted with history of gradual abdominal distension that was noticed by the mother for the last 2 years but did not seek any medical advice as there were no other associated complaints. With an increase of abdominal girth and vague abdominal pain, parents took the child to a nearby general practitioner who advised ultrasound and referred the child to our facility. On examination child appeared comfortable with abdominal fullness. Abdominal examination did not reveal a distinct mass though vague fullness was present oriented more in vertical direction. There was a definite feel of fluid thrill on palpation.
+Ultrasound done previously showed cystic mass in abdomen. With female gender a differential diagnosis included ovarian cyst in addition to mesenteric and omental cyst. CT scan abdomen was advised. This showed a large cystic mass occupying almost whole of the abdomen and located under anterior abdominal wall with viscera pushed posteriorly (Fig. 1,2). A diagnosis of omental cyst was made at this stage.
+Laparotomy was performed. On opening peritoneum a huge lymphatic cyst was found (Fig. 3). It was delivered out with difficulty and that too after partially evacuating it. More than 1500 ml of milky fluid was drained out. The anatomy was then identified more clearly. It was found between leaves of transverse colon mesentery and extending into its root (Fig. 4). The redundant leaves of mesentery were excised without jeopardizing blood supply of colon and left open so as to prevent re-accumulation of fluid. Drain was kept and wound closed.
+Post-operative course was uneventful and patient discharged on 4th day. Biopsy was reported as consistent with mesenteric cyst. Parents were counseled again as to possible recurrence of the lesion and a regular follow up was planned. At three months follow up child is well. On ultrasound a small hypoechoic area of 4cm x 4cm was noted in mid abdomen. A repeat ultrasound after a month is advised to note the progress of the lesion."
+Jasiah Neal,26,1977/9/16,728-230-5323,garciacheryl@example.net,2158 Byrd Port Suite 198,"An eight years old girl was admitted in medical ward through emergency department because of recurrent abdominal pain and melena for the last one month. She had similar complaints since the age of 3 years. The symptoms usually settled within few days. At the time of admission she was otherwise healthy but pale looking with tenderness around umbilicus. Her weight was 19 kg, hemoglobin 6.8 gram per cent and hematocrit 21 percent. Her coagulation profile was within normal limits. Abdominal radiograph and ultrasound examination were reported as insignificant.
+Radioisotope technetium scan done for suspected Meckel? diverticulum showed increased tracer uptake in right lower abdomen close to urinary bladder suggestive of ectopic gastric mucosa (Fig. 1). She was prepared for surgery with transfusion of packed cells and initially underwent laparoscopy. The lesion could not be localized so laparotomy was performed. The omentum was found adhered to a lesion in the mid ileum and gut was twisted around it. On separation about 4?5 centimeter cystic structure found in the mesentery of ileum two feet proximal to the cecum (Fig. 2). The cystic structure with adjacent part of ileum was resected and continuity of gut restored with a primary anastomosis. The duplicated part was found communicating with both proximal and distal parts of gut resected. The post-operative recovery was uneventful. Histology of resected gut confirmed the presence of gastric mucosa in duplicated part."
+Talia Simon,30,1986/10/14,353-345-7468x36331,veronicawatson@example.net,946 William Pike,"A 1-day-old male neonate weighing 2.1kg was born to a 21-year-old primigravida mother at full term. He was a product of non-consanguineous marriage and delivered by normally. He was brought with classical features of EA. The pregnancy was unremarkable other than polyhydramnios that was diagnosed 3 days prior to the delivery. His abdomen was scaphoid. There were no obvious associated anomalies. Nasogastric tube could not be passed into the stomach. Plain x-ray abdomen was gasless suggestive of isolated EA with no distal tracheo-esophageal fistula (TEF). There were 13 pairs of ribs and no vertebral anomalies were noted. Echocardiography was reported as normal. Ultrasonography of the abdomen revealed moderate left hydronephrosis.
+A staged repair of EA was planned. When laparotomy was performed for abdominal esophagostomy, the stomach was found to be distended. It was then decided to proceed with a right thoracotomy to rule out a blocked distal TEF. The thoracotomy revealed a long-gap EA with the proximal esophageal pouch hardly traversing the thoracic inlet, and right-sided aortic arch. An 8 mm long blindly-ending, distensible tracheal diverticulum was seen to arise from the right lateral wall of the trachea that was excised (Fig. 1). The right upper lobe bronchus was seen arising from the carina (Fig. 2). Thorax was then closed. Cervical esophagostomy and abdominal esophagostomy were fashioned.
+Post-operatively, a MRI chest was done that confirmed the diagnosis of right TB (Fig. 3). The histopathology of the excised tracheal diverticulum revealed fibro-collagenous tissue and smooth muscle wall lined with squamous epithelium, ciliated pseudostratified columnar epithelium and gastrointestinal type of endothelium. Few seromucinous glands were seen in the sub-epithelium. No cartilage was found. The post-operative course was uneventful and patient discharged on feeding through abdominal esophagostomy. Sham feeds from mouth were also instituted.
+At 7 month of age, a gastric pull-up was performed. Patient had severe tachycardia both intra-operatively and post-operatively. He had minor anastomotic leak in the neck that healed spontaneously. He was discharged on oral omeprazole and erythromycin that was continued for 6 months. The child has been on regular follow up for last 5 years, and doing well. His somatic growth is in 30th percentile."
+Zayne Parks,19,1978/4/2,(911)601-6887x396,jgibson@example.net,75267 Anderson Union Suite 338,"Case 2: A twelve years old female presented with recurrent episodes of abdominal pain, bleeding per rectum, and vomiting since the age of 4 years. For these complaints she received medical treatment in her native city. She was admitted in hospital received multiple blood transfusions but diagnosis could not be established. Her grandfather died of bleeding per rectum and no record of illness was available.
+Patient had colonoscopy six month earlier which showed stricture with suspicion of growth in descending colon (Fig. 2). Biopsy was taken but reported as inconclusive. Later an ultrasound was done which showed a 2.7 cm x 2.2 cm gut related mass. CT scan revealed stricture with bowel thickening at the level of descending colon (Fig. 3). There was no significant para-aortic and mesenteric lymph node involvement. Her CEA was 1.87 ng/ml and bone scan was negative for tumor metastasis. She was then referred to surgical department. She underwent laparotomy and resection of local tumor and regional lymph nodes was done. Divided colostomy was made. Patient did well in post-operative period. Biopsy revealed poorly differentiated mucinous adenocarcinoma of descending colon with margins of resected specimen free of tumor. There was significant lymph nodes involvement. Pathological TNM classification was, T3N2MX. Currently patient had received 2 cycles of chemotherapy (5 fluorouracil and leucovorin). She had single episode of intestinal obstruction during this period and in last follow up had complaints of mild dyspnea, chest and abdominal pain. She is under workup for residual disease and spread of tumor."
+Ainsley Bradford,45,1991/5/1,846-813-9416,deborahdavis@example.org,16894 Riley Skyway,"A male neonate, born to a 19-year-old primigravida at full term, of a consanguineous marriage, through normal vaginal delivery at home by a traditional birth attendant, presented at 15th day of life with bilious vomiting, failure to pass meconium and progressive abdominal distension since birth. The mother had not received any antenatal care. The baby was being breast fed all this while and he had only received some intravenous fluids for few hours before admission. His general condition was poor. A clinical diagnosis of intestinal obstruction was made, and confirmed by plain abdominal radiographs (Fig. 1).
+After adequate resuscitation, laparotomy was undertaken that revealed adhesions and calcareous deposits suggestive of meconium peritonitis and type IIIa ileal atresia, 15cm proximal to ileocecal valve. The distal collapsed ileal segment revealed an obvious intussusception (Fig. 2); a 5 cm long viable ileal segment could be retrogradely reduced from this segment of ileum. No pathologic lesion as lead point could be identified. An 8 cm of dilated proximal and 6cm of the distal ileum was resected and end- to-back anastomosis was performed. Histopathology of the resected specimen showed transmural inflammation of both proximal and distal bowel segments. The postoperative period remained stormy including sepsis, disseminated intravascular coagulation and meningitis. The child however survived and discharged on 17th postoperative day."
+Ander Wells,45,1987/4/23,976-775-2888,rgill@example.net,6431 Steven Heights,"A 25-day-old male neonate presented in surgical emergency with complaints of feculent discharge from the scrotum, abdominal distension, and vomiting for two days. There had been a history of inguinoscrotal swelling which was ignored by the parents. At presentation, his vital signs were normal except for pyrexia (101簞F). On systemic examination, abdomen was distended with visible bowel loops. On local examination there was wound in right hemiscrotum with hyperemic margins and feculent material coming through the wound. He was diagnosed as a case of enteroscrotal fistula and a laparotomy was performed through right lower transverse incision. Operative findings were strangulated inguinal hernia causing perforation of ileum leading to enteroscrotal fistula. Resection and end to end ileo-ileal anastomosis was performed and hernia was repaired from within the abdomen with purse-string sutures. Postoperative course was uneventful."
+Cecilia Boyer,32,1982/11/29,+1-779-307-0873x2917,murillolarry@example.net,4919 Mindy Lake Suite 940,"One and half month old male infant presented with mass abdomen, noted by parents, for a week that has progressed gradually. There was nothing significant on general physical examination. Abdomen was distended with a palpable mass that extended from epigastrium down to the pelvis.
+All the laboratory parameters were within normal limits except alpha fetoprotein (AFP) which was 110 ng/ml. Ultrasound abdomen showed a huge mass in midline having solid and cystic components. Abdominal radiograph depicted a mass effect in the central abdomen displacing the bowel loops and stomach. CT scan abdomen revealed a mass with different densities and calcifications in central part of the tumor (Fig. 1). Preoperative diagnosis was abdominal teratoma.
+Patient was explored through a right supra-umbilical transverse incision. A huge mass arising from the posterior wall of stomach, extending down to the pelvis found (Fig. 2).
+It was excised in-toto along with some portion of seromuscular layer of stomach while sparing the gastric mucosa. The gastric seromuscular defect was repaired. Specimens were sent for histopathology. The report came as a neoplasm derived from all three germ layers. It was comprised of immature glial tissue (at various sites), fibrocollagenous tissue and adipose tissue, multiple variable sized cysts lined by respiratory epithelium, and cartilage and bone. These features were consistent with immature teratoma grade 3. Biopsy from margins of origin was free of tumour. Postoperative course was uneventful. At one month follow up the AFP was decreased to 10 ng/ml. Patient was followed up to 6 months and later did not report back."
+Zeke Elliott,25,2003/7/24,001-231-743-9094x590,helliott@example.org,50264 Mccormick Port Suite 260,"Four days old (1.8 kg) full term male neonate presented with fever and gross scrotal swelling for two days. The baby was delivered at home and nothing significant found in perinatal history. He passed meconium within few hours of birth and had no vomiting.
+On examination, the baby was febrile (100 繙F), irritable, reluctant to feed, with heart rate of 130/min, and respiratory rate of 42/min. Chest was clear on auscultation and abdomen was non distended and soft. The umbilical stump was infected. There was a huge, irreducible, soft swelling at the right hemi-scrotum, extending proximally to the inguinal region. The scrotal skin was tense and shiny (Fig. 1). Right testis could not be palpated. Initially a diagnosis of irreducible inguinal hernia was made.
+Laboratory parameters were within normal limits. X-ray abdomen and pelvis in erect posture revealed free gas under the right dome of diaphragm and in the scrotum (Fig. 2). With the suspicion of gut perforation, laparotomy was performed.
+The scrotal swelling spontaneously reduced as the peritoneal cavity was opened. Two small perforations were found at the posterior wall of stomach near the greater curvature. Rest of the peritoneal cavity was clean and gut appeared healthy. Primary repair of the perforations was done. Post-operative course was uneventful. Baby was allowed orally on 6th post-operative day and discharged on 8th day."
+Noelle Beltran,38,1978/5/8,456-481-4091x94541,moorekevin@example.net,95821 Rebecca Path,"A 7-year old boy was hit by a motorcycle in the abdomen. The patient was brought to our hospital, immediately after the incident, by emergency rescue service of the city. Patient was in obvious pain with pulse 130/min and respiratory rate 35/min.
+Patient was resuscitated. After stabilization an abdominal radiograph and ultrasound were requested. Abdominal radiograph revealed free air under diaphragm. Ultrasound of the abdomen showed a swollen pancreas with moderate free fluid in the peritoneal cavity. A CT scan of the abdomen was then performed that too delineated pancreatic injury (Fig. 1).
+At operation, about a liter of blood mixed with bile was drained from the peritoneal cavity. There was a bruise in the area of second part of duodenum with small amount of bile in the vicinity. Pancreas was edematous and swollen. Duodenum was mobilized and an avulsion of the anterior wall of CBD having a rim of duodenal tissue (2mm) on either side was noted that resulted in a rent of about 1cm in the duodenum. Bile was freely coming from the ampulla of Vater (Fig. 2,3). The partially avulsed CBD and duodenal rim were reanastomosed with duodenum in a single layer using interrupted extramucosal stitches in the long axis of the CBD.
+A tube cholecystostomy was then performed to divert the bile flow. The postoperative recovery was uneventful. A tube cholangiogram was performed after two weeks that showed free passage of contrast into the duodenum (Fig. 4). Tube was removed and spontaneous closure of the cholecysto-cutaneous fistula occurred. Patient is doing well at a follow up of 6 months."
+Ricky Hunter,24,1994/11/3,-9348,jgibson@example.org,879 Jenna Mission,"A seven-year-old female child presented with acute onset of colicky abdominal pain and non bilious vomiting for the preceding three days. There was no history of fever and passage of round worms in stool. On examination the child was alert and of normal built. Abdomen was not distended. It was soft with a palpable elongated mobile minimally tender mass. A provisional diagnosis of mesenteric / ovarian cyst was made.
+X-ray abdomen was suggestive of mechanical obstruction. Ultrasound showed mass to be non cystic. Abdominal lymph nodes were not enlarged and other viscera were reported as normal.
+At laparotomy an intraluminal mass was found in distal ileum. It was compressible. Rest of bowel and stomach were normal. An enterotomy was made and a large trichobezoar was removed. It was 10 cm long (Fig. ). The enterotomy was then closed.
+The postoperative course remained uneventful. Further probing revealed that child had habit of eating her own hairs from the age of 2 years which persisted for about 18 months. Alopecia was reported at that age. Presently she is a normal looking average built school child interested in surroundings and quite social; but parents were concerned about her jealous behavior as to her younger sister. Child was also consulted with a psychiatrist who following a session declared that at present she has no ailment and being jealous of younger sibling is a normal phenomenon."
+Khloe Fitzpatrick,39,1998/2/26,001-808-401-6513,yudaniel@example.net,8579 Francis Terrace Apt. 463,"A two days old male baby weighing 2.5 kg presented with abdominal distension, failure to pass meconium and biliary emesis since birth. The baby was born by spontaneous vaginal delivery at home. According to the mother the patient was born with a distended abdomen and passed white pellets per rectally. The abdominal distension gradually worsened with bilious vomiting after every attempt at feeding. General physical examination revealed a lethargic and ill looking baby with obvious respiratory distress and abdominal distension. He was febrile with temperature of 100 簞F; respiratory rate 45/min, and pulse 150/min. Bowel loops were visible. A per-rectal examination revealed meconium beads. A preoperative diagnosis of neonatal intestinal obstruction secondary to meconium ileus, with a differential of distal intestinal atresia, was made.
+The newborn was resuscitated with intravenous infusion. A nasogastric tube was passed and gastric aspiration done. The neonate was given injection Vit. K and intravenous antibiotics started. X-ray abdomen showed dilated bowel loops. Contrast x-rays with gastrografin enema delineated a small caliber colon with filling defects as of meconium beads (Fig. ). As condition of the baby did not improve an exploratory laparotomy was performed. At laparotomy volvulus of distended small bowel found. The colour of the involved segment was dark and appeared congested (Fig. ). The volvulus was corrected by untwisting the mesentery. The involved gut was hugely distended due to the presence of thick tenacious meconium. The thick meconium was concentrated in distal small bowel whereas the colon was packed with small beads. An enterotomy was made at the most distended portion (distal ileum) and irrigated with diluted gastrografin. Gentle milking was then performed to remove the meconium. The large gut also washed in the similar way. Bishop Koop chimney was made after resecting a small portion of small bowel which was of doubtful viability.
+The postoperative recovery was uneventful. NG tube was removed on 4th post-op day with oral feed on following day and discharged on 7th postoperative day. The patient has an uneventful follow up after Bishop-Koop stoma closure (at the age of 6 months)."
+Blaze Baxter,37,1990/8/19,+1-451-576-7879x8324,angelagray@example.com,7981 James Mall,"A 17-year-old boy had a history of fall from fourth floor of a building three months back. There was no history of unconsciousness. The clinical examination, laboratory investigations and CT scan were reported as unremarkable at that time. The patient was discharged from hospital after 12 hours of observation.
+After a month, he experienced abdominal pain and symptoms gradually progressed. The acute exacerbation resulted in patient reporting to the emergency room of our hospital. On physical examination, there was extensive abdominal tenderness and muscle guarding with a painful mass in the left lower quadrant. The body temperature was normal. Leukocyte count was 16400. The plain abdominal film was reported as normal. Ultrasound (US) demonstrated the mass which was also confirmed on CT scan. Radiologist interpreted the condition as an internal herniation of the intestines (Fig. ).
+As the signs of acute abdomen persisted, emergency laparotomy was performed after adequate fluid replacement and administration of broad-spectrum antibiotics. At exploration, a mass located over sigmoid colon and infiltrating the lateral abdominal wall with a small abscess formation was found. Abscess drained spontaneously during manipulation. The mass was removed completely with the adjacent omentum. No other pathologies were found at except for the thickened sigmoid colon (Fig. ). The histopathological examination revealed actinomyces infection (Fig. , ). Microbiological examination did not show growth of this organism. Postoperative period was uneventful and the patient discharged on oral penicillin"
+Lara Burgess,34,1999/4/7,511-914-8606x1039,smithandrew@example.net,52951 Troy Via,"A 9-year-old boy presented with right-sided sciatica and gradually increasing swelling in the right buttock of 6-month duration. His pain was constant but unrelated to movement or activity. There were no significant constitutional symptoms. Examination revealed a mildly tender, firm to hard, fixed, large mass measuring 8.5 X 7.5 cm in the outer upper part of the right buttock. There was no lesion elsewhere in the body.
+Chest radiograph was unremarkable. MRI showed a large, relatively well defined mass lesion measuring 5.5 x 7.5 x 8.5 cm in the right gluteal region involving the gluteus maximus, medius and minimus muscles and infiltrating into the pyriformis. The lesion appeared hypointense on T1 -weighted and hyperintense on T2 -weighted images with marked heterogeneity (Fig. ). The mass was abutting the right iliac blade, though the cortical outline of the bone was well maintained. Fine needle aspiration cytology of the lesion was reported as benign spindle cell lesion with a differential diagnosis of proliferative fasciomyositis, and desmoid tumor.
+A near-total excision of mass was done after an arduous dissection. The excised mass was firm to hard, grey lesion that measured 9 x 7 x 4 cm. It was diagnosed as desmoid tumor on histopathology. Surgical margins of resected specimen were not free of tumor (Fig. ). The post-operative period was uneventful. No adjuvant therapy was administered. The child is under close follow up for six months and no recurrence is noted so far."
+Kolton Khan,20,1988/8/5,282.666.4672,christian98@example.com,856 John Pine,"A 2.5-month-old female baby presented with a large lumbosacral skin covered swelling which was present since birth. The patient was a product of consanguineous marriage and born through vaginal delivery. The swelling gradually increased in size. No abnormality was reported in relation to the urination and defecation. Head circumference was 38cm and the neurological examination was essentially normal.
+The swelling was smooth, cystic, fluctuant and transluminent, present over lumbosacral region measuring 8X6 cm2 in size with obliteration of natal cleft (Fig. ). Ultrasound showed a large cystic swelling with a defect in the spine through which meninges were protruding. An MRI depicted a double compartment cystic swelling. The inner cyst was a continuation of the spinal cord central canal that too was dilated (hydromyelia). The cyst was seen protruding from a defect in the posterior osseous elements of the lower lumbar and sacral vertebrae. The spinal cord was tethered and low lying (Fig. , ).
+The patient was operated electively. A vertical incision was made in the midline and about 250ml cerebrospinal fluid (CSF) drained. On further exploration of the external cyst, another small cyst was found close to the spine.This cyst was also opened and found to be in continuation with the central canal. The spinal cord ended slightly cephalad with a fibrous band tethering the cord to the dorsal and cephalic aspects of the inner cyst (Fig. ). The operative diagnosis was terminal myelocystocele. The untethering of the spinal cord was done after which the water-tight repair of the defect performed. The postoperative recovery was uneventful. The patient is on follow up and doing well."
+Mabel Cantu,20,1986/5/14,001-883-491-7304x2094,nicoleberry@example.net,322 Paul Locks Suite 447,"A 17-year-old boy presented to the accident and emergency room with mild diffuse abdominal pain and abdominal distension for two weeks, accompanied with vomiting of gastric contents along with metal fragments. The patient was under treatment for schizophrenia but not taking medications regularly. Physical examination revealed an afebrile patient with tachycardia and tachypnea. The abdomen was soft but distended. A mass was palpable in the epigastrium being dull to percussion. Plain radiograph of the abdomen showed multiple objects of metal density contained within the stomach (Fig. ).
+The patient was admitted and upper GI endoscopy was attempted to remove the FB but failed due to enormous size of bezoar. Open removal of the bezoar was then planned. At operation, a grossly dilated stomach found. Through a longitudinal gastrotomy multiple metal objects including: nails, copper wires, blade, screws, rubber bands, coins and the remains of partially digested food (measuring about half kilograms) were removed. The stomach was repaired in a double layer fashion. Rest of the GIT was normal. Postoperative recovery was uneventful. The patient was discharged and transferred to a psychiatric facility 7 days after surgery."
+Anakin Knapp,39,1996/10/6,846-972-5841,jdavis@example.org,2352 Erin Brook Suite 003,"An eight years old girl with cerebral palsy presented with 4-day history of abdominal distension and retching. On examination there was marked distension of left side of epigastrium. Superficial palpation revealed slight tenderness over the distended area. The child was in obvious discomfort. Her vitals were - temp 101 簞F, BP 110/70, pulse 120/min, respiratory rate 30/min. She was mildly dehydrated. Intravenous fluids and antibiotics were started. Nasogastric tube was passed but it could not decompress the distension. Baseline investigations were done; blood picture revealed leukocytosis. X-ray abdomen was performed which showed a huge air fluid level on left side with paucity of distal gas shadows (Fig. ).
+On the basis of the history, clinical examinations and x-ray abdomen, a provisional diagnosis of acute gastric volvulus was made. A decision for immediate exploration was taken. Blood was arranged and written consent was taken from parents for surgical exploration. Through supraumbilical transverse laparotomy incision a hugely distended stomach with greater curvature lying superiorly, was identified. The stomach was gently pulled out and derotated thus placing the greater curvature down to its original position. As soon as the stomach was placed in normal position the nasogastric aspirate increased and stomach got decompressed. There were ischemic patches over the anterior surface of stomach and the fundus which were left as such (Fig. , ). On further exploration of abdomen malrotation was found with duodeno-jejunal junction ( DJ) on right of midline, mobile cecum and presence of Ladd? band. The Ladd? procedure was done to correct the malrotation. There was no diaphragmatic defect and spleen was placed in its normal position. Due to ischemia of the stomach fundoplication and gastropexy were not attempted.
+The post-operative course remained uneventful and patient discharged on 8th day. In follow up she remained well and was referred to developmental OPD for management of cerebral palsy."
+Linda Barry,44,1998/9/11,934-320-4496x041,deanna76@example.org,94858 Zachary Mills,"A 13-year-old boy presented with acute pain in right iliac region for a day. The pain initially felt in the periumbilical region. There was no associated fever, anorexia, nausea or vomiting. On palpation of the abdomen, there was muscle guarding, localized abdominal tenderness in the right iliac fossa with rebound tenderness. Laboratory tests showed hemoglobin 11gm/dl and WBC count 13700/cmm with predominant polymorphonuclear cells. Ultrasound of abdomen was reported as normal. The score on Alvarado scale was 7, indicating probable appendicitis.
+At operation, normal looking appendix was observed. Appendectomy was done. The Meckel? diverticulum was not present. Further exploration revealed an enlarged lymph node adjacent to the cecal wall. The connective tissue over the lymph node was incised that revealed a necrosed lymph node (Fig. ). Specimens of the appendix and lymph node were sent for histopathology. The histopathology report showed an appendix measuring 6x0.5cm with lymphoid hyperplasia but no signs of acute inflammation. The lymph node biopsy revealed hemorrhagic necrosis of its parenchyma. The few preserved areas of lymph node were free of any malignant cells (Fig. , ). The patient had an uneventful recovery. He is counseled for diligent follow-up with repeated ultrasound abdomen. He is doing well at 6 months follow-up."
+Emery Rubio,20,2003/1/1,001-749-813-2201,kelly43@example.net,007 Allen Plaza,"A 15-day-old male baby presented with a palpable abdominal mass in left upper abdomen noted by parents since birth. There were no other complaints besides occasional non-bilious vomiting. Ultrasound of the abdomen showed a mixed echogenicity mass with solid and cystic areas. Computed tomography (CT) scan revealed a solid and cystic mass with internal calcifications suggestive of teratoma (Fig. ). All the baseline laboratory investigations were within normal limits. Alpha fetoprotein (AFP) was 21 i.u.
+At exploration, a huge mass arising from the posterior wall of the stomach was found (Fig. ). It was dissected out from the surrounding tissues. The stomach was palpated, before excision of the mass, which revealed a small extension of the mass into the gastric lumen (Fig.). The mass was excised in toto with 0.5 cm margins of the gastric wall all-around. The histopathology described the mass (mature gastric teratoma) as composed of adipose tissue, stratified squamous epithelium, dermal appendages, hair follicles, gut mucosa, and mature glial tissue. The margins were tumor free. The follow up remained uneventful."
+Hadassah Beltran,27,2004/3/29,754.295.3631,lori22@example.com,96142 Sherry Green,"Case 1: A 10-year-old boy sustained an accidental gunshot injury resulting in a shattered perineum. He had pelvic fracture with anorectal as well as urethral disruption. He underwent an emergency left transverse colostomy and a suprapubic cystostomy. Later, in another hospital, the ureters were re-implanted into the sigmoid colon that was used as an incontinent urinary reservoir. The upper end of descending colon (distal to the transverse colostomy) was obliterated with a non-absorbable ligature.
+The child presented to us for urinary undiversion. Through Posterior sagittal approach anorectoplasty and perineal reconstruction was done. Urethral repair was also performed by end-to-end anastomosis. The ureters were re-implanted into the defunctionalised urinary bladder (Cohen? method) and a Mitrofanoff procedure using appendiceal conduit was performed. Subsequently the colostomy was closed. The patient refrained from doing clean intermittent catheterization (CIC) through either conduits (urethra and appendicovesicostomy) in the sheer delight of being once again able to pass urine per urethra after 1 year of initial injury. Six months later, the Mitrofanoff appendicovesicostomy was excised on request. The child was lost to follow up.
+Five years later, he presented with hypertension, chronic renal failure and right-sided optic nerve atrophy. There was bilateral hydroureteronephrosis on abdominal ultrasound. He was diagnosed to have neurogenic bladder (hypocontractile) with a large post-void residual urine volume. Voiding cystourethrogram revealed major degree vesicoureteric reflux on both sides. Cystourethroscopy demonstrated the urethra to be normal. He was advised CIC per urethra but was not accepted as it produced pain, being sensitive??urethra.
+Bilateral ureteral re-implantation was done. Since the appendix used for Mitrofanoff appendicovesicostomy had already been excised, a continent catheterizable stoma was fashioned using the Yang-Monti principle. A 2 cm segment of ileum was mobilized with a well vascularized mesentery. The ileal segment was divided longitudinally on its antimesenteric border. The opened bowel was then tubularized over a 12 F catheter along the long transverse axis, perpendicular to the mesentery. This was done in two layers, using fine absorbable sutures for mucosal approximation followed by a second serosal layer. The ends were closed with interrupted sutures while the middle part was closed with a running suture. The end result was a lengthened segment of bowel, about 7 cm long, with a perpendicular vascular pedicle (Fig. ). This tube was re-implanted into the bladder as in appendicovesicostomy.
+The patient was advised CIC through Yang-Monti channel while awake and continuous bladder drainage at night. Though he religiously followed this advice, his compliance to other medical treatment was low. He was being treated for long time by religious leaders and quacks. This worsened his renal functions drastically. At the age of 19 years, he was advised renal transplantation, but there were no willing donors. For next two years, he required biweekly hemodialysis. At age 21, he died of chronic renal failure and its related complications."
+Ricky McLaughlin,27,1996/4/11,556-556-7232,maxwelljohn@example.com,987 Weaver Fields Apt. 857,"Case 3: An eight-year old boy presented with repaired exstrophy bladder, done elsewhere, at the age of one year. He had been leaking urine through the wide penopubic fistula all these years. No attempt had been made to reconstruct his epispadiac penis. On investigations, he was diagnosed to have small capacity bladder (approximately 20cc) and preserved renal tracts. Bladder augmentation with colon, Young-Dees-Leadbetter bladder neck reconstruction along with Mitrofanoff procedure was done. Due to the small size of the native bladder and unusual configuration of the vermiform appendix, the latter was implanted in the bowel ?ugment??and not the native bladder. The caecal end of the Mitrofanoff conduit was implanted in the ?ugment??and the appendicular tip was brought out at the skin surface. The postoperative course was uneventful.
+The patient returned after 8 months with stenosed Mitrofanoff channel. He had again started leaking from the penopubic fistula suggesting a failed bladder neck reconstruction. He was readmitted and prepared for the revision of Mitrofanoff channel, reconstruction/ closure of bladder neck and epispadias repair. At exploration, the capacity of the augmented bladder was satisfactory, but surprisingly the entire Mitrofanoff channel had disappeared. A continent catheterizable stoma with ileum was fashioned using the Yang-Monti principle. One important intra-operative complication worth mentioning here is that vascular pedicle of initial Yang-Monti channel was accidentally damaged by an assistant during surgery. A second Yang-Monti channel was similarly constructed with much ease. Bladder neck closure and Ransley? repair of epispadias was done.
+The child has been followed for 2 翻 years since the last surgery. He has been doing well on daytime 3 hourly CIC, daily bladder wash and night time bladder drainage through Yang-Monti channel."
+Stephanie Jenkins,31,1995/3/20,+1-740-869-8581x9105,olsendale@example.net,16967 Woods Knolls Apt. 795,"A 9 year old girl presented in the surgical outpatient department with history of a progressive swelling over right scapular region for the last three years. Swelling started as a small lump that increased in size during last six months. Swelling was not associated with fever, malaise and fatigue. There was no history of exposure to any carcinogenic agent or radiation. Past history was not significant. It was her school teacher who asked her parents to seek medical advise for the swelling, as she was facing difficulty in writing.
+The general examination of the child was normal. Local examination revealed a globular non tender swelling over the right scapular region, measuring 40x36x38 cm, having firm to hard consistency. It was mobile with well defined margins and not attached to deeper structures. Overlying skin was mobile, shiny with multiple visible vessels and a small ulcer noted in the center of the swelling (Fig. ). There was no neurovascular deficit distal to the tumour.
+Blood complete picture revealed mild anemia. Other blood tests including renal function test, liver function test, and serum calcium and serum alkaline phosphatase were within normal limits. X-ray and CT scan of the scapular region showed soft tissue swelling without any bony involvement (Fig. , ). Fine needle aspiration suggested malignant soft tissue tumour. Incisional biopsy confirmed the diagnosis of ES. The lesion was excised and residual defect was left as such with a plan skin grafting at a later stage. The recovery was smooth and patient was discharged on fifth postoperative day. Histopathology confirmed the diagnosis of ES. All resection margins were free of tumour. Immunohistochemistry was not done. She did not report back for follow up. After three months of surgery she attended the surgical outpatient department with almost healed wound (Fig. ). She was referred to oncologist for chemotherapy. She received VAC regimen (vincristine, adriamycin and cyclophosphamide), repeated every 3 weeks for 6 cycles and local radiotherapy was also given to the excised area. The patient responded well to treatment and has not shown any recurrence after two years of follow up."
+Declan Strong,41,1993/5/19,8853658920,davisbrenda@example.net,16788 Janet Squares,"Case 1: An eight-month-old male infant, a case of anorectal agenesis with rectoprostatic urethral fistula with status sigmoid loop colostomy, underwent posterior sagittal anorectoplasty. He was catheterized with a 6 Fr infant feeding tube intra-operatively. The surgery and the post-operative period were uneventful. Gentle traction on the catheter however failed to retrieve the catheter on seventh post-operative day. On examining along the urethra, the knotted catheter could be palpated at the perineum. Pelvic roentgenogram confirmed the diagnosis of knotted catheter in the urethra. Several attempts at forceful introduction of sterile saline and contrast material under fluoroscopy failed to unwind the loop.
+Under short dissociate anesthesia, another attempt was made to untie the knot and straighten the catheter with angiography wire through the catheter lumen. Failing this maneuver, the catheter was divided flush with the glans penis and the knotted catheter was gently manipulated out through a small perineal urethrostomy (Fig. ). A percutaneous suprapubic tube was inserted and was left in place for a week. The child had been passing urine in good stream on follow up."
+Margo Mathews,25,1992/10/26,(846)943-3202x15058,phillipsjohn@example.org,507 Brandon Spurs Suite 054,"Case 3: One and half year old boy underwent endoscopic valve incision for posterior urethra valves. The child was lost to follow-up for 5 years when he presented again with poor urinary stream. He could not be catheterized and was diagnosed to have urethral stricture at bulbo-membranous junction on retrograde urethrography. Endoscopic incision of hypertrophied bladder neck and visual internal urethrotomy of stricture was done; there were no residual posterior urethral valves. Three days later, an attempt to remove the catheter was met with resistance. The catheter was removed using local and systemic analgesia and gentle steady traction. The tip of the catheter was found knotted. The patient voided clear urine spontaneously and comfortably after few hours. He later underwent endoscopic management of bilateral major grades of vesico-ureteral reflux (deflux injection). He is under close follow up."
+Jamir Sanders,35,2005/7/6,(442)955-7634,christopher83@example.net,42561 Derek Ridge,"An 8-month-old male infant presented with incarcerated umbilical hernia. The umbilical hernia was initially reducible but for a day it turned irreducible. General physical examination was unremarkable (Temp 99F, Pulse 90/min, respiration rate 25/min, BP within normal limits). Abdominal examination showed abdominal tenderness around umbilicus and an irreducible umbilical hernia. Laboratory investigations were normal. Ultrasound of the abdomen pointed a loop of bowel being stuck in the umbilicus. X ray abdomen was not performed.
+Operation was performed by making semi-lunar infra-umbilical incision that revealed a loop of mid ileum entrapped at the umbilicus. The loop of ileum was reduced. Further exploration revealed an open safety pin causing perforation of the ileum (Fig. ). The safety pin was removed by an enterotomy at the site of perforation. The enterotomy was then closed. Umbilical hernia was also repaired. The postoperative recovery was uneventful."
+Everleigh Brandt,28,2000/3/4,(457)893-3292x953,taylor62@example.com,7748 Brown Highway,"A six-year-old female presented for definitive procedure of persistent cloaca (Fig. ). She had colostomy on 5th day of life. Ultrasound of abdomen was reported as normal. Distal colostogram showed high recto-cloacal fistula (Fig. ). Endoscopic evaluation revealed an opening at bladder neck. At operation anal sphincter was identified by nerve stimulation and dissection started by making anterior sagittal incision. The sites for the future vagina and ano-rectum were made. Abdomen was then opened by mobilizing the stoma. Urinary bladder was opened and ureteric catheterization done to avoid their damage during surgery. The anomaly was identified as high confluence of rectum and vagina opening into the cloaca at the level of bladder neck (Fig. ). The opening of vagina was very minute that could not be identified on endoscopy as well as at operation. Distal loop of the colon was mobilized and detached from common cloaca. It was tailored distally, to be used as vaginal substitute and pulled down at the perineum, while its proximal end anastomosed with lower end of the vagina that was about 1/3rd in length. Similarly proximal loop of colon mobilized to bring it down as ano-rectum, through the already identified site for anus. Feminizing clitoroplasty was added. The common channel was left as urethra. Finally perineal body was constructed (Fig. ). Patient had uneventful recovery.
+Examination done after 02 weeks of surgery showed healed patent vaginal and anal passages. On 10th week post operative visit, the mother was satisfied the urinary continence. She observed occasional soiling (Kelly? continence score 3). She was on follow up and on vaginal dilatation program."
+Damir Carr,42,2004/5/28,7209630230,lgonzales@example.com,427 Adam Lodge Apt. 077,"A 6-month-old male infant presented in surgical emergency with history of bilious vomiting for 25 days and non passage of stool for a week. There was no history of abdominal distension. The patient on presentation could not tolerate feeds rather he was reluctant to take the feeds. The baby was investigated in another hospital where upper gastrointestinal contrast study showed obstruction in proximal jejunum (Fig. 1). CT scan of abdomen revealed a rounded intra-luminal mass obstructing the bowel lumen (Fig. 2). Patient had also developed jaundice Liver function tests showed, total bilirubin 3.2mg/dl, direct 1.2mg/dl, alkaline phosphatase 220IU/lit with SGPT and SGOT were within normal limits. Abdominal radiograph showed signs of sub acute intestinal obstruction.
+Surgery was planned for sub acute obstruction intestinal obstruction. On exploration, the proximal jejunum was distended, edematous and thickened, having putty like material on palpation, being stuck and could not be moved. Enterotomy was performed which showed edematous and swollen bowel mucosa. Jelly balls formed thick sludge and caused obstruction. The jelly like material was removed from the jejunum (Fig. 3). Enterotomy was closed transversely as after retrieval of jelly material the bowel was looking healthy and not compromised. Post operatively the parents were enquired about crystal jelly balls and mother admitted that the boy from neighbors gave the baby two jelly balls and he swallowed one of them.
+The patient developed burst abdomen on 6th postoperative day and was re-operated. At exploration anastomotic leak was found. The anastomosis was revised and abdomen closed by retention sutures. The patient developed septicemia, and succumbed after 2 days of second operation."
+Rowan Montes,37,1983/7/6,764.817.9600,ujackson@example.net,1130 Veronica Ford,"A 14 year old male child had sudden onset of headache one and half month back which was associated with multiple episodes of vomiting. He was treated at local hospital and headache was reduced in intensity after oral analgesics. There was no history of fever, seizures or focal neurological deficits. His general and systemic examination was unremarkable. Higher mental functions were normal and there was no focal neurological deficit. Fundus showed bilateral early papilloedema. Blood investigations were normal. He was investigated with magnetic resonance imaging (MRI) which showed evidence of left basal ganglionic haematoma with mass effect and midline shift (Fig. 1,2). He underwent left frontal craniotomy and haematoma was approached through the middle frontal gyrus as it was approaching to the surface in that region. There was thin capsule containing altered blood which was removed completely. Histopathology showed organizing blood clot and there was no evidence of tumor cells or any abnormal vessels (Fig. 3). Child is doing well and there are no neurological deficits."
+Darren Lynn,37,1998/1/1,729-654-0890x82211,holly39@example.net,294 Butler Haven Suite 442,"A 7-year-old girl presented with abdominal mass that was noted at birth. She had abdominal pain and recurrent febrile episodes for the last 6 months that had worsened a week before presentation. On examination, she was febrile with generalized abdominal tenderness. A large well-defined, firm, fixed, tender mass, having bosselated surface and measuring 15 cms in diameter occupied entire left half of her abdomen. The fingers could be insinuated between the mass and left costal margin above and the mass and the pelvic brim below. Leukocyte count was 14,000/ mm3. Biochemical parameters were normal. Abdominal roentgenogram showed a soft tissue shadow occupying the left half of the abdomen displacing the stomach up and the bowel loops to the right. There were extensive areas of calcification (Fig. 1). Chest x ray was normal. Abdominal ultrasound revealed a large heterogeneous retroperitoneal mass pushing the left kidney and the ureter with mild to moderate left hydronephrosis. CT scan abdomen showed a well-defined retroperitoneal mass measuring 14cm x 10cm x 9cm in the left half of the abdomen having mixed density, septations, calcifications and teeth-like structures (Fig. 2,3). The mass displaced the left kidney posteriorly and cranially, the sigmoid colon anteriorly, and aorta and inferior vena cava to the right. The serum alpha fetoprotein levels were within normal range. The diagnosis of infected retroperitoneal benign teratoma was made.
+At operation a small amount of thick turbid came out. There were inter-loop pockets. The thick capsule of the tumor was found breached at 2 places. The overlying sigmoid colon was firmly adherent to the tumor capsule. The aorta, inferior vena cava and the mesenteric vessels were pushed to the right and did not pose any risk to the dissection. Both ovaries were normal.
+Excision of the large tumor necessitated resection and anastomosis of the sigmoid colon. Though the tumor could be removed in toto, there was gross spillage intra-operatively. Few para-aortic lymph nodes were sampled. The resected specimen had variegated appearance and there was evidence of cartilage, teeth, and hairs (Fig. 4).
+The patient did well post-operatively and was discharged on 15th postoperative day. The biopsy was reported as mature cystic teratoma (dermoid cyst) with evidence of extensive xanthogranulomatous reaction to keratin. The para-aortic lymph nodes had only reactive changes. She has been on close follow up since last 6 months and has been doing well."
+Samira May,24,2001/11/22,001-980-966-1731x2902,peter02@example.net,437 Woodard Corner,"A 6 year old girl, diagnosed case of popliteal pterygium syndrome, was admitted to our unit for pharyngoplasty. She had a series of surgeries for cleft lip and palate, lower lip sinus and bilateral popliteal pterygium (Fig. 1). Bilateral labioplasty was done at the age of 3 months, release of left and right knee flexion contracture at 7 months and 10 months of age, respectively (Doppler ultrasound showed no vessels in the band). Per-operatively, no nerve was found in the fibrous band. At 15 months of age mucous membrane adhesions were released (upper and lower buccal mucosa to the tongue). Palatoplasty was performed at the age of 1 翻 year. Left leg contracture was severe and had a repeat release at the age of 2 years. Soft tissue lengthening was done by releasing the fibrous band and lengthening of skin was made by doing Z-plasty. At the same time excision of lower lip pit was done.
+Her father had the same congenital anomalies for which he had multiple surgeries (Fig. 2). Her younger sister also manifested popliteal pterygium syndrome anomalies (cleft lip, cleft palate, lower lip sinus and bilateral popliteal pterygium) (Fig. 3).
+The index girl achieved all developmental milestones normally. She has learned to walk and run but she cannot put her heals fully plantigrade. Pharyngoplasty was performed at last admission and patient discharged. She is on regular follow up."
+Finley Dougherty,29,1996/1/15,5777709358,foxjack@example.net,279 White River Apt. 859,"A 12-year-old boy presented in paediatric emergency room with complaints of severe paroxysmal colicky abdominal pain for the last 6-8 hours associated with non-bilious vomiting. Patient was apprehensive and looked pale. Patient had passed stool in the morning with no history of blood or mucous in the stool. On per abdominal examination no lump was palpable. There were no signs of peritonitis. His laboratory investigations were within normal limits. Abdominal radiograph showed air fluid levels indicative of a small-bowel obstruction. Ultrasonography revealed ileo-ileal intussusception. After resuscitation, patient underwent emergency laparotomy. At operation an ileo-ileal intussusception was found (Fig. 1). The invaginated segment was situated approximately 40 cm from the ileo-cecal valve. The reduction of intussusception was carried out gently. After reduction the adjacent small intestine had a normal color and peristalsis. A firm polypoid mass was palpable in the lumen of ileum about 20 cm from ileo-cecal valve (Fig. 2,3). An enterotomy confirmed the presence of a polypoid lesion arising from antimesenteric border. This segment of ileum was resected and an end-to-end anastomosis performed. Postoperative recovery was uneventful. Histopathological examination revealed that the mass was composed of mature pancreatic acini and ducts."
+Alisson Melton,31,1978/8/25,409-541-9169x1212,atucker@example.com,5792 Sonya Land Apt. 351,"A six-year-old female child was brought with the history of swelling of upper lip with discharge. The swelling was noted shortly after birth. It discharged thick material periodically. The parents had learned to decrease the size of the swollen lip by squeezing and letting the secretions out. On examination, the patient had a palpable lump over philtrum of upper lip about 8mm x 6 mm with two minute openings, one (cutaneous) on the midline of philtrum (Fig. 1A) and another (mucosal) towards the right of frenulum (Fig. 1B). On applying gentle pressure, thick creamy sebaceous material could be expressed from cutaneous opening. The patient was operated. After partial expression of sebaceous material, 0.2cc of 0.5% methylene blue was injected (Fig. 2A). The dissection was carried out from mucosal side (Fig. 2B) and the whole of the fistula was excised. On the philtrum, a small ellipse of skin around the cutaneous mouth of fistula was excised to ensure complete excision. Histopathological examination of the specimen showed features of fibrous fistulous tract with central cystic dilatation. The inner lining comprised of stratified squamous epithelial and contained dermal appendages including sebaceous and sweat glands. At one year of follow-up, there was an inconspicuous scar in the middle of philtrum (Fig. 3)."
+Lennon Flores,29,2003/11/27,775.476.8686,leeerik@example.org,024 Keith Springs Apt. 094,"An apparently healthy 11-year-old boy presented with acute pain in central abdomen of 5 hours duration. He gave history of a trivial blunt abdominal trauma while at play. Patient also complained of a bothersome itching all over his body especially over limbs and the trunk starting soon after the injury. At presentation, the patient was lying still in bed with pulse rate of 110/min and BP 110/60 mm Hg. There was no pallor. Lesions resembling utricaria were seen over thigh and trunk. Abdominal examination revealed generalized rebound tenderness.
+Baseline investigations were normal except for leukocytosis (13200/ mm3). Roentgenograms of the chest and the abdomen were essentially normal. Ultrasonography revealed that liver was enlarged and there were 2 cystic lesions [6.4X4.6 cm and 8.1X 6.9 cm] in right lobe of liver with hypoechoic contents and floating echogenic membranes and peripheral calcifications. Lot of free fluid was also present.
+Intravenous fluids were started with a bolus of Ringer lactate (20ml/Kg) followed by Dextrose 5% in normal saline (0.9%). Intravenous Hydrocortisone and Pheniramine maleate were adminstered along with antibiotic prophylaxis. The clinical picture with sudden generalized pain in abdomen with rashes, frank peritonitis and sonographic findings were suggestive of ruptured hepatic hydatid cyst. Patient was taken for exploratory laparotomy. The peritoneal cavity was filled with approximately 500 ml of bilious fluid which was drained out. Inspecting the liver surface showed extruded bile stained flaccid hydatid cyst (Fig. 1).
+Another intact hydatid cyst was palpable in segment VI which was removed by partial pericystectomy. The entire peritoneal cavity was lavaged with hypertonic (3%) and normal saline. The bed of the first cyst was inspected for any bile leak. As there was no evidence of large cysto-biliary communication, the cavity was packed with omentum. A tube drain was placed in right sub-hepatic space. Postoperative course was uneventful. The drain was removed on the on 7th post operative day. albendazole (15 mg/kg/day) was started and plan was to continue it for 6 months (3 weekly courses and drug free period of one week with a watch on the liver enzymes and counts).
+Four weeks later, the patient presented with upper abdominal fullness not associated with any other complaint. He was afebrile and hemodynamically stable. There was no icterus. On examination, there was distension of abdomen limited to the upper half of abdomen. There was no demonstrable free fluid and bowel sounds were normal. Laboratory values were: Hb-9.2 gms/dl, TLC-6900/mm3, serum bilirubin-0.8 mg%, ALT-17 U/ L, ALP 365 U/ L, AST-28 U/ L. Sonography revealed a large multiloculated cystic mass (15cmx13cmx18 cm) antero-superior to the liver. The intra-hepatic biliary radicals and the common bile duct were not dilated. There was no free fluid. CT scan was done to know further details. It showed 13cmx13cmx16 cm cystic lesion in the right lobe of liver with well defined septa of liver parenchyma within it (Fig. 2). Another cystic lesion was found in the left sub-hepatic space and lesser sac. Based on the findings it was diagnosed to be a ?alled off??bile collection. A pig tail catheter was inserted percutaneously into the bilioma under sonographic guidance which was both diagnostic and therapeutic. It drained about 500 ml of greenish brown fluid overnight and culminated with disappearance of abdominal distension. The catheter was removed after 4 days when the effluent was negligible. Patient was discharged and on follow up 3 weeks later, found to be doing well. Currently patient is on albendazole therapy."
+Emilia Watts,34,1995/7/26,001-604-867-3804x4628,dhudson@example.com,579 Kline Knolls Suite 319,"A 4-month-old male baby presented to our hospital with the complaint of palpable mass in the right hemi-abdomen noted by the parents one day back. The patient was born at full term with uneventful birth history. The baby achieved milestones normally. Abdominal examination revealed a non-tender mass with vague margins in the right hemi-abdomen. Laboratory investigations including alpha-fetoprotein were within normal limits. X-ray abdomen showed mass impression pushing the gut shadows to one side. Bones and calcifications were also evident in the right hemi-abdomen. Ultrasound of the abdomen revealed a heterogeneous mass with calcifications suggestive of teratoma. Abdominal CT scan showed a 9.2cm ? 10.0cm heterogeneous mass containing fat, bones and soft tissues. The various bones were vertebrae, long bones like femur, tibia and fibula, and bones of hand/feet (Fig.1). Provisional diagnosis of FIF was made.
+At operation, a mass covered in whitish-gray membrane, pushing the gut loops to the opposite side in the upper retroperitoneum, was found (Fig.2). The membrane was incised to find a fetiform mass floating in clear fluid having a few well differentiated and other rudimentary organs. The fetiform mass was suspended in the amnion like cavity with an umbilical cord like stalk (Fig.3). The mass with sac was mobilized and excised completely.
+Post operative recovery was uneventful. Patient was allowed orally on 3rd and discharged on 7th post operative day. The patient is currently being followed with alpha-fetoprotein and ultrasound abdomen. At six months follow up patient is doing well.
+The FIF was of 13.75cm?12.5cm?6.25cm size with a weight of 500 grams. It was anencephalic having otic and nasal placodes and optic vesicles. The left upper limb was meromelic; lower limbs were sirenomelic. The umbilical cord had two vessels in it. The FIF had a scrotum like skin at the site of genitalia that lacked gonad in it. The FIF also lacked anus and genitalia (Fig.4). Plain radiography of the specimen revealed axial skeleton in the form of vertebrae, along with ribs, long bones of upper and lower limbs, and facial bones (Fig.5)."
+Dakota Ross,22,1986/12/18,001-309-648-1810x4857,joypace@example.net,675 Johnson Squares,"A 12-year-old girl presented with gradual onset of continuous, low to high grade fever, and cough which was initially non-productive but later productive of yellow sputum over 20 days. She had anorexia and lost weight. She developed respiratory distress which gradually worsened. Family history was significant for tuberculosis in grandmother who lived with her. She was unvaccinated. Initially they took treatment from a family physician but later referred to other facility where she was admitted and worked up as no improvement was noted. Her x-ray chest showed bilateral pleural effusions (Fig.1) and ultrasound of the chest revealed large effusions on both sides with thick internal echoes. At thoracocentesis, pus was aspirated from both the sides. She was started on anti-tuberculous treatment (Inj. streptomycin, isoniazid, rifampicin and pyrizinamide). After the thoracocentesis, her condition worsened and x-ray chest revealed left pneumo-thorax, (Fig.2) and she was referred to our centre.
+At arrival, examination revealed a thin, emaciated, 21 kgs, tachypneic girl, with a respiratory rate of 52/min and heart rate of 118/min. BCG scar was not found. Chest movements were equal but air entry was reduced on both sides. Bilateral tube thoracostomies were offered. About 250 cc thin yellow pus was drained initially from the right side and 20 cc thick yellow pus drained from the left side along with air-leak. Post intubation x-ray chest showed partial lung expansion on the right side (Fig.3).
+Laboratory investigations showed Hemoglobin of 9 gm/dl and ESR of 40 mm/1st hour. She was started on ceftazidime and amikacin injectables, empirically along with anti-tuberculous drugs and supportive treatment. The initial pleural fluid examination revealed numerous WBCs, proteins 5.7 gm%, and gram negative rods. Pseudomonas aeruginosa was isolated from the pus and no AFB was seen on Ziehl Nelson (ZN) staining. Antibiotics were changed to tazobactam (according to culture report) and anti-tuberculous drugs continued.
+Her condition worsened despite optimal medical treatment. Respiratory distress increased together with persistent air leak and oxygen desaturation. She was shifted to intensive care unit and x-ray chest was repeated which showed bilaterally well expanded lungs with pneumonic patches. Both chest tubes were in place that drained pus though she required re-adjustments multiple times. She was also given nutritional supplementation. The pus culture were repeated that grew Morganilla morgani sensitive to tazobactam.
+Gradually her condition settled. Respiratory distress improved and fever subsided. Repeat x-ray chest showed bilaterally well expanded lungs except for a cavitatory lesion at the right lower zone. Ultrasound (US) chest showed collection with internal echoes measuring 5.4 cm ? 4.5 cm, and 10 cc pus was aspirated under US guidance and sent for culture. Proteus vulgaris was isolated with same sensitivity pattern. At 42nd and 48th day of intubation, left and right sided chest tubes were removed respectively after the x-rays when the patient was asymptomatic (Fig. 4). She was sent home on anti-tuberculous treatment and vitamin supplements after a total hospital stay of 66 days. On last telephonic conversation with family the patient was reported as thriving well, gained weight and was asymptomatic."
+Peyton Rivera,39,1980/11/24,962.512.2458x38226,erin44@example.net,12857 Boyd Shore Apt. 258,"A 20-year-old male, suffered from cough, rhinorrhea, wheezing and dyspnea after exposure to rainy environmental conditions. He was diagnosed with asthma in childhood. Positive family history of asthma included his mother and three elder sisters. Following treatment with inhaled corticosteroids, the symptoms abated over the next three days. Nine days after the onset of his asthma exacerbation, he developed an unsteady gait (day 1). The symptoms persisted, and on day 3 he developed blurred vision, dizziness, and nausea. On day 12, he became intermittently drowsy, however, he could be aroused by noxious stimulation. Six days later (day 18), he experienced an episode of tonic-clonic seizures. This episode brought him to the attention of the neurological team. On neurological examination he was fully conscious, had a wide-based gait, and was unable to stand on one foot. Limitations of lateral gaze in the left eye and vertical gaze in both eyes were observed. Motor and sensory functions were intact. Brain computed tomography (CT) and cerebrospinal fluid (CSF) examination showed no abnormalities. Electroencephalography (EEG) showed a 4?? cycle per second slow wave pattern diffusely, and a 22??6 cycle per second waveform predominantly over centroparietal area, bilaterally (Figure ). Brainstem encephalitis was tentatively diagnosed, and the patient was given intravenous dexamethasone (10 mg per day) for treatment. Despite the treatment, the patient? symptoms deteriorated, his level of consciousness varied from occasional drowsiness to lethargy, and on day 21, he developed quadriplegia. On the Medical Research Council (MRC) scale, his muscle strength was grade one for all limbs. Triceps brachii and biceps brachii reflexes were decreased bilaterally, and brachioradialis reflexes were absent bilaterally. Patellar and achilles reflexes were also absent bilaterally. Plantar reflexes were equivocal. CSF examination showed albuminocytologic dissociation with 64 mg/mL protein and 2/弮L cells. Serologic and CSF screenings for IgM antibodies against cytomegalovirus (CMV), Herpes Simplex Virus I (HSV-I), Coxsackie virus (CV), Measles virus (MV), Epstein-Barr virus (EBV), as well as EBV viral capsid antigen (VCA) IgA were all negative. Serologic analysis of antibodies against ganglioside complexes (anti-GDIa, anti-GDIb, anti-GM1, anti-GM2, anti-GM3, anti-GQIb and anti-GTIb antibodies) were negative. Serum and CSF examination, revealed significantly elevated IgE levels in both the serum (14.4 mg/L, normal range: 0.1-0.9 mg/L) and CSF (0.046 mg/L, normal range: undetectable), whereas, IgA, IgM and IgG were within the normal range. Nerve conduction study (NCS) revealed peripheral nerve abnormalities characterized by axonal damage (Figure ). Both motor conduction velocity and sensory conduction velocity were normal in the four limbs. Motor nerve conduction study showed variable decreased amplitude at the median, ulnar, tibial, and peroneal nerves on both sides. The right peroneal nerve showed slightly prolonged latency. Sensory nerve conduction study recorded decreased amplitude at the left tibial nerve, but the right sural nerve, right median nerve and left ulnar nerve were relatively spared. Left median F-wave could not be elicited, but H-wave was evoked normally. Overall, the NCS findings were consistent with a diagnosis of GBS with predominant axonal damage."
+Charles Lopez,20,1997/12/16,446-529-5294x84610,wilsonannette@example.net,58900 Jones Isle Apt. 829,"A 68-year-old, right-handed Caucasian man was diagnosed with Gleason grade 4 + 3 adenocarcinoma of the prostate in March 2009. A partial prostatectomy and pelvic node dissection was completed, and our patient started androgen blockade with leuprolide (Lupron), dutasteride (Avodart) and bicalutamide (Casodex). His prostate specific antigen (PSA) levels decreased from an initial value of 41.6 to 0.07 ng/ml in April 2010. In May 2010, one month prior to admission, a transurethral debulking of his prostate was completed for difficulty in initiating a urine stream and an indwelling Foley catheter was left in place. In the 48 hours prior to admission, he developed a worsening saddle anesthesia. On the day of admission, June 10 2010, he described increasing headache as well as new-onset fecal incontinence but denied weakness. His past history, family history and a review of his systems were not significant.
+On admission, his mental status, cranial nerve and upper extremity examinations were unremarkable. A motor examination was intact in his legs but there was significant numbness below his ninth thoracic vertebra. Reflexes were absent in his lower extremities. Rectal sensation and tone were absent.
+Magnetic resonance imaging scans of his brain and thoracic and lumbar spine showed two irregularly enhancing lesions. The first, 2cm in diameter, was in the region of the fourth ventricle but was without secondary hydrocephalus. The second was a spindle-shaped intramedullary lesion of the conus medullaris (Figures , and ). The lesion was approximately 2cm in the vertical extent and appeared partially cystic.
+Our differential diagnosis included ependymoma, astrocytoma, a metastasis from the known prostate cancer or a metastasis from an undiscovered second primary tumor.
+Because of our patient? increasing neurological deficit, and given the uncertainty of the diagnosis, a decompression and an excisional biopsy were undertaken on the day of admission. With somatosensory and motor evoked potential monitoring, a twelfth thoracic to first lumbar vertebral laminectomy was completed. The level of the lesion was confirmed using intraoperative ultrasound. On opening the dura, abnormal appearing tissue was immediately identified involving the posterior surface of the conus. A small biopsy was consistent with malignant tissue. A more aggressive resection to the edges of the abnormal appearing tissue was completed and his cord appeared adequately decompressed. The closure was uneventful.
+On microscopy, the lesion showed sheets and nests of cells with abundant cytoplasm and prominent nucleoli. Mitoses were common. Intracytoplasmic and extracellular mucin was demonstrated. AEI/AE3 cytokeratin, CAM5.2, CK7, and CK20 were positive. PSA, Prostatic specific acid phosphatase (PSAP), thyroid transcription factor-1 (TTF-1), caudal type homeobox-1 (CDX-1), and S100 were negative. The pathology was consistent with metastatic adenocarcinoma of the prostate (Figure ).
+Following surgery, his sensory changes improved and the motor examination remained intact. His bowel and bladder function remained poor. The intracranial lesion and the resection cavity in the conus were both treated with CyberKnife簧 radiosurgery. The spinal resection cavity, contoured to the edge of the enhancing tumor on a postoperative scan, was treated to a marginal dose of 27Gy at the 85% isodose line in three sessions. Our patient remains neurologically stable three months after treatment, with no new neurological deficits and no new lesions."
+Gianna Holmes,34,1978/12/23,297.575.3288,richard90@example.org,732 Clayton Lane Suite 760,"An eight-year-old African boy, previously well, was referred to our unit on account of nephrotic syndrome. He had presented to our emergency department a day before with ascites, facial swelling and reduced urinary output in the preceding two weeks. After two days of hospitalization, he became deeply jaundiced with worsening of the generalized oedema. A day later, he had three brief episodes of generalized clonic seizures over a two-hour period and became increasingly drowsy. The seizures were aborted with diazepam and he remained seizure-free after a short course of phenobarbitone. A physical examination did not support a diagnosis of meningitis and other aspects of a neurological examination were normal. He had ascites and non-tender hepatomegaly; his spleen was not palpable. A review of his history did not reveal chronic or recent use of orthodox or non-orthodox medicines. In addition, there was no previous or current history of similar illness in his four siblings and close contacts. Both his parents were Africans, of the Igbo ethnic group from southeast Nigeria, but were not known to be blood relatives.
+In the second week of hospitalization, our patient developed tremors of his hands while at rest and when reaching for objects. He became clumsy when performing chores involving the use of his hands. Subsequently, he was observed to be stiff globally, with his trunk arched forward and fisting of the hands (left more than right). His gait was noticed to be shuffling with a tendency to fall forward when trying to walk. At the same time, his face retained a wry smile and his speech became slurred and dysarthric. He frequently complained of generalized body pain and derived some relief when his clenched fist was helped open. He was also noticed to be emotionally labile; he cried inconsolably when asking for food. He was reviewed by a paediatric neurologist who pointed out the possible presence of Kayser-Fleischer (KF) rings on both eyes. A slit-lamp examination by an ophthalmologist promptly revealed the presence of both KF rings (Figure ) and sunflower cataracts.
+Initial investigations showed proteinuria of grade 1+ and a spot urine protein to creatinine ratio of 1. Table shows the results for his liver function test during hospitalization. His serum electrolytes, urea and creatinine were within the normal reference range. An abdominal ultrasound scan revealed ascites and hepatomegaly with increased liver parenchymal echoes but no dilated intra- or extrahepatic ducts. However, his gall bladder was enlarged with a thickened wall and sludge within. Serology for human immunodeficiency virus, hepatitis B and hepatitis C viruses were negative. A serum sample for caeruloplasmin level was returned as having 5mg/dL of caeruloplasmin, using an immunoturbidimetric method (reference range: 25 to 45mg/dL).
+Using the scoring system proposed by the 8th International Meeting of Wilson Disease and Menkes Disease [], our patient achieved a score of 6 (compatible neuropsychiatric features = 2; K-F rings = 2 and caeruloplasmin level of 5mg/dL =2) and a diagnosis of WD was made.
+His diet was restricted to high calorie, low protein and low copper meals. Vitamins, including vitamin K, and lactulose and neomycin were commenced. Control of the generalized oedema was achieved with furosemide and spironolactone. Long-term zinc and pyridoxine therapy was started. The use of trihexyphenidyl helped achieved some control of the spasticity and rigidity, sufficient to allow resumption of basic activities such as walking and holding objects. His liver dysfunction also improved, with near resolution of the international normalized ratio (from 12 to 4)."
+King Reyes,44,2003/8/15,(941)613-0887,heatherevans@example.net,536 Wang Mall Suite 111,"A 50-year-old Hindu man from northern India presented with pain in his neck and restriction of neck movements of two months duration. The pain was not radiating to any other part, was present throughout the day and was aggravated during the night and after activity. He had no history of any traumatic episode. Our patient was experiencing little relief with analgesics. The pain was not associated with fever; he had no weakness in any of his limbs, nor difficulty in speech or deglutition. On examination, he had tenderness over the spinous processes of the upper half of his cervical spine along with spasm of his neck muscles. There was no deformity or gibbus. Our patient had gross restriction of motion of his cervical spine in all directions. He had no palpable lymph nodes in his neck. On neurological examination, there was no deficit in any limb and his tendon reflexes were normal. He had no other systemic illness.
+Laboratory investigations showed little abnormality other than an increased erythrocyte sedimentation rate (54 mm in the first hour).
+A lateral view of plain radiographs showed a fracture of the body of his second cervical (C2) vertebra with mild displacement of the fractured anterior body fragment. The odontoid process appeared to be in normal alignment with his C1 vertebra. There was also a significantly increased prevertebral soft tissue shadow anterior to the C1, C2 and C3 vertebral region (Figure ), which indicates the presence of a retropharyngeal abscess.
+A computed tomography scan showed fragmentation of his C2 vertebral body and the anterior fragment lying separate from the parent bone. Posterior elements were found to be normal (Figure A, B).
+MRI clearly depicted the extent of vertebral involvement in T1-weighted, T2-weighted and fat suppression sequences. The destruction and expansion of the C2 vertebral body was seen along with significant pre- and paravertebral collection. This appeared hypointense in T1-weighted and hyperintense on T2-weighted images. The soft tissue mass was seen compressing the airway anteriorly and was causing slight indentation of the thecal sac posteriorly. However, the cord appeared normal on signal intensity. His C2 and C3 vertebral bodies appeared hyperintense on fat suppression images, suggesting extensive bone marrow edema. His cervical intervertebral discs appeared degenerated at various levels but otherwise appeared intact (Figure C, D).
+Transoral fine needle aspiration cytology of the lesion yielded caseous material on cytology but did not show any acid-fast bacilli. Our patient was given antitubercular treatment with a four-drug regimen (rifampicin, isoniazid, ethambutol, pyrazinamide) for two months followed by a two-drug regimen (rifampicin, isoniazid) for a period of four months. His cervical spine was protected by a Philadelphia collar. On follow-up radiographs, the fracture in his C2 vertebra was found to be united by the end of 16 weeks and the prevertebral soft tissue shadow returned to its normal limits (Figure ). The pain and stiffness in his neck also improved significantly following treatment, although some terminal restriction of motion remained even at the end of 25 months follow-up."
+Audrey Pitts,24,1982/8/30,7942934080,llynch@example.net,6141 Peter Rapids,"A 56-year-old Japanese woman had visited a local clinic, complaining of a two-month history of a painless cutaneous fistula in her anterior neck with pus discharge. She was diagnosed with a pyogenic granuloma [] by her previous doctor. The pus discharge temporarily subsided after antibiotic treatment, but the cutaneous fistula persisted. She was then referred to our department for further advice. On physical examination, a non-tender reddish lesion with a fistula and granulation was seen on her anterior cervical skin. Our patient reported that she had suffered from the sensation of a foreign body in her throat after eating fish approximately one year prior to the present onset, but the symptom had spontaneously improved after a few days. Taking her anamnesis into account, a fish bone foreign body was suspected.
+Endoscopic examinations of her laryngopharynx and esophagus showed no abnormality. However, computed tomography (CT) revealed a bone-density needle-shaped foreign body sticking out anteroinferior from the esophageal wall, penetrating through the superior pole of her left thyroid lobe, and extending nearly to the anterior cervical skin (Figure ). The foreign body was surrounded by a low density area, suggesting abscess formation (Figure ). The results of a blood examination were unremarkable, with normal thyroid and parathyroid functions.
+Our patient underwent the removal of the foreign body combined with left hemithyroidectomy under general anesthesia 20 days after her initial visit to our department. A horizontal cervical incision with the spindle-shaped excision of the orifice of the fistula was made, and the skin flap was elevated. Considerable cicatricial adhesion was seen around the fistula. The fistula passed through the infrahyoid muscles and was connected to her left thyroid gland. The tip of the fish bone was exposed by cutting her infrahyoid muscles open. As seen in the preoperative imaging, the fish bone penetrated through her thyroid gland, reaching the esophageal wall. The fish bone, fistula, left thyroid lobe and an abscess were totally removed with preservation of her recurrent laryngeal nerve. The injured esophageal mucosa was sutured and closed. Figure shows the removed fish bone, measuring 28mm in length.
+Our patient? postoperative course was uneventful. No esophageal leakage was observed during an esophagography, and she was allowed oral food intake seven days after the surgery. She was discharged nine days after surgery, and no evidence of recurrence was seen over the postoperative follow-up period of 42 weeks."
+Trey Ventura,23,1982/11/13,298.866.9765x007,zcallahan@example.org,8092 Michael Pike Suite 013,"Our patient was a 28-year-old Arab woman, gravida 3 para 2 with a history of nonconsanguinity, with two previous full-term normal spontaneous vaginal deliveries and an unremarkable past medical, surgical and family history. She was referred to our hospital at 22 weeks of gestation with severe hydramnios and a placental tumor, for investigations and management. Our patient presented to us complaining of shortness of breath, backache and abdominal pain. An ultrasound examination revealed normal fetal growth for gestational age. Her amniotic fluid index was 48 cm, with the deepest pocket of 13 cm and no signs of fetal hydrops. Ultrasound middle cerebral artery peak systolic velocity (MCA PSV) color Doppler was 48 cm/s, which was 1.71 Multiple of Median (MoM) for gestational age. The placenta was implanted anteriorly with a detectable vascularized tumor measuring 42 mm ? 56 mm ? 58 mm with a noticeable feeding vessel at the root (Figures and ).
+After extensive counseling, our patient agreed to undergo percutaneous embolization of the tumor. Employing a multidisciplinary approach involving interventional radiology, we performed an amnioreduction of 3 L for maternal relief of symptoms, followed by injection of 1.5 mL of enbucrilate (Histoacryl; n-butyl-2-cyanoacrylate liquid adhesive glue) diluted with Lipiodol Ultrafluide, at ratio of 1/5, into the feeding vessel of the tumor. After the procedure, ultrasound Doppler revealed a complete absence of flow through the tumor (Figure ). Cordocentesis was then performed and revealed a hemoglobin level of 10 g/L with hematocrit 28%. The fetus was transfused 50 mL of O-negative blood and the post transfusion hemoglobin level was 14 g/L with hematocrit 42%. Chromosomal analysis revealed a normal female karyotype. Ultrasound was repeated one and four days post procedure and showed a decrease in the amniotic fluid index, of 32.2 cm with a deepest pocket of 10 cm.
+The pregnancy was followed up weekly with ultrasound, which showed normal fetal growth, stable amniotic fluid index with no signs of hydrops, and no flow through the placental tumor (Figure ).
+At 29 weeks??gestation, ultrasound Doppler of the MCA PSV was 76.3 cm/s. This was 1.97 MoM for gestational age, with the development of mild pericardial effusion. The fetus was transfused with 50 mL of O-negative blood. Pre- and post-transfusion hemoglobin levels were 10.4 g/L and 14.9 g/L, with hematocrit 29% and 44% respectively.
+At 30 weeks and 2 days of gestation, an ultrasound detected poor fetal right ventricular contractility with enlarged thick ventricular walls and mild pericardial effusion. Ultrasound Doppler of the MCA PSV was 61.3 cm/s, which was 1.51 MoM for gestational age, and an amniotic fluid index of 19.9 cm. Two intramuscular injections of betamethasone 12 mg were given 24 hours apart and then an elective Cesarean section performed. The outcome was a live female baby weighing 1.6 kg, with Apgar score 5, 7 and 8. No skin lesions or dysmorphic features were seen. The baby was transferred to the neonatal intensive care unit (NICU).
+Gross examination of the placenta revealed a yellowish, well-circumscribed firm mass measuring 5 cm ? 5 cm connected by two vessels to the placenta. Histopathologic examination revealed a placental disc 15 cm ? 17 cm ? 13 cm, with a three-vessel umbilical cord that was attached peripherally and measured 9 cm ? 1.5 cm (Figure ). The weight of the placenta was 530 g. The tumor was confirmed to be a chorioangioma.
+Our patient? baby stayed in the NICU for 42 days. Ultrasound of her head and abdomen showed no abnormalities. Echocardiography confirmed right ventricular hypertrophy with a mildly dilated right ventricle and depressed systolic function. The baby was weaned from the ventilator. Oxygen and nitric oxide were tapered along with inotropic medications. The baby was eventually discharged from the NICU at 42 days old with a follow-up appointment with our cardiology team."
+Zora Roth,41,1977/11/22,4362802185,reedlindsay@example.net,79412 James Orchard Apt. 763,"A healthy, engaged 28-year-old East Asian man presented at our hospital with a two-week history of right-side scrotal swelling and a three-month history of left-side scrotal enlargement. He had complained of temporary dull pain in his right scrotum, but the pain had disappeared within a day. He had no history of prior scrotal surgery, cryptorchidism or infections. On physical examination, his right scrotum was slightly swollen, whereas his left scrotum had marked swelling and a hard mass was detectable. A scrotal ultrasound showed heterogeneous bilateral scrotal masses that were hypoechoic on the right but hyperechoic on the left. Doppler ultrasonography indicated a diffuse hypovascular area in the right scrotal mass but iso- and hypervascular on the left. Pelvic contrast-enhanced computed tomography (CT) demonstrated that his right testis was normal in size with decreased enhancement, whereas his left testis was much larger with heterogeneous enhancement (Figure ).
+These findings seemed to suggest bilateral TGCTs as a differential diagnosis, but his right testis did not have typical features of a TGCT; therefore, we examined his bilateral testes with MRI. His right testis had a serpiginous vessel and the intratesticular lesion showed high intensity on the T2-weighted image (Figure A), but lack of contrast enhancement (Figure B). His left testis had a large multinodular tumor with high intensity on the T2-weighted image (Figure ). According to the MRI findings, his right and left testes were diagnosed with hemorrhagic infarction and a testicular tumor, respectively. Before further treatment, we performed a sperm test. Sperm were present (8 million/mL) and were cryopreserved for use in an assisted reproductive technique, although his levels of luteotropic hormone (15.6mIU/mL) and follicle-stimulating hormone (49.0mIU/mL) were high.
+Based on the preoperative diagnosis, a transverse scrotal incision was made to allow right scrotal exploration. Since inspection of his right testis revealed a necrotic testis with 270簞 intravaginal torsion of the spermatic cord, his right testis was removed. Left radical orchiectomy was then carried out.
+Pathological examination demonstrated hemorrhagic infarction and dilated vessels in his right testis (Figure A), and typical seminoma cells and atrophy of seminiferous tubules in his left testis (Figure B). Preoperative laboratory examination showed a high lactic dehydrogenase level of 580IU/L and normal alpha-fetoprotein and human chorionic gonadotropin levels in his serum. Because an abdominal CT showed para-aortic retroperitoneal lymphadenopathy, 9mm in size, we diagnosed seminoma stage IIA, which has a good prognosis according to the definition of the International Germ Cell Cancer Consensus Group. Therefore, our patient was promptly given chemotherapy in three cycles of bleomycin, etoposide and cisplatin []. At the end of the three cycles, a follow-up CT scan showed complete resolution of the previous retroperitoneal lymphadenopathy and the tumor marker level was undetectable. After bilateral castration his serum level of testosterone was markedly decreased, so we started supplemental therapy of testosterone for his erectile function."
+Roy Bush,45,1994/11/18,228-977-7572,burgessroberto@example.net,55713 Sanders Lodge Suite 925,"A 37-year-old Chinese woman presented to our department four years and 11 months ago with bilateral lower limb crush injuries sustained in a traffic accident. The lower limb injuries were at different anatomic levels (Figure A-C). On the right side, her lower limb was crushed from her hip joint to 16cm below her knee joint, but the bones and soft tissues of the lower one-third of her leg were intact with only slight injury to the skin. On the left side, the distal portion of her leg was crushed. Our patient was in serious hypovolemic shock on arrival, with a heart rate of 150 beats per minute and blood pressure of 80/60mmHg.
+After rapid infusion of intravenous fluids, our patient rapidly recovered from shock and did not develop acute renal failure or acute respiratory distress syndrome. Emergency surgery was performed. Bilateral lower limb amputations were necessary. Her lower left leg was unsalvageable, but her lower right leg was suitable for replantation to the left leg stump after debridement. We decided to perform crossover replantation of her right lower leg to the left leg stump to provide our patient with a sensate weight-bearing extremity. Her amputated right lower leg was wrapped in sterile dressings, placed on a sterile tray and stored in the refrigerator at 4簞C during fixation of the left leg fracture.
+After amputation and debridement of her right hip joint, her right lower tibia was fixed to her left upper tibia (Figure D). The fibula was not fixed. The tendons, blood vessels and nerves of her left leg were anastomosed to the amputated lower right leg structures. The anterior tibial artery and posterior tibial artery were anastomosed crosswise, and the ends of the great saphenous vein, small saphenous vein and four deep veins were anastomosed without crossover. The sural nerve and saphenous nerve were anastomosed crosswise, and the anterior and posterior tibial nerves were anastomosed without crossover. Heterotopic replantation of her right lower leg to the left leg stump was thus completed. A stump was created on the right side at her hip joint. Routine antibiotic, anti-coagulant, and anti-angiospasm treatments were administered post-operatively. In a second operation, a soft tissue defect of the replanted limb was covered by a microvascular-free latissimus dorsi muscle flap. The post-operative anti-coagulation regime was as follows: dextran 40 (500mL) twice a day for seven days; aspirin (100mg) orally three times a day for three days; narceine (30mg) four times a day for seven days; and tolazoline (25mg) three times a day for seven days. Routine post-operative blood tests, including coagulation tests, were performed for seven days.
+The replantation was successful and our patient was discharged after two months (Figure A). She was rehabilitated with a contralateral prosthesis and ambulates with a walking stick. One year post-operatively, X-ray examination showed perfect union of the tibia (Figure C). There was no ulceration of the replanted extremity or the right-sided amputation stump at 39 months post-operatively. The sole of her foot on the left side regained complete protective sensation (Figure B). Our patient described the functional result of the replantation as satisfying, and found that the prosthesis on the right side caused more problems than the replanted left lower limb. She had no complaints about the cosmetic result. In addition, she experienced restoration of perceived body height with the crossover replantation."
+Everlee Hunter,28,1994/4/21,315-431-1186x15271,margaret37@example.com,2624 Patrick Rapids,"A 29-year-old woman Para 2 was admitted to the emergency department with increasing lower abdominal pain. The patient had no history of systemic disease or chronic abdominal tenderness. Her past obstetric history revealed a caesarean section performed at 38 weeks because of a breech presentation three years earlier.
+The patient had undergone an uncomplicated elective repeat caesarean section 7 days before being admitted to the emergency department. Indication for CS was breech presentation at term. The operation was without complications except some heavy bleeding occurred after the incision of the lower uterine segment; the bleeding was controlled by means of haemostatic stitches. The postoperative course was uneventful and the patient was discharged in good clinical conditions four days after CS.
+Three days after CS she reported a significant decrease of postpartum discharge (lochia) as well as a sudden complete stop of vaginal bleeding and discharge on day 4 after SC.
+On admission, patient was alert, conscious, and well-oriented. She complained of severe low abdominal pain. Blood pressure was 140/80 mm Hg, HR 105 b/min, and temp. 37.4. The pain started the day before the admission as an abdominal discomfort with a sudden increase during the following day. At the time of her admission the patient described a constant low abdominal/pelvic pain with colicky exacerbations. Examination at this stage found no vaginal bleeding. Palpation revealed a painful swelling on the right side just above the pelvis. There was no sign of peritoneal irritation or abdominal distension. The wound seemed to be healing well. Lab tests at admission: Hb 12,8 g/dL, Hct 35, PLT 280, and WBC 10,5 ? 109/L.
+Routine urine examination was normal. Ultrasound investigation showed a strongly involuted uterus (LD 7.5 cm, TD 4.2 cm, APD 3.7 cm) which was localized centrally in the pelvis and also an oval-shaped mass on the right side of the lower abdomen (25 cm ? 8 cm), showing thickened walls with complex internal echo patterns apparently suggesting a organized haematoma. In the pouch of Douglas, there were no signs of active bleeding or clots. Despite of the administration of meperidine hydrochloride 100 mg IM, a reassessment after two hours showed increased symptoms with additional signs of peritoneal irritation and restlessness whereupon an explorative laparotomy was decided.
+Access was gained through the previous Pfannenstiel incision. At the opening of the abdomen a large amount of coagulated, dark red blood was evident amongst the intestinal loops. A further exploration of the pelvis showed an involuted uterus without signs of recent hysterotomy. On the right side, at the level of right iliac fossa, there was an oval, reddish, soft structure with a maximum diameter 25 cm. Mobilisation and further inspection revealed an enlarged uterus situated on the right side in respect to the small one (uterus didelphys). This second uterus showed a torsion of 90簞 on its axis and had a congested appearance.
+The uterine cavity was filled with blood (lochia) coming out the tubae by squeezing of the uterus. There were no signs of uterine weakening. During the inspection before detorsion it was noted a transverse hysterotomy suture on the right side of the uterus which was not bleeding. The other smaller uterus appeared firmly fixed to the anterior pelvic fascia and the lower segment of the left anterolateral wall of the other uterus (). Both adnexa were normal at inspection. All adhesions needed to be removed before attempting a complete emptying and detorsion of the organ (). Postoperative recovery was uneventful and the patient could be discharged 5 days after the operation in good clinical condition. She got prescribed enoxaparin 20 mg per day for 6 weeks to prevent thromboembolism."
+Archer Washington,38,1986/10/16,001-300-759-2990x6277,raymond18@example.net,11744 Natalie Square Suite 649,"The patient is a 12-year-old boy presented to our institution with intermittent gross painless haematuria, which lasted for the 11 months prior to his first under hospital observation. The haemoglobin value on presentation was 8.6 g/dL. He was initially submitted and managed with continuous saline bladder irrigation, not needing blood transfusion or any other treatment.
+He denied any other urological signs or symptoms, namely, dysuria or other low urinary tract symptoms (LUTS), flank pain, fever, asthenia, or fatigue. His physical examination was normal. The urine analysis confirmed gross haematuria and no other abnormalities namely, the presence of urinary casts. The immunological markers ANCa and ANA were negative.
+The ultrasonography showed normal kidney measurements and echogenicity, excluding hydronephrosis, renal masses or stones. The Doppler study revealed turbulent pattern of venous blood flow of the posterior LRV branch behind the aorta (). The abdominopelvic computer tomography (apCT) revealed LRV duplication with a dilated retroaortic branch, entrapped between the aorta and the vertebral column, promoting the renal nutcracker syndrome (Figures and ). The cystoscopy showed normal bladder and urethra mucosa, and a bloody ejaculate only from the left ureter meatus.
+Thereafter he was counseled to intense physical exercise restriction, oral iron supplements showing reduction of the haematuria episodes and substantial improvement of anaemia (actual Hg: 10.6 g/dL). The child is currently asymptomatic and proposed to clinical and analytical assessment."
+Valerie Park,21,1980/1/27,750.570.4293x697,brian15@example.com,369 Frank Lake,"A 50-year-old female presented to the ER of an inner city teaching hospital after experiencing a generalized seizure episode. She had a medical history significant for immune thrombocytopenia for 30 years and seizure disorder since experiencing a right occipitoparietal stroke at the age of 47 years, for which she took lacosamide and aspirin. She reported being allergic to sulpha drugs. She had smoked 1/2 packs per day for 30 years but quit 3 years before. She reported feeling out of breath after walking less than a block and a persistent cough without much expectoration for the past 8 to 10 months. Upon hospitalization, she received supplemental oxygen in addition to her home medications. A chest radiogram done on admission () showed bilateral patchy infiltrates; pulse oximetry done the day after showed oxygen saturation of around 94% on room air dropping to 90% after a 6-minute walk. A repeat chest radiogram done on the third hospital day () revealed significant clearance of the infiltrates with much improvement in her oxygen saturation values both at rest and with ambulation. Cardiac markers and 2D echocardiogram were normal. The patient did not experience any more seizures during hospitalization and was discharged on the fourth day to be followed up in the office. The diagnosis of NPE was made based on rapid resolution of the symptoms."
+Daxton Simpson,28,2004/12/10,622-888-2855,milessteven@example.net,5327 Salinas Views Apt. 377,"A 63-year-old Mediterranean Caucasian woman presented with mild dyspnea on exertion and a progressive worsening of a dry cough of nine months??duration. Born in Turkey, she had a history of exposure to asbestos via building materials commonly used in eastern Turkey. She immigrated to the United States at the age of 37. Shortly after arrival in New York she was diagnosed with and treated for pulmonary tuberculosis. (The diagnosis and treatment records were confirmed by the New York City Department of Health.) She had no fever, night sweats, hemoptysis or weight loss. She had no history of allergies; she had never smoked or used illicit drugs. Other than her birth in Turkey and immigration to the US she had no other travel history.
+Initial examination included a chest X-ray, which showed fibrocalcific changes at the upper lung fields bilaterally as well as a right lower lobe mass density. A computed tomography (CT) scan of the chest revealed multifocal pleural scarring, appearing metastatic in nature, throughout both lung fields with early mediastinal invasion in the right infrahilar region (Figure ). Positron emission tomography (PET) scan revealed FDG (fluorodeoxyglucose (18 F))-PET positive multiple lung masses. A computed tomography (CT)-guided core biopsy of a dominant right lower lobe lung mass was obtained. The histopathological specimen findings included chronic granulomatous inflammation (multi-nucleated cells with central necrosis) with numerous budding yeast forms that were positive for Grocott's methenamine silver stain (GMS), Periodic acid-Schiff (PAS) and mucin stain, consistent with cryptococcosis. Ferruginous bodies were also present, consistent with asbestos bodies (Figure ). Cultures of the specimen examined for acid fast bacilli and fungi were negative, as were bacterial cultures. Serum cryptococcal antigen and HIV enzyme-linked immunosorbent assay (ELISA) were negative. A summary of the significant clinical data is illustrated in the table.
+She was treated with fluconazole (400mg (6mg/kg) per day orally) for four months. She reported a marked improvement in her symptoms and improvement in her general condition. At her four-month follow up, a chest radiograph showed a significant reduction of the basilar infiltrates bilaterally."
+Anastasia Collier,42,1999/7/20,663.416.1987x3959,christian03@example.net,893 Eric Divide,"Three years prior to her presentation with a fractured femoral neck, a 37-year-old Caucasian woman was admitted via our emergency service with a painless, swollen finger. We diagnosed a fracture of the third proximal phalanx of her right hand based on the findings on physical and radiological examination and performed percutaneous pinning under local anesthesia. At follow-up six weeks later, she complained of swelling of her right foot. We observed three metatarsal fractures on X-ray examination and treated them conservatively.
+Six months later, our patient presented with limping and edema of her left thigh. Radiographic evaluation resulted in the diagnosis of a Fielding type III subtrochanteric femur fracture with excessive callus formation; this was treated non-surgically, with bed rest []. Two weeks later, she again presented to our hospital, this time for right hip deformity and pathologic displacement after falling in the bathroom. Radiographs indicated a Fielding type I right subtrochanteric femur fracture without callus. We considered this a fresh fracture and performed intramedullary nailing under general anesthesia (Figure A). We observed a dropped foot at follow-up two months later due to excessive callus formation, which had entrapped the sciatic nerve. We resected the hypertrophic callus and freed the sciatic nerve.
+Our patient did not attend any follow-up appointments over the next eighteen months, but then presented to our hospital with similar symptoms, including a swollen thigh and limping. The neurologic deficit in her right foot had resolved. We detected a right femoral neck fracture; intramedullary nailing had previously been performed for a subtrochanteric fracture of the same femur (Figure B). We performed cementless total hip arthroplasty after removal of the nail under general anesthesia (Figure C). As was true for previous operations, she required no analgesia postoperatively. There were no anesthetic or infectious complications. We allowed mobilization with crutches two days after surgery. At her most recent follow-up, six months after the surgery, her active hip flexion was 100簞, abduction 40簞, and external and internal rotation 20簞 without any instability, and she could walk with full weight bearing.
+We made a thorough evaluation and established a definitive diagnosis of CIP on the basis of the characteristic findings of multiple perioral mucosal ulcers, shortening of her nails and acro-osteolysis, a prematurely aged facial appearance, an undersized skeletal structure and Charcot arthropathy of her right ankle. We also detected anosmia, insensitivity to temperature differences and mild intellectual disability (according to Cattell Culture Fair Intelligence Test and The Kent Inventory of Developmental Skills). She had no evidence of muscular weakness or sweating disorders. In an intradermal histamine test (histamine phosphate 0.05mg/mL or 1:1,000 dilution), the axon reflex response, pain, wheal and flare were all absent. Dermal biopsy specimens showed no pathologic changes. On neurologic examination, her cerebellar function, proprioception and muscle strength were normal, however both deep and superficial sensation was absent."
+Edison Ho,41,1990/10/21,754.895.0196,evelyn22@example.com,949 Michael Pines,"We report the case of a 48-year-old Sri Lankan man who was admitted to our facility with an intermittent fever associated with joint pains and a skin rash for three months. He had an inflammatory type symmetrical arthralgia confined to large joints with early morning stiffness for 30 minutes. Skin rash, which was non-itchy, non-scaly and non-photosensitive, appeared initially on the trunk but became generalized within a period of two weeks. He was overwhelmed with marked malaise, severe anorexia, weight loss of 19 kg over three months with significant hair loss and multiple painful oral ulcers. He had a watery diarrhea of three to four bowel movements a day of one month duration associated with occasional episodes of vomiting and a vague abdominal pain. His past medical history was unremarkable except for two uncomplicated episodes of malaria about twenty years previously. He denied either exposure to high risk sexual activities or intravenous drug use. He did not consume alcohol and was a non-smoker.
+On examination, the patient was ill looking, febrile (temperature of 38.4簞C), dyspneic and moderately pale. Jaundice, finger clubbing, cyanosis and lymphadenopathy were absent. He had a generalized erythematous maculopapular skin rash involving the palms and soles (Figure ), a non-scaring alopecia and multiple shallow ulcers in the oral mucosa. On admission, his pulse rate was 100/minute, his blood pressure was 100/70 mmHg and his respiratory rate was 46/minute. Breath sounds were reduced in the base of the right lung with occasional rhonchi heard over both lung fields. He had a tender, firm hepatomegaly of 14cm span with a smooth surface and a regular edge. There was no splenomegaly, abdominal masses or ascites. His rectal examination was unremarkable but several non-painful ulcers were present in his scrotum. Optic fundus showed cotton wool spots around the disc; otherwise his neurological examination was normal. Deformities or edema of the small or large joints were absent but joint line tenderness was demonstrable in his wrist, elbow, shoulder, knee, and ankle joints bilaterally. However, his spinal movements were preserved and movements of the pelvic and shoulder girdles were painful at full range.
+Laboratory tests revealed normochromic normocytic anemia (hemoglobin: 8.7g/dL, mean cell volume: 86.5fL) with a total leucocytes of 5.4 x 109/L (neutrophils: 75%, lymphocytes: 19%), and a platelet count of 64 x 109/L. Inflammatory markers were elevated (erythrocyte sedimentation rate: 140mm; C-reactive protein: 60mg/dL) and he had an extremely high serum ferritin level of 34,674ng/ml. Arterial blood gas analysis revealed moderate hypoxia (PaO2: 78.7mmHg). Chest X-ray did not show evidence of consolidation or cavitations but his right hemidiaphragm was elevated. His liver functions were abnormal (aspartate aminotransferase: 252IU/L [<35IU/L], alanine aminotransferase: 69IU/L [<35IU/L], alkaline phosphatase: 1857IU/L [<300IU/L], gamma glutamyl-transferase: 2089IU/L [<54IU/L]) with a reversed albumin/globulin ratio (albumin: 1.9g/dL, globulin: 4.6g/dL). Serum billirubin (11.9弮mol/L) was not elevated and serum creatinine (1mg/dL) was normal. Abdominal sonography revealed uniformly increased echogenicity of the enlarged liver but evidence of billiary obstruction or focal lesions was absent. A battery of serological investigations including enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV), a hepatitis panel, blood testing for malaria parasites, rickettsial antibody, sputum for acid fast bacilli acid-fast bacillus acid-fast bacillus (AFB) and tuberculin skin test were all negative. Repeated blood cultures did not yield any bacterial growth and a venereal disease research laboratory screen for syphilis (VDRL) was non-reactive. His rheumatoid factor was 128IU/mL(<8IU/mL) but autoantibody screen including anti-nuclear factor, U1 ribonucleoprotein (RNP) complex, anti-smooth muscle antibody (ASMA), antimitochondrial antibody (AMA) and anti-neutrophil cytoplasmic antibodies (ANCA) were negative. Biopsy of the skin rash was inconclusive (Figure ). Bone marrow examination revealed evolving marrow hypoplasia although evidence of marrow infiltration by metastatic deposits or granulomata was absent. Polymerase chain reaction (PCR) for Mycobacterium tuberculosis in bone marrow aspirates was negative. His clotting profile was mildly abnormal with a prothrombin time of 15 seconds (INR: 1.3) and a partial thromboplastin time of 58 seconds (control 35 to 42 seconds).
+His dyspnea and tachypnea, attributable to bronchospasm associated with systemic inflammatory reaction (SIRS) was probably worsened by high fever, marked myalgia, right hypochondrial tenderness with enlarged liver and anemia. Considering the possibility of sepsis, broad spectrum antibiotic treatment with intravenous meropenem 1g daily and metronidazole 500mg every eight hourly was instituted from the day of admission. His symptomatology and respiratory distress was only slightly improved with bed rest in a propped up position, antipyretics, salbutamol nebulization, analgesics and blood transfusions to correct the anemia. He underwent liver biopsy on day two of admission after the correction of clotting abnormalities.
+A presumptive diagnosis of AOSD with granulomatous liver disease was made based on the clinical criteria of Yamaguchi (Table ) and extremely high serum ferritin levels [,]. He was started initially on indomethacin 25 mg every eight hourly followed by intravenous methylprednisolone 1g daily pulses for three days under broad spectrum antibiotic cover. These measures failed to improve his clinical picture. He died on the sixth day after admission due to sepsis and multi-organ dysfunction. The liver biopsy revealed noncaseating granulomas in the background of fatty liver, later found to be culture positive for M. tuberculosis (Figure )."
+Calliope Blair,31,1980/9/21,789-849-8540x31224,victoria17@example.net,82288 Schmidt Knoll,"A 34-year-old Caucasian man was referred to our hospital with complaints of abdominal pain in the right upper quadrant and pain in his right shoulder. The pain was not associated with nausea or vomiting, and there was no history of fever or jaundice.
+His medical history included an open ductus venosus and an Abernethy malformation complicated by the development of pulmonary arterial hypertension (mean pulmonary artery pressure 48mmHg), which had been diagnosed three years before and treated successfully with the endothelin receptor antagonist bosentan. At the time of presentation, he was in New York Heart Association functional class I. Physical examination displayed no signs of icterus, and cardiac examination revealed a hyperkinetic cardiac impulse outside the midclavicular line and a loud second heart sound. He had a soft abdomen without organomegaly. His laboratory test showed a hemoglobin level of 9.2mmol/L, an elevated liver enzyme profile with aspartate aminotransferase 46U/L, alanine aminotransferase 50U/L and bilirubin 32弮mol/L. 帢-Fetoprotein (AFP) concentration was normal (3弮g/L) as was hepatic synthetic function.
+Computed tomography (CT) displayed the presence of a tumor, and magnetic resonance imaging (MRI) was performed for characterization of the lesion. The lesion was hypointense on T1-weighted images and hyperintense on T2-weighted images in the venous phase, and arterial enhancement and washout were demonstrated, as is typical for a HCC (Figure ). The presence of a shunt of 2 cm between the left extrahepatic portal vein and the inferior vena cava was confirmed (Figures and ). Preoperatively, workup included several tests, such as lung capacity (lung function test), cardiac function (electrocardiogram) and hepatic synthetic function (laboratory tests). If the results of these tests were normal, the patient would be eligible for surgery. In the preoperative workup, no biopsy of the tumor neither a biopsy of the normal liver parenchyma was found necessary. Because of his pulmonary hypertension, he was categorized as an American Society of Anesthesiologists (ASA) class 3 patient. There were no other contraindications for surgery, and the patient underwent a successful right hemihepatectomy and surgical discontinuation of the portocaval shunt. Postoperatively, his pulmonary hypertension increased, and he needed oxygen for five days, after which his condition recovered. Furthermore, a small biloma was diagnosed, which was treated by percutaneous drainage.
+Histological examination of the resected specimen revealed features of grade II fibrosis []. A tumor with a diameter of 16cm was characterized as HCC with the presence of microvascular invasion. A tumor-free surgical resection of 5mm was recorded.
+The follow-up of the patient consisted of a routine serum tumor marker AFP determination and contrast-enhanced CT or MRI at six months intervals starting three to six months after surgery. After nearly two years of follow-up, the patient is doing well and is free of HCC recurrence. His cardiac output is normalized, and his pulmonary hypertension is stable."
+Troy O’Connor,30,1996/6/16,420-914-4987,wesleylynch@example.com,25924 Anne Loaf,"A 54-year-old Caucasian man presented to our facility with a left breast gynecomastia-like nodule. Clinically it was mobile, non-tender and not fixed to the skin or underlying muscles. The results of renal and liver function tests were normal.
+Ultrasonography showed a hypoechoic mass with irregular margins, measuring 4.0 ? 3.0cm in size. Doppler ultrasound did not show any significant vascularization.
+Since a breast carcinoma was suspected, a tru-cut biopsy was performed. From the biopsy results a diagnosis of FL was formulated. The fluorescence in situ hybridization (FISH) demonstration of t(14,18) suggested systemic disease. Two weeks later, the nodule was totally removed, as well as the axillary lymph nodes. The histomorphological features confirmed a diagnosis of lymphoma.
+Staging procedures showed positron emission tomography (PET)-positive mediastinal and abdominal lymphoadenomegaly and splenomegaly. A bone-marrow trephine did not show lymphoma infiltration.
+Six cycles of R-CHOP (rituximab-cyclophosphamide, hydroxydaunorubicin, Oncovin (vincristine), prednisone/prednisolone) chemotherapy for systemic lymphoma were administered.
+Two years later, a new nodule in the right breast was observed. The morphology and immunohistochemistry results of a new biopsy were superimposable to the previous samples. After another six cycles of R-CHOP chemotherapy our patient developed acute myeloid leukemia, from which he died some months later.
+All tumor samples from our patient were stained with EE (Ematossilin/Eosin) and then immunohistochemical studies were performed.
+The tru-cut biopsy showed proliferation of atypical lymphoid cells with a nodular pattern of growth, with small lymphoid cells (centrocyte type) and centroblast-like cells.
+The surgical specimen was represented by a wide excision of the central quadrant extending to the subareolar spaces. Macroscopically the tumor was poorly circumscribed with irregular margins, measuring 4.0 ? 3.0cm, with a solid, fleshy cut surface. Histologically the neoplastic proliferation showed similar features to the previous biopsy in in the adipose tissue.
+On immunohistochemical analysis the atypical cells were positive for CD20, B cell lymphoma 2 (Bcl2), CD10 and Bcl6 and negative for CD5, CD43 and melanoma associated antigen (mutated) 1 (MUM1) protein; the proliferative index evaluated by Ki67 immunostaining was higher than 50%.
+In the interfollicular areas there were sheets of CD20+/CD10+ atypical lymphoid cells. Centroblasts numbered more than 15. A final diagnosis of grade 3 FL was made (Figure ).
+Histology results of the right breast relapse sample showed similar features to previous breast samples.
+FISH analysis for the t(14;18)(q32;q21) translocation was performed on the tru-cut biopsy of the primary breast nodule using the Vysis LSI IGHSpectrumGreen/LSI BCL2 SpectrumOrange probe set (Vysis, Downers Grove, IL, USA). This probe set uses the dual-color, dual-fusion strategy and consists of a mixture of locus-specific fluorophore-labeled DNA probes containing sequences homologous to the IgH and Bcl2 genes.
+FISH analysis again showed the presence of t(14;18) translocation on the surgical sample from the left breast and the biopsy of the right relapse (Figure ).
+Then, after DNA extraction from a paraffin embedded sample, we performed multiplex polymerase chain reaction (PCR) for the identification of the rearrangement of heavy chain (IgH) CDR1-CDR3.
+DNA purified from the paraffin sample was of good quality as shown by the presence of discrete bands for both FR1, FR2 and FR3 rearrangements, indicative of a B monoclonal pattern (Figure )."
+Charli Bruce,34,1996/3/28,566.954.4430x2200,kimberlymiller@example.com,67531 Wolf Plaza,"A 30-year-old Indian man was brought to our Emergency Room after a road traffic accident, in which he was riding a motorcycle and was hit by a truck at a speed of approximately 50 miles per hour. Our patient complained of pain in his right arm and the inability to move it. An examination of his extremities revealed contusions over his right upper arm without any evidence of penetrating injury. There was marked swelling and tenderness in the middle part of his right arm associated with a closed injury. His cranial nerves were intact and no neurological deficits were present. No injures were found in his other limbs. In view of the above clinical findings, a radiograph of his right upper limb and a computed tomography (CT) scan of his head were suggested. While the CT scan did not reveal any abnormality, the radiograph of his right arm showed a unilateral displaced comminuted fracture of the mid shaft of his humerus (Figure ). Our patient was then given first aid in the form of a U-slab and immediately transferred to our orthopedic ward for further evaluation. His laboratory results were normal. Liver and kidney function test values were within their normal range. An electrocardiogram did not show any abnormal features.
+Our patient complained of tingling and numbness in his right little and ring fingers the following morning. On examination, there was hyperextension at the metacarpophalangeal joints and flexion at the proximal and distal interphalangeal joints with an inability to move his little and ring finger (Figure ). With the suspicion of an ulnar nerve injury due to the accident, a series of nerve conduction studies of his right upper arm nerves were suggested. The electrodiagnostic evaluation demonstrated a severe ulnar nerve conduction block along his arm with normal amplitudes of conduction along the median and the radial nerves.
+Correlating the clinical findings with the above radiological and nerve conduction findings, a diagnosis of ulnar nerve injury after the fracture of the shaft of the humerus was made. Our patient was taken to the Operating Room for surgery, during which a fragment of bone was found abutting the ulnar nerve after penetrating the triceps muscle (Figure A,B). This fragment of bone was replaced and the fracture was reduced by open reduction and internal fixation using a dynamic compression plate and screws.
+Postoperatively, the tingling and numbness of the little and ring finger gradually subsided and our patient received regular physiotherapy and was discharged two weeks after surgery. Our patient was advised to come regularly for follow-up every three months for a period of one year. Our patient first came for a follow-up appointment four months after discharge and told the attending surgeon about the recovery of the normal functioning of his right hand 14 weeks after surgery; confirming it to have been ulnar neuropraxia."
+Uriah Quintana,23,1993/3/12,001-534-855-1924,sean24@example.net,1946 Traci Village,"A 14 year old female complained of diffuse abdominal pain and distention with vomiting. These problems started suddenly three days before referring to our clinic, without any history of disease. The abdominal pain was not associated with meals. Nausea and vomiting were present too. She was referred to our clinic for further evaluation and was admitted at the Gastroenterology Ward. Past medical history was unremarkable. The family history showed that the parents were non-consanguineous and the mother had epilepsy. At physical examination, she had a puffy face and enlargement of the thyroid gland palpable in the neck. Vital signs were normal. Lungs were clear and heart sounds were normal too. The abdomen was distended with shifting dullness (due to ascites) without organomegalies. Extremities were normal without edema or deformities. Her pubertal development was appropriated for age; however (Stage II Public and III Tanner) bone age was 10 years, more retarded than the chronological age.
+Laboratory routine data including FSH and LH were within normal limits. Tumor markers tests showed strong elevation of serum CA-125 levels (105.4 u/ml) but CEA was normal. Thyroid function tests revealed very marked elevation of TSH -more than 100 mu/L, T4 and T3 depicted very low levels, 0.5 mu/L (with lower limit normal 8) for T3 and 25 mu/L (with lower limit normal 100) for T4 respectively.
+Abdomino-pelvic ultrasound and CT scan showed a cystic mass with a diameter of 40?45 mm located at the left lower quadrant (LLQ) which originated from the left ovary. The uterus was pubertal size (55?21 mm) with normal endometrial echo. Moderate free fluid was present in the peritoneal cavity. Liver, gallbladder, spleen, pancreas and kidneys were normal in structure and echo.
+Because of elevation of serum CA-125 levels, ovarian malignancy was included in differential diag-noses, but as Van Wyk and Grumbach syndrome was the main diagnosis, thyroxin (levothyroxin) replacement was started at a dose of 50 繕g per day and gradually increased weekly up to 150 繕g per day. After 4 weeks of treatment, the ovarian cyst was smaller and the ascites disappeared. In the laboratory examination not only TSH, T4 and T3 reached the normal range, but also CA-125 normalized too. The follow-up ultrasound after 5 months of initiation of therapy revealed complete regression of the ovarian cyst and the patient was well without any complications."
+Kenia Hester,27,1991/1/16,001-534-705-1809x28958,jamestorres@example.net,677 Renee Village,"A 22-year-old female presented to our centre with ten-day high fever of unknown origin. She was well and healthy until 6 months ago when she developed generalized arthralgia without obvious arthritis. She was seen by a local doctor and treated for symptomatic management. Her past medical history reveals a total mastoidectomy secondary to chronic otitis. Nonpurulent otorrhea already existed after surgery.
+On physical examination, she had generalized weakness, arthralgia, nonpurulent otorrhea, partial deafness of left ear, and tenderness at the costovertebral angles. The oral temperature was 39簞C. The rest of her physical exam was normal. The blood tests revealed anemia (Hb: 8.2 gr/L), elevated white cell count (WBC: 23700/mm3), elevated sedimentation rate (ESR: 136), and CRP. The urinalysis showed microscopic hematuria and proteinuria. The renal functions tests, serum electrolytes, and coagulation tests were in normal ranges for her age. The ultrasound study of her abdomen and pelvis showed a 6 cm heterogenic mass in the upper and lower pole of the left kidney. The patient underwent abdominopelvic spiral CT scanning with IV contrast which revealed a hypodense mass at the left kidney suggesting of a renal abscess, tumors or less likely infiltrative lesions like lymphomas ().
+The initial diagnosis was a renal abscess considering persistent fever and flank pain for 48 hours despite broad spectrum antibiotic therapy. Percutaneous ultrasound guided drainage of the presumed renal abscess was done, however, the aspirated fluid was clear without any pus or debris. She then underwent a core needle biopsy. The patient tolerated the procedure well and there was no immediate complication. Rheumatologic screening tests were also sent off. The ANCA test was positive and pathologic study of the tissue sample with H&E, Masson, and Jones revealed sclerosis, granulomatosis inflammation, multinucleated giant cells, vasculitis, and severe fibrinoid necrosis without any malignant cell suggestive of Wagener's granulomatosis (Figures , , and ). Unfortunately, a day after the biopsy, the patient died due to massive hemoptysis, and cardiopulmonary arrest."
+Rene Person,45,2004/3/16,794.331.4257,ramireznicholas@example.net,47880 Cordova Pike,"A 53-year-old woman was taken to the emergency room after an accidental fall. At the moment of the fall, the patient was holding a glass bottle that shattered with the impact. A sharp piece of glass caused a deep wound with a length of about 3 centimetres on the right cheeks. The patient showed no signs of facial nerve injury. The wound was then toileted and sutured. After 10 days from trauma the patient began to complain of the appearance of a continuous colourless and odourless fluid from the wound, which increased after food intake. Therefore the patient came under our observation on 20th day from trauma. A clinical examination revealed on the wound scar a 3 mm orifice discharging a clear serous secretion, suggesting the diagnose of posttraumatic parotid fistula. The patients were invited to limit oral intake for a week in order to reduce salivary output; steristrips were placed to close the fistula and a compressive dressing was applied for 7 days, with no results. Due to severe discomfort caused by a large amount of secretion, a device for transdermal delivery of scopolamine (Transcop Recordati OTC S.p.A. Milan, Italy) was applied on the right preauricular region (). This device is a patch of circular form containing a reservoir of 1.5 mg of drug scopolamine, which is released into the bloodstream. The daily release of scopolamine is about 0.5 mg with a duration of a pharmacological three days for each patch. In the following 3 days, the patient reported significant reduction in salivary discharge from the fistula. The patches were replaced and the successive examination after 3 days revealed that the fistula was completely healed. The treatment was well tolerated and the patient referred only to a mild dryness of the mouth in the last 2 days of treatment. No recurrence was observed during a 3-month followup."
+Dylan Duncan,36,1983/5/7,813.701.8404x23042,benjamin68@example.com,4888 Amy Circle Apt. 106,"A 57-year-old, otherwise healthy, female patient was admitted in the emergency room department complaining of midepigastric pain over the past twenty-four hours. The onset of pain was relatively gradual, two hours after a heavy meal. Nausea was present from the outset and two episodes of bile stained vomiting offered a temporal relief from the pain. The consistency of the pain as well as an increased body temperature (up to 37,8 degrees celsius) compelled the patient to seek medical assistance.
+On arrival, the patient had a body temperature of 37,5 degrees celsius, blood pressure of 120/75 mm Hg, pulse rate of 105/min, and respiratory rate of 17 breaths/min. On physical examination, the abdomen was relatively soft with however, notable tenderness elicited during the deep palpation of the midepigastrium. Signs of parietal peritoneum irritation such as rebound tenderness as well as pain during abdominal percussion were not observed. The patient had a blood gas ph. of 7.35, C-reactive protein levels of 11 mg/l while white blood cell (WBC) count were 14000/mm3. Serum amylase levels were elevated up to 500 U/dL, while liver enzyme serum levels were within normal range.
+The patient was submitted to an abdominal ultrasound that ruled out cholelithiasis as well as any gross pathology emanating from the extrahepatic bile ducts. With a suspected diagnosis of pancreatitis, despite the absence of obvious predisposing factors, the patient was admitted to the department's clinic for observational and supportive management. However, as the patient's condition did not ameliorate after two days of conservative treatment a computed tomography scan (CT) of the abdomen was decided. Surprisingly, a radiopaque foreign body in the pancreatic head, which the patient was not aware of ingesting, in continuity with the duodenum as well as the presence of air bubbles in the area of question suggestive of a probable intestinal perforation was revealed. See Figures and .
+An emergency operation was decided and a laparotomy via a midline vertical supraumbilical incision was undertaken. At laparotomy, peritoneal cavity appeared clear without evidences of gross contamination. After the mobilization of the right colonic flexure, the duodenum was clearly visualized. Then, a Kocher manoeuvre was performed to ensure the adequacy of duodenal inspection. An induration at the second portion of the duodenum and the adjacent area of the pancreatic head was observed during palpation without, however, any identifiable perforation. An oblique?n relation to the luminal axis of the duodenum?uodenotomy was performed and a sharp thin foreign body consistent with fish bone was subsequently identified. The bone was pinned at the medial-posterior wall of the 2nd portion of the duodenum just adjacent to the ampulla of Vater with an orientation towards pancreatic head. After the successful removal of the fish bone with gentle traction the duodenotomy was then closed in two layers with interrupted 3-0 absorbable suture material.
+The patient had an uneventful postoperative period and was discharged from the hospital on the 7th postoperative day. A scheduled followup at the outpatient clinic of our department thirty (30) days after the procedure confirmed the absence of any postoperative complication."
+Avery Dalton,20,1995/6/1,9537943968,ipalmer@example.net,91618 Collier Trail,"A 1-year-old boy presented with a mass localized to the right inferior aspect of genitalia in the perineal region, another small swelling was attached to the undersurface of the mass (). Both mass and swelling were present since birth. The mother's health throughout pregnancy had been uneventful, and there had been no recognized exposures to any teratogenic agents.
+The penis and the primary scrotum were completely normal, were contained testes within the scrotum. The mass just below the scrotum was soft in consistency and freely mobile. The swelling attached below the mass was soft, rugose, and contained no discernable testis-like structures. There was no other urological anomaly.
+The mass and swelling were surgically removed, and postoperative recovery was uneventful. The histological examination revealed the mass as being lipoma, and the other swelling had rugose epidermis with hair follicles and rudimentary dartos fibers, so histopathological examination confirmed the diagnosis of accessory scrotum ()."
+Lilian Warner,28,2002/8/24,(953)333-5850x396,sullivanerin@example.com,666 Kemp Stravenue,"A 24-year-old lady presented to our hospital one month after a Caesarean operation at another institute. This was her second Caesarean operation and was done as an emergency. Two days later the patient developed a pain in abdomen and fever; she was discharged on the eighth day. The symptoms exacerbated along with distension of abdomen, for which she consulted a private hospital and received cefotaxime and metronidazole. She was also referred back to the hospital where she was operated upon and she was treated symptomatically. However her condition worsened and she was referred to our hospital. She complained of fever, pain in abdomen, and vomiting. She also complained of loose stools and mucus discharge per rectum. On examination she was febrile and had tachycardia. Her abdomen was tender and lower abdomen had a vague tender mass.
+Her lab reports revealed neutrophilia and anaemia. A plain radiograph of abdomen was essentially normal. US of abdomen revealed a bulky subinvoluted uterus with a large collection within (pyometra), hypoperistaltic bowel loops, and mild hydroureteronephrosis on the right. However, the sonological impression of pyometra was not being correlated by gynaecological evaluation and hence a contrast-enhanced CT scan of abdomen was done (). It revealed a mesh-like structure in the lower abdomen with air trapped within. An oral dye was administered during the procedure which revealed a leak in the small bowel. A diagnosis of gossypiboma with bowel perforation was made. After due preparation, the patient was posted for an exploratory laparotomy.
+Abdomen was accessed through a midline vertical incision. On exploration a retained surgical sponge was found along with one litre of pus lying in a walled off cavity in the lower abdomen. The retained surgical sponge was removed (). The pus was sucked out. A pus sample was sent for culture and antibiotic sensitivity which was later reported to have grown Escherichia coli. There were multiple dense adhesions of the small bowel. On careful separation of the adhesions two ileal perforations were seen (). These perforations were half a centimetre in size and 40 cm apart. The intervening bowel was edematous. A resection of the perforation bearing bowel was done followed by anastomosis. The resected specimen was sent for histopathology which later revealed features of acute inflammation, and no granulomas were seen.
+The patient did well after the surgery. There was infection of the lower part of the abdominal wound, which was left open and a dressing was done regularly. A secondary suturing was done two weeks after the surgery and the patient was discharged.
+The hospital where the original surgery was done was informed to facilitate initiation of preventive steps. An inquiry into the details of the previous surgery revealed that the operation was done as an emergency and that it was difficult because of bowel adhesions due to previous Caesarean operation. The closure of abdomen was done by junior residents. A proper procedure for surgical counts was also found to be lacking."
+Jaxton Johns,19,1988/8/24,+1-865-235-1941x7761,jamesedwards@example.com,90579 Brian Hollow,"A 48-year-old woman with a poorly controlled diabetes mellitus for 12 years, presented with acute severe right knee pain and fever for 7 days. Three weeks before the onset, she fell on the ground accidentally and developed right knee pain. However, she was able to walk after the event and there was no open wound nor knee swelling. A physician provided a short slab for right knee immobilization, but her knee pain was progressive and she was unable to mobilize or leave her bed for one week before admission. She also complained of perianal pain during this illness. At Siriraj Hospital, body temperature was 38.2簞C, pulse rate 102/minute, blood pressure and respiratory rate were normal. Her right knee was swollen, fluctuated on the lateral sides with diameter about 7 ? 15 centimeters (cm), and marked tenderness and warmth. Anal examination found a draining abscess on the left side of perianal area, sized about 3 ? 4 cm. Others were unremarkable. An aspiration of the right knee revealed frank pus. Plain radiography of the right knee was unremarkable. Blood sugar was 413 mg/dL, complete blood count showed hemoglobin of 7.5 g/dL, hematocrit 23.6%, white blood cell count of 23,180 cell/mm3 (neutrophil 88.2%, lymphocyte 4.3%, monocyte 4.4%), platelets count of 547,000 cell/mm3, ESR 102 mm/hr, and CRP 330 mg/L. Serum BUN and creatinine were within normal limits. She was admitted to the hospital and ceftriaxone 2 g/day with clindamycin 1,800 mg/day were empirically commenced. The surgeon performed incision and drainage (I&D) of the right knee abscess and perianal abscess on the first day of hospitalization. Operative findings showed 300 mL of subcutaneous pus around the right knee without connection to the joint cavity, and 20 mL of pus drained from perianal and intersphincteric abscesses. Gram stain of both specimens of pus showed moderate gram-negative diplococci as shown in and culture on chocolate agar grew Neisseria gonorrhoeae with positive beta lactamase testing. The organism was susceptible to ceftriaxone, ciprofloxacin, and tetracycline, but resistant to penicillin by disc diffusion method. Strain and serotype identification of Neisseria spp. were not tested in the hospital. Gram stain of pus from perianal abscess showed polymicrobial micro-organisms with gram-negative diplococci, gram-positive cocci in pairs, and rare gram-positive rods. The pus culture grew mixed microorganisms without N. gonorrhoeae. All blood cultures were negative. Disseminated gonococcal infection with polymicrobial perianal and intersphincteric abscesses were diagnosed. This patient denied previously multipartners sexual activity, receptive anal intercourse, and prior sexually transmitted diseases. She has been in menopausal period for two years and has been living with her healthy husband. Her last sexual intercourse was 2 months before admission. Atrophic vaginal mucosa and minimal mucus cervical discharge were identified from per vaginal examination and no microorganisms grew from cervical swab cultures. Nucleic acid amplification test (NAAT) of the vaginal discharge was negative for N. gonorrhoeae and Chlamydia trachomatis. The NAAT of rectal specimens was not approved to detect N. gonorrhoeae and C. trachomatis coinfection by our regulatory unit. The Anti-HIV antibody test and VDRL were also nonreactive. Serum C3 and C4 complements levels were 70.5 mg/dL (normal range; 87??77) and 23.8 mg/dL (normal range; 7??0), respectively. The initial antibiotics were continued and doxycycline 200 mg/day was added for 7 days for potential chlamydial coinfection. Insulin injection was used for control hyperglycemia. The anal abscesses resolved, however, fever was temporarily subsided. Besides there was persistent pus drainage from the incised wound of right knee and progressive swelling extended downward to calf area (). Ultrasonography of the right leg was done and discovered large multiloculated peri- and intramuscular abscesses of the right calf as shown in Figures and . Repeated surgical debridements were performed on day 8 and day 16 of hospitalization, there was foul-smell pus draining from muscles of posterior part of right lower thigh and right calf. Pus culture grew moderate amount of Escherichia coli, then intravenous meropenem was then substituted for treatment of complicated pyomyositis. Fever, swollen right leg, and pus drainage were resolved, then the wound was resutured. Meropenem was discontinued after 14 days of therapy. The patient was discharged from the hospital on day 34 of hospitalization. Two weeks later, the patient's condition almost returned to normal and anemia was improving from iron supplementation. Her husband was not available for investigation of gonococcal infection because he had been working in another province."
+Giovanna Bean,35,1985/7/28,907.231.9392x737,rodriguezdaniel@example.net,979 Dillon Parks,"A 58-year-old male patient was admitted with an acute attack of cholangitis due to HJ stricture. Three years earlier, he had undergone a pylorus preserving pancreaticoduodenectomy for a pancreatic mass. The diagnosis of the pancreatic mass was lymphoepithelial cyst.
+At admission, blood chemistry tests showed slightly increased liver enzymes. The ultrasound examination revealed mild dilatation of the intrahepatic biliary ducts, which did not allow a percutaneous transhepatic cholangiographic intervention for balloon dilatation of the structured segment or biliary stenting. The magnetic resonance cholangiopancreatography (MRCP) detected stricture at the HJ anastomosis and a gallstone in the common hepatic duct just above the bilioenteric anastomosis (). The patient underwent an endoscopic retrograde cholangiography using double-balloon enteroscope, which was unsuccessful due to the sharp angle between the jejunal limb and the biliary tree. Thus, it was decided to perform surgery. During exploration, the HJ anastomosis was found to be narrowed and covered with a scattered fibrotic tissue, with an outer diameter of less than 7 mm and 2 to 3 mm length. In addition, a stone was palpated in the common hepatic duct just above the HJ anastomosis. The length of the remnant common hepatic duct from the hilar region to the HJ anastomosis was approximately 1.5 cm. We decided to perform a Heineke-Mikulicz strictureplasty. A vertical incision of 2 cm was made to the anastomotic line. After the stone was extracted, the incision was resutured in a transverse fashion with simple suture technique using absorbable 4/0 polyglactin interrupted sutures, 2-3 mm apart. The strictureplasty provided an anastomotic patency of more than 1.5 cm (). The patient's postoperative course was uneventful, and he was discharged on the fourteenth postoperative day after the duration of the antibiotic treatment for cholangitis was completed. At the end of followup, for 18 months, patient's liver enzymes and bilirubin levels were within normal ranges, and the ultrasound examination showed a patent HJ anastomosis."
+Mccoy Francis,25,2004/10/7,469-264-4200,wilsontim@example.com,2049 William Port Suite 954,"A 57-year-old man, suffering from ALS since 2009 with concomitant marked lumbar lordosis and quadriplegia, was admitted for marked disease progression, respiratory distress, and complete dysphagia (for both liquids and solids).
+Tracheostomy was initially performed and the patient was placed on mechanical ventilation. Given the significant malnutrition, percutaneous endoscopic gastrostomy was attempted but failed due to technical reasons. Then a surgical jejunostomy with Witzel technique was performed.
+The post operative course was complicated by vomiting and gastric distension treated with nasogastric tube placement that drained approximately 700??500 mL of biliary secretions per day.
+Upper oral contrast series were then performed showing some contrast stagnation at the level of the third part of duodenum (). The patient did not have any pain or abdominal signs. Biochemical markers were in the normal range. The jejunostomy was functional.
+A prokinetic medical treatment with prostigmin and erythromycin was then started resulting in intermittent occlusion. We then decided to perform a CT scan in order to achieve better visualisation of the duodenal stop. It showed third part of duodenum completely clamped between the aorta and superior mesenteric artery, with a marked narrowing of the aortomesenteric angle to 8.7 degrees measuring 7 mm (Figures and ). These findings pointed towards diagnosis of SMAS and a conservative treatment was established with total enteral nutrition to 80 mL/h done in left lateral position. The nasogastric tube was withdrawn three days later and the patient was discharged from the hospital one week after with no occlusive symptoms. At followup of three weeks, he reported weight gain and could stand in supine position without presenting any abdominal symptoms."
+Daniella Huff,29,2001/1/3,-9682,tonya86@example.org,48544 Cuevas Shores Suite 951,"A 10-year-old boy was admitted to The Children's Hospital of Alabama for medically intractable epilepsy as part of a presurgical evaluation for epilepsy surgery. His medical history was significant for herpes meningitis at age 4 months. At that time, he presented with fever for 3 days, with acyclovir treatment beginning on day 4 of his 40-day hospital course. There was no known family history of immunodeficiency, predisposition to viral infections, or epilepsy. While his developmental status had been normal at birth, he later experienced profound developmental delay beginning at about 6 months of age. He could walk but preferred to crawl, and his attention was poor. He had no language but was able to verbalize his needs in a manner interpretable by his mother. He lived at home and attended special education classes. He subsequently developed infantile spasms and ultimately a mixed seizure disorder characterized by absent, blank stares one to three times daily, sudden drop attacks about twice per month, and tonic/clonic seizures once or twice weekly. Recent video electroencephalogram showed a Lennox-Gastaut-type pattern with focal features of frequent runs of right frontotemporal spikes. His captured clinical seizure semiology demonstrated 2 types of seizures: dialeptic seizures and left arm fencing. Clinically, his seizure types also included frequent drop attacks with multiple episodes of status epilepticus. He had experienced several breakthroughs despite several drug changes and a current regimen of six antiepileptic medications. His regimen included levetiracetam 750 mg twice daily, lacosamide 200 mg twice daily, topiramate 100 mg twice daily, zonisamide 300 mg at bedtime, lorazepam 1 mg as needed, and rectal diazepam 12.5 mg as needed. In addition, a ketogenic diet had been tried without appreciable benefit. His MRI scan displayed an abnormality in the anterior portion of the right insula and right frontal operculum (). The cortex in this area was abnormally thin with increased T2 signal and a ribbon of low T2 signal around the periphery. There was some deficiency of subfrontal white matter in this region, but the abnormal area was fairly sharply demarcated. FLAIR images demonstrated some increased signal in the adjacent white matter. There was no evidence of hemorrhage or infarct. Based on these findings, the patient underwent a right frontal craniotomy for a partial frontal lobectomy. Recovery was complicated by a cerebrospinal fluid (CSF) leak requiring reoperation 1.5 weeks postsurgery. Upon reexploring the craniotomy, the previously normal-appearing dura had large, spontaneous fenestrations remote from the suture line. Postoperative herpes viral cultures and CSF herpes polymerase chain reaction (PCR) studies were negative. CSF and serum herpes antibody studies were not performed. Because of the postsurgical neuropathological findings, the patient also underwent a full, 21-day course of intravenous acyclovir therapy. This consisted of a 21-day course of intravenous acyclovir that began at 20 mg/kg but was reduced to 10 mg/kg after the surgical procedure to repair the CSF leak. This was followed by a return to neurological baseline and the patient was rendered seizure-free for approximately one month. However, this was followed by a return of seizure activity, up to several per day, in spite of the administration of multiple seizure medications. Immunological workup demonstrated a normal distribution and numbers of T, B, and NK lymphocytes, and normal functional studies for T-cell subsets and NK cells. Toll-like receptor (TLR) functional testing was normal for TLR-1?LR-8, including TLR-3, abnormalities of which have been associated with HSV-1 susceptibility. He is now one year postsurgery with no change in his preoperative electroencephalogram. He is being considered for placement of a vagus nerve stimulator."
+Finnley Larsen,21,1993/3/4,-3098,kristinagarcia@example.net,254 Bethany Plaza,"A 60-year-old woman, previously in good health and without a personal or family history of autoimmune disorders, presented to the Emergency Services with a 7-hour history of a right-sided hemiparesis and an expressive dysphasia. Physical examination confirmed signs of cerebellar dysfunction, a right-sided hemiparesis, and expressive dysphasia, and her physical examination was otherwise normal. CT head scan revealed a right-sided cerebellar infarct, and laboratory tests revealed a hemoglobin of 15.0 gr/dL (reference range 12??7 gr/dL), TTPK 39 s (range 22??0 s), prothrombin time 12 s (range 12??5 s), VHS 23 mm/hr, and C-reactive protein 0.7 mg/dL (range 0-1 mg/dL). Because of an allergy to aspirin she was started on ticlopidine 250 mg/day.
+One month later the patient developed purpura, equimosis, peripheral edema, arthralgia, and hypertension arterial of 180/110. The lesions were localized to the feet, legs, and thighs, with hemorrhagic blisters around the ankles, some in the process of healing and were associated with pruritus (). Further blood tests showed autoantibodies negative, crioglobulinemia negative, antihepatitis B and C negative, creatinine 1.06 mg/dL, hemoglobin 18.5 gr/dL, VHS 73 mm/hr, C-reactive protein 7.8 mg/dL, protrombina 13 s TTPK 56 s, and a diluted Russells Viper Venom test positive for a lupus-type inhibitor. Further questioning revealed three episodes of painless macroscopic hematuria during the previous month.
+The ticlopidine was discontinued and after skin biopsy, prednisone 60 mg/day was started for the vasculitis, as well as antihypertensive therapy. Because of the hematuria oral anticoagulation was not started. Skin biopsy revealed cutaneous detachment with necrosis of the epidermis; in the dermis there was a lymphocytic infiltration with leukocytoclasia, fibrinoid necrosis of the capillary walls, and extravasation of erythrocytes. Immunofluorescence showed deposits of C3繚 complement in the vascular endothelium of the middle and superficial dermis consistent with a leukocytoclastic vasculitis.
+A CT scan of thorax and abdomen revealed a 5 cm cystic tumor of the left kidney without evidence of metastasis (). She underwent left radical nephrectomy without complications for a clear cell renal carcinoma grade II. There was no evidence of a vasculitis in the surgical specimen. Bone marrow biopsy showed positivity for hypernephroma cells, detected using immunocytochemistry with a monoclonal antibody antihypernephroma (DAKO), consistent with micrometastases ().
+Two months later, there was no clinical evidence of the vasculitis, the TTPK was normal, and tests were negative for anticardiolipins; the diluted Russell's Viper venom test was normal, as was the VHS, C-reactive protein, and hemoglobin. One year later, repeated bone marrow biopsy failed to show the presence of hypernephroma cells. She is without active treatment and is 6 years without evidence of recurrence."
+Xiomara Macias,23,1995/8/2,(389)674-5753x0381,xdavis@example.org,0310 Joshua Plain,"M. L. is a 44-year-old G0 Caucasian woman who presented for laparoscopic supracervical hysterectomy (LSH) for large fibroid uterus after counseling on all options including myomectomy and total laparoscopic hysterectomy.
+LSH of 1570 gm uterus was performed without difficulty with estimated blood loss of 100 cc. Bipolar cautery was applied to a depth of 5 mm in the remaining endocervix. She was discharged home the morning of postoperative day (POD) 1.
+Routine visit on POD 8 was unremarkable, and the patient had no complaints. She called on POD 14 after noting a self-limited episode of vaginal bleeding and a vaginal odor. Evaluation in the office on POD 15 revealed scant brown discharge. The cervix appeared closed and normal except for a 2 mm area of cautery effect at the 3-o'clock site in the transformation zone. There was no cervical motion tenderness. Clue cells were noted on wet mount, and she was started on metronidazole.
+The patient called later that same evening with a slow continuous flow of vaginal bleeding. Upon arrival to the emergency room (ER), she began having heavy vaginal bleeding. Evaluation revealed the cervix 1 cm dilated with brisk bright red bleeding. The top of the internal os was noted to be closed after gentle palpation with a Q-tip. The bleeding was thought to be coming from the left side of the endocervix. She was without any other complaints and had a completely benign abdominal exam. After 30 min of unsuccessful attempts in the ER to stabilize the bleeding with pressure, Monsel's solution, silver nitrate and suture, EBL was 1000 cc, and she was taken to the operating room for exam under anesthesia (EUA) and possible exploration.
+She had just eaten a full meal prior to arrival, had no abdominal tenderness, and was not felt to be bleeding intraperitoneally. She was given IV sedation for EUA. Deep figure eight sutures were placed vaginally in the cervix at the lateral aspects of the internal os. A running locking stitch was placed around the circumference of the open endocervix. Excellent hemostasis was noted. Intraoperative ultrasound revealed no intraperitoneal free fluid. The vagina was not packed, and the patient was observed overnight.
+Minimal spotting was noted overnight, and she was discharged on POD 1. Follow-up exam 4 days later revealed a slow, persistent, dark flow emerging from the endocervix. She kept a bleeding diary and ultimately stopped bleeding 7 days after the second surgery. She had normal clotting studies. Her recovery thereafter was uneventful."
+Moshe Guerra,40,1984/11/26,001-430-676-4828x81105,jamessmith@example.com,47799 Ashley Crest Suite 922,"A four-month-old male infant born out of a non-consanguineous marriage at 33 weeks of gestation with perinatal history of cephalhaematoma and hyperbilirubinemia in the neonatal period presented with history of partial seizures and altered sensorium since 4 days which improved with anticonvulsants after 24??8 hours.
+Electroencephalogram showed theta-delta range asymmetric background activity with intermittently sharp waves, sharp waves and slow waves seen over left hemisphere, and no further addition by photic stimulation. Metabolic workup done at the time was normal. Initial imaging workup with CT scan of brain revealed mild cerebellar atrophy with area of asymmetrical hypodensities in bilateral posterior parietal subcortical white matter (). Subsequent magnetic resonance imaging showed asymmetric T2WI hyperintensities in bilateral temporoparietal cortex and subcortical white matter regions with involvement of the insular cortex with prominence of cerebellar folia suggesting cerebellar atrophy (). At this point MRI diagnosis of urea cycle defects like citrullinemia and biotinidase deficiency were considered as differentials. Child was treated with biotin with no clinical improvement.
+Child continued to progress with convulsions and delayed milestones till 8 months of age at which time, on repeat examination, he had reduced tone, inguinal hernia, and poor hair growth ().
+Metabolic workup revealed increased lactate, decreased serum copper ??2 ugm% (N: 75??60), and copper oxidase levels ??.10 OD (N: 0.20??.55).
+MRI showed diffuse bilateral white matter hyperintensities on T2-weighted sequences. Symmetrical cerebral and cerebellar atrophy was seen, the latter being more prominent (). Extradural and subdural hemorrhages of various stages were identified, one showing fluid-fluid levels in high parietal region (). On MR angiography, tortuosity of internal carotid arteries, proximal middle cerebral arteries with distal narrowing were seen ().
+Trichoanalysis report suggested weak shape of anagen bulb, weak hair shaft with presence of sheath with anagen-telogen ratio of epilated hair: A-6 and T-4, and diagnosis showed pili torti hair which can be present in both Menkes kinky hair syndrome and twisting hair dystrophy ()."
+Edith Blake,37,1994/10/12,+1-687-840-3586x41701,warrenmonique@example.com,6512 Valencia Lights,"A 30-year-old male patient presented with a slow-growing, soft mass in the right upper posterior alveolar region, present since 2 years and which was associated with mild pain upon eating (). Patient had noticed a mobile tooth in the same region about a year and a half back and had got it extracted. The swelling had continued to grow slowly after the extraction. His medical history was noncontributory. Examination showed that the lesion was diffuse, reddish, slightly ulcerated, and measuring about 3 ? 3 cm in size. It was rubbery to firm in consistency and mildly tender, with slight bleeding on palpation. Radiographs were taken but no changes were observed. Incisional biopsy was performed. Microscopic examination revealed epithelium overlying loose myxoid stroma accompanied by a prominent vasculature (). Myxoid stroma showed a scattered spindle to stellate-shaped cells which had distinct borders and oval nuclei. There was no cellular or nuclear atypia or hyperchromasia and mitotic activity and necrosis were not present. Small, thin-walled curvilinear blood vessels were prominent throughout the stroma. A mild inflammatory infiltrate was present predominantly neutrophils (). An immunohistochemical staining was performed using vimentin and CD34 antigens. Most of the stromal tumor cells were immunopositive for vimentin () and the endothelial cells of the blood vessels displayed immunoreactivity for CD34 (). This confirmed the diagnosis of superficial angiomyxomas. Treatment was not done due to patient unwillingness."
+Zyaire Sandoval,41,2003/10/1,(462)790-2028x843,rthompson@example.com,21431 Beverly Ridges,"A 16-year-old female presented with four months of recurrent right-sided epistaxis, nasal obstruction, and epiphora.The patient's past medical history included asthma and mild eczema.She denied oral contraceptive use and prior sexual activity.
+On nasal endoscopy, a pedunculated, grossly vascular tumor was visualized arising from the lateral surface of the middle turbinate.A noncontrast head CT demonstrated a soft tissue mass extending from the right maxillary and ethmoid sinuses to the right nasal choana ().There was no bony destruction evident on CT.
+Biopsy of the intranasal mass was performed in the office with no significant bleeding.The histopathology demonstrated a dense network of capillary-sized vessels consistent with LCH.The biopsy revealed acutely and dramatically inflamed granulation tissue.The presence of necrosis and squamous metaplasia was thought to suggest trauma with reactive changes.
+The patient was treated with image-guided endoscopic excision of the right nasal mass arising from the right middle meatus.Her surgery and recovery were uncomplicated and no recurrence has been noted six months postoperatively.The final pathology was read as lobular capillary hemangioma."
+Elsie Lin,18,1994/3/11,729-293-4661,monicabarton@example.org,934 Rachel Locks Suite 631,"A 12-year-old female presented with three months of recurrent, left-sided, epistaxis and nasal obstruction.On nasal endoscopy, the patient was noted to have a mass filling the left middle meatus.A head CT with contrast demonstrated a mass in the left nasal cavity ().The mass was biopsied in the office without significant bleeding after the procedure. Pathologic evaluation revealed proliferating small vessels and spindled cells in a myxoid stroma.These vessels assumed a lobular architecture in some foci.The pathology was read as polypoid capillary hemangioma.
+The patient underwent an image-guided transnasal endoscopic resection of this mass ().The mass was noted to arise from the left lateral nasal wall anterior to the middle turbinate.Her surgery and recovery were uncomplicated and no recurrence has been noted to date, more than three years after her surgery.The final pathology was capillary hemangioma."
+Conor Donaldson,29,1984/3/30,252-927-5401,ernest46@example.net,152 Henry Pass Apt. 769,"This is a 66-year-old patient, with four pregnancies, three normal deliveries and one abortion. She smoked from the ages of 10 to 51 years and had no family history of breast carcinoma. She reported the presence of progressively growing nodules in both breasts in 2005. In 2006, she underwent a mammography (Figure ) with suspicious findings and was referred to the hospital. She did not visit the hospital for fear of a positive diagnosis. In December 2006, she underwent another mammography, and was examined again in February 2007. Mammography showed a regular 9-cm nodule in the right breast, without skin retraction, with elastic firm consistency, diffuse bulging breast and negative axillary lymph nodes. Mammography also noted a 6-cm nodule in the left breast with bulging and skin retraction located in inter-medial quadrants and retro areolar region, hardened, partially mobile and negative axillary lymph nodes. She was referred to preoperative assessment and surgery. Incisional biopsies of both breasts were performed. Biopsy of the left breast revealed the presence of invasive ductal carcinoma (pT3pn0, pMx), Nottingham grade II, nuclear grade III. Biopsy of the right breast showed a probable benign phyllodes tumor. No core needle biopsy was performed because the technology was not available in our clinic.
+Based on the diagnosis and the size and location of the lesions, we decided to perform a simple mastectomy in the right breast and modified Madden mastectomy in the left breast.
+The anatomopathological final result showed the presence of benign phyllodes tumor in the right breast (Figure ), which measured 9 cm in its longest axis, and invasive ductal carcinoma Nottingham grade II, nuclear grade III, which measured 7 ? 6 cm in the left breast. Further evaluation indicated negative axillary lymph nodes and absence of metastasis (Figure ).
+For histological assessment, fragments were dipped in Gender liquid at 4簞C for 24 h and were cut into small pieces of 1 mm3 and post-fixed in a 1% OsO4 solution for 2 h, dehydrated and embedded in araldite. Silver or gray thin sections (60 to 90 nm) were selected on a Porter-Blum MT-B ultramicrotome. The ultra-slices were mounted on copper silver grids with 200 patches and stained with uranyl acetate and lead citrate. The fragments were fixed in formaldehyde 10% at 4簞C. Approximately 24 h later the fragments were cut in cryostat. This protocol followed the routine procedures of our laboratory [-].
+Figure shows the histological evaluation of the of phyllodes tumor. Figure shows the histological results of the carcinoma in the left breast focusing on steroid Her-2/neu-receptor. Preoperatively, history and physical exam were normal; bilateral mammography, abdominal and pelvic computed tomography (CT), usg total abdominal and pelvic, chest imaging, and biochemical tests (complete blood count, platelets, liver function tests, and alkaline phosphatase) were all normal. However, bone scan indicated a low probability metastases.
+The patient was given adjuvant therapy composed of radiotherapy and chemotherapy for phyllodes tumor and carcinoma, respectively. Chemotherapy included six cycles of the FAC regimen (5-fluorouacil, doxorubicin, dyclophosphamide). To date, the patient has not shown any clinical or laboratory alterations."
+Natasha Dyer,23,1979/12/8,303-772-3204,pobrien@example.net,480 Novak Mission Apt. 990,"A 44-year-old male was admitted to our clinic with a history of left-side nasal obstruction, episodes of epistaxis, hyposmia, and postnasal discharge over the previous 2 months. The patient had undergone endoscopic sinus surgery 2 years earlier for bilateral sinusitis at another clinic. Otherwise, his medical history was unremarkable. General and neurological examinations and routine laboratory test results were unremarkable. Non-contrast-enhanced computed tomography (CT) sections revealed an extensive hypodense non-calcified lesion occupying the left nasal cavity and pushing against the lateral nasal wall (Figure A). The lesion showed heterogeneous iodinated contrast enhancement and demonstrated remodeling of the adjacent bony structure (Figure B). Magnetic resonance imaging (MRI) showed that the tumor mass was of slightly lower intensity than the brain parenchyma on T1-weighted images and heterogeneously isointense on T2-weighted images, with significant heterogeneous contrast enhancement on gadolinium administration (Figure A-D). The preoperative CT and MRI showed an endonasal soft tissue mass with no intracranial connection. During the operation, a friable mass originating from the bony-cartilage junction of the nasal septum and extending to the lateral nasal wall was resected completely with the attached septal cartilage and nasal mucosa via an endoscopic endonasal approach. The safety margins were free of disease.
+Microscopically, the tumor cells were arranged in sheet-like growths or were uninterrupted and patternless and showed nasal septum invasion (Figure A). No cellular whorl, psammoma body, or necrosis was observed. Individual tumor cells had round-to-oval nuclei, with prominent nucleoli and dense nuclear membranes. Mitosis was seen frequently (7/10 HFP, Figure B). The immunohistochemical profile was positive for epithelial membrane antigen (Figure C) and vimentin (Figure D), focal positive for S-100 protein, and negative for cytokeratin, p63, and smooth muscle actin. This histopathological investigation led to a diagnosis of an atypical meningioma (WHO Grade II) according to WHO criteria [,].
+Two years later, the patient was readmitted to the Hematology and Oncology Department of our hospital with recurrent severe epistaxis and general weakness, which had developed over the previous month. He also described breathing difficulties. Paranasal sinus CT showed recurrence of the left nasal cavity tumor, with palate and maxilla region involvement. Histological investigation of this second tumor showed morphological characteristics similar to the primary tumor (Figure A). Positron emission tomography/computed tomography (PET/CT) was used to identify distant metastases. PET/CT showed no abnormal glucose metabolic activity, except in the nasal cavity and palate region. The patient received local external radiotherapy (6840 cGy in 38 fractions) for local recurrence of meningioma.
+Two months after local recurrence, subcutaneous tumors were found located on the left anterior chest wall (1.5 ? 1.2 cm) and left parietal region (0.5 ? 0.4 cm). The tumors were removed under local anesthesia. Histological examination showed morphological characteristics similar to the primary tumor (Figure B); however, the mitotic index (up to 40 mitoses within 10 HPF) and Ki-67 labeling index (40%) were higher than those of the primary counterpart. Foci of geographic necrosis were also found (Figure C). The tumor was classified as a malignant (WHO Grade III) meningioma.
+After radiation therapy, the nasal cavity tumor shrank markedly. However, 2 weeks after the radiation therapy, multiple small subcutaneous tumors occurred over the entire body. At that time, the patient was very debilitated and did not want any other intensive treatment. He was transferred to a palliative care facility and died 3 months later."
+Atreus Stout,29,1997/10/18,+1-889-863-5643x2913,corythompson@example.org,35678 Mclaughlin Parkways,"A previously healthy 12 month old boy presented to hospital with a right 6th nerve palsy seven days after his routine 12 month immunizations: measles, mumps, rubella (MMR) (Priorix簧, GSK) and Haemophilus influenzae type b (Hib) ??Hepatitis B (Comvax簧, Merck). He had been well for the first four days post-immunization, but then noted by his grandparents to have a ?quint??and appear lethargic. He presented for medical attention on day seven post-vaccination because of persistent concerns about his unusual eye movements.
+Two months earlier he had received his second catch-up dose of 7-valent pneumococcal conjugate vaccination (Prevenar簧, Wyeth Vaccines) and meningococcal group C conjugate vaccine (Meningitec簧, Wyeth Vaccines). He had experienced no adverse events from any of his previous vaccinations, which were up to date for his age on the routine Australian National Immunization Program schedule []. He had a past history of emergency delivery at 36 weeks gestation by caesarean section for twin-twin transfusion following a twin pregnancy conceived by in-vitro fertilization. There were no significant neonatal problems and he was developmentally age appropriate.
+On admission he was afebrile, blood pressure 117/59, pulse rate 120/min, respiratory rate 30/min and oxygen saturation of 95%. There was no history of preceding viral illness or prodrome and no symptoms developed during admission. Further evaluation by a pediatric neurologist and ophthalmologist confirmed an isolated right 6th nerve palsy, with no evidence of facial asymmetry. There was mild plagiocephaly, with a head circumference of 46.5 cm (50th centile). No ptosis was evident, and fundoscopic examination bilaterally was normal.
+Initial blood investigations included normal full blood examination (Hb 128 g/L; Platelets 284 x109/L; leukocytes 11.1 x 109/L and normal baseline electrolytes, liver function tests, creatinine kinase (CK) and serum calcium levels. The erythrocyte sedimentation rate (ESR) was normal (3 mm/hr).
+Neuroimaging with magnetic resonance imaging (MRI) and angiography (MRA) of the brain demonstrated no intracranial abnormality. Cerebrospinal fluid (CSF) examination revealed no white cells, 89 red cells x106/L, protein of 0.19 g/L (0.20-0.40), glucose 2.8 mmol/L (2.8-4.0) and lactate of 1.2 mmol/L. A random blood glucose level was 6.0 mmol/l. There was no growth on CSF cultures. The CSF opening pressure was 31 cm CSF, but this was obtained at the third attempt at a lumbar puncture in a screaming child, and the pressure was therefore likely artefactually elevated. Acetylcholine receptor antibodies were negative (0.2 nmol/L).
+The differential diagnoses with this presentation included a post viral 6th nerve palsy, idiopathic cranial nerve palsy, myasthenia gravis and benign intracranial hypertension. He was initially trialed on Pyridostigmine (Mestinon簧 Valeant) 5 mg three times daily. This was subsequently increased to 10 mg three times daily, but with no change in clinical signs it was ceased. The 6th nerve palsy persisted at one-week post vaccination, but completely resolved spontaneously over the next six weeks, with resolution confirmed on ophthalmology follow-up.
+The child then re-presented aged 20 months with a recurrent episode of a right 6th nerve palsy. On this occasion it commenced followed a different live virus vaccination ??Varicella (Varivax簧 Merck) given four weeks earlier. Again, there was no viral prodrome and he had otherwise been alert and well. He presented with identical symptoms of a squint and was brought to hospital for evaluation five weeks after immunization. Repeat examination by an ophthalmologist and pediatric neurologist again confirmed an isolated 6th nerve palsy with no evidence of papilledema. He was afebrile and haemodynamically stable. The nerve palsy worsened over the subsequent two days, then significantly improved over the next 7??0 days and had entirely resolved by 5 weeks, now a total of 9 weeks post immunisation. On this presentation, he did not have any neuro-imaging, CSF analysis or repeat blood investigations.
+Over the next 12 months the child tolerated numerous viral infections with no recurrence of the squint or any neurological symptoms. He had ongoing ophthalmology review with no abnormalities noted. A follow-up with pediatric neurology at two years of age confirmed a normal examination, with all appropriate developmental milestones reached.
+Following detailed discussion with the family it was advised that further live attenuated vaccines not be administered, even though the routine Australian immunization schedule includes a MMR vaccine (2nd dose) at 4 years of age []. The main reason for this advice was that no previous recurrent cases had been reported in the scientific literature and therefore the safety of further live attenuated vaccines in this setting was unknown."
+Chana Russell,23,2005/1/5,6506615499,fuentesjohn@example.com,72641 Kevin Cape Apt. 947,"A 63-year-old nondiabetic, nonsmoker, hypertensive male patient, who presented with a 3-year history of severe paroxysmal and lancinating right facial pain in V2 and V3 trigeminal territories. The pain used to come in sudden bursts lasting 1?? minutes and recurs 10??0 times a day. The pain was not satisfactory controlled by oral opioids, tricyclic, or dual antidepressant. On physical examination, facial trigger points in the right maxilar region have been found without other neurological findings. Magnetic resonance imaging (MRI) and magnetic resonance angiogram (MRA) of the brain demonstrated an elongated and tortuous vertebrobasilar artery causing mechanical compression at the right trigeminal nerve root (Figures and ).
+Surgical procedure (MVD) was then proposed due to refractoriness and images findings. A right retrosigmoid approach was performed with cerebellopontine angle exposure. Arachnoid dissection revealed a large vascular structure, identified as dolichoectasia of the basilar artery, dislocating and compressing the right ventrolateral region of brainstem and its respective trigeminal nerve root. As soon as the neurovascular conflicting area was identified, MVD technique placing pieces of Teflon between the trigeminal nerve and the basilar artery with displacement of dolichoectatic artery was performed. Care was taken not to injury of the artery during the vascular microdissection, because potentially fragile vessel walls in VBD.
+A very satisfactory surgical decompression result was achieved and pain attacks ceased immediately and completely after surgery. During the follow-up period (24 months), the patient has reported excellent relief of pain and currently does not need any more medications."
+Weston Vo,26,1994/10/16,960-275-7301x93039,smithbenjamin@example.com,45075 Christine Island Apt. 694,"A 26-year-old male patient was admitted to our hospital with a pulsatile mass in the right side of his neck that had been present for one week. He had no history of neck trauma. The patient had been diagnosed with Behcet's disease two years prior to admission to the hospital, suffered from deep vein thrombosis related to his Behcet's disease, and was being treated with sulfasalazine, warfarin, and prednisolone.
+Physical examination revealed an approximately 3 ? 3 cm sized painless, pulsatile mass on the right neck. The neurologic examination was normal, and his vital signs were stable. A computed tomography (CT) scan revealed a 3 ? 3 cm sized well-enhanced CCA pseudoaneurysm (). An angiogram showed a pseudoaneurysm just at the level of the bifurcation of the right CCA (). An intracranial angiogram showed collateral blood flow from the left carotid artery through the anterior communication artery during compression of the right CCA.
+We decided to treat the patient with a stent graft, which first involved placement of a 0.0035 inch Terumo guide wire (Terumo, Tokyo, Japan) via the femoral approach into the right internal carotid artery, passing the right CCA. A JOSTENT (length 28 mm; diameter 4?? mm; JOMED, Rangendingen, Germany) was then expanded in the CCA using an angioplasty balloon catheter (Ultra-Thin Diamond, 8 ? 4 mm, Medi-Tech, Watertown, MA, USA). Due to insufficient support of the guide wire, the CCA defect was not completely covered by the stent, and a subsequent angiogram revealed contrast material entering into the pseudoaneurysm sac. Reinsertion of a stent was planned; however, in order to completely occlude the defective area, the stent was placed over both the CCA and the internal carotid artery (ICA). Because this procedure could lead to backflow through the external carotid artery (ECA), a coil was first used to block the ECA. Next, a JOSTENT (length 17 mm; diameter 4?? mm; JOMED, Rangendingen, Germany) was placed into the ECA. After reinsertion of the stent, an angiogram showed that there was no longer contrast material within the pseudoaneurysm sac ().
+Several minutes after placing the stent graft, the patient complained of a sudden headache. An intracranial angiogram revealed thrombi in the middle cerebral artery. Immediately, an injection of nonpeptide Gp llb/llla antagonist was administered to the middle cerebral artery. After 15 minutes, an angiogram showed improved arterial flow and indicated that the thrombi had been resolved. The patient did not complain of subsequent headaches. Follow-up neurologic examination and a brain CT scan showed no further abnormal signs or findings. A total of seven months after placement of the stent graft the pseudoaneurysm was no longer visible on a CT scan, and blood flow of the stent area was patent."
+Artemis Terry,30,1996/4/21,+1-626-313-2161x51931,debra13@example.org,2397 Gardner Ports Apt. 863,"A 64-year-old female patient was admitted to our hospital with a suddenly enlarged pulsating mass of the right neck. The neck mass had developed two days prior to admission to the hospital. The patient had no history of neck trauma, surgery, or interventional procedure. She had been previously diagnosed with chronic obstructive pulmonary disease (COPD) and took regular medication to treat the disease. Physical examination revealed an approximately 3 ? 4 cm sized painless, pulsating mass on the right side of the patient's neck with no neurological symptoms. The patient's vital signs were stable.
+A CT scan revealed a 2.5 ? 3.4 cm sized well-enhanced CCA pseudoaneurysm (). The carotid artery angiogram showed a small defect in the proximal portion of the right CCA and a pseudoaneurysm, for which a stent graft was planned. A JOSTENT (length 28 mm, diameter 6 mm, JOMED, Rangendingen, Germany) was inserted and deployed over the CCA. After placement of the stent, a carotid artery angiogram showed no blood flow to the pseudoaneurysm (). After three months, a neck ultrasound revealed no blood flow to the pseudoaneurysm and indicated that the blood flow of the CCA was intact."
+Armani Mack,21,1987/3/22,856-422-5764,gary11@example.org,820 John Plain,"A 72-year-old man had a two-month history of a left-sided, slowly enlarging, painful mass of the cervical region. His medical history did not highlight any significant evidence. On examination, the mass was fixed to the deep plan, hard in consistency, measuring 4 cm in diameter with external signs of inflammation. The rest of examination revealed a skin ulcerated tumor of the forehead measuring 1.5 cm which appeared one month ago. The remaining systemic examination did not reveal any coexistent lesions. Cervical ultrasonography and computed tomography scan suggested enlarged cervical lymph nodes (). Random biopsies from the nasopharyngeal mucosa were normal. The patient underwent a cervical lymph node biopsy and an excision of the frontal lesion. The excised cutaneous specimen showed a dermal carcinomatous proliferation with features of LEL carcinoma, characterized by a nonneoplastic prominent lymphocytic infiltrate intermingled with a poorly differentiated epithelial proliferation with syncytial appearance (Figures and ). Cervical lymph node was massively infiltrated by a dense carcinomatous proliferation suggesting neuroendocrine differentiation, and it was made of monomorphous small basophilic cells with a very fine chromatin and minimal cytoplasm dispersed in a scanty stroma (). Frequent mitotic figures were found. Immunohistochemical stains of the cutaneous tumor and lymph node metastases showed immunoreactivity for neurofilament (), chromogranin, synaptophysin, and a characteristic dot-like perinuclear staining for cytokeratin 20 (). The tumor did not express TTF1. On the basis of these findings, the diagnosis of MCC with ipsilateral cervical lymph node metastasis was made. The patient was going to undergo radiotherapy and died 3 months after the diagnosis."
+Nadia Francis,18,1982/6/25,-10014,krystal53@example.org,09704 Kristy Crossroad Suite 076,"A 57-year-old woman presented with a two-week history of short-term memory loss, headaches, subtle left-sided weakness, and unsteady gait. MR imaging of the brain with a T1-weighted fast spin echo (FSE) sequence showed an enhancing right temporoparietal mass adjacent to the atrium of the lateral ventricle (). The referring physician started treatment with 4 mg of dexamethasone given four times daily, which resulted in improvement of the patient's neurological symptoms. A surgical biopsy was initially planned; however, a routine stereotactic MR-imaging scan for intraoperative navigation using a spoiled gradient recalled (SPGR) sequence showed striking reduction in contrast enhancement within the mass (). Although there can be changes in the degree of enhancement when comparing a SPGR with an FSE sequence, the reduction in contrast enhancement observed is significantly more than would be expected due to differences in imaging techniques. Because the patient had improved functional status and the tumor demonstrated radiographic change, the clinical course suggested lymphoma, and surgery was not performed. A tapered steroid course was begun, but because of persistent neurological symptoms, the patient was continued on a dose of 2 mg of dexamethasone twice daily. Subsequent screening for extra-axial lymphoma was negative. Two weeks later, the patient developed worsening gait imbalance, and repeat T1-weighted FSE imaging () showed interval increase in size and enhancement of the right temporoparietal mass, a prominent focus of enhancement in the splenium of the corpus callosum, and further leptomeningeal spread. Furthermore, the areas with reduced enhancement on the SPGR image corresponded with areas of evolving necrosis on the follow-up T1-weighted FSE image. These findings suggested a possible diagnosis of malignant glioma.
+The patient underwent a stereotactic-guided craniotomy for excision of the right temporoparietal mass lesion. Gross examination of the lesion revealed yellow abnormal tissue of a firm consistency. Biopsy samples were sent as frozen sections to the surgical pathologist. Preliminary results were consistent with malignant glioma. An ultrasonic aspirating device was used to remove the dominant lesion. Tumor tracking from the splenium of the corpus callosum to the contralateral ventricle was not removed. Final histological diagnosis was glioblastoma multiforme, World Health Organization grade IV ().
+At 1-month followup, the patient reported better cognitive function, resolution of headaches, and improvements in left-sided weakness and gait imbalance. She continued to require 1 mg of dexamethasone daily for symptom management. Neurooncological treatment for glioblastoma continued with a combined regimen of temozolomide and whole-brain radiation therapy. At 2-month followup, she was tolerating her cancer therapy regimen well and remained clinically stable."
+Harvey Moon,20,1995/4/29,689.412.7872x2980,zburke@example.com,7956 Cross Vista Suite 018,"A 16-year-old man was referred with a 6-month history of worsening hyponasality and a seropurulent otorrhoea. He had an unremarkable past medical history. He denied weight loss, dyspnea, epistaxis, or fever. The clinical evaluation revealed significant thickening of the posterior wall of the nasopharynx. There was no lymphadenopathy present. A CT scan showed thickening of the left nasopharynx (). A biopsy was performed. The histopathology revealed chronic inflammation and the presence of actinomyces. Gram stains of the tissue revealed gram+ with filamentous organisms oriented radially around sulphur granules.
+The patient was diagnosed with actinomycosis and successfully treated with a prolonged course of penicillin (45 days). He subsequently improved and recovered after 34 months. The evaluation of the treatment outcome was made by nasopharyngoscopy. No further biopsy or CT scan was made."
+Naya Dillon,40,1993/11/15,(514)390-3500x687,jvasquez@example.net,460 Fletcher Junction Suite 721,"A 42-year-old woman without past medical history was referred for a right neck mass associated to leanness without rhinologic or otologic problems.
+Physical examination revealed a right subdigastric 3 cm ? 5 cm nontender and firm neck node. The remainder of the head and neck examination was unremarkable except for the finding of poor dental hygiene. The blood cell count was normal. The nasopharyngoscopy showed a nonulcerated mass of the right nasopharynx. Ultrasound imaging of the neck revealed right cervical lymphadenopathy with the largest node measuring 4 cm. The CT scan showed a thickening of the nasopharynx wall with multiple right lymphadenopathy.
+The histopathology revealed the presence of actinomyces (). She was diagnosed with actinomycosis and treated with high-dose penicillin, intravenously followed by oral penicillin during 2 months. She finally recovered after 10 months."
+Alvin Fischer,25,1984/8/29,736-542-1926x52469,andre91@example.com,81250 Daniel Park Suite 323,A 42-year-old woman was referred for headache and epistaxis without nasal obstruction. Physical exam showed poor dental hygiene. The nasopharyngoscopy revealed a thickening of the right nasopharynx. The biopsy showed the presence of actinomyces. She was diagnosed with actinomycosis and treated with penicillin until recovery. (20 M/d during 45 days).
+Maci Shepard,20,1981/2/6,206.261.6932x0197,sarahgriffith@example.net,7557 Lopez Prairie Apt. 092,"Mary (Mary is the pseudonym of the client), a 62-year-old Chinese lady with 5 years of education, consulted me for depressed mood, panic attack, and numbing response triggered by conflict with her adult daughter. Her emotional functioning was unstable with chronic feelings of fear, confusion, nightmares (dreamed of baby crying), forgetfulness, mind going blank, freezing response, and flashbacks. She was experiencing moderate impairment in her daily functioning. There were times that she discovered herself crossing a road without knowing why she got there, or she found herself got injured without feeling any pain. Prior to this consultation, she consulted a family physician who prescribed antidepressants to her.
+Mary lived with her daughter and son-in-law. Her daily job was to take care of two school-aged grandchildren. She often had conflicts with her daughter over child discipline and daily household management. These conflicts set off her flashbacks of memories of traumatic situations (e.g., a ladder, an old village house, and blood on the floor). These intrusions caused her headache, stiffness of body, chest discomfort, ulcer pain, and nose bleeding. She fulfilled the criteria for complex PTSD [, , ].
+Mary reported to have encountered a number of stressful life events since early childhood. At the age of 6, she witnessed the accidental death of her brother; at 12, she saw her aunt kill her baby by throwing him from heights; at 16, she experienced her sister running away from home; at 28, she underwent an abortion because of contracting venereal disease from her husband; in her thirties, she was deserted by her spouse.
+A detailed history taking revealed that the etiological event was the death of Mary's brother. This happened when Mary was 6 years old. At that time, her parents entrusted her brother (who was then 4 years old) to her while they were away to work in daytime. This was a common practice in traditional Chinese rural society. One day, the boy fell from a ladder and died. After that, Mary was believed to bring misfortune to her family and she was labeled by her kin as comets (comets symbolize an omen of death and misfortune in Chinese culture. In traditional Chinese community, if bad things happen, women of the family are often labeled as comets, meaning that they are the origin of the bad luck.) afterwards. Because of the stigma, she had encountered numerous situations that made her feel inferior and humiliated (e.g., not allowed to attend her father's funeral). In the interview, Mary could not recall a coherent narrative of this tragedy. She could only access rudimentary memories, including images of a wooden ladder, an old village house, a frightened girl hiding underneath the bed, a loud ?ang??sound, and people's noises.
+Mary had been assessed on the Trauma Symptom Inventory [] and Impact of Event Scale (IES; []) at different points of time. The Trauma Symptom Inventory (TSI) is a self-report questionnaire with good psychometric properties. It assesses posttraumatic stress symptoms and other trauma-related symptoms (e.g., self and other relations). In responding to the TSI, participants are asked to report how often various trauma symptoms have been experienced during the previous 6 months. Ten subscales are formed from the participants' responses. T scores are used to interpret the severity of the stress symptoms and a T score of 65 or above is considered clinically significant. The psychometric properties of the Chinese TSI were found to be satisfactory []. The reliability alphas of the subscales of the Chinese TSI in 57 Chinese adults who had come across critical events were as follows: anxious arousal (AA, 帢 = .84), depression (D, 帢 = .87), anger/irritability (AI, 帢 = .82), intrusive experience (IE, 帢 = .88), defensive avoidance (DA, 帢 = .87), dissociation (DIS, 帢 = .82), sexual concern (SC, 帢 = .80), dysfunctional sexual behavior (DSB, 帢 = .74), impaired self-reference (ISR, 帢 = .83), and tension reduction behavior (TRB, 帢 = .70).
+The Impact of Event Scale (IES; []) is another well validated self-report questionnaire designed to assess intrusive and avoidant symptoms in the respondents. A global score (intrusion plus avoidance scores) of 19 is considered to have high and severe impact, while a score below 9 is regarded as having low impact []. An unpublished local study on 323 Chinese adults who had encountered traumatic events in their life indicated that the Chinese IES possessed good psychometric properties []. Reliability alphas for the intrusion and avoidance subscales and Full scales for the Chinese IES were .92, .81 and .90, respectively.
+In relation to the target memory of the death of her brother, Mary's NC was ? am responsible for his death.??Given she had difficulty to formulate a PC, she was presented with a list of PC to choose, but the list did not fit her. She later came up with a PC ? can let go of my burden??with a Validity of Cognition Scale (VOC; []) of 3. The VOC is a 7-point Likert-type scale where 1 represents an adaptive cognition that is completely unbelievable and a 7 represents one that is totally believable. After several sessions of reprocessing, the VOC remained unchanged. We had a discussion to link up her narrative story line by placing everything came up from the bilateral stimulations (BLS) into perspective. In the course of the eye movements, she began to realize that her brother might be destined to die at an early age, just like it was written in fate that she had to face many hardships in life. This realization was further supported by a visualization of her brother smiling at her during the eye movements in one of the sessions. She interpreted the brother's smile as a kind of love and accepting without blaming. I discussed with her whether the originally specified PC still fit or something better could be used. She felt another PC ? just follow my destined path of life??more appropriate. The VOC of this new PC increased from 4 to 7 after several sessions of reprocessing. At the end of reprocessing, she came up with a thought that ?ccidents were inevitable when children are left at home unattended.??This reflected that she had accepted the death of her brother as a kind of accident resulting from the negligence of caretakers.
+The level of disturbance was measured by using the Subjective Unit of Distress (SUD) scale, where 10 is the highest level of disturbance and 0 is no disturbance. In general, Mary rated 8 to 9 on the SUD scale prior to reprocessing. The bodily sensations (e.g., chest pain, breathing difficulty, stiff shoulder, and hand tremor) associated with the disturbance were also noted. She had nose bleeding intermittently during the initial sessions of reprocessing. With the continuation of eye movements, the bleeding stopped itself. After reprocessing, the SUD dropped to 0 and near to 0. We concentrated on another traumatic event on her abortion experience after the primary event was fully processed. This took only 4 sessions to achieve a resolution. Her symptoms subsided after reprocessing these two events and she no longer met the criteria for PTSD. Given this, we decided to stop using EMDR to reprocess other memories.
+In sum, Mary received 21 sessions of EMDR (17 on the death of brother, and 4 on abortion) within a total of 65 therapy sessions over 4 years. Prior to reprocessing, her subscale scores on the Trauma Symptom Inventory (TSI; []) ranged from 45 to 78. After reprocessing, all the subscale scores fell below clinical level (see ). The scores of the Impact Event Scale (IES; []) were 29 and 38 (interpreted as having moderate to severe impacts) for her primary and secondary traumatic memories pre-processing, and dropped to 8 and 6 respectively after before exposure (see ). The decrease in the scores on the TSI and IES were consistent with the change in the ratings of the SUD (from 8/9 10 to 0) and VOC (from 4 to 7). These treatment gains were maintained at a 3-month followup.
+At the time of this writing, Mary was receiving training on self-assertion skills. She was also helped to make connection between the past events and her present experience. Bilateral eye movements were sometimes used to strengthen and reinforce the insights and discoveries surfaced during this period."
+Damari Zuniga,26,1988/12/29,313.395.0340x66163,lgardner@example.net,7203 Huff Crescent,"A 69-year-old woman presented to the Rheumatology Clinic in January 2010 for evaluation of generalized morphea/localized scleroderma diagnosed 7 months after receiving local radiation to right breast for treatment of breast cancer. In September 2008, breast cancer was diagnosed by needle biopsy when an abnormal cluster of calcifications was identified by a screening mammography in September 2008. After consultation with her surgeon, oncologist, and radiation therapist, she underwent lumpectomy and sentinel lymph node biopsy. The cancer was estrogen receptor negative, and the sampled lymph nodes were negative. The tumor was estrogen and progesterone receptor positive. She opted not to take tamoxifen or other antiestrogen therapy. To prevent cancer recurrence, external beam radiation to right breast was completed (October 2008). She experienced local radiation side effects of erythema and superficial blister formation that resolved with local wound care.
+Approximately 7 months after completing radiation therapy, she developed two painful blisters in the inframammary fold of the right breast. On examination she was found to have generalized induration of the right breast and right axilla attributed to postradiation fibrosis. The breast and axilla were warm to touch and painful to palpation. That was with sparing of the areola. Additional lesions distant from the radiation field were also noted. These included hyperpigmentation of the skin at the waistline, induration of the skin in the left upper inner thigh and left groin, and a shiny patch of thickened skin on the anterior left shin. The lesions not involving the breast and axilla were not painful.
+In May 2009, a punch biopsy of the left groin lesion diagnosed localized scleroderma (morphea). On microscopy, the skin surface was thin with a slightly keratotic epidermis. The papillary dermis was edematous and homogenous. The reticular dermis had dense collagen in bundles with intervening mild lymphoid and plasma cellular inflammation present around the adnexal structures. Mild chronic inflammation in the subcutaneous fat was noted at the base of the biopsy. For treatment of the right breast and axillary lesions, topical calcipotriol and topical betamethasone dipropionate were prescribed without benefit. Painful ulcers developed in the area of application in the right axilla which healed slowly when the topical medications were discontinued. The area under the right breast remained painful with chronic superficial ulceration. Application of topical silver impregnated dressings was of no benefit.
+In addition to the skin lesions, she described fatigue and generalized arthralgias. She denied more specific symptoms of systemic connective tissue disease, that is, no history of Raynaud's, esophageal reflux, shortness of breath, cough, joint swelling, morning stiffness, sicca symptoms, pleuritis, or serositis. Prior to diagnosis of breast cancer, she had no significant past medical or psychiatric history and was on no prescribed medications. Family history was negative for connective tissue disease. Physical examination confirmed circumferential induration of the right breast with sparing of the areola. Induration extended into the right axilla. Superficial erosion of the epidermis was noted in the inframammary fold of the right breast. A band of hyperpigmented, thickened skin was noted along the anterior waistline. A hypopigmented indurated patch was noted in the left groin with a healed punch biopsy site. Thinning of the skin with hypopigmentation and superficial telangiectasias was noted in the upper left medial thigh. A 3 cm patch with central hypopigmentation was present on the left anterior mid tibia. She had no sclerodactyly. Nail fold examination for capillary changes was normal. Examination of the heart, lungs, and abdomen was normal. Laboratory testing was normal, including complete blood count, chemistry panel, thyroid function tests, and urine analysis. Sedimentation rate and C-reactive protein were normal. Lyme titer was negative. Thyroid autoantibody testing was negative. ANA was interpreted as borderline positive, with titer of 1 : 160 in a speckled pattern. Further testing for ANA subtypes was negative for anti-topoisomerase, anti-RNP, anti-Smith, anti-ds DNA, anti-SSA, and anti-SSB.
