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zhengyun21

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PMC-Patients

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3941733-1

noncomm/PMC003xxxxxx/PMC3941733.xml

Large Thoracolumbar Extradural Arachnoid Cyst Excised by Minimal Skipped Hemilaminectomy: A Case Report

A 43-year-old man presented with back pain and radiating pain of both legs for 5 years. The symptoms had developed over last 1 year. Neurologic examination revealed mild voiding difficulty. There was no history of trauma, lumbar puncture, any surgery and spinal infection. Plain radiography and computed tomography (CT) of thoracolumbar spine revealed thinned pedicles, increased diameter of spinal canal, and posterior scalloping of the vertebral bodies at T10 to L1. Magnetic resonance imaging (MRI) demonstrated a large extradural cystic lesion at T10-L1 levels with extension into the foramen and extra-foramen. The cystic lesion was iso-intense compared with CSF on T1 and T2-weighted images and no enhancement after gadolinium administration was showed (). The preoperative diagnosis was spinal extradural arachnoid cyst. Because the closure of dural defect is important for prevention of recurrence, the preoperative radiologic studies were performed to detect the dural defect. First, cine-MRI and magnetic resonance (MR) myelography were performed. We were not able to confirm the communication site by cine-MRI and MR myelography. Additionally, CT myelography was performed. It showed contrast medium leakage at T12 vertebral body lower margin (). This finding provided an evidence of a communication between the extradural cyst and normal subarachnoid space. We could localize the communication site between the cyst and subarachnoid space before the operation.\nFirst of all, right hemilaminectomy was performed from low part of T11-upper part of L1 for exploration of the communication site. A huge epidural arachnoid cyst was exposed and outer wall was incised. The yellowish cyst fluid was expelled. The cystic mass was easily separated from the dorsal thecal sac. Then, additional hemilaminectmy was performed at T10 and upper portion of T11, leaving two third of T11 lamina. The upper margin of the cyst was exposed and separated from the dura sac. Without partial resection, the separated upper part of the cyst was passed beneath L1 lamina and continually separated. But, cystic wall extending to right foramen of T11/12 was not separated due to adhesion with surrounding tissue. So, the cyst was excised, leaving small remnant at right foramen of T11/12. After removing the cyst, we found a small dural defect and CSF leak at the dorsal thecal sac at T12/L1. After repairing the defect with primary suture, the site was sealed using fibrin glue. There were no post-operative complications. The patient's pain improved rapidly. After 10 days, the patient was discharged. At 1 year after the operation follow up, CT and MRI demonstrated no recurrence (). Dynamic plain X-ray revealed no instability and kyphotic deformity.

[[43.0, 'year']]

M

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{}

3941734-1

noncomm/PMC003xxxxxx/PMC3941734.xml

Redundant Nerve Roots of Cauda Equina Mimicking Intradural Disc Herniation: A Case Report

A 50-year-old man who worked at a rice-cake shop has suffered from increasing low back pain and radiating pain on his left leg for five years. He had a nerve root block on L5 level five years ago, and the pain subsided temporarily. He was having conservative treatment but mild chronic pain still lasted and gradually aggravated and abruptly extended to the right leg a few days before his admission. Radiating pain was on posterior and lateral aspect of the leg and toe.\nHe had no significant medical history or trauma history of spine. But he has been lifting heavy things repeatedly at work. A neurological examination revealed no paresthesia or motor weakness. A straight leg raise test was positive on the left side and the bilateral knee and ankle jerk was normal. Micturition and defecation were not disturbed.\nSagittal and axial T2-weighted magnetic resonance image reveals broad base central disc protrusion at L4-5 level, and about 0.7×0.5×2.5 cm sized ovoid nonenhancing lesion in dorsal aspect of L5-S1, which seemed to be intradural disc herniation rather than intradural mass (). Although the image clearly demonstrated neither the classical ring enhancement of the intradural fragments on gadolinium contrast MRI or discontinuity of the PLL disrupted at the disc level, this finding was thought as an intradural disc herniation rather than an intradural extramedullary (IDEM) tumor such as meningioma. CT myelography showed central disc herniation at L4-5 and intradural lesion looked like intradural disc or intradural mass within the thecal sac below L4/5 ().\nA decompressive laminectomy was carried out at L4-5 levels and a herniated disc at L4-5 was removed. And we found the fragments of ruptured disc and adhesion with the dura. To determine whether there was a coexisting intradural disc rupture, we carried out an intradural exploration. After durotomy, a long, edematous and tortuous nerve root had forced out through a dural incision (). We explored the thecal sac, but there was no other intradural abnormality such as intradural disc herniation or intradural mass.\nAfter rearrangement of RNRs of the cauda equina to be released from the tangled position, the dura was carefully closed without tension.\nThe radiating pain was improved immediately in the postoperative period. The patient made an uneventful recovery and returned to normal activities. One year after surgery, he had no further pain.

[[50.0, 'year']]

M

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{}

3941735-1

noncomm/PMC003xxxxxx/PMC3941735.xml

Asymptomatic Cervical Isthmic Spondylolisthesis and Associated Occult Spinal Bifida: A Case Report

A 23-year-old female suffered from a hyperextension injury to cervical spine after a traffic accident. Following this injury, she experienced mild to moderate degree of nuchal and back pain. She had no neurological symptoms or signs. There was no history of significant illness or trauma in the past.\nPlain radiograph of the cervical spine showed bilateral pars interarticularis defect at the C6 level with cleft-bow-tie configuration, hypoplastic pedicle, grade I spondylolisthesis of C6 on C7 and spinal bifida at C6 (). Computed tomography of the C6 vertebrae showed bilateral corticated defects of the C6 articular mass, bilateral hypoplastic pedicles, lamina and spinal bifida of C6 and apparent neural foraminal enlargement at C6-7 (). The magnetic resonance image of spine showed grade I spondylolisthesis C6-7, degenerative change of C6-7 disc and acute compressed fracture at 4th thoracic vertebrae. She was subjected to controlled flexion-extension views of the cervical spine, which confirmed stability of the segment with less than 10 degrees of anterior angulations (). The cervical spine was stable on lateral flexion and extension radiography.\nShe was treated with the semihard-orthosis brace immobilization for 8 weeks followed by repeated lateral cervical spine radiography. After 10 months to injury, she was symptom free with full range of motion of cervical spine.

[[23.0, 'year']]

F

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{'6743699-1': 1}

3941751-1

noncomm/PMC003xxxxxx/PMC3941751.xml

Spinal Epidural Hematoma Related to Intracranial Hypotension

A 45-year-old female was admitted to the hospital after complaining of an orthostatic headache and cervical pain the day before. The headache occurred whenever the patient was in a sitting or standing position, but not in a supine position. She did not have a history of trauma. She was alert and did not have other neurological symptoms. There were no abnormal findings in the brain MRI.\nThe day after the patient's hospital admission, she had sudden quadriplegia and paraesthesia. The motor grade of her lower extremities was 0, and that of her upper extremities was I. The pain and high temperature on both sides were reduced, and the patient recovered with a motor grade of 3 in her upper and lower extremities. C-spine MRI was taken, and SEDH was suspected because isointensity was observed in the T1-weighted image of the epidural space from C2 to T2 while hyperintensity was observed in the T2-weighted image of the same ().\nAngiography was performed to rule out any vascular abnormality, such as arteriovenous malformation. Its result was normal. An emergency left hemilaminectomy from C4 to T1 was performed to remove the hematoma, and controlled the bleeding. During the operation, engorged epidural veins were observed, and the dura was not damaged during the operation. After the operation, the patient recovered completely from motor and sensory deficits. 6 day after surgery, myelography and computed tomography (CT) were performed due to the CSF leakage in the wound. As a high density was observed from C3 to T3 (), lumbar drainage was performed. During the lumbar puncture, the opening pressure was too low to be measured, and the lumbar drainage was minimal. The patient was treated for two weeks, for stabilization. There was increased epidural fluid collection at C2 to T3 in the spinal CT(). Second operation was thus performed, and there was no leakage at the dorsal part of the dura but there was some leakage at the C5-6 ventral part that was not found at the 1st operation. The dura defect was covered with collagen sponge (Gelfoam) and fat tissue, and sealed with adhesive sealant (Tisseel). The symptoms disappeared, and no CSF leakage was found in the follow-up myelography and spinal CT. The patient was discharged without deficits.

[[45.0, 'year']]

F

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{'6502287-1': 1, '4199149-1': 1}

3941752-1

noncomm/PMC003xxxxxx/PMC3941752.xml

Traumatic Intradural Lumbar Disc Herniation without Bone Injury

A 52-year-old man presented at the hospital with numbness in his left calf and ankle after falling accident two days ago. The patient was initially admitted at another medical center after the accident but transferred to our hospital at his request. A motor power grade was intact with slightly decreased sensation along the left L5 dermatome. The patient did not have back pain. Bladder and bowel functions were intact, and no other significant abnormalities were found upon neurological examination.\nIn his medical history, he had visited our hospital six weeks ago with complaints of radiating pain in his right leg along the L5 dermatome after falling down from 2m height. At that time, his lumbar spine magnetic resonance image (MRI) scan exhibited diffuse bulging intervertebral disc in L4-5 (). The patient had received a conservative treatment with a non-steroidal anti-inflammatory drug and discharged with the improvement of symptoms.\nAt this time, the patient's plain radiography did not present bony abnormalities such as fractures or dislocations. In his lumbar computed tomography (CT) scan, a small calcified lesion was found at the L1-2 level, posterior to the disc (). On his lumbar T2-weighted MRI, a high signal intensity with an amorphous shape lesion was located intradurally and it compressed the spinal cord anteriorly at the L1 level (). In his gadolinium-enhanced MRI, the lesion exhibited mild rim enhancement () and it presented heterogeneous low signal intensity in the gradient echo (GRE) image (). We considered the lesion to be a spinal SDH, and decided to perform a conservative treatment. At the follow up MRI scan after two weeks of treatment, the lesion still remained unchanged without any improvement of numbness, so we decided to operate.\nA subtotal laminectomy was performed at L1, which revealed an out-punching whitish soft particle on the dorsal dura. The particle was thought to be a ruptured disc material and removed gently, then sent for pathology. The pathologic results determined the particle to be degenerating fibrocartilagenous tissue corresponding to an intervertebral disc. After removing the extradural lesion, a midline durotomy was done from the dura defect uncovering large, cartilaginous disc particles in the middle of the intradural space (). After removing the disc particles, a hard bony lesion remained adhesively to the ventral dura and a small ventral dura defect was identified around the bony lesion (). The hard bony lesion was thought to be a calcified lesion at the posterior L1/2 intervertebral disc in his lumbar spinal CT scan. We tried to repair the dura defect to protect a leakage of cerebrospinal fluid (CSF), but the ventral dura tear could not be repaired due to its severe adhesion. A watertight closure on dorsal dura was performed. After the operation, the patient's numbness in his left leg has gradually improved. Two weeks after surgery, the patient was discharged from the hospital with free of symptoms.

[[52.0, 'year']]

M

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{'4844658-1': 1, '3372551-1': 1, '7035050-1': 1, '3295378-1': 1, '3467376-1': 1}

3941753-1

noncomm/PMC003xxxxxx/PMC3941753.xml

Giant Anterior Cervical Osteophyte Leading to Dysphagia

A 56-year-old man presented with increasing dysphagia, dysphonia, moderate neck pain and neck stiffness. The patient had no history of trauma to the neck. Physical examination of the neck showed a non-tender and hard mass on the left side at the level of C4-5. Neck motion was decreased. And neurologic examination was normal. Routine blood tests were also normal. Plain radiographs of the cervical spine showed extensive ossification at the anterior longitudinal ligament along the left anterolateral aspect of the vertebral bodies from C2 to T1, especially prominent at C4-5, suggesting DISH. Linear breakage of the ossification is noted at C4-5 (). In radiographs of the thoracic and lumbar spine, multiple bony spurs were identified, too. There was no definite radiographic instability on the cervical dynamic view. Cervical computed tomography (CT) confirmed the giant anterior osteophyte (). Barium contrast swallow cinematography revealed a filling defect along the pharynx with lateral displacement of the esophagus due to giant anterior osteophyte ().\nThe patient underwent surgery with a left-sided anterolateral cervical approach to the spine. The prevertebral fascia was separated and the trachea and esophagus were retracted on the right side, with the carotid sheath on the left side. The C4-5 level was exposed. The giant anterior osteophyte was removed with rongeurs and a high speed drill until the anterior spinal surface from C3 to C6 was flat. All cervical segments except C4-5 were fused due to DISH. We perceived the C4-5 segment to be unstable. So we removed the disc of C4-5 and performed C4-5 interbody fusion using an allograft mixed demineralized bone matrix (DBM) and anterior cervical plate. After several days, we performed posterior screw fixations from the C3 level to the C6 level. A postoperative lateral plain cervical spine radiograph demonstrated removal of the anterior cervical osteophyte at C4-5 ().\nAfter the surgery, the patient was mobilized with a collar. Immediately following surgery, dysphagia was improved. The postoperative barium contrast swallow cinematography demonstrated improvement of the filling defect along the pharynx due to removal of the ossified anterior longitudinal ligament (). The patient was discharged without any complications through postoperative ten days. One year later, cervical CT showed bony fusion at C4-5 bodies and no recurrence of anterior cervical osteophyte (). The patient did not complain about the dysphagia.

[[56.0, 'year']]

M

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{'7792880-1': 1, '5227134-1': 1, '5928235-1': 1, '5835278-1': 1, '4522454-1': 1, '5482169-1': 1}

3941754-1

noncomm/PMC003xxxxxx/PMC3941754.xml

Delayed Esophageal Perforation after Cervical Spine Plating

A 43-year-old man was admitted to our institute with a 3-month history of dysphagia and neck pain with swelling. He was paraplegic due to a C6-7 fracture and dislocation and has been operated on 8 years previously. Initial surgical treatment included anterior corpectomy of C7 and anterior iliac crest graft placement using a plate and screws. Hematological studies including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were normal. A simple lateral radiograph and a computed tomography scan showed partial anterior migration of the lower screw. A hydro-soluble contrast swallow image confirmed esophageal perforation (). The protruding screw was observed during emergent esophagoscopy (). Surgery was scheduled for removal of offending screw. The loose screw was removed and esophageal perforation was found during surgery and repaired directly by a cardiovascular team(). The patient was fed using a nasogastric tube for 3 weeks and subsequently oral feeding was gradually resumed. Further progress was favorable, and a contrast study performed at 3 weeks postoperatively showed no evidence of fistula.

[[43.0, 'year']]

M

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{'6763670-1': 1, '5565498-1': 1}

3941756-1

noncomm/PMC003xxxxxx/PMC3941756.xml

Surgical Treatment of Lumbar Hyperextension Injury in Ankylosing Spondylitis

A 43-year-old man was admitted for severe low back pain after slipped down on the icy roads. He had a history of AS. Findings from the physical examination consisted in tenderness to palpation of the lumbar spine at L1. The neurological findings were normal. Plain radiographs of the lumbar spine revealed a bamboo spine typical for AS, with a visible fracture line in the L1-2 spine. A whole spine computed tomography (CT) confirmed the presence of a transcorporeal bony fracture of the L2 lumbar spine. By magnetic resonance imaging (MRI), the T2 sequence disclosed high signal intensity from the body and neural arch of L2, consistent with a recent fracture. MRI also demonstrated injury of posterior interspinous ligaments and there was no thecal compression and cord signal change (). This fracture in a patient with AS involved all three spinal columns and was therefore considered unstable. We decided to perform the surgical treatment due to highly unstable fracture condition.\nPreoperative evaluation was done for general anesthesia. He had cardiovascular and pulmonary disease; aortic regurgitation, mitral valve disease and fibrous disease in the lung apex. We had to consider the patient's medical disease. When performing intubation, we did it fiberoptically in the awakening state due to typical kyphotic bamboo spine.\nAt first, we performed the posterior fixation of T12, L1, L2, L3. Post posterior surgical management, the disalignment was detected on L1-2 in the plain radiography. After that, we did anterior approach using the expendable cage. Performing combined posterior and anterior approach, the patient showed left lower extremity weakness in hip flexion of grade 2 and left knee extension of grade 1. From the retrospective review, we noticed that disalignment at the fracture site was happened in prone positioning for posterior fixation. Postoperative computed tomography revealed that the left L2 root was compressed between disaligned lamina and pedicle (). The patient was put under absolute bed rest and administrated intravenous steroid. On the first postoperative day, we performed root decompression and the patient showed improvement on the neurologic examination as the motor grade 3 of Lt. knee extension and hip flexion. After 2 days of absolute bed rest, the patient received rehabilitation treatment with the aid of orthosis for two months. On the follow-up radiographs obtained 1 and 2 months after surgery, the cage subsidence was shown gradually. But the cage subsidence was not aggravated after the last 2 months radiographs.

[[43.0, 'year']]

M

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{'7192799-1': 1, '4949174-1': 1}

3941759-1

noncomm/PMC003xxxxxx/PMC3941759.xml

Mid-term Clinical Outcomes of Stand-alone Posterior Interbody Fusion with Rectangular Cages: A 4-year-minimum Follow-up

Fourty nine years old male who complained with left leg pain had disc herniation at lumbar 4-5 level and underwent PLIF with CC cage (). Height of disc space was 9.5mm before surgery and height rise up to 12 mm. After a year, height slightly decreased to 11 mm and the height maintained in 10 mm during 7 years of follow-up. Segmental lordosis before surgery was 13.5° which merely changed after surgery. But after 7 years it decreased to 7°. Total lordosis before surgery was measured as 42.9° which decreased in 33° after surgery and changed minimally till 7 years of follow-up. His VAS score decreased from 9 to 2 and excellent in Odom's criteria.

[[49.0, 'year']]

M

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{'3941759-2': 2}

3941759-2

noncomm/PMC003xxxxxx/PMC3941759.xml

Mid-term Clinical Outcomes of Stand-alone Posterior Interbody Fusion with Rectangular Cages: A 4-year-minimum Follow-up

Sixty one year-old lady suffered from her both buttock and leg pain for 20 years. Her symptom aggravated since 2 years before admission, and diagnosed to have spinal stenosis at lumbar 4-5 level. She underwent discectomy with OIC cage insertion (). The Disc height was improved from 8.3mm to 11 mm after surgery. After a year, height slightly decreased to 9 mm with suspicion of subsidence and the height maintained in 8 mm during 8 years of follow-up but had Grade I spondylolisthesis. Segmental lordosis before surgery was 15° which have decreased to 13.3° after surgery and increased to 18° in 8 years of follow-up. Total lordosis before surgery was measured as 44.8° which decreased in 42° after surgery and gradually increased to 50° after 8 years. Her VAS score before surgery was 8 for back pain and 5 for leg pain which decreased to score 0 for both. With confidence, excellent result in Odom's criteria.

[[61.0, 'year']]

F

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{'3941759-1': 2}

3941760-1

noncomm/PMC003xxxxxx/PMC3941760.xml

Acute Spontaneous Cervical Epidural Hematoma Mimicking Cerebral Stroke: A Case Report and Literature Review

A 68-year-old female presented with sudden onset posterior neck and right shoulder pain with progressive right side weakness while falling asleep. During consult, she had reported taking anti-hypertensive medication for 20 years and was followed regularly for hepatitis C. She reported no trauma history or physical exertion for the past few weeks. Neurological examination resulted in alert mental status and the detection of right hemiparesis. Motor power of her right upper limb was grade III and ipsilateral hand grasping power was grade II. In her right lower extremity, motor power was grade IV, and her left whole extremities were intact. Right side hypoesthesia was also observed. Based on her medical history and clinical symptoms, the physician working at the emergency department ordered brain CT to rule out intracranial hemorrhage. However, brain CT did not show any positive findings (). Subsequent brain diffuse MRI was taken to rule out cerebral infarction, but it was also negative (). Cervical MRI was performed to rule out a cervical lesion based on the patient's report of posterior neck pain and revealed a mass like lesion in the right posterior epidural space at the C3-6 level compressing the right side of the spinal cord. The mass was isointensive to the spinal cord on T1WI and heterogeneously hyperintensive with central high signal foci on T2WI. At the C5 level, the MRI showed an ovoid, enhancing, nodular lesion, which was a suspected tumorous condition such as hemangioma or hemangiopericytoma (). Initial laboratory tests showed only severe thrombocytopenia (45,000/mm3). As her neurologic signs were getting worse with time, we decided to perform surgical intervention. Under general endotracheal anesthesia via light wand intubation, right C5 unilateral total laminectomy and C6 partial hemilaminectomy were performed. The mass lesion was pure hematoma and was removed (). We could find neither vascular malformation or an active bleeding point. She went into rehabilitation after her operation and finally achieved complete neurologic recovery and relief of neck and shoulder pain.

[[68.0, 'year']]

F

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{'3611058-1': 1, '6417315-1': 1, '8558013-1': 1}

3941761-1

noncomm/PMC003xxxxxx/PMC3941761.xml

Combined Chronic Occipito-atlantal and Atlanto-axial Rotator Fixation with Cerebral Palsy

A fifty-one year old man who had fallen down 16 years ago was transferred from department of neurology because of severe pain, neck stiffness, torticollis, tilt head and ambulation difficulty by keeping holding up the head with the right hand. On physical exam, there was left side 40° tilt. 30° of rotator to the right (), and he held up his chin on his hand because of the weight of head and fixed wry neck. He could not rotate it to the left side. There were no neurological deficits except diplegic cerebral palsy, athetotic type left side dominant.\nCervical computerized tomography (CT) and Magnetic resonance imaging (MRI) confirmed the occipito-atlantal and atlanto-axial rotatory fixation (). Conservative treatments such as botulinum toxin injection for 3 months were not effective in relief of symptom. We didn't perform traction because we thought it wouldn't be effective for his chronic state. Further conservative treatment plan was established and a halo vest was applied to the patient. During 2 months of halo vest appliance, he showed good compliance. But, halo vest fixation was not maintained after 60 days. Because pain was developed over time, he removed it. After that, skull fracture and pneumocephalus with hemorrhagic contusion were presented in brain CT scans. After confirming the absorbed pneumocephalus with hemorrhagic contusion in brain CT scans, we revised halo vest and finished using intravenous antibiotics. But he did not overcome headache and removed it again by himself one more time. Compared with the previous halo vest immobilization, there still remained torticollis in C-spine X-ray. The head is badly rotated on the right side and tilted on the left. He can hardly maintain this position less than 3 minutes devoting his strength. After 3minutes, he has to support his head with his hand. So we decided to operate using occiput-C1-C2 arthrodesis and C3-4-5 bilateral screw fixation for reinforcement to correct undesirable turning head because of spasmodic torticollis (). After the operation, we tried to make halo vest again for stability during 100 days. He was discharged from our hospital with plentiful of satisfaction about postoperative state after removal of all outer devices.\nOne year after the operation, he complained of headache in occipital area, we made C-spine X-ray and found occipital plate loosening. So we performed re-fixation of occipital plate and screw. After the re-fixation, we have monitored him for 2 years and not found any complication (). Now he doesn't have neurologic deficit and shows good outcome enough to sustain his head, not using his hands, in his daily life.

[[51.0, 'year']]

M

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{'3275470-1': 1}

3941764-1

noncomm/PMC003xxxxxx/PMC3941764.xml

Cervical Myelopathy Secondary to Atlanto-occipital Assimilation: The Usefulness of the Simple Decompressive Surgery

A 36-year-old male presented himself with a one-month history of numbness of all his fingertips in his left hand, hypesthesia, posterior neck pain, and left shoulder pain. The neurological examination upon his admission revealed marked restriction in the range of the left forward bending motion of his neck due to an electrical sensation that was running down his back and into his limbs (Lhermitte's sign) and that included a positive Hoffmann's sign.\nCervical plain film radiography and computed tomography (CT) revealed partial circumferential fusion of the anterior and posterior C1 arches with the basilar part of the occipital bone (complete anterior fusion and partial, asymmetrical posterior fusion) and incomplete block vertebrae on C2-3 (C2 vertebral arch and C3 lamina fusion on the left side) (). Cervical magnetic resonance imaging (MRI) revealed high signal intensity in the spinal cord on the T2 weighted images, which indicates spinal distress caused by the encroachment of the left C1 posterior arch and the left C2 vertebral arch on the neural canal (). The patient's symptoms were regar ded as the consequence of the encroachment of the bony element on the neural canal. There was also no occipitocervical instablility. Thus, the patient underwent posterior surgery for partial removal of his C1 left posterior arch and his C2 left vertebral arch to decompress his thecal sac.\nA day after the surgery, the numbness of the patient's fingertips, his hypesthesia, and Lhermitte's sign disappeared. The image of the decompression of the thecal sac was confirmed with a post-operative CT scan (). The absence of post-operative instablility was also confirmed.

[[36.0, 'year']]

M

{'9562315': 1, '16153587': 1, '12590220': 1, '10413118': 1, '3750062': 1, '34909321': 2, '8315456': 1, '34194170': 1, '32309254': 2, '28764139': 1, '24757486': 2}

{'8653923-1': 1, '7162574-1': 1}

3941767-1

noncomm/PMC003xxxxxx/PMC3941767.xml

Tophaceous Gout of the Spine Causing Neural Compression

A 64-year-old man was admitted to our clinic with weeklong weakness of both lower extremities. The patient also complained of back pain radiating to his left anterior chest for 4 weeks. Eight years prior, the patient had acute gout arthritis of the right knee. At that time, the symptoms spontaneously resolved, and the patient received no subsequent management for the condition. The back and chest pain had increased gradually and had become more severe over the previous month in spite of conservative treatment. A week before admission, paraparesis progressed to difficulty walking. The patient had no sphincter function impairment, fever, or weight loss.\nNeurological examination showed paraparesis with grade IV motor weakness of both the hip and knee with no sensory impairment. Reflexes were normoactive and within normal ranges as assessed using the straight leg raise test. The patient's white blood cell count was slightly increased to 10,960/mm3 (normal range: 4,000-10,000/mm3); erythrocyte sedimentation rate was 5mm/h (normal range: lower than 9mm/h); C-reactive protein level was 0.9mg/dL (normal range: lower than 0.5mg/dL); and serum uric acid level was 12.2mg/dL (normal range: lower than 7.0mg/dL). No symptoms of gouty arthritis such as pain or swelling were reported for other joints of the appendicular skeleton.\nComputed tomography (CT) demonstrated a low-density mass with calcification surrounding the T6/7 left facet articulation and T6 and T7 left lamina. Bony erosion was also observed at the T6/7 left facet articulation (). Magnetic resonance imaging (MRI) of the thoracic spine revealed an extradural mass compressing the posterior of the spinal cord at T5-7, with heterogeneous high and low signal on T2-weighted images and low signal on T1-weighted images. The small amount of the low signal intensity of the mass on T2-weighted MRI corresponded to the calcified lesion on CT, and this lesion showed peripheral enhancement on post-contrast MRI ().\nWe made a tentative diagnosis based on the imaging findings of an epidural cyst or benign bone-originating tumor. Thoracic laminectomy from T5 to T7 was performed for the purpose of neural decompression and for histopathological confirmation. Intraoperatively, a chalky white material was found at the interlaminar space. This material extended to the dorsal space of the thoracic dura and the T5/6, T6/7 left foramen (). After left T5/6, T6/7 facetectomy, the mass that was compressing the cord and root was removed and T5, 6, and 7 both pedicle screw fixation with posterolateral fusion was performed.\nHistopathological examination of the specimen by polarized light microscope demonstrated a granular material with a needle pattern and negative birefringence (). This finding confirmed a diagnosis of a gouty tophus. No neoplastic tissue was found in the specimen. Postoperatively, the patient regained strength in both lower extremities, and his back and chest pain attenuated. After being discharged from the hospital, the patient has been treated with medication.

[[64.0, 'year']]

M

{'17210304': 1, '33304433': 1, '8933885': 1, '30626451': 2, '31008969': 1, '28704909': 2, '12051405': 1, '27900275': 2, '32322140': 1, '19208604': 1, '26490179': 1, '15229971': 1, '19692116': 1, '12413917': 1, '14735005': 1, '15805944': 1, '33023045': 1, '26078231': 2, '17197341': 1, '11862523': 1, '19680018': 1, '17429128': 1, '30264031': 1, '32150074': 2, '15639411': 1, '9346154': 1, '28053718': 1, '29033576': 2, '15739537': 1, '16381213': 1, '17043470': 1, '34150794': 1, '24757485': 2}

{'6325858-1': 1, '5518431-1': 1, '5628693-1': 1, '7478684-1': 1, '5112347-1': 1, '5399141-1': 1}

3941770-1

noncomm/PMC003xxxxxx/PMC3941770.xml

Extra and Intramedullary Anaplastic Ependymoma in Thoracic Spinal Cord

A 48-year-old woman had experienced a radiating pain on both legs for 6 months. For 1 month before visiting our department, a radiating pain was getting worse and she recognized newly developed lower extremity motor weakness and urinary incontinence. She underwent magnetic resonance imaging (MRI) that showed suspicious IDEM spinal mass which was well-enhanced on T1-weighted image with contrast and iso-signal intensity on T2-weighted image at T7-T9. There were also intramedullary component and cord edema at T9-T10. The mass lesion was well-enhanced under gadolinium administration displacing the cord to opposite side severely (, ). There was no evidence of mass lesion in the other site of central nervous system.\nWe planned the total resection of the intra and extramedullary mass lesions under the laminectomy. When the dura mater was opened, a dark-pink colored and encapsulated extramedullary component of the tumor was observed. The compressed spinal cord was displaced to right side and there were severe adhesion and ill-defined interface between the extramedullar mass and spinal cord. Under microscope, we removed extramedullary component totally, dissected the arachnoid layer around the cord connecting to extramedullary component and attempted to remove the intramedullary component in the spinal cord. However, we stopped resection and left the residual portion of mass lesion on the cord with concern for the risk of neurological deterioration and intraoperative frozen biopsy of the extramedullary component.\nHistological examination revealed a sort of high grade glial tumor. The cells were characterized by high cellularity and nuclear pleomorphism(Hematoxylin-Eosin stain, ×200) and there were perivascular pseudorosettes and microvascular proliferations. The cells presented immunoreactivity for glial fibrillary acidic protein (GFAP) and the S100, but negative for epithelial membrane antigen (EMA) and CD34 (). Ki-67 index was approximately 40%. The final diagnosis was anaplastic ependymoma, WHO grade III.\nPostoperatively, the patient's neurological condition was improved in a lower extremity motor weakness except urinary incontinence. Six weeks after operation, she was planned to perform radiotherapy with 1.8Gy in 28 fractions and total came to 50.4Gy. There was recurrence of the tumor at the ventral epidural space with remnant component at the spinal cord of T8 level on the follow-up MRI just before the initiation of radiotherapy. The mass lesions of T8 level were disappeared and spinal cord atrophy was found on the follow-up MRI after radiotherapy. However, the patient's neurologic condition of the lower extremities was deteriorated again and there were newly developed mass lesions at the lumbosacral region on the MRI, 14 months postoperatively. It might be CSF dissemination. We recommend further treatment, but she refused.

[[48.0, 'year']]

F

{'2096607': 1, '33468988': 1, '18207493': 1, '8433142': 1, '1436426': 1, '10908946': 1, '15864145': 1, '12514338': 1, '29354756': 1, '14748579': 1, '11723373': 1, '21742501': 1, '16611771': 1, '21142461': 1, '10460357': 1, '11126915': 1, '21918734': 2, '17120902': 1, '8492903': 1, '12383361': 1, '10844761': 1, '21435777': 1, '15340819': 1, '14809577': 1, '2976124': 1, '24757483': 2}

{'3172008-1': 1}

3942214-1

noncomm/PMC003xxxxxx/PMC3942214.xml

Neuroleptic malignant-like syndrome with a slight elevation of creatine-kinase levels and respiratory failure in a patient with Parkinson’s disease

A 68-year-old woman diagnosed with PD for 4 years was admitted to our hospital with chief complaints of hyperthermia and severe muscular rigidity. The patient’s husband reported that she had been on levodopa (600 mg/day), entacapone (300 mg/day), and amantadine (300 mg/day) for almost 2 years. Before her admission, she visited a clinic for progressive impairment of muscular rigidity, where her levodopa was decreased to 125 mg/day. After 2 weeks, the patient’s husband found that his wife was so stiff that she could not even get up on her own. When she was admitted to our hospital, the patient was awake, but developed hyperthermia of 39.7°C, sinus tachycardia of 116 beats/minute, marked muscle rigidity, and aphasia, but her blood pressure was in the normal range (130/80 mmHg). Initial laboratory tests did not change markedly. Blood examination showed a white blood cell count of 8.77 × 109/L (reference range 3.69–9.16 × 109/L), CK level was mildly elevated at 144 U/L (reference range 30–135 U/L). The urine report revealed protein+++ and hematuria+++, suggesting the existence of myoglobinuria. The admission blood culture was negative, so intercurrent infections were ruled out. The immune-related and malignant diseases had also been ruled out, such as tumor markers (α-fetoprotein/carcinoembryonic antigen/Ca125/Ca199/Ca50/squamous cell carcinoma) and autoimmune antibodies (double-stranded deoxyribonucleic acid/antinuclear antibody/extractable nuclear antigen) were within the normal range. By the next day of hospitalization, the diagnosis of probable NMLS secondary to dopamine reduction was made, and her levodopa was increased to 600 mg/day. The next day, her CK level had decreased to the normal range (), but the patient deteriorated with altered levels of blood pressure (160/100 mmHg) and a high fever with a peak temperature above 41°C. On day 3 of her hospital admission, she suddenly developed an acute respiratory failure (45 breaths per minute, oxygen and carbon dioxide partial pressure were 7.55 kPa and 3.79 kPa through nasal catheter, respectively) and disturbance of consciousness (Glasgow Coma Scale score of 4). Her husband agreed to endotracheal intubation and the patient was transferred to the intensive care unit. Cranial computed tomography and magnetic resonance imaging showed atrophic changes and small focal ischemia. Finally, the patient died of lung infection and heart failure 10 days later.

[[68.0, 'year']]

F

{'16440372': 1, '23271911': 1, '12473402': 1, '8830069': 1, '6111584': 1, '21773844': 1, '11413275': 1, '33043046': 1, '12735912': 1, '34064360': 1, '20628041': 1, '12735915': 1, '16440373': 1, '27097587': 1, '21106801': 1, '30581218': 2, '24600209': 2}

{'6278220-1': 1}

3942530-1

noncomm/PMC003xxxxxx/PMC3942530.xml

Implant overdenture impressions using a dynamic impression concept

A male patient aged 57 years visited a clinic with the chief complaint of a common consultation on dentures. He showed a combination syndrome-like appearance with overall caries and a serious periodontal status of the remaining teeth at initial examination (). The panoramic view revealed severe bone resorption on the mandibular molar area and a combination syndrome-like appearance on the mandibular anterior area (). First, the teeth with a poor prognosis (#11, 14, 24, 31, 32, 41, 42) were extracted while a periodontal flap surgery was conducted on the maxilla. Subsequently, the Kennedy Class II RPD was planned for the maxilla, and a four-implant-tissue supported bar overdenture was planned for the mandible. Four implants (Osstem, Seoul, Korea) were placed in the interforamenal area (), in which alveoloplasty was performed first (). All implants were 4.1 mm in diameter and had an anodized surface. A non-submerged, single-stage placement technique was performed according to the standard surgical procedure. Three temporary implants (Osstem, Seoul, Korea) were placed between the primary implants and the areas onto which the temporary fixed partial prosthesis was placed for aesthetic problems and no loading on the primary implants (). One month later, a provisional denture was fabricated. Three months later, a tissue conditioner (Coe-Comfort; Coe Laboratories Inc., Chicago, USA) was used to take a dynamic impression with the provisional denture on the mandible (). The following day, the tissue surface of the provisional denture was poured with yellow stone (Hi-Koseton, Maruishi, Japan) and the stone cast was removed. The stone cast was in accordance with the dynamic impression surface of the provisional denture (). Multiple layers of baseplate wax (Modeling wax; Kim's International Inc, Seoul, Korea) were adapted on the abutments to maintain space for the elastomeric impression material (). The individual tray (Ostron 100; GC Corporation, Tokyo, Japan) was manufactured based on the cast to the full length of the border and trimmed with a denture bur to make the denture border 0.5 mm shorter and smooth the border. An individual tray adhesive was pasted with tray adhesive (Adhesive; GC Corporation, Tokyo, Japan) (). An implant impression was taken without border molding - wash impressions with polyvinyl siloxane impression material (Aquasil Ultra LF; Dentsply Caulk, Milford, USA) (). The bar overdenture was fabricated with a Haderbar (Sterngold, Attleboro, USA) and ERA attachment system (Sterngold, Attleboro, USA) (). The overdenture was delivered () and the 5 years follow up result was favorable ().