+She was prescribed minocycline 100 mg twice a day, and, after three days of therapy, she reported dramatic improvement in generalized pain and fatigue. The superficial erosions in the inframammary fold healed. However, despite the initial perceived benefit, the right breast remained warm and tender to palpation. New lesions occurred on the right lower extremity. In August 2010, methotrexate 7.5 mg weekly and titrated to 12.5 mg was prescribed. Folic acid 1 mg per day was prescribed to prevent methotrexate side effects. After the addition of methotrexate, no new lesions occurred. Signs of inflammation in the irradiated right breast resolved though skin thickening remained unchanged. The lesions on bilateral lower extremities softened. Minocycline was discontinued in March 2011 when abnormal pigmentation developed as a side effect. She remained without signs or symptoms of a systemic connective tissue disease."
+Leslie Jenkins,32,1983/1/2,+1-496-611-7612x245,scottcandice@example.com,4196 Catherine Forest,"A 77-year-old woman with hypertension and former tobacco use presented in March 2010 with a two-year history of progressive bilateral thigh Rutherford-Becker class 3 claudication despite medication optimization. Ankle-brachial indices were 0.65 for the right leg with monophasic wave forms and 0.86 for the left with biphasic wave forms. Angiography revealed no significant arterial calcification with a 60% stenosis of the mid-right common iliac artery with no pressure gradient and a 100% ostial right SFA stenosis with reconstitution of the distal right SFA via collateral blood flow from the deep femoral artery. The posterior tibial artery provided 1-vessel runoff to the right foot. The left lower extremity angiogram was significant for a 30??0% stenosis in the mid-SFA and an occluded mid-anterior tibial artery that reconstituted distally via collateral flow with 2-vessel runoff to the left foot.
+The patient was brought back a few weeks later for percutaneous revascularization. Retrograde access of the left common femoral artery was obtained and a 7 F 45 cm sheath was advanced over the aortic bifurcation into the right common femoral artery. The CrossBoss (Bridge-Point Medical, Plymouth, MN) catheter was advanced through the sheath to the SFA ostium, and the rotational tip was advanced through the SFA occlusion to the popliteal artery. As the tip of the catheter was subintimal, the catheter was exchanged out for the Stingray Re-Entry System catheter over a Miracle wire (Ashai Intec, Seto, Japan). The Stingray Re-Entry System balloon was dilated to 4 atmospheres to stabilize the catheter in the subintima of the popliteal artery. The dedicated Stingray Re-Entry System guide wire advanced through the catheter and exited the distal port of the balloon catheter as designed, penetrating the intima into the true lumen of the popliteal artery. Subsequently, the patient underwent angioplasty and atherectomy after placement of a distal protection device. Right iliac angiogram with runoff postintervention was performed with digital subtraction imaging revealing good angiographic results ()."
+Declan Bass,38,1990/12/16,526.400.8438x68376,ygriffin@example.net,196 Kelly Junctions,"An 81-year-old male with a history of hypertension, diabetes mellitus, and chronic kidney disease stage 3, was referred by his primary care physician for worsening Rutherford-Becker class 3 claudication of both calves despite medication optimization. Ankle-brachial indices were 0.60 in both lower extremities with monophasic waveforms. Magnetic resonance angiography of his lower extremities showed severe ostial right SFA stenosis and diffuse moderate disease distally. The left SFA had a subtotal occlusion at its origin with reconstitution of mid-to distal segments. The left foot had one-vessel runoff by the peroneal artery. The patient was taken to the catheterization laboratory for possible percutaneous atherectomy of the left SFA.
+Arterial access was obtained at the contralateral femoral artery and a 7 F 45 cm sheath was used. Angiography showed 100% ostial stenosis of the left SFA with reconstitution of the distal third of the vessel via collaterals from the profunda femoris artery. A 6 F multipurpose A2 (MPA2) guide catheter was advanced in the sheath and positioned at the ostium of the left SFA. The CrossBoss (Bridge-Point Medical, Plymouth, MN) catheter was advanced through the MPA2, and the rotational tip was advanced through the SFA occlusion. A High-Torque Ironman Guidewire (Abbott Vascular, Redwood City, Calif), and later an Asahi Confianza Pro Guidewire (Abbott Vascular, Redwood City, CA) were used to steer and support the catheter. Multiple calcified areas along the course of the artery caused difficulty in advancing the catheter. With careful manipulation, the CrossBoss catheter tip successfully reached the distal third of the vessel after running a subintimal course. The catheter was exchanged out for the Stingray Re-Entry System catheter. The Stingray Re-Entry balloon was inflated to stabilize its position. Despite repeated efforts with the dedicated Stingray guidewire, and later a Runthrough NS 180 cm wire (Terumo Cardiovascular Systems, Ann Arbor, Mchi), access into the true lumen of the distal SFA could not be obtained. The procedure was then aborted ()."
+Zahra Dawson,45,1994/5/19,+1-413-431-7674x920,dbryant@example.net,867 Wagner Walk,"A 12-year-old girl with a history of fever, fatigue, and pancytopenia had been referred to Ali Asghar's Children Hospital from a clinic in Varamin (Tehran's suburb) on September 2003.
+She had been admitted in infectious disease ward for workup of fever, pancytopenia, hepatosplenomegaly, and inguinal and cervical lymphadenopathy. The results of first CBC taken in Ali Asghar's laboratory were as follows.
+WBC: 1??03/弮L, RBC: 3.33 mil/uL, Hemoglobin: 8.7 g/dL, Platelet count: 54??03/弮L, Hematocrit: 20.1%, M.C.V: 78.9 fL, M.C.H: 26.3 pg, M.C.H.C: 33.6 g/dL.
+She had been taking antibiotic, and the bacterial culture results were all negative at the time of admission. Upon consultation with hematology oncology ward, a Bone Marrow aspiration (BM) had been scheduled, and on microscopic evaluation a hypercellular BM with complete replacement by immature lymphocytes resembling L1-FAB subtype with negative myeloperoxidase cytochemistry were observed.
+Bone Marrow samples had been sent to cytogenetic laboratory for karyotyping and molecular diagnosis of BCR-ABL fusion gene, and the results had been normal karyotype and negative for BCR-ABL (p210) and (p190) fusion gene.
+A sample had also been sent to Iranian blood transfusion laboratory for Immunophenotyping and the results were as follows:
+CD10+, CD19+, CD20+, HLA DR+ CD13?? and CD33??and the interpretation were consistent with a pre-B-ALL. After diagnosis on April 2003, the patient had been treated according to the children ALL-BFM conventional protocol (without high dose methotrexate) with prophylactic cranial irradiation (1800 Rad). She had a good response to prednisolone and on day 28 BM aspiration had been consistent with hematological remission (<5% blasts), and the results of immunophenotyping had been normal. She had no serious complication during and in between chemotherapy cycles except for few leukopenic episodes that were corrected by G-CSF therapy.
+She had completed the whole protocol on January 2007 with BM at complete remission, normal CSF, normal Immunophenotyping, and normal uterus and ovaries sonographies. CBC results at completion of treatment were as follows.
+WBC: 5.7??03/弮L, RBC: 3.47 mil/uL, Hemoglobin: 11.6 g/dL, Platelet count: 4??03/弮L, Neutrophile: 67%, lymphocyte: 30%, Monocyte: 3%.
+She stayed 3 years out of treatment and at complete remission and had regular visits, and on August 2008 she came for regular checkups and the results of her CBC were as follows.
+WBC: 69.9??03/弮L, 3.79 mil/uL, Hemoglobin: 11.3 g/dL, Hematocrit: 33.6%, M.C.V: 88.7 fL, M.C.H: 29.8 Pg, M.C.H.C: 33.6 g/dL, Platelet count: 136??03/弮L, Neutrophile: 60%, Eosinophile: 3%, promyelocyte: 2%, Band: 20%.
+On physical examination a mild to moderate splenomegaly had been noticed, and she had been put on antibiotic in case of underlying infection, and bone marrow samples had been taken for cytogenetic, molecular and immunophenotyping evaluations and another CBC sample had been also taken on October 2008 and the results were as follows.
+WBC: 82.6??03/弮L, RBC: 366 mil/uL, Hemoglobin: 10.9 g/dL, Hematocrit: 32.4%, M.C.V: 88.5 fL, M.C.H: 29.8 Pg, M.C.H.C: 33.6 g/dL, Platelet count: 152??03/弮L, Neutrophile: 51%, Eosinophile: 2%, Lymphocyte: 16%, Band: 27%, Promyelocyte: 1%, Myelocyte: 2%.
+The results of molecular evaluation of BM aspirate had been reported negative for t (4, 11), t (1, 19), and t (12, 21) and negative for BCR-ABL (P190) fusion gene and positive for BCR-ABL (P210) fusion gene (TaqMan Technology), and cytogenetic results were positive for Ph-chromosome or t (9; 22).
+She had been put on imatinib mesylate (Gleevec formerly ST-1571), and there had been a good hematologic and molecular response, and white blood cell count decreased from 76700/uL on April 2008 to 2400/uL on October 2008, and the BCR-ABL fusion gene decreased from 11700 cpn on May 2008 to undetectable on July 2010. On her last visit on April 2011, she had been under good control no organomegaly, stable condition and still receiving Gleevec, and her CBC results were as follows.
+WBC: 4.9??03/弮L, RBC: 3.38 mil/uL, Hemoglobin: 10.4 g/dL, Hematocrit: 31.7%, M.C.V: 93.8 fL, M.C.H.C: 32.8 g/dL, Platelet count: 172??03/弮L, Neutrophile: 63%, Eosinophile 1%, lymphocyte: 33.2, Monocyte: 3%.
+According to the CBC results, the patient had been in complete hematologic remission and on molecular evaluation of BCR-ABL fusion gene; the patient had also been in complete molecular response (CMR) status ()."
+Iker Rollins,36,1997/3/1,365.614.5284x97845,chelsea60@example.com,58678 Donald Crossroad Apt. 416,"A 24-year-old female presented to our outpatient department with complaints of foreign body sensation of the throat for the last 1 year. She also complained of change in voice for the past 4 months. She had no associated history of dysphagia or difficulty in breathing. On examination there was a 3 ? 3 cm smooth, grayish-white, firm, nontender swelling in the right side of base of tongue occupying the oropharynx (). No cervical lymph nodes were palpable in the neck. Rest of examination of the ear, nose, and neck, as well as general physical examination, was unremarkable.
+Contrast-enhanced computed tomography of the neck revealed a well-defined moderately enhancing soft tissue lesion involving the right side of base of tongue nearly 2.34 ? 2.29 cm in size which was compromising the oropharyngeal airway. The thyroid gland was normally located in the anterior neck (). Transoral fine needle aspiration cytology from the swelling was done which showed scattered cohesive clusters of epithelial cells surrounded by hyaline material. There was mild hyperchromasia and scattered squamous cells in background. Overall features suggested the possibility of pleomorphic adenoma.
+The patient was taken up for surgical excision. Tracheostomy was done prior to the procedure. A midline glossotomy was performed and deepened until the tumor was palpable. The lateral surface of the tumor was palpated and dissected using electrocautery. This approach provided an end on view to the lateral and inferior aspects of the tumor. The tumor was removed in toto with a cuff of normal tissue. The wound was sutured vertically in the midline from vallecula to tip of tongue (). Patient was started on oral feeding on the first postoperative day and was decannulated on the 5th day.
+Postoperative histopathology confirmed the diagnosis of pleomorphic adenoma with focal area of skeletal muscle involvement ().
+A postoperative computed tomography was done after 2 months of the operation which showed complete removal of the tumor. There has been neither functional disturbance nor any signs of recurrence to date ()."
+Araceli Montgomery,19,2002/5/18,659.617.8303,willieatkins@example.org,6408 Buchanan Ridges,"A 6-year-old boy presented to our emergency room because of vomiting and abdominal pain. His parents reported that he had a 3-day history of low-grade fever together with abdominal pain, emesis, and constipation. There was no history of altered mental status, coryzal symptoms, or headaches. He was reported to have ?utism?? and four weeks earlier he had been placed on a ?pecific carbohydrate diet??including ?gg protein shakes.??Two days later, he developed ?ives?? and the egg protein shakes were discontinued. However, pruritus continued and he developed excoriated and dry lips over the next few days. These latter symptoms continued until his presentation to our emergency room.
+His past medical history was significant for premature birth at 30 weeks gestation, nocturnal enuresis for the past 8 months with some recent improvement using a bed alarm, and an inguinal hernia repair at the age of 3 years. He had been diagnosed with pervasive behavioral/developmental disorder attributed to autism. In an attempt to manage his behavior, he was started on a casein- and gluten-free ?pecific carbohydrate diet??(eggs, fruits, vegetables without complex carbohydrates) together with protein shakes. These had been discontinued two weeks prior to admission because of the development of a skin rash and pruritis. He had also been placed on multiple dietary and vitamin supplements as part of the management of his autism. These included 6 drops/day of vitamin A (equivalent to 30,000 IU per day) added to his diet for the past 4 months, Vitamin B12 shots twice per week, a custom-made multivitamin, Vitamin E Drops, Coenzyme Q and Omega-3 fatty acids.
+Family history revealed that his father had a history of kidney stones as a young adult, which had not been further evaluated and have not recurred. Maternal grandmother had thyroid surgery for an ?veractive thyroid.??There was no family history of hyperparathyroidism, thyroid neoplasms, pheochromocytomas, pituitary tumors, or islet cell tumors.
+On examination when he was initially seen in the emergency unit, his weight was 21.6 kg (50th percentile) and height 123.5 cm (80th percentile). He was sleepy and in discomfort complaining of abdominal pain. He was mildly dehydrated. He was noted to have cheilitis and a blanching erythematous rash on his face. He had symmetric hyperreflexia in all four limbs with normal muscle tone. Funduscopic examination was within normal limits. HEENT, abdominal, cardiovascular, and respiratory exam were all within normal limits. There was no evidence of thyromegaly, and thyroid gland was nontender. Sexual maturation was Tanner Stage 1.
+On initial presentation, he had a normal basic metabolic profile except that the total calcium was 13.7 mg/dL (normal range: 8.6??0.3). Serum creatinine was 0.6 mg/dL and BUN 26 mg/dL indicative of his mild dehydration. Intravenous hydration was initiated, and he was hospitalized for evaluation and treatment of hypercalcemia. He was initially treated with intravenous hydration using 0.9% saline at 3 L/m2/day. He also received a single dose of intravenous furosemide 1 mg/kg. His calcium stabilized with hydration and furosemide therapy within 48 hours and remained stable (though still near or slightly above the upper limits of normal) off IV fluids for 24 hours (see ).
+Supplemental vitamin A was discontinued on admission. During his initial hospitalization, serum phosphorus was 4.0 mg/dL (normal: 3.0??.0 mg/dL), intact PTH <3 pg/mL (normal: 14??2), 25-hydroxy-vitamin D 22.3 ng/mL (normal: 10??5), and 1,25 dihydroxy-vitamin D 16 pg/mL (normal: 22??7). TSH 2.29 mcIU/mL (normal: 0.35??.5), Free T4 0.95 ng/dL (normal: 0.9??.8 ng/dL), alkaline phosphatase 209 IU/L (normal: 140??20), AST 76 IU/L (normal: 10??0), and ALT 34 IU/L (normal: 10??5). EKG showed normal sinus rhythm. A urinary calcium/creatinine fractional excretion ratio was 0.03, and calcium/creatinine ratio was 0.9 at the time when serum calcium was 13.1 mg/dl. Both parents had normal serum calcium and phosphorous levels. Serum vitamin A level was 1738 mcg/L (normal: 360??200 mcg/L).
+He was discharged home on the fifth hospital day with instructions for oral fluid intake of at least 1.5 L/m2/day. His total serum calcium on the day of discharge was 10.9 mg/dL. Serum calcium was to be checked by his primary physician daily and was stable for two days. Three days after discharge, he presented again to the emergency unit with recurrence of abdominal pain, vomiting, and generally not feeling well. He had not been able to keep up with the recommended oral hydration plan of at least 1.5 L/m2/day. At this point in time, mother also gave a history of hair loss since discharge. He had lost 2 kg in weight. He had marked blanching erythema on the cheeks and rest of the body together with cheilosis. Total calcium at this time was 12.6 mg/dL. He had not received any vitamin A since the initial admission seven days earlier. He was hospitalized once again and started on 3.0 L/m2/day normal saline hydration, 2 mg/kg/day of prednisone, and furosemide 1 mg/kg BID. Despite these measures, his calcium rose to 14.7 mg/dL during the next 24 hours () at which point he was given a single dose of pamidronate 0.5 mg/kg IV.
+Calcium came down to 9.8 mg/dL over the next two days and to 8.4 mg/dL five days after pamidronate. He was changed to oral hydration, and serum calcium remained normal over the next few days. He was discharged home after six days to continue oral hydration and close followup. During this second admission, he had a skeletal survey that was remarkable only for a bilateral coxa valga deformity and mild generalized osteopenia. His serum vitamin A level was 2668 mcg/L. Tuberculin test was negative, and a chest X-ray and renal ultrasound were normal. Parathyroid hormone-related peptide (PTHrP) was 0.3 pmol/L (normal: <2 pmol/L). He also had a normal bone scan. After discharged home, he remained stable without additional hypercalcemia. His serum Vitamin A level 30 days after discontinuation of vitamin A was at 1201 mcg/L and serum calcium of 8.9 mg/dL."
+Maximiliano Gutierrez,33,2003/1/21,772-652-9727,mooreanthony@example.com,0999 Black Common Apt. 594,"The patient was a 27-year-old male Staff Sergeant with 9 years of active-duty military service in the U.S. Air Force. He was an electronic warfare technician with an excellent service record who successfully supervised 20 military personnel prior to his deployment to an undisclosed location in Southwest Asia. In the six months prior to deployment, he received treatment by both military and civilian physicians for chronic low back pain associated with degenerative disc disease and secondary depression. He was prescribed a variety of medications including acetaminophen and codeine, hydrocodone and acetaminophen, acetaminophen and oxycodone, sertraline, mirtazapine, clonazepam, lorazepam, diazepam, and buspirone. He also participated in outpatient counseling with an Air Force social worker.
+Prior to his military deployment, he discontinued all medications except sertraline (200 mg per day) and diazepam (2 mg, as needed). When the patient was medically screened for deployment, he reported he was feeling well enough both physically and emotionally to be deployed. He was subsequently medically cleared for deployment, and shortly thereafter he received his first weekly dose of mefloquine for antimalarial prophylaxis. After arriving in the deployed location, approximately one week later, he took his second dose of mefloquine. Shortly after his second dose, he reported restlessness and sleep disturbances. The following week, after taking his third dose, the patient reported feeling moderately depressed. After taking his fourth weekly dose, he reported becoming very depressed and emotionally labile. His wife verified that he called home about this time and sounded very distraught and could not stop crying. Shortly after his fifth weekly dose, the patient began experiencing florid visual hallucinations, difficulty speaking, vivid nightmares, hypnopompic sleep paralysis, intense feelings of depression with uncontrollable crying, and strong suicidal ideations. He sought medical attention at a deployed medical clinic and was told to discontinue taking the mefloquine. He continued to take sertraline (200 mg per day), and his diazepam was increased from 2 mg as needed to 2?? mg twice daily to manage his acute emotional distress. He was later found wandering aimlessly on the other side of the deployed base, confused, and disoriented. Over the course of his deployment, the military service member was not exposed to any activity or stressor that might cause traumatic reactions and justify the symptoms recorded.
+The patient was subsequently aeromedically evacuated from his deployed location and arrived home a few days later, where his physical presentation and behavior alarmed his spouse. He was initially very quiet, nervous, and tense, displayed significant problems with word finding and speech enunciation, was afraid to go to sleep or be left alone, and was emotionally labile. The patient reported feeling overwhelmed by sensory stimuli and feeling ?ike a whole rush of stuff going into your brain at one time.??He perspired profusely and complained of being hot even on cold days. He continued to experience occasional visual hallucinations, violent nightmares, and ?lashbacks.??He reported that on one occasion, he became enraged and held a chair over his head, as if he was going to throw it at his wife when she did not respond quickly enough after he called her. All of these behaviors were reported to be very atypical for the patient.
+He was subsequently admitted to the inpatient psychiatric unit at Wilford Hall Medical Center in San Antonio, Texas, for further evaluation. His behavior on the inpatient psychiatric ward was very labile, ranging from agitated and confrontational, to tearful and shaky, to calm and cooperative. The patient participated in a neuropsychological evaluation over the course of two days, including an extended clinical interview and the administration of a comprehensive eight-hour battery of cognitive and personality tests. He was cooperative and appeared to put forth his best effort throughout the evaluation. His performance on ?ffort??tests and his scores on validity scales from the Minnesota Multiphasic Personality Inventory-2 were not consistent with symptom exaggeration, inadequate effort, or malingering.
+The patient's neuropsychological evaluation was considered valid. Although his full-scale intelligence quotient (IQ) was in the average range, he displayed significant deficits on certain neuropsychological tests, including moderate to severe impairments on measures of verbal learning, auditory and visual memory, verbal productivity, and upper extremity motor speed and dexterity. Milder impairments were noted on measures of sustained attention and concentration, information processing speed, visuomotor coordination and construction, and grip strength. Personality testing indicated that the patient was moderately depressed, anxious, tense, confused, and socially alienated. He reported a higher than average number of somatic complaints, reflecting his perception that his physical health was failing and his mind was not functioning properly."
+Savannah Pratt,28,1988/3/13,737-592-8686,josephbaker@example.com,7805 Henderson Mill,"A 31-year-old man presented with an asymptomatic, slowly enlarging, exophytic, brownish nodule of the abdominal wall with surface telangectasia (). His past medical and surgical history was significant for a resection of a lesion at the same localization 4 years earlier, which was histopathologically misdiagnosed as dermatofibrosarcoma protuberans. His general condition was good and the rest of systemic examination was normal. The recurrent nodule was totally excised. On macroscopic examination, tumor presented as a well-demarcated nodule of 22 mm in diameter, firm in consistency. On cut surface, it had dark-brown and yellow components. Histological findings demonstrated a well-defined unencapsulated dermal nodule with epidermal hyperplasia, an interposed grenz zone (defined as relatively normal collagen forming a boundary between normal epidermis and a dermal lesion) () and superficial involvement of the subcutis. At the periphery of the lesion, some hyaline large round collagen bundles were seen. The tumor was made of a dense proliferation of predominant histiocyte-like and fibroblast-like spindle cells arranged in interlacing fascicles or a storiform pattern. These cells were intermingled with atypical mononuclear and giant cells, sometimes with foamy cytoplasm, showing large, hyperchromatic, irregular nuclei; we found 4 mitotic figures per ten high-power fields (). No atypical mitoses were identified and no necrosis was detected. Prominent blood-filled spaces, numerous siderophages and hemosiderin deposits were noted. Immunohistochemical stains showed focal immunoreactivity for CD68 (), while cells were completely negative for S100 protein, HMB45, CD34 and alpha smooth muscle actin. These findings were consistent with the diagnosis of atypical cutaneous fibrous histiocytoma. The revision of the slides of the first tumor revealed the same morphological characteristics and immunohistochemical study was not performed. No recurrence has been detected 3 months after complete removal of the recurrent tumor."
+Rowen Moran,20,1990/11/14,001-842-458-4204x99473,danielmartinez@example.net,115 Cook Forest,"A 34-year-old man who had previously undergone craniotomy a total of three times in 2005 and 2006 presented with a progressive gait disturbance and was referred to our institution for further treatment. He presented with paraplegia involving bilateral lower extremities and a memory disturbance. Computed tomography (CT) revealed a huge isodense mass, approximately 8 cm in diameter, with strong perifocal edema involving the falx and superior sagittal sinus (SSS). The tumor invaded the calvarium and scalp, with compression of bilateral frontal lobes. Magnetic resonance imaging (MRI) showed the mass as isointensity on T1-weighted imaging and heterogeneously intense on T2-weighted imaging, with heterogeneous enhancement with gadolinium (Figures and ). Intratumoral flow voids were diffusely distributed. Cerebral angiography demonstrated that the tumor was fed by the anterior falcian, precentral, central, and middle meningeal arteries, as well as a thick branch that originated from the tentorial artery (Figures , , and ). The SSS was not visible, and the cortical veins as draining veins were dilated and drained into the sphenoparietal sinus and the superior petrosal sinus. The fourth craniotomy was carried out in 2009.
+The tumor was highly vascular, composed of elastic-hard, fibrous, grayish-white tumor and soft reddish components that invaded the calvarium. The tumor adhered tightly to the cerebral cortex with involvement of the falx and SSS, and there was arterial bleeding from the falx. Dense vascular networks were cauterized, the SSS was completely obliterated, and the tumor was dissected from the edematous cortex and then totally removed. Blood loss was 6500 mL. Postoperatively, the patient had paraparesis and was transferred for extensive rehabilitation. Postoperative MR images showed complete removal of the tumor without recurrence (Figures and ).
+Two months after the last operation, X-rays and CT scans of the chest demonstrated well-circumscribed, multinodular tumors in bilateral lungs (Figures and ). The right basal posterior segment (S10) of the lung was partially resected thoracoscopically and initially diagnosed as ?eningioma.??Two months after biopsy, the posterior segment (S2) and the superior segment (S6) were resected. The specimen showed two nodules in the upper lung (one in each of S2 and S3) and five nodules in the lower lobe (S6). These seven nodules measured 1-2 cm. Macroscopically, the multiple nodules in the lung had well-defined borders, whitish color, and firm consistency (Figures and ). The patient's postoperative course was uneventful."
+Celeste Lucero,35,1999/7/22,697-322-1351,heidi19@example.org,76481 Kelli Forest,"A 12-year-old girl was seen in the emergency room, with complaints of heavy bleeding per vaginum, since last 15 days, along with dysmenorrhea. She was referred to us from basic health unit. According to her mother, this was her first menstrual period. She had 7 siblings, 4 sisters, and 3 brothers. Her two elder sisters had normal, regular periods. Her past history was significant for bruises, epistaxis, and bleeding from gums from the age of three years. She was never transfused blood for these complaints, but did receive medical attention for the above complaints of epistaxis and bleeding from gums. One of her cousins had also died at the age of eight years, from uncontrollable hemorrhage from mouth and nose. Her maternal grandfather also died of intracranial hemorrhage, but there was no definitive diagnosis in both of the above deaths.
+At the onset of menarche, she suffered from heavy blood loss, with passage of blood clots. The amount of blood loss resulted in transfusion of one unit of blood. She was also kept on injectable tranexemic acid. The bleeding decreased initially for 48 hours, but was later followed by heavy bleeding per vaginum. At the onset of second episode of heavy vaginal bleeding, she was referred to Civil Hospital Karachi, for further management.
+General examination revealed extreme pallor, with blood pressure of 90/60 mm hg. Physical examination was unremarkable. Local examination revealed soiling of perineum, with blood and blood clots. Her hemoglobin concentration was 6 gm/dL, platelets count was 200,000, and prothrombin and partial thromboplastin time was normal. Her pelvic ultrasound was normal, with evidence of hematocolpos. She was started on injectable tranexemic acid 500 mg eight hourly, along with tab norethisterone 5 mg, three times daily. A single injection of depot medroxy progesterone 150 mg was also given. She was transfused four units of packed red blood cells. Her bleeding continued, despite the above measures. Her factor VIII level was assessed to rule out vWD and was found to be 150%. On the seventh day of her admission, her hemoglobin dropped to 3.8 gm/dL, with platelet count of 178,000. At this point we decided to perform platelet aggregation studies. Reports showed the following: ADP 18.1 (76.36??06.84%), collagen 20.4 (59??02%), epinephrine 24.1 (73.7??09.3%), ristocetin 59 (70.4??11.2%), and arachidonic acid 12.9 (55??27%). A diagnosis of Glanzmann's thromboasthenia was made. She was transfused with one mega unit (single-donor apheresis) of platelets then bleeding slowed for 6 hours and started again. She further received 4 more doses of platelets, but there was no improvement in bleeding. At this point, a decision was made for rFVIIa. She was given rFVIIa in a dose of 120 弮g/kg, dose repeated after 4 hours; bleeding slowed down a bit but continued. Subsequent two doses of 270 弮g/kg were given during next 24 hours. Bleeding decreased for 48 hours, but continued, and her hemoglobin again dropped. A decision for uterine tamponade was taken. Examination under anesthesia was done, and two Foleys catheters of size 10 F were passed in the uterine cavity and were inflated with 30 cc of normal saline to act as tamponade. They were left inside for 48 hours; then, bleeding stopped completely. She stayed in hospital for next few days and was discharged on oral contraceptive pills and ferrous sulphate."
+Felipe Sweeney,34,1992/10/8,+1-824-708-6717x8552,christy47@example.com,3142 Day Lake,"A 59-year-old-right handed man presented to the emergency department with a headache syndrome 6 months prior to admission. Head CT scan showed an enlarged sella and a suprasellar cystic mass (). His headache resolved so he sought no further treatment until one month later (5 months prior to admission) at which time he complained of a severe headache associated with a stiff neck. Examination during this episode was documented to have a headache with photophobia and nuchal rigidity. Visual fields were full to confrontation. Once again his headache improved with acetaminophen. An MRI showed an empty sella (). He re-presented to our office only three weeks later with a new MRI () that showed a large cystic lesion in the sella with suprasellar extension.
+During this visit, he appeared thin but not cachectic. There were no stigmata of Cushing's or acromegaly. His pupils were equal, round, and reactive to light and the extra-ocular movements were full and normal.
+Visual testing revealed a bitemporal upper quadrantanopia. Deep tendon reflexes were hypoactive throughout. The rest of the physical exam was within normal limits.
+Lab results were consistent with hypopituitary: TSH = 1.37 IUI/mL, Free T4 = 0.70 ng/dL, AM Cortisol = 5 ug/dL, FSH = 4.2 mIU/mL, IGF-1 = 43 ng/mL, and Prolactin = 4.12 ng/mL.
+He was started on thyroid replacement with levothyroxine and given the option of surgery. However, he was reluctant to agree to surgery and waited for 4 months. At this time he had developed a full bitemporal hemianopsia.
+Postoperatively, his visual complaints have been reversed and his fields are full to confrontation at 6 months. He remains on thyroid replacement."
+Yara Hurley,24,1978/7/1,553-289-7396x9765,rosenancy@example.org,309 Thomas Ridge Apt. 710,"A 51-year-old female presented with a 2-year history of swelling of the floor of the mouth. She was a deaf-mute since 2 years of age. Physical examination revealed deviation of the tongue to the upper side and swelling of the submandibular regions (). She was complaining of a swelling of the floor of the mouth but did not complain of dyspnea, swallowing difficulties, mastication, or phonation deficits. Blood tests were within normal limits, and a CT scan showed a low-density mass extending from the floor of the mouth to the mandible and protruding from the mylohyoid muscle (). MRI revealed that the mass measuring 50 ? 70 mm showed a homogenous, low signal intensity on a T1-weighted image and high signal intensity on a T2-weighted image (). The tumor was completely removed through a cervical approach under general anesthesia. The postoperative course was uncomplicated, and the patient was discharged. The position of the tongue returned to normal. The patient presented with neither taste disturbances nor sensitivity disturbances.
+Microscopy revealed that the circumscribed tumor consisted of interlacing bundles of spindle cells with hyperchromatic nuclei. Spindle cells were intermixed with foci comprising dense bundles of collagen fibers. Pathological diagnosis was a neurofibroma with no signs of malignancy (). Subsequent examination revealed no manifestations of VRD, and the patient's family history showed that no members of the family suffered from VRD. She had no caf矇 au lait spots and was followedup for 1 year with no signs of recurrence."
+Van Lawson,44,1999/11/2,9504859370,azavala@example.org,451 Kelly Mission Apt. 062,"The patient was a 44-year-old Venezuelan female which was referred to our center with asthenia, fatigue, fever, productive cough and respiratory difficulty. Previous past medical and chuirurgical antecedents were not significant. On examination, the patient had hepatosplenomegaly grade II. Laboratory findings revealed anaemia (Hb 5 g/dL), and hyperleucocytosis (total leukocyte count was 23, 1 ? 109/L) with the following differential count: 23% polymorphs, 20% lymphocytes, 9% monocytes, 2% eosinophils, 2% myelomonocytes, 4% metamyelocytes and 40% basophils; (platelets 120 ? 109/L). Bone marrow was infiltrated by 80% of cells with basophils granules in their cytoplasm and 20% of immature nuclei. Only a few blast cells were shown to be positive with Myeloperoxidase (MPO), the basophilic blast and the mature basophils were metachromatic in the toluidine blue stain, negative for the chloroacetate esterase, and, no reaction with acid phosphatase, Auer rods were absent. Immunophenotyping showed that the blasts were positive for CD34, CD33, and CD9 and negative for HLA-DR and CD14. Ultrastructural analysis reported the presence of azurophilic granules. Conventional cytogenetic studies using standard culture methods and GTG banding showed a trisomy of the chromosome 19 and translocation 9;22 on the 20 metaphases analyzed (). The presence of the BCR/ABL complex was detected by FISH analysis (Vysis, extrasignal) in 95% of the nuclei analyzed. Thus, myeloid chronic leukemia (CML) in blastic crisis was diagnostic. The patient was treated with oral hydroxyurea (2 g) with partial improvement, but she died two weeks later."
+Phoebe Shelton,36,1993/1/31,253.355.3883x95138,martinezjames@example.org,974 Vargas Drive,"A 53-year-old white man, suffered from type 2 diabetes diagnosed 20 years ago, was referred to our department for evaluation of recent discovery of incipient nephropathy and retinopathy. He was previously visiting another endocrinologist in the town but because of a change of job, he moved into the city. He brought a letter specifying that his glucose control had been acceptable since the diagnosis of diabetes (HbA1c lower than 7%). Recently, he was diagnosed of incipient nephropathy (microalbuminuria 200 mg/24 hours), high systolic blood pressure (140 mmHg), high LDL cholesterol (134 mg/dL), and retinal hard exudates close to the macula treated with laser photocoagulation. His current medication included metformin (2.550 mg/day), Detemir insulin (50 U/day), premeals Aspart insulin, simvastatin (20 mg/day), Candesartan (16 mg/day), and AAS (100 mg/d). Physical examination revealed the following: weight of 120 Kg, height of 174 cm, body index mass of 30,27 Kg/m2, blood pressure of 150/75 mmHg, and normal auscultation. The skin of the upper back and posterior neck was erythematous, indurated, and painless () with moderate restriction of range of motion of the shoulders and neck.
+Blood analysis revealed the following: leukocytes of 7500 弮L, haemoglobin of 16,3 g/dL, platelets of 281000 弮L, sedimentation glomerular rate of 10 mm, glucose of 135 mg/dL, creatinine of 0,3 mg/dL, cholesterol of 157 mg/dL, HDL-c of 58 mg/dL, LDL-c of 81 mg/dL, triglycerydes of 90 mg/dL, C peptide of 3,8 ng/mL, TSH of 1,78 弮UI/mL, negative antithyroid antibodies, microalbuminuria of 240 mg/24 h, and HbA1c of 6,7%. The serum protein electrophoresis was normal, excluding monoclonal gammopathy.
+When we noticed the lesion on the skin and asked about it, the patient explained that for the last 10 years he had noticed a progressive hardening of the skin of this area, that became less sensitive, and he also noticed a decrease in motility of his neck and shoulders. He did not remember if he was febrile 10 years ago when the lesion appeared on his back. He had never been studied for the skin disorder that he related with his obesity. The patient was sent to the dermatologist who suspected the diagnosis of scleredema and performed a skin biopsy. Histopathologic study demonstrated thick collagen bundles separated by spaces filled with mucin in the deep reticular dermis, consistent with scleredema adultorum of Buschke (). He recommended physiotherapy and UV-A1 therapy. The latter treatment was not made because of a lack of this modality of phototherapy in his town, then he started PUVA therapy.
+After two months of PUVA therapy (total cumulative UVA dose 120 J/cm2) and physical exercises, the patient has noticed amelioration of the mobility of the back and shoulders, and on exploration, the redness of the upper back has disappeared, and the skin was softer."
+Leonel Watts,34,1999/2/14,673.937.4423x4678,thompsonjoshua@example.org,4184 Dean Squares Apt. 509,"Mr. B is a 59-year-old African American male with a long history of bipolar disorder, maintained on fluphenazine decanoate, and lithium carbonate for over 30 years without any incidence of toxicity. His past medical history is significant for hypertension, Type II diabetes, and morbid obesity. He presented with a 1-week history of increasing confusion and lethargy, slurred speech, urinary incontinence, worsening tremor, and gait difficulties. He was found lying on the floor beside his bed on the day of presentation. The family was unaware of how long the patient had been lying there but found him awake and alert, unable to lift himself off the floor. About 2 weeks before presentation, his antihypertensive regimen was modified with a doubling of the dose of Valsartan to 320 mg/day, in addition to his regular lisinopril 20 mg/day. His other medications were lithium carbonate 450 mg twice daily and fluphenazine decanoate 37.5 mg every 3 weeks (last administered 3 weeks before admission). His last recorded lithium level was 0.7 just prior to the above medication changes. Other relevant baseline laboratory results a few weeks before onset of symptoms included Na-134 mEq/L, K-4.1, BUN, 23, and Cr. 2.4 mg/dL.
+Collateral history from his outpatient psychiatrists revealed that patient had been stable on the above regimen of lithium and fluphenazine decanoate with no medication changes made within the past 6 months.
+On examination in the ER, the patient was in moderate distress, dehydrated asking for water to drink. His vital signs were fluctuating with temperature ranging from 99.3 to 100.1, heart rate from 75 to 102, and BP from 123/69 to 223/112 all over a period of 6 hours. Cardiovascular and respiratory exams were unremarkable. Neurological exam revealed slurred speech, hand tremors, and rigidity in the extremities with decreased motor strength in the upper extremities and lower extremities. Patient was oriented to place and person but not to time.
+Admission labs showed a leukocytosis of WBC-22.6, neutrophil count of 87.9%; sodium was 142 mEq/L; potassium was 3.5 mEq/L, bicarbonate 20.1 mmol/L; BUN 35 mg/dL; creatinine 4.1 mg/dL; blood glucose 145, troponin I 5.64; CPK 6008; CK (MB) isoenzyme 36.7 and a lithium level of 1.20 mEq/L. Blood, urine and sputum cultures yielded no growth. CT/MRI brain showed old frontoparietal infarct, and EEG was reported as within normal limits for drowsiness and briefly aroused state with no epileptiform discharges. CSF from spinal tap was unremarkable.
+Patient was commenced on IV fluid hydration and broad-spectrum antibiotics. Lithium was discontinued and fluphenazine decanoate was not administered. Repeated blood cultures yielded no growth, and thus antibiotics were discontinued. Patient showed gradual improvement in his mental status, he had no problems with articulation, and he was fully orientated within a week of admission. His lithium levels had decreased to 0.89 on day 5 and 0.55 on day 7, and his renal function was back to baseline. Patient's vital signs stabilized, and there was minimal rigidity at the time of discharge."
+Melissa Carpenter,42,1978/10/3,-6647,rmitchell@example.com,947 Rachel Greens,"A 63-year-old lady presented to her GP in February 2010 with dyspepsia. She was otherwise well, but her blood pressure was 150/90. She was prescribed omeprazole 20 mg od for dyspepsia and lisinopril 10 mg od for hypertension. Her haemoglobin was 13.9 g/dL, white cell count 7.37 ? 109/L (eosinophil count 0.07 ? 109/L), and platelets 303 ? 109/L prior to treatment. The lisinopril induced a dry cough, but the medication was continued. Over subsequent months, her gastrooesophageal reflux symptoms worsened and an endoscopy was performed in July 2010. Histology from an oesophageal biopsy showed marked mucosal thickening with prominent intraepithelial eosinophils seen throughout, occurring in aggregates with microabscess formation. There was no evidence of dysplasia or malignancy. A diagnosis of eosinophilic oesophagitis was made (see biopsy image, ). No specific treatment was given.
+By November 2010, she had become unwell with anorexia, weight loss of 7 kg, and generalised malaise. She continued to have dyspepsia. Since February 2010, blood test results revealed the development of a normocytic, normochromic anaemia, a modest eosinophilia and raised inflammatory markers including polyclonal hypergammaglobulinaemia and an increase in the ferritin concentration (). She was treated with ferrous sulphate with no response.
+She was referred to the haematology department in January 2011 for further investigation of the anaemia and weight loss. A detailed history and physical examination revealed no additional abnormal findings. A chest-abdomen-pelvis (CT) was performed and ruled out an occult malignancy, and there was no evidence of infection. Her liver, renal, thyroid function and bone profile were normal. Her tissue transglutaminase was negative. She reported that she had started to feel unwell after starting the treatment for hypertension, and it was considered whether lisinopril was the explanation for her symptoms and laboratory abnormalities. The drug was stopped at the end of February 2011.
+One week after stopping the lisinopril, her systemic and gastrointestinal symptoms resolved. By April 2011, her haemoglobin concentration had increased and the ESR, ferritin, and hypergammaglobulinaemia all started to resolve (); these continued to improve and she was well in June 2011, with her weight improving towards her initial baseline."
+Jeremy Robinson,44,1984/3/13,883.561.1515x919,luis91@example.com,69293 Stout Throughway Apt. 757,"A 33-year-old Hispanic female with no significant past medical history was referred to the rheumatology clinic in May 2010 by her primary care physician for having pain and swelling in multiple joints since November 2009. Patient received a seasonal flu shot in October and a week later, she noted some joint pain and aches in hands, wrists, and knees, which resolved within a few days and patient became asymptomatic. A month later, she received H1N1 (swine influenza) vaccine and a week after started experiencing joint pain, swelling, and stiffness in hand, wrist, elbow, shoulder, and knee joints. She also complained of significant morning stiffness that last for more than one hour. On physical examination she had bilateral synovitis in fourth and fifth metacarpophalangeal (MCP), second, and third proximal interphalangeal (PIP) joints, with prominent left ulnar styloid. She fulfilled most of the criteria for classification of RA based on American College of Rheumatology (ACR) guidelines.
+Laboratory findings initially included an erythrocyte sedimentation rate (ESR) of 24 mm/hr, rheumatoid factor (RF) of 26 IU/mL, C-reactive protein (CRP) of 1.3 mg/dL, cyclic citrullinated peptide (CCP) IgG of 212. Her basic chemistry, liver function tests, hemoglobin, and complement levels were essentially within normal limits. Serological tests were positive for antinuclear antibody (ANA), RF, anticyclic citrullinated peptide (anti-CCP) and negative for SSA, SSB, hepatitis C virus, parvovirus B19 and being immunized for hepatitis B. Her radiological findings were negative for any joint effusion or destruction. On initial presentation to her PCP, she was given a 10-day course of prednisone 40 mg daily, which partially helped with symptoms in the beginning with eventual relapse of symptoms. Later she was started on methotrexate 7.5 mg weekly along with a short duration (3 weeks) of low-dose prednisone with daily folic acid and calcium/vitamin D supplementation. During her follow-up visit about 2 months later, her disease activity score (DAS) were 4.83 and number of tender joints was 7 and number of swollen joints were 5, with significant improvement in morning stiffness which lasted for 5??0 minutes. However, her pain was controlled only while she was on steroid therapy for 3 weeks and had returned thereafter. Later she was switched to golimumab (TNF-帢 inhibitor) 50 mg once monthly subcutaneously. Her methotrexate dose was also increased to 12.5 mg weekly. At her third visit her symptoms were much improved and her ESR and CRP were also within normal limits."
+Nora Bowen,18,1995/7/7,983.362.9111x33923,vpeck@example.org,91513 Mario Oval Suite 191,"A 75-year-old gentleman of Indian origin presented to a regional Ear, Nose, and Throat Department as a tertiary referral. The history of a painful lump over the left side of his upper neck was for approximately one year. The patient reported that the lump fluctuated in size and was initially painful but this improved with time. The accuracy of history was limited by the fact that the gentleman had a thick beard and may not have noticed the enlargement during shaving or from the external appearance. The pain was intermittent but worse after talking for long periods. He did not have any difficulty eating, shortness of breath, or alteration of hearing. There was no history of preceding trauma. Otherwise the patient was in good health, with no significant comorbidities.
+On examination the lump was located in the level 2 area of the neck extending into the preauricular area. The mass was firm and pulsatile. There was no facial nerve weakness or paralysis.
+All routine blood investigations, which included full blood count, renal function, clotting, C-reactive protein, liver function, fasting glucose, and lipids, were within normal limits. An ultrasound scan (US) of his left parotid region demonstrated a large aneurysm measuring 45 mm in maximum diameter, closely related to the left parotid gland. A subsequent computed tomographic (CT) angiogram was performed (Figure ()). This showed a thick walled aneurysm superficial to the mandible arising from the maxillary branch of the external carotid artery (Figure ()). Doppler US of his aorta and popliteal vessels excluded any further concurrent aneurysms.
+After discussions in the vascular surgical multidisciplinary meeting and with the patient it was decided to attempt endovascular embolisation.
+The external carotid artery was selectively catheterised with a 5 French vertebral catheter. Angiography during the procedure showed a very tortuous maxillary artery and the giant aneurysm arising from its midportion. The outflow branches appear to be arising from the sac itself and therefore we concluded that this was a true aneurysm. A microcatheter (Progreat-Terumo, Japan) was used to superselectively embolise the outflow vessel and the aneurysm inflow with (Vortex Coils-Cook Inc, USA) coils (Figure ()). Immediate angiography showed a successful procedure with no demonstrable flow in the aneurysm (Figure ()). Subsequently Doppler US of the aneurysm was performed which confirmed that there was thrombus and no flow in the aneurysm sac. There were no postprocedure complications and the patient was safely discharged home the following morning. At 6-month follow-up the mass has disappeared on clinical examination. Doppler ultrasound shows a tiny (<5 mm) area of residual flow at the aneurysm neck. No further treatment is planned."
+Trevor Trejo,20,1980/4/21,-6500,wadeterri@example.org,78987 Thomas Plain Suite 966,"A 71-year-old man developed progressive urinary obstruction symptoms and presented at our Hospital. Clinical examination suggested benign prostatic hyperplasia and a transurethral prostatic resection (TURP) was performed.
+Macroscopically, the excised tissue consist of many fragments of prostatic tissue weighing 30 grams.
+Microscopically, the histological specimens taken after TURP showed a diffuse proliferation of epithelioid and spindle cells, with a storiform and infiltrative growth pattern. There are not prostatic glands in the proliferation, no foci of necrosis, no vascular invasion. The neoplastic cells showed rare atypical mitotic figures in addition to moderate hypercellularity and moderate nuclear atypia with pleomorphism ().
+Immunohistochemically the neoplastic cells characteristically express diffusely CD34 and focally progesterone whereas no immunoreactivity was seen for cytocheratin (clone AE1?E3 and Cam 5.2), desmin, S-100, Bcl-2, chromogranin, CD117, and actin smooth muscle ().
+We evaluated additional immunohistochemical markers for their potential diagnostic and therapeutic utility. Although p53 and Ki-67 showed a very low expression.
+On the basis of the morphological and immunohistochemical features, a final diagnosis of LG-PS was made."
+Rosalyn Fisher,36,1979/6/13,(288)576-1435x67958,uanderson@example.org,89427 Mccarthy Forest,"An 86-year-old female presented to the trauma bay following a fall from standing in which she struck her face. There was no loss of consciousness, and she was not amnestic to the event. She had intractable epistaxis from both nostrils and was intubated on arrival for airway protection. On physical examination, she had profuse bleeding from both nasal passages and blood accumulating in her oropharynx. The nasal passages were packed anteriorly and posteriorly, but she continued to have bright red blood accumulate in her oropharynx. The patient was taken urgently to the angiography suite for evaluation ()."
+Gael Ingram,28,1984/11/23,5343888506,ckent@example.com,784 Michael Avenue Apt. 451,"A 25-year-old man presented with recurrent right epistaxis. Nasal endoscopy revealed a red, easily bleeding mass that filled the posterior part of the right nasal cavity. Enhanced computed tomography (CT) showed strongly enhanced tumor in the right nasal cavity with the extension to the PPF. The tumor also extended to the sphenoid sinus with bone erosion (). The tumor was considered as JNA, Radkowski stage IIA [], without performing preoperative biopsy due to the risk of bleeding. The angiography showed that the feeder into the tumor was internal maxillary artery (IMA) and the sphenopalatine artery (SPA).
+Endoscopic sinus surgery was performed under general anesthesia. Firstly, submucous inferior turbinoplasty (SIT) was performed. Vertical incision was made along the anterior margin of the inferior turbinate to expose the turbinate bone. The covering mucosa was elevated from the bone, and the inferior turbinate bone was removed with preserving the mucosa. Mucosal elevation was continued to expose the uncinate process. The inferior half of the uncinate process together with the horizontal portion of the inferior turbinate bone was then removed. SIT provided improved visualization and wide working space in the posterior part of the nasal cavity (Figures and ). The inferior turbinate mucosa was preserved throughout the surgery without swinging the lateral wall mucosa into the nasal cavity. Mucosal elevation was then continued posteriorly, and SPA, the feeder to the tumor was identified at the sphenopalatine foramen. Maxillary sinus was opened, and the mucosa was elevated from the posterior wall of the sinus. The posterior wall bone of maxillary sinus was then removed, and the PPF was widely exposed endoscopically (Figures and ). IMA was identified in the PPF and was ligated with a hemoclip, and IMA and SPA were cut with the Harmonic Scalpel (Figures and ). The tumor in the PPF was pushed into the nasal cavity. These procedures were all performed via submucous turbinate tunnel and were able to archive to manage the feeding artery safely without touching the easily bleeding tumor. Then, the tumor was resected transnasally without ethmoidectomy and was successfully removed in en bloc from the nasal cavity (Figures and ).
+No nasal packing was needed, and the postoperative course was uneventful. Postoperative histologic examination confirmed the diagnosis of JNA. No recurrences were observed at the 2-year follow-up examination. The anatomical structure of the nasal cavity and the physiological function of the nose could be preserved by this surgical technique."
+Katie Haynes,28,2000/4/1,+1-626-847-6295x6363,irush@example.net,8550 Wilson Cape Apt. 949,"An 80 year-old healthy female presented to the emergency department following a two-day history of dysphagia. On initial examination, the patient was leaning forward with her head in a sniffing position, her tongue was protruding, and soft but audible stridor could be heard. She was afebrile and had a heart rate of 84, blood pressure of 170/70, respiratory rate of 18, and an oxygen saturation of 96% on room air. Examination revealed anterior neck fullness with a deep purplish discoloration of her skin. There was significant swelling, and induration in the submandibular and submental regions extending down towards the base of neck. No major cartilaginous landmarks could be palpated. Inferiorly, the sternal notch could be palpated. Intraoral exam demonstrated some mild trismus, swelling, and purplish discolouration of the base of the tongue, and a very firm and woody floor of mouth bilaterally. Bloodwork showed WBC (12.2), Na (141) and BUN (22.2), creatinine (226), and CK (787, reference is <170) values. She was administered intravenous antibiotics and supplemental oxygen.
+A flexible nasopharyngoscopy was performed and significant airway edema including the tongue base and epiglottis was noted. A CT scan was obtained which revealed significant gas in anterior cervical space suggestive of infection (Figures and ).
+Following transfer to the OR, surgical airway and debridement was attempted. When sitting upright, the patients anterior neck was infiltrated with xylazine and an awake tracheostomy was commenced. Immediately after the incision was made, a large amount of purulent and necrotic tissue was encountered. Blunt tissue dissection was carried out until the anterior wall of the trachea was palpated. At that point the patient began to desaturate. An urgent transverse linear incision was carried out to enter the trachea and an endotracheal tube inserted and inflated. End-tidal CO2 was immediately obtained and the patient was manually ventilated until her saturations which were as low as 30% for a brief period of time stabilized at 99%. She was then placed under general anaesthesia and an extensive debridement of her anterior neck, bilateral submandibular and sublingual spaces were carried out.
+Intraoperative pathology of the necrotic tissue confirmed the diagnosis of Ludwig's angina which then developed into necrotizing fasciitis of her neck. Postoperative CT scans demonstrate clear loss of anterior neck soft tissue ().
+While recovering in the ICU, the patient developed acute renal failure and hypotension, which ultimately stabilized. Further debridements were necessary to completely remove the necrotic tissue () and the impacted mandibular molar responsible for the infection was subsequently extracted by oral surgery. Three weeks after admittance, a pedicled deltopectoral flap was used to reconstruct her soft tissue defect. The tracheostomy was eventually decannulated and the patient was discharged home."
+Kason Sweeney,21,1978/8/28,(501)394-8640,raygutierrez@example.net,38299 Mitchell Underpass,"Our patient is a 17-year-old male who was diagnosed with FA at 13 years of age when he presented with bruising, fatigue, and pancytopenia. Physical stigmata of FA included hypopigmented skin lesions, short stature (below 3rd percentile), micrognathia, and hearing loss. Diepoxybutane (DEB) testing revealed increased chromosomal breakage. FA complementation grouping was not performed. Two years later, at the age of 15, the patient experienced bruising, epistaxis, and fatigue and was diagnosed with T-cell ALL. T-cell ALL markers included CD1+, TdT+, CD2+, CD3+, CD4+, CD5+, CD7+ and CD 8+; however, cytogenetic markers were not available. He was treated with standard 4-drug induction therapy and received vincristine, prednisone, PEG-asparaginase, and 2/4 doses of daunorubicin at an outlying hospital as per Children's Oncology Group Protocol AALL0434. His clinical course was complicated by prolonged neutropenia (ANC < 500) lasting greater than 2 months and bacterial sepsis. He developed grade IV vincristine-related neuropathy by the Balis scale grading system. Within weeks of initiating vincristine dosed at 1.5 mg/m簡/dose, the patient became immobile and wheel-chair bound. He remained immobile for 12 months after vincristine therapy was terminated. He received cytarabine dosed at 125 mg/m簡/dose via continuous infusion for 3 consecutive days after which the patient developed fever and profound myelosuppression. Because of new onset respiratory symptoms, a chest X-ray was obtained that revealed a right middle lobe infiltrate. CT scan of the chest showed a cavitary lesion consistent with fungal infection and he was placed on voriconazole.
+Five months after the diagnosis of T-cell ALL, the patient was referred to our center for evaluation for bone marrow transplant. Pretransplant bone marrow aspiration and cerebral spinal fluid showed no evidence of malignant cells. MRI of the brain revealed a left parietooccipital abscess and CT scan of the chest showed enlargement of the right middle lobe cavitary lesion and small bilateral nodules consistent with fungal infection (Figures and ). CT scan of abdomen and pelvis showed multiple soft tissue abscesses of the upper thighs which were drained and found to be sterile. Antifungal therapy was initiated. The patient underwent complete surgical resection of the left parietooccipital lesion and partial resection of the lung lesion. Hyphae consistent with Aspergillus were identified on histopathologic studies from lung and brain lesions. Aspergillus species was cultured from brain tissue.
+Hematologic remission was sustained with modified dosing of cytarabine and intrathecal methotrexate. Our patient received an approximately 50% dose reduction of cytarabine (60 mg/m簡/dose) from the initial 125 mg/m簡/dose he had received previously. Cytarabine was administered over 15 minutes for 3 consecutive days instead of a 24 hour infusion in order to reduce cell exposure to chemotherapy. Reduced dose of intrathecal methotrexate (50% reduction of age-based dosing) was given followed by leucovorin rescue. Twenty-four hours after the completion of chemotherapy, filgrastim (5 mcg/kg) was started. The patient tolerated these agents well, neutrophils recovered within 12 days, and there was no progression of aspergillosis or leukemia.
+One month after partial pulmonary aspergilloma resection and 4 months after complete parietooccipital aspergilloma resection, the patient underwent a 10/10 matched unrelated donor bone marrow transplant using a modified reduced-intensity preparative regimen. The patient received voriconazole 200 mg orally daily and micafungin 100 mg IV daily for 4 months prior to BMT. Galactomanman levels remained negative, and radiographic studies of the brain and chest showed improvement and no new fungal foci. The BMT preparative regimen included fludarabine 140 mg/m2, cyclophosphamide 40 mg/kg, thymoglobulin 6 mg/kg (total doses), and 450 cGy TBI. 3 ? 106 CD34+ stems cells were obtained from the donor's bone marrow. T-cell depletion was achieved using rabbit ATG. GVHD prophylaxis included tacrolimus and mycophenolate. Neutrophils engrafted by day 14. There were no acute transplant-related complications. He received voriconazole for 6 months after BMT. At the time of this writing, 30 months after BMT the patient is without evidence of recurrent aspergillosis or leukemia, and continues to do well."
+Yara Walters,40,1985/7/14,(708)751-1012x49320,kcompton@example.net,99890 Regina Road Suite 979,"Approximately one year ago, a 24-year-old Japanese man came for treatment with the complaint of intermittent left otalgia and blood-tinged otorrhea for 3 months. He noted a slight decrease in the hearing acuity of his left ear. He denied fever, vertigo, tinnitus, or facial weakness. He had no history of recurrent otitis media, trauma, or otologic surgery. Clinical examination revealed the presence of a mass that nearly occluded in the left external canal. The mass was smooth, elastic soft (). The tympanic membrane appeared normal in fiberscope. No other skin or mucosal lesions were noted. Computed tomography scan (CT scan) revealed the soft tissue mass without bony erosion or involvement of the middle ear and appeared to originate from the inferior external canal wall (). Magnetic resonance imaging (MRI) showed that the mass measuring 10 ? 10 mm showed a homogenous, iso signal intensity on a both T1- and T2-weighted image (). We performed cytological examination, and consequently it revealed no malignancy (data not shown). Blood test and the serum chemistry were within normal range. We considered it as a benign tumor which occurred from external canal wall. The patient underwent complete resection of the lesion through a transcanal approach, and we could easily extirpate it, because there was no adhesion between the mass and cartilage of ear canal. The histopathologic examination was that the predominant cell is the foamy histiocyte. The Touton giant cell is also commonly seen in this entity. This is a multinucleated cell with a peripheral ring of nuclei and a glassy, eosinophilic cytoplasm. This histopathologic examination is compatible with xanthogranuloma (). A half year passed, and there was no recurrence. His left hearing after surgery is normal."
+Colson Sawyer,33,1984/12/20,001-286-284-7849x64302,matthewsolomon@example.org,874 Joseph Trafficway Suite 331,"A 68-year-old Hindu male, who was a known case of hypertension since 10 years, reported to us with history of low-grade fever and intermittent headache since 10 days. Headache was generalized and relieved with medication. Meanwhile patient developed c/o of right-sided nasal obstruction and proptosis since seven days. There was no history of nasal discharge/bleeding or any ear/throat pain or any discharge.
+He was admitted in local hospital for the same for 3 days; here he was diagnosed as having pneumonia with right lower zone consolidation. Antibiotics and symptomatic treatment were given. There was no improvement in his condition so he was referred to our institution for confirmed diagnosis and management.
+Patient had a past history of CV stroke followed by facial palsy 5 years back. Patient was nondiabetic but was on regular antihypertensive drugs. He did not have any history of chronic illnesses or surgery in the past. Patient had an agricultural background.
+On examination patient was afebrile with normal pulse and heart rate. All other systems were normal. On ENT examination right maxillary sinus tenderness was present. Local examination of nose showed no local deformity, and vestibules were normal. Ophthalmological examination revealed right-sided proptosis with restricted ocular movements in all directions. Conjunctival congestion with pseudophakia was present. Pupil on right side was nonreactive to light. All findings suggested 3rd and 6th nerve palsy.
+Laboratory investigations showed leucocytosis with total count of 15,800/cumm. Peripheral smear did not reveal any abnormality. Patient was hyponatremic on admission. On routine macroscopic and microscopic examination, CSF was turbid with high protein count of 75 mg/dL, and total cells were 4 cells/uL, all being lymphocytes. Patient was negative for HIV. CT scan of brain and paranasal sinuses showed mucosal thickening of all sinuses with cellulitic changes in right orbit involving extraconal, intraconal, and preseptal compartment of orbit. MRI scan suggested changes of pansinusitis with possible fungal infection in right posterior ethmoid, sphenoid, and maxillary sinuses. There was inflammatory phlegmon with early developing abscess in right medial orbit with erosion of lamina papyracea and involvement of medial orbital content with extension of infection into infratemporal fossa and intracranial extension with focal meningitis in right frontotemporal region. Provisional diagnosis based on clinical and radiological findings was acute invasive rhinosinusitis with right eye proptosis and involvement of central nervous system.
+The patient underwent endoscopic surgery under general anaesthesia. Fungal debris was removed from both nasal cavity and paranasal sinuses. Intraoperatively blackish mass along with necrotic tissues was removed.
+Clinical specimens were collected and sent to the laboratory for microbiological and histological examination. On gross examination, tissue was brown to black in colour, necrotic, and hemorrhagic. The tissue, after mincing into small pieces, was subjected to 10% potassium hydroxide (KOH) mount which showed two different types of fungal elements. There were narrow, branched, septate hyphae along with globose vesicle containing phialides and conidia. Another type of hyphae was wide, aseptate, and ribbonlike with sporangium containing round sporangiospores. To our surprise, umbrella-shaped empty sporangia along with underdeveloped rhizoids and nodal sporangiophores were also visible in wet mount preparations (). Thin, septate hyphae with vesicle and conidia along with aseptate hyphae and sporangium in KOH preparation were seen in the same field (). The minced tissue specimen was inoculated on SDA plate with antibiotics for fungal culture in duplicate; one set was incubated at 25簞C and another at 37簞C. On SDA plate, and after 48 hrs 2 types of growth were observed. One was mat-like initially having rugose texture which changed to granular and powdery with yellowish-green surface pigment; another was cottony, woolly, and fluffy (). Subculture from both types of growth was performed for isolation of both fungi. Microscopic examination with lactophenol cotton blue staining also confirmed 2 different types of fungus. There were hyaline, branched, septate hyphae with large globose vesicle containing uniseriate phialides fully covering the vesicle with chains of yellowish-green round conidia with foot cells attached at the conidiophores. LCB preparation from mixed culture showing ruptured sporangium with developing vesicle in the same field in . All these findings favor diagnosis of Aspergillus flavus. Another finding was broad, aseptate, irregularly branched ribbonlike hyphae with sporangiophores arising from the hyphae and enlarging distally into hemispherical columellae with flattened base containing round sporangia. Sporangiospores were ovoid to elliptical and light brown in colour. At some places umbrella-shaped ruptured sporangia along with underdeveloped internodal rhizoids were seen confirming the diagnosis of Rhizopus arrhizus.
+The fungus was identified as coinfection of Aspergillus flavus and Rhizopus arrhizus. The histopathological report endorsed our findings showing broad and aseptate hyphae suggestive of Zygomycetes sp. and thin, septate hyphae with dichotomous branching suggestive of Aspergillus sp. ()."
+Marina French,42,1982/5/15,2519513295,matthew14@example.org,15760 Michelle Branch,"A 29-year-old nonsmoker lady presented to our department with complaints of fever and productive cough of three-week duration. Her chest radiograph showed bilateral infiltrates more so in upper zones (). She had normal haematological and biochemical parameters. There was no clinical evidence of any immunosupression. Acid fast bacilli were found in sputum smears and subsequently culture demonstrated Mycobacterium tuberculosis. She was advised of category 1 regimen of the Revised National Tuberculosis Control Programme of India which consists of isoniazid, rifampicin, ethambutol, and pyrazinamide three times weekly for 2 months followed by isoniazid and rifampicin three times weekly for 4 months, but she refused the same and was prescribed daily regimen consisting of isoniazid (300 mg), rifampicin (450 mg), ethambutol (600 mg), and pyrazinamide (1250 mg) for two months followed by isoniazid (300 mg) and rifampicin (450 mg) for four months. After three months of chemotherapy she was readmitted in our emergency department with complaints of left-sided pleuritic chest pain and exertional breathlessness. Her chest radiograph showed pneumothorax on left side () and corresponding computed tomography of thorax (CT) showed massive pneumothorax of left side with infiltrates and cystic spaces in right upper lobe (). The patient was advised of intercostal tube drainage but she refused. So she was managed conservatively with oxygen, cough suppressants, and bed rest. Since the patient was smear and culture positive for Mycobacterium tuberculosis, both were repeated and the results were negative. With supportive care, her condition improved and was discharged with the advice to continue antituberculosis drugs and to be on regular follow-up. Chest X-ray and CT at the completion of six months of chemotherapy regimen showed complete resolution of pneumothorax (Figures and ). The patient is under our regular follow-up without any complications."
+Corey Hanson,33,1978/3/10,785-669-8355,martintheodore@example.com,46162 Steven Turnpike Suite 431,"The patient was a 19-year-old male with a ten-year history of epilepsy, as well as transient episodes of severe morning headaches with nausea, vomiting, and dizziness. At age nine during a workup for severe headaches, he was found to have a presumed right insular vascular abnormality on imaging. A month later, the patient began having seizures. He was managed medically for ten years; however, during this time, his seizures progressed in frequency from occurring approximately once every six to nine months to almost daily simple or complex partial seizures and rare generalized tonic-clonic seizures despite maintenance on high-dose antiepileptic therapy. Given his refractory and progressive disease, he eventually presented to clinic for consultation about possible surgical management. The only finding on physical examination was distal left upper extremity weakness and hand muscle atrophy resulting from an injury in a motor vehicle accident sustained at the time of a seizure.
+A magnetic resonance imaging (MRI) scan performed one year prior to surgery showed a suspected single right posterior frontal flow void with adjacent cortical foci of susceptibility artifact compatible with calcification or hemosiderin from remote, small hemorrhages suggesting an atypical vascular lesion (Figures and ). The flow void itself had the appearance of a developmental venous anomaly (DVA), but the pattern of adjacent hemosiderin deposition was noted to be unusual for DVA or an associated cavernous malformation. There were no imaging features specific for parenchymal arterial venous malformation (AVM) or dural AV fistula. The vascular abnormality identified in the right frontal operculum was not demonstrated on MRA images. Imaging was repeated and showed the same lesion again felt to likely represent an atypical vascular malformation (Figures and ).
+The patient was elected to undergo intracranial seizure monitoring with subdural grid and depth electrode placement in order to determine the location of all epileptogenic foci.
+Postoperatively, the patient had some left-sided weakness, dysarthria, and left facial weakness. At one month postoperatively, he was almost completely back to his baseline with only minimal residual left facial weakness. The patient did not experience further complex partial seizures. In the immediate postoperative period, he had occasional auras every two to three days, but at one month postoperatively, this had decreased to once every four to six days. At his 20 month visit, he had no auras and his previously almost daily seizures had been eliminated. He was continued on his antiepileptic medications; however, a few days prior to his one year postoperative visit, he stopped taking his seizure medications for two days and suffered a generalized tonic-clonic seizure. A surveillance MRI performed at this visit showed encephalomalacia and no change in the size of the residual lesion (Figures and ). The patient's seizure medications were resumed, and he has not had any seizures or auras since on dual antiepileptic therapy."
+Mariana Moon,42,1980/8/3,(258)788-2224,warnold@example.org,92024 Renee Ports,"A 17-year-old male presented to University Medical Centre with persistent hiccups for 4 months and blurring of vision (both eyes) for 1 week. On examination he was found to be hypertensive with blood pressure of 180/110 mm/Hg in both upper limbs with heart rate of 94 beats/min. Fundus examination showed bilateral papilledema with grade 4 hypertensive changes and rest physical examination was within normal limits. He was then evaluated for renovascular hypertension.
+His routine investigations were as follows: Hb: 110 g/L, Creatinine: 55 micromol/L, Urea: 5 mmol/L, Na: 137 mmol/L, K: 3.8 mmol/L, Ca: 2.4 mmol/L, and Po4 : 1.1 mmol/L. His renal artery Color Doppler showed normal renal parenchyma and renal artery diameter but showed a bilateral suprarenal mass. Patient's CT abdomen was done that showed a relatively encapsulated, heterogeneously and moderately enhancing soft-tissue density mass (right??.9 ? 5.3 ? 6.9 cm and left??.8 ? 3.9 ? 4.6 cm) bilaterally in suprarenal area with internal necrotic and cystic areas (). 24 hr urinary metanephrines estimation was 450 mmol/mol creatinine (N??0??11 mmol/mol creatinine). Patient's 24 hr urinary vanillylmandelic acid estimation (VMA) was 137.86 micromol/day (N??.02??7.91 micromol/day). In the meanwhile, patient was started initially on prazosin 5 mg twice daily which was then followed by addition of propranolol (40 mg) once daily resulted in blood pressure of 134/86 mm/Hg (supine). Patient was reevaluated but neither gave any significant family history nor had any signs suggestive of MEN 2A/2B/1, VHL syndromes, or neurofibromatosis. Patient did not show cushingoid habitus or signs of virilisation. Patient's calcitonin estimation was 2.0 ng/L (N????6 ng/L). MRI Brain did not show cerebellar or retinal hemangioblastoma. CT chest was within normal limit.
+Patient was then shifted to the surgery department for surgical removal of the mass. Bilateral adrenlectomy was performed without any intraoperative complications. The mass was sent for histopathological examination. Postoperatively patient did not have complications, he got relieved off his hiccups, blood pressure was 130/70 mm/Hg off the antihypertensives, and he was supplemented with wysolone and fludrocortisone, awaiting histopathological examination.
+Histopathological examination of adrenal mass showed tumor cells arranged in mixed trabecular and nested pattern with marked nuclear pleomorphism and increased mitotic rate (). Areas of extensive necrosis and capsular invasion were noted. Immunohistochemistry of the tissue sample was positive for chromogranin. Post operative VMA was 35.3 micromol/day."
+Nova Atkinson,23,1985/8/18,(718)878-7509,acooper@example.org,897 Mills Brooks Apt. 009,"The patient is a 27-year-old male with no past medical history who was diagnosed with multiple myeloma and multiple osseous plasmacytomas in February 2008 on presentation with hip pain and a palpable rib mass. Laboratory studies at time of myeloma diagnosis are shown in . The patient was initially treated for his myeloma with radiation therapy to the right pelvis. He then received four cycles of bortezomib (1.3 mg/m2 on days 1, 4, 8, 11 of 3-week schedule), lenalidomide (15 mg daily for 14 days), and dexamethasone (40 mg po weekly) from April through June of 2008; platelet counts during this treatment ranged from 121,000 to 216,000 ().
+The patient received an autologous peripheral blood stem cell transplantation in July 2008 with a priming regimen consisting of cyclophosphamide (4 g/m2 on day-21) and melphalan (200 mg/m2 on day-1). His outpatient posttransplantation course was notable for severe thrombocytopenia that was unresponsive to platelet transfusions for approximately two weeks (). Platelet counts recovered to 135,000 by day +19 following transplant. From October through December of 2008, the patient received consolidation chemotherapy consisting of four additional cycles of bortezomib (1.3 mg/m2 on days 1, 4, 8, 11 of 3-week schedule), lenalidomide (15 mg daily for 14 days), and dexamethasone (40 mg po weekly). Following consolidation, he was maintained on single-agent lenalidomide (25 mg daily).
+In January 2009, the patient described new onset of alopecia involving his facial, leg, and chest hair. In early March 2009, the patient developed new leukopenia (WBC 3.1), but other cell counts including hemoglobin, hematocrit, and platelet counts remained stable (). Due to concern for progressive leukopenia, the patient's lenalidomide was discontinued on March 10th, 2009. Approximately 17 days after discontinuing lenalidomide, the patient developed new petechiae on his lower legs and was found to have a platelet count of 1,000.
+On presentation with acute thrombocytopenia, the patient reported no recent travel, no viral illnesses, and no new medications. Laboratory studies obtained at time of new thrombocytopenia are shown in . Peripheral blood film confirmed absence of platelets and no evidence of schistocytes or dysplasia ( and ). A bone marrow biopsy revealed normocellular bone marrow with trilineage hematopoiesis and adequate megakaryocytes ( and ). There was no increase in plasma cells. Drug-dependent antibodies to lenalidomide were negative. Restaging studies performed in March 2009, 10 days prior to presentation with ITP, included PET scan which revealed innumerable lytic lesions within the axial skeleton but no significant interval changes compared to scans from August 2008.
+The patient was diagnosed with acute ITP and was initially treated with high-dose dexamethasone and intravenous immunglobulins. As shown in , platelet counts steadily increased on tapering of steroid therapy."
+Jazmin Gross,45,2004/12/30,001-961-975-1485,katie67@example.com,4607 Strong Crossroad,"The patient, a 43-year-old nulliparous premenopausal Greek woman, presented to the Department of Obstetrics and Gynecology of the University of Patras Medical School with a complaint of abdominal pain and abnormal uterine bleeding. Her surgical history was unremarkable. She was suffering from SSc the last 21 years. She received methotrexate, D-penicillamine, and corticosteroids after initial diagnosis of SSc. Her family history revealed no evidence of cancer among the first-degree relatives.
+On gynecologic examination, there was a palpable pelvic mass. There were no palpable inguinal lymph nodes, and the rest of pelvic examination was normal.
+Preoperative computer tomography (CT) of the abdomen and pelvis and abdominal ultrasound (U/S) revealed an intra-abdominal mass 15 ? 15 ? 12 cm. Preoperative computer tomography (CT) of the chest, chest X-ray, intravenous pyelography (IVP), colonoscopy, and urethrocystoscopy were normal. Preoperative CA-125 was elevated as 426 U/mL.
+On exploratory laparotomy, the left ovary was markedly distended, measuring 20 ? 15 ? 10 cm. Frozen section showed malignancy, and the patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, total omentectomy, appendectomy, and pelvic lymph node dissection.
+The histopathology revealed synchronous primary cancers of the endometrium and left ovary. The endometrial tumor invades less than one half of myometrium (). The ovarian tumor invades and ruptures the capsule of the left ovary, invades left fallopian tube, and extents to the omentum (). The right ovary was normal. The peritoneal washing smear was negative for malignant cells. Tumor cells in both primary cancers were positive for vimentin, cytokeratin, epithelial membrane antigen, estrogen receptor, progesterone receptor, CA-125, CA19-9, and B72.3 and negative for CEA.
+The final diagnosis was stage Ib endometrial cancer endometrioid type and stage IIIc ovarian cancer endometrioid type.
+The patient underwent postoperative adjuvant chemotherapy. She received six courses of carboplatinum (AUC 5) and paclitaxel (175 mg/m簡).
+Follow up 89 months after initial surgery, with CT of the chest, abdomen, and pelvis, abdominal U/S, chest X-ray, IVP, colonoscopy, and urethrocystoscopy, revealed no evidence of recurrence."
+Quinn Austin,42,1998/12/18,632-803-5515x659,brandon74@example.org,733 Mary Brook,"A previously healthy 49-year-old female with complaints of sudden chest discomfort stretching down both arms was admitted to the hospital. Cardiac enzymes were elevated, and an EKG showed ST segment elevation with evidence of possible acute inferolateral myocardial infarction (Table ).
+However, cardiac catheterization found no hemodynamically significant coronary artery disease. The residual ejection fraction was 30% and showed profound left ventricular dysfunction, including akinesis of the mid anterior, apical anterior, apical, and inferoapical wall segments, with dyskinesis of the mid inferior, basal inferior, and anterobasal wall segments. No potentially causative physical or emotional stressors were identified. The patient was treated with nitrates and angiotensin converting enzyme (ACE) inhibitors."
+Alivia Conner,20,2000/10/21,+1-789-995-6501x12502,obuck@example.net,665 Perez Vista Apt. 497,"A 74- year-old female with a history of seizures and hypertension was admitted to the hospital after having been ?ound down??and obtunded from a fall that occurred two days prior. Cardiac enzymes examined, CK, CK-MB, and troponin I, were significantly more elevated in this case (Table ). We believe that there may have been some component of acute kidney injury secondary to the immobilization, which may have artificially inflated the creatine kinase and creatine kinase-MB beyond what is typically seen in Takotsubo cardiomyopathy. An EKG uncovered T-wave abnormalities and a suspected anterior infarct. Echocardiogram showed apical ballooning of the entire distal lateral septal, anterior, and inferior walls. After an imaging excluded intracranial pathologies, an emergency cardiac catheterization was performed which showed normal angiographic coronary arteries, but indicated severe left ventricular systolic dysfunction. We believe that this condition was triggered by the physical and emotional stress of her fall. The patient was treated with beta-blockers and ACE inhibitors."
+Phillip Gomez,33,1992/5/18,(660)906-2644x795,juliaibarra@example.net,32819 Rebecca Orchard,"An 84-year-old female was admitted with complaints of worsening nausea, vomiting, diaphoresis, and non-radiating midscapula pain. The patient also has an extensive past medical history, which includes diagnoses of paroxysmal atrial fibrillation, cerebellar hemorrhage, subdural hematoma, orthostatic hypotension, hypothyroidism, cholecystectomy, and colon cancer. In addition, the patient reports significant family stressors. Upon examination, cardiac enzymes were elevated, and the EKG demonstrated ST elevation in the lateral leads (Table ). Cardiac catheterization showed luminal irregularities, with mild coronary artery disease, but was otherwise normal. The left ventricular ejection fraction was 20%. This event is believed to have been provoked by recent family stresses and was treated with beta-blockers, ACE inhibitors, and statins."
+Natalie Camacho,21,1983/3/28,367.642.3194,maldonadokatherine@example.org,54580 Johnson Plains Apt. 554,"A 37-year-old female with a history of hypertension developed shortness of breath and chest pain immediately following a severe allergic reaction provoked by desensitization shots administered by an allergist. In addition, the patient had been taking unspecified 'fat burning pills' for the previous four days. Elevated cardiac enzymes and suspected inferior wall myocardial infarction prompted an emergency cardiac catheterization (Table ). This procedure did not identify any coronary artery disease, but did reveal severe mid inferior wall dyskinesis and moderate mid anterior wall dyskinesis. The echocardiogram was performed three days later, at which time no abnormalities in wall movement were identified. The allergic reaction is considered a contributing factor to the onset of these symptoms. The patient was initially treated with intravenous epinephrine and heparin followed by ACE inhibitors and beta-blockers."
+Tatum Hicks,22,1979/3/27,001-463-464-2823,andrew05@example.org,96127 Owens Mission Suite 342,"A 63-year-old female with no known past medical history presented with shortness of breath. Cardiac enzymes, particularly troponin I, were only mildly elevated (Table ). The EKG showed poor R-wave progression and nonspecific ST changes. Cardiac catheterization showed only minor obstructive coronary artery disease. The LV was found to exhibit dyskinesis at the base of the anterior and posterior walls, akinesis of the mid and distal anterior wall and of the mid inferior wall, and dyskinesis of the apex. The history did not indicate any known stressors that contributed to this event. The patient was treated with ACE inhibitors and beta-blockers."
+Alina Craig,42,1983/1/6,3324518940,mark38@example.com,898 Hayes Estates,"A 34-year-old Caucasian female presented to the Emory Eye Center in March 2015 with complaints of blurry vision in both eyes for the past 1 week. The patient? past medical history is notable for multiple sclerosis (MS) diagnosed in 2011 after an episode of bilateral optic neuritis and gait instability. Her MS was initially managed with interferon beta-1a in 2011, but due to recurrent flares, she was transitioned to natalizumab in 2012. She had received monthly infusions of natalizumab with the last infusion 3 weeks prior to presentation. Visual acuity was 20/25 right and 20/50 eccentrically left eye. The pupils were equal and reactive without a relative afferent pupillary defect. Intraocular pressures were 14 in both eyes. Extraocular motility was full and non-painful in both eyes. Anterior segment exam was notable for trace cell in the right eye and 2 + cell in the left eye. Funduscopic examination showed areas of retinal whitening in the macula and periphery in both eyes with more confluent areas of necrosis in the left eye associated with retinal hemorrhage (Fig. a, b).
+The patient? clinical presentation was consistent with bilateral acute retinal necrosis, and she was admitted for further evaluation and management. A diagnostic anterior chamber (AC) paracentesis was performed, and the sample was tested for VZV, HSV, CMV, and toxoplasmosis PCR. The patient was given intravitreal injections of foscarnet 2.4 mg/0.1 cm3 and ganciclovir 2 mg/0.1 cm3 in both eyes and administered intravenous acyclovir. The diagnostic AC paracentesis was positive for VZV, and systemic work-up was unrevealing for HIV. Magnetic resonance angiography was negative for evidence of CNS vasculitis. After consultation with neurology, natalizumab was discontinued. Over the next several months, the patient was given multiple bilateral intravitreal injections and continued on systemic oral valacyclovir 1 g three times a day. The infection in the right eye resolved, and she maintained good vision at 20/30 at the last follow-up. However, despite aggressive therapy, the retinitis in the left eye rapidly spread throughout the macula and went on to involve the optic nerve with a drop in vision to hand motion. The patient later developed a macular-sparing combined tractional and rhegmatogenous retinal detachment in the left eye. Four months after presentation, the patient underwent scleral buckling and pars plana vitrectomy with silicon oil and successful reattachment of the retina. Visual acuity in the left eye at the last follow-up was hand motion, limited by macular and optic atrophy. The patient remains off natalizumab and is taking oral valacyclovir 1 g daily."
+Odin Hardy,32,1989/5/7,-10742,denisebauer@example.org,09675 Raymond Row Apt. 988,"A male patient aged 6 years reported to Department of Pedodontics and Preventive dentistry, VS Dental College and Hospital, Bengaluru. Patient? mother complained of severe bleeding from gums from past 1 week and inability of the child to eat. The child is known case of cerebral palsy with microcephaly and mental retardation with developmental age of only a few months (). Patient showed minimal response to verbal commands.
+On intraoral examination, erythematous gingival overgrowth was noted on labial and palatal aspects of 54 () and labial aspect of 64. On palpation, profuse bleeding was noted.
+A detailed case history was taken and it was noted that the patients teeth were cleaned once daily by mother by wiping with a wet cloth. No brushing or use of any dentifrice was done from the beginning.
+Depending on clinical examination and based on the oral hygiene status of the patient, a provisional diagnosis of inflammatory gingival hyperplasia due to poor oral hygiene was obtained.
+Pediatric opinion on general state of patient was obtained and after performing all the necessary blood investigations, excision of hyperplastic gingiva in relation to 54 was planned and done under local anesthesia (). The excisional biopsy specimen was sent for histopathological examination ().
+Meanwhile, mother was educated regarding the importance of oral hygiene, method of brushing and other oral hygiene practices. Chlorhexidine mouth rinse was also advised and the surgical excision of the tissue in relation to 64 was deferred till the final diagnosis was obtained.
+The histopathological examination confirmed the diagnosis of inflammatory gingival hyperplasia secondary to poor oral hygiene status.
+Patient was recalled after 1 week for excision on the other side, i.e in relation to 64 but it was observed that there was spontaneous healing of the gingival tissues probably due to the oral hygiene measures adopted ( and ). Therefore parents were advised to continue with oral hygiene measures and patient is being reviewed regularly."
+Jessica Solis,35,1992/11/2,(571)651-6085,fwilliams@example.net,082 Williams Expressway,"A 13-year-old boy reported to the Department of Pedo-dontics and Preventive Dentistry with the chief complaint of pain in upper right front tooth region. On examination there was an Ellis and Davey class 3 fracture with 11, tenderness positive with history of trauma 1 year back. Radiograph revealed incomplete root formation (). On the same day access opening, working length and biomechanical preparation was done and canal was dried with paper point and filled with calcium hydroxide for disinfection for 1 week (). After a week, Ca(OH)2 was removed and then with the help of carrier MTA was placed into apical region (). Material was then condensed into apical area and access opening was sealed with temporary filling material (). Placement of the material was confirmed with a radiograph and after a week, tooth was obturated with gutta-percha (). After 6 months follow-up radiograph revealed well sealed and healthy apical region ()."
+Ronin McDonald,31,1985/8/6,235.468.2622,erinwalker@example.org,08826 Gregory Turnpike Apt. 840,"A 9-year-old girl reported to the Department of Pedodontics and Preventive Dentistry with the chief complaint of pain in upper right front tooth region (). On examination there was a Ellis and Davey class 3 fracture with 11. Radiograph revealed incomplete root formation. Access opening was done followed by amputation of the coronal pulp with sharp excavator, carefully to prevent further damage to the pulp and perforation of the pulpal floor ( and ). The coronal pulp tissue was removed, sterilized cotton pellets over each amputation site was once placed and pressure pack was applied for a few minutes. Once the homeostasis was achieved, 1 to 1.5 mm thick layer of freshly mixed mineral trioxide aggregate was placed directly on the pulp stump surface and then gently pressure applied with a moist cotton pellet. Damp cotton pellet was placed over the material, followed by temporary restoration with Zinc Oxide Eugenol Cement (). After a week intermediate restorative material was removed and final restoration over set mineral trioxide aggregate was done followed by composite build up ()."
+Daisy Atkinson,26,2003/6/11,001-673-926-2683,douglaspearson@example.net,690 Timothy Street Apt. 653,"A 4-year-old boy came to Department of Pedodontics with chief complaint of carious lower back teeth. On examination, his all 4 mandibular primary molars were carious ().
+Radiograph revealed deep caries approaching pulp with remaining dentin thickness of about 0.5 mm (). MTA pulpotomy was planned. Under rubber dam isolation all superficial caries was removed to minimize bacterial contamination before exposure. Then the roof of the pulp chamber was removed by joining the pulp horns with bur cuts followed by amputation of the coronal pulp with a sharp excavator (). Following, coronal pulp amputation sterilized cotton pellets over each amputation site was placed and pressure was applied for 5 minutes. Then 1 to 1.5 mm thick layer of freshly mixed mineral trioxide aggregate was placed directly on the pulp stump surface and then patted with a moist cotton pellet (). With a damp cotton pellet over the material, temporary restoration was done with zinc oxide eugenol cement (). After a week intermediate restorative material was removed and mineral trioxide aggregate was placed, tooth was then restored with Glass Ionomer Cement (GIC) followed by stainless steel crown ()."
+Duke Dalton,27,1981/5/10,315-366-8281x4441,kimberlybanks@example.org,379 Hanson Unions,"A 13-year-old girl came to Department of Pedodontics with chief complaint of fractured left central incisor. On examination, there was Ellis class 3 fracture in 21 with history of trauma 1 year back and treatment was done somewhere outside the college. The tooth had root canal and labial perforation on crown. Radiograph revealed incomplete root formation ( and ).
+The working length was measured and biomechanical preparation was done. Then canal was dried with paper point and filled with MTA on perforation site for repair and at the apex for apexification. Placement of mineral trioxide aggregate was confirmed with a radiograph for adequate barrier to be created, with a wet cotton pellet. Excess moisture was removed from the pellet and placed in the canal (). Then temporary filling was removed at least after 3 to 4 hours and later a permanent filling material in the root and/or in the access cavity preparation was placed ( and ). The healing was assessed periodically using intraoral periapical radiograph."
+Lilian Le,28,1996/2/18,976.283.2179x23012,millerkimberly@example.com,249 Cassandra Corners,"A 9-year-old boy presented to the clinics of Department of Pedodontics, Dr Ziauddin Ahmed Dental College and Hospital, Aligarh Muslim University, Aligarh, with his mother. The mother stated that none of his milk teeth had yet shed.
+The cause of her concern was that she herself had faced the same condition as a child and due to lack of awareness and funds, had not had a chance to rectify the situation. At present at the age of 32 she wore over dentures.
+Upon observation, the facies and the stance of both the mother and son were suggestive of the classical manifestations of cleidocranial dysplasia ( and ).
+The child () had a short stature, flat nasal bridge, widely spaced eyes, a malformed head and short and broad hands. He had broad neck, sloping and hypermobile shoulders.
+His physical development, intelligence, hearing, spine and rest of the systemic examination were normal.
+In the mother? case ( and ), the skeletal features well as the degree of apposition of the shoulders were more pronounced.
+Clinical examination of the 9-year-old male revealed a high arched palate and malar and maxillary hypoplasia as well as fused upper left primary central and lateral incisor. There was an absence of spacing in the lower jaw (). None of this child? teeth were mobile. The mother had partial anodontia with some erupted /malformed permanent teeth and mobile deciduous teeth present ().
+The head circumference was 50.5 cm (brachycephalic), with coronal suture ridging, depressed metopic suture (), just like in the mothers case (), hypertelorism and depressed nasal bridge. His ears were set low ().
+Upon palpation, the anterior fontanelle was judged to be not fully closed and clavicles were judged to be laterally deficient. The mother had more pronounced brachydactyly () than the son ().
+An OPG and X-ray chest were advised. The OPG showed that most of the permanent teeth had formed crowns but the root formation was lagging behind (). An OPG was also requested of the mother and it showed deciduous retained teeth, poorly formed permanent teeth and impacted permanent teeth with supernumerary teeth and dental age lagging behind chronological age ().
+The X- ray chest showed clavicles were deficient laterally ().
+The diagnosis of cleidocranial dysplasia was confirmed radiographically further by obtaining X-ray skull (AP and lateral) ( and ) and X-ray hand wrist ()."
+Damien Pham,24,1991/11/24,001-306-409-0886x1846,robertslucas@example.org,3696 Kristie Falls,"A 19-year-old Japanese man developed left eyelid swelling around October 2, 2013. On October 9, 2013, he visited the ophthalmologic department of a local hospital because of subsequent gradually worsening ophthalmalgia and visual deterioration. The symptoms did not improve after the ocular administration of antibiotics. He was referred to Toho University Sakura Medical Center in Sakura, Japan (referred to hereafter as ?ur hospital?? on October 16, 2013, with a main complaint of left eyelid swelling. He had no medical, family medical, or allergy history. At the first visit, his right best-corrected visual acuity (BCVA) was 1.2; his left BCVA was 0.8 with visual deterioration. His right and left intraocular pressures (IOPs) were 17 mmHg and 36 mmHg, respectively. Prominent left eyelid swelling and exophthalmos were evident (Fig. ). A slit-lamp examination revealed prominent mucosal hyperemia, edema, and slight mucous discharge (Fig. ). Moderate mydriasis of the left pupil, direct light reflex attenuation, and positive relative afferent pupillary defect (RAPD) were present. No abnormality existed in the corneas, lenses, retinas, or optic nerve heads; however, ocular motility was omnidirectionally circumscribed. Dynamic campimetry showed neither central scotoma nor visual field deficiency. No laterality of central flicker values was revealed on central flicker examination. No systemic symptoms such as fever or infection were found on physical examination at the first visit. The blood examination exhibited a normal inflammatory response value.
+Orbital magnetic resonance imaging (MRI) showed soft tissue swelling in the left orbital muscle cone, and orbitographic MRI showed systematic trachychromatic images in the periorbital soft tissues (Fig. ).
+Clinical findings indicated suspected orbital cellulitis, although the blood examination exhibited no increase in the inflammatory response value. Intraorbital inflammatory pseudotumor was a differential diagnosis because of suspected orbital panniculitis on diagnostic MRI. He was hospitalized. An intravenous infusion of betamethasone (4 mg/day) was started on October 16, 2013.
+The following medications were started at the first visit because of the possibility of orbital cellulitis: ocular administration of levofloxacin four times daily and cefmenoxime four times daily, ofloxacin ophthalmic ointment once daily, and intravenous infusions of imipenem/cilastatin (0.5 g ? 3 times daily). Culture identification of the eye discharge was also performed on the same day. Oral administration of acetazolamide tablets (300 mg ? 3 ? 3 times daily) and potassium l-aspartate tablets (300 mg ? 3 ? 3 times daily) was also started because of left ocular hypertension. We supposed that there might be another possibility of an immunologic or inflammatory pseudo tumor besides orbital cellulitis because of the few inflammatory clinical findings; thus, we tried to use a sub-Tenon? injection of triamcinolone as a diagnostic therapy. A sub-Tenon? injection of triamcinolone (0.5 mg) in the left eye on the first day of hospitalization resulted in improvements in mucosal hyperemia and edema and the disappearance of eyelid swelling (Fig. ). The left BCVA improved to 1.2, there was a reduction in left IOP to 15 mmHg, and the left eyelid swelling nearly disappeared and did not recur. Mucosal hyperemia and edema were observed on the sixth day of hospitalization. Improvement of the left orbital panniculitis compared to the image acquired at the first visit was revealed by orbitographic MRI on the seventh day of hospitalization. He was discharged on the ninth day of hospitalization. Left and right IOPs gradually declined to approximately 15 mm Hg at discharged. Systemic and local administrations of antibiotics were discontinued on the seventh day of hospitalization because a culture of the eye discharge, which was performed at the first visit, had returned negative results. Oral prednisolone (30 mg/day) was started after hospital discharge. There was no recurrence of ocular symptoms and a favorable progression in vision to 1.2, despite a gradual reduction of prednisolone. Favorable progress in the left ocular tension to approximately 15 mmHg also occurred with the discontinuation of oral acetazolamide tablets and the initiation of the ocular administration of dorzolamide hydrochloride/timolol maleate (twice) and latanoprost (once).
+Symptoms had not recurred when he was examined at an ambulatory follow-up visit on January 8, 2014. On January 20, 2014, he visited the internal medicine department of a local hospital and was orally administered antibiotics because of a subsequent fever of 39 簞C and appendicular arthralgia. The symptoms did not improve, despite the oral antibiotic administration. A subsequent blood examination exhibited pancytopenia, hepatopathy, and an increased lactate dehydrogenase (LDH) level. He immediately revisited our department for an intensive examination and treatment on January 29, 2014 (the 15th week after the first visit) with a complaint of slight swelling of the right eyelid, whereas swelling of the left eyelid was observed at the first visit.
+Ophthalmological findings at the second visit revealed slight right eyelid swelling (Fig. ). The BCVA of both eyes was 1.2, but the intraocular pressure was 25 mmHg in the right eye and 27 mmHg in the left eye. Slight direct light reflex attenuation of both eyes was present, and positive RAPD of the right eye was also found. No abnormality was found in dynamic campimetry or a central flicker examination. However, orbitographic MRI showed right exophthalmos and orbital soft tissue inflammation. Left orbital panniculitis, which had improved (compared to the image acquired at the first visit), had recurred, compared to the image acquired during hospitalization on October 23, 2013 (Fig. ). Systemic findings included a high body temperature of 39.8 簞C and tachycardia of 103 beats per minute. A blood examination revealed leucocyte and thrombocyte cytopenia, hepatopathy, and increased coagulability: leucocytes, 3220/mm3; thrombocytes, 11.1 ? 104 mm3; aspartate transaminase/alanine transaminase (AST/ALT) level, 115/91 IU/L; LDH level, 1014 IU/L; creatinine kinase level, 362 IU/L; prothrombin time, 13.6 s; activated partial thromboplastin time (APTT), 37 s; and D-D dimer, 2.17 s. He visited the internal medicine department of our hospital for an intensive examination. Abdominal echography and abdominal/pelvic computed tomography (CT) showed moderate retention of abdominal fluid, dropsy, and an enlarged spleen.
+He was transferred to the hematology department at another hospital and was hospitalized for an intensive examination on the following day because of the possibility of hemodyscrasia, based on the increased LDH level in the blood examination results. Bone marrow aspiration examined after the hospital transfer revealed decreased numbers of nucleated cells and megakaryocytes and a small amount of corpuscular phagocytosis. A blood examination revealed leucocyte and thrombocyte cytopenia; increased levels of AST/ALT, LDH, and ferritin; and hepatopathy. Antibodies against herpes simplex virus, cytomegalovirus, and Epstein?arr virus were negative.
+Steroid administration (30 mg/day) was started with a diagnosis of HPS. After 1 week, he left the hospital because his symptoms improved. However, bubonalgia appeared immediately after hospital discharge and did not improve. He revisited the hospital on February 29, 2014. Abdominal CT exhibited suspected panniculitis in vesicular subcutaneous tissue. Cyclosporine was administered because of suspected Weber?hristian disease. The hepatopathy and increased levels of LDH and ferritin did not improve. Worsening HPS was diagnosed because of the appearance of a high fever (39.5 簞C) on the morning of March 20, 2014. A biopsy of the vesicular ventral subcutaneous adipose tissue by hypogastric transection was also performed in the anaplastic department of a local hospital on the same day. The histopathological diagnosis of the biopsy tissue revealed an aggregating tendency of nuclear irregularity-prominent atypical lymphocytes in the adipose tissue. SPTCL was diagnosed because of the surrounding arrangement (i.e., rimming pattern) of lipid droplets (Fig. ). On May 1, 2014, two aggregations of fluorodeoxyglucose in the right ilium were detected by positron emission tomography (PET) examination. Advanced malignant lymphoma was also suspected, based on the pelvic MRI findings. He was transferred to Suwa Red Cross Hospital (Suwa, Japan) on May 1, 2014 because of his requirements for intensive examination and treatment.
+After the hospital transfer, histopathological and immunohistological re-examinations of the vesicular adipose tissue exhibited poor infiltration of atypical lymphocytes into the dermis. Immunohistological findings exhibited positivity for CD3, CD8, granzyme B, T-cell intracellular antigen-1 (TIA-1), and beta F1; and negativity for C-gamma M1, CD30, CD56, and Epstein?arr virus-encoded small RNAs (EBERs), which led to a definitive diagnosis of 帢帣-type SPTCL. He was hospitalized for treatment on May 21, 2014. The standard treatment for malignant lymphomas?yclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) therapy?as administered for 5 days, and presented no efficacy. Four courses of etoposide, methylprednisolone sodium succinate, high-dose cytarabine, and platinum chemotherapy were administered beginning on June 11, 2014. On September 26, 2014, he underwent autologous peripheral stem cell transplantation because his symptoms were controlled. Hospital treatment for 6 months resulted in remission of his symptoms. Remission has been maintained."
+Raelyn Atkins,45,1994/10/6,(865)213-7162,trevor78@example.net,7903 Ortiz Glens,"A 59-year-old male was referred to the Department of Oral and Maxillofacial Surgery with a painless growth at retromolar trigone area. It had been present for 2 months and had increased in size during this period of time. Past medical history revealed a malignant mesothelioma which was diagnosed in September 2011 and treated with chemotherapy and radiotherapy until February 2014. The patient received 6 cycles of cisplatin (50 mg/100 ml, every 28 days) and premetrexed (500 mg, every 3 weeks) at the beginning. Since the lesion was inoperable, radiotherapy (50 Gy, in 25 fractions) was given after chemotherapy sessions. After radiotherapy sessions, starting from April 2012, the patient received 5 cycles of premetrexed (500 mg, every 3 weeks). A different regimen was given starting from January 2013. Cisplatin (50 mg/100 ml, every 28 days) and gemcitabine (1000 mg/m2) were prescribed. Gemcitabine was given on the 1st, 8th and 15th days. He was 71 kg when gemcitabine was started. After 4 months, the patient was 66 kg. Pemetrexed (500 mg, every 3 weeks) was prescribed instead of gemcitabine. The patient received 750 mg pemetrexed every 3 weeks until December 2013. In August 2013, positron emission tomography (PET CT) of the patient was evaluated. Figures and show the location of the tumor on the left lung and also possible metastasis on C7 vertebrae. He was 63 kg on that date. In January 2014, the patient was referred to our department because of the complaint in the oral region.
+Intraoral examination revealed a soft, haemorrhagic, ulcerated lesion at the right retromolar trigone area (Fig. ). Extraorally neither swelling nor lympadenopathy was observed. The innervation of N. trigeminus was balanced on both sides. There was no paresthesia on the lingual nerve. Radiologic examination revealed no destruction of the bony architecture (Fig. ). An incisional biopsy was performed under local anaesthesia. Haematoxylin and eosin staining showed invasive malignancy at subepithelial area (Fig. ). Syncytial aggregations composed of huge cells with pleomorphic nucleus, distinctive nucleolus and narrow cytoplasms were also detected (Fig. ). For immunohistochemical staining, the slides were stained with antibodies to calretinin (Ready to use, NeoMarkers, USA), secondary antibodies and DAB chromogen using standard procedures. Cytoplasmic/nuclear calretinin expression was considered positive. Intensity of staining was graded 3. The tumor cells were strongly positive for calretinin on immunohistochemical staining (Fig. ). Based on these histopathological and immunohistochemical findings, a final diagnosis of metastatic mesothelioma was made. The patient was informed about the possibility of multiple metastases within the body. He succumbed after 45 days following the deterioration of his medical condition.
+Malignant mesothelioma is a rare and aggressive tumor with a poor prognosis. The incidence of this disease is one or two cases per million per year []. The diagnosis of the primary malignant mesothelioma is established by clinical, histological, immunohistochemical, and radiological findings. In the present report, calretinin, a mesothelial marker turned out to be strongly positive in tumour cells on immunohistochemical staining, substantiating diagnosis of an epithelioid mesothelioma metastasis. Calretinin, a helix?oop?elix structural domain found in calcium-binding proteins and widely expressed in neural tissue, is expressed in most cases of epithelioid mesothelioma []. For radiological investigations, ESMO (European Society For Medical Oncology) recommends using CT scanning of the thorax for the localization of tumor sites and distant metastases or detecting early response to treatment. They recommend also MRI in special situations where tumor delineation is necessary []. But the diagnosis of the secondary malignant mesothelioma in the oral cavity, as in the present case, is based on the presence of known history of the tumor. Even with the presence of the primary tumor, it is necessary to make a definite diagnosis of an assumed oral metastases to allow for an appropriate management. Although the clinical behaviour and the view of the primary oral squamous cell carcinoma (OSCC) is unlikely to be misdiagnosed for a metastatic lesion by an experienced surgeon, OSCC is the most likely diagnosis of a persistent mass, without obvious traumatic or infectious origin. Wide surgical excision is often an acceptable treatment for the management of OSCC, whereas in a metastatic mesothelioma case, it will be inappropriate []. The current effective standard treatment for mesothelioma is the addition of bevacizumab to pemetrexed plus cisplatin which significantly improves the overall survival []. Unfortunately, there was no effective standard treatment for mesothelioma during the follow-up period of the present patient. Therefore, another different regimen of chemotherapy was prescribed. Although the cisplatin plus pemetrexed therapy of the present patient was the standard of care in the first-line treatment, the prognosis was poor and the patient succumbed to the disease.
+Malignant mesotheliomas frequently recurred locally in the chest and abdomen. Metastases occur at a relatively late stage of the disease. Kannerstein and Churg [] reported metastases in 18/50 autopsy cases. Distant metastases are very rare, especially in the oral region. Primary breast carcinomas are the most common types of tumour to metastasize to the jaw bones while primary lung carcinomas are the most common types of tumour to metastasize to the oral soft tissue []. These oral metastases represent about 1 % of oral malignances, and there are more cases reported arising in the jaw bones than in the oral soft tissues with a ratio of approximately 2:1 []. The case presented in this report is only the first report of a mesothelioma metastatic to the retromolar trigone. Although Kruse et al. [] and Hirshberg et al. [] reported that metastases of mesothelioma, although rare, tend to involve the oral soft tissues, especially the tongue. Sinon et al.[] reported that metastases to oral region are mostly seen in the tongue and the attached gingiva. One possible explanation for the tendency towards the tongue and the attached gingiva might be the rich capillary network, especially where chronically inflamed gingiva trap malignant cells and the fragmented basement membranes of proliferation capillaries allow easier penetration by malignant cells than in more mature blood cells []."
+Cason Dickerson,18,1994/2/23,+1-535-459-5671x11511,wthomas@example.org,915 Keller Prairie,"A 54-year-old white man was referred with a 1-week history of bilateral pedal edema, worsening hypertension, and a rise in serum creatinine from 111 弮mol/L to 213 弮mol/L over 2 weeks. He had microscopic hematuria and proteinuria quantified at 24 grams/day (see Additional file ). His serum albumin was 24 g/L compared with 35 g/L 2 weeks earlier. Other relevant investigations included negative hepatitis B and C serology, weakly positive speckled antinuclear antibody (ANA) titer of 160 (normal <40) with double-stranded deoxyribonucleic acid (DNA) of 0 IU/mL (normal <7), normal ratio of serum free light chains, negative cryoglobulin screen, negative serum protein electrophoresis, and a normal C3 of 1.77 g/L and C4 of 0.38 g/L.
+He had a background history of hypertension, obstructive sleep apnea, and a 3-year history of colorectal carcinoma with hepatic metastasis. His initial treatment included neoadjuvant chemotherapy with capecitabine and bevacizumab, and 26 fractions of radiotherapy. He then underwent a right hemicolectomy and a partial right hemihepatectomy, followed by 6 months of capecitabine and bevacizumab. One year later, a new 74 mm metastatic lesion developed in his residual right liver lobe, and a 16 mm mucin-secreting adenocarcinoma occurred at the left vesicoureteric junction, which was managed by distal ureterectomy. He was recommenced on capecitabine, bevacizumab, and cetuximab, and continued on this treatment until presentation with nephrotic syndrome.
+A renal biopsy was diagnostic of MPGN type I. Functioning glomeruli showed mesangial hypercellularity, endocapillary proliferation, and double contours in capillary loops. No hyaline deposits were noted in the capillary loops and no segmental sclerosis was seen (Fig. ). There was interstitial fibrosis and tubular atrophy together with lymphocytes, plasma cells, and eosinophils in the scarred interstitium (Fig. ). Immunofluorescence showed moderate granular deposition of IgG and C3 in the mesangial areas and around the capillary loops. Electron microscopy showed deposits in the mesangial, paramesangial, and subendothelial regions. Focal duplication of the glomerular basement membrane was seen and there was mild expansion of mesangial matrix.
+Curative therapy for the malignancy was not possible, so treatment was commenced with prednisolone for the renal disease. Four months later, his proteinuria had reduced to 1.4 grams/day, creatinine had improved to 155 弮mol/L, and albumin returned to baseline of 31 g/L."
+Opal Booker,24,1998/4/8,620.445.2697x13191,ramireznicole@example.com,8533 Edward Turnpike,"Our patient was a 77-year-old Caucasian man who, 3 years and 11 months before his death, exhibited subacute polyneuropathy that included large fibers with autonomic changes. The clinical presentation of the patient? polyneuropathy did not allow us to differentiate a paraneoplastic pathology from an atypical presentation of diabetic neuropathy. A first episode of focal epileptic crises occurred 13 months after the polyneuropathy event. Two years before the patient? death, an electroencephalogram showed epileptic discharges in the right temporal cortex (Fig. ). After that, his autonomic seizures became more frequent, and ictal pilomotor erection was a common observation.
+Two years before the patient? death, a diagnosis of probable dementia was made. The presence of rapidly progressive dementia, delusions, and autonomic seizures with pilomotor erection suggested a preliminary diagnosis of limbic encephalopathy. At that time, cerebrospinal fluid (CSF) analysis including the following was performed: herpes simplex virus (repeated three times with negative results), varicella zoster virus, cytomegalovirus, Epstein-Barr virus, HIV, human T-cell lymphotropic virus 1/2, JC virus, Borrelia burgdorferi (Lyme disease), Tropheryma whippleii (detected but not confirmed in a second sample), Treponema pallidum, and Cryptococcus neoformans. All results of these tests were negative. No growth of any bacteria or fungi was detected. The patient? protein electrophoresis result was also normal. His 14-3-3 protein test result was negative. The patient had a slightly reduced amyloid-帣42 level (543 pg/ml). However, his tau protein level was normal (210 pg/ml). His CSF was also analyzed using an established radioimmunoassay in a reference laboratory. Intracellular antibodies (Hu, Ri, Yo, and Ma2) and surface antibodies (VGKCs KV1.1, KV1.2, and KV1.6) were assessed. Negative results were obtained for the intracellular antibodies. According to the relative values provided by the reference laboratory, the results of the VGKC-Ab test were positive.
+Twenty-three months before the patient? death, cerebral imaging by 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography-positron emission tomography (18F-FDG-PET/CT) was performed according to the following acquisition protocol. Fluorodeoxyglucose (FDG) (���5.3 MBq/kg) was injected intravenously under euglycemic (6-hour fast, capillary blood glucose <140 mg/dl) and standardized resting (eyes open, reduced ambient noise) conditions. After 1 hour of uptake time, images were acquired by positron emission tomography-computed tomography (PET-CT) using a Biograph Duo lutetium oxyorthosilicate PET/CT scanner (Siemens Medical Solutions, Knoxville, TN, USA), followed by dedicated brain PET-CT image acquisition (10-minute acquisition). Next, three-dimensional iterative reconstruction was used for the brain PET images (iterations = 6/subsets = 16/full width at half maximum = 2 mm/matrix = 256). Finally, computed tomographic images were used for attenuation correction of PET data. The cerebral FDG-PET performed 23 months before the patient? death showed low FDG uptake in the frontal and temporal lobes, especially in the right hemisphere, with relative preservation of the posterior cingulum (Fig. ).
+Six months before the patient? death, he presented with normal-pressure hydrocephalus. A ventricular peritoneum derivation (VPD) was inserted. A small improvement in walking was observed, but it lasted no more than 2 weeks after the VPD implant. Three months before the patient? death, a second repeat cerebral FDG-PET scan using the same acquisition protocol as before showed diffusely low cerebral glycolytic activity with a marked increment in the severity of the metabolic deficit in the frontal and temporal lobes, as well as hypometabolism involving the parietal lobes and posterior cingulum (Fig. ). Three months before the patient? death, a biopsy done in the right axillary lymph node indicated a metastatic cholangiocarcinoma. The most common type of hilar extrahepatic cholangiocarcinoma is classified into four stages according to the Bismuth classification []. In our patient, this classification was considered stage IV. Two months before his death, a contrast-enhanced computed tomographic scan showed brain metastases in the right parietal cortex (Fig. ).
+A postmortem examination showed a cholangiocarcinoma with multiple metastases that included the lungs and lymph nodes. All other organs were studied during the autopsy, and the only primary neoplasia found was the cholangiocarcinoma; the other sites were metastatic, all exhibiting the same morphological aspects as the cholangiocarcinoma. The brain weighed 1300 g, and a catheter was well positioned in the lateral ventricle. There was mild cortical atrophy, ex vacuo dilation of the ventricles, and mild focal thickening of the cerebellar leptomeninges, which were infiltrated by the carcinoma, described as neoplastic epithelial cells (Fig. ). The morphological aspects were similar to the cholangiocarcinoma seen in the liver, histopathologically confirming the brain metastasis. There were no other changes in the cerebral cortex and white matter, except some thickened, hyalinized microvessels in the deep white matter with adjacent gliosis and calcification of vessel walls in the basal ganglia. Axonal peripheral neuropathy associated with microangiopathy, possibly related to diabetes, was also seen."
+Dominik Ali,45,1986/11/12,413-330-1207,toddwashington@example.org,842 Tina Garden,"A 74-year-old Japanese woman gradually developed general malaise and loss of appetite. In addition, arthralgia and pitting edema in her feet appeared. Her laboratory findings revealed an elevated white blood cell (WBC) count and C-reactive protein (CRP). She was admitted to our hospital for further examination. She had an operation for endometrial cancer at the age of 72 and had no family history.
+On admission, her blood pressure was 129/76 mmHg, heart rate was 101/minute, respiratory rate was 18/minute, and body temperature was 39.1 簞C. A physical examination revealed pitting edema on the dorsum of her hands and feet. Her neurological examination was unremarkable. However, she had difficulty with squatting and walking because of arthralgia in her proximal lower limbs. Laboratory testing showed a WBC of 11700/弮L, CRP of 6.7 mg/dL, erythrocyte sedimentation rate of 44 mm/hour, total protein of 5.8 g/dL, and albumin of 2.3 g/dL. Rheumatoid factor, anti Ro/SSA antibody, anti La/SSB antibody, anti Scleroderma 70 antibody, and anti cyclic citrullinated peptide antibody were negative. Serum interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) were markedly increased to 285 pg/mL (normal; <2 pg/mL) and 1820 pg/mL (normal; 262簣228 pg/mL) [], respectively. Her human leukocyte antigen (HLA) typing included B7. A chest X-ray revealed mild pleural effusion on the right side. Electrocardiography showed a complete right bundle branch block without ST-T change. Echocardiography revealed a slight pericardial effusion surrounding her entire heart.
+She had a high fever, general malaise, and muscle weakness, and her laboratory tests revealed elevated inflammatory markers including WBC, CRP, and erythrocyte sedimentation rate. Because infectious disease was suspected, tazobactam-piperacillin 13.5 mg/day was started. On day 2, atrial fibrillation appeared on the electrocardiography monitor. A chest X-ray showed that the pleural effusion had increased in both lungs. Furthermore, echocardiography demonstrated increased pericardial effusion around her heart. On day 3, she developed respiratory failure, and oxygen administration was started by nasal cannula at a dose of 3 L/minute. Enhanced chest-abdominal computed tomography (CT) showed marked bilateral pleural and pericardial effusions without neoplastic lesions (Fig. ). Analysis of the pleural effusion revealed exudate with an increased protein level and neutrophils, but cytological evaluation of the pleural effusion revealed no evidence of malignancy. Cultures of blood and pleural effusion were all negative. Our patient fulfilled the diagnostic criteria of RS3PE syndrome including: 1) pitting edema of the hands and feet; 2) sudden onset of polyarthritis; 3) onset at age 50 years or older; and 4) negative serology for rheumatoid factors []. From day 6, she was treated with methylprednisolone administered intravenously at a dose of 1000 mg/day for 3 days. After steroid therapy, her fever rapidly improved, and blood tests revealed a decrease in CRP to 1.71 mg/dL. The pleural and pericardial effusions on chest CT decreased (Fig. ). When the pericardial effusion decreased, her atrial fibrillation disappeared. After steroid pulse therapy, oral prednisolone administration at a dose of 15 mg/day was started. Her respiratory failure immediately improved, and then she no longer required oxygen administration. A chest CT performed on day 38 revealed that the pleural and pericardial effusions had disappeared (Fig. ). On day 45, she was discharged. One year later, the prednisolone dosage was decreased to 8 mg/day, but the patient experienced no recurrence of symptoms. At the 1-year examination, no malignancy was found. Serum IL-6 and VEGF were significantly decreased to 1.3 pg/mL and 562 pg/mL, respectively."
+Zelda Enriquez,31,1997/7/6,691-516-9228x7287,malik25@example.com,85222 Valerie Cliffs Suite 819,"A 26-year-old male ex-Olympic gymnast and gymnastics coach presented to our emergency department with bilateral knee pain and inability to straight leg raise secondary to jumping from the roof of his single story home, where his legs gave way after he landed on his feet. This is in the context of landing a jump vault and hearing a ?opping sound??and sudden onset pain from his knees bilaterally 3 days prior. He had a background of chronic patellar tendonitis and a repair of his left patellar tendon for partial rupture 9 years previously. The patient was otherwise well and taking no regular medications. Physical examination revealed bilateral patella alta with a palpable defect superior to the tibial tuberosity; there were no significant joint effusions (Fig. ).
+Xray demonstrated high riding patella bilaterally. The diagnosis was confirmed on ultrasound, with the right proximal insertional fibres ruptured and 1.5 cm retraction (Fig. ). The right distal tibial insertion was intact. The left had a similar appearance with some calcified areas on the retracted fibres, which were believed to represent chronic calcification and/or avulsion fragments.
+The patient was consented for a bilateral patellar tendon reconstruction rather than a primary repair due to the poor quality of the tendons. Autograft was not considered as the injury was bilateral and due to the volume of remaining tendon fibres. The aim being to return him to his elite gymnastics as soon as possible. Surgery was performed by the senior author (PT).
+Bilateral midline incisions were made over both knees, the operative findings confirmed the sonographic diagnosis. The reconstruction was performed using a ?igure 8??pattern through a transverse patellar tunnel with screw fixation to two tibial tunnels. The knee was placed at 90簞 of flexion prior to tensioning of the ligaments. The remnants of the patella tendon where sutured to the LARS ligaments using a braided, absorbable suture. The patella tendon was repaired using 2x corkscrew anchors (medial and lateral). The wound was closed in layers achieving meticulous haemostasis (Fig. ).
+Post-operative Xrays indicated adequate screw and tibial tunnel placement (Fig. ). The patient was allowed to weight bear as tolerated and placed in extension knee splints for 2 weeks to minimize the chance of wound dehiscence. Rehabilitation with physiotherapy started on day 1 focusing initially on passive range of motion (ROM) exercises then on extensor and quadriceps strength.
+At the two-week wound review post-operatively the patient still had some ongoing pain and swelling after bending the knees, however there were no signs of wound infection. The ROM of the right knee was 0-85簞 and the left 0-45簞. At this appointment the patient was able to complete a straight leg raise bilaterally indicating an intact extensor mechanism. Two months post-operatively ROM was 0-125簞 bilaterally with no reported complications. At four months his ROM had improved to 0-130簞.
+At four years post-operatively, the patient is running a gymnastics club and actively coaching young gymnasts. He still experiences mild discomfort on descending stairs if carrying heavy loads but is otherwise painfree. He has not returned to training for competitive gymnastics. The patient claims he could return to some of the gymnastics skills but would struggle with vault and floor exercises secondary to lack of training. His Tegner Lysholm Knee score is 80, Modified Cincinatti rating score is 77 and Mohtadi-QOL Knee score is 58. Physical examination demonstrates well healed scars, no ligamentous instability or pain on palpation of the patellar tendon and bilateral ROM from 0-130簞 (Fig. )."
+Elisha Bonilla,22,1998/3/19,711.922.3815x05487,tracybaldwin@example.org,431 Morales Knolls,"A 47-year-old male reported a seven day history of influenza-like symptoms, including general malaise, chills, dry cough, chest-pain, shortness of breath, and temperatures of up to 39.5 簞C, which did not respond to paracetamol or ibuprofen. The patient worked as a veterinary researcher in a laboratory where experimental intranasal infections with C. abortus were developed in sheep. The patient carried out these infections using a suspension of C. abortus sprayed into both nostrils with a multi-dose spray pump, as described previously []. Ten days after the sheep infections, the patient showed the first symptoms.
+The initial medical examination identified crackling sounds during lung auscultation. A chest x-ray showed areas of consolidation of the lower lobe of the left lung, indicating a pan-lobar pneumonia (Fig. ). Blood and biochemical tests revealed a non-significant increase in mean corpuscular hemoglobin (MCH), as well as a slight increase in urea and creatinine levels: 50.3 and 1.3 mg/dl respectively. By contrast, the C-reactive protein level was very high, 8.9 mg/dl, normal values being <0.5 mg/dl. These high values suggested a bacterial infection rather than a viral infection, in which case the values would be lower [].
+Serological analyses with several ELISA tests (all of them from Vircell Microbiologist, Granada, Spain) using specific IgG and IgM monoclonal antibodies (MoAb) were negative against Mycoplasma pneumoniae, Legionella pneumophila (serogroup 1-7), Rickettsia conorii and Chlamydia pneumoniae.
+Due to the suspicion of C. abortus infection, serum and sputum samples from the patient were sent to a laboratory at the Animal Health Department of the Murcia University (Spain) for further analysis.
+A C. abortus-specific serological test, performed using an ELISA kit (ID Screen Chlamydophila abortus indirect multi-species, IDvet), revealed high IgM and IgG optical densities (OD) in the serum samples (Table ). The serum samples were tested with a peroxidase-conjugated anti-human IgG or IgM (Sigma), and the OD were determined (DigiScan with DigiWin Software, ASYS Hitech). In addition, two serum samples from asymptomatic work colleagues were analyzed with the same ELISA kit. As might be expected, both colleagues showed antibody production against C. abortus, but with a lower OD than the patient, especially for IgM production (Table ). It was therefore assumed that antibody production on the part of the patient was due to a clinical episode and not to a progressive sensitization to C. abortus.
+C. abortus was isolated from the sputum using a McCoy cell monolayer, as described previously []. Positive cell cultures were identified by an immunofluorescence assay using the C. abortus-specific anti-MOMP FA2H10 MoAb []. The MoAb was produced using BALB/c mice and purified by immunoafinity, and was chosen because it is specific for an oligomer of the outer membrane protein of C. abortus (named as C. psittaci, serotype 1).
+C. abortus DNA was detected in the sputum sample and also in the cell culture isolates by PCR analysis. Total DNA was extracted with a commercial kit (DNeasy tissue kit, Qiagen) and was used as a template for a C. abortus-specific PCR, using primers pmp-F (5??CTC ACC ATT GTC TCA GGT GGA-3?? and pmp-R821 (5??ACC GTA ATG GGT AGG AGG GGT-3?? for the target gen pmp 90/91 [], which allow the sensitive amplification of 821-bp length DNA fragments. In order to confirm the specific presence of C. abortus in the sputum sample as well as in the cell isolates, the amplicons were sequenced (ABI Prism 3130). The PCR products showed 100 % identity to the C. abortus AB7 strain sequence obtained using MEGA5 software and BLAST簧 program. This C. abortus strain was the same strain as that used in the experimental infections in ewes carried out by the patient [].
+Once diagnosed, the patient was treated with antibiotics (levofloxacin, initial intravenous dose of 500 and 500 mg orally every 24 h for 10 days; and clarithromycin 500 mg every 12 h for 10 days), mucolytic carbocysteine lysine (2.7 g orally every 24 h), glucocorticoids (beclomethasone dipropionate inhaler 100 弮g every 12 h) and non-steroidal anti-inflammatory drugs (paracetamol 1 g orally in case of fever or pain). This treatment resulted in successful recovery of the patient in 2 weeks without sequels."
+Romina Rocha,45,1983/1/5,001-938-618-9773x546,rblanchard@example.com,4466 Garcia Fort Suite 863,"A 27- month-old girl was referred to Bambino Ges羅 Children's Hospital in 2009 after a 1-week history of vomiting associated to mild intermittent strabismus. Ophthalmologic evaluation revealed bilateral papilledema. Magnetic Resonance Imaging (MRI) showed diffuse brainstem and spinal leptomeningeal enhancement (Fig. ??. CSF analysis was unremarkable. Tuberculosis (TB) was not confirmed by a complete work-up. Nonetheless, antitubercular treatment was started based on the MRI findings. After 10 days the patient was transferred to the Intensive Care Unit for a salt wasting syndrome. A new MRI demonstrated hydrocephalus (Fig. ) and progression of leptomeningeal enhancement (Fig. ??. A new CSF examination was done and showed neoplastic cells with large cytoplasm and prominent nucleoli (Fig. ) positive for S100. Therefore, antitubercular therapy was discontinued and a ventriculoperitoneal shunt was placed because of the progression of neurological symptoms. Moreover, a spinal intradural biopsy was performed: histological examination showed pleomorphic cells with vesicular nuclei, eosinophilic nuclear pseudoinclusion and moderate cytoplasm (Fig. ). Immunohistochemistry showed intense positivity for MelanA, suggesting the diagnosis of primary leptomeningeal melanomatosis. No signs of cutaneous melanosis were observed. Chemotherapy was started, including temozolomide, cis-platinum, vindesine and peg-interferon alfa-2b. MRI was obtained every two months showing stable disease until the sixth course of chemotherapy when progression was found. At that time, radiation was associated to peg-interferon alfa-2b but the tumor rapidly spread to chest and abdomen. General clinical conditions progressively worsened and patient died 11 months after diagnosis. Molecular investigations were performed post-mortem on tumor tissue and revealed absence of BRAFV600E, GNAQQ209 and GNA11Q209 mutations but the presence of a NRASQ61K mutation."
+Onyx Gomez,43,1996/2/24,001-801-380-7157x97324,kendrahuang@example.net,69137 Manning Pike,"Patient 1, a 49-year old male (Table ), presented with gait disturbance and vertigo. MRI evaluation revealed hemangioblastoma at the right superior cerebellum. A year after excising the mass, bilateral 2.2??.0 cm tumors were found in both kidneys. Eye examination revealed a hemangioma-like lesion in the right eye. In addition, CT of the abdomen revealed a pancreatic neuroendocrine tumor (NET). Genetic testing showed that the patient harbored a novel frameshift mutation, p.Met54Glyfs*77, in the VHL gene. One of his daughters and his son were heterozygous for the same mutation. His 35 year-old daughter had 3 types of VHL-related tumors: Cerebellar hemangioblastoma, RCC in the right kidney lower pole, and pancreatic NET which invaded the superior mesenteric artery and superior mesenteric vein. His son, who was 38 years old, visited an emergency room presenting with a generalized tonic-clonic seizure. On evaluation, the brain MRI showed a well-defined mass in the left parietal area, which was pathologically found to be a meningioma."
+Natalie Vang,30,1991/11/21,818-511-4161x167,mgeorge@example.net,49749 Makayla Ridges Suite 380,"Patient 2 was a 25-year-old male (Table ) who reported frequent headaches and dizziness. MRI of the brain revealed a 0.9-cm nodular lesion at the medullocervical junctional level. This patient underwent midline suboccipital craniotomy. A heterozygous missense mutation was identified in the VHL gene: p.Glu70Lys. There was no family history. This patient regularly visited the clinic, and no other VHL-related tumor developed."
+Jimmy Neal,32,1980/12/9,979-287-3018,paula85@example.com,24921 Michelle Forest Apt. 165,"Patient 3 was a 46-year-old female who was the index patient in family 3 (Table ). She visited the clinic with a 3-month history of blurred eye vision in her left eye. Examination revealed RHB in her left eye. VHL analysis revealed the heterozygous missense mutation p.Glu70Lys. Since her sister had suffered from RHB, the mutation was considered to be passed down from her parents. Her son, a 19-year-old male, inherited the same mutation, but no VHL-related symptoms were present. He underwent surveillance for VHL manifestations. RHB was the only VHL-related phenotype in this family."
+Talia Gould,44,1996/10/21,+1-513-311-2781x424,elizabethmedina@example.org,245 Tanya Lodge Suite 352,"Patient 4 was a 20-year-old female (Fig. ). Through routine eye examination, multiple RHBs in both eyes were found. We analyzed the VHL gene and found that the patient was heterozygous for the p.Glu70Lys mutation. Her mother had been treated for RHB but refused to undergo genetic analysis. Further genetic testing and family history assessment was unavailable for this family. No other VHL-associated symptoms were observed in patient 4 and her mother.
+In family 5, two siblings (Table ) underwent surgical resection for CHB at the ages of 12 and 19. Abdominal CT revealed RCCs in these siblings. The family history revealed VHL manifestations in their father who died in 2013 and had RCC, PCC, and CHB (Table ). The proband (patient 5) harbored an in-frame deletion p.Phe76del affecting exon 1 in the VHL gene. This in-frame deletion appeared to run in this family."
+Blaine Poole,22,1983/7/20,(330)722-8361x95380,aaronmiller@example.org,31826 Todd Groves,"Patient 7 was 14-year-old male who experienced frequent abdominal distension and intermittent headaches. At a routine health check-up, multiple pancreatic cystic lesions and RHB in the temporal disc side of his left eye were found. MRI of the brain showed a tiny well-enhanced nodule at the cervicomedullary junction with an adjacent prominent vascular structure. The features of this patient? presentation were indicative of VHL. Although this patient had no family history, a heterozygous missense VHL mutation, p.Asn78Ser, was identified in patient 7."
+Bonnie Schroeder,32,2005/4/8,+1-407-762-6528x4865,erin51@example.org,1356 Phillips Parks,"Patient 8, a 38-year-old male, showed mild imbalance with gait difficulty. MRI of the brain revealed a 3.5-cm cystic mass in the cerebellum, which was pathologically found to be hemangioblastoma. When this patient underwent CT, which included the pancreas and kidney, multiple pancreatic cysts and renal cysts were found. A VHL c.464-1G > T splicing mutation was detected in patient 8 and there was no family history of VHL disease in his family."
+Izaiah Fox,24,2002/6/26,6843727771,jennifertucker@example.net,73039 Bell Keys,"Patient 9 was a 47-year-old male (Table ). He presented with dizziness and headache, which he had experienced for the 3 months prior to examination. After systemic examination, multiple VHL related tumors were revealed, including RCC, PCC, and CHB. VHL analysis detected a heterozygous missense mutation, p.Arg167Trp. He had a family history of VHL-related tumors, including CHB and RCC. His brother was diagnosed with CHB and his niece was diagnosed with CHB, RHB and RCC. The same mutation was identified in his niece."
+Juliette Bernard,45,1999/12/2,(855)474-8906x991,allison77@example.net,5648 Taylor Circles Apt. 003,"Patient 10 (Table ), a 59-year-old female, presented with indigestion, anorexia, and nausea. This patient underwent abdominal CT; multiple renal cysts, a hypervascular mass in the pancreatic body, and a cystic mass in the pancreatic head and tail were found. Pylorus preserving pancreaticoduodenectomy was performed in this patient. Two months after surgery, gait disturbance appeared. MRI of the brain revealed multiple enhancing masses in both cerebellums, which were pathologically found to be hemangioblastoma. Based on suspicion of VHL, we sequenced the VHL gene in this patient; a heterozygous missense VHL mutation, p.Arg167Gln, was confirmed. None of her family members were affected."
+Jair McConnell,45,1992/9/1,001-861-959-2378x441,renee10@example.org,22379 Brown Forest,"A 60-year-old non-smoking white male, with an alcohol history of 2-3 drinks per day, was diagnosed in July 2013 with squamous cell carcinoma (SCC) of the right retromolar trigone with extension into the adjacent buccal mucosa. He was treated with primary surgery on September 12, 2013, consisting of a right lateral pharyngotomy and segmental resection of the right posterior mandible and adjacent buccal mucosa, and a right selective neck dissection followed by left free fibula osteoseptocutaneous flap reconstruction. Final pathology showed metastatic keratinizing SCC measuring 0.96 cm with a 0.5 cm depth of invasion. There was an invasion of the bony mandible into the cortex and medulla. There was no lymphovascular space or perineural invasion and all margins were free of cancer, with the closest being 0.18 cm medially. One of 12 lymph nodes in right Level I and one of one facial lymph nodes were positive for metastatic disease, the latter with extranodal extension. No cancer was found in any of 20 lymph nodes from Levels 2-4. Pathologic stage was T4aN2b with an R0 resection.
+After multidisciplinary tumor board discussion, it was recommended that he receive adjuvant radiation therapy (RT) with concurrent cisplatin chemotherapy. Starting six weeks postoperatively, he received a radiation dose of 6,000 cGy in 30 fractions over six weeks to the tumor bed and involved nodal regions via a 5-field IMRT plan using 6 MV photons, along with a q3 weekly bolus of cisplatin, 100mg/m2.
+He completed all adjuvant treatment on December 3, 2013, uneventfully and without unplanned delays or unexpected toxicities. His last clinical follow-up appointment on January 28, 2015 revealed no evidence of locoregional recurrence and no significant late treatment toxicities.
+In February 2015, he presented to the emergency room with acute shortness of breath, palpitations, and a recent history of air travel. Electrocardiogram (ECG) showed rapid atrial fibrillation. CT scan of the chest, using a pulmonary edema (PE) protocol, showed a small pericardial effusion, measuring up to 1.3 cm in width, and moderate-sized, uncomplicated bilateral pleural effusions. There was a single 0.9 cm short axis prevascular lymph node, which was felt most likely to be reactive. He was discharged with arrangements for an outpatient cardiology follow-up. His atrial fibrillation proved to be difficult to control, in part because of intolerance of beta blockers due to pre-existing asthma. On July 1, 2015, he re-presented with shortness of breath on exertion and peripheral edema. Initial bloodwork revealed the N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was elevated at 1650 (0-300) with mild high sensitivity troponin elevation at 20 (0-14). ECG showed a septal infarct, right axis deviation, and a marked ST segment abnormality. The rhythm was variant between sinus tachycardia and atrial flutter. After admission, an echocardiogram was performed, and a large mass was identified in the right ventricle.
+The following day he underwent pulmonary function tests (PFTs), which showed both FVC and FEV1 < 50% of predicted values. A CT scan of the neck showed stable post-treatment changes and no evidence of primary or residual tumor, while CT of the chest, abdomen, and pelvis revealed the growth of the prevascular mediastinal lymph node to 1.7 x 1.2 cm. Also noted were hepatic venous congestion and the right ventricular mass. Retrospectively, this was thought to have been visible as a small abnormality on the CT/PE study from 4.5 months earlier. Cardiac MR (Figures -) showed the mass to be 6.7 x 3.8 x 4.5 cm and centered on the right ventricular free wall. There was a narrowing of the tricuspid valve and mass extension into the right atrium. A large pericardial effusion was associated with this mass.
+A biopsy was attempted via right heart catheterization through the right internal jugular vein under transthoracic echocardiogram guidance. Repeated attempts were unsuccessful and yielded only normal myocardial tissue because of catheter deflection as it entered the right ventricle. Diagnostic thoracentesis of his left pleural effusion showed only rare atypical cells.
+After much consideration and discussion with the patient about potential benefits and risks, it was decided to proceed with an open biopsy. On July 14, 2015, he underwent sternotomy with direct visualization and biopsy of the pericardium and the right ventricular mass. Pathology showed metastatic poorly differentiated squamous cell carcinoma arising from within the myocardium of the right ventricular free wall (Figures -). A full immunohistochemical panel revealed the tumor to be p63, 34BE12, E-cadherin, pancytokeratin (PCK), and cytokeratin 5/6 (CK5/6)-positive. It was negative for melanin, S100, WT1, CD34, and CD45 and, hence, felt to be consistent with metastatic disease from his original oral cancer.
+Shortly after biopsy, palliative radiotherapy with 2,000 cGy in five fractions was discussed with the patient. The goals of treatment would have been to try and improve his cardiac function. Risks were discussed, including potential worsening of arrhythmias and catastrophic cardiac rupture due to regression of a tumor that was replacing much of the cardiac wall. He appreciated the risks and uncertain benefits and consented to treatment as described. Unfortunately, after discharge, he began decompensating again and, hence, pursued comfort measures only. He passed away within one week of this decision and exactly one month after presenting in heart failure."
+Denise Wilkinson,19,1997/2/17,001-568-888-4100,kayla98@example.org,415 Hatfield Mountain,"A 67-year-old Caucasian woman admitted to hospital due to a mass on the scalp. This lesion was present for almost a year. It was a semimobile cyctic mass that elevated the scalp. There was no change in the skin color. Its dimensions were 1.5 ? 1 ? 0.6 cm. The laboratory, clinic, and radiologic findings (head x ray) of the patient were normal. It was evaluated a benign lesion such as lipoma or epidermal cyst by surgeon due to a small semimobile mass and no erosion of the skull. It was excised by a local surgery excision. The skin is sent as a different part from this excision material.
+In pathological examination, there were solid and cystic spaces including tubuloalveolar, ductal, and papillary structures protruding into cistically dilated lumina (Fig. ). These structures were lined by atypical epithelial cells including hyperchromatic, pleomorfic, and big nucleus (Fig. ). Necrotic areas and mitotic figures were present (Fig. ). There was no epithelial invasion.
+These histopathologic findings were compatible with ADPA. For elimination of a metastatic primary papillary carcinoma focus such as lung, breast, thyroid, etc. An immunohistochemical study was performed. EMA, PanCK, and CEA were positive. SMA, Calponin, and P63 were negative. These immunohistochemical dyes support diagnosis of ADPA. In the examination for elimination of probably a metastatic focus, TTF1 for lung, ER and PR for breast, CK19 and HBME1 for thyroid, and GFAP for brain were negative. In clinical investigation before pathologic report for the ADPA, it is approved that there was not any mass in lung, breast, thyroid, brain, and ovary. The patient is in the 4th month in the postoperative period and there was no pathologic finding."
+Leonard Boyer,21,1999/6/20,+1-265-806-9792x0851,csmith@example.org,0362 Guerra Flats,"A 19-year-old female patient with a history of congenital afibrinogenemia. According to the French law, in case of retrospective study, the ethical approval was not necessary.
+She was admitted to the emergency department of a local hospital with acute abdominal pain and nausea. Her genetic fibrinogen mutation was allele 1: FGG IVS2??c>G, allele 2: FGG IVS2??c>G. She was being treated monthly with fibrinogen concentrates, tranexamic acid (during menstrual periods), and oral contraception. She had suffered from massive bleeding 7 years ago, diagnosed as hemoperitoneum complicating an ovarian cyst rupture.
+On clinical examination, her abdomen was tender but not tense, she was afebrile and hemodynamically stable. There was no history of trauma. Her laboratory tests showed: hemoglobin 13.5 g/dL, hematocrit 40%, liver enzymes: aspartate transaminase 196 U/L, alanine transaminase 239 U/L, bilirubin 14 弮m/L, International Normalized Ratio 8.4, activated cephalin time of 180 seconds (ratio 5.4), a platelets count of 234,000 mm??, a white blood cells count of 17,000 mm??, a C-reactive protein of 19 mg/L. Abdominal ultrasonography revealed an unexpected large liquid picture measuring 10 cm by 5 cm over hepatic segments number VI, VII, and VIII. Abdominal computed tomography (CT) confirmed this suspicion of hematoma (Fig. ).
+A few hours later, she exhibits tachycardia, increased abdominal pain, and hypotension. Hemoglobin decreased to 5 g/dL. Fluid replacement therapy with crystalloids was started. Packed red blood cells and fresh frozen plasma transfusion were given. At the same time, fibrinogen concentrate (3 g) was administered (Clottafact [1.5 g/100 mL] LFB Biomedicaments, France). Decision was made to transfer the patient to a tertiary referring university hospital for endovascular embolization. The surgeon decided to implement abdominal packing as damage control therapy, to ensure safe conditions before transferring the patient. Active bleeding continued during the intervention and norepinephrine was introduced. At that time, 10 units of blood suspensions, 6 units of fresh frozen plasma, 4.5 g of fibrinogen concentrates, and 2 g of tranexamic acid were given. Selective catheterization of the 2 branches of the right hepatic artery was successfully performed (Fig. ).
+On day 2, the patient underwent further surgery to remove abdominal packing but subcapsular hepatic hematoma was still bleeding and another packing therapy was necessary. Fibrinogen concentrates were infused just before this 2nd surgery to optimize coagulation disorders. The removal of abdominal packing was possible on day 4, without any abdominal bleeding (plasmatic fibrinogen 1.9 g/L before surgery, Von Clauss coagulation micromethod[). Three grams of fibrinogen concentrates and tranexamic acid were administered at the beginning of the 3rd surgery. The time course of plasma fibrinogen concentrations is described in Fig. . Simultaneously, she presented an early ventilator acquired pneumonia (methicillin sensitive Staphylococcus aureus). Despite an appropriate intravenous antimicrobial use, fever and ileus remained and white blood cells increased to 35,000 mm??. On day 6, abdominal CT scan showed abundant pelvic peritoneal effusion and diffuse infiltration of the peritoneum, suggesting a postoperative peritonitis. Laparotomy was performed with abundant cleaning of the peritoneal cavity and drainage (plasmatic fibrinogen was 3.1 g/L after infusion of 4.5 g of fibrinogen concentrates). Antimicrobial therapy was switched to imipenem, vancomycin, and amikacin. No septic shock occurred. Purulent peritoneal effusion was infected with methicillin resistant Staphylococcus haemolyticus allowing de-scalation to vancomycin alone for 10 days. In the postoperative period, no bleeding occurred, bowel transit was normal, and drainage tubes were removed quickly. No thrombo-embolic adverse event occurred. Thrombo-embolic prophylaxis by low molecular weight heparin was introduced on day 7, after prophylactic intermittent legs compression during the 1st week. The patient was discharged to surgical ward on day 11."
+Chaya Atkinson,45,1993/10/3,200.746.3518x10645,francoisaac@example.com,4465 Roberto Neck,"In September 2015, a 36-year-old, emaciated, Hungarian man presented with a 3-month history of widespread, red, rust-colored papules and nodules partially erosive and crusted as well as a 4 cm wide, prominent, skin-colored, subcutaneous tumor at the left zygomatic arch (Fig. ). The oral mucosa was free of lesions. The patient was occasionally homeless in Austria, his travel history was unremarkable and he reported intravenous drug use. The latter comorbidity and the clinical presentation prompted HIV rapid testing, which provided a positive result.
+HIV infection was confirmed by Western blot and quantitative HIV PCR (4.70 log copies/mL). The CD4+ cell count was 47 cells/弮L (CD4+/CD8+ ratio: 0.06), indicative for severe immunosuppression. In addition, the patient was HCV positive and the viral load was 2.62 ?106 copies/mL (genotype 1a). The white blood cell count was within normal range, and the patient was subfebrile.
+Related to the rust-colored papules, BA, vascular tumors-like multiple pyogenic granulomata (PG), and HIV-associated Kaposi sarcoma were suspected. A biopsy of the nodular skin lesions from the dorsum revealed solid, abundant telangiectatic vessels in the upper dermis with prominent endothelial cells surrounded by neutrophils and lymphocytes, compatible with BA and PG. Immunohistochemical staining for human herpes virus 8 was negative. The Warthin?tarry stain showed clusters of microorganisms. High levels of serum IgG antibodies against B henselae and B quintana were detected in an indirect immunofluorescence assay (Euroimmun, L羹beck, Germany) strongly suggesting BA.
+For direct pathogen identification, an EDTA blood sample and tissue samples of the nodular skin lesions were analyzed in PCR assays. DNA was extracted and processed from both samples using a peqGOLD Tissue DNA Mini Kit (Peqlab) according to the manufacturer's protocol. DNA isolates were amplified with a real-time PCR targeting the ssrA gene of Bartonella spp.[ An ABI7900 cycler (Applied Biosystems, Foster City, CA, USA) was used with a thermal profile of initial enzyme activation at 95簞C for 2 minutes, 45 cycles of denaturation at 95簞C for 15 seconds, followed by annealing and elongation at 61簞C for 1 minute. Bartonella spp. DNA was detected in all samples. Amplicons for sequence analysis were generated in conventional PCR. The PCR products were loaded onto a 1% agarose gel and amplicons of size 301 bp were purified using the QIAquick Gel Extraction Kit (Qiagen, Austria). DNA sequencing was carried out by Eurofins Genomics DNA sequencing service (Eurofins Genomics GmbH, Ebersberg, Germany). The forward and reverse DNA sequences obtained were used for homology searches in the National Center for Biotechnology Information (NCBI) database BLAST search program ().
+The skin tissue was further cultured on Columbia blood agar plates (Biomerieux, Vienna, Austria) at 37簞C in an atmosphere of 5% CO2 and 95% humidity. After 4 weeks of culture, microbial growth was detected by clinical characteristics and selected colonies were propagated by culture via dilution streak plating. Single colonies were then picked and sub-cultured, and the DNA was purified and tested by a Bartonella-specific PCR assay.[4] Sequencing (BLAST analysis) demonstrated a clearly positive result for B quintana.
+Contrast-enhanced computed tomography (CT) scans of the head, chest, and abdomen (Fig. ) revealed hepatosplenomegaly and several abscesses located in lung, stomach wall, pancreatic tail, subcutaneous tissue, and the large lesion (4.5 ? 2.8 cm) at left zygomatic arch already eroding the adjacent bone. No pathological findings were seen on x-ray of the long bones or on echocardiography.
+In order to exclude a different pathology of the facial subcutaneous mass, such as Burkitt lymphoma, a biopsy was performed. Histology revealed neutrophil infiltrations with no evidence for a malignant process. In addition, DNA was extracted from the paraffin-embedded tissue for broad spectrum fungal PCR (MycoRealFungi, Ingenetix, Vienna, Austria) and no pathogens could be identified. The same tissue was tested for B quintana by PCR as described above and the result was positive. Silver impregnation staining showed bacilli.
+In view of the advanced immunosuppression, a screening for other opportunistic infections was performed. Atypical and typical mycobacterial infections were excluded by negative cultures from blood, urine, and skin biopsies. The TBC-specific interferon-gamma release assay and Cryptococcus neoformans antigen were also negative. Among several blood cultures from venous blood only one was positive for Staphylococcus epidermidis.
+After 23 days of treatment with doxycycline 100 mg bid, an improvement of the skin lesions, partial regression of the facial tumor and resolution of fever were observed. The HIV viral load had decreased to 2.02 log c/mL after initiation of antiretroviral therapy with emtricitabine/tenofovir 200/245 mg qd and dolutegravir 50 mg qd. A follow-up CT scan could not be performed, because the patient abandoned the hospital and was lost for follow-up."
+Duke Harmon,43,1997/2/23,525.782.5611,fordgabriel@example.org,01841 Alicia Lakes Apt. 886,"A 60-year-old man with a 3 ? 3 cm calculus in the left renal pelvis was scheduled for percutaneous holmium laser lithotripsy. He weighed 65 kg and was 172 cm tall. He had a history of mitral valve-replacement surgery and was on warfarin therapy. He also had a history of asthma for more than 20 years with severe pulmonary decompensation. International normalized ratio (INR) at admission was 2.26. He was shifted from warfarin to low molecular weight heparin therapy. INR decreased to 1.23 on the day prior to the operation. Because of pulmonary decompensation and the need for intensive anticoagulation therapy, he was a high-risk case for both general anesthesia and neuroaxial block. After careful discussion with multidisciplinary team and due deliberation and with the consent of patient and his family, PCNL was performed under ultrasound-guided PVB."
+Maren Sloan,33,2001/12/5,+1-466-850-2591x720,april89@example.org,972 James Streets Apt. 464,"A 67-year-old man with multiple calculi in the right renal pelvis and calyces was scheduled for PCNL. His weight and height were 60 kg and 163 cm. He had a history of stroke sustained 6 months prior to admission, which resulted in hemiplegia. He also had a history of chronic obstructive pulmonary disease. Preoperative pulmonary function tests revealed severe obstructive ventilatory impairment. Preoperative electrocardiogram indicated atrial fibrillation. 24-h Holter monitoring revealed long RR interval (>3 seconds, 3 times). Temporary pacemaker was implanted before the operation. This patient was at increased risk for general anesthesia because of poor pulmonary function. He had a relative contraindication to neuroaxial block because of hemiplegia. Based on our successful experience with PVB in the previous patient, we decided to adopt the same technique for this patient. With the consent of patient and his family, ultrasound-guided PVB was performed. PCNL was successfully performed with minimal interference with cardiopulmonary function."
+Ocean Velasquez,22,1994/2/9,-5989,brandon27@example.net,82989 Deleon Mountains,"A 27-year-old man with staghorn calculi was scheduled to undergo a second PCNL. His weight and height were 70 kg and 172 cm. He had a history of lumbar vertebral fracture and had a relative contraindication to neuroaxial block. He had undergone PCNL under general anesthesia one week earlier. Postoperatively, he experienced severe nausea and vomiting. He refused to accept general anesthesia this time. With the agreement of patient, we chose ultrasound-guided PVB for him."
+Esme Flowers,36,2000/12/11,+1-862-528-6404x7618,joseph53@example.org,4407 Matthew Turnpike,"A 43-year-old female patient referred to our hospital? emergency department in August 2014 with complaints of fever and severe pain in right breast. She noticed a soft lump and mild pain in her breast a week back. The intensity of pain increased gradually and for the last 2 days and her temperature increased. The patient had a history of 5 years of RA. The patient was not pregnant or lactating. She had three children with the last one delivered 6 years back.
+On physical examination, the right breast was tender and swollen. A mobile, sensitive, soft, fluctuating mass of around 4 by 5 cm located in the right lower quadrant was palpable. The mass was not fixed to the upper skin. The upper skin was warm and erythematous. There was no nipple retraction or discharge from the nipple. Axillary lymph nodes were not palpable. The patient? respiratory, digestive, nervous system physical examinations were normal. Physical examination of the musculoskeletal system revealed swelling in 2nd and 3rd proximal interphalangeal joints of the right hand and swelling and limitation of motion in the right knee.
+Ultrasonography (USG) of the right breast revealed a heterogeneously hypoechoic deep-seated irregular collection of approximately 40?38 mm size. The patient was diagnosed with a breast abscess. The abscess was drained by USG guided drainage, and oral amoxicillin clavulanic acid 625 mg bid therapy was started empirically.
+The drained fluid was sent to medical microbiology laboratory in a tightly capped, sterile container. On macroscopic examination, it was observed that the material had yellowish cream colour and dense consistency. Gram staining of the material showed abundant polymorphonuclear leukocytes and gram-negative bacilli. The material was inoculated on 5 % sheep blood and eosin methylene blue (EMB) agars plates. One of the sheep blood agar plates was incubated under anaerobic conditions. After incubation at 37 簞 C for 24 h smooth, straight-edged colonies without hemolysis grew on sheep blood agar. On EMB agar, lactose-negative colonies were detected which tested negative for oxidase production. These colonies were identified as Salmonella species by Phoenix BD (Becton, Dickinson, USA) automated system and Salmonella group by Maldi-TOF MS (bioM矇rieux, France). The microorganism was identified as Salmonella enterica serotype Typhimurium according to the Kauffmann-White scheme by using specific antisera (Difco, Becton, Dickinson, USA). No anaerobic bacteria were isolated. The microorganism was found susceptible to ampicillin, ciprofloxacin, trimethoprim-sulfamethoxazole, erythromycin, chloramphenicol, ceftazidime, and ceftriaxone by antibiotic susceptibility testing with Phoenix BD (Becton, Dickinson, USA) automated system.
+The patient was called back to the surgical outpatient clinic to obtain a detailed history. It was learned that 2 months ago she had diarrhoea for approximately 3 days and did not receive any antibiotic treatment. The patient had RA for 5 years and was on prednisone therapy. There was no history of contact with animals or trauma to breasts. There was no history of similar swelling in the other breast; no history of diabetes mellitus, hypertension, bronchial asthma, and tuberculosis. When the patient? laboratory tests were examined leukocyte count was 12,400/mm3 (83.9 % neutrophils), hemoglobin was 13.3 g/dL, fasting blood glucose was 108 mg/dL, erythrocyte sedimentation rate was 31 mm/h, CRP was 32 mg/l, RF was 28 IU/ml and anti CCP was 267.9 U/mL. Alkaline phosphatase, amylase, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transpeptidase, bilirubin levels were within normal limits. HBsAg, anti-HCV and anti-HIV (ETI-MAX 3000 analyzer; DiaSorin S.p.A., UK), anti-HBc (Cobas 6000 analyzer, Roche Diagnostics, USA) tests were found to be negative. Chest X-ray was normal. Stool, urine, and blood samples were obtained for culture and found negative for Salmonella spp. Gruber Widal test was also found negative. Figure shows a timeline of events.
+The patient was fully treated with the surgical draining of the breast abscess under general anaesthesia and oral ciprofloxacin 500 mg twice daily. At the end of 2 weeks, the patient was fully healed with no clinical signs of abscess. The control examination with USG after 4 months showed no sign of recurrence of the abscess."
+Saul Fields,30,2005/4/5,+1-344-984-7701x56045,martineznancy@example.org,74650 Brian Locks Suite 559,"A 57-year-old woman had underlying systemic iron deficiency anemia. She presented to our outpatient clinic with abdominal pain in March 2013. Panendoscopy and colonoscopy were performed and no organic lesions were detected in the upper and lower GI tract, and only gastritis was noted. However, the abdominal discomfort could not be eliminated and it worsened. Because of progressive abdominal pain, the patient was transferred to the emergence department after 1 week. Abdominal computed tomography (CT) (Fig. ) revealed a marked, approximately 10-cm mass in the pancreatic head. The pancreatic head tumor was initially diagnosed and she was then admitted for further examination.
+During hospitalization, laboratory analysis did not show hyperbilirubinemia and elevated amylase or lipase levels. The levels of tumor markers including carcinoembryonic antigen, carbohydrate antigen 19-9, and carbohydrate antigen 125 were within normal limits. CT-guided aspiration of the cystic component was performed, and cytological analysis showed only some macrophages. We performed surgical exploration on March 22, 2013.
+During the operation, we found that the lesion was approximately 10 cm in size with cystic and solid components (Fig. ). The tumor appeared to originate from the pancreatic head and presented as a cystic hematoma protruding downward into the mesocolon. We performed partial cystectomy for hematoma evacuation, and tumor tissue was obtained from the pancreatic head for pathologic analysis. Examination of frozen tissue section did not indicate any malignancy. Finally, gastrojejunostomy bypass was performed without radical resection of the tumor. The patient showed good postoperative recovery. The final pathologic analysis confirmed the DT diagnosis and immunohistochemical staining showed focal positivity for smooth muscle actin and desmin but negativity for Mdm2, CDK4, and CD34. The tumor showed strong positivity for beta-catenin (Fig. ).
+The patient received one 200-mg tablet daily of the non-steroidal anti-inflammatory drug (NSAID) celecoxib for half a year. We obtained a follow-up abdominal CT scan in October 2013 after 6 months of celecoxib treatment. The CT images showed a marked regression of the existing pancreatic head mass and complete disappearance of the cystic lesion. Therefore, the dose was modified from one tablet daily to one tablet every other day with the same dose of celecoxib starting from the date of the 6-month follow-up until now. The abdominal CT scan obtained at the 18-month follow-up in September 2014 showed no local recurrence (Fig. ). There is no side effect noted by the patient in the period of celecoxib treatment. The patient is still receiving celecoxib treatment for the control DT.
+DT originates from the abnormal proliferation of myofibroblasts. It is a very rare disease and presents with a benign pathology; however, it exhibits local invasiveness indicating clinical malignancy. The DT location can be classified as extra-abdominal, abdominal, or intra-abdominal. Genetic screening for defects showed that mutations in the FAP gene were a risk factor that was more frequently associated with intra-abdominal DT []. Other studies showed that intra-abdominal DT frequently had pelvic and mesenteric origins. DTs originating from pancreas are very rare. To date, only 12 cases of pancreatic DT have been reported [?. Among these articles, only three of them reported DTs that originated in the pancreatic head, and all patients underwent tumor resection [?. The present case is the fourth case of DT originating from the pancreatic head; however, it is the only case treated by medication and achieved completed remission.
+The clinical presentation of most patients with DT is usually asymptomatic and otherwise presents non-specific abdominal pain. DT diagnosis could not be confirmed via laboratory analysis or radiological images. Therefore, the definitive diagnosis of DT could only be based on histological and immunohistochemical findings []. In present case, DT diagnosis was confirmed by the final immunohistochemistry staining that showed strong positivity for beta-catenin and focal positivity for smooth muscle actin and desmin.
+The current first-line treatment for DT is complete resection with free margins. Sometimes, performing resection with wide, free margins for the prevention of tumor recurrence is difficult because of the locally invasive behavior of the tumor. Chemotherapy, molecular-targeted therapy, and radiotherapy are considered in cases with high surgical risk. Another case that was successfully treated with NSAIDs was previously reported [].
+Further analysis showed the stabilization of the beta-catenin protein in DT caused by mutation in either the APC or beta-catenin gene []. If mutated, beta-catenin accumulates in the cell and activates the T cell factor, which triggers the transcription of target genes including COX-2 []. Therefore, an elevated COX-2 protein level was observed in DT; COX-2 partially regulates proliferation through beta-catenin stabilization []. Therefore, the degradation of this protein or reduction of the nuclear accumulation of beta-catenin might decrease tumor growth. A molecular model suggests an interaction between NSAIDs and beta-catenin. However, the mechanism of beta-catenin inhibition by NSAIDs has not yet been elucidated.
+In the present case, the patient achieved complete remission on treatment with a COX-2 inhibitor, celecoxib. The initial plan was to treat the patient with tamoxifen; however, owing to its side effect, we did not proceed with this treatment option. At the end of the 2-year follow-up, the patient showed no tumor recurrence with maintenance therapy using celecoxib.
+Tanaka et al. [] reported that a patient who received etodolac, another COX-2 inhibitor, only achieved partial remission. NSAIDs indeed have a cytoreductive effect on DTs. However, different types of NSAIDs appear to have different efficacies in DT size reduction.
+Although resection is the only radical treatment option for DT according to the current consensus, medical therapy also has an important role in the treatment of patients with comorbidities or in those where resection is contraindicated. Chemotherapy has a relatively high complication rate for patients, and the results of radiotherapy treatment were not optimistic. Therefore, NSAIDs offer another treatment option for DT with fewer side effects. However, additional clinical trials and molecular analyses should be performed to test the effect of NSAIDs in the treatment of DTs."
+Annie Lu,42,1977/12/1,(243)269-7178x495,hmills@example.com,39070 Hanna Park Apt. 365,"A 72-year-old Japanese woman was referred to our hospital by her general practitioner with a 10-day history of swelling and pain in her right forearm without a previous history of trauma. A physical examination revealed that her right forearm was tense and swollen from the area directly proximal to her wrist to immediately below her elbow (Fig. ). She complained of increasing pain with passive extension and slight numbness of her fingers. Computed tomography revealed a low-density area in the muscles of the anterior aspect of her right forearm (Fig. ). Laboratory investigation showed a white cell count of 184.5 ? 109/L, including 1 % blast cells, 2 % eosinophils, 6.5 % basophils, 2.5 % promyelocytes, 14 % myelocytes, 18 % metamyelocytes, 44 % neutrophils, 7.5 % monocytes, and 4.5 % lymphocytes. In addition, her hemoglobin level was 66 g/L, and her platelet count was 3610 ? 109/L. Routine coagulation parameters revealed slightly prolonged prothrombin time (15.9 seconds, international normalized ratio 1.28). However, her activated partial thromboplastin time (32.6 seconds) was within the normal range of 24.0 to 35.0 seconds, as was her bleeding time (90 seconds). Plasma fibrinogen and D-dimer levels were slightly elevated to 390.8 mg/dL and 3.3 弮g/mL, respectively (normal 200 to 380 mg/dL and 0 to 1.0 弮g/mL, respectively), although her fibrin degradation product level was within normal range (8.2 弮g/mL). The von Willebrand factor (vWF) antigen level was normal (111 %), and the vWF ristocetin cofactor activity, at 70 %, was undiminished. Multimeric analysis of vWF did not show a decrease of large vWF multimers. Furthermore, factor 8 and 13 activities, at 82 % and 72 % respectively, were not reduced. Laboratory values are summarized in Table . She did not have any apparent skin and mucosal bleeding tendency such as petechial hemorrhage. Bone marrow aspiration revealed hypercellularity with marked myeloid proliferation, but only 3 % of the cells were blasts (Fig. ). These findings led to the presumption of a myeloproliferative disorder (MPD) such as CML, polycythemia vera, or essential thrombocytosis (ET). Because the level of her neutrophil alkaline phosphatase score was markedly reduced to 49 (normal 150 to 350), we deemed CML to be the most likely diagnosis.
+Cytoreductive therapy with hydroxyurea (1500 mg/day) was initiated as the most credible therapy to reduce her platelet count, because we could not rule out the possibility of MPD which does not respond to tyrosine kinase inhibitors. An urgent orthopedic opinion was obtained, and compartment syndrome was confirmed after the compartment pressure was found to be 39 mmHg. Emergency fasciotomy for decompression of the anterior compartment was conducted, which confirmed a tense compartment and pathologically proven hematoma in the right anterior compartment. There was no evidence of leukemic cell infiltration.
+Persistent local bleeding developed during the latter part of the operation despite no surgical cause. After decompression, the wound was left open and managed with a wet dressing. Sustained postoperative oozing of blood resulted in hypovolemic shock and required massive red cell concentrate transfusion for hematologic and cardiovascular resuscitation. She continued to require 4 to 8 units of red blood cell concentrate on a daily basis (in Japan, 1 unit of red cell concentrate is derived from 200 mL of donated whole blood).
+Chromosome analysis of her bone marrow cells demonstrated a karyotype of 46,XX,t(9;22)(q34;q11.2) (Fig. ). In addition, fluorescence in situ hybridization detected a BCR?BL fusion signal in 93 % of the cells (Fig. ). Thus, she was diagnosed with chronic-phase CML []. Following this definitive diagnosis, dasatinib therapy (100 mg/day) was initiated. Although there were no signs of improvement in the oozing of blood while her platelet count remained high, her bleeding tendency began to improve after her platelet count decreased to less than approximately 1000 ? 109/L. During her clinical course her coagulation parameters remained stable. Although her D-dimer level, which reflects the dissolution of blood clots, remained slightly elevated (0 to 3 弮g/mL) for a period of time, her prothrombin time and fibrinogen levels soon recovered to their normal range. Complete hemostasis was achieved 7 days after the fasciotomy, and the fasciotomy site was closed on postoperative day 20.
+She continued dasatinib therapy, with good hematological and molecular responses. She obtained complete cytogenetic response and major molecular response at 12 and 18 months, respectively, after the initiation of dasatinib administration."
+Duncan Kane,36,1996/11/4,(997)623-3807x853,sheltondanielle@example.com,4781 Parker Mills,"A 69-year-old male presented to the otolaryngology office with complaints of right sided neck mass and otalgia. His past medical history was significant for 50 years of smoking, regular alcohol use, and colonic adenocarcinoma managed with a colectomy several years prior. He was diagnosed with T4aN2aM0 hypopharyngeal carcinoma involving the right pyriform sinus with a single 4 cm metastasis to the right level V. He was offered surgical resection followed by GPU reconstruction and planned adjuvant radiotherapy.
+Of note, during surgical planning, it was felt that the mediastinal esophagus was likely not involved with the tumor. Thus, tumor resection was expected to produce a circumferential pharyngeal defect extending into the cervical esophagus, but not the mediastinal esophagus. Faced with such a defect, to avoid the morbidity associated with entering the abdominal cavity, many surgeons would advocate for reconstruction with a tubed cutaneous free flap rather than with the GPU []. However, at our institution one of the authors (D.W.A) working alongside the thoracic surgery team has been able to achieve better functional outcomes with the use of GPU as compared to reconstruction with tubed cutaneous free flaps. After careful consultation with the thoracic surgery team, a joint decision was made to pursue GPU reconstruction.
+A laryngopharyngectomy and right modified radical neck dissection were performed without complication. Following the resection, the thoracic surgery team proceeded with the esophagectomy and gastric mobilization. Gastric mobilization was hindered by intrabdominal adhesions related to the previous colectomy as well as dilated gastric veins related to apparent liver cirrhosis. Nevertheless, a well-vascularized and tensionless gastropharyngeal anastomosis was attained and a jejunostomy tube inserted.
+Postoperatively, the patient was managed in the intensive care unit due to difficulty weaning from the ventilator. His early postoperative course was complicated by sepsis, and an anastomotic leak was considered despite serosangouinous neck drains and no wound breakdown. He was managed conservatively with antibiotics until postoperative day 7, when he lost vacuum on the negative pressure suction drain in the neck. Dehiscence was confirmed using a water-based dye.
+The patient was then taken to the operating room and found to have circumferential necrosis of the proximal GPU extending inferiorly into the upper mediastinum (Fig. ). The necrosis was debrided until well-vascularized gastric mucosa was reached. A large defect remained extending from the distal oropharynx to the proximal superior mediastinum. The reconstructive options to re-establish the continuity of the alimentary tract in this patient were severely limited. Due to the patient? history of colonic resection and recent gastric pull up, intra abdominal tissue transfer, such as jejunal transfer or colonic interposition were not available. The two remaining options included a vascularized free tissue transfer or creating a controlled pharyngeal fistula and over sewing the proximal stomach. A 20 cm by 15 cm elliptical ALT flap was chosen as the donor free tissue transfer, and was folded on itself in conical design to reconstruct a neopharynx (Fig. ).
+Postoperatively, the patient spent 22 days in the intensive care unit and another month in the hospital undergoing rehabilitation and addressing psychosocial issues. His jejunostomy tube was removed prior to discharge as he was supporting himself nutritionally with a pureed diet. An endoscopic view of the ALT anastomosis one month post reconstructive surgery is shown in Fig. . At four months recovery he remains on an oral diet. His laryngostoma is shown in Fig. ."
+Ellianna Griffith,34,1991/12/20,-11682,ogray@example.net,46337 Juarez Club Apt. 872,"A 20-year-old female who presented with an intermittent fever for two years and double lower limb numbness and weakness for one month was admitted to hospital in January 2015. In April 2013, she underwent a right lung pneumonectomy for ?ung cancer,??while the postoperative pathology referred to a ?ecrotizing granulomatous mass.??Seven months after the operation, a computed tomography (CT) scan showed an enclosed outstanding mass in the right chest wall (Fig. ). Thereafter, the patient was hospitalized three times due to a repeated fever and multiple bump biopsies from the enclosed outstanding mass; however, there was no clear diagnosis. One month before this admission, in addition to a fever, the patient suffered from worsened lower limb numbness and weakness, difficulty walking, and dysuria. In the past, she was healthy and had good nutrition.
+A physical examination showed an abnormal and oncotic hard mass (10 cm ? 5 cm) that protruded from the right chest wall. A 0.3-cm-diameter external fistula was seen in the central part of the pack (Fig. ), which oozed a nonodorous, yellowish turbid liquid. Coarse sounds without moist rales or rhonchi were heard with left lung auscultation. Superficial feeling of the abdominal wall was decreased from the T7 and T8 level, while a deep feeling was present. Muscle strength for both lower limbs was decreased: 1簞 right and 3簞 left. Muscle tension of both lower limbs was also diminished. The bilateral Babinski sign was positive, but concavity swelling of the lower limbs existed.
+Laboratory tests showed a white blood cell count of 18.21 ? 109/L, a hemoglobin level of 82 g/L, a platelet level of 509 ? 109/L, a C-reactive protein concentration of 98.00 mg/L, an erythrocyte sedimentation rate of 98.00 mg/L, and negative 1-3-帣-D glucan and glactomannan (GM) tests. Post right pneumonectomy, the thoracic CT scan revealed uneven density flake soft tissue shadows in the right chest cavity, multiple sizes of nodules in the left lung, a soft tissue mass (12.5 cm ? 5.9 cm) around a small pneumatosis in the right chest wall, and a reduced density in the right liver lobe near the diaphragmatic top (January 2015, Fig. ). The thoracic magnetic resonance imaging (MRI) results showed that a space-occupying lesion existed in the right pleural and chest wall with the T3-6 vertebral body and the right rib damaged, invading the spinal channel and spinal cord (January 2015, Fig. ).
+A biopsy through the right chest wall mass and thoracic mass by fistula of chest wall showed broad nonseptate hyphae with right-angle branching, consistent with mucormycosis (Fig. ). The mucormycosis was widely disseminated, invading the lung, skin, liver, vertebrae, and spinal cord.
+The patient quickly developed type II respiratory failure. A noninvasive ventilator assisted breathing, and intravenous amphotericin B (AmB) was administered. When the dose of AmB increased to 0.5 mg/kg/day, with the cumulative dose reaching 150 mg, mental disorders (agitation, fear, etc.) and cardiac arrhythmias occurred. The adverse events disappeared when AmB was changed to liposomal AmB.
+After treatment for 28 days, the patient? body temperature became normal and her respiratory function as well as lower limb sensory and motor function recovered. The size of the right chest wall mass became smaller, and the fistula dried. Laboratory and imaging examinations indicated that the lesions of the lung, liver, and thoracic vertebrae were significantly smaller. The patient was discharged back to the local hospital for further antifungal treatment and had recovered by the 3-month follow-up exam, and plastic surgery was suggested to repair the thoracic wall."
+Franklin McCann,33,1983/3/8,6775247359,carteranthony@example.net,65036 Carpenter Causeway Suite 408,"A 40-year-old woman was referred to our strabismus clinic with a complaint of double vision. She had already been diagnosed with hyperthyroidism, and her thyroid function had normalized after 2 months of treatment with antithyroid medication; subsequently, 2.5 mg carbimazole was used as a maintaining dose. She did not take systemic steroid medication, because her dysthyroid ophthalmopathy was not severe (Clinical Activity Score, CAS 2) and there was no aggravated symptomatic sign. She subsequently developed worsening diplopia and proptosis in her left eye 1 month prior to presentation. At the initial examination, her visual acuity was normal in both eyes (20/20), and 2 mm exophthalmos was noted in her left eye. She exhibited left hypotropia of 35 prism diopters (PD) in the primary position with marked limitation of left eye elevation (Fig. ). Asymmetric enlargement of the inferior and medial rectus muscles was demonstrated in her left eye on computed tomography (CT), and was compatible with dysthyroid ophthalmopathy (Fig. ). The forced duction test (FDT) revealed restriction in the upward direction in her left eye. She described a highly predictable fluctuating pattern of diplopia, that spontaneously switched at approximately 8 o?lock every night. To differentiate the causes of the fluctuating diplopia, such as myasthenia gravis, we performed laboratory tests, including a determination of acetylcholine receptor antibody titer; all results were normal. Based on her description, we recommended that she keep a diary to record her diplopia episodes and have her picture taken during episodes of both mild and severe diplopia. At the next visit, during which she exhibited relatively mild diplopia, cover testing revealed left hypotropia of 7 PD in the primary position with mild limitation of left eye elevation (Fig. ). Her diary clearly revealed the ?very-other-day??pattern of diplopia. During the 6 months since the first visit, her thyroid function remained normal and the proptosis of her left eye decreased. A cycle involving diplopia-free days was gradually predominant. Finally, the left hypotropia of 7 PD remained, but without a cyclic pattern. Her diplopia was well compensated with mild chin elevation."
+Joyce Fisher,30,1988/9/10,847.563.0146,sean89@example.net,83255 Griffin Cliff,"The patient is an 11-year-old male with attention deficit hyperactivity disorder (ADHD) who presented with an unintentional 20 lb. weight loss that was initially attributed to ADHD medication. Exam was notable for cervical lymphadenopathy. Laboratory workup showed leukocytosis with left-shifted granulocytes (WBC 210,000 cells/弮L; 65 % neutrophils, 6 % bands, 5 % lymphocytes, 3 % monocytes, 2 % eosinophils, 3 % metamyelocytes, 13 % myelocytes, 2 % promyelocytes, 1 % blasts), normocytic anemia (Hgb 10.8 g/dL, MCV 92 fL), elevated LDH (1,858 U/L), and elevated uric acid (7.0 mg/dL). Abdominal CT scan showed splenomegaly.