[[57.0, 'year']]

M

{'20553174': 1, '17499095': 1, '4892778': 1, '280636': 1, '20557148': 1, '9452668': 1, '17451474': 1, '21821161': 1, '290790': 1, '22250917': 1, '24605209': 2}

{}

3942545-1

noncomm/PMC003xxxxxx/PMC3942545.xml

Schizophrenia-Like Psychosis and Dandy-Walker Variant Comorbidity: Case Report

30-year-old female patient with a 2-year history of psychosis presented with schizophrenia-like symptoms including, auditory and visual hallucinations, sense of insecurity, delusions of reference, of persecution, of being controlled; inapropriate and labile affect; irritability, aggression, workplace absenteeism, sleep disruption, and having suicidal and homicidal thoughts was brought to the emergency department with her brother and sister. The patient was being followed in different outpatient clinics with irregular use of various psychotropic medications such as risperidone, olanzapine, sertraline etc. This was her first hospitalization. About two weeks before admission, she manifested strange behaviors (covering toilet windows with toothpaste, having a knife under the bed to sleep, occasionally trying to attack to relatives with a knife). Premorbid educational performance and social adjustment were reported as normal. Family history of psychosis in one of his brother was reported. No remarkable anomaly was found by physical examination and laboratory testing. The mental status examination revealed slowness of thought, stereotypic and vicious thought content, blunted affect, absence of spontaneous speech, psychomotor retardation, social withdrawal, poor rapport and lack of insight. Borderline intelligence activity was found on Weschler Adult Intelligence Scale-revised in Turkish (WAISRT) and full intelligence quotient was 75. Her overall cognitive functions were obviously impaired; (poor attention, impaired recent and remote memory, visuospatial distortion, simple arithmetic) but the abstract reasoning was roughly good. Electroencephalogram revealed moderate bioelectric disorganization in each frontal and right temporooccipital regions and the presence of sharp wave discharges in the both centroparietal regions was reported. MR scanning disclosed cerebellar vermis hypoplasia and large cerebellar medullary system in the 4th ventricular posterior cisterna magna (keyhole deformity) that is compatible with Dandy-Walker variant (). Initial treatment with Risperidone 50 mg depot and 6 mg/day p.o, biperiden 4 mg/day p.o treatment and lorezepam 2.5 mg/day p.o achieved nearly 35% reduction in Positive and Negative Symptoms Scale (PANSS) scores (from 144 to 90) within 10 days. Treatment with injectable risperidone 50 mg fortnightly eliminated positive psychotic symptoms and most of the negative symptoms within two months except social isolation.

[[30.0, 'year']]

F

{'11163776': 1, '17150294': 1, '8790444': 1, '2816648': 1, '33937630': 2, '4343429': 1, '21983277': 1, '30815635': 2, '16318996': 1, '9798740': 1, '9255858': 1, '28757777': 2, '28658885': 1, '11368032': 1, '19996266': 1, '15377747': 1, '21253417': 2, '29033643': 1, '7631171': 1, '17478081': 1, '12884883': 1, '16958432': 1, '7356066': 1, '1953406': 1, '24605131': 2}

{'3022320-1': 1, '8054076-1': 1, '6362872-1': 1, '5509203-1': 1}

3942558-1

noncomm/PMC003xxxxxx/PMC3942558.xml

Low-Dose Acetazolamide in the Treatment of Premenstrual Dysphoric Disorder: A Case Series

A 34-year-old single, childless Caucasian woman with a cyclothymic premorbid temperament, suffered from a severe form of PMDD since her adolescence. For more than 10 years she had abused substances (mainly cocaine) and alcohol. Her mood was consistently unstable, with bouts of self-inflicted injuries (self-cutting of the whole body), eating disorder (bulimia with self-induced vomiting) and impulsiveness, meeting DSM-IV-TR criteria for Borderline Personality Disorder. She had voluntarily interrupted a pregnancy when she was 32.\nIn the last two years, she had stopped drug and alcohol abuse, but her clinical picture remained as before. We instituted therapy with lithium up to 600 mg/day, maintaining lithium blood levels up to 0.6 mEq/L, while slowly titrating lamotrigine up to 200 mg/day.\nHer mood stabilized after six months of treatment, with the exception of the period before menses. According to the diary chart, during this period she experienced depressive feelings, severe anxiety, irritability, insomnia, binge eating, desperate crying spells, desire of self-cutting. Her Clinical Global Impressions severity scale score (CGIs) was 6. All symptoms lasted for 7-10 days and disappeared suddenly by the first day of menses. Three months later, we added 125 mg/day acetazolamide, with intermittent monthly intake limited from ten days before the menses to the first day of menses. Since the first month, PMDD symptoms improved significantly (CGIs, 2), while no significant adverse event occurred. However, blood pressure slightly decreased, from 110/80 mm Hg to 100/70 mm Hg. After one year of treatment, the patient continues on add-on acetazolamide and is free from premenstrual symptoms (CGIs=1).

[[34.0, 'year']]

F

{'10768298': 1, '9122290': 1, '11422329': 1, '1743323': 1, '21225438': 1, '7606084': 1, '16997381': 1, '12953326': 1, '7791258': 1, '7189081': 1, '7779245': 1, '17607683': 1, '10732657': 1, '8474504': 1, '2301479': 1, '9778611': 1, '18343915': 1, '18622361': 1, '21585348': 1, '10530636': 1, '19370564': 1, '10577620': 1, '3299178': 1, '15757488': 1, '17280571': 1, '17454164': 1, '9241004': 1, '10565662': 1, '3526218': 1, '11432692': 1, '9307345': 1, '17884175': 1, '17937566': 1, '2695413': 1, '13032605': 1, '16271802': 1, '2564578': 1, '7714309': 1, '12659404': 1, '8463989': 1, '16126936': 1, '19370644': 1, '18448752': 1, '12646300': 1, '8498881': 1, '20719394': 1, '9794277': 1, '18240988': 1, '8533564': 1, '10537770': 1, '8740334': 1, '3367333': 1, '22094484': 1, '17472544': 1, '9807636': 1, '2301523': 1, '2407209': 1, '7804393': 1, '16740643': 1, '6812522': 1, '6442984': 1, '24605130': 2}

{'3942558-2': 2, '3942558-3': 2, '3942558-4': 2, '3942558-5': 2, '3942558-6': 2, '3942558-7': 2, '3942558-8': 2}

3942558-2

noncomm/PMC003xxxxxx/PMC3942558.xml

Low-Dose Acetazolamide in the Treatment of Premenstrual Dysphoric Disorder: A Case Series

A 29-year-old, single, nulliparous Caucasian woman with cyclothymic premorbid temperament and DSM-IV-TR diagnosis of Bipolar Disorder, type II, had severe PMDD since her teens. The bipolar onset may be traced back to age 15, when she had a first depressive episode. Since then, she had four depressive and three hypomanic episodes. She took several antidepressant drugs with little benefit.\nSince the onset of PMDD, she had developed feelings of worthlessness and emptiness, a bleak outlook of future, and an imminent sense of death.\nWe treated her bipolar disorder with lithium up to 450 mg/day (lithium blood levels, up to 0.7 mEq/L) and oxcarbazepine up to 600 mg/day. Her mood stabilized after four months of treatment. Nevertheless, as emerging from the daily diary, important PMDD symptoms persisted. During the late luteal phase of the menstrual cycle, she was profoundly depressive, hopeless, hypersensitive and emotional, irritable, and unable to make any plan for the future (CGIs, 6). Acetazolamide 125 mg/day was added. The patient took the medication monthly for a 10-day period before menses. PMDD symptoms subsided soon (CGIs, 1). After three months of treatment, the patient stated she was living one more week per month compared to before. No side effects emerged. Improvement still persists at the 12-month follow-up.

[[29.0, 'year']]

F

{'10768298': 1, '9122290': 1, '11422329': 1, '1743323': 1, '21225438': 1, '7606084': 1, '16997381': 1, '12953326': 1, '7791258': 1, '7189081': 1, '7779245': 1, '17607683': 1, '10732657': 1, '8474504': 1, '2301479': 1, '9778611': 1, '18343915': 1, '18622361': 1, '21585348': 1, '10530636': 1, '19370564': 1, '10577620': 1, '3299178': 1, '15757488': 1, '17280571': 1, '17454164': 1, '9241004': 1, '10565662': 1, '3526218': 1, '11432692': 1, '9307345': 1, '17884175': 1, '17937566': 1, '2695413': 1, '13032605': 1, '16271802': 1, '2564578': 1, '7714309': 1, '12659404': 1, '8463989': 1, '16126936': 1, '19370644': 1, '18448752': 1, '12646300': 1, '8498881': 1, '20719394': 1, '9794277': 1, '18240988': 1, '8533564': 1, '10537770': 1, '8740334': 1, '3367333': 1, '22094484': 1, '17472544': 1, '9807636': 1, '2301523': 1, '2407209': 1, '7804393': 1, '16740643': 1, '6812522': 1, '6442984': 1, '24605130': 2}

{'3942558-1': 2, '3942558-3': 2, '3942558-4': 2, '3942558-5': 2, '3942558-6': 2, '3942558-7': 2, '3942558-8': 2}

3942558-3

noncomm/PMC003xxxxxx/PMC3942558.xml

Low-Dose Acetazolamide in the Treatment of Premenstrual Dysphoric Disorder: A Case Series

A 31-year-old, single, nulliparous Caucasian woman with cyclothymic premorbid temperament and DSM-IV-TR Bipolar Disorder, type II, had suffered from PMDD since her adolescence. PMDD was characterized by depressive mood, apathy, hypersomnia, anxiety, severe irritability and inner tension, impossibility to concentrate, fatigue, loss of interest in normal activities, crying, and severe binge eating. Her bipolar onset dates back to her twenties, when she presented with a first hypomanic episode. Since then, she had three depressive and four hypomanic episodes. She sporadically took antidepressant drugs.\nWe introduced lamotrigine up to 150 mg/day and immediate release quetiapine 100 mg/day to treat her mood disorder. Bipolar symptoms subsided after eight months of treatment, but PMDD persisted. On the diary, she reported that the above described picture of PMDD emerged during the pre-menstrual phase (CGIs, 5) and abruptly disappeared with menses. We added 125 mg/day acetazolamide. After the second month of treatment, PMDD started to improve, and had completely subsided by the fourth month of treatment (CGIs, 1). No side effects were reported.\nOne year later, the patient was fully asymptomatic. However, when she skipped acetazolamide one month, she re-experienced exactly the same PMDD syndrome as before. The next month, the patient reintroduced treatment, and this was followed by complete symptom resolution.

[[31.0, 'year']]

F

{'10768298': 1, '9122290': 1, '11422329': 1, '1743323': 1, '21225438': 1, '7606084': 1, '16997381': 1, '12953326': 1, '7791258': 1, '7189081': 1, '7779245': 1, '17607683': 1, '10732657': 1, '8474504': 1, '2301479': 1, '9778611': 1, '18343915': 1, '18622361': 1, '21585348': 1, '10530636': 1, '19370564': 1, '10577620': 1, '3299178': 1, '15757488': 1, '17280571': 1, '17454164': 1, '9241004': 1, '10565662': 1, '3526218': 1, '11432692': 1, '9307345': 1, '17884175': 1, '17937566': 1, '2695413': 1, '13032605': 1, '16271802': 1, '2564578': 1, '7714309': 1, '12659404': 1, '8463989': 1, '16126936': 1, '19370644': 1, '18448752': 1, '12646300': 1, '8498881': 1, '20719394': 1, '9794277': 1, '18240988': 1, '8533564': 1, '10537770': 1, '8740334': 1, '3367333': 1, '22094484': 1, '17472544': 1, '9807636': 1, '2301523': 1, '2407209': 1, '7804393': 1, '16740643': 1, '6812522': 1, '6442984': 1, '24605130': 2}

{'3942558-1': 2, '3942558-2': 2, '3942558-4': 2, '3942558-5': 2, '3942558-6': 2, '3942558-7': 2, '3942558-8': 2}

3942558-4

noncomm/PMC003xxxxxx/PMC3942558.xml

Low-Dose Acetazolamide in the Treatment of Premenstrual Dysphoric Disorder: A Case Series

A 30-year-old, single, nulliparous Caucasian woman with hyperthymic premorbid temperament and DSM-IV-TR recurrent major depressive disorder since age 20, had PMDD preceding her mood disorder by two years. A total of four depressive episodes occurred in ten years; these were characterized by depressive mood, initial insomnia, restlessness, and anxiety, but also by mixed features, such as racing and crowded thoughts, increased energy level, goal directedness, and inner tension. She had received trials with selective serotonin reuptake inhibitors (SSRIs).\nWe treated her for her mood disorder with oral amitriptyline, 50 mg/day, and oxcarbazepine, titrated to 600 mg/day. After three months of treatment, her mood stabilized. During the pre-menstrual period, however, she continued to experience low mood, hypersomnia, fatigue, anxiety, irritability, feeling of being overwhelmed, and concentration difficulties (CGIs, 5). We added acetazolamide 125 mg/day, for ten days before menses. After the first month of treatment, PMDD improved, resolving completely by the second month of treatment (CGIs, 1). No side effects occurred. After one-and-a-half year of add-on acetazolamide the patient has no premenstrual symptoms (CGIs=1).

[[30.0, 'year']]

F

{'10768298': 1, '9122290': 1, '11422329': 1, '1743323': 1, '21225438': 1, '7606084': 1, '16997381': 1, '12953326': 1, '7791258': 1, '7189081': 1, '7779245': 1, '17607683': 1, '10732657': 1, '8474504': 1, '2301479': 1, '9778611': 1, '18343915': 1, '18622361': 1, '21585348': 1, '10530636': 1, '19370564': 1, '10577620': 1, '3299178': 1, '15757488': 1, '17280571': 1, '17454164': 1, '9241004': 1, '10565662': 1, '3526218': 1, '11432692': 1, '9307345': 1, '17884175': 1, '17937566': 1, '2695413': 1, '13032605': 1, '16271802': 1, '2564578': 1, '7714309': 1, '12659404': 1, '8463989': 1, '16126936': 1, '19370644': 1, '18448752': 1, '12646300': 1, '8498881': 1, '20719394': 1, '9794277': 1, '18240988': 1, '8533564': 1, '10537770': 1, '8740334': 1, '3367333': 1, '22094484': 1, '17472544': 1, '9807636': 1, '2301523': 1, '2407209': 1, '7804393': 1, '16740643': 1, '6812522': 1, '6442984': 1, '24605130': 2}

{'3942558-1': 2, '3942558-2': 2, '3942558-3': 2, '3942558-5': 2, '3942558-6': 2, '3942558-7': 2, '3942558-8': 2}

3942558-5

noncomm/PMC003xxxxxx/PMC3942558.xml

Low-Dose Acetazolamide in the Treatment of Premenstrual Dysphoric Disorder: A Case Series

A 35-year-old, Caucasian, woman with two children of 9 and 8 years of age, with a cyclothymic temperament and without a DSM-IV-TR axis I diagnosis, had suffered since adolescence from PMDD, characterized by mood swings, severe irritability, desperate crying spells, hopelessness and inner tension during the days immediately preceding menstruation. The patient was psychotropic medication-naïve. PMDD was absent during pregnancies.\nThe patient filled-out the daily symptom diary for three consecutive months and reported the above-mentioned symptoms during the 10 days before menses (CGIs, 6). Acetazolamide 125 mg/day was added during the critical days. Right after the first month of treatment she no more experienced the usual symptomatology (CGIs, 1), and reported no side effect. When she suspended premenstrual treatment with acetazolamide for two months PMDD reappeared as before. PMDD resolved completely when treatment was initiated again. No side effects occurred. The patient has already completed 14 months with add-on acetazolamide and is fully asymptomatic (CGIs=1).

[[35.0, 'year']]

F

{'10768298': 1, '9122290': 1, '11422329': 1, '1743323': 1, '21225438': 1, '7606084': 1, '16997381': 1, '12953326': 1, '7791258': 1, '7189081': 1, '7779245': 1, '17607683': 1, '10732657': 1, '8474504': 1, '2301479': 1, '9778611': 1, '18343915': 1, '18622361': 1, '21585348': 1, '10530636': 1, '19370564': 1, '10577620': 1, '3299178': 1, '15757488': 1, '17280571': 1, '17454164': 1, '9241004': 1, '10565662': 1, '3526218': 1, '11432692': 1, '9307345': 1, '17884175': 1, '17937566': 1, '2695413': 1, '13032605': 1, '16271802': 1, '2564578': 1, '7714309': 1, '12659404': 1, '8463989': 1, '16126936': 1, '19370644': 1, '18448752': 1, '12646300': 1, '8498881': 1, '20719394': 1, '9794277': 1, '18240988': 1, '8533564': 1, '10537770': 1, '8740334': 1, '3367333': 1, '22094484': 1, '17472544': 1, '9807636': 1, '2301523': 1, '2407209': 1, '7804393': 1, '16740643': 1, '6812522': 1, '6442984': 1, '24605130': 2}

{'3942558-1': 2, '3942558-2': 2, '3942558-3': 2, '3942558-4': 2, '3942558-6': 2, '3942558-7': 2, '3942558-8': 2}

3942558-6

noncomm/PMC003xxxxxx/PMC3942558.xml

Low-Dose Acetazolamide in the Treatment of Premenstrual Dysphoric Disorder: A Case Series

A 43-year-old, single, nulliparous Caucasian woman with a premorbid cyclothymic temperament developed since early adulthood intermittent periods of unpredictable mood fluctuations, causing her problems in her personal and professional life and leading to severe impairment of the social and work domains. She received DSM-IV-TR diagnosis of Cyclothymic Disorder. Her PMDD had its onset at early puberty, with depressive mood, inner tension, affective lability, decreased interest in usually pleasurable activities, irritability, and sense of being out of control. Symptoms occurred during the luteal phase, some days after ovulation, and ended few days after onset of menses. She described this intense and painful state as "the worst pain ever experienced".\nShe received gabapentin 600 mg/day. The amplitude of mood swings diminished from the first month, with mood reaching stabilization after five months of treatment. Nevertheless, the diary completed during follow-up showed that treatment was ineffective in reducing the luteal phase symptoms (CGIs, 7). Premenstrual symptom persistence for more than two consecutive cycles allowed us to diagnose PMDD. We added 125 mg/day acetazolamide during the critical days. Symptoms improved quickly during the next month (CGIs, 2), leading to complete remission within three months. No side effects were reported whatsoever, and the patient is still asymptomatic after twelve months of add on acetazolamide (CGIs=1).

[[43.0, 'year']]

F

{'10768298': 1, '9122290': 1, '11422329': 1, '1743323': 1, '21225438': 1, '7606084': 1, '16997381': 1, '12953326': 1, '7791258': 1, '7189081': 1, '7779245': 1, '17607683': 1, '10732657': 1, '8474504': 1, '2301479': 1, '9778611': 1, '18343915': 1, '18622361': 1, '21585348': 1, '10530636': 1, '19370564': 1, '10577620': 1, '3299178': 1, '15757488': 1, '17280571': 1, '17454164': 1, '9241004': 1, '10565662': 1, '3526218': 1, '11432692': 1, '9307345': 1, '17884175': 1, '17937566': 1, '2695413': 1, '13032605': 1, '16271802': 1, '2564578': 1, '7714309': 1, '12659404': 1, '8463989': 1, '16126936': 1, '19370644': 1, '18448752': 1, '12646300': 1, '8498881': 1, '20719394': 1, '9794277': 1, '18240988': 1, '8533564': 1, '10537770': 1, '8740334': 1, '3367333': 1, '22094484': 1, '17472544': 1, '9807636': 1, '2301523': 1, '2407209': 1, '7804393': 1, '16740643': 1, '6812522': 1, '6442984': 1, '24605130': 2}

{'3942558-1': 2, '3942558-2': 2, '3942558-3': 2, '3942558-4': 2, '3942558-5': 2, '3942558-7': 2, '3942558-8': 2}

3942558-7

noncomm/PMC003xxxxxx/PMC3942558.xml

Low-Dose Acetazolamide in the Treatment of Premenstrual Dysphoric Disorder: A Case Series

A 39-year-old, single, nulliparous Caucasian woman, with cyclothymic/anxious temperament, suffered from severe PMDD since the age of 12. The premenstrual syndrome consisted in depressed mood, anxiety, difficulty in concentrating, and decreased interest in usually pleasurable daily activities.\nAt age 30, she began suffering from episodes of tachycardia, sweating, tremors, feelings of choking, and wheezing. Symptoms recurred frequently through the following years, forcing her to ask for a companion when she had to leave home or for activities like driving a car. This led to impaired social and working life. She received a diagnosis of DSM-IV panic disorder with agoraphobia. She tried several antidepressants, with no apparent benefit. When she came to our attention, we introduced 200 mg/day gabapentin and 0.5 mg/day clonazepam, while gradually discontinuing the SSRI antidepressant she was taking. Frequency and intensity of panic attacks diminished, to disappear completely after four months. Nevertheless, according to the daily diary, symptoms beginning typically few days after ovulation and ending with onset of menses remained unchanged (CGIs, 6). Hence we added during the luteal phase, i.e., 10 days before menses, 125 mg/day acetazolamide. The following month premenstrual symptoms improved (CGIs, 2) and completely disappeared after three months of treatment. She reported no side effects. More than one year after the introduction of add-on acetazolamide, the patient is premenstrual symptom-free (CGIs, 1).

[[39.0, 'year']]

F

{'10768298': 1, '9122290': 1, '11422329': 1, '1743323': 1, '21225438': 1, '7606084': 1, '16997381': 1, '12953326': 1, '7791258': 1, '7189081': 1, '7779245': 1, '17607683': 1, '10732657': 1, '8474504': 1, '2301479': 1, '9778611': 1, '18343915': 1, '18622361': 1, '21585348': 1, '10530636': 1, '19370564': 1, '10577620': 1, '3299178': 1, '15757488': 1, '17280571': 1, '17454164': 1, '9241004': 1, '10565662': 1, '3526218': 1, '11432692': 1, '9307345': 1, '17884175': 1, '17937566': 1, '2695413': 1, '13032605': 1, '16271802': 1, '2564578': 1, '7714309': 1, '12659404': 1, '8463989': 1, '16126936': 1, '19370644': 1, '18448752': 1, '12646300': 1, '8498881': 1, '20719394': 1, '9794277': 1, '18240988': 1, '8533564': 1, '10537770': 1, '8740334': 1, '3367333': 1, '22094484': 1, '17472544': 1, '9807636': 1, '2301523': 1, '2407209': 1, '7804393': 1, '16740643': 1, '6812522': 1, '6442984': 1, '24605130': 2}

{'3942558-1': 2, '3942558-2': 2, '3942558-3': 2, '3942558-4': 2, '3942558-5': 2, '3942558-6': 2, '3942558-8': 2}

3942558-8

noncomm/PMC003xxxxxx/PMC3942558.xml

Low-Dose Acetazolamide in the Treatment of Premenstrual Dysphoric Disorder: A Case Series

A 32-year-old, Caucasian, nulliparous woman, with cyclothymic premorbid temperament and without a DSM-IV-TR axis I diagnosis, had suffered since adolescence from PMDD, characterized by severe irritability, mood swings, inner tension, desire of "being elsewhere", desperate crying during the days immediately preceding the menstruation. The patient was psychotropic medication-naïve.\nThe patient filled-out the daily symptom diary for three consecutive months and reported the above-mentioned symptoms during the premenstrual phase (CGIs, 6). Acetazolamide 125 mg/day was added during the critical days. Right after the first two months of treatment she no more experienced the usual symptomatology (CGIs, 1), and reported no side effect.\nAfter four months of treatment she stopped taking the medication and she re-experienced exactly the same PMDD syndrome as before. She resumed acetazolamide intake as scheduled before, and symptoms disappeared once more; after further nine months of treatment, the patients manifests no premenstrual symptoms (CGIs, 1).

[[32.0, 'year']]

F

{'10768298': 1, '9122290': 1, '11422329': 1, '1743323': 1, '21225438': 1, '7606084': 1, '16997381': 1, '12953326': 1, '7791258': 1, '7189081': 1, '7779245': 1, '17607683': 1, '10732657': 1, '8474504': 1, '2301479': 1, '9778611': 1, '18343915': 1, '18622361': 1, '21585348': 1, '10530636': 1, '19370564': 1, '10577620': 1, '3299178': 1, '15757488': 1, '17280571': 1, '17454164': 1, '9241004': 1, '10565662': 1, '3526218': 1, '11432692': 1, '9307345': 1, '17884175': 1, '17937566': 1, '2695413': 1, '13032605': 1, '16271802': 1, '2564578': 1, '7714309': 1, '12659404': 1, '8463989': 1, '16126936': 1, '19370644': 1, '18448752': 1, '12646300': 1, '8498881': 1, '20719394': 1, '9794277': 1, '18240988': 1, '8533564': 1, '10537770': 1, '8740334': 1, '3367333': 1, '22094484': 1, '17472544': 1, '9807636': 1, '2301523': 1, '2407209': 1, '7804393': 1, '16740643': 1, '6812522': 1, '6442984': 1, '24605130': 2}

{'3942558-1': 2, '3942558-2': 2, '3942558-3': 2, '3942558-4': 2, '3942558-5': 2, '3942558-6': 2, '3942558-7': 2}

3942593-1

noncomm/PMC003xxxxxx/PMC3942593.xml

Hemangiopericytoma of the foramen magnum in a pregnant patient: A case report and literature review

A 23-year-old female patient, with no known past medical history, was referred to our centre at the 9th week of her first pregnancy because of incoercible vomiting and mild dehydration. She was admitted to the Obstetrics department, where she received symptomatic treatment with antiemetics and prokinetics. She was discharged on the third day with the diagnosis of hyperemesis gravidarum. Nevertheless, 2 weeks later, the patient was readmitted for presenting incoercible vomiting, dizziness, and headaches. On this occasion, vitamin B6 was added to her treatment, and she was discharged on the fifth day.\nOn the 16th week of gestation, the patient was readmitted because she persisted with the symptoms. At this time, the patient was obtunded and disoriented, and she also complained of an oppressive occipital headache. On physical examination, left VI cranial nerve palsy, papilledema, and right ankle clonus were found. Brain magnetic resonance imaging (MRI) was performed, suspecting a dural sinus thrombosis. However, the study revealed triventricular hydrocephalus with transependymal edema due to a tumor in the posterior fossa [Figures and ].\nThe patient was assessed by the authors, and she underwent an urgent ventriculoperitoneal shunt with a high pressure valve without any complications. In spite of a favorable course in the immediate postoperatory period, the patient experienced neurological decline with blurry vision, vomiting and headaches 10 days later. These symptoms did not respond to medical treatment with dexamethasone. In view of the latter, an endoscopic third ventriculostomy was performed, and her derivative system was removed. At the same time, we discussed with the Obstetrics department the need to operate on the mass, since the patient showed progressive involvement of the brainstem.\nAt 22 weeks of gestation, the patient underwent a right sub-occipital craniotomy with partial resection of a highly vascularized mass in the posterior margin of the foramen magnum. Its intraoperative biopsy reported a low-grade stromal tumor, suggestive of hemangioblastoma. The surgery was performed without any obstetric or neurologic complications. In the postoperatory period, the patient only presented mild right hemiparesis, which remitted within a few days. The definitive biopsy showed the presence of a vascular neoplasm with irregular “stag-horn” cells, and positive immunohistochemistry for CD34 and vimentin. All of the latter was compatible with hemangiopericytoma. The patient continued to be followed at the Neurosurgery and Obstetric outpatient clinics after the 26th week of gestation. She underwent a cesarean section at the 36th week because of intrauterine growth restriction, and it was performed without any complications. Currently, both the mother and the baby are in good health.

[[23.0, 'year']]

F

{'16570277': 1, '34595730': 1, '15609304': 1, '21359526': 1, '9247278': 1, '22790838': 1, '19408979': 1, '18559459': 1, '15980981': 1, '17126003': 1, '20802020': 1, '20485168': 1, '22106098': 1, '18843008': 1, '28791194': 2, '15725854': 1, '22513749': 1, '19155008': 1, '24678429': 2}

{'5525461-1': 1}

3942609-1

noncomm/PMC003xxxxxx/PMC3942609.xml

Congenital Anomaly of the Atlas Misdiagnosed as Posterior Arch Fracture of the Atlas and Atlantoaxial Subluxation

A 28-year-old woman was referred to the emergency department with left hip pain, wrist pain and neck pain after being involved in a traffic accident. On physical examination, her neurologic system showed no abnormal findings. Roentgenographic studies showed left acetabular fracture and left distal radius fracture. A lateral cervical radiograph taken initially in the investigations suggested posterior arch fracture (). A trans-oral anterior-posterior view of the atlas revealed an atlantoaxial subluxation (AAS) (). Computed tomography (CT) images with three-dimensional (3D) reconstruction demonstrated the absence of the posterior arch and the presence of a persistent posterior tubercle. Like the cervical radiograph, there were signs of AAS in the CT images ( and ). Magnetic resonance images (MRI) showed no definite evidence of rupture of the alar or transverse ligament or soft tissue swelling ().\nNo evidence of traumatic injury was shown on whole body bone scinitigraphy (). The patient's neck pain resolved spontaneously. Post-recovery flexion and extension films revealed the absence of the posterior arch of the atlas but there was no evidence of atlantoaxial instability (). The patient was asymptomatic at a follow-up visit six months after the accident.

[[28.0, 'year']]

F

{'15333558': 1, '16484387': 1, '8192068': 1, '9733322': 1, '34353977': 1, '28849400': 1, '12811285': 1, '11511900': 1, '6766017': 1, '4354561': 1, '24605195': 2}

{}

3942612-1

noncomm/PMC003xxxxxx/PMC3942612.xml

The “extended” endoscopic endonasal approach for the removal of a mixed intrasuprasellar germinoma: Technical case report

A 12-year-old girl was admitted to our hospital with a few-month history of polyuria, polydipsia, and secondary amenorrhea. A neurological examination, including visual field exam and visual acuity, showed amaurosis in the left eye and rapidly worsening temporal hemianopsia in the right eye. A complete preoperative endocrinological assessment revealed mild elevation of the serum prolactin level (76 ng/mL, n.v. 2-25 ng/mL), secondary hypothyroidism (TSH: 0.15 mUI/ml, n.v. 0.4-4 and FT4: 0.52 ng/dl, n.v. 0.9-1.7) and secondary hypocortisolism (morning cortisol: 31 ng/ml, n.v. 50-200). Neuroradiological investigation, by means of magnetic resonance imaging (MRI) scans, demonstrated a large mass arising from the sella with a significant suprasellar component, compressing the optic chiasm and extending into the third ventricle, showing nonhomogeneous enhancement after intravenous contrast administration [Figure –].\nOur diagnostic hypothesis were either a craniopharyngioma or a GCT. However, the evidence of diabetes insipidus as a presenting symptom in a pediatric patient was more suggestive of a germinoma. Unfortunately, it was not possible for technical reasons to perform the serum and/or CSF assay of Alpha-fetoprotein (AFP) and Human chorionic gonadotropin (beta-HCG) before surgery.\nAfter careful consideration of many factors, including patient age, daily progressive visual impairment, lesion size and midline location without any parasellar extension, it was decided to treat the tumor by using an extended endoscopic endonasal transtuberculum/transplanum approach,[] few days after the admittance.\nThe postoperative course was marked by a conspicuous improvement of temporal hemianopsia in the right eye and light perception was reported in the left eye. No postoperative infection or CSF leak was detected. The patient was discharged without any neurological defect of new onset. The postoperative serum level of AFP was 103.9 UI (n.v. 0-5.5 UI) while level of beta-HCG was 165.7 mUI (n.v. <3.5 mUI). Afterwards, the patient was referred to the pediatric oncologist for the adjunctive chemotherapy and radiation therapy treatment. One month postoperative MRI confirmed near-total tumor removal [Figure –]. Three months after surgery, the girl was still being medicated with desmopressin acetate for the diabetes insipidus, but her condition was otherwise normal.

[[12.0, 'year']]

F

{'20887129': 1, '19408020': 1, '18425005': 1, '18504924': 1, '11708543': 1, '15335421': 1, '22791074': 1, '16078817': 1, '21166570': 1, '26015870': 1, '17228252': 1, '12434181': 1, '9046301': 1, '9892101': 1, '20043736': 1, '18447729': 1, '17330530': 1, '23317752': 1, '1848284': 1, '18383814': 1, '18586924': 1, '21918862': 1, '15001260': 1, '11151718': 1, '8952565': 1, '9308946': 1, '24678430': 2}

{}

3942613-1

noncomm/PMC003xxxxxx/PMC3942613.xml

Bilateral telovelar approach: A safe route revisited for resections of various large fourth ventricle tumors

A 60-year-old male presented with progressive paraparesis and intractable headaches. The patient was known to suffer from neurofibromatosis type 2, and already had multiple meningiomas removed in the past. Magnetic resonance imaging (MRI) with I/V contrast revealed an oval shaped, partially cystic but homogeneously contrast enhancing, well demarcated tumor, which reached from the mid fourth ventricle to the aqueducts Sylvii mesencephali. The tumor extended also into the lateral recess []. To treat associated hydrocephalus, the patient first underwent an uncomplicated endoscopic third ventriculostomy from a right sided precoronal approach 3 days prior to definite open surgery.\nFor surgery, the patient underwent standard general endotracheal anesthesia and was placed into prone position in Mayfield 3-point skeletal fixation. He was resting on a Wilson frame with the neck in a highly flexed position. The Brain-LAB navigation system was used and fiducials were registered. Landmarks such as the superior sagittal sinus were marked and best trajectories were visualized. A standard bilateral suboccipital approach was chosen and the incision was carried out at the midline, starting about 3 cm above the inion and reaching down to the level of the C2 spinous process. A chiari-type bilateral suboccipital craniectomy was performed using a high-speed craniotome, thus achieving a bone window spanning high from near the inion to the foramen magnum. The margin of the bone flap was extended laterally to expose the sigmoid sinus. The posterior arch of C1 was resected bilaterally up to the sulcus arteriosus of the lateral mass. The best approach-angle was confirmed according to Brain-LAB criteria. A y-shaped durotomy was performed and the dural leaves where tagged up with 4-0 Nurolon (Ethicon) to expose the underlying cerebellum. The pia was transected and cerebrospinal fluid (CSF) was removed. Arachnoidal adhesions were lyzed. We then used a Greenberg retractor and both tonsils were gently retracted upwards and outwards under the microscope, after opening the bilateral cerebellomedullary fissures to gain access to the fourth ventricle. The floor of each cerebellomedullary fissure, composed by tela choroidea and inferior medullary velum, was exposed. Then the bilateral tela choroideae, lucent membranes covering the fourth ventricle around the foramen of Magendie, were opened with microinstruments to visualize and access the posterior-superior part of the fourth ventricle. Using this approach, an inferior vermian split was avoided and the caudal vermis could be easily elevated. Both the Posterior inferior cerebellar artery (PICAs) and the veins of each cerebellomedullary fissure were preserved. Tumorous tissue lodged in the fourth ventricle was immediately encountered and identified when looking from the obex superiorly. A small specimen was obtained upfront for intraoperative fresh frozen histopathological analysis.\nIn patient number 1, this revealed the diagnosis of a meningioma with some atypical features. Careful microscopic dissection in a circumferential plane and internal debulking were performed alternately. Cutting the margin of the inferior medullary velum on each side created a wide operative field allowing panoramic views superiorly toward the mesencephalic aqueduct as well as laterally toward the foramina Luschkae. At the end of the tumor dissection and its gross total removal, the caudal aqueductal opening and CSF egress via the bilateral foramina of Luschkae was seen. After absolute hemostasis was achieved, the ventricle was copiously irrigated until the irrigant remained clear and the durotomy was closed with a pericranial autograft. The latter was sutured in with a running 4-0 Nurolon stitch and augmented by a fibrin tissue sealant. The wound was closed in layers. The patient was kept intubated until imaging and the postoperative magnetic resonance image (MRI) revealed no residual tumor burden []. No new neurological deficit was noticed after the operation and the patient was successfully extubated POD#1. The patient had an unremarkable postoperative course and was discharged to rehab on POD #4.