+A bone marrow study revealed hypercellular marrow (>95 %) with increased myeloid cells at all stages of maturation, increased eosinophils, scattered basophils, few erythroid progenitors, so-called dwarf megakaryocytes, and sea-blue histiocytes (Fig. ). Blasts were <5 % morphologically. Flow cytometry identified a population of atypical CD3+ MPO- TDT+ T lymphoblasts (9 % of total events). IHC of the bone marrow core biopsy confirmed these latter findings, showing individual and clusters of CD3+ TDT+ T lymphoblasts comprising ~10 % of overall cellularity and 20??0 % of cells in restricted areas (Fig. ).
+RT-PCR from peripheral blood was positive for the BCR-ABL1 p210 transcript. Cytogenetic analysis of the bone marrow showed 46,XY,t(6;9;22)(p22;q34;q11.2)[]/46,sl,inv(3)(q21q26.2)[], confirming the presence of a variant three-way translocation generating the BCR-ABL1 fusion. The presence of a subclone (11 of 20 cells analyzed) with inv(3)(q21q26.2) suggested disease progression. Following identification of this inversion and validation of a novel MECOM antibody, combined IHC for MECOM and CD3 was performed on the bone marrow core biopsy. Interestingly, the CD3+ population and the MECOM-overexpressing population were non-overlapping (Fig. ), indicating the T lymphoblastic transformation was independent of the acquisition of inv(3)(q21q26.2).
+Based on these findings, a diagnosis of CML with T lymphoblastic transformation was rendered. The patient was started on hydroxyurea and allopurinol, followed by single-agent treatment with imatinib (500 mg daily). Repeat bone marrow studies on day 25 of treatment showed restoration of trilineage hematopoiesis and normal cellular morphology, with abnormal T lymphoblasts comprising 1 % of total cellularity by flow cytometry. Subsequent to this study, he was transitioned from imatinib to dasatinib (100 mg daily) due to the development of oral ulcers, and continued to improve clinically on TKI alone. A third bone marrow biopsy and aspirate at day 54 showed 0.02 % T lymphoblasts. Peripheral blood quantitative RT-PCR analysis at three months showed a 1.4 log reduction of BCR-ABL1 transcripts (4.3 % IS units) (Table ). Despite this response to TKI monotherapy, a matched unrelated stem cell donor was identified and transplantation is scheduled given the high-risk features of his disease."
+Gael Conner,22,1987/3/4,570.413.0302x29658,brandypeterson@example.com,17176 Wells Ways Suite 082,"A 74-year-old female noted visual impairment in her left eye. The best corrected visual acuity (BCVA) was 0.25 in the left eye. Fundus photography (Fig. ) shows retinal hemorrhage with a white lesion superior to the optic nerve. FA revealed staining in the early phase (Fig. ) and leakage in the late phase (Fig. ). The OCT showed a round cavity with a hyperreflective wall and a dark lumen in the area of the RAM (Fig. ). Cystoid retinal edema was adequately visualized in the en face OCT image (Fig. ).
+The OCT angiogram also showed the RAMs. An interruption of blood flow in the area of the RAM was observed in the superficial retinal OCT angiogram (segmented with an inner boundary at 3 弮m beneath the internal limiting membrane and outer boundary at 15 弮m beneath the inner plexiform layer) (Fig. ). The deep retinal OCT angiogram (segmented with an inner boundary at 15 弮m beneath the inner plexiform layer and the outer boundary at 70 弮m beneath the inner plexiform layer) and the OCT angiogram of the outer retina showed high blood flow in the RAM (Fig. and ). Using cross-sectional OCT angiography, it is possible to visualize the level of blood flow in the RAMs (Fig. )."
+Alondra Sloan,40,1990/4/12,(519)256-2951,mosesrichard@example.org,4652 Crystal Falls Apt. 153,"A 68-year-old female noted acute visual loss in her left eye, the BCVA was 0.1. Fundus photography, FA and OCT angiography findings of a superotemporal macroaneurysm with intraretinal hemorrhage are presented in Fig. -.
+The superficial retinal OCT angiogram shows reduced blood flow in the RAM (Fig. ). Blood flow was detected in the same area in the deep retinal OCT angiogram (Fig. ) while no flow was detected in the outer retinal OCT angiogram (Fig. ). In this case, the RAM must have its origin in the inferior part of the vessel, as the saccular RAM can be perfectly visualized in the deep retinal OCT angiogram (Fig. ). Two months after intravitreal anti-vascular endothelial growth factor therapy it was not possible to visualize the RAM despite varying the segmentation (Fig. - )."
+Ocean Griffith,39,1983/1/17,540.580.8048x6514,jsalazar@example.org,0028 Arnold Extension,"A 72-year-old female developed a deterioration of visual acuity in the left eye. The RAM is superotemporal in relation to the fovea, as in Case 2 (Fig. ). Using information from FA, SD OCT and OCT angiography (Fig. -), two main parts can be determined in the RAM: a smaller part (Fig. ) located mainly above the retinal vessel with blood flow seen in the superficial retinal OCT angiogram (Fig. ) and a fusiform part located below the retinal vessel (Fig. ) with blood flow seen mainly in the deep retinal OCT angiogram (Fig. ). The shape of the RAM is shown best on the early fluorescein angiogram (Fig. ). The cross-sectional OCT angiography visualizes the level of blood flow in the RAMs (Fig. )."
+Alicia Grimes,37,1977/11/2,2813678694,anthony23@example.com,376 Maddox Plaza,"This 29 years old female presented with 1 week history of low grade intermittent fever with constitutional symptoms and a persistent worsening of cough for the same duration. Her fever did not associate with chills or rigors and she did not have hemoptysis. She was previously healthy and she was a housewife who engaged herself actively in gardening at her own backyard. She did not have a contact history or a past history of tuberculosis. She had no history of foreign travel. She did not have any other symptoms to note. On examination, she was average built with a BMI of 24 kg/m2. She was febrile. She was neither pale, nor she had lymphadenopathy or organomegaly. Her pulse was 120 bpm and blood pressure was 86/60 mmHg on admission. There were few scattered crackles in her lungs. There were no signs of focal consolidation, effusions evident on examination. She did not have skin ulcers, cellulitis or skin abscesses. She had no features of meningism, focal neurological deficits and had normal fundi.
+Her investigations showed a haemoglobin of 11.2 g/dl with neutrophil leukocytosis (total 18,000/繕l with 82 % neutrophils) with platelet count of 540,000/繕l. Her ESR was 60/1st h and CRP was 458 繕/l (<6). Chest radiograph showed bilateral patchy shadows involving both lung fields (Fig. ). Her high-resolution computed tomography (HRCT) scan showed multiple bilateral cavitary lesions in the upper, middle and lower zones of lungs without air-fluid levels (Fig. ). We administered broad spectrum intravenous antibiotics (Ceftriaxone 2 g 12 h and Clindamycin 600 mg 8 h) for 5 days, in spite of which she continued to have high fever spikes and showed clinical deterioration. Her blood and urine cultures revealed negative results. Since her Mantoux test and sputum smear and culture for acid fast bacilli (AFB) were negative, we proceeded to perform an early fibro-optic bronchoscopy. Bronchoscopy was normal and the broncho-alveolar lavage fluid (BALF) specimens were negative for AFB, Pneumocystis jiroveci and fungi. All BALF cultures including bacterial, fungal and mycobacterial were performed and special cultures were requested for melioidosis due to poor response to initial broad spectrum antibiotics. Surprisingly, culture for melioidosis using Ashdown? agar became positive for Burkholderia pseudomallei, while all other cultures were negative. On Ashdown? agar, the colonies showed typical purple, wrinkled morphology after 72 h of incubation. Melioidosis antibody titre (Indirect Haem-agglutination Assay) was detected to be highly positive at a titre of 10,640. Her transthoracic and trans-esophageal echocardiogram did not show vegetations. Autoimmune panel with ANA and ANCAs were negative. Contrast CT chest and abdomen did not reveal any visceral lymphadenopathy or abscesses. Her HIV, TPHA/VDRL, HbA1c (5.5 %), renal, liver functions and serum immunoglobulin levels were all normal.
+After detecting BALF cultures and antibody titre positivity for Melioidosis, we changed the antibiotics to high dose intravenous Meropenem (2 g 8 h). She showed excellent response for these antibiotics within few days and demonstrated a marked clinical improvement and radiographic resolution. After 7 days of intravenous antibiotics, melioidosis antibody titers reduced to 2750 and subsequently to 160 after 4 weeks.
+We continued her intravenous antibiotics for a month and discharged her on oral Doxycycline (100 mg 12 h) for another 24 weeks. In review of the patient, her recovery was uncomplicated after completion of the course of antibiotics."
+Harlan Moon,32,1980/7/6,2922112331,richard37@example.net,813 Jennings Isle Apt. 663,"A 17-year-old man complained of diarrhea and bloody stools and was referred to our hospital in 2000. His family had no particular disease. He was diagnosed with total-type UC by total colonoscopy (TC). The patient had no primary sclerosing cholangitis. Mesalazine at 2250 mg/day was prescribed. In June 2005, he underwent TC. Immunohistochemical analysis of a rectum biopsy showed LGD with an overexpression of p53 protein. The following month he complained dyspnea and edema of the whole body and he gained 4 kg in weight. He was consulted by a nephrology physician. Laboratory data showed total protein of 4.5 g/dl, albumin of 1.4 g/dl, total cholesterol of 352 mg/dl, creatinine of 1.7 mg/dl, and blood urea nitrogen of 43 mg/dl in the serum. His urine showed proteinuria 3.6 g/day. He was diagnosed with NS according to the criteria. Biopsy of the kidney demonstrated a minimal change in NS histologically. Prednisolone at 35 mg/day was initiated. Cyclosporine at 250 mg/day and mizoribine at 150 mg/day were added because of steroid resistance. His symptoms disappeared after 3 months of medication.
+Mesalazine had not been administered to the patient since 2008. Prednisolone was tapered to 12.5 mg. TC was performed in 2013 and a stenotic lesion was detected in the rectum. Biopsy of the rectum showed LGD histologically.
+In July 2014, he complained of abdominal distension. Abdominal X-ray showed distension of the colon and an abdominal computed tomography (CT) scan showed a rectal tumor associated with swellings of multiple abdominal lymph nodes. He was admitted to our hospital.
+Laboratory data at admission is shown in Table . Serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were markedly elevated. Urinalysis did not show occult blood, proteinuria, and glycosuria. TC showed a round shaped elevated lesion in the rectum with an ulcer on top (Fig. ). A colonoscope was passed through the stenosis site and inflammation of the colorectal mucosa was mildly active. Biopsy of the rectal tumor showed well-differentiated adenocarcinoma with mucin production. Overexpression of p53 protein was observed immunohistochemically. Magnetic resonance imaging (MRI) showed multiple swellings in the rectal mesentery lymph nodes and lateral pelvic lymph nodes.
+Transverse colostomy was performed under general anesthesia. As KRAS gene mutation was not detected in the biopsy specimen, the patient received a total of two cycles of modified FOLFOX6 and panitumumab [] over 2 months as neoadjuvant chemotherapy. Adverse effects of chemotherapy were peripheral neuropathy (grade 1) and skin rash in the face (grade 1). Repeated CT scan and MRI did not show shrinkage of the tumor indicating stable disease. Five weeks after the completion of chemotherapy, the patient underwent a total proctocolectomy with a stapled ileal pouch anal-canal anastomosis, total mesorectal and bilateral pelvic lymph node dissection, and temporary loop ileostomy. The patient fared well in the postoperative course.
+The resected specimen showed an irregular shaped, round, elevated mass that was 3 cm in diameter at the rectum (Fig. ). Background colorectal mucosa was flat with mild inflammation confirming UC. Histological examination of the specimen revealed mucinous adenocarcinoma with well and moderately differentiated adenocarcinoma. Over expression of p53 protein was observed immunohistochemically (Fig. ). Metastases were observed in 25 lymph nodes including the mesorectal and bilateral pelvic lymph nodes. Colorectal mucosa showed active UC with cryptitis and crypt abscess histologically. The pathological stage of the carcinoma was pT3N2bM1a, stage IV, according to the TNM classification of UICC, 7th edition [].
+The patient was discharged from the hospital after receiving 1 cycle of modified FOLFOX6. He received additional 7 cycles of modified FOLFOX6 in 4 months at the outpatient unit. Adverse effects of postoperative chemotherapy were peripheral neuropathy (grade 2). The patient is currently alive without evidence of recurrence of the carcinoma 12 months after colectomy.
+We report a case of an UC patient where disease was associated with advanced rectal carcinoma. UC was associated with NS after treatment of UC with mesalazine for 5 years. Firwana et al. reported a case of NS after mesalazine treatment for Crohn? disease []. He also reviewed six case reports of NS after the treatment of UC with 5-amino-salacylic acid derivatives. All six patients were given steroids and improved. However, the relationship between mesalazine and NS is currently unclear.
+Kiran et al. reported that carcinoma was present in 29 % of UC patients with preoperative HGD compared with 3 % in those with LGD []. Thus, the risk of carcinoma in UC patients with HGD is substantial. In the current case, the patient showed advanced rectal carcinoma 8 years after LGD was detected by surveillance colonoscopy. He received steroids and immunosuppressants for the treatment of NS. However, these reagents might accelerate the progression of rectal carcinoma from dysplasia.
+The standard surgical procedure for patients with UC is restorative proctocolectomy with construction of an ileal pouch. Colectomy for UC patients with carcinoma requires sufficient lymph nodes resections []. In this case, 25 metastatic lymph nodes including the pelvic lateral lymph nodes were resected surgically. It is very rare that so many metastatic lymph nodes were detected in resectable sporadic or colitic carcinoma cases without distal organ metastases. This patient was under immunosuppressive conditions induced by the steroid and immunosuppressant treatment for NS. The possibility exists that this immunosuppressive condition was precipitated the aggressive lymph node metastases.
+Advanced carcinoma affects the lifespan of UC patients. In a study conducted in Japan, Watanabe et al reported that patients with CRC-associated UC showed poorer survival rates than those with sporadic CRC in the advanced stages, while no difference was observed in the early stages []. It is important to detect dysplasia and carcinoma at an early stage by surveillance. LGD with an overexpression of p53 protein was detected in this patient by surveillance colonoscopy. p53 mutations have been shown to occur at an earlier phase in the progression of UC-associated neoplasia []. It had already developed to an advanced carcinoma when he underwent the follow-up colonoscopy. This is a rare case, and there are still problems concerning the method of surveillance and follow-up colonoscopy."
+Naya Cantrell,20,1986/2/21,690-932-9652,jhardy@example.net,83696 Patricia Center,"A 42-year-old man who had been treated for depression for 3 years visited our clinic because of right motor weakness and aphasia that had worsened progressively over 1 month. Manual muscle testing (MMT) revealed right motor weakness of 3/5 in the upper limb and 4/5 in the lower limb and he had total aphasia. Head magnetic resonance imaging (MRI) (Fig. ) demonstrated multiple cystic lesions in the left temporal lobe. These cysts had low signals in T1-weighted (T1WI) and diffusion-weighted images (DWI), and high signals in T2WI. The parenchymal components around the cysts showed slightly high signals in DWI. The parenchymal portions and cyst walls were enhanced by gadolinium dimeglumine. A pronounced left to right midline shift caused by the mass effect of the cysts and brain edema was evident. Neuroradiologists commented that the most possible diagnosis was GBM and malignant oligodendroglioma should be a differential diagnosis considering the patient? age.
+The tumor was partially removed and the largest cyst opened under general anesthesia (the white arrows in Fig. indicate the resected portion.). The tumor was yellowish and soft and the fluid in the cyst was weakly xanthochromic. Histological examination of the resected tissue resulted in a diagnosis of GBM (Fig. ).
+One month after surgery, radiation of 60 Gy (2 Gy ? 30 times) and oral temozolomide (TMZ) treatment (75 mg/m2) for 42 days were initiated []. After this treatment, the right lower extremity? motor function recovered to 5/5 on MMT; however, the right upper limb motor weakness and aphasia did not improve with the treatment. One week after completion of irradiation and TMZ treatment, the patient was discharged to home and continued to take TMZ treatment for 5 days every 4 weeks. Three months later, he was brought to our emergency room because of deterioration in consciousness. His Glasgow coma scale was 4 (E1M1M2), and MRI demonstrated enlargement of several of his cysts, causing uncal herniation (Fig. ). The patient? parents refused further treatment on his behalf and he died 5 days after this admission. An autopsy was performed 6 h after his death with the permission of the patient? parents.
+Histological examination of the operative specimen resulted in a diagnosis of GBM, and this diagnosis was based on the following characteristic features; high cellularity, pleomorphism with giant cells, endothelial proliferation, pseudo-rosette formation, necrosis (Fig. a, b, c), and a high Ki-67 index of 20 % (Fig. d).
+On gross morphological examination, the cysts in the tumor shrank after formaldehyde fixation and the parenchymal portion of the tumor was clearly identified. An absence of destructive tumor invasion of the white matter indicated it was not aggressive (Fig. ). On low magnification of hematoxylin and eosin (HE) stained sections, tumor necrosis was evident but the boundary between the tumor and normal surrounding tissue was well-defined (Fig. ). Examination under higher magnification confirmed well-defined tumor boundaries (Fig. a, b, c). The histologic appearance was heterogenous and pleomorphic giant cells were readily identified (Fig. d). Clear xanthomatous cells with foamy cytoplasm were apparent (Fig. e) and were strongly positive on silver staining (Fig. f). The tumor was strongly glial fibrillary acidic protein positive (Fig. g) and Ki-67 index was extremely low as 1 % (Fig. h)."
+Harris Randolph,42,1982/3/20,(314)569-3276x7170,lbarron@example.net,8530 Rodriguez Walks,"A 61-year-old male with a history of alcoholism and open cholecystectomy was admitted to our hospital for hematemesis. On examination, he was tachycardic and tachypneic. His blood test results were as follows: total white blood cell count 16.1 ? 103/L, platelet count 9.3 ? 104/L, C-reactive protein level 10.3 mg/dL, blood urea nitrogen level 30 mg/dL, serum creatinine level 1.37 mg/dL, and endotoxin level 7.5 pg/mL. Upper gastrointestinal endoscopy revealed a left-sided rupture of the lower esophagus (Fig. ), and a chest CT scan revealed pneumomediastinum (Fig. ), which was suggestive of the intra-mediastinal type of Boerhaave? syndrome. The patient underwent emergency surgery 24 h after the onset of his symptoms. A 7-cm upper midline incision was made through the skin for the hand-assisted laparoscopy technique. Two 5-mm ports were produced in the left hypochondrium and left flank. A 12-mm port for a video camera was made in the left upper quadrant. Under hand-assisted laparoscopy, while expanding a field of vision of the esophageal hiatus, the abdominal esophagus was encircled and the left diaphragmatic crus was dissected with ultrasonically activated scalpel. Subsequently, intraoperative endoscopy was performed; we identified the site of the esophageal rupture at the same level as diaphragm. A longitudinal perforation of the left side of the esophagus measuring approximately 2 cm was clearly visible (Fig. ). A cloudy fluid collection with gastric juice and blood clots was seen around the site of perforation in the mediastinum.
+The associated crushing injury was mild, and the rupture site was closed with a two-layered suture under hand-assisted laparoscopy (Fig. ). The closed site was not covered by the omentum or any other tissue. A leakage test was performed. Ultimately, a drain was placed in the posterior mediastinum, and a feeding jejunostomy was constructed. The patient recovered without any complications. He was transferred from the intensive care unit to a general ward in their progress from being critically ill to recovering. A diatrizoate meglumine esophagogram obtained at 9 days after the operation did not show any extravasation. He was discharged from hospital at 3 weeks after the operation.
+Boerhaave? syndrome involves the spontaneous transmural rupture of the esophagus and was first described in 1724 by Dr. Herman Boerhaave []. Despite considerable improvements in diagnostic, therapeutic, and intensive care techniques, esophageal perforation remains a life-threatening condition and is associated with high morbidity and mortality rates (ranging from 10 to 50 %) []. It is considered to be caused by a rapid increase in pressure within the esophagus, e.g., during vomiting, together with the failure of the cricopharyngeus muscle to relax. Such ruptures often occur at sites of anatomical weakness, e.g., the part of the left posterolateral wall of the lower third esophagus located 2 to 3 cm from the gastroesophageal junction [].
+In cases of esophageal rupture, the most important aim of any treatment should be immediate closure of the esophageal tear. There have been several reports about cases in which Boerhaave? syndrome was successfully managed with a self-expandable metallic stent [?. Recently, endoscopic closure using a clipping device has also been reported [?, but surgical treatment is usually selected, as advanced mediastinal intrapleural contamination by the contents of the gastrointestinal tract is often seen at the initial examination. Regarding surgery for spontaneous esophageal rupture, previous reports have suggested that most procedures are performed via a thoracotomy or laparotomy, and there have been few reports about camera-assisted operations being performed for spontaneous esophageal rupture.
+A search of PubMed using the keywords ?horacoscopy,???aparoscopy,??and ?oerhaave? syndrome??revealed that camera-assisted operations have been performed for spontaneous esophageal rupture in seven cases [?, and simple suture closure of the perforated site under thoracoscopy or laparoscopy was carried out in six of these cases [?? ]. Ashrafi et al. state that indications for the minimally invasive technique for spontaneous esophageal rupture are limited to patients with stable hemodynamics, without signs of escalating sepsis, and without concomitant conditions contraindicated for surgeries, including laparoscopic or thoracoscopic surgery []. However, Vaidya et al. reported that they selected a thoracoscopic approach for a patient with septic shock []. Thus, at present, there are no clear strategies for the selection of endoscopic treatment. Previous studies, including ours, reported that the perforations were 2?? cm in diameter, suggesting that endoscopic surgery is well indicated for patients in whom the perforation site is small, but that, in patients in whom the perforation site is so large that it must be closed with sutures and covered by the omentum or any other tissue, open-chest or abdominal surgery needs to be performed to secure sutures without sticking to endoscopic surgery. The advantages of endoscopic surgery include the following: (1) it is minimally invasive because it minimizes the injury to the chest and abdominal walls; (2) it carries a low risk of wound infection; and (3) it provides a wider surgical field. On the other hand, its disadvantages are as follows: (1) the operative time is prolonged; (2) the removal of contaminants may be insufficient; and (3) the surgeon needs to be skillful in the manipulation of sutures.
+As for the approach used to gain access to the mediastinum, the transabdominal approach is considered to be more useful than the transthoracic approach as it causes less operative stress and allows a drain to be inserted into the appropriate part of the posterior mediastinum, the use of the greater omentum, and the addition of an intestinal fistula. In the present case, as the perforation did not open into the thorax, we selected the transesophageal approach. Patients with esophageal perforations are often in a poor physical condition, and camera-assisted operations, which take a considerable amount of time, are not suitable for such cases. However, at our hospital, camera-assisted approaches have been selected for standard esophageal and gastric operations since 2003. In the current case, we selected a laparoscopic approach, even though the patient required an emergency operation, based on the assumption that the enlarged view that this would provide would allow us to definitively identify and close the perforation site. In addition, since the patient had a history of cirrhosis, and preoperative CT revealed marked enlargement of the left hepatic lobe, we predicted inadequate widening of the surgical field at the esophageal hiatus under complete endoscopic visualization and performed hand-assisted laparoscopic surgery. Successful lifting of the lateral hepatic segment and traction of the stomach by the surgeon? left hand enabled us to close the perforation in a wide surgical field.
+Concerning the closure of the perforation site, it has been reported that dysraphia is more likely to occur in cases in which 24 h or more have passed since the onset of the condition [], but as the enlarged view provided by the laparoscope revealed that the perforation site was small in diameter and did not exhibit necrosis or severe crushing, we performed simple closure under hand-assisted laparoscopy, and the patient? postoperative course was favorable.
+It is not possible to conduct a comparative study of the various methods that can be used to treat spontaneous esophageal rupture in cases that require emergency surgery, as the number of cases is limited. Therefore, the further accumulation of cases is necessary, but as camera-assisted operations are minimally invasive, such procedures should be considered under certain conditions (e.g., depending on the skill level of the surgeon and whether the institution has the appropriate facilities to perform such operations)."
+Kailey Whitaker,37,2000/1/23,271-685-5421,jonathangordon@example.net,4075 Johnson Causeway Apt. 408,"An 18-month-old boy without previous health problems presented with abdominal pain, vomiting, and poor appetite for 6 days. The medical history revealed that he had been given a multivitamin preparation once daily (50.000 International Unit (IU) of vitamin D and 10.000 IU of vitamin A) by his pediatrician for a wide anterior fontanelle for about three months. The physical examination on admission revealed only agitation. Vital signs were normal. Serum calcium was 11.5 mg/dL (normal 8??0.4), phosphorus was 4.3 mg/dL (normal 4.5??.5), alkaline phosphatase (ALP) was 91 IU (normal 60??21), creatinine was 0.5 mg/dL, 25-hydroxyl-vitamin D (25-OHD) levels were 2271 ng/mL (normal 30??00), and parathyroid hormone (PTH) was <3 pg/mL (normal 4.6??8.1). Urinary calcium/creatinine ratios were 1.1 mg/mg (normal <0.21). The patient was treated with intravenous hydratation of 150 mL/Kg/day and furosemide at 2 mg/kg/day, with a diet with low calcium and phosphorus content. Renal ultrasonography showed medullary nephrocalcinosis with symmetric bilateral involvement (); so prednisolone 1 mg/kg/day was also added to the treatment regimen. The ECG, hearing test, and ophthalmological examination were all normal, in particular there was no ?apilledema.??With this therapy, the total calcium level decreased rapidly and we observed a clear improvement in clinical conditions. When he was discharged, his 25-OHD level was still elevated at 630 ng/mL and his calcium concentration was 9.5 mg/dL. His discharge instructions included avoidance of products containing vitamin D. On follow-up examination at 1 month the patient was normocalcemic with normal urinary calcium excretion and 25-OHD levels were at 150 ng/mL. The patient is being followed up for nephrocalcinosis."
+Keith Hanson,26,2005/4/18,(742)729-1746x995,hjones@example.com,5968 Michael Cliffs Suite 808,"An 88-year-old man was admitted to the hospital with worsening malaise, fever, and weakness. The patient had a prior medical history of bilateral hip prosthesis, high blood pressure, and hypercholesterolemia. In the months preceding his admission, he had developed a right-sided hip pain. On the day of admission, his family had found him lying on the floor, too weak to walk. His blood pressure was 94/22 mmHg, heart rate 64 beats/min, and temperature 38.9簞C. The examination of his head, neck, heart, lungs, and abdomen did not reveal anything abnormal. He had no wound nor sore. The mobilization of his right hip showed a limited range of motion without pain.
+Laboratory analysis revealed leukocytosis with a white blood cell count of 15.3 ? 109/L (normal: 4 ? 109/L to 11 ? 109/L), a normal hemoglobin level of 135 g/L (normal: 132 g/L to 170 g/L), and platelet count of 155 ? 109/L (normal: 130 ? 109/L to 400 ? 109/L). The creatinine was at 151 弮mol/L (normal: 58 弮mol/L to 110 弮mol/L), aspartate aminotransferases (AST) were at 63 U/L (normal: 17 U/L to 59 U/L), creatine phosphokinase (CPK) was at 669 U/L (normal: 55 U/L to 170 U/L), C-reactive protein (CRP) was at 230 mg/L (normal <10 mg/L), and procalcitonin was at 1.1 ng/mL (normal <0.1 ng/mL). Four sets of aerobic and anaerobic blood cultures were collected on two consecutive days.
+A preliminary diagnostic of septic arthritis of the patient's right hip was suspected and a computed tomography (CT) scan of the pelvis was ordered. It showed no asymmetry or fluid collection around the hip prosthesis. The chest X-ray was read as normal. The patient was kept under observation, without antibiotic therapy.
+The four anaerobic blood culture bottles became positive after 29 hours of incubation. Their Gram stain revealed the presence of Gram-negative rods. The culture showed the bacillus to be anaerobic, Gram-positive, and sporulated, typical of a Clostridium species. No other organism was isolated. A commercial anaerobic manual identification panel (RapID ANA II System, Remel, Lenexa, KS, USA) identified the bacillus as Clostridium butyricum, with >99.9% of probability. However, the isolate could not be identified by matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS) (Bruker, Madison, WI, USA), after a complete extraction. Both empirical antibiotherapy with intravenous piperacillin-tazobactam and the search for the source of infection were initiated. A CT scan of the abdomen and pelvis showed multiple stones in the gallbladder without cholecystitis and no ascites nor colonic masses. A transthoracic echocardiogram revealed an aortic valve sclerosis without vegetation. A colonoscopy revealed three benign polyps without any sign of colitis or cancer. The patient defervesced after four days of intravenous piperacillin-tazobactam. On the 6th day of antibiotherapy, he was switched to oral amoxicillin for eleven more days. He was discharged from the hospital still weak, using a walker. Four months later, he had recovered his strength and was able to walk with a cane. He had no relapse of fever nor worsening of his right hip pain.
+Due to the discordance in identification between the RapID ANA II System and MALDI-TOF MS, the bacterium was sent to the Laboratoire de Sant矇 Publique du Qu矇bec (LSPQ) for further characterization. It was designated LSPQ-04253 and was identified by 16S rRNA sequencing using the BigDye Terminator v3.1 Cycle Sequencing Kit on an ABI 3130xl Genetic Analyzer (Applied Biosystems, Foster City, CA, USA) []. Its nucleotide sequence was determined and showed 99.2% identities with its orthologous sequence in Clostridium lavalense type strain CCRI-9842T. To identify the taxonomic neighbors of the clinical isolate, the 16S rRNA gene sequences were used for an initial BLAST search () against GenBank. Phylogenetic and molecular evolutionary analyses with closely related Clostridium species were performed on 1,344 nucleotides with MegAlign簧 version 10 (DNASTAR, Madison, WI).
+Multiple sequence alignment and phylogenetic analysis using 16S rRNA gene sequences of LSPQ-04253 (GenBank accession number KX024579) and those of C. lavalense CCRI-9842T and CCRI-9929, C. asparagiforme DSM15981T, C. bolteae WAL16351T, C. citroniae CCUG52203T, C. clostridioforme ATC2553T, C. aldenense CCUG52204T, and C. butyricum VPI3266T revealed that LSPQ-04253 clustered with the two C. lavalense strains and was distant from C. butyricum VPI3266T (). The antibiotic minimal inhibitory concentrations were determined using the agar dilution method [] and E-test only for vancomycin and teicoplanin. The bacterium was susceptible to clindamycin, cefoxitin, meropenem, metronidazole, piperacillin-tazobactam, vancomycin, and teicoplanin and intermediate to penicillin ().
+No vanB gene was found in isolate LSPQ-04253 as described in the type strain CCRI-9842T. The vanB gene is carried by a mobile genetic element (transposon Tn5382) in the type strain CCRI-9842T that could be missing in isolate LSPQ-04253."
+Mariana Burton,35,1985/5/6,970.506.0647,fgarcia@example.org,00528 Jackson Circle,"A 62-year-old male patient presented in January 2011 with cough and hemoptysis, microhematuria, polyarthritis of both ankles, knees, and left wrist, bilateral lymphadenopathy, and pulmonary nodules revealed by a CT-scan (). This nonsmoker had worked from 1974 to 1986 in a uranium mining being exposed to silica dusts. His ANCA titer was 1 : 640 with a specificity of PR3-ANCA at 193 U/mL. Neither rheumatoid factors nor anticyclic citrullinated peptide (CCP) was detectable. Although a kidney biopsy was inconclusive, the diagnosis of granulomatosis with polyangiitis was suspected, and cortisone treatment resulted in an amelioration of symptoms. A thoracoscopically resected pulmonary lesion from the left upper lobe (, arrow) revealed necrotic granuloma with centrally located silicoanthracosis consistent with silicosis. No vasculitis was found in lung or kidney at that time. In February 2011, the patient had a resection of a clear cell carcinoma in the upper pole of the right kidney (pT1 cN0 cM0 G2). Meanwhile, methotrexate and nonsteroidal antirheumatic drugs (NSAR) were added due to ongoing and immobilizing polyarthritis, leading to a rapid and significant improvement of inflammation and pain. While ANCA titers gradually decreased over time to 1 : 40, and PR3-ANCA titers almost normalized, antinuclear antibodies showed a constant level of 1 : 80. However, complement factors and also IgG levels showed normal values throughout the entire clinical course.
+A follow-up thoracic CT scan (January 2014) revealed new bilateral multiple round lesions (). Histological specimens provided by transbronchial forceps biopsy could only reveal fibrotic areas with anthracosis and birefringent crystals by compensated polarized light microscopy, corroborated by the aforementioned pathological diagnosis of anthracosilicosis. During the following short time period of 6 months, the patient developed an increasingly nagging cough with repeated expectorations of putrid and musty material several times a day. A CT scan (June 2014) showed a massive bilateral progression of nodules in size and number (Figures and ), further aggravating the patient's symptoms. A bronchoscopic forceps biopsy with radial endobronchial ultrasound (R-EBUS) under fluoroscopic guidance from the largest lesion (), but also from other lesions, was performed; however, these biopsies were not diagnostic. Therefore, three representative nodules of the right lung were thoracoscopically resected and appeared as whitish, star-shaped lesions on the pleural surface, highly suggestive of metastases (). Inside, they showed a white-greyish surface with dark spots and of crumbly consistency. Histology confirmed anthracosilicotic dust bands, regional necroses, and vasculitis. However, there were no necrobiotic granulomas (Figures ??. As a new finding, vasculitis with fragmentation of the internal lamina elastic wall was found (, arrow), and therapy with rituximab was started. In parallel, therapy with NSAR and methotrexate was stopped, leading to reoccurrence of intolerable joint pain and polyarthritis within several weeks. X-rays of the hands showed hook-like osteophytes in the metacarpophalangeal (MCP) joints, cartilage calcification, and joint space narrowing and subluxation of MCP joints but no RA typical features such as joint erosions. These findings were highly suggestive of calcium pyrophosphate crystal deposition (CPPD) disease as a cause of the patient's polyarthritis. The patient was restarted on NSAR and methotrexate and improved rapidly. At a follow-up visit in October 2015, the patient reported a clear improvement of the polyarthritis and respiratory symptoms."
+Zander Whitaker,23,1984/10/30,889-897-4652,megan56@example.com,7076 Preston Wall,"A 41-year-old unemployed, single woman with suspected insulinoma and a 13-year history of refractory schizophrenia (diagnosed according to The Diagnostic and Statistical Manual of Mental Disorders IV Criteria) was transferred from a mental hospital to the inpatient psychiatric unit of the Osaka General Medical Center (OGMC) for persistent hypoglycemia (fasting plasma glucose = 50~60 mg/dL) combined with elevated levels of immunoreactive insulin (IRI; 12.7 弮U/mL) and C-peptide immunoreactivity (CPR; 4.1 ng/mL). Although the patient did not present with any relevant physical or mental symptoms, she had previously been hospitalized five times for aggravation of psychotic symptoms. On this admission, she received antipsychotics (paliperidone 12 mg/day, bromperidol 36 mg/day, and levomepromazine 200 mg/day), mood stabilizers (sodium valproate 1200 mg/day), and benzodiazepines (flunitrazepam 2 mg/day and brotizolam 0.5 mg/day). While her psychiatric condition did not improve, side effects such as extrapyramidal symptoms and persistent hypoglycemia were observed.
+Blood tests for insulinoma were requested, with the following results: fasting plasma glucose (FPG) = 51 mg/dL and immunoreactive insulin (IRI) = 12.7 弮U/mL. The results of clinical diagnostic tests for insulinoma were as follows: Fajans index (IRI/PG; PG: plasma glucose) = 0.24 (insulinoma > 0.3), Grunt index (PG/IRI) = 4.01 (insulinoma < 2.5), and Turner index (IRI ? 100/PG-30) = 60.4 (insulinoma > 50). Her blood test results did not meet the criteria for insulinoma under the Fajans and Grunt indexes. Chest and abdominal computerized tomography (CT) did not reveal tumor lesions. Therefore, we suspected drug-induced hypoglycemia instead of insulinoma and promptly discontinued the benzodiazepines. However, we resumed oral administration of benzodiazepines when the symptoms of hypoglycemia did not resolve. We then reduced the dose of paliperidone, after which the symptoms of hypoglycemia gradually improved (). Although some of the patient's other medications could affect blood glucose levels (e.g., bromperidol and levomepromazine), they were not changed.
+Diabetes management therapy, including blood glucose monitoring and diet therapy, was initiated after discontinuation of paliperidone because we detected glycophilia. Since the hyperglycemia persisted, we performed an oral glucose tolerance test (OGTT) to evaluate for abnormal glucose tolerance, and the following results were obtained: fasting: 61 mg/dL; 30 min: 204 mg/dL; 60 min: 172 mg/dL; 90 min: 64 mg/dL; and 120 min: 77 mg/dL. She was diagnosed with reactive hypoglycemia in the early stage of diabetes."
+Ivanna McMahon,36,1993/8/17,+1-980-255-0211x8441,wtaylor@example.org,676 Smith Way,"A 50-year-old Asian woman known for end stage kidney disease secondary to IgA nephropathy received a kidney transplant from a 50-year-old deceased donor. The pretransplant crossmatch (CDC) was negative despite a PRA value of 25% and a complete HLA mismatch (in B and DR). The cold ischemia time was 7 hours and the patient was induced with basiliximab and methylprednisolone. Subsequent maintenance immunosuppression consisted of tacrolimus, mycophenolate, and prednisone.
+After transplant, the recipient had delayed graft function requiring three dialysis sessions. Ultimately, the clinical course was favorable and she was discharged with a good renal function (creatinine value of 128 弮mol/L (1.48 mg/dL)).
+One week after discharge, the patient was readmitted for graft dysfunction with a rise in creatinine to 194 弮mol/L. An urgent biopsy showed moderate glomerulitis and the presence of inflammatory cells in peritubular capillaries, but C4d was negative. As C4d-negative antibody-mediated rejection (AMR) was not a recognized entity in 2013; she was only treated with intravenous pulses of methylprednisolone and the creatinine stabilized at 160 弮mol/L. A few weeks later, an analysis revealed the presence of a donor specific antibody (DSA) (DQA0302) with MFI of 1800. This DSA was present before the transplant (MFI 1600) but we were not aware of its presence at the time of transplant. The DSA titers decreased mildly after initial treatment (MFI 900).
+At 3 months after transplantation, despite a CMV infection treated with ganciclovir, renal function remained stable. However, after 5 months, the recipient presented again with severe acute graft dysfunction (creatinine up to 400 弮mol/L) but, this time, there were signs of thrombotic microangiopathy (TMA): thrombocytopenia, decreased haptoglobin, increased LDH, decreased fibrinogen, and hemolytic anemia. A second biopsy was performed and it showed an acute active type 2 AMR with lesions of TMA, peritubular capillaritis, and glomerulitis (negative Cd4) associated with a grade IA cellular rejection (). Immunohistochemistry for CMV was negative. She was then treated aggressively with a combination of pulse steroid therapy (3 doses), thymoglobulin (2 doses), plasmapheresis (3 exchanges), intravenous immune globulin (4 doses), and rituximab (4 doses).
+Two weeks after the intensive treatment, despite a stabilization of renal function (creatinine of 200 弮mol/L), signs of AMR (TMA) still persisted in a repeat biopsy (3rd biopsy) and DSA remained elevated (MFI 1300). We decided to treat the recipient with 3 doses of eculizumab (1200 mg, 900 mg, and 900 mg) (). Following the therapy, blood markers of TMA significantly improved (). However, because of the heavy immunosuppressive state, the patient suffered from multiple infections: CMV reactivation, pulmonary aspergillosis, and Clostridium difficile colitis. DSA titers were not repeated after eculizumab treatment.
+The last graft biopsy (8 months after transplant) showed ongoing AMR and progression of chronic lesions (moderate tubular atrophy and interstitial fibrosis) (). However, transplant glomerulopathy and peritubular capillary basement membrane multilayering were not seen in the electron microscopy (EM). One year after transplant, renal function declined progressively (creatinine up to 250 弮mol/L) and haptoglobin gradually decreased, but platelets were normal and there was only mild anemia. All infectious complications resolved."
+Jakob Browning,40,1980/11/23,001-632-280-1561x3997,qjohnson@example.net,3284 Gregory Stream Suite 635,"A 60-year-old man was admitted to our hospital with the primary symptom of confusion. He lived in the dormitory of a factory that had a public bathhouse, in which bath water was circulated through a sterilizer system and reused. His medical history was unremarkable. He did not use any drugs but had a 60 pack-year history of smoking. Four days before admission, he had developed cough. On the day of admission (Day 1), his colleague noticed that he could not stand by himself and had slurred speech; thus, he brought him to the emergency department of our hospital.
+On admission, he was restless and could not obey our orders. His temperature was 40.1簞C, blood pressure was 154/82 mmHg, and pulse rate was 102 beats/minute. His oxygen saturation was 90% with oxygen supplementation at 4 L/minute using a facial mask. Pulmonary auscultation revealed coarse crackles in his right lung. Laboratory tests revealed a normal white blood cell (WBC) count but detected neutrophilia (WBC count, 8.36 ? 103/弮L; neutrophils, 96.5%), hyponatremia (Na, 128 mEq/L), a markedly increased creatine kinase (CK) (3254 IU/L), and increased fibrinogen/fibrin degradation products (FDP) (31.2 弮g/mL). Chest CT revealed extensive patchy shadows mainly in the right upper lung lobe. Based on these findings, an intravenous broad-spectrum antibiotic (tazobactam/piperacillin, 18 g/day) was initiated.
+On Day 2, a Legionella urinary antigen test was positive for Legionella pneumophila serogroup 1, suggesting a Legionnaire pneumophila infection. The patient's clinical presentation and rapid progression of respiratory failure supported this diagnosis. Thus, intravenous levofloxacin (500 mg/day) and azithromycin (500 mg/day) were initiated.
+On Day 3, the patient required a respirator, and low-dose hydrocortisone and sivelestat sodium hydrate, a selective neutrophil elastase inhibitor, were initiated. The patient's respiratory condition gradually improved, and he was extubated on Day 17.
+However, even after the cessation of sedatives, the patient demonstrated a variety of neurologic symptoms. He was awake but was disoriented, was dysthymic, and could not speak. He was able to lift his upper limbs but exhibited muscle weakness in his right upper and lower limbs. He could not move his limbs smoothly and showed a lack of coordination in the finger-to-nose test. Subsequent MRI of the brain revealed no abnormalities (). Cerebrospinal fluid (CSF) analysis revealed that the CSF cell counts, protein and glucose concentrations, and immunoglobulin G index were all normal. Gram staining and bacterial culture of the CSF were also negative. One week after the initial examination, the patient exhibited improvements in limb movement, but his disorientation remained. Electroencephalography showed diffuse slow activity. SPECT of the brain using a technetium-99m-ethyl cysteinate dimer (99mTc-ECD) was performed on Day 23 and showed multifocal hypoperfusion mainly in the frontal and temporal lobes (). Thereafter, his consciousness gradually became clearer without any treatment, and he was able to speak simple words. Six weeks after the initial examination, a second SPECT scan was obtained and revealed that the hypoperfusion in the frontal and temporal lobes had improved to almost normal levels (). At that time, laboratory tests revealed that most values, including FDP, had returned to normal limits. He recovered the strength in all 4 extremities by Day 60, and the patient was able to walk and speak falteringly when he was discharged on Day 68."
+Princess Bass,27,1980/3/8,(952)901-7052x191,justin61@example.net,76990 Harris Wells Apt. 278,"A 59-year-old man was admitted to our hospital for difficulty in breathing. He had a medical history of subdural hematoma caused by an accident but had been well without any neurologic abnormalities. He lived in the same dormitory and used the same bathroom as the patient in Case 1. He did not drink alcohol regularly but had a 20 pack-year history of smoking. He had developed a cough 2 days before admission and had experienced a headache and tremors the following day.
+On admission (Day 1), his body temperature was 36.9簞C, and chest auscultation revealed normal respiratory sounds. He was confused, and neurologic examination revealed disorientation and bilateral intention tremor. Laboratory tests revealed an increased WBC count (20.19 ? 103/弮L), increased C-reactive protein (21.16 mg/dL), mild hyponatremia (Na, 132 mEq/L), mild liver dysfunction (aspartate aminotransferase, 59 IU/L; alanine aminotransferase, 54 IU/L), mildly increased CK (240 IU/L), and an increased D-dimer (5.12 弮g/mL). Chest radiography and CT showed left lower lobe consolidation. A Legionella urinary antigen test was positive for Legionella pneumophila serogroup 1. Thus, the patient was diagnosed as having Legionnaires' disease, and intravenous levofloxacin (500 mg/day) and azithromycin (500 mg/day) were initiated.
+On Day 10, the patient's chest radiography showed improvement, and he was afebrile. However, his consciousness was still impaired, and his Mini-Mental State Examination (MMSE) score was 19/30. Brain CT showed a left subdural hematoma with a mild mass effect and a pituitary tumor, but acute lesions were not observed. Thus, we suspected that his neurologic symptoms were caused by the Legionella infection.
+On Day 13, SPECT of the brain using 99mTc-ECD revealed multifocal hypoperfusion mainly in the parietal, precuneus, and posterior cingulate cortices and in the right cerebellum (). His symptoms gradually improved without any treatment, and his MMSE score increased to 23/30. The patient had mild disorientation and slurred speech when he was discharged on Day 24."
+Landen Spence,22,1992/6/22,-4024,rodneybrewer@example.com,151 Tyler Valley Suite 146,"A 40-year-old woman in the 27th week of her fourth pregnancy was referred to our rheumatology clinic because of a three-week history of a skin rash, arthralgia, and weak positive anti-nuclear antibody test by immunofluorescence assay (ANA-IFA). Her previous three pregnancies were uneventful. She did not have a history of recent infections nor a potential exposure to toxic or medical agents. Physical examination on admission revealed bilateral periorbital edema and erythema on her eyelids (heliotrope rash) as well as diffuse rash on the face (). She had bilateral erythematous macules on the extensor surfaces of the metacarpophalangeal and proximal interphalangeal joints (Gottron's sign). There was also symmetrical and proximal muscle weakness in the upper and lower extremities. Other physical examination findings were unremarkable. Laboratory findings were as follows: serum creatine kinase (CK): 2138 U/L (normal: 29??00), lactate dehydrogenase: 520 U/L (normal: 140??80), aspartate aminotransferase: 113 U/L (normal: <35), and alanine aminotransferase: 58 U/L (normal: <35). ANA-IFA was weakly positive at 1/100 titration (homogenous pattern). Anti-Ro52 was positive, but antibodies to Jo-1 or other extractable nuclear antigens were negative. Serum anti-double stranded DNA, rheumatoid factor, and complement levels were within normal ranges. Serum creatinine level and urine analysis were normal. Erythrocyte sedimentation rate was 31 mm/h and serum C-reactive protein level was 17.9 mg/L (normal 0??). Electromyography of the right deltoid muscle revealed fibrillations and small polyphasic motor unit action potentials. Magnetic resonance imaging showed diffuse edema in thigh muscles (). She declined muscle biopsy. Investigations for occult malignancies including breast ultrasound, pelvic and abdominal ultrasound, peripheral blood smear, and fecal occult blood test were all negative. Serum CA-125 level was 6.5 U/mL (normal 0??5). She was diagnosed with dermatomyositis according to Bohan and Peter's criteria [, ] and started on methylprednisolone 32 mg/day orally. Five weeks later, however, no improvement was noted in muscle strength, skin rash, or serum CK level. Her blood pressure was 180/120 mmHg and she had developed bilateral pretibial edema. She was diagnosed as having preeclampsia and her pregnancy was terminated by an emergency caesarean section at the 32nd week of the gestation. She gave birth to a 1800 g male infant with no apparent congenital malformation. In postpartum period, we searched the mother for the presence of anti-phospholipid antibodies. Anti-cardiolipin and anti-帣2 glycoprotein-1 antibodies (immunoglobulin G and M isotypes) were found to be negative. Lupus anticoagulant test could not be performed due to technical limitations.
+After delivery, her muscle strength and rash improved rapidly. The dosage of methylprednisolone was tapered off. At postpartum 6th week, she was on methylprednisolone 8 mg/day and serum CK levels were within normal limits. There was only mild facial rash left, but heliotrope rash and Gottron's sign had completely resolved."
+Aislinn Malone,37,1985/6/30,629.836.9150x6140,perezfrank@example.com,9537 Ashley Station,"The patient is a 24-year-old male with a history of Down syndrome who was brought to our hospital from Yemen by his brother after 10 days of fever (39.5簞C), productive cough, shortness of breath, and right side chest pain. He developed the symptoms after few days of being found eating a sandwich that he hid in an organic fertilized soil of his house backyard. He was brought to our hospital in Jordan after he failed a course of moxifloxacin for assumed diagnosis of community acquired pneumonia.
+On presentation he was still complaining of same symptoms, and he denied any jaundice, abdominal pain, nausea, vomiting, or diarrhea. On physical examination he was alert, oriented, sweaty, and in mild respiratory distress. His vital signs were as follows: temperature 38.3簞C; pulse 110 bpm; respiratory rate 26 bpm; blood pressure 90/45 mmHg; and O2% of 82% on room air. He had cracked lips, protruded tongue, erythematous, and dry mucous membranes of the oropharynx. Chest exam revealed significant decreased air entry and tactile vocal fremitus with crackles and minimal wheezes on the right side and normal heart sounds with no murmurs or rubs or gallops. His abdomen was soft and nontender with no evidence of organomegaly.
+He was immediately resuscitated with IVF bolus and oxygen supplementation; his chest X-ray revealed right sided obliteration of costophrenic angle and displaced right lung (). CT scan showed right sided pleural effusion with pocket mainly in lateral aspect and in the oblique fissure, multiple gas bubbles with air fluid levels, and partial atelectasis of right middle and lower lobes that are medially displaced (). Abdomen ultrasound and CT scan showed no evidence of obvious gross liver pathology.
+He was diagnosed with right sided pneumonia complicated with multicystic empyema, and he underwent thoracotomy with drainage, decortication, and chest tube placement. Light microscopic examination of both pleural fluid and bronchoalveolar lavage sample revealed Entamoeba cysts and trophozoites. Microbiology revealed negative acid-fast stain or fungal infection. Aerobic and anaerobic blood culture showed no growth.
+Colonoscopy was done and biopsy revealed mixed inflammatory infiltrate suggestive of infection with no demonstrable amoeba. And stool analysis ?3 was also negative for Entamoeba cyst or trophozoites. Serological test was not done due to unavailability.
+The patient was treated with metronidazole 750 mg three times daily; luminal agent was not given due to unavailability in Jordan. His clinical condition significantly improved after 48 hours of antibiotic treatment. On one-month follow-up visit he was free of symptoms, and he returned back to Yemen."
+Ruben Berry,22,2005/5/17,844.409.7849x9284,mayfrank@example.net,15448 Heather Camp,"A 4-year-old girl was referred to our center with presentation of abdominal pain. Diagnostic sonography revealed an intussusception in this patient. Surgery was performed and a large mass was seen in ileocecal area. After the mass biopsy, Burkitt's lymphoma stage IIb was diagnosed since other organs were not involved.
+Chemotherapy was performed in accordance with the intermediate risk group protocol named LMB89. The first course started with one dose of COP (CPM 300 mg/m2 vincristine 1 mg/m2 and 60 mg/m2 prednisolone; prednisolone was continued for 7 days). One week later, the second course was administered with COPADM1 (CPM IV 250 mg/m2/dose, MTX 3000 mg/m2, doxorubicin 60 mg/m2, Vincristine 2 mg/m2, and 60 mg/m2 Prednisolone; prednisolone was continued for 5 days). Three days after the second chemotherapy course, the patient experienced febrile neutropenia. In spite of appropriate antibiotic therapy ceftazidime 800 mg IV, vancomycin 250 mg IV, and fluconazole 50 mg were administered with supportive therapy. The patient deteriorated and suffered from massive lower GI bleeding. Her blood test is described in . Since our patient suffered from Burkitt's lymphoma, she did not experience b symptoms.
+The patient received several units of pack cell, 0.25 unit/kg platelets, 15 cc/kg fresh frozen plasma, and some doses of cryoprecipitate for more than 3 days which is explained in . Different abdominopelvic sonographies, which were complemented with CT scan, showed pancolitis. Treatment was administrated with octreotide at a dose of 1 弮g/kg/h. It is worth mentioning that octreotide administration in this situation counts as an off-label indication but, because of its perfect efficacy at esophageal bleeding, we used it for second-line therapy, but no clinical response was observed.
+After 72 hours of refractory and sever bleeding, the patient was switched to 90 弮g/kg injection of AryoSeven. Bleeding was successfully controlled 1 hour after administration of a single dose of AryoSeven. Vital signs were stabilized. The lowest haemoglobin concentration at the time of blood haemostasis was 6 g/dL and no more decrease in hemoglobin concentration was observed. The patient received 10 cc/kg pack cell (PC) two times as a result of the latest severe bleeding and low hemoglobin. Patient's PT, PTT, and INR are declared in .
+In order to identify the source of bleeding, the patient underwent endoscopy and colonoscopy after her general condition was stabilized. No specific finding, except for a severe mucosal fragility, was found. Her last lab data are presented in , 12 hours after administration of AryoSeven.
+Patient's chemotherapy was continued, her primary disease was at remission, and there was no sign of GI bleeding ever since. For other chemotherapy cycles, GCSF administration was performed to prevent febrile neutropenia. The levels of fibrinogen were not evaluated during the study because the required equipment was not available."
+Annabelle Jenkins,23,1990/12/8,(723)834-5293,johnnyjackson@example.net,4727 Boyle Ranch Apt. 274,"Patient 1 was a 10-year-old girl admitted with 2 days of fever, retroorbital headache, vomiting, and myalgia. Her white blood cell (WBC) count on the 3rd day was 2.2 ? 103 with 65% neutrophils and platelet count of 117,000. Alanine transaminase (ALT) was 17.8 and aspartate transaminase (AST) was 55.2. Treatment was commenced as dengue fever in febrile phase. By the 4th day, she became sleepy and lethargic and the level of consciousness gradually deteriorated. She was moved to high dependency care for further management. On neurological examination, she had increased tone in all four limbs with cogwheel rigidity. The lowest Glasgow coma scale documented was 10/15. Her vital parameters and serial packed cell volume readings remained stable without signs of fluid leakage.
+Lowest WBC count (1.9 ? 103) was reported on day 5 of the illness and lowest platelet count was 50,000/mm3 on day 6. Liver enzymes deteriorated (ALT: 357, AST: 478) and serum albumin was 38 g/dL and INR was 1.17 on day 6. Tender liver was palpable 2 cm below the costal margin. Renal functions (sodium: 142 mEq/L, potassium: 4.2 mEq/L, blood urea: 7.6 mmol/L, and serum creatinine: 52 弮mol/L) remained normal. Serum calcium remained between 2.08 and 2.69 mmol/L. Primary dengue infection was suggested by the presence of IgM antibodies and absence of IgG antibodies to dengue virus. Dengue NS-1 antigen and the viral load were not performed due to lack of laboratory support. A CT scan revealed hypodense areas in bilateral thalamic and basal ganglia regions (). Cerebrospinal fluid examination did not reveal any cells and had normal protein levels (42 mg/dL). Over the next 2 weeks following the acute illness, she showed complete recovery with no residual neurological disability."
+Declan Salinas,39,1999/6/15,8865838571,steven10@example.net,353 Jacqueline Manors Suite 933,"Patient 2 was a 3-year-old girl who presented with 3 days of continuous high fever, intermittent abdominal pain, vomiting, and retroorbital headache. There had been one episode of gum bleeding on the first day of illness. She had been apparently a well child without any significant illnesses in the past. WBC count done on day 2, on request of the general practitioner, was 8.15 ? 103 with 85% neutrophils and platelet count was 120,000 mm3. She had right hypochondrial tenderness with just palpable liver on day 5. ALT and AST were 16 mEq/L and 69.7 mEq/L, respectively, on day 3 and they increased to 29.7 mEq/L and 122.2 mEq/L on day 5. Initial C-reactive protein was 6 mg/dL and remained normal. She was monitored for vital signs including urine output and packed cell volume (PCV). Baseline PCV was 32 and the highest noted was 35. The lowest platelet count documented was 67,000/mm3 and the lowest WBC count was 2.27 ? 103. She did not show signs of fluid leakage. However, there was a second episode of gum bleeding on day 5 with normal clotting profile (INR: 1.1 and APTT: 35). She was positive for IgM and negative for IgG antibodies for dengue virus.
+On the 5th day of illness, she developed tremors in her upper limbs. She had cogwheel rigidity, mask like face, and staccato speech. Power was grade four in all four limbs with normal reflexes. CT scan of brain revealed diffuse hypodense areas in bilateral basal ganglia and thalamus with predominant involvement of right side (). During the first 48 hours after the onset of neurological symptoms, she showed rapid deterioration and became aphasic with severe paucity of movements. Cerebrospinal fluid examination showed 2 lymphocytes without any polymorphs and normal proteins. She recovered dramatically and showed complete recovery within 3 weeks after onset of illness."
+Royalty Schultz,19,1986/8/21,226-921-8447,kylie28@example.org,68410 James Neck,"A 34-year-old Nigerian man presented to the Mental Health/Psychiatry Clinic following a referral from the Surgical Outpatient Department on account of persistent testicular pain of a psychogenic nature and an insistence on a bilateral orchidectomy. History shows bilateral testicular pain of six-year duration, initially affecting the left testes alone, with the pain radiating to the perineum and pelvis, associated with pins and needles sensation and said to have affected his sleep and sex life. Although there is a positive history of multiple heterosexual partners, barrier contraception in the form of condoms was practiced. There was no history of fever and other constitutional features, undescended testes, childhood mumps, steroid Prune belly syndrome, perineal trauma, scrotal sores/or itching, exanthematous and pigmentary changes to the scrotum, change in testicular consistency, penile discharge, and pain on micturition and masturbation.
+Testicular pain is, however, associated with inability to perform the sexual act as well as masturbation.
+Due to the persistence of symptoms, he proceeded to General Hospital Ahoada, Rivers State, Nigeria, where a battery of unknown tests were carried out (involving drawing blood and several X-rays and ultrasound scans), results did not detect any abnormalities, drugs were prescribed, and he cannot recall their names; however, the pain persisted. Subsequently, he proceeded to a tertiary center (BMH, PH), where further tests were done and drugs were administered on an outpatient basis; however, the pain was persistent. He then proceeded to Navy Hospital, Borokiri, Port Harcourt, Nigeria, where an abdominal X-ray as well as abdominal and testicular ultrasound scans was done, as well as a thorough physical examination of the external genitalia; he was told that nothing was wrong with him and drugs were administered, but the symptoms were persistent. Similar findings were reported when he went to a tertiary health facility, UPTH. He also went to unorthodox, tradomedical practitioners in a quest for a permanent solution; several unknown concoctions were administered to him as well as incantations, all to no avail. He came to this facility in 2010 (after relocating to Bayelsa State, Nigeria); the battery of tests aforementioned earlier were made, including semen analysis (obtained via masturbation, a fact, he had earlier denied but is present in his medical record), and he began complaining a feeling that the right testis was ascending up into his stomach; a surgery (nature of surgery unknown to him) was performed in March, 2014; on recovery and discharge, pain persisted, with no worsening or relief; he claims that dribbling of urine began after the surgery.
+There were associated feelings of worthlessness following the pain symptoms, loss of ?anliness/sexual ability,??suicidal ideation, and suicidal attempts of 6-year duration, which has increased in intensity, frequency, and duration and progressively worsened after visits to doctors/several hospitals did not provide relief. Feeling of worthlessness was associated with low energy, loss of interest in pleasurable activities, cessation of self-employed work, loss of income, decreased willpower to live, loss of self-esteem, and feeling of extreme helplessness; however, patient claims he has a zest for life. Suicidal ideation is of 5-year duration; following failed attempts at obtaining a cure after consulting unorthodox medical practitioner, he began thinking about taking poisons to end his life; however, he did not tell anyone about his thoughts; there were no associated delusions, hallucinations, or other disturbances perceptions. Suicidal attempts began 4 years earlier; he ingested ?oisonous??plants, battery acid, and ?aygon??insecticide. There is no history of attempts to end his life by violent means, self-mutilation, or ingestion of sleeping pills. Suicidal attempts were not revealed to anyone; however, the last ?ttempt??to end his life occurred 3 weeks prior to psychiatric consultation, with his mother privately reporting that he came to her privately, weeping bitterly and showed her some ropes he had in his possession for the purpose of killing himself, but he never carried through with the plan; he summarily denied this but later admitted it as a fact. Feeling of loss of ?anliness??was of 5-year duration and began after he noticed that he could not have sex anymore due to the intense pain. This was associated with an increased desire to have his testicles removed, in order to be relieved of the pain. Although he considers himself as male, he insists he feels unmanly and incomplete; there was, however, a strong insistence that he is not a female on further probing during history taking.
+However, no history of increased activity, agitation, restlessness, aimless wandering, increased libido, irrational talk, loss of appetite and sleep disturbances as well as hearing voices, social withdrawal, paucity of self-care, violent behavior, gathering of debris, or any abnormal behavior. Past psychiatric history revealed that there was a positive history of psychoactive drug use, specifically, Cannabis, which he used via smoking of dried leaves wrapped in a strip of paper; he began using it at age 16/17 (17 years ago); he was introduced to it by friends and a desire to experiment and rebel; he used drugs independently and with friends; habit was sustained by his allowance and stealing from his parents; drug use continued for a few years and ceased in his early twenties. In his mid-twenties, in 2006 (9 years ago), he became socially withdrawn, left the house for no apparent reason, and began living alone; then he disappeared for 3-4 months (he later admitted he travelled to Niger in a failed bid to emigrate to Europe) and returned home voluntarily, only to begin living in uncompleted buildings and talking irrationally, with history of provoked violent attack on a shopkeeper after being stigmatized as ? mental case.??Subsequently, in 2008, he was admitted to the Neuropsychiatric Hospital, Rumuigbo, and a diagnosis of ?ubstance Use Disorder??was made; several investigations were done and drugs administered; he was discharged after a month and a fortnight. Follow-up was regular for two months; however, he defaulted because he claimed he was not ?ental??and because of the side effects of drugs. There is no history or evidence of a relapse following discharge. In the past medical history, there was no history of hypertension, epilepsy, asthma, diabetes mellitus, sickle cell disease, neurocutaneous disorders, and erectile dysfunction. Family history showed that he is the only male as well as the first of four children in a monogamous setting. However, his mother had 2 children in a later marriage after the divorce of his parents, making a total of 6 children, 3 full sisters and 2 half-sisters. His mother is a middle aged matron with tertiary level of education. His father is deceased, had tertiary level of education, and was a senior civil servant with the Ministry of Agriculture. He was not close to his father and appeared to have had a troubled relationship with him following the divorce of his parents; his father died three years earlier, at age 61, from an unknown medical condition. The personal history revealed that the patient completed his basic education. However, he did not pass the UME with good scores and failed to obtain a university admission, and he was said to be an average student. He enrolled in a part time program, in the National Open University, 2 years earlier, but did not complete the course because of his present illness. Subsequently, he said he has received training as an electrician and construction worker. He claims to be a single father of an 18-year-old boy (with elaborate information about the nonexistent child); however, his mother denies this and he later admitted he told us this so that we would remove his testes since he has a child. Social history showed that, in the past, he occasionally drank alcoholic beverages but has seldom done so for the past seven years. He smoked tobacco in cigarette form occasionally. Patient seldom interacts with people except his family members whom he lives with; he initially said he lives alone but his mother said he lives with her and he admitted this. Psychosexual history as elicited showed that adrenarche was attained at age 14 while onset of nocturnal emissions began at age 17. First sexual activity was with a female partner, experience was pleasurable and exciting, and subsequent experiences have been pleasurable and in almost all cases barrier contraception in the form of male condoms was used. The patient insisted that his sexual orientation and love interest has been strictly heterosexual. He has seldom had any early morning erections over the last 6 years and cannot recall having experienced any nocturnal emissions within the same period. He denies any masturbation as well as orgasm/ejaculation; however, semen for analysis was obtained via masturbation without the use of pornography. In the forensic assessment history, patient has not been convicted for any crime, sentenced to jail, or jumped bail; however, he has been arrested thrice and detained for minor offences such as moving at night during a curfew. Premorbidly, leisure activities included watching football matches; he formed deep ties in relationships, had few friends, and was introverted/quiet. His prevailing mood was happy.
+Appearance and behavior showed a well dressed and well groomed young man (with attention paid to minute details such as manicured nails and perfectly styled hair) appearing appropriate for age, maintaining good eye contact, and holding an umbrella with depressed posturing. The tone of speech was low to moderate tone, reactive to circumstances, coherent, and relevant. The mood was sad and affect was depressed. Perceptual abnormalities present included somatic hallucination. There were no disorders of the thought process or formal thought disorder detected. Under cognition, patient was fully oriented to time, place, person, and circumstance. Attention, concentration, comprehension as well as calculator ability, and abstraction were within normal range. In addition, immediate recall, long and short memory are within normal range. Judgement was good and insight was partial (he did not believe the drugs will be of any benefit and his case is hopeless).
+Primary diagnosis was hypochondriasis with comorbid secondary diagnosis of severe depression with psychotic features.
+Patient was managed using the biopsychosocial model. Drug treatment was done using tricyclic antidepressant (Amitriptyline) and antipsychotic medication (Olanzapine). Psychotherapy carried out involved cognitive behavioral therapy. Finally a letter was sent to SOPD about diagnosis and unsuitability for bilateral orchidectomy as requested.
+Initial improvement (evidenced by reduction in pain intensity) was seen for the first 3 weeks; however, pain has been persistent. There was insistence on a bilateral orchidectomy during his last visit."
+Cody Bryant,36,1989/9/19,943.483.2141x38393,melissa82@example.org,0201 Tammy Spring,"A 20-year-old Caucasian male presented to the cardiac clinic for evaluation of chest pain and elevated blood pressure. His chest pains were sharp, occurred randomly, and were mostly nonexertional. He also had an abnormal EKG demonstrating nonspecific ST/T wave changes (see ). His past medical history was unremarkable. He is a smoker and drinks alcohol socially and denied illicit drug usage. An echocardiogram performed in the office was normal, with the coronary arteries arising from the appropriate cups.
+A cardiac computed tomography angiography (CCTA) was performed revealing anomalous origin of the right artery from the left coronary cusp. The proximal portion had an acute-angle take-off with an intramural course with a 70??0% stenosis. The vessel also coursed between the aorta and pulmonary arteries (see )."
+Parker Payne,44,2005/6/30,001-239-958-9513x9029,jrose@example.net,28269 Anderson Lock,"A 68-year-old female consulted the Department of Oral, Maxillofacial and Plastic Surgery with a painful swelling on the right infraorbital side of the face (). Intraorally, no signs were noted (), apart from scars in the region of the unattached gingiva of the maxilla (). The patient underwent a Caldwell-Luc operation at the age of 13 on both sinuses due to chronic maxillary sinusitis. She had a mastectomy for breast cancer following irradiation 31 years previously. MRI and CT found a cystic lesion of the right maxillary sinus with orbital floor elevation. In the left maxillary sinus, a cyst was detected as well (). Bony defects were visible in the nasal part of the right sinus and the orbital floor (). At operation, after incision of the gingiva, no bony wall of the right maxillary sinus was evident (). The cystic tissue was adherent to the buccal soft tissue and the infraorbital nerve. Cystectomy was performed with infraorbital nerve preservation and cystic tissue was removed intact (). A sinuscopy revealed minor damage of the orbital floor; the medial sinus wall was missing after Caldwell-Luc surgery. No further reconstruction was necessary. A pack was inserted in the inferior nasal meatus for 5 days. On the left side, cystic tissue was removed in the same way as described above and a pack in the inferior meatus was removed after 3 days. Clinical signs and histological report confirmed a postoperative bilateral maxillary cyst (Figures and ). No diplopic images were stated but the patient complained about hypoesthesia of the right infraorbital nerve. After half a year, CT control showed no recurrence. Sensory disturbances disappeared during the follow-up examinations within one year after removal of the cysts."
+Edward Duncan,36,1990/6/23,(826)420-6118x032,wramsey@example.net,4437 Cunningham Island,"A 7-year-old girl complained of pain in her left thigh, and she was limping. She had no history of trauma, disease, or surgery. She had left thigh pain for 3 weeks before visiting the outpatient clinic. The ranges of left hip motion were as follows: flexion, 130簞; abduction, 30簞; extension, 10簞; internal rotation, 45簞; and external rotation, 10簞. The circumferences of the right and left thighs were 29.5 cm and 28.5 cm, respectively. Plain radiographs obtained at the initial visit showed no abnormalities (). T2-weighted magnetic resonance imaging (MRI) scan of the hip joints showed no abnormal findings, except left hip joint effusion (). TS was diagnosed on the basis of the patient's medical history and imaging findings, and we continued follow-up. She was on bedrest for 4 weeks, and we instructed her to avoid weight bearing during this time. However, her left thigh pain and limping did not improve. The ultrasonic joint spaces (distance from the anterior cortex of the femoral neck to the front of the capsule [the width of the joint space]) measured 6.0 mm on the right side and 8.7 mm on the left side at 4 weeks after the initial visit. Joint effusion was diagnosed on the basis of anechoic findings of the left hip joint space. T1-weighted and T2-weighted MRI scans of the hip joints showed a linear low-signal-intensity region at the left femoral capital epiphysis 2 months after the initial visit (). Although no abnormalities were found, follow-up continued. The ultrasonic joint space measured 11.6 mm on the left side 2 months after the initial visit (). Synovitis was diagnosed on the basis of echoic findings of the left hip joint space. A culture of the joint aspirate showed negative results. The laboratory data showed no abnormalities. The ultrasonic joint space measured 12.3 mm on the left side 3 months after the initial visit. Hence, we determined that synovitis progressed. Plain radiograph showed bone resorption at the left femoral capital epiphysis 3 months after the initial visit (). Bone scintigraphy findings showed a cold-in-hot pattern at the left femoral capital epiphysis (). We diagnosed the patient as having LCPD on the basis of these imaging findings. We instructed her to wear a hip abduction and non-weight-bearing brace. We categorized the disease as Catterall group II and Herring group B according to the findings from plain radiographs 8 months after the initial visit (). Plain radiographs showed a continuous subchondral bone 15 months after the initial visit. We removed her brace and continued follow-up. Plain radiographs showed good remodeling of the necrotic area at the left femoral capital epiphysis 7 years after the initial visit. She did not have a lower limb discrepancy, left thigh pain, or limping ()."
+Elise Hayes,41,2002/10/9,(652)671-3598x397,danielvargas@example.net,660 Karen Key Suite 434,"A 7-week-old boy presented with a cystic swelling of the left tongue tip and inferior side of the tongue. The cyst was discovered on ultrasound at 28 weeks of gestation. An immediate postnatal MRI revealed a well-defined midline structure in the anterior half of the tongue of 3.6 cm (Figure ). Because the cyst was asymptomatic, surgery was delayed until the age of 1 year."
+Legend Hutchinson,41,1982/9/27,466.672.2560x075,andreasmith@example.net,792 Butler Drive Suite 492,"A 2-year-old boy was referred to our department for macroglossia. Clinical examination showed a cystic midline protrusion of the tongue tip and corpus and a tongue ankylosis. MRI confirmed a well-demarcated cyst of 4.6 cm (Figure ). At the age of two, two connected cysts were resected. A lingual frenulotomy was performed."
+Jamie Houston,38,2001/8/18,668.852.0681x498,brittanyrobinson@example.net,7782 Hall Branch Apt. 319,"A 14-month-old girl was referred to us with an infection of the floor of the mouth following attempted needle aspiration of a suspected ranula 1 week earlier, not ameliorating under Amoxicillin?lavulanic acid. The swelling had been noticed since the age of 2 months. The infection cooled down after partial needle aspiration of the liquid content, relieving pressure and facilitating penetration of antibiotic treatment with Piperacillin/tazobactam (Tazocin簧) and metronidazole (Flagyl簧). After remaining asymptomatic for 7 months, the swelling recurred. A prophylactic antibiotic treatment with Amoxicillin was started and the operation date was accelerated."
+Sylas Lucas,22,1990/12/6,336.988.8215,michael14@example.com,53591 Megan Vista Apt. 052,"A 29-year-old man consulted us with a slowly progressive swelling, medially in the floor of the mouth, since 10 years. Clinical examination showed a soft well-defined cyst medially in the flour of the mouth and descending submentally. MRI showed a 7-cm bilocular midline cystic lesion in the floor of the mouth."
+Phoenix Haynes,30,1995/4/21,001-447-321-0180x2376,timothy20@example.org,8113 Barber Mews,"A 55-year-old female patient with serious bilateral maxillary molar eruption visited the hospital to secure space for mandibular molar prosthetics. For diagnosis, she received clinical and radiological examinations (Fig. ).
+She had serious bilateral maxillary molar eruption (bilateral vertical dimension on the first molar 0 mm), bilateral mandibular molar edentulous condition, lack of proper vertical dimension for prosthetic treatment, and multiple dental caries, and retained dental root were observed.
+PMSO was planned to restore decreased vertical dimension due to serious eruption of the bilateral maxillary molar, and we decided to shift the molars in a posterior-superior direction by approximately 7 mm from the maxillary and mandibular right first premolar.
+Incision was conducted in accordance with local analgesia under general anesthesia, and a buccal flap was formed. Horizontal osteotomy was performed from the bilateral first premolar to the first permanent molar, while vertical osteotomy was conducted on the mesial surface of the bilateral first premolar.
+After palatal osteotomy, the maxillary posterior segment was separated, and excessive bone fragments were removed. The segmented bone fragments were shifted using the wafer, which was made before operation, and then they were fixed using the mini plate and screws. And the operation was finished following intra-oral suture and intermaxillary fixation (Fig. ).
+At 2 weeks, stitch-out and removal of the intermaxillary fixation were conducted, and at 4 weeks, the wafer placed on the maxillary teeth was shifted. Then, implant placement and prosthetic treatment were done (Fig. ). One, 2, and 6 months after the surgery, we confirmed stable occlusion and no complications such as necrosis of the osteotomy site."
+Kason Reed,44,1980/5/16,691.707.1983x16842,hmcdonald@example.org,104 Ronnie Mountain,"A 43-year-old female patient visited the hospital for treatment of the erupted maxillary right molar and the molar width discrepancy and protruded upper lip. She was able to bite just in the left due to excessive eruption (downward canting, 3 mm) of the maxillary right molar and scissor bite in clinical and radiological examinations (Figs. and ). Over eruption and scissor bite of right maxillary molar teeth, maxillary and mandibular hypo-growth (SNA 75.68, SNB 71.41), maxillary arch length discrepancy (maxillary inter molar width 46 mm, mandibular intermolar width 40 mm) (Fig. ), acute nasolabial angle (90簞), and protruded upper lip (upper lip E-line 1.95) were found, and for surgical treatment, Le Fort I osteotomy and PMSO were performed. According to the analysis and surgical planning, total setback 5.5 mm, posterior impaction 3.0 mm, and medial shift of maxillary right molar 5.0 mm was planned.
+Le Fort I osteotomy was conducted in accordance with local analgesia under general anesthesia.
+After maxillary down fracture was performed, maxillary setback was secured using the intermediate wafer. And then, vertical osteotomy and palatal osteotomy were conducted between the maxillary right lateral incisor and maxillary right canine, and osteotomy of the maxillary right molar was finished (Fig. ). Medial shift of the segmental bone fragment was identified using the final wafer, and then it was fixed using the plate and screws, and intra-oral suture and intermaxillary fixation were carried out (SNA 67.66, SNB 66.41).
+At 2 weeks, stitch-out and intermaxillary fixation were removed, and at 4 weeks, the wafer was removed. She continued postoperative orthodontic treatment and she had stable occlusion (Figs. and ). Maxillary arch length discrepancy (Fig. ) was also effectively decreased (maxillary inter molar width 41 mm, mandibular inter molar width 40 mm), enabling the patient to chew with bilateral molars and satisfying the lateral profile of the upper lip (upper lip E-line ??.82)."
+Valentina Boyer,20,2003/12/26,+1-427-763-9590x701,qyoung@example.org,263 Leslie Ford,"A 54-year-old male with past medical history of end-stage renal disease on hemodialysis, hepatitis C, ischemic stroke, depression, and anxiety was brought to the emergency department with the complaints of fever (100.2簞F) and increased surgical site pain in left thigh. He underwent creation of a left superficial femoral artery to greater saphenous vein prosthetic AV graft 1 day prior to admission. Few hours after the procedure, he started having increased surgical site pain, erythema, and small vesicles at the margins of wound. On examination, the left thigh AV fistula site staples were intact. There was mild erythema, tenderness, and vesicles at margins. Serous discharge was noted from vesicles but no purulent drainage from wound area. Lab investigations showed creatinine level of 12.6 mg/dL and a potassium level of 6.4 mEq/L at the time of admission prompting hemodialysis. On admission, his vitals were normal and white blood cell (WBC) count was 10 000/cumm. The next day, his left thigh wound pain and swelling worsened concomitant with erythema, tenderness, and purulent discharge. Blood cultures were taken and drainage sample was sent for culture and sensitivity. His WBC count increased to 13 000 and erythrocyte sedimentation rate was 45; therefore, on suspicion of AV graft infection he was started on vancomycin 1.25 g intravenously given after each hemodialysis session. The vancomycin trough level was therapeutic, and blood cultures and drainage culture were negative. Despite the antibiotic therapy, his symptoms worsened with each passing day. Repeat blood and drainage cultures were consistently negative. Computed tomography scan of pelvis showed extensive edema and congestion of the subcutaneous fat extending from the left external oblique musculature inferiorly along the lateral aspect of the pelvis into the left upper extremity (). Because of worsening symptoms, he underwent exploration of left thigh AV graft and samples were collected from perigraft tissue and perigraft fluid for culture and sensitivity. Once again, all cultures came back negative. Over the next couple of days, he started having purulent drainage from multiple locations along the skin overlying the graft (). The decision was then taken to surgically remove the graft. The drainage sample from excised graft was also negative for bacteria. After graft removal, his symptoms markedly improved with complete resolution of symptoms in 7 days. In the meantime, he was given topical emollients for symptom relief only. Due to abrupt onset of symptoms within hours after AV graft placement, the diagnosis of AV graft contact dermatitis was made."
+Zeke Moss,33,1988/5/5,001-592-930-6414,ecohen@example.com,9408 Dougherty Club,"A 78-year-old woman presented with a 2-week history of progressive lower limb weakness and bilateral numbness from her hips to her toes. Her primary care physician referred her for physical therapy, which did not improve her strength. Her symptoms continued to worsen until she became bed bound and presented to the hospital 2 months after the initial onset of symptoms. Her past medical history included stage IIIC ovarian adenocarcinoma 17 months prior to presentation. At that time, her Ca 125 level was 1612 units/mL. She received 6 cycles of neoadjuvant chemotherapy with carboplatin and Taxol, followed by exploratory laparotomy, bilateral salpingoopherectomy, splenectomy (due to concerning lesions in the spleen), and 3 cycles of chemotherapy. Two subsequent abdominal computed tomography (CT) scans showed no evidence of recurrence and Ca 125 levels had decreased to normal.
+On exam she had left lower extremity weakness; 2/5 in both hip and knee flexion and extension, 4/5 in dorsiflexion and plantar flexion. Right lower extremity strength was 0/5 in both hip and knee flexion and extension, and 3/5 in dorsiflexion and plantar flexion. Ca 125 levels were normal. Cerebrospinal fluid analysis indicated nonspecific inflammatory changes and no sign of infection. Spinal magnetic resonance imaging (MRI) showed an intramedullary lesion at T11-T12 (). Positron emission tomography CT revealed focally increased FDG avidity at T11-T12. A laminectomy and biopsy of the lesion were performed; pathology indicated metastatic ovarian cancer ().
+The patient received high-dose corticosteroid therapy for 1 week after her presentation. She was discharged to a rehabilitation facility and underwent outpatient radiation therapy with 30 Gy in 10 fractions of 300 cGy each, from T7 to L1. She tolerated the treatment well and gained slight improvement in sensation and weakness, but was unable to ambulate. She received a subsequent 6 cycles of chemotherapy with Taxol and carboplatin. On completion of this chemotherapy, her weakness improved with motor strength in the left lower extremity 4/5, and in the right lower extremity 3/5 in all muscle groups. MRI of the thoracic spine 4 weeks after the last cycle showed widespread bony metastases but no spinal cord compression. An MRI of the cervical spine showed no enhancing lesions. A CT of the abdomen and pelvis was without masses in the pelvis. Ultimately, patient gained improvement in her lower extremity strength, but she did not regain full function."
+Bianca Valdez,23,1983/7/21,(264)635-0630x58262,jodiknox@example.org,2935 Williams Stravenue Suite 254,"A 70-year-old male with past medical history of hypertension only presented to the emergency department with left hand weakness and numbness for past 7 hours. He was unable to extend his wrist and fingers and had loss of sensation and paresthesia on the dorsum of the left hand. He had experienced a similar episode 3 days ago, which resolved in a few hours; the patient had initially attributed these symptoms to old age and muscle spasms. Today his symptoms did not resolve in the past few hours, hence he decided to come to the emergency room for further investigation. He denied any dizziness, lightheadedness, loss of consciousness, slurring of speech, ambulatory dysfunction, or difficulty maintaining balance. He denied any weakness or loss of sensation in any other extremity. His home medications were amlodipine, benazepril, and vitamin D3. He did have a family history significant for stroke and diabetes mellitus. He denied smoking or alcohol or drug abuse.
+His vitals were temperature 36.9, heart rate 98, respiratory rate 20, blood pressure 140/65, oxygen saturation 98% on room, weight 68 kg, height 170 cm. On examination he was alert and oriented in time, place, and person. His gait and cranial nerves were intact. Motor examination demonstrated weakness of left wrist and finger extensor muscles with a muscle strength grading of ??. Strength in the left bicep, brachoradialis, tricep muscle, flexors of the fingers and wrist was normal. Sensory examination demonstrated mild decrease in sensation on the dorsal aspect of the left hand, predominantly in the anatomical snuff box. Strength and sensation in the other extremities were normal. Other systemic examinations were unremarkable."
+Kyler Camacho,37,1984/11/8,472-921-1674,olivervictoria@example.com,988 King Street Apt. 099,"A 22-year-old female university student with no medical and psychiatric history spontaneously presented to the emergency unit of our university hospital, complaining of speech disorders, physical and mental fatigue. Four days earlier she had developed a stuttering episode with concentration difficulties. A side effect of a recently prescribed antihistaminic drug (cetirizine) was suspected, and the medication was stopped. She was discharged home. Two days later, she was readmitted to the hospital because of an increase in subtle chorei form movements (perioral, hands), as well as memory impairment. She also presented with decreased mobility, lack of right hand grip, paraesthesia of the left hemibody, dysarthria, and tinnitus. illustrates the intensity of neurological and psychiatric symptoms throughout the different phases of the disease.
+In the following days, her orofacial dyskinesia worsened and she developed a swallowing disorder, speech deterioration, vomiting, wide pupils and facial flush, right upper limb weakness associated with paranoid delusions, as well as auditory and olfactory hallucinations. Over the following 2 weeks she developed delirium and increased impairment of consciousness, requiring endotracheal intubation and ventilation in the ICU. A large differential diagnosis was considered, including most common causes of encephalitis: viral, autoimmune, paraneoplastic and toxic-metabolic. Electroencephalogram (EEG) performed shortly after inpatient admission (2 weeks after the initial symptoms) was suggestive of anti-NMDAR encephalitis, showing poorly reactive rhythmic delta activity over the frontal regions []. This was confirmed by a positive anti-NMDAR antibody test in cerebrospinal fluid and serum (Serum: 1/100, Cerebrospinal fluid: 1/2). A nodule in the right ovary observed by ultrasound and removed by laparoscopy did not show a tumoural lesion by histology (no teratoma).
+During the following months, the patient, while unconscious and mechanically ventilated, received specific immunological treatments (high-dose steroids, 15 cycles of plasma exchange, 8 cycles of cyclophosphamide, 4 cycles of rituximab, and 4 cycles of intravenous immunoglobulin), with high-dose midazolam (and at times propofol) sedation. Although we did not formally identify a clinical or electrographic seizure, she received non-sedating intravenous antiepileptic treatment (valproic acid and lacosamide), because the rhythmic delta activity by EEG represented an ictal correlate []. Her clinical course was characterized by hemodynamic, breathing, cardiac arrhythmias, infectious, metabolic, and nutritional dysfunctions. Throughout this long ?nresponsive phase??there was no contact with the patient. Sometimes she opened her eyes but remained mute and unresponsive to visual stimuli. Orofacial and arm dyskinesia were regularly present upon weaning of the sedation, and her EEG showed a rhythm delta over the frontal regions alternating with a disorganized, relatively fast activity.
+After several months of being in an unresponsive state in the ICU under continuous immunotherapy, the patient started to improve. Limited contact became possible: she opened her eyes and responded to simple orders. She was finally extubated eight months after her admission. After awakening, the patient presented with an acute confusional state but her neurological status improved slowly. Over the following weeks, she was slow and hypomimic with ataxic movements. However, delirium persisted with episodes where she was mute, a kinetic, and unresponsive to verbal commands. For four months the patient presented with severe psychopathological manifestations.
+Episodes of psychomotor agitation with overt aggressive behaviour were very challenging, including throwing objects around the room, slapping her hands on the bed, trying to pull out the feeding tube, sometimes requiring sedation (intravenous midazolam and propofol) and even physical restraint for short periods.
+Psychotic features were clearly recognizable upon speaking indicating paranoid delusions as well as auditory and olfactory hallucinations. She was also tremendously anxious or perplexed, and refused contact (e.g. actively kept her eyes closed) with the ICU staff or even with her family.
+Affective elements were also present, including depressive withdrawal, suicidal ideation culminating in attempted self-harm by knife or strangulation with a cable. She also presented with severe insomnia and nightmares.
+Interactions with her caregivers were marked by irritability and emotional manifestations, recurrent refusal of care and feeding, and even requests to be killed or that we let her die. This highly challenging situation for the ICU team required that an additional nurse be hired allowing ?ne to one??continuous supervision of the patient to prevent accidents.
+Besides midazolam and propofol she received quetiapine XR (orally through a nasogastric tube). Despite benzodiazepine and antipsychotic treatments, the patient remained impulsive and aggressive with psychotic symptoms for several weeks. An improvement occurred after 1 month when quetiapine XR was increased to 600 mg/day. In parallel, physiotherapy was started in the ICU to improve swallowing and reduce feeding difficulties. A specific team (not the C-L team) delivered these therapies. The neuropsychological rehabilitation therapies were used to target attention disorders, immediate and episodic anterograde memory, and language disorders such as dysarthria, lack of words and ideomotor apraxia.
+Four months after coma resolution (12 months after admission), we observed a significant improvement that was chronologically linked to a decrease in plasma anti-NMDAR antibodies. A further increase of quetiapine allowed a low tapering of benzodiazepines, at which time, there was a complete disappearance of psychomotor agitation. However, hallucinations as well as feelings of sadness, anger, and fluctuating suicidal ideation were still present.
+Five months after coma resolution, the patient was transferred to a psychiatric unit for management and treatment of the residual psychotic symptoms. Her autonomy increased and she better engaged in social interactions with therapists and other patients. She was collaborative in psychiatric consultations, physiotherapy and occupational therapy activities. She began to take better care of her body, applying make-up or asking for an appointment with the hairdresser. Contacts with family and friends were more frequent and a source of pleasure. She started to make plans for her future (wish to be discharged home and return to her university studies). After 2 months at the psychiatric unit, the psychotic and affective symptoms gradually resolved.
+At that point, cognitive deficits were still present, with attention disorders, deficits in immediate and episodic anterograde memory, language disorders (dysarthria, lack of words, paraphasia and agrammatism), and ideomotor apraxia. The patient was transferred to a neurorehabilitation unit (NRU) for about 6 weeks. She was trained by neuropsychological tasks and showed improved interference management, information retention in episodic and verbal memory, and mental calculations. Furthermore, she benefited from intensive ergotherapeutic and physiotherapeutic approaches. In particular, ergotherapy by NRU staff focused on cognitive, speech-language deficits, communication skills and social-motivational occupations. The clinical evolution was remarkably good, with an improvement in cognitive and executive functions and social organizational activities.
+Sixteen months after her first contact with our hospital, the patient was discharged home. She was followed up by liaison psychiatry consultation once a week. She took quetiapine (300 mg/day) treatment for 6 more months, which was then successfully discontinued. Nine months after discharge, the patient and her parents reported social, personal and family stability. The patient resumed university attendance and successfully passed her exams. She has little recollection of the 16 months of admission and treatment, particularly the ICU phase. At the last follow-up, 2 years after the event, she only complained about the tracheostomy scar."
+Armani Brady,39,1978/6/8,(370)912-9439x61169,richard20@example.net,56851 Shelby Mews,"The first patient is a 30-year-old female less than one month post-partum who presented with rapid onset obtundation. MRI/V revealed superior sagittal sinus thrombosis with venous infarctions in both frontal lobes. The patient was started on a heparin drip. Her exam declined while on heparin, and she required intubation. A CT scan demonstrated increased cerebral edema as well as progression of the previously identified thrombus into the right transverse sinus (Figure ). She was brought to angiography for possible intervention secondary to failed medical management. This confirmed that the occlusion had spread to the right transverse sinus. Both stent retriever (Solitaire FR, Medtronic) and aspiration (ACE, Penumbra, CA) were attempted without success. A 0.010-inch microcatheter (Eschelon 10, Medtronic) was placed in the anterior third of the superior sagittal sinus. The bolus dose of IV tPA was calculated to be 10 mg. This was diluted in a 500 ml bag of heparinized saline and set up for a ten-hour infusion at 100 ml per hour for a dose of 1 mg/hr in 50 ml/hr of fluid. We chose this dose after reviewing Rahman et al., and picking a dose on the low side of the spectrum provided. Unfortunately, the catheter became clogged after only three hours.
+She was taken back to angiography where persistent occlusion was demonstrated. To prevent further clogging of the catheter, the 0.010-inch microcatheter was swapped out for a larger 0.027-inch microcatheter (Marksman, Medtronic). The tPA dose was doubled to 20 mg and dissolved in a 1 liter bag of heparinized saline. The infusion was then 2 mg/hr in 100 ml/hr of fluid. This infused the entire ten hours without clogging. CTA revealed a recanalized sinus still with thrombus and no new hemorrhages (Figure ). Heparin was then restarted. On discharge one month later, she was neurologically intact."
+Reed James,20,2000/5/11,846-348-8998x4720,sjimenez@example.net,484 Mueller Dam Apt. 883,"The second patient is a 70-year-old female with a diagnosis of multiple myelomas who presented with a seizure. MRA/V revealed a right temporal venous infarct and an occluded right transverse sinus (Figures -). She was started on a heparin drip. Seven days later, she experienced a neurological decline and required intubation. Repeat imaging revealed occlusion of the superior sagittal sinus, the vein of Galen, the torcula, as well as both transverse sinuses. There was some minor edema in the thalami bilaterally. Given her precipitous decline, it was decided that if any recovery were possible, acute intervention was needed, and waiting for an MRI to rule out thalamic infarction was not feasible.
+She was taken to angiography and both stent retriever and aspiration thrombectomy were attempted without recanalization (Figures -). A 0.027-inch microcatheter was placed in the thrombus in the sagittal sinus, and 20 mg of tPA was dissolved in a 1 liter bag of normal saline and infused at 2 mg/hr for ten hours. She was brought back to angiography at the completion of the infusion, which revealed recanalization (Figure ). MRI confirmed bilateral thalamic infarcts. After twenty-four hours of no improvement in her clinical exam, her family elected to withdraw care."
+Quinn Hale,28,1992/5/18,001-602-871-0783x67090,brianna25@example.com,373 Heather Brook Apt. 742,"The third patient is a 40-year-old female who presented with a seizure. A CT scan revealed bilateral temporal venous infarcts and superior sagittal sinus, the straight sinus, vein of Galen, and the right transverse sinus (Figure ). She was intubated for airway protection and started on heparin. On day two, she became hemiplegic with CT evidence of an extending thrombus but no new hemorrhage. She was taken to angiography where both stent retriever and aspiration thrombectomy were attempted without recanalization. A 0.027-inch microcatheter was placed in the anterior third of the sagittal sinus, and 20 mg of tPA was dissolved in a 1 liter bag of normal saline and infused at 2 mg/hr for ten hours. CTA at the completion of the infusion revealed recanalization (Figure ). She was discharged two weeks later with 3/5 strength on the left upper and lower extremity and was neurologically intact three months later at her follow-up."
+Ezequiel Ward,45,1987/7/31,(946)462-3816x16332,scott80@example.org,364 Tom Shores,"A 24-year-old white man presented to the authors institution with progressive kyphosis and severe back pain. The patient had undergone a previous thoracic fusion operation at the age of 17 for Scheuermann's Kyphosis, which was complicated by a postoperative infection requiring hardware removal and brace immobilization for approximately 1.5 years. Exertion, lifting, and attempting to maintain horizontal gaze worsened his symptoms while rest was the only method to improve his pain.
+On physical examination, the patient was 5 feet 5 inches, 190 lbs., and demonstrated severe thoracolumbar kyphosis (Figure ). He had well healed operative scars of the posterior midline as well as a right thorax. His neurological exam was normal. Deep tendon reflexes and straight leg raising tests were all normal.
+Imaging revealed severe focal lumbar kyphosis of 69 degrees at L2-L3 (Figure ). There was evidence of a robust posterior fusion mass from T10-T12 and from L1-S1 with pseudoarthrosis and spinal stenosis at the T12-L1 level (Figure ).
+The original operative plan was T4-pelvis instrumentation with a Ponte osteotomy at L2 and laminectomy at T12-L1 for stenosis at the area of pseudoarthrosis. This was to be followed by a posterior vertebral column resection (VCR) of L2 for correction of the deformity. The operation commenced with the placement of pedicle screw instrumentation from T5 to S1, pelvic fixation using standard iliac screw technique, and finally with transverse process hooks at T4. Pedicle screws were placed above and below the level of pseudoarthrosis at T12-L1 and originally left out of L2 in preparation for the VCR. A functional laminectomy with removal of fibrocartilaginous scar at T12-L1 was then performed. A Ponte osteotomy was completed at the L2-L3 disc space, and preparation for an interbody fusion started.
+Once the blunt paddles were placed within the disc space and sequentially dilated, the space became mobile, and a complete correction of deformity was demonstrated on intraoperative fluoroscopy (Figure ).
+Two titanium cages were filled with autograft bone and implanted in the disc space. Additional screws were then implanted into L2, and two titanium rods were contoured to provide maximum lordosis over the corrected spine followed by placement of the bone graft (Figure ) in the interlaminar spaces as well as the intertransverse gutters. Due to the intact laminae at L5 and S1 enabling a large surface area for interlaminar fusion of the L5-S1 segment, it was not felt that an L5-S1 interbody graft was necessary (as has been recommended in long segment thoracolumbar fusions).
+The patient experienced a postoperative ileus that resolved in four days with conservative measures. A CT angiogram of the abdomen was performed and did not support any acute abdominal pathology or mesenteric ischemia. The patient did not experience any other perioperative complications.
+The patient was discharged on postoperative day eight. At the six-month follow-up, his posture was normalized, and he regained horizontal gaze, helping him achieve ambulation without the use of his previous walking device (Figure )."
+Ariana Sanford,31,2004/4/28,001-683-637-8055x08227,greenchristopher@example.net,74943 Catherine Brooks Suite 039,"A 36-year-old man was referred after failure of internal fixation to an open fracture (Gustilo?nderson IIIA) of the distal meta-diaphysis of the left femur 5 months earlier. This initial injury was managed by emergency debridement, irrigation and distal femoral locking plate fixation. At presentation with the non-union, the patient had healed scars with no evidence of sepsis. The painful non-union was evident clinically and associated with a varus deformity of the femur in the region of the fracture site.
+Local and systemic staging confirmed the patient to be smoker with no other co-morbidities. Radiographs displayed a broken locking plate and a femoral non-union with a 12簞 varus and 5簞 procurvatum deformity (Fig. ). Knee motion was reduced, with a passive range of motion from full extension to 50簞 flexion. No evidence of infection was found after routine biochemical investigation and confirmed after intra-operative sampling.
+Surgery consisted of plate and screw removal through an exposure along the entire length of the plate followed by circular external fixator application (TL-Hex, Orthofix SRL, Verona, Italy) using the ?ings first??method. Proximal fixation consisted of three hydroxyapatite coated half pins secured to a 5/8th ring and an arch. Distal fixation consisted of one 1.8 mm tensioned transverse wire and two hydroxyapatite half pins secured to a full ring (Fig. ). The non-union site was left undisturbed, and no bone graft used.
+After a latency period of 7 days, gradual correction was achieved over 6 days. This included 5 mm of distraction at a rate of 1 mm per day to facilitate reduction. Final anatomical alignment in the coronal and sagittal plane was confirmed on radiographs. Functional rehabilitation was encouraged with the assistance of a physiotherapist during the correction and consolidation phases. Full weight bearing was allowed from the first post-operative day. Pin track care followed our standard protocol and included twice daily cleaning with an alcoholic solution of chlorhexidine [, ].
+The only complications encountered during the treatment period were minor pin track infections. One half pin developed a Checketts and Otterburn stage II infection that responded to oral antibiotics []. The tensioned wire developed a stage III infection at a late stage of treatment. The wire was removed without further complications.
+Radiographs confirmed solid union with exuberant callus formation after 13 weeks. The external fixator was removed when painless weight bearing on a dynamized frame was achieved. At last follow-up, 9 months after frame removal, no deformity had occurred at the union site and knee range of motion had improved at full extension to 90簞 flexion (Fig. )."
+Truett Coleman,39,2000/7/25,(482)334-2985x945,fburnett@example.net,5510 William Streets Suite 523,"A 54-year-old man presented with a history of epigastric pain and melena over the last few days. The patient did not have hormone-related symptoms. He had received treatment for a myocardial infarction at the age of 51 with an antiplatelet therapy; therefore, we considered that there was a possibility of tumor bleeding by antiplatelet therapy. Blood biochemical examinations indicated slight anemia. Serum carbohydrate antigen 19-9 and carcinoembryonic antigen (CEA) levels were not elevated. The 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) level was 3.2 mg. Upper gastrointestinal endoscopy showed a bulging papilla with bleeding (Fig. ). A biopsy was not performed at that time because of the active bleeding. Endoscopic examination on day 7 revealed an approximately 10-mm mass of the ampulla of Vater with a superficial ulcer (Fig. ). Pathological findings of the endoscopic biopsy of the ampulla revealed a well-differentiated NET. Immunohistochemically, the tumor stained positive for CD56, chromogranin A, and synaptophysin. An upper gastrointestinal series showed an ampullary mass without any obvious lesions of the jejunum (Fig. ). An enhanced abdominal computed tomography (CT) scan revealed a 10-mm hypervascular tumor at the ampulla of Vater and a 41-mm multilocular cyst adjacent to the wall of the jejunum near the ligament of Treitz (Fig. ). The wall of the multilocular cyst showed the same enhancement patterns with the tumor. The patient underwent magnetic resonance imaging that was negative for visceral metastasis. About the cyst, the preoperative definitive diagnosis was not provided.
+The patient was referred to our hospital for treatment of the NET. We performed a pylorus-preserving pancreaticoduodenectomy with regional lymph node dissection. The operative time was 497 min, and the volume of blood loss during the surgery was 1220 ml. The resected specimen was macroscopically a 9-mm white solid tumor (Fig. ). Tumor cells confined to duodenal mucosal layer. There was a 52-mm cyst in the superior mesentery adjacent to the wall of the jejunum (Fig. ). Microscopically, the tumor consisted of small-sized round cell proliferations with a solid nest pattern (Fig. ). The cyst preserved the structure of the lymph node and was the superior mesenteric lymph node metastasis of the tumor (Fig. ). We performed D2 lymph node dissection, and there was no metastatic lymph node except for the superior mesenteric lymph node. Immunohistochemically, the resected specimen revealed that the tumor and the lymph node metastasis were positive for chromogranin A (Fig. ) and CD56 and negative for synaptophysin. The Ki-67-labeling index of the tumor cells determined with MIB-1 was 2.0 %. The final diagnosis was sporadic non-functional NET G1 of the ampulla of Vater (pT1N1M0 stage IIIB). The patient was discharged 36 days after the operation. He has had no recurrence for 4 years after surgery. No further treatment was administered.
+NETs of the ampulla of Vater are rare and difficult to diagnose [, ]. Jaundice (60 %) and abdominal pain (40 %) are the most frequent symptoms. Upper gastrointestinal bleeding is a rare presentation (<3 %) [, ]. In our case, the patient presented with abdominal pain and melena. On admission, upper gastrointestinal endoscopy revealed a bulging papilla with active bleeding. When we performed gastric endoscopy again 7 days later, we found a 10-mm mass of the ampulla of Vater with a superficial ulcer.
+Diagnosis of NETs is established by histological and immunohistochemical analysis of endoscopic biopsy specimens []. NETs of the ampulla of Vater usually appear as submucosal masses that are small and spherical with a smooth surface and an intact duodenal mucosa. Consequently, superficial biopsies are negative and deeper biopsies are required for a diagnosis [, ]. In our present case, we could get the biopsy specimen from the mass because it had an ulcerated surface. Thus, the correct diagnosis of a NET was established preoperatively. However, we could not diagnose the cyst adjacent to the wall of the jejunum as a lymph node metastasis at the time of resection.
+Previous reports have suggested that the biological behavior of ampullary NETs is distinct from that of duodenal NETs and they are more aggressive []. Randle and colleagues reported that ampullary NETs were larger, higher grade, and higher stage and had a higher rate of lymph node metastasis than duodenal NETs []. The incidence of lymph node metastases in patients with resected ampullary NETs and duodenal NETs was 72.9 and 48.4 %, respectively.
+In the case of ampullary NETs, even in tumors smaller than 2 cm, a high percentage have lymph node metastases [, ?. Nikou et al. reported that lymph node metastases were found in two cases of ampullary NET with tumor sizes of 1.0 and 1.2 cm, respectively []. In the present case, the histologic examination revealed metastasis to distant lymph nodes despite the tumor only being 9 mm in diameter and within duodenal mucosal layer. These findings suggest that there is no correlation between tumor size and metastatic potential in ampullary NETs. We consider that an anatomical reason is one of the reasons why NETs at the ampulla of Vater have high incidence of metastasis. Ampullary carcinoma with perisphincteric or duodenal submucosal invasion showed more frequent lymph node metastasis and a greater tumor recurrence rate than tumor limited within the sphincter of Oddi muscle []. Moreover, the perisphincteric and duodenal submucosal space is relatively small and closer to the next layering of duodenal proper muscle and the pancreas. Thus, the malignant potential of perisphincteric and/or duodenal submucosal invasion may be greater than that of other gastrointestinal tract tumors. Moreover, previous studies have reported that lymph node metastasis is difficult to detect on preoperative imaging [, ]. Although some authors report the existence of lymph node metastasis of NETs is not correlated with patient prognosis, this could be due to metastasis to the liver or some other organ, which is an important prognostic factor for NETs. Therefore, radical resection with lymph node dissection is recommended as a treatment of ampullary NETs regardless of tumor size [, , , , ].
+We performed a pylorus-preserving pancreaticoduodenectomy with regional lymph node resection and also resected a 52-mm lymphatic metastasis adjacent to the wall of the jejunum. Despite the lymph node involvement, the Ki-67-labeling index was low (2 %) and the patient has had no evidence of recurrence for 4 years after surgery.
+Randle et al. indicated that tumor size was correlated with poor prognosis, but the presence of positive lymph nodes was not a predictive outcome in resected ampullary NETs []. Untch et al. reported that only tumor size and tumor grade were associated with recurrence []. Thus, we can perform radical resection and completely remove the tumor with good clinical outcomes."
+Julia Allison,33,2005/6/18,001-556-931-6453x01066,eric95@example.net,61411 Annette Parkways Suite 299,"A 57-year-old woman with no past medical history presented at our emergency department (ED) with 1 day of posterior neck pain, followed by weakness in her left upper limb and both lower limbs, and inability to pass urine since that morning. There was no history of trauma to the head or spine. Two weeks prior to the ED visit, she experienced severe neck ache and consulted a chiropractor, who performed manipulation and needle acupuncture of her back, with relief of her initial symptom.
+On examination, the patient was afebrile, with a blood pressure of 116/55 mmHg, a pulse rate of 108 beats per minute, a respiratory rate of 18 breaths per minutes and an oxygen saturation of 97 % in room air. Palpation of her abdomen revealed a bladder distended to the level of the umbilicus. Neurological examination disclosed weakness of the left upper limb and spastic paraparesis. Power in the right upper limb was full. There was also decreased sensation from the level of the neck downwards but with sparing of the right upper limb. A lax anal tone was obtained on digital rectal examination.
+X-rays of the cervical and thoracolumbar spine showed disc narrowing at the C5/C6 and C6/C7 levels, and grade 1 spondylolisthesis of L4 on L5. The white blood cell count was 30.13 ? 109 cells/L (normal range, 4??0 ? 109 cells/L) with neutrophilia, and the C-reactive protein and erythrocyte sedimentation rate levels were 391 mg/L (0.2??.1 mg/L) and 119 mm/h (3??0 mm/h), respectively. Her procalcitonin level was 2.4 弮g/L (<0.5 弮g/L).
+Magnetic resonance imaging (MRI) of the spine showed multiple spinal abscesses in the posterior epidural space from C5 to T1 and from L4 to L5. The former measured 0.7 ? 1.3 ? 5.1 cm, displacing the cervical cord anteriorly and compressing it at C7-T1, with a high T2 signal intensity in the cord (see Fig. ). There was also a high T2-TIRM signal in the C6-7 vertebral bodies and intervening disc with abnormal enhancement, in keeping with osteomyelitis and discitis. This was also seen in the lumbar spine (see Fig. ).
+In the lumbar spine, another collection measuring 0.4 ? 1.2 ? 3 cm was noted in the right posterior epidural space along the right lamina of L4/L5. Together with a disc bulge, this compressed the thecal sac and cauda equina (see Fig. ).
+She was admitted to the orthopaedic surgery high dependency unit, and intravenous (IV) antibiotics were commenced. Surgical decompression of the spinal cord and drainage of the epidural abscesses was performed early the next day. Blood cultures and intra-operative fluid cultures grew pan-sensitive Staphylococcus aureus. Following advice from the infectious disease specialist, the patient completed 6 weeks of IV penicillin G. Repeat blood cultures taken 1 week after initiation of antibiotics were negative.
+Post-surgery, she underwent intensive physical therapy for a month, after which she was discharged independent without aid in the community. A follow-up MRI scan performed 4 months later showed resolution of all the abscesses.
+A spinal epidural abscess (SEA) is a pyogenic infection of the potential space between the vertebral body and dura mater of the spine. Although rare, their incidence has been rising gradually over the past decade, possibly due to increasing intravenous drug abuse, an ageing population with multiple comorbidities and more frequent use of spinal instrumentation.
+SEAs can be either primary or secondary. Primary SEAs result from haematogenous spread of pathogens from a distant focus to the epidural space, while secondary SEAs occur after spinal trauma, injections, surgery or direct inoculation of a pathogen into the epidural space [].
+In a literature review of 40 studies published from years 2000 to 2013 [], the most common symptoms and signs reported in SEA were neck and back pain, fever and neurological deficits. Altered mental state and incontinence were also documented. However, presentation can be ambiguous and variable, resulting in delayed diagnosis. The most common predisposing factor is diabetes mellitus. Others include alcoholism, renal failure, intravenous drug abuse, chronic inflammatory conditions, bacteremia and previous spinal intervention.
+The neuroimaging study of choice is MRI. It visualizes soft tissues as effectively as computed tomography (CT) myelography, with a comparable sensitivity for SEA. It also provides superior identification of perimedullary lesions with no risk of introducing pathogens into the thecal sac. MRI is able to differentiate between SEAs and other spinal lesions such as subdural abscesses and tumours. The classical description of an SEA on MRI is the collection in the epidural space which is iso- or hyperintense on T1 images which enhances with gadolinium contrast, and a T2 image with a non-homogeneous and hyperintense signal [].
+A systematic review of 12 studies published after 1999 [] reported S. aureus as the most common causative pathogen, followed by Streptococcus species.
+SEA formation following acupuncture is rare, and a literature search yielded only seven such cases between 1998 and 2015, summarized in Table . There is variability in patient profile, clinical presentation, spinal level of involvement, causative organism and treatment.
+Acupuncture is an early form of medical intervention that originated in China thousands of years ago and continues to be practised today, especially in Asian countries. Studies report its clinical benefits for chronic painful musculoskeletal disorders, headaches and hypertension. Major complications are uncommon, with an incidence of 0.55 per 10,000 individual patients in 12 prospective surveys []. The most common infection is hepatitis B (>60 %) due to transmission via contaminated needles. Only three cases of spinal infection were reported in this review.
+Treatment of SEA includes antibiotics for systemic manifestations and surgery for local disease control. One literature review of 28 case series acknowledges that SEAs are rare, with significant variation in their causes, anatomical locations and rate of progression, making it difficult to build a strong evidence base to stratify patients to the most effective treatment algorithm [].
+However, there is relative consensus that patients with acute or progressive neurological deficit, progressive deformity, spinal instability, or disease progression despite antibiotics require surgical intervention [].
+When surgery is required, a posterior laminectomy is the most common approach. Less invasive methods of surgical evacuation include CT-guided needle aspiration, hemilaminectomy and interlaminar fenestration, which report promising results. For extensive SEA, suction irrigation catheters passed through end- or intermediate-level laminectomies or multilevel unilateral fenestrations may be performed to avoid a multilevel laminectomy [].
+Based on the best available evidence, medical management should be considered in the following patients []:Those who are unfit for surgery (medically unstable, serious comorbidities) Complete paralysis for >48 h without significant concern for an ascending lesion (surgical risks likely to outweigh the chance of functional recovery) Risk factors for failure of medical treatmentDiabetes mellitis Bacteremia White blood cell count >12.5 ? 109 cells/L C-reactive protein >115 mg/L Ring enhancement of lesion on MRI Methicillin-resistant S. aureus infection
+Although the period of antibiotic therapy is debatable, this should last at least 4 weeks because studies have shown a 25 % rate of relapse in patients who were treated for less than 4 weeks [].
+The patient and treating physician should bear in mind that even in the absence of risk factors, there is no guarantee that medical treatment will not fail and that the patient will not require surgery eventually. The risk of failed medical management has been reported to be between 8.3 and 17 %. The best predictor of post-operative neurological outcome is preoperative neurological status []."
+Dennis Steele,43,1987/11/29,+1-639-731-4669x8841,marthacarter@example.com,272 Davis Junctions Apt. 443,"A 64-year-old woman with an unremarkable medical history was admitted to a nearby hospital for a high fever and diarrhea that had lasted for 1 week. She had vision loss in her right eye, exacerbation of renal dysfunction (serum creatinine level, 4.96 mg/dL), and thrombocytopenia (platelet count, 14,000/弮L) within 48 h from initial presentation. Therefore, she was transferred to our institution for treatment of severe infectious disease. On admission, she was alert and had no alteration of mental status, no hypoxia on room air, and normal vital signs (temperature, 36.7 簞C; blood pressure, 126/80 mmHg; pulse rate, 74 beats/min; respiratory rate, 12 breaths/min). However, she had almost complete ablepsia of the right eye. Laboratory data showed severe inflammation (white cell count, 21,700/弮L; C-reactive protein level, 28.2 mg/dL; procalcitonin, 46.4 ng/mL), liver dysfunction (aspartate transaminase, 147 IU/L; alanine transaminase, 345 IU/L), thrombocytopenia (platelet count, 32,000/弮L), an increased serum creatinine level (1.35 mg/dL), and coagulopathy (fibrin/fibrinogen degradation product, 56.6 弮g/mL; D-dimer, 24.2 弮g/mL; prothrombin time-international normalized ratio, 1.15)(Table ). Computed tomography showed a low density area in the right lobe of the liver, and she was diagnosed with a liver abscess (Fig. ). Broad-spectrum antibiotic therapy with meropenem (3 g/day) was immediately started. Endogenous endophthalmitis of the right eye was also diagnosed, and emergency vitrectomy was performed on the day of admission. The blood culture at admission showed K. pneumoniae, and the antibiotic therapy was changed to ceftriaxone (2 g/day) on day 4 because all of the cephalosporin had high susceptibility (Table ) and ceftriaxone was known to penetrate to the liver in high concentration, which was continued to day 14. Percutaneous drainage of the liver abscess, which was unresolved by medical treatment, was performed after coagulopathy improved on day 6 (Fig. ). The culture of the drainage fluid also showed K. pneumoniae. The drainage tube was removed on day 14, and the patient was discharged in a good general condition on day 22, with an additional 2-week course of oral levofloxacin on days 14??8. However, she had complete ablepsia of the right eye. Capsular probing via PCR for the presence of magA (serotype K1) and K2A (serotype K2) genes was performed by using the magA-specific primers (forward, 5??GGTGCTCTTTACATCATTGC-3?? and reverse, 5??GCAATGGCCATTTGCGTTAG-3?? and k2A-specific primers (forward, 5??CAACCATGGTGGTCGATTAG-3?? and reverse, 5??TGGTAGCCATATCCCTTTGG-3?? as previously described[]. The virulence-associated gene rmpA was also screened using PCR by using the rmpA-specific primers (forward, 5?? ACTGGGCTACCTCTGCTTCA-3?? and reverse, 5?? CTTGCATGAGCCATCTTTCA-3?? as previously described []. The reaction mixtures of these samples were kept at 95 簞C for 5 min, followed by 35 cycles of 95 簞C for 1 min, 50 簞C for 1 min, and 72 簞C for 1 min and then 72 簞C for 7 min. The K2A gene, which is consistent with the K2 serotype, was detected by PCR. PCR was also positive for the virulence-associated gene rmpA. To assess for the presence of hypermucoviscosity, a string test was performed on the organism grown in 5 % sheep blood agar. The formation of a mucous string of >5 mm in length after touching a colony with a loop was considered positive []. The isolated K. pneumoniae had a positive string test consistent with a hypermucoviscous phenotype (Fig. ).
+We present the case of invasive liver abscess syndrome with endogenous endophthalmitis caused by the K2 serotype of K. pneumoniae extending to complete ablepsia despite improvement of the pathophysiology of severe sepsis. One systematic review reported K. pneumoniae had been the most common causative organism (27 %) in endogenous bacterial endophthalmitis. Following other organisms were Staphylococcus aureus (10 %), Pseudomonas aeruginosa (6 %), Group B streptococci (6 %), and Neisseria meningitidis (5 %) []. Therefore, use of broad-spectrum antibiotics must be considered until identification of causative microorganism.
+This case of a primary liver abscess caused by the definite K2 serotyping of K. pneumoniae is the first adult case in Japan. This invasive syndrome caused by K. pneumoniae serotypes K1 or K2 has been reported mainly in Southeast Asian countries, especially in Taiwan. We found around 50 cases with liver abscess caused by K. pneumoniae serotype K2 all over the world [, ]. However, in Japan, only three cases?wo in elderly men infected with the K1 serotype and one in a 7-year-old child with the K2 serotype?ave been reported [?, when we searched PubMed and the Igaku Chuo Zasshi databases for papers published between Jun 01, 1970, and Dec 31, 2015, by using combinations of the following keywords: ?lebsiella pneumoniae,???iver abscess,???1??or ?2,??except minutes and selected articles about this invasive syndrome published by Japanese authors.
+Almost 30 cases of primary liver abscess caused by K. pneumoniae with endogenous endophthalmitis have been reported in Japan (all reports in Japanese); we conducted a search of the medical literature published using the Igaku Chuo Zasshi database and ?iver abscess,???ndophthalmitis,??and ?lebsiella pneumoniae??as search terms. In addition, we could find two more Japanese literatures related to invasive liver abscess syndrome when we searched Igaku Chuo Zasshi database by using following keywords: ?lebsiella pneumoniae,???iver abscess,??and ?mpA??[, ]. The K1 and K2 serotype were suspected in all cases because of the clinical features, but examination of the serotype has never been reported. Therefore, an invasive liver abscess caused by the K1 or K2 serotype of K. pneumoniae may not be rare in Japan.
+The virulence-associated gene rmpA was positive in our case. rmpA is not an independent factor contributing to a liver abscess, but it aids in capsule synthesis. One report showed that all K. pneumoniae strains that cause liver abscesses and abscesses at other sites are rmpA-positive. rmpA has been confirmed as a gene that regulates capsular polysaccharide synthesis []. Thus, in our case, rmpA was probably associated with liver abscess formation."
+Rylie Dickerson,22,1990/1/18,(763)464-3781,jesse81@example.org,4943 Kennedy Rapid Suite 020,"A 79-year-old woman visited a local internal medicine clinic because of intermittent right upper quadrant abdominal pain. The patient was admitted to our hospital due to suspected acute cholecystitis and had Murphy? sign on admission. The patient was being regularly treated for diabetes, hypertension, and dyslipidemia, but she did not smoke or drink alcohol. Additionally, the patient had a history of breast cancer diagnosed 22 years previously that had been treated with mastectomy. Routine laboratory evaluation showed white blood cell count at 10,100/弮l, total bilirubin at 7.9 mg/dl, aspartate aminotransferase (AST) at 113 U/l, alanine aminotransferase (ALT) at 2 U/l, and C-reactive protein (CRP) at 30.38 mg/dl. We regrettably did not check tumor markers. The patient underwent ultrasonography (US) and computed tomography (CT), with and without contrast, for screening. The US images revealed many small stones and sludge in the gallbladder (Fig. ). CT images similarly revealed a thick-walled gallbladder containing multiple stones (Fig. ). Multiple 3-cm-sized round nodular lesions with heterogeneous enhancement were also noted in the peri-cholecystic and peri-pancreatic area, which were suggestive of metastatic lymph nodes (Fig. ). Percutaneous transhepatic gallbladder drainage was then performed, as an alternative interim strategy before surgery. Abdominal symptoms subsequently improved, and endoscopic ultrasound-guided fine needle aspiration of enlarged lymph nodes resulted in a diagnosis of small cell carcinoma or adenocarcinoma. However, we could not identify the primary lesion. Therefore, our surgical procedure included radical cholecystectomy with partial liver resection together with lymph node dissection. Pathology of the resected specimen showed that the entire gallbladder was tumorous. Additionally, the tumors invaded into the liver (Fig. ). Histopathological examination of the tumors revealed neuroendocrine carcinoma, small cell type (Fig. ). The tumor stage of this patient was IVb, T3aN1M1. On immunohistochemical study, the tumor cells showed positive staining for chromogranin and negative staining for synaptophysin (Fig. ). Postoperatively, the patient developed progressive jaundice unrelieved with biliary stenting and died 13 weeks after the surgery.
+Neuroendocrine tumors (NETs) usually appear in the gastrointestinal and bronchopulmonary systems. There are no neuroectodermal cells in the gallbladder mucosa. Therefore, primary gallbladder neuroendocrine tumors are postulated to arise from either a multipotent stem cell or neroendocrine cells in intestinal or gastric metaplasia secondary to cholelithiasis and chronic cholecystitis []. In neuroendocrine neoplasms of the gallbladder, SCC is extremely rare: although 1002 cholecystectomy cases have been performed at our hospital since 1997, the case described was our first of gallbladder SCC. In recent years, gallbladder SCC has attracted increasing attention for improved understanding and diagnosis. As shown in Table (compiled from our literature survey), the average age of diagnosis is 64 years, with a male-to-female ratio of 1:1.9. In most cases of gallbladder SCCs, patients typically present with recurrent right upper quadrant pain. Less frequent presentations include abdominal mass, weight loss, and ascites []. Gallbladder SCCs are commonly associated with stones, with cholelithiasis found in 49 % of cases (Table ). A preoperative diagnosis of gallbladder SCC is very difficult because the presentation generally consists of nonspecific symptoms. And, despite the development of imaging studies, it is also still difficult to diagnose gallbladder SCC by ultrasonography, CT, or magnetic resonance imaging. Therefore, the diagnosis is often made incidentally at the time of cholecystectomy performed for cholecystolithiasis or polyps. Recent studies indicate that the role of 18F-FDG positron emission tomography (PET)/CT might prove to be useful in diagnostic imaging for the detection of gallbladder SCC []. However, we regrettably do not have a PET-CT scanner in our hospital.
+Gallbladder SCC usually presents as a large mass containing extensive necrosis with marked propensity for invasive submucosal growth []. Histopathologically, about 80 % of cases are pure SCC and the remaining 20 % are combined SCC (Table ). Microscopically, the WHO classification defines small cell carcinomas as neuroendocrine tumors with >20 mitoses/2 mm2 (mean 75/10 hpf) and small cell cytological features []. Immunohistochemically, the tumor cells expressed neuroendocrine markers, such as chromogranin A, synaptophysin, and/or CD56. In comparison to NETs which usually are diffusely positive for neuroendocrine markers, SCCs show more focal staining []. Surgical treatment remains the best curative option and appears to prolong life, with chemotherapy adding a marginal advantage. The operative procedures that we deem appropriate range from cholecystectomy alone to extensive surgical resections, including regional lymph node clearances and hepatic lobectomy. However, therapeutic options are limited because the disease presents in an advanced stage. In fact, stage IV is found in 67 % of cases (Table ). In cases of nonresectable tumors, the primary management is chemotherapy, and the chemotherapeutic agents of choice are cisplatin, etoposide, and 5-fluorouracil. Actually, there are few papers that showed specific chemotherapy regimens [, ]. Surgical treatment and chemotherapy are found in 74 and 59 % of cases, respectively (Table ). The role of radiotherapy remains undefined due to paucity of data []. As shown in Table , distant metastasis at presentation is present and is most often located in adjacent lymph nodes (70 %) and the liver (56 %). Median survival for gallbladder SCC is only 8 months. Based on SEER data, gallbladder SCC has no survivors at 10 years, in contrast to the 10-year survival of 36 % for carcinoid tumors []."
+Flynn Lowe,42,1983/8/22,254.922.1462,hernandezsandra@example.org,600 Clark Mews,"A 13-year-old female patient, who was previously diagnosed with Melnick-Needles Syndrome (OMIN 309350) at eight years of age, sought dental follow-up at the Specialized Pediatric Dentistry Clinic of the Brazilian Association of Dentistry in the state of Alagoas, Brazil, accompanied by her mother.
+The diagnosis was based on pathognomonic and radiographic findings: small face with a prominent brow, exophthalmia, micrognathia, cranial hyperostosis, poor alignment of the teeth, short upper limbs, bowed long bones (especially the humerus and tibias), metaphyseal thickening, genu valgum, shortened distal phalanges, narrow pelvis and shoulders, tapered ribs with irregularities, elongation of the vertebrae, and kyphoscoliosis (Figures , , and ).
+The extraoral photographs of the face revealed the prominent brow, exophthalmia, and micrognathia (Figures and ).
+Intraoral examination revealed considerably poor tooth alignment, with upper dental crowding and anterior deep bite (Figures , , and ).
+The panoramic radiograph revealed hypoplastic coronoid processes of the mandible, left stylohyoid ligament suggesting ossification, and diverse dental development anomalies, such as maxillary anterior crowding, agenesis of tooth 15, retention of teeth 65 and 85, impacted teeth 33, 37, 43, and 46, and semi-impacted tooth 36 ().
+A teleradiography was requested due to cephalometric analysis, in which we observed that there was no proportionality between the effective lengths of the maxilla and mandible, according to the length of the mandible condyle from the point Co to the point Gn. According to McNamara, for a given size jaw there is a directly proportional mandible size ().
+The patient was submitted to prophylaxis, advice regarding oral hygiene and topical application of fluoride. As immediate treatment, the primary teeth retained in the arch were extracted due to the fact that these teeth were impeding the normal eruption of the permanent successors.
+The patient will continue in medical and dental follow-up with orthodontic accompaniment and there is a probability that she will undergo orthognathic surgery or mandibular distraction after the growth phase. She is also being assisted by a program focused on the prevention of dental caries, periodontal disease, and occlusal problems."
+Amari Rodriguez,25,2001/10/19,235.919.0867,cookeana@example.com,56959 Larry Ranch,"A 77-year-old woman was transferred to the intensive care unit (ICU) of our hospital with altered mental status that was thought to be secondary to carbon dioxide retention caused by aspiration pneumonia. In the ICU, she progressed into hemodynamic shock. A central venous cannulation was attempted via the right internal jugular vein. Before performing the central venous cannulation, her heart rate was averaging 70??0 beats per minute. Following the cannulation, her heart rate suddenly dropped to 20 beats per minute and the cardiac tracing on the monitor showed a complete heart block (CHB). A stat electrocardiogram (EKG) was obtained which confirmed complete heart block with an escape rhythm (). Atropine was administered which failed to correct the heart rate. A chest radiograph showed the tip of the catheter in the superior vena cava. A transcutaneous pacemaker was immediately placed followed by a temporary transvenous pacemaker placement. Her previous EKG revealed a preexisting left bundle branch block (LBBB) (). 24 hours following this event, the CHB resolved and she was back in sinus rhythm with a LBBB. The transvenous pacemaker was removed. An echocardiogram showed normal left ventricular function with an ejection fraction of 55%. Since the CHB was transient and was thought to be due to mechanical inhibition of the right conduction system caused by guide wire insertion, further electrophysiologic studies were not felt warranted. Following this, she had a complicated medical course but she eventually recovered and was discharged in a stable condition without a pacemaker."
+Henry Sweeney,37,1987/6/27,342-509-3750,cynthiawilliamson@example.org,3684 Jon Keys Apt. 635,"A 50-year-old female with a past medical history of SLE diagnosed 20 years ago, ESRD on hemodialysis and atrial fibrillation on anticoagulation, presented to the emergency department after a syncopal episode. The patient was sitting on the side of her bed when she suddenly lost consciousness falling to the floor striking the right side of her face. She sustained significant facial trauma; however there were no signs of intracranial hemorrhage on CT scan of the brain. She described palpitations with chest pressure prior to the event. Initial electrocardiogram (ECG) reported by emergency medical services did not reveal any acute arrhythmias, such as TdP. Due to the complaints of chest pressure she was evaluated for cardiac ischemia utilizing cardiac biomarkers, CKMB and Troponin I. A total of three sets were completed every eight hours apart; all studies were reported within normal limits ruling out cardiac ischemia. Troponin I values were less than 0.045 ng/mL and CKMB values were all less than 0.5 ng/mL. ECG on presentation revealed 1st-degree AV block with corrected QT (QTc) interval of 689 ms (). Patient's ECG from two years prior showed a baseline prolonged QTc interval of 500 (). She was evaluated for reversible causes of QT interval prolongation including electrolyte derangements, medications, and SLE flare. Her electrolytes were within normal limits including potassium (3.9 mmol/L), magnesium (2.3 mg/dL), phosphorous (4.2 mg/dL), and calcium (9.0 mg/dL). C3 levels were low, with normal C4 and ESR, and anti-dsDNA was negative making SLE flare unlikely. Patient continued to have dialysis on her normally scheduled days.
+After evaluation by electrophysiology there was concern for presumed TdP due to her clinical presentation and grossly abnormal QTc interval. She was placed on mexiletine 150 mg BID and was initially recommended to have defibrillator implantation to protect against sudden cardiac death from cardiac arrhythmias. Evaluation of the patient's medications revealed that she was taking HCQ for the past two years for treatment of refractory SLE. HCQ was discontinued and the patient's QT interval slowly decreased to a QTc interval of 500 over the next 7 days (). She was monitored on the telemetry unit for one week and did not have any further arrhythmic events. After further discussion with the patient's Cardiologist and Rheumatologist she had been noted to have a prolonged QTc interval of approximately 500 ms while on therapy with HCQ. She was trialed off the medication for two months without resolution of the QT interval abnormality, possibly due to undiagnosed underlying SLE cardiomyopathy. The patient's ejection fraction on echocardiography one year prior was estimated at 65% with Doppler parameters consistent with abnormal relaxation suggesting heart failure with preserved ejection fraction. Implantable defibrillator placement was discussed with the patient prior to admission due to the prolonged baseline QTc interval. However, she was reluctant to proceed as she did not want indwelling devices due to concern for possible Permacath placement in the future for dialysis if her arteriovenous fistula malfunctioned.
+The risks and benefits of continuing HCQ were discussed with the patient, and she decided she wanted to continue the medication due to well controlled SLE flares. She had noted adverse reactions to steroid therapy and limited treatment options for SLE due to her underlying renal failure. We discussed the risks of recurrent syncopal episodes if she was to continue HCQ therapy, and the high risk for intracranial bleed while on anticoagulation if she was to have another syncopal episode. Final recommendations were made to proceed with defibrillator placement if she was to continue with HCQ to protect against life threatening arrhythmias. She had a subcutaneous defibrillator placement and was to be restarted on HCQ as an outpatient with dose reduction and close monitoring of QTc interval.
+At three-month follow-up the patient remained off HCQ as after discussion with her Rheumatologist the risks related to syncope and possible intracranial bleed while on anticoagulation treatment greatly outweighed the benefits of HCQ therapy. She continues to be closely monitored for SLE flares, and treatment decisions are to be strategized as clinical issues arise. Subcutaneous implantable defibrillator interrogation showed no recorded events at three months. Her ECG continues to show a prolonged QTc interval of 508 ms. Due to the prolonged QTc interval she is still at high risk of ventricular arrhythmias despite discontinuation of HCQ. Therefore, the subcutaneous implantable defibrillator is providing secondary prevention of sudden cardiac death due to prolonged QT interval."
+Yara Bernal,18,1994/1/26,393-900-0729x19710,ashlee17@example.org,7147 Adams Glen Suite 277,"A 12-year-old child, male, was admitted to the Department of Neurology in Beijing Chaoyang Hospital. Three weeks before his admission, he received the vaccination of hepatitis B. He was with symptoms of myasthenia of limbs and alteration of consciousness. He also had high fever, with the body temperature maintained between 38簞C and 38.5簞C. He was with no symptoms of headache, dizziness, nausea, vomit, sphincter dysfunction, and optic neuritis. Four years ago, he had suffered from essential thrombopenia, which relapsed two years ago. He had no history of toxic substance, allergy, operation, trauma, blood transfusion, and inheritance history. He was a full-term baby, with normal vaginal delivery. His mother had suffered from a disease of allergic purpura.
+Physical examination on his admission showed that he was with somnolence and uncooperative. His pupils were equal in size and round. The optic nerve was normal. Bilateral light reflexes retained. Muscle strength of limbs grading (II level) was found with hypomyotonia. Sensory tests were uncooperative. Abdominal reflex and cremasteric reflex were negative. The signs of bilateral Babinski and Gordon were positive. Ankle clonus was also detected. Neck resistance was also found.
+On admission, the results of blood test were as follows. WBC level (15.8 ? 109/L) and the proportion of neutrophils (85.2%) were markedly increased. Procalcitonin was 0.05 ng/mL, which indicated no bacterial infection. C-reactive protein was increased, which was 1.14 mg/dL (0??.8 mg/dL). ESR was 50 mm/H (2??5 mm/H). IgG was 1750 mg/mL (751??560 mg/mL). IgA, IgM, C3, and C4 were normal. Sputum cultures of bacteria, fungus, virus, and tuberculosis were negative. Total protein and albumin in blood were decreased. Globulin and total bilirubin were normal. The cerebrospinal fluid (CSF) examinations showed increased pleocytosis (52/弮L) and leucocyte count (40/弮L). The CSF was composed of 90% mononuclear cells and 10% polynuclear cells. Pandy test was negative. Total protein was normal. Glucose (4.77 mmol/L) was slightly increased (2.5??.4 mmol/L). Chloride (115.1 mmol/L) was slightly decreased (118??29 mmol/L). Oligoclonal band was found. The aquaporin 4 antibody was negative. Bacteria, mycobacterium tuberculosis, virus (e.g., herpes simplex encephalitis virus, cytomegalovirus, and Epstein-Barr virus), and fungal cultures from CSF and blood serology, with PCR also performed, were negative.
+Three days after his admission, MRI of brain and spinal cord also revealed some abnormal findings. His brain MRI showed widespread abnormal signals on FLAIR image (). Spinal cord MRI showed that there were abnormal multifocal, strip long T1 and T2 signals at the cervical and intumescentia lumbalis (). Furthermore, evoked potential such as brainstem auditory evoked potentials and somatosensory evoked potential also showed some abnormal changes in this case. The visual evoked potential was normal.
+With treatment with high-dose methylprednisolone and intravenous immunoglobulin and also with some antibiotic and antiviral therapy, he showed a dramatic improvement of the clinical and CSF results. About four months later, he recovered completely and there was no relapse during three years of follow-up."
+Eithan Felix,19,1992/2/10,+1-503-859-4646x7199,ronaldsantiago@example.net,47759 Ryan Street,"A 61-year-old right hand dominant housewife sustained an injury to her right upper limb following a low energy mechanical fall.
+The patient attended the Emergency Department (ED) due to significant right arm pain, swelling, and deformity. No neurovascular deficit was documented on initial clinical assessment. X-rays confirmed a short spiral fracture of the humeral diaphysis with slight angulation ().
+A Bohler-U cast was applied and repeat X-ray demonstrated excellent alignment on both anteroposterior and lateral views (Figures and ). On return from the X-ray department the patient reported new onset of paraesthesia in the right hand and difficulty moving her fingers. On detailed questioning, the patient admitted to very slight alteration of sensation at the thumb base and posterior aspect of the forearm prior to application of the Bohler-U cast. Examination confirmed MRC grade 0/5 power in wrist and finger extensors and reduced sensation at the base of thumb and posterior aspect of the forearm in keeping with a dense radial nerve palsy. Peripheral pulses were easily palpable and capillary refill was normal.
+Due to the onset of new neurologic deficit following fracture reduction and cast application, the clinical concern was of iatrogenic nerve injury. Urgent surgical exploration was performed via an anterolateral approach. Intraoperatively, the radial nerve was found to be interposed in the fracture ().
+The nerve was in continuity, though there was evidence of significant contusion. Following careful extraction of the radial nerve, the fracture was reduced and stabilised using a 10-hole AO (Arbeitsgemeinschaft f羹r Osteosynthesefragen) large fragment dynamic compression plate and interfragmentary compression screw ().
+Postoperatively, there was no immediate improvement in radial nerve function. A custom-made thermoplastic wrist extension splint was initially fitted. Examination at one week from date of surgery demonstrated some early return of sensation in the distribution of the superficial branch of the radial nerve though the dense motor deficit remained unchanged. An early rehabilitation programme consisting of passive range of movement exercises and dynamic splinting was commenced under the supervision of departmental hand therapists. Full active shoulder and elbow range of movement exercises commenced 4 weeks from date of surgery. Examination at 3 months demonstrated MRC grade 3/5 finger extension and wrist extension. At 3 months from date of surgery, the fracture also appeared radiologically united. Complete recovery of radial nerve function was evident at 8 months (MRC grade 5/5). highlights our patient's recovery process as described above."
+Paisleigh Pope,22,1991/4/3,001-539-738-0825,dallen@example.com,925 King Underpass,"An 80-year-old man developed sudden severe back pain with no history of trauma, and then he tried to walk. However, due to weakness and numbness in his legs, he could not walk and collapsed to the ground. He presented to an outside hospital with paraplegia, and then he was transferred to a tertiary center for further management. On admission, neurological examination of his motor power was reduced (0/5) in both lower extremities (paraplegia), tendon reflexes in both lower limbs had increased, Babinski responses were positive, there was anesthesia/hypoesthesia for light touch, and there was hypoesthesia below the thoracal (T5-T6) dermatome. His knee- and ankle-jerk reflexes were absent bilaterally. There were urine and stool incontinence. The complete blood count (hemoglobin, hematocrit, and platelet count), biochemistry profile (kidney function, liver function, proteins, and glucose), prothrombin time, and INR were normal, and he did not have additional comorbidities (hypertension, diabetes mellitus, etc.). In addition, he did not use an anticoagulant therapy. At the time of admission to emergency, only subcutaneous low molecular weight heparin (0.3 mL) was conducted. A high-dose steroid treatment was given on the day of his admission (bolus 30 mg/kg administered over 15 minutes with maintenance infusion of 5.4 mg/kg per hour infused for 23 hours).
+The Computed Tomography (CT) scan was not diagnostically helpful. Magnetic resonance imaging (MRI) revealed an intramedullary mass with signal intensity surrounded by a zone of high and low signals on both T2 weighted images (Figures , , and ). Unfortunately, because of the lack of time, we did not have contrast-enhanced MRI or spinal angiography, so we could not eliminate the vascular pathologies. Because of mass effect, there was obstruction of cerebrospinal fluid and syrinx. After written informed consent was obtained from the patient and his family, an operation was performed.
+The patient underwent the operation on the day of admission. After thoracic vertebra 5 and 6 laminectomy, microscopic dural opening was revealed, a small paramedian myelotomy was performed at the level, and blunt dissection and aspiration of the hematoma were done. A hematoma was completely removed (). There were no vascular abnormalities and tumors. The pathology report confirmed the diagnosis of intramedullary hemorrhage. After the operation, there was no recovery of sensory or motor functions, and he began receiving rehabilitation treatment."
+Gunnar Spencer,34,2000/3/13,908-527-2014x294,jessica68@example.net,1763 Elizabeth Fork,"A 43-year-old male construction worker presented with left medial ankle pain. He fell and twisted the left ankle at the age of 25 years. Fibular fracture was diagnosed using simple X-rays and then he was admitted to the emergency department for open reduction and internal fixation using a fibular plate at a hospital near the accident location. Five years later, left ankle pain developed and the range of ankle motion became limited, so he underwent resection of bone hyperplasia. Thereafter, the left ankle became intermittently painful, which persisted for about one year.
+The initial examination at our hospital (18 years after the ankle fracture and 43 years old at this time) revealed tenderness along the posterior tibial tendon and a left ankle range of motion from 10簞 of dorsiflexion to 60簞 of plantarflexion. He was overweight at that time (his body mass index was 35.6 kg/m2). The left foot was relatively flat, but too much toe sign was not visible and he could perform left single-leg heel raises. X-rays revealed bone hyperplasia between the distal tibia and fibula (). Three-dimensional computed tomography (3D-CT) revealed tibial bone hyperplasia along the posterior tibial tendon (). The posterior tibial tendon had spotted isointensity in regions of low intensity on T1-weighted magnetic resonance (MR) images and spotted high intensity in low-intensity T2-weighted images (). Injecting lidocaine into the posterior tibial tendon sheath relieved the pain. Thus, we diagnosed posttraumatic posterior tibial tendinitis.
+We planned a tendoscopic procedure instead of an open procedure because an open procedure needs opening the tendon sheath and postoperative immobilization such as a cast or brace. The patient underwent left posterior tibial tendoscopy using a 2.5 mm 30簞 arthroscope under spinal anesthesia. We used the two main portals described by van Dijk in 1997 []. The distal portal was 2 cm below and anterior to the medial malleolus, whereas the proximal portal was 2 cm posterior and superior to the medial malleolus. An ultrasound machine (Noblus; Hitachi Aloka, Tokyo, Japan) and a high-frequency linear probe (L64 linear probe 18?? MHz; Hitachi Aloka) are prepared with a sterile ultrasound probe cover and sterile gel. We used an ultrasonography in order to introduce a scope easily, reliably, and safely. Irrigation solution was injected into the posterior tendon sheath under long-axis view along the posterior tibial tendon of sonography just before incising the skin (). We opened the tendon sheath via the skin incision by blunt dissection using a hemostat under sonography. Tendoscopic findings revealed tenosynovitis and fibrillation on the surface of the tendon. We cleaned and removed the synovium surrounding the tendon using an arthroscopic shaver system and a radiofrequency wand for small joints (). Moreover, we deepened the groove for the posterior tibial tendon using a bone cutter/shaver so as the posterior tibial tendon can move smoothly. After groove deepening, there was one- or two-millimeter space around the tendon. Weight-bearing ambulation was permitted one day after surgery and the patient returned to full-time work in the construction industry six weeks after surgery. At the most recent review two years after surgery, he had no medial symptoms and he was capable of all types of heavy work despite occasional slight pain related to sinus tarsi syndrome. His preoperative and postoperative scores on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale were 71 and 90 points, respectively.
+Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research. The patient and his family were informed that data from the case would be submitted for publication and gave their consent."
+Alyssa Park,43,1995/8/21,7172847976,kevin93@example.net,7980 Spence Inlet Suite 033,"A 48-year-old man presented with symmetrical arthritis of the wrists, metacarpophalangeal and proximal interphalangeal joints, elbows, and knees. He had had intermittent inflammatory back pain since the age of 40 years. His brother suffered from psoriasis. The physical examination revealed alopecia areata, which he said he had had for a long time, but he had never had psoriasis or other skin manifestations. Radiography showed bilateral sacroiliitis but no erosions of hands or feet. His serology was notable for a high-titer positive anti-SSA antibody of ??40 kU/L (ref. <7), a low-titer positive anti-dsDNA antibody of 14 kIU/L (<10), and a positive IgM-rheumatoid factor of 19 kIU/L (<10). Anti-CCP and HLA-B27 were negative, and proteinuria was not present. However, he had no symptoms of systemic lupus erythematosus or Sj繹gren syndrome. A diagnosis of spondyloarthritis was made, and his symptoms improved on NSAID and prednisolone. However, he developed diabetes mellitus, and sulfasalazine was prescribed.
+A week after starting sulfasalazine, he presented with erythema of the trunk and neck. A cutaneous drug reaction was suspected, sulfasalazine was immediately stopped, and methotrexate was prescribed instead. Three weeks after stopping sulfasalazine, he was admitted because of fever, cough, dyspnea, loss of appetite, night sweats, and weight loss. The erythema had spread to the extremities with a dark red, confluent maculopapular exanthema, and bullae and denudation of the epidermis in large patches of the back were now observed (). MRI of the sacroiliac joints and lumbar spine was consistent with bilateral sacroiliitis but showed no active inflammatory changes. His serology was negative for hepatitis B, hepatitis C, and HIV and not indicative of current infection with EBV, CMV, or parvovirus. Anti-dsDNA antibody had increased to 43 kIU/L, and he had proteinuria 0.7 g/day.
+He was managed with intravenous antibiotics and continued on prednisolone 7,5 mg qd, and his skin gradually improved. After 3 weeks, high fever recurred, erythroderma with small pustules on the trunk and extremities was observed, and he developed TEN-like lesions of 10% of body surface area (), mostly the back and nates. He was transferred to an intensive care unit due to Staphylococcus aureus sepsis and stabilized with intravenous immunoglobulin (IvIg), intravenous antibiotics, methylprednisolone 100 mg qd, and Flamazine cream.
+After recovering from the sepsis, PET-CT revealed multiple pathologically enlarged lymphatic glands with increased FDG uptake in the neck and axillary and inguinal regions, near porta hepatis, and in the retroperitoneum. A lymph node biopsy showed large areas of histiocytosis but was not diagnostic for dermatopathic lymphadenopathy or hemophagocytosis. Skin biopsy was consistent with TEN-like lesions, showing full thickness necrosis of the epidermis and pigment incontinence (). His mucous membranes were not involved. Bone marrow biopsy showed an increased number of myelopoietic precursor cells, sparse erythropoiesis, and slight interstitial infiltration of B and T lymphocytes but no malignancy. Renal biopsy showed focal mesangial hypercellularity and 1 of 15 glomeruli with sclerosis, a faint linear reaction for IgG, and a slight unspecific reaction in IgM and IgA but no complement deposition, and this was not found to be indicative of glomerulonephritis."
+Daxton Tate,28,1987/5/13,(997)251-5095,drussell@example.com,7008 Karen Via Suite 058,"Our patient is a 70-year-old Japanese man with diabetes. He was admitted to our hospital 4.5 years ago for further investigation and treatment of recent-onset insulin allergy. He had a 30-year history of type 2 diabetes mellitus and an approximately 6-year history of insulin injection administration, with an average glycated hemoglobin (HbA1c) level of 7.0 %. He reported a past history of myocardial infarction, hypertension, and dyslipidemia and had undergone coronary artery bypass grafting at 68 years. During that surgery, intravenous protamine sulfate was administrated, which induced anaphylaxis.
+At that time, 4.5 years prior to the current presentation, he was receiving 100 mg/day aspirin, 100 mg/day clopidogrel, 100 mg/day imidapril, 20 mg/day isosorbide mononitrate, 5 mg/day nicorandil, and 10 mg/day pravastatin, and these had been stable for more than 3 years. In addition, he was being treated with 20 U/day insulin lispro and 8 U/day insulin glargine, which had also been unchanged for approximately 3 years. Finally, he had been receiving 0.9 mg/day voglibose to supplement his insulin therapy for approximately 5 years.
+Approximately 5 months before his current presentation, he reported that he had started to develop wheals with redness and itching at the injection site, which occurred immediately after injecting insulin. Of note, these symptoms only occurred following the use of insulin lispro and not after insulin glargine. Over the subsequent months, part of the surface of the wheals had hardened and further investigation was performed. Two months before his current admission, blood samples were taken that revealed high serum levels of human insulin-specific immunoglobulin E (IgE; 4.21 U/mL; normal range <0.35 U/mL), hypereosinophilia (total white blood cell count, 6000/弮L; total eosinophil granulocyte count, 780; percentage, 13 %), and a high level of total IgE (403 IU/mL; normal range <173 IU/mL). A pathology sample was taken 2 months before his admission, which revealed eosinophilic infiltration in the hardened part of the injection site (Fig. ). Therefore, just before admission, he was diagnosed with insulin allergy and was switched from insulin lispro plus glargine to insulin aspart plus glargine.
+He was admitted to our hospital for treatment of his poor glycemic control and to evaluate his residual ability of insulin secretion. On admission, his physical examination was largely unremarkable (height, 157.1 cm; body weight, 53.0 kg; body mass index, 21.5 kg/m2; body temperature, 36.5 簞C; blood pressure, 104/62 mmHg; and pulse, 75 beats/minute, regular), although there was induration with slight redness of his abdomen. His laboratory data at that time are shown in Table . Of note, his fasting plasma glucose level was 346 mg/dL, and his HbA1c level was 12.3 %. In addition, we detected high serum insulin, anti-insulin IgG antibody, and anti-insulin receptor antibody levels. Although there were no further symptoms of local allergy (wheals, redness, and itching) after injecting with insulin aspart, his postprandial hyperglycemia continued at approximately 350 mg/dL. Therefore, he was switched to insulin glulisine (24 U/day) plus glargine (22 U/day) after admission. On day 17 of admission, his 24-hour blood glucose profile was 88, 241, 241, 295, 297, and 292 mg/dL at 7:30 a.m., 10:00 a.m., 11:30 a.m., 2:00 p.m., 5:30 p.m., and 8:00 p.m., respectively, with an energy intake of 1600 kcal. On days 18 and 19, his urinary excretion of C-peptide was 42.8 to 51.5 弮g/day (normal range 40 to 100 弮g/day). On day 19, a glucagon stimulation test was performed, and his serum C-peptide response ranged from 3.2 to 3.6 ng/mL (Table ). On day 22, although his high glucose levels persisted, he was discharged because we had confirmed his ability to secrete insulin. Although his hypereosinophilia was not resolved before his discharge, he had no further allergic symptoms (wheals, redness, and itchiness) at the injection site for glulisine, and the area of induration had almost disappeared.
+Figure summarizes his clinical course before and after the introduction of liraglutide. After discharge, although glulisine and glargine were continued, his glycemic control worsened, with fasting and postprandial hyperglycemia levels of approximately 200 and 300 mg/dL, respectively, and high serum insulin levels persisted (Fig. ). Therefore, 2 months after his admission, we added 0.3 mg liraglutide, discontinued the insulin glulisine, and added 2 mg/day glimepiride and 500 mg/day metformin to decrease his total insulin requirements. However, he also started to develop intermittent induration at the site of insulin glargine injection, and although there was no evidence of wheals or redness, his hypereosinophilia persisted. Based on these findings, we reduced the dose of glargine (32??2??6??0 U/day) and increased the dose of liraglutide (0.3??.6??.9 mg/day; Fig. ). This was followed by improvements in his HbA1c, serum insulin, and eosinophil levels; therefore, we decided to completely discontinue the insulin glargine after 3 months of the liraglutide treatment. On his new regimen of 0.9 mg/day liraglutide in combination with oral antidiabetic agents, his HbA1c level was maintained at approximately 7.0 %. The induration had almost completely disappeared 1 month after the insulin injections were discontinued. In addition, his body weight decreased by 1.7 kg after 2 months of liraglutide treatment. Table indicates his diabetes-related medical history.
+We also elucidated the changes in the characteristics of anti-insulin IgG antibodies before and after treatment with liraglutide. Scatchard analysis of the anti-insulin IgG antibodies in our case indicated that there was a high binding capacity and a low affinity constant for the high affinity sites before liraglutide therapy (Fig. ). After 1 year of treatment with liraglutide, the Scatchard plot indicated that the binding capacity decreased and the affinity constant for high affinity sites increased (Fig. ). Of interest, the anti-insulin receptor antibodies had completely disappeared within 1 year after the injection of liraglutide."
+Skye Goodman,28,1979/4/11,791.620.1237,keithbecky@example.org,679 William Springs,"The patient was a 65-year-old Japanese man. The cutaneous and inguinal specimens after fixation in 10 % neutral buffered formalin were embedded in paraffin for histological or immunohistochemical examinations. Furthermore, we prepared more than 10 step-serial H&E staining sections of the entire primary site (right sole), and absolutely confirmed the absence of residual foci of MM cells [, , ]. All immunohistochemical stainings were carried out using Dako Envision kit (Dako Cytomation Co., Glostrup, Denmark) according to the manufacturer? instructions. [?. We counted the numbers of CD4 (Dako, diluted 1:1)?nd CD8 (Nichirei Biosciences Inc., Tokyo, Japan, diluted 1:1)?ositive infiltrating T-lymphocytes in the cutaneous pigmented lesion (right sole) in 10 randomly selected fields of per section (original magnification: ?400) [?.
+All histological and immunohistochemical slides were evaluated by two independent observers (certified surgical pathologists in our department) [?. Agreement between observers was excellent (>0.9) for all antibodies investigated as measured by interclass correlation coefficient. For the few instances of disagreements, a consensus score was determined by the third board-certified pathologists in our department [?. All values are expressed as the mean 簣 SE. Significant differences were analyzed using Student? t test. Values of P < 0.05 were considered to be statistically significant.
+The patient had an unremarkable previous medical history, except for essential hypertension. The patient was admitted to hospital due to an approximately 2-months history of inguinal growing mass and pain. There had been no history of malignancy, immunosuppressive disorders, use of immunosuppressive medications, or unusual infections, including acquired immunodeficiency syndrome (AIDS).
+He had noticed a gradually growing, hemorrhagic and verrucous hypopigmented macule since approximately 2 years before, and it turned to be a solitary bluish to black patch with surrounding depigmentation, accompanied by recent decrease in size, measuring up to 20 mm in the right sole (Fig. a). There were no other primary cutaneous lesions identifiable by his history or careful physical examination that could represent the original MM. In parallel, he suffered from a rapidly growing and painful black-pigmented mass lesion with surface skin ulcer at the right inguen especially for recent 2 months (Fig. b), partly extending to the right scrotum and thigh (Fig. b). A pelvic CT scan showed a relatively well-defined huge and low-density mass with peripheral enhancement, measuring approximately 12 ? 10 cm (Fig. c). CT scans of the head, neck, chest and abdomen disclosed no definite evidence of neoplastic foci or other metastases in the lymph nodes or other organs. Laboratory data, including blood cell count, chemistry and tumor markers, were within normal limits. Within the post-operative 2 years with additional treatment of chemotherapy, including dacarbazine, nimustine, cisplatin, tamoxifen, (DAC-tam) and interferon-帣, recurrence of small (less than 5 mm) MMs in situ was noted in the right foot, waist and back at 1 month after the operation. But, surprisingly, the patient had neither local invasion nor metastases of the other sites, respectively, and he was alive and well.
+The surgical cutaneous specimen from the right sole (Fig. a) showed a hyperpigmented lesion made up of an aggregation of melanophages with surrounding variably sclerotic fibrosis mainly in the middle to deep layer of dermis. On high-power view, these aggregated round to oval cells had bland-looking small nuclei and abundant melanin-pigmented cytoplasm (Fig. b). In addition, reactive vascular networks were occasionally seen in these fibrous stroma, associated with mild interstitial and perivascular lymphocytic infiltrate (Fig. c). The covering non-disordered epidermis exhibited attenuated and atrophic change with absence of rete ridge, carrying no in situ MM cells within our thorough examination (Fig. a, c). Interestingly, the peripheral epidermis sometimes showed exocytosis of focal nested lymphocytes (Fig. c). Nevertheless, there was no MM cells infiltration from the epidermis to dermis, subcutis in all of the prepared step-serial H&E staining sections. Based on these features, we first diagnosed it as a benign cutaneous lesion, such as blue nevus. Immunohistochemically, these melanophages were strongly positive for CD68 (KP-1; Dako, diluted 1:100) (Fig. b), whereas completely negative for S-100 protein (Dako, diluted 1:900), HMB45 (Enzo Life Sciences Ltd., New York, diluted 1:100), and Melan A (NOVOCASTRA, 1:50) (data not shown). Furthermore, we counted the numbers of CD4- and CD8-positive infiltrating T-lymphocytes in this cutaneous lesion (Fig. d). Intriguingly, CD8-positive T-lymphocytes were markedly larger than CD4-positive lymphocytes in number (CD4: 1.8 簣 0.5 per 1 high power field vs. CD8: 54.6 簣 5.2 per 1 high power field; P < 0.0001) (Fig. d).
+Next, gross examination of the surgical specimen from the inguinal to scrotal and femoral mass showed that the huge, relatively well-demarcated and multi-nodular tumor, measuring approximately 13 ? 11 ? 7 cm, had gray-whitish to yellow-whitish cut surfaces with hemorrhagic and yellowish necrotic foci (Fig. a). Microscopically, the inguinal tumor consisted of a diffuse proliferation of markedly atypical large cells (Fig. b) having hyperchromatic, pleomorphic mono- to multi-nuclei, and abundant eosinophilic to sometimes clear cytoplasm, appearing predominantly as single cells, admixed with a large number of likely pre-existing lymphocytes (Fig. c). These proliferating tumor cells involved and erased the remarkably enlarged lymph node tissue, partly surrounded by fibrous capsule (Fig. b). On high-power view, the large tumor cells occasionally had melanin pigments in the cytoplasm and often showed autophagy (Fig. c). In immunohistochemistry, these malignant cells were specifically positive for melanocytic markers, such as HMB45 (Fig. d) and Melan A (Fig. d), and S-100 protein (data not shown), whereas negative for CD68 (data not shown).
+Based on all the clinicopathological features, we confirmed that these proliferating atypical cells were derived from MM, and finally made a diagnosis of complete regression of primary cutaneous MM on the right sole, associated with distant inguinal lymph node metastasis of MM."
+Philip Pope,25,1987/5/11,529.515.1841x34364,ian51@example.org,371 Lopez Passage,"A 20-year-old woman with diagnosis of ASs was referred to our department for reduced vision in her left eye (LE) of 2 weeks onset; she was negative for pseudoxanthoma elasticum or any other systemic disease. The patient signed a comprehensive consent form according to Good Clinical Practice guidelines, before proceeding with all examinations and treatments. Her best-corrected visual acuity (BCVA) was 20/20 in the right eye (RE) and 20/100 in the LE, with no signs of inflammation in the anterior chamber and vitreous of either eye. Fundus biomicroscopy revealed ASs in both eyes (BE). RE had no evidence of inflammation at the fundus observation (Fig. ). Interestingly, only the LE had multiple discrete grey-white lesions (dots) scattered over the fundus, from the paramacular area up to the mid-periphery, and the macula had a granular appearance (Fig. ). Fluorescein angiography (FA) (HRA, Heidelberg Engineering, Heidelberg, Germany) indicated mild optic disk leakage with some hyperfluorescent changes scattered throughout the fundus (paramacular area and mid-periphery). No CNV was detected (Fig. ). Indocyanine green angiography (ICGA) (HRA, Heidelberg Engineering, Heidelberg, Germany) disclosed late hypofluorescent lesions scattered at the posterior pole and in the mid-periphery (Fig. ); we interpreted these as signs of zonal outer retinal inflammation. Spectral-domain optical coherence tomography (SD-OCT) macular scans showed disruption in the photoreceptor layer (Fig. ). Automated static threshold perimetry indicated visual field defects mainly located paracentrally and temporally (Fig. ).
+On the basis of all these findings a diagnosis of ASs and coincident MEWDS was made. The patient was prescribed oral prednisone (1 mg/kg) for 7 days then half the dosage for another 7 days.
+Two weeks later, LE BCVA improved up to 20/25, with resolution of the MEWDS findings, except for the granular appearance at the macula; RE BCVA was 20/20 with no signs of inflammation at the fundus evaluation.
+Two months later, the patient returned because of sudden vision loss in her LE (20/100). FA indicated CNV in the paramacular area in LE. FA and ICGA showed no signs of choriocapillaris inflammation in BE (Fig. ). We proposed to the patient an intravitreal injection of ranibizumab as an off-label treatment option. She signed informed consent and was given a single injection of ranibizumab (0.5 mg/0.05 mL) following the normal procedure. One month after the injection BCVA improved up to 20/40, the CNV showed regression (Fig. ), and there was no need for retreatment up to her latest follow-up visit 1 year after the injection, when BCVA had improved up to 20/25.
+ASs are often complicated by the appearance of CNV [, ]. To date there are no reports of AS associated with acute ocular inflammation. MEWDS is a unilateral inflammatory disease, which usually resolves spontaneously, with full recovery []. Here we describe a patient with ASs, who was diagnosed with coincident MEWDS. Two months after this diagnosis she developed CNV, which was effectively treated by intravitreal ranibizumab. In the current literature there are only six cases of CNV that developed after (from 4 weeks to 13 years) the diagnosis of MEWDS [?? ]. Only two were effectively treated by intravitreal anti-vascular endothelial growth factor (VEGF) [, ]. In all other cases the visual loss was permanent despite treatment [?.
+The case described is unusual: the CNV occurred in a patient with ASs, 2 months after the diagnosis of MEWDS. Although both ASs and MEWDS may contribute to the onset of CNV, the patient? young age, good prognosis after intravitreal ranibizumab and the presence of MEWDS involving the macular area may indicate an inflammatory etiology of the CNV.
+Though the pathophysiologic mechanism remains unclear, it has been suggested that alterations of Bruch? membrane or the outer retinal barrier caused by choroidal inflammation may be associated with ischemic and/or inflammatory CNV []. It has also been hypothesized that the inflammatory processes induce the release of chemokines that favor angiogenesis []. This patient was in fact younger than the mean age at which CNV usually develops associated with ASs [, ]. Moreover, in this case a single intravitreal ranibizumab injection had a lasting effect (up to at least 1 year), as shown by FA and OCT, and by the maintenance of good BCVA.
+Our results are in agreement with Rouvas et al. who have described the good responses to intravitreal treatment with ranibizumab for inflammatory retinal diseases []. This might be explained by the different nature of the CNV, in which inflammation may have played an important pathogenic role, compared to other CNVs secondary to ASs which tend to be associated with a worse visual prognosis, and need more injections []."
+Aurelia Rosas,19,1994/5/6,448.903.7196x996,bhull@example.net,631 Donald Dale Apt. 937,"The patient, a 16.3 year-old girl, was in excellent health, both physically and emotionally, with no known adverse drug reactions or allergies and good oral hygiene. The major concern of both the patient and the referring general dentist was the persistence of several deciduous teeth. Possible systemic, endocrine, metabolic or genetic-syndromal disorders as possible etiologic factors could not be detected by a physician and endocrinologist, to which the patient was referred prior to orthodontic examination. In addition, there was no family history of eruption failure of permanent and persistence of deciduous teeth. The first deciduous upper molar on the right side (tooth 54) was extracted 1 year earlier by the referring general dentist, but no spontaneous eruption of the permanent first premolar could be achieved within this timeframe (Table ). Thus and due to no previous referral by the general dentist or presentation of the patient for orthodontic planning, treatment was started quite late.
+The clinical examination and study model analysis (Figs. and ) in conjunction with the panoramic radiograph (Fig. ), taken by the referring general dentist, showed initially nine persisting deciduous teeth ??all deciduous canines and molars of the upper jaw and those on the right side of the mandible, minus the already extracted upper right deciduous molar. All upper permanent canines and premolars were impacted and malpositioned. The lower right canine, which was severely rotated, was also impacted to a higher and the lower right first and second premolars to a lesser degree, whereas the corresponding teeth on the lower left side were in good occlusion and showed no signs of impaction. No adequate root resorption of the deciduous teeth could be detected radiologically with exception of the lower deciduous molars on the right side. Radiographically the impacted teeth showed no evident signs of ankylosis. Some physiological spacing of the incisors was present and both the first permanent molars as well as the deciduous canines were in good occlusion and had a class I relationship with a shallow curve of Spee in both jaws. The second permanent molars were also in occlusion and all four third permanent molars present radiologically within their germ stage. No reduction of the extraction space due to a mesial or distal drifting of the neighboring teeth was evident. The patient also showed a lower alveolar midline deviation to the right side (about 2 mm), most likely due to the unilateral failure of eruption at the lower right side, which caused a more mesial eruption and inclination of the lower left permanent canine and the lower incisors, as evidenced by the gap formed between the canine and lower left premolar.
+3D CBCT diagnostic imaging was declined by the patient and her guardian due to concerns about a potential health risk by the radiation exposure. The cephalometric analysis according to Ricketts (Table , Fig. ) revealed a vertical dolichocephalic growth type, hyperdivergent jaws and a large mandibular plane angle, thus a further vertical development had to be avoided during treatment. In addition, the mandible was found to be prognathic with an ortho- to retrognathic upper jaw, resulting in a slight skeletal class III, which was dentally compensated (class I molar relation). Both approximately normally inclined upper and lower incisors were distinctly protruded, whereas Ricketts??E-line indicated a retrusion of the upper lip due to the proganthic lower jaw. Furthermore, overjet and overbite were increased.
+The radiologically evident complete root development of all permanent impacted teeth with closed apices in conjunction with the persisting deciduous teeth without distinct signs of root resorption in absence of genetic-systemic causes formed the basis for our diagnosis of idiopathic multiple bilateral impactions, confirmed by the failure of spontaneous eruption of the first upper left premolar after extraction of the corresponding deciduous predecessor.
+The main treatment objective was to align the nine impacted teeth at the occlusal level by means of controlled guided traction after their surgical exposition and ligation and after extraction of the preceding deciduous teeth. Secondary objectives were a levelling of the arches, a correction of the lower dental midline shift, establishing a physiological overjet and overbite and achieving a stable and functional occlusion. We opted for treatment with a fixed multi-bracket appliance in conjunction with the Easy-Way-Coil System??(EWC) []. To minimize treatment time, a simultaneous alignment of all impacted upper six permanent teeth was planned (4 weeks discrepancy in start of treatment between right/left side). Vertical and horizontal relations as well as dental class I were to be kept stable during treatment and the risk of root resorption at the second incisors was minimized by excluding them from the appliance. Due to the higher treatment complexity of the maxilla, treatment within the mandible was started at a later date.
+The patient and her legal guardians were informed and motivated about the necessity of good oral hygiene and compliance during the treatment as well as about the expected duration of treatment and the risks involved - particularly root resorptions and failure of eruption, which would necessitate a later implant and restorative treatment. Informed consent was obtained and ethical regulations according to the Declaration of Helsinki (1964) and its later amendments were observed at all times.
+The best choice of treatment was discussed and considered both with the patient and an oral surgeon and a combined surgical-orthodontic approach with simultaneous traction of the impacted teeth by means of an Easy-Way-Coil??was deemed to be most promising and time-efficient.
+The most simple approach to treat multiple impactions would have been to just extract the persisting deciduous teeth and wait for a spontaneous eruption. However, the advanced age of the patient, the complete root development and the already failed attempt by the general dentist made a success of this approach seem unlikely.
+An alternative method described by Schmidt and Kokich [] to extract the deciduous teeth and only expose the impacted teeth surgically without traction to facilitate spontaneous eruption, which for canines usually occurs after 6?? months [], was rejected by the patient for cosmetic reasons. This also excluded the possibility of a surgical luxation of the impacted teeth to facilitate tooth movement. In addition, the impactions were considered to be too deep for an exposure without traction to be successful. For this reason, we also opted for a closed instead of an open eruption technique in this case [, ].
+If the impacted teeth were ankylosed, an extraction and consecutively implant-restorative treatment would be indicated. This option was considered as potential alternative, if the primary therapy failed in case of confirmed or developing ankylosis or invasive cervical root resorption during treatment, whereas at baseline no ankylosis of the impacted teeth could be confirmed. In this case a mesialisation of the upper permanent molars by means of skeletal anchorage and a mesial sliding appliance [] could have been used to reduce the resulting gaps, enable an occlusal alignment of the third molars and reduce the number and extent of necessary implants and restorative treatment.
+A sequential extraction of persisting deciduous teeth [] and also sequential traction of the impacted teeth individually as described by Krey et al. [] could have reduced the risk of extensive tooth loss in case of alignment failure. This approach, however, was rejected due to the unwillingness of the patient to accept prolonged treatment times, her already advanced age for treatment and a persisting deciduous dentition. The patient rather preferred implant-restorative treatment in case of treatment failure.
+At the beginning of treatment brackets (slot 0.018?? were bonded only to the upper central incisors and bands were placed on the first molars. These were connected by a transpalatinal arch (Burstone, 0.032??? 0.032??stainless-steel) for anchorage. Second molars were stabilized by connecting them with the first molars with a passively bonded partial arch-bow (0.017??? 0.025??stainless-steel) (Fig. ).
+At the level of the second transversal palatal ridges one mini-screw of the BENEfit??system (2.0 ? 11 mm, dental line, Birkenfeld, Germany) [] was inserted into the palate to carry a screwed standard abutment with a welded 1.1 mm stainless-steel wire. This wire was shortened, bent to the upper central incisors in shape of a U and bonded to their palatal surface (Fig. ). The upper central incisors and first molars were then connected with a 0.017??? 0.025??stainless-steel arch-wire (straight-wire technique) within a passive closed coil spring (Fig. ). The lateral incisors were intentionally left out of the fixed appliance to avoid any root movement and contact with the impacted canines.
+Treatment was started at the upper right quadrant. After extraction of the persisting deciduous teeth a mucoperiosteal flap was raised and the impacted permanent teeth were surgically exposed up to the assumed cemento-enamel junction. Three EWC??appliances were bonded to the individual teeth at the palatal surface (canine) and at the buccal surfaces (premolars) and directed towards the arch-bow used for anchorage (Fig. ). The mucoperiosteal flap was then repositioned and fixated with surgical sutures (closed eruption technique).
+After 1 week the sutures were removed and the EWC??springs activated. The direction of traction was chosen to be disto-buccal for the canines and buccal for the premolars. A suitable anchorage spot was chosen on the circular arch-bow and a gap introduced into the passive closed coil spring by gently closing a ligature cutter at this location. This way a displacement of the ligature wire used for connecting the EWC??spring with the arch-bow was effectively prevented. The correctly aligned EWC??springs were then shortened to create a gap of exactly 2 mm (canine) and 1 mm (premolars) between arch-bow and the spring. By gently closing the ligature cutter 1 mm proximal to the shortened end of the EWC??spring, an eyelet consisting of the terminal three coils was formed, which was connected seamlessly to the gap formed at the arch-bow coil spring by means of a ligature wire (Fig. ). The EWC??spring activation of 2 and 1 mm ensured a predictable force level of 0.32 N and 0.16 N, respectively.
+Four weeks later the same procedure was performed at the contralateral upper left jaw side (Fig. ). At the same time the EWC??springs at the right side were reactivated by clipping 2 mm (canine) and 1 mm (premolars) off the springs at their anchorage point and re-fixating them with a ligature wire (Fig. ). This procedure was repeated every 4 weeks at both upper jaw sides until the impacted teeth erupted. Then the EWC??springs were removed and lingual buttons attached to the occlusal surfaces of the premolars (Fig. ) and buccal surfaces of the canines (Fig. ). The teeth were then further moved in buccal direction by means of a PowerTube??5 (Ormco B.V., Netherlands) until brackets could be bonded to the labial surfaces (Fig. ). Final extrusion and levelling of all impacted teeth was achieved by a superelastic Nickel-Titanium (NiTi) arch-wire initially (Fig. ) and subsequent rigid TMA (Titan-Molybdenum-Alloy) arch wires.