[[60.0, 'year']]

M

{'7666224': 1, '12845541': 1, '18814123': 1, '28190209': 1, '1620293': 1, '27778210': 1, '21346396': 1, '10983303': 1, '17415573': 1, '10794296': 1, '15605202': 1, '15352607': 1, '28676975': 1, '12657182': 1, '22209142': 1, '7155330': 1, '24678432': 2}

{'3942613-2': 2, '3942613-3': 2}

3942613-2

noncomm/PMC003xxxxxx/PMC3942613.xml

Bilateral telovelar approach: A safe route revisited for resections of various large fourth ventricle tumors

A 2-year-old girl presented with slight headache and gait disturbances, which had developed over the month prior to admission. MRI with contrast enhancement showed an irregularly shaped, avidly enhancing tumor mass, measuring about 40 mm in diameter and located in fourth ventricle. There was rostral extension into the cerebral aqueduct and also extension into the lateral recess accompanied by obstructive hydrocephalus []. For definite surgery, the patient was positioned in the left lateral decubitus position with the head well flexed. A standard external ventricular drain (EVD) was placed. The p-fossa access was achieved via an incision that was carried out in the midline, from about 1 cm above the inion to the level of C4 spinous process. A bilateral suboccipital craniotomy was performed as described earlier and the mid portion of the posterior arch of C1 was resected. Durotomy was performed and the underlying brain was exposed. CSF was released gradually after opening the cistern magna. A microscopic dissection was started. After opening the bilateral cerebellomedullary fissures both cerebellar tonsils were retracted upwards and laterally using a Leyla-type retractor equipped with Ruggles blades. The bilateral tela choroidea and inferior medullary velum were exposed. Then the tela choroidea was opened bilaterally to access the dorsal fourth ventricle. We stayed away from any resection involving or splitting the inferior vermis. Both PICAs and the veins of the bilateral cerebellomedullary fissures were preserved. Tumorous tissue in the fourth ventricle was immediately visible and adequately accessible. Careful establishment of a circumferential plane was achieved and internal tumor debulking was performed. Cutting the lateral margins of the inferior medullary velum created a wide operative field with easy visibility toward the aqueduct and the bilateral foramen Luschkae. At the end of the tumor dissection and removal, the caudal opening of the aqueduct and both foramina Luschkae were well visible. The case was closed as pointed out above. No new neurological deficit was encountered after this operation. The postoperative MRI revealed no residual tumor []. Histopathological analysis revealed a solitary fibrous tumor of the central nervous system WHO I with low mitotic index. Since a gross total resection was achieved, no adjuvant radiation was recommended. At 6 months follow-up, the patient was neurologically without deficit.

[[2.0, 'year']]

F

{'7666224': 1, '12845541': 1, '18814123': 1, '28190209': 1, '1620293': 1, '27778210': 1, '21346396': 1, '10983303': 1, '17415573': 1, '10794296': 1, '15605202': 1, '15352607': 1, '28676975': 1, '12657182': 1, '22209142': 1, '7155330': 1, '24678432': 2}

{'3942613-1': 2, '3942613-3': 2}

3942613-3

noncomm/PMC003xxxxxx/PMC3942613.xml

Bilateral telovelar approach: A safe route revisited for resections of various large fourth ventricle tumors

A 72-year-old male presented with progressive nausea, occasional vomiting, and intractable morning headaches. The patient had an unremarkable past medical history and was treated by his primary care physician for a stomach bug for several weeks.\nEventually, imaging was requested for non-resolving symptoms and MRI with I/V contrast revealed a multilobulated, irregularly shaped, partially cystic but avidly contrast enhancing, mostly well demarcated tumor, which reached from within the mid fourth ventricle posteriorly toward the inferior velum and laterally into the recess of the fourth ventricle []. There was no significant associated hydrocephalus.\nAs for patient 1, this patient underwent standard general endotracheal anesthesia and was placed into prone position in Mayfield fixation pins with the neck in a highly flexed position. The Brain-LAB system was used and best trajectories were determined. A standard wide bilateral suboccipital approach was chosen. Durotomy was performed as described earlier and the arachnoidea was dissected off. The tonsils were retracted, the cerebellomedullary (CM) fissure split and the tela choroidea was opened on both sides to access the posterior-lateral part of the fourth ventricle. Both PICAs were immediately visualized and could be dissected of the tumor mass and the veins of the cerebellomedullary fissure could also be preserved. Tumor tissue in the fourth ventricle was readily identified and some of the left sided cystic portions of the lesion could be accessed and drained, which greatly facilitated our dissection. A small specimen for intraoperative histopathological analysis revealed a well differentiated ependymoma. Careful microscopic dissection in a circumferential plane was performed. Cutting the juncture of the tela and inferior medullary velum on each side created a wide operative field allowing bilaterally panoramic views especially laterally toward the recess. After gross total resection, brisk CSF flow from the aqueduct and through the foramina Luschkae was observed. Absolute hemostasis was achieved, the ventricle was copiously irrigated and the durotomy was closed as described earlier with pericranial autograft and fibrin sealant augmentation. The patient was successfully extubated in the OR and no neurological deficit was noticed upon examination. Postoperative MRI revealed no residual tumor burden []. The patient had an unremarkable postoperative course and was discharged to home on POD #4.

[[72.0, 'year']]

M

{'7666224': 1, '12845541': 1, '18814123': 1, '28190209': 1, '1620293': 1, '27778210': 1, '21346396': 1, '10983303': 1, '17415573': 1, '10794296': 1, '15605202': 1, '15352607': 1, '28676975': 1, '12657182': 1, '22209142': 1, '7155330': 1, '24678432': 2}

{'3942613-1': 2, '3942613-2': 2}

3942864-1

noncomm/PMC003xxxxxx/PMC3942864.xml

Fractured Anterior Chamber Intraocular Lens (ACIOL) Complicating Nd: YAG Laser for Peripheral Iridotomy

A 74 year old lady on anticoagulation therapy for atrial fibrillation, referred to our department complaining for blurred vision in her left eye (LE). Her best corrected visual acuity (BCVA)was 1/10 and intraocular pressure (IOP) was 17mmHg. Slit-lamp examination revealed a hypermature cataract with pseudoexfoliation. Fundoscopy did not reveal any macular disease although it was performed with difficulty due to the hypermature cataract. She underwent left eye phacoemulsification; after the removal of the cataract, the capsular bag was not stable enough to insert an intraocular lens (PCIOL) in the bag and an ACIOL (MTA3UO ALCON) was inserted in the anterior chamber (AC). Even though the insertion of the ACIOL wasuneventful there was massive bleeding from the iris angle as soon as the lens was supported on the iris angle.\nAt this time it was decided that a peripheral iridotomy could not be performed safely. The first day after surgery, the AC was filled with blood and intraocular pressure was 28mmHg. Dexamethazone, Chloramphenicol as well as anti-glaucoma drops were administered and the patient was followed up every 2 days. Eventually, in 3 weeks postoperatively, best corrected visual acuity improved to 6/10LE and intraocular pressure (IOP) was within normal limits with no additional medication. The patient was advised that a PI should be performed with Nd:YAg laser, however, she refused further treatment.\nFifteen days later, the patient presented complaining for LE pain. BCVA was 2/10, there was corneal edema and IOP was 40mmHg due to the development of pupillary block. Anti-glaucoma eye drops and acetazolamide were administered to reduce IOP. As soon as the IOP was reduced and the corneal edema partially subsided the patient consented to undergo Nd:YAG iridotomy in order to release the pupillary block. The iris was dark brown (Fig. ) and the energy was increased to 6mj; after one single shot on the iris, the haptic of the lens was fractured in pieces (Figs. , ).\nIn the following days after a consultation with her cardiologist the anticoagulant treatment was reduced and the patient was taken to theatre; the fractured IOL was removed, a new ACIOL was inserted and a PI was performed surgically. Three months later BCVA was 6/10 and IOP within normal levels.

[[74.0, 'year']]

F

{'17244660': 1, '22336823': 1, '11030835': 1, '3708429': 1, '20539317': 1, '24600484': 2}

{}

3943115-1

noncomm/PMC003xxxxxx/PMC3943115.xml

Delayed onset neuropathy along with recurrent laryngeal nerve palsy due to organophosphate poisoning and the role of physiotherapy rehabilitation

A 20-year-old female patient attempted suicide by ingesting a large amount of OP insecticide. She was admitted in a private hospital in an unconscious, gasping state with frothing from the mouth, smelling of insecticide. Pupils were miotic and fasciculations were evident. She was immediately intubated and was kept on synchronized intermittent mandatory ventilation (MV).\nSeven days later she was brought to Medical and Neurological Intensive care unit of our hospital on MV. On admission, she had poor respiratory effort. She was conscious, oriented, had grade four muscle power in upper and lower limbs, without sensory symptoms. On day 12, lobar pneumonia was diagnosed. She had copious purulent secretions which necessitated tracheostomy. She was treated with Piperacillin-Tazobactam. Chest physiotherapy along with respiratory muscle training by inspiratory muscle trainer with threshold resistance for strengthening of weak respiratory muscles proved an adjunct for the weaning off of the patient from mechanical ventilation. In stepdown care, her muscle power slowly reduced to grade two in upper limb and grade three in lower limb. Three days post-extubation, she developed rapid onset deterioration in muscle power to grade zero and absent deep tendon reflexes, but without respiratory deterioration. She developed bilateral foot drop and claw hand deformity. Nerve conduction studies indicated pure motor axonal neuropathy. Patient developed stridor when an attempt to close the tracheotomy was carried out. Bronchoscopy revealed tracheal stenosis 2.3 cm distal to the vocal chords along with bilateral adductor vocal cord paralysis indicating involvement of recurrent laryngeal nerve, which explains aphonia evident during partial closure trial of tracheostomy.\nForty five days from the ingestion of OP insecticide, she developed grade II spasticity according to Modified Ashwarth Scale in bilateral upper and lower limbs with flexor spasms in lower limbs and exaggerated deep tendon reflexes, which indicate pyramidal tract involvement. Sensitive symptoms of muscle pain, tenderness and cramps developed in bilateral quadriceps and calf muscles. This suggested the presence of OPIDN.\nPhysiotherapy was aimed at preventing neuro-musculoskeletal co-morbidity. Electrical stimulation with intermittent galvanic current was given to paralyzed distal muscles of upper and lower extremities to restore their properties and hence prevent further muscle wasting. Strengthening and proprioceptive neuromuscular facilitation for weak muscles, stretching of hand flexors and gastrosoleus and orthotic devices prevented further deformities. Tilt table supported standing helped to overcome the effects of prolonged bed rest and postural hypotension. After discharge the patient was referred to a community rehabilitation center for further management.\nMarital discord with violently abusive husband was the reason for this patient to attempt suicide. The patient and her relatives were counseled by psychiatrist. Her parents gave her emotional support and agreed to support her socially and financially. She was happy to separate from her husband.

[[20.0, 'year']]

F

{'16042503': 1, '3029588': 1, '9538454': 1, '16856766': 1, '2188574': 1, '7909679': 1, '32913352': 1, '9048731': 1, '18063499': 1, '11146591': 1, '22177963': 1, '26550404': 1, '24678153': 2}

{}

3943116-1

noncomm/PMC003xxxxxx/PMC3943116.xml

Coiling of central venous catheter in the left subclavian vein, a rare complication

A 73 year old female, a post sternotomy for retrosternal goitre resection was admitted with sternal dehiscence (having sero-sanguineous discharge from chest wire site) and respiratory distress on the third post operative day. On the day of surgery, a right subclavian CVP (because of neck surgery and possibility of tracheostomy) was placed and tracheostomy performed because of surgical concern. The patient received ventilator support, hemodynamic monitoring, empiric broad spectrum antibiotics, colostomy bag at wound site care for two hourly suction and general ICU care. On the sixth day of ICU admission pus at CVC insertion site was noticed, and was decided to change the catheter as per protocol. To change the site, left subclavian vein was cannulated with a 7.5F triple lumen CVP catheter (Edward) using standard Seldinger technique with ultrasound guidance (USG) (Sonosite, USA) under all aseptic precautions. We used the lateral approach with the needle inserted longitudinal to the transducer. The guide wire was confirmed well in position in the vein. The guide wire movement was free at insertion and during its removal after the placement of the CVP catheter. All channels of the CVC were aspirated for blood and fixed at 12 cm. On attaching the transducer to the monitor the CVP waveform appeared dampened, and despite all described standards measures it could not be improved []. A chest radiograph performed after insertion to confirm the position of catheter revealed that it was coiled in a C- shaped pattern either in the same vein or possibly in one of the large venous tributaries of the left subclavian vein []. The left subclavian CVC was removed and a new left internal jugular (IJV) catheter was placed by Seldinger technique using USG guidance. The guide wire was confirmed well in position in the vein- it could be traced much beyond the subclavian vein. A repeat chest radiograph confirmed the correct placement with normal CVP tracing.

[[73.0, 'year']]

F

{'1535901': 1, '21494105': 1, '22090752': 2, '28928586': 2, '25538423': 1, '18326129': 1, '9226858': 1, '9619168': 1, '20882184': 1, '14709471': 1, '24678154': 2}

{'3214515-1': 1, '3214515-2': 1, '5594805-1': 1}

3943117-1

noncomm/PMC003xxxxxx/PMC3943117.xml

Acute pancreatitis induced thrombotic thrombocytopenic purpura

A 43-yrs-old Indian male was admitted to the hospital with abdominal pain of one-day duration. The pain was mainly in the epigastrium, was severe in intensity and radiating to the back, and associated with nausea and vomiting.\nHis past medical history was insignificant except for alcoholism. His physical examination was normal apart from tenderness over the epigastrium.\nLaboratory findings showed an elevated serum amylase of 878 μ/L. His urea was 6.7 mmol/L, creatinine being 87 mmol/L. Total bilirubin was 29 μmol/L with a direct component of 6 μmol/L and indirect bilirubin of 23 umol/L. His aspartate aminotransferase (AST) was 45 IU/L, blood glucose of 7.3 mmol/L, and Lactate dehydrogenase (LDH) was 190 IU/L. His white blood count was elevated to 12,000 cells/mm3. Hematocrit was 42%, with a hemoglobin of 14 g/dL and platelets were 1,97,000/mm3. Ultrasound abdomen showed gallstones and a bulky hypo echoic pancreatic tail representing the area of pancreas. Computed tomography abdomen also showed the tail of pancreas to be edematous with fat stranding and a calculus at the neck of the gall bladder []. Bilateral pleural effusions were also noted which was mild to moderate, more on the left than the right. The patient was diagnosed as acute pancreatitis secondary to gallstones. He was started on the standard treatment for acute pancreatitis.\nOn the 4th day of admission, his platelets dropped to 14,000/mm3, along with a fall in hemoglobin to 8.7 g/dL. LDH rose to 2,037 IU/L, associated with an increase in indirect hyperbilirubinemia. The urea and creatinine increased to 17 and 169 mmol/L, respectively. Peripheral smear showed significant schistocytes of 4%. The fibrinogen levels and the coagulation profile remained normal. ADAMTS 13 enzyme assay was not done as the test was not available in our hospital. Based on these typical lab values, a diagnosis of TTP was made as the patient was having thrombocytopenia, MAHA, and renal impairment. The only other differential diagnosis is hemolytic uremic syndrome (HUS). The severe thrombocytopenia with mild renal impairment went in favor of TTP rather than HUS, which is expected to have severe renal impairment with mild thrombocytopenia. The patient underwent pan CT, which ruled out malignancy anywhere else as a triggering factor for TTP. The patient was commenced on plasmapheresis in addition to methylprednisolone, which is an established treatment for both TTP and HUS.\nPatient's platelet counts, urea, creatinine along with hemoglobin started to improve after the second session of plasmapheresis. His recovery was complicated by the progression of bilateral pleural effusion, which resulted in respiratory compromise, requiring intubation and mechanical ventilation. Bilateral intercostal drains were inserted and the patient was weaned off the ventilator by the 7th day. He had a total of eight sessions of plasmapheresis and the laboratory parameters were back to normal and the patient was discharged from the hospital on the 20th day of admission. Follow up of the patient a month after discharge from hospital found him to be doing well.

[[43.0, 'year']]

M

{'31493291': 1, '12823037': 1, '30374015': 1, '9820399': 1, '26905311': 1, '11034007': 1, '19008177': 1, '18637802': 1, '29574435': 1, '17606444': 1, '27987277': 1, '12637323': 1, '19036107': 1, '24678155': 2}

{}

3943118-1

noncomm/PMC003xxxxxx/PMC3943118.xml

Spontaneous splenic rupture: A rare presentation of dengue fever

A 26-year-old female presented to the emergency department with an acute abdominal pain and prostration in a background of intermittent fever and watery diarrhea for 4-5 days. Her past medical history was unremarkable. On examination, she had severe pallor, tachycardia (pulse 120/min), tachypnea and a blood pressure (BP) of 90/60 mm Hg. There was a marked tenderness over all quadrants of the abdomen with ascites and hepatosplenomegaly. Other systemic examinations were non-contributory. Initial investigations revealed, hemoglobin (Hb)-3.4 g/dl, total leukocyte count-3.3 × 109/l (N-90%, L-8%, E-2%), platelet count -40 × 109/l packed cell volume 12.2%, mean corpuscular volume 87 fl; microscopic examination of urine was normal.\nLiver function test, serum amylase, lipase and electrolytes were within normal limits, but values of serum urea was 88 mg/dl and serum creatinine was 2 mg/dl. An urgent straight X-ray abdomen showed no evidence of pneumoperitoneum, whereas the chest X-ray revealed bilateral pleural effusions []. Diagnostic ascitic fluid tap from multiple quadrants showed hemoperitoneum. She was resuscitated with intravenous normal saline and blood transfusions (4 units of packed cells and 6 units of platelets) dopamine was used transiently in the first 24 h when fluids failed to raise BP adequately. After she became hemodynamically stable, ultrasonography was done and the report corroborated with clinical findings. The tourniquet test was normal. There was no growth of any organism in ascitic fluid and blood culture. Card test for pregnancy was negative. Subsequently computed tomography scan of the abdomen showed perisplenic hypoattenuating collection with the splenic border displaced by mass effect. There was also ascites and hepatosplenomegaly []. Patient denied any abdominal trauma; hence a diagnosis of hemoperitoneum due to spontaneous splenic rupture was entertained. Partial thromboplastin and activated partial thromboplastin time were within normal range. She was seronegative for malaria dual antigen, Widal test and human immunodeficiency virus. Blood test for Epstein-Barr virus was negative but dengue serology was positive for non-structural protein 1 (antigen capture ELISA) and immunoglobulin M (IVD micro-well ELISA DF kit) sent on the 2 day of admission (7th day after the onset of fever). Meanwhile her hemogram improved on the 4th day onward-Hb 11.4 g/dl, platelet 130 × 109/l and hematocrit was 47%. She was discharged after 7 days of in-patient stay.

[[26.0, 'year']]

F

{'18187775': 1, '28428659': 1, '19034976': 1, '12188420': 1, '21500704': 1, '9493849': 1, '17859065': 1, '5634140': 1, '11859699': 1, '18564675': 1, '23227374': 2, '21788711': 1, '14636483': 1, '24678156': 2}

{'3514804-1': 1}

3943119-1

noncomm/PMC003xxxxxx/PMC3943119.xml

Severe methemoglobinemia due to insecticide poisoning

A 26-year-old lady with no premorbid illnesses allegedly consumed about 20 ml of an insecticide called ‘Kick’ (composition: Biological extracts-2%, Stabilizers-8%, and Fillers and others-90%) with suicidal intent. She was found unresponsive and was taken to a local hospital where she was intubated and mechanically ventilated. She was referred to our hospital after 24 hours of ingestion for further management. At presentation, she was cyanotic with a heart rate of 160/min and blood pressure of 110/70 mm Hg. Saturation measured by pulse oxymetry was 80% on 100% oxygen and her blood was noted to be dark brown in color []. This raised the suspicion of methemoglobinemia and was confirmed by serum MetHb levels of 91% on co-oximetry. Glucose 6 phosphate dehydrogenase (G6PD) level was normal. She was administered 2 mg/kg of methylene blue and a repeat Arterial Blood Gas (ABG) at 1 hour showed a reduction in MetHb level to 27%. Another bolus dose was administered following which the MetHb level decreased further to 13.6%. In view of possible rebound increase in MetHb levels, methylene blue infusion was started at 10 mg/hr for 24 hours and gradually tapered off over the next 24 hours. On the 3rd day, she developed hemolysis and methylene blue had to be discontinued following which hemolysis resolved. Three pints of packed red cells were transfused to maintain the hemoglobin level above 9 gm%. MetHb levels slowly decreased and reached levels of <2% only after 6 days. High dose injection Vitamin C and Riboflavin was also administered. Her sensorium improved with the above measures and she was slowly weaned off the ventilator after 9 days. She had complete neurological recovery at discharge from the ward.

[[26.0, 'year']]

F

{'10533013': 1, '24987247': 1, '32435103': 2, '25521592': 1, '29398814': 1, '18561168': 1, '21686768': 1, '24678157': 2}

{'7225755-1': 1}

3943150-1

noncomm/PMC003xxxxxx/PMC3943150.xml

A case of passenger lymphocyte syndrome following minor ABO incompatible renal transplantation

Here we report one such case of PLS in a 27-year-old male renal allograft recipient of the B Rh D-positive blood group who received a kidney from a donor of the O Rh D-positive blood group. Indication for transplantation was end-stage renal disease and basiliximab induction was given. The patient was transfused with B Rh D-positive packed RBCs (PRBCs), 4 units during the surgery and 2 units postoperatively in the next 24 hours. The postoperative course of the patient was uneventful and graft function was normal by day 5. However, day 10 onwards, the patient showed a declining hemoglobin (Hb) level from 7.4 to 6.6 g%. His blood sample was sent to the blood bank, requesting for 1 unit of PRBCs. It showed no group discrepancy or unexpected antibody. The patient was transfused with 1 U of cross-match-compatible PRBCs of the B Rh D-positive blood group, following which there was a steep fall in his Hb level from 6.6g to 3.2g% over a period of 12 hour. Investigations showed that platelet count and coagulation parameters were normal, reticulocyte count was 11.1%, lactate dehydrogenase (LDH) level was 990 U/l and unconjugated bilirubin level was 2.4 mg/dl. The treating unit suspected hemolytic uremic syndrome associated with tacrolimus administration in the patient, which was excluded on the basis of absence of fragmented red cells on peripheral blood smear.\nA request for 2 units of PRBCs was again sent to the blood bank. ABO and Rh grouping were performed using the conventional test tube technique at room temperature, which showed no discrepancy; however, cross-match with B Rh D-positive PRBCs using the LISS Coomb column agglutination technique (Bio-Rad, Diamed GmbH, Cressier FR, Switzerland) at 37°C showed incompatibility. On performing direct anti-globulin test (DAT) using the LISS Coomb column agglutination technique (Bio-Rad, Diamed GmbH, Cressier FR, Switzerland), the patient's red cells were found to be strongly positive (4+). Elution was performed using the gentle heating method and the eluate showed the presence of anti-B. Indirect anti-globulin test of the patient's serum using a three-cell panel of O group (Diacell, Bio-Rad, Diamed GmbH, Cressier FR, Switzerland) was negative, ruling out the presence of any unexpected antibody and anti-B was detectable in the serum. Titration of anti-B using B-group red cells showed a titer of 32 in the indirect anti-globulin test phase. The antibody was probably of IgG class. The antibody was reactive only at 37°C and was unaffected by dithiothreitol treatment. The cross-match showed compatibility with O group so 2 units of O Rh D-positive PRBCs were issued for the patient and a provisional diagnosis of PLS was made.\nSerial titration of the kidney donor's serum in the indirect anti-globulin test phase showed anti-A and anti-B titers of 64 and 1024, respectively. Hemolysin test showed a positive result with B cells, indicating that the donor's blood group was the dangerous O-type.\nThe patient was treated with three doses of intravenous methylprednisolone. His Hb level did not show significant elevation and investigations showed a persistently raised reticulocyte count, LDH and creatinine []. He was subsequently transfused with PRBCs of O group and underwent two sessions of plasmapheresis. One volume exchange was done every alternate day and replacement was done with 5% albumin solution. The patient was serially monitored and the sequence of events that followed is depicted in . Nineteen days postoperatively, his Hb rose to 6.7 g% and anti-B titer was 2. Thereafter, his condition improved gradually and was discharged on day 29 in stable condition with good urine output, a serum creatinine level of 1.2 mg %, Hb level of 8 g% and an anti-B titer of 2.

[[27.0, 'year']]

M

{'2264320': 1, '16041664': 1, '15142057': 1, '11961243': 1, '3079641': 1, '21239807': 1, '21062381': 1, '9122907': 1, '1986468': 1, '3547785': 1, '24678177': 2}

{}

3943151-1

noncomm/PMC003xxxxxx/PMC3943151.xml

A Rare case of Guillain-Barré syndrome in pregnancy treated with plasma exchange

A 28 years old female, Gravida 1 Para1was referred to Gynecology and Obstetrics Department of our hospital at 36 weeks of pregnancy with 4 days history of progressive weakness of limbs and difficulty in walking, which culminated in loss of ability to walk; the weakness progressed gradually to upper limbs, with a 1 day history of difficulty in swallowing and breathing.\nThe patient was in her usual state of health 4 days back when she noticed weakness in both lower limbs after she got up in the morning. The weakness worsened the following day and she was unable to walk. By the end of 3rd day, weakness was also noted in upper limbs and had difficulty in lifting her arms. On the 4th day of her illness, she had difficulty in swallowing and breathing and was referred to the hospital.\nOn examination, the patient was found acutely ill, pale, afebrile, acyanosed, anicteric, and hydration status was satisfactory. She was dyspneic with shallow breathing. Her breathing was vesicular with no added sounds. Cardiovascular examination showed no abnormality. On abdominal examination, she was almost in full — term pregnancy (36weeks) and was not in labor. On neurological examination, she was found to be conscious but restless, and apprehensive. She was aphonic and had weak cough reflex and gag reflex; all her cranial nerves were normal. She presented with all the features of flaccid quadriplegia with grade zero power in both lower limbs and grade three in upper limbs. Muscle tone was decreased and deep tendon reflexes were lost. There was no sensory impairment or bladder and bowel involvement. Nerve conduction tests and cerebrospinal fluid analysis suggested diagnosis of GBS.\nThe patient was taken up for Cesarean Section, surgery was conducted under general anesthesia, and a 2.5 kg healthy baby was delivered. The patient could not be extubated following surgery as she was not able to maintain spontaneous breathing. She was then shifted to ICU and kept on ventilator and the next day plasma exchange was started; this was the 5th day of illness. Therapeutic plasma exchange was performed as first line treatment and IVIG or steroids were not tried before, after, or simultaneously with plasma exchange. Plasma exchange was done on alternate days, with a total of five sessions and in each session; 2308.8 ± 182.73 ml (range: 2105-2562 ml) of plasma was removed. This was in accordance with the guidelines of removing 1-1.5 times plasma in each session. Five percent albumin was used as replacement fluid. No plasma was used as the patient's coagulation profile was within normal limits. Peripheral femoral access was used to carry out the procedure; proper catheter care was maintained and lines were flushed with heparin before and after the exchange. The patient had no complications during these sessions. Complete coagulation profile including: prothrombin time (PT), prothrombin index (PTI), activated partial thromboplastin time (APTT); complete blood count (CBC) including haemoglobin, platelet count; electrolytes (Na+, K+, Ca++); s. protein levels were checked before and after the procedure and remained within normal limits throughout the treatment period. After three sessions of plasma exchange, i.e., on the 9th day of illness, the patient was weaned off the ventilator and physiotherapy started. The patient was discharged on 14th day of illness. At the time of discharge, the power was 5/5 in upper limbs and 3/5 in the lower limbs. Follow-up of the patient after 2 months showed no residual weakness.

[[28.0, 'year']]

F

{'11085768': 1, '2277161': 1, '1552913': 1, '3404161': 1, '31704796': 1, '11205660': 1, '11435020': 1, '11762620': 1, '9746040': 1, '15269509': 1, '3983516': 1, '9010009': 1, '1459875': 1, '11444365': 1, '28438080': 1, '8817501': 1, '10577623': 1, '24678178': 2}

{}

3945142-1

noncomm/PMC003xxxxxx/PMC3945142.xml

Intratracheal Administration of Umbilical Cord Blood-Derived Mesenchymal Stem Cells in a Patient with Acute Respiratory Distress Syndrome

A 59-yr-old man with a history of pulmonary tuberculosis (TB) and no significant family history was diagnosed with idiopathic thrombocytopenia in June 2008. The patient was treated with corticosteroid therapy. In October 2008, he developed a cough, sputum, and rhinorrhea and five days later displayed fever and dyspnea. He was subsequently admitted to hospital. His chest radiography and computed tomography (CT) scan showed multifocal patchy ground-glass opacities (GGOs) in both lungs with underlying emphysema with large bullae in the left lower lobe and focal irregular nodular lesions in the right upper lobe that were presumed to be TB sequelae. He was assessed as having atypical pneumonia. Considering his immunocompromised status, antibiotic therapy was commenced empirically.\nAfter five days, he was transferred to our hospital, a tertiary referral center, and admitted to the medical intensive care unit. At admission, he had tachypnea with a fever of 39℃. He had progressive bilateral diffuse infiltrations on his chest radiography. His initial SaO2 level was 75% and his PaO2/FiO2 (P/F) ratio was 166 mmHg. He was diagnosed with ARDS caused by atypical pneumonia. He then received mechanical ventilation (MV). We started a course of methylprednisolone at a dose of 40 mg twice a day to treat a possible Pneumocystis jiroveci pneumonia in conjunction with a continuing regimen of empirical antibiotics and an antiviral agent. However, no specific pathogen was identified in any specimen from this patient, including bronchoalveolar lavage, blood or sputum. Then, his chest radiography was stationary and his P/F ratio began to gradually improve.\nOn hospital day (HD) 7, he underwent tracheostomy to enable early weaning from MV. However, he then developed hospital-acquired pneumonia and hydropneumothorax due to a ruptured bullae with bronchopulmonary fistula (BPF). The repeated lung infections made him dependent on MV and weaning proved difficult. He was conscious during this time but he could not communicate with the medical team or even his family members. A psychiatrist diagnosed a hypoactive delirium due to his poor condition. On HD 87, he had a follow-up high-resolution CT, which showed aggravation of diffuse GGOs and interlobular septal thickening in both lungs. This indicated the progression of pulmonary fibrosis as a post-ARDS sequelae. After discussing the possibility of administering MSCs with his family, we commenced with a trial of this therapy.\nThe MSC trial was approved by the Institutional Review Board of Asan Medical Center. The umbilical cord blood (UCB)-derived MSCs (UCB-MSCs) were prepared as follows. UCB was obtained from a full-term delivery with informed maternal consent. UCB-MSCs were produced at the Good Manufacturing Practice facility of Medipost Co., Ltd., Seoul, Korea. Quality control and quality assurance for the production of these cells were performed according to the standards of the Korea Food and Drug Administration. Flow cytometry analysis of expressed surface antigens showed that these cells were uniformly positive for CD29, CD44, CD73, CD105, and CD166 and negative for the hematopoietic lineage markers CD34, CD45, CD14, and HLA-DR. The final UCB-MSCs preparations used in the infusion were harvested from cell culture passage 6 and suspended at a final density of 7.5×106/1.5 mL in normal saline.\nOn HD 114, the patient underwent the intratracheal administration of UCB-MSCs at a target dose of 1×106/kg. Before the procedure, the ventilator was set to the pressure-controlled ventilation (PCV) mode of 26 cmH2O of inspiratory pressure (IP) and 0.45 of FiO2. We evenly infused 5.5×107 MSCs into both bronchi by wedging each bronchus. There were no peri-procedural complications.\nThe next morning (16 hr later), he was able to communicate effectively with our medical team, which had not been possible in the previous few months. The IP was reduced to 24 cmH2O with 0.4 of FiO2. After 24 hr, we changed the PCV to a pressure support mode with 18 cmH2O of support pressure with 0.4 of FiO2. After 48 hr, PCV was applied again with 22 cmH2O with 0.35 of FiO2. The dynamic compliance of his lung improved from a pre-procedure value of 22.7 to 26.5, 27.3, and 27.9 mL/cmH2O after 24, 48, and 72 hr, respectively. His P/F ratio subsequently increased from pre-procedural 191 to 328 mmHg on day 1 after the procedure and to 334 mmHg on day 3 (). A follow-up chest radiography showed a slight decrease in bilateral lung infiltrates ().\nOn day 3, however, he suddenly experienced six generalized tonic-clonic seizures during the course of the day with a fever near to 39℃. He had no focal lateralizing signs. A brain CT was performed and showed no hemorrhage. His electroencephalogram showed no abnormal epileptiform discharge. We discussed the case with neurological specialists and determined that the current use of carbapenem was the most probable cause of his seizure. We discontinued it and started him on an anticonvulsant. Subsequently, he had no more seizures.\nThe weaning trial was restarted for our patient and the IP was reduced to 12 cmH2O with 0.3 of FiO2 during the following week. However, he could not be weaned because his repeated infection by multidrug-resistant pathogens was not controlled. Eventually, he suffered septic shock due to empyema and died on HD 231 or day 118 after MSC administration.