+After the deciduous teeth had been extracted in the lower jaw, the permanent premolars at the lower right side erupted spontaneously (Fig. ). A fixed multi-bracket appliance was bonded in preparation for aligning the impacted lower right canine, which was performed in analogy to the technique used in the upper jaw (surgical exposure, 0.017??? 0.025??stainless steel anchorage arch-bow with passive closed coil spring, EWC??system and 2 mm activation). To prevent intrusion and tipping of the incisors at the lower right side, the continuous arch-wire was separated and only the lateral tooth segment used for anchorage (Figs. and ).
+After removing the upper skeletal anchorage, remaining spaces in the upper dental arch were closed and incisors slightly re- and intruded with a T-loop bow (0.017??? 0.025??TMA, Fig. /i) to achieve physiological overjet and overbite. The lower alveolar midline deviation was corrected during levelling by uprighting the mesially inclined lower right canine into the gap to the first premolar with consequent distalisation of incisors aided by a buccal power chain placed on top of the arch-bow from the lower right second incisor to the left first premolar (Fig. ).
+Total treatment time was 22.8 months. The required time for aligning the upper jaw from surgical exposure to finishing with a 0.017??? 0.025??TMA arch-bow was 19.6 months with a total 26 sessions in the office. The corresponding treatment time for the lower jaw was 20 months with a total of 19 office visits.
+All impacted teeth could be successfully aligned within the levelled dental arches. Class I canine and molar relation were maintained at both sides (Figs. and ) and the patient (19.7 years) was happy with the treatment result. The cephalometric analysis after the end of treatment (Table , Fig. ) as well as the superimposition of pre- and posttreatment tracings (Fig. ) showed a slight intensification of the mesial skeletal tendency to a skeletal class III jaw relation (dentally compensated), caused by anterior rotation of the mandible, whereas the vertical hyperdivergence of the upper and lower jaw decreased by posterior rotation of the maxilla and anterior rotation of the mandible. The protrusion of the upper, but not lower incisors, both normally inclined, was reduced during treatment. Upper incisors were intruded. The lower alveolar midline deviation could be successfully corrected and a physiological overjet of 2.5 mm and overbite of 2.2 mm was achieved. The retrusion of the upper lip remained unchanged during treatment due to the still prognathic mandible.
+For retention purposes, the patient was instructed to wear a removable Hawley-retainer for 24 h a day within the first 6 months and then to gradually reduce wear time (only at night, every second night etc.). In addition, a coaxial annealed retainer wire (Penta-One??0.0215?? Masel Orthodontics, Carlsbad, USA) was bonded to the palatinal surfaces of the lower incisors and canines due to the severe rotation of the aligned lower right canine and thus increased risk of rotational relapse [].
+A total of nine deciduous teeth were extracted and seven permanent teeth surgically exposed, ligated and aligned. The two initially impacted permanent premolars at the lower right side erupted spontaneously after extraction of the deciduous molars and did not require additional traction. Post-treatment clinical examinations and radiographs (Fig. ) showed no indications of avital or traumatized teeth, root resorption, periodontal problems (probing depths < 3 mm for all teeth and locations) or other iatrogenic damages. At the end of treatment the patient was referred to the oral surgeon for possible extraction of the third molars, since proper eruption of the lower right molar seemed unlikely due to the radiographically evident lack of space and problematic angulation."
+Remi Coleman,38,1993/12/11,804-452-5531,mortonhaley@example.com,47369 Reyes Park Apt. 708,"A 23-year-old woman, gravida 1, para 0, at unknown gestational age presented to our emergency department with lower abdominal pain, vaginal spotting, and lightheadedness for 2 days. The patient? medical history was significant for morbid obesity with body mass index, history of Chlamydia infection and pelvic inflammatory disease at age 15, and laparoscopic cholecystectomy at age 19. Physical examination including a transvaginal ultrasonographic evaluation revealed a ruptured ectopic pregnancy. The patient was hemodynamically stable and underwent a laparoscopic right salpingectomy. The procedure was performed in a standard ?ow??lithotomy position (using Allen簧 stirrups). Care was taken not to flex hips or knees beyond 90簞, with hip abduction less than 45簞 and neutral hip rotation (Fig. ). The patient was in Trendelenburg position to allow for adequate visualization of the pelvis. Pneumatic compression devices on both calves were in place throughout the procedure. Skin-to-skin surgical time was 90 min due to the need for lysis of omental adhesion and the presence of pelvic adhesive disease consistent with the patient? prior surgical and gynecologic history. Intraoperative findings and pathologic evaluation confirmed the diagnosis of a ruptured ectopic pregnancy. Immediately upon awakening from general anesthesia, the patient complained of severe bilateral calf pain. Initial evaluation of the lower extremities revealed no compression marks, ecchymoses, erythema or edema, and the peripheral neurovascular exam was unremarkable. Serum electrolytes were within normal limits. Serum creatine kinase (CK) was elevated at 22,760 units/L (Norm: 38??76 units/L), consistent with rhabdomyolysis. An urgent bilateral lower extremity Doppler ultrasound was obtained which ruled out a deep venous thrombosis. The patient was treated symptomatically with analgesics and muscle relaxants. As her pain continued to escalate, a concern for acute compartment syndrome (ACS) was raised and the orthopedic surgery service was consulted. Based on the high level of suspicion for ACS in light of the clinical exam and exacerbating pain out of proportion, the patient was taken back emergently to the operating room by the orthopedic surgery team for bilateral lower extremity four-compartment fasciotomies. Surgery was accomplished approximately 8 h after her initial laparoscopic surgery. Intraoperatively, the diagnosis of ACS was confirmed. All muscles in the four compartments in bilateral legs were viable on clinical exam and bovie stimulation testing, without any signs of muscle necrosis. The patient required two additional staged surgical procedures for scheduled 2nd looks, soft tissue debridement and delayed primary wound closures. Her serum CK decreased to 1278 units/L prior to discharge and she did not sustain any renal failure or crush syndrome throughout the hospitalisation. The patient? serum creatinine remained in a normal range of 0.6??.8 mg/dL (Norm: 0.5??.0 mg/dL). She was discharged home on postoperative day four after definitive wound closure, with home physical therapy arranged. She had an uneventful further recovery, with pristine wound healing, no infection and a normal neurovascular status on bilateral lower extremities on follow-up exam. By 3 months after discharge from the hospital, she had regained full unrestricted function and a normal quality of life.
+We present a rare case of bilateral lower extremity acute compartment syndrome that developed in a healthy 23-year-old female after undergoing a laparoscopic salpingectomy for ruptured ectopic pregnancy in the usual lithotomy position. This case highlights a rare complication that has been previously associated with lithotomy or hemilithotomy positioning [, , , ]. Lower extremity ACS is a pathologic condition in which increased tissue pressure within a closed osseofascial space compromises blood circulation and normal function of tissues within the compartment leading to tissue hypoxia and necrosis [, ]. If left untreated, patients with ACS can develop muscle contracture, sensory deficits, paralysis, possible need for limb amputation, and potentially multi-system organ failure secondary to crush syndrome [, ]. The osseofascial lining of the four lower extremity compartments (anterior, lateral, superficial and deep posterior) form an enclosed environment of muscle, blood vessels and nerves with limited ability to expand or accommodate increased volume or pressure [, ]. ACS in the postoperative state occurs as a result of intraoperative compression with a prolonged decrease in arterial pressure and/or increase in venous pressure, followed by reperfusion []. Local ischemia can subsequently damage endothelial cells resulting in leakage of proteins and fluid into the interstitial space. The subsequent increase in interstitial pressure elevates compartmental pressures, thus perpetuating the cycle of hypoperfusion and tissue ischemia []. Specifically, in the lithotomy position, ischemia occurs from compressive forces of the external leg holsters and diminished blood flow from leg elevation and kinking of the popliteal artery, leading to ischemia/reperfusion injury with subsequent compartment syndrome []. When the lower extremities are taken out of lithotomy position and elevation, limb reperfusion occurs and can lead to injury with the formation of oxygen free radicals and cytokines that perpetuate endothelial damage and interstitial edema []. In addition to lithotomy position, other risk factors associated with ACS after surgery include: ankle dorsiflexion, Trendelenburg position, leg holders, length of surgery greater than 2 h, intraoperative hypotension or hypovolemia, and epidural analgesia []. Bauer and colleagues recently published two articles documenting cases of lower extremity ACS following gynecologic surgery in the lithotomy position and found that the vast majority of ACS cases occurred following procedures lasting longer than 4 h [, ]. Other studies have demonstrated that calf compartment pressure increases at a rate of 1.1 mmHg per hour in the lithotomy position []. In addition, elevation of the leg above heart level (?igh??lithotomy positon) has been associated with increased risk of compartment syndrome []. Intermittent pneumatic compressive devices used for the prevention of deep venous thrombosis intraoperatively, as applied in the patient presented in this case report, have also been identified as causative factors for ACS []. We postulate that lithotomy with adjunctive Trendelenburg position was likely the contributory root cause of bilateral lower extremity ACS in the young 23-old patient described in this case report. Multiple technical tricks have been described to prevent ACS in lithotomy position, including intraoperative repositioning of the legs, avoiding pressure in the popliteal fossa and kinking of the popliteal artery by avoiding knee flexion beyond 90簞 [, ]. Lower extremity ACS remains a clinical diagnosis, and immediate recognition and surgical management are paramount in avoiding long-term impairment and poor outcomes []. The most common clinical symptom is represented by uncontrolled pain out of proportion and exacerbated pain by passive stretch of the toes and ankle joint []. Measurement of the compartment pressure can aid in the diagnosis, albeit there is dispute among orthopedic surgeons regarding the pressure threshold for the diagnosis of ACS and subsequent need for fasciotomy. The most effective method of diagnosis of ACS remains a clinical diagnosis requiring a high level of suspicion by the treating physician. Given the short duration of our patient? procedure and lack of risk factors with the exception of lithotomy position and her full recovery after immediate recognition and surgical management, our case highlights the imperative of understanding the pathophysiology of ACS in lithotomy position and raising a high level of suspicion in a patient with postoperative calf pain after gynecological procedures."
+Julia Barnett,41,1994/11/28,+1-317-889-1058x0747,wattscharlotte@example.net,104 Hanson Mills,"A 60-year-old man who was admitted with persistent diarrhea and a 10 kg weight loss in 17 months. After a tentative diagnosis of coeliac disease he was followed in another hospital for 8 months. His laboratory data revealed hypoproteinemia and elevated soluble interleukin-2 receptor (sIL2R). Anti-gliadin and anti-transglutaminase antibodies, serum-specific markers for coeliac disease, were negative []. Abdominal computed tomography (CT) revealed thickening of the jejunal and ileal walls and mild dilatation. On upper GI endoscopy, a reddish depressed lesion with erosion was seen in the gastric body; in the second portion of the duodenum, the edematous mucosa was accompanied by villous atrophy (Fig. ). Upper GI endoscopy with narrow-band imaging (NBI) showed an edematous mucosa, while magnifying endoscopy with NBI revealed a cerebriform or flat pattern with villous atrophy in the second duodenal portion (Fig. , ). Capsule endoscopy demonstrated a diffuse edematous and granular mucosa with villous atrophy and circumferential ulcers in the jejunum and ileum. On lower GI endoscopy, an edematous mucosa with small erosions at the ileocecal valve were present (Fig. ) whereas the findings along the whole colorectal mucosa were nearly normal. Biopsy specimens from the gastric, duodenal, jejunal, and cecal mucosae showed diffuse intramucosal invasion by small to medium-sized atypical lymphocytes with irregular hyperchromatic nuclei, in addition to many atypical IELs (Fig. , ). Immunohistologically, the atypical lymphocytes were positive for CD103, TCR-帣F1, CD3, CD7, CD8, CD56, and TIA1. Other biopsy specimens from the duodenal second portion showed villous atrophy and chronic inflammatory infiltrates. The T-IELs comprising the infiltrates were positive for CD103, CD3, CD7, CD8, and TIA1 but negative for CD56 and CD5. Evaluation of the colorectum showed colitis with an increased number of T-IELs, all of which were of the same phenotype (Fig. ). A bone marrow biopsy revealed scattered infiltrates of CD103-, CD3-, CD8-, CD56-positive and CD5-negative atypical lymphocytes; these accounted for ~30 % of the nucleated cells. The patient was treated with a chemotherapy regimen of CHASE (cyclophosphamide, cytarabine, etoposide, and dexamethasone) and underwent autologous stem cell transplantation. Despite a partial response to chemotherapy, he died of sepsis 3 years after disease onset."
+Stephen Crawford,38,2000/7/29,+1-247-630-5330x415,hayesstephanie@example.com,68529 Garcia Common Apt. 713,"A 40-year-old woman who was admitted with diarrhea and a weight loss of 6 kg in 3 months. Her laboratory data revealed hypoproteinemia and an elevated sIL2R level. On upper GI endoscopy, the gastric mucosa was nearly normal in its appearance whereas the mucosa of the duodenal second portion was edematous. Antegrade double-balloon endoscopy of the duodenal third portion and the jejunum showed a diffuse edematous mucosa, erosion, and ulcerative tumors in both. On lower GI endoscopy, an edematous mucosa and reddish polypoid lesions were seen in the terminal ileum together with an edematous colorectal mucosa. Biopsy specimens from the duodenal third portion, intestine, and colon showed a diffuse, intramucosal infiltrate of medium-sized atypical lymphocytes with coarse chromatin together with many atypical IELs. Other biopsy specimens from the duodenal second portion (Fig. , ) and intestine revealed chronic inflammatory changes with villous atrophy and an abundance of CD103-, CD8-positive, CD56-negative T-IELs. Scattered infiltrates of CD3-, CD4-, and CD8-positive, CD103- and CD56-negative lymphocytes were identified on bone marrow specimens but there was no evidence of bone marrow invasion. She was treated with a chemotherapy regimen of THP-COP (pirarubicin, cyclophosphamide, vincristine and prednisolone) but 10 months after the initial diagnosis was readmitted to our hospital with acute abdominal pain due to intestinal perforation. A partial jejunal resection revealed multiple and circumferential ulcerated tumors with or without perforation; the mucosa surrounding the tumors was characterized by fold thickening with granular changes (Fig. ). Histologically, a diffuse infiltrate of medium-sized atypical lymphocytes accompanied by atypical IELs was present in the mucosa, in the peripheral zones of the tumors (Fig. ). Enteropathy-like lesions with villous atrophy and an abundance of IELs were evident in the mucosal layer outside the main tumors. Preoperative biopsy specimens obtained from the ascending colon to the rectum revealed colitis, with increased CD3- and CD8-positive and CD56-negative T-IELs (Fig. , ). She died of the disease 2 months after surgery."
+Aubree Singh,39,2002/2/20,452.293.3862x02255,tylermartin@example.org,02640 Tucker Bridge Suite 155,"A 50-year-old woman who was admitted to our hospital for abdominal distension. Her laboratory data revealed an elevated sIL2R. On abdominal CT, long segmental thickening of the jejunal and ileal wall with dilatation was evident. Upper GI endoscopy revealed an edematous and reddish granular mucosa with white villi in the duodenal second portion (Fig. ). On lower GI endoscopy, a diffuse granular mucosa with villous atrophy in the terminal ileum, an edematous mucosa with multiple erosions in the ascending and sigmoid colon, and reddish longitudinal ulcers in the rectum were seen (Fig. ??. Biopsy specimens from the duodenal second portion, intestine, and colorectum revealed a diffuse intramucosal infiltrate of medium-sized atypical lymphocytes with many atypical IELs (Fig. , ). Other biopsy specimens from the duodenum, jejunum, and colorectum indicated chronic inflammatory changes of the propria mucosae and increased CD3- and CD8-positive, CD56-negative T-IELs. An invasion by CD3-, CD8-, and CD56-positive atypical lymphocytes was seen on the bone marrow specimens. She was treated with cyclophosphamide, doxorubicin, vincristine, and prednisolone and high-dose methotrexate/cytarabine followed by allogeneic stem cell transplantation. Despite a partial response to chemotherapy, she died 9 months after disease onset."
+Louis Hubbard,29,1983/4/16,737.962.2658,michaelcunningham@example.org,16952 Steven Road,"A 70-year-old man admitted for nausea. His laboratory data revealed pancytopenia and hypoproteinemia. Helicobacter pylori IgG antibody was positive in serum. Abdominal CT showed a 30-mm-diameter tumor in the duodenal second portion and thickening of the jejunal wall. On 18F-fluorodeoxyglucose (FDG) positron emission tomography, there was FDG uptake in the duodenal second portion. Upper GI endoscopy revealed pinhole-like severe stenosis, a submucosal tumor at the anal side of the stenosis, and edematous mucosa in the duodenal second portion. Lower GI endoscopy showed a granular mucosa of the terminal ileum and edematous or normal-looking mucosa in the colorectal mucosa. Duodenitis with villous atrophy and abundant IELs was evident on biopsy specimens from the duodenal second portion taken outside the tumor. The tumor itself consisted of small to medium-sized atypical lymphocytes both among the epithelial cells and in the mucosal layer. The cecal mucosa was characterized by a severe infiltrate of atypical IELs (Fig. ). Other biopsy specimens from the duodenum, descending colon, and rectum showed chronic inflammatory changes with increased CD3- and CD8-positive, CD56-negative T-IELs (Fig. , ). Infiltrating atypical lymphocytes of the bone marrow were positive for CD3, CD8, CD103, and TCRC帠M1, but negative for CD56. He was treated with a chemotherapy regimen of SMILE (dexamethasone, methotrexate, ifosfamide, L-asparaginase and etoposide). After chemotherapy, abdominal CT revealed a reduction of the tumor. Despite a partial response to chemotherapy, he died of sepsis 9 months after disease onset."
+Rosie Long,45,1984/4/7,(605)855-2969x080,bstewart@example.net,59420 Garza Course,"A 47 year-old female had been complaining of asthenia and a significant weight loss in the previous 2 months. She was smoker (about 20 cigarettes per day) and had no underlying diseases such as diabetes or hypertension. Test to detect Helicobacter pylori was negative. After gastroendoscopy and other explorations, such as computerized axial tomography scan, histological analysis of the tumour confirmed the diagnostic of gastric adenocarcinoma: diffuse adenocarcinoma with signet-ring cells. The proband died during the study.
+Some of her relatives presented previous history of malignant colorectal polyp (one sister), hyperplastic gastric polyp (a nephew) or gastric cancer (great-uncle) (Fig. ). Thus, search for CDH1 germline mutations was conducted in the patient and in other members of the family (three sisters, a great-uncle and a nephew of the proband), after genetic counseling and informed consent.
+In order to determine the expression level of the protein, paraffin tissue samples were subjected to immunohistochemical staining with monoclonal antibody against E-cadherin (clone 36B5, Leica Biosystems, UK) in an automated Bond system in combination with Bond Polymer Refine Detection (Leica Biosystems, UK) according to manufacturer instructions.
+Genomic DNA extraction was carried out from peripheral blood by using QIAamp DNA Blood Mini Kit, and from paraffin embedded tissue (from proband? gastric biopsy) with QIAamp DNA FFPE Tissue Kit; following manufacturer instructions. In the proband, RNA was also isolated from peripheral blood with QIAamp RNA Blood Mini Kit and from tissue using RNeasy FFPE Kit, and then stored at ??0 簞C.
+The CDH1 gene was studied by analyzing the entire coding sequence, including intron?xon boundaries, by PCR and sequencing. The presence of the mutation was confirmed at RNA level in the proband material.
+Pathogenicity of the new variant was predicted by in silico analysis with bioinformatics tools such as sorting intolerant from tolerant (SIFT) and Mutation Taster. ExAC browser of Broad Institute, 1000 Genomes database and dbSNP138, as well as, the human gene mutation database (HGMD), Leiden open variation database (LOVD) and ClinVar databases were checked to assess the presence/absence of detected alterations in variations repositories.
+A novel heterozygous deletion in exon 9 of CDH1 gene (NM_004360.4:c.1220_1220delC; NM_004360.4 (CDH1_i001): p.(Pro407Glnfs*10)), has been found in the proband and subsequently in other family members. This variant was not found in 100 healthy controls and it is not present in 1000G, ExAC and dbSNP, pointing out that this variant is not common in population. To the best of our knowledge this variant has not been previously described, and it is not included in ClinVar, HGMD or LOVD. Variant has been included in ClinVar database (SCV000266475). This mutation, generates a premature stop codon at position 407 giving rise to a truncated protein, that leads to a pathogenic variant (Corso et al. ). The presence of the mutation was corroborated both, at DNA and RNA level in peripheral blood. The mutation was not found in 100 control samples. The variant was considered pathogenic/disease causing by in silico predictors SIFT and Mutation Taster. Furthermore, this variation is considered to be pathogenic, according to American College of Medical Genetics and Genomics (ACMG) interpretation: null variant in a gene where loss of function is a known mechanism o disease, absent in population databases, protein length changing variant, co-segregation with disease in multiple affected family members in a gene definitively known to cause the disease, and patient? phenotype highly specific for gene (Richards et al. ).
+One of the sisters (subject IV-2), who was found a malignant colorectal polyp at the age of 49, presented also the deletion, and her son (nephew of the proband; (subject V-1)) harboured also the mutation and had been previously diagnosed with hyperplastic gastric polyp. Neither of the other relatives tested harboured the mutation and they were healthy, but for the great-uncle (subject III-1) who had been suffered indeterminate-type GC and did not present the mutation. There were other relatives which had been suffered hyperplastic colon polyps (subjects II-4; III-10), GC (subject II-2; III-2), and other kind of cancer (subjects II-3; III-7), but samples were not available for this study.
+The sister, carrier of the mutation, and asymptomatic at the time of this study, underwent PTG. Her son (subject V-1), refused the procedure and is under annual endoscopic surveillance (recently, hyperplastic gastric polyps has been detected).
+It was not possible to establish the origin of this mutation with the data collected. It should be necessary to test more relatives in order to determine in which point its origin is.
+In the tumor cells of proband? gastric biopsy, the immunohistochemical expression of E-cadherin was absent or frankly reduced. In contrast, normal continuous membranous staining for E-cadherin was evidenced in gastric tumor cells of great-uncle (Fig. )."
+Jace Hughes,26,1982/12/24,233.650.5852x1913,ericmiller@example.com,0452 Vasquez Terrace,"A 59-year-old man was admitted to our hospital for the treatment of a rectal tumor.
+The tumor was found via colonoscopy during an examination at a medical checkup. The colonoscopy revealed an ulcerated tumor at the anterior rectum, 4 cm from the anal verge. Histopathologic examination revealed moderately differentiated adenocarcinoma. CT and MRI scans showed that the rectal tumor was contiguous with the prostate and the left seminal vesicle. PET-CT showed no evidence of metastasis. The carcinoembryonic antigen (CEA) level was elevated at 105.1 ng/mL. After neoadjuvant chemoradiotherapy (CRT) (S-1 100 mg/m2/6 weeks, 2 Gy*25/5 weeks = 50 Gy), CEA level decreased to 24.3 ng/mL but the size of the tumor and the degree of invasion were unchanging (Fig. ). From the CT and MRI, the invasion to adjacent organs was still undeniable; therefore, we thought that TPE was appropriate surgery for this patient from the point of view of curability. We performed LTPE 8 weeks after chemoradiotherapy.
+The patient was placed in the Trendelenburg lithotomy position. The surgeon and the cameraman stood on the patient? right side. Five ports were placed as follows: 12-mm ports at the umbilicus and the lower right quadrant and 5-mm ports at the upper right and left and lower left quadrant. First, the inferior mesenteric artery and vein were skeletonized, clipped, and divided with adequate lymph node dissection. After dissecting the mesentery of the sigmoid colon, the sigmoid colon was transected with a linear stapler (Endo GIA, purple, 60 mm; Covidien, Norwalk, CT, USA). Next, the left ureter was dissected to the level of the ureterovesical junction, where it was clipped and divided. The surgeon moved to the patient? left side, and the same procedure was performed for the right ureter after mobilizing the cecum to the level of the duodenum. We did not place ureteral catheters. The superior hypogastric nerve was divided at the level of the aortic bifurcation. The surgeon moved to the patient? right side again and dissected the posterior rectal space. After recognizing the left internal iliac vessels, the left vas deferens was clipped and divided. The branches of left internal iliac artery were clipped and divided until the entry point to Alcock? canal. Left en bloc lateral lymph node dissection was performed, and the same procedure was then performed on the right side. Bilateral obturator nerves were preserved. After dissecting the dorsal cavity of the rectum to the level of the levator ani muscle, the prerectal peritoneum was incised and the medial ligament was clipped and dissected. The Retzius space was dissected, and the dorsal vein complex (DVC) was exposed after incising the bilateral puboprostatic ligament and the endopelvic fascia (Fig. ). At first, we tried to dissect the DVC with a linear stapler (Endo GIA, purple, 60 mm), but we were unsuccessful because of the thickness of the DVC. The black staple, used for thick tissue, was insufficient to dissect it. We dissected the DVC carefully with Ligasure??Maryland (Covidien), taking care to not cause bleeding of the cutoff stump. The urethra was exposed and dissected with a linear staple (Endo GIA, camel, 45 mm). The levator ani muscle was divided laterally at its origin from the tendinous arch.
+After the patient? legs were elevated, the surgeon and the first assistant moved to the anal side and closed the anus with double purse-string suture. After the perianal skin was incised, a multiple access port (GelPoint簧Mini; Applied Medical, Rancho Santa Margarita, USA) was set using the transanal minimal invasive surgery (TAMIS) technique. Three small ports were installed, and perirectal tissue and muscles were dissected until we reached the abdominal cavity under the pneumoperirectum (Fig. ). The entire specimen was removed from the perineal opening, and the perineal opening wound was closed (Fig. ).
+An ileal conduit and a sigmoidostomy were then constructed extracorporeally through the extended umbilical incision. The total operative time was 760 min, and the estimated amount of bleeding was 200 ml. The postoperative course was good, and the patient was discharged on postoperative day 15. Histopathological analysis revealed no apparent invasion of the tumor to adjacent organs, and the pathological stages were ypT3 and ypN0.
+Currently, laparoscopic technique is used for various surgeries; thus, opportunity to perform laparoscopic surgery has increased for many surgeons. The laparoscopic approach has advantages not only for patients but also for surgeons, i.e., less pain, smaller wounds, earlier recovery, and a magnified view. LTPE is a challenging and complicated operation, but some studies have reported on the safety and feasibility of it not only for urologic or gynecologic malignancies [, ] but also colorectal malignancies [, , , ]. This is our initial experience with LTPE, and so far, we have not encountered any complications. We have routinely performed lateral lymph node dissection for locally advanced lower rectal cancer, and we believe that this previous experience enabled our current success. Upon histopathological analysis, no apparent invasion of the tumor to adjacent organs was observed, but this was difficult to detect before the surgery; therefore, this patient should have been treated by TPE. This case did not include a posterior invasion, so the surgery time was comparatively short. We did not reconstruct the perineal defect, change the patient? position, or place ureteral catheters after dissecting the ureters. We believe that these factors contributed to shortening the surgery time. We did not monitor the urine volume after dissecting the ureters, but intraoperative and postoperative complications did not occur.
+During the anal-side procedure, we used the TAMIS technique. With the TAMIS technique, we could keep a good visual field even after penetration to the abdominal cavity because the pressure of pneumoperirectum can be kept by the pneumoperitoneum. In addition, the perineal wound becomes smaller, which may lead to reduction in the perineal surgical site infection, and pnuemoperirectum can reduce the amount of bleeding. In the middle of the procedure, the wound retractor broke due to contact with the blade of the Sonicision??(Covidien) and the pneumoperirectum could not be kept thereafter, which will require further attention."
+Samantha Allen,36,1990/12/18,274-697-9505x9976,allensusan@example.org,2312 Neal Falls Apt. 187,"A 73-year-old Japanese male presented to our hospital with dyspnea and swelling of the lips and eyelids which occurred 30 minutes after eating boiled broccoli. He had no history of allergic reactions to latex or fruits. The patient's clinical findings suggested he was experiencing an immediate-type hypersensitivity reaction to broccoli, such as oral allergy syndrome (OAS) or PFAS. Therefore, tests for allergic reactions including the CAP fluorescent enzyme immunoassay RAST (CAP-FEIA RAST) test and a skin-prick test (SPT) were performed. A blood test revealed an elevated level of serum immunoglobulin E (IgE: 681 IU/mL; normal range: 0??70 IU/mL) and IgE antibodies specific for mugwort (0.83 UA/mL; normal range: 0??.34 UA/mL) were detected in the CAP-FEIA RAST test, although no IgE antibodies specific for almond or mustard were detected. An SPT was then performed using the prick-to-prick technique with samples of mugwort, broccoli, cauliflower, cabbage, mustard, almond, and peanut. The results of the SPT were assessed as false positive (+), positive (2+), strongly positive (3+), and most positive (4+) when the average wheal diameter was more than 25%, 50%, 100%, and 200%, respectively, of a positive control induced by 10 mg/mL of histamine dihydrochloride 30 minutes after administration []. Positive reactions were observed for mugwort (3+), raw broccoli (4+), and mustard (3+) (). Heated broccoli (4+) and heated mustard (3+) also showed positive reactions. The test was negative for cauliflower, cabbage, almonds, and peanuts. Based on the clinical symptoms and the results of the allergy tests, the patient was diagnosed with MMAS due to broccoli consumption. The patient was therefore advised to avoid consuming broccoli and mustard. He has not experienced any symptoms of MMAS since."
+Carter Patterson,38,1993/6/14,(688)710-3155x06442,kevin17@example.org,982 Nicole Walks Suite 680,"A 68-year-old woman went to a dermatologist for an opinion regarding the thickening and yellowing of the nail plate on the fifth toe of the left foot, which had appeared gradually over the past 2 years. She had no history of prior traumatism, and the lesion was pain-free. Clinical examination showed a thickening of the nail plate, a xanthonychia, and distal splinter haemorrhages of the nail plate on the 5th toe (). Dermoscopy revealed visible holes in the thick portion of the nail plate. All other nails on both the hands and the feet were lesion-free. She had no relevant medical history. Analysis of two mycological samples was negative. For diagnostic purposes, a nail avulsion under local anaesthesia was performed, which revealed the presence of a villous tumour on the nail matrix (). The tumour was excised, and after eight months of follow-up, the nail regrew without any signs of relapse or ungual dystrophy."
+Kaylee Vega,26,2004/8/8,972.236.9314x1766,jterry@example.net,722 Justin Shoal Suite 772,"A 46-year-old African American woman presented to the emergency room with respiratory distress requiring intubation. She was found to have severe pulmonary edema on initial evaluation. A transthoracic echocardiogram showed global hypokinesis of the left ventricle and severe systolic dysfunction, with an ejection fraction of 30%. A myocardial perfusion test showed no evidence of stress-induced ischemia, and she was diagnosed with nonischemic cardiomyopathy. Her physical appearance was remarkable for prominent loss of subcutaneous adipose tissue in the extremities and trunk but excessive adipose tissue deposition in her neck with severe acanthosis nigricans suggestive of partial lipodystrophy. Sequence analysis of LMNA gene showed a heterozygous missense mutation at exon 8 (c.1444C>T) causing amino acid change, p.R482W. Her glycosylated hemoglobin was 5.8, indicating that she had prediabetes. One year later a coronary angiogram performed due to retrosternal chest pain showed mild coronary artery disease in left anterior descending artery (LAD) and right coronary artery with an ejection fraction of 25%. The patient was continued on medical therapy. At this point she was diagnosed with diabetes mellitus (glycosylated hemoglobin 6.6%). A lipid profile showed total cholesterol 215 mg/dL, triglycerides 260 mg/dL, low-density lipoprotein 124 mg/dL, high-density lipoprotein 39 mg/dL, and very low density lipoprotein 52 mg/dL. Primary hyperparathyroidism and euthyroid multinodular goiter were also diagnosed. She continued having multiple recurrences of chest pain. A nuclear perfusion scan showed inferior wall scar with moderate amount of peri-infarct ischemia. A series of coronary angiograms performed during a period of 12 months showed significant coronary artery disease: firstly of right coronary artery (90%) that required stenting followed by LAD (80%) that was stented, distal left main coronary (), proximal left anterior descending and obtuse marginal (OM) managed by coronary artery bypass graft (CABG) surgery. An angiogram performed for recurrence of chest pain 4 months after the CABG showed inadequate flow from the left internal mammary artery graft to the LAD but patent saphenous vein grafts to the OM and posterior descending artery. Stenting was done across the left main to the LAD. She improved clinically following this procedure.
+Two years after her initial presentation, she had asymptomatic transient complete heart block, which was thought to be related to 帣-blockers. This was managed conservatively. Four years after the initial presentation, she had symptomatic sinus node dysfunction with bradycardia. She had episodes of sinus arrest with idioventricular escape rhythm. Since she had persistent left ventricular dysfunction with an ejection fraction of 25%, an implantable cardioverter-defibrillator (ICD) was done. Nine months later she had erosion of the ICD pulse generator in the absence of infection and needed explanation followed by reimplantation on the contralateral side. Six years after the initial presentation she was diagnosed with symptomatic typical cavo-tricuspid isthmus dependent atrial flutter that required ablation. Seven years after the initial presentation, she developed left bundle branch block and underwent upgrade of the ICD to a biventricular cardioverter defibrillator. The patient stated that her deceased mother, a son, and her grandson may have the disease. We offered genetic studies for the son and grandson but both declined to have testing."
+Aidan Boyer,32,1983/7/9,001-787-856-6926x481,trujillopaul@example.com,004 Martha Forges,"A 27-year-old white man with an unremarkable medical and family history presented to our emergency department with nausea, vomiting, fever reaching 38.8簞C, and bloody-mucoid diarrhea 10 to 13 times a day for the past 2 days. In that period, Salmonella had been found in some meat cultures in the city center of Sivas and an endemic diarrhea presenting with the same clinical manifestations had been defined. He stated that he had eaten from the meat that had previously been shown to contain Salmonella. His blood pressure was 120/70 mmHg and his pulse rate was 78/minute, but other physical examination findings were normal. His baseline biochemical analysis was unremarkable except for leukocytosis of 21.6?103/mm3. Stool microscopy demonstrated 7 to 8 red blood cells per high-power field and 1 to 2 white blood cells in some fields. No growth was detected in his blood or stool cultures. He was hospitalized in the infectious diseases clinic for gastroenteritis, and he was started on ciprofloxacin 500 mg treatment twice daily.
+One week after hospitalization, his laboratory results were as follows: blood urea nitrogen 75 mg/dL, serum creatinine 10.4 mg/dL, lactate dehydrogenase (LDH) 1539 U/L, total protein 4.5 g/dL (5.7 to 8.2), and albumin 2.8 g/dL (3.2 to 4.8). His urine analysis results were normal. He was transferred to our nephrology department because he was anuric, and the possibility of HUS was under consideration. In that period, his blood pressure was 130/80 mmHg, pulse rate was 84/minute, and body temperature was 36簞C; there were no pathologic findings in his physical examination. There was no growth in the specific stool culture performed for enterohemorrhagic Escherichia coli. Two days later, his hemoglobin (Hb) concentration dropped to 10 g/dL, direct Coombs test was negative, his reticulocyte ratio was 6 %, and there were schistocytes in his peripheral blood smear. His serologic tests were negative for anti-nuclear antibodies, cytoplasmic anti-neutrophil cytoplasmic antibodies, hepatitis B surface antigen, antibodies to hepatitis B surface antigen, antibodies to hepatitis C virus and human immunodeficiency virus, perinuclear antineutrophil cytoplasmic antibody and anti-glomerular basement membrane results; his C3 was 0.511 g/L (0.9 to 2.1) and C4 was 0.151 g/dL (0.1 to 0.4).
+A urine analysis performed 2 weeks later when his urine output began to increase, revealed +4 proteinuria and normal microscopy, whereas micro-total protein in 24-hour urine was measured as 18 g/day. In addition, valsartan 160 mg/day and prednisolone 1 mg/kg/day was added to the treatment because his blood pressure increased (maximum to 170/100 mmHg), and hemodialysis and plasma exchange were commenced for aHUS plus acute renal failure. His hemodialysis therapy was discontinued after eight sessions because his creatinine levels decreased and urine output increased. Plasma exchange was performed for a total of 12 sessions until his platelet count and LDH levels returned to normal. He also received a red blood cell transfusion (two units) for symptomatic anemia (Hb 7 g/dL, hematocrit 22 %). The pathology report of the samples obtained through renal biopsy was consistent with C3 glomerulonephritis; therefore, azathioprine 100 mg/day was added to his treatment. A renal biopsy specimen stained with hematoxylin and eosin revealed six glomeruli with increased mesangial cells and matrix, and minimal focal interstitial lymphocytic inflammation. There was no pathologic finding in the tubules and blood vessels (Fig. ). Direct immunofluorescence staining of the tissue sections revealed a total of eight glomeruli, which showed only mild to moderate mesangial granular staining for C3; no immunofluorescent staining was detected with immunoglobulin A, immunoglobulin G, immunoglobulin M, C1q, and fibrinogen. Congo red staining was negative. One month later, his serum creatinine was found to be 1.1 mg/dL, LDH was 232 mg/dL, his platelet count was 190,000/mm3, Hb was 12.8 g/dL, albumin was 3.5, C3 was within the normal ranges, and the micro-total protein in 24-hour urine was 1.3 g/day."
+Chaya Phelps,21,1989/1/23,(865)410-4764x73067,scottautumn@example.net,23831 Jennifer Circles,"A 37-year-old woman purposely came to the outpatient department of our district hospital in the North West Region of Cameroon for a refill of her propranolol medication. She reported taking the drug routinely for palpitations. On further inquiry, she reported being well until 12 months prior to presentation when she suddenly became aware of her heartbeat, initially on moderate exertion and then even at rest. It had been recurrent and lasting several minutes each time it occurred. It progressively became associated with dyspnoea initially on moderate exertion and then on mild exertion, such that she had to quit farming which was her main source of income. After consulting at various health facilities in the North West Region of Cameroon, she was prescribed irregular and alternate daily regimens of 40 mg propranolol and 0.25 mg digoxin which she had been taking for 12 months at the time she presented at our hospital. Although the medications conferred her some relieve, she noticed a progressive weight loss over the 12-months period prior to consulting at our hospital, from 85 to 58 kg despite an abnormal increase in her appetite for food. She also experienced frequent watery stools (averagely six times daily). About 6 months prior to presentation, she complained of heat intolerance and profuse sweating resulting in sleeping with minimal clothing. In addition, she noticed spontaneous resting tremors of her hands which started at the same time as the heat intolerance. Three months prior to presentation at our hospital, she noticed a painless lump on her neck that progressively increased in size.
+On reviewing her medical records, we noticed a number of investigations requested at various hospitals which she visited during the 8 months preceding her presentation at our hospital. These included electrocardiographs, echocardiograms, HIV tests, full blood counts, fasting blood sugar, thyroid hormone assays, which were all without particularity but for the electrocardiography results which always showed a sinus tachycardia. She has no known history of exposure to radiations or family history of malignancies.
+Physical examination revealed a chronically ill-looking middle aged woman. Her eyes were normal (Fig. ). Her voice was clear. She had fine resting tremors of her hands with her arms outstretched. There was a left anterolateral neck mass measuring 4 ? 3 cm (Fig. ). The mass was rubbery, mobile, non-tender, moved with swallowing, and not fixed to overlying or underlying tissue. No bruit was heard over the mass. There was no palpable cervical lymphadenopathy. Her vital signs were normal but for regular respiratory and pulse rates of 35 breaths/min and 104 beats/min respectively. Her BMI was 20.1 kg/m2. There was discrete bilateral pedal pitting oedema. The rest of the physical examination was without notable findings. In view of this presentation, a presumptive diagnosis of HT was made and we placed her on propranolol, 40 mg twice daily. Our hospital was not equipped with the necessary diagnostic tools, so we referred the patient to a regional hospital which is about 10 km from our locality. To confirm our diagnosis, we requested for a functional [serum T3, T4, Thyroid stimulating hormone (TSH)] and structural (ultrasound) assessment of the thyroid. The patient was counter-referred to us with the following results:Functional assessment of the thyroid: levels of serum T3, T4, and TSH (Table ). Structural assessment of the thyroid (ultrasound scan): The left thyroid lobe appeared enlarged, heterogeneous, with a fairly iso-echoic, well-defined homogenous solid mass (3.6 ? 1.8 ? 2.9 cm in size). The right lobe was without particularity. No cervical lymphadenopathy was observed.
+In view of these findings, we concluded on a primary HT most likely due to a toxic uninodular goiter. Again, due to the limited resources in our hospital, we referred the patient to a hospital which is over 30 km from our locality for initiation of a course of methimazole. She was placed on 60 mg methimazole daily, 4 weeks after which she underwent a left thyroid lobectomy. The resected lobe (Fig. ) was sent for histopathology. The postoperative course was uneventful.
+The lobe weighed 33.5 g and was received in formalin as two grey-tan soft tissue fragments: a large (6.5 ? 5 ? 3.5 cm) and a small (3 ? 1.5 ? 1 cm) fragment. Cutting demonstrated a red tan cut surface with a 3 ? 2.3 ? 2 cm nodule inside the bigger piece. Microscopic examination of representative sections of the large fragment with a full thickness section of the nodular structure revealed a nodular proliferation of enlarged pale cells with marginated chromatin and overlapping nuclei. Pink ?ubble gum??like colloid was focally noted. The lesion was partially encapsulated and displayed areas with fibrosis and more follicular appearance of the aggregates. Based on these, a histological diagnosis of PTC (pT2N0M0) was made.
+We monitored the patient through scheduled regular visits and referrals. Figure shows the Incision site on the anterior aspect of the neck 2 weeks after lobectomy. We observed a progressive decline in hyperthyroid symptoms and signs: the palpitations regressed as well as the diarrhoea and polyphagia; the heat intolerance regressed and 1 month postoperatively, her weight increased from 58 to 68 kg."
+Hamza Palmer,23,1988/5/20,2236771279,lwatson@example.com,131 Berry Lodge Suite 009,"A 67-year-old man with untreated diabetes mellitus developed dizziness, followed by dysarthria and dysphagia, 4 days before admission to our hospital. On admission, he was fully conscious, and the physical examination was almost normal except for hypertension and tachycardia in a regular rhythm. Neurological examination revealed equal and round pupils with a normal light reflex. His extraocular movements were full range without diplopia, but he showed gaze-evoked horizontal nystagmus, dysarthria, and dysphagia. He had no complaint of dysgeusia. Muscle tonus was normal without obvious paralysis in all four limbs. Examination of the sensory system revealed hypothermia and hypoalgesia with normal tactile sensation over the left side of his face and right half of his trunk and limbs. Vibration and position sensation were normal in all four limbs. He presented with ataxia in his left upper and lower limbs. Tendon reflexes were normal in his upper limbs and absent in his lower limbs without the extensor plantar reflex. Brain magnetic resonance imaging (MRI) demonstrated hyperintensity in the left side of the dorsolateral medulla with diffusion weighted imaging (DWI) with hypointensity on apparent diffusion coefficient (ADC)-map (Fig. ). He was diagnosed as having lateral medullary syndrome and was treated with oral clopidogrel (continued during admission), intravenous argatroban for 3 days, edaravone for 9 days, and hydration with normal saline (1.5 L/day).
+Hematological examination showed normal serum sodium levels of 139 mEq/L on admission, however, the serum sodium levels decreased gradually, and 9 days after admission (13 days after onset), he developed asymptomatic hyponatremia (109 mEq/L) with a decreased serum osmolarity of 223 mOsm/L (normal range, 275 ??295 mOsm/L). The turgor in all four limbs was normal, and he did not present with obvious thirst. Thyroid, renal, and adrenal functions were normal, but increased serum levels of antidiuretic hormone (ADH) (6.9 pg/mL; normal range, 0.3 ??4.2 pg/mL) were observed. Urine osmolarity was 668 mOsm/kgH2O (normal range, 100 ??1,300 mOsm/kgH2O), and urine sodium was 121 mOsm/L (normal range, 40 ??90 mOsm/L). Thoracoabdominal CT images showed no abnormalities, such as mass lesions or lymphadenopathy. He was diagnosed as having SIADH based on the diagnostic criteria of Bartter and Schwartz []. He was treated with fluid restriction and intravenous furosemide injections.
+Laboratory examination on the 23rd day after admission showed almost normal serum sodium levels (136 mEq/L) with normal serum ADH levels (1.2 pg/mL). His neurological symptoms, such as dizziness and dysarthria, also gradually resolved, and thereafter, hyponatremia was not observed."
+Juniper Kim,24,1996/7/27,754.407.3829,murphyvictor@example.net,81296 Torres Court Suite 275,"A 29-year-old white male farmer sought medical attention because of left upper-quadrant abdominal discomfort and unintentional weight loss of 8 kg. His initial clinical examination revealed light pallor and splenomegaly, 10 cm below his left costal margin. However, no lymphadenopathy or hepatomegaly was detected. Laboratory analysis showed a leukocyte count of 38 ? 109/L, a hemoglobin level of 10.5 g/dL, and a platelet count of 289 ? 109/弮L. He denied fever or drenching night sweats and was not taking medication.
+He was referred to our Department of Hematology, at our university hospital, where a bone marrow aspiration and biopsy were performed. Microscopic examination showed a left-shifted granulopoiesis, and the Ph + was found with no other chromosomic aberrations. BCR-ABL fusion transcript was identified by polymerase chain reaction (PCR) and both transcripts (b2a2 and b3a2) were present. The diagnosis of CML in chronic phase was made: Sokal score 0.85 (low risk <0.8; moderate risk 0.8 to 1.2; high risk >1.2) and Hasford score 741 (low risk <780; moderate risk 780 to 1480; high risk >1480).
+He was initially treated with hydroxyurea, which was later substituted by imatinib 400 mg daily starting in early January 2013. We observed a slow progression of the splenomegaly until complete spleen regression by 3 months. The first reevaluation was made at 3 months of imatinib (early response). During that period he showed no symptoms and gained weight (4 kg). Early response was detected through a cytogenetics analysis and quantitative polymerase chain reaction (qPCR) assessment. There was no cell growth to perform an analysis of the Ph + through the G-band method. Fluorescent in situ hybridization revealed 3.5 % of cells with the gene fusion, while PCR assessment was not conclusive due to the low quality of deoxyribonucleic acid (DNA). He was considered an optimal responder.
+He persisted on imatinib 400 mg for 6 months before the agent was discontinued because of pancytopenia. His neutrophil count fell to 0.5 ? 109/L, platelets dropped to 85 ? 109/弮L, and hemoglobin was 6.4 g/dL (Fig. ). Transfusion was not necessary. After imatinib cessation, we waited 1 week until a new hemogram was done. Because there was no improvement in his hemogram we decided to examine his bone marrow. A bone marrow study was performed showing complete remission of CML and numerous Leishmania amastigotes within the macrophages (Figs. and ). IgM antibody to Leishmania K39 antigen was positive. He was admitted to our hospital and began treatment with pentavalent antimonials. His hemogram started to improve at 10 days of leishmaniasis treatment and normalized by 2 months. New bone marrow aspirate showed no more leishmaniasis after 60 days of therapy. Complete recovery of symptoms and examinations (bone marrow and hemogram) was seen after that time (Table ).
+Acute cardiac toxicity required suspension from treatment. An electrocardiogram showed prolongation of the QT interval and bradycardia. The medication was stopped when his heart rate dropped below 45 beats per minute; it was replaced by amphotericin B regimen. After 3 months, TKI therapy was resumed and he again showed adequate response to imatinib. The last PCR showed deep molecular response (MR 4.0)."
+Roman Hanson,35,2004/8/28,5165696685,tinaharvey@example.org,7001 Christina Street Suite 397,"A 33 year-old woman presented with a history of moderate abdominal pain and recurrent nausea. Recently, she experienced lancinating pain in her right leg and hot flashes. She did not report unintended weight loss, fatigue or fever. Previously, she had undergone body contouring plastic surgery after a weight loss of 35 kg. She carried a levonorgestrel-releasing intrauterine device (IUD) for several months. Computed tomography (CT) revealed a retroperitoneal mass adjacent to the right psoas muscle. Since a retroperitoneal sarcoma was suspected, the patient was referred to our institution. The laboratory test yielded normal blood levels of chromogranin A, neuron-specific enolase, CA15-3, and CA125. Urine and blood samples did not show elevated production of catecholamines, vasoactive intestinal peptide or androgens. Gynaecological examination including transvaginal ultrasound showed normal findings and confirmed the correct position of the IUD. Magnetic resonance imaging (MRI) demonstrated a solid tumour (68 ? 35 ? 28 mm) between the anterior circumference of the right psoas muscle and the anterior surface of the third and fourth lumbar vertebra as well as laterally extending to the to the right ureter, the inferior vena cava and right common iliac vein (Fig. ). A CT-guided percutaneous core needle biopsy was performed to allow a histological diagnosis before surgery. The core biopsies contained only mature tissue with bundles of Schwann cells. Prominent, but also mature, ganglion cells were within the stroma, and there were no other histological signs of malignancy. Therefore, histopathological examination assumed a GN (Fig. ).
+Institutional interdisciplinary tumour board recommended a primary surgical resection. Prior to surgery, a double J stent was placed in the right ureter. Explorative laparotomy exposed the paravertebral tumour extending to the lower pole of the right kidney. The uterus and the adnexa with ovaries were without any pathological findings. After ureterolysis, the tumour was cautiously dissected from adherent structures such as the right common iliac vein and the kidney which were both not infiltrated by the tumour. Finally, the tumour was completely removed by means of blunt and sharp dissection and bipolar coagulation under a surgical microscope (the microscope has been used to save most of the branches of the lumbar plexus and nerves of the sympathetic trunk which was partly incorporated into the GN).
+Neuropathological examination of the tumour established the diagnosis of a typical GN with extremely low proliferation (Ki67 less than 1 %) and no evidence of a ganglioneuroblastoma. Within the tumour, a ganglion with mature ganglion cells was embedded and a peripheral nerve was observed being penetrated by the tumour (Fig. ).
+The postoperative course was uneventful. After surgery, the patient reported heat sensations of stocking distribution in the right lower leg. Follow-up 4 months after surgery still revealed a small hyperthermic area and stocking-like heat sensations in the right lower leg that was interpreted to relate to a lesion of the sympathetic trunk partly incorporated into the GN. MRI at follow-up did not show tumour recurrence.
+Clinical manifestations of GNs are diverse. In most cases, symptoms result from compression or displacement by the growing tumour and represent disturbances such as disruption of venous flow [] and lower abdominal pain []. Most GNs are located mediastinal or retroperitoneal. In addition, a primary intraosseous GN of the sacrum has been described as a rare manifestation []. GN usually represents a non-secreting tumour. Occasionally, GN may release hormones that can cause diarrhoea, sweating and arterial hypertension []. Tumours may also cause tenesmuses and weight loss []. In our case, we additionally observed lancinating pain in a leg most likely caused by irritation of branches of the lumbar plexus running along the anterior surface of the psoas muscle.
+Important differential diagnoses of retroperitoneal masses like the GN are retroperitoneal soft tissue sarcoma, and retroperitoneal fibrosis, and rarely lymphoma, a primary germ cell tumour, or metastatic testicular cancer.
+The complete removal of the GN is described as adequate therapy with an excellent prognosis. Nevertheless, surgical morbidity has to be considered. In a retrospective series of 146 children with GN, surgical tumour resection resulted in an excellent long-term survival, but, nevertheless, 22 of the 146 patients (15 %) suffered surgery-related complications, of which two were fatal and seven were severe (e.g. Horner syndrome, rupture of thoracic aorta and thoracic haemorrhage) []. Residual GN after incomplete resection remains stable for years without malignant transformation []. In addition, Retrosi et al. did not observe recurrences after incomplete excision in a series of 23 children with thoracic (n = 14), abdominal (n = 7) or pelvic GN (n = 3) []. Surgical complication rate reached 30 % []. Therefore, Retrosi and De Bernadi recommended less radical surgery in childhood GN to reduce surgery-related morbidity and mortality [, ]. Even a watchful waiting could be an option in selected cases after secured diagnosis. Interdisciplinary discussion and image-guided biopsy prior to surgery is recommended to prevent unnecessary expanded surgical approaches with significant postoperative morbidity. From our experience, we would suggest surgical resection of GN, but with a less radical approach in order to preserve the adjacent organs and structures where appropriate."
+Mariana Lin,43,1996/10/28,333-931-6595x0388,andrewwagner@example.com,53918 Sparks Harbor Suite 081,"A 27-year-old white man was hospitalized on 17 September 2014 with dyspnea and cough, which had started the day before, and a 1-month history of small-volume hemoptysis, which had aggravated in the last 24 hours. He also reported a history of weight loss, corresponding to 12 % of his corporal mass in the past year, but no other accompanying symptoms. He reported a cigarette smoking habit of 4 pack years, having occasionally smoked recreational drugs (cannabis). He was also professionally exposed to chemical toxics: thinners. There was no previous history of renal or pulmonary disease. No family disease was known and he had no other relevant findings in his past medical history.
+On examination at the time of admission he was apyretic, his respiratory rate was 29 breaths/minute, pulse rate was 118 beats/minute, and blood pressure (BP) was 151/86 mmHg. We observed pallor of his skin. Pulmonary auscultation revealed rales in his right hemithorax and left base. A chest X-ray (CXR) showed bilateral infiltrates (Fig. ). An analytical study (Table ) showed a normocytic normochromic anemia with a hemoglobin level of 7.2 g/dL and leukocytosis with normal renal function and coagulation times. His erythrocyte sedimentation rate was 34 mm/hour and procalcitonin level was 0.309 ng/mL at the time of admission. A urine analysis had no erythrocyturia or eosinophiluria. His oxygen saturation was 96.8 % on 21 % oxygen with no signs of carbon dioxide (CO2) retention and no electrolytic or acid-base changes. Chest computed tomography (CT) revealed a reticulonodular infiltrate of both lungs with extensive ground glass appearance (Fig. ).
+He was initially treated with aminocaproic acid 3 g orally every 8 hours and codeine 20 mg orally every 6 hours, having also completed 7 days of daily ceftriaxone 1 g administered intravenously and daily azithromycin 500 mg administered orally. Transfusion of two blood units was performed with an increase in hemoglobin count up to 8.9 g/dL (Table ) without complications. His serum urea and creatinine levels were 43 mg/dL and 0.78 mg/dL, respectively, at this time. A bronchoscopy performed on the second day revealed hematic traces with no other alterations or apparent lesions (Fig. ). On the fourth day of admission, he developed deterioration of ventilatory parameters and of respiratory rate (32 breaths/minute) needing oxygen supplement via high flow mask. Due to respiratory failure with a partial pressure of oxygen (pO2) of 48.3 mmHg and an oxygen saturation of 83.6 % on 100 % oxygen, he was transferred to our intensive care unit (ICU), but did not require mechanical ventilation. Sputum cultures were negative, as were the rapid urine antigen tests for Legionella pneumophila and Streptococcus pneumoniae. DNA analysis for Mycobacterium tuberculosis was negative, as were the studies for Influenza A, Influenza B, and Influenza H1N1, and the serologic markers for human immunodeficiency virus, hepatitis C and hepatitis B. Direct and indirect Coombs test were both negative. An echocardiogram was performed showing no significant findings. Serologic tests for auto-antibodies (antinuclear antibodies, anti-neutrophil cytoplasmic antibodies, and anti-GBM antibodies) were negative.
+After 5 days, he was transferred out of our ICU with a good clinical and analytical evolution (Table ). At the end of the tenth day his general state deteriorated with fatigue and hematuria (327 erythrocytes/L) and in 3 days he developed deterioration of renal function with a serum creatinine level of 4.55 mg/dL and a serum urea level of 189 mg/dL, with recurrence of hemoptysis and anemia, showing a hemoglobin value of 6.1 g/dL (Table ). His pO2 value dropped to 55.5 mmHg with an oxygen saturation of 89.4 % on 50 % oxygen. Immunosuppression with daily prednisolone 1g administered intravenously was initiated. An urgent bronchoscopy was repeated after new transfusion of three blood units, showing no evidence of lesion again. His hemoglobin level rose to 9.1 g/dL after the transfusion. A renal biopsy was performed 24 hours after the bronchoscopy and showed fibrinoid necrosis in glomeruli (19 glomeruli were assessed) and cellular crescents in 26 % of glomeruli (Fig. ). Immunofluorescence revealed a linear deposition of IgG, compatible with GS. Immunosuppressive therapy with daily cyclophosphamide 120 mg orally was added. Because of renal failure with a serum creatinine level of 5.13 mg/dL, he was transferred to a referral center where he underwent 21 sessions of plasmapheresis and four sessions of hemodialysis. Four weeks after initial presentation, his serum creatinine level was 1.8 mg/dL at the time of his discharge from the reference center. Over the course of 6 months, he completed treatment with daily prednisolone 60 mg orally and daily cyclophosphamide 100 mg orally, maintaining regular follow-up with out-patient nephrology, with currently no need of hemodialysis. No further episodes of hematuria or hemoptysis have been reported so far."
+Conor Rush,25,1992/10/20,656.575.3912x35380,qjohnson@example.net,1436 Powers Port Suite 237,"We report the case of an 8-year-old girl of Colombian origin and mixed race ancestry (Mestizo) who is the product of the first pregnancy of non-consanguineous parents; her mother was 32-years old and her father was 31-years old at the time of her gestation. Her mother? prenatal history shows no evidence of teratogen exposure or any other relevant exposures or pathologies. Ultrasound reports during weeks 14 and 25 of gestation showed no morphological alterations.
+Delivery care was performed at 38 weeks of gestation by spontaneous vaginal delivery, after which bilateral clubfoot and heart murmur were identified. An echocardiogram showed the presence of an atrial septal defect of 7.4 mm with a left to right shunt, dilated coronary sinus, subaortic interventricular communication of 4.8 mm and 6.8 mm with a left to right shunt. She underwent surgery for her congenital heart disease at 51-days old due to the presence of dyspnea, fatigue, anorexia, and diaphoresis. Currently she has a unicameral pacemaker.
+She is currently 8 years of age, and has the following clinical findings: delayed psychomotor and language development, cognitive deficits, anthropometric measurements within normal percentiles, upward slanting palpebral fissures, divergent strabismus, rotated and low-set ears, tall and broad nasal bridge, flat philtrum, bifid uvula, posterior cleft palate, increased anteroposterior diameter of the thorax, scoliosis, and umbilical hernia. Her extremities evidenced clinodactyly of her fifth bilateral fingertips, bilateral ulnar deviation, right thumb with the presence of two interphalangeal grooves, thenar hypoplasia, gait abnormality, bilateral clubfoot (corrected), bilateral sandal gap, nail split of the second toe of her right foot, and a social personality (see Figs. and ).
+Complementary studies were conducted: magnetic resonance imaging (MRI) of her brain evidenced brain stem and corpus callosum hypoplasia, and cortico-subcortical atrophy; thoracic spine MRI showed a left middle thoracic scoliotic curve (see Fig. ). Electroencephalogram had an abnormal vigil tracing with frequent repetitive discharge points, isolated biphasic spike, associated with right frontotemporal high voltage slow waves. Hip radiography confirmed bilateral coxa valga and hip subluxation; foot and ankle radiography documented a varus foot, her first metatarsal talus mechanical axis was altered by lateralization of the astragal axis, and the presence of ankle valgus.
+G-banding karyotyping was performed in 20 metaphases, which reported a 46,XX female; subsequently, chromosomal analysis was performed by CGH array that showed a loss of approximately 3.608 Mb on chromosome 21q22.3, and a copy number gain of 12.326 Mb on chromosome 7q35q36.3 (see Fig. ); these alterations affect approximately 112 and 186 genes, respectively (see Table ). Both copy number changes are terminal, which suggests an unbalanced translocation between chromosomes 7 and 21, resulting in a derivative chromosome 21.
+Complementary studies were performed with both parents using fluorescence in situ hybridization (FISH). The results showed our patient? mother has a reciprocal translocation between chromosomes 7 and 21 ish t(7;21)(q35;q22.3) (RP11-10L20-, RP11-75J5 +; RP11-75J5-, RP11-10L20 +)."
+Maleah Dudley,26,1989/12/26,8676576904,howellbrett@example.net,0006 Miller Wells,"A 51 year old woman with a 12 year history of hypertension developed hypokalemia (as low as 2.2 mmol/L). Her blood pressure was controlled with amlodipine 10 mg once daily and she received potassium supplements to maintain eukalemia. Her serum aldosterone was 2832 pmol/l with undetectable plasma renin activity. Her aldosterone to renin ratio (ARR) was therefore estimated at greater than 28,000 pmol/l/ng/ml/h (normal less than 2000 using renin activity of 0.1 ng/ml/h to avoid over-inflation). Her serum creatinine was 75 umol/l with eGFR of 85 ml/min. Abdominal CT showed a 3.5 cm low density left adrenal mass and adrenal vein sampling confirmed left lateralization with lateralization index values of 23:1 and 28:1 pre and post cosyntropin infusion. She underwent left adrenalectomy for what was reported as a 15.6 g adrenocortical adenoma on pathology. The post-operative biochemical course is presented in Table . At 2 weeks post-operative follow up, her blood pressure was 124/80, serum potassium 4.5 mmol/L and serum creatinine 52 umol/l without any medications. Her serum aldosterone was less than 70 pmol/l and renin activity of 0.36 ng/ml/h yielding ARR less than 194. However, at 6 weeks post-operative, she presented with serum potassium of 6.7 mmol/l, serum creatinine of 152 umol/l associated with persistent diarrhea (determined to be non-infectious) and clinical volume depletion. After fluid resuscitation she was started on fludrocortisone 0.1 mg daily and up-titrated to 0.1 mg bid over a 1-week period. At the higher fludrocortisone dose she became normokalemic and her serum creatinine decreased to 134 umol/l (Table ). One month later, her serum potassium continued to be 4.8 mmol/l and serum creatinine 112 umol/l and so a dose reduction in fludrocortisone was attempted but at 0.1 mg per day, her potassium promptly rose to 5.6 mmol/l with creatinine 140 umol/l. Hyperkalemia persisted in the fluid replete state. She was not on any medications causing hyperkalemia. In the context for fludrocortisone responsive hyperkalemia we did not calculate TTKG (trans tubular potassium gradient). The fludrocortisone dose was increased again with similar normalization of potassium and drop in serum creatinine but her resultant blood pressures rose to 160/100.
+Another attempt was made to decrease the fludrocortisone to 0.1 mg daily which was initially tolerable but by 2 months on this dose, her serum potassium was again found to be 6.4 mmol/l with creatinine 152 umol/l. This was transiently treated with higher dose fludrocortisone but the patient felt unwell on the medication, complaining of abdominal pain and so the drug was stopped in favour of furosemide 20 mg daily. Off of the fludrocortisone, her blood pressures were 135/88 but there was resultant hyponatremia, mild hyperkalemia and a sharp rise in serum creatinine to 188 umol/l and so the furosemide was stopped in favour of a return to fludrocortisone once more. Again, her potassium normalized to 4.5 mmo/l with drop in serum creatinine to 127 umol/l. Nephrology was consulted and the patient started on sodium bicarbonate 650 mg tid with cessation of fludrocortisone. During the last 8 months of such therapy, her blood pressures have been normal (122/88), potassium levels have been near-normal (5.2 mmol/l) with stable renal function (creatinine 160 umol/l, eGFR 31 ml/min)."
+Colter Montoya,33,1980/9/10,885-305-3802x04041,lparsons@example.org,2274 Gibson Row,"A 60 year old man with a 30 year history of hypertension and serum potassium as low as 2.9 mmol/l was referred for assessment. At presentation he required five antihypertensive agents to control his blood pressure which ranged from 130-150/80-100. His medications were perindopril 8 mg once daily, irbesartan/hydrochlorothiazide 300/25 mg once daily, nifedipine 60 mg twice daily and carvedilol 6.25 mg twice daily. After temporarily stopping carvedilol, irbesartan/hydrochlorothiazide and perindopril, his serum aldosterone was 1041 pmol/l with plasma renin activity of 0.2 ng/l/s yielding an aldosterone to renin ratio (ARR) of 5205 pmol/l/ng/ml/h (normal less than 2000). CT abdomen showed a multinodular left adrenal gland with a 1.3 cm dominant nodule. Adrenal vein sampling (AVS) showed left lateralization with lateralization indices of 4:1 and 12:1 pre and post cosyntropin infusion. Preoperative serum creatinine and GFR were 77 umol/l and 60 ml/min respectively. He underwent left adrenalectomy for 1.5 cm adrenocortical adenoma in the setting of background adrenal hyperplasia. At 4 weeks follow up his blood pressure was 128/80, serum creatinine 77 umol/l, serum aldosterone less than 70 pmol/l with renin activity of 0.31 ng/l/s yielding ARR of less than 225 pmol/l/ng/ml/h. At that time his irbesartan/hydrochlorothiazide was discontinued and nifedipine was reduced to 60 mg daily instead of twice daily and he continued to take carvedilol and perindopril. At 2 months follo up his serum potassium was found to be 6.0 mmol/l and serum creatinine 141 umol/l. He admitted using four pills of Ibuprofen for a fall related injury. At that visit his ACE inhibitor was stopped. A day later his serum creatinine came down to 121 umol/l but potassium remained at 5.9 mmol/l. He was started on fludrocortisone 0.05 mg daily. Two months later his serum creatinine was 115 umol/l and potassium 5.3 mmol/l. He did not have clinical signs of volume depletion and no other apparent reason for high potassium was found; therefore he was switched to furosemide 20 mg once daily. He required loop diuretic to normalize his serum potassium for 6 months after which it was stopped as his serum potassium remained 4.5??.9 mmol/l without further intervention. At that time his only medications were nifedipine 60 mg daily and carvedilol 6.25 mg daily. At 15 months post-operative, he was successfully weaned off of carvedilol and his only continuing medication was nifedipine 30 mg daily with average blood pressures of 136/90."
+Kamryn Kaur,19,1990/4/13,001-304-817-4272,perezcynthia@example.org,175 Alvarado Divide Suite 775,"A 52 year old woman with type 2 diabetes and congenital right kidney aplasia was referred with a 12 year history of hypertension and hypokalemia as low as 2.3 mmol/l. At presentation she required amlodipine 10 mg once daily, telmisartan 80 mg once daily and spironolactone 25 mg once daily to maintain normotension and eukalmeia. Off of spironolactone, her aldosterone was 1157 pmol/l and direct renin was 3 ng/l yielding ARR of 368 pmol/l/ng/l (normal < 60 using the newer direct renin assay). CT abdomen showed 1.5 cm hypodense left adrenal mass. AVS showed left lateralization with lateralization index of 20:1 pre and post stimulation. Preoperative GFR was 69 ml/min and serum creatinine of 80 umol/l. She underwent adrenalectomy for what was reported as 2 cm adrenal cortical mass with no surrounding hyperplasia. Two weeks after the surgery she presented to emergency department with intermittent nausea and vomiting. Her serum potassium was 6.3 mmol/l and serum creatinine was 150 umol/l. After fluid resuscitation her serum potassium dropped to 5.1 mmol/l but creatinine persisted at 160 umol/l. She was started on sodium bicarbonate 650 mg bid. At 2 weeks follow up her serum creatinine was 208 umol/l and potassium remained at 5.1 mmol/l. She did not require any more antihypertensive medications and her blood pressure was 140/70. She was started on fludrocortisone 0.05 mg once daily and at 1 week follow up lab work her serum creatinine reduced to 170 umol/l with serum potassium of 5.2. She is currently on fludrocortisone 0.05 mg once daily."
+Augustine Bautista,32,1992/10/5,360.774.6480x759,brennankelly@example.com,19087 Carlos Oval,"A 6-year-old Iraqi boy of Arab-Asian ethnicity who had developed cerebral palsy (CP) with mental retardation and epilepsy after encephalitis at the age of 9 months. Since that time, he had been treated with oral VPA (30 mg/kg/day, twice a day) to control the seizures. His family history was unremarkable apart from that his next older brother had acute lymphoblastic leukaemia and died due to severe infection a year and a half before the birth of this case of KS. Our patient was the youngest among 4 siblings of healthy second-cousin parents. The other 2 older siblings are healthy. Our patient suffered from recurrent respiratory tract infections and was hospitalized twice. The latest episode was on December 1st, 2013 when he was 6 years-old. Although he had middle lobe atelectasis, he responded well to a 1-week treatment with non-specific antibiotic and his chest roentgenogram showed improvement.
+One week after being discharged from the hospital, painless skin lesions appeared in the form of a bluish-purple plaque (blue-violet to black hue) on the middle and little toes of his left foot and extended to the upper lateral sole area (Fig. ). Physical examination revealed a spastic quadriplegic type of CP, mentally subnormal with open mouth, mouth breathing, and misalignment of the teeth with malocclusion. He was in full-body hypertonia with legs being affected more than arms and hyperreflexia with clonus. Systemic examination of the chest revealed harsh vesicular breath sound and normal heart sounds. His abdomen was soft, with no organomegaly, mass or free fluid. The investigations performed included complete blood count, blood film, erythrocyte sedimentation rate, coagulation profile, blood chemistry, liver and renal work-up, urinalysis, chest x-ray and ultrasound examination of the abdomen were all normal. Serological screening for hepatitis B and C as well as HIV was negative.
+In January 2014, palpable bluish-purple nodules appeared on the left leg and then on the right leg. The skin discoloration extended to the plantar surface, and edema of the left foot became obvious (Fig. ), but peripheral arterial pulse and the perfusion in the lower extremities were intact. A skin biopsy was taken on February 15th, 2014 from the lesion on the left foot, thereafter the patient experienced pain. During February and March 2014, new skin nodules appeared in an ascending pattern: 2 around the groin, 2 on the left arm, 1 in the right sub-axillary area, and on the face (medial angle of left eye and both ear cartilages) (Fig. , ). Small cervical lymphadenopathy also became palpable. Meanwhile, a purple, slightly elevated lesion erupted on the hard palate. He was kept on his VPA dose with no additional therapy apart from analgesic agents, as the family refused hospital admission. On April 3rd, 2014 the patient had developed sudden respiratory distress, and died before arrival to the hospital just 3 days before getting his final biopsy test results.
+The skin biopsy material was re-evaluated in Japan because of the lack of facilities for HHV-8 detection in Iraq. The results are presented in Fig. , the spindle cells reacted with monoclonal antibodies against CD34 and CD31 antigens. Additionally, these cells were positive for HHV-8, hence the diagnosis of KS was confirmed. The ?ARE??checklist is available as Additional file 1. This child? clinical course is summarized in the accompanying supplemental time-line file (Additional file 2)."
+Antonella Wong,26,1991/1/12,(641)865-7128x73112,ryanrichmond@example.org,0703 Hernandez Divide Apt. 492,"A 66-year-old woman presented to our outpatient services in 2011 with the complaint of progressively puffy eyelids on both eyes in the most recent 3 months. Her past medical history showed hypertension, type 2 diabetes mellitus, ischaemic heart disease, and end-stage renal disease. Additionally, she had been undergoing haemodialysis three times a week since 2009 (3 years ago). With the history of chronic haemodialysis, in 2011, a computed tomography angiography (CTA) revealed an occlusion of the right subclavian vein at the junction with the superior vena cava (SVC), and there was a subtotal occlusion at the SVC orifice in the arteriography (Fig. ). Progressively, her appearance changed, with marked oedema of the face and neck, but without any obvious lymphadenopathy or palpable mass on the neck (Fig. ). Additionally, she experienced dyspnoea and intermittent nocturnal coughing. The patient received cataract surgery for both eyes 10 years ago. There was no use of corticosteroids in her medical records and no positive family history of glaucoma.
+A general inspection revealed the orthotropic primary ocular position without proptosis. The eyelids were swollen without tenderness or local heat, and initially, the intraocular pressure was normal. There was moderate congestion of the conjunctiva in both eyes; the corneas were clear, and the anterior chambers were deep and quiet. In 2013, two years after SVC syndrome was diagnosed, pneumatic tonometry revealed bilateral high IOP (22 mmHg OD, 23 mmHg OS) compared to a prior visit. Then, the IOP increased progressively to 30 mmHg, even with the combined use of brimonidine, dorzolamide and latanoprost, which was aimed at controlling IOP. At that time, the patient? best-corrected visual acuity (BCVA) was 20/60 in the right eye and 20/400 in the left eye. Gonioscopy demonstrated wide-open angles in both eyes without peripheral anterior synechiae or neovascularization of the angle. Upon fundus examination, the cup-to-disk ratio was found to have increased to 0.7 in both eyes after one and half years of treatment with an anti-glaucoma agent. Optical coherence tomography showed the superior and inferior thinning of the retinal nerve fibre layer (RNFL) in both eyes, which was worse on the left side. Specifically, the patient had an average RNFL of 65.57 弮m in the right eye and 47.51 弮m in the left eye. Standard automated perimetry showed a three-fourths quadrant depression in the right eye and more generalized depression in the left eye; the mean deviations were -17.57 and -27.07, respectively.
+Due to the progressive course of glaucomatous change, we suggested that the patient first have filtering surgery for the left eye. We performed a trabeculectomy, which resulted in a postoperative IOP reduction (from 30 to 12 mmHg) on the first day. No complications occurred intraoperatively and none was reported at the one-month post-operative review. However, over the next three months, although the filtering bleb significantly elevated, the intraocular pressure (IOP) increased gradually, reaching approximately 40 mmHg (Fig. ). Subsequently, this patient received the placement of one ExPRESS miniature glaucoma device P200 (Fig. ), which resulted in the lowering of the IOP (from 45 to 17 mmHg), and no further deterioration of visual acuity occurred 6 months after this intervention, while the IOP of the other eye still ranged between 33 and 35 mmHg.
+During the management of intractable secondary glaucoma, we reviewed the patient? past medical history and image data and found that the patient was susceptible to vascular thrombosis and stenosis, as evidenced by the high venous pressure observed during haemodialysis, and while creating the vascular shunt, repeated angioplasty and thrombectomy for venous outlet thrombosis were required. There were multiple attempts at creating vascular accesses during the initial 2 years. First, a right neck Hickman catheter was inserted for temporary haemodialysis access, after which a second was placed in her right arm, but failed within a short time. Third, an arteriovenous fistula (AVF) was created in the left arm with a radial arterial-cephalic vein anastomosis, which failed in three years and was replaced by an arteriovenous graft (AVG) between the brachial artery and the axillary vein in the left arm after 6 months. The patient had been under haemodialysis via AVG since then, but encountered acute occlusion once and received a balloon percutaneous transluminal angioplasty (PTA). In 2011, the patient was admitted once for SVC syndrome after an unsuccessful attempt to place a Hickman catheter from the right and left internal jugular vein to bypass the complete obstruction of the right subclavian vein and right brachiocephalic vein. PTA was performed unsuccessfully, despite the spontaneous resolution of oedema on the left side of the face. However, the patient presented with intermittent recurrence and indolent face and neck oedema afterwards. Over the next 3 years, marked SVCS, accompanied by uncontrollable IOP, led to irreversible glaucomatous optic neuropathy. Although femoral double lumen creation and venous bypass construction were suggested as alternative haemodialysis access routes, along with the ligation of the previous AVF in the left arm, the patient refused any cardiovascular surgical options."
+Walter Copeland,40,1997/10/16,001-537-994-4949,ppoole@example.com,369 Francis Harbors,"A 32 year old married African female from the North west region of Cameroon, G4P4004 (four previous pregnancies, four term deliveries, no abortion, no preterm deliveries, and four living children), with a history of mild recurrent right iliac fossa (RIF) pain presented at our emergency service with an acute exacerbation of the pain over a 2 day duration and an episode of post prandial vomiting. She reported anorexia, and a low grade fever. She had no past history of a sexually transmitted infection.
+On examination, she was ill looking, tachycardic (pulse rate = 144 beats per minute) and febrile (maximum temperature = 38.4 簞C). She had a RIF tenderness, and positive Blumberg? (Rebound tenderness at the RIF), Rovsing? (increased pain at the RIF on deep palpation of the left iliac fossa), Obturator (abdominal pain on flexion and internal rotation of the hip) and Psoas (abdominal pain on passive extension or active flexion of the thigh at the hip) signs.
+A full blood count revealed a leucocytosis at 13,000 cells/mm3. A urinalysis and stool exam were normal and a pregnancy test was negative. The patient had a total Alvarado? score of 10 and a diagnosis of an acute appendicitis was further advocated by an abdominopelvic ultrasound which showed; an indistinct mass in the RIF, an inflammed appendix and collection of fluid in the pouch of Douglas. A diagnosis of an acute appendicitis associated with an indistinct RIF fossa mass was proposed, and an exploratory laparotomy via a midline infra-umbilical incision was performed.
+Intraoperatively, an inflammed, suppurative, and distorted right fallopian tube measuring 8 ? 4 cm, attached to the caecum and the terminal ileum by means of pseudo-membranes was found compressing and occluding the lumen of an inflammed appendix (Figs. , ). There was extensive damage of the right tube with complete obliteration of its lumen rendering saline irrigation and intraluminal adhersiolysis impossible. The left fallopian tube was also inflammed, measuring 4 ? 4 cm and discharging pus. The ovaries and uterus were macroscopically normal. A right salpingectomy and classical appendectomy were done. The pus from the left fallopian tube was drained, and the tube irrigated with normal saline followed by abdominal lavage. A pus sample was collected but could not be analysed due to financial constraints.
+The patient was therefore placed on intravenous (IV) antibiotics and the post-operative period was uneventful. The patient had positive Chlamydia Immunoglobulin M titres and a negative TPHA (Treponema Pallidum Haemagglutination Assay) test. She and her spouse were treated with doxycycline 200 mg once daily and metronidazole 500 mg 8 hourly upon discharge to complete a 14 day course of treatment. She returned for a follow up visit 2 weeks later with no further complaints."
+Dayana Patel,45,2000/8/19,361.727.6383x816,djohnson@example.org,39384 Kyle Throughway Apt. 625,"A 46-year-old Syrian Alawis woman without a significant personal or familial medical history presented with a 1-month history of multiple sclerosis, fatigue, loss of weight, fever, and an elevated white blood cell (WBC) count. An initial evaluation revealed that she had anemia (8.5 g/dL), leukocytosis (total leukocyte count 134 ? 109/L), and thrombocytopenia (23 ? 109/L). She was pale and did not have lymphadenopathy.
+Our patient was transferred to the hospital because she was unconscious and making noise during breathing. Novel hematological parameters included anemia (8.2 g/dL), thrombocytopenia (29 ? 109/L), leukocytosis (229 ? 109/L), a plasma concentration of fibrinogen of 37 mg/dL (normal value, 200??00 mg/dL), and a prothrombin time of 18 s (normal value, 10.0??3.0 s). She received several blood transfusions. Our patient stayed in the hospital for 1 week. On the same day of treatment initiation with ATRA (45 mg/m2 daily dose), our patient died, 10 days after her diagnosis. An autopsy revealed death was due to hemolysis, intracranial hemorrhage, thrombocytopenia, and DIC. Cytogenetic and immunophenotyping analyses were also carried out. Our patient was diagnosed with APL according to the World Health Organization (WHO) classification and was considered high risk based on her WBC. Her brother gave consent for a scientific evaluation of her case and the study was approved by the ethical committee of the Atomic Energy Commission, Damascus, Syria.
+A chromosome analysis using GTG-banding was performed according to standard procedures [] before treatment with ATRA and revealed a karyotype of 46,XX,t(15;17)[8]/46,XX,t(1;2),t(15;17)[11]/46,XX [1] (Fig. ). Further studies were performed based on molecular cytogenetics (Figs. and ). Dual-color fluorescence in situ hybridization (D-FISH) using a specific probe for PML and RARA (Abbott Molecular/Vysis, Des Plaines, IL, USA) revealed the presence of the PML/RARA fusion gene on der(15) (Fig. ). Chromosomes 1, 2, 15, and 17 were studied with Whole Chromosome Paint (WCP) probes (MetaSystems, Altlussheim, Germany) [], which did not provide any information on the cryptic translocations (data not shown). Array-proven high-resolution multicolor banding (aMCB) [] was performed using probes corresponding to chromosomes 1 and 2, which were identified by GTG-banding as being involved (Fig. ). The following final karyotype was determined prior to chemotherapy treatment using a fluorescence microscope (AxioImager.Z1 mot, Carl Zeiss Ltd., Welwyn Garden City, UK) equipped with appropriate filter sets to discriminate between a maximum of five fluorochromes plus the counterstain DAPI (4',6- diamino-2-phenylindole). Image capture and processing were performed using an ISIS imaging system (MetaSystems, Altlussheim, Germany):
+46,XX,t(15;17)(q22;q21)[8]/46,XX,t(1;2)(q42~43;q11.2~12),t(15;17)(q22;q21)[11]/46,XX[1].
+Image capture and processing were performed using an ISIS imaging system (MetaSystems).
+Immunophenotyping was performed using a general panel of fluorescent antibodies against the following antigens typical for different cell lineages and cell types: CD1a, CD2, CD3, CD4, CD5, CD8, CD10, CD11b, CD11c, CD13, CD14, CD15, CD16, CD19, CD20, CD22, CD23, CD32, CD33, CD34, CD38, CD41a, CD45, CD56, CD57, CD64, CD103, CD117, CD123, CD138, CD209, CD235a, and CD243. In addition, antibodies to kappa and lambda light chains, IgD, sIgM, and HLADr were tested. All antibodies were purchased from BD Biosciences, San Jose, CA, USA. Samples were analyzed on a BD FACSCalibur??flow cytometer. Autofluorescence, viability, and isotype controls were included. Flow cytometric data acquisition and analysis were conducted by BD Cellquest??Pro software. Flow cytometric analysis of a peripheral blood specimen from our patient characterized this case as APL according to WHO classifications. The abnormal cell population (97 % of tested cells) was positive for MPO++, CD45+dim, CD34?? HLADr?? CD33+, CD13+, CD16?? CD64+, CD15+dim, and CD14??"
+Parker Boyle,28,1981/3/6,848-909-2740,jennifer63@example.net,45154 Crystal Ville,"An 85 year-old Caucasian gentleman with hypertension, paroxysmal atrial fibrillation, hypothyroidism, stage 3 chronic kidney disease, mixed ischemic and non-ischemic cardiomyopathy, severe biventricular systolic dysfunction, secondary prevention cardiac resynchronization therapy device implant with defibrillator function, and frequent monomorphic VT presents with VT storm. Heart failure medical therapy was optimized and included beta-blockade. A prior trial of sotalol therapy provided no arrhythmia suppression. Amiodarone therapy provided some relief, particularly when augmented by mexilitine therapy, however drug-related lung and neurologic toxicities limited amiodarone use. Transvenous catheter VT ablation was attempted however the arrhythmia recurred a month later.
+On presentation, the patient had recurrent VT at 215 beats per minute. 12-lead electrocardiography revealed a monomorphic wide complex tachycardia with left bundle branch block like morphology, inferior axis, and late precordial transition. His arrhythmia precipitated frequent appropriate implantable cardioverter defibrillator anti-tachycardia pacing and shocks therapies. There was no evidence of ongoing reversible myocardial ischemia or metabolic and electrolyte abnormalities.
+Given his severe biventricular failure, prior sotalol and mexilitine failure, and drug-toxicities with amiodarone, antiarrhythmic options were limited. The patient was not a good candidate for a repeat ablation procedure or cardiac transplantation given his age and frail status. Having exhausted antiarrhythmic options, dronedarone therapy was considered for off-label use. After discussing potential benefits and risks regarding dronedarone use in the treatment of VT based on the limited data available in the scientific literature, the patient consented to an off-label trial of the agent at 400 mg twice daily. After only three doses, it was discontinued due to severe nausea and the development of multisystem organ failure including acute severe hepatotoxicity. This brief trial of dronedarone therapy had no appreciable effect of the patient? VT burden. The duration of the VT episodes was brief and not felt to be the cause of the patient? multi-organ failure that was temporally associated with the initiation of dronedarone therapy. Five days prior to dronedarone administration, the patient? serum alanine transaminase was measured at 59 U/L (normal 11??3 U/L), serum creatinine at 135 umol/L (normal 50??20 umol/L), and estimated glomerular filtration rate at 41 mL/min/1.73 m2 (normal >80 ml/min/1.73 m2). Two days after dronedarone administration a marked decline in kidney and liver function was observed with a serum alanine transaminase level increase to 1045 U/L, serum creatinine level of 231 umol/L, and estimate glomerular filtration rate of 21 ml/min/1.73 m2. Dronedarone therapy was subsequently discontinued. Unfortunately the patient? liver and renal failure continued to worsen despite drug discontinuation. He died eight days later from multi-organ system failure and metabolic shock."
+Aliya Blair,21,1992/8/25,6598881065,cortezangela@example.net,354 Smith Stravenue,"A 53-year-old white woman presented with increasing fatigue, loss of appetite, and severe epigastric pain radiating to her back. She had a history of MTC (pT2pN1b), diagnosed 25 years ago and treated by complete thyroidectomy and bilateral cervical lymph node dissection, followed by repeated surgical resection of lymph node metastases 19 and 12 years ago. No further specific treatment modalities (for example radiotherapy) had been employed. No genetic analysis had been performed for germline or somatic RET proto-oncogene mutations, nor for other somatic mutations (HRAS, KRAS, NRAS). On clinical examination, however, there was no indication of other manifestations of multiple endocrine neoplasia type 2 (MEN2), especially no clinical signs of pheochromocytoma. Since data on the RET proto-oncogene status have been missing in our patient, no risk category (moderate, high, highest) according to the revised American Thyroid Association Guidelines for the management of MTC [] had been assigned. However, based on the American Joint Committee on Cancer (AJCC) TNM-Classification, the MTC had been a stage IV A tumor (pT2pN1b) at the time of the initial complete thyroidectomy in our patient. Post complete thyroidectomy, she had hypoparathyroidism, which was treated with calcium and calcitriol. She received levothyroxine replacement therapy. Repeated biochemical and clinical evaluations during the course of the disease did not demonstrate any signs of paraneoplastic adrenocorticotropic hormone (ACTH) and/or corticotropin-releasing hormone (CRH) secretion. Medical therapy of the MTC included octreotide 20 mg every 4 weeks, which was switched to the tyrosine kinase inhibitor vandetanib 300 mg/day 11 month ago when computed tomography (CT) scanning revealed progressive mediastinal lymph node and diffuse and symptomatic pulmonary metastases.
+Standard laboratory tests in our patient revealed moderate leukocytosis (18.3 G/l) as well as slightly elevated serum CRP levels (12.58 mg/l); her serum lactate was 5.5 mmol/l. Pancreatitis was ruled out because her serum amylase and lipase levels were within normal range. An upper endoscopy was performed and demonstrated multiple centrally ulcerated lesions in her gastric mucosa of up to 4 mm in size (Fig. ). Two-phase contrast-enhanced multi-detector CT of her chest and abdomen revealed stable pulmonary and mediastinal lymph node metastases; however, there was a single new intrahepatic lesion of 4 mm size suspicious for liver metastasis. Contrast-enhanced multi-detector CT of her neck revealed multiple, new, centrally hypodense supraclavicular lesions up to 12 mm in size suggestive of lymph node metastases. In addition, multiple noduli within her stomach wall were apparent (Fig. , I?II). Three-phase bone scintigraphy showed no evidence of bone metastasis.
+Additional laboratory tests revealed a dramatic increase in her basal serum calcitonin levels from 563 pg/ml to 6487 pg/ml within 2 months, indicative of rapid tumor progress of the underlying MTC. Of interest, at the same time she had rather stable carcinoembryonic antigen (CEA) serum levels of 40.7 ng/ml (from 62.3 ng/ml 14 months earlier). Histologic and immunohistochemical analyses of gastric biopsy specimen demonstrated diffuse mucosal infiltration of MTC (Fig. ) with a KI-67 index of up to 40 %, proving metastatic disease of MTC to the gastric mucosa. Of note, while immunohistochemical analysis of calcitonin was strongly positive (Fig. ), staining for CEA demonstrated merely focal and weak staining (Fig. ); staining for thyroglobulin remained completely negative (data provided in Additional file ). She rapidly deteriorated and died due to multiorgan failure before third-line treatment could be initiated."
+Troy Sullivan,28,2002/10/14,460-983-4661x21279,onealkatherine@example.org,9704 Scott Island,"A 37-year-old woman went to the clinic of a local hospital because of abdominal pain and hematochezia for one week. Colonoscopy examination showed a polypoid mass protruding into the rectum cavity, measuring approximately 5 cm in maximum diameter, with a rough and uneven surface (Fig. ). Then the patient underwent a partial rectectomy. The lesion was considered as a myogenic sarcoma, preferring pleomorphic leimyosarcoma by the referring pathologists. The postoperativ adjunctive therapy was not administrated . There was no evidence of recurrence or metastasis 8 months after surgery."
+Melanie Jones,40,2005/7/17,001-682-453-0285x014,bryanhernandez@example.org,989 Fischer Skyway,"The patient was a 55-year-old man who complained of abdominal pain and distension lasting for two days. Physical examination showed abdominal mass with tenderness. No obvious mass was found by colonoscopy. X-ray displayed intestinal obstruction. Computed tomography (CT) scan demonstrated a solid mass in the pelvic cavity (Fig. ). Clinically, the lesion was suspicious of gastrointestinal stromal tumor (GIST). Intraoperatively, the mass was found on the terminal ileum nearing the ileocecal junction. Partial ileal resection and appendectomy with intestinal anastomosis were performed shortly after. The lesion was originally diagnosed as malignant mesothelioma by the referring pathologist. After reevaluation of the H&E slides with application of immunohistochemistry and FISH analysis, the diagnosis of EIMS was finally rendered. The patient developed local recurrence 2 months after surgery. A re-excision of the recurrent tumor with adjuvant chemotherapy was performed. He was free of disease at 10-month follow up."
+William Patton,23,1997/7/30,-7321,xrodgers@example.net,6876 Harris Keys Apt. 674,"A 22-year-old young man presented with abdominal mass with intermittent abdominal pain for eight days and fever for five days. Subsequent CT scan revealed a solid heterogeneous mass of the right abdominal cavity, suspicious of GIST. After the admission, the patient underwent a complete excision of the abdomen mass and partial transverse colectomy soon. Intraoperatively, an enormous mass measuring approximately 20 ? 15 cm was identified, with multiple small omental or mesenteric nodules. Pathological examination of the submitted specimen showed that malignant tumor was suspected as GIST. To confirm the diagnosis, the pathological materials were sent to our department for further consideration. With the adjunctive study of immunohistochemistry and FISH, the lesion was re-diagnosed as EIMS. The patient developed local recurrence 2 months after surgery. The targeted therapy of ALK inhibitor (crizotinib) was administrated later. He achieved a partial response to the treatment. He was alive with disease at 14-month follow up."
+Lorelei Nelson,44,1993/6/9,001-703-713-2217,nwatson@example.org,46256 Daniel Mountain Suite 082,"The patient was a 58-year-old woman who complained of a slowly enlarging and painless mass on the abdomen for two months. Physical examination showed an ill-defined solid mass of the right lower abdominal wall with no tenderness. Then she received a local resection. Intraoperative examination revealed that the mass was firm in consistency and infiltrated into the skeletal muscle of the abdomen wall. Pathologically, the tumor was considered as pleomorphic sarcoma by the referring pathologist. After surgery, the patient was treated with the additional chemotherapy. She developed local recurrence 2 months later and died of disease at 8-month follow-up."
+Dylan Hudson,40,1995/7/2,931.643.0338x10215,eharris@example.net,6923 Jamie Rapids,"A 15-year-old young woman complained of recurrent abdominal pain for four months and abdominal mass for four days. Physical examination revealed a well-defined solid mass of the right abdomen with mild tenderness. Ultrasonography displayed an abdominal tumor with heterogeneous internal echoes, measuring about 10.2 ? 7.5 cm. Subsequently, the patient received a complete excision of the abdomen mass and partial transverse colectomy. During the operation, the tumor was identified on the transverse colon and measured approximately 12 ? 8 cm, with multiple enlarged omental or mesenteric lymph nodes. The lesion was considered as fibrosarcoma with inflammatory cell infiltrates by the referring pathologist. After surgery, the patient did not receive the adjunctive therapy. She was free of disease at 7-month follow up."
+Kamila Nichols,27,2003/12/28,(397)307-8203,kim40@example.com,10968 Carlson Street Suite 354,"A 63-year-old man was referred to our hospital because of pain, redness and swelling in his left leg persisting for 1 month. At the onset of symptoms, he consulted the neighboring dermatological clinic where he was diagnosed with cellulitis. Antibiotics and nonsteroidal anti-inflammatory drug were administrated, but his symptoms did not improve. After 1 month, he was referred to our VTE specialist department.
+The patient had a history of hypertension, which was treated with a calcium channel blocker and an angiotensin receptor blocker. At the initial examination, his body mass index was 33 kg/m2, the vital signs showed a mildly elevated blood pressure (134/84 mmHg) and his peripheral oxygen saturation was 98 % in ambient air. The physical examination revealed a tender and swollen left leg. Laboratory test showed elevated levels of urinary acid (8.3 mg/dL) and blood glucose (116 mg/dL). His HbA1c was 5.7 %. Prothrombin and partial thromboplastin times were normal, although D-dimer concentrations were increased to 5.9 ���g/mL (normal, <1.00 弮g/mL). Plasma protein C, protein S, and antithrombin levels were within normal limits, and creatinine clearance was 113.8 mL/min, as calculated using the Cockcroft?ault method. Chest X-rays showed no abnormalities. Echocardiography was significant for mild concentric left ventricular hypertrophy with normal left ventricular function and showed no signs of increased right ventricular pressure.
+DVT was suspected because of the patient? symptoms and elevated D-dimer concentrations. Ultrasonography revealed a thrombus in the left but not in the right femoral vein (Fig. ), and computed tomographic angiography revealed clots in the right distal pulmonary artery. The maximum circumference of the thighs showed a swelling in the left leg (left calf: 47 cm, left ankle: 28.5 cm, right calf: 44 cm, right ankle: 27 cm).
+We instructed the patient to wear medical compression stockings and provided the anticoagulant treatment with subcutaneous injections of fondaparinux (7.5 mg once daily for 5 consecutive days on an outpatient basis), followed by oral administration of edoxaban (60 mg once daily from day 6). Different from western countries, the self- injection of fondaparinux is not allowed in Japan, so the patient was required to visit the hospital every day. After 2 weeks, swelling of the left leg improved, although redness and pain persisted. Subsequent ultrasound examination of the leg after 3 months of treatment with edoxaban revealed no clots in the left superficial femoral vein and soleus muscle vein. Moreover, D-dimer concentrations had dropped to normal levels, indicating decreased activation of secondary fibrinolysis. However, because some clots were still observed in the popliteal vein (Fig. ), treatment with edoxaban was continued.
+After 6 months, the swelling and redness in the lower leg had completely disappeared, and D-dimer concentrations remained normal. Ultrasonography showed further regression of the clots in the left popliteal vein, leaving only mural thrombi (Fig. ). Throughout the treatment period, doses of fondaparinux and edoxaban were not changed, and no bleeding complications occurred. The symptom of recurrence of pulmonary embolism was not observed during the clinical course. We suggested to end the edoxaban therapy after 6 month, but the patient hoped for a continuation of the anticoagulation therapy.
+Until recently in Japan, proper management of DVT required continuous antithrombotic therapy using unfractionated heparin followed by VKA administration within the optimal therapeutic range. In Japan, fondaparinux was approved in 2011. The approval of fondaparinux injections for VTE has relieved patients and physicians of the need for complex dose adjustments, 24-h infusion control, and blood tests every 6 h. Fondaparinux is associated with recurrent VTE and major bleeding rates similar to those occurring with intravenous unfractionated heparin (UFH) [, ]. The reasons for outpatient treatment in this case were that the patient was hemodynamically stable and did not suffer from renal failure, cancer, massive pulmonary embolism, heart failure, or bleeding. Furthermore, he had a good understanding about his illness.
+Edoxaban was approved in Japan prior to the world as an oral factor Xa inhibitor, and the ESC guidelines recommend the use of edoxaban following acute-phase parenteral anticoagulation therapy. Dabigatran also gained approval as an oral VTE treatment following acute-phase parenteral anticoagulation therapy by Europe and United States besides Japan.
+The RE-COVER and Hokusai-VTE trials mandated at least 5 days of heparin or low molecular weight heparin (LMWH) treatment prior to initiation of dabigatran or edoxaban [?. Dabigatran and Edoxaban both showed a no inferiority to warfarin for the prevention of recurrent VTE, and a significantly lower risk of major bleeding. Additionally, a lower proportion of the administered dose of edoxaban is eliminated via the kidneys (35 %) compared to dabigatran (85 %) [, ]. The pharmacokinetics of edoxaban were not affected by enoxaparin, whether administered concomitantly or 12 h apart []. Edoxaban is a once daily tablet, which is easier to swallow than dabigatran. In addition, dabigatran is not approved for VTE treatment in Japan. These reasons led us to choose this regimen using fondaparinux and edoxaban in this case.
+The ACCP guideline stated that in patients with acute DVT of the leg, the guideline suggest early ambulation over initial bed rest (Grade 2C), and that in patients with acute DVT of the leg and whose home circumstances are adequate, the guideline recommend initial treatment at home over treatment in hospital (Grade 1B). Unfortunately this patient couldn? be hospitalized, so we started the anticoagulant therapy carefully. According to the RIETE registry [], home treatment of DVT is appropriate in younger men with adequate weight who have no complications of heart failure, respiratory diseases, or cancer. Additionally, we suggest that patients must also understand their condition of illness, visit the hospital daily for fondaparinux administration at least 5 days, and put on and remove medical stockings by themselves or with the help of a family member. Moreover, other medical institutions, including specialist facilities that manage hemorrhagic events or pulmonary embolism, and clinics that cooperate with appropriate specialist institutions are appropriate alternatives to hospitals.
+The objectives of DVT treatment include the prevention of recurrence and regression of thrombotic clots, although echogenic masses tend to regress slowly []. The precise mechanism by which the factor Xa inhibitor edoxaban causes thrombus regression remains unclear, and no fibrinolytic activity of this agent has been described. Initiation of fibrinolysis occurs through a number of orchestrated interactions among fibrin and plasminogen as well as its activator and results in the generation of plasmin []. Therefore, the efficacy of edoxaban may reflect the potency of the fibrinolytic response relative to that of the coagulation response.
+Edoxaban reportedly exerts a stable anticoagulant effect compared with conventional drugs [, ] and serum D-dimer concentrations are widely used as a marker for secondary fibrinolysis following clot formation. In the present case, D-dimer concentrations rapidly normalized within 2 weeks and remained in the normal range at 6 months. However, clots continued to regress after the normalization of D-dimer concentrations, warranting the development of more sensitive markers of fibrinolysis during slow regression of thrombosis.
+In the Hokusai-VTE Study [], edoxaban was compared with VKA. A therapeutic range was achieved ??0 % of the treatment period and the reoccurrence of thrombosis was effectively prevented. Factor Xa inhibitors may provide more stable effects on the fibrinolytic system easily.
+The ESC guidelines recommend that treatment for DVT be continued for at least 3 months, and extensions of the treatment period should be considered depending on individual patient conditions. Our patient? VTE risk was idiopathic, which is why we treated him with NOACs for more than 3 months.
+In this case, symptoms improved after 3 months, and thrombotic clots remaining in the popliteal vein subsequently regressed further while continuing treatment, indicating the importance of thorough follow-up with ultrasonography and monitoring of subjective symptoms and blood parameters.
+Attention is described at the end. In this case, he was misdiagnosed with cellulitis at the onset. The initial misdiagnosis leads to delay of treatment. Cellulitis is an acute, spreading pyogenic inflammation of the dermis and subcutaneous tissue, usually complicating a wound, ulcer, or dermatosis. The area, usually on the leg, is tender, warm, erythematous, and swollen. The differential diagnosis of cellulitis is very important to DVT []."
+Atlas Cortes,23,1999/1/2,-4447,wendy10@example.net,056 Frazier River,"The patient is a 32 year old female at 24 weeks of gestation who presented in January 2014 with bilateral submandibular swelling and pain with radiation to head, neck, chest, and back for 2 weeks. On her initial presentation she was found to have WBC 164 ? 109/L with a differential of 94.4 % lymphoblasts, platelets 27 ? 109/L, and hemoglobin of 10.4 gm/dL. A peripheral blood flow cytometry revealed abnormal immature B cell population that comprised 90 % of the total cells and were positive for CD10, CD19, CD22, CD34, Tdt, but negative for CD 20. These findings were characteristic for precursor B-cell ALL. Cytogenetics was negative for Philadelphia chromosome. Karyotyping showed a normal 46XX chromosome display. FISH was negative for BCR/ABL and MLL gene rearrangement on chromosome 11q23.
+Due to the pregnancy status, she underwent chemotherapy induction with the modified Linker regimen in 01/2014 [?. This included cyclophosphamide (1 gm/m2) on day 1, vincristine 2 mg IV on days 1, 8, 15, 22, 30, 37, and 44; daunorubicin 50 mg/m2 on days 1??, 30 and 31, and prednisone 100 mg po days 1??, 80 mg on days 5??8, tapered slowly to off on day 62. Cerebral spinal fluid was negative for malignant cells.
+On day 38, she had a bone marrow biopsy revealing a hypocellular marrow, erythroid hyperplasia, dyserythropoiesis and atypical immature B-cells consistent with residual disease of precursor B-ALL. Concurrent flow cytometry of the aspirate showed an immature B-cell population (1.8 % of total B cells) expressing CD19, Tdt. Clinically she was in complete remission by standard definition with platelets 140 ? 109/L absolute neutrophil count (ANC) 1.43 ? 109/L.
+She had C-section at gestation week 34 and delivered a healthy girl.
+The second cycle of chemotherapy began 1 week post-partum with standard hyperCVAD regimen B in 3/2014 [, ]. She had Ommaya reservoir placed and received intrathecal methotrexate twice per cycle following the standard protocol defined in the hyperCVAD regimen. This was followed by six more cycles of hyperCVAD. Shortly after completion of last hyperCVAD, she started to have progressively worsening cytopenia. In November 2014, a bone marrow aspiration and biopsy were done to evaluate her disease status. The flow cytometry study of the aspirate showed a 79 % lymphoblast population expressing the following markers: CD19, CD10, Tdt, and CD34. This was consistent with full relapse of her precursor B-cell ALL. Karyotyping was 46XX. The patient received re-induction chemotherapy with high dose cytarabine (3 gm/m2 daily IV over 3 h ? 5), and mitoxantrone (60 mg/m2 once) [].
+A repeat bone marrow aspirate and biopsy was performed in 1/2015 and revealed 43 % lymphoblasts. This confirmed persistent refractory precursor-B ALL. Salvage chemotherapy with CLAG regimen (cladribine, cytarabine and G-CSF) was started immediately [?. Four weeks later, a repeat bone marrow biopsy showed 68 % lymphoblasts, consistent with refractory disease to the CLAG regimen.
+In February 2015, she was treated with blinatumomab. She was started with 9 mcg/day. On day 3 of blinatumomab therapy, the patient started spiking fever to 102.7 簞F, with tachycardia and hypotension. The patient was transferred to the ICU for closer monitoring. Chemotherapy with blinatumomab was temporarily held for suspected cytokine release syndrome (CRS). The patient received one dose of tocilizumab 8 mg/kg IV once in addition to methylprednisolone. She required aggressive fluid resuscitation and was on vasopressors for 2 days. Blinatumomab was restarted 2 days later at 9 mcg/day. In total she received 9 days of blincyto at 9 mcg daily. The dose was increased to 28 mcg per day and continued to day 28. Her blood counts improved steadily. A bone marrow biopsy was performed. Flow cytometry of the aspirate revealed no immature B-cell population. Pathology revealed trilineage hematopoiesis with no increase in blasts. A concurrent peripheral blood counts showed platelets of 247 ? 109/L and ANC > 1 ? 109/L. At this point, the patient had a pathology documented complete remission (CR) after one course of single agent blinatumomab.
+Since she was not eligible for allogeneic hematopoietic stem cell transplantation (HSCT), maintenance chemotherapy with MTX, vincristine, pegylated asparaginase and dexamethasone was given. However, she developed acute pancreatitis after four cycles of the PEG-asparaginase-containing regimen. Upon recovery from the pancreatitis, a bone marrow biopsy confirmed that the patient remained in CR in August 2015.
+In September 2015, she was started on a 2-week cycle of blinatumomab as maintenance. Due to lack of convincing scientific data for using blinatumomab as maintenance treatment, further treatment with blinatumomab was stopped. She maintained normal blood counts and had normal activity. Unfortunately, in February 2016, her WBC increased to 16.4 ? 109/L, platelet counts decreased to 75 ? 109/L. Bone marrow biopsy at this point showed an abnormal immature B-cell population expressing CD19 (dim), CD22, CD10, CD34, TdT, HLA-DR, CD9 and CD38 (heterogeneous). The findings were consistent with relapsed preB-ALL. Since CD19 was still positive, blinatumomab was started. Two weeks later, the WBC rose to 74.4 ? 109/L, platelets down to 19 ? 109/L. Peripheral blood had 71 % blasts. Therefore, her ALL was refractory to blinatumomab re-treatment. At the time of this report, she was receiving additional treatment."
+Lea Bowen,29,1984/12/11,001-558-442-0131x02341,erin54@example.com,355 Malik Turnpike Suite 442,"The client, a single woman in her late 30s, presented for BATD exhibiting sadness, anger, poor familial relationships, feeling that her life was ?oring?? the wish to die, self-hatred, feelings that no one listens to her, and lack of compassion. She also reported recurrent thoughts about harming (and killing) her family members. The client lived with her brother and his family. The client had experienced significant trauma resulting from the Halabja chemical attack, where she lost her parents and was displaced to the town of Hawar with her brother. She was there for 7 months before she went to Iran for chemical treatment. The client visited a psychiatric hospital after the Halabja bombing, where she received psychotropic medication. With the onset of BATD, the client identified her core values and generated specific activities tied to those values. For instance, she valued compassion, sincerity, loyalty, honesty, and nurturing her brother's children as her own siblings. In accordance, she identified talking on the phone with her family, cooking, and helping them with their work as activities tied to these values. She also specified activities in line with her values of honesty, having good friends, loyalty, sincerity, learning new information, performing jobs appropriately, maintaining good relationships with employers, better self-care, psychological improvement, and completing daily chores. The CHW reported the client was motivated to participate in BATD and completed 12 sessions. Difficulties with her treatment included her brothers??resistance to her treatment given concerns about stigma including unintended consequences for the family if others became aware of her seeking treatment. This barrier, in addition to her demanding work schedule, hindered her ability to attend weekly sessions. As a solution, her treatment provider who arranged home and work visits spoke with her brother regarding treatment, which resulted in his willingness to allow her to continue treatment. As a result of BATD, the client experienced many positive changes in her life. Specifically, she reported improved relationships with her family, loving herself and the people around her, the desire to live and enjoy life, reduced sadness and anger, and improved job performance. Indeed, her brother witnessed these positive changes, and even asked to be a client himself. The focus of BATD on adherence to her daily goals helped engender the congruence of her lifestyle and value system, her motivation to treat her depression, and her perseverance and commitment to continue treatment despite logistical constraints. Furthermore, her treatment allowed her to obtain a referral to a psychiatrist and be properly diagnosed with epilepsy, which had been misdiagnosed previously."
+Trevor Pope,33,2003/11/27,261.998.5603,erica93@example.org,3692 Richard Tunnel Suite 530,"A 60-year-old Caucasian male with a past medical history of hypertension and coronary artery disease initially presented with acute onset left arm weakness and left facial droop. He was first evaluated by a local health care facility where a CT scan of his head was done and revealed a right frontal intraparenchymal hemorrhage with surrounding edema, mass effect, and midline shift. He was transferred to the neurosurgery service at our medical center for further management. The patient had been seen at an outside institution a week prior to admission for recent back pain and was found to have an elevated international normalized ratio (INR) of 6.1 at that time. He denied fevers, chills, shortness of breath, chest pain, early satiety, nausea, vomiting, or abdominal discomfort at admission. He had a history of hypertension and coronary artery disease with ischemic cardiomyopathy and left ventricular ejection fraction of 25% with a left ventricular aneurysm and apical thrombus for which he has been on chronic anticoagulation. Medications on admission included aspirin, lisinopril, allopurinol, metoprolol, niacin, simvastatin, warfarin, venlafaxine, and Ambien as needed. He had no known allergies. He lived with his wife, used to drink one or two beers a couple of times a week, and denied any recreational drugs use. One of his sons was diagnosed with acute lymphoblastic leukemia (ALL) at the age of 13 and was 21 years out from his treatment. He has no family history of hematological or other neoplastic diseases. The patient agreed to participate and was explained the nature and objectives of this study, and informed consent was formally obtained. No reference to the patient's identity was made at any stage during data analysis or in the report.
+His physical examination did not reveal any lymphadenopathy or splenomegaly. No focal neurological deficit was noticed. Initially, the patient? intracranial hemorrhage was thought to be in the setting of a supratherapeutic INR due to chronic anticoagulation with coumadin for left ventricular apical thrombus. However, his admission laboratory data showed leukocytosis with a white blood cell count (WBC) of 298,000/cmm with early forms (promyelocytes 7%, myelocytes 8%, metamyelocytes 4%, blasts 1%). The differential count at that time was neutrophil 61%, band 11%, lymphocytes 2%, basophils 2%, eosinophils 2% with platelet count of 76,000/cmm, hemoglobin of 10.1 gm/dL. Due to the concern of probable leukostasis secondary to leukocytosis contributing to the intracranial hemorrhagic stroke, the patient underwent leukapheresis (two units of whole blood phlebotomized) and received two units of red cell transfusion which resulted in a significant decline in WBC count to 228,000/cmm. Flow cytometry and FISH revealed 9:22 translocation; Philadelphia chromosome was consistent with the diagnosis of CML. A bone marrow biopsy also confirmed the diagnosis of CML, and there was no evidence of increased blasts in the bone marrow, indicating that he was in the chronic phase of CML. Quantitative PCR showed 43.1% B2A2/GUS. During hospitalization, aspirin and warfarin were stopped, and he was managed conservatively with platelet transfusions and close observation. He did not require surgical intervention and began rehabilitation therapy for his left hemiparesis. He was started on hydroxyurea (Hydrea) two grams daily titrated up to two grams twice daily followed by imatinib (Gleevec) 400 mg orally daily.
+The patient returned for a follow-up to the hematology clinic two weeks after discharge; labs showed a WBC of 3,500/cmm with no immature forms, and the differential count was neutrophil 60%, band 0%, lymphocytes 29%, basophils 1%, eosinophils 1% with platelets of 50,000/cmm, hemoglobin of 12.1 g/dL. Peripheral smear showed decreased platelet count with normal-looking neutrophils without any immature forms such as myeloblasts or promyelocytes and no evidence of dysplasia such as hypogranulated neutrophils, basophilic stippling in the red cells, or giant platelets. He was in hematologic remission, and the dose of Gleevec was decreased to 300mg daily from 400mg daily in the setting of thrombocytopenia that was initially attributed to Gleevec.
+The patient returned to the clinic after two months for follow-up; Gleevec was increased back to 400mg daily since there was no significant change in his platelet count by decreasing the dose, and his platelet count at that time was 65,000/cmm. He was then followed up in clinic every two months, and quantitative FISH demonstrated a complete cytogenetic response at nine months. The patient had a decrease in BCR-ABL PCR transcript on testing at twelve months follow-up from 43.1% to 0.29%, demonstrating a major molecular response.
+The patient returned to the clinic for an interval follow-up. Following several months of conservative management and evaluation of worsening lower back pain over five months that was initially attributed to long hours of driving, he had a CT scan done at an outside hospital which demonstrated a likely perforation of the rectosigmoid colon, and was hospitalized for management. Upon admission, Gleevec was discontinued with the identification of bowel perforation as a potential rare but serious complication of Gleevec. He continued to have episodes of pain up to 8-10/10 in intensity and hence transferred to our facility. A repeat CT scan of the abdomen and pelvis with contrast showed evidence for extravasation of the administered rectal contrast into the perirectal region. Multiple pockets of gas were seen posterior and lateral to the distal rectum in the presacral region and in the region of the rectal wall with noted surrounding inflammatory changes but no organized fluid collection. This was followed by a colonoscopy with special care taken to avoid overinflation or advancement of the colonoscope beyond the affected region based on CT findings. However, colonoscopy did not reveal perforation. He was managed conservatively after consulting surgery and finally discharged home in improved condition. Also, he was resumed on Gleevec.
+One month later, he presented with recurrent lower GI bleeding. A repeat colonoscopy was done that reportedly revealed a rectosigmoid fistula into the retroperitoneal space, confirming the previous perforation. Gleevec was discontinued indefinitely at that time.
+He had a follow-up in 14 days with a flexible sigmoidoscopy which showed an edematous mucosa 10 cm from the entry point, and biopsy was consistent with chronic nonspecific inflammation and mild focal hyperplastic changes and reportedly negative for malignancy.
+Unfortunately, he again presented to the emergency department with similar symptoms of rectal pain and bleeding. CT scan at that time showed the possibility of abscess in the same area. An examination under anesthetic (EUA) along with incision and drainage of a perirectal abscess was performed along with a drain placement. He was followed up in four weeks both in hematology and surgery clinics. At this time, a follow-up CT scan of the pelvis showed that the cavity is smaller, but the track is still open which was thought to be reasonable since the drain fell out three days prior to presentation. The patient had no new accumulation of pus, no fevers, no chills, no back pain, and the perianal irritation was improving."
+Aurelia Raymond,40,1983/12/2,414-998-4450x2493,michaelflores@example.com,9044 Williams Wells Suite 748,"A 71-year-old female patient was presented to the emergency department after falling from her own height with a direct contusion on both hands, with the wrist and elbows in extension. She had a past medical history which was positive for arterial hypertension (treated with Captopril) and rheumatoid arthritis (treated with Leflunomide).
+Her fall resulted in localized pain in both shoulders, and limited range of motion leading to an inability to perform activities with her arms raised above the head. X-rays were taken on an anteroposterior (AP) bilateral view (Figure ), and she was diagnosed with a Neer III bilateral displaced proximal humerus fracture.
+Simple X-rays are the most commonly used diagnostic method for a proximal humerus fracture, and often two different views are necessary to analyze the pattern of a fracture. AP and lateral views should be taken. In cases of complex fractures or uncertainty based on the x-rays, a computed tomography (CT) scan can be used.
+After a clinical evaluation of the patient, though there was no contraindication for surgical treatment, conservative treatment was chosen to address the pathology. Two hanging casts were placed using two slings on both arms. A week later, a control x-ray was taken showing a reduction of some of the fragments (Figure ).
+At week three of treatment, a new x-ray was taken showing even more bone fragment reduction when compared to week one (Figure ). Clinically, the patient showed consolidation with partial radiographic consolidation, so the casts were removed. She continued to use the bilateral slings and initiated pendulum movements for the following three weeks at home. She initiated active movements at week six.
+At the week seven follow-up consultation, she arrived with only mild pain during any activity behind the back during active internal rotation on both arms. The bilateral ranges of motion were as follows: flexion, 100簞; extension, 15簞; internal rotation, 100簞; external rotation, 90簞; abduction, 100簞; adduction, 30簞; muscle strength, 5/5; with no alteration of the distal neurovascular status (Figure ). We obtained the Disabilities of the Arm, Shoulder and Hand (DASH) Score of 16/100 (100 representing the worst-case scenario)."
+Maurice Contreras,35,1995/2/7,7659168530,mooneycody@example.org,12722 Rachel Shoals,"A 57-year-old woman was referred to our orthopaedics and traumatology clinic with a painful lump in the left arm. Physical examination revealed a red-colored mass on the left arm (Fig. ) and an enlarged lymph node measuring almost 5 cm in the left axillary region and 3 cm in the right axillary region. Magnetic resonance imaging (MRI) of the left arm showed a 17.7 ? 5.8 ? 7.3 cm enhancing mass in the medial aspect of the left biceps muscle and multiple left axillary lymph nodes with a maximal diameter of 4.8 ? 3.4 cm. Tru-cut biopsy of the mass in the left arm revealed infiltration of atypical centrocyte-like cells with or without clear cytoplasm with a K襤-67 proliferative index of 30 % and stained positive for CD20 and pax-5 and negative for CD5, CD10 and bcl-2, positive for CD21 in the follicular dendritic cell network, findings consistent with MZL (Figs. , ). With a final diagnosis of MALT lymphoma infiltrating the skeletal muscle, she was referred to our hematology department. The patient had no B symptoms. Her hemoglobin was 12 g/dL, white blood cell count 8420/mm3 with a lymphocyte count 2800/mm3 and platelet count was 292,000/mm3. On biochemical tests, the following were abnormal: lactate dehydrogenase 1218 U/L (240-480), CRP 40 mg/L (0??), ESR 120 mm/h (0??0) and 帣2-microglobulin level 3.52 mg/L (0.7??.8). Serum protein electrophoresis showed polyclonal gammopathy with an increased component with gamma fraction of 1.51 g/dL. Hepatitis B, C and HIV infection serology and screening for autoimmune disorders were negative. Bone marrow biopsy was negative. Cervical computed tomography (CT), and abdominopelvic CT were normal. On chest CT, there were multiple left axillary lymph nodes with a maximal diameter of 5 cm and a 3 cm right axillary lymph node. Diagnosed with stage 2 disease, R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, methylprednisolone) was initiated. After 6 cycles, mass in the medial aspect of the left biceps muscle regressed to a size of 3.2 ? 1.1 ? 1 cm and bilateral axillary lymph nodes totally disappeared. Two additional infusions of rituximab were administered after the sixth cycle of R-CHOP. Subsequently, the patient underwent radiotherapy to the left arm at a dose of 30 Gy. Physical examination 1 and 6 months and 1 year after treatment revealed no palpable residual mass, swelling or skin erythema. 6-months and 1-year after completion of treatment, MRI of the left humerus demonstrated no evidence of residual disease. Also, cervical, chest and abdominopelvic CT at 1 year showed no disease involvement."
+Daniela Arellano,29,2005/3/21,(419)879-2452,uray@example.net,588 Zachary Brooks,"A 4-year-old girl with unexplained hypergastrinemia was referred to our department after abdominal ultrasonography detected a cystic lesion at her prepyloric antrum. When she first presented with a duodenal ulcer at 2 years of age, her serum gastrin levels had ranged between 700 and 1000 pg/ml. The imaging studies with a contrast-enhanced computed tomography (CT) scan had repeatedly revealed no tumor around the pancreas or duodenum suggestive of gastrinoma but revealed only a thickened wall of the duodenum potentially due to the initially severe duodenal ulcer. She had continuously taken a proton pump inhibitor (PPI) until the referral since the first presentation of the duodenal ulcer, which had relieved its symptoms such as epigastric pain.
+At the referral, the patient? physical and mental development were normal for her age. She was afebrile, and other vital signs were also within the normal ranges. A physical examination revealed no particular symptoms. Her blood tests were unremarkable except for elevated serum gastrin (877 pg/ml, normal range 37??72 pg/ml). Upper gastrointestinal series revealed a 2.5 ? 5 cm cystic lesion on the anterior wall of the antrum, communicating with the gastric lumen (Fig. ), which was also detected as a solid mass with slight enhancement on abdominal contrast-enhanced CT (Fig. ). Upper endoscopy showed a scar at the duodenal bulb, but no erosion or ulcers in the stomach or the duodenum, and we could not detect the opening of the lesion. A gastric tissue biopsy did not demonstrate Helicobacter pylori. According to these findings, we suspected gastric duplication. As we speculated that the lesion might have caused the duodenal ulcer in this patient, we proceeded with operative treatment for the lesion. The operation was performed with the umbilical approach. A 2 ? 3 cm protruded lesion was observed on the anterior wall of the gastric antrum (Fig. a) and resected with the common muscular layer with the opening to the gastric lumen (Fig. b). A pathological examination was consistent with gastric duplication with antral mucosa, which strongly stained positive for gastrin (Fig. ) and also contained heterotopic pancreas tissue. The postoperative course was uneventful, and the patient was discharged on the eleventh postoperative day (POD). Her serum gastrin level remained elevated after the operation (755 pg/ml on POD 7 and 727 pg/ml on POD 98) but started to decrease after PPI was switched to famotidine 3 months after the operation (228 pg/ml on POD 148 and 235 pg/ml on POD 291) and finally normalized after famotidine was stopped 10 months after the operation (151 pg/ml on POD 365 and 77 pg/ml on POD 461). She has remained entirely asymptomatic during a follow-up of 20 months.
+Enteric duplications are ectopic cystic or tubular structures composed of smooth muscle surrounding the mucosa of the gastrointestinal tract and occur most commonly along the ileum, esophagus, or colon []. Gastric duplications are relatively rare in children, accounting for only 4?? % of all enteral tract duplications []. They are usually spherical or tubular cysts in the greater curvature of the stomach and may not communicate with the gastric lumen []. Their presentations range from asymptomatic to an acute abdomen and include gastric outlet obstructions, pancreatitis, hemoptysis, gastrointestinal bleeding, and an ulcerated antral mass []; hypergastrinemia has been rarely reported [] as one of the complications associated with a gastric duplication.
+Normally, acid in the gastric lumen acts directly on the somatostatin cells (D cells) to stimulate the release of somatostatin, thereby preventing gastrin release from gastrin cells (G cells) by a paracrine mechanism. When gastric antral mucosa is isolated from its usual acidic environment, such as in cases of a retained gastric antrum following partial gastrectomy with Billroth II reconstruction, there is no hydrogen ion feedback inhibition of gastrin release, leading to hypergastrinemia followed by increased gastric acid production, recurrent ulceration, and bleeding []. We speculate that this same mechanism caused hypergastrinemia and the resultant peptic ulcer at the initial presentation in our case whose ectopic antral mucosa in the duplication barely communicated with her gastric lumen. If more gastric acidic juice comes into the duplication lumen through a larger opening and/or the amount of the G cells is less than that in our case, hypergastrinemia may not happen. A literature review revealed only one case of a gastric duplication [] and another of a pancreatic duplication [] presenting with hypergastrinemia. Stephen et al. [] reported a female who presented with hematemesis and melena at 2 weeks of age. The possibility of gastrinoma was excluded using a secretin stimulation test and imaging studies; however, exploratory laparotomy could not detect any pathology, and thus, antrectomy and Billroth II reconstruction were performed. The pathological findings revealed gastroduodenal erosions and an antral duplication cyst with deep glands at the intracystic mucosa that stained positive for gastrin. Siddiqui et al. [] reported the case of a 2-year-old girl who presented with failure to thrive and gastroesophageal reflux with continued low gastric pH levels. Portal and pancreatic venous sampling in that patient during the operation revealed elevated levels of gastrin to the pancreatic venous cascade, and CT demonstrated a cystic lesion in the head of the pancreas. The patient underwent local resection of the lesion, and a pathological study confirmed the duplication with gastric mucosa (immunostaining of gastrin was not performed).
+Although the time course of the serum gastrin level of the latter patient was not described, that of the former patient normalized promptly after the operation. In contrast, the reason why hypergastrinemia in our case did not improve until PPI and famotidine were stopped may be explained by another mechanism related to the preoperative long-term use of PPI. A modest increase in the serum gastrin level in adult patients under a long-term treatment with acid-lowering compounds, especially PPI, has been reported []. PPI causes potent suppression of gastric acid secretion and leads to persistently high intragastric pH, and long-term PPI therapy has been reported to be associated with a significant increase in the G cell numbers and the ratio of G to D cells in the gastric antrum in children [].
+According to previous reports [, ], we speculate that the pathophysiology of our case was as follows: (1) the antral mucosa in the duplication was isolated from its typically acidic environment, which led to the lack of hydrogen ion feedback inhibition of gastrin release, and therefore, resultant hypergastrinemia caused the duodenal ulcer; (2) PPI suppressed gastric acid secretion and improved the duodenal ulcer, but the secretion of gastrin continued from the duplication for 2 years until it was removed, with an increase in the antral G cell numbers and the G to D cell ratio caused by the long-term use of PPI, thus additionally leading to hypergastrinemia; and (3) even after the removal of the duplication, hypergastrinemia continued until PPI and famotidine were stopped by the same mechanism."
+Kellan Estrada,19,1991/2/1,4798471411,kimberly63@example.org,332 Weiss Roads Suite 415,"A 26-year-old gentleman presented to his primary care physician with right knee swelling after a direct fall on his knee during a Frisbee game 2 days earlier. He denied hearing or feeling a popping sensation. The swelling had developed over a few hours but started diminishing since the day before the visit. His moderate pain has been improving since the incident. He had been able to walk with minimum discomfort. His past medical, social, and family histories were unremarkable. On physical examination, he had a mild ecchymosis and abrasion in the superior aspect of his knee with mild swelling. Plain radiography demonstrated soft tissue swelling anteriorly without osseous abnormality (). He was advised to rest and use ibuprofen as needed for pain. He presented to our sports medicine clinic with continuous, painless swelling in the same region 19 days after injury. He denied mechanical symptoms and his physical examination was significant for a nontender, moderate sized swelling in the superomedial aspect of his right knee (). There was no palpable joint effusion. In-office ultrasound revealed a homogeneous, anechoic fluid collection with scattered hyperechoic substance between the superficial quadriceps fascia and subcutaneous tissue which was compressible (). After proper cleansing and local anesthesia with 1% lidocaine, using ultrasound for needle placement and an 18-gauge needle, 38 mL serosanguinous fluid was aspirated (). Patient was advised to use a compression wrap following the procedure. He presented for recurrence of his knee swelling on day 25 after injury. Another aspiration provided 35 mL of serosanguinous fluid. After the second aspiration, his symptoms were completely resolved with no reaccumulation of the fluid. At latest follow-up, 4 weeks from injury, he is asymptomatic and had returned to full, unrestricted activity."
+Sawyer Simon,28,2005/2/22,001-335-498-0886x2609,browncarlos@example.org,58666 Manning Crossing Suite 538,"A 41-year-old healthy male was crushed by a forklift and brought to our ER in hemorrhagic shock. He suffered a massive open injury to his left leg and pelvis (). ATLS protocol was followed, the massive transfusion protocol was activated, and a pelvic binder applied for his APC 3 pelvic injury. He was transferred to the OR for intra-abdominal bleeding identified on FAST exam and a lack of response to transfusion. A laparotomy was performed where intra-abdominal bleeding was eventually controlled and then the aorta and IVC were clamped low in the abdomen to stop the bleeding from his pelvis and left lower extremity. During this time the left leg wound was debrided and irrigated, and it was realized that a high above knee amputation was required as the leg was nonviable. A pelvic EXFIX was placed, and the patient was given a high diverting colostomy. Urology placed a suprapubic catheter and removed an avulsed devascularized left testicle. Once the vessels were ligated distally, the aorta and vena cava were released (). He was transferred to the ICU. He received 31 units of PRBC, 18 units of FFP, 25 units of platelets, and 5 units of cryoprecipitate over the first 24 hrs and stabilized hemodynamically.
+The patient underwent serial debridement because of ongoing and progressive tissue necrosis in the stump, treated with negative pressure wound vacs and antibiotic beads. The above-the-knee amputation was converted to a hip disarticulation but the patient still had a massive wound over his pelvis and his lower abdomen. The wound vacs were difficult to apply with the external fixator and the pelvis was still relatively unstable so the external fixator was removed and reduction of his pelvic ring injury was performed with a subcutaneous anterior internal fixator, as well as one percutaneous SI joint screw (). This presented somewhat a challenge given the extent of the patient's open wounds on the left hemipelvis leaving part of the internal fixator exposed to air on the left side. The construct stabilized the injury and the low profile of the INFIX allowed easy application of the wound vac.
+The wound and patient stabilized, and skin grafts were applied to the defect once good granulation tissue was apparent around the pelvic INFIX ().
+The patient underwent removal of his suprapubic catheter and eventual reanastomosis of the bowel once all the wounds had healed. He was fortunate to have functional return of his urethra.
+The traumatized area under the skin grafts has had formation of heterotopic bone which required removal on 2 occasions due to pain with prosthetic fitting. This is finally underway 2 years after the injury."
+Zayne Conner,28,1983/1/26,(407)548-0677x0777,jerome06@example.org,282 Cole Circle Suite 116,"This is a 62-year-old male who was involved in a motor vehicle accident. His open injury was missed initially when he arrived in extremis and developed a massive pelvic soft tissue infection requiring debridement over the first 3 days. He had a colostomy, superpubic catheter, percutaneous reduction of his iliac wing, SI screws, and an anterior INFIX. His testicles were implanted under the medial thigh and he had extensive wound care (Figures and ). This was followed by a long ICU course and dressing changes daily. The wound granulated in and the INFIX was removed once we felt that there was adequate healing (5 months). The patient had skin grafts and still has a colostomy."
+Alondra Rush,25,1989/11/18,001-267-880-2479,holly56@example.com,7350 Colleen Islands,"A twenty-eight-year-old Caucasian female, weighing 50 kg, mentally retarded, but with no other dysfunction or any detected genetic abnormalities, had suffered from a refractory form of epilepsy for many years and had been treated in a special neurological unit with multimodal antiepileptic medication regime consisting of carbamazepin, topiramate, and clobazam and stimulatory impulses of the vagal nerve.
+The patient had a history of developing tonic-clonic seizures of which there were several episodes during the week before admission. Following admission to the intensive care unit (ICU), the usual antiepileptic medication was supplemented with valproate, phenytoin, and levetiracetam without successfully alleviating seizures. The patient was finally anaesthetized with propofol and remifentanil infusions and intubated to secure airway.
+The mean dosage of propofol infusion was 12 mg/kg/h over a period of 78 hours, but the maximal infusion rate was 84 mg/kg/t before successful burst suppression was achieved.
+The first symptom suspected to be PRIS manifestation was unexplained metabolic acidosis with increased lactate concentration which initially appeared 48 hours after admission to the ICU. It was decided to decrease the rate of propofol infusion. Blood pressure declined, despite norepinephrine infusion; therefore, propofol infusion was terminated. A possible alternative relying on thiopental infusion was considered, but this treatment option was not achieved.
+The ECG changes of ventricular extrasystole and then bradycardia with junctional rhythm occurred 7 to 8 hours after lactate acidosis had developed. Noradrenalin infusion was increased to 1 弮g/kg/min to keep MAP above 70 mmHg and adrenaline infusion was also added.
+It took about 100 minutes for cardiac arrest (severe bradycardia, right bundle branch block, and then asystole) to occur after propofol infusion was stopped. The patient died after 22 minutes of resuscitation."
+Kaiser Burton,27,1990/3/4,226-938-4814,qroach@example.net,40291 Brown Glen Apt. 875,"AB is a 15-year-old female student of south-Asian descent. She presented with concerns of anxiety and symptoms of hypoglycemia as well as difficulty concentrating, fatigue, headaches, asthma, and frequent urinary and vaginal infections.
+Her anxiety met criteria for GAD and she rated the intensity of anxiety as 8/10, with 10 being the highest level of anxiety possible. The anxiety started three months prior to the initial appointment and had worsened in the previous month. She described excessive worry that was difficult to control and impacted her daily functioning by causing her to be absent from school on several occasions. She experienced a number of somatic symptoms including heart palpitations, shakiness, discomfort in her stomach, and muscle tension. In response to the anxiety symptoms, she would eat foods like chocolate, chips, or fruit. AB was working with a counsellor to manage the anxiety symptoms and was finding some benefit.
+AB had experienced episodes suggestive of hypoglycemia since 12 years of age. The symptoms included muscle weakness and shaking, headaches, nausea, anxiety, and loss of concentration. Her symptoms were ameliorated by eating sweet foods. AB reported that her hypoglycemia was at its worst at 12 years of age when she had to eat a granola bar hourly in order to concentrate.
+A diet history revealed the following typical daily food intake:Breakfast: fruit smoothie containing fruit, fruit juice, and water. Morning snack: bagel with margarine. Lunch: pasta or white rice with vegetables. Afternoon snack: granola bar or cookies or gummy candies. After school meal: white pasta; it may include meat. Dinner: white rice or spaghetti; it may include meat. Evening snack: cookies and toast. Beverages: 2 liters of water, 1 cup of juice, 1 cup of lactose-free milk, and 1 cup of tea.
+Due to her difficulty concentrating, AB was prescribed dextroamphetamine 5 mg. While she found that it improved concentration, this medication caused her to lose weight. As the patient's weight was initially on the lower end of normal (weight: 115 lb., height: 5???聆€? and BMI: 18.6) the dose was reduced to 2 to 3 times per week, as needed.
+AB lives with her mother, father, and sister. AB's sister experienced mental health concerns in the previous years which created elevated stress levels in the family home.
+Repeated assessments of random and fasting blood glucose and screening physical examination were within normal range.
+At the initial visit, the following dietary plan was prescribed:Breakfast: it includes a smoothie containing fruit, water, 1 scoop of protein powder, and 1 tablespoon of flax seeds or olive oil. Lunch and dinner: they include a serving of protein (meat, legume, and soy) and a serving of vegetables. Snacks: they include protein when possible (e.g., apple with sunflower seed butter, vegetable sticks with hummus, and pumpkin seeds). Continue to eat carbohydrate-containing snacks as needed for the management of hypoglycemia symptoms. She was asked to follow these dietary guidelines daily until the follow-up visit. While eggs, nuts, and fish would have normally been recommended as well, the patient had an anaphylactic allergy to these foods.
+At the first follow-up, four weeks later, AB reported that she had complied with the dietary plan since the previous visit. She reported a significant decrease in anxiety (4 to 5/10), as well as improved energy, less-frequent and less intense hypoglycemia symptoms, and fewer headaches (once per week compared to daily) in addition to improved concentration and mood. She required fewer snacks during the day and decreased her intake of granola bars, cookies, and candies (1-2 servings per day). She also reported a cessation of chronic vaginal discharge. The substantial improvement in her anxiety symptoms prompted AB to temporarily discontinue her counselling sessions.
+At a subsequent follow-up visit four weeks later, AB reported that she had briefly reverted back to her original diet for a period of one week and experienced a worsening of anxiety symptoms within one day. After returning to the dietary intervention prescribed, her anxiety symptoms decreased within two days."
+Miriam Harper,38,1992/8/13,(763)707-4611,dballard@example.org,6456 Thomas Loaf,"A 13-year-old girl presented with deteriorating school performance for 2 years with repetitive impulses to touch others inappropriately and believing that there is a devil living inside her body for a duration of 6 months.
+She has had normal developmental milestones and average school performance for 2 years back. Over the past 2 years, she had inattention, lack of interest in school work, and deteriorating school performance. During the 6 months prior to presentation, she had poor sleep, had become irritable, and had developed grandiose delusions, claiming that she had attained nirvana. She also had bizarre delusions with somatic hallucinations, believing that a devil was residing inside her and feeling this devil's movements. She had episodes of aggression and attributed these to the devil, which was consistent with a delusion of control. There were no mood symptoms. Over this period, she had obsessional impulses to perform certain acts of sexual nature. A diagnosis of schizophrenia with obsessive compulsive symptoms was made and she was commenced on risperidone 2 mg at night and escitalopram 20 mg in the morning.
+Over time, she showed poor response to medication and started refusing to go to school as she believed her classmates were talking about her. She started acting out on her obsessional impulses and tried to touch her classmates inappropriately. She displayed odd behaviors such as putting match sticks in her dog's mouth and sleeping on the roof.
+On mental state examination, she was disinhibited evident by her behavior during the interview where she made inappropriate sexual advances towards the interviewer. Her speech lacked prosody. Her mood was flat. She had persecutory delusions and ideas of reference regarding her classmates. She had obsessional impulses to touch others inappropriately, which she resisted minimally. There were no perceptual abnormalities. Her verbal fluency was reduced. Other frontal lobe functions measured by categorical fluency, proverb interpretation, Luria 3-step test, go/no-go test, and written sequencing were normal. Parietal and temporal lobe functions measured by left-right orientation, clock drawing test, and drawing reproduction and memory measured by recall of 5-item address were normal. Nonverbal IQ measured by TONI-3 (Tests of Nonverbal Intelligence-3) was normal. Physical examination revealed bradykinesia, but no rigidity, hyperreflexia, or reduced muscle power. There were no abnormal movements, cerebellar signs, or sensory deficits. Examinations of the cardiovascular, respiratory systems, and the abdomen were unremarkable.
+Her investigations revealed the following. Full blood count, blood picture, and erythrocyte sedimentation rate done with a view to detect any underlying inflammatory conditions including autoimmune disorders were normal. Tests for thyroid function were done to rule out psychiatric manifestations arising due to thyroid dysfunctions. Both free thyroxine and thyroid stimulating hormone were normal (free thyroxine 1.12 ng/dL and thyroid stimulating hormone 3.87 IU/L). Electroencephalography recorded in the alert state was normal for the age. An eye referral excluded the presence of Kayser-Fleischer rings. Cerebrospinal fluid lactate done to exclude mitochondrial diseases was normal. Computerized tomography brain showed an asymmetrically dilated 4th ventricle, with a cerebrospinal fluid filled cleft connected to right sigmoid sinus, bisecting cerebellar hemispheres which were poorly formed (). Appearance was consistent with a Dandy-Walker syndrome variant.
+Risperidone was increased to 2 mg twice daily and escitalopram continued at the same dose. Over 6 months of treatment, her psychotic symptoms, disinhibition, and obsessions showed partial response and she continued to have odd behaviors with deterioration of school performance. The option of changing the antipsychotic to olanzapine or quetiapine was discussed with the patient and her family. However, they preferred continuing the current medication due to the higher incident of side effects of weight gain and sedation associated with these medications. In addition, commencing a newer antipsychotic such as aripiprazole, which is not available in the government sector in Sri Lanka, was considered, but family was unable to afford it. Neurology opinion was sought and it was decided that no active surgical interventions were indicated at this stage."
+Hayes Phillips,43,1998/5/10,+1-459-241-3430x158,mdavis@example.org,916 Price Groves,"A 56-year-old female presented with bilateral otalgia and hypoacusis gradually progressing for the past two weeks and left sided facial palsy significantly increasing within two days. She has been previously twice unsuccessfully treated with antibiotics in another hospital due to chronic otitis media. She also had a history of psoriasis and hyperthyreosis. AAV may occur with antithyroid drug therapy. However, the patient was treated only one month before the blood test; thus the possibility of drug-induced AAV is low.
+Otoscopic examination revealed bilaterally thickened and reddish eardrums. There was a subtotal perforation of the right tympanic membrane and an anterior perforation of the left tympanic membrane with effusion. Left facial nerve palsy was categorized as grade IV according to House-Brackmann. Nose examination was normal. The pure tone audiometry showed severe bilateral mixed hearing loss on the level of 80??00 dB with air bone. On the right the threshold is on the level of 95??00 dB with air bone gap of 50 dB. On the left the threshold gap is 70 dB. Chest X-ray revealed signs of bronchitis. Urine analysis was normal.
+High resolution computed tomography scans of the temporal bones showed bilateral sclerosing mastoiditis and opacification of the right tympanic cavity with an air-fluid level. No signs of bony destruction within the ossicular chain, the internal ear, or facial canal were present (). Magnetic resonance imaging (MRI) with the use of T2-weighted, T1-weighted, and contrast enhanced images was performed and showed normal appearance of cerebral structures and mastoid cells filled with fluid on both sides. Hypertrophic pachymeningitis sometimes shows in the GPA patients wit hear involvement. In this case there were no signs of pachymeningitis on MRI examination. The diagnosis of acute otitis media with peripheral facial nerve paralysis was made and intravenous antibiotics treatment was started. As there was no response to drug therapy, the patient was referred to myringoplasty and antromastoidectomy with facial nerve decompression. During surgery, granulation in the mastoid cavity was found. There was no granulation on the facial nerve canal. The facial nerve was pale and swollen during decompression. After surgery otalgia and hearing on the left side improved slightly, but facial paralysis did not show any improvement. The patient was discharged and sent home with prescribed antibiotic treatment.
+After two months, the patient's condition deteriorated significantly as she presented with bilateral facial paresis (House-Brackman grades IV-V), horizontal nystagmus directed to the right ear, severe hearing loss (70??0 dB), otalgia, and otorrhea. Blood tests showed WBC of 12,93 thousand/弮L (normal range: 4??0) and CRP of 147,76 mg/L (normal range: 5,0). Laboratory tests showed hyperthyreosis with positive results for antibody to thyroglobulin: A-TG of 180 U/L (normal range: 0,0??0). Renal function tests and abdominal ultrasound were normal. Intravenous antibiotic treatment was administered.
+Chest X-ray showed bilateral hilar mass lesions. Chest CT scans revealed mediastinal nodules and parenchymal consolidations in both lungs (). Head MRI showed no pathological changes except for complete opacification of mastoid cells and middle ears bilaterally. Ophthalmic evaluation revealed bilateral scleritis.
+Due to the suspicion of lungs metastatic disease, the patient was referred to thoracotomy. The histopathology tests of pulmonary lesion suggested tuberculosis, which resulted in introduction of tuberculostatic treatment. With no improvement after tuberculostatic treatment and suspicion of GPA, serological ELISA tests were performed and c-ANCA tests were positive. Subsequently the patient was transferred to Rheumatology Department, where the diagnosis of GPA was confirmed. Control laboratory tests showed WBC of 14,9 thousand/弮L (normal range: 4??0), markedly increased value of c-ANKA > 150 U/L (>8,0 U/mL positive result), and abnormal urine analysis with the presence of protein and red blood cells. Follow-up head CT showed chronic inflammatory changes with polyps in paranasal sinuses.
+The patient was commenced on systemic steroid therapy in the form of Solu-Medrol 2,0 g per day and cyclophosphamide (Endoxan) 600 mg per day with the protection of Uromitexan. The total dose of Endoxan was 5,4 g. In the course of treatment, the patient's condition improved concerning hearing and nystagmus. Facial nerve palsy regressed from 5th to 2nd grade bilaterally in House-Brackman scale.
+Unfortunately, the patient's renal function deteriorated gradually and she died 2 years after the initial otological symptoms due to progressive renal disease."
+Naomi Hansen,43,2003/5/1,241-600-3717,bpeters@example.net,04007 Miller Squares Apt. 235,"A 25-year-old male patient presented with a history of fall of a large stone on chest at a construction site followed by loss of consciousness and fall on back. On initial presentation, blood pressure (BP) was 60/36 mmHg and pulse was 184 beats/min. He was immediately intubated and resuscitated with fluids and inotropes. The patient responded by stabilising BP to 110/60 mmHg. Bilateral intercostal drains were put. Contrast enhanced CT (CECT) chest showed mild pericardial fluid, fractured third rib, and bilateral hemopneumothorax. The patient also had grade 3 liver injury. The patient was shifted to the intensive care unit (ICU) for further management.
+On arrival at the ICU, there was a sudden drop in BP with new onset arrhythmias. Electrical alternans was noted on electrocardiogram as well. 2D echocardiogram (Fig. ) demonstrated mild to moderate pericardial fluid, regional wall motion abnormality, and low ejection fraction. Therefore, urgent pericardiocentesis was done, and BP improved marginally afterwards. The patient developed repeated episodes of atrial fibrillation (Fig. ) and ventricular tachycardia with hemodynamic instability requiring frequent defibrillations. The patient became hemodynamically stable with control of arrhythmias within 2 days. CPK MB, troponin T, and troponin I were found to be positive. Repeat echocardiography showed a decreased ejection fraction of 25 % to 30 %.
+On the third day after ICU stay, the patient developed cellulitis on the back and half of thigh with high grade fever episodes and new onset hemodynamic instability. Immediately, cultures (blood, urine, and tracheal) were sent and antibiotics were escalated. However, no organism could be isolated probably because antibiotics had been initiated empirically. Meanwhile, crystalloids were administered cautiously under echo guidance. However, the patient continued to deteriorate and succumbed to septic shock on the fifth day of injury.
+Most patients with cardiac injury have fatal outcome before reaching the hospital. Penetrating cardiac injury, requirement of inotropes, and the presence of new onset arrhythmias are associated with worse survival. However, sepsis as a worse prognostic factor has not been reported previously. Here, we present a case where sepsis complicated the blunt cardiac injury and leads to fatal outcome.
+Wijngaarden and associates et al. in their 10-year institutional review noted a 14 % mortality in patients with blunt cardiac trauma which increased to 58 % in patients requiring inotropic support []. The presence of arrhythmias decreases the survival to only 12 % to 13 % [].
+Blunt cardiac injury manifests with wide array of signs and symptoms varying from benign ectopic beats to fatal cardiac arrhythmias, shock leading to sudden collapse and death. It may also result in the rupture of the myocardium, pericardium, or valve assembly presenting with gross hemodynamic instability. The right ventricle is the most commonly to be injured portion of heart. However, subtle signs such as flail chest, ecchymosis, and sternal fractures may be the only presentation. Combined use of ECG and troponin I has been found to be one hundred percent sensitive for detection of clinically significant blunt chest trauma [] (defined as cardiogenic shock, dysrhythmias requiring treatment, or structural cardiac abnormalities) []. A normal screening ECG rules out any significant cardiac injury and predicts a benign course []. However, troponin has also been found to be elevated in patients with septic shock making it unreliable for diagnosing in septic patients []. Echocardiography is an excellent tool for diagnosing and monitoring patient with blunt cardiac injury []. However, its interpretation becomes confounded by the presence of sepsis (Table ).
+Sepsis added to cardiac injury may lead to worse prognosis. Myocardial depression, in the form of biventricular dilation and decreased ejection fraction, has been demonstrated in most patients with septic shock []. This further complicates the management of patients with cardiac injury by acting as a ?econd hit??to the injured heart. This depression is however reversible over 7 to 10 days in survivors. End-diastolic dysfunction and end-systolic dysfunction are also found contributory to poor prognosis []."
+Charlie Holland,34,1991/10/8,001-203-606-4372x825,powerssheri@example.org,5987 Kevin Street,"Case 1 (female, 20 days old, Hui nationality) was admitted to our hospital on the 21st of March 2012 due to a skin ulcer on the occiput for the previous 10 days. After birth, the parents placed a brick wrapped in a towel under the neonate? occiput because they thought her head shape was too rounded and unattractive. Ten days prior, the parents found a coin-sized skin ulcer on the occipital site and then went to the local hospital. No particular treatment was given because the neonate was too young. The skin lesion gradually formed a black, dry scab, which fell off two days prior to their admittance of our hospital, exposing the occipital bone. The neonate came from a secondary pregnancy and was a full-term, normal delivery. The examination on admission included the following: Temperature, 36 簞C; Respiration rate, 21 times/min; Pulse, 102 beats/min; Weight, 5 kg. The baby showed normal development, modest nutritional status, normal head size, and no abnormalities upon heart and lung examination. A 2.0 cm ? 2.0 cm skin lesion was located in the middle of the occipital site and deep to the occipital bone. Although the occipital periosteum disappeared, the color of the occipital bone was normal and a small quantity of purulent secretion appeared on the wound. The color of the skin surrounding the wound was normal with no swelling (Fig. ). Under the condition of necessary preoperative preparation, local rotational flap repairing was undertaken after debridement under general anesthesia on the 28th of March 2012. Routine anti-infection treatment was given, and a dense sponge-made head frame was used to restrain the head in a suspension position to avoid pressure on the occiput (Fig. ). Seven days after the surgery, the stitches were removed and the patient was discharged with primary wound healing (Fig. )."
+Mariah Love,39,1997/5/6,001-740-888-8050x4818,ugamble@example.net,0144 Gill Pass Suite 697,"Case 2 (male, nine days old, Dongxiang minority nationality from Linxia Dongxiang autonomous county,Gansu Province) was admitted to our hospital on the 25th of August 2013 due to the presence of a skin sore on the occipital site and exudation for five days, as well as having a fever for one day. The parents placed a tile wrapped in a towel under the neonate? occipital site with the intention of changing his rounded occipital head shape to a flat occiput. Five days prior, the parents observed that the occipital site was pale, which was followed by the presence of a sore and exudation. Improvement was not achieved after treatment in a local clinic, and the lesion size gradually increased to exposure of the occipital bone. The neonate came from a first pregnancy with full-term normal delivery. The examination on admission included the following: Temperature, 38.5 簞C; Respiration rate, 28 times/min; Pulse, 156 beats/min; Weight, 3 kg. The neonate showed normal development, modest nutritional status, normal skin color, normal head size, and no abnormalities upon heart and lung examination. There was a 2.8 cm ? 1.8 cm size skin defect in the middle of the occipital site, where the occipital bone was exposed and the occipital periosteum was absent. The color of the occipital bone was normal with an irregular lesion edge. There was the presence of purulent secretion, tenderness was apparent, and the skin color around the lesion site was normal with no swelling (Fig. ). After systemic support, control of wound infection and preoperative preparation, occipital debridement and bilateral sliding skin flap transposition were performed to cover the exposed skull on the 30th of August 2013 (Fig. ). Routine hemostasis, infection control and further systemic support were given, and a dense sponge-made head frame was used to avoid occipital pressure. Lesion dehiscence was observed after stitches were removed nine days later (Fig. ); therefore, local suturing was undertaken on the 11th of September 2013. The stitches were removed nine days later, and the wound was healed. The patient was discharged on the 22nd of September 2013 (Fig. )."
+Jeffrey Webster,45,1984/9/16,8388705445,sharon44@example.net,372 Peterson Street,"An otherwise healthy 37-year-old white man had chemorefractory classic Hodgkin lymphoma, treated with the following regimens: (1) doxorubicin, bleomycin, vinblastine, and dacarbazine; (2) ifosfamide, carboplatin, and etoposide; (3) brentuximab; (4) gemcitabine and vinorelbine; (5) bendamustine; (6) everolimus; (7) sirolimus and vorinostat; (8) lenalidomide; and (9) dexamethasone, cytarabine, and cisplatin. He then underwent an ASCT from a 10/10 matched unrelated donor, with a fludarabine and melphalan conditioning regimen.
+Three months after the ASCT, the disease relapsed in his abdominal and pelvic lymph nodes. He was treated with intensity-modulated RT to his para-aortic and pelvic lymph nodes, starting on day 119 after the ASCT. At that time, no evidence of GVHD was present, and the tacrolimus was tapered off. The plan was to treat his abdominal and pelvic lymph nodes with a total dose of 39.6 Gy in 22 fractions. However, after completing 28.8 Gy in 16 fractions, he experienced severe abdominal pain, nausea, vomiting, and copious watery diarrhea. An endoscopy revealed an erythematous gastrointestinal mucosa with superficial ulcers. Biopsies taken throughout his gastrointestinal tract were consistent with GVHD. In his stomach and duodenum, the mucosa showed loss of glands, dilated glands with eosinophilic and granular debris, and increased apoptotic cells (Fig. ). In his colon, increased apoptotic cells and loss of glands were identified.
+These findings led to a diagnosis of grade 4 GVHD of the gastrointestinal tract, experienced after 28.8 Gy. His bowel, contoured as ?owel space,??received a maximum dose of 31.8 Gy and mean dose of 14.8 Gy. The volume of bowel space that received ??0 Gy was 39 cc, ??0 Gy was 1400 cc, and ??0 Gy was 2450 cc. His stomach received a maximum dose of 25 Gy and mean dose of 2.9 Gy. The volume of stomach that received ??0 Gy was 4.3 cc and ??0 Gy was 31 cc (Fig. ). Initial treatment with tacrolimus and steroids (2 mg/kg/day) had no effect, but subsequent pentostatin and photopheresis produced a good response. At last follow-up, 6 months after RT had been stopped, his GVHD was quiescent on photopheresis and tacrolimus, with no evidence of active Hodgkin lymphoma in his abdomen or pelvis."
+Kensley Wilkins,24,1983/4/4,606.480.0614x96711,kyleevans@example.org,9447 Sharon Plains,"As previously reported [], an otherwise healthy 24-year-old white man with relapsed Philadelphia-positive B-cell acute lymphocytic leukemia was treated initially with cyclophosphamide, vincristine, doxorubicin, dexamethasone, cytarabine, and methotrexate (hyper-CVAD) with dasatinib. Disease relapse in his central nervous system (CNS) and bone marrow during maintenance therapy was salvaged with augmented hyper-CVAD and dasatinib, followed by a 10/10 human leukocyte antigen (HLA)-matched related ASCT from his sister, with a busulfan and clofarabine conditioning regimen.
+On day 82 after the ASCT, he presented with a headache; he was diagnosed as having an isolated CNS relapse and was treated with rituximab, asparaginase, dasatinib, high-dose methotrexate, and intrathecal cytarabine, followed by consolidative CSI. The CSI was with proton therapy, to a total dose of 24 cobalt Gy equivalent (CGE) in 12 fractions. His brain was treated with right and left posterior oblique beams, and his spine was treated with three posterior-anterior beams. The CSI was begun on day 197 after the ASCT, and no evidence of GVHD was present at that time. The tacrolimus dose was reduced during RT.
+One month after completing CSI, he developed severe dermatitis within the RT portals and conjunctivitis, keratopathy, and conjunctival ulceration. The dose delivered to his skin had been 22 CGE []. A skin biopsy showed inflammatory cell-poor interface dermatitis with vacuolar alterations of the basal keratinocytes and dyskeratotic cells, consistent with grade 2 to 3 GVHD. Treatment with tacrolimus and methylprednisolone (2 mg/kg/day) resulted in resolution of his cutaneous GVHD; however, keratoconjunctivitis sicca persisted despite prednisolone ophthalmic drops. His cutaneous GVHD returned several months later, both within and outside the RT field. This extensive chronic GVHD progressed despite steroids, tacrolimus, and photopheresis, manifesting as ulcerations, scleroderma-like changes, and chronic osteomyelitis that necessitated bilateral above-the-knee amputations. He died of aspiration pneumonia and respiratory failure 4.5 years after the ASCT, with no evidence of leukemia."
+Yusuf Ramirez,22,1980/7/16,+1-758-980-1601x3458,daniel06@example.net,387 Kenneth Flats Apt. 148,"A 63-year-old male presented with a history of hepatitis B virus (HBV) infection for 20 years and no anti-HBV treatment. In mid-Jan. 2015, the patient developed progressive and dull chest pain without obvious inducement. Chest CT scan revealed multiple pulmonary nodules and enlarged mediastinal lymph nodes. The level of serum alpha-fetal protein (AFP) reached 24793 ng/mL. Due to no hepatic lesion found by contrast abdominal CT and MRI scan, F-18 positron emission tomography-computed tomography (PET/CT) was carried out. Unexpectedly, PET/CT definitely showed that multiple lesions in the thoracic and abdominal cavities, including several lung nodules in the maximum size of 1.7 cm ? 1.7 cm (Fig. a1), mediastinal lymph nodes in the maximum size of 6.4 cm ? 3.2 cm (Fig. a2), and intraperitoneal mass in the fundus of stomach, cardia, portal fissure and abdominal aortas in the size of 4.6 cm ? 2.2 cm (Fig. a3), but still no hepatic lesion (Fig. ). On Mar. 6th, 2015, the patient underwent a wedge resection of right pulmonary. The pathological morphology displayed cancer cell nest with pseudoglandular structure and focal necrosis area, typical hepatocellular carcinoma cells with polygonal shape, eosinophilic cytoplasm and big anachromasis nucleus. And immunohistochemistry showed the expressions of CK18 ++, Glypican-3 ++, Hepatocyte +, P53 + and Ki??7 60 - 70 %, which confirmed the diagnosis of primary HCC (Fig. a-f). Thus, the patient was a rare case of EHCC in an advanced stage.
+Following the standard therapy of HCC in National Comprehensive Cancer Network (NCCN) guidelines [], the patient began to take sorafenib 400 mg twice daily together with Chinese medicines (Jinlong capsule, Jiansheng Company, China) and immunopotentiative agents (ubenimex capsules, Yuandong Company, China) on Mar. 19th, 2015. On the tenth day (Mar. 28th, 2015), red maculopapules appeared in the face, neck, abdomen, back and legs (Fig. a and b). From the same day, the patient began to suffer from continuous high fever, with highest body temperature ranging from 39.0 簞C to 39.6 簞C each day. The patient did not decrease the dose or stop the use of sorafenib despite feeling dizzy and fatigue. There was no abnormality in blood routine or blood culture examination, no pulmonary infection or other inflammatory signs. After taking non-steroidal drugs with antipyretic and anti-allergic properties and withdrawing all drugs except sorafenib, no significant improvement was observed in high fever and maculopapules. Therefore, the patient was asked to cease the use of sorafenib from Apr. 3rd, 2015. Strikingly, the high fever and maculopapules were alleviated quickly. On the third day, the body temperature returned to the normal level, and on the fourth day, the maculopapules almost completely disappeared. Next, the patient began to take sorafenib again at the standard dose of 400 mg twice daily on Apr. 7th, 2015. As expected, the fever developed, raising the body temperature to 38.1 簞C on exactly the same day, to 38.4 簞C the next day and 38.8 簞C the third day. Also, the red maculopapules relapsed at the same time. Hence, prednisone was administered at a dosage of 30 mg/day on the fourth day. The body temperature was decreased and maculopapules relieved quickly. The dosage of prednisone was gradually reduced from 30 to 10 mg/day in one month, and then kept at 5 mg/day for another two weeks. After the patient? temperature has returned to normal for more than one month, he intermittently took ubenimex and Jinlong capsule again. There has been no recurrence of fever and maculopapule to date. The dynamic change in body temperature is reflected in Fig. . Other common side effects also need to be mentioned, such as hand-foot syndrome and rash in the scalp and ears and body (Fig. c and d). During the follow-up, the tumor response of both intrathoracic and intraperitoneal lesions reached partial response (PR) according to RECIST 1.1 criteria. The lung nodules, mediastinal lymph nodes and intraperitoneal mass shrank gradually from Mar. 19, 2015 to Apr. 12th, 2016 (Fig. b1-b3, c1-c3 and d1-d3), with the maximum size of 0.8 cm ? 0.6 cm, 3.7 cm ? 2.2 cm and 2.0 cm ? 1.9 cm at the date of Apr. 12th, 2016, respectively. There was still no lesion in liver, revealed by repeated examinations of abdominal ultrasound, CT and MRI (Fig. e and f). In addition, serum AFP gradually dropped from 24793 ng/mL to 2.19 ng/mL on Apr. 12th, 2016 following the disease control (Fig. ). Until Apr. 14th, 2016 in the last review, the patient had maintained a good condition with progression free survival (PFS) of 392 days + ."
+Grace Trevino,26,1995/1/5,703.701.8289,crystal96@example.com,126 Herrera Drives Suite 310,"A 12-year-old healthy girl had suffered a deep third degree scald burn at the age of 2 years. The burned area covered all of her right chest wall area. It was treated conservatively with no skin grafting. At the beginning of puberty, the right breast tissue was unable to grow because of the contracted lower pole (Fig. ). In the preoperative planning, an Integra 10 cm ? 15 cm was selected. The patient was operated under general anesthesia. First, the contracted area was excised and a gap of 7 cm? 5 cm resulted. The unmeshed Integra was putted above the exposed area and attached to the skin borders with absorbable sutures (Vicryl 4/0) (Fig. ). A tie-over dressing with Xeroform and sponge was putted above the Integra and was stapled to the skin. Operative and postoperative management were uneventful. After 4 weeks, the patient went through the second operation. Under general anesthesia, the silicone layer of the Integra was removed and a thin split skin graft (0.01 in.) taken from the anterior aspect of her thigh was put on the integra and attached to it with absorbable sutures (Vicryl 4/0) and staples. A tie-over dressing with Xeroform and sponge was putted above it. The operative and postoperative management were uneventful. After 4 days, the skin was taken and the dressing was exchanged (Fig. ). Follow-up of the patient included measurements of the suprasternal notch to nipple distance (SN-N), nipple to inframammary fold distance (N-IMF) and graft size (Table ). The patient was seen until the age of 19 (7 years post operation) with satisfying results and symmetric development of her breasts (Fig. ).
+Reconstruction of the post-burn breast includes excision of the contracted scar, releasing of fibrotic tissue and covering it with one of the following modalities: split thickness skin graft, expanded full thickness skin graft, musculocutaneous or fasciocutaneous flaps, or an artificial dermal matrix.
+Split thickness skin grafting is very common due to its ease of harvest and availability. It can be meshed up to 1:9, thus enabling a large area of coverage. Yet, it assumed to cause contraction of the reconstructed area because of secondary contraction forces of the graft. This drawback should be considered when one chooses this modality for areas of esthetic and functional importance as in our case.
+The full thickness skin graft is preferable because of better esthetic results and less secondary contracture of the skin. Its main drawback results from the necessity to first expand the donor site in order to get enough skin for reconstruction. This means another operation with a period of a few months of inconvenience until the expansion phase is completed. Moreover, consideration should be taken of the risks and possible complications regarding the expanders (extrusion, infection, damage to the skin, etc.). In our case, the patient was 12 years old when she first came to us. The use of an expander in her abdomen was assumed to be hard to tolerate.
+Musculocutaneous or fasciocutaneous flaps are other alternatives for reconstruction, with good ability of coverage and which can be matched to the defective area, thus leading to very good functional and esthetic results. The main drawbacks of these alternatives are donor site morbidity and the risks of complications and failure.
+The artificial dermis has become more popular in recent years for reconstruction because of its simplicity and the predictability of the reconstructive results. The biodegradable dermal replacement layer serves as a matrix for the macrophages, fibroblasts, and endothelial cells from the host tissue. It causes a new dermis to grow, thereby creating a functional tissue instead of the excised one. The only donor site that is needed is a very thin split skin graft for final closure after the dermal graft has taken. The main drawback of this reconstructive modality is its price which is very expensive.
+In the patient herein presented, we decided to use an artificial dermis matrix to reconstruct the defect. This method has been described in the literature for variety of reconstructions including burned breast [, ]. Palao et al. used artificial dermis in reconstruction of burned breast of 12 patients. They showed in their study that after 1 year, the host collagen completely replaces the artificial one, and elastic fibers were observed in the dermal regeneration template. They had high satisfaction rate after 1 year of follow-up (1). Two of their patients were at puberty age during the reconstruction (13 and 14 years old), though, they had no follow-up for more than 1 year, so there is no way to get knowledge from their study of the long-term development of the reconstructed breast.
+Our case is the first to be published that use this method for breast at the beginning of the puberty and has follow-up of 7 years until the end of the puberty period at 19 years old. By that, we showed that the burned breast developed as well as the other breast, with satisfying symmetric size and shape. The importance of this case is that it emphasizes the long-term advantage of Integra as a reconstructive tool for having a natural functional tissue."
+Jaime Kelley,42,2001/12/31,+1-574-493-8210x7246,william80@example.net,35652 Jeffrey Squares Suite 002,"A 42-year-old previously healthy Russian man living in Estonia was hospitalised due to a one-year history of progressive cognitive decline, confusion attacks, rare hallucinations, gait disturbances and involuntary movements.
+At the beginning of the symptoms he was often sent on short sick leaves because of his employer? doubt about his health. He resigned 6 months after the first symptoms appeared, being unable to perform his duties at work.
+In addition, his spouse could not allow him to leave home due to his progressive disorientation. The patient became unable to cope with daily activities like dressing, brushing teeth and washing. He soon became dependent in most daily life activities. Therewith, he came to the neurologist for the first time.
+On neurological examination he had predominantly left-sided bradykinesia and rigidity and intentional tremor in his left hand and both legs. There was no weakness on motor examination. Deep tendon reflexes were brisk and more pronounced in the left but there were no extensor reflexes. His gate was cautious and wide-based. There were myoclonic jerks in his legs and left arm that were more pronounced in action (stimulus-sensitive) (Additional file ). According to the neuropsychological testing he had severe dementia with the mini mental state examination (MMSE) Score 12/30. The results were affected by severe attention deficit. He had affective symptoms like irritability, aggressive behaviour and delusions. His speech was dysarthric and dysphonic with mixed aphasia that included difficulties in word finding, impaired articulatory agility, verbal stereotypes, some paraphasias in running speech and difficulties in understanding longer sentences. He had anisocoria (the left pupil was larger), with pupils nonreactive to light, and horizontal nystagmus.
+Head magnetic resonance imaging (MRI) scan revealed brain atrophy (Fig. ). There was focal slowing and epileptiform discharges in the right fronto-temporal regions on the electroencephalography (EEG) (Fig. ).
+Blood tests were normal including hepatic function and thyroid tests, although the level of vitamin B12 was slightly decreased (124 pmol/l, reference range 141??89 pmol/l). Human immunodeficiency virus (HIV) 1 and 2 antibodies were negative but the rapid plasma reagin (RPR) test as well as the T. pallidum hemagglutination assay (TPHA) were highly positive (RPR 1:32 and TPHA 1:1520) in serum as well as in cerebrospinal fluid (CSF) (RPR 1:8 and TPHA 1:640). CSF showed predominantly lymphocytic pleocytosis (12 cells/mm3), the protein was elevated to 0.63 g/l, as well as IgG index (4.31).
+Based on clinical pictures and laboratory data, neurosyphilis was diagnosed and intravenous penicillin-G treatment 24 million units per day for 14 days was initiated. Thereafter intramuscular benzathine penicillin of 2.4 million units once per week was injected for 3 weeks. Complementary treatment with divalproex sodium was started as there were epileptiform discharges on the EEG that demonstrated an increased risk for developing of epilepsy, and the patient had emotional problems and agitation.
+On the follow-up 6 months later, he had a mild dementia (MMSE 25/30), but there were neither myoclonus nor parkinsonism. Deep tendon reflexes were still brisk but symmetrical. He still had Adie? tonic pupil in the left and very little constriction to direct light bilaterally. No clinical features of cerebellar dysfunction were detected. Both the serological markers [RPR (1:2) and TPHA] and the above mentioned CSF measures changed to negative.
+The patient continued treatment with divalproex sodium 300 mg bid, and enalapril with amlodipine for hypertension. On the subsequent follow-up visits (twice a year), no consistent changes have been found."
+Rosalie Cortez,37,1990/12/1,2227012582,karen40@example.net,4361 Rebekah Pass Apt. 589,"A 14-year-old female attended the Orthopedic Oncology Clinic at The First Affiliated Hospital of Nanchang University (Nanchang, China) for a follow-up. She underwent two operations successively due to pathological fractures in the left femur and tibia in a local hospital about 1 year ago. Then, she was diagnosed with FD according to the postoperative pathological examinations. Recently, she had no obvious symptoms and discomfort. Physical examinations showed nothing remarkable, but a little swelling in her left distal thigh. She had a negative family history of bone tumor. There was no fever or respiratory embarrassment accompanying the swelling. No history of weight loss or exposure to tuberculosis was mentioned.
+In a further examination, physical examination showed no palpable head, neck, supraclavicular, axillary, or epitrochlear lymph nodes. Inflammatory markers were within the normal limits. Plain radiographs indicated an expansile osteolytic lesion with marginal sclerosis and a matrix with a ground glass appearance and without periosteal reaction of the left distal femur, which was consistent with FD (). Then, a diagnosis of recurrence of FD in the left femur was made given the medical history of FD, symptoms, and imaging findings.
+Based on the exclusion of surgical contraindications, professional surgeons, who specialized in treating bone tumors, performed the surgery of curettage and grafting in the left femur. Histologic analysis of hematoxylin and eosin-stained specimens showed irregularly shaped spicules of immature bone without osteoblastic rimming and fibrous stroma with few mitotic activities (). Immunohistochemical analysis showed positive for CD68 and Vim but negative for bcl-2, CK, CD34, CD99, EMA, SMA, and S100. According to the above findings, the diagnosis of the recurrence of FD of the left femur was finally confirmed.
+Nevertheless, she presented to our clinic again with a chief complaint of pain and swelling in her left tibia and calcaneus 4 months later. Radiographic review showed a prominent osteolytic lesion located in the distal portion of the tibia and calcaneus with cortical destruction (). The patient underwent surgery with the removal of the tumor tissue and reconstruction with allogenous bone graft. According to the histological and immunohistochemical findings, the diagnosis of PMH secondary to FD was confirmed by an expert pathology consultant.
+Finally, the patient had to undergo an amputation of the left thigh. The tumor consisted of densely distributed pleomorphic cells, ranging in configuration from small spindled elements to large plump epithelioid variants with prominent pink cytoplasm. Scattered cells with vacuolated cytoplasm were also present. Prominent pleomorphic nuclei contained optically empty centers with peripheral marginalization of the chromatin, in addition to conspicuous nucleoli. Multinucleated cells were also present. Vasoformative elements, such as multi-cellular vascular channels or intracytoplasmic vacuoles, were identified (). Immunohistochemical analysis showed positive for CK, CD31 (), but negative for s-100 and CD34. According to the above findings, the diagnosis of PMH secondary to FD of the left lower limb was finally confirmed.
+The patient was discharged without any complications 1 week after the amputation. At the time of the 3-month follow-up, the patient reported no pain or discomfort in her left lower extremity. No evidence of recurrence or distal metastasis was noted during the 3 months after surgery. However, it is necessary to perform continuous observations of the patient because of a high rate of recurrence and metastasis.
+Pseudomyogenic hemangioendothelioma is a rare soft tissue tumor?istinct from epithelioid hemangioendothelioma []?riginally described as a ?ibroma-like variant of epithelioid sarcoma??[]; it has been recently concluded that the ?pithelioid sarcoma-like hemangioendothelioma??is essentially the same pathological entity []. PMH affects predominantly young males. The tumor is multifocal, involving different tissue planes and, although, it shares some histopathologic features with epithelioid sarcoma, it has a different, spindle cell morphology with common positivity for CD31, lack of CD34 reactivity, and intact INI-1 immunoreactivity [, ].