[[59.0, 'year']]

M

{'32820868': 1, '21506195': 1, '17625088': 1, '34407861': 1, '30651777': 1, '21164399': 1, '27066082': 1, '34164564': 1, '32779878': 1, '33529945': 1, '18468541': 1, '26865361': 1, '32839921': 1, '27570489': 1, '28430622': 1, '30186329': 1, '32472653': 1, '33178392': 1, '34750382': 1, '22504891': 1, '29235254': 1, '24616596': 2}

{}

3945143-1

noncomm/PMC003xxxxxx/PMC3945143.xml

Living Donor Liver Transplantation for an Infant with Osteogenesis Imperfecta and Intrahepatic Cholestasis: Report of a Case

A one-month-old male infant was transferred to the Seoul National University Children's Hospital because of neonatal cholestasis and bone fragility on December 29, 2011.\nFibular fracture and bilateral bowing of the femora were noticed just after birth. And right femur shaft fracture, left humerus fracture and left femur fracture occurred at 1, 2, and 3 months of age respectively (). He showed blue sclerae with a triangular face and his father showed the OI type IB. In mutation analysis for COL1A1 and COL1A2 encoding alpha 1 and 2 chains of type I collagen (MIM 120150 and 120160), a novel heterozygous mutation c.1036-2A > C, (of IVS19) in COL1A2 was identified in both the patient and his father.\nAt one month after birth, he developed white stool and abdominal distension. Liver function tests were abnormal; total bilirubin 7.3 mg/dL, AST 128 IU/L, ALT 82 IU/L, alkaline phosphatase 386 IU/L, albumin 4.0 g/dL, prothrombin time (PT, INR) 1.04, platelet 853 × 103/µL. The screening tests for metabolic diseases were normal. Viral markers for hepatitis A, B, C, and TORCH were all negative. Ultrasonography was incompatible with biliary atresia. Liver biopsy showed cholestasis with periportal fibrosis and damaged bile ducts without definite cause. At the seven month follow-up, his liver function had deteriorated (total bilirubin 19.3 mg/dL, direct bilirubin 12.9 mg/dL, AST 211 IU/L, ALT 165 IU/L, albumin 3.0 g/dL, PT INR 1.09, Platelet 254×103/µL). His CTP score was 9 and pediatric end stage liver disease (PELD) score was 13. Preoperative dynamic liver CT revealed hepatomegaly with surface nodularity and splenomegaly. Because his cholestasis had begun in infancy and had progressed to cirrhosis within seven months, progressive familial intrahepatic cholestasis (PFIC) was suspected. But abnormality was not detected in PFIC type III gene. Body weight was 7.9 kg (10th percentile) and height was 69.6 cm (20th percentile) at the time of LT.\nBefore surgery, the patient was treated with pamidronate infusion therapy (1.5 mg/kg per each cycle) for 4 cycles with vitamin D and calcium medications. His dual energy X-ray absorptiometry (DEXA) bone density showed 0.254 g/cm2 in spine L1-4, 0.301 g/cm2 in femur neck, and 0.393 g/cm2 in femur total after 3rd cycle of pamidronate therapy before LT. These values were comparable to reference values (-).\nLT was performed at the age of 8 months using the left lateral section from his mother under intravenous anesthesia because of the risk of malignant hyperthermia. An endotracheal tube was inserted smoothly under laryngoscopy without a difficult airway related with neck extension. There was no intractable metabolic acidosis during and after LT. Hyperthermia did not develop during the operation.\nThe graft weight was 215 gm and a graft versus recipient weight ratio was 2.72%. The retractors were not used because of high risk for rib fracture. Instead of that, skin was fixed to upper lateral portion in the chest wall with sutures to form the operation field (). The operation lasted for 420 min; cold ischemic time - 78 min, warm ischemic time - 24 min. Hepatic vein was anastomosed via piggyback method with strengthened fencing venoplasty. The recipient's main portal vein was anastomosed to the graft portal vein. The hepatic artery was anastomosed under a surgical microscope (×10). And hepatico-jejunostomy was done. The estimated blood loss was 530 mL. One unit of leukocyte depleted packed red blood cell was transfused during operation.\nHyperthermia developed up to 40℃ on postoperative day (POD) one, and went down within normal range at POD 2 without any cause. A newly developed fracture line of his right humerus shaft was detected at POD 2 (), but it healed under conservative treatment. He was transferred to the general ward from intensive care unit at POD 10 and discharged at POD 15. The pathologic report of the explant liver was secondary biliary cirrhosis, damaged interlobular bile duct, bile duct proliferation with cholestasis and septal fibrosis. He remains well on follow-up 9 months later at the outpatient clinic.

[[1.0, 'month']]

M

{'23091773': 1, '20432809': 1, '27498779': 1, '19878741': 1, '14992109': 1, '27433164': 2, '18626241': 1, '17560761': 1, '8565526': 1, '16382469': 1, '17449925': 1, '14617125': 1, '9477392': 1, '24616597': 2}

{'4940536-1': 1}

3945144-1

noncomm/PMC003xxxxxx/PMC3945144.xml

Computed Tomography and Magnetic Resonance Images of Adrenocortical Oncocytoma Cases

In May 2012, a 10-yr-old girl presented to our outpatient clinic for the evaluation of precocious puberty, which was diagnosed elsewhere. The patient reported no specific past history and no specific clinical symptoms, such as flushing, fever, or abdominal pain. A physical examination revealed elevated breast buds and the start of menstruation. The results of laboratory evaluations showed increased levels of androstenedione (23.1, normal range: 1.7-2.7 ng/dL) and estradiol (46.61, normal range: 0.2-3.0 ng/mL). Testosterone was mildly increased (1.64, normal range: 0.03-0.68 ng/mL), cortisol was slightly decreased (5.49, normal range: 6.2-19.4 µg/dL), and normal ranges of follicle stimulating hormone, luteinizing hormone, and adrenocorticotropic hormone were observed. There were no chromosomal anomalies. Abdominal CT scans detected a well-circumscribed, oval-shaped, 6-cm mass in the left adrenal gland, located superior to the left kidney, which demonstrated stippled calcifications on a precontrast scan. After the injection of a nonionic contrast medium (Omnipaque 350®, GE Healthcare, USA), volume of 100 mL of contrast medium was injected at a rate of 3 mL/s via an antecubital vein, heterogeneous well enhancement was visualized during the 1-min delayed scan, and enhancement washout was demonstrated on the 15-min delayed scan (). The CT Hounsfield unit (HU) was 40 HU on precontrast, 140 HU at 1 min, and 70 HU at 15 min. The absolute washout value ([Enhanced CT HU-Delayed CT HU]/[Enhanced CT HU-Unenhanced CT HU]×100) was approximately 70% (a value of more than 60% indicates adrenal adenoma), and the relative washout value ([Enhanced CT HU-Delayed CT HU]/Enhanced CT HU×100) was 50% (a value of more than 40% indicates adrenal adenoma) (). Initially we thought that functional adrenal adenoma should be included in the differential diagnosis. A left adrenalectomy was performed. During the operation, there was no evidence of hypertension associated with palpation of the mass or direct invasion to the surrounding organs. The tumor was approximately 6×4 cm, well-encapsulated and dark brown in color (). The tumor consisted of multiple small hemorrhagic vascular lakes with old blood. The microscopic examination revealed that the neoplasm consisted of polygonal cells with abundant eosinophilic cells and granular cytoplasm. Nuclear cellular atypia with enlarged nuclei were identified (×200, ×400 High Power Field [HPF], hematoxylin and eosin [H&E], ). An electron microscopic study was performed, and electron-dense inclusion and closely packed mitochondria with Golgi complex were found (×400 HPF, ). Thus, we concluded that the final diagnosis in this case was adrenocortical oncocytoma. The patient had an uneventful postoperative course and was doing well one year after surgery without new lesions.

[[10.0, 'year']]

F

{'9490968': 1, '19508984': 1, '17701888': 1, '1755111': 1, '16198960': 1, '1423199': 1, '15306935': 1, '8626901': 1, '21237489': 1, '1997708': 1, '10396247': 1, '1721751': 1, '15487257': 1, '18296908': 1, '34307624': 1, '18603692': 1, '1410337': 1, '7992738': 1, '3751804': 1, '29200669': 2, '24616598': 2}

{'3945144-2': 2, '5686962-1': 1, '5686962-2': 1, '5686962-3': 1, '5686962-4': 1, '5686962-5': 1}

3945144-2

noncomm/PMC003xxxxxx/PMC3945144.xml

Computed Tomography and Magnetic Resonance Images of Adrenocortical Oncocytoma Cases

In June 2010, an incidentally detected left adrenal mass was found in a 54-yr-old man via CT performed at another hospital. Abdominal CT scans detected a lobulating contoured, well-demarcated, well-enhancing solid mass in the left adrenal gland, which contained the central necrotic portion.\nMR images were obtained with a 1.5 T unit using a contrast agent (Gadovist®, Bayer Healthcare, Germany). On a T2-weighted gradient echo image (TR/TE: 3.7/1.6), the mass was primarily of slightly high signal intensity with a hyperintense central portion. This mass primarily demonstrated hypointensity on T1-weighted gradient echo images (TR/TE: 175.0/5.0), without a definite signal drop (suggesting a fat component) on the opposed-phase correlated with the in phase. The previously highly hyperintense focus on T2-weighted images showed hypointensity on the T1-weighted images, suggesting a necrotic portion, and a central hemorrhagic component was revealed within the necrosis by demonstrating a hyperintense foci on a T1-weighted image and hypointense foci on a T2-weighted image (). Contrast-enhanced MR images heterogeneously demonstrated the enhancement of the solid tumor portion at the 1-min, peak enhancement at the 3-min, and slight washout at the 5-min delayed phases. Intratumoral hemorrhagic necrosis was not constantly enhanced (). The blood vanillylmandelic acid, total metanephrine, epinephrine, and norepinephrine were within the normal ranges.\nBased on these observations, adrenal carcinoma and metastasis were included with the differential diagnosis. The patient underwent meticulous examination for the primary origin, including colonoscopy, gastroscopy, and chest CT; there was no evidence of a primary focus. The most probable preoperative diagnosis was adrenal carcinoma. The patient underwent laparoscopic adrenalectomy, and histology suggested adrenal oncocytoma with uncertain malignant potential.\nThe tumor was a soft oval mass measuring 9×6×5 cm in dimensions and 116 g in mass. The outer surface was well encapsulated by a thin fibrous capsule, and it was focally attached to a normal adrenal gland. Upon sectioning, the mass showed a brownish-yellow, fish-flesh-like cut surface with a multifocal brownish hemorrhagic necrosis and focal cystic changes ().\nThe tumor was composed of epithelial cells with abundant acidophilic cytoplasm, with nuclear pleomorphism and a diffuse growth pattern, as shown using a light microscope (), and the oncocytic cytoplasm was filled with a large number of mitochondria, as well as some lysosomes, Golgi bodies, small lipid particles, and glycogen particles (), the histological features of which were consistent with adrenocortical oncocytoma. The tumor showed a low mitotic count (<5/50 HPFs), the absence of atypical mitosis, and venous invasion, but it also showed focal necrosis and inconspicuous capsule invasion, the histological features of which were consistent with uncertain malignant potential (borderline) behavior. Electron microscopy showed that microscopic and immunohistochemical findings were compatible with an adrenocortical oncocytoma. Because of this finding, we performed a careful follow-up study to exclude the possibility that the adrenal tumor was malignant over a three-year follow-up period. This workup included multiple abdominal ultrasounds examinations, as well as chest and abdominal CT scans. All of the imaging findings were unremarkable. We concluded that the final diagnosis in this case was primary adrenocortical oncocytoma.

[[54.0, 'year']]

M

{'9490968': 1, '19508984': 1, '17701888': 1, '1755111': 1, '16198960': 1, '1423199': 1, '15306935': 1, '8626901': 1, '21237489': 1, '1997708': 1, '10396247': 1, '1721751': 1, '15487257': 1, '18296908': 1, '34307624': 1, '18603692': 1, '1410337': 1, '7992738': 1, '3751804': 1, '29200669': 2, '24616598': 2}

{'3945144-1': 2, '5686962-1': 1, '5686962-2': 1, '5686962-3': 1, '5686962-4': 1, '5686962-5': 1}

3945145-1

noncomm/PMC003xxxxxx/PMC3945145.xml

Different Clinical Phenotypes in Familial Severe Congenital Neutropenia Cases with Same Mutation of the ELANE Gene

Patient 2, a 37-month-old Korean girl, had a medical history of recurrent oral ulcers and persistent neutropenia (< 200/µL) and several times of hospitalization for treatment of cervical lymphadenitis, pneumonia and oral ulcers with fever. She underwent bone marrow aspiration and biopsy three days before her sister's admission (patient 1). Her ANC was also low (162/µL) on the day of the bone marrow examination, and serum immunoglobulin G, A, and M levels were normal, and chromosome analysis showed normal female karyotype (46, XX). Her bone marrow finding showed myeloid hypoplasia with maturation arrest at the promyelocyte stage ().

[[37.0, 'month']]

F

{'23463630': 1, '22148006': 2, '16551967': 1, '10581030': 1, '16497969': 1, '20582973': 1, '11543999': 1, '16822461': 1, '20445326': 1, '20008220': 1, '30775052': 1, '30123081': 1, '14962902': 1, '25659730': 1, '17761833': 1, '19775295': 1, '12963840': 1, '24616599': 2}

{'3945145-2': 2, '3230029-1': 1}

3945145-2

noncomm/PMC003xxxxxx/PMC3945145.xml

Different Clinical Phenotypes in Familial Severe Congenital Neutropenia Cases with Same Mutation of the ELANE Gene

Patient 3, a 32-yr-old Korean woman, had also showed neutropenia (ANC 329/µL). She had had severe recurrent oral ulcers until her early 20s. However, her stomatitis has no longer recurred after her marriage.\nConsidering the clinical courses and hereditary patterns of the two young girls and their mother, autosomal dominant congenital neutropenia was strongly suspected. Direct DNA sequencing analyses of the ELANE gene on chromosome 19p13.3 were performed on this family. The mutational analyses demonstrated substitution of the 597th base (G to A) in intron 4 (c.597+1G>A) on patients 1, 2, and 3, with negative study on their father and their eldest daughter ().\nDespite administration of vancomycin for 7 days to patient 1, enlarged lymph nodes and inflammatory changes around lymph nodes did not improve. From the 17th hospital day, we started administration of subcutaneous 5-10 µg/kg/day granulocyte colony stimulating factor (G-CSF). Although we gradually increased the dose of G-CSF up to 25 µg/kg/day, her lesion remained unchanged until excision under general anesthesia. After her discharge, she needed hospitalization twice more for 5 months due to stomatitis and severe acute otitis media, respectively. Patient 2 had three episodes of stomatitis with fever for 5 months. Despite administration of G-CSF 5-10 µg/kg, her ANC was also lower than 500/µL. Her mother has had no fever and oral ulcer since then.

[[32.0, 'year']]

F

{'23463630': 1, '22148006': 2, '16551967': 1, '10581030': 1, '16497969': 1, '20582973': 1, '11543999': 1, '16822461': 1, '20445326': 1, '20008220': 1, '30775052': 1, '30123081': 1, '14962902': 1, '25659730': 1, '17761833': 1, '19775295': 1, '12963840': 1, '24616599': 2}

{'3945145-1': 2, '3230029-1': 1}

3945396-1

noncomm/PMC003xxxxxx/PMC3945396.xml

Advanced peri-implantitis cases with radical surgical treatment

A 60-year-old Caucasian woman was referred to a private practice specializing in periodontics, dental implants and advanced restorative techniques to replace a 'failed' implant. The author informed the patient that the soft and hard tissues around her implant (tooth position 34 according to the World Dental Federation notation) showed evidence of peri-implantitis. The implant had been placed 20 months prior to her visit (to the current practice), and the crown fitted 4 months after the implant surgery. She reported a problem-free implant surgery and subsequent healing period; however, she reported that from the day the crown was fitted, the crown and adjacent gum had never felt 'comfortable.' The patient completed normal hygiene visits during her dental check-ups, but since the crown was fitted onto the implant in position 34, she had visited a hygienist every 3 months for help with this implant site. During visits to the hygienist, topical antibiotics were inserted on several occasions into the pocket to treat infections and pocket/implant surface debridement was carried out. The referring dentist had already warned the patient that the implant should be removed. Upon visiting our office, the patient described feeling very unsatisfied with the loss to her buccal tissue and bone at the implant site and asked if the implant could be replaced. Additionally, the tooth anterior to the implant (position 33) had also suffered extreme recession, which she felt was attributed to the development of peri-implantitis at position 34. The patient had no contraindicating medical condition. Clinical examination showed a very pronounced loss of attachment at positions 33 and 34 (). The patient was diagnosed as having a mixed 'thin and thick' gum phenotype. The width of keratinized gingivial tissue (KGT) in the lower arch varied between 0 and 6 mm. We performed a radiographic examination that produced periapical, panoramic and linear tomograms (). The initial diagnosis was controlled chronic adult periodontitis with horizontal bone loss affecting both the upper and lower dental arches. Peri-implantitis was also present at implant position 34 with no buccal KGT present. The aetiology of the problem was described to the patient, and a suggested treatment plan that involved the elective removal of the implant affected by peri-implantitis was suggested. In addition, we explained that bone loss was present at not only the implant site but also the anterior tooth and that both teeth should be removed to allow for the re-establishment of normal crestal bone at the site. With the elective removal of both the affected implant and anterior tooth, we had to create a stable peri-implant gingival apparatus. As a result, the width of the KGTs required reestablishing. The advantages of using a free split gingival graft was explained to the patient. Advantages included the presence of a stable, wide band of KGT conducive to ease of surgical handling and the carrying out of oral hygiene techniques. Because of the extreme bone loss suffered at site 34, new implants had to be placed at positions 33 and 35. The surgery was divided into three separate interventions as follows:\nThe removal of tooth 33 and the implant at 34 followed by Guided Bone Regeneration GBR to re-establish the width and height of the hard tissue A free split gingival graft to reconstruct the width of KGT to extend from position 33 to 35 Placement of implants into positions 33 and 35\nOne hour prior to surgery, the patient received systemic coverage of 2-g amoxicillin, 400-mg ibuprofen and 2-mg dexamethasone. Additionally, a mouth rinse of 2% chlorhexidine gluconate was administered 20 minutes before surgery. The surgery was carried out under intravenous sedation (midazolam) and local anaesthesia (4% articaine, Septodont, Saint-Maur-Des-Fosses, France). The mucoperiosteal flap was raised and tooth 33 and implant 34 were removed with periotomes to preserve the socket walls (). The sockets were debrided of all inflammatory and granulation tissue, but the remaining sulcular epithelium from the soft tissue margin was left intact (). The lingual soft tissue was then reflected to allow the submucosal placement of a resorbable membrane (Bio-Gide, Geistlich Pharma, Wolhusen, Switzerland) (). The vacated sockets were then packed with xenograft Bio-Oss (Geistlich Pharma, Wolhusen, Switzerland) with a particle size of 0.25-1.0 mm and covered with Bio-Gide (), thus attempting to re-establish a normal height in the crestal hard tissue. Last, 4.0 Prolene sutures were used to close the wound ().\nFour months postoperatively, a periapical radiograph was taken to display the newly augmented crestal bone (). Afterward, the second stage of surgery was carried out under the same surgical protocol. The free split gingival graft was carried out using donor tissue from the left palatal vault (), and the wound was covered with an eugenol-free pack for 7 days. Preparation of the recipient site involved the removal and apical reflection of the supraperiosteal mucosa, and this was sutured into the sulcus with 6.0 Prolene sutures (Ethicon, Johnson and Johnson, Wokingham, Berks, UK). Next, the 'free-graft' from the donor was sutured into the recipient site with 6.0 Prolene sutures ().\nTwo months later, the third stage of surgery was performed under the same surgical protocol. The implants were placed by centralizing them to the 'bony ridge' (MIS, SEVEN, Tel Aviv, Israel). The primary stability of all of the inserted implants was high; both implants had an initial seating torque of 50 Ncm as calibrated on the seating apparatus (Implantmed, W&H Dentalwerk, Buermoos, Germany). The final placement of the implants (torque value>50 Ncm) was carried out using a hand wrench. The crestal bone was further augmented with the xenograft (), and periapical radiographs were taken immediately postoperation ().\nFive months later, the implants were exposed via a crestal incision displaced to the lingual side, and healing abutments were fitted. The final fixed bridge was fitted eight weeks later (). Periapical radiographs were taken systematically at the bridge fitting and one, six and 12 months postloading (). All treatments proceeded uneventfully, and the results showed a marked improvement in marginal gingival tissue levels and bone levels (). Every six months, the patient has been examined and radiographs taken, which will continue for two years. After two years, observational radiographs will be taken every 12 months. The patient remains in supportive periodontal therapy.