+By contrast, fibrous dysplasia (FD) is a common tumor-like lesion characterized by solitary or multifocal polyostotic intramedullary lesions []. It has a frequency of 2.5 % for all bone lesions and 7 % for benign bone tumors []. While any bone can be affected by FD, the most common sites of the disease are the femur, the tibia, the ribs, the skull, the facial bones, the humerus, and the pelvis. Although many bones can be affected at once, FD is not a disease that spreads from one bone to another. Multiple affected bones are often found unilaterally [].
+However, malignant transformation of FD is rare and occurs in less than 1 % of the cases [, ]. The most commonly observed malignant transformations are osteosarcoma, fibrosarcoma, and chondrosarcoma []. As far as we can see, the current case is the first case reported ever of PMH secondary to FD, which is extremely rare and worthy of special remark.
+FD can be divided into two major types: monostotic and polyostotic []. According to the largest series, malignant changes seem more likely to occur in polyostotic than in monostotic FD [, ]. It is consistent that the current research described a malignant change in a polyostotic FD. Although it is important to recognize malignant transformation as early as possible, it may not be easy as in our case. Suspecting from malignant transformation can be extremely difficult especially in cases with monostotic disease having either subtle symptoms or none. In the reported cases up to date, the special symptoms of the malignant change were mainly pain, swelling, and late appearance of a bony mass [, ]. But given the fact that the pain is a nonspecial finding and is the most common complaint followed by pathological fracture in FD [], great care should be taken when evaluating this symptom. Pain which is rapidly becoming worse over a relatively short period without trauma should be considered alarming [].
+PMH is extremely difficult to diagnose because of no morphological evidence suggestive of endothelial differentiation is present to confirm a radiological pattern of vascular neoplasm (multiple well-limited purely lytic lesions) []. The tumor is composed of large spindle cells, arranged in sheets or fascicles. Tumor cells with epithelioid cytomorphology are also often present. In this case, the tumor consists of spindle cells, and round epithelioid cells exist. The cells are large and have abundant eosinophilic cytoplasm, mimicking a myoid tumor or epithelioid carcinoma cells. The tumor cells are plump but show no apparent pleomorphism. The nuclei of the cells have small nucleoli without notable atypia, and the mitotic activity is scarce.
+Based on previous reports in other locations, PMH has a more indolent clinical course with a small risk of metastasis []. Therefore, complete macroscopic excision is the treatment of choice. Local recurrence must be considered, even with complete, gross surgical resection; close follow-up and adjuvant therapy are warranted."
+Zayn Erickson,37,1981/11/28,001-229-543-5158x9292,shannon54@example.net,45454 Aguilar Burgs Suite 279,"A 7-year-old boy was brought to the emergency room with history of crush injury by bullock cart 1 h before presentation. The boy was complaining of severe pain in the upper abdomen and had two episodes of non-bilious vomiting. On examination, pulse rate was 130/min and BP was 110/70 mmHg. The abdomen was tender over the right hypochondrium and lumbar region. The right lower limb was flexed at the hip joint, and passive extension was painful. There was no pallor. An abdominal radiograph was nonspecific and without evidence of free air. Abdominal ultrasound demonstrated minimal fluid in the pelvis and unremarkable solid organs. In view of the hemodynamic stability and unavailability of expert radiologist, the child was initially managed expectantly. The investigations revealed?emoglobin 120 g/dl, hematocrit 32 %, total leukocyte count 26 ? 103/弮l, and serum amylase 30 U/L.
+He had few episodes of bilious vomiting in the next 12 h. The patient complained of increased abdominal pain and had local abdominal tenderness despite adequate bowel rest. Although the child was hemodynamically stable, he had fever spikes with temperature reaching up to 38.9 簞C.
+A contrast-enhanced computerized tomography (CECT) of the abdomen was done, which revealed free fluid of high density in the peritoneal cavity around the hepato-renal pouch and localized free air in retroperitoneum around second part of duodenum, which was communicating with the lumen (Fig. ). An exploratory laparotomy was subsequently performed that revealed copious frank pus in the peritoneal cavity. The hepatic flexure was inflamed and revealed numerous flimsy inter-bowel adhesions. After reflecting the cecum and ascending colon medially, the duodenum was identified and was noted to be covered with bile-stained slough. After kocherization, a 2 ? 2 cm perforation was seen on the lateral wall of the second part of duodenum (Fig. a).
+Since the defect was less than 50 % of the circumference, duodenorrhaphy was performed by closing the perforation in a transverse fashion. A pedicled omental patch was added (Fig. b). The patient was kept nil per oral for 10 days with supplemental parenteral nutrition and had an uneventful recovery.
+IDP in pediatric trauma is scarcely reported. Only isolated cases of IDP following blunt abdominal trauma exists in the English literature [?. DuBose et al. in 2008 reported a series of five adult cases of IDP, which was the largest series thus far in the literature []. Concomitant injuries are more common, and overall outcome depends on the nature and the severity of these injuries.
+Road traffic accidents are the most common mode of blunt injury to the duodenum []. In addition to this, other peculiar mechanisms commonly encountered in children are falls, bicycle handlebar injuries, child abuse, and playground accidents [?. IDP following blunt trauma abdomen (BTA) may occur as a result of ?rush injury??or ?istraction injury?? The duodenum may get crushed between spine and other hard objects like handlebar or a steering wheel []. In our case, the duodenum got crushed between the spine and heavy bullock cart. ?istraction??injuries with perforation occur at the junction of the first and second part of the duodenum []. This usually follows sudden deceleration as after high-speed motor vehicle accidents.
+Presentation in IDP may be nonspecific initially. Specific signs of perforation may appear late. Symptoms may be mild at the outset and range from mild to severe upper abdominal pain with recurrent vomiting. There are reports of patients with milder symptoms having been discharged from the emergency department only to be readmitted a few hours later as the symptoms worsened [, ]. An in-depth review of the literature on IDP showed vomiting and abdominal pain, localized to the right upper abdomen, being the most prevalent symptom []. Leukocyte count has been found to be elevated in almost all cases [, , ]. Serum amylase levels may be raised but is less specific [, ]. The triad of vomiting, upper abdominal pain, and leukocytosis, though individually less specific, when present together in BTA, may suggest duodenal injury []. Our patient had all these symptoms, which gradually progressed. In addition, he also had painful flexion attitude of the right hip, which may had been related to spasm of right psoas muscle secondary to irritation from the surrounding duodenal fluid. This finding of ?soas spasm??in blunt abdominal trauma was noted in our case and has not been described in literature earlier. Therefore, if consistently present, along with the aforementioned triad, it may clinically suggest duodenal injury.
+Abdominal radiograph and sonography may not be useful in diagnosis of IDP due to its retroperitoneal location []. The role of early CECT abdomen with oral contrast at this point is crucial. When multi-detector CT is used, sensitivity of 88??3 % can be achieved for detecting bowel injuries in patients with blunt trauma []. However, such sensitivity and specificity data of CT in diagnosis of isolated duodenal injuries do not exist in current literature due to its uncommon occurrence []. Duodenal perforation is suggested if there is a retroperitoneal collection of contrast medium, extra-luminal gas, or a lack of continuity of the duodenal wall []. Since majority of blunt trauma cases in children with stable hemodynamics are managed expectantly, clinical correlation with mentioned CECT features can help surgeons in early decision-making. We retrospectively correlated the clinical symptoms and learned that an early CECT would have helped us in early exploration of this case.
+In most of the cases where the perforation is less than 50 % of the circumference, simple duodenorrhaphy is adequate []. In addition to primary repair, feeding jejunostomy or a gastrojejunostomy may be added to safeguard the repair []. For perforation sizes that preclude a primary repair, techniques like jejunal serosal patches and pedicled mucosal flap with jejunal or gastric island flap have been described in experimental setting with minimal impact in actual clinical setting []. Another technique with Roux-en-Y duodenojejunostomy has been described with encouraging results in clinical setting as well []. Irrespective of the technique used, the outcome however also depends on the timing of intervention. It has been noted that in duodenal perforation with concomitant injuries, a delay of more than 24 h has a poor outcome []. Thus, early recognition of this rare injury is necessitated for a better outcome."
+Sabrina Massey,42,2005/4/3,+1-427-600-2548x9574,heatherjohnson@example.org,214 Amanda Plain,"A 56-year-old white male, former pipefitter, 68 kg /169 cm, with no particular personal or familiar medical-surgical history, presented with a lesion of oral cavity of recent apparition. The cancer risk factors included unweaned smoking, valued at about 40 pack-years, and alcohol consumption (weaned for 3 years). Physical examination revealed an ulcerative lesion on the right anterolateral floor of oral cavity, which was adherent to the gingival fibro mucosa. Several leukoplakias were also observed on the gingival mucosa. The rest of the otorhinolaryngology examination was unremarkable.
+A biopsy confirmed the lesion as an invasive well- / moderately-differentiated squamous cell carcinoma. A contrasted computer tomography (CT) scan showed a tumoral process involving the muscles of the anterolateral floor of oral cavity, which extended about 3 cm in the long axis and remained lateralized to the right (Fig. ). The lesion was in contact with the mandible and furthermore developed a suspicious bone notch. No cervical lymph nodes of significant size and no other suspicious lesions on the cervical-thoracic level were present in this CT scan. A 18F-fluorodeoxyglucose positron emission tomography / computed tomography (18F-FDG PET/CT) scan found a lesion of intense hypermetabolism next to the right genio-glosse triangular muscles and lips, which seemed to repel the omohyoid muscle without infiltrating it (Fig. ). A lytic aspect of the cortical bones of the mandible body suggested a bone extension. 18F-FDG uptakes were perceptible in lymph nodes of right groups Ib and II. The patient received a panendoscopy under general anesthesia. The upper gastrointestinal endoscopy and the bronchoscopy did not find any abnormalities.
+The TNM staging was classified as T4N2M0 (according to American Joint Committee on Cancer 2009) [] and noninterruptive pelvimandibulectomy was validated as the primary treatment by a multidisciplinary meeting. The surgery was performed in a satisfactory manner 2 months after the first consultation. The post-operative care was performed by standard procedures without abnormalities. The pathological analysis of excised specimens confirmed the squamous cell carcinoma histology as well as the lymph node metastases (Fig. ), suggesting the definitive TNM stage as pT4aN2cM0. In addition, the margins were negative but multiple tumor nodules were found in the muscle. Immunohistochemical analysis for HPV showed the staining of p40 but no expression of p16.
+At the end of 6 weeks postoperative follow-up, the patient complained of a painful cervical edema as well as a trismus. A CT scan was ordered, which found regional multiple recurrences (Fig. ). A multidisciplinary meeting updated the treatment strategy including a surgical retake, followed by radiochemotherapy. However, the patient died 2 weeks later due to cancer related complications.
+The patient was recruited into a clinical research program (VADS - EudraCT N簞: 2010-A00586-33, approved by the regional ethic committee ?omit矇 de Protection des Personnes Est III??, which aimed to evaluate the prognostic value of CTC in HNSCC. Venous blood samples were collected at three time points (preoperative day-1, intraoperative, and postoperative day 7) for the detection of CTC. The manipulations were performed by using the CellSearch簧 system (Veridex LLC, Raritan, NJ) according to a standard protocol []. The commercially available CellSearch簧 Tumor Phenotyping Reagent Epidermal Growth Factor Receptor (EGFR) kit (Veridex LLC, Raritan, NJ, USA) was used on the fourth channel of fluorescence of the CellSearch簧 system following the manufacturer? instructions. The pre-, intra-, and post-operative enumerations of CTC are shown in Fig. . A high count of CTC was already detected at baseline (400 CTC), decreasing by 67.5 % at the intra-operative time point (150 CTC), after which it increased significantly (1400 CTC). In particular, all CTC were EGFR negative. Typical images of CTC are shown in Fig. ."
+Donald Reyna,18,1985/8/13,2798455257,williamsmelissa@example.net,3540 Perez Islands Apt. 151,"A 33-year-old normotensive, non-diabetic Bangladeshi Bengali female presented with sudden onset severe retrosternal chest pain and two episodes of syncope over 4 h. Chest pain was worse on deep inspiration and associated with shortness of breath, orthopnoea and palpitations for 2 days. She had an ankle fracture and was on a cast with plaster immobilization for the preceding month, and admitted to unilateral leg pain and swelling.
+On admission, she was cyanosed with gasping respiration; pulse and blood pressure were non-recordable. She developed asystole soon after, and reverted to sinus rhythm following 2 min of cardio pulmonary resuscitation (CPR). After resuscitation, heart rate was 136 beats/min and blood pressure was 80/55 mmHg. SpO2 was 90 %. Respiratory rate was 35 breaths/min. She was given high flow oxygen, intravenous (IV) normal saline and dopamine infusion for hypotension. Electrocardiogram (ECG) revealed sinus tachycardia (rate 136/min), right bundle branch block (RBBB) with S1Q3T3 pattern (Fig. ). Bedside echocardiogram revealed dilated right atrium (RA) and RV (Fig. ), floating thrombus in RA (Fig. ; Additional file : Video S1); impaired RV systolic function [tricuspid annular planar systolic excursion (TAPSE) was 9 mm] with no evidence of RV hypertrophy; there was mild tricuspid regurgitation and pulmonary hypertension with pulmonary artery systolic pressure ~45 mmHg and normal left ventricular systolic function (ejection fraction 60 %). Immediate thrombolysis was done with IV streptokinase 1.5 million units over 2 h as per accelerated regimen of European Society of Cardiology (ESC) guidelines, resulting in a subsequently normal ECG (Fig. ). Subsequent CT pulmonary angiogram done immediately revealed an approximately 2 cm filling defect in the descending branch of left pulmonary artery extending up to the lateral and posterior basal segmental arteries, suggesting thrombus (Fig. ). d-dimer assay was positive. Troponin-I was 1.27 ng/mL (high risk??.11??.60). Complete blood count revealed neutrophilic leucocytosis. As she had no episodes of bleeding following thrombolysis, she was commenced on low molecular weight heparin (LMWH) at a dose of 1 mg/kg body weight for 5 days with simultaneous oral warfarin titrated to a therapeutic PT/INR of 2.0??.0. Review echo done 2 days later revealed no thrombus or pulmonary hypertension, normal RA and RV. She was discharged on warfarin 5 mg daily and was asymptomatic with therapeutic PT/INR at 3 month follow up. She denied use of the oral contraceptive pill and was advised against its use owing to its potential as a risk factor. Hypercoagulability evaluation including Protein C and S levels, antinuclear antibody, anticardiolipin antibody and serum homocysteine levels were within normal range, thus eliminating other causes of hypercoagulability as possible aetiology of thrombosis."
+Luella Hines,33,1981/12/18,(702)972-4351x317,oorozco@example.net,46862 Sellers Ramp Apt. 385,"A 12-year-old Irish boy suffered a near total facial burn as a toddler when his Halloween costume caught fire. Eleven prior surgeries for correction of lip and eyelid ectropion were marginally successful. On initial exam, dense keloid scars were present over the entire face, chin, jaw, and neck (Fig. ). Central elements (the nose and upper lips) were predominantly spared. On profile, dense bands of contracting scar extended obliquely across the cervicomental angle causing substantial retrusiveness of the chin (Fig. ). The lower lip was foreshortened and evaginated with exposure of lower dentition and the dento-alveolar ridge. Multi-stage autogenous facial reconstruction was accomplished by MV free transfer of a patterned radial forearm to the neck (Fig. ) followed by bilateral sequential patterned scapular free flaps to the right and left hemiface/cheeks, respectively (Fig. ). Architectural modifications were coordinated with each of the flap transfers. A bimalar fascia lata sling was inset during neck reconstruction to elevate the lower lip (Fig. ). A Porex chin implant provided the chin thrust. Fascia lata slings from the malar arches to the lateral lip modioli were placed beneath each of the scapular flaps for lateral lip support (Fig. ). All autogenous free flaps were 100 % successful. Additional aesthetic refinements included modest debulking of the cheeks, lower lid canthoplasties, dermal plication of the nasolabial creases, and laser resurfacing of the scars. Six months after the final surgery, facial planes are restored and flaps are well incorporated into the facial geometry with seam hidden at junctions of the aesthetic units (Fig. ). On profile, neck contraction is mitigated; cervicomental angle is acute; and chin projection is restored (Fig. )."
+Uriel Brock,45,2001/11/27,(800)230-3567,robert66@example.com,543 Wilkinson Mountain Suite 354,"A 10-year-old girl sustained 80 % TBSA burns during a crib fire as an infant in Columbia. She was abandoned by her biological parents and brought to the United States for treatment where she was adopted by caring foster parents. Prior to treatment at The Mount Sinai Medical Center in NYC, she had undergone 10+ prior surgeries with limited success. On exam, the face was grotesquely deformed characterized by obliteration of facial planes, displacement of the LT ocular adnexae, nasal collapse, and microstomia (Fig. ). On profile, the chin was marked retrusive and the lower lip ectropic with exposure of the lower dentition (Fig. ). Nasal tip and bridge projection was deficient. Multi-stage autogenous reconstruction was initiated with sequential pre-patterned, sculpted MV scapular flaps to the RT and LT hemiface, respectively (Fig. ). Deep facial foundation was restored with insertion of fascial lata slings for suspension of lateral lip commissures in conjunction with each of the scapular flaps (Fig. ). Peri-ocular reconstruction was achieved by re-alignment of the medial canthal tendon by transnasal wire fixation and repositioning of the lateral canthal ligament to the lateral orbital rim. Both upper and lower lids were resurfaced with single sheet grafts to the orbital subunit with single slits opened at the ciliary apertures (Fig. ). Total nasal reconstruction included architectural enhancement of the nasal tip with conchal cartilage grafts and dorsal resurfacing with a patterned, pedicled forehead flap using partial thickness burned skin (Fig. ). The divided pedicle base was ?iggy backed??to the lower eyelid for ectropion repair prior to permanent inset. Nostril patency was restored with FTSGs wrapped around nasal stents. Additional refinements included debulking/contouring of the nasal and cheek flaps, SAL, insertion of a Porex chin implant, levator advancement OS, dermal strip grafts for upper lip augmentation, nostril thinning and repositioning, scar revisions, and laser resurfacing. Six months after the final surgery, facial planes have been restored with seams hidden at junction of aesthetic units (Fig. ). Facial components (lips, eyes, nose) are balanced, symmetrical, and complementary. Smile is symmetrical. On profile, nasal, chin, and lip projection are proportional (Fig. )."
+Jada Parra,22,1995/9/7,326-534-9237x470,jamesmclean@example.com,19113 Smith Common,"The patient was a 28-year-old woman who was referred to our Burn Institute 1.5 h after a flame burned her head, trunk, and limbs. The patient had a distressed facial expression and was cooperative in the physical examination. She had no breathing difficulty, although obvious swelling, particularly on the head, was observed. No ashes or blisters were found on the oropharyngeal mucosa by laryngoscopy examination. Physical examination data on admission were as follows: body weight, 56 kg; blood pressure, 132/67 mmHg; pulse rate, 88 bpm; body temperature, 36.8簞C; and respiratory rate, 15 bpm. The burn wounds were distributed on the face, neck, trunk, and limbs, and the total burn area was 50% TBSA. Wounds were presented as red, or red and white in appearance, and parts of them were dry with diminished sensation. The laboratory results were as follows: blood routine examination: WBC, 18.64 ? 109/L; neutrophil granulocyte, 90.3%; Hgb, 105 g/L; RBC, 4.03 ? 1012/L; Hct, 0.329; platelet, 296 ? 109/L. The liver and kidney function indexes were all in the normal range except that the total protein level was 50 g/L and the albumin level was 24 g/L. The obstetric examination results were as follows: The patient was 35 weeks and 5 days pregnant, the uterine fundus was halfway between the umbilicus and xiphoid process, and the fetal outline was palpable. No vaginal bleeding or discharge was observed, and uterine contraction was not palpable. Fetal movements were occasionally felt. The cervix was not open, and the fetal membranes had not broken. The fetal heart rate (FHR) was 150 bpm. There was no gestational hypertension, gestational diabetes, or other combined diseases reported. The admission diagnosis was that the flame burned 50% TBSA (superficial second-degree 20% TBSA, deep partial thickness burn 30% TBSA) with a third-trimester pregnancy.
+During emergency treatment, lactate Ringer? solution was infused for fluid resuscitation, and 1,500 mL of lactate Ringer? solution was infused during the first 9 h after injury. The burns were covered with Vaseline gauze after simple wound cleaning. Nine hours after the injury, after consulting and discussing with the obstetrician, a cesarean section was performed under spinal epidural anesthesia, and a live baby girl was delivered. The surgery lasted approximately 1 h, and the blood pressure was stable during the surgery. The Hgb level after the surgery was 97 g/L. The baby had a body weight of 2,220 g and a body length of 46 cm with APGAR scores of 10?? 10?? and 10?? The vital signs of the patient were stable during surgery. After delivery of the baby, intravenous fluid resuscitation was continued for the patient using the Ruijin (Resuscitation) formula. Ruijin? formula involves the infusion of a crystalloid solution, which comprised primarily lactated Ringer? solution and/or colloids, usually plasma, at a rate of 1.5 mL/kg/percentage of the burned body surface area for the first 24 h and half of the amount of the actually infused crystalloid and colloid solution for the second 24 h. In addition, 2,000~3,000 mL of physical-demanding water was applied every 24 h after injury. The type and volume of the solution delivered for liquid resuscitation are summarized in Table . The hourly urine output was 50~350 mL during the first 48 h after the burn injury. The treatment for the patient included the application of silver sulfadiazine cream on the wounds when the dressing was changed every 2 days, infusion of imipenem for the antimicrobial prophylaxis of infection, and administration of oxytocin and Chinese herbal medication to promote uterine involution. No systemic infection or dysfunction of internal organs was found during the patient? stay in the hospital. The patient discharged herself without postpartum complications at 15 days after injury due to financial reasons. At discharge, the superficial second-degree and part of the deep partial thickness burn wounds that were relatively superficial were healed, and less than 10% TBSA deep partial thickness burn wounds remained on the neck, right upper limb, and both legs. No signs of difficulty of healing that could imply the connection of impaired healing and pregnancy were observed. Physical examination results were as follows: blood pressure, 119/76 mmHg; pulse rate, 90 bpm; body temperature, 36.4簞C; and respiratory rate, 17 bpm. Laboratory results were as follows: blood routine examination: WBC, 8.76 ? 109/L; neutrophil granulocyte, 71.3%; Hgb, 111 g/L; RBC, 4.12 ? 1012/L; Hct, 0.337; platelet, 359 ? 109/L; glutamic pyruvic transaminase, 19 IU/L; glutamic-oxalacetic transaminase, 23 IU/L; alkaline phosphatase, 81 IU/L; TP, 71 g/L; albumin, 36 g/L; urea nitrogen, 3.6 mmol/L; creatinine, 37 弮mol/L."
+Davion Nielsen,29,1988/9/3,956.335.4102,rdalton@example.com,419 Kelly Forge Apt. 223,"A previously healthy 19-year-old male was transferred to hospital with extensive deep burns covering approximately 85 % total body surface area (TBSA). After initial assessment and debridement in the operating room, he was brought to the general systems intensive care unit (ICU) for acute renal failure likely due to myoglobulinuria. He remained in the ICU for 34 days until he was transferred to the burn unit. Several operations including multiple debridements and allograft applications were performed throughout his time in the ICU and burn unit. During his extended stay, he was treated for many complications, including multiple infections, pancreatitis, deep vein thrombosis, pleural effusion, cardiomyopathy, chronic diarrhea, depression, as well as upper airway and upper gastrointestinal tract bleeding secondary to ulcers. As well, he developed another acute kidney injury thought to be secondary to acute tubular necrosis and had multiple instances of elevated liver enzymes and abnormal liver function tests. Both of these organ insults were thought to be secondary to medications administered, as these values corrected with discontinuation of these insulting agents. In total, his acute care admission lasted approximately 15 months with 33 operations/procedures needed before he could be transferred to a rehabilitation unit.
+Throughout his prolonged stay, he was worked up for anemia as he required massive amounts of RBC transfusions to maintain an average hemoglobin value over his admission of 95 g/L. This value fluctuated regularly falling into the low 70s on many occasions necessitating the use of blood products. Multiple gastrointestinal bleeds presenting with melena were thought to be large contributors to this laboratory abnormality. The question of hemolysis was raised as early on in his treatment course; he occasionally had elevated lactate dehydrogenase and bilirubin values, as well as positive direct antiglobulin tests. However, his haptoglobin never fell below the normal range and multiple peripheral blood smears had minimal morphological evidence of hemolysis. His chronic anemia was managed with multiple RBC transfusions throughout his hospital admission.
+While in hospital, he had multiple zinc, selenium, and copper serum values in the low and normal ranges. However, he was noted to have elevated serum iron levels and an increased iron saturation index reaching 94 % (normal <60 %). His iron indices were followed throughout his stay as all values progressed to outside the normal limits (Table ). Subsequent magnetic resonance imaging (MRI) of the abdomen verified the diagnosis of hemochromatosis by showing iron deposition in the liver and spleen (Fig. ). A search for etiology revealed that in just less than 15 months, he had received 292 units of packed RBCs. He did not receive any exogenous administration of iron during his treatment course. With this information, it was thought that the increased iron saturation was due to a transfusional iron overload. Given his ethnicity and age in the presence of a clear alternative diagnosis, the clinical decision to forego genetic testing was made by the Internal Medicine and Hematology services. He had not manifested any typical signs or symptoms of secondary hemochromatosis. The Hematology service was consulted, and as per protocol, he was started on twice weekly phlebotomies []. Due to pre-syncopal episodes, he was unable to tolerate this, and thus, phlebotomy was performed weekly.
+There is a wide differential of potential causes to consider in patients presenting with iron overload. In this case, the MRI suggested a pattern of iron overload consistent with a secondary (i.e., non-hereditary) process. A review of secondary causes reveals that he did not receive parenteral iron during his stay, did not have a history of chronic anemia or liver disease prior, is not of African descent, and did not have any neurological dysfunction to suggest aceruloplasminemia. Based upon the quantity of RBC transfusions administered during his course, it appears this is the most likely diagnosis.
+This is the first reported case of transfusional iron overload resulting in secondary hemochromatosis in a burn patient. Previously, this phenomenon has been shown to occur in patients receiving chronic transfusions over an extended period of time for treatment of blood disorders [, ]. This evidence is in keeping with the notion that secondary hemochromatosis due to transfusions is mainly a concern in chronically transfused patients. It has been suggested that signs of iron overload could be present with as few as 10??0 transfusions []. This case substantiates that multiple acute transfusions may also lead to secondary hemochromatosis.
+Based upon this report, a screening protocol for secondary hemochromatosis may be useful in burn patients receiving acute transfusions, as has been suggested in the population receiving chronic transfusions; however, the details of such a protocol require further study []. Screening for secondary hemochromatosis requires straightforward measurement of serum iron indices, and treatment includes iron chelation and/or serial phlebotomy. There is a technique for phlebotomy described in the hereditary hemochromatosis population that could possibly be applied to transfusionally overloaded patients. The suggested regiment includes removing one unit of blood once to twice a week as serum ferritin analysis is performed periodically to ensure its decline []. Given the simplicity of screening and availability of treatment options, which reduce long-term morbidity, further research in this area is essential to document the prevalence of secondary hemochromatosis in the burn population and the potential need for such a screening protocol."
+Vienna Duran,29,1982/5/8,001-881-450-8984x50001,bonillalarry@example.com,309 Miller Parkway Suite 910,"Further, we closely followed up the case of a 29-year-old female who was referred to our hospital for the evaluation of her cervical polyps. A diagnostic hysteroscopy with fractional curettage was performed revealing an endometrial carcinoma (grade II). The patient underwent a radical hysterectomy. Postoperative therapy included brachytherapy in afterload technique in the vagina. Approximately 12 months later after a routine clinical examination, she displayed a nodular goiter. The patient underwent a subtotal thyroidectomy. Due to unclear intestinal complaints, a colonoscopy was performed. In an endoscopic examination small polyps were found in the sigmoid colon and rectum from which a biopsy was taken (Figure ). Histopathological investigations revealed the overall picture of a mucosal ganglioneuroma. The neurological examination showed significant dysdiadochokinesia on both sides, as well as an ataxic uncertain gait pattern. Cerebral magnetic resonance imaging (MRI) was performed for further evaluation. MRI scans revealed two infra-tentorial tumorous lesions on the left side (Figure ). Due to tumor increase, a resection was performed, and the histopathological examination of the excised tumor tissue showed meningioma WHO簞 I (Figure ). Physical examination revealed macrocephaly, multiple facial papules, gingival fitrichilemmomas and acral keratoses. The family history was inconspicuous concerning CS and neurological syndromes.
+The patient presented clinical signs all indicative for the Cowden syndrome (Table ). Subsequently, human genetic test detected a novel germline G132F mutation in PTEN gene. This mutation occurs within exon 5, which encodes a portion of the phosphatase domain. Interestingly, the G132F missense mutation has not previously been reported in association with Cowden syndrome.
+Finally, we summarized 109 cases of CS from the peer-reviewed literature featured in ."
+Ismael Bullock,19,1980/12/30,+1-746-580-5552x0969,hilljennifer@example.net,006 David Wells Apt. 375,"A 66-year-old male patient began to experience vision difficulties, developed a persistent right fronto- temporal headache and memory loss for recent events. On September 3, 2013, after an evaluation, a CT of the brain was done in Panama City, Panama. The CT demonstrated a right temporal occipital tumor with significant mass effect. The patient was started on oral dexamethasone and opted to seek further management in Houston, Texas. He was evaluated at our institution by the neurosurgery team and found to have a dense left homonymous hemianopsia. A brain MRI confirmed the presence of a medial right temporo-occipital lobe mass measuring 3.8 ? 5.8 ? 4.7 cm3 with peripheral enhancement and centrally decreased T1 signal. There was increased T2 signal throughout the white matter, with effacement of the atrium and right lateral ventricle and with lateral displacement (Figure ). In addition, there was superior medial displacement of the adjacent posterior cerebral artery. In September 19, 2013, he underwent a right parieto-occipital craniotomy with maximal tumor removal (Figure ). Surgical pathology revealed a GBM WHO grade IV. Gene sequencing analysis as well as morphoproteomic analysis of the tumor was requested. Four weeks after the surgery treatment was initiated with chemo-radiotherapy. He received a total of 60 Gray (Gy) in 30 fractions with a concurrent dose of temozolomide of 75mg/m2 BSA daily for 42 days through the duration of the radiotherapy. Four weeks after completion of the chemo-radiotherapy he was started on adjuvant treatment with a combination of temozolomide and plerixafor. The temozolomide dose was 150mg/m2 BSA daily for five days the first month of treatment and subsequently escalated to 200mg/m2 BSA daily for five days monthly. Plerixafor was given subcutaneously at a dose of 0.24mg/Kg of body weight once a week. In addition he received a daily dose of lapatinib, niacinamide and metformin. At the completion of twelve months the temozolomide was stopped. He has continued the administration of the weekly plerixafor and daily niacinamide and metformin. Since completion of his concurrent chemo-radiotherapy and initiation of his adjuvant treatment there has been progressive stabilization of his clinical condition and of his brain MRI images (Figure ) with no evidence of recurrence of his tumor. His vision has improved with the assistance of special lenses and he has returned to work. Adverse events experienced during this treatment include a skin rash with diarrhea associated to the lapatinib, infrequent periods of thrombocytopenia during the temozolomide period of treatment and a right popliteal venous thrombosis treated temporarily with enoxaparin. Initially he experienced several months of depression requiring the administration of an antidepressant. His initial weight loss improved once the temozolomide was discontinued and with the assistance of a short course of anabolic steroids and physical therapy.
+The hematoxylin-eosin stained section of the patient's GBM revealed an infiltrating, cellular glial neoplasm comprised of an astrocyte-like and tumor cells. Mitotic index was estimated 14 per 10 high power fields. Morphoproteomic analysis [] demonstrated the following: epidermal growth factor receptor (EGFR total and EGFRvIII ) was expressed at 2-3+ (scale 0-3+) on the plasmalemmal surface of the malignant glial cells; cytoplasmic and plasmalemmal expression of protein kinase C (PKC)-alpha; activation of downstream effectors and pathways of convergence evidenced by the constitutive activation of the mammalian target of rapamycin (mTOR)/Akt pathway with predominant nuclear compartmentalization of p-mTOR (Ser 2448) and of p-Akt (Ser 473), up to 3+ signal intensity, for both, indicating dominance of the mTORC2 component of the pathway[-]; Sirt1 (silent mating type information regulation 2 homolog 1), an NAD+ histone deacetylase, was found to have variable nuclear positivity up to 2+ in tumor cells; and enhancement of Zeste homolog 2 (EZH2), an histone methyltransferase, was expressed up to 3+ in the majority of tumoral nuclei in some regions(EZH2 has the potential to block differentiation, promote proliferation, and promote tumorigenesis by methylating tumor suppressor genes. It can work collaboratively with Sirt1 in promoting tumorigenesis []). In general there was strong expression of the C-X-C chemokine receptor type 4 (CXCR4) on the patient's tumor endothelial cells including areas of tumoral angiogenesis along with occasional scattered mononuclear cells in the adjacent tissues. The tumor cells per se were negative to weakly positive (簣) but only focally. These are illustrated in Figure . Correspondingly, in the same regions of tumoral angiogenesis, there was an associated over-expression of vascular endothelial growth factor (VEGF)-A. The gene sequencing study (Foundation One, Boston, Mass.) revealed an unambiguous amplification of EGFRvIII and suggested an equivocal amplification of the AKT3 gene.
+The integration of the morphoproteomic and genomic findings with the pharmacogenomic and targeted therapeutic implications of temozolomide, plerixafor, lapatinib, metformin, niacinamide in this context are addressed in the pathway analysis provided by biomedical analytics (Figure )."
+Winnie Galindo,24,1996/2/10,001-435-992-7369x644,olsenlauren@example.net,2946 Lynn Keys,"A 51-year-old male patient who underwent laparoscopic partial gastrectomy for early gastric cancer had been given intravenous cefazolin for 2 days preventively and 5 days after the surgery suddenly developed a high-grade fever (over 39 簞C) and severe diarrhea. We immediately administered oral vancomycin (VCM), Lac-B, viz. probiotics; and enough extracellular fluid because we empirically suspected that these symptoms were due to CDAC or methicillin-resistant Staphylococcus aureus-associated enteritis. A diagnosis of CDAC was rapidly made by confirming the presence of toxin A in his feces. Although these medications were initiated, 24 h after the onset the patient developed septic shock requiring vasopressor agents and MODS composed of DIC and acute renal failure (ARF). When he was transferred to the intensive care unit (ICU), his Acute Physiology and Chronic Health Evaluation (APACHE) II score [] was 22, which estimated his risk of hospital death to be 42.4 % (Table ). According to the clinical and radiological findings, he did not have any colonic perforation or toxic megacolon; thus, we avoided an invasive surgery (such as subtotal colectomy) but alternatively treated him using both PMX-HP to improve septic shock [? and rhTM to control DIC [?. In the first 6 h after starting both treatments, his systolic blood pressure (SBP) improved, requirement for the vasopressor agent decreased, and body temperature (BT) dropped by approximately two degrees. Twenty-four hours after the treatments, septic shock was dramatically improved (Fig. ). Three days after the treatments, an improvement in severe inflammation was noted according to white blood cell (WBC) count and C-reactive protein (CRP) level (Fig. ) and an improvement in DIC according to the fibrin degradation product (FDP) level and prothrombin time (PT) (Fig. ). A temporary decline in the platelet count was controllable with platelet transfusion (Fig. ). Although four cycles of continuous hemodiafiltration (CHDF) were necessary as a replacement therapy to ARF, the further progression of MODS was not observed and the APACHE II score satisfactorily decreased daily (Fig. ). Although clinically moderate diarrhea and a mild fever were observed, his general condition also improved. Consecutive toxin A tests, except the first one, were all negative. Five days after the treatments, the patient overcame fulminant CDAC through the use of the abovementioned therapies. Throughout the entire clinical course, neither endotoxemia nor bacteremia was observed.
+Currently, CDAC is endemic and a common nosocomial enteric disease encountered by surgeons in modern hospitals due to prophylactic or therapeutic antibiotic therapies [?. Recently, both the incidence and the severity of CDAC have been increasing, and one possible explanation for these increases is the emergence of highly toxigenic and lethal strains of CD [?. The above shows the need for surgeons to consider more serious treatment against CDAC. In fulminant CDAC, which has a higher lethal rate, it is especially necessary for surgeons to promptly decide whether or not to perform an invasive surgical treatment, such as subtotal colectomy, which means the removal of the septic sources and probable improvement of the patients??ill condition [?.
+In our case that suddenly developed fulminant CDAC with septic shock requiring vasopressor agents and MODS composed of DIC and ARF, prompt surgical treatment in order to remove the septic sources was recommended. However, we alternatively treated the patient with both PMX-HP and rhTM therapies. The reason for having chosen these treatments is as follows: (1) there was neither colonic perforation nor toxic megacolon, which absolutely requires surgery; (2) PMX-HP is an effective extracorporeal blood purification treatment for improving septic shock []; and (3) rhTM can effectively inhibit systemic dissemination of intravascular coagulation [?. The combination therapies produced excellent outcomes in this case, namely the dramatic improvement of septic shock and DIC, the inhibition of MODS progression, and the patient? survival. We speculate that the two below-mentioned factors corresponded to the removal of the septic source, namely as result of the surgical treatment. First, oral VCM medication could suppress CD? proliferation and the further production of CD toxins. Second, both PMX-HP and rhTM could completely inhibit the CD toxin-induced mediators??cascades. This notion is based on the following evidence. First, fulminant CDAC with MODS is caused by the shift from an inflammatory response at a local mucosal level to a general systemic inflammatory reaction in which CD toxin-induced mediators??cascades disseminate [?. Second, although PMX-HP removes circulating endotoxin by adsorption and theoretically prevents the progression of the biological cascade of sepsis, several studies and published reports have demonstrated that PMX-HP can reduce the plasma levels of cytokines and sepsis-related factors, namely TNF-帢, IL-6, IL-10, N-arachidonoylethanolamine (AEA), 2-arachidonoyl glycerol (2-AG), and high-mobility group box-1 (HMGB-1) [, , , ]. Indeed, there were case reports published which showed that PMX-HP decreases the serum levels of endogenous cannabinoids (anandamide and 2-AG) and inflammatory cytokine (IL-6) in parallel with the clinical improvement of fulminant CDAC [, ]. Third, many studies and fundamental researches have shown that rhTM also has an anti-inflammatory ability through both the activated protein C and the lectin-like domain-dependent pathway [?. In particular, the thrombin-rhTM complex demonstrates an anti-inflammatory ability through neutralizing HMGB-1 [, ], which is known to be a mediator of lethality and is released from necrotic cells or macrophages/activated dendritic cells with potent pro-inflammatory function, which in turn causes shock or MODS when being disseminated in the systemic circulation [?. Finally, septic shock and MODS in our case were not induced by endotoxemia or bacteremia, and a dramatic improvement was observed immediately after the initiation of the combination therapies."
+Salvatore Webb,27,1980/10/31,327.345.1388x6781,victoriamorales@example.net,076 Sarah Rapid,"An 85-year-old man presented to our hospital with a 5-h history of abdominal pain and distention. He attended the outpatient department at our hospital for regular checkups but had been asymptomatic until he visited out emergency department. At age 82 years, he had undergone laparoscopy-assisted distal gastrectomy with Roux-en-Y reconstruction for early gastric cancer. An antecolic isoperistaltic gastrojejunostomy was performed using an endoscopic linear stapler. A serosubmucosal single-layer hand-sewn anastomosis (Jourdan?) was performed through a small abdominal incision for Y reconstruction. The mesentery of the Y loop was closed using nonabsorbable braided polyester (3-0) interrupted sutures, while the Petersen? defect was not closed. Pathology revealed a stage IB (T2N0M0) tumor; the resection stumps were negative. His postoperative course had been unremarkable. Computed tomography (CT) performed 1.5 months prior to admission showed no evidence of tumor recurrence and no ascites. The patient had no other relevant medical history.
+Physical examination on arrival showed focal tenderness and distention in the epigastrium. His body temperature was 36.4 簞C.
+Laboratory data were unremarkable except for a white blood cell (WBC) count of 8.7 ? 109 cells/L (normal, 4.0??.0 ? 109 cells/L) and a C-reactive protein (CRP) level of 16.2 nmol/L (normal, < 2.9 nmol/L). A contrast-enhanced abdominal CT scan (Fig. ) showed dilation of the transverse colon, severe ascites, and a whorl-like appearance of the superior mesenteric artery (SMA) and branches wrapped with adjacent mesentery and small bowel loops (the ?hirl??or ?horl??sign) [], which is characteristic of small bowel volvulus. Given these findings, we performed emergency laparotomy.
+Intraoperatively, a massive amount of milky fluid was observed in the peritoneal cavity, and approximately 1 L was removed (Fig. ). The greater part of the small bowel passed through the defect between the jejunal mesentery and the mesocolon (Petersen? defect). The small intestine was displaced to the left and was obstructed due to jejunal volvulus (Fig. ). The jejunum was rotated 180簞 counterclockwise around its long axis and compressed the transverse colon. The entire small bowel was edematous but viable, with no evidence of a mobile cecum, peritoneal tumor, or perforation. The volvulus and internal hernia were reduced, and the Petersen? defect was sutured closed. No bowel resection was required. Extensive lavage of the abdominal cavity was performed until the return fluid was clear, and intraperitoneal drains were placed in the rectovesical pouch and under the right hemidiaphragm. The triglyceride (TG) level of the ascitic fluid was 642 mg/dL. The cultures and cytology of the peritoneal fluid were negative for infection and malignancy, respectively.
+The patient? postoperative course was uneventful. The color of the ascites changed from milky to light yellow, and the TG levels decreased to 21 mg/dL on postoperative day 4. The patient was not required to eat a fat-restricted diet during hospitalization and was discharged from the hospital 16 days after surgery. He underwent a physical examination and CT scan in the outpatient department 10 months after discharge from the hospital. There was no evidence of ascites (Fig. ). He had made favorable progress by the time of the 28-month postoperative follow-up, with evidence of weight gain and no evidence of recurrent ascites (Fig. ).
+Chylous ascites typically develops due to congestion of the lymphatic system. Malignancy?articularly lymphoma?s a relatively common cause of chylous ascites in adults []. Metastasis of the malignancy into the lymphatic channels and the resulting occlusions can cause leakage from the dilated subserosal lymphatic system into the peritoneal cavity [, ]. However, there have been few reports of chylous ascites associated with intestinal obstruction [].
+In the present case, an abdominal CT scan showed a dilated colon and severe ascites with a whorl-like appearance of the SMA and mesentery, findings generally suggesting small bowel obstruction from volvulus [, ], which may be strangulated [, ]. High TG levels, typically >200 mg/dL, in the ascitic fluid are critical in defining chylous ascites []. Given that our patient had TG levels exceeding 600 mg/dL, the milky fluid was diagnosed as chylous ascites. The CT value of the ascites was 5.0 HU, not suggestive of hemoperitoneum and indistinguishable from that of water [?. Major lymphatic leaks can sometimes be visualized with MR lymphography [], aiding the diagnosis of chylous ascites. However, minor leaks may be undetectable. After surgery to repair the internal hernia, the TG levels decreased from 642 to 21 mg/dL without any ligation of lymph vessels or dietary restriction. These observations prompted us to diagnose the patient as having chylous ascites associated with small bowel obstruction.
+We identified eight case reports of chylous ascites with bowel obstruction in the English language literature (Table ). Chylous ascites associated with intestinal obstruction was first mentioned by Mackman in 1967, and our present case is the first case report of chylous ascites occurring with a Petersen? hernia. As in our case, all previous cases were characterized by the presence of small bowel obstruction. Detecting a cause of chylous ascites associated with bowel obstruction is difficult, because these cases are so rare. Of note, however, no previous studies [? reported the requirement for an enterectomy, and their postoperative courses were uneventful.
+The abdominal CT scan showed that there was an intestinal obstruction and large amounts of ascites. These findings sometimes indicate strangulated obstruction. Our case was interesting in that the physical examination and laboratory tests did not match the severity of the problem as shown on CT. It is difficult to explain this discrepancy, and it is difficult to prove accurately what caused the chylous ascites. This situation is very rare. The absence of bowel ischemia suggests that the arteriovenous system was patent while lymphatic channels were occluded in this case. This vascular patency may explain the discrepancy between the laboratory values and physical findings and the imaging findings, and the fact that no previous cases have reported the requirement for an enterectomy. The obstruction of the lymphatic system resulted in the extravasation of chylous fluid []. Pre- and intraoperative evaluation of ascites may be helpful in making decisions concerning therapeutic strategies, because bowel obstruction with chylous ascites may indicate intestinal viability."
+Ariella Webster,34,1983/4/3,2622133603,lisafowler@example.com,9953 Greene Hill,"A 64-year-old man presented with two weeks of progressive proximal muscle weakness causing him difficulty ambulating, combing his hair, and raising himself from a seated position. He also reported dysphagia to solids over the past week. The patient was recently admitted twice to an outside hospital for an elevated creatine phosphokinase, and diagnosed with ?habdomyolysis.??Past medical history was significant for poorly controlled diabetes mellitus. On exam, vitals were within normal limits. Cardiovascular exam revealed regular rate and rhythm with no extra heart sounds and lung exam revealed clear lungs on auscultation. On neurologic exam, patient was awake, alert, and oriented. Cranial nerves II through XII were grossly intact. There was proximal muscle weakness to 4/5 bilaterally in the shoulders and hips, but preserved strength distally. Sensation to light touch remained intact. Hemoglobin was 10.5 g/dL with a normal MCV, WBC were 3.8 K/uL, and platelets were 246 K/uL. Basic metabolic panel revealed a sodium of 141 mEq/L, a potassium of 4.8 mEq/L, and a creatine of 0.90 mg/dl. Transaminases including AST and ALT were 65 and 36 U/L, respectively. CPK was 2705 U/L. ESR and CRP were within normal limits and RF, anti-Ro/La, anti-Jo1, anti-RNP, anti-centromere, anti-Scl-70, and anti-dsDNA were all negative. An MRI of the right arm revealed prominent edema involving the deltoids and an MRI of the bilateral thighs revealed myositis with no discrete collections. An EMG showed evidence of irritative myopathy affecting the bilateral deltoids. A muscle biopsy of the right deltoid was negative for inflammation but presumed to not be representative. He was started on oral Prednisone 60mg daily with resolution of symptoms including weakness and pain and normalization of creatine kinase within one month of starting therapy."
+Shawn Hester,29,1978/7/23,703-237-5267,theodore55@example.net,029 Davis Cliffs,"A previously healthy 15 year-old female presented with behavioral changes with incoherent speech, restlessness, anxiety, and expressed the feeling that ?verything is happening to me??after attending a 2-day spiritual retreat. One week before the presentation of psychiatric symptoms, she had unspecific common cold symptoms, but with no fever. On the second day of psychiatric presentation, she had a transient period of agitation and visual hallucination with spontaneous remission (she saw Jesus and her deceased grandparents). On the third day, she was brought to the emergency room (ER), for the first time, owing to an episode of agitation and speech blockade that happened at school. Concomitantly, she had somatic manifestations, such as swallowing impairment, odynophagia for water and food refusal. She showed regressive behavior, such as asking for help for basic hygiene and refusal to sleep alone. At this point, episodic speech changes, such as echolalia and verbal perseveration and intermediary insomnia were documented. Of note, there were no changes in the flow of thoughts or indication of disorganized behavior. The patient was medicated with risperidone (0.5 mg once a day) by the ER child and adolescent psychiatry attendant, and referred to the Child and Adolescent Psychiatry Outpatient Clinic. However, a few hours later, she was re-admitted in the pediatric ER with panic symptoms (tachypnea, tachycardia, shaking hands, and sweating). She was discharged and medicated with lorazepam (0.5 mg two times a day) and risperidone (1 mg once a day) with no improvement, namely, the visual hallucination persisted.
+At the first child and adolescent psychiatry outpatient appointment (day 7 after symptoms onset), she was oriented, and presented with unexpressive facial mimicry, provoked speech, and psychomotor retardation. No changes in the form, rhythm or flow of thoughts, or delusions were documented. The patient had anxiety with no mood changes, although she had a regressive attitude. The patient was medicated with anxiolytics (diazepam 5 mg two times a day), and risperidone (1 mg) was increased to twice daily. At the next child and adolescent psychiatry appointment (day 10 of the disease), she maintained episodes of agitation with tremor of the upper limbs, screaming, and a desperation gaze that was attributed to hallucinations, according to her family. During these episodes, the patient said that ?hey are after me (?? I am a saint (?? nobody will survive?色€? On other occasions she would experience periods of elation, with tendency to sing and express grandiose delusions: ? will be the best student at my class?? During the mental state examination she was extremely sleepy, calm with provoked speech, and answered with monosyllables. Therapy was adjusted, and risperidone was replaced with olanzapine (10 mg once a day). She was recommended for hospital admission, but the patient? family refused this recommendation.
+On day 18 of the disease, with no signs of clinical improvement, the patient was brought to a new appointment, and admitted in a psychiatry ward. At admission she was oriented to time, place, person and situation but showed periods of negativism, mutism, echolalia, echopraxia, motor agitation, upper limb tremor (that occurred at rest, with sudden onset and remission and disappeared when she was distracted), These symptoms occurred in bursts alternated with periods of normal speech but with pervasive prostration. Also, she was unable to take care of her own hygiene. At physical examination she did not have fever or changes in blood pressure, and cardiac or respiratory frequency. Pulmonary and cardiac auscultation were unremarkable, abdomen examination was also normal, and at the examination she had no changes of the skin and upper and lower limbs. At that point, the following diagnostic hypotheses were considered: prodromal phase of an affective psychosis, anxiety disorder with conversion traits, dissociative disorder (depersonalization disorder), organic disorder, and psychosis with catatonic features. Due to the catatonic symptoms, the diagnosis of neuroleptic malignant syndrome was also raised and a possible treatment with dopamine agonist was considered. However, this specific intervention was deferred since the patient had no fever or changes in the blood pressure, cardiac or respiratory frequency or laboratory imbalance. The diagnostic hypotheses were based on the clinical presentation, physical examination, and mental state examination. We did not apply the mini-mental state examination or any other rating scale for psychosis, mood, cognitive or neurologic symptoms.
+Laboratory results and brain CT scan were normal. Psychiatric medication for psychosis was started. At day 5 after admission (day 23 of clinical disease), a lumbar puncture was performed with screening for antibodies for anti-NMDA receptors in the spinal fluid. Since the hypothesis of anti-NMDA receptors encephalitis was raised, it is mandatory to first rule out possible underlying neoplasm. Because the patient was female and ovarian teratoma can occur in up to 59 % of cases [], a pelvic ultrasound was performed, but no changes were found. On the same day, the patient experienced tachycardia and decreased consciousness, with the need for intensive care unit (ICU) admission. No rating scale was applied during the stay in the intensive care unit. However, antibodies for NMDA receptors were detected and diagnosis of anti-NMDA receptor encephalitis was established.
+At the ICU the patient experienced periods of delusion and agitation with loud screaming. She was medicated with midazolam (2 mg intravenous if needed), oral lorazepam (1 mg three times a day), and chloral hydrate (1 g every 6 h). Within the first few hours, risperidone was introduced at 0.5 mg daily and then titrated to 1 mg daily. She was subsequently treated with immunoglobulin (2 mg/kg/day), methylprednisolone (30 mg/kg/day), and plasmapheresis and rituximab (375 mg/m2/week). Regarding the maintenance psychopharmacology, the patient was on risperidone (1 mg two times a day) and lorazepam (2.5 mg if needed).
+Two months after specific treatment for anti-NMDA receptor encephalitis, the patient still had difficulty with verbal articulation, but there were no changes regarding form, course, rhythm or thought content, and her mood was euthymic. She reported periods of emotional lability, although less frequent than before treatment, and there were no auditory or visual hallucinations. She reported moderate verbal memory impairment, attention and concentration difficulties at school. Although a formal neuropsychological evaluation was not performed, it was known that before disease onset, the patient had no cognitive difficulties at school since her IQ was considered within the normal range, and her grades were average. She started psychotherapy, physiotherapy, and learning support at school. She had progressive clinical improvement but still experienced emotional lability, anxiety, and verbal memory impairment, attention and concentration difficulties at school that justified her enrolment in a vocational educational school. Ten months later she had a seizure episode and a new treatment cycle was started. Since she experienced depressive symptoms after the encephalitis episode, sertraline (25 mg once a day) was added to her medication regimen. As of this writing, she is medicated with oxcarbazepine (450 mg two times a day), quetiapine SR (100 mg at bedtime), sertraline (25 mg once a day) and lorazepam (1 mg if needed). Also as of this writing (almost 3 year after the disease onset), the patient? psychiatric symptoms have improved, but she still experiences verbal memory impairment, and attention and concentration difficulties."
+Zendaya Humphrey,44,1995/4/23,267.816.6246x99619,smithjeffrey@example.com,160 Swanson Corner,"The first patient was a 57-year-old woman treated for a uterine fibroid. For the induction of the sedation, the following strategy was applied: the remifentanil was kept at a constant dosage, while the propofol dosage was slowly increased to lower the breathing frequency to 5/min. Final dosages for propofol and remifentanil were 1.4 mg/kg/h and 2.5 弮g/kg/h, respectively. This stable breathing pattern was reached after <2 h."
+Krew King,43,1985/3/25,001-563-989-5180x193,enewman@example.org,660 Smith Manors,"The second patient was a 72-year-old woman with bone metastases of which one was located in the shoulder. Here, the strategy was to start with a higher dosage of remifentanil. However, the remifentanil dosage was slowly decreased during the treatment, while the propofol dose was slowly increased to induce a deeper state of sleep. A stable, low frequency (5/min) breathing pattern was reached with 1.6 mg/kg/h propofol and 0.3 弮g/kg/h remifentanil in a little under an hour."
+Victoria Munoz,31,1983/3/5,688.396.2670x51907,barnesmary@example.net,60465 Kathleen Ramp Apt. 692,"The third patient was 41 years old and treated for a uterine fibroid. The dosage of remifentanil was kept constant at 4.2 弮g/kg/h and the dosage of propofol was adjusted to the patient? state of sedation during the treatment and was finally 2.2 mg/kg/h. After the treatment was completed, an additional MR scan (spoiled gradient echo with echo planar imaging, EPI-factor 25, TE 15 ms, TR 39 ms, flip angle 20簞, acquisition matrix 120 ? 98, pixel size 2.34 ? 2.34 mm, slice thickness 7 mm) was performed to visualize the displacement of the diaphragm due to respiration.
+One hundred percent oxygen was continuously offered using a nasal prong in all three patients. End tidal carbon dioxide (ETCO2) was measured using capnography. Furthermore, breathing frequency, blood pressure values, and heart rate were monitored."
+Justin Luna,26,1982/8/26,001-771-682-7701x769,millerbarbara@example.net,7558 Samuel Crossing,"A 64-year-old man with gross swelling in the anterior mandibular gingiva for 1 month after lower incisal teeth extraction was referred to us for a closer evaluation. Oral examination revealed a firm mass measuring 2.6 ? 2.1 cm in size arising from the extraction site (Fig. ). The surface of the mass lesion showed erosion at the site equivalent to the wounds after tooth extraction. There was no hemorrhage or paralysis in the mandibular region, and the condition was painless.
+For the past medical history, the patient underwent low anterior resection of a rectal malignancy diagnosed as moderately differentiated adenocarcinoma 7 years previously. There was no evidence of regional lymph node and distant metastases. Three years after the primary surgery, the patient showed bilateral lung metastases. Thus, the middle lobe of the right lung and the lower lobe of the left lung were partly resected. Four years later, multiple lung metastases and metastases to the vertebral bodies of the VI?III vertebrae were observed. The patient received 60 Gy of irradiation to control the pain from the lesion involving the vertebra.
+Computed tomography (CT) scan of the head and neck showed a solid mass and bony resorption in the anterior alveolar ridge of the mandible (Fig. ). There was no lymphadenopathy. Magnetic resonance imaging (MRI) revealed a heterogeneous signal on a T1-weighted image after gadolinium administration and an intense signal on a diffusion-weighted image (Fig. ).
+For the laboratory examination results, the serum carcinoembryonic antigen and cancer antigen 19-9 levels were 947.6 ng/ml and 1059.2 U/ml, respectively. Pathological examination by incisional biopsy of the gingival mass lesion revealed a moderately differentiated adenocarcinoma. The tumor was composed of proliferating columnar to polygonal epithelial cells with moderate atypia that showed a papillary tubular pattern (Fig. ). Immunohistological analysis demonstrated that the adenocarcinoma cells were positive for cytokeratin 20 (CK20) and negative for cytokeratin 7 (CK7) and positive for caudal type homeobox transcription factor 2 (CDX2) (Fig. ). The biopsy findings from the mandibular mass lesion were consistent with those from the resected rectal carcinoma 7 years previously.
+The tumor had grown gradually and an ulcer was formed on the surface, making mastication difficult. The patient received palliative radiotherapy for the mandibular mass lesion. However, once the tumor showed a tendency to decrease in size, pneumonia developed and the patient? cachexia deteriorated. Thus, the radiotherapy was discontinued, but the patient unfortunately died 2 months postradiotherapy.
+Oral metastatic tumors are uncommon and comprise approximately 1 % of malignant oral neoplasms []. Most cases were previously diagnosed in reference to a primary neoplasm and were treated accordingly. Therefore, the primary site is usually assumed based on the past clinical history. However, 23 % of oral metastases were shown to be the first sign of the metastatic process []. In the present case, the origin of the metastatic lesion was clarified based on the past history of rectal adenocarcinoma resection and the subsequent lung metastases. The most common primary site in women is the breast followed by the female genital tract, kidney, and colon-rectum. In men, the most common primary site is the lung followed by the kidney, liver, and prostate [].
+In the oral site where metastatic tumors arise, most tumor lesions are observed in the jawbones, and only 16 % are found in the soft tissues such as the gingiva []. The metastatic rate in the posterior body of the mandible is higher than that in the symphyseal region []. The gingivae (55 %) followed by the tongue (30 %) are the most common soft tissue sites affected by metastatic malignancy []. In the present case, the metastatic lesion has been presumed to develop in the gingival tissue of the symphysis. This lesion was an exophytic growing mass, and the radiological appearance of the mandibular bone invasion was not demonstrated apparently. Likewise, some case reports have shown that the metastatic site was the gingiva for the primary lesion of colonic and rectal adenocarcinomas [?.
+Adenocarcinoma of the colon and rectum commonly spreads to the regional lymph nodes, liver, and lungs, but less commonly to the peritoneum, bone, adrenal glands, brain, kidney, thyroid, pancreas, ovaries, and skin. Clausen and Poulsen proposed the following three criteria for metastatic oral tumor: firstly, the metastatic tumor is pathologically similar to the primary tumor; secondly, the oral tumor is considered to be a metastasis clinically and pathologically; and thirdly, the oral tumor is atypical compared with common oral primary tumors []. The most common primary tumor arising from the oral mucosa is squamous cell carcinoma. Therefore, there may be a need to differentiate metastatic adenocarcinoma from adenocarcinoma derived from the salivary gland, although the frequency of occurrence is very low. Three clinical courses may be considered to underlie the metastasis of colonic adenocarcinoma to the oral cavity as follows: (1) direct metastasis with identification of the primary tumor, (2) secondary metastasis derived from metastasis in another site after treatment of the primary tumor, and (3) occult metastasis without identification of the primary tumor. The present case follows the second clinical course in which the secondary metastasis in the jawbone was derived from multiple lung metastatic lesions. The primary rectal tumor has already been resected completely. The present case conformed to Clausen? criteria.
+Histopathologically, approximately 70 % of the metastatic lesion in the oral region is reportedly adenocarcinoma, followed with much less cases by clear cell carcinoma from the kidney and squamous cell carcinoma from the lungs []. Also in the present case, the hematoxylin and eosin-stained section showed features of adenocarcinoma arising from the rectum. Furthermore, the histological diagnosis was supported by the immunohistochemical analysis. The metastatic tumor cells demonstrated a CK20-positive and a CK7-negative phenotype. In the evaluation of gastrointestinal tract carcinomas, the great majority of well-differentiated or moderately differentiated large intestinal adenocarcinomas reportedly showed a CK7-negative/CK20-positive phenotype. Adenocarcinomas of the upper gastrointestinal tract were also reported to be positive for both CK7 and CK20 in 78 % of cases []. Thus, an assessment of the CK7 and CK20 phenotype may help in determining the primary site of a metastatic tumor []. In addition to the CK7 and CK20 immunoprofiles, the tumor cells showed CDX2 immunoreactivity. CDX2 is a sensitive and specific maker for adenocarcinoma with a colorectal origin []. CDX2 expression has also been shown in a subset of adenocarcinomas arising from the colon, rectum, stomach, esophagus, and ovary []. Accordingly, CK7, CK20, and CDX2 may be useful for the diagnosis of metastatic tumors of gastrointestinal origin.
+In the case of oral metastatic tumors, they usually have a poor prognosis because often they have already spread to other sites. Therefore, the appropriate palliative treatment has to be carefully selected. If the tumor is widely disseminated, palliative radiotherapy is recommended []. However, when possible, surgical resection may be recommended mostly for metastatic lesions in the soft oral tissue []. In the present case, as the oral metastatic lesion was rapidly growing with accompanying multiple lung metastases, resection was not possible under general anesthesia. Accordingly, we performed palliative radiotherapy for the mandibular mass. Alternatively, chemotherapy with the FOLFIRI regimen (5-FU, leucovorin, irinotecan) is usually performed for advanced metastatic colorectal carcinoma []. Although the IRIS regimen (irinotecan, S-1) plus bevacizumab (monoclonal antibody targeted against vascular endothelial growth factor) was planned when the lung metastasis occurred to play the role of another second-line chemotherapeutic regimen, the patient showed no response to the chemotherapy.
+Patients with distant metastasis of colorectal adenocarcinoma usually have a poor prognosis. In particular, if a secondary metastatic oral tumor is identified, the disease state may be commonly progressive and the prognosis is extremely poor. In cases involving metastasis to the oral cavity, the mean survival period from the time of mass appearance to the time of death of a patient has been reported to be about 7 months []. Regarding metastasis to the gingiva, some cases have been documented showing that the duration of survival from the indication of gingival mass development was only within 1 year [, , ]. The present case also showed a short survival period of 4 months."
+Journey Parks,34,1992/6/30,+1-849-770-5390x06499,melissaanderson@example.net,804 Lee Falls,"The first patient is a 43-year-old male, who consulted our center for night sweats and weight loss in the last 3 weeks. He had no previous history or records in our center. The physical examination was normal except for a slight splenomegaly and the blood test was compatible with hyperleukocytosis, anemia and thrombocytopenia, (leukocytes 136.00 繚 109/L, hemoglobin 11.70 g/dl, platelet count 39.70 繚 109/L) and 93 % of small-medium sized lymphoblast in the Grunwald-Giemsa blood smear. The bone marrow aspirate examination had an hypercellular infiltration of 90 % which was confirmed by immunophenotype (CD19+, CD10+, CD34+, TdT+, DR+, CD79 alfa+, CD20?? cytoplasm IgM negative). 80 % of the blast cells also expressed CD33+. A fresh sample from the bone marrow aspirate was collected for molecular and cytogenetic analysis. The assay revealed the presence of the following karyotype:46,XY,t(9;22)(q34;q11) [2] /46,XY,del(9)(p22)t(9;22)(q34;q11) [4] /46,XY,del(9)(p22)t(9;22)(q34;q11),del(20)(q13) [5] /46,XY [9]. FISH analysis confirmed the presence of BCR-ABL1 fusion gene (Fig. ). The patient? RNA was isolated from the peripheral blood and subjected to a two round multiplex reverse transcription and polymerase chain reaction (RT-PCR). In order to avoid RNA quality and/or handling errors, we included an internal positive control in where a 690-bp segment of the ubiquitously expressed transcription factor E2A mRNA was amplified. The primers and PCR conditions used in the first and second round of the nested PCR reaction are described by Pallisgaard et al. []. We identified an atypical amplification band of approximately 100 bp, much smaller than the p190 (e1a2) fragment. In order to confirm the presence of a BCR-ABL transcript this band was extracted from the agarose gel, purified and then analyzed by DNA sequencing. cDNA sequence revealed the presence of the e1a3 variant (Fig. ).
+The patient started induction treatment with ALL-type polychemotherapy and Imatinib, achieving complete response by morphology and immunophenotype. However, the BCR/ABL was still detected by RT-PCR at the end of the induction phase. He is ongoing consolidation with allogenic stem cell transplantation (SCT) from an HLA-identical sibling donor, 7 months after diagnosis."
+Gianni Schaefer,36,1997/10/27,+1-346-897-7899x773,morganmichael@example.com,8912 Guzman Mountain,"The second patient is a 65-year-old male who consulted for pain in the right leg and a history of recurrent periodontal infections in the last month. An eco-doppler confirmed a thrombophlebitis and the blood test found hyperleukocytosis and anemia (leukocytes 223.00 繚 109/L, Hemoglobin 11.60 g/dl, platelet count 118 繚 109/L) and the presence of 80 % lymphoblasts in the Grunwald-Giemsa blood smear. The bone marrow aspirate found an infiltration of 25 % lymphoblast which was confirmed by immunophenotype (CD19+, CD34+, DR+, CD10+, CD22+, low intensity CD20?? TdT+, cytoplasmatic IgM negative, CD33+). The karyotype was 46,XY,t(9;22)(q34;q11) [20]. FISH analysis confirmed the presence of BCR-ABL1 fusion gene (Fig. ). The patient? RNA was isolated from the peripheral blood. We identified an atypical e1a3 variant after a two round PCR amplification by DNA sequencing (Fig. ).
+The patient started induction treatment and Imatinib. The bone marrow aspirate on day 34 confirmed progressive disease with 30 % blast and persistence of BCR/ABL. After a second line of intensive ALL-type induction therapy the patient finally died due to toxicity (gastrointestinal bleeding). No SCT had been planned due to age and unfit status. It is noteworthy that the blood counts in a regular check-up 4 months before the diagnosis had a slight leukocytosis that was not studied."
+Mavis McMillan,27,1989/8/4,566.572.9131,robert96@example.org,4844 Taylor Spring,"A 72 years old female complaining of hemoptysis, dyspnea, fatigability and weight loss was referred to the surgery clinic. A history of 7 abortions was obtained. 33 years ago she self-induces an abortion using a knitting needle without extraction of the foreign body.
+Clinical exam showed a decreased mobility of the right hemidiaphragm but no scars. Hemoglobin and hematocrit were borderline low (HGB 11.6 and HCT 38.4), with RBC indices suggestive for anemic status (MCV 67.5, MCH 20.4). Pulmonary function tests showed decreased forced vital capacity (FEV) and Forced expiratory volume in 1 s (FEV1).
+Initial radiological workup included a chest x-ray which showed a linear metallic foreign body extending from mid-thorax into the abdomen (Fig. ). Two more x-rays were performed (Fig. and ), one focused on the lesion and another one in lateral view, establishing its caudal end at the level of the liver and its size at 18 cm. In retrospect a focal increased density lesion is viewed in the posterior-basal segment of right inferior lobe.
+Following clinical meeting a CT was ordered showing the foreign body extending from right liver lobe (segment V and VIII), transdiaphragmatic, to the right upper lobe, where it ends in a thick walled cavity of 3 cm (Figs. and ). No traces of migration have been described in the abdomen or pelvis. A 3.9 cm consolidation in the posterior-basal segment of RLL was also described with associated mediastinal adenopathy. No abdominal or bone lesions were detected.
+Right posterolateral thoracothomy was performed. Intraoperative examination detected pulmonary right lower lobe to diaphragm adhesions and fibrous tissue delimiting a thoracoabdominal transdiaphragmatic fistula due to a foreign body (Fig. ). An 18 cm metallic foreign body producing a hepatic fistula of 4 cm and RLL fistula of 8 cm is extracted (Fig. ). Wedge resection of RLL and diaphragmatic mesh suture with infradiaphragmatic drainage were performed.
+The postoperative results were good, with the patient discharge 8 days later. Only one follow-up was available; at 3 months??control the patient was in good status with no complains."
+Rocky Curtis,24,1984/11/29,+1-932-771-3442x234,ohughes@example.net,860 Nicole Well,"A 56-year-old woman began to suffer from an occipital headache for 7 days before admission to our hospital, and dizziness appeared 5 days later. On admission, she complained of dizziness and a mild occipital headache. She showed nystagmus and the right nose-finger-nose test was positive. In peripheral blood cell counts and biochemical studies, elevations in white blood cells (9,200/弮l) and low-density lipoprotein cholesterol (215 mg/dl) were observed. Coagulation studies and immunological studies were normal. Head computed tomography (CT) showed low-density areas in the right cerebellar hemisphere, diffusion weighted imaging (DWI) of magnetic resonance imaging (MRI) displayed high-intensity signal areas in the cerebellar vermis and the right cerebellar hemisphere (Fig. ). In addition, a high-intensity signal area was observed just adjacent to the right VA on T1-VISTA (Fig. ), whereas no such high intensity was detected on conventional T1 image. Conventional MRA did not depict the right PICA or any abnormal findings of the right VA (Fig. ). Echocardiography and 24-hour electrocardiography showed no findings suggestive of cardioembolic causes. According to these findings, ischemic stroke of the cerebellum induced by the right PICA-D was diagnosed, and after confirming that she had neither hypertension nor aneurysmal formation, combined therapy with clopidogrel and unfractionated heparin administration was started. T1-VISTA showed a slight expansion of the high-intensity area at 3 days after admission, but still no lesions on T1 images. At 9 days after admission, cerebral angiography revealed the ?earl and string sign??at the proximal portion of the right PICA (Fig. ). At 12 days after admission, the patient was discharged with single antiplatelet therapy (clopidogrel). On T1 images, a pale high-intensity area was documented at the dissected lesion at 19 days after admission. Thereafter, the right PICA was gradually depicted on MRA and completely visualized at 5 months after the onset. In parallel with that, the high-intensity signal area on T1-VISTA gradually decreased in size and disappeared by 5 months after the onset (Fig. ). Clopidogrel administration was then stopped."
+Alexis Harrington,36,1997/2/27,001-989-411-8724x51206,allison33@example.net,642 Paul Lights,"A 52-year-old woman suddenly experienced vertigo and vomited while cleaning her bathtub at home and was subsequently transferred to our hospital by an ambulance. Head CT showed no abnormal findings, thus she was admitted under the suspicion of acute drug poisoning by a detergent. Although no abnormalities on a physical examination or in laboratory data were observed, her nausea and dizziness persisted. Neurologically, she presented only mild dizziness. MRI was then performed at 4 days after the onset, which showed an acute infarction in the left cerebellar hemisphere (Fig. ). The left VA was poorly visualized on MRA as compared to the right VA (Fig. ). In addition, the external diameter of the left VA on basiparallel anatomic scanning (BPAS) was narrowed, suggesting hypoplasia. The proximal portion of the left PICA was not visualized, and the adjacent distal portion appeared to be dilated on MRA (Fig. ). T1-VISTA showed a high-intensity signal area at the dilated portion (Fig. ). Conventional T1 image was obtained on admission and at 24 days after admission, but no high-intensity area was observed at both time points. Cardioembolic causes were excluded by echocardiography and 24-hour electrocardiography. According to these findings, Ischemic stroke of the cerebellum caused by dissection of the left PICA was diagnosed, and the administration of unfractionated heparin was started. Three days later, the dilated portion was enlarged on MRA, therefore, we discontinued unfractionated heparin administration. Since her blood pressure was not high, we even didn? use antihypertensive treatment. At 8 days after the onset, cerebral angiography demonstrated the ?earl and string sign??at the proximal portion of the left PICA (Fig. ). Dilatation gradually normalized on MRA and the high-intensity signal area on T1-VISTA gradually reduced and disappeared at 4 months after the onset (Fig. )."
+Omari Duke,20,1983/8/23,(969)588-1021,ameyer@example.org,69222 Kristen Divide Apt. 784,"A 26-year-old Polish male was diagnosed with GD at the age of 3 years. His past medical history was significant for splenomegaly, identified at the age of 12 months, and severe pancytopenia. Gaucher cells were not found in aspiration biopsies of the bone marrow. He was splenectomized at the age of 3 years due to massive splenomegaly, and the diagnosis of GD was established by the presence of low activity of glucocerebrosidase in peripheral blood leukocytes. Further direct DNA sequencing revealed the homozygous mutation c.1448T > C in the GBA1 gene (i.e. mutated alleles L444P/L444P), which suggested GD3. At nearly 6 years of age, he developed avascular necrosis of the left femoral head.
+The patient started intravenous ERT with macrophage-targeted recombinant glucocerebrosidase at the age of 8 years, immediately after ERT became available in Poland. At the age of 20, his ERT was discontinued for 4 months during the unintentional world-wide imiglucerase (Cerezyme簧, Genzyme Corporation, Cambridge, MA, USA) supply shortage (). This was followed by a rapid increase in plasma chitotriosidase activity (), pathological bilateral forearm fractures and fractures in the left brachial bone and both fibulae. The fractures healed slowly, caused chronic pain, and created difficulties in walking for the patient. Currently, the patient is receiving infusions of imiglucerase at a dose of 56 units/kg of body weight, administered every other week.
+The patient had annual ophthalmologic follow-up examinations from diagnosis. His eye fundus examinations were normal until lesions were first noted at the age of 18 (i.e. 15 years from his diagnosis of GD and 10 years from the start of ERT). The fundus lesions were described as white spots located peripherally and in the posterior pole.
+In January 2012, when the patient was 23 years old, his eye changes were documented in photographs ( and ). At that time, the lesions were located on the surface of the retina and in the preretinal part of the vitreous body. OCT confirmed the presence of discrete lesions located preretinally, intraretinally in the nerve fiber layer, and in the vitreous body (). Electroretinography (ERG) did not show any pathological pattern, thereby indicating normal retinal function.
+A recent ophthalmologic examination (performed in December 2014) showed a best-corrected visual acuity of 20/20 bilaterally and an intraocular pressure of 19 mmHg (normal values: 11??1 mmHg). Ocular motility examination demonstrated limitations in abduction of both eyes. Dilated fundoscopy revealed optic discs with well-defined borders and pink color in both eyes. The maculae were normal. Further examinations showed yellowish-white punctuate deposits in the posterior pole and the periphery of the fundus bilaterally. A 3-year follow-up OCT examination was performed in January 2015, and no signs of progression of the fundus lesions were evident."
+Melani Wise,34,1987/10/11,328.357.3936x628,yolandadixon@example.com,318 John Manor,"The patient was a 10-month-old Chinese female who was first diagnosed with HLH when she showed various symptoms, such as persistent high fever of unknown origin, seizures, jaundice, pancytopenia, coagulopathy, and hepatosplenomegaly. Physical examination also revealed lethargy, pallor, cervical lymph node swelling, and hepatosplenomegaly. Laboratory evaluations showed Hg b at 9.7 g/dl, H ct at 19.7 %, platelet at 60 K/弮L, WBC at 2.67 K/弮L, ferritin at 622 ng/mL, triglyceride at 532 mg/dl, ALT at 4068 U/L, AST at 9162 U/L, ALP at 1016 U/L, lactate dehydrogenase (LDH) at 12,108 U/L, total bilirubin at 100.9 umol/L, direct bilirubin at 51.5 umol/L, fibrinogen at 390 mg/dl, PT/PTT at 20.5/65.4 s, thrombin time of 46.7 s, and D-dimers at 851 ng/L. In summary, the patient fulfilled 5 out of 8 HLH-2004 criteria []. The cerebrospinal fluid examination showed protein at 3.5 g/L and pleocytosis at 20 ? 109/L. A magnetic resonance imaging (MRI) of the brain revealed no abnormality. Polymerase chain reaction (PCR) analysis for the EBV EBNA-1 was positive in peripheral blood. The EBV-DNA in blood was 6.25 ? 104 IU/mL. Bone marrow examination showed increased hemophagocytic histiocytes (HS) (Fig. ), which is consistent with HLH. Cytogenetic analysis was normal. A hereditary defect predisposing to HLH was not excluded. However, the long recurrence-free period argues against an hereditary background.
+The patient received chemotherapy according to the HLH-2004 protocol, which includes etoposide, steroids, intrathecal methotrexate, and cyclosporin. The patient achieved complete remission of the disease at the end of the initial treatment period of 16 weeks. The patient did not achieved full remission of the disease until the end of the initial treatment period of 8 weeks. Treatment was thus continued until week 16 and was then stopped asl the parents declined further therapy. In total, the patient? cumulative dose of etoposide was 2100 mg/m2 during the 16-week period.
+After 23 months, the patient was readmitted with fever, leukocytosis, anemia, diffuse lymphadenopathy, and hepato-splenomegaly of 5 and 4 cm, which is palpable below the costal margins. LDH was elevated at 1788 U/L. Bone marrow examination revealed 89 % monoblasts, without evidence of HS (Fig. ). Flow cytometry studies indicated that 86.4 % of leukocytes were positive for CD33, CD7, CD11b, CD13, CD15, CD34, CD38, CD64, CD117, myeloperoxidase (MPO), and cytoplasmic CD68. Chromosome analysis of 48 h culture from bone marrow aspiration revealed complex karyotype aberrations. The karyotype was interpreted as 46, XX, d e r (11) t (11; 19) (q23; p13) inv (11) (q23 p15), and d e r (19) t (11; 19). The fusion gene was MLL/ELL. The diagnosis of AML (M5b) was made,. Induction chemotherapy with idarubicin and Ara-C (DA) was given, and the patient achieved complete remission in bone marrow morphology after two courses.
+The patient is currently on chemotherapy for AML, and her bone marrow revealed no residual or recurrent leukemia cell after the initial complete remission."
+Frederick Macias,45,2003/5/12,650.469.4086x37873,ncaldwell@example.net,0525 Robert Expressway,"A 15-year-old girl presented to her primary care provider with episodes of altered behavior. She reported a 30-minute period of fatigue, confusion, poor concentration, irritability, and ?taring off??which was noted by parents while the patient was getting ready for school. The patient herself did not recall the event. Her parents had witnessed several similar events lasting up to 30 min, at least once per week, in the morning, for the past 5 months. Their daughter? symptoms would resolve after eating breakfast. They had not sought medical care previously, assuming her behavior was related to early morning drowsiness. When the frequency of these episodes increased to several times per week, they presented to their primary care physician. Following her primary care visit, the patient was scheduled for an outpatient EEG after BMP, thyroid studies, and UDS which were normal. The patient became unresponsive during the EEG study and was referred to the local hospital with the following laboratory data when she was symptomatic: point-of-care glucose 36 mg/dL (65??10), insulin 36.8 uIU/mL (2.6??4.9), C-peptide 4.6 ng/mL (1.1??.4), and betahydroxybutyrate 0.6 mg/dL (0.2??.8). Her mental status immediately improved with intravenous dextrose. In search of an insulin-producing mass, she underwent abdominal CT with contrast which was negative per the local radiologist? report. Her EEG was interpreted as abnormal prompting the initiation of valproic acid therapy for potential seizure activity. She was discharged home from the emergency room with a glucometer and planned neurology follow-up. An outpatient endoscopic ultrasound was pursued as another attempt to localize any potential insulin producing mass, and this too was unremarkable. She was subsequently referred for subspecialty consultation with a pediatric endocrinologist. Prior to her scheduled endocrinology appointment, she was admitted to a tertiary care pediatric center due to near daily episodes of hypoglycemia associated with altered mental status. The patient became hypoglycemic overnight while fasting in less than 6 h (Fig. ). A critical sample was obtained and confirmed hyperinsulinemic hypoglycemia (Table ). Testing for sulfonylurea ingestion was performed and the result was negative. An MRI of the abdomen revealed a 0.9 ? 1.1 ? 1.3 cm pancreatic mass (Fig. ). Valproic acid was stopped and her hypoglycemia medically managed successfully with diazoxide 150 mg orally 3 times per day (8 mg/kg/day) and two tablespoons of cornstarch at bedtime. She ultimately underwent laparoscopic distal pancreatectomy with pathologic examination of the mass confirming a benign insulinoma (Fig. ). She had mild hyperglycemia post-operatively which resolved within 48 h without insulin therapy and was discharged home on post-operative day three. Gene sequencing by using DNA from a peripheral blood sample for multiple endocrine neoplasia was negative.. The patient remained euglycemic, asymptomatic, and lost 15 kg in the 10 months following tumor resection which dropped her BMI from the 87th to 45th percentile. A follow up EEG was performed and was completely normal. She is now considered cured. The time from onset of symptoms to correct diagnosis, tumor localization, and surgical management was approximately 8 months."
+Adley Simmons,23,1991/3/12,001-956-696-6630x03462,lauraroberts@example.org,770 Ashlee Parkway,"A 30-year old male truck driver presented in our center with a 10-day history of abdominal crash injury followed by secondary lower back pain, lower extremity pitting edema, scrotal edema, dyspnea and a temperature of 38簞C. On examination, he was hemodynamically stable and his abdomen was soft with mild right upper quadrant abdominal tenderness. Hematological analysis confirmed no anemia and the lactate dehydrogenase level was normal and the C-reactive protein was markedly elevated at 190 mg/L. All other hematological, coagulation, thrombophilic tests and biochemical analyses were normal. Bilateral lower limb arterial examination was normal. Plain X-rays of the chest, abdomen and lumbar spine were normal. Laboratory results also showed urea (23 mg/dl), creatinine (1.2 mg/dl), sodium (136 mmol/L), and potassium (3.6 mmol/L) that were normal. Urinalysis, using a urine dipstick, revealed three pluses of proteinuria, which equates to ??g urinary protein per day. Lab examination for the measurement of serum albumin revealed hypoalbuminemia. Doppler ultrasound of the femoral veins demonstrated marked expansion of both vessels without intra-luminal thrombus. A trans-thoracic echocardiography revealed a free floating mass in the IVC entrance extended to the right atrium ( and ). Poor view abdominal sonography revealed a probable clot in the supra hepatic IVC but the IVC and bilateral iliac veins were distended and no tumor was found in liver or retroperitoneal spaces. The patient was scheduled for emergency open heart surgery. Median sternotomy and vertical pericardiotomy were performed. Cardiopulmonary bypass (CPB) was established with aortocaval cannulation. The pulmonary artery was dissected and clamped. After cooling to 20簞C, cardioplegic arrest was achieved with cold blood cardioplegia. Total circulatory arrest was established. The right atrium (RA) was opened parallel to the atrio-ventricular groove. The thrombus was extracted. The IVC was thoroughly irrigated with normal saline. The circulation was temporarily restarted to flush out any small remnant of the thrombus in the IVC. The venous cannula was advanced into the SVC and the SVC was snuggled. The main pulmonary artery was opened and the left and right pulmonary artery suctioned and a large clot was found in the left pulmonary artery. Circulation was restarted and the RA was closed. CPB was weaned off after re-warming. The perioperative course was uneventful. The CPB and aortic cross-clamp times were 55 and 21 minutes, respectively. Total circulatory arrest time was 5 minutes. With continuation of lower extremity edema and signs of nephrotic syndrome, an IVC venogram via the femoral vein in the post-operative period demonstrated patency of the IVC inferior to the right atrium and patent renal veins and hepatic veins ( and ). Anticoagulation with warfarin was started on the day following surgery and continued for 6 weeks. At the four month follow up, there was no evidence of recurrent thrombosis in the hepatic vein, IVC or RA or proteinuria. It was felt on balance that treatment should be directed towards the thrombus. His bilateral lower limb pain and edema resolved at an early stage and the patient remained well two months later with regular vascular and hematological clinical review."
+Harrison Maynard,30,1982/4/13,536-296-8672,angelabrady@example.com,57523 Christina Views Suite 377,"A 59-year-old woman with follicular lymphoma was initially treated with six cycles of chemotherapy and prednisolone. After 2 months, the patient had received a total of 1350 mg of prednisolone and was on her fourth cycle of chemotherapy. She fell from bed and sustained a blow to her left shoulder. She complained of pain in her left shoulder and was examined on the same day. The shoulder was swollen with tenderness over the ACJ. Radiographs showed an ACJ dislocation with a distal clavicle fracture and CP deformity (). Three-dimensional computed tomography (3D-CT) reconstruction clearly showed a small CP bone fragment at the CCL insertion site (). We diagnosed the patient with a CP avulsion fracture. She was treated nonoperatively in a sling for 3 weeks, followed by progressive range-of-motion exercises. One month after her injury, the patient's shoulder functioned normally without pain."
+Carolyn Brock,25,2004/10/24,(981)337-4675,jrosales@example.net,43876 Mcdowell Ports Suite 351,"A 28-year-old lady, gravida 3 para 2 live 2 with previous one LSCS, married for 8 years arrived in gynecological emergency of the institute with two months of amenorrhea, excruciating pain abdomen ?1 day, and 5-6 episodes of vomiting ?1 day. She had not been using any contraception. Her previous menstrual cycles were regular of thirty days with bleeding period of 3 days. Upon missing her periods and a positive UPT at home, she took MTP pill as advised by a local doctor for unwanted pregnancy. However in event of RPOCs, she underwent a dilatation and curettage at a private hospital in the vicinity of her residence. Following the same, pain abdomen and spotting per vaginum still persisted. When abdominal pain became unbearable she was brought to hospital. Her past medical and family history were not significant.
+Her general condition on admission was guarded with maternal tachycardia (pulse 110 per minute), hypotension (BP = 70/40 mmHg), RR = 20/min, and pallor. Her abdomen was tender on palpation with positive rebound tenderness and guarding and absent bowel sounds. Pelvic bimanual examination revealed a bulky uterus with cervical excitation and bilateral adnexal fullness and tenderness that was more marked in the right fornix. A transvaginal ultrasound scan showed an empty uterus with thickened endometrium and a right adnexal mass that was suggestive of a right tubal pregnancy with a moderate amount of free fluid in the pouch of Douglas. Culdocentesis done was positive. Her investigations revealed Hb 7.6 gm%, TLC 12,200, DLC N88 L12, platelets 3.46 Lac, PT, PTTK normal, blood urea 24, creatinine 0.4, Na 131, and K 3.9. Ultrasound revealed ruptured left tubal pregnancy with significant free fluid in the abdomen and pelvis. There was no obvious ultrasonic evidence of right tubal disease.
+She was resuscitated and taken up in emergency for exploratory laparotomy and proceed in view of deteriorating vitals, after written informed consent. Consent for tubal ligation was also taken because she was multiparous. Preoperatively 2 litres of hemoperitoneum was drained. There was a ruptured left sided ampullary ectopic pregnancy ~6 ? 3 cm; right tube revealed ?? ? 3 cm organized hematoma seen attached to fimbrial end. Uterus and bilateral ovaries are normal (). A bilateral salpingectomy was hence performed. She was transfused three units of packed red blood cells intraoperatively. She had an unremarkable postoperative recovery and was discharged on the third postoperative day. Histopathological examination showing chorionic villi and trophoblasts in both tubes confirmed the diagnosis of bilateral tubal ectopicpregnancy with evidence of rupture on one side (Figures and )."
+Julio Logan,38,1986/5/7,402.482.3173x706,derekhamilton@example.com,605 Carr Glens,"A 49-year-old Chinese female was admitted to the hospital with gait disturbance, dysarthria, and involuntary movement of limbs for 10 days, with a history of edema in both lower extremities for 10 years, hypertension for almost 8 years, and diabetes mellitus for 2 years. Seven years ago when her serum creatinine level reached 2300 弮mol/L, she began taking regular hemodialysis treatments twice a week and then three years later this increased to three times a week due to her restless legs syndrome (RLS) secondary to chronic renal failure. Besides, she had polycystic kidney disease and hyperparathyroidism. There was no previous history of movement disorders and family history of this kind. Clinical examination revealed her highest blood pressure to be 200/100 mmHg. Generalized chorea was noted mainly on the extremities. Laboratory results showed elevated concentrations of blood urea nitrogen (BUN) of 33.6 mg/dL and creatinine (Cr) of 5.4 mg/dL, serum potassium of 6.1 mmol/L, and parathyroid hormone of 1457 pg/mL. Axial brain MRI revealed symmetric edema in the bilateral basal ganglia, which exhibited hypointensity on T1-weighted images () and hyperintensity on both T2-weighted images () and fluid-attenuated inversion recovery (FLAIR) images (). Diffusion-weighted imaging (DWI) demonstrated slightly higher inhomogeneous signals in the involved regions (). Concurrently, increased apparent diffusion coefficient (ADC) values were demonstrated in the periphery compared with normal brain tissue (), indicating vasogenic edema rather than cytotoxic edema. Follow-up MRI of brain was performed 3 weeks later, which showed lesions worsened and extended in both T1WI () and T2WI (). Simultaneously, MR imaging revealed demyelination around bilateral ventricles and lacunar infarctions in FLAIR (). MR angiography showed atherosclerotic alterations of small brain vessels. Proton (1H) MR spectroscopy (MRS) (Figures and ) with region of interest pinpointed on the left basal ganglia lesion displayed a decrease of N-acetylaspartate (NAA) peak and lactate (Lac) doublet. 3D-ASL results () reflected the local perfusion condition, and the increased regional cerebral blood flow (rCBF) suggested hyperperfusion in the corresponding lesion area. Some dotted low signals were noted in the susceptibility weighted imaging (SWI) findings (). After two months, we were surprised to find that the abnormal signals of the lesions totally disappeared when we scanned her again, and this demonstrated that the acute bilateral basal ganglia lesions are reversible. The reports have been approved by the Institutional Review Board with patient informed consent."
+Kora Fuller,19,1982/6/16,001-939-983-8753,drice@example.com,105 Shelley Square,"A 20-year-old right-handed woman presented with pain on her left elbow radiating along the radial side of the forearm since the age of 14. At that time, our young patient had undergone surgical decompression of ulnar nerve at the cubital tunnel for the first time due to ulnar neuritis confirmed by nerve conduction studies. One year later, medial epicondylectomy was performed additionally. Because of poor results, nerve conduction studies were repeated and concluded that there was no ulnar nerve lesion.
+The young patient presented at our department four years later and she was methodically examined to investigate her chronic pain. At first, a thorough history was taken. Apart from two surgical decompression procedures of the ulnar nerve, she reported no previous elbow trauma and no previous medical history. Physical examination was carried out and revealed full range of motion of the elbow. She had negative Tinel's sign and Phalen's test and no tenderness at the epicondyles.
+Since there were no significant clinical findings; a radiographic examination of her left elbow was undertaken. Radiographs showed an area of dense mineralization along with surrounding reactive sclerosis at the bicipital tuberosity of the radius ().
+To confirm the diagnosis, further imaging with a three-phase bone scan () and an MRI control of the region was made. The bone scan showed a high tracer uptake during all phases in the proximal end of the radius. The MRI scan revealed an intraosseous lesion that had no expansion at the surrounding tissues.
+Surgical removal of the tumor was decided. The lesion was excised en bloc, under general anesthesia and tourniquet application. We used demineralized bone matrix graft to fill in the gap of the radius. There was no need to transpose the bicipital insertion in the radius.
+Postoperatively, no evidence of elbow instability was observed. The diagnosis of the osteoid osteoma was confirmed histologically.
+Since then, our patient has been pain-free and reports no need for painkillers. There was no need for physiotherapy to obtain full motion of the elbow. The normal follow-up visits for the patient were one after 6 weeks and a second after one year. Eight years after the operation, the patient visited again our outpatient department, had a full range of motion, and reported not consuming any painkillers for her elbow. She was fully satisfied by the operation and the final outcome ()."
+Andre Vance,44,1992/4/20,+1-879-637-7264x005,timothy89@example.org,97819 Rios Glens,"A 62-year-old otherwise healthy Caucasian male complained of some minor nonspecific respiratory symptoms for a few days. These complaints evolved into a more worrisome pulmonary disease characterized by cough and progressive respiratory distress 2 days prior to the hospitalization. Chest CT scan on admission to an outside hospital showed diffuse bilateral alveolar and interstitial lung infiltrates. A diagnosis of atypical pneumonia and possible myocarditis was made and the patient was given antibiotic treatment and was discharged two weeks later. However, dyspnea persisted and he was admitted to our hospital for further workup. On admission, patient was found to have fever, acute hypoxic respiratory failure, pleural effusion, pericardial effusion, and irregular heartbeats with bouts of ventricular fibrillation. Upon hospitalization, additional diagnoses were made including acute renal failure, as well as possible liver disease marked by an elevation of liver function tests. A poorly defined pancreatic mass was noted on the CT scan. Head CT without contrast was performed which showed minimal mucosal thickening in the left maxillary sinus. There was opacification of several left ethmoid air cells with fluid levels in the left sphenoid and left maxillary sinuses. A nasoenteric tube was in place in nasal cavity. There was no mass lesion, erosion, or bone destruction. These finding were most consistent with mild inflammatory changes ().
+Sepsis was suspected and he was given antibiotics without improvement of his clinical condition. His condition rapidly deteriorated with progressive dyspnea and pulmonary infiltrates which by X-ray examination involved all five lobes (). Extensive microbiological studies were performed with no positive bacteriologic, viral, or fungal isolates. The only positive test was a mildly increased DNA load of Epstein-Barr virus (EBV) in blood with 0.5 copies per microliter detected by a quantitative PCR assay. EBV capsid IgG and nuclear antigen/antibody were positive. Peripheral blood smear showed mild normocytic anemia with moderate thrombocytopenia. White cells count was within the normal range with absolute lymphopenia and no atypical lymphocytes or lymphoma cells.
+As his condition deteriorated, he developed signs of cardiac tamponade. Pericardial effusion was drained and sent to the pathology laboratory. He developed uncontrollable ventricular fibrillation with subsequent cardiac arrest, which could not be reversed by resuscitation. At the same time, patient hemoglobin and platelet count decreased to 6.9 mg/dL and 22,000/弮L. His fibrinogen was decreased (178 mg/dL), ferritin was markedly elevated (1763 ng/Ml), and lactate dehydrogenase was elevated (628 U/L). Neutrophil count and triglyceride were within normal range. Hemophagocytic lymphohistiocytosis (HLH) was suspected. However, the final diagnosis of HLH was never made since the patient's condition deteriorated quickly and he died in a cardiopulmonary failure.
+The pericardial fluid sent for cytological analysis one day before his death contained numerous markedly atypical lymphoid cells () which were positive for Epstein-Barr virus (EBV) as detected by in situ hybridization (). Immunohistochemical stains performed on the cell block showed that the atypical cells were positive for CD45, CD2, and CD3 () and negative for CD4, CD8, CD56 (), CD138, pan-cytokeratin, MOC-31, Ber-EP4, chromogranin, synaptophysin, calretinin, S-100, and HHV8. Ki-67 (MIB-1) showed an increased proliferation index of approximately 20% reflecting the number of EBV-positive atypical cells. Flow cytometry confirmed that the lymphoma cells were CD2 positive. There was cytoplasmic CD3 positivity, but there was no surface CD3 expression. Bone marrow aspiration and core biopsy revealed a normocellular marrow for age (30??0% cellularity) with active trilineage hematopoiesis and left shifted granulopoiesis but no evidence of lymphoma. Cytogenetic analysis did not reveal any clonal chromosomal abnormalities.
+At autopsy, the decedent was found to have cardiomegaly (weight 650 grams) () with four-chamber dilatation and serous pericardial effusion (100 mL). Patchy whitish discoloration was found on the surface of epicardium and endocardium, and the myocardium had a mottled appearance on cross section (). The right and left lungs were heavy and weighed 1000 and 940 grams, respectively. The pleural surfaces were smooth, glistening, and unremarkable and the cut surface revealed patchy consolidation of pulmonary parenchyma with red and grey discoloration. There was 500 mL of straw colored pleural fluid in each of the pleural cavities. The pancreas was enlarged and the cut surface showed scattered areas of fat necrosis with hemorrhage. There was 500 mL of opaque fluid present in the abdominal cavity. The spleen was enlarged, weighed 330 grams, and had a smooth intact capsule covering red-purple semiautolytic parenchyma. The splenic white pulp was grossly unremarkable. Other organs were grossly unremarkable. Under microscopic examination, the myocardial tissue was found to be diffusely infiltrated by atypical lymphoid cells (). These cells had abundant pale cytoplasm, irregular nuclear contours, granular chromatin, and inconspicuous nucleoli (). In situ hybridization performed on the cardiac tissue showed that the atypical lymphoid cells were strongly positive for EBV. Immunohistochemical stains performed on the same tissue showed that the lymphoid cells were positive for CD3 (cytoplasmic stain) () and granzyme B () and negative for CD5, CD10, CD20, CD30, CD34, CD43, and CD56. Cells infiltrating the lung parenchyma in all five lobes (Figures and ) had the same immunohistochemical features. Diffuse infiltrates of identical neoplastic cells were found in the pancreatic () and gastric tissue ()."
+Maxine Valentine,28,1981/7/19,551-579-4215,ksmith@example.net,4895 Heather Keys,"Month 0: A 44 year-old man, 12 years of education, started complaining acutely of slowness and sustained attention difficulties. He had neither clinical comorbidities nor relevant familial history.
+Within three weeks after the first complaints, his status rapidly worsened and the patient needed help for every daily life activities. He was hospitalized, and presented significant cognitive impairment and walking difficulties related to marked parkinsonian syndrome. Depression with suicidal ideation was reported. No cerebellar features were observed. Neuropsychological assessment showed marked cognitive slowness and impairment of anterograde memory, mental calculation, verbal fluency, praxies and mental flexibility (Table ). Electroencephalogram (EEG) showed slow cerebral activity without any epileptic or pseudo periodic abnormalities. Tianeptine and ropinirole treatments were introduced.Month 2: His condition worsened, and he was hospitalized in the Department of Neurology, in University Hospital, Toulouse, France. In the absence of sustained stimulation, the patient remained motionless and speechless, due to severe apathy. Falls occurred frequently (about once a day), due to altered postural reflexes. After marked stimulation, it was noticed that the patient was depressed but not melancholic or suicidal. Marked symmetric and axial parkinsonian syndrome did not improve after L-dopa challenge. Slight reflex myoclonus was noticed in the upper limbs. Ocular saccades were slow but not limited. Apraxia and executive dysfunctions had worsened. Detection of 14???? protein performed from cerebrospinal fluid (CSF) sample by western-blot was positive, whereas cytology and biochemistry were normal. Structural cerebral MRI revealed fronto-temporal atrophy on visual assessment of T1 sequence, with no abnormality on diffusion weighted imaging (DWI). Ropinirole, and tianeptine treatments were replaced by citalopram, oxazepam and zopliclone. Month 6: Daily risperidone treatment was introduced due to delusions of persecution and rare visual hallucinations. Month 7: Parkinsonism did not deteriorate with the addition of neuroleptic agents. Delusions and hallucinations remained present, although less prominent, and cognitive functions kept worsening. Structural MRI was unchanged, and 18F-FDG-PET visual assessment showed severe hypometabolism in parietal regions. Month 10: The patient only experienced few hallucinations without delusions. Risperidone treatment was stopped but parkinsonian symptoms had worsened: he had severe dysarthria and was not able to walk without assistance because of his instability.
+The patient had to be institutionalized 12 months after symptoms onset.Month 20: Axial parkinsonian symptoms had worsened: he had difficulties swallowing, severe dysarthria, freezing in narrow place and total loss of postural reflexes. He was bed-ridden most of the day. CSF 14???? protein remained positive, while total-tau (238 pg/mL) and A帣42 (511 pg/ml) levels were within the normal ranges (norm < 450 pg/mL and > 500 pg/mL, respectively).
+MRI showed moderate striatal, brainstem, and bilateral fronto-temporo-parietal atrophy on visual assessment.Month 43: Parkinsonian symptoms were very severe, and myoclonus more pronounced. Important perseverations, imitations, and grasping were reported. Speech was unintelligible. Detection of 14???? protein in CSF was negative.
+The patient died one year later, aged 49, after a total duration of 55 months. Cerebral histopathological examination was performed.
+Grey matter density was assessed in our patient from his first T1 MRI sequence (Fig. ), and compared to the grey matter density of a group of 30 age-matched healthy controls (age = 44.9 簣 3.8) from the online database OASIS (), using a whole brain z-score map. The 18F-FDG-PET scan from our patient (Fig. ) was also compared to another group of 23 age-matched healthy controls (age = 44.3 簣 9.4) using z-scores map (for details on the control population and imaging processing procedures, see Additional file ). All z-scores below ?? or above 2 were considered as significant.
+The patient showed global bilateral decrease of grey matter density affecting all cortical regions as well as subcortical structures and cerebellum (Fig. and Additional file ). Negative z-scores below ?? were found in parietal, temporal, but also frontal and insular cortices. Left hippocampus and bilateral thalami were spared. No z-score > 2 was found.
+Regarding 18F-FDG-PET, the patient showed widespread significant bilateral hypometabolism, encompassing all cerebral lobes, most predominant in the parietal lobe (Fig. and Additional file ). Negative z-scores below ?? were found in parietal and medial temporal regions. No difference compared to controls was found in the thalamus, orbitofrontal regions, or the posterior cingulate. Hypermetabolism was found in the putamen.
+Preliminary examination was carried out on hematoxylin-eosin stained paraffin sections, completed by immunohistochemistry with the following antibodies: anti-tau AT8 (Thermo Fisher Scientific, Illkirch, France), anti-amyloid-beta A4 (Dako, Trappes, France), anti-alpha-synuclein (Leica Biosystems, Newcastle, UK), and anti-prion protein 12 F10 (Spibio, Montigny Le Bretonneux, France). Macroscopic brain examination showed a marked palor of the substantia nigra, while anti-alpha-synuclein immunohistochemistry revealed numerous Lewy bodies and Lewy neurites in the frontal and temporal cortices, hippocampus, substantia nigra, locus c?ruleus, as well as in the dorsal motor nucleus of the vagus, occipital and entorhinal cortices, and more rarely in the thalamus, caudate nucleus, putamen, and pallidum (Fig. ). Spongiosis was absent and anti-prion protein immunohistochemistry was negative. A few AT8-positive neurofibrillary tangles were noticed in the hippocampus and the entorhinal cortex, whereas anti-amyloid-beta 4 staining revealed neither neocortical deposits nor amyloid angiopathy.
+SNCA gene (encoding the alpha-synuclein) mutations were investigated using bidirectional Sanger sequencing on an ABI 3730 automated sequencer (Applied Biosystem) and SeqScape v2.6 software (Applied Biosystems), and multiplex ligation-dependent probe amplification (MLPA, MRC-Holland). PRNP gene (encoding the prion protein) mutations were investigated using a previously described protocol []. Neither missense mutations nor multiplications were found in the SNCA gene (alpha-synuclein), and no mutation was identified in the PRNP gene (prion protein) either. The polymorphism at codon 129 was methionine-methionine."
+Demetrius Marsh,30,2003/8/9,639-486-7774x047,woodanthony@example.com,0378 Hill Circle Apt. 815,"The proband is a 17-year-old white female with agenesis of the uterus and vagina who had a peripheral blood karyotype revealing a de novo balanced translocation 46,XX,t(3;16)(p22.3;p13.3). She has no associated renal, skeletal, or hearing anomalies. She has two unaffected sisters and two brothers (Fig. ). Both parents and her unaffected sister II-5 have normal karyotypes, and all three nieces (III-1, III-2, and III-3) have no known mullerian, renal, or skeletal defects."
+Adelina Espinoza,35,1979/6/28,(355)443-5855,scottkathleen@example.org,7303 Carol Junctions Suite 671,"A 31-year-old Caucasian woman was diagnosed with lupus in 2011. She initially presented with arthritis, serositis (pleuritis), autoimmune hemolytic anemia, idiopathic thrombocytopenia (ITP), positive antinuclear antibody (ANA), Smith and RNP antibodies, and low complement levels. She also has a history of autoimmune hepatitis and diabetes mellitus type 1. She was initially treated with intravenous immunoglobulin (IVIG), rituximab, and splenectomy. Her disease was relatively stable on hydroxychloroquine 200 mg BID and mycophenolate mofetil (MMF) 500 mg twice a day. In June 2013, she presented with complaints of dyspnea, lower extremity swelling, fevers, anorexia, and jaundice.
+Initial workup revealed worsening of chronic anemia with hemoglobin of 5.2 g/dL (her baseline, 8??0 g/dL, and normal, 11.2??5.7 g/dL), hyperbilirubinemia with total bilirubin of 9.2 mg/dL (normal, 0.2??.2 mg/dL), direct bilirubin of 6.4 mg/dL (normal, 0.0??.3 mg/dL), alkaline phosphatase of 250 弮/L (normal, 35??04 弮/L), normal ALT and AST, and a right-sided pleural effusion on chest X-ray. She was treated for a flare of autoimmune hemolytic anemia with IVIG, blood transfusions, intravenous pulse doses of methylprednisolone, empiric treatment with broad spectrum antibiotics for pleural effusion, and continuation of the home dose of hydroxychloroquine 200 mg daily and MMF 500 mg twice a day. Antibiotics were stopped after pleural fluid and blood cultures were found to be negative. Liver biopsy showed iron overload in hepatocytes and no significant inflammation or fibrosis.
+Her creatinine increased from a baseline of 0.8 to 1.8 mg/dL and peaked at 2.81 mg/dL (normal, 0.5??.10 mg/dL) on the fifth day of hospitalization. Urinalysis showed large protein and blood, and urine microscopy showed many red blood cells (RBCs) with few dysmorphic RBCs and many granular casts, fatty casts, and white blood cell casts but no RBC casts. Urine random protein/creatinine ratio was elevated at 2.49 (normal < 0.15).
+Renal biopsy () showed glomeruli with cellular and fibrocellular crescents, focal segmental necrosis, and mild interstitial and tubular injury. IF showed only trace C3, IgM, and fibrinogen deposits. Electron microscopy (EM) showed endothelial and podocyte injury with glomerular basement membrane (GBM) remodeling; no electron dense immune deposits were seen. The findings were consistent with pauci-immune crescentic glomerulonephritis with focal acute activity and mild chronic changes.
+Additional laboratory testing revealed a positive ANA with a titer of 1 : 640 (homogenous pattern), elevated anti-Smith antibody of >8.0 (normal, 0.0??.9 AI), RNP antibody of 7.2 (normal, 0.0??.9 AI), p-ANCA at >1 : 640 (normal, <1 : 20), anti-myeloperoxidase (MPO) antibodies at 86.0 U/mL (normal, 0.0??.0 U/mL), anticardiolipin IgM at 27 U/mL (normal, 0??2 U/mL), and positive lupus anticoagulant. She had a low C3 level of 56 mg/dL (normal, 90??80 mg/dL) and normal C4 level. Anti-double stranded DNA antibodies (dsDNA), c-ANCA, anti-proteinase 3 (PR-3) antibodies, and beta-2 glycoprotein antibodies were negative.
+Based on biopsy results, MMF was switched to cyclophosphamide 175 milligrams daily orally. Creatinine returned to normal and her anemia improved. She was tapered off of cyclophosphamide and switched to azathioprine for maintenance therapy."
+Dallas Monroe,41,2003/12/29,(791)866-1612x6224,brendahaas@example.net,18958 Stephen Harbor,"A 58-year-old African American woman was diagnosed with mixed connective tissue disease (MCTD) in 2000. She initially presented with Raynaud's phenomenon, myalgia, synovitis, esophageal dysmotility, and positive anti-RNP antibody. She also had interstitial lung disease with a nonspecific interstitial pneumonitis (NSIP) pattern and was treated with cyclophosphamide. She has no sclerodactyly or skin findings suggestive of scleroderma. She was hospitalized at our institution in September 2009 for acute renal failure with a creatinine level of 5.52 mg/dL (normal, 0.5??.10 mg/dL); her baseline was 1.12 mg/dL. Other than increased nocturia she had no other symptoms. Urinalysis showed 2+ blood, 2+ protein, and RBC casts. Urine random protein/creatinine ratio was elevated at 1.28 (normal < 0.15). Renal biopsy was performed for further evaluation.
+Renal biopsy () showed predominantly sclerotic glomeruli with occasional fibrous and fibrocellular crescents and focal segmental necrosis. Marked background tubular atrophy and interstitial fibrosis were also noted. IFE revealed weak, nonspecific reactivity for C3 and fibrinogen. Electron microscopy showed glomerular damage and rare electron dense C3 deposits. The findings were consistent with pauci-immune crescentic glomerulonephritis with focal acute activity and marked chronic changes.
+Additional laboratory workup revealed that ANA was high at 64 by EIA (normal, 0??0 U/mL). C3 and C4 were within normal limits. Anti-double stranded DNA antibody, anti-centromere antibody, anti-topoisomerase antibody, anti-JO 1 antibody, anti-ribosomal P protein antibody, anti-SSA/SSB antibody, anti-Smith antibody, anti-MPO antibody, anti-PR-3 antibody, c-ANCA, p-ANCA, and atypical ANCAs were negative. She received a pulse dose of IV methylprednisolone along with five monthly infusions of cyclophosphamide IV and was transitioned to MMF and low dose oral prednisone. Her renal function continued to worsen, and she was started on hemodialysis and underwent renal transplant in 2014. She remains on MMF, tacrolimus, and prednisone; she has had no recent flares of her MCTD. Her transplanted kidney continues to function well, as demonstrated by a stable creatinine of 1.11??.17 mg/dL."
+Carly Castro,45,2001/4/17,5419485465,gburch@example.net,89817 Michael Mill Apt. 732,"A 24-year-old African American female with past medical history of asthma and eczema presented to our emergency room with nausea, vomiting, myalgia, and fever in May 2015. Her mother has rheumatoid arthritis. Physical exam was unremarkable. Initial workup revealed creatinine of 4.25 mg/dL (normal, 0.5??.10 mg/dL) and WBC count of 20 10e3/弮L (normal, 4.0??0.0 10e3/弮L). Urinalysis showed 2+ blood, 2+ protein, and WBC and granular casts. Urine random protein/creatinine ratio was elevated at 1.90 (normal < 0.15). Ultrasound of the kidneys showed enlarged and edematous kidneys. Further workup revealed elevated ANA of >8 (normal < 0.9 AI), anti-dsDNA antibody at 32 (normal < 5 IU/mL), and anti-chromatin antibody of 7.3 (normal, 0.0??.9 AI). Anti-MPO, anti-PR-3, anti-Smith, anti-RNP, and anti-SSA/SSB antibodies, C-ANCA, P-ANCA, lupus anticoagulant, and anti-cardiolipin antibody were negative. C3 and C4 were within normal limits. Kidney biopsy was performed for further evaluation.
+Renal biopsy () showed cellular crescent formation, focal segmental necrosis, and mild interstitial fibrosis. IFE showed sparse positivity for C3 and strong reactivity for fibrinogen within necrotic foci. EM was unremarkable. The findings were consistent with pauci-immune crescentic glomerulonephritis with acute activity and mild chronic changes.
+She was treated with pulse dose IV methylprednisolone 1000 mg/day for 3 days followed by oral prednisone at 1 mg/kg/day. She received rituximab 375 mg/m2 every week for a total of 4 doses. Her kidney function improved and creatinine returned to normal. She is on rituximab infusions for maintenance therapy and continues to do well."
+Jasper Torres,44,1978/12/6,-7155,kristinapaul@example.com,683 Eddie Ridge Suite 323,"A 56-year-old male Caucasian, 60-pack-year smoker with a past medical history of sleep apnea presented as an outpatient with gradual abdominal distention. During the last 2 months he reported painless swelling of the right testis. Physical examination revealed ascites and right scrotal hard mass with enlarged testis. Complete blood count and biochemistry were normal, while serum CA 125 was increased (319 弮/mL). In November of 2015 he was admitted to the Oncology Department for further investigation.
+Computed tomography of the thorax and abdomen revealed a minimal pleural effusion of the left hemithorax, diffuse peritoneal fluid in the abdomen, and peritoneal implants (). Since no solid literature data exist (apart from the sensitivity of PET/CT scan in hidden primaries mainly of head neck) no PET/CT scan was requested in our case. Upper and lower GI endoscopy revealed no abnormalities. Patient had a scrotal ultrasound imaging that revealed an enlarged right epididymis with small amount of fluid in the right side of the scrotum. Abdominal paracentesis revealed exudative fluid with neoplastic signet-ring cells indicative of metastatic adenocarcinoma. Gross evaluation of the tissue specimen revealed several poorly defined, whitish, and hard in consistency foci throughout the testicular parenchyma, the epididymis, and the spermatic cord. The tunicae surrounding the testis were thickened. Microscopical examination of multiple tissue sections taken from the grossly described foci showed the presence of a poorly differentiated carcinoma composed of signet-ring cells (). Perineural and neural invasion as well as vascular invasion were observed.
+By histochemical stains (PAS, Alcian Blue) a large amount of mucin was demonstrated in the cytoplasm of tumor cells (). Immunohistochemically, the neoplastic cells were diffusely positive for cytokeratin 20 and EMA, focally positive for cytokeratin 7, CEA, and c-kit (CD117), and negative for PLAP, a-fetoprotein, CD30, inhibin, calretinin, PSA, p504S (AMACR), TTF-1, and Melan A (). The pathological diagnosis was in favor of a metastatic adenocarcinoma, probably of gastrointestinal origin. Tissue HER2 was negative.
+Taking into consideration the aforementioned findings, the primary site could not be established and the case was classified as CUP. In November 2015 he started on systemic therapy consisting of Capecitabine and Oxaliplatin. Up till January 2015, he has received three cycles of the above regimen with good partial remission of his ascites and excellent drug toleration. However, just before the fourth cycle he developed right pleural effusion with accompanying moderate dyspnea (). Pleural fluid cytology was positive for metastatic adenocarcinoma with signet-ring cells.
+A second-line regimen consisting of Doxorubicin, Cyclophosphamide, and Fluorouracil (DCF) was administered. Up till now, the patient has received six cycles of DCF with complete response of the disease on abdominal and thoracic CT scans as well as normalisation of serum CA 125 (6 弮/mL)."
+Violet Curry,18,1992/6/1,415.508.5518x8914,aboyd@example.org,310 Timothy Dam,"A 53-year-old female presented to our outpatient clinic with rather acute chronic severe left-sided knee pain. The pain was not trauma related and had lasted for a few days. There were symptoms of locking. The knee joint has not been operated on before. Clinical findings confirmed a stable left knee joint with limited motion for full flexion as well as extension (110-5-0). Lachman, anterior, and posterior drawer were negative. The collateral ligaments were stable in full extension as well as in 30簞 of flexion. The patellofemoral alignment was normal and there was no apprehension sign. Clinical test for the menisci was negative (partly false positive for the anterior part of the medial meniscus). There was mild effusion and clear sharp pain at the medial femoral condyle. Conventional X-rays confirmed no significant pathology, no signs of advanced arthritis, and a straight mechanical axis (not shown). Subsequent magnetic resonance imaging (MRI) confirmed a large area of freshly appearing bone marrow edema (BME) at the dorsomedial femoral condyle with overlying highly irregular cartilage (). The remaining joint appeared normal on MRI. After discussing the case with the patient we indicated to approach with knee joint arthroscopy first in order to inspect the medial condyle and debride the lesion plus potential antegrade drilling for relieve of the BME. During arthroscopy there appeared a large just recently separated pure chondral fragment at the dorsomedial femoral condyle with healthy appearing surrounding and opposing cartilage (). The medial meniscus appeared intact. The remaining joint structures appeared intact. With regard to a recent separation and healthy appearing surroundings we decided to proceed with arthrotomy in order to repair the cartilage defect by mincing the healthy appearing cartilage piece. Following arthrotomy the large fragment could be retrieved easily. It was purely chondral. A refixation was deemed not promising. Consequently the large fragment with healthy appearing cartilage was minced into multiple small cartilage chips (<1 ? 1 ? 1 mm) using a scalpel at the back table. In parallel the defect was debrided to create a stable and healthy cartilage rim. The subchondral bone was intact. Defect dimensions after debridement were 2.5 ? 1.5 cm and ICRS grade 3b. Yet, with regard to the BME seen on MRI, we frequently drilled into the subchondral bone at different locations and in different angles using a constantly water cooled 1.4 K-wire in antegrade fashion. Hereafter, the autologous chips were placed into the debrided lesion and fixed using fibrin glue. The chips had more than enough quantity to cover the lesion. After dehydration the joint was put through multiple full range of motion procedures. The repair tissue remained in place. Subsequently, the joint was closed in layers. Rehabilitation was performed as previously reported []. Following an uneventful postoperative course the patient presented without pain or locking sensations at our outpatient department at 6 weeks, 12 weeks, and 6 months postoperatively. Albeit no full muscular function, swimming and biking were already possible at last follow-up. Six-month MRI was in display of almost full regression of the BME and satisfying novel cartilage surface with good integration into the surrounding cartilage and subchondral bone. The transplant signal appeared almost isointense to the neighbouring cartilage (). The calculated MOCART [] score was 85 points. Lysholm score was 80 points. The patient was subjectively very satisfied with the procedure and would undergo it every time again."
+Briggs Fields,32,1998/2/27,879.218.6470,cruzwendy@example.org,090 Brewer Drive Suite 360,"An 80-year-old woman was admitted with reported fever that started 12 days before with no associated symptoms. According to her medical history, she was diagnosed with a myelodysplastic syndrome (MDS) 8 years ago, which was effectively managed with erythropoietin. Seven years earlier, she was diagnosed with ulcerative colitis, treated with mesalazine 800 mg twice daily. Finally, a tuberculosis (TB) infection was reported more than 40 years before. A former urine examination had revealed a urinary tract infection (urinary culture with the presence of E. coli > 105 CFU susceptible to almost all antibiotics). She received amoxicillin/clavulanic acid for a week and subsequently ciprofloxacin, one week prior to her presentation to the emergency department, but fever failed to settle.
+At presentation, her body temperature was 38.5簞C and she was hemodynamically stable. She reported no cough, dyspnea, abdominal pain, diarrhea, or dysuria. She had no clinical signs indicating a respiratory, urinary, or abdominal infection while a systolic aortic valve murmur was present. Her ECG revealed a 1st-degree AV block and her chest X-ray showed a cavity at the right upper lung field. Her tests revealed anemia (HCT = 23%, HGB = 7.2 mg/dL), a low WBC count, an elevated ESR (>100 mm/h), and CRP = 71.4 mg/L (0.0??.0 mg/L); thus, she received 1 RBC unit for treating anemia. Fever was initially considered as a symptom of a urinary tract infection, which did not respond to the antibiotic treatment per os, and therefore she was treated with intravenous meropenem. At the same time, the patient received multiple blood transfusions, due to the fact that she was not responding to erythropoietin.
+Since fever was persisting even after antibiotic treatment, simultaneously further investigation was deemed necessary. The patient had a CT scanning of the chest and the abdomen. The chest scanning revealed a cavity at the right upper lung field, which was consistent with the history of the old TB infection and the chest X-ray findings. The abdominal scan did not reveal any significant findings apart from the presence of edema at the rectum ().
+Subsequently, the patient had a colonoscopy, which revealed a thickened fold of rectum mucosa and diverticulosis of the sigmoid with redness of the surrounding mucosa. The patient was treated for 12 days with meropenem before the colonoscopy and diverticulosis was excluded as the cause of pyrexia since her fever did not settle. However, the coexistence of diverticulitis in remission could not be excluded. A few days later, the biopsies from colonoscopy revealed a mild chronic, unspecific inflammation of the sigmoid and the rectum.
+Awaiting the results of the biopsies, the patient had a gastroscopy, which only revealed a mild gastritis. The transthoracic cardiac ultrasound confirmed a mild aortic valve stenosis with no other findings indicating endocarditis; thus, we did not proceed to a transoesophageal echocardiogram (multiple blood cultures were all negative). A myelogramconfirmed the MDS, RARS type. Moreover, a full laboratory examination of the immune system was conducted (ANA, anti-dsDNA, anti-ENA, anti-RNP, anti-Ro, anti-La, anti-sm, C-ANCA, P-ANCA, anti-MPO, anti-PR3, and anti-CCP) as well as serum protein electrophoresis, right temporal artery biopsy, and investigation for possible relapse of the old TB infection (Mantoux, urine, gastric fluid, sputum and bone marrow Ziehl-Neelsen stain, and culture for 帣-Koch). Pending the results, the patient was discharged with prescription for paracetamol to treat the fever.
+A few days later, the patient was readmitted for a blood transfusion and she was still febrile. The results of the immunologic tests were inconclusive {ANA (??, anti-ENA (+), and anti-RNP (+)}; the serum protein electrophoresis and the temporal artery biopsy were negative and so were the tests for the reactivation of the old TB infection. The patient was evaluated by a rheumatologist who recommended treatment with 20 mg of prednisone daily. After 21 days, the patient remained febrile and thus underwent a gallium-67 scintigraphy searching for a hidden focus of inflammation. The gallium-67 scintigraphy revealed persistent diffuse concentration of the gallium in the ascending colon () at 24-hour imaging, in discordance with the colonoscopy (no signs of active inflammation at the ascending colon).
+The gallium-67 diffuse uptake of the ascending colon remained stable at the repeated 48- and 72-hour imaging without any topographic change after the use of laxatives ().
+Considering the results of gallium-67 scintigraphy, colonoscopy, biopsies of rectum and sigmoid, and the absence of another diagnosis, the patient was started on 30 mg of prednisone daily with mesalazine, as treatment for active ulcerative colitis. At the same time, she was receiving isoniazid and rifampicin as prophylaxis for the old TB infection. Subsequently, the patient's condition improved markedly, the fever retreated, and the need for blood transfusions also substantially decreased. The patient was discharged. One month later, she was reevaluated with a gallium-67 scintigraphy, which was notably different, with total absence of gallium-67 concentration in the ascending colon ().
+The cortisone dosage was decreased and close monitoring of the patient continued on an outpatient basis."
+Annie Cline,33,1995/3/28,8708375137,penningtonbrandon@example.com,7443 Stephanie Passage,"Our patient is a 75-year-old African-American woman with a history of diabetes mellitus, hypertension, hyperlipidemia, and four prior cerebrovascular accidents with mild right sided residual weakness and ventral hernia status after surgical repair. She has no prior history of smoking, alcohol use, illicit drug use, or family history of premature coronary artery disease. She initially presented with shortness of breath, rhinorrhea, and cough productive of yellowish sputum and tested positive for influenza A for which she was started on oseltamivir. On her second day of hospitalization she reported mild retrosternal chest pain accompanied with a Troponin I elevation up to 0.3 ng/mL with an unchanged EKG showing right bundle branch block (RBBB) (). She received Aspirin, Clopidogrel, and Heparin drip in addition to Diltiazem and Atorvastatin as treatment for a NSTEMI.
+On the following day, she underwent a coronary angiogram revealing only minor luminal irregularities and no significant CAD (). Two days later, she underwent nasopharyngolaryngoscopy for progressive dysphonia that showed inflammatory changes of true and false vocal folds, mild granulation changes of the subglottis, and pachydermia. This was deemed secondary to her upper respiratory tract infection and the resulting acute tracheobronchitis. Subsequently, she was started on intramuscular dexamethasone 10 mg Q8 hours.
+One day later, she complained of severe retrosternal chest pain with a blood pressure of 90/65 mmHg, heart rate of 95 bpm, and oxygen saturation of 95% on room air. Cardiovascular exam was unremarkable revealing regular heart rate and normal S1 and S2 with no appreciated murmurs, rubs, or gallop. She had no JVD and clear lungs on auscultation. Distal pulses were well felt without appreciated lower extremity edema. The EKG however showed ST elevation in the anterior leads, V2 to V5 (). Bedside echocardiogram revealed a left ventricular ejection fraction (EF) of 30??5% and regional wall motion in the form of apical dyskinesis and severe hypokinesis in the mid to apical anteroseptal, anterior, apical inferior, inferoseptal, and lateral segments. Of note, the pre-MI echocardiogram showed a normal EF with no appreciated regional wall motion abnormalities. The Troponin I level was 0.1 ng/mL (cutoff value of 0.2 ng/mL). She was immediately transferred to the catheterization lab where the angiogram surprisingly revealed a filling defect, likely a thrombus, occluding the midsegment of the LAD (). Subsequently, a 2.5 ? 18 mm drug eluting stent was deployed with pre- and postballoon dilation resulting in TIMI III flow (). Eptifibatide was started in addition to Ticagrelor, Aspirin, Deltiazem, and Atorvastatin. The chest pain resolved shortly after the intervention and the EKG returned to baseline ().
+Blood work revealed a platelet count of 461 k/cumm, hemoglobin of 10.5 mg/dL, and white blood cell count of 9 k/cumm. Homocysteine level was mildly elevated (15.5 micromoles/L, normal range 3.2??0.7). High sensitivity CRP was elevated at 40.9 mg/L. Factor VIII activity (325%, normal range: 63??50), factor XI activity (211%, normal range: 71??24), and thrombin antithrombin complex (13.7 ng/mL, normal range: 0.7??.2) were all increased while factor VII activity was normal. Fibrinogen level and protein C and S activity were normal. Cardiolipin antibody, JAK2 V617F mutation, and Factor V Leiden were all negative."
+Cullen Harvey,30,1989/6/9,(892)905-3447x04439,jeffreyschwartz@example.net,055 Kristen Ports Suite 927,"A 48-year-old Chinese woman with a history of a right parasagittal meningioma with surgery and gamma knife excision done, was first put on valproate but then stepped up to topiramate 26 months later for uncontrolled seizures. The initial dose was topiramate 25 mg twice a day, which was eventually stepped up to 100 mg twice a day for adequate seizure control. She was referred to our ophthalmology clinic for dry eyes before the use of topiramate, with an examination showing a baseline visual acuity of 1.2 in both eyes with unremarkable anterior segment and fundoscopy examination. There was no family history of retinal diseases.
+She complained of blurring of vision in both eyes after using topiramate for 9 months. She was not on other medications when her visual symptoms developed. On examination, her visual acuity was 0.7 in both eyes. Her pupils were equal with no relative afferent papillary defect. The intraocular pressure, Ishihara test, and anterior segment examination were within normal limits. A fundus examination revealed there was bilateral diffuse pigmentary retinopathy (Fig. ). Automated perimetry showed bilateral peripheral constrictions (Fig. ) while microperimetry showed normal macula sensitivity (Fig. ). Autofluorescence fundus pictures showed loss of autofluorescence at the periphery, which is compatible with areas of pigmentary retinopathy (Fig. ). A fundus fluorescein angiogram also showed blocked fluorescence in the areas of pigmentation (Fig. ). Optical coherence tomography was unremarkable. A full field electroretinogram (ERG) according to International Society for Clinical Electrophysiology of Vision (ISCEV) standard was performed at 16 months after onset of symptoms (25 months since topiramate was first given). Both photopic and scotopic responses were found to be within normal limits. Administration of topiramate was immediately ceased due to suspected correlation with her eye signs and symptoms. She was switched to levetiracetam monotherapy. There was no more seizure recurrence after this treatment change.
+All investigations were repeated 1 year after discontinuation of topiramate. Bilateral diffuse pigmentary retinopathy was still present, with visual field test showing similar peripheral constriction, although her visual acuity improved back to 1.0 in both eyes and she reported subjective improvement in vision."
+Nicole Garrett,29,1997/3/5,716.876.5024,amandalarson@example.org,9020 Carter Ramp,"A 7-year-old male child was referred to the Department of Oral and Maxillofacial Surgery, Dr ZA Dental College, Aligarh Muslim University, Aligarh from primary health care center, Aligarh. The chief complain of the patient was wide mouth and compromised feeding. Child looked thin and was underweight as compare to the children of same age group. He was born prematurely at six months of gestation by cesarean operation. The obstetric history of mother was G3P2Ao (Gravida 3, Para 2, Abortion O). Child had a history of blood transfusion but the parents of the child neither could furnish any documented evidence nor tell the disease for which of blood transfusion was done.
+The extraoral examination revealed that the child had a wide mouth. The angles of the mouth were extending posteriorly on either side but not beyond the anterior border of the masseter. The cleft is not beyond the anterior border of masseter was identified by asking the patient to clinch his teeth. Since the muscle is close to skin, it can be easily palpated. When it contracts on clenching, its anterior border stands clearly. Bilaterally, the clefts were lined with skin externally and with buccal mucosa internally. The demarcation between end of the lips and beginning of the defect was noticeable on close observation (). Intraoral examination revealed mixed dentition, with normal eruption time and sequence. Orthopantomogram, revealed mild hyperplasia of the mandible. On further local and systemic physical examination no other abnormalities or congenital anomalies were found."
+Kairo Ponce,39,2002/9/10,(986)537-5188,wmcbride@example.net,6373 James Fords Apt. 098,"A 16-year-old Indian female patient was referred for endodontic treatment of mandibular left first molar with chief complaint of spontaneous pain. The tooth was percussion sensitive, cold and heat sensitive, although there was no referred pain. Radiographical examination revealed an additional distolingual root (). Tooth was anesthetized and isolated with rubber dam. The pulp chamber was opened, and one distal and two mesial canal orifices were located using an endodontic explorer (DG-16 Endodontic Explorer, Ash Instruments, Dentsply, Gloucester, United Kingdom). Upon visual inspection with a surgical loupe (Neitz BLS-3, Japan), a dark line was observed between the distal canal orifice and the distolingual corner of the pulp chamber floor. At this corner, overlying dentin was removed with a diamond bur with a noncutting tip (Diamendo, Dentsply Maillefer) and a second distal canal orifice was detected. The root canals were explored with a K-file #15 (Dentsply Maillefer, Ballaigues, Switzerland). The radiographical length measurement was performed with the Rinn set (Dentsply Rinn, Elgin, IL, USA) () and confirmed with an electronic apex locator (Raypex 5, VDW GmbH, Munchen, Germany). The root canals were shaped with protaper rotary instruments (Dentsply Maillefer) up to the F2-Protaper. During preparation EDTA (Glyde File Prep, Dentsply Maillefer) was used as a lubricant and the root canals were disinfected with a sodium hypochlorite solution (2.5%). The canals were obturated with protaper gutta-percha F2 () and AH Plus sealer (Dentsply Maillefer). The pulp chamber was sealed with Ketac Fil glass ionomer cement (ESPE, Seefeld, Germany) and tooth was restored with silver amalgam."
+Aileen Serrano,37,1989/7/23,418-856-4675x7555,ortizkeith@example.com,646 Lee Gateway Suite 483,"A male child aged 4 years was brought to the hospital with a complaint of swelling on the upper anterior teeth region since 15 months. Upon analyzing the history, the father in-formed that, the right upper central incisor was not erupted till the age of 2 and the child was taken to the dental clinic. Dental records stated that opperculectomy was done in 51 region following which the tooth erupted. 6 months later the patient developed a small swelling in the gum region in relation to 51. Swelling was gradually increasing in size with the displacement of incisor teeth and associated with pain.
+On examination, a single well-defined sessile growth was evident on the anterior maxillary region encircling the crown of right upper central incisor (). The size was approximately 4 ? 3 cm anteroposteriorly and mediolaterally protruding between the lips (). Mouth closure was incomplete. Mucosa overlying the growth was erythematous. Palpatory findings include bony hard consistency, fixation to the deep structures, tenderness and bleeding. 51 and 61 were not mobile and no response was elicited on using electronic pulp vitality tester. No evidence of paresthesia on lip and para-oral structures.
+Above features made us to think, bony sarcoma and odontogenic tumor as possible differential diagnosis.
+Maxillary occlusal view in relation to 51 and 61 region showed well-defined radiopaque mass with numerous specks producing ground - glass appearance between widely displaced 51 and 61. The opaque mass was surrounded by unilocular radiolucency. No evidence of root resorption in relation to 51 and 61. Tooth buds of permanent central incisors were found above the radiopaque mass ().
+CT maxillary view demonstrated expanded cortex in the anterior alveolar region with ill-defined mixed mass surrounded by areas of corrugated margins ().
+Microscopic analysis of incisional biopsy specimen demonstrated nonencapsulated rich cellular connective tissue stroma composed of proliferative plumps of fibroblasts along with collagen fibers (). Round to ovoid areas of osteoid and slender trabeculae of woven bone were interspersed in the connective tissue stroma (). Few giant cells were present. No evidence of mitotic figures.
+Clinical, radiographic and histopathological corelation suggested the final diagnosis of juvenile ossifying fibroma."
+Milan Phillips,26,1980/10/22,976-343-2491x1391,lisacardenas@example.com,9462 Alexandra Trail,"A 9-year-old female came to the pediatric dental clinic for dental treatment. The medical and family history was noncontributory. Clinical examination disclosed carious lesions in primary and permanent molars, and a prominent cusp-like structure on the palatal surface of the maxillary left lateral incisor. It was pyramidal in shape and extended from CEJ half-way to the incisal edge causing minimal occlusal interference ().
+Clinically, the tooth was asymptomatic and responded normally to pulp vitality tests. The grooves at the junction of the cusp and palatal surface were stained and contained dental plaque. Maxillary right lateral incisor displayed a deep lingual pit suggesting type I invagination. Further, prominent bifid cingulae with deep stained fissures were apparent on the palatal aspects of both maxillary right and left central incisors. White spot lesions were visible in the invagination and around the tubercle ().
+A periapical radiograph showed a ???shaped radiopaque structure superimposed on the affected crowns, with the ???pointing towards the incisal edge. In addition, periapi-cal radiograph revealed an invagination lined by enamel, adjacent to the tubercle indicating probable Oehler? type I invagination in 22. Radiographically no evidence of associated pathosis was found ().
+The treatment plan consisted of oral hygiene instructions, restoration of carious teeth, and prophylactic restorative procedures in the maxillary central incisors and lateral incisors. The prophylactic treatment consisted of selective grinding of extra cusp with flare-shaped diamond bur under water coolant using high-speed hand piece at 3-month intervals.
+Each grinding session was followed by the application of a desensitizing/remineralizing agent with 0.2% fluoride (GC Tooth mousse plus, Recaldent, GC Co. Japan), to the surfaces of reduced cusp, after polishing, to reduce dentin sensitivity. The treatment lasted 12 months, during which preventive measures to caries were followed regularly.
+Invasive sealing of the cusp-tooth intersection in incisors was planned. After prophylaxis of affected teeth, ameloplasty was performed on the grooves/fissures near the bifid cingulum using carbide bur in a high-speed hand piece and were then sealed with an acid-etch flowable composite resin to avoid penetration of irritants and microorganisms into the invagination (). After 18-month follow-up period, the tooth was still asymptomatic and responded normally to vitality tests. Patient is under regular clinical and radiographical re-evaluation to assess the occlusion and the progress of pulp recession."
+Naomi Hogan,40,1994/2/15,001-779-430-5125x30113,grobinson@example.net,4458 Solis Terrace,"A 6-year-old female presented for a routine dental examination. Her medical history was noncontributory and extraoral examination did not reveal any abnormalities. On intraoral examination, the left maxillary deciduous lateral incisor (62) was slightly mobile and revealed an extra cusp which extended from CEJ halfway to incisal edge, at right angles to the mesiodistal surface of the tooth crown on the lingual surface resembling an eagle? talon, suggesting dens evaginatus. The cusp measured 2 to 2.5 mm in length (inciso-cervically), 1 to 1.5 mm in width (mesiodistally) and about 2 to 2.5 mm in thickness (labiolingually) approximately ().
+She was born out of consanguineous marriage and family history was free of similar dental abnormalities. A periapical radiograph of 62 revealed a radiopaque structure superimposed on the crown. Further, the unerupted left maxillary permanent lateral incisor presented an invagina-tion like appearance lined by enamel with possible aspect of Oehler? type I dens invaginatus. Additionally, an unerupted supernumerary lateral incisor (supplemental type) was noticed mesial to 62. No evidence of any periapical pathosis was evident radiographically ().
+There were neither esthetic concerns nor clinical signs of any problems associated with deciduous maxillary lateral incisor. So no immediate dental intervention was advised and the patient is under regular follow-up."
+Sonny Villalobos,39,1985/6/11,001-406-801-8702,gallegosdavid@example.net,843 Huffman Fords Suite 714,"A 28 years old male, the first kid/sib of healthy parents with consanguineous marriage admitted to Hasheminejad hospital with hypertension, lower extremities edema, and high serum creatinine level. Past medical history was remarkable for hyperuricemia and gout. On admission the blood pressure was 160/90 and pitting edema of both lower limbs was found, other organs were otherwise normal. On sonographic examination right kidney was 114 mm and contained a thick wall cyst measured 23 ? 24 mm and left kidney was 90 mm, with increased cortical echogenicity in the cortex of both kidneys. Doppler sonographic findings were RI=0.65 in right and 0.7 in left kidney.
+In the family history, his father and mother were cousins, his elder brother was diagnosed with gout and renal failure at age 33, and other positive findings were hyperuricemia and renal stone in his two cousins. Laboratory examination was as follow:
+Due to renal failure and normal kidney size, a renal biopsy was done, which revealed advanced glomerulosclerosis in focal and segmental pattern, severe tubular atrophy and proportional fibrosis mostly secondary and mild to moderate arterionephrosclerosis ().
+We proposed Familial juvenile hyperuricemic nephropathy as the most possible diagnosis for this patient with respect to clinical manifestations, paraclinical findings, and family history, which led us to perform genetic study to confirm the diagnosis. Sequencing analysis showed that the patient is homozygous for a novel nonsense mutation, c.589G>T; p.E197X, in exon 3 of the UMOD gene (). This confirms and interprets his involvement in familial juvenile hyperuricemic nephropathy."
+Zoya Cano,21,2001/12/2,(202)312-4187,alan78@example.net,469 Dunlap Rapid,"An 86-year-old caucasian woman presented with Stage-IV colorectal cancer. The patient agreed to participate and was explained the nature and objectives of this study, and informed consent was formally obtained. No reference to the patient's identity was made at any stage during data analysis or in the report. The patient had a large, undifferentiated tumor at the splenic flexure along with liver metastasis. She underwent resection of the primary tumor due to an impending obstructing tumor. Because of her advanced age, it was decided to proceed with monotherapy consisting of capecitabine only. A pre-treatment genetic testing for capecitabine consisting of thymidine synthase (TYMS) and dihydropyrimidine dehydrogenase (DPD/DPYD) analysis was performed that showed intermediate risk for 5-FU and related agents' toxicity.Therefore, capecitabine was initiated at a low dose (500 mg BID) and then gradually increased to a maximum dose of 1500 mg/m2/day for two-weeks-on and one-week-off schedule days = 1 cycle). She tolerated it well except mild intermittent diarrhea (Grade 1) and Grade 1 HFS manifested as erythroderma on the palms of both hands and later some dry desquamation of limited duration which promptly resolved when capecitabine was held. Her restaging imaging including a PET-CT scan showed a good response in the liver metastasis. All of her symptoms resolved when capecitabine was discontinued.
+After a few months of treatment with capecitabine, she noticed 'dry skin with itching' had developed for which she saw a dermatologist. Subsequently, she also developed a progressive cough and shortness of breath, hoarseness, mild hypertension, and symptoms of gastroesophageal reflux disease (GERD) manifested as heartburn with reflux symptoms. During that period, she was evaluated by a multi-disciplinary team comprising of a pulmonologist, rheumatologist, ear-nose-throat (ENT), and gastroenterology in addition to her oncologist. Pulmonary fibrosis was noticed on the CT scan of the chest. In addition, she also developed a new onset renal dysfunction during that period.
+Anti-nuclear, anti-centromere, antibodies to Smith antigen, antibodies to ribonucleoprotein, and anti-scl 70 antibodies were all negative. However, complement fixing antinuclear antibodies (C-ANA) on HEP-2 cells showed higher titer (320) with speckled pattern and C-ANA/ANA titers ratio of 320/40. A C-ANA with such a pattern and C-ANA/ANA titers ratio is suggestive of systemic sclerosis or one of the other diseases in group A of systemic connective tissue diseases. Moreover, a skin biopsy was performed. A biopsy with surface dimensions of 2.5 mm x 2 mm was reviewed from the upper right wrist skin lesion. For the C+DIF test, a fresh source of complement was added to the biopsy sections followed by fluorescein-labeled antibodies to the C3 component of the complement. This biopsy included skin of the epidermis and dermis with no structural deformities. Direct immunofluorescent studies of the skin biopsy specimen showed granular focal deposits of fibrin at the dermal-epidermal junction and deposits of IgG, IgA, IgM, fibrin, and trace C3 in the connective tissue fibers to the epidermal nuclei. These positive C+DIF reactions and serum results are consistent with or at least suggestive of systemic scleroderma or another 'group A' systemic connective tissue disease.
+She was placed on nifedipine, aspirin, lisinopril, and omeprazole. She was also started on cyclophosphamide treatment at the starting dose of 500 mg and then dose escalated to 700 mg and finally to 900 mg as tolerated per her Rheumatologist's recommendation []. She did not tolerate the 900 mg of the third cycle; therefore, the dose was decreased back down to 700 mg, and she completed six cycles of treatment. Cyclophosphamide was stopped and replaced with mycophenolate mofetil (MMF) at a dose of 0.5 g per day to a maximum of 2 g per day []. Her dyspnea resolved with treatment with mycophenolate. Her lung function also improved and eventually normalized. She was tapered off of mycophenolate after 23 months of therapy. Six months after cessation of mycophenolate, her lung function remained stable."
+Terry Acosta,25,1980/8/20,909.683.0990,deborahbryant@example.com,6671 Braun Mills,"A 73-year-old woman presented with nausea, increasing confusion, ataxia, and mechanical falls. MRI imaging revealed a 6.4 x 4.3 x 3.8 cm multilobulated fluid collection in the supracerebellar cistern and quadrigeminal cistern consistent with a complex arachnoid cyst (Figure ). The patient agreed to participate and was explained the nature and objectives of this study, and informed consent was formally obtained. No reference to the patient's identity was made at any stage during data analysis or in the report.
+Because she had symptomatic hydrocephalus due to the mass effect of the arachnoid cyst, an external ventricular drain was placed into the right lateral ventricle at the time of admission. She was then taken for definitive surgical treatment with decompression and fenestration of the cyst through a superior cerebellar approach as described in detail below. She tolerated the procedure well and post-operatively recovered in the intensive care unit. Her symptoms resolved, and after a cisternogram confirmed that the cerebral aqueduct was patent with good fenestration of the arachnoid cyst (Figure ), the external ventricular drain was removed on postoperative day two.
+The patient did well, symptoms resolved, and on postoperative day eight she was discharged in good condition."
+Kaia Stein,34,2004/1/25,(959)410-9710x7235,jacksonnoah@example.com,66581 Christopher Brook,"The patient was a 41-year-old widowed male at the time of screening who started drinking at age eight and progressed to become a regular drinker by age 16. At screening, he reported heavy drinking for the last ten years and had a positive family history of alcoholism. He reported excessive drinking (one-two pints of hard liquor daily, [8.5 - 17 drinks]) after a major life event occurred as the death of his spouse (approximately eight months prior to admission). His BMI was 22; he reported heavy smoking (one pack daily), and recent involvement in unsafe lifestyle practice. He showed confirmatory signs of alcohol use disorder with withdrawal symptoms during the psychiatric evaluation. Patient also reported that he was never tested positive for viral infection or taken medication for its treatment during intake. This patient was diagnosed with positive HCV and HIV viral tests during the screening. HCV RNA IU quantification was at 8,920,000 with genotype 1A. HIV infection was detected based on both the criteria for confirmation for HIV infection as developed by the Center for Disease Control; with HIV-1 Ab detection, and western blot assay at viral load of >50. His sCD4 count was 210, which put him in the category 2 according to the CD4+ T-Lymphocytic classification. The test was reconfirmed with western blot band with second positive test at bands p24, gp41, and gp120/160. There was no other remarkable systemic observation and he was not diagnosed with any other relevant medical condition, other than the discussed drug abuse and viral infection. This patient presented asymptomatic conditions of HIV infection (resembling criteria for ?linical category A??.
+This patient presented with a remarkable liver injury profile (), with all the liver injury markers showing above the normal values. In co-infected HIV+HCV cases, even with severe liver fibrosis and cirrhosis, 10% to 25% patients have shown normal alanine aminotransferase (ALT) levels []. Therefore, this case seems to show added severity in liver injury due to heavy alcohol drinking. Also, clinically relevant complete blood count (with differential) was identified at low hemoglobin (13.3, normal: 13.7 - 17.5 g/dL), hematocrit (37.2, normal: 40.1% - 51.0%) and MCV (78.6, normal: 79.0 - 92.2 fL) levels showing suppression of blood cell production this state of the infection. Ferritin was identified as high, 408 (26 - 388) as is generally observed in infections. Abnormal levels of leucocytes (WBC: 146/mcl; normal 0 - 25) were present and specific subtypes namely monocytes and lymphocytes [] as shown in . In this patient, fatty acid panel tested with blood (plasma) specimen showed that linoleic acid was the only PUFA that was abnormally high at 3957 nmol/mL (normal range: 2270 - 3850) that has shown important role in liver injury []. Both HCV and HIV cause dysregulation of lipid metabolism, especially in polyunsaturated fatty acids (PUFAs) []. We also evaluated the ?-6/ ?-3 ratio, which was 18 (Total ?-3 was 0.3; and Total ?-6 was 5.4, units mmol/L) in this patient supporting significant increase in the pro-inflammatory shift []. Triene Tetraene ratio was at the lower margin at 0.01 (normal range: 0.010 - 0.038). No other clinically significant change was observed in the FAs involved in inflammation; or in the lipid panel. Immunoglobulin panel at this point was not abnormal. Patient received adequate medical management for alcohol withdrawal during the screening process [] and was referred for infectious disease specialty."
+Creed Alexander,31,2000/4/27,967.496.5647,ronaldatkins@example.org,0484 Bryan Branch Apt. 604,"A 30-year-old otherwise healthy female presented with the sudden onset of headache and subsequent obtundation. Upon arrival to our emergency department, her airway was secured with endotracheal intubation. Initial vital signs revealed bradycardia. The Glasgow coma scale score on admission was a 4T, as the patient had decerebrate posturing. Her eyes deviated downward with non-reactive, pinpoint pupils. Informed consent was waived due to the patient's neurological presentation. A CT scan of the head revealed a calcified lesion in the right cerebellar cortex with an acute intralesional hemorrhage and adjacent subdural hematoma. Effacement of the fourth ventricle with associated obstructive hydrocephalus was also noted (Figure ).
+An emergent right frontal external ventricular drain was placed in the emergency department as a temporizing measure. The opening pressure was over 30 cm H2O (Figure ).
+A CT angiogram of the head and neck to rule out underlying vascular lesions was unremarkable. The patient was then taken to the operating room for surgical decompression. A paramedian suboccipital craniotomy was performed on the right side. The dura was opened and a subdural hematoma was quickly encountered and evacuated. An intra-axial cerebellar tumor rapidly presented as the dissection proceeded and a significant amount of intratumoral hemorrhage was noted. A gross total resection was undertaken (Figure ).
+A very small amount of tumor was purposefully left on the brainstem in an effort to avoid significant morbidity from an injury to the lower cranial nerves and the vertebral artery branches that were involved within the tumor. Final pathology of the tumor revealed a pilocytic astrocytoma (Figures -).
+The patient was following commands on the first postoperative day and was extubated a few days later. Postoperative neurological assessment revealed bilateral sixth cranial nerve palsies, right sensorineural hearing loss, and gait ataxia. The external ventricular drain was weaned and removed without any need for permanent CSF diversion. She was transferred for acute rehabilitation and was eventually discharged home with significant clinical improvement. At her one-year follow-up, she had minimal residual brainstem and cerebellar deficits. Adjuvant radiation therapy was considered, but the radiation oncologist felt that the risks of radiation therapy were not justified. She was able to walk independently and eventually return to work. Three years after her initial presentation, the patient got married and had a child via Caesarean section. During the postoperative period and during her pregnancy, her residual tumor has remained stable and no further episodes of hemorrhage or growth have been noted. Some of her symptoms, such as ataxia, got worse when she was pregnant but improved after delivery of the child."
+Lyla Lee,42,1982/2/20,+1-910-541-9064x95705,mcgeemike@example.org,95010 Brewer Cliff Suite 444,"A 45-year-old woman presented with a 13-month-history of pain and swelling in the anterior aspect of the right elbow. There was no history of trauma or any other exacerbating factor. She had been taking analgesics for last nine months due to intermittent pain which affected her ability to use the dominant elbow.
+Local examination revealed a 3 cm x 3 cm soft tissue swelling on the anterolateral aspect of the elbow, which was tender on palpation. The swelling was mobile in all directions. Elbow range of movement was from zero degrees to 125 degrees. There was no associated erythema around the elbow and over the swelling.
+The MRI showed a multiseptate fluid collection measuring 1.73 x 1.32 cm on the lateral aspect of cubital fossa anterior to the radio-capitellar joint space possibly communicating with it showing T1 hypo and T2/STIR hyperintense signals. Anteriorly it was burrowed into the brachioradialis muscle (Figure , ).
+This symptomatic swelling was excised through an anterolateral approach to the elbow joint [], after making a plane between brachialis and brachioradialis. A cystic swelling of about 2 cm x 2 cm in size was found (Figure ).
+It was carefully isolated from the surrounding soft tissues and excised en-masse. The stalk of the lesion was found to be originating from the radio-capitellar joint (Figure ).
+The rent in the capsule was then closed with an absorbable Vicryl 3-0 suture (Figure ).
+The excised lesion was sent for histopathological examination, which confirmed the diagnosis of a ganglion cyst.
+Written consent was obtained from the human subject who participated in this case study. Institutional Review Board of Indraprastha Apollo Hospital, India approved the research for this case."
+Jack Huang,38,1981/1/22,7419814785,taylor61@example.org,9064 Debra Port Suite 056,"An 18-year-old female patient was presented with a slowly growing, painless swelling at the lateral aspect of left ankle since four months. There was no other significant contributing history. Local examination revealed a well-defined bony hard swelling (7 cm x 4 cm) which was nonadherent to the overlying skin. The ankle and subtalar joints had full range of painless movements.
+Plain radiographs revealed a multi-loculated, expansile and well-defined lesion involving the lower end of fibula mimicking a soap bubble like appearance (Figure ).
+The radiographic findings were suggestive of a GCT. A Computed Tomogram (CT) confirmed the presence of a large lesion in the distal fibula with no cortical breach with preserved ankle mortise (Figure ).
+An extensive curettage of the tumour along with chemical cauterization was done using phenol (Figure ).
+The bone defect was reconstructed using a tricortical iliac crest autograft (Figure ) and fixation was done with a 3.5 mm (8 holes) reconstruction plate. Two screws were passed through the syndesmosis to augment it. The lateral fibular wall containing the tumour was excised, preserving the medial wall (with syndesmosis) and lateral malleolar articular surface.
+She was mobilized nonweight bearing, with crutches, with a below knee cast for 3 months, until the bone graft got incorporated. The histopathological features showed multinucleated giant cells (Figure ) which were suggestive of a diagnosis of GCT. There were regular and uniform distribution of stromal cells and giant cells. The stromal cells are mononuclear, resembling macrophages while giant cells are large, multinucleated (10-50 nuclei) with similar nuclei as stromal cells, resembling osteoclasts.
+At 18 months follow-up, there was no evidence of local recurrence, with a full range of pain-free movements of ankle and subtalar joints (Figure )."
+Francesca Collier,39,1980/3/30,431-494-3589,david24@example.org,24719 Reyes Gardens,"Patient A, a 5-day-old infant female, 2.2 kg, born prematurely at 35 weeks gestational age, was transported to an outside hospital emergency room via emergency medical services following an apneic event at home that resolved after the administration of a few rescue breaths by the mother. Upon presentation to the emergency room, the patient demonstrated stable vital signs and was subsequently transferred to our pediatric intensive care unit (PICU) for respiratory monitoring and diagnostic workup for the cause of the apneic event. Upon arrival to the PICU, the patient was vigorous, crying, and tachypneic, but, otherwise, with relatively normal vitals signs (HR 145, BP 77/44, 97% on 1 LPM NC O2). Given the patient? age and history of apnea, a workup to rule out serious bacterial infection was initiated. Basic labs were sent, and a lumbar puncture was completed showing 20 WBC/弮L (2,030 RBC/弮L) with 33% neutrophils. Broad-spectrum antimicrobials were initiated including ceftriaxone (50 mg/kg/dose prior to arrival to PICU), acyclovir (60 mg/kg/day), and ampicillin (400 mg/kg/day). Initial labs were significant for thrombocytopenia (platelets 39,000/弮L) but without any other cytopenias (Hgb 17.1 g/dL, WBC 8,760/弮L).
+At hour 6 after admission, the patient rapidly decompensated and developed lethargy, respiratory failure due to apnea, and was intubated and mechanically ventilated. At hour 10 after admission, additional laboratory testing revealed very elevated liver transaminases (ALT 2,214, AST > 7,500), severe coagulopathy (PT > 120, INR > 16.6, PTT > 200) and a ferritin of 241,000 ng/mL (result verified with duplication). The patient? triglyceride level was 41 mg/dL, and serum lactate level at this time was significantly elevated at 14 mmol/L.
+At hour 18 after admission, the HSV PCR from CSF returned positive for HSV-2, and the C-reactive protein (CRP) was elevated (2.09 mg/dL). We made the preliminary diagnosis of HSV-associated hemophagocytic lymphohistiocytosis (HLH) based on a similar case report (). The patient? respiratory and hemodynamic profile continued to deteriorate (Figure A) in spite of escalating vasopressor support (Figure B), and the patient needed repeated fluid boluses of colloid (5% human serum albumin in NS) and blood product administration (Figure C) to maintain mean arterial pressure (MAP) of at least 40 mmHg. At this time, 30 mg/kg methylprednisolone was administered to ameliorate the inflammatory process and, with the addition of norepinephrine, the patient stabilized transiently, and we were able to wean the epinephrine support slightly (Figure B).
+At hour 30 after admission, the patient again became unstable and required repeated volume resuscitation in the form of colloid fluid boluses to maintain the MAP goal of 40 mmHg, and then, even this MAP goal became unobtainable. After long discussion with the parents, it was decided that recovery was unlikely and technological support was withdrawn. The parents agreed to an autopsy, and the report stated that ?he presence of hemophagocytosis was demonstrated with the bone marrow and spleen exhibiting large cells containing particles consistent with ingested, disintegrating blood cells. Given that diagnostic guidelines for HLH designate bone marrow, lymph node, and spleen as the organs, which most reliably show the histologic features, and secondary HLH can be triggered by systemic infection, as this patient had, the findings post-mortem supported a diagnosis of HLH.??,[[5.0"
+Edison Arroyo,32,1986/2/10,4726007373,nancybolton@example.org,95438 Ramsey Path,"Patient A, a 37-year-old healthy male, underwent open reduction and internal fixation (ORIF) of an open fracture of his right distal tibia and fibula 22 years ago. This was complicated by posttraumatic osteomyelitis and resulted in multiple re-operations with debridements of the bone, removal of most hardware and free flap coverage of a soft tissue defect. He was referred to our hospital with a persistent clinical infection around his right distal tibia and a near wound breakdown of the scar. Medical imaging was requested (a) to confirm the diagnosis of osteomyelitis and (b) to determine the anatomical location of the suspected osteomyelitis.
+First, according to the diagnostic imaging protocol in our hospital, a three-phase bone scan was performed since the fracture and surgery were >2 years ago. All three phases of the bone scan were positive, only the late phase (Fig. , g: anterior view, h: lateral view) is presented here. This increased osteoblastic uptake can be the result of an infection, but also due to a healing fracture or recent surgery. For further differentiation, the patient underwent a WBC scan (Fig. , a?: images after 4 h, e?: images after 24 h). This showed increased uptake in both intensity and size over time, suspect for an infection. To localize this accumulation of leukocytes a SPECT-CT was performed (Fig. ) which revealed that the uptake was located outside the bone, in the soft tissue. Final diagnosis was a soft tissue infection."
+Kyra Brewer,25,1996/3/14,521.803.9232x491,uwashington@example.net,36722 Jay Islands,"Patient B, a 46-year-old schizophrenic but otherwise healthy male sustained an open and comminuted talar neck fracture after a fall from height. This was initially treated with multiple soft tissue debridements and an external fixation, later augmented with screw and K-wire fixation of the fracture. The soft tissue defect was closed with a local myocutaneous flap. Two months after this last procedure, the patient presented with a draining sinus in the scar on the lateral side of the ankle joint. Medical imaging was requested to (a) assess the viability of the talus and (b) to determine the anatomic location of the suspected osteomyelitis. The X-ray is shown in Fig. (left image).
+To answer question (a) a three phase bone scan was performed. The first phase (flow phase) is shown in Fig. (upper row images): positive flow at the talar region of the left foot. Obviously also the second phase (blood pool phase, middle image lower row) and the late phase (combined with CT image, right image lower row) are positive. This means the bone is viable. However, differentiation between infection or healing fracture is not possible. Therefore, WBC scintigraphy was performed (Fig. , upper row: images after 4 h, lower row: images after 24 h). The uptake decreased in time, meaning that the leukocyte accumulation is the result of a healing fracture and not of an osteomyelitis. After proper wound care further healing was uneventful."
+Cruz Cox,34,1996/9/4,001-531-735-2603,slee@example.net,2480 Taylor Estate Suite 218,"Patient C, a 33-year-old healthy male was referred to our hospital because of a suspected posttraumatic osteomyelitis in combination with a malunion of his left tibia. He sustained a gunshot wound to his left lower leg in the middle east conflict 2 years prior to this presentation which was treated with a prolonged immobilization in an external fixator combined with several wound debridements. The last operation was only a few months prior to presentation. On examination, apart from the obvious malalignment of his left lower leg, we noted a closed but unstable scar on the medial side of his left tibia. Medical imaging was requested to (a) confirm the diagnosis and (b) to determine the anatomic location of the suspected osteomyelitis.
+Since his last surgery was <6 months ago, immediately a WBC scan was performed (Fig. , left image: anterior view after 4 h, right image: anterior view after 24 h): uptake is visible at three locations. When calculating the ratios (uptake focus-to-contralateral side) the uptake at the most proximal and most distal focus decreases in time. This means these uptakes are due to regeneration of bone marrow. However, the uptake at the middle focus increases in time, which is suspect for an infection. The SPECT-CT (Fig. ) shows the uptake in the bone and a small fistula to the bone marrow. Indeed, surgery revealed an infection at this location."
+Sadie Mullins,36,1983/8/17,6117760677,oturner@example.net,1678 Mark Course Apt. 775,"A 56-year-old female presented to the emergency room with a three-day history of right hip pain. She reported decreased range of motion and difficulty ambulating. She denied constitutional symptoms or fever. She had undergone intra-articular steroid injection of her right hip three days prior. Review of systems was otherwise unremarkable. Her past medical history was relevant for hereditary spherocytosis with splenectomy at age 14 and chronic right hip osteoarthritis. Her only medication was celecoxib as needed. She denied any drug allergy. She was unaware of her immunization history. She worked as a flight attendant, denied smoking or recreational drug use, and had not recently travelled outside of Canada. On initial examination she was afebrile and her vital signs were within normal limits. On examination of her right hip she had limitation of internal rotation with reproducible pain, but her physical exam otherwise was unremarkable. Her initial investigations showed elevation in C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) at 22.9 mg/L and 25 mm/hr, respectively. Her white blood cell count was not elevated. An X-ray of her right hip showed severe joint space narrowing with osteophytosis consistent with severe osteoarthritis. Arthrocentesis was performed and synovial fluid samples were directly inoculated onto solid culture media, including blood agar and chocolate agar. Two of three samples also underwent cytospin centrifugation and direct Gram stain. Gram-negative bacilli were observed in one sample though heavy neutrophils were observed in both. Synovial fluid analysis for cell count and chemistry was not performed due to insufficient sample. She was admitted to hospital for 24 hours of observation and was subsequently discharged with instructions to return to hospital if her symptoms worsened or if cultures subsequently grew a pathogenic organism.
+Three days later she was seen in a follow-up clinic. In the interim she had developed a fever (38.3簞C), had chills, and had worsening right hip pain. Repeat physical examination showed deterioration in range of motion at her right hip with significant pain. Cardiovascular examination was unremarkable with no appreciable murmur. Synovial fluid cultures from the initial arthrocentesis were now growing Haemophilus parainfluenzae with colonies observed on solid media within 24 hours of inoculation. She received one dose of ceftriaxone and subsequently underwent right hip arthrotomy with synovectomy and irrigation. The Infectious Disease service was consulted the following day. The organism was susceptible to ceftriaxone and cefuroxime and resistant to ampicillin and ciprofloxacin (). Blood cultures and intraoperative tissue cultures did not demonstrate growth, likely due to the administration of antibiotics prior to collection. The patient was treated with intravenous ceftriaxone and was subsequently discharged with outpatient follow-up for home intravenous antibiotics. Ongoing pain, difficulty ambulating, and persistently elevated inflammatory markers necessitated a prolonged, nine-week course of antimicrobial therapy (). At the time of treatment discontinuation, she reported pain and her functional ability had not yet returned to baseline. She is currently awaiting evaluation for total hip arthroplasty."
+Allen Kirby,23,2001/9/20,(381)301-4994,harry07@example.com,30186 Miller Grove Apt. 377,"A 58-year-old male presented in the summertime with fever, generalized weakness, and encephalopathy after being found unconscious. Upon arrival to the hospital, he was disoriented to place and time, dysarthric, and amnestic to details of the event. Review of systems was positive for one week of progressive gait instability but negative for any other preceding or ongoing infectious or neurologic symptoms. He had no recent travel or exposure to sick contacts.
+Seven months prior to his presentation, the patient had been diagnosed with a poorly differentiated neuroendocrine carcinoma, which presented primarily in his parotid gland. He had completed seven cycles of chemotherapy, with the last cycle given two weeks previously. Two months earlier, he had developed numerous asymptomatic brain metastases. A whole-brain radiation therapy was recommended for him; however, he declined. Other chronic medical problems included a history of prostate cancer in remission, dyslipidemia, and hypertension. He also had a history of ?isual seizures??for which he was taking daily antiepileptic medication.
+On presentation, the patient was somnolent but arousable. His vital signs revealed that he was febrile (temperature of 102.4 F) and tachycardic (heart rate of 126), blood pressure was 150/105 mmHg, respiratory rate was 14, and oxygen saturation was 95% on 2 liters per minute nasal cannula. Cardiopulmonary and gastrointestinal examinations were otherwise unremarkable. On neurological examination, the patient exhibited a resting tremor in both upper extremities, which his family reported was new within the past few days. There was no evidence of tongue biting, urinary incontinence, photophobia, or nuchal rigidity. Muscle strength, tone, and deep tendon reflexes were normal and symmetric. Babinski signs were absent. Sensory examination was normal.
+Laboratory evaluation was significant only for mild hyponatremia (132 mmol/L) and elevated creatinine kinase (236 mmol/L). Tests for liver function, complete blood count, and urinalysis were unremarkable. Blood cultures and urine cultures were sent upon presentation and eventually revealed no growth. Urine drug screen was positive for cannabinoids only. Chest radiograph revealed no acute abnormalities. A noncontrasted head computed tomography was unremarkable with poor visualization of his known intracranial metastases. Initially, there was suspicion for an infectious etiology or progression of previously known brain metastases; therefore, the patient was started on empiric broad-spectrum antibiotics and systemic glucocorticoids for potential vasogenic edema until further diagnostic evaluation could be performed. His antiseizure medication was also continued.
+One day after presentation, the patient's mental status was remarkably improved, although not completely to baseline. The transient nature of his encephalopathy raised suspicion of a generalized seizure as the inciting event with resultant temporary postictal state. Given this, an electroencephalogram (EEG) was obtained, revealing mild-to-moderate generalized background slowing, indicating diffuse encephalopathy, without any epileptogenic foci identified.
+Two days after presentation, the patient remained febrile and tremulous; however, his cognition continued to improve. Because no definitive diagnosis had been reached and he continued to have unexplained fevers, a lumbar puncture was performed for further evaluation. Cerebrospinal fluid (CSF) studies revealed lymphocytic inflammation with an elevated glucose (84 mg/dL), elevated protein (89 mg/dL), and elevated total nucleated cell count (95/cumm), with a differential of neutrophils 8%, lymphocytes 53%, plasma cells 25%, and monocytes 14%. CSF Gram stain was negative, and cytology was negative for malignant cells. Herpes Simplex Virus-1 (HSV-1) and HSV-2 reverse transcription-polymerase chain reaction (RT-PCR) tests were negative, as was Cryptococcus neoformans antigen. CSF and serologic testing for West Nile Virus (WNV) IgM, IgG, and PCR was also ordered.
+Approximately one week after presentation, a final diagnosis of acute WNV encephalitis was made. Although CSF IgG and PCR for WNV were negative, the patient's serum and CSF WNV IgM were qualitatively positive, establishing the diagnosis of WNV neuroinvasive disease [, ]. Empiric antibiotics and steroids were discontinued. Brain magnetic resonance imaging was obtained, which revealed stable intracranial metastases compared to one month earlier. Over a period of several days, his mental status improved completely to baseline and his fever and tremors subsided. He did, however, continue to have significant diffuse weakness, presumably secondary to prolonged hospital stay and systemic glucocorticoids. The patient was eventually discharged to a subacute rehabilitation facility."
+Skyla Brewer,28,1988/4/19,(267)624-8590x64931,kayla15@example.net,430 Stephanie Wall Suite 020,"We present a 58-year-old female who presented to the emergency department with violent behavior and agitation. The patient had a history of bipolar affective disorder as per DSM-5/ICD-10 classification. According to medical records and collateral history from the patient's legal guardian, the patient was diagnosed with this mood disorder over 20 years ago due to repeated manic episodes which include irritability, labile effect, increased energy, and erratic behavior. Past medical history includes cellulitis, hypertension, hypothyroidism, and repeated urinary tract infections. The patient has a history of developmental delay with a diagnosis of intellectual disability. There was an absence of psychiatric illness in her family. During evaluation by the psychiatrist in the emergency room on admission, patient was clearly distressed, with her hair not groomed, and was slightly disheveled in her appearance. The patient was loud, yelling at the psychiatry and medical staff in the hospital, and was routinely uncooperative and belligerent. Patient was also clearly agitated which appeared in behaviors such as kicking and hitting the unit staff. There were no signs of psychosis, as the patient denied hallucinations in all sensory modalities and no delusions were elicited, and there was no evidence of disorganized thinking or paranoia. Her mood overall was angry and irritable, with a labile effect. At the time of examination, she was alert and oriented to person, place, and time. Due to her intellectual disability, she lacked judgment and had poor insight regarding her mental illness.
+Patient was admitted with acute mania to the inpatient psychiatry unit and was continued on her home dose of valproic acid (VPA) at 1000 mg PO twice daily as well as continuing her other home medications (atorvastatin 10 mg PO at night, levothyroxine 175 micrograms PO once daily, and metoprolol 12.5 mg orally PO twice daily). It should be noted that the patient has been on VPA for over 10 years for treatment of her bipolar affective disorder, and her therapeutic levels and dosages are monitored by her outpatient psychiatrist. The high dose of her valproic acid is due to many years of outpatient psychiatry evaluation and titration of the dose to a level that allows for the patient to attain mood stability. Admission laboratory tests were all within reference range (CBC, BMP, and LFTs) and she had VPA level of 58 弮g/mL (therapeutic range: 50 to 100 弮g/mL). EKG showed slight sinus tachycardia, HR: 108.
+During her admission, patient had episodes of severe agitation and her behavior was very unpredictable but was eventually controlled through psychotherapy and group therapy while being an inpatient. Patient was also encouraged to be compliant with her pharmacotherapy, particularly her mood stabilizer medication valproic acid. According to medical records, patient had a history of high ammonia levels on previous admissions, and therefore VPA levels and ammonia were monitored during the course of her hospital stay (Tables and ).
+In the morning of day 51 of admission, patient was examined on the daily ward round. She was alert and oriented to person, place, and time and consciousness indicated that she was very much awake and aware of her surroundings, with no signs of altered consciousness. Patient was calm and cooperative during the psychiatric interview, with her appearance being well groomed. Her speech was of normal rate, rhythm, tone, and volume. There was no evidence of psychosis, and the patient appeared to be relatively euthymic with a full and congruent affect. Thought process was linear and thoughts were logical. Her judgment was still relatively poor and she had poor insight, but this was attributed in part to cognitive deficits. She had no neurologic deficits peripherally, and all cranial nerves were grossly intact. Lower extremity deconditioning secondary to lack of use had been an ongoing issue for over one year. Gait could not be assessed as she is nonambulatory but no abnormalities or deficits were present in her upper body chronically, and the patient had a Glasgow Coma Scale Score of 15 (Eyes: 4, Verbal: 5, and Motor: 6). Conclusively, patient elicited no clinical concerns from a neurological standpoint and therefore no clinical signs of encephalopathy or delirium.
+Laboratory testing revealed an ammonia level of 225 弮mol/L (reference range: 10??0 弮mol/L) and VPA level of 117 (reference range: 50??25 弮g/mL). According to routine laboratory protocol, 0.5 mL of blood had been taken from the patient and transferred into a heparinized vacutainer and placed immediately on ice (for ammonia level). The specimen was transferred to the lab within 15 minutes of collection from the patient. Based on the Naranjo score of 9, it is reasonable to conclude that the elevated level of ammonia was secondary to VPA therapy []. Liver functions tests were within normal limits, congruent with her baseline. It was decided to treat the hyperammonemia with lactulose 20 grams orally twice a day as per standardized protocol, as she had 2 previous episodes of high levels of ammonia during her admission that resolved with the same dosing of lactulose (20 grams PO twice daily). Levocarnitine 990 grams PO three times daily was also started. More importantly, valproic acid was not discontinued since the patient reported no symptoms of valproic acid toxicity or hyperammonemia, as she was cognitively and neurologically intact.
+After dual treatment with carnitine and lactulose, the patient's ammonia levels soon began to decline, from 225 弮mol/L to 163 弮mol/L to 27 弮mol/L within 2 weeks. The patient's dose of VPA did not change and she continued to receive this medication. During the course of these events, the patient did not develop any clinical signs or symptoms of hyperammonemia and remained stable neurologically and psychiatrically."
+Cruz Walls,32,1993/7/17,(410)672-0376x885,sandersashley@example.com,63095 Murray Tunnel,"A 35-year-old African American female with no prior history of coronary artery disease and no significant family history presented with sudden onset of exertional chest discomfort with radiation to the back. The patient became unresponsive shortly after arrival to the emergency department and was subsequently found to be in ventricular fibrillation-cardiac arrest (V-fib). The patient was in V-fib for 6 minutes, with conversion after electrical cardioversion and subsequent development of PEA-arrest for a total of 4 minutes. Repeat EKG after return of spontaneous circulation demonstrated inferolateral STEMI (). The patient received tenecteplase and heparin prior to urgent transfer to the catheterization laboratory. Left heart catheterization showed 99% thrombotic occlusion of mid-distal LAD (Figures and ). Two overlapping drug eluting stents (Xience RX 2.5 mm and Xience RX 2.75 mm) were placed in the distal LAD, and TIMI III flow was achieved (). Due to severely decreased ventricular function with ejection fraction of 10??5%, the patient received ventricular support with an Impella, with discontinuation soon after secondary to hemolysis. Further evaluation revealed positive toxicology screen for amphetamines. Pertinent laboratory results for possible autoimmune causes of the acute myocardial infarction were negative, including antinuclear antibody (ANA), ribonucleoprotein antibody (RNP), RA latex turbid, anti-chromatin IgG antibodies, SSA (Ro) and SSB (La) antibodies, and double stranded DNA antibody (dsDNA).
+The patient's cardiac function recovered with medical management. Subsequent transthoracic echocardiograms revealed improved ejection fraction to 60??5% after 11 days and a new finding of left ventricular apical thrombus. The patient received anticoagulation with intravenous heparin, as well as continuous treatment with dual antiplatelet therapy with aspirin and clopidogrel.
+The patient remained in the coronary care unit (CCU) for a total of 17 days. CCU course was further complicated by development of pulmonary edema with diffuse alveolar hemorrhage and developing MRSA and pseudomonas pneumonia.
+Due to the need for prolonged mechanical ventilation, the patient received a tracheostomy and continued to improve in terms of her pulmonary function while treated with antibiotics for ventilator-associated pneumonia. Her neurological status improved significantly, and on interview, she denied any use of Adderall, amphetamines, or illicit drugs that could have precipitated this event. She reported that recently she had increased her level of physical activity in order to lose weight and was supplementing such efforts with the addition of a natural weight loss dietary supplement."
+Lilianna Vasquez,38,1979/7/8,703-433-5199x803,elizabeth35@example.org,2418 Daniel Canyon,"A 43-year-old man with a past medical history of HIV, bipolar disorder, and epilepsy was admitted to the neurology service for a video electroencephalogram (vEEG) to characterize syncopal episodes that were felt to be epileptic in origin. These episodes started about ten years priorly and were associated with a preceding aura followed by loss of consciousness. He described this aura as a numbness that spread from head to toe and left him unresponsive for several minutes. He denied posturing, incontinence, eye deviation, tongue biting, or clonic activity during the events. He reported postevent disorientation and lethargy lasting from several hours to a full day. He had been on multiple antiepileptic medications without resolution of his episodes.
+On examination, the patient was an anxious appearing well-built gentleman with normal vital signs and normal cardiac and neurologic exams.
+During the vEEG, he experienced symptoms of his typical aura. Concurrently, his vEEG activity was normal, but his cardiac telemetry demonstrated pauses of up to six seconds (), reflecting a transient symptomatic high degree AV block. He was transferred to the cardiac care unit for close monitoring and temporary pacemaker placement. An MRI of the brain and neck showed a mass in the left posterior carotid space at the skull base (). The differential of this mass included a left vagal schwannoma or a lymph node in proximity to the vagus nerve.
+Neurosurgery declined surgical intervention, recommending Lamotrigine as seizure prophylaxis and serial MRIs to examine progression of the mass. The patient underwent permanent dual chamber MRI-compatible pacemaker placement for his heart block during the admission and was discharged with plans for outpatient follow-up.
+Follow-up MRI after 4 months revealed a stable left carotid space mass. The patient denied further syncopal episodes since pacemaker implantation. He did, however, endorse episodes of numbness, decreased vision, and change in alertness occurring nearly daily, for which he was advised to consult his cardiologist."
+Rowan Boyle,39,1997/12/3,540.766.6680x1856,nancyhoffman@example.net,6882 Gutierrez Green,"The patient was a 22 year old woman who was referred to the surgery ward early in the February 2014 from the orthopedic ward for multidisciplinary surgery. Patient had a mass in anterior thorax and clavicle, discovered 6 months earlier. It had grown steadily and was not painful at first but the patient complained of pain at the time of referral. She had no history of alcohol or drugs, nor did she have a history of smoking. She had no family history of known diseases.
+In examination, a large mass with the dimensions of 10*6 centimeters was discovered, taking up two thirds of the clavicle. Head, neck, heart, lungs, organs and the pulse were normal in physical examination.
+Needle biopsy
+The patient underwent core needle biopsy and was diagnosed as grade II chondrosarcoma.
+CT scan and MRI
+In CT scan and MRI, a 91*57*59 millimeters mass was observed, proximal. There was no metastasis ().
+Due to the tumor? situation and its proximity to neurovascular network, the patient was sent to Shariati Hospital's surgery ward to be operated on by a multidisciplinary team consisting of thoracic, vascular, orthopedic surgeons. Decision on surgical resection of the mass was made after a review meeting between the mentioned surgical team and oncologists.
+Pathology report
+Pathologic stage is definitely important in prognosis, grade I chondrosarcoma has low malignant nature while grade II and grade III chondrosarcoma are high malignant. Five year survival in grade I is 90%, it falls to 60% for grades II and III. In the aforementioned patient the chondrosarcoma was grade II ( and )."
+Aliya Sandoval,36,1992/6/25,879-974-0959,brandy97@example.com,1129 Paul Locks,"A 74-year-old woman underwent emergency replacement of the ascending aorta because of Stanford type A acute aortic dissection at another hospital. The entry of the Debakey type I aortic dissection was located in the middle of the ascending aorta, and extended distally to the distal abdominal aorta. The brachiocephalic artery and left common iliac artery were also dissected. Graft replacement of the ascending aorta was done, which were used by Teflon felt strip and GRF glue to reinforce the anastomosis of the dissection aortic wall. The post-operative course was unremarkable except for leg paresis that might have been due to spinal infarction caused by the dissection.
+She was diagnosed with a small cerebral infarction, jaundice and anemia 10 years later and admitted to our hospital. Blood tests revealed severe hemolytic anemia. The laboratory results were Hb, 7.3 g/dl; T. BIL, 4.06 mg/dl; and LDH, 3020 IU/l. Microscopy revealed fragmented red blood cells. No stigmata were found that could be associated with TTP or ITP. CT revealed severe stenosis at the proximal anastomosis of the inner felt strip and aortic intimal flap (Fig. ), which was one of two layers of Teflon felt strips positioned using the sandwich technique to reinforce the dissecting aortic wall. The pressure gradient at the site was not measured because it was impossible to insert a catheter. Transthoracic echocardiography (TTE) showed mosaic pattern in the felt flap of the ascending aorta although pressure gradient could not be measured (Fig. ). We thus considered that the cause of the hemolytic anemia was mechanical injury caused by disrupted blood flow and repaired the proximal anastomosis.
+The patient underwent a second operation. ECC was established via a median sternotomy with a cannula at the distal site of the ascending aortic graft and a two-staged venous cannula in the right atrium. A thrill was felt at the ascending aorta, and we cross-clamped the distal site-of the ascending aorta. We opened the prosthetic graft to explore the proximal anastomosis and found that the inner felt strip was turned up and that it had reduced the diameter of the inner lumen (Fig. ). We also identified local dissection and intimal flap of the proximal site of ascending aorta at non cusupid valve site (Fig. ). The proximal site of the graft, local dissection of the ascending aorta and the Teflon strips were removed, and the ascending aortic was replaced once again with a 22-mm graft that was directly sutured to the previous graft at the distal site of the ascending aorta. The patient was quite easily weaned from ECC and hemostasis achieved without difficulty.
+The postoperative course was uneventful, and no fragmented red blood cells or progression of anemia was observed. The serum LDH and T.BIL levels gradually returned to normal."
+Brantley Wilcox,29,1978/3/20,6974403953,cory30@example.org,2530 Williams Parkways,"A 17-year-old Asian male adolescent was admitted to our hospital with a chief complaint of sudden-onset fever and altered consciousness. He had a 6-month history of DM complicated by HLH controlled with corticosteroids (60 mg daily) and no obvious family, psychosocial, and genetic history. At the time of diagnosis (6 months prior to admission), heliotrope eruption was seen. A blood examination showed no evidence of myositis-specific antibody (anti-aminoacyl antibody). A muscle biopsy revealed lesions that were consistent with myositis; he met the diagnostic criteria of DM. A positron emission tomography-computed tomography (PET-CT) examination (Fig. ), bone marrow examination, and liver biopsy had shown no malignancy; therefore, his corticosteroid dose was gradually reduced to 8 mg daily. However, he experienced intermittent leg pain, and laboratory data showed a gradual elevation of creatine kinase (CK) levels and progression of leukopenia over the preceding 6 months; therefore, his steroid therapy was increased to 30 mg daily.
+On the day of admission, he was irritable, but there were no remarkable findings on physical examination. Laboratory data showed increased levels of CK (1869 U/L), soluble interleukin-2 receptor (4120 U/mL), and ferritin (967.4 ng/mL) and decreased counts of white blood cells (3910/弮L) and platelets (124,000/弮L). C-reactive proteins were hardly detected (0.01 mg/dL). We suspected exacerbation of DM and HLH. Active hemophagocytosis and no malignancy were observed on bone marrow examination. Brain magnetic resonance imaging (MRI) revealed multiple bilateral subcortical lesions (Fig. ). Systemic computed tomography (CT) did not show any evidence of interstitial pneumonia or malignancy. Cerebrospinal fluid (CSF) aspiration revealed the presence of 12 cells (nine neutrophils and 3three lymphocytes), glucose levels of 57 mg/dL, protein levels of 44 mg/dL, adenosine deaminase levels of 3.9 (>1) U/L, and interleukin-6 levels of 91.9 (>4.3) pg/mL. Polymerase chain reaction (PCR) analyses of his CSF showed no evidence of a recent infection with the Epstein?arr virus, cytomegalovirus, varicella zoster virus, human herpes virus 6, and herpes simplex virus. We could not perform a PET-CT examination on admission because of his altered consciousness. On the basis of the MRI findings, elevation of CSF interleukin-6 levels, peripheral blood cell count, and biochemistry results, and the hemophagocytosis observed in the bone marrow, we diagnosed the CNS lesions as leukoencephalopathy secondary to DM and HLH.
+The clinical course of our patient is presented in Fig. . Dexamethasone (DEX) pulse therapy (20 mg daily for 3 days) and intravenous immunoglobulin therapy (400 mg/kg/day for 5 days) were initiated on the day of admission to treat his CNS lesions. Methylprednisolone (mPSL; 60 mg daily) was administered post-treatment. His CK levels improved rapidly (from 1869 U/L on the day of admission to 287 U/L on day 14); however, his bicytopenia (leukopenia and thrombopenia) remained unchanged, and his CNS lesions were still observed. Therefore, cyclophosphamide pulse therapy was added on day 8. On day 24, a second bone marrow examination revealed that his hemophagocytosis remained, for which cyclosporine was started the next day. On day 28, the 60 mg daily mPSL was changed to 20 mg daily DEX because DEX diffuses to the CSF more easily than does mPSL. In addition, as his hemophagocytosis persisted, etoposide (120 mg/body) was started on day 38 and was administered once per week between days 38 to 89 (eight times in total). On day 47, tacrolimus was administered instead of cyclosporine to suppress hemophagocytosis because both drugs have the same effects and because of a severe liver function disorder due to cyclosporine (aspartate transaminase and alanine transaminase levels increased to 318 and 917 IU/mL, respectively). Subsequently, his bicytopenia (leukopenia and thrombopenia) recovered to within normal ranges, and his CNS lesions disappeared.
+He was administered sedative drugs to produce a state of calmness, to help him sleep, and to prevent acts of violence caused by his altered state of consciousness that lasted for 5 months. The medications were eventually discontinued because altered consciousness was no longer observed. However, disturbances of his higher cerebral functions remained. Five months after his initial admission, he could speak and walk like a very young child. Corticosteroid therapy was successfully tapered without a relapse of his symptoms (including fever and altered consciousness), and without changes in his laboratory and MRI findings.
+Eight months after admission, a follow-up brain MRI revealed a recurrence of the CNS lesions (Fig. ), although these recurrent lesions were different from the previous lesions, considering that there was no fever and no altered consciousness. Moreover, his laboratory findings were normal. We hypothesized that the pathology of the new CNS lesions differed from the pathology of the previous lesions and presumed that they were caused by progressive multifocal leukoencephalopathy or drug-induced (tacrolimus) leukoencephalopathy. However, a PCR analysis for the John Cunningham virus in his CSF (to diagnose progressive multifocal leukoencephalopathy) was negative, and no improvement in CNS lesions was observed when tacrolimus was discontinued.
+One month after the recurrence of the CNS lesions, his abilities to walk and speak deteriorated. A MRI revealed a progression of the CNS lesions; therefore, a brain biopsy of his right frontal lobe was performed on day 297. On day 325, a diagnosis of peripheral T-cell lymphoma (PTCL) was made based on the T-cell receptor rearrangement seen in the tumor cells of his brain specimen. Therefore, on day 330, chemotherapy combined with high-dose methotrexate and cytarabine was initiated. A follow-up MRI on day 345 revealed that his CNS lesions had increased in size, suggesting that the chemotherapy regimen was ineffective, and he died of sepsis on day 348.
+An autopsy revealed yellowish to brownish extended geographic lesions with softening, atrophy, and cavitation in the white matter of the frontal, temporal, and occipital lobes. Hepatomegaly (1910 g) and splenomegaly (205 g) were also observed. Microscopy of the cerebral white matter showed bilateral extended multiple liquefaction necroses (Fig. ). Infiltration of predominantly CD8(+) T cells undergoing dyskaryosis or mitosis was observed in the Virchow?obin space (Fig. ), bone marrow, liver, and spleen. The rearrangements of the TCR gene were confirmed by PCR of a brain specimen. Hemophagocytosis was observed in the spleen and bone marrow. On immunohistochemistry, no cells were positive for herpes simplex virus or John Cunningham virus, and Epstein?arr virus-encoded ribonucleic acid in situ hybridization was negative."
+Ashlyn Hancock,39,1978/2/15,909-377-2224x937,smayer@example.net,85062 Wheeler Points,"A 74 year-old Caucasian female never-smoker initially presented with a pleural effusion and was diagnosed with invasive adenocarcinoma following a pleural biopsy. The pleural biopsy performed revealed dense fibrous tissue with invasive adenocarcinoma with mucin production and associated psammomatous calcifications. The patient was initially treated with carboplatin, paclitaxel, and bevacizumab with good response, and she continued on maintenance bevacizumab for four years after diagnosis. Subsequently treatment was switched to pemetrexed but had to be stopped due to secondary fatigue and failure to thrive. Molecular (EGFR/ALK) testing was carried out on tissue procured from the initial right pleural biopsy. Using this sample with 35 % viable tumor tissue, the patient was found to be both EGFR wild-type and ALK-negative by FISH.
+Chest computed tomography (CT) scan showed that the patient had marginal progression of her right pleural rind along with slow progressive growth of right chest wall nodule. She also received palliative radiation to her right chest nodule at this time. In year six, a re-biopsy was carried out on the chest wall skin, and the results indicated the presence of a well differentiated adenocarcinoma, with mucinous features. Immunohistochemistry stains were positive for nuclear thyroid transcription factor-1 and negative for estrogen receptor and progesterone receptor, which were consistent with a lung primary tumor. The tissue obtained was analyzed by NGS to identify potential actionable mutations. NGS testing results (Foundation Medicine, Inc., MA) indicated that the tumor was ALK-rearrangement positive for EIF2AK3-ALK fusion, and the patient received crizotinib treatment for 19 months. The patient responded well to crizotinib in the first 12 months of treatment (Fig. ), with significant interval decrease in the pleural based tumor, mediastinal lymphadenopathy, and subcutaneous metastatic deposits. Continued decreases in the size of nodules associated with the right pleural-based tumor, mediastinal lymphadenopathy and subcutaneous metastatic deposits was seen, followed by stable disease until 16 months into treatment, when CT showed disease progression. This manifested as an increase in right diaphragmatic pleural-based masses, an increase in right lateral chest wall tumor, and an increase in subcarinal lymphadenopathy (from prior study). 18 months after the start of crizotinib treatment, another CT scan showed a significant response (this was the last CT scan while on crizotinib treatment), with significant interval decrease in size of diaphragmatic pleural-based masses and minimal interval decrease in pleural thickening as described above. Despite the patient? overall pronounced response to crizotinib, the treatment was eventually discontinued due to disease progression and gastrointestinal adverse events of Grade 3 nausea and vomiting.
+Treatment with orally administered ceritinib at a starting dose of 450 mg/day was initiated two months after crizotinib treatment ended. This ceritinib dose was administered with food; meals were generally relatively bland and small in size (taken three times a day), and red meat and spice-free. Ceritinib treatment is being well tolerated, and no gastrointestinal adverse events (nausea, vomiting, or related bowel problems) have been reported to date. Proactive treatment regimens have been reported as effective in the management of gastrointestinal AEs in patients taking ceritinib [], but regimens of this type were not required for this patient, who was treated with ceritinib 450 mg/day with food, and are not currently considered necessary for her future treatment. Overall, the patient has reported suffering from minimal side effects with the exception of some bloating and rhinorrhea. The patient has also shown a good response to ceritinib, as demonstrated by CT scans (Fig. ), and treatment is currently ongoing. There was no central nervous system (CNS) involvement."
+Rex Garza,40,1984/12/10,2673121210,plloyd@example.org,883 Michelle Plain,"A young Caucasian female patient aged 28 years came to our hospital complaining of chronic right upper quadrant pain. Physical examination was unremarkable as was her medical history. She was investigated with upper abdominal ultrasound that was negative for chololithiasis but revealed dilated gallbladder and common bile duct with a diameter of 2.1 cm. Her laboratory values were within normal limits with total bilirubin of 0.28 mg/dl, alkaline phosphatase (ALP) at 42 U/l, and 帠- GT 16 U/l. Serum tumor markers were within normal limits. The patient was further studied with computerized tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography (Fig. ) that proved dilation of common bile duct between the confluence of hepatic ducts down to the upper pancreatic border. The intrapancreatic portion was normal. The investigation was negative for choledocholithiasis and otherwise unremarkable. Pancreaticobiliary junction was normal.
+With a diagnosis of a choledochal cyst, Type Ia according to Todani classification, the patient underwent excision of the extrahepatic biliary tree with Roux-en-Y reconstruction. An intraoperative cholangiography was performed for diagnosis confirmation (Fig. ).
+The patient had an uneventful recovery and left the hospital at the seventh postoperative day. Specimen was sent for histological examination (Fig. ). On histology, the gallbladder, the cystic duct, and partly the common bile duct showed a prominent intraluminal papillary proliferation of neoplastic epithelial cells with delicate fibrovascular stalks. Papillary epithelium consisted of columnar cells with eosinophilic cytoplasm and round nuclei with minimal irregularities and mild pseudostratification, resembling slightly dysplastic biliary epithelium. Immunohistochemical staining revealed MUC1 and MUC5AC expression while tumor cells were negative for MUC2. Findings were consistent with intracystic papillary neoplasm of the gallbladder and intraductal papillary neoplasm of the cystic and common bile duct with low-grade dysplasia, pancreatobiliary subtype (Fig. )."
+River McIntosh,36,1978/8/9,368.380.8181x29185,cmiller@example.com,2170 Reese Plaza Apt. 351,"A 72 year-old female was transferred to our Department of Cranio-Maxillofacial Surgery at the University Hospital of M羹nster with a hyperplastic gingivitis and intraoral pain in October 2015.
+The patient was diagnosed with GPA already in 2007. Since that time she has developed glomerulonephritis, nephrosclerosis, pulmonary emphysema, Raynaud? phenomenon, sinusitis maxilliaris and had surgery on an orbital pseudotumor in 2014. Since the first diagnosis of GPA in 2007 the patient was treated with prednisolone and cyclosporine. She also suffered from a steroid-associated osteoporosis which has been treated intravenously with denosumab, a human monoclonal antibody directed towards osteoclast-mediated bone resorption by binding to osteoblast-produced RANKL. Mild hypertonia and presbyacusia of both ears were also diagnosed. Oral manifestations like ?trawberry gingivitis??did not occur since the first diagnosis of GPA in 2007, but a basal cell carcinoma developed in 2015. The patient was first diagnosed with hyperplastic gingivitis by her dentist in April 2015 and was treated subsequently by non-surgical periodontal therapy without antibiotics. However, since the therapy lacked any beneficial effect the patient was sent to a periodontist in September 2015. The periodontist did not conduct any treatment. He recommended gingivectomy of the hyperplastic gingiva and due to the additional intravenous denosumab therapy, he transferred the patient to our Department for further treatment.
+In the intraoral examination, alterations of the gingival volume were observed. Plaque control was poor since handling with the toothbrush was too difficult for the patient. Additionally, we noted the absence of petechia on the buccal and oral gingiva in the upper as well as in the lower jaw and bleeding in the buccal area of 13??5. (Figs. and ). She described intraoral pain and was handicapped during food intake. In the orthopantomogram the patient showed an impacted canine, furcation involvement of the first upper molars, and horizontal bone loss according to the age (Fig. ). Thus, the gingival volume appeared uncommon.
+At the time of the patient? visit at our Department the medication for the therapy of GPA consisted of a combination of prednisolone 10 mg/day and cyclopsporine 150 mg/day prescribed by her family doctor. The patient? full medication is presented in Table .
+As periodontal therapy has previously failed and cyclosporine has been given since 2007 without any intraoral side-effects like gingival hyperplasia, we decided in suspicion of the recurrence of GPA with gingival hyperplasia to take a biopsy from the palatinal premolar region under local anesthesia. The biopsy was then sent for routine histopathological analysis which revealed inflammation with parakeratosis and neutrophil-granulocytic infiltration (Fig. ). These findings were conveyed to her family doctor who decided to refer the patient to the Clinic of Internal Medicine at the University Hospital of M羹nster. Since the staining for c-ANCA tested positive, the recurrence of GPA was suspected. Therefore, they decided to treat the patient with rituximab via infusion. In addition to prednisolone 10 mg/day, the patient was given 375 mg/m2 rituximab weekly for a total of 4 doses. After one week of therapy, she was re-evaluated at our Department. At the follow-up visit, the patient showed complete remission of the hyperplastic gingiva (Figs. and ), the absence of pain, and the patient was able to eat without problems. Periodontal probing depths of 5 mm or more only appeared at the molars. Table shows the diagnostic and treatment process of the patient in chronological order."
+Kristian Perkins,23,2005/6/5,001-756-247-5747x6176,jennifer06@example.org,652 Cox Common Apt. 843,"An abnormal shadow was detected in a 59-year-old man during a routine medical examination. He was asymptomatic and his past history was unremarkable. The chest roentgenogram showed a mass shadow in the right upper lung field. Chest computed tomography (CT) imaging showed a 4.5 cm ? 4.0 cm mass in the S1 segment of the right lung (Fig. ). At the same time, we incidentally found an anomalous vessel. This vessel originated from the right upper lobe and drained into the superior vena cava (SVC) (Fig. ). We diagnosed the abnormality as a PAPVC. Positron emission tomography?omputed tomography using 18F-fluorodeoxyglucose (FDG) showed a nodule with maximum standard uptake value of 10.6. The echocardiogram showed normal cardiovascular activity without an atrial septal defect. The preoperative blood gas analysis revealed a partial pressure of arterial oxygen (PaO2) of 77.1 mmHg and partial pressure of arterial carbon dioxide (PaCO2) of 41.3 mmHg in room air. Spirometry revealed normal respiratory function.
+Because the mass may have been lung cancer?nd if so, it was believed to be a resectable lesion with a clinical staging of T2aN0M0 stage IB? right upper lobectomy was performed using video-assisted thoracoscopic surgery. The anomalous pulmonary vein drained into the SVC. The pulmonary vein (V2t) was normally connected to the left atrium (Fig. ). Based on needle biopsy, the lesion was diagnosed as non-small cell lung cancer. A right upper lobectomy and dissection of the lymph-node were curative. The anomalous vein was mechanically cut and sutured using a stapler. We thereafter ligated and cut the normal V2t. The surgery was completed successfully. His postoperative course was uneventful without any cardiac failure. The postoperative blood gas analysis revealed a PaO2 of 72.1 mmHg and a PaCO2 of 39.1 mmHg in room air. In the resected specimen, the tumor measured 4.7 cm. It was histopathologically an invasive adenocarcinoma. The pathologic stage of the lung cancer was IB (i.e., T2aN0M0). Four months after the surgery, he remains in good health without relapse of lung cancer."
+Sage Marin,25,1995/11/3,331-625-4009,rodriguezmatthew@example.com,0954 Todd Plains Suite 577,"The three cases were diagnosed in the outpatient unit of the Nephrology Department at Strasbourg University Hospital, France.
+Patient #1 was a 60-year-old man who underwent transplantation at the age of 52 for chronic renal failure due to polycystic kidney disease. He initially received immunosuppressive treatment, consisting of tacrolimus (4 mg/day), mycophenolate mofetil (MMF) (1 g x 2/day), and prednisone (7.5 mg/day). Eight years after renal transplantation, he presented with watery diarrhea, nausea and vomiting starting 15 days before consulting (September 25th, 2014). Physical examination revealed asthenia, weight loss (6Kg), hypotension, dry mouth, and acute renal failure (glomerular filtration rate [GFR]: 30 ml/min/1.73 m2). The patient reported no recent travel or contact with swimming pool water, non-drinking water or farm animals, but admitted to own a dog. No other family member experienced diarrhea.
+Patient #2 was a 64-year-old man of Malian origin who had lived in France for 40 years and undergone transplantation at the age of 62 for chronic renal failure secondary to glomerulonephritis. Immunosuppressive treatment consisted of tacrolimus (7 mg x 2/day), MMF (750 mg x 2/day), and prednisone (10 mg/day). Two years and 4 months following renal transplantation, he presented with watery diarrhea and abdominal pain lasting for 15??0 days (starting September 26th, 2014). Physical examination revealed weight loss (13Kg), esophageal pain, and acute renal failure (GFR: 36 mL/min/1.73 m2). The patient also presented leucopenia and neutropenia, initially attributed to an overdose of tacrolimus. He reported no previous contact with non-drinking water, swimming pool water or farm animals, but had travelled to Mali for 2 months shortly before the onset of diarrhea. No other person of his family experienced diarrhea.
+Patient #3 was a 34-year-old man of Kosovar origin who underwent transplantation aged 24-year-old for an undetermined reason. Acute transplant rejection 2 years later led to a second transplantation in September, 2014. Immunosuppressive treatment consisted of tacrolimus (6 mg x 2/day), MMF (750 mg x 2/day), and prednisone (25 mg/day). Ten days following the second renal transplantation (September 21th, 2014), the patient exhibited watery diarrhea and abdominal pain. Physical examination indicated weight loss (10Kg) and acute renal failure (GFR: 16 ml/min/1.73 m2). The patient, who reported no contact with non-drinking water, swimming pool water or farm animals, had travelled to Kosovo for 1 month before transplantation. His 2-year-old daughter also presented with diarrhea from an unknown cause that lasted for 3 days. No stool analyses were done for the daughter.
+For all three patients, stool examinations performed at the first consultation revealed the presence of Cryptosporidium oocysts, using a modified Ziehl-Neelsen staining method (5??0 oocysts/slide, >100 oocysts/slide, and 1?? oocysts/slide for cases #1, #2, and #3, respectively). All stool samples were negative for the bacteria Clostridium difficile, Salmonella, Shigella but also for rotavirus and norovirus, and for parasites Giardia and microsporidia.
+DNA was extracted from the stool samples using a NucliSENS easyMAG device (bioM矇rieux, Marcy l?toile, France) []. Briefly, it consisted of adding 400 mg of stool samples to 1 mL of NucliSENS lysis buffer in a tube containing ceramic beads (lysing matrix D; MP Biomedicals, Illkirch, France), disrupted in a FastPrep-24 grinder (MP Biomedicals) at maximum power for 1 min. After 10 min of incubation at room temperature to ensure complete lysis, the tubes were centrifuged at 10,000 ? g for 10 min and extraction was performed with 250 弮L of supernatant. Elution was performed at 70 簞C with 100 弮L of elution buffer. An in-house real-time polymerase chain reaction (PCR) assay was set up to enable the detection and identification of the most common Cryptosporidium species/genotypes []. To this end, we used a single reaction tube with fluorescence-labelled probes for the real-time detection of Cryptosporidium, in addition to melting curve analyses of PCR products to differentiate between the Cryptosporidium species/genotypes. We conducted the amplification of a 258 bp DNA fragment located in the 18S ribosomal ribonucleic acid (rRNA) gene (GenBank accession n簞L16996; positions 80 to 337) using the following primers: Cry80F: 5??GTTAAACTGCRAATGGCT-3?? Cry337R: 5??CGTCATTGCCACGGTA-3?? The CryAnch-labelled hybridization probe (5??CCGTCTAAAGCTGATAGGTCAGAAACTTGAATG-fluorescein-3?? hybridizes in a region that is conserved among all Cryptosporidium species and the CrySens labelled hybridization probe (5??LCRed640-GTCACATTAATTGTGATCCGTAAAG-3?? hybridizes in a polymorphic region (nucleotides 260 to 264) with various mismatches. Thermocycling and fluorescence detection were performed by means of a LightCycler 2.0 system (Roche Diagnostics) in a final volume of 20 弮L, using a Roche LC Faststart DNA Master HYPROBE (Roche Diagnostics) with 0.5 弮M of each primer, 0.2 弮M of hybridization probe, 0.5U of UNG (Roche Diagnostics), and 5 弮L of extracted DNA. After applying 95 簞C for 10 min, amplification was commenced consisting of 50 cycles of 10-sec denaturation at 95 簞C, 15 sec of annealing at 50 簞C (with a touchdown protocol beginning at 60 簞C), and 15 sec of elongation at 72 簞C. The fluorescent signal (640 nm) was detected following the annealing step of each cycle. Species/genotypes differentiation was based on differences in the melting temperatures of the PCR-probe complexes, which were determined based on the extent of complementation of the probes to the target strand of the PCR product. For the melting curve analysis, a quick denaturation step was performed at 95 簞C followed by a 30-sec annealing step from 45 簞C to 80 簞C (ramp-up rate: 0.1 簞C/s), with continuous detection throughout the ramp up. The technique was validated using Cryptosporidium DNA of a stool collection already characterized at the genus level and positive controls for C. parvum and C. hominis [].
+The five predominant human pathogenic Cryptosporidium species were identified based on their melting curve profiles (61.9 簞C, 53.8 簞C, 48.8 簞C, 56.7 簞C, and 51.8 簞C for C. parvum, C. hominis, C. felis, C. meleagridis, and C. canis, respectively). Given that C. cuniculus, an emergent human species, possesses the same melting curve profile as that of C. hominis, with both species exhibiting the same DNA sequence at the hybridization probe locus, all isolates identified as C. hominis were then sequenced to differentiate C. hominis from C. cuniculus.
+For sub-genotyping analysis, DNA samples were subjected to amplification of an 850-bp fragment of the gp60 gene using a nested PCR method []. The total volume of PCR mixture was 50 弮L, containing 5 弮L of DNA for the primary PCR or 5 弮L of the primary PCR products, primers (outer primers: AL3531 and AL3535; inner primers: AL3432 and AL3534) at a concentration of 0.4 弮M, 0.2 mM deoxyribonucleotide triphosphate mix, and 1.25U of DreamTaq DNA polymerase. Each PCR reaction was subjected to 40 cycles of 30s denaturation at 95 簞C, 60s annealing at 55 簞C, and 60s extension at 72 簞C, with an initial 5 min denaturation at 95 簞C and a final 10 min extension at 72 簞C. PCR products were visualized by electrophoresis on an ethidium bromide stained 2 % agarose gel electrophoresis. Amplicons were purified and sequenced in both directions with the forward and reverse primers used in the secondary PCR at a concentration of 0.32 弮M. Sequencing was performed using a BigDye Terminator v3.1 Cycle Sequencing Kit (Applied Biosystems, USA) and an ABI PRISM 3100 Genetic Analyzer簧 (Applied Biosystems, USA). We analyzed the quality of the generated electrophoregrams from each strand using 4Peaks software and compared them with those available in the GenBank database using the basic local alignment search tool. Subtype assignment was based on the number of trinucleotide repeats (TCA, TCG or TCT) in the coding for serine [].
+For Patient #1, genotyping revealed a C. felis infection. For Patient #2, genotyping revealed C. hominis sub-genotype IaA13. For Patient #3, the C. parvum sub-genotype IIaA13G1R2 was identified.
+All three patients were treated with nitazoxanide (500 mg x 2/day for 14 days). For Patient #1, the stools tested negative 2 weeks after treatment initiation, with no recurrence of diarrhea observed 4 months after the first episode. For Patient #2, a reduction of tacrolimus was initiated and the diarrhea regressed 8 days after treatment initiation, although 3 months after therapy was started, his stools still tested positive. A second administration of nitazoxanide was thus prescribed and we requested a stool sample from his daughter for testing. One month after the second treatment course, his stools were tested negative for Cryptosporidium oocysts. For Patient #3, tacrolimus was also reduced and his diarrhea was regressing 1 month after treatment initiation. Four months after the second treatment course, his stools were tested negative for Cryptosporidium oocysts."
+Aldo Moon,26,2005/9/5,237.384.7917,carlvaughn@example.com,59814 Amber Extension Suite 462,"A 52- year old perimenopausal caucasian woman, gravida 3 para 3, with a 10-week long vaginal bleeding, bloating, fatigue, weight gain (>7 kg), and hypogastric mass was admitted to the local emergency room for an epigastric pain and a mild dyspnea. She also observed breast tenderness for the last 3 months. Her personal history included: appendectomy, amiodarone-induced hypothyroidism, chronic atrial fibrillation and breast abscess but not hypertension. Her last delivery was 23 years ago and she discontinued oral contraceptive pill at least 18 months back. She then observed hot flashes and menstrual irregularity with longer menstrual cycles and her last menses occurred 4 months ago.
+A computed tomography (CT) scan of the chest, abdomen and pelvis showed a uterine enlargement (15 ? 12 cm axial) with a heterogeneous hypodense endometrium punctuated with nodular areas enhanced by iodinated contrast (Fig. & b). Neither fetus nor adnexal mass was detected. Diffuse bilateral pulmonary nodules were observed (Fig. ). While her serum hCG level was 0.96 ? 106 IU/L, an endometrial trans-cervical biopsy showed two non-malignant chorionic villi.
+When she was referred to the regional cancer center ten days later, she was further diagnosed with the following signs of early onset preeclampsia (EOP): new onset of severe hypertension (170/100 mmHg), proteinuria, oliguria, headache, hyper reflexivity in lower limbs and growing epigastric pain radiating to both hypochondria. While her fundal height was measured to be 18 cm, her laboratory tests including TBC, kidney and liver function were initially normal except a serum hCG test rising to 1.266 ? 106 IU/L. Blood pressure and diuresis were stabilized after a parenteral treatment of severe hypertension and pain. Her biological results, however, rapidly deteriorated with hemolytic anemia (hemoglobin 97 g/L, haptoglobin <0.06 g/L), thrombocytopenia (75 G/L), and elevated liver enzymes (ALT 120 IU/L, AST 252 IU/L). Additionally, she developed severe proteinuria (1.85 g/24 h). Together, she presented a complete form of HELLP syndrome. The patient was transferred to the intensive care unit and a salvage total abdominal hysterectomy with bilateral salpingo-oophorectomy was immediately decided in accordance with the French Trophoblastic Disease Reference Centre advice. Gross examination of the specimen showed an enlarged and tensed uterine body (22 ? 20 ? 10 cm, Fig. ) whose longitudinal incision released macroscopic vesicles without any identifiable fetus (Fig. ). Histological examination further revealed a complete and invasive hydatidiform mole (Fig. c & d). Histology was reviewed within the French network of trophoblastic disease referent pathologists.
+One week after hysterectomy, her biological results markedly improved (hemoglobin 105 g/L, haptoglobin 2.7 g/L, platelets 311 G/L, ALT 24 IU/L, AST 23 IU/L and hCG 31.240 ? 103 IU/L.
+Thoraco-abdomino-pelvic CT scan, liver MRI, brain CT and 18 F-FDG PET/CT detected diffuse metastases limited to the lungs (visible on chest CT scan but not by chest-X-ray). She was thus considered to develop a post-molar high-risk GTN with a FIGO stage/score of III:7 []. Therefore, an EMA-CO multi-agent chemotherapy was initiated at day 20 post-operative, as the patient left the intensive care unit []. She was subsequently registered in the national database with her informed signed consent []. Complete remission of GTN was ascertained by the rapid hCG regression within 10 weeks (Fig. ). She was administered five EMA/CO cycles with two more consolidation courses after normalization of serum hCG levels that were periodically followed up to 24 months []. A complete response was observed on the thoracic CT four months after diagnosis. The patient is disease-free for ten years."
+Naya Singleton,39,2001/12/16,(379)678-3106x594,marilynmcdaniel@example.net,170 Edward Brook,"A 58-year-old Muhajir Pakistani man presented to our surgery clinic with a swelling in his neck of 5 days??duration, which he had noticed while shaving. On physical examination he had a left-sided thyroid nodule, approximately 6?4 cm with no lymphadenopathy. He was advised to have a thyroid function test, a thyroid ultrasound, and fine-needle aspiration (FNA) of the suspicious nodule. His laboratory investigations on follow-up showed thyroid-stimulating hormone (TSH) of 1.58 (0.4 to 4.2), thyroxine (T4) of 7.83 (5.1 to 14.1), and triiodothyronine (T3) of 1.99 (1.3 to 3.1). Ultrasonography of his thyroid gland revealed a multinodular goiter with largest nodule measuring 1.1?0.8 cm in right lobe and 2.3?1.2 cm in left lobe. Ultrasound-guided FNA of the left lobe of his thyroid showed a follicular lesion. According to American Thyroid Association (ATA) classification he was classified as an intermediate risk patient. A left lobectomy was planned for him but perioperative frozen section examination of the left lobe revealed a follicular carcinoma (Fig. , ); therefore, a total thyroidectomy was performed and the tumor was completely resected. Surprisingly, histopathology of the thyroid specimen (right lobe) showed thyroid parenchyma infiltrated by a neoplastic lesion which had a papillary architecture (Fig. , ). The papillary carcinoma measured 2?1.5?1 cm and was 0.2 cm away from the capsule; the follicular carcinoma measured 6?6 cm with no capsular breech. The cancer had a non-aggressive histology and no lymph nodes were involved. Well-formed papillary fronds were identified with prominent fibrovascular cores. In addition, psammoma bodies were also seen. After the surgery, he received 5550 MBq (150 mCi) radioactive iodine131 (RAI131) for remnant thyroid tissue ablation. His postoperative stimulated thyroglobulin levels were 19.10 (1.6 to 59.9) with a TSH of 39.12 (0.4 to 4.2). At 6-month follow-up, his stimulated thyroglobulin had increased to 56.56 ng/dl (1.6 to 59.9) with TSH of 94.66 (0.4 to 4.2). An ultrasound of his neck was normal and a whole body scan was negative; therefore, no distant metastasis was present. Considering the above laboratory values a second dose of 3700 MBq (100 mCi) iodine131 was given. He has been on regular follow-ups for the last 6 years without any evidence of recurrence."
+Landyn McGuire,27,1986/4/29,692.927.4452x6448,daviskevin@example.com,798 Baker Turnpike,"Patient 2 is a younger brother of Patient 1; Patient 2 is a 55-year-old man from Karachi, Pakistan who underwent a thyroid ultrasound for screening purposes although he was asymptomatic. No abnormality was noted on physical examination. His ultrasound showed an enlarged right lobe as compared to the contralateral side measuring 20.2?24.3?39.5 mm. At least three hypoechoic nodules with predominant solid components were seen in his right lobe with tiny calcification present within. The largest nodule measured 20.8?17.0 mm. Ultrasound-guided FNA revealed clusters and groups of follicular cells with architectural atypia, with a few of the cells forming papillary structures. Some nuclear grooving and intranuclear inclusions were seen with a group of H羹rthle cells against a background of hemorrhage. He was classified as ATA intermediate risk and underwent total thyroidectomy with central neck dissection at another tertiary care facility. His histopathology report revealed a classic papillary thyroid carcinoma, 5.0 cm in diameter, with minimal extra thyroidal extension (right thyroid lobe). In addition, papillary microcarcinoma, H羹rthle cell variant (0.5 cm), and follicular adenoma (left thyroid lobe) were reported as well with level VI lymph node micrometastasis. However, no capsular invasion was seen. He received postoperative 5550 MBq (150 mCi) RAI131 for remnant tissue ablation and was started on suppressive thyroid hormone replacement. He has been in follow-up for 3 years with no evidence of residual or recurrent disease."
+April Bradley,37,2003/1/18,323-232-4095,smithnathan@example.net,61547 Carl Forks Suite 489,"Patient 3 is the youngest brother of the family; Patient 3 is a 52-year-old Pakistani man who visited an endocrinologist in another hospital with the complaint of chronic urticaria. He had no other symptoms and had a normal physical examination. He was advised to have thyroid antibody tests which showed anti-thyroid peroxidase (TPO) of 695.10 (normally less than 35) and anti-thyroglobulin of 29.50 (normally less than 40). A thyroid function test showed TSH of 1.80 (0.4 to 4.2), T4 of 8.80 (4.6 to 10.5), and T3 of 2.01 (1.23 to 3). Considering the strong family history of papillary thyroid carcinoma, he was advised to have a thyroid ultrasound which showed a multinodular goiter. Fine-needle aspiration cytology (FNAC) revealed papillary carcinoma of the thyroid. A few clinically suspicious lymph nodes were also present bilaterally and he was classified as a high risk patient according to ATA guidelines. He underwent total thyroidectomy with bilateral selective neck dissection: level II, III, IV and VI. Histopathology confirmed papillary carcinoma, classic variant, which was 7?5.5?3 cm with capsular invasion and lymph node metastasis to level II, II, IV and IV bilaterally with no distant metastasis (Fig. , ). He received postoperative 6660 MBq (180 mCi) RAI131 for remnant thyroid tissue ablation; he was started on suppressive thyroid hormone therapy. His follow-up ultrasound at 6 months showed a 14?11 mm heterogeneous area in his right paratracheal region with few lymph nodes and preserved hilum. The largest lymph node was on the right side and measured 15?5 mm. His thyroglobulin level was 46 ng/dl (1.6 to 59.9) whereas a whole body RAI131 scan was negative for residual disease. He underwent a positron emission tomography (PET) scan which showed a hypermetabolic, 8 mm right level II node: standardized uptake value (SUV) of 5.2. He therefore underwent a second surgery for residual disease and right-sided neck dissection in 2015. Histopathology showed metastatic lymph nodes. He has kept regular follow-ups for 2 years."
+Richard Maxwell,29,1981/9/4,(505)898-8969x992,john02@example.net,7432 Mclean Brook Suite 194,"Here we present a case of a rare coronary anomaly in a 47-year-old white man with an unremarkable past medical history who presented with atypical angina in late 2012; he does not have a family history of any heart disease, he is not allergic to anything, and he has never had any cardiac procedure. A physical examination and resting electrocardiogram results were normal, and transthoracic echocardiography showed no wall-motion abnormality and normal global left ventricular systolic function. His biochemical parameters were within normal limits. The treadmill exercise test showed 1-mm down-sloping ST-segment depression in leads V4 to V6. Multidetector computed tomographic angiography was performed to evaluate coronary artery disease and revealed an accessory coronary artery arising from the proximal RCA. It took an intramuscular course between the right ventricular outflow tract in the interventricular septal area to the anterior interventricular sulcus (AIVS), giving off septal perforators that reentered the medial LAD. Both vessels ran after the anastomosis in the AIVS as a single vessel (Figs. and ). A coronary angiography was performed to characterize the coronary anomaly and to detect any resultant ischemia. His RCA was dominant, giving origin proximally to an anomalous accessory coronary artery that reentered his medial LAD and ran as a single vessel (Fig. ). The left main artery arose from the left coronary sinus and branched into a proper LAD and a circumflex artery (Fig. ). There was no significant obstructive coronary artery disease. We measured the pressure-derived fractional flow reserve (FFR) to detect ischemia in the distal LAD after the anastomosis of the accessory coronary artery using a 0.014-inch (0.3556 mm) pressure wire (Volcano Corporation) during infusion of increasing doses of dobutamine (5, 10, 20, and 30 弮g kg?? minute??, each in 5-minute increments). The FFR was >0.95. Thus, this anomaly did not cause ischemia during exercise. It was decided that his chest pain might be musculoskeletal in origin; therefore, he was given non-steroidal anti-inflammatory medication, after 1 month of follow up visits his pain was gone."
+Kyla Vance,25,1991/11/2,5756205027,megan86@example.org,5705 Jesse Square Apt. 174,"A 70-year-old man was diagnosed with lung adenocarcinoma (clinical T4N0M0) involving a right upper lobe mass of 4.0 cm in diameter and a metastatic nodule in the middle lobe. He underwent right upper and middle bilobectomy and systematic lymph node dissection through a posterolateral thoracotomy. On the second postoperative day, 1750 mL of white turbid fluid was drained through the chest tube and the effusion was diagnosed as chylothorax. During the first 24 h following implementation of a fat-free dietary regimen, the color of the discharge became transparent, but another 630 mL of discharge was observed. Although the amount of discharge reduced gradually, it was persistent. Chemical pleurodesis was performed on the sixth postoperative day for which 5 KE of OK-432 (Picibanil; Chugai Pharmaceutical, Tokyo, Japan) and 300 mg of minocycline were administered into the thoracic cavity. The discharge began to progressively diminish. Three days thereafter, the amount of discharge had decreased to 150 mL/day, and on the ninth postoperative day, the chest tube was removed. On the 14th postoperative day, the patient complained of dyspnea and dysphagia, and an upper mediastinal mass was detected on chest radiogram (Fig. ). Chest computed tomography revealed a large mediastinal fluid collection 6 cm in diameter surrounded by a thick capsule that was compressing the trachea and esophagus (Fig. ). The mass was suspected to be a mediastinal chyloma. Since the patient? symptoms were gradually progressing, we performed surgery on the 15th postoperative day. Thirty minutes before the surgery, ice cream was given to the patient to help confirm the leakage point in the thoracic duct. Thoracoscopy revealed a small amount of chylous effusion in the thoracic cavity and an elastic mass in the upper mediastinum. When the thick capsule was incised, chyle began to spill out (Fig. ). Once the chyle had drained completely, we confirmed the point of leakage and repaired it using a Z-suture with 4?? Prolene (Ethicon, Somerville, NJ) (Fig. ). The postoperative course was uneventful and the patient was free of any symptoms. He remained asymptomatic 12 months after discharge from the hospital."
+Casen Schultz,34,1982/12/21,347-824-6854,qblair@example.net,26026 Daniel Forest,"A 28-year-old man was referred to our hospital because of right-sided spontaneous pneumothorax (Fig. ). He was an active smoker with a 10-year history of smoking 40 cigarettes a day, but otherwise his medical history was unremarkable. A chest drainage tube was inserted. After re-expansion of the lung, active air leakage was not apparent. The right lung collapsed with the drainage tube clamped, and VATS was performed. Thoracoscopic examination revealed a few small bullae at the apex of the right upper pulmonary lobe (Fig. ). An intraoperative submersion test did not reveal active air leakage. Wedge resection was performed for the small bullae in the right upper lobe. The staple line was ligated at both ends and covered with regenerated oxidized cellulose mesh and autologous blood.
+Three months later, the patient was referred to our hospital for recurrent right-sided pneumothorax. The air leak disappeared after chest drainage was performed, and an initial clamp test showed collapse of the lung. However, a second clamp test did not result in collapsed lung, and the patient was discharged.
+One month after the second visit, the patient was again referred to our hospital for recurrent right-sided pneumothorax (Fig. ). Because intermittent air leakage was noticed with the patient in a seated position after chest drainage, we performed surgery. An intraoperative submersion test revealed air leakage dorsally from the S6 pleural surface and a minute culprit lesion (Fig. ), which were not seen during the first operation, confirmed the site of leakage. The affected area was ligated and coated with regenerated oxidized cellulose mesh and autologous blood. The surgery was performed immediately, at the time that air leakage was noted, and we were able to identify the culprit lesion by examining the entire lung in a study to water-seal."
+Briella Park,33,1978/10/21,912-779-4889x84931,thomas18@example.org,4307 Luis Court,"A 26-year-old male stonemason was referred with a 6-month history of unproductive cough, exertional dyspnoea, 3 kg weight loss, and infiltrates on plain chest X-ray. He had a background history of skin psoriasis that was well controlled on 12 months of adalimumab, a TNF-alpha inhibitor. He was a lifelong non-smoker and had been working as a stonemason for the past five years. He reported daily exposure to silica dust and only intermittently wore a protective mask. Although he had travelled through tuberculosis endemic regions, he denied any known contact exposure.
+Examination was unremarkable with normal oxygen saturations, a clear chest to auscultation, no clubbing or lymphadenopathy, no evidence of pulmonary hypertension, and no signs of connective tissue disease apart from his skin psoriasis. Initial chest X-ray on specialist presentation demonstrated bilateral upper lobe predominant infiltrates with loss of volume, suggestive of fibrosis (Fig. A). His lung function tests showed a moderate restrictive ventilatory deficit with a mild reduction in gas transfer. He underwent a high-resolution computed tomography scan (HRCT) that confirmed bilateral upper lobe predominant reticulonodular changes with fibrosis as well as prominent mediastinal and hilar lymphadenopathy (Fig. B).
+At this point, the differential diagnosis consisted of possible silicosis, sarcoidosis, drug-related interstitial lung disease, connective tissue-related interstitial lung disease, and infection?pecifically reactivation of pulmonary tuberculosis. He underwent a bronchoscopy with bronchioalveolar lavage (BAL), a transbronchial lung biopsy (TBLBx), and an endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA). He also underwent a full connective tissue disease screen and was informed to avoid further silica exposure and to cease his adalimumab.
+The bronchoscopy and CTD-screen were non-diagnostic but importantly returned a negative result for acid-fast-bacilli and culture, did not show any evidence of granulomatous inflammation consistent with sarcoidosis or granulomatous infection, and did not demonstrate any specific interstitial lung disease pattern.
+He then underwent a surgical lung biopsy, which demonstrated silicosis with fibrosis (Fig. A,B). His case was discussed at a designated Interstitial Lung Disease Multi-Disciplinary Meeting, and given the combination of his history, radiology, lung function, and histology, he was diagnosed as having accelerated silicosis with significant fibrosis.
+The patient was told to avoid any further silica exposure and was commenced on prednisolone 0.5 mg/kg daily with a plan to slowly wean. Unfortunately, despite complete avoidance of any further silica and the introduction of the steroid sparing agent methotrexate, his radiology and lung function continued to decline. He is now likely developing PMF and is awaiting review for consideration of possible lung transplantation in the future."
+Daxton Collier,40,1998/10/2,730-405-7107x542,phillipray@example.net,298 Miller Greens,"G.B. is a 62-year-old male with a 7-year history of right-sided PD symptoms, including bradykinesia, rigidity, and a resting tremor. He was officially diagnosed with PD 5 years prior after consultation with a movement disorder specialist. In the initial phase of his treatment, G.B. responded quite well to standard l-DOPA therapy, as is typically the case with idiopathic PD. However, as the course of his disease progressed, the dosage and frequency of l-DOPA had to be increased to maintain therapeutic effect, eventually leading to troublesome breakthrough symptoms and dyskinesia. Socially, G.B. is extremely high-functioning, with a college degree, and employed as a caretaker in a nursing facility. In December 2015, G.B. was referred for neurosurgical implantation of DBS.
+During neurosurgical consultation, G.B. initially demonstrated enthusiasm for DBS therapy, and strongly met objective criteria for implantation. He had no absolute contraindication to DBS therapy. During the preoperative discussion, the ?wake??procedure was described in detail, including (1) placement of a stereotactic head frame, secured by four percutaneous screws placed under local anesthetic, (2) rigid fixation of the head and frame to the bed, limiting movement of the head throughout the procedure, (3) positioning the head and body in a semi-reclined position, (4) an intraoperative CT scan, (5) sterile draping that partially obscures the face and visual fields, (6) incision and transcranial perforation, (7) neurophysiological monitoring, (8) active stimulation testing, and (9) permanent lead implantation. With this description, G.B. expressed his concerns, which included sensitivity to claustrophobia, anxiety, and subjective positional breathing difficulties. Based on these concerns, a surgical rehearsal was suggested, and he agreed to participate.
+Three days later, G.B. and his spouse presented to the Inova ASTEC (Advanced Surgical Technology and Education Center), a 7,000 square foot facility, containing two replica OR suites, a classroom space and other medical simulation facilities. The replica OR was situated in a similar fashion to what would be anticipated in a real DBS implantation. G.B. was brought into the OR, where he was placed on the surgical table. The Cosman?oberts?ells (CRW) (Integra, Burlington, MA, USA) rigid stereotactic frame was placed over his head without the percutaneous screw fixation that would be required in the real setting (Figure ). The patient was then positioned in a supine position, with the CRW frame rigidly fixed to the bed (Figure ). The intraoperative CT (Bodytom, Samsung) was then maneuvered into place, to provide G.B (Figure ) with a realistic appreciation of the process. The patient was able to experience a first-person perspective of his rigidly fixed visual field (Figure ). Once the CT machine was removed, standard sterile prepping and draping was performed (Figure ), recreating the ?wake??spatial environment (Figure ). Intraoperative neurological testing was practiced to educate G.B. on what would be required of him during the real procedure. The entire rehearsal took ~1 h, with another 30 min dedicated to further discussion with the patient and spouse. All figures presented in this report were recreated for demonstration purposes, as the patient declined to be photographed.
+During this rehearsal, it was evident that G.B.? concerns of tolerating an ?wake??procedure were well-founded. He noted significant anxiety even prior to simulated placement of the CRW frame. During the positioning and simulation of the CT scan, he noted even more anxiety, and subjective pharyngeal discomfort that he felt was impacting his breathing. He noted an elevated heart rate as well. During our post-rehearsal discussion, he had a more clear understanding of the process and the reasoning behind each step. While acknowledging the benefits of the ?wake??procedure, he acknowledged that his fears and anxieties were irrational, yet significant enough that he would not choose an ?wake??procedure. G.B. endorsed a clear desire for the ?sleep??procedure, which he ultimately underwent at a later date."
+Ivory Barron,41,1978/11/1,7395952396,pgallagher@example.net,1343 Aaron Garden Suite 084,"A 62-year-old male without known coronary artery disease, recently diagnosed with rheumatoid arthritis (RA) treated with methotrexate for 5 days, was admitted to our emergency department with acute and typical chest pain for an hour. On ECG, ST-segment elevation myocardial infarction (STEMI) in anterior and inferior leads were noted. There were hypertension and hyperlipidemia as risk factors of coronary artery disease. After the patient was treated with 300 mg of aspirin, 600 mg of clopidogrel, as well as a weight-adjusted (70 IU/kg) bolus of unfractionated heparin, coronary angiography was performed showing an ostial left main coronary artery (LMCA) thrombus with 90% obstruction (, ), a total occlusion of the mid left anterior descending artery (LAD) () and a mid right coronary artery (RCA) thrombus with 80% obstruction (, ). From this point on we had three possible strategies. The first one was the interventional strategy (stenting/aspiration with high risk of cerebral and peripheral embolism, which would have exposed the patient to short and long-term risks). The second one was the coronary artery bypass graft surgery (the coronary artery bypass grafting may represent a high risk of early occlusion because of normal native coronary flow after dissolving the coronary thrombus with medical therapy) and the third one was pharmacological strategy (thrombolytic therapy), eventually followed by the pharmacological strategy. Thus, based on the STEMI guideline of European Society of Cardiology; alteplase (rt-PA) 15 mg was injected intravenosus as a bolus dose and subsequently 50 mg alteplase was infused for 30 minutes (0.75 mg/min) and 35 mg was infused for 60 minutes. After the fibrinolytic therapy, clinical and electrocardiographic success criteria were obtained. Repeated coronary angiography was performed 24 hours later, revealing that the large thrombus in ostial LMCA () and mid portion of RCA () was totally dissolved but only the apical portion of the LAD was occluded (). In addition, laboratory workup for hypercoagulability was negative."
+Dustin Cunningham,24,2005/8/3,(648)376-7182x8402,mendozakristen@example.org,1651 Hill Common,"We present a case of a 51-year-old white man who initially presented with substernal chest pain to the emergency department and was found to be in sepsis. Upon presentation, the patient was found to be tachycardic and hypotensive, accompanied by a leukocytosis. He was diagnosed with sepsis secondary to a urinary tract infection (UTI). Urine cultures were sent but empiric treatment was begun with cefepime based on his previous history of recurrent urinary tract infection with Pseudomonas aeruginosa sensitive to cefepime.
+On admission, cardiac biomarkers were also sent for analysis and troponin ultra was found to be elevated to 3.312 ng/mL (reference range 0.006??.06 ng/mL), without any ST-T wave changes. On admission, leukocyte counts were elevated 15,800/弮L and also lactate was 2.1 mmol/L. The patient was subsequently admitted to the coronary care unit and placed on aspirin, clopidogrel, and enoxaparin, treating him for a possible non-ST elevation myocardial infarction. The patient was not started on a beta-blocker due to hypotension. Since admission, the patient had progressive T wave changes (Figures and ).
+For the purpose of this case, the patient's past medical history consisted of a neurogenic bladder with recurrent UTIs, recurrent deep vein thrombosis on coumadin, multiple sclerosis, hypertension, and hyperlipidemia. After the patient was admitted to the coronary care unit, the patient was found to be in torsades de pointes (TdP) pulseless polymorphic ventricular tachycardia (). The patient was successfully electrically cardioverted. After cardioversion, T wave inversions worsened with evidence of prolonged QTc (). The patient was intubated to maintain and protect airways.
+Subsequently, the patient was started on pressor support to maintain his mean arterial pressure greater than 65 mmHg. The following day, his mental status improved and he was tolerating a continuous positive airway pressure trial. He was then extubated and found to be stable on 3 L nasal cannula.
+After the patient was hemodynamically stable, the plan was to gather more information on the underlying nature behind his TdP and long QT. The patient was scheduled for a transthoracic echocardiogram (TTE) and a cardiac catheterization the following day. The TTE revealed a reduced left ventricular ejection fraction (25%??0%) with apical wall motion abnormalities consistent with a great likelihood of classic takotsubo cardiomyopathy, the apical type (). A coronary angiogram was performed a few days later and did not show any significant coronary artery disease ().
+This case shows TCM in the setting of sepsis secondary to UTI. Urine culture was positive for Pseudomonas putida and Escherichia coli on day 3 of admission and blood cultures were negative. We believe that the TCM in this patient led to a malignant ventricular rhythm in TdP, which eventually needed direct current cardioversion to resolve. The patient's hospital course was stable following the treatment, with a resolving white cell count and a treated UTI. The patient was discharged with a life vest. Patient had repeated echocardiogram three months later and left ventricular ejection fraction improved to >55% without any wall motion abnormality ()."
+Marley Owens,30,1996/9/12,(687)286-6901,hjensen@example.com,4989 Robinson Route Apt. 429,"The patient was a 57-year-old man with a history of chronic myelogenous leukemia, hypertension, dyslipidemia, colon polyp (tubular adenoma, low-grade malignancy), and bilateral lower leg amputations due to a burn. He was also a heavy drinker and presented with chronic mild watery diarrhea. He had started experiencing bilateral upper extremity weakness and numbness, which gradually deteriorated. Two weeks later, he could not move by himself, and he was admitted to the hospital. His daily medications included imatinib 400 mg/day, valsartan 80 mg/day, atenolol 50 mg/day, eperisone 150 mg/day, ranitidine 300 mg/day, and irsogladine 1.5 g/day, but he had not taken them for several days before admission.
+On admission, his blood pressure was 154/100 mmHg, pulse rate was 106 beats/minute in the supine position, and arterial oxygen saturation was 100% on room air. On physical examination, he showed dry mouth, hypoactive bowel sounds, weakening of tendon reflexes, 3/3 on a manual muscle test, a right-handed squeeze of 6 kg, a left-handed squeeze of 3 kg, and pain with pressure at the femurs; he did not show jugular vein distension, edema, or ascites. Electrocardiography revealed ST depletion, a tall U wave, and QTc prolongation. Laboratory data revealed serum concentrations of sodium of 140 mmol/L, chloride of 92 mmol/L, potassium of 2.0 mmol/L, corrected calcium of 2.2 mmol/L, phosphorus of 0.36 mmol/L, and magnesium of 1.2 mmol/L, with a serum anion gap of 10.2 mmol/L. Serum urea nitrogen and creatinine concentrations were 4.6 mmol/L and 61.0 弮mol/L, respectively. Other serum biochemistry values were as follows: aspartate aminotransferase level, 622 IU/L; alanine aminotransferase level, 116 IU/L; lactate dehydrogenase level, 994 IU/L; creatine kinase level, 20,340 IU/L (CK-MM, 94%); and urine occult blood reaction, strongly positive; urinary erythrocytes were not identified. Arterial blood gas analysis showed a pH level of 7.586, carbon dioxide tension of 44.1 mmHg, and bicarbonate level of 37.8 mmol/L, compatible with metabolic alkalosis. Urine electrolyte levels of sodium, potassium, and chloride were 50 mmol/L, 6.4 mmol/L, and 66 mmol/L, respectively, with a urine anion gap of ??.6 and pH level of 6.0. Levels of thyroid-stimulating hormone, free T4, adrenocorticotropic hormone, and serum cortisol were 1.51 mIU/L (normal, 0.35??.94 mIU/L), 0.15 pmol/L (normal, 0.09??.19 pmol/L), 4.33 pmol/L (normal, 1.58??3.93 pmol/L), and 14.6 弮g/dL (normal, 4.0??8.3 弮g/dL), respectively, in the early morning. Plasma renin activity and plasma aldosterone concentration (PAC) were 11 弮g/L/h (normal, 0.3??.9 弮g/L/h) and 0.72 nmol/L (normal, 0.83??.40 nmol/L), respectively, in the supine position. The transtubular potassium gradient was 2.9 in pOsm 288 mOsm/kgH2O and uOsm 319 mOsm/kgH2O, with fractional excretion of potassium of 2.1%, sodium of 0.24%, and urea nitrogen of 15.6%.
+A diagnosis of severe hypokalemia and volume depletion due to chronic watery diarrhea and concomitant chronic poor oral ingestion, complicated by rhabdomyolysis, was made. The patient received standard doses of potassium chloride (40??0 mmol/day) with normal saline intravenously in order to improve his serum potassium concentration and volume depletion. The clinical course is shown in . His muscle weakness gradually improved over the clinical course. The mild watery diarrhea also gradually improved, and he was able to intake orally. After discharge on hospital day 23, the patient's serum potassium concentration was maintained within its normal range."
+Adriel Jensen,23,1996/1/21,711-522-7791,krobinson@example.org,99871 Kevin Lodge,"A 55-year-old woman without medical or surgical history of interest was referred to our team with 1-year history of isolated lower back pain. She reported neither fever nor recent weight loss; there was no tuberculosis contagion. On physical examination, the patient was afebrile. Palpation of the sacrococcygeal region was too painful. Respiratory, cardiovascular, and abdominal system examination was normal. Higher mental functions and cranial nerve examination were normal. There were no meningeal signs. Motor and sensory examination in the lower limbs was normal. There was no bowel or bladder incontinence. Biologic parameters were within normal limits. Chest X-ray was normal. These were followed up by AP and oblique X-ray of pelvis () which were not suggestive of any lesion and showed blurry margins of the sacrococcygeal region. Initial CT scan of the pelvis () revealed a large hypodense heterogeneous solid lesion with enhanced peripheral portions after contrast administration, affecting both of sacrum and coccyx causing osseous destruction and suggesting a malignant process. The magnetic resonance imaging (MRI) () was performed showing a process of hypointense signals in T1W images and hyperintense signals in T2W images. The lesion was moderately enhanced in its periphery after gadolinium administration. The spread of lesion to right piriformis muscle and large gluteal muscles was noted.
+Based on these radiological findings, a malignant process such as chordoma was suspected.
+The patient underwent a surgical intervention and an open biopsy was performed to establish the tissue diagnosis. Histopathological report () confirmed the diagnosis of skeletal tuberculosis by showing tuberculous granuloma with central caseous necrosis surrounded by epithelioid cells and Langhans type giant cells. The patient was treated with antibacillary chemotherapy for a period of 9 months. Treatment was initiated with a four-drug antibiotic regimen (isoniazid, rifampicin, pyrazinamide, and ethambutol) for initial intensive phase of two months followed by continuation phase with two-drug regimen (isoniazid and rifampicin) for next 7 months with a favorable evolution. The follow-up period was of 36 months. There was a full recovery and the patient was asymptomatic at the last follow-up after 3 years with standard radiographs showing no evidence of recurrence ()."
+Jane Harding,41,1980/7/9,(970)497-3478x36539,ncampbell@example.org,6958 Duran Mission,"A 32-year-old man was admitted to emergency area for left-cervical pain, starting minutes after deep scuba diving in the Mediterranean sea six days before. At the same time, the patient noticed a feeling of pressure in his left ear. There was not a rapid ascent to the water surface, which may have caused a decompression illness. The weight of the diving gear did not exceed the usual weight range for recreational diving. The sea was calm and the water temperature was about 21簞C. The whole dive took 3 hours. He was an experienced diver.
+That morning he presented an increasing pain in the upper anterolateral left-cervical region. He was treated with anti-inflammatories nonsteroidal the days before without improvement.
+He was allergic to povidone-iodine and smoker of 4-5 cigarettes per day. He denied past medical problems and did not usually take any medications. He denied alcohol or other drug use.
+The examination of the cranial nerve territory showed a myosis and ptosis ipsilateral. The rest of the neurological examination was normal. The haematological and biochemical profiles were normal.
+The electrocardiography trace showed sinus rhythm at a rate of 56 bpm. The chest X-rays and computed tomography scan of the head and neck were both normal.
+The patient was diagnosed with a painful left-sided, incomplete Horner's syndrome based on the anisocoria and ptosis. He was hospitalized to complete the study.
+A magnetic resonance image of the brain and MRA of the extra- and intracranial arteries were performed. It revealed a decrease in the calibre of the left ICA with an eccentric and irregular stenosis (string sign) (red arrow) at the base of the skull (). The axial slices demonstrated the characteristic half-moon appearance of an internal carotid dissection of the left internal carotid artery ().
+A thrombophilia screen was requested including protein C, protein S, and lupus anticoagulant. This detailed screen did not reveal any abnormality.
+The patient was started on intravenous heparin therapy for management of the ICAD followed by vitamin-K-antagonists (acenocoumarol) with an INR of 2.0??.0 to prevent thromboembolism. After five days his clinical condition improved and he was discharged home. The ptosis and the cervical pain resolved after eight weeks. Out-patient follow-up at three months showed a minor myosis. The rest of the neurologic examination was normal. Repeat MRI examination at six months confirmed that the internal carotid artery had become patent with normal flow. After being anticoagulated for 6 months he started 100 mg of acetylsalicylic acid once daily."
+Brodie Holland,39,1990/1/12,001-792-710-3666x80317,daniel61@example.com,033 Neil Light,"We present the case of a 63-year-old man with progressive gait dysfunction and headache for four years. Computed tomography (CT) head revealed communicating hydrocephalus at an outside institution a year prior to our encounter (). He had been offered, but declined, a ventriculoperitoneal shunt (VPS) given his history of frequent falls, ataxia, and dizziness. We additionally learned of his cognitive decline, urinary incontinence, chronic headache, dysarthria, and intermittent walker use. Medical comorbidities included hypertension, hyperlipidemia, and a left cerebellar stroke 3 years earlier with evidence of basal ganglia lacunar infarcts on imaging. He had a 50-pack-year history of tobacco. He was on disability at the time of admission and had most recently lived alone with a pet cockatoo in New Jersey for 6 years. Previously, he had been a truck driver and had resided in Florida for 30 years, during which he had also cleaned wastewater treatment plants. Notably on exam, he was slow to respond and dysarthric and had dysmetria with finger-to-nose and heel-to-shin testing. Gait assessment showed a normal base but severe ataxia, an inability to put feet together, and minimal retropulsion ability.
+He had four serial lumbar punctures performed (), which revealed elevated protein (153??00 mg/dL), hypoglycorrhachia (19??7 mg/dL), lymphocytic pleocytosis (89??5% lymphocytes, WBC 67??03 mg/dL, and RBC 34??08 mg/dL), and normal opening pressure (13??6 cm H2O). Gait assessment was variable after large volume lumbar punctures (LPs) with no improvement after the second LP (gait assessment not performed after first LP) and some improvement after the third LP (distance walked improved from 2 to 6 ft in 20 sec and ability to lift legs off the ground more readily) and the fourth LP (ability to get up from the chair more readily and take few steps with less assistance). Empiric treatments while the diagnosis was pending included pulse dose intravenous methylprednisolone, carbidopa/levodopa, and acetazolamide.
+Direct CSF CrAg, both the Remel Cryptococcus Antigen LA (Thermo Scientific, Remel, Lenexa, KS) and the IMMY LFA (Immuno-Mycologics, Norman, OK), were performed on 3 of 4 LPs and were negative. Multiple direct antigen tests were utilized due to a high suspicion for cryptococcal meningitis. Fungal cultures were performed on the 1st and 4th collection of which only the 4th (high volume, 31 mL) had a light growth of C. neoformans on Sabouraud dextrose agar (SABs) 7 days after inoculation. The 4th collection was tested for prozone effect by both LA and LFA and remained negative. Since the initial colony type did not have typical morphology, a Remel Rapid Yeast ID panel was performed and provided an identification of C. neoformans. The rough colonies () were observed with India ink, noting an appropriate cell size but missing the capsule. Identification was confirmed by growth of dark colonies on birdseed agar (melanin production) and production of a positive reaction (pink) on rapid urea media. Additionally, matrix-assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF-MS) (Bruker Biotyper MicroFlex, Massachusetts) confirmed the isolate identification as C. neoformans. Upon subculture of the original colony to SABs, the colony began reexpressing capsule () as noted by both the colony appearance (white and mucoid) and India ink stain of the subbed colony.
+Following the positive culture, he was readmitted for induction with amphotericin B and flucytosine and consolidation/maintenance with flucytosine. He had a prolonged hospital course complicated by an epidural hematoma, deep venous thrombosis, pneumonia, and acute respiratory failure and unfortunately died due to complications.
+We sought to determine differences in the patient's immune response compared to individuals either without cryptococcal infection or infected with an immunocompromised state. We retrospectively compared levels of Th1 (IP10/CXCL10, IFN帠, TNF帢, GRO/CXCL1, interleukin (IL)-8, and IL12p40) and Th2 (IL10 and IL6) inflammatory cytokines using a fluorescent bead-based ELISA (Luminex簧) in patients with idiopathic intracranial hypertension (six noninfectious controls) and patients with cryptococcal meningoencephalitis (two HIV-positive, our immunocompetent patient, and one after cardiac transplant on immunosuppression). Although we were unable to evaluate statistical significance from inadequate sample size, shows relative higher levels of Th1 cytokines, higher levels of the Th2 cytokine IL10, and a lower level of IL6."
+Mariah Bruce,45,1988/12/30,755.846.1081x60641,mjennings@example.com,887 Walters Mill Apt. 288,"A 74-year-old lady presented to accident and emergency department with vomiting and general malaise. She was found to have an acute kidney injury and metabolic acidosis. She had no history of liver disease. The past medical history included a cardiac pacemaker in situ for 20 years. Liver function tests were normal. Renal function was impaired with an eGFR of 38 mL/min. Tumour markers including serum alpha-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 19-9 levels were within normal limits. Due to a history of recent weight loss, abdominal CT scan was performed, demonstrating a large liver tumour and complete situs inversus (Figures and ).
+The patient was considered unfit for surgery due to pulmonary hypertension and left atrial dilation/dysfunction. An echocardiogram revealed a dilated left atrium of 4.7 cm and an estimated left atrial volume of 68 mL. The decision was therefore undertaken to perform an ultrasound guided lesional biopsy. There was proliferation of epithelioid cells with an oncocytic appearance dispersed with an intervening florid lymphocytic reaction. Immunohistochemistry showed lesional cells staining for HMB-45 and smooth muscle actin. Hep-Par 1 and S100 stains were negative. Immunostaining for SAA was focal and proliferative activity was low, with Ki67 labeling less than 1% of neoplastic cells. The tumour was located in segment 8 in the right lobe of the liver and measured 61 ? 57 ? 46 mm.
+These appearances were compatible with angiomyolipoma. Due to the low proliferation index and the high risk of surgery, a decision was made for conservative management. Follow-up was conducted with ultrasound at three-month intervals. After one year, there has been no change in morphology or lesion size."
+Uriah Berger,28,1980/12/27,+1-831-734-4953x24871,ujones@example.net,2400 Reginald Ports,"A 73-year-old female patient reported in the Department of Oral & Maxillofacial Pathology of Guru Nanak Institute of Dental Sciences and Research, Kolkata, India, with the chief complaint of a painless swelling present over the tongue for the last four months. The swelling had increased gradually to attain the present dimension. The patient did not complain of any difficulty in swallowing, chewing, tongue movement, speech, and breathing. She had no deleterious oral habit. Her medical history revealed hyperthyroidism which was controlled with medication. General physical examination showed a moderately built, nourished female with steady gait and satisfactory vital signs. There were no signs of clubbing, anaemia, and cyanosis. Extraoral examination revealed nothing significant. Cervical lymph nodes were not palpable.
+Intraoral examination revealed the presence of a well-circumscribed, pale pink, round, single, soft to firm, sessile, nontender, nonpulsatile, slightly mobile nodule measuring about 1.0 cm ? 1.0 cm over the dorsum of tongue near the left lateral border. The overlying mucosa was nonulcerated and without any vascular prominence (). Oral hygiene of the patient was good. There was presence of carious broken left lower first molar and sharp cuspal edges of left upper first molar.
+Based on the clinical examination and history given by the patient, the growth was thought to be a benign neoplasm and a provisional diagnosis of ?ibroma??was made. Our differential diagnosis included lipoma, traumatic neuroma, neurofibroma, schwannoma, fibrous histiocytoma, granular cell tumor, leiomyoma, and rhabdomyoma.
+The patient's routine haemogram was found to be within normal limits. After written informed consent from the patient, an excisional biopsy was performed under local anaesthesia. A vertical incision was given to expose the tumor mass from the overlying mucosa and it was gradually separated from the surroundings through blunt dissection ().
+The gross specimen was well-circumscribed, yellowish white, and oval shaped and measured 10.0 mm ? 5.0 mm ? 5.0 mm in dimension (). Cut surface was homogenous, white, firm, and without any evidence of haemorrhage or necrosis ().
+Histopathological examination of the section stained with haematoxylin & eosin revealed the presence of a fibrous capsule at some places (). The tumor consisted of myxoid connective tissue stroma interspersed with numerous vascular spaces and elongated spindle shaped cells having wavy nuclei (). There was also proliferation of multiple spindle shaped cells and round cells with pale round to oval nuclei (). Based on the histopathological evaluation, a differential diagnosis of ?eurofibroma??and ?enign fibrous histiocytoma??was considered. Further, toluidine blue staining of the soft tissue section revealed numerous mast cells scattered in the fibrous stroma. Immunohistochemistry using vimentin, S-100, and CD-68 was done for confirmatory diagnosis. The tumor showed strong immunoreactivity for vimentin and S-100 and negative immunoreactivity for CD-68 (). Based on the clinical, histological, and immunohistochemical findings, a definitive diagnosis of ?eurofibroma??was made.
+The patient was further examined and her family history was elicited. Absence of caf矇-au-lait spots, Lisch nodules, and axillary freckling and no history of similar findings or growth in the family members helped to rule out NF-1. There were no signs of recurrence or NF-1 over a follow-up period of 12 months."
+Laylah Espinoza,18,1984/3/15,(982)270-9819x53777,umartinez@example.net,0553 Rodgers Meadows,"A 15-year-old female presented at our institution with a slowly growing mass in left groin, noted for 2 years, in menarcheal period. On abdominal examination, the lesion appeared as a smooth, nontender, irreducible mass measuring about 6 ? 2,5 cm, fixed in the left inguinal region, and had well-defined margins.
+The patient reported a previous failed surgical excision in local anesthesia, attempted in an adult surgery department of another hospital; the first attempt failed because of the unexpected intraoperative detection of the left ovary in inguinal region.
+The patient was, then, admitted to our institution 2 months later; the first surgical approach and a further US described a multicystic left ovary (5,5 ? 2,5 cm) in inguinal region with a hyperechogenous 3,3 cm nodule containing calcific inclusions ().
+Magnetic resonance imaging (MRI) showed a hernia sac extending into the left inguinal region and containing ovarian tissue with an inner cystic-solid mass; there were fat-fluid levels within the mass and a dissection plane between the mass and ovary was evident on MRI (Figures and ).
+Because of the suspected diagnosis of ovarian MCT incarcerated in an inguinal hernia, serum levels of alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (BHCG), and lactate-dehydrogenase (LDH) were investigated, revealing normal serum values.
+Surgical excision of the mass and reconstruction of the inguinal region were performed.
+During surgery the mass was detected at external inguinal ring and isolated from ovarian tissue (); the ovary, opened along its major axis, showed evidences of previous surgical operation; nevertheless, it appeared in good macroscopic condition of viability. Fallopian tube elements were isolated and mass was excised radically from ovarian tissue at which margins were sutured. Gonad and adnexa were replaced into abdominal cavity. Finally the hernia defect was repaired through a med mesh plug fixed on the margins of the internal inguinal ring. The inguinal canal was closed in double layer.
+The postoperative period was uneventful. Drain was removed on the third postoperative day and the patient was discharged on the third day postoperatively.
+At macroscopic pathology, the cystic mass revealed a sebum-like material containing hair. Histopathologic examination of the cyst wall showed keratin composed flooring epithelium with underlying connective tissue including skin adnexa and cylindrical ciliated epithelium. These morphological features were compatible with a MCT.
+So, the girl was enrolled in a clinical and imaging follow-up in order to detect any eventual relapse or involvement of the residual ovarian tissue. Pelvic US performed 24 months after surgery showed normal ovaries. Actually, she remains clinically well after a 30-month follow-up ()."
+Dallas Hubbard,39,2000/5/19,589-245-6433x078,louisallen@example.com,5081 Schneider Walk,"Patient is a 57-year-old woman that presented with an inflammatory syndrome in February 2008. Clinicians diagnosed her with multiple myeloma on the basis of a positive myelography, a monoclonal IgG-庥 gammopathy (M-protein: IgG 40 g/L; Kappa: 373 mg/L; Lambda: 195 mg/L), a 帣2-microglobulin 2 ? ULN, and a diffuse infiltration of the spine detected by MRI. From March 2008 until December 2009, gammopathy was treated with bortezomib followed by lenalidomide, achieving partial remission. In June 2009, spinal MRI was normal and IgG was 30 g/L with no other abnormalities of the blood count and without renal failure. In May and December 2009, this patient received antimicrobial therapy for two episodes of pneumococcal pneumoniae. In November 2010, spinal MRI was normal. In January 2011, a combination of bortezomib, liposomal doxorubicine, and dexamethasone was initiated following worsening of gammopathy (IgG: 53 g/L), with IgA 1.74 g/L, IgM 11.03 g/L, normocytic anemia (107 g/L), platelet count 208 ? 109/L, creatinine 45 弮mol/L, normal calcemia, LDH 2 ? ULN with anicteric cholestasis, 帣2-microglobuline 5 ? ULN. Karyotype was normal. After 4 chemotherapy cycles with poor hematological tolerance, IgG was 25 g/L, and allogenic SCT was proposed. Of note, the patient presented with a new episode of pneumococcal pneumonia in March 2011. In August 2011, the patient underwent HIV testing before SCT; she tested positive for HIV with severe immune depression (CD4+ cell count: 24 cells/mm3; normal value: 600??200) and HIV viral load 316228 copies/mL (5.5 Log10/mL). SCT was cancelled, and chemotherapy with bendamustin was proposed. An antiretroviral regimen combining tenofovir/emtricitabin/efavirenz and opportunistic prophylaxis (against pneumocystis jiroveci, toxoplasma gondii, and cytomegalovirus) was proposed by multidisciplinary staff, including a pharmacologist and virologist, to limit the risk of drug-drug interactions. After 34 months of followup, complete and sustained remission of gammopathy (IgG: 15 g/L; Kappa: 21 mg/L; Lambda: 21 mg/L; ratio 1.22) was achieved, associated with sustained HIV suppression and significant immune restoration (CD4+ T cell count: 450/mm3; 15%; ), which allowed for effective pneumococcal immunization without relapse."
+Rosie Shepherd,44,1982/6/15,(589)399-3666,dennis88@example.net,6968 Nguyen Forks Apt. 009,"The 2nd patient (BrS2) was a 67-year-old male with a history of syncope who presented with a type 1 BrS ECG during a hospital admission for an inferior myocardial infarction (). His ECG showed a prolonged PR-interval (230 ms) with a normal QRS-duration and QTc-interval. Moreover, the patient had episodes of paroxysmal atrial fibrillation. During electrophysiological investigation ventricular arrhythmia could be evoked, after which an ICD was implanted. Apart from the proband, no relatives were identified with a type 1 BrS ECG at baseline, while flecainide provocation tests in 15 first- and second-degree relatives revealed 6 individuals fulfilling the ECG criteria of BrS. In the patient? family, sudden cardiac death was reported in several members."
+Ronald Wright,43,1995/4/11,3948526525,michellebond@example.net,6753 Tony Plains Apt. 569,"The 3rd patient (BrS3) was a 24-year-old female who presented at the outpatient clinic because of episodes of syncope. She had a type 1 BrS ECG seen in ECG leads placed over the 3rd intercostal space cranially from V1 and V2 (). Additional electrophysiological investigation revealed inducible non-sustained ventricular tachycardias in the right-ventricular outflow tract, after which an ICD was placed. Conduction parameters revealed PQ-interval prolongation (220 ms), with a normal QRS-duration and QTc interval. Screening of family members by ajmaline provocation revealed 5 individuals fulfilling the BrS ECG diagnostic criteria among 12 individuals tested in whom no ECG abnormalities were identified at baseline. No history of sudden cardiac death was reported in the family of the patient.
+Genetic screening of the coding region of SCN5A did not uncover any novel or rare variants (MAF <1%) in the three patients. Moreover, BrS1 and BrS2 were negative for such variants in all other BrS-associated genes. BrS3 carried a rare variant in the CACNA1C gene (present in 5 of 120140 alleles in the ExAC database). However, this variant, which is present at position ?? of intron 19 (numbering according to Ensembl transcript ENST00000399634), does not appear to entail a nucleotide change that negatively affects splicing (pyrimidine to pyrimidine change in the polypyrimidine tract), and analysis of the wild-type and variant sequence surrounding the 3??splice site of intron 19 using three different splice site prediction programs did not uncover any splicing motif alteration. This led us to conclude that this variant has probably no impact on splicing."
+Lily Kane,22,1982/9/16,(854)366-7209x197,mackenziecallahan@example.net,44398 Wade Spur Apt. 850,"Before presentation of the case, informed consent was obtained from the patient.
+This patient was 28 years old female, married 5 years ago, at the GA of 20 wks referred with suddenly diffused abdominal pain. She had a history of infertility for 4 yrs and, appendectomy in 2008 & abdominal myomectomy in 2009 with Pfannestiel incision, which 19 myoma were extracted throughout the uterus and the patient was emphasized that termination of pregnancy should be with cesarean section. She also had a history of hysteroscopy and laparoscopy in 2013 for infertility follow up which was reported a lot of abdominal and pelvic adhesion. Patient had no history of pregnancy and just had an unsuccessful IVF attempt.
+This pregnancy was induced by IVF and prenatal care was performed by a specialist. The last visit was done about 2 wks ago and everything was reported normal via sonography, and there was no mention about the exact location of the placenta. On examination, the abdomen was tender in hypogastria and fundal height of uterus was about 20 wks. Observations showed hear beatt of 86 beats per min, and blood pressure (BP) was 90/60 mmHg. Sonography was performed in emergency ward urgently that showed free fluid in coledusac & pelvic fossa, fetus with bradycardia in amniotic sac in abdominal cavity, near the abdominal wall. In hemogram, Hb, HCT and PLT were 10.1 gr /dl & 29.8 & 238000 respectively, and other coagulation tests also were normal.
+After vital sign stability and fixing 2 IV lines and reserving packed cell for transfusion, patient transferred to operation room. An emergency laparotomy was performed immediately with simultaneous ongoing resuscitation. Intraoperative findings revealed about 1000 ml blood in abdominal cavity and between of intestinal loops. Uterus was torn in corneal zone and huge part of gestational sac with fetus and amniotic fluid moved away from tearing zone. Rupture was in uterus fundal and cornea in previous myomectomy scar (, ). During surgery uterus repair was done and 4 units packed cell and 2 units FFP were transfused. She was discharged from hospital with good condition."
+Brock Lozano,18,1981/7/23,8296095598,weekserica@example.net,13313 Ronald Park Suite 724,"A 54-year-old African-American man presented to our resident clinic at Johns Hopkins Hospital for discharge follow-up after admission for wrist pain and a suspected viral gastroenteritis. He did not have a primary care physician due to lack of health insurance and had been seen in our emergency department several times over the past year.
+He had been well until 7 months earlier when he developed unilateral pain and redness of his right eye. An ophthalmologic evaluation in our emergency department revealed anterior uveitis, which resolved with topical steroids. Five months later he sought care for right ear pain. Computed tomography (CT) imaging revealed inflammation of his pinna, consistent with auricular chondritis. This resolved spontaneously without treatment. Two months later, he again returned to our emergency department with pain and redness of his right wrist. He was diagnosed with cellulitis and empirically treated with oral clindamycin for 7 days with minimal improvement. Just 3 days later, he was admitted for sudden onset of fever and diarrhea. A viral etiology was suspected given the quick resolution of his symptoms and management with conservative therapy. He was discharged home within 48 hours with follow-up in our internal medicine resident clinic.
+At his out-patient visit a few days after discharge, he had persistent swelling of his right wrist that limited his ability to operate motor vehicles at his job as a valet. Further questioning revealed a 27 kg (60 pounds) unintentional weight loss over the past 6 months. He denied epistaxis, cough, hemoptysis, chest pain, dyspnea, recurrent ocular symptoms, rash, low back pain, abdominal pain, frequent stools, melena, or hematochezia. He had no significant past medical or surgical history. His family history was unremarkable. He did not smoke tobacco, drink alcohol, or use illicit drugs.
+On examination, he was a well-developed well-nourished black man who appeared comfortable. He was alert and fully oriented. His vital signs were within normal limits. He had no rash, oral ulcers, or cutaneous nodules. There was no lymphadenopathy. Sclerae were not injected. A comprehensive musculoskeletal examination revealed mild synovitis of his right wrist without overlying erythema but limited range of motion due to pain. Cardiac, pulmonary, abdominal, and neurologic examinations were unremarkable.
+A laboratory evaluation during admission revealed iron deficiency anemia with hemoglobin of 10.1 g/dL, and a white blood cell count of 12,100 cells/mm3 with a normal differential. His albumin was low at 2.9 g/dL, alkaline phosphatase was elevated at 182 U/L, and there was mild transaminitis. There was microscopic hematuria: red blood cells (RBC) 55/high-power field (hpf); he had normal creatinine and no proteinuria. His inflammatory markers were elevated with C-reactive protein 11.1 mg/dL and erythrocyte sedimentation rate 124 mm/hour. His fecal lactoferrin was positive. A chest radiograph showed a small ill-defined patchy infiltrate in the upper lobe of his right lung. An infectious workup included the following negative studies: bacterial stool and blood cultures, human immunodeficiency virus (HIV) viral load, cytomegalovirus (CMV) serum polymerase chain reaction (PCR), gonorrhea and chlamydia urine PCR, stool Clostridium difficile toxin, and stool ova and parasites. Anti-nuclear antibody, anti-mitochondrial antibody, anti-smooth muscle antibody, rheumatoid factor, and anti-cyclic citrullinated peptide were negative. His complements were normal. C-ANCA was positive at a titer of 1:40 with elevated proteinase 3 by enzyme-linked immunosorbent assay (ELISA; 102.6 units). Perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA) and myeloperoxidase by ELISA were negative.
+With infection effectively ruled out, his clinical picture seemed most consistent with GPA. He was seen in consult by rheumatology, and started on prednisone 60 mg daily with marked improvement in symptoms and laboratory abnormalities.
+However, 8 weeks later he developed hematochezia, left lower quadrant pain, and a perirectal abscess and fistula. A colonoscopy was performed and multiple biopsies were taken. Histologic examination of the biopsy from his descending colon (Fig. ) showed cryptitis and crypt abscesses. A biopsy from his rectum (Fig. ) showed early crypt distortion and basal plasmacytosis. In the absence of an infectious etiology, these findings were suggestive of a chronic colitis and/or IBD. There were no granulomas, vasculitis, or dysplasia.
+Treatment for IBD was initiated with azathioprine and infliximab with healing of his fistula and continued clinical improvement. Therapy was well tolerated. For the past 1.5 years, he has been doing well on the same therapy with no further GI or extraintestinal manifestations of IBD."
+Cecelia Esparza,22,1977/12/15,209.271.0122,vkim@example.com,193 Garcia Centers Apt. 770,"A 65-year-old woman was referred to perform a dacryocystorhinostomy for chronic epiphora with mucopurulent secretions resistant to several topical antibiotic treatments. The patient had no history of lacrimal plug, palpebral surgery or trauma. This patient had been initially diagnosed with chronic conjunctivitis and dacryocystis. However, her clinical presentation included a lower eyelid erythema and a red, pouting punctum expressing a mucopurulent discharge after bidigital massage (Fig. ). Slit lamp examination showed pericanalicular inflammation without lacrimal sac involvement. Probing and irrigation showed permeability of the lacrimal drainage system. Chronic canaliculitis was finally diagnosed and the patient underwent canaliculotomy under general anaesthesia involving a linear incision into the conjunctival side of the canaliculus, curetting of concretions and tubing with a silicone stent (Mini Monoka silicone stent, FCI Ophthalmics, Paris, France) for six weeks; followed by topical dexamethasone 1 mg/mL combined with tobramycin 0.3 % QID for 15 days. Culture of the secretions and concretions on 5 %-sheep blood Colombia agar incubated under a strict anaerobic atmosphere for seven days remained sterile but culture on a chocolate agar (PolyViteX, bioM矇rieux, Marcy l?toile, France) incubated in a 5 % CO2-enriched atmosphere yielded Aggregatibacter aphrophilius identified by matrix-assisted laser desorption ionization time-of-flight mass-spectrometry (MALDI-TOF-MS) with an identification score of 1.737. Using the disk diffusion method, the isolate tested susceptible to amoxicillin (minimum inhibitory concentration (MIC), 0.5 mg/L), ceftriaxone (MIC <2 g/L), gentamicin (MIC, 0.25 mg/L) and rifampicin (MIC <2 g/L). The microbial community structure of the canaliculitis was studied by Fluorescence in situ hybridization (FISH) incorporating probe EUB338 5??GCTGCCTCCCGTAGGAGT-3??labeled with Alexa fluor-546, specific for Eubacteria 16S rRNA gene and probe ARC915 5??GTGCTCCCCCGCCAATTCCT-3??labeled with Alexa fluor-488, specific for Archaea 16S rRNA gene. FISH revealed cocci detected by EUB338 probe (red fluorescence), while the ARC915 probe (green fluorescence) remained negative (Fig. ). Histological analysis after hematoxylin and eosin staining showed clusters of elongated microorganisms surrounded by neutrophils. After ablation of the silicone stent at six weeks, the four-month follow-up showed no sign of infection and the patient was judged cured."
+Carl Raymond,24,1988/7/17,(479)491-4246x164,lindarobinson@example.org,0141 Lynn Extensions Apt. 811,"A 54-year-old woman with no medical history presented with a complaint of periumbilical pain and weight loss. Physical examination indicated tenderness in the epigastrium. Her initial blood tests showed hemoglobin level, 13.4 g/dL; white blood cell count, 5600/弮L; platelet count, 281000/弮L; and levels of amylase, 48 U/L; lipase, 61 U/L; CA 19-9, 605 U/mL; and CEA, 1.2 ng/mL.
+Abdominal computed tomography (CT) and magnetic resonance imaging revealed a 3.5 cm, pancreatic mass abutting the celiac axis, splenic vein, and superior mesenteric artery. There was also hypermetabolic left inguinal lymphadenopathy. She was diagnosed with stage T4N1M0.
+The patient was initially treated with concurrent radiotherapy (total of 50.0 Gy) and chemotherapy of gemcitabine (600 mg/m2 weekly for 5 weeks). The patient was then treated with gemcitabine and erlotinib. Gemcitabine was administered at a dose of 1000 mg/m2/week for 3 weeks every 4 weeks, and erlotinib (dosed 100 mg once daily) was administered without cessation. After 2 cycles of chemotherapy, the patient visited the emergency room (ER) for epigastric pain, nausea, and vomiting. Abdominal CT scan showed a substantial decrease in the size of the pancreatic mass from 3.5 cm to 2.0 cm, but also revealed diffuse thickening of stomach wall (Fig. ). The patient underwent an esophagogastroduodenoscopy (EGD). Initial endoscopic findings revealed multiple, deep active ulcers in the gastric antrum (Fig. -), and microscopic examination of gastric biopsy specimens showed chronic gastritis. The patient discharged on anti-ulcer medication including a PPI. Two months later, she revisited ER with the same symptoms and gastric ulcers still were observed on subsequent EGD. The patient? symptom had relieved with symptomatic care. Therefore, she received 4 additional cycles of maintenance chemotherapy with gemcitabine and erlotinib and did not have any other side effects with chemotherapy. On the 6-month follow-up examinations, abdominal CT revealed improved thickening of the gastric wall and EGD showed improvement of the gastric ulcers (Figs. ; -)."
+Hadlee Trejo,37,1990/2/2,537.214.3622x9032,hodgewilliam@example.com,928 Corey Route,"A 70-year-old male was admitted to our hospital complaining of exertional chest pain on effort. His coronary risk factor was only hypertension. A twelve-lead electrocardiogram at rest demonstrated a normal sinus rhythm and no significant ST-segment change. Ultrasound echocardiography showed slight motion abnormality in the inferior wall. Coronary computed tomography angiography revealed an image which resembled coronary dissection in the mid-portion of the right coronary artery (RCA). Therefore, we performed cardiac catheterization with a left trans-radial approach, and a moderate stenotic lesion with some linear opacity was observed there (Fig. ). Also, the right ventricular (RV) branch bifurcated from the stenotic lesion (Fig. ,). Considering his clinical background and the findings of the examinations, we decided to perform percutaneous coronary intervention (PCI) for this lesion in the mid RCA.
+A 6Fr Sherpa NX ACTIVE JR4 guiding catheter (Medtronic Inc., MN, USA) was engaged in the RCA ostium, and a Sion blue guidewire (Asahi Intecc Co., Ltd., Aichi, Japan) was advanced along the side of the greater curvature of the RCA toward the distal RV branch. Then, we tried to introduce the Sion guidewire (Asahi Intecc) along the side of the lesser curvature of the RCA toward the distal RCA (Fig. -). We performed OCT scanning with a Dragonfly imaging catheter (St. Jude Medical, Inc., MN, USA) around the lesion, and typical pictures of a lotus root appearance were observed along the full length of the stenotic lesion (Fig. ). The OCT findings also clearly showed that the Sion blue guidewire branched off toward the RV branch from a point (Fig. ,Red arrows) more proximal than the true bifurcation point (Fig. , Arrowheads) and some partition walls existed between the two guidewires (Fig. ,). Therefore, we tried to re-cross the new third guidewire into the main RCA before deploying the stent. For that purpose, we used the Crusade catheter (KANEKA Corp., Osaka, Japan), a dual lumen microcatheter, mounted on the Sion blue guidewire in the RV branch, and re-crossed the third guidewire Fielder FC guidewire (Asahi Intecc) through the over-the-wire lumen of the Crusade catheter toward the main RCA via the nearer point to the RV branch ostium as close as possible (Fig. ). After re-crossing the third guidewire to the distal RCA, we checked the OCT mounted on this third guidewire (Fig. -). It was verified that the third guidewire crossed from the nearest point of the RV branch ostium to the distal RCA through the communicating vascular lumen (Fig. -).
+We inflated the scoring balloon NSE ALPHA (GOODMAN Co., Ltd., Aichi, Japan) with a 2.5-mm diameter and then deployed a Resolute Integrity drug-eluting stent (Medtronic) of 3.5/22 mm in the main RCA crossing over the RV branch (Fig. ). After re-wiring with the Sion guidewire through the stent strut to the RV branch with the Crusade catheter, we completed the procedure with kissing balloon inflation using a TREK balloon catheter (Abbott Laboratories, IL, USA) with a 3.5-mm diameter in the main RCA and Kamui balloon catheter (Asahi Intecc) with a 2.0-mm diameter in the RV branch (Fig. ). We inflated both balloon catheters to a pressure of 10 atmospheres. Finally, we performed proximal optimization therapy using a Hiryu balloon catheter (Terumo Corp., Tokyo, Japan) with a 4.0-mm diameter at the proximal lesion in the stent. The final angiogram demonstrated favorable dilation of the lesion in the mid RCA with good patency of the RV branch (Fig. ,).
+His chest symptom fully resolved after this intervention and no adverse events have been observed since then. We performed follow-up coronary angiography (CAG) at 8-month after PCI. Favorable blood flow was observed in both the main RCA and the RV branch, and OCT findings showed better strut apposition and coverage with neointimal formation."
+Wesson Bonilla,25,1997/5/8,759.396.5166x7891,sherryware@example.com,223 Goodwin Way Apt. 274,"This 60-year-old male was hospitalized due to moderate ARDS from COVID-19 with symptoms of fever, dry cough, and dyspnea. We encountered several difficulties during physical therapy on the acute ward. First, any change of position or deep breathing triggered coughing attacks that induced oxygen desaturation and dyspnea. To avoid rapid deterioration and respiratory failure, we instructed and performed position changes very slowly and step-by-step. In this way, a position change to the 135簞 prone position () took around 30 minutes. This approach was well tolerated and increased oxygen saturation, for example, on day 5 with 6 L/min of oxygen from 93% to 97%. Second, we had to adapt the breathing exercises to avoid prolonged coughing and oxygen desaturation. Accordingly, we instructed the patient to stop every deep breath before the need to cough and to hold inspiration for better air distribution. In this manner, the patient performed the breathing exercises well and managed to increase his oxygen saturation. Third, the patient had difficulty maintaining sufficient oxygen saturation during physical activity. However, with close monitoring and frequent breaks, he managed to perform strength and walking exercises at a low level without any significant deoxygenation. Exercise progression was low on days 1 to 5, but then increased daily until hospital discharge to a rehabilitation clinic on day 10."
+Romina Cunningham,26,1986/2/22,001-319-335-6604x102,ashley27@example.com,976 Finley Isle Apt. 192,"A 39-year-old man was hospitalized due to an increasingly reduced general health condition, after persistent fever and dry cough for 2 weeks. The patient initially needed 4 L/min of oxygen, had a rapid and shallow breathing pattern at rest and became severely breathless during minor physical activities. In the beginning, physical therapy focused on patient education about dyspnea-relieving positions, the importance of regular mobilization, and deep-breathing exercises. However, it quickly became evident that his anxiety from fear of dying and worries about his future aggravated his dyspnea and vice versa. The patient was so dyspneic, anxious, and weak that he was barely able to walk to the toilet. To counter this vicious circle, the physical therapist actively listened to the patient, explained why he was experiencing breathlessness, and tested suitable positions to relieve his dyspnea. He seemed to benefit from the education and the relaxing breathing exercises, as seen on day 2, when his respiratory rate could be reduced from 30 breaths/min to 22 breaths/min and his oxygen saturation increased from 92% to 96% on 4 L/min oxygen after guiding him through some deep-breathing exercises. Over the next days, his dyspnea and anxiety started to alleviate and he regained his self-confidence. Therapy was progressively shifted to walking and strength training and the patient rapidly advanced to walk 350 m without a walking aid or supplemental oxygen before his discharge home."
+Alejandro Huff,19,1998/1/2,001-377-733-5706x742,josephdoyle@example.net,3785 Bell Vista Apt. 578,"One week after a positive COVID-19 result this 57-year-old male was admitted to the ICU because of oxygen desaturation (70%) with worsening tachypnea and dyspnea. Physical therapy started immediately after ICU admission. We found a highly dyspneic patient with a high breathing frequency and significant symptom exacerbation from the slightest effort. With hands-on physical therapy guidance, the patient managed to achieve a 135簞 prone position and to perform deep-breathing exercises resulting in an increase in oxygen saturation from 88% to 96%. Intensive physical therapy and positioning was continued along with 6 to 12 L/min of oxygen therapy over the next days and intubation was avoided. The major challenges in achieving a prone position were the patient? profoundly reduced respiratory capacity and the high risk of exacerbating his symptoms. However, standard ICU monitoring enabled safe implementation at an individually adapted pace to allow sufficient time for convalescence. After 3 days with this regime, he could be transferred to the normal ward, where physical therapists carried on his rehabilitation with walking and strength training. The patient? severe instability remained a challenge. Nevertheless, 9 days after ICU admission, the patient was able to leave the hospital as a pedestrian."
+Karsyn Stone,42,2002/10/1,750-450-8910x47394,jerry85@example.com,9031 Smith Circle,"This 69-year-old male was admitted to the ICU after a dry cough for 2 weeks, oxygenation was poor and computer tomographic imaging showed typical COVID-19 pneumonia. Initially the patient received lung-protective ventilation and targeted sedation, but was otherwise stable. Treatment interventions included passive range of motion and positioning including passive mobilization into a side-edge position (). Over the next days, the patient deteriorated with hemodynamic instability and severe ARDS leading to intermittent prone positioning and continuous renal replacement therapy. The role of physical therapists during proning was to ensure correct joint positioning and pressure prophylaxis to prevent secondary complications such as nerve lesions, contractures, or pressure ulcers. Nevertheless, the long duration and repeated positioning resulted in a small pressure ulcer on the patient? forehead. After tracheostomy, passive range-of-motion exercises, and passive side-edge mobilization were slowly resumed, whereby asynchronous ventilation and hemodynamic instability remained 2 major problems leading to further sedation and relaxation, thus inhibiting any active participation. After 24 days in the ICU, the patient scored 1/50 points on the Chelsea Critical Care Physical Assessment Tool (CPAx) and showed severe signs of muscle loss. The patient died soon after withdrawal of life support."
+Finn Ayers,30,1996/5/27,633.426.7531x7572,briana57@example.org,5093 Edward View Suite 339,"This 57-year-old male was admitted to the ICU with dyspnea, heavy dry cough, and fever 6 days after testing positive for COVID-19. Initially, he was able to exercise and sit in a chair with a physical therapist, but progressive respiratory failure necessitated intubation and proning. The patient had large amounts of bronchial mucus and required regular suctioning along with respiratory therapy. Secretions were assessed with pulmonary auscultation (presence of crackles) and by analyzing expiratory flow on the ventilator (sawtooth pattern). When suctioning failed to improve these clinical signs, 1 to 2 physical therapists used manual airway clearance techniques. The goal of these techniques was to sufficiently increase expiratory flow for effective airway clearance while avoiding alveolar collapse. To achieve this, manual compressions on the chest and abdomen were performed with just enough intensity to modify expiratory flow. After extubation, the patient was still unable to effectively clear his mucus due to weak cough. He continued to need intensive manual airway clearance techniques, nasal rinsing to induce cough and to help expectoration as well as upper and lower airway suctioning. To this end, the patient was treated up to 6 times per day/night. Additional physical therapist interventions included passive range of motion, assisted exercising, and mobilization. At the time of writing, the patient was still in the ICU without ventilatory support."
+Simone Bravo,22,1980/2/27,-10278,millerchristopher@example.com,6815 Tammy Expressway Suite 066,"This 52-year-old male tested COVID-19 positive 4 days after the beginning of a dry cough, fever, and head and limb pain. One day later, he was hospitalized with exertional dyspnea. He was diagnosed with pneumonia that developed into moderate ARDS needing mechanical ventilation and intermittent dialysis. After extubation, oxygenation was stable with 2 to 3 L/min of oxygen. However, the patient was disoriented and could not communicate verbally. His global weakness (CPAx 11/50) was accompanied by oral and pharyngeal weakness and paresthesia. Spontaneous swallowing frequency and tongue control were severely reduced, and the patient showed insufficient protection from aspiration. This was confirmed by a specialized physical therapist with the Gugging Swallowing Screen, which confirmed severe dysphagia with 2/20 points. He was treated nil by mouth and received dysphagia therapy such as intensive oral stimulation, facilitation of swallowing, and training of protection mechanisms. After initial agitation and disorientation, the patient started to communicate in single-word phrases, but dysphagia continued to be severe with massive oral and pharyngeal dry saliva residuals that compromised his paresthesia and required regular mouth care. Over the next days, the patient managed to swallow pure矇d food and mildly thick fluids under supervision, although cough strength was still weak (Gugging Swallowing Screen 13/20, CPAx 30/50). Nevertheless, he continued to progress and became capable of independent food ingestion (Gugging Swallowing Screen 20/20, CPAx 39/50) before his discharge to a rehabilitation clinic 25 days after admission."
+Genesis Reeves,21,1986/11/17,444-714-4640x41873,tammie80@example.com,799 Larry Prairie,"Paramedics found this 59-year-old female with dyspnea and an oxygenation of 65% on room air and performed immediate tracheal intubation. Moderate ARDS with reduced lung compliance was diagnosed and treated with deep sedation, neuromuscular blocking agents, and prone positioning.
+On day 14, a trial of sitting on the edge-of-bed (SOEB) was performed, while she was still intubated and under pressure support ventilation. SOEB required 3 physical therapists to maintain the position, but resulted in a significant increase in her level of consciousness and collaborative state. The next day, she was able to hold her head and sit for about 15 minutes with 2 therapists. Her muscle strength indicated ICU-acquired weakness, with a Medical Research Council sum-score (MRC-SS) of 40/60; still she continued with small but consistent improvements and started to participate actively in physical therapy sessions. She was encouraged to mobilize herself with exercises against gravity and was actively transferred to a chair each day with the help of 2 physical therapists. She was successfully extubated, but presented postextubation dysphagia. The physical therapy team closely monitored her for secretion management and cough stimulation and continued her physical rehabilitation. On day 19, she started to walk with a walking aid, although at this point oxygen desaturation during exercise training became evident (89% with 3 L/min of oxygen). After 25 days, she was transferred to the institution? rehabilitation facilities, where a battery of tests indicated persistent physical function impairment (MRC-SS 52/60, physical function ICU test score17 9/12, Timed Up & Go 23 seconds, short physical performance battery 4/12)."
+Lana Edwards,28,2001/10/21,001-871-432-0567,williamschristina@example.net,5044 Mccullough Mountain,"We report a rare case of a cough related stress fracture of the ninth rib, traumatic rupture of the diaphragm and abdominal herniation in a patient with a chronic cough history.
+A 59 year old male patient (86 kg; 1,75 m) collapsed at home following intensive coughing. The medical history includes hypertension being treated with a beta-blocker, house-dust-allergy, chronic bronchitis related cough, and two operations on a spinal disc prolaps. The patient is known to have smoked (15 pack years).
+There was no previous history of trauma.
+On admission to hospital examination revealed a 10 cm well demarcated area of haemorrhage in the right side of the epigastrium. The abdomen was painful, but soft with no palpable mass or herniation. An abdominal computed tomography showed a fracture of the ninth right rib with a surrounding haematoma and hematothorax; however, no bowel herniation or muscle tear was evident (Fig. , ). A thoracic drain was inserted for two days. During the hospital stay the patient's abdomen became meteoristic and painful. He had no bowel movements for five days. A CT scan confirmed an intestinal obstruction, showing an ileus due to a massive herniation on the right lateral side of the abdomen (Fig. , ). An operation followed in which a crosswise incision along the ninth rib was made. The herniation was reduced without bowel resection. During the operation a rupture of the diaphragm also was found. The diaphragm and the internal and oblique abdominal muscle were adapted and the abdomen was reinforced with a prolene net.
+Post operation the patient remained intubated for six days to prevent coughing.
+At the time of discharge the patient was well. A clinical and radiographic investigation six months later showed no renewed herniation, and the patient remained well."
+Adrian Reyna,42,2000/4/4,7609982051,heathersmith@example.org,82008 Michael Gardens Suite 415,"A 68-year-old man with a diagnosis of anemia was admitted to Wakayama Medical University Hospital. He had a history of extended right hepatectomy for hilar cholangiocarcinoma (stage 2) 20 months earlier. On arrival, his blood pressure and pulse rate were 99/54 mm Hg and 101/min, respectively. Initial laboratory studies showed his hematocrit and hemoglobin were 25.8% and 8.2 g/dL. Nasogastric tube lavage revealed a material that looked like coffee grounds. Emergent gastrointestinal endoscopic examination was performed immediately and disclosed a giant peptic ulcer with active bleeding at the posterior wall of the duodenal bulbs (Figure ). Angiography was performed for the bleeding duodenal ulcer, which was not controlled by endoscopic hemostasis. Extravasation of contrast medium was not noted at the artery around the duodenum; however, transarterial embolization (TAE) was accomplished for the duodenal branch of the gastroduodenal artery. Massive hematemesis and anal bleeding occurred on the sixth day after the first TAE. The bleeding point of the ulcer was endoscopically treated with a clip (Figure ). Nevertheless, because bleeding from the duodenal ulcer occurred repeatedly, endoscopic treatment and TAE was performed, and endoscopic hemostasis was performed on the 10th, 14th, and 17th day, and TAE was performed on the 10th, 14th, 19th day. Finally, we embolized the common hepatic artery, the bilateral subphrenic artery, and the jejunal branch for hepaticojejunostomy. However, the patient died of sudden massive hematemesis on the 20th hospital day. At autopsy, a peptic ulcer measuring 1.5 cm was present in the bulbus of the duodenum. The communication with the main portal vein and duodenal ulcer was manifested by insertion of a stick (Figure )."
+Luella Gibbs,44,1981/11/24,642.284.2668x87618,melissa03@example.net,017 Meadows Drive Apt. 663,"A 77-year-old Caucasian female presented to the Head & Neck Unit/University College London Hospital with one month history of altered voice, no other associated symptoms were reported.
+The medical history of the patient included respiratory failure secondary to childhood polio at the age of ten; the airway management included performing a surgical tracheostomy. She had been managed with cuirass ventilation for numerous years but was recently maintained on unassisted ventilation using a silver negus tracheostomy tube. There was no other significant medical, family or social history.
+Clinical examination showed she has low volume hoarse voice, but was otherwise normal apart from a tracheostomy.
+Flexible naso-laryngoscopy revealed normal but paralyzed vocal folds. Unusually she had a soft mass arising from the posterior pharyngeal wall obscuring the view of the posterior commissure and vocal folds. The shape of the mass altered with respiration and on performing valsalva maneuvers (Figure ). A plain lateral neck radiograph revealed a large air filled sac originating from the laryngeal cartilages and extending along the posterior pharyngeal wall (Figure ).
+The diagnosis of a laryngocele was primarily made on the basis of the laryngeal examination, confirmed by the presence of an air filled saccular cavity on plain radiography. The patient was then treated by endoscopic laser marsupialization and reviewed annually."
+Deacon Espinoza,29,1985/2/5,(854)345-7886x26776,lmcclure@example.org,8261 Hall Shoals Suite 841,"A 26-year-old male suffering global ischemic/hypoxic brain injury after attempted suicide by hanging was admitted to University College London Hospitals (UCLH) intensive care unit for resuscitation following respiratory arrest. The patient remained in coma for 12 days with Glasgow Coma Scale (GCS) of 3??. Gradual improvement was noticed and the patient started showing signs of alertness and increasing muscle tone of the upper and lower limbs, however they were still in spasm (flexion of upper limbs and extension of lowers). CT scans revealed diffuse low attenuation change in the supratentorial compartment, loss of grey-white matter differentiation and loss of sulcus pattern due to cerebral swelling; a diagnosis of global ischemic/hypoxic brain injury was then reached.
+After one month, the patient responsiveness to touch and voice increased, he responded to eye contact and answered questions by yes/no and his GCS reached 15. However, he continued to suffer muscle spasm, have no control over his bladder or bowels and had difficulty in speaking as well as feeding problems; he is currently under multidisciplinary care.
+The patient was then referred to the Department of Oral & Maxillofacial Surgery (OMFS), UCLH suffering from trismus and bruxism. Clinical examination revealed a mouth opening of 0 mm; the patient was fed by a Percutaneous Endoscopic Gastrostomy (PEG) tube as oral feeding was impossible. Botulinum toxin was then suggested as a possible treatment for his problem.
+The treatment (injections) was carried out in the following visit. Botulinum toxin-A (Botox; Allergan Inc, Irvine, CA) was injected into the right and left masseter and temporalis muscles. One hundred units were reconstituted with 2.5 mL of sterile preservative-free saline and drawn up into an insulin syringe. The skin was cleansed with an alcohol wipe, and the masseter muscle was palpated at its insertion at the angle and body of the mandible. Two injections of 4 Units (2 ? 4 U) were given 1 cm superior to the inferior border of the mandible and two other injections of 4 Units (2 ? 4 U) were given 1 cm inferior to the inferior border of the zygomatic arch. A fifth injection (1 ? 4 U) was given in the centre of the masseter muscle. Three more injections of 4 Units (3 ? 4 U) were given 1 cm inferior to the origin of the temporalis muscle. The process was repeated on the contralateral side. (Figure )
+Three weeks later, the patient was reviewed and had shown a great improvement in his trismus with a mouth opening of 15 mm, with no bruxism reported. There was no erythema, swelling, or any clinical abnormality at the injection sites.
+Botox was injected again in the masseter and temporalis muscles 2 weeks later. One week after the second treatment, the patient showed signs of good recovery from trismus and the mouth opening was 20 mm. The patient was discharged from the OMFS care but continued to be under the care of the multidisciplinary team."
+Lucille O’Neill,43,1984/4/29,311.977.4656x44872,sextonjoshua@example.org,291 Lawson Trail,"Case 1: A 57 year-old Caucasian man had a previous history of cataract surgery, left eye (OS), in 1984. In 2000, the patient presented with recurrent orbital cellulitis and endophthalmitis OS. The OS was blind and painful and an enucleation was performed (Figure ). Histopathology revealed a malignant uveal melanoma, epithelioid cell type (Figure ), invading the sclera and orbital tissues. No signs of metastatic disease were detected after four years of follow-up."
+Marcel Maddox,36,1997/1/11,620-348-6246x74409,philip48@example.org,60597 Norris Mills Apt. 199,"Case 2: A 54 year-old Caucasian man suffering from Steinert's syndrome had a blind, atrophic OS since 1980. Past medical history includes systemic hypertension and several ophthalmic procedures OS, including a cataract surgery (1971) and a rhegmatogenous retinal detachment (1978). In 1992, the patient presented with pain in the OS and an uneventful enucleation was performed (Figure ). Histopathologic examination disclosed a monotonous and diffuse proliferation of small lymphocytes in the uveal tract with extra ocular extension. Immunohistochemical study was strongly positive for CD20 (B lymphocytes) and negative for CD45RO (T lymphocytes), consistent with a well-differentiated B-cell lymphoma (Figure ). No signs of systemic involvement were detected. The patient was lost to follow-up six years after surgery.
+Severe pain may develop in blind eyes for various reasons including surgical and non-surgical trauma, and retinal detachment. Management of a blind painful eye represents a challenge for the ophthalmologist and is limited to topical medications, retrobulbar alcohol injection, evisceration or enucleation.[]
+Relief of ocular pain is the most common reason that enucleation is performed in BPE.[] In the past, ocular melanomas arising in a BPE could account for more than 10% of all diagnosed uveal melanomas.[] Volcker and Naumann[] in 1976 described 36 cases of unsuspected ocular melanoma that were diagnosed after enucleation. The clinical diagnoses in those cases were secondary glaucoma (30), retinal detachment (2), iritis (2), and end/panophthalmitis (2). Review of the literature today shows that the clinical suspicion rate of an intraocular malignancy in BPE is not well established. Previous studies of enucleated globes do not correlate blindness with unsuspected intraocular tumors.[]
+In this particular report, the unsuspected melanoma was present in a blind painful eye of a mentally handicapped patient. Intraocular lymphomas of the uveal tract have been discovered in functional eyes with symptoms of retinal detachment and increased intraocular pressure.
+Intraocular tumors arising in blind painful eyes are probably under diagnosed and underreported. Several uveal melanomas, [,,] two adenocarcinomas of the retinal pigment epithelium [,] and an unspecified sarcoma [] have been described (Table ). In two of those cases, enucleation was performed to relieve the pain and an early stage malignant tumor was found,[,] leading to a good prognosis. However, in cases with advanced disease and extra-ocular involvement, an enucleation was performed due to a high index of suspicion of an intraocular malignancy.[-] In those cases the prognosis was poor.
+Several authors emphasized the importance of ultrasonographic studies to diagnose intraocular tumors in blind painful eyes.[,]"
+Zainab Barajas,35,1996/12/25,001-521-731-7071x1602,jessicapowell@example.net,609 Anderson Branch,"A 55-year-old man presented to our hospital complaining of fever, rash, and a sore mouth. Twenty-three days prior the patient had undergone orthotopic liver transplantation for chronic active hepatitis C with a T1N0M0 hepatocellular carcinoma. His transplantation was without immediate complication, and he was discharged on the following new medications: bactrim ss daily, aspirin 325 mg daily, azothioprine 100 mg daily, tacrolimus 2 mg daily, and valgancyclovir HCl 900 mg daily. The patient had been treated with antithymocyte globulin during induction of immunosuppression.
+The patient did well until 17 days after transplant when he presented with fever. Abdominopelvic computed tomography demonstrated a hepatic subcapsular hematoma, and he was treated with piperacillin/tazobactam for a presumed infected hematoma. He was discharged on posttransplant day 21 on oral ampicillin/sulbactam. Shortly after discharge, he developed diffuse erythroderma, fever, and a sore mouth and returned to the hospital. The burn service was consulted.
+The patient was ill-appearing with an oral temperature of 104簞F, a heart rate of 122, a blood pressure of 120/64 mm Hg, and a respiratory rate of 24; he had widespread macular erythema and a few hemorrhagic bullae, as well as oropharyngeal ulceration. Nikolsky's sign was positive in multiple locations. He was admitted to the burn intensive care unit and topical antimicrobials were applied to his wounds.
+The patient had no known drug allergies. His past history was notable only for type 2 diabetes mellitus and ethanol dependence (abstinent for 1 year). He was taking no alternative medicines. The patient's laboratory results were notable for a serum creatinine level of 1.4 mg/dL (increased over a normal baseline) and a white blood cell count of 0.1 with a differential showing no neutrophils. A skin biopsy revealed full-thickness epithelial necrosis, consistent with a diagnosis of Stevens-Johnson syndrome or TEN. There was a sparse lymphocytic infiltrate in the papillary dermis.
+Although his airway was initially stable, within 24 hours of admission he was intubated for airway protection as his oropharyngeal mucosa began to disintegrate. Meanwhile, his bullous erythroderma progressed until most of his epidermis had sloughed off and he developed intermittent atrial fibrillation and a vasopressor requirement. In consultation with infectious disease medicine and transplant surgery services, the patient was begun on empiric vancomycin and aztreonam and all of his immunosuppressants were held except for tacrolimus (dose adjusted down).
+Over the next several days, the patient's condition continued to decline with anuric renal failure and Staphylococcal/Candidal septic shock. Filgrastim failed to evoke an increase in his circulating neutrophils. He became progressively hypothermic and his septic shock worsened. An ultrasound of the hepatic artery showed that it was patent. Continuous renal replacement therapy was started 4 days after admission. The patient gradually became increasingly acidotic and hypotensive and died 7 days after admission. The patient was given human intravenous immunoglobulin (IVIG) during his course because of a very low measured serum IgG level. At the request of the transplant surgery service, he also received a short course of high-dose solumedrol. Among candidate etiologic agents, sulfa and beta-lactam antibiotics stood out: both of these had been started within the 3 weeks prior to the patient's presentation with TEN and both are known to be frequently implicated in TEN.,"
+Brennan Singh,20,1992/3/29,485-838-8414,victoria16@example.org,95509 Dean Keys,"A 64 year old Caucasian male presented to the Emergency Department with haematemesis and melaena for 3 days. He was a known smoker with no history of analgesic or alcohol abuse. 28 years previously, he had sustained a stab injury to left hypochondrium for which he was managed conservatively.
+On examination he was pale, tachycardic and hypotensive (pulse rate of 106/min, blood pressure of 94/55 mm of Hg and saturating 100% on air). Systemic examination revealed no abnormality except black tarry stools in the rectum.
+Haemoglobin concentration on admission was 5.9 gm/dl, with a serum urea concentration of 16.2 mmol/lit and serum creatinine of 116 mmol/lit. Liver function test including clotting profile, auto antibody and hepatitis B & C screen were normal. A chest radiograph done revealed opacity in the left lower zone (Fig ).
+He responded transiently to fluid resuscitation with the haemoglobin concentration falling to 4.9 gm/dl. An urgent upper gastrointestinal endoscopy was done, which revealed the presence of antral erosions in the stomach and complex gastricfundal varices. No therapeutic intervention was performed.
+An ultrasound scan of abdomen revealed an enlarged spleen (15.2 cms), portal vein measuring 11 mm in diameter (upper limit of normal) and prominent veins noted at the splenic hilum. The liver and biliary tree appeared normal.
+A computerised tomography scan of abdomen in arterial and venous phase confirmed the presence of a diaphragmatic tear and the spleen to be lying in the left hemi thorax (Fig ). Considerable number of varices was demonstrated in the splenic hilum and perigastric region. The portal vein, its confluence with the splenic vein and the superior mesenteric vein were patent. The appearances of the splenic vein on the scan were consistent with thrombosis.
+A diagnosis of left sided portal hypertension as a result of isolated splenic vein thrombosis secondary to trauma causing a diaphragmatic tear and splenic herniation into the left hemi thorax was made. The patient was offered splenectomy with diaphragmatic repair to treat his splenic vein thrombosis and gastric varices.
+The patient declined to have surgery and self discharged himself against medical advice."
+Vivienne Munoz,25,2003/6/20,668.573.9245,hbaker@example.net,8184 Arthur Tunnel,"A 47-year-old male individual was involved in a fight and sustained a human bite resulting in almost a complete amputation of his right ear. Only the ear lobe was left intact. The amputated auricle was placed in a plastic bag with saline, surrounded by ice, and brought to the emergency room with the individual. The patient was immediately started on intravenous antibiotics (Ampicillin/Sulbactam 3 g qid plus metronidazole 500 mg qid), and was led to the operating room approximately four hours following the accident. There, it was decided to reattach the ear as a composite graft. In order to enhance the ""take"", the epidermis and outer layer of the dermis of the posterior aspect of the graft were sharply excised with a scalpel. In addition, multiple small fenestrations were made in the cartilage and posterior-anterior perichondrium. The skin margin of the amputated stump was dermabraded for a distance of 0.5 mm from the edge and a postauricular flap was elevated. Both the graft and the amputated stump of the ear were meticulously cleaned with rigorous use of normal saline and povidone iodine 10%. No injection of topical vasoconstricting agents was used. The anterior skin of the graft was sutured in layers to the amputated stump of the ear and the skin of the helical rim was sutured to the elevated postauricular flap. Two vicryl 3-0 sutures were used for fixation of the graft to the tissues of the mastoid bed (Figure ). A Penrose drain was inserted and a loose bandage was applied. The drain was removed three days later and the patient received additional treatment postoperatively with pentoxiphylline orally (400 mg q8h). Antibiotics were administered for a total period of ten days (five days I.V and five days orally). The patient was strongly advised to stop smoking, and was released from hospital on the 7th postoperative day. The ear developed some epidermolysis during the first 3 weeks following surgery but went on to reepithelialize spontaneously (Figure ). Finally, the replantation was deemed absolutely successful. Three months later, the patient underwent a second operation during which the ear was elevated and the postauricular area was reconstructed with the use of a split-thickness skin graft. No complications have been noted after more than 18 months of follow-up, except of an approximately 10% diminishing in the total size of the auricle compared to the normal side (Figure )."
+Justin Ramirez,45,2004/11/17,431-670-2300,yhenry@example.net,1602 Wilson Shores Apt. 038,"The patient was a 70 year old woman, with a history of diabetes mellitus, who was admitted to the hospital with confusion and inability to walk. Six months prior to admission, her relatives had started recognizing neurological symptoms, such as gait disturbance, memory loss and behavioral disturbances (irritability and aggression). Over the six month period that preceded the admission to the hospital, a rapid deterioration of her cognitive function was observed. She also displayed visual hallucinations and delusions requiring antipsychotic treatment.
+On admission, the patient was bedridden, incontinent, severely confused with generalized hyperreflexia, bilateral Babinski sign, startle responses elicited by mild external stimuli, and multifocal generalized myoclonus which evolved to rhythmic. Two months later she developed akinetic mutism. The patient died three months after hospitalization.
+Routine hematological and biochemical examinations produced normal results. CSF examination (protein, glucose and cell count) was normal, while EEG showed generalized findings, periodic triphasic sharp waves, recurring at intervals of 0.5?? sec (Fig ). Magnetic resonance imaging of the brain showed no significant abnormalities, except for a minor brain atrophy which could be related to the patient's age.
+There was a lack of family history concerning neurological disorders. Although the clinical course followed the typical rapid progression of CJD, the relatives did not consent to having a neuropathological examination carried out, neither did they agree to further genetic investigation of the immediate family members, and thus it has not been possible to determine if the mutation has been passed to the patient's offspring.
+Cerebrospinal fluid (CSF) was collected by lumbar puncture. Both the lumbar puncture and the EEG, were performed three and eight days after the patient's admission to the hospital (about six months after the occurrence of the reported symptoms observed by family members).
+The proteins contained in 30 弮l of CSF were separated on a 12% polyacrylamide gel and then transferred onto a polyvinylidene fluoride (PVDF) membrane. The membrane was stained as described [] with a polyclonal anti-14-3-3帣 antibody (Santa Cruz, sc-629) and an alkaline phosphatase conjugated secondary antibody (Pierce, 31340). CDP-Phototope Star (New England Biolabs, N701) was used to develop the membrane.
+Detection of 14-3-3 protein in CSF, is considered to be a sensitive and specific marker for sporadic CJD. CSF tested positive twice for the presence of 14-3-3 protein (Fig. ), supporting a probable CJD diagnosis [,].
+Genomic DNA was isolated from whole blood using Promega's Wizard genomic DNA purification kit according to the manufacturer's instructions. The proper quality and quantity of the genomic DNA for polymerase chain reaction (PCR) amplification was confirmed by spectrophotometry. The PRNP open reading frame was amplified by PCR with the following primers designed as cloning primers; HumoS: 5'- GCT CTA GAG CAT GGC GAA CCT T and HumoAS: 5'- GCT CTA GAT CAT CCC ACG ATC AGG AA. The bases of the primers corresponding to the open reading frame of PRNP are shown in bold. Amplification was confirmed by agarose gel electrophoresis. Sequencing was performed first at MWG-Biotech (Ebersberg, Germany) and then the sequencing results were confirmed by two other independent laboratories (Department of Neurology, University of Crete, MRC Prion Unit and Department of Neurodegenerative Diseases, University College, London).
+PRNP sequence analysis revealed the existence of a causative mutation at codon 193. Upon comparison with the 762 bp sequence of the human PrP cDNA record (Genebank accession number M13899), it was found that the sequenced PRNP gene exhibits a point mutation at codon 193, comprising nucleotides 577??79. The point mutation occurs as a C to T transition at position 578 which causes the switch of codon 193 from ACC, encoding threonine, to ATC, encoding isoleucine. As shown on the electropherogram (Fig. ), the patient is heterozygous for threonine and isoleucine at codon 193. The patient was found to be homozygous for methionine at codon 129 (M129)."
+Grace Preston,18,1979/11/14,7438939975,xmiller@example.com,742 Michael Radial,"A 39-year-old married housewife with 2 children aged 16 and 12 years was electively admitted for treatment of worsening depression.
+She had a 5-year history of recurrent severe depressive episodes; there had been no history of mental health problems prior to this. She had been an in-patient for most of the last 5 years, and had required one-to-one nursing on one admission because of self-harming behaviour, which included cutting and trying to set herself on fire.
+She had been raped at the age of 12 years; however, prior to her first episode of depression she had a well-adjusted pre-morbid personality, having not had any symptoms suggestive of post traumatic stress disorder prior to her history of depression. A diagnosis of post traumatic stress disorder had been considered, however, rejected because her depressive affective symptoms dominated her clinical presentation, and she did not suffer flashbacks to her index traumatic episode. Other diagnoses that merited consideration included schizoaffective disorder and bipolar disorder, however, she did not suffer from first rank symptoms of schizophrenia or hypomanic/manic episodes which excluded her respectively from both of these diagnoses according to ICD-10.
+The depressive symptoms followed soon after a triggering event of a horse-riding accident from which she suffered concussion. A CT scan at the time was reported as normal.
+She had a family history of mental disorder, with a sister who suffered from schizophrenia.
+During this present admission she had experienced 5-month deterioration in mood. She had a 1-week period of insomnia and increasing suicidal ideation. There was no history of alcohol/substance misuse or any medical problems. She had been receiving ECT treatment twice weekly in the community for the 4 months preceding the admission. The ECT continued after she was admitted. Her medication was:
+Lithium carbonate 1000 mg once daily
+Mirtazapine 60 mg at night
+Olanzapine 20 mg at night
+Chlorpromazine 50 mg at night
+On MSE, she had psychomotor retardation with poor eye contact and a constant rocking motion. Her affect was melancholic. There was no formal thought or perceptual disorder, or evidence of cognitive impairment.
+On 13/8/01 she was started on a 4-day course of dexamethasone, which is an unusual but published treatment for resistant depression (Dexamethasone augmentation in treatment resistant depression Acta Psychiatr Scan 1997; 95 58??1). There were no obvious beneficial effects, and she still felt low in her mood, now with a blunted affect. Her speech was slower and more monotonous. She had decreased motivation. She had worsening suicidal ideation.
+On 19/8/01 the patient became very agitated and started lashing out. Several staff members were needed to restrain her and she was sedated with IM lorazepam. The following day she reported hearing voices of her rapists saying derogatory comments to her.
+The patient's mirtazapine, chlorpromazine and olanzapine medication were stopped and she was started on haloperidol and amitriptyline. Two days later, she started experiencing second person auditory hallucinations of the rapist who assaulted her in her childhood. She became more restless and agitated. Her suicidal ideation increased and she had difficulty thinking clearly. She continued to receive ECT treatment and her medication was increased to 200 mg amitriptyline and 40 mg of haloperidol.
+We felt it was important to formulate an EBM question that could be researched in view of possible treatment approaches that we could offer. We had already tried her on a variety of medical treatments, which had limited benefit.
+The question formulated was as follows: 'In a patient who has depression with psychotic symptoms, is the use of clozapine and an antidepressant more beneficial than standard treatments for psychotic depression, in improving mood and psychotic symptoms.'
+The literature search that was conducted used the following databases:
+Cochrane Database, ACP Journal Club, CCTR, 1986??002
+Medline 1966??002.
+EMBASE 1993??996.
+PSYCHINFO 1887??002
+The manufacturers of clozapine were also contacted.
+The keywords used were:
+1 'Depression/Depressive disorder/mood disorder/affective disorder/Psychosis/Psychotic'
+2 The above keywords were combined with 'clozapine and antidepressant agents'.
+The search was originally limited to the years 1986??002, English language, and human research (however, the limitations were not valid in Cochrane, ACP, DARE, CCTR). However, an up to date review on the above databases up to 2006 was conducted on follow up of the patient which yielded no further pertinent papers.
+The original search initially yielded 147 articles but on further inspection only 8 were thought to be pertinent to the question. The lists of references for these papers were also reviewed."
+Vincenzo Bonilla,18,1995/8/26,415-302-5495,lcarlson@example.org,088 Benjamin River Suite 775,"A 52-year old obese man with known ischemic heart disease but no history of any neurological disease underwent coronary artery bypass surgery. Preoperative routinely performed diagnostic workup revealed no significant findings. During surgery he was laid supine on the operating table with both arms fully adducted to his side, fixed in the neutral position. Intraoperative monitoring included electrocardiography, pulse oxymetry and automatic blood pressure monitoring using a standard-size adult cuff affixed to the patient's right upper arm. No particular events occurred during anesthesia or surgery and recovery was good so that patient was transferred within a day from the intensive care unit to the normal ward.
+However, on the first postoperative day he complained of wrist drop on the left. Neurological examination revealed a severe decrease in muscle power of the wrist and finger extensor muscles (0/5 MRC) and a slight brachioradialis paresis (4/5 MRC) accompanied by hypoaesthesia on the radial aspect of the dorsum mani. Biceps and triceps reflexes on the affected left arm were normoactive whereas the brachioradialis reflex was diminished. All muscles innervated from the median and ulnar nerve, as well as all the muscles above the elbow remained unaffected. The clinical diagnosis of radial nerve injury was set and rehabilitation therapy was recommended.
+After hospital discharge and about three weeks after surgery the patient was referred for neurophysiological evaluation. In the meanwhile the extensor muscles had already begun to improve. Nerve conduction studies of both radial nerves were performed using surface electrodes. Compound muscle action potentials (CMAP) were recorded from the extensor digitorum communis muscle. The opposite radial nerve was examined for comparison. Supramaximal nerve stimulation was achieved by gradually increasing the stimulation power until the point where the amplitude of the waveform did no longer increased was reached. Electrical stimulation at the elbow, below and above the spiral groove, revealed an amplitude decline of the CMAP that was indicative of a partial conduction block of the left radial nerve along the spiral groove, whereas CMAP recordings of the right radial nerve were normal (Table ). Moreover, motor axonal loss due to wallerian degeneration distal to the site of the lesion was suggested by the low distal CMAP. Needle electromyography enhanced this finding by revealing moderate impairment in recruitment with fibrillation potentials in radial innervated muscles below the elbow and normal findings in both triceps and deltoid muscles. The motor unit potentials were normal, a finding that is consistent with a recent nerve injury. In conclusion, all electrophysiological findings were indicative of a radial nerve injury in the spiral groove. The involvement of the brachioradialis muscle and the fact that both deltoid and triceps muscles remained unaffected practically excluded the differential diagnostic alternative of a posterior interosseus neuropathy and a posterior cord brachial plexus lesion respectively."
+Romina Bradford,30,1982/7/29,001-270-852-1671x5447,michaeldavis@example.com,63823 Cantu Curve Apt. 581,"Another 50-year-old obese man was referred for neurological and neurophysiological evaluation one month after having undergone coronary artery bypass surgery. He also reported suffering from a left wrist drop since the first postoperative day. Similarly to the previous case no incidents occurred during anaetshesia and surgery, during which exactly the same procedures were followed. Electromyography and nerve conduction studies were conducted and revealed identical findings suggestive of an injury of the left radial nerve in the spiral groove."
+Ander Carey,22,2005/4/1,651-322-9719x3063,phillip61@example.net,43858 Wyatt Mission Apt. 525,"A 25-year-old male was presented in October 2004 with a monthly history of a gradually enlarging, painless, left cervical mass. He had no history of prior thyroid disorder or other disease. Clinically the mass was hard in palpation, firmly attached to the surrounding tissues and was located at the anatomic area of the carotide triangle. Thorough physical examination revealed only a marginal hepatomegaly and splenomegaly. Routine blood tests, biochemical markers and thyroid function tests ??including triiodothyronine (T3), thyroid stimulating hormone (TSH), thyreoglobulin and anti-thyroid antibodies- were within normal limits, with the exception of a moderately elevated erythrocyte sedimentation rate (ESR = 44). Subsequent cervical and thoracic CT scan revealed a multilobular mass (4,3 ? 4,7 ? 7 cm) probably arising from the left thyroid lobe, with infiltrating features and heterogeneous density with regions of central necrosis and hemorrhage. The mass submerged into the anterior-posterior mediastinum, in proximity with the great vessels of the heart, dislocating the left common carotid artery and the left vagus nerve without infiltrating them (Fig. and ). Significant mediastinal lymphadenopathy was also noted, whereas ultrasound of the abdomen excluded liver involvement. Differential diagnosis included thyroid carcinoma, lymphoma, thymoma, malignant congenital branchiac cyst or cystic hygroma and germ cell tumours of the upper mediastinum. Fine-needle aspiration biopsy of the cervical mass was performed and the cytological findings were consistent with papillary thyroid carcinoma with anaplastic features. Based on these findings, the patient was referred for surgical removal of the lesion. At surgery, a large mass, measuring 9,5 ? 6,3 ? 4,5 cm was found behind the left srenocleidomastoid muscle, located lateral to the left carotid artery/jugular vein and was not firmly adhered to the left thyroid lobe. The mass was easily separated from the surrounded tissues and was removed. Based on the results of preoperative fine needle aspiration biopsy, a total thyroidectomy was performed at the same time. Pathology examination of the mass revealed extensive infiltration by large or giant malignant cells with morphological features consistent with syncytiotrophoblasts within necrotic and hemorrhagic elements (Fig. ). Positive immunohistochemical staining with 帣-subunit of human chorionic gonadotrophin (帣-hCG) suggested the diagnosis of choriocarcinoma of the upper mediastinum (Fig. ). The pre-operation serum concentration of 帣-hCG was >100.000 mIU/ml, whereas the immediate post-operation levels declined to 17.300 mIU/ml. Alpha- fetoprotein (a-FP) and carcinoembryonic antigen (CEA) levels were within normal limits, while lactate dehydrogenase (LDH) level was two-fold higher than the normal upper limit. Based on these data, scrotal ultrasound examination was performed, disclosing a small multilobular mass measuring 2,1 cm in greatest diameter-not evident at previously performed physical examination- located on the upper pole of the left testicle with echomorphological and hemodynamic characteristics consistent with seminomatous tumour. Subsequently, the patient underwent left radical inguinal orchiectomy with high ligation of the left spermatic cord and implantation of synthetic testicular prothesis. Histological diagnosis of the testicular tumour revealed almost typical seminoma (1,8 ? 1,2 ? 1 cm) consisting of large clear-cytoplasm cells with hypodense nucleus and a few atypical mitosis, without any signs of infiltration of rete testis or the spermatic cord. Complete inhibition of spermatogenesis and hyperplastic reaction of Leydig cells were also observed (Fig. ). Although immunohistochemical staining for 帣-hCG was positive in a few cells, their morphological characteristics did not meet the diagnostic criteria for syncytiotrophoblasts (Fig. ). On postoperative day six (6), the patient developed slightly painful cervical mass at the anatomic site of the first surgical intervention and 帣-hCG levels started rising up again (帣-hCG = 29.850 mIU/ml) (Fig. ). Complete pre-therapeutic staging was immediately performed, including negative CT scan of the brain and negative bone scan, whereas CT scan of the thorax and the abdomen disclosed multiple round metastatic nodules of various size (0,1 ??2 cm) in both lungs and marginally enlarged iliac and para-aortic lymph nodes without liver or other parenchymal organ involvement. In November 2004, one month after his initial admission to the hospital, the patient received 1st line chemotherapy for high-risk germ cell tumour with the BEP regimen (Bleomycin 30 mg: d1-d8-d15, Etoposide 100 mg/m2: d1-d5 and Cisplatin 20 mg/m2: d1-d5 in 21-day cycles). Pre-chemotherapy levels of 帣-hCG were 93.400 mIU/ml. The patient completed 4 cycles of therapy without experiencing remarkable toxicity (Neutropenia grade I-II according to the NCI-CTC criteria) and is currently (October 2006) asymptomatic, with ongoing complete clinical and biochemical remission according to the RECIST criteria (No evidence of tumour mass, regression of all enlarged lymph nodes, necrotic post-chemotherapy elements in the remaining lung nodules confirmed by CT-guided fine-needle aspiration biopsy and PET scan and consecutively normal levels of 帣-hCG). A schematic presentation of the whole diagnosis and treatment course including 帣-hCG titer and chest Xray findings is illustrated in Fig."
+Alora Navarro,31,1982/7/27,512.697.7432x691,susanroberts@example.org,963 Jennifer Alley Suite 432,"A 37 year old female presented to her primary care physician with nonspecific abdominal pain. She underwent CT imaging that revealed bilateral ovarian masses and ascites. Preoperative CA125 was the only tumor marker examined and it was within normal limits. A presumptive diagnosis of ovarian cancer was made and she underwent exploratory laparotomy which revealed macroscopic peritoneal metastases to ovaries, omentum and pelvic peritoneum. At that time total abdominal hysterectomy, bilateral salpingoopherectomy, pelvic lymph node sampling, partial omentectomy, appendectomy and evacuation of mucinous ascites was performed. Final pathology revealed low grade mucinous adenocarcinoma in all specimens, arising from an appendiceal primary. The patient received no additional therapy and was followed clinically. She developed recurrent abdominal pain approximately 2 years later. Computed tomography (CT) scan revealed progressive nodularity in the mesentery and peritoneal surfaces consistent with recurrent disease. This was further evaluated with a laparoscopy, which revealed mucinous tumor implants along the anterior abdominal wall, right retroperitoneum, diaphragm, and remaining omentum (Figure ). At this time, the patient was referred to the University of Cincinnati for consideration of cytoreductive surgery and intraperitoneal hyperthermic chemoperfusion. The patient's past medical history was significant only for a seizure disorder which was managed by anticonvulsant medication and an implanted vagus nerve stimulator. Preoperative CA19-9 was elevated at 59, while CEA and CA-125 were normal. The patient was felt to be an appropriate candidate and underwent exploration. At surgery, extensive disease was noted over the peritoneal surfaces. A complete cytoreduction was achieved requiring, right colectomy, splenectomy, cholecystectomy, omentectomy, and perionectomies of the diaphragms, anterior abdominal wall, and pelvis. Tumor nodules were excised from the small bowel and large bowel mesentery. The cytoreductive portion of the operation was completed in approximately 210 minutes. Per our current practice protocol, a 90 minute perfusion was performed using an inflow temperature of 44簞C, with peritoneal surface temperatures averaging 40.5??1.5簞C. Intraperitoneal temperatures were measured via four temperature probes, one within the liver parenchyma, and three within separate quadrants of the peritoneum. Core temperature was recorded via the bladder and esophageal temperature probes. Per our standard protocol, the carrier solution was peritoneal dialysis fluid (2.5%). The patient's maximum recorded core body temperature during the procedure was 38.7簞C and the maximum recorded liver temperature was 38.8簞C. Mitomycin C was delivered using a total dose of 10 mg/L perfusate, delivered in divided doses of 7 mg/L at initiation and redosed after 45 minutes at 3 mg/L. A total dose of 45 mg was delivered in this patient. During the operation, the patient had no significant electrolyte abnormalities aside from the expected glucose elevation seen during the perfusion period. The maximum serum glucose was 355 mg/dL and the lowest serum sodium was 135. The operation was generally uneventful; no blood transfusions were required and the patient was transferred to the ICU in stable condition. Postoperatively, all serum electrolytes were normal and albumin was 3.4 mg/dl compared with 4.3 mg/dl, preoperatively. The patient was easily arousable and followed commands appropriately. However, approximately 4 hrs later, the patient complained of headache and right eye pain. Her headache was treated with analgesics, however 3 hours later, she was found to be tachypenic, bradycardic, and hypotensive, and was unresponsive with fixed, dilated pupils. She was emergently intubated and resuscitated. After approximately 15 minutes, she regained consciousness, and responded appropriately to commands. Her pupils returned to 3 mm and because reactive. Neurology was consulted and she was loaded with Dilantin due to her history of seizure disorder. An urgent CT scan was ordered. On route to the CT scanner, she once again became bradycardic and hypotensive with fixed, dilated pupils. The CT scan revealed diffuse cerebral edema (Figure ). ICP monitoring revealed pressures of 70??0 mmHg. Mannitol was used in an attempt to lower intracranial pressure without success. EEG was consistent with diffuse brain dysfunction. A brain death protocol revealed that she had suffered brain death and care was subsequently withdrawn. At autopsy, diffuse cerebral edema with tonsillar herniation was noted (Figure ). No pathologic findings were present to indicate the cause of the cerebral edema. The final pathology on all resected specimens reconfirmed the diagnosis of mucinous adenocarcinoma (Figure )."
+Reid Proctor,25,2005/5/3,8494566324,andreaflores@example.org,805 Anita Hills Apt. 343,"A 66-year old woman presented in July 1999 with 2-week history of
+flu-like illness and progressive exertional dyspnea. She was found
+to have a cardiac mass on transesophageal echocardiogram.
+MRI-magnetic resonance imaging revealed a 3.5/4/4-cm mass in the
+right atrium and ventricle extending into the anterior superior
+mediastinum. The patient underwent sternotomy and exploration, and
+the mass was found to be in the atrioventricular junction. Biopsy
+revealed a high-grade angiosarcoma. Staging evaluation revealed a
+pulmonary metastasis in the left base posteriorly. Her performance
+was 2 on the ECOG scale. After detailed discussion of treatment
+options, the patient opted for minimal intervention with minimal
+toxicity. Liposomal doxorubicin has been used in soft tissue
+sarcoma and is well tolerated; hence she was treated with Doxil
+40??0 mg/m2 q 4 weeks for total 11cycles. She had an
+excellent clinical response after 2 cycles and radiological
+response after the third cycle (Figures , ).
+She enjoyed good quality life and had no significant side effects
+from chemotherapy. However, she relapsed with extensive pulmonary
+disease after 15 months. Thereafter the patient received two
+cycles of combination chemotherapy consisting of MAID regimen
+(mesna, adriamycin, ifosfamide, and dacarbazine) with minimal
+response. The patient eventually succumbed to metastatic disease
+16 months after her initial diagnosis."
+Chandler Dudley,36,1991/2/28,(953)847-3833,elizabeth36@example.net,2226 Matthew Inlet,"The patient was a fit and well 21-year old man who initially presented to
+his GP with a painful right knee with no history of trauma. This was
+diagnosed as a soft tissue injury, but, six months later, he noticed a
+swelling in his right proximal tibia. A plain x-ray showed a pathological
+fracture of the proximal tibia () and he was referred to the regional sarcoma centre via his local fracture clinic.
+His initial investigations of blood tests, chest x-ray, and abdominal ultrasound showed no abnormalities, but MRI right knee clearly demonstrated an osteosarcoma in the proximal tibia with further lesions in the distal femur ().
+A biopsy of the proximal tibial lesion confirmed the diagnosis of high-grade
+intramedullary osteosarcoma (). Neoadjuvant chemotherapy of five
+cycles of doxorubicin and cisplatin was commenced.
+The preoperative CT chest was clear and a further biopsy of both the distal
+tibial and proximal femoral lesions confirmed high-grade intramedullary
+osteosarcoma with necrosis. Because of this good response to chemotherapy,
+the decision was made to conserve the leg. Therefore, six months after
+diagnosis, the patient underwent resection of the right proximal tibia and
+distal femur with prosthetic replacement (). The final histology showed necrotic bone tumour in the femoral and tibial lesions.
+The patient underwent three months of postoperative chemotherapy
+and he remains clinically well. Nine months later, he was
+walking unaided and with knee flexion in excess of 90 degrees.
+There are no radiological signs of recurrence, either on plain x-ray or on MRI. A further MRI scan is planned shortly."
+Colter Levy,32,1999/5/23,(801)339-3418,carrolldavid@example.com,591 Greene Mount Suite 023,"A healthy 45-year-old woman with no antecedent trauma presented to
+our department with a 10-year history of problems extending her
+left elbow. Examination demonstrated 50 degrees of fixed flexion
+contracture of her left elbow. There were no palpable masses and
+no convincing tenderness around the elbow. An X-ray and CT scan of
+the elbow were unremarkable but an MRI scan showed a soft tissue
+mass lying on the anterior capsule of the elbow, deep to
+brachialis muscle ().
+She underwent excision biopsy of the mass. An arm tourniquet was
+used. Through an anterolateral approach the brachioradialis muscle
+was identified and reflected laterally. Furthermore the radial
+nerve was identified and reflected. As brachialis muscle was
+lifted up a long fatty, vascular mass deep to it was encountered
+which was about 3 ? 1.5 cm in size. It was
+removed from underlying bone and capsule of elbow joint and sent
+for histology. A gentle capsular release was performed as well.
+An examination under anaesthetic showed that the elbow was now
+fully extended but was spring due to tight muscles. At the end of
+the operation, the fixed flexion contracture was 20 degrees. The
+patient was discharged the following day and outpatient
+physiotherapy was arranged. At six weeks follow up the patient had
+full extension of the elbow.
+Histological examination showed a
+tumour, which was composed of dilated vascular channels with
+smaller amounts of smooth muscle. These findings were consistent
+with a benign cavernous angioleiomyoma (Figures and )."
+Flora Rivers,24,1997/8/12,+1-992-766-0305x573,vbernard@example.net,22651 Oneal Flats Suite 288,"A 65 year-old male presented to the hospital with a two week history of diarrhoea and vomiting. He had no abdominal pain and no symptoms or signs of gastro-intestinal blood loss. He was initially thought to have gastroenteritis, stool samples were sent and he was treated conservatively. He was noted to be mildly anaemic with a haemoglobin level of 10.7. A flexible sigmoidoscopy (FS) was performed to begin investigation of his diarrhoea. This showed a small polyp which was benign on histology and no other abnormality. He settled and was then discharged home. Barium enema (BE) was booked as an outpatient investigation to assess the rest of the colon, and if negative, oesophageogastroduodenoscopy (OGD) would then be performed to investigate his anaemia. The waiting list for colonoscopy was too lengthy at that time, and the combination of BE and FS routinely replaced colonoscopy.
+The patient was readmitted three weeks later in hypovolaemic shock with a blood pressure of 88/56, pulse 110. During this admission, he was noted to be cachetic, weighing just over 55 kilograms (Body mass index = 16.2). On further questioning he had lost over 12 kilograms in weight since the onset of his vomiting several weeks before. His admission haemoglobin level on this admission was 7.5.
+In view of the worsening anaemia on this admission and a past history of duodenal ulcer in 1996, in-patient OGD and BE were requested. Meanwhile, the patient continued to receive intravenous fluid, blood and acid suppressing agents. OGD revealed an opening in the second part of the duodenum, which was biopsied. Histology showed poorly differentiated adenocarcinoma and one piece of normal colonic mucosa. BE clearly demonstrated a fistula between the hepatic flexure and second part of duodenum (figure ), and the patient vomited the barium following his enema.
+Subsequent isotope bone scan and liver ultrasound did not show any signs of metastasis. Computed tomography (CT) of the abdomen showed a locally advanced carcinoma of the proximal transverse colon (figure ), with a fistula to the duodenum. The regional lymph nodes were noted to be enlarged and there was enlargement of the left adrenal of uncertain significance. There was also a small volume of ascites.
+Clinically during the patients admission a subcutaneous nodule developed on the right abdominal wall. The mass was erythematous, non-tender, mobile and deep to skin. Fine needle aspiration cytology confirmed subcutaneous metastasis of poorly differentiated adenocarcinoma (figure ). Over the next few weeks a similar subcutaneous metastasis developed over his left scapular area.
+The patient's nutritional status was corrected. His vomiting had stopped. It was explained to him and his family that surgery was inappropriate. He was discussed at the multidisciplinary meeting but the feeling was that chemotherapy would serve only to enlarge the fistula and be likely to exacerbate his symptoms without any great benefit to him. Radiotherapy directed at the subcutaneous lesions was utilised as the only feasible option of palliation. A palliative ileostomy with a feeding jejunostomy was considered, however, the patient was reluctant with the prospect of having an ileostomy especially his symptoms were well controlled. His care was subsequently transferred to a palliative care unit. The patient died 4 months after discharge from hospital."
+Bear Garner,40,2004/10/4,898-511-9808,diana01@example.net,80689 Parker Fork Suite 688,"A 40 year-old Nigerian housewife was seen at the oncology clinic of the University College Hospital (UCH) Ibadan, Nigeria in June 2002 with a 1 year 8 months history of painful left breast lump which had been previously excised in another hospital but recurred 8 months before presentation at UCH. There was no information about histological diagnosis of the excised breast lesion from the first hospital. There were no systemic symptoms. She was Para 7+1 and had no family history of breast or ovarian cancer. Physical examination revealed globular enlargement of the left breast measuring 20 cm ? 18 cm. The mass occupied the whole breast, was warm, multinodular and fixed to the pectoralis fascia. The ipsilateral axillary lymph nodes were enlarged, but examination of the other systems was normal. A clinical diagnosis of locally advanced cancer of the left breast was made.
+Plain radiograph of the chest and abdominal ultrasound scan were normal. A core-needle biopsy of the mass was done and histology showed a malignant neoplasm comprising islands of chondroblastic and osteoblastic stromal cells, with no normal breast tissue seen. A diagnosis of osteogenic sarcoma was made. The patient had a left modified radical mastectomy and latissimus dorsi musculocutaneous flap to cover an anterior chest wall defect. The mastectomy specimen weighed 350 g. Cut sections revealed areas of cystic degeneration and necrosis, with focal areas that were firm with a cartilaginous consistency. Conventional representative sections were obtained from each of the four breast quadrants, areola region, resection margins and axillary lymph nodes. Microscopic examination of the sections showed a malignant breast neoplasm displaying fibrosarcomatous, chondrosarcomatous (Figure ) as well as osteosarcomatous (Figure ) differentiation. There was metastasis to one of the lymph nodes. She was scheduled for radiotherapy to the chest wall but she defaulted. Contact tracing revealed that she died about 6 months after mastectomy."
+Jacqueline Blair,39,1979/12/27,842.765.1860,rhamilton@example.net,79190 Roberts Islands Apt. 114,"A 48-year-old male presented with haematuria and dull aching pain in the right flank. The general examination of the patient was unrevealing, with no lymphadenopathy or bony tenderness. The chest, cardiovascular and neurological examination was normal. Abdominal examination revealed a mildly tender mass palpable in the right lumbar region. Routine laboratory investigations including a full blood count, chest X-ray, and renal function tests were normal. Urine examination showed plenty of RBCs in high power field.
+An ultrasound examination of the abdomen revealed an echogenic mass in the upper part of the right kidney measuring 11 ? 10 cm. No calcified areas were noted; the renal pelvis and renal vein were not involved. The other abdominal viscera were radiologically normal. There was no lymph node enlargement. A provisional diagnosis of renal cell carcinoma was made and right radical nephrectomy performed.
+Grossly, the nephrectomy specimen weighed 480 grams and showed a solid spherical tumor measuring 10.5 ? 10 cm. The cut surface was variegated with grey white, fish flesh appearance. The adjacent renal parenchyma appeared normal. The renal capsule was intact. There was no involvement of the renal pelvis or vein.
+Microscopically, the tumor was highly cellular comprising of epithelial, blastemic and stromal elements. The epithelial element comprised of tubules admixed with blastemic cells (Fig. ). The tubular lining cells had elongated, molded, and wedge shaped nuclei exhibiting frequent mitoses. The tubular pattern resembled pseudo-rosettes at places (Fig. ). The blastemic component had solid areas showing cells with oval nuclei and scanty cytoplasm. The stroma with spindle cells had no specific differentiation. There was no area showing anaplasia. A final diagnosis of adult Wilms' tumor with triphasic pattern and a favorable histology, stage 2, was made.
+Adjuvant treatment was started as per Intermediate Risk protocol for Stage I Node negative disease with vincristine 1.4 mg/m2 and actinomycin D 15 mcg/kg. The patient remains in complete remission after 14 months of follow up."
+Troy McKee,41,2000/5/8,691.458.1752x9916,charlesjennings@example.net,414 Charles Crescent Suite 374,"A 58-year-old male had been symptomatic for the preceding 3 years with a chief complaint of involuntary movements of jaw-opening triggered mainly by talking and/or eating. His symptoms made his eating difficult requiring him to bite down with effort in order to keep his mouth from opening. He wore out his regular dentures and special dentures had to be manufactured for him. Yelling would ameliorate the involuntary movements. There was no personal or family history of other neurological disorder and the patient denied any exposure to dopamine-blocking drugs. He denied any weight loss, but admitted to eating difficulty and social embracement due to his jaw-opening OMD. His neurological examination was otherwise unremarkable.
+The patient was successfully treated with BTX-A injections to his lateral pterygoids (75 units/side). After 9 sessions he continues experiencing the same marked benefit and no longer complains of eating difficulties."
+Kori Cameron,42,1982/8/20,454-360-0457x906,patriciajones@example.org,14880 Chapman Lake,"A 48-year-old female was initially evaluated for OMD of one year evolution. She complained of intermittent involuntary movements of jaw-opening accompanied by tongue thrusting. While eating her tongue would protrude causing substantial eating and swallowing difficulties that had lead to a 15 lbs weight loss (from 110 to 95 lbs). A barium swallowing test at the time revealed her swallowing function to be moderately impaired secondary to decreased bolus preparation and decreased bolus propulsion without evidence of aspiration. After the unsuccessful injections of BTX-A (4 sessions) to her lateral pterygoids (50 u/side), she was placed on a regimen that included tetrabenazine 75 mg/day, trihexyphenidyl 3 mg/day, and lorazepam 4.5 mg/day with significant improvement of her symptoms and gradual weight gain."
+Rayan Hendricks,42,2003/10/30,+1-431-455-6326x66839,brittany62@example.com,8127 Victoria Centers Apt. 049,"A 32-year-old male presented with new-onset jaw-closure spasms (jaw spasms with any kind of stimulus-able to open his mouth only 1/4 inch). This process increased in severity for three weeks, after which he could not take any food in, except through a straw. For the ensuing two months there was a gradual albeit limited improvement where he was able to open his mouth 3/4 of an inch, and from then on his condition had remained stationary. He had to change to a soft, pureed diet. Chewing would result in pain, particularly on the left mandibular area. His dystonic disorder also interfered with his speech, forcing him to keep his tongue behind the teeth to prevent from biting it. The patient was successfully treated with BTX-A injections to his masseters (50 units/side). After 4 sessions he continues to experience the same marked benefit and no longer complains of eating difficulties."
+Dani Cameron,32,1995/6/5,561.743.6449,garcianicole@example.org,05065 Marisa Trafficway Suite 388,"A 49-year-old female presented with a 2-year history of jaw opening movements, which caused substantial drinking difficulties. A year later these movements became constant and were complicated with movements of the tongue (tongue protrusion and dyskinesias) with consequent impairment of fluid and food manipulation overlapping with chewing difficulties caused by her jaw-opening OMD. The patient reported a 15 lbs weight loss due to her condition (from 130 to 115 lbs).
+She was subsequently placed on tetrabenazine (125 mg/day) with moderate benefit in the frequency and intensity of the jaw-opening movements. However, tongue protrusion and dyskinesias were not affected. The patient developed a hypokinetic extrapyramidal syndrome as a side effect to tetrabenazine therapy but insisted on continuing the drug (at a lowered dose of 75 mg/day) because of its beneficial effects on her symptoms. Within about 6 moths after the initiation of tetrabenazine the patient gained 10 lbs. In an effort to further control her symptoms the patients had trials with clonazepam and gabapentin. A combination of tetrabenazine (75 mg/day) and gabapentin (300 mg/day) improved her symptoms by a reported 75%. She also received BTX-A injections to lateral pterygoid muscles (25 units/side) without benefit. Ten years into her condition she still experiences substantial benefit from her treatment."
+Rayan Campos,34,1989/11/5,997-519-4790x0794,floydjose@example.net,3021 Wilson Oval Suite 028,"A 56-year-old female presented with a chief complaint of involuntary jaw movements. The patient had a long (35-year) history of migraines for which she had received a number of treatments (triptans, beta-blockers and calcium-channel blockers, anti-epileptics, anti-depressants, clonazepam) with limited success. Her first trial with an atypical neuroleptic (off-label use) was 2.5 years before presentation when she had been started on ziprasidone (80 mg/day) []. The patient experienced a moderate decrease in the frequency and severity of her migraine attacks, but 11 months later started noticing mild involuntary movements of the tongue. Ziprasidone was gradually discontinued. Within 2 weeks jaw-opening involuntary movements were superimposed on the involuntary movements of the tongue. Gradually, her symptoms intensified, causing eating difficulties accompanied by weight loss (from 123 to 110??3 lbs). She also experienced occasional tongue and oral mucosa injuries. Her neurological examination was otherwise unremarkable. The patient had already received BTX-A injections on the lateral pterygoids at least on two occasions without success prior to visit to our clinic and declined repeat injections. She was lost to follow-up."
+Sutton Shepard,35,1991/6/25,+1-437-201-8722x62495,samantha29@example.org,897 Walter Underpass Suite 053,"A 45-year-old woman presented with a painful swelling on the left side of her jaw of 5 months duration. The swelling had recently started to grow rapidly. There were no associated sensory symptoms. In addition, a few teeth adjacent to the swelling had become loose, carious and had fallen off. Local physical examination showed a 4.0 ? 3.2 ? 3.0 cm, tender, firm, irregular lump that appeared to arise from the left mandible. Intra orally, the tumor could be seen as a pink, bulging and fleshy mass. Two lymph nodes were palpable, one in left submaxillary region measuring approximately 1 ? 1 cm and the other in the left cervical region and was barely palpable. Remainder of the physical examination was not contributory and no other swelling was noticed. Orthopantomogram (OPG) of the jaw showed a radiolucent lesion with irregular margins, centered in and destroying a portion of the left mandibular body (Figure ). The teeth adjacent to the mass were carious and some were missing. A computed tomography (CT) scan of the oral cavity and neck was advised but was not done due to financial reasons. A clinical diagnosis of ameloblastoma with suspicion of lymph node involvement was given.
+An incisional biopsy of the lesion was submitted for pathologic evaluation. Microscopic examination of the tissue showed a neoplasm composed of epithelial cells arranged in irregular nests separated by fibrovascular septa. The cells adjacent to the fibrovascular septa were cuboidal to columnar with high nuclear-cytoplasmic ratio and eosinophilic cytoplasm, while those in the center of the nests were larger and polygonal, with abundant clear cytoplasm (Figure ). Each cell had a single nucleus with fine chromatin and prominent eosinophilic nucleolus. The cells at the periphery of the nests occasionally demonstrated nuclear palisading away from the basement membrane, i.e., reverse nuclear polarity (Figure ). These peripheral cells also showed occasional mitoses. The central areas of the nests and fibrous septae showed infiltration by neutrophils. The cells were immunoreactive for pan-cytokeratin, epithelial membrane antigen, and S-100 protein; they did not stain for vimentin, smooth muscle actin, and HMB-45. The abundant, clear cytoplasm of the cells was strongly positive for periodic acid-Schiff (PAS) (Figure ). This PAS positivity was diastase sensitive indicating intracytoplasmic glycogen (Figure ). A diagnosis of clear cell odontogenic carcinoma was entertained. Fine needle aspiration from the submaxillary node was done but was inconclusive.
+The patient was referred to a specialty cancer hospital where she underwent left hemimandibulectomy with ipsilateral functional neck dissection (level1 to level 5). The reconstruction was done using ipsilateral 12th rib and the soft tissue coverage was given by pectoralis major flap. Postoperative histopathological examination showed tumor morphology similar to incisional biopsy and 1/11 lymph nodes (submaxillary) was positive for the tumor metastasis without any extranodal spread. The tumor was extending into the soft tissue and the left bony margin was positive for the tumor cells. Due to the positive margin, the patient was referred for adjuvant radiotherapy for which she refused to give consent. At the time of discharge the patient was accepting soft diet and the suture line on the neck and chest were healthy. Subsequent to the discharge, the patient was lost to follow-up only to reappear after 8 months and at that time had no signs of local or regional spread. Since then patient is again lost to follow-up."
+Damari Randolph,25,2002/2/25,708-477-7631x9515,imiller@example.net,4167 Rogers Locks,"43year old male presented to the Emergency Department with a day old history of acute left upper abdominal pain; nausea and vomiting for 2 days with some associated dizziness and anorexia. The patient underwent an emergency contrast enhanced CT scan of the abdomen/pelvis which showed an markedly abnormal spleen, inhomogeneous and enlarged, approximately 20 ? 11 cm with fluid in the inferior aspect of the mesenteric fat, with free fluid in the abdomen and enlarged retroperitoneal lymph nodes.
+The patient was volume resuscitated following admission to the hospital, and his Hct was serially followed. Since there was no history of trauma and the CT did not look like a traumatic splenic laceration the oncology service was contacted who felt that the findings were most compatible with lymphoma and because there was some bleeding going on did not recommend trying to treat it without a tissue diagnosis.
+The patient underwent a splenectomy. He was found to have a massively enlarged spleen with areas where it appeared to be tumor extruding through the splenic capsule. There was a lot of ecchymotic tissue inferior to where the spleen had been and there was slight oozing which was controlled as much as possible as the area was quite friable. The tail of the pancreas was identified and left alone as there was no bleeding. The estimated blood loss was approx 2 L.
+Following extubation the patient had some issues with agitation which was attributable to ETOH withdrawal. The patient had a history of 6pack qd ETOH abuse. He was placed on CIWA protocol. His mental status remained at the level of agitation and confusion for the next 4 days not helped by serax or ativan or haldol. Psychiatry consult was given and they felt the agitation was secondary to post op delirium vs. paradoxical ativan reaction. At that point it was thought that the agitation and delirium was secondary to possible 'pain vs. sepsis.' He was started on cefazolin 1 gm q8 hrs post op which was changed to meropenem 1 gm q 12 hr on POD#4.
+In the post operative period the patient's Hct remained stable on serial examination. however his Bilirubin continually rose and peaked at 10.5 on post op day # 3. Other LFT s were mildly elevated. Gastroenterology team was consulted who felt that the increase bilirubin was secondary to sepsis. Differential diagnosis of hemolysis was considered but was thought unlikely as the Hct remained stable. Biliary obstruction was unlikely given his LFT s were only mildly elevated. A hepatitis panel was run and the patient was found to be positive for Hepatitis C. Anesthesia related rise in bilirubin was also considered but again AST and ALT were mildly elevated.
+The patient was discharged home on post op day #9 on PO Moxifloxacin 400 mg q d for 5 days to complete a 14 day course of antibiotics. His liver function test lab values were almost near normal on discharge."
+Kailey Wade,22,1991/8/16,586.725.8626,wcooley@example.net,51333 Richard Pass Apt. 620,"A 45-year-old woman was admitted to the hospital because of a 5 month history of paroxistic abdominal pain and vomiting. The patient's past medical history included ovarian endometriosis treated with bilateral oophorectomy in another hospital seven years earlier. She subsequently received treatment with medroxyprogesterone and transdermal estrogens.
+On physical examination the abdomen was distended and bowel sounds were increased. Laboratory values were unremarkable, and abdominal x-rays confirmed the diagnosis of intestinal obstruction. Laparotomy revealed an ileal mass protruding into the lumen. A right hemicolectomy including 40 cm of ileum was performed. The female genital tract and pelvis had no macroscopic evidence of endometriotic lesions.
+Histopathology revealed the following: the resection specimen consisted of 16 cm of right colon and 39 cm of ileum. A tumor measuring 5.5 cm was found within the wall of the ileum 2 cm from the ileocaecal valve. Morphologic and immunohistochemical features were typical of an endometrioid adenocarcinoma (cytokeratin (CK) 7-positive, vimentin-positive, CK20-negative) (figure ). The high nuclear grade tumor involved the mucosa, the muscularis propria and the subserosal fat. Vascular invasion was noted as well as metastatic involvement of 5 out of 40 isolated lymph nodes. Several foci of endometriosis were identified adjacent to this mass and in the caecum. Both, the epithelial and the stromal cells tested positive for estrogen receptors and for CK7, while tests for CK20 proved negative. The tumor itself showed only weak positivity for estrogen receptors.
+After surgery the patient received subsequent chemotherapy with 5-fluorouracil and leucovorin. Twenty months later the patient noted rectal bleeding. A colonoscopy discovered a mass at 15 cm from the anal edge. The biopsy showed an adenocarcinoma. A second endometrioid adenocarcinoma was not suspected before surgery.
+During laparotomy a tumor in the anterior wall of the rectum was seen. It was fixed to the uterus, occupying the recto-uterine pouch which it seemed to invade. No macroscopic endometrioid foci were seen in the pelvis. En bloc resection including rectum, uterus and the fallopian tubes was performed, as an invasion of the uterus was suspected. Transit restoration was achieved by termino-terminal anastomosis using the EEA-stapler device.
+Histopathology revealed the following: The resection specimen consisted of 18 cm of rectum, the uterus and the fallopian tubes. Histological examination confirmed the presence of a tumor measuring 3.5 cm in diameter, located in the anterior wall of the rectum and embedded to the posterior wall of the uterus. The poorly differentiated adenocarcinoma involved all layers of the intestine up to the uterus which was not invaded microscopically. The uterus and the fallopian tubes had no major microscopic changes. Morphological and immunohistochemical features of this endometriotic adenocarcinoma were similar to the previously removed tumor (CK7- positive, vimentin-positive, and CK20 negative) (figure ). There was no lymph node involvement in any of the 17 removed lymph nodes. Multiple microscopic foci of endometriosis were seen, especially in the peritumoral and peritubaric areas. Once again, immunohistochemical features of these foci included positive estrogen receptors and a positive result on CK7 in the epithelial and stromal cells, and negative results for CK20. After the second operation, the patient started treatment with raltitrexed (Tomudex簧) and 5-Fluorouracil. After five years, she remains asymptomatic and has no evidence of recurrence."
+Jake Lucas,29,1986/12/18,(220)823-6806x62380,david87@example.net,35658 House Bypass,"A 28 year old male student of Nepalese origin living in the United Kingdom for 3 years presented to the Accident and Emergency department with a 3 week history of increasing right hip pain, with associated fevers but no other symptoms and no history of trauma. 5 years previously, he had been treated for pulmonary tuberculosis with a 6 month course of chemotherapy. There was no positive family history. The remaining history was unremarkable.
+On admission he was partially weight bearing on the affected side. On inspection there were no signs of inflammation. Flexion was limited to100 degrees; extension to 20 degrees; internal and external rotation were reduced to 10 degrees with normal adduction and abduction. There were no further positive findings on the remainder of physical examination or X-ray (figure ).
+Blood results on admission were haemoglobin 12.5 g/dl (12.5??8.0 g/dl), white cell count 6.47 (4.0??1.0 ? 109/l), Platelets 378 (150??00 ? 109/l), C reactive protein (CRP) 205 (<5 mg/l), Erythrocyte sedimentation rate (ESR) 96 (2??2 mm/1st hour). His biochemistry revealed an alkaline phosphatase (ALP) 342 (30??00 iu/L), bilirubin 15 (3??7 弮mol/L), alanine aminotransferase (ALT) 45 (3??5 iu/L), aspartate transaminase (AST) 42 (3??5 iu/L), corrected calcium 2.82 (2.12??.65 mmol/L), lactate dehydrogenase (LDH) 782 (iu/L). Renal function was normal.
+An Ultrasound of the hip revealed a moderate right sided joint effusion. Magnetic resonance imaging (MRI) of the pelvis and hips (figure ) confirmed the effusion with marked soft tissue swelling and synovial thickening. There was oedema in the proximal femur.
+Our working diagnosis was septic arthritis, with tuberculosis of the hip as a differential, in view of his past medical history. He was thus managed accordingly with a washout and commenced on chemotherapy. Microbiology of the synovial fluid revealed no organisms; auramine tests were repeatedly negative, as was syphilis serology, Human Immunodeficiency Virus (HIV), Hepatitis and melioidosis.
+There was little clinical response to treatment and inflammatory markers 2 weeks after admission were elevated at a CRP of 130 and ESR of 114.
+He then developed an episode of diarrhoea and vomiting as an inpatient. Initial investigations for amoeba, cysts, ova, parasites were all negative. Colonoscopy was undertaken and revealed a stricture in the sigmoid colon. Multiple biopsies revealed a moderately to poorly differentiated adenocarcinoma on histological examination. An immunohistochemical panel showed the tissue to be cytokeratin 20 (CK-20) positive, cytokeratin 7 (CK-7) negative and villin negative, thus in keeping with a colorectal primary tumour. Carcinoembryonic antigen (CEA) was measured at 100.7. Genetic screening and microsatellite instability (MSI) testing on the tumour were negative.
+The synovial fluid was re-examined for cytology following the histological diagnosis and this confirmed a malignant joint effusion.
+A computerised tomogram (CT) revealed multiple para-aortic lymph nodes, with no evidence of metastases other solid organs. A bone scan (figure ) revealed high uptake areas in the skull vault, spine, ribs, pelvis, proximal ends of both femurs and sternum; all in keeping with widespread metastatic disease.
+In view of the advanced nature of the adenocarcinoma the primary tumour was not resected and he was commenced on Oxaliplatin 130 mg/m2 (day one of cycle) and Capecitabine 1.25 g/m2 (twice daily for fourteen days) for a planned eight cycles (each cycle of twenty-one days). He responded well initially with an improvement symptomatically after 2 cycles of chemotherapy, and objectively on computerised tomogram (CT) of his abdomen and pelvis with reduction in the size and number of significant lymph nodes. However was unable to tolerate more than 3 cycles and died 4 months after his initial presentation."
+Phoenix Bruce,22,1995/2/21,(403)385-4042x0908,hilljonathan@example.net,7862 James Ways,"A 40-year-old-woman with a history of Gardner's Syndrome status post prophylactic colectomy presented with an enterocutaneous fistula and for reevaluation of desmoid tumors. She had three previous abdominal operations including a prophylactic colectomy in 1992. In 1995, she had a resection of small intestine and marginal resection of associated desmoid tumors causing small bowel obstruction. In 2002, an emergent resection of small intestine and desmoid tumors for intestinal perforation removed only a portion of the diffuse mesenteric disease. This operation was complicated by an enterocutaneous fistula from the jejunum that subsequently healed with conservative care. She had no adjuvant radiation therapy at any point. Estrogen and progesterone receptor expression of the tumors was never assessed.
+Despite treatment with anti-inflammatory agents, the patient's abdominal desmoid tumors continued to grow and she was re-admitted 10 months later for recurrence of her enterocutaneous fistula. Radiographic studies showed near-complete small bowel obstruction by desmoid tumor (Figure , ) and complete diversion of the fecal stream through the fistula. She began total parenteral nutrition (TPN). The fistula was not amenable to operative repair without resolution of the distal small bowel obstruction. Options for resolving the distal obstruction included operative resection of the desmoids, a procedure associated with much potential morbidity, or systemic therapy to reduce the size of the desmoids. The patient was offered therapy with anti-estrogen agents or investigational therapy with imatinib. Imatinib was initiated and was ineffective, possibly related to the patient's difficulty with gut absorption. Imatinib was discontinued, and she began a regimen of cytotoxic therapy that is active for sarcoma, including doxorubicin 20 mg/m2 IV on days 1, 2, and 3 and ifosfamide 2 g/m2 daily for 3 days of a 21 day cycle. She received five cycles of this regimen, with a clear radiographic response on CT scan (Figures , ). However, her high-output fistula continued.
+A barium enema (Figure ) demonstrated resolution of the distal obstruction with reflux of contrast through the fistula. Enterocutaneous fistula resection with primary enteroenterostomy was performed without complication. The patient was discharged on TPN for continued nutritional support, although she was able to tolerate oral feedings with normal bowel function. Her midline surgical wound subsequently healed by secondary intent. With the return of gastrointestinal function, antiestrogen therapy with tamoxifen 20 mg po daily was initiated."
+Uriah McKinney,44,1989/1/14,233.478.0041,leehorton@example.org,3947 Foster Pike,"A 38-year-old male, a heavy smoker, was admitted to our department, because of fever (38.4簞C), weakness, arthralgias, non-pitting edema of the lower extremities and chest discomfort for the previous two weeks. The arthralgias were partially responsive to nonsteroidal anti-inflammatory drugs (NSAIDs). The patient also reported skin eruptions on his elbows and lower extremities that had appeared six months previously. His past medical history was unremarkable.
+On physical examination, sharply demarcated erythematous plaques covered by silvery white scales were observed on the right elbow and the lower extremities below the knees (figure ). The patient's ankles were painful and edematous. On palpation, firm and painless subcutaneous nodules could be found on the occipital part of the scalp. The rest of the physical examination was unremarkable.
+Basic laboratory tests were normal except for an increased erythrocyte sedimentation rate (57 mm/h) and C-reactive protein (45.2 mg/l). Further investigations, which included serum complement analysis, rheumatoid factor, antinuclear antibodies, antineutrophilic cytoplasmatic antibodies, immunoglobulin levels, and serological tests for hepatitis A, B and C and human immunodeficiency virus, disclosed no apparent pathologies. PPD skin test was negative. Neither arterial blood gases nor pulmonary function tests showed significant abnormalities. Radiographic examination, using x-ray and high resolution computed tomography of the chest, revealed bilateral hilar and right paratracheal lymphadenopathy with small nodules along the bronchovascular bundles. Fiber-optic bronchoscopy and bronchoalveolar lavage (BAL) were performed. BAL fluid analysis revealed lymphocytosis (35%) with an increased CD4+/CD8+ ratio (4.2). Microbiological and cytological examinations were negative. Transbronchial lung biopsies were non-diagnostic.
+A labial biopsy and biopsies from the cutaneous lesions were also obtained. The labial biopsy demonstrated the presence of small epithelioid (sarcoid form) granulomas (figure ), while the skin biopsies were typical of psoriasis (figure ). Immunohistochemical analysis of tissue samples with periodic acid-Schiff staining was negative. We concluded that the patient suffered from two separate clinical entities: pulmonary sarcoidosis and psoriasis vulgaris.
+The articular manifestations responded partially to NSAIDs. Consequently, a short course of 30 mg prednisone daily and topical therapy to manage the psoriatic lesions were applied. This resulted in a significant clinical improvement. Three months after his discharge the patient remains asymptomatic."
+Gwendolyn Good,23,2000/3/28,500-486-6303,qking@example.com,9166 Keith Parkway Apt. 126,"A 24-year-old Tunisian woman was admitted to the hospital 2 weeks after vaginal delivery with a 10-day history of pain in the right leg, right iliac fossa, and flank. In the following days, these symptoms worsened. The patient developed chest pain, tachycardia, dyspnea, and fever increasing in severity. She was unresponsive to antibiotic therapy. A detailed past medical history revealed that she had no risk factors, but had been diagnosed with BD 2 years before with recurrent oral and genital aphthous, pseudofolliculitis, and erythema nodosum in the lower extremities. Colchicine therapy had been started, but after a while the patient stopped the therapy on her own. Physical examination upon admission revealed a fever of 38.5簞C. She also had oral ulcers on the lips, hypopigmented genital scars, and pseudofolliculitis. Heart sounds and bilateral lung areas were normal upon auscultation. Laboratory tests were consistent with an inflammatory condition with a high erythrocyte sedimentation rate of 130 mm in the first hour, a C reactive protein level of 78.3 mg/dl (normal range 0?? mg/dl), a hemoglobin value of 11 g/dl and a leukocyte count of 5400/mm3 with a normal differential count. Urinalysis, and liver and kidney function were normal; antinuclear antibody tests were negative ; platelet count, protein C, protein S, and antithrombin III levels were within normal limits ; and anticardiolipin antibodies and lupus anticoagulant were absent. Her plasma total homocysteine level was 17 弮mol/l (normal < 10 弮mol/l). Chest radiography and electrocardiogram were normal with the exception of sinus tachycardia. Color Doppler echography and abdominal computed tomographic scan (CT) revealed an ascending thrombosis of the iliac and right ovarian veins (Figs. and ). Chest helical CT revealed a bilateral mural thrombus of segmental pulmonary arteries and a triangular area of opacity representing a pulmonary infarct at the posterior segment of the right lower lobe. The patient was treated with anticoagulants, 1 g of methylprednisolone per day for 3 days, then 1 mg/kg/day orally before tapering gradually, colchicine 1 mg/day, and six monthly pulses of intravenous cyclophosphamide followed by azathioprine at a dose of 2.5 mg/kg/day. The patient's symptoms diminished. One year later, the patient was asymptomatic and color Doppler ultrasonography revealed no evidence of ovarian or iliac vein thrombosis."
+Davian Hinton,24,1986/9/2,288-238-3986x929,matthew55@example.org,87757 David Neck Apt. 648,"A 50-year-old female presented in January 2004 with a 4 cm left tonsillar mass. Her general and systemic examinations were unremarkable. There was no lymphadenopathy or hepato-splenomegaly. Her hemoglobin was 12.5 gm/dl, white blood cell (WBC) count was 7700/mm3, erythrocyte sedimentation rate (ESR) was 50 mm/hour and random blood sugar (RBS) was 96 mg/dl. Renal and liver function tests were normal. VDRL, HIV and HBsAg were non-reactive. Chest X-ray, ultrasound scan of the abdomen, upper gastro-intestinal endoscopy, peripheral blood smear and bone marrow biopsy were normal. There was no past history of diabetes mellitus, hypo or hyperglycemic episodes. Biopsy and histopathological examination of the tonsillar mass was consistent with Non Hodgkin's lymphoma-diffuse large B cell type. Immunohistochemistry showed the tumor cells to be CD20 positive. She was treated using R-CHOP (rituximab 375 mg/m2 + cyclophosphamide 750 mg/m2 + doxorubicin 50 mg/m2 + vincristine 1.4 mg/m2 + prednisolone 100 mg orally) chemotherapy on a three weekly schedule after obtaining informed consent. About 24 hours following rituximab, she developed hypoglycemic symptoms like fatigue, restlessness, sweating and drowsiness. There was no other rituximab infusion related toxicities. Her RBS at that time was 39 mg/dl. Her symptoms subsided following intravenous (IV) glucose administration and RBS became normal. During the next 48 hours, she developed three more symptomatic hypoglycemic episodes, with RBS nadir 54 mg/dl, 61 mg/dl and 70 mg/dl respectively and were managed with IV glucose administration. Three days after rituximab her hypoglycemic symptoms subsided completely and the RBS improved to normal range. During the subsequent courses of rituximab, she was given IV glucose support during the first 72 hours. There were no further episodes of symptomatic hypoglycemia."
+Jaelynn Acosta,26,1996/5/28,652.864.3708x5416,michaelmann@example.org,4496 Ellison Garden Suite 764,"In August 2001, a 79-year-old man was admitted to a community hospital because of a violaceous, thickened, dyskeratosic and painless lesion (diameter 2 ? 2 cm) on his tongue with a deep central ulcer. A biopsy of the lesion showed deep inflammatory infiltration with macrophages containing numerous Leishmania amastigotes.
+The patient, a farmer living in the rural area around Rome (Italy), was referred to our Institute. He had a glucose-6-phosphate dehydrogenase deficiency, suffered from asthma, and was given chronic corticosteroid (CS) therapy. The laboratory data on admission are reported in Table . Protein electrophoresis showed a mild hypergammaglobulinaemia. The immunofluorescence assay (Diamedix Corporation簧, Miami-Florida) for the detection of anti-Leishmania infantum antibodies was positive (1:640). The search for antibodies against HIV resulted negative. A bone marrow aspirate did not show Leishmania amastigotes and a restriction fragment lenght polymorphism polymerase chain reaction (PCR-RFLP) [] for the search of Leishmania DNA on bone marrow and peripheral blood resulted negative. L. infantum was identified by PCR-RFLP on the tongue biopsy.
+The patient was treated with liposomal amphotericin B (3 mg/kg daily i.v. on days 1??, 14 and 21) with complete recovery. After a 3-year follow-up, no relapse was noted."
+Jensen Phelps,45,1994/3/6,975.987.6987x6751,ashley98@example.com,33538 Kim Centers Suite 114,"In February 2004, a 72-year-old housewife complained of weight loss, recurrent fever, and diarrhea after pneumonia. She lived in the rural area around Rome (Italy) and had been taking CS and myorelaxants for 16 years because of myasthenia gravis. In the year 2000, the patient was treated for visceral leishmaniasis with bone marrow involvement. A course of liposomal amphotericin B (1 mg/kg daily for 10 days) was repeated one year later for a relapse with involvement of bone marrow and duodenum: a clinical remission of fever and diarrhea was obtained.
+On admission to our Institute, the patient was taking prednisone 25 mg daily and pyridostigmine 60 mg four times daily. She was febrile (38.5簞C) with an impaired nutritional status (35 Kg) and a severe muscular hypotrophy. Upon examination, a first trigeminal branch herpes zoster, and mild hepatomegaly were found; the left nostril presented a cutaneous squamous and crusty lesion that had appeared 4 months earlier.
+The results of hematochemical assays are shown in table ; particularly, a severe lymphopenia (lymphocytes 538/mm3) with 215 CD4+ lymphocytes/mm3 and 132 CD8+/mm3 was found. HIV antibody test was negative. The chest X-rays showed an evolution from a single right basal consolidation to multiple bilateral pneumonic foci. The anti-Leishmania infantum serologic titer was 1:640 and the bone marrow biopsy showed numerous amastigotes of Leishmania spp. Intra-macrophagic amastigotes were also seen at histologic examination of the nasal lesion. L. infantum was identified by PCR-RFLP on peripheral blood and on nasal lesions. The patient was treated with liposomal amphotericin B (3 mg/kg daily for 10 days, total 30 mg/kg), and with levofloxacin (500 mg daily for 10 days), obtaining clinical remission with a gradual improvement of the nasal lesion. No relapse was reported during a 9-month follow-up.
+A 54-year-old male, a farmer living in the rural area around Grosseto, Tuscany (Italy), was admitted to our Institute in March 2004 with a relapse of visceral and mucocutaneous leishmaniasis. In 1997 he complained of edema of the lips with maculopapular, non-itching lesions: a Miescher's granulomatous cheilitis was diagnosed and he was treated with local and systemic CS courses. The lesions of the perioral region disappeared, unlike the lips edema. In April 2003, he was admitted to a community hospital with remittent fever (40簞C) associated to increasing asthenia and normocytic anemia. Amastigotes of Leishmania were recognized in the bone marrow and lip biopsies. The patient was treated with liposomal amphotericin B (3 mg/kg daily i.v. on days 1??, 14 and 21, total 21 mg/kg). The fever disappeared and the edema of the lips substantially decreased. However, few weeks after the end of the therapy febrile episodes recurred, and in December 2003 a new course of amphotericin B therapy was prescribed (liposomal amphotericin B, 5 mg/kg daily i.v. for 10 days). Clinical improvement with persistent detection of L. infantum PCR-RFLP on peripheral blood was observed.
+On admission to our Institute the patient was febrile (39簞C) and presented lips edema with erythematous and cutaneous squamous lesions, diffuse lymphadenopathy and hepatosplenomegaly. The results of blood tests are shown in the table . The patient experienced a progressive reduction of hemoglobin (8.5 g/dL) and received two whole blood transfusions. Multiple blood cultures, HIV and Parvo virus B19 antibody searches were all negative. The anti-Leishmania infantum antibodies were positive (1:640), while the PCR-RFLP on peripheral blood resulted negative. The patient was treated with two subsequent 28-day courses of meglumine antimonate (20 mg/kg daily): he experienced a rapid clinical improvement and no adverse reactions. After a 6-month follow-up the patient is still in good condition, although a modest lip edema still remains. The antibody titer for Leishmania infantum is 1:160. The PCR for Leishmania spp. on peripheral blood is negative. The bone marrow biopsy shows no evidence of infection."
+Laney Stephenson,45,1985/9/24,901-956-0016,bakerstephanie@example.com,44117 Evans Harbors Apt. 203,"A 33-year-old woman with no family history of breast carcinoma presented with a nodule in the upper outer quadrant of the right breast wich had been discovered about four mounth previously and had gradually increased slightly in volume during the intervening period. Clinical examination showed the presence of a hard, mobile, non-painful nodule with regular margins, a smooth surface and about 1,5 cm in diameter. No clinical alterations were found either in the ipsi- or contralateral lymph nodes. Ultrasound examination of the breast showed an ovular hypoechogenic formation with regular margins and 1,5 cm in diameter, diagnosable as a fibroadenoma of the breast.
+Not only for this reason, but also following the patient's specific request, core biopsy of the tumour was not performed and the patient therefore immediately underwent surgical removal of the nodule under local anaesthetic. The histopathological examination of the surgical piece showed the presence of a secretory carcinoma the lesion had no capsule, since one of the resection margins was not very clear, and showed small, glistening, mucus-like foci on the cut surface.
+For microscopic examination, 5 micron sections were obtained from formalin-fixed, paraffin- embedded material and stained with hematoxylin-eosin and Alcian PAS. The lesion showed solid cell nests, intermingled with tubular structures and separated by fibrous bundles. The neoplastic nests consisted of small, uniform, well-differentiated cells, with granular or vacuolated cytoplasm and vescicular nuclei containing small nucleoli. Mitoses were scanty and atypia was mild. Eosinophilic, PAS-positive secretory material was frequently observed in the ductular lumina and, in the form of globular structures, in the intracytoplasmic vacuoles of many neoplastic cells (fig ). Peripherally, in the more ductular areas, extracellular Alcian blue-positive material (reminiscent of a mucinous carcinoma) was present. Vascular invasion was not evident. Immunohistochemically the neoplastic cells showed a strong positive stain for cytokeratins (MNF116, CK7) EMA, S100 (fig ) and e-cadherin (fig ). In addition, an extremely focal, weak stain for 34beta E12 and CD10 was observed.
+Chromogranin, sinaptophysin, NSE, smooth muscle actin, p63, Her-2, oestrogen and progesterone receptors were negative, Mib1 (Ki67) and P53 were positive in less than 5% of the cells. The histological diagnosis was G1 secretory breast cancer.
+Analysis of the DNA cell content of the secretory carcinoma proves to be diploid with low proliferative activity [-] and, in fact, in our own case, flow cytometry performed on the cell DNA (65,520 cells) also showed a diploid-type histogram (DI = 1.0) with low proliferative activity (S-phase = 4.5%).
+After an interdepartmental discussion, an upper outer quadrantectomy of the right breast on the previous site of removal of the nodule was proposed to the patient, together with a biopsy of the ipsilateral axillary sentinel lymph node.
+The sentinel lymph node was identified with the use of a radiocolloid and intravital stain.
+The day before the operation, the sentinel lymph node was observed by means of lymphoscintigraphy after an intradermal injection into the surgical scar of human albumin (Nanocoll) bound to technetium 99 (0,2 mCi of 99 mTc in a volume di 0,4 ml). Ten minutes before the start of the operation 0.5 ml of intravital stain was injected subdermically into the same site. A portable radioisotope detector was a further help in the intraoperative identification of the sentinel lymph node, which showed up as bright blue and was therefore removable without any difficulty. Frozen section of the sentinel nodes was not performed since at the time when this case was observed (1999) the extemporary histological examination of the sentinel lymph node was not well-codified in our department and was therefore not in routine use.
+The subsequent histological analysis performed on the removed quadrant showed the presence of some small areas of ""in situ"" secretory carcinoma, mixed with focal aspects of ductal papillomatosis with atypia of the epithelial cells.
+The lymph node defined as the sentinel had a maximum diameter of 1 cm. It was fixed in formalin, paraffin-embedded, completely sectioned and histologically analysed. It presented metastases with a maximum diameter of 0,3 cm (fig ); the metastatic cancer cells showed intracytoplasmic vacuoles containing secretory globules similar to those of the primary tumour cells (Fig )
+A total axillary lymphoadectomy under general anaesthetic was therefore performed during a subsequent operation. Histological examination of the 18 axillary lymph nodes removed showed no signs of metastases. The patient was given adjuvant chemotherapy consisting of six cycles of CMF and radiotherapy of the residual mammary gland.
+Periodic follow-up examinations after completion of the surgical, medical and radiotherapy treatment have shown no evidence of either local regression or distant metastases and seven years later, the patient is still free of the disease."
+Joe Carter,26,1993/11/23,990.264.7767,owagner@example.org,90910 Robert Rapid Apt. 240,"In April 2004, a 79-year-old man presented with a 4 month history of subcutaneous abdominal nodules and bilateral inguinal lymphadenopathy; no other signs or symptoms were present.
+The patient was retired after various occupations; he had also worked for 7 years at the local port and for 3 years in a motor factory, but he had no memory of direct exposure to asbestos. He had no smoking history. Medical history included partial gastric resection due to gastric and duodenal ulcers with concomitant cholecystectomy for cholelithiasis at 44, surgical removal of a renal stone at 74, diagnosis of benign prostatic hypertrophy at 76.
+A CT of the chest, abdomen and pelvis showed the presence of a large mass occupying the epigastrium and the left upper region of the abdomen (longest diameter: 9 cm), and multiple diffuse abdominal nodules along the peritoneal surface and below the anterior abdominal wall (longest diameter: 5 cm); imaging confirmed the presence of bilateral inguinal lymphadenopathy. A small amount of ascites was present; liver, spleen and kidneys were spared. Chest CT was negative, with no evidence of pleural or pulmonary parenchymal abnormalities. An excisional biopsy of the left inguinal lymphadenopathy was performed. Histological analysis showed malignant neoplasm with a micropapillary, microcystic, and solid growth pattern infiltrating the adjacent soft tissues. Immunohistochemical analysis revealed positive staining of tumour cells for cytokeratins 5 and 7, vimentin, epithelial membrane antigen (EMA), epithelial specific antigen (ESA), calretinin; no reactivity was observed for carcinoembryonic antigen or Tag/B72.3. Histological and immunohistochemical findings were consistent with a well differentiated biphasic malignancy of mesothelial origin.
+In July 2004 the patient was referred to our Department for management. At admission, he reported progressive clinical deterioration (Karnofsky Performance Status 80), fatigue, unintentional weight loss of 6 kg and persistent fever over the last few weeks. His medications were terazosine and finasteride. Physical examination showed a subcutaneous epi-mesogastric mass (9 ? 6 cm) and bilateral inguinal lymphadenopathy. Complete blood count showed haemoglobin 11.6 g/dL, platelet count 559,000 per cubic millimeter, and white cell count 8,400 per cubic millimeter, with a normal differential count; renal function and liver function tests were normal.
+In consideration of patient's age, and type and stage of disease, palliative chemotherapy with single-agent pemetrexed at 500 mg/m2 i.v. every 3 weeks was proposed []. Pemetrexed was provided by Eli Lilly (Indianapolis, IN) within an Expanded Access Programme. Before chemotherapy start, a written informed consent was obtained and a repeat CT was performed, showing a size increase of all lesions (longest diameter of the mass in the abdominal left upper region: 12 cm) (Fig. ). Treatment started in early August 2004. During the treatment, the patient received vitamin B12 and folic acid supplementation, and steroid prophylaxis []. After the first 2 cycles, a clinical improvement was observed with reduction of frequency and intensity of febrile episodes. Partial response was documented by physical examination (decrease in size of the subcutaneous abdominal mass and bilateral inguinal nodes) and by CT (decrease in size of all known lesions and no new lesions). Treatment was well tolerated with only grade 2 neutropenia, and grade 2 nausea and anorexia. Therefore, pemetrexed was continued for 3 cycles and further tumour shrinkage was documented at physical examination and imaging. Toxicity persisted acceptable with only grade 2 nausea and fatigue; fever disappeared after the third cycle. Three further cycles of pemetrexed were administered without increase in toxicity except for mild fever lasting few days after drug administration. After a total of 8 cycles, the epi-mesogastric mass and the inguinal bilateral lymphadenopathy were no more detectable at physical examination, whereas abdominal CT in April 2005 showed a minimal residue of disease (Fig. ). His Karnofsky Performance Status was 80 and his weight was increased of approximately 10% since treatment start. At that point, after multidisciplinary evaluation and discussion with the patient about therapeutic options, we decided to stop the treatment.
+In August 2005, a follow-up CT revealed the reappearance of nodular peritoneal lesions. Due to the significant benefit observed and the duration of response (11 months) the patient was retreated with pemetrexed for 4 cycles from August to November 2005, resulting in disease stabilization. At the time of his last appointment at our Department in February 2006, a CT scan confirmed stable disease."
+Lucy Ashley,20,1996/12/9,(436)765-2278x2076,brenda34@example.org,985 Blair Forest,"A 20 year-old male suffered a severe penetrating skull base injury caused by a screwdriver which he was holding in his right hand when he accidentally slipped off a ladder. The crossed-head tip of the screwdriver pierced into the right maxilla and the steel shank penetrated through the skull base. The total penetration trajectory measured roughly ten centimeters. The patient was admitted in GCS 11. He presented a scotoma in the left eye and a CSF leak in the maxillary area. The 3-D CT-scan revealed an oblique trajectory of the screwdriver through the right maxilla, into the ethmoidal plane and as far as the left sphenoid wing (Fig. ).
+An emergency left pterional approach surgery was performed. The tip of the screwdriver was lodged just above the left optic nerve and adhered tightly to the intracranial part of the nerve trunk. The tip was detected in the left Sylvian area next to the M1 narrowed tract.
+First, the screwdriver tip was carefully detached from the artery and, then, the screwdriver was slowly extracted from the skull base. The dura lacerations were repaired with artificial dura, while the skull base fractures were closed with a fragment of temporal muscle and fibrin glue.
+The post-operative course was uneventful. The patient's visual acuity began to improve ten days after surgery and, within six weeks from surgery, his visual acuity was completely restored."
+Kylen Knapp,39,2005/8/14,637-380-5066,suzanne59@example.org,37650 John Forks Suite 551,"We report on a 73-year-old female patient with an 8-year history of thyroid nodules for which she underwent regular clinical examination and blood tests. Three weeks before referral to our endocrinological surgery unit she developed a swelling of her head and neck lymph nodes. Her past medical history included surgical removal of a benign breast tumor 22 years ago. Her family history was unremarkable regarding any endocrinological or thyroid disease. Besides her obesity she was suffering from reflux disease and hypertension. She had a regular pulse of 68/per minute and blood pressure of 120/70 mmHg under antihypertensive medication. Her muscle tone was reduced. She had observed a change of her voice and had lost 20 kg of weight within the past 4 months. A thyroid scintigram showed multiple confluencing cold nodules which were highly suspicious for malignant neoplasm of both thyroid lobes and regional lymph node metastases along both jugular veins. Clinical exam and sonography showed multiple enlarged lymph nodes of the head and neck. Pre-operative serum calcitonin was 5.3 pg/ml (normal range 0.8??.9 pg/ml). Based on the history, clinical presentation and the scintigram we suspected an anaplastic thyroid carcinoma and performed a radical oncologic thyroidectomy with bilateral modified neck-dissection and resection of the right internal jugular vein and the left recurrent laryngeal nerve. Intraoperatively the tumor was tightly adherent to the surface of the trachea. Because of the impressing clinical picture a fine needle aspiration was not performed prior to surgery. In the authors' point of view it would have had no prognostic effect at this advanced stage of disease. A pre-operative pentagastrin test was also not performed as clinical presentation made the presence of an anaplastic carcinoma highly suspicious. Surprisingly, histopathology showed a pT3 L1 V1 R1 N1b low-differentiated medullary-thyroid carcinoma with massive lymphangiosis and haemangiosis carcinomatosa. Immunhistochemistry revealed weak positive staining for calcitonin and carcinoembryogenic antigen (CEA) (Figure ). Post-operative serum calcitonin decreased to 2.47 pg/ml still being within normal range (0.8??.9 pg/ml). Post operatively the patient was in the intensive care unit for 6 days. A pentagastrin stimulation test was not performed due to the bad condition of the patient. A permanent tracheostoma was established to ensure a patent airway as the patient aspirated after initial extubation. Additionally massive crust formation obstructed the patient's airway which was treated with a humidifier and frequent irrigations with physiological saline solution and subsequent suctioning of the trachea. Unfortunately the patient developed central lung emboli in the right pulmonary artery. A postoperative CT scan showed multiple lung and intracerebral metastases (Figure and Figure ). The patient died six weeks after diagnosis."
+Linda Jimenez,35,1980/4/20,-4083,whitneymichael@example.org,889 Todd Underpass,"A 42-year-old man presented with sudden-onset hematemesis. Everything had started a year before, when he had developed shortness of breath along with a plethoric face. The patient was admitted to the Surgery Department and was diagnosed with SVC thrombosis by means of Doppler ultrasonography and spiral computed tomography (CT) scan of chest (figure ). The subject underwent thoracotomy out of suspicion of mediastinal mass effect on SVC, detected on thoracic spiral CT scan to be a thymoma or a thymus-associated mass. In the operation, no discrete mass was found and the thymus gland was removed and sent for pathologic review. No pathologic finding was detected and the gland had normal histological appearance. The patient received anticoagulant therapy in the form of warfarin 5 mg/day for 9 months. Then, he developed arthralgia of knee, wrist, elbow and ankles but no documented arthritis. He was examined by a rheumatologist when he was discovered to have positive pathergy test (positive cutaneous hypersensitivity reaction to intradermal injection of saline) and an oral aphthous ulcer. The history of genital ulcer was also positive in the patient. The diagnosis of Behcet's disease was made and the patient was treated with prednisolone tablets, 15 mg/day, and azathioprine, 100 mg/day; warfarin was also continued. A follow-up CT scan showed prominent mediastinal collateral veins close to the esophagus (figure ).
+Two weeks later, the patient presented with sudden onset of hematemesis and was admitted to the Emergency Room. He did not mention any past history of upper gastrointestinal bleeding. Review of systems was not contributory. The patient was conscious and agitated. His blood pressure was 110/70 mmHg, but he had orthostatic hypotension with resting heart rate of 104/min. The patient had plethoric face and engorgement of jugular vein. Conjunctivae were pale and sclerae were anicteric. Pemberton's sign was detected; i.e. within 30 seconds after raised both arms simultaneously (Pemberton's maneuver), marked facial plethora (Pemberton's sign) developed, indicating compression of the jugular vein. Abdomen was soft with no tenderness, organomegaly or shifting dullness. Nervous system, musculoskeletal system, joints and the peripheral vascular system were all normal. A nasogastric tube was inserted and coffee ground secretions were revealed. Lab data were as follows: WBC: 6400, Hb: 6.5 g/dl, MCV: 97, MCH: 32, Platelet: 241,000, PTT: 40 seconds, PT: 18 seconds, INR: 2.1, albumin: 4 g/dl, ALT: 23, Alkaline Phosphatase: 170 (normal), BUN: 18 mg/dl, Cr: 0.6 mg/dl, Na: 138 meq/dl, K: 4.2 meq/dl.
+The patient received 6 fresh frozen plasma (FFP) units and 4 units of packed red cells and his INR was rechecked after FFP infusion, when it was corrected to 1.3.
+Because of underlying vasculitis, the diagnosis of portal vein thrombosis and bleeding due to esophageal varices was considered. The patient received intravenous infusion of octreotide and intravenous infusion of ranitidine. The bleeding stopped and the patient was closely monitored in the Emergency Room. Warfarin and azathioprine were discontinued and intravenous hydrocortisone was started instead of oral prednisolone. The patient underwent upper endoscopy on the day of admission and esophageal varices were found. Gastric and duodenal mucosae were intact. Abdominal ultrasound was normal and no evidence of ascites, splenomegaly and chronic liver disease was found. To rule out portal vein thrombosis as the cause of esophageal varices, Doppler ultrasonography was performed and mesenteric, splenic, portal and hepatic veins were evaluated; no discrete thrombosis was detected. He was not able to perform MR angiography because of his economic status. The patient underwent re-endoscopy by a second endoscopist and red color sign or stigma of recent bleeding plus esophageal varices were found in the upper half of esophagus tapering to the middle part of esophagus (figure ); the diagnosis of ""downhill"" esophageal varices was made and band ligation was performed successfully (figure ). He received oral cyclophosphamide 100 mg/day upon recommendation of rheumatologist. Omeprazole was administered too.
+The patient was discharged from hospital the following day without any complication. Two weeks later, the third endoscopy along with the second band ligation was performed. He was discharged without any further episodes of bleeding. After 1 and 6 months, the patient underwent the 4th and 5th endoscopies and ""downhill"" esophageal varices were found to have been eradicated. Warfarin was initiated for patient and he has been well with no bleeding during the past 16 months. We are going to do surveillance endoscopies in this patient every 1?? years."
+Silas Choi,24,1979/9/3,228-543-9407,gonzalesjason@example.org,4406 Wesley Crossing Apt. 636,"An 87-year-old woman with history of systemic hypertension and dyslipidemia was admitted to our hospital after having had severe chest pain of sudden onset radiating to the back and followed by syncope. She presented with marked hypotension (60/40), sinus tachycardia (130 beats per minute), and livid legs. She needed oral tracheal intubation, mechanical respiratory assistance, volume expansion and inotropic support. An urgent transesophageal echocardiogram revealed aortic intramural hematoma compromising the anterior wall of the ascending aorta (Fig. ) with no evidence of aortic dissection, and severe pericardial effusion with cardiac tamponade and periaortic hematoma that involved the pulmonary artery generating circumferential wall thickening of its trunk (Fig ) and right branch (Fig. ) with no evidence of flow obstruction (Fig. ) [see ]. Urgent surgery was performed (drainage of pericardial hematoma and replacement of ascending aorta) but the patient died in the operating room.
+The post mortem examination, in the operating room, confirmed that there was an extensive hematoma around the aorta and beneath the adventitial layer of the pulmonary artery with no evidence of flow obstruction."
+Karla Drake,21,1990/4/27,347-848-3734,fordcaleb@example.net,73014 Rodriguez Courts Apt. 080,"A 4 year old female presented with huge abdominal swelling first noticed by her parents at 2 years of her age (See Figure ). The swelling had increased in size since then to occupy almost whole of the abdomen. Right labia had a swelling which increases in size on standing and decrease on lying down. On examination abdomen was found to be distended, felt tense with flanks full. The swelling over the labia was reducible on manipulation suggesting its continuity with the abdominal swelling.
+Ultrasound abdomen showed 30 ? 20 ? 20 centimeters huge, multiloculated, multiseptate, lesion extending from xiphisternum to pelvis with extension into the right labia majora. Lesion was causing lateral and posterior displacement of bowel loops and compression of liver and both kidneys. A provisional diagnosis of omental, mesenteric or ovarian cyst was made. CT scan was done to throw some more light on the site of origin. Non-contrast film showed the cyst filled with clear fluid possibly arising from the mesentery. Contrast film was suggestive of multiloculated cyst. Pelvic films proved the labial extention of the cyst (See Figure ), but still the exact site of origin remained unclear.
+Patient was taken up for exploratory laparotomy and midline vertical incision was kept. After opening the peritoneum a thin walled cyst was seen popping out of the skin incision (See Figure ). On exploration it was found attached to the greater omentum (See Figure ).
+Cyst was deflated partially by aspiration and we found the swelling over labia majora got reduced as we deflated the cyst and no adhesions were found between the cyst wall and labia. Complete excision of the cyst wall along with part of omentum was done. Histopathological report of the cyst wall showed endothelial cell lining, foam cells, lymphatic spaces, lymphoid tissue and smooth muscles which are diagnostic of lymphangiomatous cyst (See Figure ). Patient was under follow up for since six months and had no clinical and radiological signs of recurrence."
+Jalen Pittman,26,1998/8/17,-3640,andrewroman@example.com,504 Good Light Suite 297,"The patient was a 46-year-old man, afflicted with a cleft palate but no other serious diseases, when he first came to our departement for consultation complaining his loose fitting denture and asking for prosthetic treatment.
+Clinical and radiographic examination (including 3D DVT scan [digital volume tomography, New Tom 9000, New Tom Marburg, Germany]) revealed an edentulous moderately severe atrophied mandible, a partialy edentulous maxilla, with severe posterior maxillary alveolar atrophy and skelettal class-III conditions due to cleft palate (figures and ).
+In March 2004 extraction of the teeth 12, 17, 22, bilaterally sinus lifting procedure and a simultaneous alveolar ridge augmentation of the maxilla and the mandible were peformed under general anaesthesia. A mixture of cancellous bone from the iliac crest and Grafton簧-DBM-Putty (Osteotech, Eatontown, NJ, USA) was used for the maxillary sinus floor augmentation. The lateral augmentation was performed using screw fixed autogenous corticocancellous block grafts and particulate bone grafts from the iliac crest mixed with Grafton簧-DBM-Putty (Osteotech, Eatontown, NJ, USA). To fulfill the patient's desire the teeth 11 and 21 were left in the maxilla.
+After three months screws were removed and auxiliary implants placed in the mandible.
+6 weeks later screws were removed from the maxilla and using preoperative fabricated surgical guides a total of 12 endosseous Camlog簧 implants were accurately positioned in the mandible and the maxilla according to the predefined planning that was made up of DVT scan and a wax up. Again bone augmentation around the dental implants was performed using filter collected bone and a bioresorbable collagen membrane (BioMend Extend簧, Zimmer Dental, Carlsbad, CA, USA).
+Based on the ideal implant position temporary protheses were fabricated and used for performing the modell-operation to correct the maxillo-mandibular relation. Three months later Le Fort I osteotomy with high horizontal bone cut was performed under general anaesthesia. The carefully downfractured maxilla allowed an unique view from above to the grafted sinuses (figure ). The grafted bone showed high consistency and stability and except for a small mucocele in the right sinus no signs of any inflammatory irritation were detected. According to the preoperative planning the maxilla was placed in the new advanced position and then fixed with microplates (figure ).
+Postoperative healing was uneventful, except for a local infection that occurred two month later in the left upper canine region therefore the implant there had to be removed.
+Six month later after extraction of teeth 11 and 21 the miniplates were removed from the maxilla and the implants uncovered. In addition abutments with protective healing caps were installed. After placing definite abutments and removing the auxililary implants final restauration was placed (figure )."
+Marie Shelton,37,1978/11/25,929-521-2905,mooreedward@example.org,71796 Lori Motorway Suite 655,"A 70-year-old man was referred for coronary revascularization with angina (Canadian Cardiovascular Society class 2), three vessel disease and good left ventricular function. He was otherwise well, with no significant past medical history and physical examination was unremarkable. Preoperative risk assessment scores were: EuroSCORE standard 3 (age), logistic 1.82. Preoperative investigations revealed a white cell count (WCC) of 15.6 ? 109/L (neutrophils 10.1 ? 109/L, monocytes 2.5 ? 109/L) and urinalysis positive for blood. He denied any urinary or respiratory symptoms but was treated empirically for a lower urinary tract infection and discharged home. Urine culture was negative. Two weeks later, the WCC remained elevated at 14.2 ? 109/L (neutrophils 10.5 ? 109/L, monocytes 1.6 ? 109/L), although he remained asymptomatic and was keen to proceed.
+Coronary artery bypass grafting was performed using the left internal mammary artery and saphenous vein grafts. Cardiopulmonary bypass (CPB) time was 76 minutes with aortic cross-clamp for 39 minutes, using antegrade cold crystalloid cardioplegia. The patient came off CPB easily and remained haemodynamically stable thereafter. He was extubated expeditiously and returned to the ward on the first postoperative day. Routine blood tests demonstrated a leukocytosis (46.9 ? 109/L) with marked neutrophilia (38.5 ? 109/L) and monocytosis (8.4 ? 109/L).
+Late on the first postoperative day, his condition deteriorated with progressive hypoxia, oliguria and metabolic acidosis. He was readmitted to the intensive care unit for non-invasive ventilation and inotropic support. On the morning of the second postoperative day, he remained hypoxic and oliguric. A pulmonary artery catheter revealed low cardiac output state and low systemic vascular resistance. He was reintubated and mechanically ventilated, inotropic therapy was increased and continuous veno-venous haemofiltration and broad-spectrum antibiotics were commenced. A cardiac origin of low cardiac output was excluded and sepsis or splanchnic ischemia were considered as causes of his systemic inflammatory response syndrome (SIRS) and multi-organ dysfunction (MOD). Computed tomography of the thorax and abdomen showed bilateral ground glass shadowing of the lung parenchyma consistent with acute respiratory distress syndrome but no other significant findings. The leukocytosis increased to 91.7 ? 109/L (neutrophils 54.1 ? 109/L, monocytes 33.0 ? 109/L) and his condition deteriorated. A haematology opinion was sought and confirmed a diagnosis of probable leukaemoid reaction on a background of CMML. Despite maximal therapy, the patient died on the third postoperative day. Post-mortem findings were of an enlarged spleen and widespread SIRS, manifesting as pulmonary congestion with patchy hemorrhagic necrosis of the small and large bowel."
+Leonel Small,30,1981/1/13,+1-722-655-5914x7363,rhardy@example.org,576 Michael Center,"FG is a 74-year-old right-handed man. He has a grade eleven education and worked as an auxiliary nurse. He had suffered from a chronic bipolar disease since 1982, with multiple episodes requiring many hospitalizations. He came to our attention in July 2005 for acute exacerbation of a bipolar disorder with suspected psychotic features requiring inpatient treatment. At admission, symptoms were compatible with manic exacerbation. Psychotic features were not confirmed. Mental status examination revealed signs of his primary psychiatric disorder. Moreover, a foreign accent, English-sounding, was noted. FG had learned to deal with this long-lasting symptom so he did not report it spontaneously. However, on explicit questioning, he reported that this accent was socially invalidating and completely impossible to control or repress. FG is a native speaker of Quebec French but people who met him thought he came from somewhere else, most often Acadia (French-speaking areas of Eastern Canada (New Brunswick, Prince Edward Island and Nova Scotia) where the accent is markedly different from Quebec French), France or an English-speaking foreign country. Apart from this foreign accent, he also reported some German- or Spanish-sounding words occasionally and spontaneously coming to his mind. No meaning is associated with these words and the patient easily controls their occurrence with no anxiety. Neurological examination completed during the index hospitalization was unremarkable except for an observed inability to turn back on one foot (decomposition of the half-turn) when walking, slight incoordination of the left arm on the cerebellar testing, and slight micrographia. Snout and palmomental primitive reflexes were also noted.
+FG's past medical records reported the presence of this foreign accent in January 2003. It was first noticed at the psychiatric outpatient clinic consultation, shortly after he was discharged from the inpatient service, which was required for manic exacerbation of his bipolar disorder in the fall of 2002. The presence of agrammatism was also recorded during the same period. Psychological factors were suspected because of the patient's psychosocial background (abuse by his father and emotional closeness to his mother, who was English-speaking). Even though he was exposed to English as a child, he never spoke or learned this language. Without any other neurological symptoms, his psychiatrist ascribed the foreign accent to a psychological phenomenon operating at an unconscious level.
+His neurological history is noteworthy for epilepsy between the ages of 6 and 14 but without any other symptomatic seizures thereafter. He also suffered from delirium due to lithium intoxication 6 months before the onset of the foreign accent. Finally he has been treated for an essential tremor for many years and has neurosensory hypoacusia. Otherwise, there was no prior history of stroke, cranial trauma or encephalitis. When he developed the language disorder, he was on stable doses of lithium, valproate, quetiapine and perphenazine.
+Although they appeared approximately 3 years earlier, the functional origin of the FAS and agrammatism was explored in FG through an extensive neuropsychological and brain imaging study.
+Neuropsychological testing showed no impairment in tasks exploring orientation to time and space. FG's performance was normal on the task exploring concentration and selective attention []. He showed good face recognition and presented no clinical signs of visual agnosia []. There were no signs of unilateral neglect. Praxis abilities were well preserved []. FG performed normally on tasks exploring episodic memory. His performance was within the normal range for the three recalls of the DMS-48, a visual forced-choice recognition test [], as well as for the pictorial recognition memory test and the short recognition memory test for faces []. The patient's short term memory was normal in the visuospatial modality (forward span = 5; backward span = 4) []as well as in the verbal modality (forward digit span = 4; backward digit span = 3; forward word span = 4). FG presented with deficits on tests exploring working memory and executive functions. He presented with a severe impairment on the interference condition of the Brown-Peterson task [], a test that taps the ability to encode, maintain, and manipulate information in working memory (see Table ). His performance on the Stroop Test [], an instrument designed to evaluate inhibition abilities (i.e. inhibition of a habitual or more automatic response in favour of an unusual one), was influenced by interference. He obtained normal scores in the word reading and colour naming but his performance was impaired in the colour-word conditions. FG also showed abnormal performance on the Trail Making [], a test exploring mental flexibility (ability to manage more than one stimulus at a time and to shift the course of an ongoing activity). He made no mistakes but was slow on part A and his performance was poor on Part B (alternated switching between numbers and letters). Finally, FG's performance was impaired (2 SD below the normal range) on the D-Kefs Tower Test [], a complex task that measures the executive functions of spatial planning, rule learning, and inhibition of impulsive responding.
+With regard to language, speech output was fluent and well articulated, with no signs of word-finding difficulties. The patient however presented with mild agrammatism. There were no phonemic or verbal paraphasias but speech was sometimes telegraphic with omissions of function words and grammatical bound morphemes as well as impoverished syntactic structure. Auditory and visuo-verbal input components were largely preserved. Comprehension abilities at the lexical-semantic level [] as well as at the syntactic-semantic level [,] were normal (see Table ). Reading and immediate and delayed repetition were flawless for both words and nonwords. Written spelling of nonwords was flawless but the patient's performance on word writing to dictation was canonical of surface agraphia with exclusive production of phonological plausible errors and performance affected by orthographic regularity and lexical frequency. However, the patient did not completely master the written language so that these results cannot be interpreted as actual deficits. FG's performance was normal in confrontation naming [] but he showed difficulties in letter and semantic category fluency tasks [] (see Table ), a performance that could be attributed to the deficit in executive functioning. FG showed many characteristics usually reported for FAS. There were no signs of dysarthria (no slow, slurred, groping or laboured articulation) or apraxia of speech (no dysfluency and no problems with phoneme sequencing) but acoustic analysis performed on speech samples recorded in Digital Audio Tape showed the presence of abnormalities at the segmental and suprasegmental levels. Unfortunately, we had no premorbid recording of the patient's speech. However, FG himself as well as one of his close friends, who has known him for over 30 years, confirmed that he never had this particular strange accent before its sudden appearance in January 2003.
+Neuroimaging studies were performed while the patient was in euthymic condition. A magnetic resonance imaging (MRI) study including sagittal FLAIR and T2-weighted sequences and axial FLAIR, proton density, T1 and T2-weighted sequences was performed on December 8, 2005 using the standard protocol. The first interpretation was normal except for slight diffuse cerebral atrophy considered normal for his age (see Figure : serie 3 31/10 = axial T2-weighted sequence showing diffuse cortical atrophy predominating at the left sylvian fissure).
+An 18F-fluorodeoxyglucose brain positron emission tomography was obtained with a dual-head coincidence camera (Vertex MCD-AC, Phillips). After a 30-minute rest, 111 MBq 18F-FDG were injected in a veinous catheter. There was another 30-minute rest before starting the acquisition (64 ? 64 ? 16 matrix, 64 steps, mean of 25 seconds/step with decay correction). Measured attenuation and scatter correction were applied to the iterative reconstruction method.
+The reconstructed images showed diffuse hypometabolism in the frontal, parietal and temporal lobes bilaterally whereas the cerebellum, occipital lobe and subcortical structures were spared. There was also a focal deficit in the area of the anterior left temporal lobe with prominence of the sylvian sulcus (see Figure ). When compared to the MRI, these deficits were related to asymmetric atrophy, which was retrospectively seen in the left temporal and frontal opercular/insular region without a focal lesion."
+Zaria Pearson,29,1980/12/24,(965)775-1679x532,dmendez@example.com,51620 Sarah Burg,"A 72-year-old man presented with abdominal discomfort with small amount of bleeding per rectum and a clinically palpable lump in the right iliac fossa. He also had a large, firm, mobile lump on his left thigh.
+He had been treated six years previously for prostatic carcinoma which was Gleason's grade 3+3= 6. Bony metastases had been diagnosed recently. He was on Zoladex簧 injections.
+Clinical examination showed a 6 cm hard, mobile, non-tender mass in his right iliac fossa. Digital rectal examination was unremarkable. Rigid sigmoidoscopy revealed radiation proctitis, which would explain his bleeding per rectum. CT scan of abdomen showed a caecal tumour with regional lymphadenopathy and vertebral metastasis (Figure ). A non-palpable left iliac mass was identified: this was defined as internal iliac nodes lymphadenopathy, associated with partial obstruction of the left ureter (the possibility of prostatic metastasis to these nodes was considered). A fatty mass lesion was identified in the left thigh, the CT appearances of which were that of a simple lipoma; this has remained unchanged on subsequent CT scans. Bone scan confirmed bony metastasis in the 12th thoracic and 1st lumbar vertebrae and rib cage. In 2003, there was a gradual rise in his PSA levels which had gone upto 233 nmol/ml. Zoladex簧 injections were then started and his PSA levels fell to 6.3 nmol/ml by January 2004. This however had gradually risen again to 254.4 nmol/ml on admission, inspite of being on Zoladex簧.
+The patient underwent a right hemicolectomy for what appeared to be an obvious locally advanced luminally protuberant caecal carcinoma with mesenteric lymph nodal involvement. Histopathological examination of the specimen showed a poorly differentiated adenocarcinoma of the caecum extending throughout the whole bowel wall and breaching the serosa with metastatic involvement of 5 of 15 paracolic lymph nodes (Figure ). The possibility of prostatic metastasis was considered and confirmed on immunohistochemical staining for PSA (Figure ) and, given this, stains for CK7, CK20 and CDX2 immunoprofile were considered unnecessary. The final histological diagnosis was of a metastatic prostatic adenocarcinoma to the caecum. The patient underwent adjuvant chemotherapy with Docetaxel and Paclitaxel and is free from recurrence a year later."
+Gunner Lugo,24,1995/7/18,(372)348-1431,nmurphy@example.org,74087 Heidi Common,"A 37 years-old Caucasian male with no significant past medical history presented with pain and discomfort in the lower chest and left upper quadrant abdominal area for 6 months. Chest and abdominal computed tomography showed a 7.8 ? 7.3 cm irregular, partially cystic mass in the body and tail of the pancreas, suspicious for malignancy. In addition, two lesions were seen in the liver compatible with metastases. He underwent an endoscopic ultrasound (EUS), which revealed a 4.9 ? 3.7 cm irregular mass in the pancreatic tail and body. The mass was hypoechoic, heterogeneous, lobulated, multicystic, and septated. There were two masses found in the left lobe and in the perihilar region of the liver, measuring 1.9 ? 1.5 cm and 2.2 ? 2.2 cm in maximal cross-sectional diameter respectively. Fine needle aspiration was performed on one of the two masses in the left lobe of the liver, after color Doppler imaging was utilized prior to needle puncture in order to confirm a lack of significant vascular structures within the needle path (Figure: ). Three passes were made by a 22-gauge needle with a stylet using a transgastric approach. A cytopathologist (HQP) was present and performed a preliminary cytological assessment during the procedure. An adequate sample was obtained after the first two passes but a third pass was requested for special studies due to the unusual morphology seen on site evaluation. The decision to not sample the pancreatic mass was made by the endoscopist.
+Two passes were used for 2 sets of Air-Dried smears. One smear of each pass was stained on-site by the Diff-Quick method for immediate assessment. The other Air-Dried smear slides were stained with the Papanicolaou method upon return to the lab for re-hydration. The third pass was directly rinsed in CytoRich Preservative Fluid (TriPath Imaging?? Inc, Burlington, NC 27215) for paraffin-embedded cell block preparation."
+Kaylie Zimmerman,22,2004/4/20,-7360,zrichard@example.net,47330 Mcdaniel Trace Suite 727,"A 48-year old Caucasian female with active
+rheumatoid arthritis was diagnosed with a low-grade myxoid
+liposarcoma of the left thigh in 1981. This was treated with surgery followed by
+radiotherapy. In 1991, she was discharged from routine oncological
+followup. In 1998, she was rereferred by her GP for investigation
+of a left groin mass. Biopsy of the groin mass confirmed recurrent
+liposarcoma and restaging investigations confirmed that the lesion
+was isolated. Surgery and radiotherapy (5000 Gy in 25
+fractions) were used to treat the recurrent liposarcoma. The
+pathology report revealed that the tumour had transformed into a
+?igh-grade myxoid/round-cell liposarcoma surrounding the iliac
+artery and vein, involving the deep resection
+margins.??Over the next 6 years, the patient continued on close outpatient
+followup with regular chest X rays. During this time, persistent
+left leg oedema became problematic. In addition, her rheumatoid
+arthritis remained symptomatic despite treatment with
+hydroxychloroquine, methotrexate, and indomethacin.
+In October 2004, the patient was admitted as a
+medical emergency with a 5-day history of nausea and vomiting,
+severe occipital headache, photophobia, and diplopia. In
+addition, she described a strange sensation in her tongue with
+impaired tongue movement. On examination, a 3 cm ? 3 cm smooth mobile cervical neck node was noted in
+addition to a left VI cranial nerve palsy, a right XII
+cranial nerve pals, y and hypotonia of the left side of the
+tongue. A lumbar puncture, CT brain, and blood tests including a
+vasculitic screen and viral serology were normal. An MRI
+demonstrated a ?igh signal at apex of the temporal bone??but
+was otherwise normal. Over the next 10 days, the patient
+continued to complain of a persistent dull throbbing headache and
+developed a right-sided VI nerve palsy. FNA of the neck node
+confirmed metastatic liposarcoma and a CT scan of the
+chest/abdomen and pelvis revealed ?idespread tumour deposits in
+the right psoas muscle and pelvis.??The lungs were clear of
+metastatic disease. A repeat MRI done 3 weeks following her
+admission this time showed that ?t the skull base, the clivus
+gives an abnormal marrow signal with infiltration, most likely due
+to metastatic disease.??Due to intractable symptoms, she went on
+to receive palliative radiotherapy to the base of skull (30 Gy
+in 10 fractions). A repeat CT scan done 6 weeks after the last
+scan showed progressive disease in the abdomen and pelvis with new
+lung metastases. Whilst waiting to commence palliative
+chemotherapy, the patient developed neurogenic dysphagia and died
+from aspiration pneumonia. At postmortem, meningeal thickening was
+noted in the area of the mid brain (). Further
+neuropathological examination revealed liposarcoma cells within
+blood vessels in the subarachnoid space () in
+addition to deposits of metastatic liposarcoma in the subarachnoid
+space itself ()."
+Sergio O’Connor,23,1999/12/7,4909441461,rmiller@example.net,9259 King Shoals,"We report what is to our knowledge the first case of a
+urinary tract infection caused by Photobacterium damsela,
+a virulent pathogen, in a 22-year-old gravid female at 23-week
+gestation.
+The patient initially presented for routine prenatal care. At this
+time she reported frequency and dysuria with no other complaints.
+She denied any significant past medical history. The only finding
+on physical examination was suprapubic tenderness and leukocytosis
+was noted on the urine dipstick. A urine culture was obtained and
+the patient was treated empirically with Cephalexin 500 mg qid
+for one week. The urine culture subsequently demonstrated growth
+> 100000 colonies of Photobacterium damsela, which was
+sensitive to cephalosporins,
+trimethoprim-sulfamethoxazole, and aminoglycosides.
+Given the rarity of infection with this
+pathogen, a more detailed history was obtained where the patient
+stated have had sexual intercoursein the Caribbean Sea off the
+coast of Puerto Rico, one week prior to her office visit.
+One week after having her first office visit and the urine culture
+with the above findings, the patient presented to labor and
+delivery complaining of fever, chills, and foul smelling urine at
+24-week gestation. On the day prior to admission, she noted that
+her urine was malodorous. She complained of suprapubic tenderness
+and mild right flank pain. On examination she was noted to have an
+oral temperature of 101.6 and suprapubic tenderness, no
+costovertebral angle tenderness was noted. No contractions were
+palpated and on vaginal examination a closed uneffaced cervical os
+was noted. The white blood cell count was 8800 with 79%
+polymorphonuclear lymphocytes and no bandemia was present.
+A urinalysis showed trace blood, positive nitrites, and some
+bacteria. The fetal heart rate was reassuring and no contractions
+were noted on the tocometer.
+Given the history of the unusual pathogen that grew a week prior
+to this presentation, the patient was admitted with the diagnosis
+of pyelonephritis in pregnancy and was started on Cefazolin
+2 g IV every 6 hours, and Gentamicin 120 mg IV every 8
+hours. The patient remained febrile for 24 hours at which time she
+had her last temperature spike of 101.6 and fetal tachycardia
+was noted to 180 beats per minute. She was maintained on the
+aforementioned antibiotic therapy and defervesced. A complete
+blood count was repeated on hospital admission day number 3 and
+her white blood cell count remained within normal limits. On
+admission day 3 the peak and trough for gentamicin showed
+therapeutic levels of the antibiotic. No growth was observed on
+the blood cultures done on admission. The patient was discharged
+home on hospital day number five. She was advised to take Bactrim
+for one week followed by suppressive therapy with Macrobid for the
+remainder of the pregnancy. Urine cultures were repeated monthly
+for the next 3 months and all remained negative."
+Charli Hampton,31,1987/7/24,539.839.6165x56528,jeanneandrews@example.com,7016 Alyssa Courts,"A 41-year old nulligravida presented to the University of Michigan
+(UM) Reproductive Endocrinology and Infertility clinic for an
+evaluation of a six year history of primary infertility. Her prior
+fertility evaluation and treatment history was significant for
+four previous cycles of ovulation augmentation with clomiphene
+citrate in conjunction with timed intercourse and a normal
+hysterosalpingogram several years earlier. Her initial workup at
+UM revealed normal ovarian reserve testing, normal values for TSH
+and prolactin, and her husband's semen analysis was normal.
+Transvaginal ultrasonography showed persistent bilateral
+3.5 cm ovarian cysts that had a ground-glass appearance
+consistent with endometriomas []. The patient underwent
+laparoscopic evaluation due to the large endometriomas at which
+time she was diagnosed with stage IV endometriosis. Due to dense
+adhesive disease, the procedure was converted to an
+exploratory laparotomy. Three right
+ovarian endometriomas were removed, and the cyst wall of each was
+excised with subsequent cauterization of the bases for hemostasis.
+The left ovarian endometrioma was approached; however, it was not
+removed due to severe adhesions and the patient's desire for
+fertility. The patient's postoperative course was unremarkable.
+Five weeks after surgery, the patient underwent a
+hysterosalpingogram which showed a normal uterine cavity, right
+tubal patency, and left hydrosalpinx without spillage of dye. She
+subsequently underwent two cycles of gonadotropins in conjunction
+with intrauterine inseminations, but had suboptimal responses.
+Nine months after surgery, the patient presented to
+the emergency room with fever and abdominal pain. Her temperature
+was 38.7簞C. Her abdominal and pelvic exams showed
+moderate tenderness, small amount of vaginal discharge and
+bacterial vaginosis as evidenced by clue cells on a normal saline
+wet prep. Gonorrhoeae and chlamydia cultures were obtained.
+Transvaginal ultrasound showed a 7 cm left adnexal mass with
+uniform echogenicity (). Her WBC was
+16.7 K. She was admitted to the hospital for intravenous
+antibiotic administration but despite broad-spectrum coverage,
+high-grade fevers continued. On hospital day 3, after discussion
+of risks, benefits, and alternatives that included conservative
+management, she was consented for definitive surgical management
+and underwent a modified radical hysterectomy with bilateral
+salpingo-oophorectomy and lysis of adhesions.
+Although all cervical, blood, and urine cultures were negative
+on hospital admission, the left ovary contained an ovarian abscess
+with gram negative rods within the left-sided endometrioma.
+Gonorrhoeae and chlamydia cultures were negative. There was an
+evidence of BV on normal saline wet prep and culture. Histology of
+the left fallopian tube and ovary revealed an endometriotic cyst
+with massive edema, hemorrhage, acute inflammation, and marked
+eosinophilia () with an associated pyosalpinx
+consistent with a TOA."
+Hank Velez,23,1990/11/5,(935)306-8764,hernandezanthony@example.com,451 Mark Islands Suite 170,"A 40-year-old female, non smoker was referred by her family physician with migraine-type headache complaints and mild nasal congestion. The pain was located over the forehead and behind the left eye. Headaches occurred once every 3 weeks, triggered by weather and barometric changes with mild improvement during the menstruation. The duration of the headache was 3 days approximately and the pain was not associated with nausea, photophobia, vertigo or tinnitus. Its intensity was 9 on a 0??0 visual analogue scale.
+The patient reported nephrotic syndrome at the age of 3, for which she had been on prednizolone for 10 years. A history of recurrent episodes of rhinosinusitis was also obtained.
+Nasal endoscopy revealed a mild septal deviation, a right concha bullosa of the middle turbinate and a paradoxically curved middle turbinate on the left side. Coronal computed tomography (CT) scan confirmed the above findings and additionally revealed a superior concha bullosa and mild mucosal disease on the left side (Fig. ).
+The patient underwent a detailed laboratory examination to exclude any other possible causes of headache. Whole blood cell count, urinalysis, thyroxin level, biochemical tests, tumor markers, as well as Mantoux test and monotest were normal. Chest radiography, electrocardiography, and ultrasonography of the thyroid gland were also normal. Biochemical and serologic tests of hepatic dysfunction were negative. Serologic tests of complement fixation titers of the plasma antibodies against various common viruses were performed and were found normal as well.
+The patient underwent nasal rigid endoscopy after application of local anesthetic and decongestant, which revealed the presence of a large superior concha in close contact with the nasal septum (Fig. ). Direct application of local anesthetic (1% tetracaine hydrochloride solution) at the point of contact between the superior concha and the nasal septum improved headache by 4 points (score 5 at the scale of 0??0). Injection of local anesthetic (0.5 ml of 2% xylocaine with epinephrine 1:100.000) into the superior turbinate under endoscopic visualization eliminated the pain completely.
+The patient was given endonasal steroids for 20 days without improvement. Then she was advised surgical intervention which she initially denied. The patient was followed for 3 months without any improvement and she, finally, decided to undergo surgery. Septoplasty and bilateral endoscopic sinus surgery was performed, including partial removal of both the pneumatized middle turbinates in conjunction with gentle lateralization and resection of the lower half of the left superior turbinate. The interior of the superior turbinate was found devoid of fluid or any other content. The patient reported prompt relief of her headache and at 13 months of follow-up postoperatively she remains free from headache or any other nasal symptoms. Although the patient did never report anosmia, she was examined by using the ""Sniffin' sticks"" test 1-year-postoperatively []. The examination showed that odor threshold, odor discrimination and odor identification were within normal limits. It appears, thus, that although part of the olfactory mucosa might had been removed by the partial resection of the superior turbinate, sufficient olfactory epithelium had remained intact, resulting in preservation of normal olfactory function.
+Although pneumatization of the middle nasal turbinate has been occasionally reported [], pneumatization of the superior and inferior turbinates are very rare findings [,]. The presence of a superior concha bullosa is not always recognizable with nasal endoscopy alone, due to the minimally accessible area of the upper nasal cavity. For this reason, the superior nasal turbinate has been called the forgotten turbinate []. Coronal CT-scan provides useful information for this inaccessible area.
+Association of a massive extensively pneumatized superior turbinate with headache is very rare. In these cases the superior turbinate is forced anteriorly and inferiorly at the area between the middle turbinate and the nasal septum, leading to intranasal mucosal contact []. Although the phenomenon of referred headache owed to intranasal mucosal contact was recognized as early as 1888 by Roe [] and has been since, occasionally, reported, with the advent of functional endoscopic sinus surgery and CT imaging, resurgence of interest in headache of nasal origin has been observed. Stammberger and Wolf [] reviewed the possible mechanisms involved in the genesis of referred headaches in the nasal area. According to them, afferent fibers from pain receptors in the nasal mucosa terminate in the same group of sensory neurons in the sensory nucleus of the trigeminal nerve, as fibers innervating cutaneous receptors, located at several peripheral segmental dermatomes of the ophthalmic and maxillary divisions of the trigeminal nerve. These two common pathways converge along the same final neurons to a common area of the cortex. Accordingly, the cortical center can not distinguish the original peripheral source of the pain impulses and they may be misinterpreted as coming from other skin areas, such as the temple, the zygoma or the forehead. The pain may be perceived also from other end-organs innervated by terminal branches within the trigeminal system, such as dura, intracranial and scalp vessels or the eye [].
+An important issue in the generation of headaches of nasal origin is mediation of neuropeptides, such as substance P [,,]. These may be released by mechanical pressure induced in areas of contacting opposing mucosal surfaces, such as the superior turbinate and the nasal septum. Substance P can be liberated at both the central and the peripheral ends of a sensory neuron, mediating not only central pain reflexes, via afferent C fibers, but at the same time local reflexes at the nasal mucosa, resulting from reverse impulses and manifestating as vasodilation, extravasation of plasma, hypersecretion, and smooth muscle contraction. This axon reflex can explain why an initial small localized lesion, such as a limited mucosal lesion or area of nasal mucosal contact, may trigger severe long-standing headaches, frequently projecting to different areas of the head.
+Many areas of the nose and the paranasal sinuses have been implicated as causes of referred headaches, including superior concha bullosa as a rare occurrence. Clerico [] was the first who suggested the superior turbinate as a source of referred headache, with features consistent of common migraine. Two more reports on this issue followed [,]. Clerico [] proposed that before surgery, the application of local anesthetic and/or decongestant (diagnostic block) on the area of the superior turbinate, under endoscopic visualization, might confirm this anatomic variation as the source of headache. We performed this test, and although significant reduction of the pain was obtained, the pain was not completely eliminated. This was probably due to the fact that local decongestants and anesthetic sprays are deposited primarily in the anterior half of the nasal cavity and may not adequately reach the superior turbinate. Complete relief of headache was obtained only after injection of local anesthetic into the superior turbinate under endoscopic guidance. The positive finding of this diagnostic test and resolution of the symptoms after surgical intervention prove the association of our patient's headache with the presence of the massive superior concha bullosa.
+Finally, the presence of a nasal osteoma as a rare cause of headaches of nasal origin should be mentioned. Paranasal sinus and intranasal osteomas are histologically benign and slow-growing tumors, which are usuallly asymptomatic, but when they enlarge they may produce pressure symptoms such as headaches. They occasionally cause obstruction or infection and may grow into the orbit or intradurally causing neurological manifestations. Paranasal sinus osteomas usually occur in the frontal sinus and less frequently in the other sinuses []. A few cases of intranasal osteomas were also reported, mainly in the middle turbinate and once in the superior turbinate []. All cases of turbinal osteomas were characterized by accompanying headache, probably due to the same pathogenetic mechanisms implicated in headache caused by the presence of a pneumatized superior concha, as previously mentioned. CT scan may assist in differential diagnosis by depicting the lesion and providing detailed information concerning the bony structures of the region."
+Megan Franklin,37,2005/8/20,201.994.8756x480,idean@example.org,301 Middleton Motorway Apt. 234,"A 36 year-old man was admitted to our hospital with chief complaint of left sided neck mass. He had a history of left orchiectomy in 1988 in another center because of testicular teratocarcinoma. At that time he was referred to our center because of huge retroperitoneal mass medial to the left kidney (Figure ). The first line chemotherapy with bleomycin and etoposide and cisplatin followed by retroperitoneal mass resection revealed mature teratoma and lead to complete remission. He had been in long-term remission for 17 years, but he had regular follow-up for the first 5 years. In November 2005, he was admitted again because of 5 ? 5 cm left supraclavicular mass, which had appeared the year before. In physical exam there was no other abnormality and pathologic sign. Serum markers (AFP, beta HCG and LDH) were normal. CT scan of the thorax showed a 5 ? 5 ? 8 cm lobulated neck mass with extension to anterior mediastinum. (figure ). The other parts especially paraaortic area were normal in imaging studies. Incisional biopsy of the neck mass confirmed mature teratoma so it was treated by radical surgical resection (figure ). The specimen consists only of teratoma without any other components especially immature teratoma."
+Simon Sosa,34,1999/2/16,(959)881-0138x1638,pearsonariel@example.com,846 Martha Groves Apt. 700,"A 59-year-old female who was a lifelong non-smoker underwent a modified radical mastectomy in August 2002 for an adenocarcinoma of her left breast, staged pT2N2M0. Adjuvant chemotherapy consisting of 4 cycles of doxorubicin (60 mg/m2) with cyclofosfamide (600 mg/m2) was administered from September to November 2002, followed by tamoxifen 20 mg daily. The patient was then referred for adjuvant radiotherapy on the left thoracic wall and the axillary lymph nodes. After CT planning, she received radiation from 6th February to 20th March 2003 to a total dose of 50 Gy in 25 fractions. The thoracic wall was irradiated using tangential 6 Mv photon fields, and regional lymph nodes using an anterior-posterior photon field (6 Mv) dosed at 3 cm, with a posterior top-up field to the axilla. The V20, i.e. volume of total lung receiving a dose of 20 Gy or more, was 32%.
+In April 2003, the patient complained of shortness of breath. Physical examination revealed a temperature of 38.0簞C and pulmonary auscultation revealed inspiratory crackles and bronchial breathing sounds. Peripheral O2 saturation was 97% measured by a pulse-oxymeter during treatment with 2 litres of O2 a minute. Blood analysis revealed a CRP of 189 mg/L(0??0 mg/L) and a one-hour sedimentation rate of 105 mm/hour(0??0 mm/hour), haemoglobin was 5.4 mmol/L(7.5??0.0 mmol/L), WBC count was 6.0 ? 109/L(4.4??0.0 ? 109/L) with a slight eosinophilia of 12%(0??%), platelet count was 365 ? 109/L(150??00 ? 109/L). Further serum chemistry, renal, liver functions, and urinalysis were normal. A chest radiograph showed a patchy consolidation zone in the upper lobe and the apex of the lower lobe of the left lung. Computer tomography (CT) revealed multiple ground glass opacities in the upper and lower lobe of the left lung, and no abnormalities were seen in the right lung.
+A clinical diagnosis of radiation pneumonitis was made and treatment with prednisone 20 mg 3 times daily was initiated, with an improvement in clinical symptoms seen within 4 days. In the following months, the dose of prednisone was gradually tapered to 15 mg once daily. The chest radiograph in July 2003 showed a reduction of the ground glass opacities. In August 2003, patient was hospitalised due to shortness of breath. A new CT showed an increase of the patchy infiltrates in the left lung, but also new patchy infiltrates in the middle lobe of the right lung (figure ). To rule out an infectious cause, a bronchoscopy was performed which revealed no endobronchial abnormalities. No biopsies were performed but broncho-alveolair lavage showed a normal cell count and negative cultures. Consequently, a diagnosis of interstitial lung disease due to radiotherapy was made, most probably BOOP, and the prednisone dosage was increased to 20 mg four times daily. A clinical improvement was seen within two weeks, after which the prednisone dosage was tapered in the following 12 months. Radiological improvement was observed in the right lung (figure ). However, abnormalities consistent with radiation fibrosis remained within the radiation field in the left lung.
+A 92-year-old patient presented with multiple intradermal metastases from a breast cancer on the right thoracic wall 10 years after undergoing an amputation of the right breast for a pT3N0M0 breast cancer. No adjuvant post-surgical therapy was administered after the initial surgery. Restaging revealed no regional or distant metastasis and the chest wall lesions were resected. Pathological examination showed an irradical resection after which she was referred for radiotherapy. She received thoracic and axillary radiotherapy to a total dose of 60 Gy in once-daily fractions of 2 Gy using non-CT based planning. Radiotherapy to 50 Gy was performed using an anterior electron field (10 MeV) matched to a lateral photon field (6 Mv) dosed at 3 cm. The dose on the axilla was supplemented using a posterior field. This was followed by a boost of 10 Gy to the site of irradical excision on the chest wall using 10 MeV electrons.
+Three months after completing radiation therapy, the patient was hospitalised for complaints of fever and shortness of breath. She was febrile (38.0簞C) and auscultation revealed bronchial breath sounds over the right lung while no abnormalities were heard on the left side. The one-hour sedimentation rate was 98 mm/hour(0??0 mm/hour), WBC count was 9.8 ? 109/L(4.4??0.0 ? 109/L). Chest radiograph showed a density of the right upper lobe and, to a lesser degree, the right lower lobe of the lung. The left lung showed a normal pattern. Bronchoscopy revealed no endobronchial abnormalities or evidence for infection. Bronchial biopsies showed normal tissue.
+A diagnosis of radiation pneumonitis was made and high-dose prednisone 40 mg once daily was started. The clinical condition of patient improved significantly within two weeks and patient was discharged. During follow up, the improved clinical condition and radiological imaging lead to a tapering of the prednisone, with discontinuation after 6 months. The symptoms recurred two months later and a chest radiograph showed an increase in the density of the right lung and a density in the left upper lobe. As the radiological abnormalities were migrating beyond the radiation field, a diagnosis of BOOP following radiotherapy was made. Treatment with prednisone 10 mg was resumed and led to a resolution of her symptoms within two weeks. The prednisone dose was gradually tapered and totally discontinued again after 6 months."
+Cassandra Armstrong,19,1984/4/14,702-989-4849x76246,qandrews@example.com,20284 Butler Burgs Suite 556,"A 60-year-old man with mental retardation of unclear origin who was otherwise healthy suffered a focal seizure with speech disturbance. Two intracerebral lesions were identified by magnetic resonance imaging (MRI) of the head (Figure ).
+The patient's neurological status on admission was normal. There were no clues to phakomatosis in the patient's or in the family history. Neither did the clinical findings point in this direction. No further seizures occurred after initiation and starting phenytoin therapy.
+Initial MRI demonstrated a contrast-enhancing lesion in the left frontal lobe and a smaller lesion in the right frontal lobe (Figure ). No other focal lesions were identified. Laboratory tests were normal except for elevations of the following parameters: D-dimer level of 254, neuron-specific enolase level of 13.1, and lambda and kappa light chain levels of 1.63 and 4.64, respectively. The CSF cell count and protein content were normal.
+Since the lesions had no mass effect, initially a stereotactic biopsy was obtained from the left frontal lesion. Histologically, a semimalignant melanocytoma with the differential diagnosis of a MPNST was diagnosed. The lesion was then removed microneurosurgically. Postoperatively, the patient underwent whole-brain irradiation (30Gy). Due to the advanced stage of the malignancy and to gain control over further intracerebral metastasis, which were not visible on the MRI, no local radiotherapy such as radiosurgery was chosen. No postoperative or radiation-related complications were observed.
+Fluorodeoxyglycose positron emission tomography (FDG PET) identified no body lesions except for an area of increased accumulation lateral to the right jugular vein, which corresponded to an enlarged lymph node, suggesting a nodal metastasis on MRI. PET even failed to demonstrate the right frontal lesion that was still present prior to cerebral irradiation. Only whole-body MRI (T2WI) identified several structures of increased signal intensity in the right thigh. One of the lesions was contiguous with the sciatic nerve (Figure and ). The radiologic criteria were indicative of a peripheral nerve tumor, suggesting that this was the primary tumor. Spinal MRI demonstrated further metastases at the level of S1 and S2 but no relationship to spinal nerves (Figure ).
+Based on the patient's poor prognosis due to extensive local tumor spread and the presence of distant cerebral and vertebral metastases and a high risk of neurological deficits associated with a resection of the thigh tumors, a removal was considered unjustified. Stigmata of neurofibromatosis were excluded, as were pulmonary and visceral metastases.
+The first follow-up examination was performed after 3 months. MRI identified no tumor recurrence in the left frontal lobe and no progression of the lesion on the right (Figure ). The patient had no clinical or neurological symptoms and suffered no seizures on continuous phenytoin medication (300 mg/day). At the last follow-up 11 months later, MRI showed unchanged cerebral findings and no progression of the lumbar vertebral lesions. However, there was an increase in the size of the cervical lymph node metastasis, and MRI for the first time demonstrated metastases in the area of the right thigh. Nevertheless, the patient continued to be free of neurologic deficits or epileptic seizures and no further therapy was initiated.
+Hematoxylin-eosin (H&E) staining demonstrated tumor tissue with spindled epithelioid cells, some of which contained melanin (Figure ). The cells were arranged in nestlike clusters with an altogether heterogeneous appearance. Immunohistochemically, strong expression of vimentin (dilution 1:600; Zymed, Wien/Austria) and S-100 (dilution 1:6000; DAKO, Glostrup/Denmark) was demonstrated (Figure ). The pigmented cells were positive for HMB45 (dilution 1:500; DAKO, Glostrup/Denmark) and there was isolated expression of EMA (dilution 1:100; DAKO, Glostrup/Denmark). The overall expression of Ki67 antigen (dilution 1:200; DAKO, Glostrup/Denmark) was low, but some foci with an index of 30% were identified. There was no immunoreaction to LU-5 (cytokeratin; dilution 1:500; Biomedicals, Augst/Switzerland), NF (neurofilament; dilution 1:200; Zymed, Wien/Austria), or SYN (synaptophysin; dilution 1:150; BioGenex; San Ramon/U.S.A.). Furthermore electron microscopy investigation showed a basal lamina, strongly indicating peripheral nerve origin. The histological diagnosis of MPNST was based on the demonstration of spindled cells and their arrangement, the pattern of immunoreactions as well as the electron microscopy investigation. Due to the overall low expression of the Ki67 antigen and the histological characterization, the tumor was graded WHO簞I, according to the WHO classification for soft-tissue tumors[]. The histological diagnosis was verified by several reference pathologists."
+Grant Callahan,31,1986/6/9,001-795-483-7623x650,leachchristina@example.com,488 Edward Park,"The patient was a 40-year-old male admitted for chronic cough and a 2-month history of intermittent afternoon fever. He denied both a history of traveling and contact with animals over the previous 3 months. Associated symptoms included general malaise, anorexia, and the loss of 6 kg body weight within the previous 2 months. On admission, the vital signs were shown as blood pressure: 124/68 mmHg; pulse rate: 80/min; respiratory rate: 22/min; body temperature: 38.5簞C. Physical examination revealed a pansystolic murmur over the apex and left lower sternal border. An abscess in a molar cavity that required debridement was found, although the patient had not complained of dental pain. Laboratory tests revealed a WBC count of 9250/弮L with elevated neutrophils (82.7%); normocytic anemia with a hemoglobin level of 10.4 g/dL; an elevated ESR level (123 mm/1 hr); and abnormal liver function with AST/ALT of 49/79 IU/L. A chest x-ray film revealed increased infiltration over the right upper and lower lobes, and abdominal sonography showed mild splenomegaly. Diagnosis of pulmonary tuberculosis was excluded by negative results from serial acid-fast stain and culture of Mycobacterium tuberculosis. Transthoracic echocardiography revealed a vegetation with size of 0.9 cm over the anterior leaflet of mitral valve, and moderate mitral regurgitation. However, the cardiac systolic and diastolic functions were normal with the ejection fraction of 78.9%, fraction shortening of 47.8%. Ultimately, definite subacute endocarditis was diagnosed according to the Duke criteria, including two blood culture results of B. vesicularis; the presence of vegetation on the mitral valve revealed by an echocardiogram (Fig. ); and such clinical and laboratory features as fever, splenomegaly, heart murmur, anemia, Osler's node (Fig. ),,and Roth's spot (Fig. ).
+The pathogen was identified as B. vesicularis on the basis of the biochemical characteristics tested by the API ID 32 GN automatic identification system (bioM矇rieux, Marcy I' ?toile, France). These included the characteristics of positive activity of D-maltose/D-glucose oxidation; negative activity of inositol/D-sorbitol/L-arabinose oxidation; negative activity of L-alanine/capric acid/potassium 5-ketogluconate/trisodium citrate decarboxylation; negative activity of nitrate reduction and indole production. The organism was susceptible to amikacin, gentamicin, piperacillin, aztreonam, cefepime, meropenem, netilmicin, ampicillin, amoxicillin, ciprofloxacin, cefazolin, cefmetazole, ceftazidime, cefotaxime, ceftriaxone, and ticarcillin, according to the susceptibility test performed by the disc diffusion method with interpretation criteria for Pseudomonas []. The patient was treated with a combination of cefazolin (2 gm/8 hr) and gentamicin (80 mg/8 hr) as empiric antibiotics during the first 3 days and fever subsided gradually.
+Ampicillin/sulbactam (3 gm/6 hr) was used alternatively for covering the infection of oral anaerobes while the patient underwent removal of the abscessed tooth. Treatment with amipicillin/sulbactam failed, however; the patient developed a flare-up of fever, the appearance of a new Osler's node on the fourth digit of the left hand (Fig. ), and pain in the right femur with right inguinal lymphadenopathy. Treatment with a combination of ceftriaxone (2 gm/12 hr) and gentamicin (80 mg/8 hr) was administered subsequently. The femoral-inguinal symptoms and fever improved gradually with the antimicrobial therapy and therefore were ascribed to embolism. Although the clinical symptoms and signs improved after use of these antibiotics, ciprofloxacin (400 mg/12 hr) was administered as an alternative due to the eruption of a skin rash from an allergic reaction after 7 days' treatment with ceftriaxone. Ultimately, the patient received the treatment regimen for one month and was discharged. There were no sequelae at 6-month follow-up and the mitral vegetation disappeared in the follow-up echocardiogram performed one month after discharge."
+Kimber Robinson,26,2004/3/29,647-626-4583x827,christine78@example.org,038 Beth Grove Suite 283,"A 39 year-old man with a multifocal abdominal recurrence of a small bowel gastrointestinal stromal tumor presented to the hospital following loss of consciousness preceded by weakness, dizziness and nausea. His serum glucose was 20 mg/dL (normal 80??10 mg/dL) and required a continuous infusion of high dose (10%) dextrose to maintain a serum glucose concentration above 70 mg/dL. Serologic workup demonstrated no evidence of factitious hypoglycemia and it discarded the diagnosis of islet cell-induced hypoglycemia. The insulin like growth factor (IGF) I and IGF binding protein 3 level were below the normal range, while insulin, pro-insulin, C-peptide and IGF II levels were all in the normal range (table ).
+An abdominal computed tomography demonstrated a large, multicentric tumor with extensive collateral circulation (Fig and ). Preoperative selective embolization of associated vessels was performed to reduce operative bleeding. The following day, extensive tumor debulking of both the dominant mass and 99% of the remaining multifocal 40 cm ? 25 cm ? 10 cm GIST was achieved (Fig and ), obtaining an R1 resection. Immediately after completing the resection, the patient became euglycemic without requiring intravenous glucose. The patient was euglycemic, active and without radiographic evidence of progression 6 months after his surgery. Due to gastrointestinal intolerance to imatinib, he is currently on therapy with sunitinib with stable disease.
+Pathologic analysis identified the presence of KIT (CD-117) in the tumor; confirming GIST histology. Extracted DNA was amplified by polymerase chain reaction for exons 9, 11, 13 and 17 of KIT. No mutations were found in exons 11, 13 or 17; however one allele at position 1530 in exon 9 contained a 6 bp tandem repeat insert (GCCTAT). This led to a duplication of amino acid residues alanine 502 and tyrosine 503 (Fig ). The mutation was confirmed by a TOPO cloning system (Invitrogen, Carlsbad, California USA), which detected the presence of one normal allele and one with the 6 bp insert as described.
+The patient's serum and tumor were sent to the University Medical Center in Utrecht (The Netherlands) for further analysis. The concentration of II E [68??8] (""big"" IGF-II) in plasma was 51.9 ng/mL (normal: 6.5??7.5 ng/mL). The levels of IGF binding protein 6 (IGFBP-6) were reported to be within the normal range. In situ hybridization of the tumor samples demonstrated high expression of IGF II mRNA and elevated pro-IGF II (figure ).
+It has been found that specific KIT mutations in GIST may predict a patient's prognosis. Mutations on exon 11 are the most common (79%), while those on exon 9 are only found in about 11% of GIST. Most patients with exon 11 mutations respond to treatment with imatinib, while less than half of those with exon 9 mutations respond and are almost twice as likely to recur [-].
+The particular mutation we found in our patient has been reported very infrequently, and is thought to induce a ligand-independent gain-of-function with homodimerization and constitutive autophosphorylation [,]. The significance of the association of this mutation and non-islet cell tumor hypoglycemia (NICTH) has yet to be established.
+The incidence of NICTH is thought to be one fourth that of functional insulinomas (1 case of NICTH per million people-years) [,]. NICTH usually occurs with large or metastatic tumors that are usually of mesenchymal origin, but may also present in other types of cancer []. Searching via MEDLINE, PubMed, Gold Rush and article cross-referencing, we only found 4 other publications of NICTH in GIST; four of which had overexpression of ""big"" IGF II and in two there was overexpression of pro-IGF II [-].
+High concentrations of pre-pro-IGF II genes that are not properly glycosylated result in the high molecular weight ""big"" IGF II. Compared to physiologic IGF II, it has a significantly higher affinity to the insulin receptor, and a lower affinity to its binding protein [,]. The association of ""big"" IGF II and NICTH was first identified by Daughaday in a patient with a fibrosarcoma []. Non-islet cell tumor-induced hypoglycemia secondary to ""big"" IGF II is difficult to confirm because laboratory tests for it are not readily available. A landmark observation by Teale et al. was that IGF I and II levels in patients with hyperinsulinemic hypoglycemia were both usually low, while patients with NICTH had normal levels of IGF II []. Consequently, Hizuka et al. demonstrated that IGF I was always low in hypoglycemic patients with ""big"" IGF II, while those without elevated ""big"" IGF II had both low IGF I and II [].
+The management of most patients with NICTH requires prompt intravenous hydration and glucose infusions. Once stable, the ideal treatment is to remove the source of hypoglycemia. In NICTH, the hypoglycemia is not due to a dysfunctional insulin receptor nor abnormal K-ATP channels, therefore diazoxide is unlikely to be effective []. Attempts with imatinib as a first-line therapy may fail due to resistance to the drug, or take as long as 5 weeks before being able to interrupt the intravenous glucose infusions []. A recent report by Hamberg et al. [] found in one patient with NICTH from GIST that elevated concentrations of imatinib seemed to worsen hypoglycemia, while another patient spontaneously resolved without any GIST-related therapy. Alternative nonoperative cytoreductive techniques such as selective embolization and radiofrequency ablation may have a role in alleviating hypoglycemia; however these have not been reported in the literature. Additionally, they may potentially result in greater circulating ""big"" IGF II during necrosis of the GIST and may explain Hamberg's findings in a patient treated with imatinib alone that had hypoglycemia proportional to the dose of imatinib. In other (non GIST) cases of NICTH, low dose steroids and growth hormone have allowed palliative weaning from intravenous glucose [,,]. Surgical resection remains as the most rapid and cost-effective therapy to normalize glucose metabolism in most cases of NICTH."
+Matthew Harper,25,1990/7/8,001-285-328-0942x21014,ckane@example.org,3911 Bennett Ports,"A 77-year-old man without a particular family history but with a past medical history of peripheral arterial occlusive disease that was surgically treated including long-term oral anticoagulation with coumarin presented with sudden onset chest discomfort at rest. He was admitted to our hospital. Hemodynamics were stable. There were no rales or heart murmurs, except S4 of the heart sound. Electrocardiography showed sinus rhythm with non-specific ST-segment changes in leads I, II, aVL, aVF and V3??. Arterial blood pressure was 130/100 mmHg on the right arm and 110/60 mmHg on the left. The chest pain initiated with a blow and then migrated toward the lumbar area over time. Chest X-ray was unremarkable but contrast computed tomography confirmed aortic dissection from the ascending aorta to the abdominal aorta. Stanford type A aortic dissection with a possible tear entry near the aortic arch was diagnosed. The patient was oliguric 8 hours after admission. No other symptoms suggesting cerebral, spinal or peripheral perfusion deficits or hematoma formation were present. Laboratory examination identified elevated D-dimer levels and an INR of 3.44; other blood tests including cardiac markers and renal function tests were normal. PCC at a dose of 45 IU per kg body weight were administered i.v. in combination with 10 mg of vitamin K1. He was then transferred to Verona University Hospital approximately 10 h after the onset. Two and a half hours after intravenous administration of PCC the INR was 1.6. Emergency graft replacement of the ascending aorta was performed. Surgical therapy was performed without complication and the postoperative clinical course was uneventful. Renal other organ functions remained normal and unaffected, respectively. The patient was transferred to his home hospital in Germany on the 6th postoperative day in stable condition after oral anticoagulation with coumarin was again begun."
+Ana Summers,44,1998/11/30,683-664-5042,zdean@example.org,6993 Katherine Valley,"A 28-year-old man was referred to our Clinic for treatment of a recurrence of ameloblastoma, previously treated in another institution (Fig. ). Panoramic radiograph showed a multiloculated lesion on the left mandibular body (Fig. ). The surgical procedure was first planned on the virtual digital model (Fig. ), it helped us to measure exactly and to visualize the entity of the resection. A stereolithographic model of the left mandible was constructed. Prior to surgery, a mandibular reconstruction plate was pre-bent using the stereolithographic model as a reference. Screw placement was also planned and marked on the model, as well as screws length, which were recorded by measuring the thickness of the model at each plate hole (Fig. ).
+The focus of the treatment was to resect the tumor and preserve the form of the mandible. Before resection, the reconstruction plate was placed intraorally along the inferior border of the mandible, and screw holes were drilled to facilitate later fixation of the plate. The time spent in adapting the reconstruction plate was less than 5 minutes because no adjustments to the plate were necessary.
+The iliac microvascular flap was harvested and modelled using the dimensional data recorded during the preoperative planning on the digital model and on the stereolithographic model. The insertion of the flap in the osseus gap was easy and with excellent fit (Fig. ). 6 months after the reconstruction, the plate was removed and implants were inserted (Fig. , , )."
+Darius Davidson,19,2005/8/7,623-526-2233x2978,millerjill@example.net,1185 Gabriel Plaza Apt. 215,"The patient was a 50-year-old man who had a T4N0M0 squamous-cell carcinoma of the gingiva invading the left mandible (Fig , , ). The planning was made according to the aforementioned protocol (Fig. , ).
+Reconstruction was planned with a iliac microvascular osteo-muscolar flap with the use of a portion of the internal oblique muscle for the reconstruction of the intraoral mucosa. The resected specimen included the left mandible from premolars to the entire ramus, saving the condyle. The reconstruction plate was then placed; no intra-operative modifications were necessary (Fig. , ). There were no signs of recurrence 1 year after surgery. The plate could be removed and the reconstruction appeared suitable for the use of bone-integrated dental implants (Fig. , , )."
+Jayla Salgado,35,1999/8/27,001-677-833-7567,mejiaamanda@example.com,26836 Taylor Manors Apt. 583,"A 36-year-old Hispanic woman had an appendicitis-associated appendectomy at 6 years of age, and post-Cesarean section uterine atony-related total abdominal hysterectomy at age 26 years. Other medical, surgical, or family histories were unremarkable.
+The patient was seen with a 6-month history of abdominal distention and discomfort. At physical examination, no abdominal masses or ascites were detected. A pelvic ultrasound (US) was performed, and an adnexal cystic mass of 19 ? 16 ? 12 cm with solid component was observed in the area of the left adnexa. There was no ascites or any other abnormalities observed in the pelvic cavity. Serum CA-125 was 4.13 U/ml, and routine preoperative laboratory tests were obtained and reported as normal, as was the chest x-ray. A CT scan was conducted as part of the preoperative evaluation; the scan confirmed the US findings and revealed solid areas in a cystic tumor (Figures and ).
+An exploratory laparotomy was performed with the diagnosis of a suspicious malignant adenexal mass. During the procedure, a tumor measuring 19 ? 16 ? 12 cm was found in the left retroperitoneal space, the tumor completely separated from the ovaries or other intrapelvic structures. Complete and intact removal of the lesion was obtained; this was sent for frozen section, and was subsequently reported as mucinous cystadenocarcinoma. At the time of the surgery, both ovaries and fallopian tubes were grossly normal, as were all intra-abdominal structures. The patient's postoperative course showed no complications or adverse events. Six courses of adjuvant chemotherapy were administered with carboplatinum at a dose of 6 area under the curve (AUC) and paclitaxel at 175 mgs/m2. CA-125 was obtained after the fifth chemotherapy course and was reported as 5.3 U/ml. A pelvic US was performed 8 months later, and a new pelvic mass measuring 7 ? 6 ? 6 cm at the same site was found. An exploratory laparotomy was conducted and a sigmoid resection was required due to a mass involving this. Infracolic omentectomy was also carried out due to multiple nodules. The surgery was considered optimal cytoreduction with no visible lesion remaining. The Pathology report stated mucinous cystadenocarcinoma.
+Second-line chemotherapy was initiated with oral etoposide (50 mg daily for 21 days). After one cycle, disease progression was identified and the patient decided to stop chemotherapy. Tamoxifen (20 mg/day) was instituted as palliative management."
+Trace Compton,42,1982/8/14,(807)262-6813,ivelazquez@example.net,1345 Lee Flats,"The patient, a 21-year-old female with no remarkable previous medical or surgical history complained of diffuse abdominal discomfort 1 month prior to the patient's presentation at the Emergency Service due to acute abdominal pain and intestinal occlusion-compatible clinical data. Abdominal and pelvic US was performed, revealing a cystic mass with solid areas (Figure ). An emergency laparotomy was performed; during the surgery, a retroperitoneal tumor measuring 26 ? 18 ? 16 cm was observed. The latter was totally removed, ascitic fluid was detected and drained, and cytology was reported as negative for malignant cells. The tumor was located near the pancreas, but was not attached to this organ or to any other intra-abdominal or pelvic structures. Ovaries, uterus, colon, and appendix were macroscopically normal, as were other intra-abdominal structures. Postoperative serum CA-125 was 105 U/ml (0??1), while CA-15-3 was 32.2 U/ml (0??3) and CA-19-9 was 5.4 U/ml (0??7).
+Systemic adjuvant chemotherapy was proposed; nonetheless, the patient refused this treatment. Therefore, close follow-up was advised, and the patient has been seen at the Medical Oncology Service over the last 6 months with serial CA-125 serum levels at latest measurement of 13.3 U/ml. An abdominal CT was performed, and no evidence of disease was found."
+Elina Rosario,34,1993/3/2,788-385-3010,bakerlaura@example.org,144 Sherry Terrace,"A 28-year old man presented with a three month history of an asymptomatic scrotal swelling. He had previously undergone orchidopexy in childhood for a mal-descended right testis. There is otherwise no other significant medical or family history. The mid-scrotally located mass measured 4 ? 7 cm and was nodular, hard and clinically separate from the testes. It was not attached to the scrotal skin or other underlying structures. Lymphadenopathy was not detected.
+Initial ultrasonography (Fig ) showed a large extra-testicular and multinodular mass in the midline of the scrotum. The largest nodule, located behind the right testis was cystic. Both testes appeared normal. Subsequent staging Computer Tomography (CT) of the scrotum, abdomen and chest was performed, which identified a similarly localised heterogeneous mass of 6.9 ? 3.7 cm, separate from the testes (Fig ) and did not extend into the tunica vaginalis. There was no evidence of distant or nodal metastases.
+An initial diagnostic wedge biopsy indicated the lesion could be an ancient schwannoma. Curative surgical excision with partial scrotectomy was undertaken for removal of the mass and for definitive diagnosis. At resection, the tumour appeared to be superficial to the tunica vaginalis, testes and corpus spongiosum. Inferiorly, the tumour was attached to the bulbospongiosus requiring partial resection of the superficial muscle fibres.
+The resected specimen (Fig ) was white and multinodular, with areas of cystic change and haemorrhage. Microscopically (Fig ), proliferation of spindled shaped cells with fibrillary cytoplasm was seen, with dense fibrous bands arranging the cells into nodules. In some cells, marked nuclear hyperchromaticism and atypia were seen. Mitoses were not present. Within the lesion, cellular areas were interspersed with looser myxoid and cystic areas. Blood vessels with thickened hyalinised walls were noted. Staining for S100 protein was positive in the tumour cells. The histological features are that of an ancient schwannoma. The margins of this specimen were ragged and the completeness of excision was difficult to assess."
+Jedidiah Anthony,39,1993/6/18,638.454.8448,brownbrandy@example.net,5953 Max Burg Apt. 352,"A 53-year old woman was admitted to emergency room with one week history of purpuric lesions limited to both legs, accompanied by paresthesias, very painful arthralgias which confined her to wheel chair and distal edema in both lower extremities. She had a previous history of modified mastectomy with axillary lymphadenectomy for a retroareolar, canalicular breast carcinoma 6 months before, whose histological diagnosis was a ductal carcinoma measuring 4.5 cm of diameter, estrogen and progesterone receptor-positive and HER2 negative. She received adjuvant radiation and started tamoxifen 20 mg daily four months before admission. At the clinical examination, she had several purpuric papular lesions in both distal extremities, some were confluent, within a 1 cm diameter on the left external heel. Arthritis was also present in both ankles and knees. Liver function tests demonstrated a cholestatic damage, with increase of alkaline phosphatase (196; normal: 40??50 U/L), GGT (213; normal> 12??3), SGPT (249; normal 5??6 U/L), SGOT (110; normal 9??5 U/L); other liver tests, and the rest of laboratory, including SMA-18, blood cytology, coagulation studies, viral hepatitis infection markers, antinuclear antibodies, coagulation tests and crioaglutinines were normal. Tumor markers, including CA15-3 were negative or normal. Liver ultrasound showed none focal lesions and was considered normal. Histopathology analysis of skin biopsies showed deposits of fibrinoid material in the walls and infiltration by lymphocytes and neutrophils in dermis vessels, which was diagnosed as vasculitis.
+Tamoxifen was withdrawn and methylprednisolone at 1 g daily was administered during 3 days. Thereafter, 0.5 mg/kg prednisone was indicated during 7 days and subsequently decreased. Lesions disappeared after one week. Currently she is alive and well receiving anastrazole."
+Macy Meadows,27,2003/9/15,826.717.2181x6818,omay@example.org,296 Victor Knolls,"The second girl (10 years old) complained about back pain after she had fallen from her bike. She had grown normal along the 50th height percentile. X rays of her spine revealed oedematous changes of 3 and compressions of 2 thoracic vertebrae (# 9, 11). At first these were considered trauma related, however, especially posterior oedematous changes of the 8th vertebra were considered not to be typical sequels of a trauma (figure figure ). In addition, a technetium bone scan did show an additional lesion in the right 4th rib (figure ). The rib lesion was also analysed by MRI of the thorax. It did show a strong T2/TIRM/STIR signal. Thus Langerhans' cell histiocytosis was suspected at that time. A biopsy of this rib, however, revealed a sterile lympho- plasmocytoid osteomyelitis suggesting multifocal CNO. There were no elevated inflammatory parameters (ESR, CRP, leukocytes). A differential blood count did not show signs of malignancy. Further workup revealed normal serum levels of beta-HCG (human choriogonadotropin), neuron specific enolase, cortisol and angiotensin converting enzyme. HLA B 27 was present. Total alkaline phosphatase levels (401, 426, 316, 378, 185, 189 U/l) measured over time were in the normal range. Compared to a cohort of genetically diagnosed childhood hypophosphatasia patients [,] these levels were considered unremarkable. However, a nephelometric measurement of the bone alkaline phosphatase revealed a reduced level (8.9 microg/l; normal 36??0 microg/l). Therefore, a more reliable and specific measurement of the tissue non-specific alkaline phosphatase in leukocytes was done. The result was below normal (1.8 nmol/min/mg Protein; normal: 2 ??18) []. In addition, pyridoxal phosphate in the plasma was slightly elevated (31 ng/ml; normal: 5 ??30 ng/ml), phosphoethanolamine excretion in the urine was normal. We suggested that a partial defect in the TNSALP gene was present. She may be a carrier of one severely mutated allele of alkaline phosphatase, because slight elevation of plasma pyridoxal levels has been demonstrated in obligatory heterozygotes (parents of index patients) with severe alleles []. Thus, the patient might be a carrier for the hypophosphatasia trait. The family refused a diagnostic genetic workup.
+Based on our experience in treating hypophosphatasia patients with non-steroidal anti-inflammatory agents [,], in addition to the anti-inflammatory treatment of chronic non-bacterial osteomyelitis patients [] we started a therapy using naproxen at a dose of 15 mg/kg/d in both patients. This therapeutic protocol was approved by the ethics committee of the University of Wuerzburg.
+The treatment rapidly reduced clinical symptoms including pain and soft tissue swelling (figure ). Parallel to this clinical improvement subsequent MRI analysis after 3, 6 and 12 months revealed subsequent reduction of bone marrow oedema and local gadolinium enhancement. 12 months later MRI showed almost unremarkable lesions (figure ). Mild hyperostosis of the os zygomaticum was still present after 12 months at treatment cessation. 24 months later the patient was still in remission.
+The medication did abrogate pain completely after the first 3 months of treatment. Parallel to this clinical improvement subsequent MRI analysis (figure ) after 3, 6 and 12 (figure ) months revealed subsequent reduction of bone marrow oedema and local gadolinium enhancement. 12 months later MRI showed an unremarkable 8th thoracic vertebra, whereas the 9th and 11th still showed compression without sign of acute inflammation (figure ). The rib lesion was unremarkable after 6 months of treatment. No further structural improvement was noted after 24 months. Thus, treatment was terminated."
+Wayne Dougherty,39,1997/1/17,772-295-3519,ian47@example.net,367 Brandi Garden Suite 299,"A 78-year-old woman presented with a 6-month history of dyspeptic symptoms, epigastric pain and weight loss. Gastroscopy showed mucosal nodularity and ulceration at the proximal gastric body with an ""hour glass"" deformity, an appearance suggestive of malignancy. Multiple mucosal biopsies were obtained and histopathology revealed a poorly differentiated adenocarcinoma and chronic gastritis. Computed tomography of the abdomen showed diffuse thickening of the gastric wall and a few enlarged lymph nodes in the lesser sac.
+The patient underwent an elective D2 total gastrectomy with splenectomy as the bulky gastric tumour was extending into the splenic hilus and a Roux-en-Y reconstruction was performed.
+The histopathological examination of the specimen macroscopically showed firm texture of the proximal stomach and vague nodular appearance of the mucosa over a 100 by 80 mm area. Microscopically the proximal stomach showed transmural infiltration by poorly differentiated diffuse adenocarcinoma, which had reached the serosal surface. There was vascular invasion, infiltration of 10 out of 34 nodes and numerous extranodal tumour deposits. A nodule of firm white tissue, 9mm diameter, was present on the external surface of the gastric antrum. Histological examination revealed this nodule to be a benign gastrointestinal stromal tumour (GIST), which had arisen from the muscularis propria. It was composed of interwoven cytologically bland spindle shaped cells that were demonstrated by immunohistochemistry to be uniformly positive for CD117. Scattered spindle cells of the GIST also expressed smooth muscle actin, desmin and S-100 (Fig. , , ). Cytoceratin immunohistochemistry was negative. An additional finding was the presence within the GIST of numerous cytokeratin positive polygonal-shaped gastric carcinoma cells (Fig. ). These cells were cytologically similar to those of the main gastric tumour. They were seen mainly around the peripheral parts of the GIST but were also present within its centre."
+Alisson Roberson,32,1979/10/1,001-387-623-0689x0533,gmiller@example.net,07322 Kayla Rue Suite 414,"B.S. a 4-year-old male child was admitted to the pediatric surgical ward at Jordan University Hospital because of two days history of swelling, redness and pain of his scrotum (Fig. ). There was no history of trauma. The pain was moderate, not characteristic of torsion, and not the chief complaint. Oral temperature was 37.8簞C and pulse 94/min. Physical examination revealed bilateral red swollen scrotum, moderately hot and tender allowing examination of the testes, which were in normal position and of equal size and not tender. There was a small amount of fluid bilaterally detected on transillumination. The rest of the physical examination was unremarkable. Laboratory work up showed Hb. 10.5 gm/dl, Hct. 32%, WBC 12.7 ? 103/mm3 and normal serum amylase. Ultrasound examination confirmed the equal sized testes, with normal echogenicity, the presence of small amount of fluid in the scrotum, and the edematous scrotum. On further examination of the scrotum, a streak of redness extended along the midline raphe to the perineum, where a visible wire through an eroded perianal skin was seen (Fig ). The patient underwent a Thiersch wire insertion for a rectal prolapse one year before. The patient was started on broad-spectrum antibiotics (Ampicillin, Gentamycin and Metronidazol). It was decided that the Thiersch wire has to be removed in theatre under general anesthesia. While examination under anesthesia the perineum appeared healthy, without signs of inflammation, or suppuration but moderate amount of induration. Rectal exam was normal; there was moderate narrowing and fibrosis at the anal verge. After removal of the wire the tract was intact with minimal discharge, which cleared in few days following wire removal. The sinus tract was very short lived and closed without any problems thereafter.
+Culture taken from the site of the wound grew streptococcus fecalis sensitive to the administered antibiotics. The scrotal swelling and redness subsided gradually. The child was discharged without any complications. Follow up was uneventful for both the scrotal redness and swelling as well as the rectal prolapse."
+Shepherd O’Connell,21,1989/5/11,+1-837-474-7430x3408,morgancathy@example.com,477 Ashlee Parks,"A 3-year-old boy presented with a large bosselated swelling over the cheek extending to the submandibular, submental, postauricular region and which was still further increasing in size (Figure ). A trucut簧 biopsy was suggestive of fibromatosis. Computerized tomogram (CT) scan revealed a large soft tissue mass infiltrating the massetter, parotid gland, floor mouth, submandibular gland, the lateral oro-nasopharyngeal wall and the pterygoid muscle. The horizontal ramus of mandible was eroded and the mass extended across the midline. Excision of the mass with segmental mandibulectomy was performed. Reconstruction with a free fibula was deferred for a later stage in view of the young age, large mass and concern of recurrent disease. Since the mucosal defect following excision was not large enough primary closure was performed. Histopathology confirmed juvenile fibromatosis and all cut margins of resection were free of tumour. The patient presented after 13 months with recurrent swelling over the cheek with significant difficulty in swallowing and constant dribbling of saliva due to inadequate mouth closure (Figure ). A CT scan revealed presence of a large recurrent mass in the floor of mouth, infiltrating the infratemporal fossa (ITF) and reaching up to the base of skull (Figure ). In view of the extensive recurrence low dose chemotherapy (weekly vinblastine, methotrexate and tamoxifen) was started. After completion of 12 weeks of chemotherapy, a partial response was achieved. Excision of the mass with ITF clearance was performed subsequently. A portion of tongue and its base along with the lateral oropharyngeal and the soft palate was also excised (Figure. ) The defect following resection was large and a free flap was not feasible as the external carotid artery was ligated at previous surgery. Reconstruction with a PMMC flap for providing mucosal cover and soft tissue bulk for defect was considered. In view of the large mucosal defect a large skin paddle was taken incorporating the nipple-areola complex. The technique for harvesting the PMMC has been described previously [] (Figure ). The edges of the flap were sutured circumferentially to the mucosa of the oral cavity except superiorly where the mucosa was deficient; the flap was anchored to the hard palate with non-absorbable sutures.
+Patient had an uneventful recovery and was discharged after ten days. The flap was well taken without any necrosis or other complication. Guide bite prosthesis was used after a week of surgery to prevent malocclusion. Histopathological examination revealed all cut margins to be free of tumour. Patient further received 12 weeks of low dose chemotherapy. At one year follow-up the patient is having normal speech and swallowing and is free from recurrent disease."
+Jillian Sawyer,38,1990/3/6,576-638-0049,robinsonbrian@example.org,766 Pearson Cove Apt. 895,"Patient 1 is a 29-year-old Iranian-Jewish woman diagnosed at age 24 years. She presented at age 17 with inability to abduct her legs against any resistance on an exercise machine; other muscle groups were strong. Following her first pregnancy at age 20, she noticed weakness, difficulty climbing stairs, and tripping and falling that progressed in frequency over the next 3 years from once a month to once a week. A muscle biopsy and genetic testing confirmed the diagnosis of HIBM with homozygous M712T mutations in GNE. At age 25, she noted difficulty fastening snaps and could not raise her arms to pull back her hair. Progression was gradual, with more significant decline following illnesses. Treatments included solumederol, 1 g intravenously for 3 days, which resulted in improved strength but was followed by relapse. On one occasion, IVIG (dose unknown) was given over 3 days, providing no improvement but complicated by aseptic meningitis requiring hospitalization. For the 6 months prior to admission, the patient used a wheelchair and required assistance walking and with transfers. Medications included sertraline for depression and anxiety, and vitamins.
+At the NIH Clinical Center, the patient was wheelchair dependent, but could go from sit to stand and ambulate a few feet with support. She had bilateral foot drop and significant weakness of upper and lower extremities, with some sparing of the quadriceps. Muscle atrophy was universally apparent. Cranial nerves and sensation were intact. MRI of the calf showed pronounced fatty involution of the musculature bilaterally, worse proximally. The lateral soleus and posterior tibial muscles were somewhat spared distally. A quadriceps muscle biopsy revealed moderate type II fiber predominance. The muscles were atrophic (type II worse than type I) and demonstrated necrosis, active degeneration, and red rimmed vacuoles, consistent with severe chronic myopathy without inflammation. Imunohistochemical staining for NCAM, a surface glycoprotein reflecting muscle regeneration [,], showed a significant number of positive fibers."
+Jefferson Li,27,1990/7/26,001-972-852-5865x8866,tiffany64@example.net,80606 English Knoll Suite 830,"Patient 2 is the 42-year-old brother of patient 1. He was diagnosed with HIBM at 37 years of age, following the diagnosis of his sister. Weakness upon raising his arms overhead first appeared at age 27. At 34, he began tripping and, in the subsequent year, had difficulty climbing stairs and lifting his son. The upper extremities were most affected, but leg weakness was evident by decreased endurance, speed of walking, and getting in and out of a car. He occasionally used his hands to lift his legs. Symptoms were largely stable, but exacerbated by emotional events. He did not receive any treatment for his myopathy, and medications included only multivitamins.
+At the NIH Clinical Center, there was wasting of the triceps and the interosseus and thenar muscles of the hand. Contractures of approximately 5??0 degrees were present in the elbows, with decreased range of motion upon supination of the forearm. The patient had no foot drop. Muscles of the shoulder girdle, pinch, grip, and proximal lower extremities exhibited weakness. The gait was normal, and cranial nerves and sensation were intact. MRI of the thigh revealed advanced atrophy with fatty involution in the proximal posterior compartment and adductor magnus muscles bilaterally. The sartorius and rectus femoris muscles were also involved. There was relative sparing of the quadriceps with the exception of the rectus femoris muscles. On biopsy, the quadriceps muscle showed several small vacuolated fibers with a few degenerating fibers, but no inflammation. Immunohistochemical staining was negative for NCAM, indicating negligible damage to individual muscle fibers."
+Paige Silva,42,1992/4/23,001-507-861-3303x376,kwalker@example.org,471 Rodriguez Estate,"Patient 3 is a 39-year-old woman of Bohemian/Czech/French Canadian ancestry diagnosed with HIBM at the age of 31 years. Following a year of progressive tripping and falling, she awoke one day with numbness from the waist down that spread to her entire body. She was diagnosed with mild multiple sclerosis, based on the presence of oligoclonal bands in her cerebrospinal fluid and a brain MRI showing a possible ""spot."" Muscle biopsy also provided evidence of inclusion body myopathy. Currently, she has difficulty arising from a supine position due to weak abdominal muscles, weakness in her hands, arms, and shoulders, and inability to climb stairs. She wears ankle braces to walk. She uses bronchodilators for asthma and sertraline for depression. Confirmatory mutational analysis demonstrated compound heterozygous GNE mutations, i.e., R246Q and A631V, affecting the epimerase and kinase domains, respectively.
+At the NIH Clinical Center, the patient had bilateral foot drop with a compensated gait. She was able to transfer independently from sit to stand and from stand to sit. There was proximal muscle and neck weakness and limited endurance. Cranial nerves and sensation were intact. MRI of the calf showed end-stage myopathy with advanced fatty involution, but with preservation of muscle volume. Signal alteration was present in areas of non-atrophic muscle. The popliteal muscles in the upper calves and the distal posterior tibial muscles were relatively spared. On biopsy, the quadriceps muscle showed significant necrosis with replacement of muscle by fat and connective tissue, but without inflammation. NCAM staining was minimal."
+Luka Weaver,33,1992/7/22,564.387.7960x9366,brittney41@example.org,3711 Renee Station Suite 391,"Patient 4 is the 46-year-old brother of patient 3. He was diagnosed with HIBM at the age of 33 years following a one-year history of progressive tripping and falling, decreased muscle strength and inability to lift his foot. As a cabinetmaker, he relied on this action to support the cabinets as he made them. A muscle biopsy was initially read as consistent with either polymyositis or inclusion body myopathy, but intravenous steroids provided no relief, and HIBM was diagnosed. Plateaus were interspersed with declines, which occurred with lack of exercise but not with illnesses. The lower extremity weakness extended throughout the body. The patient currently wears ankle braces to walk, uses an electric wheelchair for distances, and has assistive devices to drive. He has difficulty holding a pen. Medications include acyclovir, Metamucil, multivitamins, tramadol and diazepam.
+At the NIH Clinical Center, there was muscle wasting of the triceps and the interosseus muscles of the hands, along with tightness of the heel cords, hips, and hamstrings. The patient was partially independent when going from sit to stand, and when executing transfers to and from his wheelchair. He could ambulate a few steps using ankle-foot orthotics and support from the wall. He had significant weakness in the proximal upper extremities, triceps, wrist and hand, and decreased strength on hip flexion, hip extension, ankle dorsiflexion, and plantar flexion. Deep tendon reflexes could not be elicited in the upper or lower extremities. Sensation and cranial nerve functions were intact. MRI of the calf showed end-stage myopathy with advanced fatty involution but preservation of muscle contours. Signal alteration occurred in areas of the remaining muscle. There was relative sparing of the popliteus, the tibialis posterior, and the flexor digitorum longus muscles. Quadriceps muscle histology revealed vacuolated and moth-eaten muscle fibers, with degeneration and regeneration. Connective tissue was slightly increased with no signs of inflammation. Immunohistochemical staining with NCAM was negative."
+Teagan English,45,2003/2/5,001-382-405-1083x1594,mmack@example.net,85362 Jillian Extensions,"A 22-year-old female with two prior full-term deliveries underwent
+an elective abortion at 15 weeks gestation at a clinic, 8 weeks
+prior to admission at our medical center. The procedure was
+uncomplicated; the patient does not remember receiving antibiotics
+or being tested for GBS. Her past medical history was
+noncontributory although she reports a negative HIV test one month
+prior to admission. She denies using illicit drugs, any injection
+therapy, or any recent tattoos.
+One week after the abortion, she developed low-grade fever and
+malaise and returned for a repeat cervical dilation and uterine
+evacuation. Genital cultures grew GBS, Candida albicans,
+and oxacillin-sensitive Staphylococcus aureus. She was
+discharged with 7 days of amoxicillin.
+Two weeks later, she presented to another hospital complaining of
+fever, chills, productive cough, dyspnea, and diffuse chest pain
+of 5 days duration. She was febrile with enlarged tonsils, no
+evidence of cardiac abnormalities, rales in bilateral lung bases,
+and a benign abdomen. A sterile speculum exam revealed
+yellow-green discharge from the cervix; cultures were sent. She
+was admitted and treated with ceftriaxone, azithromycin, and
+metronidazole. CT showed diffuse, patchy infiltrates in the lower
+lobes with cavitations and no evidence of a pulmonary embolism.
+Blood cultures grew gram-positive cocci in chains presumed to be
+S pneumonia and nafcillin was added. She left against
+medical advice and two weeks later presented to our Emergency
+Department (ED) with worsening fevers, chills, SOB, productive
+cough, and pleuritic chest pain. In the ED, she was again treated
+with cefotaxime and azithromycin for presumed community acquired
+pneumonia and intravenous heparin for possible PE.
+On exam she was febrile, hypotensive, tachycardic, and tachypneic.
+Oxygen saturation was 87% on room air. She had pale
+conjunctivae and dry mucous membranes. Lung exam revealed diffuse
+rhonchi and decreased breath sounds on the right. On
+cardiovascular exam, her neck showed cannon v waves along with a
+3/6 holosystolic murmur best heard at the lower left sternal
+border. Abdominal and extremity exams were benign. There were no
+signs of Osler's nodes or Janeway lesions.
+Her CBC revealed a WBC of 19.3, hemoglobin of 9.6, and platelets
+of 81 000. D-dimer was 4540 ng/mL; beta hCG was negative. Chest
+radiograph showed bilateral, fluffy, lower lobe infiltrates with
+peripheral cavitations. Ultrasound of the lower extremities for
+deep vein thromboses was negative. EKG revealed sinus tachycardia
+and right ventricular conduction delay (RSR'). CT of the chest,
+abdomen, and pelvis revealed large, bilateral, peripheral lower
+lobe cavitary lesions.
+She was admitted to the ICU and treated with penicillin G,
+gentamicin, and clindamycin. Transthoracic echocardiogram showed
+estimated pulmonary artery systolic pressures of 55 mmHg,
+right atrial and right ventricular dilation, and large tricuspid
+valve vegetation with severe tricuspid regurgitation ().
+Left ventricular ejection fraction was
+56%.
+Blood cultures were reported positive in 12 hours with GBS,
+sensitive to penicillin (MIC 0.12) and cefotaxime (MIC 0.12).
+Clindamycin was stopped.
+Throughout her stay, the patient was persistently febrile. Repeat
+CT of the chest, 2 weeks after admission, showed improving
+pulmonary infiltrates; multiple, bilateral cavitary lesions
+increased in size; cardiomegaly with a very large right atrium and
+suprahepatic inferior vena cava, along with a severely enlarged
+liver suggesting right heart failure.
+She was treated with 3 weeks of gentamicin and discharged on
+continued intravenous penicillin G for a total of 6 weeks of
+therapy. Although her echocardiograms and CT scans showed evidence
+of right heart failure, she had no clinical evidence of this; it
+was decided to monitor the patient closely and forgo surgery. The
+patient missed two followup appointments after her discharge.
+She appeared in the ED a few months later complaining of chest
+pain and dyspnea on exertion. CT scan of chest showed left
+descending pulmonary artery aneurysm without clot or dissection
+but clear evidence of pulmonary hypertension. Echocardiogram in
+the ED revealed normal LV motion and ejection fraction, complete
+resolution of the vegetation, pulmonary artery peak systolic
+pressure of 41 mmHg, a thickened tricuspid valve with severe
+regurgitation, and septal flattening consistent with right
+ventricular volume overload. The cardiologist evaluated the
+patient and recommended her to followup for a possible tricuspid
+valve replacement. However, the patient was again lost to followup."
+Junior Howell,33,1998/10/18,(623)921-4669x204,snovak@example.org,4791 Rogers Squares,"A diabetic 55 year old woman was admitted to Zonguldak Karaelmas
+University emergency clinic with a complain of an insidious onset
+of swelling in the left part of vulva, a pain radiating to the
+left inguinal region, chills and high fever over a week. She has
+had hypertension and type II diabetes mellitus and has used oral
+anti-diabetic and anti-hypertension drugs for 8 years. She had no
+history of previous trauma, operation, underlying skin lesion, use
+of foreign body or human bite on her vulvar region. Two days after
+onset, her left part of the vulva became swelling and the lesions
+color turned to red. Even though she had used
+amoxicilline-clavulanic acid and ornidasole for three days, the
+lesion on the vulva and pain worsened.
+In clinical examination her fever 38簞C,
+pulse 96/dk, blood pressure 160/80 mmHg, in the left part
+of the vulva there was an erode lesion in the certain part of the
+inflammatory halo. The lesion was 5 ? 4 cm in size, red,
+hot, swollen, and painful and fluctuant. Local tenderness and
+edema were also marked (). The borders of the
+lesion was not elevated and sharply demarcated.
+Laboratory values were as follows: WBC count, 18200/ mm3
+(82% neutrophils, 8% lymphocyte, 8% monocytes)
+[4000??0000/mm3]; erythrocyte sedimentation rate (ESR), 122 mm/hour [0??0 mm/hour];
+C-reactive protein, (++++)[negatif]; and blood glucose,
+235 mg/dL [70??10 mg/dL].
+Vulvar abscess was diagnosed and it was drained. In Gram stain of
+the pus, granulocytes (80% neutrophil), Gram-negative rods
+and Gram-positive cocci were detected. Ampicilline-sulbactam
+4 ? 1 gr IV/day, ciprofloxacin 2 ? 400 mg
+IV/day and local care with 2% eau borique fluid were started
+empirically. Her oral anti-diabetic drugs stopped and IV insulin
+treatment started. The blood glucose was in regular limits after
+IV insulin treatment began. Following drainage, her fever,
+leucocyt count became normal and, edema, pain and erythema of the
+lesion subsided.
+Eikenella corrodens and metisilline sensitive Staphylococcus epidermidis (MSSE) were isolated from culture of the pus. After 3 days of the treatment her fever,
+white blood cell count was normal, ESR was 100 mm/hour. The
+patient completed 14 days of treatment with resolution of signs
+and symptoms. The ESR was 72 mm/hour in the first week of
+the treatment, 30 mm/hour at the end of the treatment. An
+informed consent was obtained from the patient to use of her
+photographs."
+Mckenna O’Connell,27,1981/2/15,361.730.9322x94926,martindavid@example.com,13778 Davis Vista Suite 973,"A 7-month-old female infant from a Sudanese western tribe was referred as a case of malnutrition. At presentation, the patient had confluent eyebrows that appeared arched and well-defined, long curly eyelashes, low front and back hairlines, turned-up nose, down-turned angles of the mouth and thin lips, long philtrum, small lower jaw and protruding upper jaw, microcephaly, excessive body hair, short neck, and small broad hands with simian crease and proximal insertion of the thumb, and clinodactyly of the fifth finger. X-ray showed delayed bone development. She had low-pitched cry, short neck with limited movement, stiff muscle tone (unable to sit, she was still fisting), fixed flexion of both elbows, and she did not show any sign of speaking or babble (Fig. and ). Moreover she had tied tongue and thin skin. Her brain stem evoked potential test showed conductive hearing loss. She was about 27 inches in length, her weight was 3 kilograms and there were no records about her birth weight. Her skull circumference was 35 cm. Finally, she showed a number of features not typical of BDLS, including crowded ribs by chest by X-ray (distance between each rib is short). Hepatomegally was shown by ultrasonography.
+Peripheral blood from the patient was subjected to short-term culture in RPMI 1640 medium for 72 hours. After metaphase arrest through exposure to Colcemide, cells were harvested, treated with hypotonic solution, and then fixed with methanol and acetic acid according to standard procedures. The harvested cells were dropped on clean slides and stained with Wright's stain, for chromosome banding []. The clonality criteria and the karyotypic descriptions were according to the ISCN recommendations []. Analysis of 11 metaphase cells showed 46, XX in all cells."
+Jovanni Velazquez,30,1978/6/5,+1-756-532-9066x147,brownchristopher@example.org,91981 Johnson Underpass,"In August 2003, a 20-year-old 16-week pregnant mother of one, presented to the orthopaedic outpatient clinic with a 2-month history of a slowly growing painless mass located in the right hypothenar eminence. She was right-hand dominant and a housewife. There was no history of trauma, insect bites or drainage from the area. There was no significant past medical or surgical history. She was not on any prescribed medication. There was no family history of tumours. She denied smoking, alcohol and drug abuse. On examination, a non-tender, firm to palpation, well-demarcated and tethered to the subcutaneous tissues mass, surrounded by mild erythema, and measuring approximately 2.5 cm ? 3.0 cm was revealed, in the absence of palpable lymph nodes at the ipsilateral elbow or axilla. There were no other abnormal signs.
+Haematological and biochemical investigations were within the normal range. A plain X-ray of the right hand and forearm was unremarkable. Magnetic resonance imaging showed the mass to have infiltrated all skin layers and to have encircled the ulnar artery without involvement of the underlying bones (Figure ). The absence of a signal void from within the mass excluded a diagnosis of haemangioma. Ultrasound-guided needle biopsy showed lesional areas consistent with collagenous fibrous tissue of varying cellularity, with little evidence of mitotic activity. Immunohistochemistry showed focal positivity for smooth muscle actin (SMA), suggesting myofibroblastic differentiation. Histological appearances were in keeping with fibromatosis.
+Three weeks after initial presentation, the lesion was excised preserving the ulnar nerve and artery. Histology showed a multi-nodular, well-circumscribed uniform spindle cell lesion with varying cellularity and fibrosis. In one section, central cyst formation was observed. Occasional mitoses of normal morphology were seen. Necrosis was not a feature. In several areas, the lesion appeared to be intravascular, the vessel was lined by an apparent endothelium (Figure ). Scattered osteoclast-like multi-nucleate giant cells were also observed. Immunohistochemistry replicated diffuse positivity for SMA, but not for desmin, CD34 or S100 protein. Appearances were consistent with a myofibroblastic proliferation, confirming a diagnosis of intravascular fasciitis (IVF).
+The patient had an uneventful recovery and required no further therapy. She continues to be evaluated for local recurrence every 6 months, with no sign of recurrence at the 2-year follow-up."
+Jaliyah Zuniga,34,1996/5/22,4033126299,jlivingston@example.org,9409 Walker Port,"A 29 year old man, was referred complaining of mild exertional dyspnea, dizziness and chest pain during the last 3 years. These symptoms remained stable during this time. When he was 15 years old, he had meningitis complicated by a cerebral abscess; at that time, in another institution, a harsh cardiac murmur was heard at the left external border and an echocardiographic examination have shown a four millimeter VSD, right ventricular hypertrophy and increased pulmonary flow. The cerebral abscess was surgically drained and the patient, after recovery, remained asymptomatic for the following 11 y. In the current clinical evaluation, physical examination revealed no cyanosis, heart rate of 80 bpm, arterial blood pressure of 110 ? 70 mmHg; apical impulse was normopositioned at the 50 intercostal space. Cardiac rhythm was regular and there was a harsh intense ejection murmur in the low external border.
+The ECG showed: sinus rhythm, right axis deviation, right ventricular overload and a minor degree of right bundle branch block. Transthoracic echocardiography (Figure and Figure ) showed: a 17 mm perimembranous VSD associated to a slow velocity flow from left to right ventricle; aortic root was slightly deviated to the right. In addition, there was RV hypertrophy and a muscular septation inside this cavity causing obstruction with a peak gradient of 80 mmHg. There was no obstruction to flow in the right outflow tract and the site of the right obstruction was displaced proximally preserving the right ventricular infundibulum. The pulmonary valve was completely normal.
+Based solely on the echocardiographic findings, the patient was referred to surgery which confirmed anatomical and functional abnormalities. VSD was closed and the right anomalous muscle band (Figure ) was successfully removed. After the procedure, patient remains free of symptoms and medications."
+Sincere Mitchell,24,1992/3/4,+1-475-969-8387x02103,glennthornton@example.net,723 Morrow Spur Suite 050,"A 46-year-old male with chronic lymphocytic leukemia underwent allogenic non-myeloablative stem cell transplantation (HSCT). The post-transplant course was complicated by severe graft-versus-host disease (GvHD) of the skin, thrombocytopenia, and systemic cytomegalovirus (CMV) infection, causing treatment-induced renal failure that necessitated hemodialysis (Table ).
+Nine months after HSCT, he was admitted to the intensive care unit (ICU) with septic shock, which was treated with empiric antibiotics, vasoactive medication, and mechanical ventilation. Seven days after ICU admission, the FiO2 requirement suddenly increased to 1.0 and fresh blood was coming from the endotracheal tube. The platelet count was 10 ? 109 per liter and the activated partial thromboplastin time (APTT) was 40 seconds. Despite platelet transfusion to a platelet count of more than 100 ? 109 per liter and FFP administration to an APTT of less than 35 seconds (in addition to the standard treatment as described in Materials and methods), the bleeding increased in severity. rFVIIa was administered intravenously in doses of up to 120 弮g/kg without hemostatic effect. Bronchoscopy revealed fresh bleeding from both lungs. rFVIIa (50 弮g/kg) dissolved in saline was administered by BAL into the left and right main bronchi simultaneously with the systemic i.v. administration of 50 弮g/kg rFVIIa. This resulted in an immediate cessation of the bleeding from the endotracheal tube. The arterial oxygen pressure (PaO2)/FiO2 ratio increased the subsequent day. The hemostatic effect lasted for approximately 36 hours, after which bleeding recurred. The treatment was repeated twice also, and bleeding ceased for more than 24 hours. Hereafter, the patient received rFVIIa (50 弮g/kg) by BAL alone twice, and bleeding ceased for 24 to 36 hours after each administration. Complete hemostasis was obtained after the third BAL administration of rFVIIa and lasted for three months (Table ). The patient died three months after the first rFVIIa treatment, due to respiratory and circulatory failure secondary to septic shock without evidence of active pulmonary bleeding. Postmortem examination revealed no signs of acute respiratory distress syndrome (ARDS) in the alveoli or thromboembolic complications."
+Willow Warner,27,1980/11/4,2326031278,suecooper@example.net,113 Morris Parkway,"A 63-year-old male with progressive neurosarcoidosis was treated with infusion of methotrexate. After the second treatment, he developed pancytopenia and septic shock and was transferred to the ICU, where he was intubated and mechanically ventilated. Fresh blood was observed from the tracheal tube, and chest x-ray showed interstitial diffuse alveolar infiltrates indicating pulmonary bleeding. Standard treatment was instituted, resulting in an increase in platelet count from 18 ? 109 per liter to 88 ? 109 per liter with a reduction in APTT from 45 to 36 seconds (Table ). Multiple organ failure developed and increasing amounts of fresh blood were observed from the tube while the FiO2 requirement increased from 0.7 to 1.0. A single dose (20 弮g) of i.v. desmopressin did not improve hemostasis. Bronchoscopy revealed ongoing bleeding from the distal bronchial tree bilaterally. A 50 弮g/kg dose of rFVIIa was administered via BAL, resulting in immediate cessation of the pulmonary bleeding. Four hours after rFVIIa administration, FiO2 could be reduced to 0.8 and was further reduced to 0.6 the following morning (Table ). Despite continued improvement in pulmonary function, increasing circulatory instability secondary to septic shock became evident and the patient died four days after rFVIIa treatment. No pulmonary bleeding or thromboembolic complications were found after the intrapulmonary administration of rFVIIa."
+Jaxton Valencia,30,1980/2/28,+1-855-917-5394x51652,trobbins@example.org,3004 Johnson Falls,"A 44-year-old male with acute myeloid leukemia (AML) developed high fever and hemoptysis 14 days after induction of a combination of chemotherapy comprising cytarabine, amsacrine, and etoposide. Chest x-ray showed bilateral infiltrations, and BAL revealed Stenotrophomonas maltophilia. The patient was admitted to the ICU, where mechanical ventilation was instituted with an FiO2 of 1.0, and was started with inotropic support and antimicrobial therapy (i.v. ceftazidime and inhalation of colistin). Pulmonary bleeding increased despite standard treatment (Table ). Bronchoscopy revealed ongoing bleeding from the distal bronchial tree bilaterally, and rFVIIa (50 弮g/kg) was administered by BAL. The bleeding ceased and the FiO2 was decreased to 0.45 over the next 24 hours. Over the next 12 days, the situation stabilized and improvement of the pulmonary and the circulatory functions was observed and the patient could be weaned off of the ventilator and discharged from the ICU. No pulmonary bleeding or thromboembolic complications were observed after the intrapulmonary administration of rFVIIa."
+Maddison Buck,33,1987/11/22,001-456-624-3258x714,steve95@example.org,371 Burke Point Apt. 102,"A 34-year-old woman was suspected of having Wegener's granulomatosis on the basis of eosinophilia, positive anti-neutrophil cytoplasmatic antibodies, hematuria, and proteinuria. Treatment with systemic corticosteroids was instituted, but due to respiratory distress and the presence of hemoptysis, the patient was admitted to the ICU. Chest x-ray showed interstitial subtle bilateral alveolar infiltrates indicating pulmonary bleeding. The patient was intubated and mechanically ventilated with an FiO2 of 1.0, and systemic antibiotic treatment was initiated in conjunction with pulse treatment with methylprednisone (1,000 mg intravenously every day for three days and then 40 mg every day). Treatment including continuous aprotinin infusion was instituted. The pulmonary bleeding ceased, FiO2 demand was reduced to 0.35, and antifibrinolytic treatment was discontinued. Twelve hours after discontinuation of aprotinin, fresh pulmonary bleeding again became apparent, together with an increase in FiO2 requirements to 1.0. The bleeding was refractory to standard treatment, including aprotinin. Bronchoscopy revealed ongoing bleeding at the segmental level, and rFVIIa (50 弮g/kg) was administered by BAL, leading to immediate cessation of the bleeding; FiO2 was reduced to 0.3 at six hours after rFVIIa treatment, and the patient was extubated the following morning.
+A biopsy from the skin showed perivascular eosinophilic infiltration indicating Churg-Strauss vasculitis, and the patient responded to the corticosteroid therapy treatment with regression of paresis and normalization of urine tests. Three days after extubation, bleeding from the lungs reoccurred together with an increase in O2 demand. To avoid re-intubation, rFVIIa was administered through a jet nebulizer with a prompt hemostatic effect. The aerosolized rFVIIa was repeated twice over the following 12 hours. A sustained hemostasis and a decrease in O2 requirements from 15 to 4 liters/minute were obtained. The further clinical course was uneventful, and the patient was discharged from the ICU three days later."
+Jon Swanson,23,1980/2/24,994.468.8533,valencialoretta@example.org,24480 Wilson Spring Suite 860,"A 44-year-old HIV-positive female with chronic hemodialysis requirement, severe critical illness polyneuropathy, and enterocolitis due to Clostridium difficile infection, for which she received i.v. vancomycin, underwent surgery due to gastrointestinal bleeding. Postoperatively, she was transferred to the ICU, receiving mechanical ventilator support, and developed ventilator-associated pneumonia due to Pseudomonas aeruginosa, which was treated successfully with broad-spectrum antibiotics. In addition, a systemic CMV infection developed for which she was treated with Foscarnet, leading to stabilization over the following weeks. At 51 days after ICU admission, however, fresh bleeding occurred from the tracheotomy but did not respond to standard treatment as described previously. BAL revealed localized bleeding at the segmental level bilaterally, and rFVIIa (50 弮g/kg) dissolved in 50 ml of sodium chloride was administered with 25 ml in each main bronchus. The pulmonary bleeding ceased but reappeared within 24 hours after the treatment, and rFVIIa administration by BAL was repeated. Hereafter, the bleeding ceased to occur. The patient expired due to infection and respiratory insufficiency 115 days after rFVIIa treatment, without any signs of thromboembolic complications."
+Helen Vaughn,43,1996/8/21,001-343-830-1883x2415,daniel03@example.org,80435 Amy Hills Suite 300,"A 63-year-old male with AML underwent non-myeloablative stem cell transplantation. The post-transplant course was complicated by GvHD of the skin and temporary poor graft function with pancytopenia. Six months post-transplant, the patient was transferred to the ICU due to respiratory insufficiency secondary to pulmonary infection. The patient was intubated and mechanically ventilated with an FiO2 of 0.45. Diagnostic BAL showed fresh blood at segmental levels bilaterally, but the focus of bleeding could not be identified. The platelet count was 35 ? 109 per liter and APTT was 40 seconds, for which the patient received FFP to achieve an APTT of less than 30 seconds and PCs to achieve a platelet count of more than 80 ? 109 per liter but without significant effect on the bleeding. The patient received empirical broad-spectrum antibiotics and antimycotics, resulting in a decrease of the C-reactive protein over the next five days. Twelve days after ICU admission, the pulmonary bleeding increased and the FiO2 demand was increased to 0.6. The patient had a normal TEG (thrombelastografic in vitro coagulation) profile, a platelet count of 80 ? 109 per liter, and an APTT of 27 seconds, indicating a localized coagulopathy. Due to further increase in bleeding and FiO2 demand, a diagnostic BAL was performed, showing fresh bleeding bilaterally at segmental levels; rFVIIa at a dose of 50 弮g/kg dissolved in 50 ml of saline was administered, resulting in immediate cessation of the pulmonary bleeding. The FiO2 was reduced to 0.35 within the next eight hours, and the patient was extubated the following morning. Three days after treatment with local pulmonary rFVIIa, the patient was discharged from the ICU without further bleeding episodes."
+Remy Dean,37,1992/2/2,981-819-9631,hansonrussell@example.org,9395 Hensley Cliffs Suite 547,"A 70-year old woman attended mammography screening. The mammograms revealed en equivocal lesion. Ultrasonography identified a 14 mm tumor that was suspicious for malignancy. A FNAC was done under ultrasound guidance.
+The smears were stained with Diff-Quick簧 (Dade AG, D羹dingen, Germany). The aspirates were cellular and consisted mainly of single spindle or polymorphic, polygonal cells with a few admixed groups of benign ductal epithelial cells (Figure ) and lymphocytes.
+The nuclei were generally large, ranging from 2 - > 5 ? RBC. Most nuclei had a distinct medium-sized nucleolus. The nuclear outlines were irregular with buds and folds. The chromatin was granular. A few cells showing intranuclear cytoplasmic vacuoles were found (Figure ). The cytoplasm was bluish, variable in amount and often dense (Figure ). In the background there was abundant granular metachromatic ground substance and some metachromatic stromal fragments (Figures , and ). A few mitotic figures were found (Figure ). There was no necrotic debris.
+The cytologic diagnosis was suspicious for malignancy and a metaplastic carcinoma where only the non-epithelial component had been aspirated, or a non-epithelial lesion, was suggested. No smears were available for immunocytochemistry.
+The histopathological characteristics are shown in Figures , , , , , , , , , , , . Macroscopically the tumor was round, seemingly well circumscribed, firm and with a white cut surface. The diameter was 14 mm. On microscopy, the lesion was cellular (Figures and ), consisting of spindled and polygonal cells with distinct pleomorphism (Figures , , ). There were variable amounts of eosinophilic ground substance (Figures , and ) and a focal admixture of lymphocytes (Figures and ). There were 6?? mitoses per high power field (HPF) (Figure ) The tumor infiltrated in the surrounding fatty tissue (Figures , , ).
+On immunohistochemistry, the tumor cells were positive for smooth muscle actin (DAKO, Glostrup, Denmark) (Figure ), keratin MNF 116 (a pan-keratin with both high- and low molecular weight keratins from DAKO, Glostrup, Denmark) (Figure ) and vimentin (DAKO, Glostrup, Denmark)(Figure ). About 30 % of the tumor cell nuclei were positive for Ki-67 (DAKO, Glostrup, Denmark) (Figure ). Desmin (DAKO, Glostrup, Denmark) and S-100 (DAKO, Glostrup, Denmark) were negative. Estrogen- and progesterone receptors (DAKO, Glostrup, Denmark) as well as HER-2 (Novocastra, Newcastle upon Tyne, UK) were all negative.
+Ultrastructurally, there were abundant tonofilaments (Figure ), including globular filamentous bodies and granulated endocytoplasmic reticulum with many dilated cisterna. Desmosomes were not identified, but the tissue was poorly preserved. A few lysosomes were seen.
+The histologic diagnosis was malignant myoepithelioma. The sentinel axillary lymph node was examined and was negative."
+Julianna Pope,25,1978/7/30,+1-853-274-0592x849,munozanthony@example.net,6364 Grant Glen Suite 190,"A 33-yr-old woman was admitted to Department of Hepatobiliary Surgery at Cancer Hospital of Tianjin Medical University, China, with the diagnosis of hepatic hamartoma. Eight years previously, she was diagnosed with hepatic hamartoma by fine needle biopsy. She did not accept effective treatment, and subsequently presented with epigastric distention. A history of hepatitis (HBV, HCV) and hepatic cirrhosis were excluded with appropriate tests. Physical examination revealed slight paleness of the skin and mucosa and no jaundice. Abdominal palpation demonstrated the presence of shifting dullness and hepatomegaly without obvious tenderness. No other abnormal signs were found.
+The patients' blood results were as follows:
+Hematology; RBC: 3.64 ? 1012/L, Hb: 61 g/L, WBC: 4.40 ? 109/L and PLT: 126 ? 109/L. Biochemistry; showed: ALT 23 U/L, AST 35 U/L, ALP 386 U/L, ALB 28.0 g/L, TP 50.4 g/L, GLB 22.4 g/L and GGT 254 U/L. Serum markers for HBV and HCV were negative. AFP, CA125, CA199 and CEA were normal.
+Both ultrasonography and spiral computerized tomography (CT) revealed an enlarged liver with rugositied surface. Multinodular focuses involved the whole liver accompanied with calcified plaques, cholecystolithiasis, multiple tiny nodules under the peritoneum and ascites (figure ).
+After a multidisciplinary consensus, the patient underwent surgery including omentectomy and excisional biopsy of liver tumors. In the operation, asymmetrical nodules were noticed on the whole liver and beneath the peritoneum. One was located at colic omentum with 1.5 cm diameter. Frozen section biopsy revealed angiosarcoma. Therefore, only colic omentum resection and hepatic multi-point biopsy were performed.
+Postoperative pathology revealed angiosarcoma (figure ) arising from hepatic hamartoma (figure ) accompaniedwith coelio-implantation metastasis. Subsequent immunohistochemistry revealed the lesions were CD34(+) (figure ), Vimentin(+) (figure ), S-100(-), CEA(-) and CK(-) (Zymed).
+The patient survived 4 months after surgery, and died from liver failure."
+Gunnar Patel,38,1977/9/22,001-221-651-5894,vnelson@example.org,621 Moran Lights,"A 16-year-old boy presented with a history of headache of 8 months duration, progressively decreasing vision for 3 months and more recently had an episode of generalized seizure 1 month back. Neurological examination did not reveal any focal neurological deficit except bilateral papilledema on fundus examination. MRI scan revealed a large 10 ? 8 cm extra-axial hyperintense contrast enhancing mass lesion on the T1-weighted image, occupying the anterior cranial compartment [Fig ]. The tumor was compressing the frontal horns of lateral ventricles along with anterior part of corpus callosum. It was also seen encroaching upon the superior saggital sinus. A bifrontal free bone craniotomy was performed and total excision of the tumor was achieved. Intraoperatively, the tumor was seen adhering to the frontal bone, a part of which was excised with the tumor.
+Gross examination of the resected tumor showed a 10 ? 8 ? 2 cm soft tissue with its cut-section showing grayish-white, irregular surface with focal necrosis [Fig ]. Histopathological examination revealed a tumor tissue composed of sheets of cells arranged in perivascular pseudopapillary pattern [Fig ] along with few well formed papillae with central fibrovascular core [Fig , inset]. These papillary structures in some places were mixed with meningothelial sheets and whorls. The tumor cells in the papillary area displayed abundant eosinophilic cytoplasm, vesicular nuclei but frequent mitoses and foci of necrosis. MIB-1 labeling index was high with mean LI of 12% [Fig ]. Immunohistochemical positivity to epithelial membrane antigen (EMA) [Fig ] and vimentin was seen while Cytokeratin (CK), GFAP and S100 were non-reactive. A pathological diagnosis of Papillary meningioma, WHO grade 3 was given."
+Madeline Cain,37,1987/12/30,313.931.4919x8598,lthompson@example.org,1603 Clark Locks,"A 64-year-old man was diagnosed 6 years earlier with cirrhosis secondary to chronic hepatitis B. He was noted to have splenomegaly in a routine follow up. Laboratory data were as follows: aspartate aminotransferase, 126 U/litre (normal, < 40); alanine aminotransferase, 66 U/litre (normal, < 36); alkaline phosphatase, 123 U/litre (normal, < 96); and 帠-glutamyltransferase, 178 IU/litre (normal, < 96). Serum fetoprotein was 256 弮g/litre (normal, < 20). Serum hepatitis B virus surface antigen was positive and antihepatitis C virus antibody was negative.
+Magnetic resonance imaging of the abdomen showed an approximately 3.5 cm in diameter with a heterogeneous, hypervascular enhancing mass in the left lateral segment of the liver. A multiple, small-to-moderate nodules composed of a low-density area throughout the parenchyma was present in the enlarged spleen. There were no tumor thrombi within the portal veins and lymphadenopathy (Figure ).
+Positron emission tomography findings revealed the ringed dense uptake of 18F-fluorodeoxyglucose in the spleen. It was not absorbed in the lymph nodes of the splenic hilus and behind the pancreatic head; there were no abnormal hot areas in the liver.
+After the liver tumor and spleen were resected, the serum fetoprotein concentrations returned to within the normal range. However, the patient who was treated symptomatically and not treated with chemotherapy due to poor general condition died 6 months after surgical resection.
+Grossly, the resected liver tissue measured 10 ? 7 ? 5 cm. There was a well circumscribed tumor measuring 4 ? 3 ? 3 cm. The mass was grey and soft with a small area of bleeding, necrosis and intact capsule. The non-tumorous portion showed obvious cirrhotic nodularity. The resected spleen measured 25 ? 17 ? 7.5 cm and weighed 1750 g. The outer capsule was smooth, glistening, and intact. Cut surface of the spleen was red-purple and had a diffuse reticulonodular appearance indicative of prominent white pulp. Splenic hilar and mesenteric lymph nodes were not enlarged obviously.
+On histologic sections, the tumor cells were growing in cords of variable thickness, which were separated by sinusoid-like blood spaces in the liver mass. Diffuse fatty change of tumor cells was found in small area (Figure ). The non-tumour part showed cirrhotic change. The tumor in the spleen was characterised by a micronodular lymphoid infiltrate located in white pulp, with variable red pulp infiltration, marginal zone differentiation and follicular replacement by neoplastic cells (Figure ). The white pulp tumoral nodules were composed of an inner central zone of small lymphocytes, located in the mantle zone and replacing the germinal center, and a peripheral zone of medium-sized cells with clear cytoplasm and scattered blasts (Figure ), the marginal zone component. Splenic hilar and mesenteric lymph nodes were not effaced with intact capsules, sinuses, and germinal centers.
+Immunohistochemical staining of the neoplastic cells showed positivity for CD20, CD79帢 (Figure ), Pax-5, bcl-2 and lacked co-expression of cyclin D, CD30, CD3, CD5, bcl-6, bcl-10, CD68, and cytokeratin, indicating that the tumor was B-cell lymphoma. The proliferative index is low, and Ki67 staining showed a distinctive annular pattern, outlining the presence of an increased growth fraction in the germinal center and marginal zone.
+Amplification of Immunoglobulin heavy chain genes was performed by semi-nested PCR, using primers directed to the framework 2 (FR-2) region and to the joining region (JH) as described previously [,] Gene rearrangement studies also supported a clonal B-cell process with heavy chain rearrangement (Figure ).
+Therefore, the liver mass was well and moderately differentiated HCC, the diagnosis of SMZL was made from the splenic specimen. The final pathological diagnosis was coexistent SMZL with HCC in the course of chronic HBV infection."
+Benson Leon,29,2005/2/10,+1-459-939-6263x8641,laura43@example.org,71660 Kelsey Street,"In August 2000, a 37 year old Native-American male received a cadaveric liver transplant after approximately 20 years of chronic HCV infection, genotype 1a. He was a former intravenous drug user (IVDU) and had been enrolled in a MMT program since 1990, taking between 80 and 100 mg methadone daily. He also had a history of anxiety and mood disorders, and had been taking clonazepam, 1 mg 4 times daily since 1999. At transplant evaluation, the patient had solid psychosocial support (family and counseling) and had a consistent ten year adherence to his MMT, including negative toxicological screens. The UCDMC transplant team determined that it would be in the patient's best interest to continue his MMT pre and post transplant.
+The patient had a MELD score of 15 at the time of transplant. He tolerated the operation well with no major complications during surgery, although he did require more intraoperative anesthesia than the average non-MMT patient. Post-operative pain management during hospitalization required consultation with pain specialists and the doses of hydromorphone and morphine were higher than the average non -MMT transplant patients. On post-operative day six, the patient resumed a normal diet; his pain was managed with oral narcotic analgesics; he was fully ambulatory and was discharged from the hospital. Immediately post-transplant, the patient's methadone was 100 mg daily.
+In June 2001, the patient showed biopsy proven recurrent HCV in the transplanted liver. There were no signs of rejection. The patient was continuing MMT ~80 mg daily and was compliant with his immunosuppressive therapy and transplant follow up care. In January 2002, the patient began HCV treatment using an escalating regimen of INF combined with RBV. He reached full dose INF (3 MIU three times per week) and RBV (1200 mg daily) at approximately 10 weeks of treatment. The intention was to treat for 48 weeks on combination therapy. The patient started treatment with a low viral load (410,760 IU/mL). At approximately six months of therapy, he was HCV-RNA quantitatively virus negative.
+Overall, the patient had common side effects to the combination therapy. His physical symptoms included fatigue, nausea, headaches, and flu-like symptoms. These side effects were treated symptomatically and either resolved or were well-tolerated. Although the patient was taking immunosuppressive drugs throughout his HCV therapy, his white blood cell and absolute neutrophil counts remained stable. By treatment week 12, he did experience significant hemolytic anemia (Hgb 10.7 g/dL) and was started on 40,000 units per week of erythropoietin. The patient's RBV was reduced to 800 mg daily for two weeks and then was increased to 1000 mg daily for the remainder of treatment.
+Due to a history of anxiety and mood disorders, the patient was started on low dose antidepressants, citalopram 10 mg daily, three months prior to starting treatment. Additionally, the patient experienced psychiatric side effects to IFN/RBV including mood swings, angry outbursts, insomnia, and forgetfulness. His citalopram, 10 mg daily, was increased twice (20 mg daily at week 12 and 40 mg daily at week 40). Quetiapine, 25 mg 1?? tabs daily, and bupropion, 150 mg twice daily, were also added halfway through treatment to further control these psychiatric side effects. These additional psychotropic medications were managed in conjunction with the patient's methadone clinic; during treatment the patient's methadone was gradually increased from 84 mg daily to a maximum of 110 mg daily. Twenty-four weeks after treatment, the patient's methadone was reduced to 80 mg daily and has incrementally decreased to his current dose of 4 mg daily in 2006. The patient has continued to take clonazepam, 1 mg 3 times daily, and quetiapine, 50 mg daily, post treatment. In 2004, he was able to find a job after many years of unemployment. In 2006, four years after treatment, he continues to be: (a) HCV free with annual liver biopsies showing no signs of disease or fibrosis, (b) stable on immunosuppression, (c) on minimal doses of methadone (15 mg/d), and (d) compliant with medical advice and medications."
+Amora Lucas,40,1989/4/24,(858)568-3709x65505,patriciastevens@example.org,1623 Williams Courts Apt. 845,"A 54-year-old man was admitted for ascites and acute renal failure revealing Child-Pugh stage C13 alcoholic cirrhosis. A liver biopsy showed severe acute alcoholic hepatitis and treatment with prednisolone 1 mg/kg a day was started. Human immunodeficiency virus (HIV) serology was negative, as were viral hepatitis B (HBV) and viral hepatitis C (HCV) tests. Over the following 21 days, four episodes of hemorrhagic shock from grade II esophageal varices occurred. A transjugular intrahepatic portosystemic shunt was placed on day 21. On day 22, severe sepsis developed with middle lobe alveolar consolidation on the chest x-ray. Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) was performed before initiating empirical antibiotic therapy with piperacillin-tazobactam and ofloxacin. Microbiological examination of the BAL fluid evidenced the presence of mycelia, hence the addition of fluconazole to the treatment. On day 23, the patient deteriorated and was admitted to the ICU (Simplified Acute Physiology Score II -SAPS2-61, Organ dysfunction and/or Infection -ODIN 4/7). The chest x-ray radiograph showed bilateral diffuse alveolar opacities. The patient was mechanically ventilated (PaO2/FiO2158 mmHg). The total neutrophil count was 21,000/mm3 (lymphocytes 219/mm3). Blood and urine samples, pleural and peritoneal fluids, and all catheters yielded negative cultures. Microbiological examination of repeated BAL fluid (performed on day 24) was negative, but the aspergillosis latex antigen agglutination test was positive at 1/256 (Platelia Aspergillus EIA for immunoenzymatic detection of galactomannan antigen of Aspergillus in serum; Bio-Rad, Marnes la Coquette, France). Aspergillus serology was negative (Protide Immunoelectrophoresis Aspergillus FSK1-MICROGEN, Beckman-Coulter, Fullerton, USA). Blood aspergillosis antigen tests (Platelia Aspergillus EIA for immunoenzymatic detection of galactomannan antigen of Aspergillus in serum; Bio-Rad, Marnes la Coquette, France) were positive on two occasions (possible false positive in the first instance because of the administration of piperacillin-tazobactam [,]). Fluconazole was switched to intravenous voriconazole (loading dose 400 mg two times on day 1, maintenance dose 200 mg twice daily) on day 27. The patient died on day 29. The family refused necropsy."
+Chance Knox,43,1989/10/24,764-470-8031x687,sandraking@example.org,68935 Reese Brooks,"A 55-year-old man was first admitted for severe pneumonia with rhabdomyolysis, acute renal failure and encephalopathy, revealing Child-Pugh stage C12 alcoholic cirrhosis. Empirical antibiotic therapy with piperacillin-tazobactam and ofloxacin was started. The serology tests for HIV, HBV and HCV were negative. On day 2, septic shock developed and the patient was transferred to the ICU (SAPS2 92; ODIN 5/7). He was mechanically ventilated (PaO2/FiO2 104 mmHg), placed under continuous hemodiafiltration, and received hemodynamic support plus intravenous hydrocortisone hemisuccinate (50 mg every 6 hours, 6 days). Upon the results of initial blood cultures idenfying Streptococcus pneumoniae as the likely cause of the pneumonia, antibiotic therapy was switched to high dose amoxycillin (6 g daily). The patient improved. He could be weaned from mechanical ventilation after two weeks, and from continuous hemodiafiltration after three weeks. Mechanical ventilation was resumed two weeks later because of a catheter-related Staphylococcus infection causing septic shock. After one additional week, new bilateral pulmonary infiltrates appeared. Microbiological examination of BAL fluid was negative for bacteria, while the histopathological examination yielded signs of alveolar damage with alveolar hemosiderosis (Golde score 38). At this time, the total leucocyte count was 8,600/mm3 (258 lymphocytes). BAL fluid and plugged telescopic catheter specimen grew Aspergillus fumigatus (five colonies). Two serum aspergillosis antigen tests were positive at a four days interval, both at 6.3 ng/ml (Platelia Aspergillus EIA for immunoenzymatic detection of galactomannan antigen of Aspergillus in serum; Bio-Rad, Marnes la Coquette, France). Aspergillus serology was negative (Protide Immunoelectrophoresis Aspergillus FSK1-MICROGEN, Beckman-Coulter, Fullerton, USA). Intravenous voriconazole was prescribed (loading dose 400 mg two times on day 1, maintenance dose 200 mg twice daily) but the patient developed multiple organ failure and died on the second day of this treatment. The family refused necropsy."
+Kallie Gallagher,40,1998/4/21,(282)541-2747x782,nancy72@example.net,7493 Mason Canyon Suite 093,"A 64-year-old woman with a C14 alcoholic cirrhosis (Child Pugh score) and a histologically proven alcoholic hepatitis was admitted after one month of oral corticosteroid therapy, with a diagnosis of hepatic encephalopathy, in the context of a Klebsiella urinary tract infection. Amoxicillin/clavulanic acid was prescribed. The serology tests for HIV, HBV and HCV were negative. Over the week following admission, the patient developed acute respiratory failure, with bilateral pulmonary infiltrates and severe hypoxemia (PaO2 57 mmHg with oxygen 10 L/min). There was fever (38.5簞C) and a total leucocyte count of 10,100/mm3 (300 lymphocytes). The patient was transferred to the ICU (SAPS2 39, ODIN 3/7) and fiberoptic bronchoscopy was performed. Microbiological examination of BAL fluid and bronchial aspiration showed hyphae, and both types of sample grew Aspergillus fumigatus. No other infectious agents were identified. Aspergillosis antigen tests were negative (Platelia Aspergillus EIA for immunoenzymatic detection of galactomannan antigen of Aspergillus in serum; Bio-Rad, Marnes la Coquette, France). The Aspergillus agglutination test was positive with one arch and a titer of 1/320 (Protide Immunoelectrophoresis Aspergillus FSK1-MICROGEN, Beckman-Coulter, Fullerton, USA). Intravenous voriconazole was prescribed (loading dose 400 mg two times on day 1, maintenance dose 200 mg twice daily). The patient developed multiple organ failure with severe hepatic dysfunction and died 2 weeks after admission (third day of voriconazole treatment). The family refused necropsy."
+Marcos Norman,42,1977/12/8,001-423-262-7231x554,martindennis@example.net,9531 Miller Ridge Apt. 385,"A 23-year old male patient who had severe mandibular hypoplasia referred to the Department of Oral and Maxillofacial Surgery for treatment. His main complaints were unaesthetic appearance, snoring, wheezing, and difficulties during respiration, speech, and chewing.
+In the extraoral examination, severely convex profile with a receding chin and a prominent nose was observed. Intraoral examination revealed a Class II Division I malocclusion with an excessive overjet. Maxillary arch had a triangular form. Right lateral incisor was missing, mild rotation of the left central incisor, palatoversion of the left lateral incisor and buccoversion of the left canine were observed due to arch length deficiency. Lower second premolars, first and second molars were missing at both sides and first premolar was also absent at left side. Mesial tipping of right and left third molars was observed due to missing of the adjacent teeth (Figure , , and ).
+To determine the skeletal deformity, cephalometric analysis and measurements on stereolithographic three dimensional skull prototype model obtained through three dimensional computerized tomographic images of the patient were used. The stereolithographic model was built by Spectrum Z510 Color 3D Printers (Z Corporation-Burlington, USA).
+Cephalometric analysis indicated severe skeletal Class II discrepancy confirmed by an ANB of 13簞. Point A and point B were 6 mm and 42 mm behind the nasion vertical (NV), respectively. These norms supported each other and revealed that the patient had a severely retruded mandible. Ramus length (Ar-Go) was 41 mm and corpus length (Go-Gn) was 49 mm revealing deficiency of both ramus and corpus. Increases in the mandibular plane, gonial angle and Y-axis emphasized the posterior rotation of the mandible. The anterior facial height was 129 mm, posterior facial height was 64 mm and the ratio of these values was 49.61 % revealing that the patient had a long face. Overjet and overbite were measured as 15 mm and 4 mm, respectively. The cephalometric landmarks used in our report are demonstrated in Figures , and and the pre and post treatment measurements of the cephalograms are presented in Table .
+Ramus and corpus lengths were also measured on the stereolithographic models. The preoperative distance between condyle and gonion was 50 mm and the distance between gonion and menton was 69 mm for the right side. They were 44 mm and 68 mm, respectively for the left side. The patient had severe mandibular hypoplasia due to inadequate ramus and corpus length, therefore using an extraoral multiplanar distractor was inevitable. Tritrac簧 External Distractor (Ucmed Medical Ltd. Co.-Ankara, Turkey) was used for the treatment of the presented case.
+Preadjusted appliances (0.018 ? 0.022 inch) were placed in the maxillary and mandibular arch and open coil spring was used to open space for the left lateral incisor. Following the leveling phase, 0.016 ? 0.022 inch arch wires were placed on the upper and lower teeth.
+Because of the limitation of the mouth opening, nasotracheal intubation was performed with fiberoptic bronchoscope. Under general anaesthesia, after completing the intraoral incisions and exposing the cortex of mandibular corpus and ramus on both sides, the device was secured to the mandible via 6 percutaneous pins. This system had 3 pairs of pins to be secured; one pair to the ramus, the other to the angulus and the last one to the corpus region inferior to the mandibular canal. During this procedure extraoral incisions and trochar were used. The mandibular osteotomy was then performed with round and fissure burs and osteotomes. Two osteotomies on each ipsilateral side were planned. One of the osteotomies was on the ramus and the other one was anterior to the second molar. After the completion of the osteotomies, the distractors were tested and were placed paralell to each other. Then, the incisions were primarily closed.
+A 7 days of latency phase was waited for callus formation. Afterwards, distraction was performed at a rate of 0.5 mm, twice a day. Ramus was distracted for 7 days and corpus was distracted for 45 days. While the corpus was being distracted, the angles of distractors were reduced 5簞 on days 10, 20, 30, 40 so as to decrease the gonial angle. Paralellization of the distractors were protected during this procedure. Once the desired bone length had been acquired, 3 months of consolidation was allowed. Following the consolidation phase the distractor was removed under local anaesthesia and the extraoral wounds were debrided and primarily closed and left for recovery.
+The patient used class II intraoral elastics at night time in order to prevent relapse and elastic traction was completed after 3 months. The patient was followed-up for one more month in order to determine whether relapse would occur. Brackets were debonded 4 months after consolidation period. The total treatment time was 14 months.
+Finally the prosthetic rehabilitations of the missing teeth in the mandible were solved with stationary restorations."
+Malani Swanson,43,1994/1/6,731-262-5390,mfinley@example.org,92366 Jennifer Glens Suite 258,"A 51-year-old female patient presented with a mass originating from the posterior wall of the right external auditory meatus. She had a history of progressive right sided hearing loss and recurrent external otitis over a period of 12 months. Physical examination revealed an ovoid mass covered with normal skin without any pigmentation or ulceration. The mass completely obliterated the lateral half of the right external auditory meatus hindering the visualization of underlying tympanic membrane. Pure tone audiometry revealed a mild conductive hearing loss on the lesion side. Computer tomography (CT) scan of the temporal bone demonstrated a well-circumscribed soft tissue mass, 16 ? 17 mm in size in the lateral part of the external auditory canal posterior wall (Fig. ). The mass showed patchy contrast enhancement with no invasion of middle ear or surrounding bone/cartilaginous structures.
+An excisional biopsy via transmeatal approach was performed under local anesthesia. The mass was totally removed while preserving the integrity of the overlying skin and the surrounding osteocartilaginous structures. At the end of the operation medial half of the canal wall and the tympanic membrane were seen to be intact and disease-free.
+Diagnosis was reported to be schwannoma by histopathologic examination (Fig. ). Schwann cells arranged in the 2 characteristic patterns referred to as Antoni A and B. Immunoperoxidase staining demonstrated a strong positivity to S-100 protein. There were no signs of local recurrence or narrowing of the external auditory canal during a 6 months of follow-up period."
+Hugo Conrad,41,2001/8/18,+1-624-552-9849x9774,kimberly51@example.org,7050 Vasquez Corners Suite 785,"Case 1, a 51-year-old male, had been employed in the plant since 1986 and moved to the unslaked lime process with two other co-workers in July 2000. In April 2001, he had a single episode of chest pain. In early May, while he was hospitalized for the operation of sudden onset retinal detachment, his liver function was abnormal [aspartate aminotransferase (AST), 317 IU/L; alanine aminotransferase (ALT), 156 IU/L; alkaline phosphatase (ALP), 225 IU/L; total bilirubin, 2.2 mg/dL]. Ten days later his liver function was improved. He returned to work in the separator process in September, and then moved to the dry evaporative incinerator in October. However, his liver function worsened in November and peaked in December (AST, 482 IU/L; ALT, 507 IU/L). After stopping work, his liver function normalized."
+Bexley Rosas,35,1989/4/25,(786)568-0239x2997,susanwhite@example.org,101 Burke Views,"Case 3, a 41-year-old female, had been a repair and maintenance worker since 1993. In early July 2001, she felt severe fatigue and took two packs of herbal medicine given to her by case 2. On 14 July, her liver function test was normal. However, 1 week later her urine darkened and jaundice developed in her eyes. She was admitted to the hospital on 30 July with markedly increased liver enzymes (AST, 1,670 IU/L; ALT, 1,223 IU/L; ALP, 495 IU/L). Her condition improved steadily, and she was discharged on 19 September 2001. After returning to her job for 3 days, she felt so fatigued that she did not return to the workplace afterward."
+Remi Vega,21,1985/12/13,751-764-6504,stephaniegraham@example.com,6921 Davis Street Apt. 187,"Case 5, a 26-year-old male, was employed in February 2001 and had been working in the dry evaporative incineration process. He was admitted to the hospital on 20 October 2001 due to jaundice and severely abnormal liver function results (AST, 1,336 IU/L; ALT, 1,368 IU/L; ALP, 198 IU/L). His condition improved, and he was discharged 8 November.
+summarizes the employment and exposure history and clinical characteristics of cases 1??. presents the clinical course of the cases as shown by AST concentration.
+Liver biopsy was performed on all but one case (case 2) in December 2001 (). The pathologic findings showed diffuse spotty hepatocytic necrosis. The portal tracts were slightly enlarged, and inflammatory infiltration was present in all cases. Clumped Kupffer cells containing periodic acid-Schiff (PAS)-positive material were abundant, especially around the terminal hepatic venule (). These findings were compatible with the remission stage of acute hepatitis and also with toxic hepatitis. Wide periportal necrosis was also identified in cases 1 and 4 (), and necrosis was found in the central-to-portal or portal-to-portal region, with bridging necrosis in all cases (). In case 4, regenerative nodules were present, suggesting the development of cirrhosis. Cholestasis and fatty changes were also evident in cases 4 and 3, respectively.
+Markers for hepatitis A (anti-HAV IgM) and B (HBsAg, HBeAg, anti-HBs, anti-HBc IgM) were negative in all cases. Anti-hepatitis C (anti-HCV) was positive in one case (case 1), but HCV was not detected on polymerase chain reaction (PCR).
+This study was approved by the institutional review board of Dongguk University, Gyeongju Hospital. Written informed consent was received from all of the cases."
+Dakota Calderon,43,1995/6/16,750-360-0684,michael15@example.net,426 Cox Isle Apt. 583,"In March 2002, a 27-year-old man presented with sudden loss of central vision in the right eye. Visual loss in the left eye followed within 18 days. At the time of onset, the patient was a very light occasional drinker and a moderate smoker (15 cigarettes/day for 5 years; unfortunately, cotinine and trans-3??hydroxycotinine were not measured to assess tobacco smoke exposure). He suffered from chronic headaches, which responded to common painkillers. The headaches had reportedly worsened when he started work in a glue factory in 1998 (he had previously been an electrician) and worsened remarkably when he was transferred to the glue preparation department, where he had worked for 6 months before the loss of vision. At fundus examination, both eyes showed micro-angiopathy and pseudoedema of the optic disc. A cycle of corticosteroids was ineffective at this time. One month later, visual acuity was 1/100 in the right eye and 7/10 in the left eye. We observed the patient in June 2002 and found a bilateral paleness of optic discs and the inability to count fingers with either eye; at that time, the patient complained of disturbing photopsias. A therapy with idebenone (270 mg/day) and brimonidine (2 drops, 3 times/day) was initiated (; ). Mitochondrial (mt) DNA testing on a blood sample was positive for homoplasmic 11778G ??A/ND4 mutation. Haplogroup definition showed that this patient? mtDNA belonged to haplogroup H (DdeI 10394-, AluI 7025-, MseI 14766-) (). These findings are consistent with a diagnosis of Leber hereditary optic neuropathy (LHON), a maternally inherited loss of central vision that preferentially affects young men (); three mtDNA point mutations (positions 11778G ??A/ND4, 3460G ??A/ND1, and 14484T ??C/ND6) are found in over 90% of patients worldwide.
+Until January 2003, visual function progressively deteriorated, reaching almost complete loss of vision (apart from hand motion) with rapid, involuntary eyeball oscillation (nystagmus). Progression of the fiber loss was documented by serial optical coherence tomography (). shows the retinal nerve fiber layer (RNFL) thickness in each quadrant, as measured by optical coherence tomography, for each of the patient? eyes after 9, 10, and 15 months, alongside values for historical groups of healthy subjects and of patients in an advanced stage of LHON (with atrophy of the optic nerve) (). Compared with the control group, both of the patient? eyes at 9, 10, and 15 months follow-up showed a progressively thinner RNFL in all quadrants.
+By January 2003 (10 month follow-up), the patient needed assistance to walk. After June 2003, he reported a slow but progressive improvement. A full clinical reevaluation was performed in September 2005; abnormal findings were limited to poor visual acuity, pale optic discs, and sluggish pupillary light reaction. On a standardized cycloergometer test (), serum lactic acid levels were almost normal (11.5, 11.9, 23.0, and 13.0 mg/dL; normal range, 5.8??2.0 mg/dL). Folate and vitamin B12 were normal, whereas creatine phosphokinase was high (289 U/L; normal value, < 170 U/L). Muscle biopsy showed nonspecific changes, with an observable parcellar subsarcolemmal increase of succinic dehydrogenase staining, indicating some mitochondrial proliferation. The patient is now able to count fingers and is without nystagmus (both eyes). He is able to walk without assistance and is continuing the same treatment.
+Because the mutations associated with LHON affect complex I subunits and, in most families, are homoplasmic (100% of mtDNA copies are mutant), we performed genealogical reconstruction for the maternal lineage of the patient? family. After obtaining informed consent, we collected blood from the patient? siblings and mother for mtDNA testing by restriction fragment length polymorphism analysis, as described by . These subjects were unaffected carriers of the homoplasmic 11778/ND4 LHON mutation. No history of occupational or environmental exposure to solvents (or other particular toxic substances) was reported for any of the family members tested (). These results are in accordance with the current concepts regarding LHON; the mtDNA mutation is a necessary but not sufficient condition for LHON, and only a minority of carriers develops optic neuropathy. Penetrance is incomplete (and lower in women), implying that additional mitochondrial/nuclear genetic factors and possibly also environmental factors contribute to phenotypic expression of LHON (); however, these triggering factors are poorly defined.
+Between 1998 and 2000 the patient had worked in the ?ot-melt??department, where he controlled hot layering of a synthetic adhesive containing styrene-isoprene copolymer, isopropilic alcohol, toluene, xylene, and octanes. An environmental exposure assessment requested by factory inspectors in 2003 indicated vapor levels of the individual solvents were 10??0% of American Conference of Governmental Industrial Hygienists (ACGIH) threshold limit values (TLVs) (). During 1998??000, the patient recalled experiencing nausea, dizziness, asthenia, and paresthesia of the upper and lower limbs (in addition to chronic headaches) whenever he had to clean the machines? task he performed using a mixture of styrene, isopropilic alcohol, toluene, xylene, and octanes. In 2000??001 the patient worked in the rubber-mincing department, where he was indirectly exposed to n-hexane and toluene (no quantitative data are available). In the glues preparation department, where the patient worked from October 2001 to March 2002, exposure to n-hexane and toluene was presumably more direct because of the nature of his duties: He prepared coloring mixtures containing rubber, hydrocarbonic resin of toluene, and n-hexane in a closed production cycle, and he opened dissolver machines 5 times/day to determine if the tanks were empty. The only available environmental monitoring data for the department (again requested post hoc in 2003) report peak values of 10.7 mg/m3 for n-hexane (ACGIH TLV, 176 mg/m3) and 1.5 mg/m3 for toluene (ACGIH TLV, 188 mg/m3). In this department, the patient reported constantly feeling nauseous and dizzy. Also, during the 6-month period, four overflow accidents occurred, each reportedly followed by several hours of intensified dizziness and nausea, asthenia, tingling of the upper and lower limbs, and dysesthesia of the hands (the same set of symptoms the patient recalled experiencing after using solvents for cleaning tasks in the hot-melt department). Biological monitoring data routinely collected throughout the period of employment indicated that after the patient moved to the glue preparation department, he had a > 4-fold increase in urinary 2,5-hexandione (a neurotoxic metabolite of n-hexane) from 0.5??.9 to 4.1 mg/L, accompanied by a > 1.5-fold increase in urinary hippuric acid (a toluene metabolite) from 360??00 to 1,040 mg/L (roughly corresponding to an increase from 0.26??.5 to 0.74 g/g creatinine)."
+Oakley Moses,32,1998/8/31,+1-473-367-3011x781,newmanrobert@example.com,271 Blair Mill Suite 100,"A 22-year old woman was seen in the emergency department with acute onset of intractable nausea and vomiting. Nausea and vomiting were predominantly post-prandial and seemed to respond partially to metoclopramide. Over the next few weeks she also developed dysphagia, blurry vision, paresthesias involving her lower and upper extremities, and problems with balance. Physical exam was significant for nystagmus on lateral gaze, quadriparesis, absent deep tendon reflexes in all four extremities, a negative plantar reflex, and a positive finger-nose test. No history of vertigo was obtained, cranial nerves were intact, and fundoscopic examination was normal. Her hospital course was complicated by renal failure secondary to dehydration, which subsequently resolved. She had a jejunal feeding tube (J-tube) placed for nutritional support. Laboratory analysis was significant for elevated creatinine initially which later resolved. Cerebrospinal fluid (CSF) analysis was remarkable only for oligoclonal bands (OB's). Magnetic resonance imaging (MRI) of the head and the cervical spine revealed a focal area of demyelination near the cervico-medullary junction (Figure ). There was an interval increase in the size of this lesion over the next few weeks. A scintigraphic four-hour gastric emptying test (GET) was performed. The patient consumed a low fat (2%) Eggbeater meal (255 kcal) labeled with 1mCi99Tc sulfur colloid and 170 cc of water. 46% of the meal was retained at the end of 4 hours (Normal: < 10% retention at the end of 4 hours) Upper endoscopy (EGD) was negative for gastric outlet obstruction. As the patient's symptoms were worsening intravenous methylprednisolone at a dose of 1 gram daily for 2 weeks was instituted followed by a prednisone taper resulted in improvement in nausea, vomiting, and other neurological deficits. The total duration of corticosteroid use was for two months. A repeat MRI after treatment showed resolution of the lesion in the medulla (Figure ). A follow up GET was normal with 8 % retention of the radionuclide meal at the end of four hours. After the patient's oral intake improved and she could keep up with her nutritional requirements, the J-tube was discontinued after 6 months of initial presentation. At the 1-year follow up visit the patient had no neurological or gastrointestinal (GI) complaints, was off all medications, actively employed, and functioning with no complaints."
+Karter Powers,19,2000/3/18,215.494.1733x03838,strongpamela@example.com,18998 Richardson Hollow,"A 24 year old woman was referred to our hospital with symptoms of persistent post-prandial nausea, vomiting, new onset right sided weakness, and paresthesias. Symptoms started 2 weeks prior to presentation. Physical exam was positive for facial nerve palsy on the right side, reduced motor strength in the right upper and lower extremities, absent deep tendon reflexes on the right side, plantar- flexor response, abnormal finger-nose test, and a broad-based unsteady gait. Fundoscopic examination was normal. EGD was negative. GET performed by the previously described technique was conclusive for gastroparesis with 83% retention of food at the end of four hours. MRI revealed demylenating lesions in distal medulla, extending caudally through the cervico-medullary junction. The patient was started on 1 gram of methylprednisolone daily intravenously for 10 days, followed by a tapering dose of oral prednisone and this resulted in a gradual improvement of her nausea, vomiting, and neurological symptoms. GET repeated after 10 days showed remarkable improvement with only 13% retention of food at the end of 4 hours. Three months later, she developed additional neurological symptoms and was diagnosed with multiple sclerosis (MS). No recurrence of GI symptoms was reported."
+Sean Kent,18,1997/1/30,413-960-2957,tjohnson@example.com,4296 Oconnell Way,"A 67 year-old male with a past history of angina and arthritis presented with a one week history of melaena and lethargy. He was found to be anaemic (Hb 6.7 g/dl, MCV 92.2 fl). Endoscopy revealed moderate haemorrhagic gastritis and a Campylobacter-like organism (CLO) -positive duodenal ulcer, but no signs of recent bleeding. His non-steroidal anti-inflammatory medication was stopped and eradication therapy prescribed. He remained an in-patient for one week, during which time seven units of blood were transfused to correct his Hb to 11.6 g/dl.
+Six weeks later he presented with abdominal pain and further melaena requiring a 2-unit blood transfusion. Endoscopy revealed mild antral gastritis and a normal duodenum but no source of bleeding. Colonoscopy was normal. Two weeks later endoscopy was repeated which showed a small amount of fresh blood in the duodenal bulb, but no obvious lesion was seen to account for the bleeding.
+Three weeks later, he remained symptomatically anaemic, requiring further blood transfusion. Because of the history of melaena he underwent a fourth endoscopy which revealed a small, highly vascular polyp in the duodenum just beyond the angulus which bled easily on contact. Multiple biopsies were taken. The endoscopist was concerned about the possibility of a pancreatic neoplasm eroding into the duodenum and therefore an abdominal CT was arranged. Surprisingly, this demonstrated a large left renal mass with evidence of left adrenal and lung metastases, and a polypoidal mass in the medial wall of the second part of the duodenum arising from the pancreas (Figure ). Histology from the duodenal polyp showed small, vacuolated, clear cells highlighted by immunostaining with CAM 5.2 and showing strong reactivity with Vimentin. These findings confirmed the diagnosis of metastatic RCC.
+Over the three month period from initial presentation to diagnosis he required transfusion of a total of twenty units of blood for recurrent symptomatic anaemia. Given the history of recurrent melaena, coeliac angiography was undertaken with a view to trans-catheter embolisation. This was performed successfully via occlusion of the anterior and posterior pancreaticoduodenal vessels using coils (Figure and ).
+He subsequently underwent palliative left nephrectomy and histology from the resected specimen confirmed a grade 2 clear cell variant of RCC. He completed a course of interferon therapy and was able to lead a normal life for approximately 18 months, with no recurrence of anaemic symptoms or melaena. He subsequently developed painful maxillary metastases for which he received a course of radiotherapy, but died at home nearly two years after his initial presentation."
+Jazmine Harding,35,1979/5/13,595.386.3694x194,peckkevin@example.net,12964 Miller Cliff,"A 75 year old male with a past history of left nephrectomy 9 years previously for RCC was referred for out-patient investigation of iron-deficiency anaemia (Hb 10.3, MCV 78.9). Gastroscopy revealed a CLO-negative duodenal ulcer. Duodenal biopsies were within normal histological limits. Proton-pump inhibitor and iron therapy was prescribed and the patient was scheduled for review in the out-patient department.
+He remained anaemic three months later and repeat gastroscopy and a colonoscopy were arranged. Colonoscopy was normal, but gastroscopy revealed a fleshy vascular polyp in the duodenal bulb which was biopsied. A CT scan of the chest and abdomen, and a bone scan revealed a pancreatic mass invading the duodenum (Figure ) but no metastatic disease elsewhere. Histology from the polyp showed multiple large clear cells which stained positively for MNF116 and Vimentin, confirming the diagnosis of metastatic RCC.
+The patient was unable to tolerate interferon therapy. He became jaundiced due to tumour invasion of the distal common bile duct which was managed successfully by endoscopic biliary stenting. He received a total of 13-units of blood for symptomatic anaemia around the time metastatic disease was diagnosed, but since being commenced on a proton pump inhibitor his haemoglobin has remained stable."
+Brodie Prince,20,2001/8/7,527.464.3208x1951,dmartin@example.com,1356 Henderson Viaduct Apt. 853,"A 78 year-old male presented to the emergency department with a ten day history of mild abdominal pain, nausea, and distention, worsening over the last day. He did not recall having a bowel movement for at least three days. His past medical history was significant for hypertension, gout, osteoarthritis, and an eighty-pack year smoking history. He had no prior surgeries and took only a blood pressure medication. He guarded during physical exam, and his abdomen was noted to be quiet, distended, and tender to palpation, but without rigidity or peritoneal signs. His laboratory evaluation was unremarkable. The emergency department obtained a CT scan of his abdomen and pelvis, which demonstrated a large amount of free air and fluid, and a mass could be visualized within the lumen of the cecum. A surgical consultation was emergently obtained (Figure ).
+After fluid resuscitation, he was brought to the operating room for exploration, where we encountered a minimal amount of fecal contamination and perforation of the cecum. A six centimeter non-obstructive mass and a hard mesenteric nodule were found in the cecum just distal to the site of perforation. The remainder of the colon was palpated and noted to be full of hard stool but otherwise without obvious abnormalities. We proceeded with copious irrigation of the peritoneal cavity and performed a right hemicolectomy with primary anastamosis without difficulty.
+Post-operatively, the patient was extubated but progressed slowly. Final radiologic interpretation of the CT obtained on arrival additionally noted a mass in the tail of the pancreas, a finding the surgical team did not detect on the CT prior to surgery or grossly at exploration. Pathologic evaluation found that the cecal mass contained only tubulovillous adenomatous components and the perforated area demonstrated localized mucosal ischemia but had relatively sharp margins. Well-differentiated metastatic adenocarcinoma was found within the mesenteric nodule, without lymphatic components (Figure ). The primary tumor responsible for this metastatic nodule was not contained within the surgical specimen. The patient had a slow return of bowel function consistent with ileus, but his abdominal distention increased dramatically overnight on post-operative day five. A repeat CT demonstrated colonic distention proximal to a now apparent mass at the splenic flexure, with distal colon decompression, concerning for a large bowel obstruction (Figure ). The patient returned to the operating room for reexploration and resection of the obstructive distal colon mass missed at initial operation.
+At the second exploration, the entire colon was mobilized, and this time, a mass could clearly be palpated at the splenic flexure of the colon. Continued mobilization revealed that this mass involved the splenic hilum and tail of the pancreas. An en bloc resection of the pancreatic tail, spleen, and left colon was completed without difficulty, and primary anastomosis was completed (Figure ). The patient was extubated postoperatively and progressed more quickly this time. Final pathologic evaluation of the second specimen was surprising, consistent with mucinous pancreatic adenocarcinoma, extending into the splenic flexure of the colon (T3, N0, M1). At three-month follow up, the patient is doing well living in an extended care facility."
+Greta English,42,1984/4/3,+1-305-238-7823x96898,melissa29@example.com,2807 Fletcher Lock,"The patient was a 41-year-old male who presented with pain in the nape of the neck of one week duration in December 2005. Also there was a history of headache on and off for the past one year and vertigo for two and a half years. Magnetic resonance imaging showed a predominantly solid tumor with ill defined margins. The mass showed a heterogeneous hyper-intense signal on T2 weighted images with no obvious cystic degeneration. It was occupying the cerebral parenchyma of the left temporal and parieto-occipital regions. There was involvement of posterior part of body and splenium of the corpus callosum with extension of the lesion across midline to the right parietal region. The left side of midbrain, thalamus and basal ganglia appeared distorted along with tentorial herniation. The posterior part of the body of the left lateral ventricle was compressed and the third ventricle was displaced to the right side. The tumor was close to but did not reach the cortical surface. Calcification and perilesional edema were absent (Figure ). Craniotomy was done with near-total excision of the tumor. There were no post operative complications and the patient was discharged after a few days. No radiotherapy was offered to patient and there were no signs of recurrence till last follow up."
+Junior Clayton,38,1984/8/12,594-953-2136x54698,stevenbriggs@example.net,033 Christopher Falls Apt. 666,"A 60-year old male was admitted in the emergency ward with the history of massive hematemesis the previous night. Patient had difficulty in swallowing and retrosternal discomfort for the past 2 months for which he was being treated. Once in the hospital there was no fresh bout of hematemesis. On admission the patient's pulse rate was 124/minute and blood pressure was 100/70 mmHg. Hemoglobin level was 9.9 g/dl and the white blood cell count was 13,200/cmm. The chest X-ray showed bilateral emphysematous bullae. Upper GI endoscopy showed esophageal ulceration at 32 cm.
+Contrast enhanced chest CT images acquired at thoracic region showed a penetrating aortic ulcer into the thoracic esophagus and focal anterior aortic defect with pseudo aneurysm formation [Fig , , ]. There was no pleural effusion. A diagnosis of aortoesophageal fistula due to penetrating aortic ulcer was made and the patient taken up for an emergency surgery.
+He was intubated with double lumen endotracheal tube. Left radial and dorsalis pedis arteries were cannulated for the arterial pressures monitoring of upper and lower body respectively. A pulmonary artery catheter was introduced. An epidural catheter was placed to facilitate cold saline irrigation of the epidural space during aortic cross clamping. Injection Methylprednisolone 1 G was given intravenously for spinal cord protection. While securing of the femoral artery and vein in the left groin was being done, thoracotomy was performed through a posterolateral incision. There was no hematoma or effusion or pus in the pleural cavity. Descending thoracic aorta was enlarged but not to aneurismal proportions [Fig ], the medial portion of the lower lobe of the left lung was adherent to the esophagus in the region of the fistula. Aorta was mobilized from the left subclavian artery to the diaphragm except for the area with dense adhesions that contained the fistula. Heparin was given at 1 mg/Kg and after obtaining an ACT of > 400 seconds and aortic cannulation was done distal to the left subclavian artery and also the left femoral artery cannulated using appropriate arterial cannulae and were connected by an 1/4th inch polyvinyl chloride [PVC] tube establishing an aortofemoral shunt. The aorta was cross-clamped and the intercostals arteries were controlled with micro bulldog clamps. The distal aortic pressure maintained between 60 to 70 mmHg. Aorta was opened with a longitudinal incision and the aneurismal mouth was seen in the anteromedial aspect measuring 3 cm ? 2 cm in size and oval in shape [Fig ]. The base of the ulcer was filled with clots. Rest of the aorta appeared normal and edge of the defect appeared healthy. The defect was closed with a gelatin sealed Dacron vascular prosthesis [Vascutek Gelweave woven Dacron graft manufactured by Sulzer Vascutek USA, Inc., Austin, TX78752] cut into an oval shape measuring 3 cm ? 3 cm using 4/0 polypropylene continuous suture technique. The aortotomy was closed with 4/0 polypropylene sutures reinforced with Teflon felt on either side. Aortic cross-clamp was released and aortofemoral shunt clamped. The total cross-clamp time was 65 minutes. Heparin was reversed with protamine. Decannulation was performed and the femoral artery repaired with 6/0 polypropylene continuous sutures. Due to dense adhesions present between the pseudoaneurysm, the esophagus and the hilum of the left lung, further dissection of the esophagus was abandoned. A Ryle's tube was introduced and its' position in the distal esophagus confirmed by palpation. Chest and the mediastinum were copiously irrigated and drained with two 36 F chest tubes. Patient maintained stable haemodynamics with adequate urine output and was able to move both lower limbs. He was kept nil orally for the next 5 days with continuous Ryle's tube aspiration. Total parenteral nutrition was begun in the immediate postoperative period and he was maintained on peri-operative antibiotic coverage of Vancomycin, cefpirome, Metranidazole and Amikacin. The per-operative culture from the thoracic cavity revealed no growth of organisms 48 hours later. On the sixth postoperative day gastrograffin esophagography revealed no esophageal leak. A contrast enhanced CT scan of the chest revealed neither aortic nor esophageal leak [Fig. , ]. Patient was encouraged to take sips of sterile water.
+The patient was afebrile, tolerating soft diet and ambulatory on the ninth postoperative day when he was discharged from the hospital on an antihypertensive drug."
+Saige Webster,22,1993/4/16,-6687,swilson@example.net,15409 Linda Cliffs,"We present the case of a 65 year-old lady referred to us from a rural hospital where she was treated with thrombolytic therapy for a presumed acute anterior myocardial infarct. She had presented with central chest pain radiating down her left arm with ECG findings of 2 mm ST elevation in V2 and V3. There was no recent history of psychological stress although she had been on antidepressant drugs for two years. Four hours after thrombolysis she developed acute pulmonary oedema and a new systolic murmur. At this stage it was presumed she had acute mitral regurgitation secondary to a ruptured papillary muscle, ischaemic dysfunction or an acute ventricular septal defect.
+She was transferred on heparin and glyceryl trinitrate infusion, in acute pulmonary oedema (confirmed by chest X-ray), with a systolic blood pressure of 110 mmHg, and heart rate of 130/minute. Urgent echocardiogram showed severe mitral regurgitation (see Figure ). Her mitral valve annulus was slightly widened at 3.2 cm and subvalvular structures were intact. She also had left ventricular apical ballooning (LVAB) and systolic anterior motion (SAM) of the mitral valve leaflet with septal contact ??left ventricular outflow tract gradient (LVOT) 60??0 mmHg (see Figures and ). Coronary angiography fourteen hours after her presentation showed no obstructive coronary lesions. Ventriculogram revealed akinesis of the anterolateral wall and apex of her left ventricle, more extensive than any single coronary territory, and grade 4/4 mitral regurgitation (see Figures and ).
+She had an intra-aortic balloon pump (IABP) inserted and was transferred to theatre shortly thereafter. She was in cardiogenic shock, with severe MR and SAM still prominent, despite the IABP. We elected to replace her mitral valve, and at operation, the mitral valve was mildly myxomatous but there were no structural abnormalities, chordae and papillary muscles being intact. She had a mechanical mitral valve replacement (MVR) with a 29 mm St Jude valve. The anterior leaflet was excised and PTFE (gore-tex CV4) was used to reconstruct the subvalvular apparatus. The posterior leaflet was plicated to the annulus. Post-operatively there was no LV outflow obstruction and ventricular function improved to within normal limits by the 10th post-operative day. She recovered well."
+Shawn Morgan,20,1987/9/29,2593700312,smartin@example.com,73048 Ballard Viaduct Apt. 897,"A 62 year-old man with a history of hypertension, alcoholism, and mild renal insufficiency, presented to our hospital with a two-day history of fevers, lower back pain, and new onset of urinary retention. One week prior to admission, the patient had undergone diagnostic cardiac catheterization for new onset of atrial fibrillation and had been started on coumadin. Other medications prior to admission were digoxin, diltiazem, furosemide, lisinopril, metoprolol, omeprazole, simvastatin, coumadin. Vital signs on admission were: blood pressure 100/60, temperature 101.4簞F, heart rate 100, respiratory rate 20, He had an irregular heart rhythm without murmurs and mild right flank pain. There was a small non-tender and non-purulent ecchymotic area in the right groin at the site of previous catheterization. His neurologic exam was nonfocal except for new 4/5 bilateral lower extremity weakness. White blood cell count was 18.4 K/mm3, with 75% neutrophils and 12% bands. Hemoglobin and platelets were normal. Sodium 128 mmol/L, blood urea nitrogen 46 mmol/L, creatinine 1.7 mmol/L. INR was 11.21. Amylase and lipase were 557 and 325. A chest x-ray, and a computed tomography (CT) scan of the lumbar spine were unremarkable. A CT scan of the abdomen showed mild early pancreatitis without dilatation of the biliary tree. Blood and urine cultures were sent and the patient was diagnosed with mild pancreatitis and coagulopathy secondary to coumadin overdose. He was was started on intravenous levofloxacin 500 mg, with resolution of the fever by the next day. He received vitamin K and his coumadin was temporarily stopped.. Over the next days, his INR decreased to 1.3 and his abdominal pain and leukocytosis improved, but the back pain and urinary retention continued. By the sixth day of admission, he complained of stool incontinence. A magnetic resonance image (MRI) study of the lumbar spine showed inflammatory diskitis with fluid in the L5/S1 disc space, along with osteomyelitis and a posterior epidural abscess with moderate-to-severe vertebral canal stenosis. The Spine Surgery Service was consulted, but they felt that the neurological findings were not explained by the lesion seen on MRI and recommended non-operative management.
+Blood cultures from admission later grew Gram-positive bacilli, and repeat cultures confirmed Corynebacterium striatum bacteremia on the sixth day of admission. At this time, antibiotics were changed to vancomycin 1500 mg iv daily with subsequent improvement of the back pain, urinary retention and stool incontinence. Follow up blood cultures were negative. A transesophageal echocardiogram (TEE) revealed moderate aortic insufficiency and a 3?? mm vegetation on the non-coronary cusp of the aortic valve, with a perforation at the same site. Cardiovascular surgery recommended that a valve replacement be deferred pending initial antibiotic treatment. A follow-up MRI of the spine reported no significant change on the fluid collection. Surgery was offered, but the patient refused stating he felt decreased weakness and wanted to pursue a conservative management. Over the next days, the patient showed progressive improvement in his lower extremity strength and was able to ambulate with the help of a physical therapist. His urinary retention and bowel dysfunction improved as well.
+Three weeks later, the patient became febrile and acutely dyspneic. An emergent TEE showed an increase in the regurgitant jet through the aortic valve perforation. The patient underwent emergency coronary aortic bypass grafting and aortic valve replacement. Pathology of the aortic valve revealed a heavily calcified aortic valve, and the gram stain showed gram positive coccobacilli. Cultures of the valves were negative, however, the valve had been mistakenly placed on formalin prior to submission to the Microbiology Laboratory. The patient did well postoperatively and was discharged on intravenous vancomycin. At a two-month follow-up appointment the patient's back pain had resolved and an MRI showed resolution of the epidural abscess. Post treatment surveillance blood cultures were sterile after a total of 12 weeks of intravenous vancomycin after his discharge from the hospital. At follow up over two years later the patient remained infection free."
+Delilah Andrade,23,1992/7/2,963-835-6538x3836,julie79@example.com,28272 Ruiz Mews,"A 16-year old male, unrestrained passenger was a victim of high speed frontal collision of the car with an electricity pole, and 30 min thereafter was admitted to the emergency room (ER). On admission, he was complaining of thoracic and abdominal pain, and presented free airways, normal chest expansion, BP:70 ? 40 mmHg, HR: 120 bpm, RR: 18 epm, GCS: 15, RTS: 6.4, abdominal tenderness, and a closed right femur fracture. Plain X ray films suggested a widened mediastinum. After 3000 mL of warmed saline infusion, his BP was 60 ? 30 mmHg, and his HR was 120 bpm. A diagnostic peritoneal lavage was positive for blood. As ultrasonography was unavailable, a laparotomy was performed, with splenectomy and cauterization of a superficial liver injury. After infusion of 6000 more mL saline, 8 units PRBC, and 9 units fresh frozen plasma, the patient's conditions worsened, with muffled heart sounds, undetectable peripheral pulses, and CVP of 20 cmH20. Cardiac tamponade was suspected, and confirmed through a subxiphoid pericardial window. A thoracotomy was performed, with pericardiotomy and removal of blood clots from the pericardial cavity. A 0.5 cm bleeding tear in the apex of the RAA was found, and closed with sutures. The thoracotomy incision was closed. The patient was discharged from the hospital on the 20th postoperative day. His injury severity score (ISS) was 50, and his TRISSCAN was 0.31.
+The main data of this case are presented (see Table ) together with the main data of the 8 cases (cases 1 through 8) of isolated RAA rupture reported in the literature [,-]. Eleven other RAA cases mentioned in the literature without clear informative data are not included here [,].
+The 9 cases (see Table) comprised 5 men and 4 women, aged 15 to 34 (mean: 28) years, all involved in high speed MVC (8 cars and 1 motorcycle). The victims were a motorcyclist (case 1), unrestrained car drivers (cases 2, 3, 4, 5, 8), or passengers (cases 7 and 9), or unspecified position (case 6). Overall, the main diagnostic findings in these 9 cases included hypotension or persistent unresponsive shock (cases 4, 5, 8, 9), muffled heart sounds (cases 1, 2, 3, 4, 9), high CVP values (cases 1, 3, 9), neck vein distension (cases 2, 5, 6), thoracic imaging alterations (cases 2, 4, 5, 6, 9), and traumatic ascitis (case 7). Cardiac tamponade was present in the 9 cases. All the patients underwent a thoracotomy allowing RAA injury identification and repair, and all patients survived. The length of hospital stay ranged from 8 to 20 days."
+Abdiel Conley,42,1978/10/16,001-424-390-9288x3389,dawn81@example.net,113 Lisa Forge Suite 093,"A 6-day-old Pakistani boy was admitted to hospital in June 2005 for bleeding from the left nipple. His parents are first cousins. He has two siblings aged 8 and 6 years. There was no family history of bleeding diathesis. The mother had a normal pregnancy with full antenatal care. Mode of delivery at term was an elective Caesarean section due to previous Caesarean sections. His birth weight was 2.7 kg. 1 mg of Vitamin K was given intramuscularly at delivery. His first neonatal check was normal. He had a small amount of self-limiting bleeding from the umbilical cord on day 3 of life. He went home on day 4.
+On day 6 of life he had mild spontaneous left sided nipple bleeding, which presented as spots of blood stains on the left side of his baby dress.
+Over the next 7 days he had two further episodes of a similar nature. Baseline biochemistry and full blood count were normal but a coagulation screen showed a prolonged prothrombin time of 41 s (control 14 s), a prolonged partial thromboplastin time of 132 s (control 33 s) and normal thrombin time of 15 s (control 14 s). In view of the mild nature of bleeding, the child was only treated with 1 mg of i.v. vitamin K. Subsequent coagulation assays revealed a plasma factor V activity of less than 0.01 IU/ml (normal range 0.50??.50 IU/ml) determined by factor V clotting assay with all other coagulation factors in the normal range. Hence the diagnosis of congenital factor V deficiency was made. A cerebral ultrasound done at this stage was within normal limits. Oral transexamic acid at a dose of 15 mg/kg/dose 3 times daily was started.
+Mother was found to have a plasma factor V activity of 0.44 IU/ml (normal range 0.5??.50 IU/ml) and the father of 0.52 IU/ml by factor V clotting assay. Both levels are compatible with heterozygous factor V deficiency. The siblings had factor V activities of 0.61 and 1.1 IU/ml respectively. Genetic analysis at the St. Thomas Hospital hemophilia molecular genetics laboratory showed that the affected child is homozygous for a frame shift mutation resulting in a premature termination sequence at codon 2178 in exon 25 of the factor V gene and both parents are heterozygous for this mutation.
+The infant presented at day 15 of age with a further episode of bleeding from the umbilical stump. The bleeding stopped promptly following administration of 20 ml/kg of fresh frozen plasma (FFP, methyleneblue sterilized, single donor and US sourced). Small bruises were noted around the venepuncture sites from the previous admission. A hematoma measuring 2 cm in diameter was noted on the anterolateral aspect of the left thigh. It was attributed to the injection of vitamin K at birth. His head circumference was increasing within normal range and a repeat cerebral ultrasound was normal.
+The patient presented again at 5 weeks of age with pallor, irritability, lethargy and reduced feeding. His anterior fontanelle was bulging and tense. He was hemodynamically stable. His hemoglobin was 5.6 g/dl, which represented a significant drop from the previous estimation 3 weeks back. The cerebral ultrasound was repeated and showed a large intracerebral hemorrhage extending from the frontal lobe to the parieto-occipital region. There were a few cystic areas seen within this bleed, which suggested that the bleeding started at least a few weeks ago. The child was immediately transfused with 20 ml/kg of FFP and 15 ml/kg of packed red blood cells. He had a series of generalized fits within 5 hours of admission. The patient was transferred to the regional tertiary referral centre for specialised neurosurgical and haematological management. A cranial computed tomography (CT) scan showed a right, large, intracerebral bleed causing a shift of the midline to the left. The ventricles were not enlarged and the bleed did not extend into the ventricles (See Figure ). A Hickman line insertion was arranged to enable regular FFP infusions. Preoperatively he was transfused again with 20 ml/kg FFP and 10 ml/kg of platelet concentrate to achieve adequate hemostasis. Platelets are known to be a good source of factor V as it is stored in the platelet alpha granules. He was also given recombinant factor VIIa (Novoseven, NovoNordisk簧) as an empirical adjunctive agent in the peri-operative period in view of the fact that reliably hemostatic levels of factor V (0.25??.30 IU/ml) are difficult to achieve in this condition. Factor VIIa is unlikely to work in the absence of any factor V but can contribute to increased thrombin formation once factor V is present. Postoperatively a regime of FFP (15 ml/kg/dose) administration was set up: FFP twice a day for the first 10 days followed by once a day for the next 10 days. This was followed by at least alternate days (every 48 hours) of FFP at 20 ml/kg/day up to the present. Plasma factor V activity has been monitored: A maximum factor V level of 0.23 IU/ml was achieved within 20 minutes after transfusion. Trough levels were between <0.01 to 0.05 IU/ml. When undetectable factor V levels were noted inhibitor assays were performed. Inhibitors have not been detected so far. No further bleeding has been noted up to the present day. Immunisations including hepatitis B vaccination were given subcutaneously as is normal practice for children with severe bleeding disorders. Follow up until the present (21 months of age) revealed an appropriate increment in head circumference. Neurodevelopment has been within normal limits."
+Salem Bradshaw,35,1992/4/8,373-601-7054x81823,carolinebecker@example.net,4267 Benjamin Trace,"The proband ??was a 19 year-old male, with no relevant personal or family history showing mild involuntary orofacial movements and chorea in all four limbs. Psychomotor assessment revealed no cognitive impairment. No psychiatric manifestations were evident and the Beck Depression Inventory Scale proved that there was no concomitant depression. EEG and brain MRI did not reveal any pathological findings. Normal EMG and NC activity was detected. Cardiomyopathy was excluded, fundoscopic examination showed no retinal degeneration, and the expression of the Kell blood group antigens was normal. Haematological parameters were within normal ranges, but a marked presence (95%) of abnormal shaped erythrocytes known as acanthocytes were identified on wet-film preparations. The patient's mother (age at examination: 37 years old) and sister did not show any neurological disorders, while a relevant presence of acanthocytic erythrocytes was observed in peripheral blood (35% and 39% respectively).
+A decreased content of 4.1R protein was evident in the patient, his mother, and his sister (Table ). A marked increase in spectrin dimers (35%, Reference Values < 15%) was apparent in the patient (Figure ). Self-association of spectrin dimers into tetramers is a critical interaction for membrane structure and function []. The percentage of spectrin dimers and tetramers in crude extract reflects their relative distribution in the red cell membrane in vivo. Increased percentage of spectrin dimers is indicative of membrane fragility. The presence of a 4.1 R protein defect seems to give rise to the cytoskeleton instability.
+The diagnosis of HD was excluded by DNA molecular testing and no disease mutations or single nucleotide polymorphisms (SNPs) were found in the ChAc gene."
+Emory Curry,20,1993/4/20,001-428-601-8893x4759,gonzalezmason@example.com,9523 Melissa Rapid,"The proband ??was a 72 year-old diabetic woman. She was hospitalized for two unexpected falls and the insidious onset of involuntary right arm movements. She developed a progression of continuous choreic-ballistic movements in all four limbs associated with impaired gait and orofaciolingual dyskinesias. Brain MRI scans showed bilateral putaminal T2 hyper intensities, however EEG did not reveal any pathological findings. The Beck Depression Inventory Scale showed a moderate depressive status. The EMG and NC results show axonal neuropathy. No cardiological anomalies were evident, retinal degeneration was absent, and the expression of the Kell blood group antigens was normal. Haematological parameters were within normal ranges, but numerous acanthocytes (77%) were observed on the peripheral blood film preparations. The patient's daughter showed no evidence of any neurodegenerative disorder, although acanthocytes were present in her blood (31%). Exclusion of Wilson's disease and non-Wilsonian hepatolenticular degeneration were presumed since hepatic copper content via liver biopsy was within the normal range and due to the absence of liver failure.
+Analysis of RBC membrane proteins (Fig. and Table ) showed a decreased content of 4.1R protein and protein band 3 (data not shown), while the spectrin dimers (Fig. ) were comparable to the control (11%, R.V. < 15%). Therefore the 4.1R defect might affect vertical interactions of skeletal attachment to membrane. Furthermore, the patient's daughter showed the erythrocyte 4.1R defect (Table ) in spite of the absence of neurological signs.
+The genetic analysis of the CAG distribution and adjacent polymorphic CCG repeats in the HD gene was normal and an absence of mutations in the ChAc gene was reported."
+Alison Castro,22,1996/7/29,3065806211,dannypearson@example.org,50444 Jones Fall Suite 729,"The proband ??was a 65 year-old man suffering from hypertension. He reported a five-year history of depression and orofaciolingual involuntary movements. The depression had been treated with tricyclic drugs and selective serotonine-uptake inhibitors. The neurological examination showed orofaciolingual diskinesias and right distal limb dystonia. The Beck Depression Inventory showed a moderate depressive status. EEG and brain MRI did not reveal any pathological findings. The EMG and NC recordings showed normal electrical activity. Cardiological assessment was normal, retinal degeneration was not present, and the expression of the Kell blood group antigens was normal. Haematological parameters were within normal ranges, although acanthocytes (32%) were observed on the peripheral blood film preparations.
+In this patient a decreased content of 4.1R protein was observed (Fig. and Table ) and an increased amount of spectrin dimers was measured (31%, R.V. < 15%) with an impairment of the dimer self-association into tetramers.
+A normal distribution of CAG and adjacent polymorphic CCG repeats in the HD gene was reported and a genetic search for ChAc gene mutations was negative."
+Jasper Singh,42,1986/5/29,(720)285-3681x6698,xreeves@example.com,82642 Frazier Causeway Apt. 638,"The proband ??was a 38 year-old man who was admitted to hospital because of an isolated generalized tonic-clonic seizure. He reported a four-year history of abnormal involuntary upper limb movements of variable severity. In his case history an acute episode of aggressive behaviour associated with delirium of persecution was also reported. Neurological examination showed ballistic and choreic movements of the arms (left > right) associated with trunk dystonia and orofaciolingual diskinesias. Psychiatric evaluation revealed anxiety, paranoia, depression, obsessive behaviour, and marked emotional instability. EEG and brain MRI did not reveal any pathological findings. Axonal neuropathy was detected by EMG and NC recordings. Cardiomyopathy was not found, fundoscopic examination was normal, the same as the expression of the Kell blood group antigens. Haematological parameters were within normal ranges: however, acanthocytes (85%) were observed on the peripheral blood film preparations.
+Hypoxanthine-guanine phosphoribosyltransferase (HPRT) enzyme activity in cells from cultured fibroblasts was normal, excluding adult onset Lesch-Nyhan syndrome. The diagnosis of Gilles de la Tourette syndrome was excluded by reason of onset after 18 years of age and because of the absence of both multiple motor and one or more vocal tics during the illness.
+In this patient a decreased content of 4.1R protein was observed (Fig. and Table ) and an increased amount of spectrin dimers was measured (25%, R.V. < 15%) with an impairment of the dimer self-association into tetramers.
+The CAG units and adjacent polymorphic CCG repeats in the HD gene were in the normal range and no disease-causing mutation was found in the ChAc gene."
+Vivienne Barker,32,1985/6/26,+1-323-386-1739x6144,carlsondiana@example.org,08781 Heidi Isle Apt. 105,"A 69-year-old man was referred to us because of about 100 small submucosal rectal tumors detected at examination by his private physician. Multiple biopsies reported to be a tentative diagnosis of multiple carcinoid tumors. He had never been diagnosed as having multiple endocrine neoplasia (MEN) or other multiple tumor syndromes. His family history was not contributory. Physical examination revealed no abnormalities. Serum serotonin level was within normal range, 221 ng/ml. Tumor markers were within normal limits, CEA (carcinoembryonic antigen) 2.3 ng/ml, CA (carbohydrate antigen) 19-9 <2.0 U/ml. Computed tomographs of the brain, chest, abdomen and pelvis did not show any abnormality. He underwent abdominoperineal resection. Pathology revealed carcinoid tumors for about 30 submucosal nodules, which especially concentrated in the lower rectum (Figure , Figure ) and diffuse ganglioneuromotosis (Figure ). Both carcinoid tumors and ganglioneuroma located within the mucosal and submucosal layer. There was neither metastasis to the liver nor the lymph node. The patient had an uneventful recovery and is maintaining good health at 6 months after surgery at this writing."
+Kade Weaver,20,1999/5/2,595.620.0148x530,walteramanda@example.org,46477 Cunningham Radial,"A 15 year old girl with HIV since birth had to stop her antiretroviral treatment due to side effects. She started zidovudine monotherapy at the age of six, but continued to deteriorate clinically and immunologically during four years until she started HAART when it became available 1996. At the time she was hospitalized and severely ill with a Mycobacterium avium intracellulare sepsis. After treatment initiation with stavudine (30 mg QD), lamivudine (150 mg QD) and indinavir (600 mg TID) a remarkable recovery took place and her CD4-cell count increased from 10 to 410 in one year, and further to 920 ? 106/L during the following three years.
+However, the TID dosage of indinavir was inconvenient and to render BID dosing possible, a ritonavir boosted regimen with indinavir (800 mg BID) and ritonavir (100 mg BID) was started about 1.5 months before treatment cessation. It was not known at that time (2001) that such high indinavir dosage very often resulted in nephrotoxic side effects, and the serum creatinine concentration increased from 59 to 132 弮mol/L after the change. Consequently, her antiretroviral treatment was stopped and the creatinine concentration normalized again within two months.
+Twelve days after the treatment discontinuation she presented with fever (39??9.5簞C), lymphadenopathy, splenomegaly and abundant sweating during the nights. Her physical examination was normal and a chest radiography showed clear lung fields. Besides confirmed enlargement of the spleen, nothing abnormal was found with ultrasound or CT-scan of the abdomen. Blood cultures for bacteria, including mycobacteria, were negative. Serological testing for Epstein-Barr Virus (EBV), CMV and toxoplasmosis did not give any evidence of an ongoing infection. Routine laboratory showed discrete leucopenia and thrombocytopenia and slightly increased hepatic aminotransferase levels. Serum lactate and C-reactive protein were normal. Two weeks after treatment interruption the plasma HIV RNA level had increased from <50 copies/mL to >750000 copies/mL and the CD4 cell count decreased from 770 to 210 ? 106/L, figure .
+Treatment with stavudine (30 mg BID), lamivudine (150 mg BID) and efavirenz (600 mg QD) was re-started just over one months after cessation, resulting in decreased HIV RNA and increased CD4 cell count again. The fever disappeared a few days before treatment was re-initiated."
+Teagan Atkinson,37,1984/2/10,(327)572-2032,handrews@example.net,39885 Boyle Cliff Suite 889,"In October of 2006 a 41-year-old otherwise healthy man presented to the University of Maryland, Department of Oral and Maxillofacial Surgery for an evaluation of an expansile mass in the left zygomatic, preauricular region. Five months earlier the patient complained of headaches and increasing fatigue at the end of a normal work day. He then noticed increasing left jaw pain and trismus along with the headaches. He was seen and evaluated by his primary care physician. Initially he was treated for temporomandibular disorder. However, the patient's symptoms failed to subside and subsequently he was referred to an oral and maxillofacial surgeon. Computed tomography of his head and neck was obtained, revealing a destructive mass in the left condyle (Fig. ). He was subsequently referred to the University of Maryland Medical Center for definitive treatment.
+Examination of the patient revealed slight facial asymmetry with a nontender, slightly indurated mass in the left zygomatic, preauricular region. Further examination produced questionable paresthesia in the distribution of the maxillary division of the left trigeminal nerve. No facial nerve weakness was appreciated. Evaluation of the axial and coronal CTs revealed a 4.0 cm soft tissue mass involving the neck of the left condyle, infiltrating the masseter and pterygoid muscles. A whole body PET scan showed increased metabolic activity (SUV 9.2) in the left condyle. No other abnormal activity was seen in the neck, chest, abdomen or pelvis. Laboratory findings: WBC: 4.7 K/mcL, HGB: 13.9 g/dl, HCT: 41.0%, RBC: 4.77 M/mcL, Platelets: 308000 K/mcL. An open biopsy was performed in the operating room via a preauricular incision and a pathological diagnosis of malignant spindle cell tumor was made.
+In view of the diagnosis of sarcoma the patient subsequently underwent a vertical compartment resection with exposure via hemicoronal incision extending to a modified Blair incision. The specimen was removed en-bloc with a margin of normal tissue, preserving the facial nerve. The patient was primarily reconstructed with a microvascular free fibula flap from the contralateral leg. He was extubated on post-operative day one, and discharged from the intensive care unit on post-operative day three. The rest of his hospital course was uneventful and he was discharged on post-operative day seven. Following the final pathologic diagnosis he was discussed at the institutional tumor board and recommended for adjunctive radiotherapy."
+Duke Blanchard,21,1985/10/5,881-561-0766,zbenitez@example.org,52470 Maynard Point,"A 48 year-old man presented with gynaecomastia, having first noticed a swelling of the left breast twenty years previously. This had gradually increased in size. Following an episode of recent weight loss the swelling had become more prominent.
+On examination, he had a 4 ? 4 cm firm mass which appeared to be attached to the skin and was situated immediately below the left nipple. There was no fixation to the underlying muscle and no lymphadenopathy. In addition, there were no features of neurofibromatosis and in particular there were no caf矇 au lait spots.
+Mammograms showed a well-defined mass measuring 36 mm in its maximum diameter and immediately adjacent to the left nipple (Figure ). It was situated centrally within the breast tissue and immediately deep to the skin. The density of the mass was relatively low for its size.
+Fine needle aspiration cytology showed stromal fragments containing spindle cells suggesting a soft tissue lesion of neural origin. Core needle biopsy revealed a spindle cell infiltrate. The spindle cells had irregular nuclei, many expressing S-100 protein. No mitoses were seen. Although a neurofibroma was suspected, several atypical features were present, including hyperchromasia of some nuclei, increased cellularity and the presence of relatively broad and long fasicles.
+The tumour was excised under general anaesthetic with an ellipse of overlying skin but preserving the nipple areolar complex. The incision was an inferior periareolar incision to ensure optimum cosmesis. The overlying skin was taken because of the proximity of the tumour to the skin.
+Macroscopically the tumour measured 4 ? 3 ? 2.5 cm, was white and well circumscribed. Microscopically it was moderately cellular and it contained spindle cells with irregular and focally pleomorphic nuclei. No mitoses or necrosis were seen (Figure ). No Antoni A areas were present. A definitive histological diagnosis of a benign cellular neurofibroma was made. After 5-years no recurrence has been observed."
+Layne Cantrell,24,1987/5/7,+1-908-517-3169x820,schmidthayley@example.org,91933 Rebecca Heights Suite 376,"A 77-year-old lady presented with the complaints of a left-sided breast lump of 1-month duration. She had been a heart patient and had been on treatment for the last 4 years. On clinical examination a 3 ? 2 cm firm, mobile, non-tender lump was identified in the outer quadrant of her left breast. The overlying skin of the breast along with nipple and areola were unremarkable. There was no significant axillary or cervical lymphadenopathy. The other breast was normal. She underwent a mammographic examination, followed by fine needle aspiration cytology (FNAC) that was essentially inconclusive. Subsequently, she underwent a frozen section for a primary diagnosis.
+On mammography, a 2 ? 2 cm ill-defined mass with irregular margins was identified in the left upper outer quadrant. No micro-calcifications were seen. The right-sided breast was normal. (Figure ).
+The lumpectomy specimen on cut surface revealed a firm, grey-white, fibrous, un-encapsulated nodular tumor measuring 2 ? 1.2 ? 0.8 cm with infiltrative borders. No area of calcification was identified. The closest margin was the base and was found to be 0.5 cm away from the tumor.
+Frozen sections revealed a tumor with predominant spindle cells showing mild atypia, amidst a sclerotic stroma and conspicuously infiltrated the adjacent fat. A diagnosis of a low-grade sarcoma was favored over a metaplastic carcinoma. Therefore, a sentinel lymph node biopsy and/or an axillary node dissection (ALND) were not conducted at the time of surgery.
+Histological sections revealed a spindle cell tumor showing an infiltrative growth pattern with prominent areas of sclerosis reminiscent of keloid formation. The cells were mainly arranged in fascicles and displayed tapering nuclei with mild anisonucleosis. Mitoses were inconspicuous. Occasionally, the cells were plump with epithelioid shapes and revealed mild atypia with an occasional small cluster formation. Interspersed were foci of benign ductal hyperplasia and papillary hyperplasia, including a micropapilloma along with focal aggregates of chronic inflammatory cells. The micropapilloma did not show any significant atypia. (Figure ). No discrete squamous differentiation was identified. No focus of Ductal-carcinoma-in-situ (DCIS) was seen in any of the sections. The two closest differential diagnoses considered were fibromatosis and a ""fibromatosis like"" metaplastic carcinoma. A wide panel of IHC antibody markers was performed (Table ). The tumor cells were simultaneously diffusely positive for epithelial markers i.e. the various cytokeratins CK, CK7, High molecular weight (HMWCK) and epithelial membrane antigen (EMA), along with a mesenchymal marker i.e. vimentin. (Figure and ). All the cytokeratins were positive in the interspersed benign ducts that acted as internal controls. The tumor cells were negative for Gross cystic disease fluid protein (GCDFP), estrogen (ER) and progesterone receptor (PR). The myoepithelial markers i.e. smooth muscle actin (SMA) and p63 showed focal, positive expression. (Figure ). S100 and Desmin were negative. Ki-67 (proliferation marker) showed focal positivity in less than 5% tumor cells (Figure ). The tumor cells were negative for CD34 and CerbB-2/HER-2/neu. (Figure ). A diagnosis of a low-grade ""fibromatosis-like"" metaplastic carcinoma, associated with a micropapilloma, was finally made. All the cut margins were free of tumor.
+A portion of fresh tumor tissue fixed in 3% glutaraldehyde was processed for electron microscopy. Ultra thin sections stained with uranyl acetate and lead citrate were observed under an electron microscope model: Zeiss 109, Germany.
+Ultrastructurally, the tumor cells embedded in a collagenous stroma showed fibroblastic and myoepithelial features along with presence of peripheral villous processes with a focal basal lamina and intercellular junctions (Figure ).
+After surgery, the patient completed adjuvant radiotherapy (RT). Thereafter, she has been on a regular 2 monthly follow-up; including her metastatic work-up with Positron emission tomography (PET-CT) of the body and bone scan. Due to a high cardiac risk, a second surgery for an ALND was not performed. Nevertheless, till 1 year and 4 months of her follow-up she has not been identified with any lymphadenopathy, recurrent lesion or metastatic lesions in her body."
+Harris Shelton,37,1986/3/1,001-347-924-8199,nolanelizabeth@example.com,9721 James Plaza,"A 24 years old female with Thrombocytopenia absent radius syndrome (TAR) was admitted with fracture of pelvis in our department. Diagnosis of TAR syndrome had been made on the basis of radiographic findings of absent radii, radially deviated hands, presence of thumbs and a low platelet count. There was no family history of consanguinity or congenital malformations. USG was performed for recurrent urinary tract infections which revealed absent kidney on the right side. Further investigations including IVU, MRI scan and renal isotope scans revealed a crossed fused renal ectopia (fig , , )."
+Makenzie Fitzgerald,23,1999/3/29,001-664-503-5799x399,janetspencer@example.net,11381 Richard Trafficway,"A 52-year-old male with a history of hepatitis C, genotype 1b, was nearing completion of a one-year course of treatment with pegylated interferon 2a (180 ug subcutaneously each week) and ribavirin (1200 mg orally each day). His initial hepatitis C viral RNA had declined from 2.2 ? 106 IU/ml at onset of treatment, to <65 IU/ml by six months, and remained undetectable thereafter. Toward the end of his course of treatment, he developed fatigue, malaise, drenching night sweats, intermittent fever and chills. On the last visit for hepatitis C treatment, axillary and cervical lymphadenopathy was noticed. His symptoms were initially attributed to adverse effects of interferon 帢, prompting premature discontinuation of treatment after 10.5 months. One month after onset of symptoms, he presented to a nearby hospital for further workup.
+He was transferred to the Buffalo VA Western New York Healthcare System with complaints of malaise and left sided mid back pain. He had a documented weight loss of 40 lbs over the previous year. He appeared chronically ill and fatigued. He had a temperature of 101簞F and a heart rate of 105 beats per minute. Generalized lymphadenopathy was noted, including cervical, axillary, inguinal and right epitrochlear lymph nodes. The nodes were 1?? cm wide, firm, movable and nontender. He had left sided abdominal fullness and mild tenderness, but no guarding or rebound. The remainder of his examination was noncontributory.
+CBC revealed hemoglobin of 11.7 g/dl (13.5??7), white blood cell count of 7.6 K/cmm (4.4??0.7), platelet count of 511 K/cmm (140??75) and ESR of 80 mm/hr. Serum chemistries included a sodium of 130 mEq/L (135??45), creatinine of 0.9 mg/dl (0.7??.4). SGOT was 68 units/l (12??4), SGPT: 95 units/l (25??5). A serum ELISA for human immunodeficiency virus was negative. Rheumatoid and anti-nuclear antibody titers were also negative.
+Computerized tomography (CT) scan of chest and abdomen revealed mild lymphadenopathy and multiple contrast enhancing hypodense lesions in the spleen (Figure ).
+Initial clinical suspicion included lymphoma and he underwent a lymph node biopsy. Further history revealed exposure to numerous cats. He frequented a neighbor who had 6?? cats, including kittens, with which the patient had played, and from whom he received numerous scratches. Serologic studies were sent for antibodies to Bartonella, Chlamydia, Toxoplasma and Brucella. He was given ibuprofen for symptomatic relief.
+A biopsy of an epitrochlear lymph node displayed necrotizing granulomata with peripheral palisading epithelioid cells, with an admixture of plasma cells and lymphocytes. Areas of stellate necrosis with microabscesses were evident, consistent with cat scratch disease (Figure ). Stains for acid-fast bacilli and fungi showed no organisms. Lymph node biopsy material was cultured for routine pathogens, acid-fast bacilli and fungal organisms. Although the Gram stain displayed abundant white blood cells, all cultures were sterile.
+Over the next 3?? days, the patient defervesced and improved symptomatically on ibuprofen alone. By the eighth day, serum antibody titers (IgG and IgM) for Bartonella henselae were reported as >1:16,384. He continued to improve without further treatment. Six months later he was doing well and had regained 25 lbs of weight. An abdominal CT scan revealed complete resolution of splenic lesions."
+Peyton Weeks,38,2003/9/16,+1-355-340-9347x516,sandra12@example.org,6201 Smith Lock Suite 245,"A 73 years old male patient was found to have calcified aortic stenosis after a syncopal episode. He had a history of hypertension and a previous diagnosis of obstructive chronic broncopneumopathy. He was 170 cm tall, his weight was 75 kilos and body surface area was 1.85 sqm. At preoperative investigations he was found to have a borderline dilated ascending aorta of about 45 mm (Figure ). At the time of aortic valve replacement a written informed consent was obtained even for treatment of the ascending aorta if needed but no specifications were made about the type of intervention.
+After median sternotomy, cannulations of distal ascending aorta, right atrio-caval, coronary sinus and left ventricle via right superior pulmonary vein were performed. For myocardial protection intermittent anterograde and retrograde warm blood cardioplegia was used. At inspection, the mid ascending aorta showed an external diameter of about 50 mm (Figure ). Aortic wrap was constructed before aortic cross-clamping: a vascular dacron prosthesis 12 ? 26 mm (Woven Dacron Gelweave, Vascutek Ltd, Inchinnan, Scotland, UK) was taken. The prosthesis was cut into two halves of 6 cm length (Figure ). Both halves were opened longitudinally by a curved cut. As a reference the black lines on the prostheses were used. The cuts were about 4 mm apart from the black line in the centre of the length of the prostheses, and 4 mm apart from the black line on the opposite sides at the extremities (Figure ). Thus two dacron sheets were obtained from the prostheses, each of them having one concave and one convex side. Finally the sheets were joined by suturing the two convex sides together and the two concave sides together too (Figure ). A curved dacron hose 5 cm in diameter was obtained for external wrapping of the ascending aorta (Figure ). The joining sutures of the two sheets were made of single separate stitches so that the extremities could be shortened if needed. After cross clamping, the aorta was cut transversally above the commissures at the sinotubular junction. Aortic valve replacement was then performed as usual. A 25-mm biological prosthetic aortic valve was inserted with 15 pledget-supported stitches. Then, before aortic closure, the posterior aspect of the ascending aorta was freed completely from the pericardial reflection up to the innominate artery. In this way the custom-built prosthesis was easily inserted, like a trouser leg, to wrap the ascending aorta. The aorta was closed by a continous running suture. The cross clamp was released after 64 min while extracorporeal circulation was arrested after 78 min without inotropes. Then, the prosthesis was pulled down to cover the suture line and fixed with few adventitial stitches. No solid transmural stitches were needed because the curved prosthesis fitted the curved ascending aorta best. Similarly, after decannulation, the prosthesis was pulled up to cover the cannulation site. Therefore the whole ascending aorta was covered by the prosthesis which appeared to fit perfectly without wrinkles or bends (Figure )."
+Karen Barrett,41,1991/4/20,(296)236-7684,graveschristopher@example.org,314 Arnold Row,"An 81 years old lady had a right radical nephrectomy in 1999 for conventional renal cell cancer (RCC). She was discharged from the urology and oncology clinics in 2004 after 5 1/2 years follow-up with no signs of local or regional recurrence.
+In December 2004, she noticed a lump in the right breast after sustaining a fall. She was referred to the breast clinic in July 2005 for further assessment.
+Clinically, she had a mass in the upper outer quadrant of the right breast. The left breast was normal and there was no axillary lymphadenopathy. Abdominal examination was normal.
+Radiology confirmed a 17 ? 13 ? 9 mm well circumscribed hypoechoic mass in the right upper quadrant of the right breast (Figure ). The mass was core biopsied.
+The histopathological examination revealed tumour growth consistent with conventional renal cell carcinoma. Tumour cells strongly expressed vimentin. CT scan of the chest and abdomen showed a 12 mm mass in the right breast and a 2.7 cm metastatic deposit at the right renal bed (Figures and ). The lungs and the liver were normal. The lump was excised in October 2005.
+The gross examination of the specimen confirmed metastasis from a renal primary (Figure ). There was no evidence of in situ ductal or lobular disease.
+The patient was offered Interferon treatment, but she preferred to hold on therapy as an alternative. She is under regular follow-up in the oncology clinic."
+Angelo Dunlap,41,1995/8/3,(683)538-0439,josephwhite@example.com,73284 Anita Plains,"A 47-year-old male presented with a gradually increasing, painful soft tissue mass of 7?? months duration, measuring 4 ? 3 cm in the inner side of his right thigh. A computed tomogram (CT) scan revealed an abnormal enhancing lesion in the perianal region. All the visceral organs were found to be normal. No bowel wall thickening, free fluid or abdominal lymphadenopathies were noticed.
+Subsequently, he underwent a marginal excision for this mass, elsewhere. It was diagnosed as a poorly differentiated carcinoma on biopsy and referred to us in form of a single hematoxylin and eosin (H & E) stained micro section along with a paraffin block for review.
+At our Hospital, his tumor marker levels for carcino embryogenic antigen (CEA) were normal i.e. 1.8 ng/ml (normal range: 0.3??.7 ng/ml)
+On review histology, a diagnosis of a ""proximal-type"" epithelioid sarcoma was offered. The patient was recommended a wide excision post a magnetic resonance imaging (MRI) for fear of residual disease. However, he was lost to follow-up.
+Six moths later, he presented with an enlarging mass at the same location. During this time gap, he revealed a history of having undergone adjuvant chemotherapy (CT) and radiotherapy (RT) that were well tolerated. However, he developed difficulty in walking as a result of the persistent lesion. He underwent a chest X-ray along with CT scan and a real time B-mode high frequency ultrasonographic (USG) examination for the persistent mass that was re-excised and re-submitted to us for review.
+An oval, hypoechoic, solid lesion measuring 2.9 ? 2.2 ? 2.1 cms was seen in the deep subcutaneous region of the right, upper, inner thigh up to 5??0 mm superior and anterior to the scar of the earlier excision. Other, two, small oval hypoechoic solid lesions of sizes 10 and 8 mm were seen in the subcutaneous layer. The main lesion showed an ill-defined echogenic wall with peripheral echogenic linear echo entering the lesion, suggestive for a lymph node. Eccentric cortical parenchyma showed a distorted architecture. The overlying skin was normal with slightly prominent subcutaneous fat lobules. No significant flow lesion was seen in the color Doppler. Radiologically, the differential diagnoses included a tumor mass vs a lymph node mass. (Figure ).
+Grossly, the first excision specimen was in form of grey-white soft tissue bits aggregating to 3.5 ? 2 ? 2 cms. Details regarding the marginal status were unavailable.
+On histology, the tumor revealed a multi nodular pattern as a result of investing thin fibrous septa with cells predominantly arranged in a cohesive manner. At places cellular disintegration was observed in combination with hemorrhage resulting in a 'pseudoangiosarcomatous' pattern. The cells were oval to polygonal and exhibited moderate nuclear pleomorphism. Interspersed were larger cells with vesicular nuclei, prominent nucleoli and abundant cytoplasm, including intracytoplasmic inclusions reminiscent of a 'rhabdoid' morphology along with focal areas of tumoral necrosis. Mitoses were noted, however, not conspicuously. (Figure , and ).
+Special histochemical stains were carried out with a wide panel of IHC markers (Table ). The reticulin staining highlighted the nodular growth pattern of the tumor. (Figure ). IHC showed a diffuse strong positivity for CK and vimentin in the tumor cells. CK-7 and EMA were also strongly positive. (Figure and ). Desmin was focally positive (Figure ). In addition, CD34 was found to be strongly positive (Figure ). SMA, Myo-D1, CK-20, CEA, S-100, HMB-45, CD 31, C-kit and LCA were negative. A diagnosis of a proximal-type epithelioid sarcoma of was formed.
+The re-excision showed a similar histology. In addition, increased number of larger cells was noticed along with tumor giant cells and several mitoses."
+Iliana Marin,19,1994/6/21,438-877-0498x59884,eallison@example.net,06795 Devin Estates Apt. 377,"A 50-year-old woman had lacrimal mass presented with progressive exophthalmos and visual disturbance in the left eye in 2000. Orbital CT scan showed a well-circumscirbed mass at lateral aspect of the left orbit without bone involvement (Figure ). She underwent subtotal resection of a smooth, encapsulated, and multilobulated mass at the referring hospital. The histological diagnosis was pleomorphic adenoma of the lacrimal gland. The clinical course was uneventful until 4 years after the operation, when a local recurrence with protrusion of the left eye and swelling of the left temporal muscle area required subtotal resection at the Department of Ophthalmology, Yonsei University Hospital. The mass was extended to periorbital tissue, lateral orbital rim, and temporal muscle. The histological diagnosis was poorly differentiated adenocarcinoma, suggesting malignant carcinomatous changes in the recurrent pleomorphic adenoma (Figure ). MRI surveillance of the lesion was initiated. Six months after second surgery, MRI demonstrated increased extent of orbital mass, extending to the cavernous sinus. The patient underwent intensity-modulated radiation therapy (IMRT) with two different planning target volumes (PTVs): 1) 45 Gy to extracranial portion, 2) 30 Gy to intracranial portion.
+Six month later, the patient complained of the left eye pain and the left facial paresthesia. An ophthalmological examination revealed ptosis, exophthalmos, and ophthamoplegia of the left eye. Facial sensory change on the left whole trigeminal territories was noted. MRI revealed a well-circumscribed mass of the left cavernous sinus extending to the infratemporal fossa and clivus. The patient underwent Gamma Knife stereotactic radiosurgery with a marginal dose of 15 Gy and maximum dose of 30 Gy to 29.7 ml of tumor volume. Dose was adjusted to the right optic nerve and optic chiasm (8.4 Gy) and to the left optic nerve (15 Gy) (Figure ). Intentional high dose to the left optic nerve was planned due to useless vision caused by the left complete occulomtor nerve palsy.
+Six months later, follow-up MRI revealed a slightly decreased tumor size extending to orbital, cavernous sinus, infratemporal fossa, and clivus. However, small nodular enhancing lesion on the interhemispheric fissue and superior cerebellar peduncle, and leptomeningeal seeding was suspected (Figure ). Whole spinal MRI was indicated due to neck and back pain, and it revealed multiple nodular enhancing masses on the cervico-thoracic area (Figure ). Palliative radiotherapy for the intracranial and spinal metastases was planned, but the patient refused further active treatment. The patient was discharged and underwent hospice care. Five months later, the patient died due to pneumonia and sepsis related to terminal stage of metastatic cancer."
+Aldo Butler,43,1984/9/28,319-222-2063,hensonholly@example.net,84369 Brown Village Suite 167,"A 78-year-old man was referred to our Institution for the presence of an anal mass accidentally discovered during a routine physical exam. Past medical history was significant for cancer of the right lung, treated with right pneumonectomy 1 year before. Routine blood test were within normal limits as well as common neoplastic markers. The rectal exam showed a well defined mass on the left-anterior aspect of the anal canal, beginning at 1 cm from anal verge and extending cranially for about 4 cm. Endoanal ultrasonography confirmed the presence of a 4 ? 2 cm mass in the thickness of the sphincteric muscles (Fig and ). Total body CT scan confirmed the presence of the mass and did not show any lymph node enlargement in the proximity or distant metastases. The mass appeared circumscribed and not infiltrating the surrounding tissues (Fig. ).
+The patient was brought to the operating room, placed in jack-knife position, and a local excision was carried out, resecting just a small amount of fibers of the anal sphincter. This has been possible since the mass was well capsulated and not firmly adherent to the surrounding structures. Gross pathological examination showed a 3.5 ? 2 ? 1.2 cm fibrous-elastic mass. Histological examination showed a proliferation of densely packed spindle cells, with prominent nuclear palisading (Fig. ). Nuclear atypia was absent and mitotic count was of 4 mitosis/50HPF. Neoplastic cells showed diffuse and marked cytoplasmic positivity for KIT protein and CD34 in the majority of cells (Fig. ). Neoplastic cells were negative for desmin that stained residual smooth muscle fibers of bowel wall at the margins of the neoplasm. A diagnosis of GIST, with low risk aggressive behavior was made (Table )[], therefore no further treatment was necessary.
+Postoperative course was uneventful. No implications on anal continence were observed and the patient was discharged on postoperative day 3. The patient underwent follow up at 6 and at 12 months, and rectal ultrasonography as well as CT scan did not show local recurrence or distant spread."
+Athena Sandoval,39,2000/4/9,(330)598-1711x50147,gmarks@example.com,25400 Medina Landing Apt. 512,"A 62 year-old man with a several month history of abdominal pain was referred to The Ohio State University Medical Center in June, 2006. His past medical history was significant for hypertension, arthritis and chronic back pain. On computed tomography scan he was found to have a heterogeneously enhancing solid mass at the junction of the head and body of the pancreas (Figure ). Based on initial imaging, the differential diagnosis included pancreatic ductal adenocarcinoma, pancreatic endocrine tumor, solid pseudopapillary tumor, and metastatic carcinoma.
+The patient was offered resection for diagnosis and definitive therapy. After undergoing diagnostic laparoscopy to rule out carcinomatosis in the peritoneal cavity, a distal pancreatectomy with splenectomy was completed.
+The patient tolerated the procedure well and was discharged after an uneventful hospital stay.
+Gross examination of the resected specimen demonstrated a 4.2 ? 2.5 ? 2.0 cm solid, well circumscribed, non-encapsulated mass adjacent to the pancreatic duct (Figure ). The cut surface of the tumor contained thick fibrous bands without hemorrhage or necrosis. The surrounding pancreatic parenchyma was noted to be grossly unremarkable, and surgical margins were negative. On hematoxylin and eosin stain, the architecture of the mass was solid with cells arranged in nests, acini and trabeculae, separated by thick, hypocellular fibrous bands (Figure ). Rare small cystic areas were seen microscopically (less than 1% of the tumor). The tumor was homogenous and consisted of polygonal cells with centrally placed small, round to ovoid nuclei (Figure ). No mitoses or cellular atypia were noted. The cells contained abundant clear cytoplasm which was PAS positive and diastase sensitive suggesting the presence of glycogen (Figure ). No vascular or perineural invasion was seen.
+Mucicarmine stain was negative. Immunohistochemistry showed positive staining for cytokeratin 7 (CK7), cytokeratin 19 (CK19), neuron-specific enolase (NSE), 帢-inhibin and calponin; and negative staining for vimentin, 帢1-antitrypsin (A1AT), synaptophysin, carcinoembryonic antigen (CEA), renal cell carcinoma stain (RCC), CD10, S-100 protein, and smooth muscle actin. These findings support the final diagnosis of solid microcystic adenoma."
+Brantley Phan,42,1988/5/15,001-875-544-9316,jarvisrobert@example.net,8474 Caitlin Parkway Apt. 844,"A 21-year-old gentleman initially was referred with weight loss, fevers and hepatosplenomegaly. He had previously been investigated for lymphadenopathy. A left inguinal lymph node excision 3 years earlier had shown ""unusual histology, possibly reactive or due to a low-grade lymphoma"" and a decision for close follow up was made. A second lymph node biopsy was performed 1 year later for persistent right cervical and right inguinal lymphadenopathy. Histology showed granulomatous lymphadenitis, again with unusual histology, reported as ""possibly due to sarcoid or reactive secondary to infection"". At this time he was also noted to have hepatosplenomegaly, abnormal liver function and pancytopenia. A liver biopsy was performed prior to referral showing abnormal architecture, lymphoid proliferation and multiple non-caseating epitheliod granulomas.
+On examination he was pale with low-grade pyrexia of 37.5簞C. Cardiovascular and respiratory examinations were normal, but he had cervical lymphadenopathy. Abdominal examination revealed massive hepatosplenomegaly without ascites. Computed Tomography of the chest and abdomen showed hepatosplenomegaly with mediastinal and para-aortic lymphadenopathy suspicious of lymphoma. Pulmonary function testing showed decrease in diffusion capacity. Liver function and full blood count were abnormal (Table ). Serum ACE (angiotensin converting enzyme) was raised at 80 U/L (normal range 8??2). Other bloods including liver screen, autoimmune screen and virology screen were all negative.
+A clinical diagnosis of sarcoidosis was made and he was commenced on steroid treatment with prednisolone 40 mg daily. Within two days his pyrexia settled, his liver function improved and his splenomegaly improved. He was discharged home on 20 mg prednisolone. Over the next twenty-four months, his liver function continued to improve and the patient remained clinically well. However, his pancytopenia worsened and a bone marrow biopsy revealed normal haematopoesis with a few non-caseating granulomas. The pancytopenia was felt to be due to hypersplenism and the decision was made for him to undergo splenectomy.
+During admission for splenectomy the patient complained of cough and was noted to be pyrexial and tachycardic. A chest radiograph revealed left basal consolidation with right basal changes. Despite a two-week course of moxifloxacin he remained symptomatic with cough, night sweats, fevers up to 40簞C and was noted to be hypoxic. Computed Tomography of the thorax showed mediastinal lymphadenopathy with extensive consolidation, and a lung biopsy showed non-specific inflammation. Microbiological culture of the biopsy specimen grew a bacteria belonging to the Burkholderia cepacia complex, Burkholderia multivorans which was subsequently confirmed on broncho-alveolar lavage.
+In light of the unusual organism, the histology was reviewed and the possibility of chronic granulomatous disease was raised. Neutrophil burst test (Figure ) showed impaired neutrophil oxidative burst consistent with CGD. Western blot showed decreased expression of the gp91phox protein consistent with X-linked CGD (Figure ). His mother and sister were also tested and found to be carriers as evidenced by dual population of normal and abnormal neutrophils (Figure ). Genetic analysis confirmed a mutation in exon 9 of the gp91phox gene. The patient was treated with cotrimoxazole and commenced on prophylactic itraconazole. He made a good clinical improvement and was discharged nine days later on prophylactic antibiotics and antifungals. The steroid dose was gradually tapered down. His splenomegaly has gradually improved with the spleen decreasing in size from 24 cm to 18 cm. The haemoglobin and platelet counts returned to normal. His lymphocytes remained low probably reflecting continued enlarged spleen. and after 18 months follow up remains well."
+Elsa Meadows,23,2003/3/22,(204)237-3546x91865,bennetttoni@example.net,405 Nathan Crescent Apt. 209,"In April 2006, a 75-year old man who had been successfully treated for colon cancer 13 years ago, thyroid cancer 12 years ago, and was receiving endocrine therapy for prostate cancer from last year was transferred to our hospital for a fracture of his left proximal femur. The chest radiograph showed a solid mass in the hilum of left lung, and the thallium scintigram demonstrated abnormal uptake at the left proximal thigh and the hilum of left lung. In addition, the screening of tumor markers revealed extremely high level of CEA (1250 ng/ml), slightly high level of NSE (16.6 ng/ml) and SCC (2.2 ng/ml), and low level of thyroglobulin (0.3 ng/ml) and PSA (0.009 ng/ml). Thus the fracture was considered to be a bone metastasis from his fourth primary pulmonary cancer. Physical examination showed no hyperpigmentation of his all body surface. Laboratory investigation revealed serum sodium of 134 mmol/l, potassium 4.7 mmol/l, and plasma glucose 110 mg/dl, with normal renal and liver function.
+He uneventfully underwent local excision and proximal femur replacement with a mega-prosthesis under general anesthesia. The bone tumor was pathologically diagnosed to be moderately differentiated adenocarcinoma. Later, the immunohistochemical examination revealed that cytokeratin 7 (CK7) and thyroid transcription factor 1 (TTF-1) were distinctly detected but cytokeratin 20 (CK20) never expressed. Recently, Chhieng et al. described that an adenocarcinoma was likely a primary lung tumor when it was of the CK7 positive/CK20 negative and TTF-1 positive phenotype []. Thus, the bone tumor was finally diagnosed to be a metastatic lung cancer.
+The estimated intraoperative blood loss was 400 ml. The patient was extubated as usual, but the level of awakening was very poor. Postoperative laboratory examination demonstrated anemia and severe hyponatremia (126 mmol/l), but showed normokalemia (4.3 mmol/l) and normoglycemia (92 mg/dl). Despite the transfusion of blood and the administration of normal saline, the patient subsequently became hypotensive (SBP 60??0 mmHg), tachycardic, hypoxic, febrile (40.5簞C) and confused. Re-intubation was required for respiratory distress. A chest radiograph showed diffuse pulmonary edema. We initially suspected this condition of acute pulmonary emboli. Immediately, the patient underwent CT examination from head to abdomen. Enhanced chest CT revealed a left hilar mass suggesting a primary lung cancer but no pulmonary embolus. A ventilation/perfusion scan performed on the next day showed no perfusion defect and confirmed definitely no evidence of pulmonary embolism. Concomitant brain and abdominal CT scan also demonstrated a low density area in the parietal lobe of the left brain and massively enlarged bilateral adrenal glands consistent with metastases (Figure ). After the CT evaluation, we finally diagnosed adrenal crisis due to extensive destruction of adrenal tissue caused by metastases. Blood was drawn at 8:00 on the first postoperative day for serum cortisol levels that were found to be 2.0 弮g/dl on the third postoperative day. Betamethasone (2 mg) was given to the patient at first, and switched to hydrocortisone, 100 mg administered intravenously every 8 hours. Dramatic improvement occurred in the subsequent hours following administration of hydrocortisone. The fever and hypotension promptly subsided and hyponatremia instantly disappeared. The patient recovered his consciousness and could be successfully extubated. On postoperative day 3, he was started on early remobilization by physical therapy. On postoperative day 7, the patient could sit down on the edge of a bed without assistance, followed by transfer exercise to a wheelchair. Although he could not undergo a CT-guided biopsy of the adrenal gland due to the flat refusal of his family, the following CT examination on postoperative day 35 demonstrated that bilateral adrenal glands neither decreased in size nor showed atrophic change, suggesting that adrenal enlargement was mainly caused by metastasis rather than hemorrhagic complication. The patient was transferred to the related hospital for further rehabilitation on postoperative day 39."
+Wayne Hendrix,40,1981/6/28,582-433-3264,patrick35@example.net,2991 Valenzuela Rapid,"A 50-year-old man presented to the emergency department after sustaining blunt trauma to the head secondary to a fall from a horse. The patient's forehead struck the ground with his neck extended. The patient complained of neck pain and left arm weakness and paresthesias, and denied loss of consciousness. The patient's past medical history was otherwise unremarkable, and did not include use of anticoagulants or anti-platelet agents. Laboratory studies, including coagulation profile and platelet count, were within normal limits both immediately after admission and on the following day. A rigid cervical collar was applied upon arrival to the emergency department. The patient's vital signs were stable and he was treated conservatively with intravenous maintenance fluid and opioid medication for pain control. The patient received no anticoagulation therapy (specifically no low molecular weight heparin), no platelet inhibitors or non-steroidal anti-inflammatory medications and no treatment modalities which could have potentially contributed to a coagulation disorder. Initial computed axial tomography (CT) of the cervical spine revealed bilateral fractures of the anterior arch of C1 and a fracture of the right C4 spinous process. Mild prominence of the prevertebral soft tissues was noted without significant encroachment on the pharynx (Figures , ).
+Approximately 20 hours after his initial presentation, the patient underwent magnetic resonance imaging (MRI) of the cervical spine to further evaluate his upper extremity neurologic deficits. While undergoing MRI, the patient developed sudden dyspnea and hoarseness. MRI demonstrated development of a marked increase in the prevertebral soft tissue prominence due to an enlarging retropharyngeal hematoma. Severe compromise of the oropharyngeal airway was evident (Fig. ).
+The patient was treated with oxygen at the MRI suite while members of both the surgery and anesthesiology department were contacted for emergent management. Upon their arrival, the patient had a blood pressure of 150/80 mmHg, pulse of 66 beats per minute, a 99% oxygen saturation level, respiratory rate of 24 breaths per minute, and appeared in mild distress. He was immediately transported to the intensive care unit by the physician team for definitive airway control. The patient was prepared for awake nasal fiberoptic intubation with intravenous glycopyrrolate and lidocaine spray topically to the nasopharynx. The bronchoscope was passed through the nasopharynx, vocal cords, and into the trachea. The pharynx and superior trachea were severely distorted and compressed. A 7.0 mm endotracheal tube was passed over the bronchoscope and positioned approximately 3 cm above the carina. The patient was comfortable and did not move during the procedure. Cervical spine immobilization was maintained throughout. Additionally, a surgeon and instruments were present throughout the procedure in anticipation of emergent tracheostomy if fiberoptic intubation were unsuccessful. After intubation, the patient was sedated and mechanically ventilated.
+The following day the patient underwent surgical decompression. A moderate sized hematoma at the level of C4 was evacuated and a drain was placed for further decompression. A follow-up MRI was performed which revealed a bi-lobed disc herniation (determined to be chronic in nature) with secondary spinal canal encroachment and mass effect on the cervical spinal cord (Figures , ). The retropharyngeal hematoma had resolved. The patient was successfully extubated with the use of a Cook exchange catheter on post-operative day one and discharged two days later."
+Zhuri Pruitt,32,1978/6/10,712-679-5343x4339,rjennings@example.org,900 Pennington Inlet,"A 36 year old man sustained a degloving injury to his right, middle finger (which he caught in a machine, while at work) resulting in a large volar soft tissue defect extending from the tip of the distal phalanx to the mid portion of the middle phalanx. Bone and part of the profundus tendon was exposed (Fig. ). The tip of the distal phalanx was crushed, without any other bony injury.
+A primary debridment was done on the day of injury, because the wound was contaminated with grease and grit in the emergency operation theatre. The exposed tendon and bone was covered with a collagen dressing.
+When the wound was inspected on day 3, it was found to be healthy and a flap was planned to cover the exposed tissues.
+We have had a lot of experience with cross finger flaps and free flaps from the toe and foot. However, they have been associated with lack of patient compliance, morbidity to the donor areas and immobilization in the case of cross finger flaps. Therefore, we planned to do a free thenar flap, based on the superficial branch of the radial artery. We had carried out cadaver dissections and found the vascular supply consistently associated with this fasciocutaneous flap. This fasciocutaneous flap would have a texture similar to the pulp tissue. The other main advantage of the free thenar flap would be its sensory supply by either of the nerves (palmar cutaneous branch of median nerve, lateral antebrachial cutaneous nerve or branch of superficial radial nerve).
+On day 4, a free fasciocutaneous thenar flap was performed under regional block. A blue print of the flap is shown in the figure . No upper limb exsanguinations was done, which helped in identifying the thin vessels under the loupe. An upper limb tourniquet was used to minimize bleeding. A thenar flap measuring 4 ? 2.5 cms was dissected with the vascular and neural pedicle (a branch of the superficial radial nerve). The tourniquet was released intra-operatively after the neuro-vascular anastomosis was completed. Blood flow was adequate (figure ). The donor site over the palmar aspect was primarily sutured. The operation took approximately 6?? hrs. A rigid dressing was applied to reduce post operative edema. The middle finger along with the wrist was immobilized (4 days) to reduce postoperative pain and to help in initial wound healing.
+On day 9 (post-operative day 5), the digit was redressed. Both the donor and the recipient site were found healthy. Sutures were removed on day 15 (11 days after the operation). Physiotherapy was started for the middle finger and wrist, from the 4th post-operative day.
+6 months after the injury, the patient is satisfied with the flap. He is happy about the texture of the flap which matched the other fingers
+(Figure and figure ). He has 90% deep touch sensations and approximately 50% soft touch sensations. The only uncomfortable sensation he has had was transient tightness over the palmar scar which had disappeared with time."
+Gatlin Porter,21,2002/2/28,695-680-1062,steeleeric@example.org,614 Jones Club,"A 25-year-old Caucasian female with skin type 2 (Fitzpatrick classification) presented because of a plum-sized pedunculated keloid on the upper part of her left helical rim. She reported that 10 years ago she had already experienced formation of a nodule in this area which became evident 6 months after an ear piercing. This keloid-like nodule was excised twice and injected with steroids. At the time of presentation the plum-sized keloid on her helical rim had been increasing in size and was accompanied by severe pruritus (Fig ). We introduced our patient to an audiology technician in order to design and build a specially silicon pressure splint for her left ear (Fig ).
+The keloid was then excised with cold steel. Immediately after the operation a combination of 0.5 ml triamcinolonacetonid and scandicain 2 % was intralesionally injected. The custom made silicon splint was applied directly after surgery and steroid injection (Fig ). The injections were repeated at intervals of 8 weeks for 12 months. The patient was instructed to wear the splint for 24 h a day, 7 days a week. A clinical check-up one year and 24 months after the last injection showed no tendency to relapse (Fig and Fig )."
+Ryleigh Bernard,40,1993/9/28,(399)849-3843,imcintosh@example.org,943 Dawson Corners,"A 14-year-old girl presented to the Emergency Room in December 1999 with her first episode of severe gross, painless hematuria. Past history was unremarkable. On examination she was pale, dehydrated and continually bleeding per urethram. Heart rate was 120/minute, blood pressure 90/55 mmHg and she was afebrile. Hemoglobin was 5.9 gm/dl, hematocrit 18 with coagulation profile and routine chemistry being normal. Urinalysis showed large amounts of RBC's and 08 WBC's/HPF. Urine culture and sensitivity was later negative for bacterial growth. At emergency cystoscopy following resuscitation, she was found to have an 8 ? 10 cm highly vascular, solid, infiltrative tumor occupying the right lateral wall and ipsilateral half of the trigone. The tumor involved the right ureteric orifice and extended to 1 cm short of the bladder neck. Preoperative intravenous pyelogram showed a non-excretory right kidney due to hydronephrosis with normal contralateral system. Transurethral resection of the tumor till bladder wall level was done. She needed 5 units of packed cells transfusion. Subsequently, right percutaneous nephrostomy was done, which was later internalized with a double J stent.
+Microscopic examination of the tissue revealed cohesive groups of cells arranged in lobules by dividing fibrous septae. There was no evidence of muscle invasion. The cells contained abundant granular eosinophilic cytoplasm with round monomorphic nuclei and showed focal positivity with PAS stain (Figure &). Immunohistochemical studies revealed diffuse positivity with S-100 protein, and negativity with Desmin and Vimentin, thus consistent with granular cell tumor instead of the suspected sarcoma. Positivity with neuron specific enolase, chromogranin and synaptophysin was not seen and S-100 staining was seen in tumor cells and not in sustentacular cells as noted in pheochromocytoma
+CT scan of the abdomen/pelvis and chest X-ray showed no metastases. There was localized thickening of the bladder wall with no extravesical extension. At repeat cystoscopy 2 weeks later, there was no obvious residual tumor and deep biopsies from previous resection site were clear. Hence, it was decided to treat the patient conservatively. Follow-up CT scan of the abdomen/pelvis 4 months later showed a normal-looking bladder (Figure ). Cystoscopy with multiple bladder biopsies was again negative for tumor recurrence and only showed acute on chronic inflammation. The double J stent was removed. Follow up IVP at 12 months was normal. She now remains free of disease at over 4 years since the operation."
+Jair Miles,26,1996/7/13,478.771.3908,joshuaroth@example.com,691 Koch Park,"A 47-year-old lady, married with 6 children, diabetic and hypertensive, presented to the urology clinic in July 1995 with gross intermittent hematuria and dysuria for one year. She also complained of urgency and urge incontinence. About 25 years back, she had a laparotomy for intestinal obstruction secondary to tuberculosis and had received a one year course of antituberculous medical therapy. Physical examination was unremarkable except for some fullness in the left lower quadrant of abdomen. Hemoglobin was 8.5 gm/dl, hematocrit 26.2 (normal = 35.4 ??42.8%) with coagulation profile and routine chemistry being normal. Urinanalysis showed hematuria and pyuria while urine culture was negative for bacterial growth. Ultrasound revealed a 2.6 ? 1.8 cm polypoidal mass in the left posterior wall of urinary bladder with bladder wall irregularity. An IVP showed normal upper urinary tracts with a filling defect in the bladder.
+Cystoscopy revealed an approximately 4 ? 3 ? 3 cm solid tumor in the left postero-lateral wall, above the ureteric orifice. Multiple biopsies of the tumor from the base and edges, as well as random bladder biopsies, were obtained.
+The tumor was arranged in large clusters with diffuse sheets invading and insinuating in between the smooth muscle fibers. The tumor cells exhibited pleomorphism, nuclear hyperchromasia, with 2?? mitoses/10 HPF (Figure &). Random bladder biopsies were normal. Immunohistochemical studies showed the tumor cells to be S-100 positive and cytokeratin Cam 5.2, AE/A13 negative, illustrating a non-epithelial origin. The pathologic diagnosis of a muscle-invasive, malignant granular cell tumor of the urinary bladder was made. Neuroendocrine markers such as neuron specific enolase, chromogranin, synaptophysin were negative.
+A radionuclide bone scan was negative for metastasis. A CT scan of abdomen and pelvis showed no extravesical tumor extension or distant metastasis. A cystic left ovarian mass was recognized, which later turned out to be benign ovarian cyst with no malignancy. A planned radical cystectomy, bilateral salpingo-oophorectomy, hysterectomy, ileal conduit and pelvic lymph node clearance with resection of the anterior wall of the vagina was carried out in June 1995 realizing the malignant nature of the tumor. She made an uneventful recovery and histopathology confirmed a pT3N0M0 malignant granular cell tumor of the urinary bladder. She remains free of disease recurrence at 8 years since the operation."
+Alessandra Pearson,44,2005/6/18,662-971-3103x6194,oconnorkristen@example.org,26149 Valdez Walk,"A 19-year-old man with recently diagnosed HCM was referred for sudden death risk assessment. The patient had mild exertional dyspnea (New York Heart Association functional class II), but without syncope or chest pain. There was no family history of HCM or sudden death. The patient's blood pressure was 130/70 mmHg and a grade 3??/6 systolic ejection murmur was present at the apex. ECG showed a left ventricular (LV) hypertrophy with strain pattern. A two dimensional echocardiogram revealed an asymmetric type of LV hypertrophy; anterior ventricular septum = 49 mm; posterior ventricular septum = 20 mm; anterolateral free wall = 12 mm; and posterior free wall = 6 mm (Figure ). The patient had 2 types of obstruction; a LV outflow obstruction due to systolic anterior motion of both mitral leaflets (Doppler-estimated 38 mm Hg gradient at rest); and a midventricular obstruction (Doppler-estimated 43 mm Hg gradient), but without apical aneurysm or dyskinesia (Figure ) [see Additional file ]. The LV end diastolic diameter was 45 mm and the left atrium was 45 mm. The patient had a normal blood pressure response on exercise test and no episodes of non-sustained ventricular tachycardia in 24-h ECG recording. Cardiac MRI showed a gross late enhancement at the hypertrophied septum. Based on the extreme degree of LV hypertrophy and the myocardial hyperenhancement, an implantation of a cardioverter-defibrillator was recommended prophylactically for primary prevention of sudden death. Written consent was obtained from the patient for publication of study.
+This case is a rare example of a patient with subaortic and midventricular hypertrophic cardiomyopathy with extreme segmental hypertrophy exceeding the usual maximum wall thickness reported in the literature, although Maron et al have published a case of a patient with an even greater hypertrophy (60 mm) []."
+Gunner Serrano,26,2004/6/30,(652)502-3375x719,andrewhughes@example.org,990 William Ville Suite 833,"A 57-year-old Caucasian male was first seen by a rheumatologist in 1998 for arthralgias and myalgias of his proximal upper extremities. His medical history included obesity and hypertension. There was no family history of rheumatologic disease. He worked as a glazier, and had no substance abuse history. Physical examination showed synovitis of his metacarpophalangeal joints and wrists. Erythrocyte sedimentation rate was >120 mm/hr, and rheumatoid factor was negative. He was diagnosed with seronegative rheumatoid arthritis, and prednisone was initiated at 10 mg daily in 1999. His arthralgias and myalgias responded clinically to the prednisone.
+In late 1999, because of new symptoms of fatigue, weight loss, and fevers, 10 mg of weekly methotrexate was added to his regimen. An infectious disease consultation was obtained to rule out infection as a cause of his symptoms, and an extensive workup was performed. A chest radiograph was normal, and computed tomography (CT) scans of the abdomen and pelvis were unremarkable. A bone marrow biopsy was normal and cultures for bacteria, mycobacteria, and fungi were negative. Multiple blood cultures for bacteria were negative. With the exception of a persistently elevated sedimentation rate of 133 mm/hr, laboratory results were normal, and no infectious etiology for his symptoms could be found. Because of a lack of response, his methotrexate was discontinued after 3 months of therapy. His weight loss and fevers stopped, and only his fatigue continued.
+In January 2002, still on oral prednisone, he was diagnosed with degenerative arthritis of both shoulders. His prednisone was increased to 15 mg daily, and azathioprine 100 mg daily was added. In April 2002, his left acromioclavicular joint was injected with a corticosteroid for symptomatic relief. In June 2002, both acromioclavicular joints were injected with corticosteroids. In December 2002, he first noted an erythematous, warm rash that began simultaneously on both shoulders at the sites of his shoulder injections.
+In April 2003, he transferred his rheumatological care to our institution. His immunosuppressant regimen consisted of prednisone 10 mg daily, azathioprine 100 mg daily, and hydroxychloroquine 200 mg twice daily. He complained of fevers, fatigue, worsening bilateral shoulder pain, and progressive bilateral shoulder rash. In addition, he noted new dyspnea without cough. His shoulder pain now prevented him from carrying objects and performing his job. His left shoulder rash, shown in Figure , was macular, warm, erythematous, non-tender, and blanched with pressure. At its center was a 5-centimeter crusted ulcer with modest serosanguinous drainage, overlying the acromioclavicular joint. The surrounding erythema had progressed to include his entire left breast to the level of the nipple. It extended slightly onto the left arm and upper back, and did not cross the midline. On the right shoulder, there was a 5-centimeter circular patch of mottled erythema and warmth without ulceration or drainage, overlying the right acromioclavicular joint and symmetric with the central focus of the left-sided rash. There was no appreciable lymphadenopathy. Physical examination of the shoulders was limited by pain with both active and passive range of motion in all directions. There was a palpable effusion of the left shoulder, but not the right. Physical examination of his fingers, wrists, elbows, knees, ankles, and feet was otherwise normal with no evidence of synovitis.
+The consulting rheumatologist concurred with the original diagnosis of seronegative rheumatoid arthritis. However, due to the presence of the unexplained rash, alternative and additional diagnoses were considered, including dermatomyositis, sarcoidosis, cutaneous leukemia or lymphoma, and infection. Erythrocyte sedimentation rate was >140 mm/hr, and C-reactive protein titer was 1:16. Anti-nuclear antibodies, uric acid, rheumatoid factor, C3, and C4 were normal. White blood cell count was 13,400 cells/mm3 with a neutrophilic predominance, hemoglobin was 10.6 g/dL and platelet count was 400,000 cells/mm3. Serum albumin was 2.8 gm/dL. Serum electrolytes, renal function, liver tests, and creatine kinase were normal. A serum electrophoresis showed polyclonal hypergammaglobulinemia, and ferritin was elevated at 356 ng/ml, suggesting chronic inflammation. A chest radiograph was normal. A skin biopsy of the left shoulder cellulitis in July 2003 revealed non-caseating granulomatous inflammation consistent with sarcoidosis. Stains for fungus and acid-fast bacilli (AFB) were negative, but cultures were not performed.
+He was diagnosed with cutaneous sarcoidosis and treated with azathioprine 100 mg daily, prednisone 40 mg daily, and rofecoxib 25 mg daily. Chest CT revealed subtle reticulonodular parenchymal changes with lower lung zone predominance. Though the CT findings were compatible with the diagnosis of sarcoidosis, the lower lobe involvement and absence of lymphadenopathy were atypical.
+Because the clinical syndrome was not entirely consistent with sarcoidosis, repeat skin biopsy was performed in September 2003, this time with fungal and AFB cultures in addition to the routine pathology stains. Once again, pathology revealed granulomatous inflammation consistent with sarcoidosis with negative fungal and AFB stains. However, AFB cultures grew mycobacteria after only eight days. The diagnosis of MAI was made by DNA probe, and confirmed by culture. Bacterial and fungal cultures were negative. Serology for HIV was negative.
+Antimicrobial therapy consisting of azithromycin, ciprofloxacin and ethambutol was initiated in December of 2003 by an infectious diseases consultant. Azathioprine was discontinued and corticosteroids were tapered to 7.5 mg po qd, which was the lowest tolerable dose for the patient because of a return of his myalgias and arthralgias. Shoulder plain films and magnetic resonance imaging (MRI) revealed large joint effusions and evidence for avascular necrosis, greater on the left side (Figure ). Joint aspiration of the left shoulder revealed MAI by culture, and surgical drainage and debridement was performed in January 2004. Intraoperative findings included multiple rice bodies within the joint and a large cloudy effusion. Post-operatively, he was prescribed intravenous amikacin, which was discontinued after 2 weeks due to the development of renal insufficiency. In March 2004, because the cutaneous lesions over his shoulders continued to progress despite initiation of antimicrobial therapy and decrease in immunosuppression, ciprofloxacin was changed to moxifloxacin, and rifabutin was added to his regimen.
+The patient completed 21 months of multi-drug therapy with relief but not complete resolution of his rash and shoulder pain. In September 2005, his azithromycin, moxifloxacin, ethambutol, and rifabutin were discontinued on a trial basis because of cumulative drug toxicities. Unfortunately, fevers returned and the rash over the left anterior shoulder worsened. A repeat aspiration of his left shoulder confirmed persistence of MAI septic arthritis with a sensitive isolate. A follow-up CT scan of the chest showed no progression of his previously seen nodules. Antimycobacterial therapy has been re-initiated, and he has undergone a second debridement of his left shoulder. He has since responded to continued antimicrobial therapy documented by a negative joint aspiration, although he continues to have severe arthritic pain from permanent joint damage.
+One of two possible mechanisms probably explains the occurrence of MAI in the skin and shoulder. The first possibility is that MAI was introduced directly into the tissue at the time of injection. MAI is ubiquitous in the environment, including water sources, and can contaminate injectable solutions []. Because MAI grows slowly, a six-month lag between injection and clinical presentation, as seen in our patient, is biologically plausible. Hoffman et al estimated that 40% of the 19 patients with septic arthritis due to atypical mycobacteria in his series had had previous joint injection; however, only 1 of the injected patients had MAI []. It is not reported whether any of the 7 MAI septic arthritis patients in Kozin et al had been previously injected or aspirated []. Czachor et al reported a kidney transplant patient who developed MAI septic arthritis months after a diagnostic arthrocentesis for the diagnosis of gout []. In our patient, the temporal relationship between the shoulder injections, the subsequent appearance of simultaneous bilateral MAI skin infections at the site of the injections, and the eventual occurrence of left shoulder MAI septic arthritis, provides strong circumstantial evidence for the causative role of joint injection in this patient. Cellulitis of the overlying skin has not been described in previous reports of MAI septic arthritis [-,].
+The second possibility is that the patient had undiagnosed disseminated MAI at the time of joint injection, and the trauma of injection caused concentration of the organisms at the injection sites. There is some evidence that this phenomenon occurs in patients with disseminated MAC. Freed et al reported a case of MAI soft tissue infection documented post-mortem at an IV injection site in an HIV- and MAI-infected patient []. Meadows et al reported an abscess due to MAI at the site of an intramuscular injection in an HIV-infected patient []. Prior to intra-articular injection, our patient had been treated with corticosteroids for approximately 3 years as well as short-term methotrexate and azathioprine. While this degree of immunosuppression makes disseminated MAI possible, there is little evidence to support the theory of pre-existing undiagnosed disseminated MAI infection in our patient, though it remains a possibility. Another possibility may be increased susceptibility to mycobacterial disease due to an underlying genetic defect in the IFN-帠 response pathway []."
+Allie Avila,26,1996/3/29,416-656-0788,brian90@example.net,7349 Pena Wall Apt. 370,"We report on a 56 year old male patient diagnosed with an esophageal carcinoma located in the middle of the esophagus with a subtotal stenosis at 32 cm from the incisor teeth. Endosonography performed preoperatively revealed a locally advanced tumor (uT3, N+). Following the oncological recommendations the patient underwent neoadjuvant radiochemotherapy with a total of 50 Gy and a 5-fluorouracil (5-FU) based chemotherapy (5-FU 15 mg/kg body weight on days 1??, cisplatin 75 mg/qm on day 7, repeated in week five). Thereafter, a subtotal esophageal resection combined with mobilization of the stomach through midline laparatomy and of the esophagus through the fifth intercostal area was done. The esophagogastric anastomosis was performed with a 25 mm stapler. Histological evaluation of the resected specimen revealed complete response of the esophageal carcinoma to the neoadjuvant radiochemotherapy with no tumor tissue detectable (ypT0, ypN0, ypMx). Increasing concentrations of acute-phase reactants in line with a dramatically decreasing general condition of the patient indicated a leakage that was confirmed by a gastrografin swallow demonstrating a anastomotic leak with gastrografin effusion into the left mediastinum (Fig. ). After lavage of the mediastinum and abdomen both were drained by a chest tube. Additionally, total parenteral nutrition as well as broad spectrum antibiotics were given. However, this nonoperative management to close the leak was unsuccessful and endoscopic stent implantation was planned.
+The endoscopic examination showed a wide leak in the anastomosis located 25 cm from the incisor teeth (Fig. ). Because of the excellent prognosis of the patient, we initially used a Polyflex self-expanding covered plastic stent (Willy R羹sch GmbH, Kernen, Germany; stent dimensions: 25 mm flare with 21 mm body, length 120 mm) placed 2?? cm distal the upper esophageal entrance to close the leakage (three weeks after the esophageal resection). Clinical change for the worse was suspicious of stent migration, but the endoscopic examination revealed that the polyflex stent was placed correctly. However, the caliber of 21 mm was undersized to attach tightly to the mucosa of the esophageal wall enabling running of fluids through the anastomotic leak (Fig. ). Without a commercial available esophageal stent with a larger inner diameter on hand a resection of the esophageal remnant and a hand made cervical esophageal anastomosis was performed six weeks after the first operation.
+Unfortunately, a leak in the hand made anastomosis was detected again. To close the leak we decided to use for the first time a covered colorectal Hanarostent (MTW Endoskopie, Wesel, Germany) (stent dimensions: 30 mm body, length 60 mm) which was placed four weeks after the second operation. This stent is designed for colorectal applications. The unique structure of the membrane connects the several separated segments made of nitinol wire to increase the flexibility of the stent and to prevent migration and tumor growth.
+This stent was placed without complications. Control endoscopy demonstrated a close seat of the stent to the gastric tube with complete covering of the anastomotic leak (Fig. ). Thereafter, the general condition of the patient increased continuously in line with a decrease of the acute-phase reactants. One week after metal stent implantation, oral feeding was restarted and the patient could be discharged from the hospital after another three weeks. Sixteen weeks after the second stent implantation, the stent was extracted and follow up endoscopy and gastrografin swallow indicated complete mucosal healing of the esophageal leak (Fig. )."
+Jaylen Wang,36,1996/3/4,411-999-3289x1488,davisjacqueline@example.org,53181 Lopez Gateway Suite 443,"A 55 year old woman developed anorexia, vaginal bleeding, and a non-productive cough over one month. Her last menstrual period was 11 months earlier, and she had noted some vaginal spotting for 5 months. CT scans revealed a large uterine mass and multiple lung nodules. An endometrial curetting showed small fragments of tumor consisting of two components; aggregates of atypical plump mononuclear cells with hyperchromatic, pleomorphic nuclei were interspersed with numerous large multinucleated osteoclast-type giant cells, some of which had more than 30 benign-appearing nuclei (Figure , Top). Up to ten mitoses power high-power field were observed in the mononuclear cells. Immunoperoxidase stain for the histiocytic marker CD68 was positive in a subpopulation of mononuclear cells and in the osteoclast-type giant cells. These cells were negative for the epithelial marker cytokeratin (AE1/AE3) which highlighted scattered benign endometrial glands. A fine needle aspirate of the lung showed sheets of atypical mononuclear plump cells and numerous scattered benign-appearing osteoclast-type giant cells (Figure , Bottom). Some mononuclear cells were positive for the endometrial stromal marker CD10; all mononuclear and multinucleated cells were positive for the mesenchymal cell marker vimentin; CD117 (c-kit) was weakly positive in multinucleated cells. All cells were negative for estrogen receptors, cytokeratins (7, 20, AE1/AE3), muscle specific actin and mucin.
+On presenting to our clinic, her history was remarkable for anorexia, uterine bleeding, dyspnea on exertion, a non-productive cough, and a 10 pound weight loss during the previous month. Her past history was notable for treated hypertension and hypothyroidism, an episode of gout, and monoclonal gammopathy of undetermined significance. Her medications were lisinopril, L-thyroxine, and a multivitamin. Her physical examination was notable for scattered crackles and occasional wheezes, and mild lower abdominal tenderness and fullness. A repeat CT scan revealed prominent tumor progression during the preceeding month, with a 11.6 cm uterine mass and lung nodules, some >4 cm in diameter (Figure ). Hemoglobin was 8.5 g/dl, AST, alkaline phosphatase, bilirubin, creatinine, and electrolytes were normal. Treatment was begun with pegylated-liposomal doxorubicin (45 mg/m2, day 1), ifosfamide (9 g/m2 total dose given by continuous infusion over 6 days, days 1??) with mesna uroprotection [], and bevacizumab 5 mg/kg every 2 weeks, with pegfilgrastim 6 mg given subcutaneously on day 7, with cycles repeated every 28 days. After the first cycle of chemotherapy, repeat CT imaging revealed a tumor response in the lung nodules (Figure ), although her symptoms were unchanged. At the start of cycle 3 her cough, vaginal bleeding, and dyspnea on exertion had noticeably improved. The dose of pegylated-liposomal doxorubicin was decreased by 10% for the third and subsequent cycles due to mucositis and skin rash. A CT scan before cycle 4 showed continued tumor regression. Blood pressure remained controlled and no proteinuria was noted. After 7 cycles the tumor had stabilized by CT imaging (Figure ). The lung nodules had largely disappeared, but the uterine mass remained at about 8.5 cm. She was given cycle 8 without bevacizumab in anticipation of hysterectomy. Repeat CT imaging showed stable disease, and she underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy 8 weeks after cycle 8.
+The uterus contained a poorly demarcated tumor that measured 4.8 ? 4.0 ? 3.5 cm arising in the left lateral wall (Figure , Top). Multiple leiomyomata ranging from 0.3 to 2.2 cm were also identified. Sections from the tumor (Figure , Bottom) showed atypical mononucleated plump to spindle shaped tumor cells diffusely infiltrating the myometrium and within dilated blood vessels. Tumor cells accounted for approximately 30 % of the cells. Vascular invasion was observed. Occasional multinucleated giant cells of osteoclastic-type were also recognized; however, these were rare and tended to form small aggregates. Extensive areas of necrosis showed dystrophic calcification. Large numbers of histiocytes with foamy cytoplasm and hemosiderin granules were observed throughout the tumor; these cells accounted for approximately 70% of the cellular population. A subpopulation of mononuclear cells was positive for CD10; osteoclastic cells were non-reactive. Some of the mononuclear plump and spindle cells were weakly positive for actin; they were negative for desmin and smooth muscle myosin. CD117 was weakly positive in the osteoclastic cells. The cell division marker Ki67 was positive in tumor cells and negative in histiocytes and osteoclasts; Stains for common leukocyte antigen (CD45) and for the histiocytic marker CD68 were positive in histiocytes and osteoclasts, but were negative in tumor cells. Stains for lysozyme were weakly positive in histiocytes and osteoclasts but were negative in tumor cells. Stains for cytokeratin (AE1/AE3), estrogen receptors, and progesterone receptors were negative. Pelvic washings were negative; the cervix, parametria, tubes, and ovaries were free of tumor.
+Two months after the hysterectomy, progression of the lung nodules was noted on CT imaging and therapy with pegylated-liposomal doxorubicin and bevacizumab was begun, but progression was noted after 2 months. Gemcitabine (675 mg/m2 intravenously over 90 min given days 1 and 14 with pegfilgrastim days 2 and 15 due to neutropenia on day 8 of the first cycle, with cycles repeated every 28 days) [,] with bevacizumab was begun, but progression was noted after two months. Therapy was then begun with ifosfamide and etoposide [] and bevacizumab, and a partial response was observed after two months, with stabilization at 4 months. The patient received a total of 6 cycles of ifosfamide, etoposide, bevacizumab, although bevacizumab was held on day 14 of cycle 6 due to proteinuria. Two months later significant progression was noted. She received 1 cycle of dacarbazine, mitomycin c, and cisplatinum, with a very good response, but prominent toxicity including myelosuppression and fatigue. Two months later tumor progression was noted."
+Kailani Dodson,41,1991/9/19,(923)406-1091x695,brittanythompson@example.net,561 Cruz Station,"A 47 year old female who was otherwise healthy presented with a sudden onset vertical diplopia associated with right sided headache and right eye pain. On examination she had a right hypotropia measuring 20^ for distance. Eye movements were limited in dextroelevation with associated discomfort. Ocular motility testing with a Lees chart showed a restrictive profile (figure ). There was no proptosis, ptosis or lid retraction. Snellen visual acuities were 6/5 in each eye. Colour vision and visual fields were normal. Anterior segment and fundal examinations were unremarkable.
+Thyroid function tests and inflammatory markers were within normal limits (Free T4 14.2 pmol/L, Free T3 5.9 pmol/L, TSH 1.48 mu/L, C-Reactive Protein 13 mg/L). An initial diagnosis of orbital myositis was suspected due to the marked painful limitation in elevation of the right eye. MRI of the orbits revealed no muscle or tendon abnormality but an incidental pituitary lesion was identified. Further intracranial imaging with contrast delineated a cystic pituitary mass compressing the chiasm which showed ring enhancement of the tumour, measuring 1.72 cm ? 1.28 cm ? 1.29 cm (figures , ). There was no radiological evidence of any intracerebral aneurysm or of invasion into the cavernous sinus.
+Pituitary hormone levels and serum osmolality were within normal limits (Prolactin 446 miu/L, Testosterone 1.7 nmol/L, FSH 13.0 iu/L, LH 6.4 iu/L, Growth Hormone 1.19 miu/L, IGF 1 22 nmol/L, Serum Osmolality 297 mosm/kg).
+The following week the patient developed anisocoria, slight right sided ptosis and her visual acuities fell to 6/12 right eye and 6/9 in the left eye. Although initially a macroadenoma or craniopharyngioma was suspected, further histological analysis revealed a benign squamous epithelium lined lesion which was consistent with an epidermoid cyst, dermoid cyst or a teratoma. There were no signs of infarction or haemorrhage. The lesion was removed by transphenoidal resection, leading to a gradual resolution of symptoms.
+There have been reports of recurrent or intermittent third nerve palsy as well as ptosis as a presenting feature of pituitary tumours [-]. However, an acute presentation with pain on eye movements and a restricted ocular motility pattern has not been previously documented. A large pituitary mass may compress any of the cranial nerves within the lateral wall of the cavernous sinus however this tends to be late in the course of tumour growth []. The third and fourth cranial nerves are more susceptible as the abducent nerve affords some protection from the internal carotid artery. Direct invasion of the tumour through the sinus wall may also occur. Mechanical compression of the oculomotor nerve against the unyielding interclinoid ligament of the cavernous sinus wall tends to bring about a slow onset paralysis. Rapid onset of third nerve paralysis has been attributed to compromise of the vascular supply to the nerve [], due to compression of the vasa nervorum originating in the internal carotid artery []. Sudden symptoms have also been seen in pituitary apoplexy [], where immediate treatment with bromocriptine and steroids has been advocated, on the basis that most macroadenomas are prolactinomas []. Finally, the possibility of a coincidental pituitary tumour and a spontaneously recovering micro-infarctive third nerve palsy must also be considered."
+Seven Torres,29,1986/3/21,476-287-0640,tinamartinez@example.org,58145 Brian Villages Suite 482,"A healthy 15-year-old girl was referred following a five day history of a unilateral red left eye. The eye was becoming progressively more inflammed, with epiphora, photophobia and blurred visual acuity.
+On examination, the visual acuity in the affected eye was 6/6 compared with 6/5 in the other eye. The conjunctiva was inflamed with a follicular reaction including the corneal margins superiorly. There were enlarged pre auricular nodes. A diagnosis of viral conjunctivitis was made and viral plus bacterial swabs were taken.
+The patient was commenced on fucithalmic to prevent secondary infection and told to re attend if she deteriorated. Five days later, she returned feeling that the eye had become more tender with increased swelling of the lids plus tenderness over the maxillary sinus.
+On examination, there was marked oedema of the upper and lower lids accompanied by erythema. The tarsal conjunctiva revealed follicles. Extra ocular movements were full but uncomfortable on elevation. Pupil, colour vision examination and direct visualisation revealed a healthy disc. She was apyrexial and systemically otherwise well. A secondary diagnosis of bacterial pre septal cellulitis was made and the treatment was changed to oral ciprofloxacin 750 mg twice daily for one week, plus two hourly topical exocin drops.
+Two days later the patient was reviewed. She now complained of a large amount of purulent discharge. The pre septal swelling was still marked and examination of the conjunctiva again revealed large numbers of follicles and large papillae.
+All bacteriology and viral swabs had been negative and the patient was re swabbed for chlamydia despite denying any genitourinary symptoms. Giemsa staining of conjunctival scrapings revealed cytoplasmic inclusion bodies and the patient received a one gram single dose of Azithromycin. She was asked to attend the local genitourinary clinic and to alert any current and previous sexual partners to their need to do likewise. Her symptoms completely resolved following administration of the Azithromycin and there were no further complications. Unfortunately, the patient declined to have photographs taken."
+Violet Morris,29,2001/1/4,001-772-697-0498x8706,melissa99@example.org,09332 Robert Cape,"A 41-year-old man had tolerable pain in his shoulder, which developed gradually over a 10 years' period. The pain occurred with shoulder motion, particularly in relation to his golf swing, since he was aiming at a professional career as a golfer. On physical examination of the scapula, ""clunking"" was noted once from 90 degrees of abduction to 180 degrees. However, active range of motion (ROM) was normal. There was no winging of the scapula. The upper extremity and shoulder girdle muscle strength was normal.
+A trans-scapular roentgenogram showed a pedunculated type of a bony projection, which was continuous with the scapula (Figure ). Computed tomography (CT) images revealed a bone tumor on the anterior surface of the right scapula and inferior to the spine. The size of the tumor was 1.8 ? 1.5 ? 1.0 cm. The images demonstrated the continuity between the bone tumor and the scapula (Figure ). The lesion was diagnosed as an osteochondroma resulting in a snapping scapula syndrome. Removal of the tumor was performed to relieve pain with the ""clunking"" of the scapula.
+Under general anesthesia, the patient was placed in a prone position, with the right arm draped free to allow a full range of motion. The lesion was approached through a 2-cm incision along the lower lateral aspect of the scapula. The teres major muscle was dissected on the same line. Then scapula was elevated by a retractor and then the 2.7-mm-diameter, 30 degrees Hopkins telescope (Karl Storz, Tuttlingen, Germany) was introduced into this portal. Since the tumor was covered by the subscapularis muscle, a part of the muscle was removed to access the tumor by use of graspers. Consequently, the tumor was visualized and resected in a piece-by-piece manner by the use of graspers of different sizes (Figure ). Finally, a Black Max cutting burr (Anspach, Florida, USA) was applied to smooth the remnants of the tumor. Both the graspers and the burr were introduced through the same portal. The wound was closed over a suction drain, which was removed after 24 hours. The duration of surgery was 2 hour and a half. The patient did not need shoulder immobilization with sling.
+Immediately after the operation pain relief was obtained, and the ""clunking"" disappeared during full range of active shoulder motion. CT images showed complete tumor resection (Figure ). The patient could start playing golf one week after the surgery. Histology confirmed the clinical diagnosis of osteochondroma (Figure ). The scar was small to which the patient was satisfied (Figure )."
+Christian Lugo,42,1985/12/28,(535)575-2303x655,edward61@example.org,52251 Nancy River,"A 28-year-old woman presented to A&E with a short history of diarrhoea and vomiting associated with high fevers, sore throat and flushing of her skin. There had been no recent foreign travel, exposure to toxins or drugs, nor gynaecological symptoms. There had been no recent use of tampons. She had not been menstruating while using 3-monthly intramuscular injections of Depo-Provera, a long-acting progesterone, as contraception.
+Interestingly, 6 years earlier she had been admitted with a toxic shock-like syndrome to another hospital and required ITU care. At that time and without serological confirmation, it was presumed that a staphylococcal or possibly streptococcal infection had triggered her condition.
+On examination she looked unwell. She was distressed and flushed with widespread erythema of her skin. Her temperature was raised at 39.6簞C and pulse elevated at 120 beats per minute with regular rhythm. Her blood pressure was maintained at 110/70 mmHg. Cardiac auscultation was normal, as was the rest of the clinical examination. A subsequent pelvic examination was normal.
+Blood tests showed a white cell count of 9.4 ? 109/l with left shift of neutrophils. The CRP and ESR were raised at 250 ng/ml and 45 mm/hr respectively. Arterial blood gases demonstrated respiratory alkalosis with pH 7.57, pO2 13.8 kPa and pCO2 2.2 kPa. A chest radiograph was normal.
+She received aggressive intravenous fluid resuscitation. After blood was drawn for culture, intravenous cefuroxime and clarithromycin were empirically prescribed for a presumed bacterial septic illness. However the antibiotics failed to control either her pyrexia or her tachycardia. Her rash initially resembled severe sunburn but went on to exfoliate and then desquamate after two days. Dermatology opinion agreed that the skin condition was consistent with a diagnosis of TSS, and supportive treatment recommended. Her serum albumin dropped to 20 g/l during the first few days of her admission. Her temperature remained elevated at 38??9簞C. Repeated blood cultures were sterile while stool cultures were negative for bacterial pathogens. All throat, skin and high vaginal swabs yielded no growth. Paired acute and convalescent antistreptolysin 0 titres and antistaphylolysin 0 titres showed no rise. Rheumatoid factor, antinuclear and other autoantibodies were negative. C1 esterase inhibitor and complement levels were normal. Screens for viruses, toxic metals, cardiolipin antibody, urinary porphyrins and porphobilinogen were all negative.
+Five days after admission her fever rose to 40簞C and she became more unwell with delirium. Her pulse rose to140 beats per minute. An echocardiogram was normal. She was transferred to the ITU for further observation. Since no bacteria had been cultured after 5 days and since she had made no response to antibiotics and remained very unwell, a decision was made to empirically administer corticosteroids. This decision was based on anecdotal reports, and a retrospective analysis had suggested possible benefit from corticosteroid use []. She was given intravenous methylprednisolone 1 g daily for three days. Administration of this corticosteroid rapidly and dramatically improved her clinical condition with resolution of her temperature and tachycardia. She was converted to oral steroids and discharged home with prednisolone 30 mg daily. The dose was subsequently tapered over 6 weeks at outpatient follow up, and she remains well 2 years later."
+Kaylie Bradford,40,1981/11/8,(403)552-7105x935,hancockolivia@example.com,56611 Williams Rapid Apt. 711,"A 38 year-old male ophthalmologist was seen at the Ophthalmic Accident and Emergency Department with a five-hour history of a right watery red eye. He had been exposed to several conjunctivitis patients during the preceding few days, whilst working at the same department.
+An initial diagnosis of probable viral conjunctivitis was made, and the patient was prescribed chloramphenicol eye drops. Conjunctival swabs were taken and sent to the microbiology laboratory for analysis. A day later the conjunctivitis had become bilateral and purulent. Several hours after the conjunctivitis became bilateral the patient also developed a sore throat. The previous swab cultures isolated Streptococcus pneumoniae as the infective pathogen. Three days later, the patient noticed tenderness and swelling of the proximal interphalangeal joint of the index finger in the left hand, which became progressively more swollen and tender over the next couple of days. The patient had become febrile; however, there were neither chills nor rigors. He was prescribed oral amoxicillin 500 mg TID and flucloxacillin 500 mg QID, in the belief this was septic arthritis.
+Two days after the swelling started he was seen by a rheumatologist, who made a diagnosis of reactive arthritis. The patient was fully investigated (see following text and Table ). Plain X-ray showed a little soft tissue swelling over the proximal interphalangeal joint of the left index finger. The patient was negative for antineutrophil cytoplasmic antibodies (ANCA), rheumatoid factor (RF), anti-DNA antibodies and antinuclear antibodies; complement factors C3 and C4 were within the reference range. No pathogen could be grown in blood culture and joint aspiration (performed by the rheumatologist) yielded no synovial fluid. The patient was HLA-B27 negative. A firm diagnosis of reactive arthritis as a sequel to pneumococcal conjunctivitis was made. Anti-inflammatory drugs resolved the swelling and pain within 48 hours. The conjunctivitis had already recovered though the antibiotics were continued until the course was completed."
+Ander Leach,38,1984/6/30,(448)862-2465,mhenderson@example.com,71178 Ramsey Orchard,"A 13-year old girl presented with a rapidly progressive paralysis and encephalopathy. She had a mild viral-like illness for the preceding week, with lethargy. Over the days preceding presentation she developed back pain and difficulty in walking. On the morning of admission, she developed a headache, vomiting, a fluctuating level of consciousness and became unable to move her limbs.
+Neurological examination showed an encephalopathic girl, with four limb paralysis, absent deep tendon and abdominal reflexes, and mild bilateral facial weakness. A high thoracic (C4) sensory level, severe urinary retention and stool incontinence was evident. Systemic examination did not reveal pyrexia, rash, lymphadenopathy, hepatosplenomegaly or sepsis.
+Her remote clinical history was notable: at age 2 years, she had developed acute lymphoblastic leukaemia (ALL), common B-cell variant. Six months after completing chemotherapy using the UKALLXI protocol, the girl re-presented with an encephalopathy due to a CNS and bone marrow relapse of the leukaemia. The girl received cranial irradiation and further chemotherapy on the MRC UKALL R2 relapse protocol which achieved a further remission. Because of the high risk of further relapses, she proceeded to have an bone marrow transplant (BMT) with a matched unrelated male donor. Total body irradiation was used in conditioning for the BMT. Following the BMT, the girl was in prolonged remission for the following 7 years with no overt CNS or systemic sequelae.
+Initial MR imaging showed diffuse involvement of the CNS (Figures and ). The spinal cord was diffusely swollen showing central cord T2 hyperintensity from C1 to the conus. There were multifocal grey and white matter lesions in the cerebral cortex, subcortical areas and cerebellum which showed diffuse gadolinium enhancement. The appearances were consistent with an infective or inflammatory encephalomyelitis, but the girl's remote history and presentation raised the concern of a recurrent CNS relapse of ALL.
+CSF examination revealed 125 white cells with a lymphoblastic appearance and 5 red cells. CSF protein (0.61 g/l) and CSF:blood lactate ratio (3.2:1.2 mmol/l) were raised with a low CSF: glucose ratio (4.3:8.9 mmol/l). CSF cytospin showed increased proportion of lymphocytes which further increased suspicion of ALL relapse (Figure ). Immunophenotyping of the CSF cells demonstrated the cells were CD10 negative, strongly CD2 and CD7 positive and terminal deoxynucleotidyl transferase (TdT) negative. These findings suggested that the cells were mature T-cells. Cytogenetic studies and FISH using centromeric X and Y-chromosome markers on the CSF lymphocytes confirmed that the overwhelming majority of cells were of male donor type (6??4% of cells were of host origin but not clonal). These CSF findings, along with a normal peripheral blood count and normal bone marrow biopsy confirmed that the girl's illness was not due relapse of her previous ALL.
+The girl was treated with intravenous high-dose methylprednisolone and aciclovir. Blood-brain barrier studies showed an abnormal CSF IgG index; oligoclonal bands were not detected. Further negative tests included: CSF culture; CSF PCR for HSV1 and 2, VZV, EBV, HHV6/7, adenovirus, echovirus, parechovirus, enterovirus and echovirus; serology for influenza, mycoplasma, Chlamydia, and toxoplasma; ASOT, ANA, ANCA, anticardiolipin antibodies, tissue autoantibodies. Immune function tests did not reveal an underlying inmmunosuppression. A presumptive diagnosis of ADEM with associated transverse myelitis was made.
+The girl's encephalopathy resolved over succeeding days without overt cerebral sequelae, but spinal recovery was much slower. A repeat MRI at 2 weeks after onset showed resolving brain and spinal lesions. Her disability slowly improved over several months: Barthel activities of daily living index was 15/100 at 3 weeks, 40/100 at 7 weeks, and 85/100 at discharge from hospital 3 months after onset. At last review, 10 months after onset, her Barthel index was 100/100. She was mobile on her feet without aids, and had just ceased intermittent catheterisation for urine voiding. She was unable to walk on her heels, and had lingering fatiguability."
+Martha Roberts,44,1978/6/29,(542)385-2535,erica69@example.com,240 Emma Key Apt. 263,"A 72-year old male was referred to the vascular outpatient clinic with an asymptomatic right carotid bruit, for work up before planned coronary artery bypass grafting. His duplex ultrasound showed a 70??0% stenosis of the right internal carotid artery. He was found also to have an incidental 5.6 cm infra-renal abdominal aortic aneurysm (AAA). He underwent multi-sequence MR imaging pre- and 36 hours post USPIO infusion. Multi spectral imaging was acquired at 1.5 Tesla using a whole body system (GE Medical Systems, Milwaukee) and a custom designed 4-channel phased array neck coil (Flick Engineering Solutions BV) along with a standard body coil to improve signal to noise ratio. The patient subsequently (24 hours) underwent a right carotid endarterectomy and was discharged home after an uncomplicated hospital stay of three days.
+The ex-vivo specimen was kept fresh and immersed in an MR inert fluid (Fomblin, Performance Fluids Ltd, UK) and imaged in a dedicated single channel micro-coil 4 hours after surgery. Following this, the specimen was washed, fixed in formalin and embedded in paraffin wax. The paraffin block was divided into 3 mm sections and thin sections were cut from each block. These sections were stained using various techniques including haematoxylin and eosin (H&E) and elastin Van Giesen (EVG). This histology was co-registered with the ex-vivo and in-vivo MR using the bifurcation as a point of reference. There were no problems with the co-registration of the in-vivo images with the ex-vivo images or the histology (see Figure ).
+An elective endovascular repair of his AAA has been scheduled."
+Josiah Meyer,41,2004/4/11,910-476-0917x7472,earlcarpenter@example.com,2995 Henry Spurs,"A 39-year-old woman had a left kidney tumor incidentally discovered during CT scan as part of a diagnostic workup for colonic diverticulosis. She had no personal or family history of TSC, lymphangioleiomyomatosis, renal cyst, renal malignancy, or estrogen hormonal therapy. The CT scan revealed a 2.5-cm complex cystic mass in the upper pole of the left kidney with a 1-cm enhancing nodule in its wall, radiologically worrisome for cystic renal cell carcinoma. In view of this concern of malignancy, the patient elected to undergo laparoscopic left partial nephrectomy for definitive surgical treatment. The entire tumor was surgically resected with an excellent margin of 5-mm of normal parenchyma surrounding the entire cyst wall, and the tumor was confined to the kidney.
+Grossly, the tumor was well demarcated and partially cystic, with the largest cyst measuring up to 1.1-cm. Sectioning of the tumor revealed part of the cyst wall contained a single 1-cm mural nodule with homogenous tan cut surface. The entire tumor was submitted for histological examination and revealed three components. The first component was cystic or multicystic spaces lined by epithelium, that ranged from flat to cuboidal to columnar. Whilst the cuboidal to columnar cells had unremarkable clear cytoplasm, the flat cells had abundant eosinophilic cytoplasm with nuclei that often protruded into the lumen, resulting in a hobnailed appearance (Figure ). The second component was a subepithelial ""cambium-like"" condensation of small stromal cells with indistinct cytoplasm immediately subjacent to the cyst epithelium. This subepithelial stroma showed prominent capillary vasculature (reminiscent of endometrial or mullerian-like stroma) and prominent lymphoplasmacytic infiltrate (Figure ). The third component was a thick exterior wall of plump smooth muscle cells with focally clear cytoplasm arranged in poorly formed fascicles, often appearing to emanate from irregular and tortuous blood vessels (Figure ). The third component was exterior to the subepithelial stroma and was typical of myomatous or muscle-predominant predominant AML. Additionally, non-cystic native renal tubules were observed entrapped within this exterior muscular wall (Figure ).
+Immunohistochemically, HMB45 (Figure ) and Melan-A labeling was patchy in the exterior muscle-predominant AML component, but were most intense and concentrated in the compact subepithelial cellular stroma. Conversely, smooth muscle actin (Figure ) and desmin labeling was most intense and concentrated in the exterior muscle-predominant AML component, but were patchy in the compact subepithelial cellular stroma. Similarly, the compact subepithelial cellular stroma showed strong and diffuse nuclear labeling for estrogen receptor (ER) (Figure ) and progesterone receptor (PR) (Figure ), along with strong and diffuse cytoplasmic labeling for CD10 (Figure ), but labeling for ER (Figure ), PR (Figure ), and CD10 (Figure ) were patchy in the exterior muscle-predominant AML component. However, vimentin (Figure ) showed strong and diffuse cytoplasmic labeling of all 3 components equally. The cyst lining was positive for epithelial markers (pancytokeratin [Figure ], AE1-AE3, and CK7), but negative for melanocytic (HMB-45 [Figure ] and Melan-A), muscular (smooth muscle actin [Figure ] and desmin), and hormonal (ER [Figure ] and PR [Figure ]) markers. The tumor showed low proliferative index with Ki67 labeling less than 1% of neoplastic cells (Figure ). Additionally, RCC marker antigen, inhibin, WT-1, c-kit (CD117), S-100 protein, and CK20 did not label any of the 3 components of the tumor (not shown). Except for patchy labeling of blood vessels, CD34 (endothelial markers) did not label any of the 3 components of the tumor (not shown). The patient herein presented is alive with no evidence of recurrence or metastatic disease, 12 months postoperatively, and follow-up with interval abdominal imaging studies is planned."
+Sara Bridges,31,1977/10/6,(627)765-2649,huffsharon@example.com,5813 Brandon Curve,"A 73 year old African American male with history of SCCA of the esophagus presented with mild dysphagia. Subsequent endoscopy (EGD) revealed recurrent SCCA of the esophagus. Seven years prior he was diagnosed with a T1-2, N1 SCCA of the left anterior tonsillar pillar and treated with radiation therapy (XRT) (6660 cyG to the primary tumor). Four years later he developed Stage III esophageal SCCA (T4, N0, M0), by chest CT, located at 33 cm from the incisors that was 3 cm in length. This lesion was treated with 5400 cGy XRT and chemotherapy with curative intent. On the third (current) presentation, a moderately differentiated, T2, by endoscopic ultrasound (EUS), SCCA lesion at 24 cm was discovered (Figure and ). This new lesion was above the prior field of XRT and proximal to the original stage III esophageal SCCA.
+The patient was evaluated by the institution's tumor board and deemed neither a surgical nor XRT candidate based on significant cardiac comorbidities and maximum dose XRT with his prior treatments. Palliative treatment options were explored. Based on the success with ablation of esophageal lesions as described above, palliation via CSA was pursued for this patient. At the time of this case, the device was under an investigational device exemption (IDE) issued by the FDA. Therefore, an FDA Humanitarian Use Device exemption was requested and granted for use of the CSA device. The patient signed a consent form approved by the authors IRB and the FDA. The patient's 2 cm long, hemi-circumferential SCCA was treated with two 30 second pulses of CSA under direct endoscopic visualization on an outpatient basis (Figure ). This particular dosimetry was chosen based on early clinical trials in Barrett's esophagus and swine data. The first CSA of Barrett's esophagus in clinical trials used a dose of 40 seconds (two 20 second applications separated by a 20??0 second thaw). Early animal studies at the author's institution (unpublished) have demonstrated that the depth of injury correlates with duration of freeze. High grade dysplasia has been effectively treated with CSA at 20 seconds times three cycles. Thus in hope of achieving greater depth of injury without excessive necrosis, two cycles of 30 seconds each were applied. CSA was applied in such a way that the entire tumor with margins of 1?? cm was frozen. This technique resulted in a near circumferential freeze of the esophagus but with a focus on the tumor which endoscopically appeared hemi-circumferential in distribution. Interestingly, freezing of the tumor under direct endoscopic visualization demonstrated that the tumor differentially retracted when frozen relative to the surrounding esophageal mucosa making the margins of the tumor more distinct. Prior to freezing, the margins of the tumor diffusely blended into the esophageal wall.
+This patient was treated with lansoprazole 30 mg BID throughout the CSA period. The patient experienced no initial complications. One month latter a follow-up EGD revealed endoscopic resolution of the tumor, but biopsies remained positive for moderately differentiated SCCA (Figure ). CSA of the area was repeated, treating 40% of the esophageal circumference 4 cm in length spanning the prior SCCA with three, 20 second pulses. This shorter pulsed duration of CSA was chosen because less depth of injury was desired based on the significant response with the initial treatment. Increased numbers of CSA cycles are associated with greater tissue injury. Therefore the intent was a more intense treatment but with less depth of injury. Twenty-four hours later, the patient experienced odynophagia requiring oral narcotics for 3 weeks followed by the development of a stricture at one month post-CSA. This was treated with Savary dilation but has subsequently become a persistent esophageal stricture at that the site. Biopsies at the cancer site 6 weeks after the second cryoablation and bimonthly in the subsequent 12 months of follow-up were completely negative for dysplasia or neoplasia.
+The persistent esophageal stricture (Figure ) has required multiple dilations with various types of dilators (with and without corticosteroid injections) and temporary (3 month) esophageal stent (Polyflex簧 by Wilson Cook) placement. The patient continues to work and remains cancer free 24 months post-treatment."
+Mohammed Duarte,45,2000/3/9,+1-721-384-9987x4818,bethward@example.org,12121 Donald Loaf Suite 690,"A 53-yr-old male with T3N2M1 non-small cell left upper lobe lung cancer with bilateral brain metastases diagnosed one-month prior was referred for management of dyspnea and hemoptysis. The patient had noted a dramatic increase in dyspnea over the prior 3 days. Past medical history was unremarkable and he had a negative smoking history.
+Physical exam revealed reduced breath sounds in the left lower zone. Chest x-ray demonstrated a left hilar mass with loss of volume and post obstructive pneumonia in the left lower lobe (Figure ). Axial Computed tomography (CT) angiogram of the chest also revealed multiple segmental and subsegmental pulmonary emboli and the patient was admitted for anticoagulation with low molecular weight heparin (enoxaparin). The CT study also confirmed total occlusion of the left mainstem bronchus by a tumor invading from the left hilum (Figure ).
+After two days of anticoagulation, rigid bronchoscopy was performed using an Efer-Dumon rigid bronchoscope. Normal vocal cords, trachea, carina and right bronchial tree were confirmed. A large endobronchial lesion with complete occlusion of the left mainstem bronchus was identified (Figure ). After an unsuccessful attempt to pass the lesion using a pediatric video bronchoscope, debulking was attempted using a combination of polypectomy snare and electrocautery. There was still 100% obstruction of the airway from the residual tumor and therefore the ERBE argon plasma electrocoagulator簧 (APC) was utilized to devitalize the tissue. The devitalized tissue was then debulked using the Straightshot簧 microdebrider with rotating tip (Figures , ) and the bevel of the rigid bronchoscope. The length of the microdebrider is 45 cm and outer diameter is 4 mm. The rotating tip is controlled by a fly-wheel on the hand-piece, which allows for better maneuverability and is angled at 12 degrees providing better visualization. The blade was serrated and an oscillator mode was used at 1000??200 RPMs. In this manner the left main stem was recanalized and the channel was opened into the left lower lobe bronchus. Hemostasis was achieved using a combination of suction and APC with less than 20cc blood loss. Visual examination revealed that there was some degree of extrinsic compression in the left lower lobe bronchus as well; however, the superior segment bronchus and the basal segmental bronchi were noted to be patent. Post procedure residual obstruction in the left main stem bronchus was estimated at less than 20%. Since the left upper lobe had been completely replaced by tumor, a guidewire was then placed into the left lower lobe bronchus and a 4 cm ? 14 mm covered nitinol self-expandable metal stent was placed over the guidewire under direct vision into the left lower lobe bronchus. The stent was deployed under direct vision and adjusted in terms of its position using rat-tooth forceps. At the end of optimal positioning, the distal aspect of the stent was noted to be just inside the left lower lobe basal segmental bronchus with the superior segment being ventilated through the uncovered portion of the stent. The proximal aspect of the stent was noted in the left main stem bronchus well above the proximal extent of the tumor (Figure ). Follow-up chest x-ray (Figure ) revealed aeration of the left lower lobe with resolution of dyspnea and hemoptysis."
+Kynlee Walsh,42,1979/6/13,+1-410-498-7525x47860,sarahpeters@example.net,076 Hughes Land,"A 22-year-old lady was presented with an abdominal
+swelling?round a previous caesarian section scar?radually
+increasing in size for one year. In the last 2 days, it became
+tense, increased in size, and very painful. There was no vomiting
+or abdominal distention and she had normal bowl habits. She had
+mild fever but no otherwise significant symptoms. There was no
+past history of trauma or thorn prick injury to the site of the
+swelling and no other body swellings. She was not known
+diabetic or having any other chronic illness.
+On examination, she looked ill but not pale nor emaciated. Her
+pulse rate was 100 per minute, her temperature was 38簞C.
+Her abdomen was not distended; there was a subumblical midline
+scar. There was a swelling involving the umbilical region and
+encroaching the hypogastrium about 5 ? 8 cm, the swelling
+was tense, and did not increase in size with coughing, skin over
+it was normal. It was tense, tender, hot, firm in consistency, and
+nonreducible. There was no organomegaly and bowl sounds were heard
+normal.
+A provisional diagnosis of obstructed incisional hernia containing
+an omentocele was put and the patient was prepared for surgery.
+Her hemoglobin was 10.5 g/dl, her urine was clear, and her
+renal and liver function tests were within normal range.
+There was no peritoneal sac identified intraoperatively; instead a
+nodulated mass which involved the anterior and posterior walls of
+the rectus sheath together with the rectus abdominis muscle. The
+peritoneum was intact. On dissecting the mass, pus was found
+trickling from cavities containing black grains. The mass was
+excised with a margin of safety, the field was soaked with iodine
+tincture 2%, and the rent was closed. The patient was put on
+ketoconazole tablets 400 mg/d for 6 months to be followed in
+the referred clinic.
+Histopathological examination revealed macroscopically 4 masses of
+soft tissue measuring 1, 2, 4.5, and 4 cm. Microscopic
+sections showed grains of Madurella mycetomatis,
+surrounded by heavy neutrophilic inflammatory cells (type 1
+reaction)."
+Bodhi Lang,39,1985/4/14,+1-609-631-0671x2517,ogoodwin@example.net,098 Rodriguez Garden Apt. 919,"A 50-year-old lady presented with a rapid increase in the size of a thyroid swelling of 20 years duration associated with pain, fever, dysphagia, hoarseness of voice and stridor. She was toxic, pale (Hb = 7 gm%) and tachypnoic with engorged neck veins. There was a 5 ? 3 cm ulcero-proliferative growth in the region of the thyroid(fig. ). Indirect laryngoscopy was suggestive of a paralyzed left cord and fine needle aspiration cytology (FNAC) revealed pus with necrotic debris consistent with diagnosis of thyroid abscess. Ultrasonography and CECT(contrast enhanced computed tomography) neck were however suspicious of thyroid malignancy with cystic degeneration and pressure effects on trachea (fig. ). Chest radiograph/ultrasound abdomen and thyroid function tests were normal. In view of the pressure symptoms and suspicion of malignancy, the patient underwent surgery in the form of left hemi-thyroidectomy with drainage of abscess and central neck dissection.
+Gross examination of the specimen revealed a weight of 35 grams with a nodule measuring 3 ? 3 ? 2 cm with a thin capsule. The cut surface was grey-white with focal areas of purulent material. On histopathological examination polygonal tumor cells were seen adjoining an area of lymphocytic thyroiditis and focal necrosis. Squamous differentiation of tumor cells was seen as cellular keratinization and keratin pearl formation. There was marked pleomorphism of nuclei and occasional abnormal mitosis and no evidence of associated follicular adenoma/carcinoma or papillary carcinoma. The level VI lymph nodes showed squamous cells with necrotic changes. Staining with mucicarmine and PAS (periodic shiff test) were negative. Immunohistochemistry showed pancytokeratin positivity while thyroglobulin and calcitonin were negative. Histopathological diagnosis was squamous cell carcinoma of thyroid with metastasis to pre and para tracheal lymph nodes (fig. ).
+The postoperative period was stormy but she eventually recovered and was discharged on the tenth day. She received adjuvant radiotherapy (50 Gy) but succumbed to her disease within 7 months of her surgery."
+Amirah King,39,1991/1/28,001-488-209-6482x97962,woodsean@example.org,548 Donald Place,"A 60-year-old gentleman presented to the surgical emergency with difficulty in breathing, hoarseness of voice and stridor. He had undergone subtotal thyroidectomy for a non-toxic goitre 25 years previously at a remote district hospital. Emergency tracheostomy had to be done since he was in respiratory distress. There was a 5 ? 6 cm, hard, ulceroproliferative growth in the midline with hard, palpable lymph nodes in the pre and paratracheal region (fig. ). CECT head and neck revealed a thyroid growth infiltrating in to the larynx with metastatic (level-II, III, VI) cervical lymph nodes. No other site of malignancy could be detected inspite of an exhaustive battery of investigations including CECT (chest) and panendoscopy. Fine needle aspiration cytology from the swelling revealed a poorly differentiated squamous cell carcinoma of thyroid.
+Surgery in the form of wide local excision including the skin around the swelling and ulcer, total thyroidectomy with laryngectomy and resection of the anterior wall of pharynx was performed. Modified radical neck dissection (Type-I i.e. preserving internal jugular vein on left side) and radical neck dissection (on right side) along with central neck dissection were performed. In view of the skin and tissue loss the reconstruction was done using bilateral deltopectoral (DP) fasciocutaneous flaps. Histopathological examination of the specimen revealed squamous cell carcinoma of thyroid with anaplastic changes and clear margins. Postoperative period was stormy but the patient eventually recovered and received adjuvant radiotherapy (50 Gy) in fractionated doses. He however died of an acute attack of myocardial infarction nearly one year after his surgery."
+Julian Burke,36,1985/4/3,764-902-1517,tinabrown@example.net,597 Claire Junctions Suite 207,"A 58-year-old-male from an endemic zone of goiter (sub-Himalayan belt of north India) presented with a recurrent thyroid swelling which had been increasing in size rapidly for the past three months(fig. ). He had undergone subtotal thyroidectomy for goiter, 15 years back. He was in distress with engorged neck veins and stridor along with a midline 5 ? 5 cm ulcero-proliferative growth along and left cervical lymphadenopthy (levels-II, III, VI). The fine needle aspiration cytology of the swelling and the edge biopsy from the ulcer confirmed the diagnosis of squamous cell carcinoma of thyroid. No other site of the squamous cell carcinoma could be detected inspite of an exhaustive clinical and radiological/endoscopic evaluation. The patient was managed by curative wide local excision, including total thyroidectomy and left sided radical neck dissection. He received adjuvant radiotherapy (50 Gy in fractionated doses) and follow up of one year is satisfactory."
+Vera Hardy,26,1994/6/18,001-981-319-7663x811,xreed@example.org,347 Shelby Plains,"A 40-year-old para four obese Caucasian woman with two-year history of lower abdominal pain was referred from a peripheral hospital for the further management of bilateral adnexal masses. The computerised tomography (CT) scan of abdomen and pelvis revealed a complex cystic lesion of 7?? cm in the right adnexum and bilateral ureteric obstruction. All baseline blood tests including haematology and tumour markers (CA 125 -26 IU/ml) were normal. The serum tests showed normal liver function and moderately impaired renal function (creatinine 10??5, urea > 200).
+She had a complex medical history including obstructive sleep apnoea, asthma, glaucoma, hypothyroidism, hypertensive cardiomyopathy and bipolar disorder; registered disabled. She also had a copper intra uterine contraceptive device in situ for the past three years. Given her body habitus (BMI 42), abdominal and pelvic examination was difficult and non-specific. The only finding of relevance was bilateral adnexal fullness.
+She was managed within the gynaecological oncology multi disciplinary framework (MDT). On reviewing the CT films the features noted include bilateral basal pleural thickening, bilateral hydronephrosis, retroperitoneal lymphadenopathy associated with retroperitoneal fibrosis and bilateral adnexal cystic masses. There was a small volume of ascites.
+Magnetic resonance imaging (MRI) was performed for further characterisation of the adnexal masses. The right adnexal complex cystic lesion measured 8 ? 7 ? 7 cm in diameter and had a thick wall (up to 2 cm), which was irregular. There were several septations, some of which measured 3 ??4 mm. There were no enhancing papillary formations, although the wall and septa enhanced. The appearance suggested an ovarian lesion with possible involvement of the Fallopian tube. The left adnexal cyst measured 5 ? 6 ? 4 cm, had a smooth wall and contained a single thin septation, consistent with a benign ovarian cyst. Both cysts contained fluid, which was low on T1 and high on T2, with no evidence of fat or blood. Surrounding the cysts posteriorly, the fat was streaky in appearance and there was marked thickening of the adjacent fascial planes, with thickening of the mesorectal fascia up to 1 cm. The fascial thickening extended up the pre-sacral space and along the posterior aspect of the pelvic sidewalls, resulting in the obstruction of the ureters. Enlarged lymph nodes (up to 1.8 cm in short axis) were present along both pelvic sidewalls, which were striking due to the very high T2 signal intensity (Figure ). Nodes were also seen in the inguinal and para-aortic regions. Although the imaging appearances could not rule out an ovarian neoplasm, the features noted above were suggestive of an inflammatory process. In view of the woman's medical history and clinical status the MDT recommendation was clinical review and imaging guided biopsy of lymph nodes.
+The woman underwent CT guided right inter iliac node biopsy, following an unyielding biopsy of inguinal nodes. Histology revealed non-caseating granulomatous lymphadenitis with negative stains for acid-fast bacilli and fungi. There was no foreign body seen. Given the histological findings our attention was directed towards an inflammatory process. She was subsequently referred to respiratory physicians, with a working diagnosis of sarcoidosis. She was also referred to urologists for the management of retroperitoneal fibrosis and bilateral hydronephrosis. Abdominal pain prompted insertion of bilateral JJ ureteric stents. The physicians initiated a (step-down) course of prednisolone. Symptomatic improvement was observed but the renal function did not change. Repeat imaging demonstrated resolution of hydronephrosis.
+The woman was reviewed again clinically after the course of steroids. During this interval the physicians ordered an autoantibody screen as autoimmune disease can co-exist with sarcoidosis; the screen was negative (Rheumatoid factor, anti-DNA antibody and antinuclear antibody). On examination there was no evidence of any palpable lymphadenopathy. An ultra sonographic examination six months later demonstrated a bulky uterus and reduction in the size of the right adnexal cyst. Repeat imaging (MRI axial T2W image) a further two months later demonstrated resolution of the left adnexal cyst. There was a small residual cyst on the right and marked decrease in the thickening of the mesorectal fascia. The lymph nodes appeared normal (Fig ). The retroperitoneal fibrosis on imaging had resolved. Her CA125 remained normal. Currently the patient is under joint care between the respiratory and renal physicians with symptomatic improvement."
+Jayceon Delgado,26,1991/10/22,001-985-359-7859,smithjoanne@example.com,2062 Kevin Trafficway Suite 139,"An eight year old Malay boy, with a history of Henoch-Schonlein Purpura and G-6-PD deficiency, presented with left hand swelling and punctate rashes on the dorsum of his left hand, four hours following his transfer out from intensive care unit (ICU).
+The history dated back to two weeks prior to admission when he noted rashes on the dorsum of his feet and had intermittent, diffuse abdominal pain. He then developed migratory pain in his ankle joints, knee, elbow and small finger joints in that order. He refused treatment.
+He had no drug allergies. Developmental milestones were normal and immunization was complete.
+A week later, he was admitted to the general pediatrics ward for intermittent vomiting, severe generalized abdominal pain and passing red-current stools. The pain was constant, unrelenting and aggravated by solid food intake despite intravenous omeprazole (16 mg bd), metoclopromide (3 mg tds) and tramadol (30 mg 4 hourly). Rashes now developed on his left flank, buttock and medial aspects of both feet. He was febrile and micturation was normal.
+His vital parameters were as follows: BP 127/96, PR 99/min, RR 24/min and SpO2 97% on room air. Clinical examination revealed non-blanching purpuric rashes on the dorsum of his feet, left flank and buttock [Fig. ]. There was also localized tenderness on deep palpation of his left iliac fossa. Hematological, coagulation and renal profiles were within normal limits.
+Urgent transabdominal ultrasound did not show any ""pseudokidney"" or ""doughnut sign"" to suggest intussusception."" Peristalsis was normal. All intraabdominal organs were normal and there was no free fluid. There was, in the left iliac fossa, a bowel loop filled with echogenic material likely to be a stool.""
+Thirty-six hours later, he was admitted to the pediatric ICU owing to poor intake, severe per rectal bleeding and deteriorating general conditions. Fluid challenge with 300 mls of Ringer's Lactate solution and 2 units of packed red cell transfusion were given. Intra-arterial cannulation of the left radial artery was performed for continuous blood-pressure monitoring. Intravenous fluids, methylprednisolone (16 mg od), PCA morphine (bolus 0.5 mg, lockout at 15 mg), intravenous ceftriaxone (800 mg od) and metronidazole (120 mg tds) were administered.
+Following two days of stabilization, he was transferred out from ICU after the removal of his arterial line and urine catheter. Clinical examination in the morning showed diffuse, oedematous swelling on the dorsum of the left hand and all fingers with non-blanching purpuric rash restricted to an area 4 cm in diameter. There were no signs of fluid extravasations, inflammation or infection at the site of cannulation.
+An urgent Doppler ultrasound of the left forearm was performed to exclude a thrombo-embolic event. Both radial and ulnar arteries and corresponding veins were patent. Normal Doppler flow pattern was obtained within these vessels up to the level of cubital fossa.
+In the late afternoon, the whole left hand was swollen intensely, with extension of the purpura from the hand, up the wrist into the forearm. The metacarpophalangeal joints of all the left fingers were extended with flexion of all the distal interphalangeal joints. Capillary refill was normal. Emergency fasciotomy decompression of the dorsal [Fig ], thenar and hypothenar compartments [Fig ] of the left hand were performed. Serous fluid accumulation was noted in all compartments with marked tissue oedema. Additional hematoma was noted in the hypothenar compartment. The rashes and swelling subsided quite quickly and he was discharged uneventfully on the fifth post-operative day."
+Alani Chen,24,2003/5/31,+1-833-473-5585x50126,roconnor@example.com,5430 Powers Hills Apt. 868,"The patient was a 9 year old boy with Ewing Sarcoma initially diagnosed just before his 6th birthday. He underwent peripheral blood stem cell transplant. One year later he presented with recurrent disseminated disease and restarted chemotherapy and received radiation. He was also referred to the pediatric hospice program.
+His symptoms included lower extremity paralysis and significant weakness of the upper extremities. He developed a partial gastric outlet obstruction, which later resolved to the point that he was able to resume oral feeding, but had difficulty taking oral medications. At the time of treatment his weight was 23 kg.
+He had multiple pain complaints including headache, back pain and generalized arthralgia/myalgia. There was a particularly troubling bone pain involving his forearms, wrists and hands bilaterally. The arm pain was unpredictable, episodic and intense with aching and burning qualities. There were no shooting pains or electrical shock sensations, nor was there hyperalgesia or allodynia. Pain was assessed by verbal self-report as he did not want to use any of the standardized childhood pain scales, and by the nurse's assessment using the Canuck Place Comfort Assessment Tool.
+His pain was treated with continuous subcutaneous or transdermal fentanyl at 75 micrograms/hour. He had hydromorphone for breakthrough pain, 3 milligrams subcutaneously as needed every hour. Adjuvant analgesics included round-the-clock gabapentin and naproxen. He received lorazepam as needed and ondansetron and nabilone for nausea. PEG 3350 and docusate were used as laxatives. The above regimen achieved satisfactory analgesia for all his pains except for bone pain in the arms.
+The clinical team opted to try a bisphosphonate class drug for the bone pain. Selecting a medication route was a challenge; an indwelling vascular access device had been removed several weeks previously at the completion of chemotherapy. He refused to have a peripheral intravenous (IV) line placed because he found it uncomfortable and associated it with his previous unpleasant hospitalizations. Oral medications were considered, but with his recent history of gastric outlet obstruction, and his general reluctance (but not refusal) to take pills, this was not a reliable route. He refused rectal medications.
+We therefore opted for a subcutaneous route, which was acceptable to him. A dose of 300 milligram of clodronate (~15 mg/kg) was prepared in 40 ml of normal saline (7.5 mg/ml). It was infused subcutaneously over an 8 hour time period and vital signs were monitored. There were no side effects and the infusion did not cause localized pain. There was no subsequent bone pain exacerbation. Serum calcium levels 4 days post infusion were 2.3 mmol/L with an albumin level of 28 g/L. Four days after the infusion he reported the onset of relief of the bone pain in his arms. Functionally he was improved, for example being able to use a video game controller without pain and manipulate board game pieces. The Comfort Assessment Tool provided additional information that pain was improved. He required no increases in his other analgesics; because they were providing adequate relief for other pains he experienced we did not decrease them either. The analgesic effect lasted almost 4 1/2 weeks, when he again reported intense bone pain, and the 300 mg dose was repeated, with good results 4 days later. Thereafter he received regular infusions every 4 weeks, prior to the expected recurrence of pain.
+In order to minimize procedures in accordance with the emphasis on patient comfort, imaging studies were not obtained and laboratory studies were kept to a minimum. During this period he moved between home and hospice with readmissions for family care, respite and symptom management. He died peacefully at home 7 months after acceptance to the pediatric palliative program, and 19 days following his last clodronate infusion,
+When we decided to introduce a bisphosphonate because his extremity pain was not responsive to opiates or a series of adjuvant medications we were faced with the questions of which drug to use and by what route. Cancer-related bone pain is a particularly difficult symptom to treat. Bisphosphonates have gained acceptance as a standard approach to bone pain in adults. In the idealized scenario evidence exists to guide clinicians to the most effective drug with support for a dose and frequency. Similarly in the idealized scenario, the choice of medication route depends primarily on pharmacokinetic and pharmacy factors such as drug formulation. There is however a dearth of evidence regarding bisphosphonates in children, and controversy regarding dosing.
+The major effect of bisphosphonates is to decrease recruitment and function of osteoclasts and thereby reduce bone turnover. Bisphosphonates act via multiple mechanisms at the cellular and molecular level []. The initial widespread use of bisphosphonates was in Paget's disease in the late 1970's and early 1980's. Bisphosphonate therapy was extended to the treatment of a number of other adult conditions such as cancer associated with bone destruction and hypercalcemia.
+Noting the effectiveness in reducing bone turnover in a variety of adult conditions, bisphosphonates were then considered for use in children. Pamidronate is used routinely for children with Osteogenesis Imperfecta, given by IV. Since then bisphosphonate therapy has been trialed in a number of childhood diseases [,]. It should be noted, however, that none of the reports describe bisphosphonate use to treat malignancy-related pain in children. A recent publication describes treating two children with osteoporosis secondary to leukemia; however, there was no mention of pain [].
+Our patient expressed a strong preference not to have an IV. The oral route was not considered to be reliable. He expressed no objection to a subcutaneous line, having already experienced subcutaneous infusions for chemotherapy and analgesia. We therefore explored this route of administration for bisphosphonates.
+We reviewed the literature on bisphosphonates [Medline 1966??003] and engaged in email and telephone discussion with authors and expert clinicians in palliative medicine and pediatric endocrinology. []. The evidence was clear that pamidronate was safe and tolerable in children, but if given subcutaneously may have toxicities []. On the other hand, the best evidence for subcutaneous bisphosphonate infusions supported clodronate, but only for adults []. Zoledronic acid was also considered as it requires only a very brief IV infusion. There was no data, however, on its use in children; a subsequent report showed a high frequency of side effects in this population [].
+The only published report of clodronate use in children was by Zacharin and Cundy who gave it by IV infusion to a child with a genetic bone disease, osteoporosis pseudoglioma syndrome []. (An additional case report was published after we treated our patient []). The drug was well tolerated and helped to improve bone mineral density in their patient. These clinicians extrapolated from adult doses and used first 300 mg, then 600 mg, IV (10??0 mg/kg). [Personal communication. T. Cundy. Clodronate dosing [online]. Email to H. Siden () 19 Jan 2004].
+Because there were no reports on using clodronate to treat malignancy-related bone pain in children, we developed the regimen empirically. We relied on the dose reported by Zacharin and Cundy; in order to reduce fluid in the subcutaneous infusion, the maximum concentration described for drug preparation was used. The 8 hour infusion was chosen to minimize localized swelling; a shorter time period may work as well. We closely monitored our patient following the first two infusions and determined that 300 mg repeated every 4 weeks appeared to prevent pain recurrence."
+Emmanuel Sawyer,22,1988/12/24,460.498.7647x2746,michael68@example.net,1309 Debbie Glen,"The proband was a 63 year-old, Caucasian male who presented to the NCI Clinical Genetics Branch in October 2004 for evaluation of familial testicular cancer. He developed a left testicular pure seminoma at age 28 (per medical records; no pathology was available for review); he underwent a left radical orchiectomy followed by adjuvant cobalt irradiation to the retroperitoneum, and has remained free of testicular cancer.
+At his initial NIH visit, the patient reported resection of multiple colonic polyps on successive colonoscopies, beginning in his early 50 s. Materials from several excised polyps were reviewed at the NIH Laboratory of Pathology, and revealed a mixed polyposis of 5 adenomatous polyps, 2 hamartomatous polyps (Figure ), and multiple hyperplastic polyps.
+Physical examination revealed a muscular, mesomorphic white male (he is an avid body-builder) with multiple subcutaneous lipomas in the extremities and trunk. He had multiple dark brown to black, irregularly-shaped pigmented macules on the chest, back, arms, and legs, which were clinically suggestive of dysplastic nevi. Biopsy of the clinically most atypical lesion showed a simple lentigo, without melanocytic atypia. Protocol-related blood work, including testosterone, estradiol, chemistry panel, prostate specific antigen, alpha-fetoprotein, follicle stimulating hormone, luteinizing hormone, and beta-HCG, were normal. Ultrasound of the right testis showed early microlithiasis. Computed tomography of the chest, abdomen, and pelvis revealed an unexpected left inferomedial renal mass (Figure ), which was confirmed by MRI. Further evaluation of the left kidney mass was recommended, but not pursued due to other medical issues.
+He returned for a scheduled clinic visit one year later and reported having an elevated growth hormone (GH) level detected during a complementary/alternative health evaluation. The patient also stated that his head and hands had been ""getting bigger"". He reported taking various dietary supplements, none of which was found to contain androgens upon review of their ingredients, as well as testosterone gel, which was started at the time of his complementary/alternative health evaluation due to a low serum testosterone level. On examination, he had an acromegalic appearance, including protruding supra-orbital ridges, a prognathic jaw, wide nose, and diffuse soft-tissue thickening of the hands, all of which were judged clinically to be more prominent when compared with the year before.
+Laboratory studies demonstrated a normal fasting glucose, elevated levels of insulin-like growth factor-I (IGF-I) [943 ng/ml; normal range 71??90 ng/ml] and IGF binding protein-3 [8.4 弮g/ml; normal range 3.2??.6 弮g/ml]. A pituitary MRI revealed a hypoenhancing, diffusely-enlarged pituitary measuring approximately 2 cm, consistent with an adenoma (Figure ). A follow-up renal CT showed the left inferomedial kidney mass had grown compared with the study performed one year earlier; the adrenal glands were normal.
+On January 23, 2006, the patient underwent trans-sphenoidal resection of the pituitary mass, yielding a GH-producing adenoma. On February 22, 2006, he underwent a left nephrectomy for a stage III, poorly-differentiated renal cell carcinoma, with sarcomatoid features (Figure ). By November 2006, his growth hormone levels had returned to normal, and he had no evidence of recurrent kidney cancer.
+Detailed family history review revealed a son with seminoma (confirmed by outside pathology report) at age 34 (cancer-free at age 36), and a sister who developed urinary bladder cancer (death certificate confirmation) at age 53. His son had no evidence of lipomatosis or multiple lentigines on examination at the time of study enrollment, and has had a negative screening colonoscopy. The proband's father was reported to have lipomatosis, but was deceased. There is no history of other benign or malignant neoplasms reported in the rest of the family.
+Based on his personal history of multiple cancers, a pituitary adenoma, multiple pigmented skin lesions, multiple lipomas, and multiple colon polyps with varying histology, the patient underwent genetic testing for Cowden syndrome (the PTEN gene), Carney complex (the PRKAR1A gene), and multiple endocrine neoplasia syndrome type 1 (the MEN1 or menin gene). No germline mutations were detected in any of these genes."
+Marina Sosa,41,1981/9/10,(664)969-8004x528,ksmith@example.com,16466 Ashley Drive,"A 50-year-old female presented with complains of painless progressive swelling in right cheek region of two months duration. Examination revealed a 6 ? 4 cm bony hard swelling in right zygomatic region near and below lateral canthus of right eye (Figure ) Roentgenogram of the paranasal sinuses showed a lesion arising from right maxilla and right zygoma. Computerized tomographic (CT) scan revealed two separate masses one in right orbit and other infiltrating zygoma and maxilla (Figure ), radiographic picture was suggestive of osteogenic sarcoma or Ewing's sarcoma. A fine needle aspiration was carried out that showed typical polygonal and spindle cells with moderate amount of cytoplasm and vesicular nuclei with nucleoli, many with intracellular pigment; seen singly and clusters, the picture was suggestive of malignant melanoma (Figure ). The ophthalmologic consultation revealed that there was no useful vision in the right eye. A B-scan of the right eye showed an organized mass within the vitreous cavity indicating vitreous haemorrhage (figure ). A detailed clinical examination failed to show any other melanocytic lesion on skin and other mucus membranes.
+With a provisional diagnosis of melanoma of the maxilla and zygoma with vitreous haemorrhage and no useful vision in right eye a wide excision of the lesion including anterolateral maxillectomy, zygomectomy, and removal of superolateral wall and floor of orbit with en bloc exenteration of the right eyeball was carried out (Figure ). Histopathological examination of the resected eyeball specimen showed a neoplasm in choroid, filling posterior chamber with no extraoccular extensions, composed of sheets, nests and cords of polygonal cells and vesicular nuclei. Prominent nucleoli and eosinophilic cytoplasm containing abundant melanin pigment were noted (figure ). Similar tumours were seen in the extra ocular soft tissue and resected maxilla and zygomatic bones. A final diagnosis of choroidal melanoma metastasizing to maxillofacial bones was made. Differential diagnosis of primary bone melanoma with metastasis to choroids was kept.
+Surgical excision was followed by 40 Gy./15 fractions of radiotherapy to right face using lateral portal. Patient is on regular follow-up two years after surgery and is free of any local or systemic recurrences."
+Emir Reyna,41,2004/4/11,986.583.6154,plopez@example.net,62657 Hannah Park,"A 40-year-old woman with a diagnosis of bipolar illness presented in an acute manic state. Previous but not current medication included depot clopixol and lithium. There was recent usage of heroin and other illicit drugs. Current dosage of diazepam was 80 mg/day. After admission 2 doses of clopixol acuphase (75 and 100 mg respectively) given over 5 days had little effect other than some sedation. Immediately prior to being given IM olanzapine 10 mg her behaviour was loud, over familiar and intrusive. The patient requested an IM sedative and was not detained under the Mental Health Act (MHA). Neither concomitant benzodiazepines nor anticholinergics were given. PANSS-EC scores shown in table . The nursing staff reported the patient as being much ""quieter"" but not asleep after 60 minutes. Following a single dose of intramuscular olanzapine, depot clopixol was reinstated with valproate. No adverse events were reported."
+Luella Velazquez,26,1993/12/18,6435863237,amandafigueroa@example.net,222 David Causeway,"A 28-year-old woman with a diagnosis of schizophrenia presented in a psychotic and uncooperative state refusing medication. Medication prior to admission was 800 mg quetiapine and 1 mg lorazepam daily. Her behaviour became overtly aggressive including making a hole in the hospital bedroom wall and attempted assaults on staff. She was placed under the MHA and given IM olanzapine 10 mg. Neither concomitant benzodiazepines nor anticholinergics were given. PANSS-EC scores shown in table .
+Nursing observations showed that the patient was asleep after 120 minutes post-IM (01.00) and remained ""quieter and more relaxed for the next 2 days"". Patient feedback was that she felt calmer after IM olanzapine. No adverse events were reported by the patient or physician. Patient however continued to refuse oral medications and currently receives depot risperidone."
+Drew Barnett,35,1980/3/5,477.928.7927x688,pduran@example.net,1795 Butler Radial Apt. 906,"A 49-year-old woman with a long standing history of bipolar affective disorder presented in a mixed affective psychotic state having had no relapses for 2 years. Her previous medication regimens included citalopram, lithium, valproate and lamotrigine. At admission her medication was lamotrigine 100 mg. Her behaviour was reported as ""aggressive, confrontational and entertaining beliefs suggestive of delusional jealousy and suspiciousness about family"".
+Oral medication was refused and the patient was sectioned under the MHA. IM olanzapine 10 mg was given and no concomitant benzodiazepines or anticholinergics were administered. Nursing staff reported a moderate degree of tranquilisation (calm, relaxed and not sleeping) and that confrontation was avoided. Little effect upon delusional beliefs was noted. The patient began to engage with staff within 36 hours post IM olanzapine and at which stage oral olanzapine was accepted. No adverse events were reported."
+Harlow Webb,44,2003/8/8,+1-979-658-7522x538,stanleysamantha@example.com,4624 Blevins Gardens Apt. 590,"An 18-year old male with a diagnosis of schizophrenia was admitted in an acutely psychotic state under the MHA. He refused oral medication and presented in an extremely agitated state expressing paranoid delusions such as ""people have put fish bones in my food"". He was not currently on medication (although previously had received olanzapine 10 mg orally) and was known to have used illegal substances in the past. There was an additional forensic history. He was treated with 10 mg olanzapine IM and the nursing notes state, ""he soon went to sleep"". Around 12 hours later he became agitated again and barricaded himself in his room. He was given 10 mg olanzapine IM and 2 mg IM lorazepam. The nursing notes report that within 30 minutes he was ""settled"" and had ""calmed down"". Around 2 hours post-injection he was asleep. Subsequently he was transferred onto olanzapine 20 mg orally. No adverse events were reported."
+Lorenzo Long,28,1984/7/3,(631)581-4627x666,emcdowell@example.com,9575 Robin Brooks,"A 65-year old male with a diagnosis of schizoaffective disorder was admitted under the MHA in an extremely agitated state and expressing suicidal ideation. There was evidence of persecutory delusions. Around midnight he received 10 mg olanzapine IM. No benzodiazepines were administered. The nursing notes report that he ""slept well"" and ""settled"" soon after medication. No concomitant benzodiazepines were given. No adverse events were reported."
+Jade Henry,22,1981/6/16,840.761.0354x50994,johnsonbradley@example.org,87006 Sean Squares,"A 40-year old female with a diagnosis of bipolar disorder was admitted in an acutely manic state. Her normal medications included olanzapine 20 mg and sodium valproate. The nursing staff report that she was ""restless, agitated, verbally aggressive and had evidence of an elevated mood"". She was treated with 10 mg olanzapine IM. The notes report that she settled after medication and ""slept undisturbed"". No benzodiazepines were administered. Within the first 24 hours after IM olanzapine she was commenced on depot clopixol 200 mg/weekly. No adverse events were reported."
+Carlos Parks,31,2002/9/12,(932)226-3559,stewartamanda@example.net,8344 Jennifer Shoals,"A 46-year old male with a 10-year history of schizophrenia was admitted in an acutely psychotic state. He had relapsed having been changed from IM depot haloperidol to risperidone LAIM. For the 2 weeks prior to admission he had received additional oral risperidone and sodium valproate He had showed features of paranoid and grandiose delusions together with elevated mood and had been asked to leave work, as ""colleagues could not understand his talk"". On admission, he was given a single injection of IM olanzapine 10 mg at around 18.00. No concomitant benzodiazepines were administered. The nursing reports state that ""later that night he was no longer laughing without reason and was quiet. He slept well"". The response was not maintained and he was reported as grossly psychotic again at midday the next day. No adverse events were reported."