[[60.0, 'year']]

F

{'33081038': 1, '6188765': 1, '30254440': 1, '28823063': 1, '18067597': 1, '8126246': 1, '22754901': 1, '4507712': 1, '6575981': 1, '20151801': 1, '23062130': 1, '330574': 1, '7050339': 1, '16553638': 1, '9326899': 1, '23062134': 1, '19722789': 1, '17092244': 1, '17868376': 1, '12787220': 1, '18380550': 1, '16117768': 1, '26877903': 1, '24616833': 2}

{'3945396-2': 2}

3945396-2

noncomm/PMC003xxxxxx/PMC3945396.xml

Advanced peri-implantitis cases with radical surgical treatment

A 44-year-old Caucasian man was referred to our office to replace implants that were expected to be imminently lost. Over the past five years, the patient reported receiving multiple implant therapies where many of the implants were removed and replaced. There were sites where the implants had been replaced on three occasions during that period. The patient did not understand the aetiology of the loss, had never received oral hygiene instruction or other forms of long-term supportive periodontal therapy and had no concept of peri-implantitis. The initial diagnosis was uncontrolled chronic adult periodontitis with horizontal bone loss affecting both the upper and lower dental arches. Additionally, peri-implantitis was present in varying degrees of aggression at all implant positions. Multiple photographs and radiographs were included in the initial diagnosis. The aetiology of the problem was described to the patient. Supportive periodontal therapy was initiated, and various surgical designs for implantotomywere applied with great success. Because of the degree of bone loss associated with the implant in position 42 (), the corrective surgical therapy was complicated and divided into two stages as follows:\nThe removal of implant 42 followed by GBR to re-establish the width and height of the hard tissue Placement of a 'remedial' implant into position 42 accompanied by a subepithelial connective tissue graft to replace the missing width of KGT at the site and further GBR (if necessary)\nThe same surgical protocol as in the preceding case was followed.\nA mucoperiosteal flap was raised to allow full visualization of the affected site (). The site was partially debrided and implant 42 was removed by luxation, which minimizes trauma to the socket walls (). The socket was debrided of all inflammatory and granulation tissue, but any remaining sulcular epithelium was kept intact in the soft tissue margin (). The lingual soft tissue was then reflected to allow the submucosal placement of the Bio-Gide membrane (Geistlich Pharma, Wolhusen, Switzerland). The vacant void was then packed with xenograft Bio-Oss (Geistlich Pharma) with a particle size of 0.25-1.0 mm and covered with Bio-Gide. These efforts attempted to re-establish a crestal hard tissue of a normal height. Last, 5.0 Prolene sutures were used to close the wound ().\nFive months postoperatively, a periapical radiograph was taken to display the newly augmented crestal bone (). After that, the implants (MIS, SEVEN) were placed by centralizing them to the 'bony ridge' and following the same surgical protocol (). The primary stability of both inserted implants was high; both implants had an initial seating torque of 50 Ncm as calibrated on the seating apparatus (Implantmed). Final seating of the implants (torque value>50 Ncm) was carried out using a hand wrench (). The crestal bone was further augmented with the xenograft and covered with Bio-Gide. Connective tissue was harvested from the right palatal vault and sutured to the underside of the extended, reflected labial mucosal flap ().\nFive months later, the implants were exposed via a crestal incision displaced to the lingual side, and healing abutments were fitted. The final fixed bridge was fitted four weeks later (). All of the treatments proceeded uneventfully, and the results showed a marked improvement in marginal gingival tissue levels and bone levels (). To date, the patient has received periodic examinations and radiographs over two years. After two years, observational radiographs will be taken every 12 months. The patient remains in supportive periodontal therapy.

[[44.0, 'year']]

M

{'33081038': 1, '6188765': 1, '30254440': 1, '28823063': 1, '18067597': 1, '8126246': 1, '22754901': 1, '4507712': 1, '6575981': 1, '20151801': 1, '23062130': 1, '330574': 1, '7050339': 1, '16553638': 1, '9326899': 1, '23062134': 1, '19722789': 1, '17092244': 1, '17868376': 1, '12787220': 1, '18380550': 1, '16117768': 1, '26877903': 1, '24616833': 2}

{'3945396-1': 2}

3945633-1

noncomm/PMC003xxxxxx/PMC3945633.xml

Loose cell clusters with vascular coats: Zellballen pattern of paraganglioma on cytology

We describe a case of a 42-year-old woman presenting with fever on and off since 1 year and neck swelling of 5 months duration. Ultrasonography (USG) showed a well-defined heterogeneous highly vascular lesion in right cervical region. Thyroid, parotid, submandibular gland and neck vessels were normal. Clinical impression was lymph node metastasis or a carotid body tumor. Clinical examination revealed a solitary 3 cm × 2 cm non-mobile non-tender mass present at the right angle of mandible. FNAC was bloody and Pap stained smears revealed cells in clusters, microacinar and rosette like formations as well as singly. The cells were monomorphic, round to plasmacytoid with round to oval nuclei and a moderate amount of pale granular cytoplasm. There was evidence of mild anisonucleosis. Many of the cells showed stippled nuclear chromatin. There were in addition, few large loose clusters of cells enveloped by vascular channels on all sides. The cells within these clusters were arranged in curved rows. These cells showed same cytomorphologic features as surrounding cells [Figure and ]. There was no evidence of necrosis or mucin in the smears.\nIn view of monomorphic cells with the absence of necrosis and mucin, metastatic adenocarcinoma was ruled out. Metastasis of medullary carcinoma of the thyroid was considered on cytomorphology, but was ruled out on the basis of a normal thyroid on USG and absence of specific cytologic features. Hence a cytological diagnosis of carotid body paraganglioma was offered. After 2 weeks, the patient underwent surgical excision with due precautions. Histopathological examination confirmed the diagnosis of a benign carotid body paraganglioma [].

[[42.0, 'year']]

F

{'31168271': 1, '10097711': 1, '9134336': 1, '14674085': 1, '18833816': 1, '32851012': 2, '24648676': 2}

{'7396616-1': 1}

3945634-1

noncomm/PMC003xxxxxx/PMC3945634.xml

Cytopathological features of scar endometriosis mimicking an adenocarcinoma: A diagnostic pitfall

This was a case report of a 33-year-old, non-obese, Asian, lady physician, P1, A0 sustained a minor scald over her right inguinal region. The scald was adjacent, but not involving the right lateral aspect of her 3-year-old Pfannenstiel incision scar. The wound completely re-epithelialized within 10 days, leaving behind slight skin discoloration. A month later, she noticed a “thumb-sized” swelling in the same area. She had a normal menstrual history.\nClinically, the swelling was superficial to abdominal muscles and measured 2 cm; was non-tender, non-inflammatory, firm and mobile. She underwent FNAC, followed by incisional biopsy and excision.\nThe patients’ serum tumor marker levels, including celomic antigen (CA) 125, carcino embryogenic antigen and CA 19.9 were within the normal range.\nHer abdominal and pelvic ultrasonogram revealed a 3 cm sized subcutaneous, hypoechoic, solid mass with scattered internal echoes.\nMagnetic resonance imaging (MRI) showed a heterogeneous subcutaneous soft tissue mass measuring 3 cm × 2.5 cm × 2 cm. The lesion was hypointense on plain T1-weighed images, hyperintense on T2-weighed and short inversion time recovery axial images. Post-contrast T1-weighed images showed heterogeneous enhancement within the lesion [].\nOn review, Hematoxylin and Eosin (H and E), as well as Giemsa stained smears were hypercellular and revealed epithelial cells in groups and glandular architecture, imperceptibly admixed with numerous, relatively smaller, short spindly cells. Epithelial cells exhibited mild to focally, moderate nuclear enlargement. Interspersed were metaplastic cells against a hemorrhagic background []. Whereas the initial diagnosis offered was a metastatic adenocarcinoma, on review, endometriosis was suggested.\nIncisional biopsy revealed fibrocollagenous tissue and few glands exhibiting focal nuclear atypia that was interpreted as dysplasia.\nExcision specimen measured 5.5 cm × 4.5 cm × 2.5 cm with an overlying skin that showed a linear scar. On serial sectioning, a firm nodule was identified in the subcutaneous region measuring 1.3 cm × 0.5 cm × 0.4 cm. Cut surface of the nodule was grey-white with focal areas of hemorrhage.\nConventional H and E stained microsections showed glandular structures, exhibiting focal dilatation, surrounded by stromal cells, indicative of endometrial tissue with focal inflammation and metaplasia. Epithelial cells exhibited focal atypia. However, there was insufficient atypia to label it as an adenocarcinoma. Diagnosis of endometriosis was offered. Immunohistochemically, the glands were diffusely positive for estrogen receptor and progesterone receptor while the stroma was diffusely positive for CD10. Diagnosis of endometriosis was reinforced []. All the resection margins were free of the lesion.\nPost-surgery, patient is on gonadotropin releasing hormone analogues; is currently free of disease since 12 months and is on follow-up.

[[33.0, 'year']]

F

{'18335552': 1, '16575366': 1, '3067928': 1, '21987456': 1, '21187878': 2, '17572279': 1, '8042426': 1, '12781893': 1, '29468004': 1, '20058306': 1, '24648677': 2}

{'2983076-1': 1}

3945635-1

noncomm/PMC003xxxxxx/PMC3945635.xml

Cytodiagnosis of the primary breast lymphoma in a young woman

A 23-year-old non-lactating (para 2, gravida 0) lady came with a left breast lump and lymphedema of the left arm of 1-month duration. She recently had lumpectomy done in the same breast 1-month earlier at a peripheral hospital, which was diagnosed as breast abscess on histopathology. Her ultrasound examination previous to lumpectomy was available that showed an irregular hypoechoic mass of size 2.6 × 2.1 × 1.6 cm in the left breast having both solid and cystic components, perilesional inflammatory changes, and architectural distortion. The ultrasound findings of the left breast suggested focal mastitis with abscess formation. The right breast was normal and bilateral axillary lymphadenopathy was absent at this point of time. Her examination at the present visit revealed an irregular hard tender fixed mass of 6 × 4 cm in the outer lower and upper quadrants of the left breast. The skin overlying the mass was erythematous, nodular, and showed a surgical scar mark just above the areola []. The largest left axillary lymph node measured 4 × 2 cm. FNAC of the left breast mass and left axillary lymph nodes was done in Department of Pathology. Ethanol-fixed Papanicolaou-stained smears were prepared for cytological study. The breast mass FNAC showed richly cellular monomorphic population of loosely cohesive single lymphoid cells of two to three times the size of mature lymphocytes with moderate anisonucleosis, 1-3 prominent nucleoli and fragile cytoplasm []. The ductal epithelial cells of the breast were not seen in the cytology smears. Similar cytomorphologic features were also present in the aspirate from left axillary lymph nodes. A cytological diagnosis of non-Hodgkin lymphoma- large cell type was given. A tru-cut needle biopsy of the breast mass also showed features of non-Hodgkin lymphoma. Her formalin-fixed, paraffin-embedded blocks of the prior lumpectomy specimen was then retrieved from the peripheral laboratory and reviewed. Hematoxylin and eosin (H and E)-stained sections showed replacement of the breast parenchyma by diffuse sheets of monomorphic lymphoid cells []. On higher magnification, the lymphoid cells showed moderate anisokaryosis, clumped nuclear chromatin, prominent nucleoli, and minimal amount of eosinophilic cytoplasm on a background of lymphoglandular bodies []. Lymphoepithelial lesion was characterized by infiltration of lymphoma cells into the sparsely present duct epithelium of the breast []. Immunohistochemical studies were performed on formalin fixed, paraffin-embedded blocks of the lumpectomy specimen. Cytokeratin immunostaining showed strong cytoplasmic reactivity in the duct epithelium while the lymphoma cells stained negative []. In contrast, the lymphoma cells expressed diffuse strong membranous positivity with antibodies against leukocyte common antigen [] and CD 20 [] while negative for CD 15, CD 30, and CD 3. There was no primary elsewhere as evidenced by the absence of hepatosplenomegaly and the absence of any lymph node enlargement other than left axillary lymph nodes. The final diagnosis was primary diffuse large B-cell lymphoma of the breast, stage II. The patient was planned for chemotherapy, her baseline laboratory investigations and ultrasound examination of abdomen was normal. However, further management and follow up of the patient could not be done as she escaped from the hospital against the medical advice.

[[23.0, 'year']]

F

{'12199758': 1, '33776711': 2, '10375092': 1, '10849995': 1, '4555557': 1, '2249200': 1, '17457172': 1, '24648678': 2}

{'7983620-1': 1}

3945636-1

noncomm/PMC003xxxxxx/PMC3945636.xml

Recurrent benign cutaneous granular cell tumor: A case report

A 42-year-old male presented to surgery OPD with a gradually increasing, painful, right-sided swelling in the back for two years. There was no history of any other painful nodules or local trauma. On physical examination, a firm, mobile subcutaneous swelling with well-defined margins, measuring 7 × 6 cm in size was noticed over right side of back. No discoloration or vascular distension was identified []. Past history of excision of similar swelling from the same site few years back was present; however, records of previous surgery were not available.\nA FNA of the swelling was performed using standard technique. The smears prepared from the aspirate were air dried and stained with Giemsa stain. A portion of the aspirate was submitted for cell block. Sections from the cell block were stained with hematoxylin and eosin (H and E). The FNA smears revealed moderate to high cellularity comprising of singly scattered as well as clusters of uniform polygonal cells with low N/C ratio, moderate to abundant granular, fragile cytoplasm, and eccentrically placed round to oval nuclei with few cells showing mild nuclear pleomorphism []. A small number of cells had prominent nucleoli while occasional cells showed prominent intranuclear inclusions []. Few binucleate and multinucleate cells were also noticed. No necrosis or mitoses was identified. Based on the cytomorphological features, a diagnosis of granular cell tumor was given. The cell block sections showed uniform polygonal cells with periodic acid- Schiff (PAS)-positive, diastase-resistant granular cytoplasm The cells also demonstrated positivity for S100 []. Hence, the diagnosis of granular cell tumor was confirmed.

[[42.0, 'year']]

M

{'22837582': 1, '4336487': 1, '9669341': 1, '13937258': 1, '6322491': 1, '11284316': 1, '23439997': 2, '28951863': 2, '10432874': 1, '34434082': 2, '24648679': 2}

{'8369402-1': 1, '3573450-1': 1, '5606912-1': 1}

3948443-1

noncomm/PMC003xxxxxx/PMC3948443.xml

The effect of long-term oral dantrolene on the neuromuscular action of rocuronium: a case report

A 52-year-old male patient with a height of 163 cm and a weight of 65 kg was admitted to the hospital due to right femoral edema, and following a diagnosis of right femoral abscess, an incision and drainage procedure was performed.\nWith regard to medical history, the patient was paraplegic from the level of the fourth thoracic vertebra due to a T2-level spinal cord injury from a car accident 4 years previously. Due to tetany symptoms in both lower limbs, he had been regularly taking an oral dantrolene formula of 50 mg (Anorex® Cap. 25 mg, Yooyoung Pharmaceutical, Seoul, Korea) every night for the previous 3 years.\nPrior to the operation, the patient's blood pressure was 100/60 mmHg, and his heart rate was 94 beats per minute. There was a systemic inflammation response due to the right femoral abscess, accompanied by an increase in body temperature (38.3℃); in addition, the prothrombin time was outside the normal range (INR 1.21). Hence, the decision was made to perform the operation under general anesthesia.\nAs pretreatment for anesthesia, 0.2 mg of i.m. glycopyrrolate was administered 30 minutes prior to entering the operating room. When the patient entered the operating room, the standard anesthetic monitoring devices were applied, and the blood pressure and heart rate were 123/78 mmHg and 86 beats per minute, respectively.\nThe neuromuscular monitoring device (TOF-Watch®, Organon, Boxtel, Netherlands) was attached to the ulnar nerve of the left forearm flap. Propofol 2 mg/kg was intravenously administered for induction of anesthesia, and i.v. rocuronium 0.3 mg/kg (ED95) was administered while ventilating with 5 L/min of oxygen and 4 vol% of sevoflurane.\nThe TOF ratio did not fall under 0.25 2 minutes after rocuronium administration, and 10 mg (0.15 mg/kg) of i.v. rocuronium was additionally administered. After 2 minutes, the TOF count still had not decreased to 0, and 0.15 mg/kg of i.v. rocuronium was repetitively administered. Thereafter, the TOF count decreased to 0, and endotracheal intubation was carried out.\nThe mandible was sufficiently relaxed at the time of endotracheal intubation; there was no movement of the vocal cord, and coughing or movement was not observed after intubation. The anesthesia was maintained with 1.2-1.5 vol% of sevoflurane and 50% N2O during the operation.\nThe TOF ratio was 0.37 at the end of the operation, which was 35 minutes after the last dose of the muscle relaxant had been administered. Intravenous pyridostigmine 0.15 mg/kg and glycopyrrolate 0.003 mg/kg were administered as antagonists of the muscle relaxant. Extubation was carried out; the TOF ratio was maintained above 0.9 at around 55 minutes after the last dose of the muscle relaxant had been administered. No sign of respiratory depression was observed after extubation, and no particular signs and symptoms were observed in the recovery unit.\nThree months later, the patient was diagnosed with chronic osteomyelitis, and an incision and drainage operation was planned. It was decided to perform general anesthesia in consideration of the state of systemic inflammation and the patient's preference.\nAs pretreatment for anesthesia, 0.2 mg of i.m. glycopyrrolate was administered 30 minutes prior to entering the operating room. When the patient entered the operating room, the standard anesthetic monitoring devices and the neuromuscular monitoring device were applied in the same manner as in the previous operation.\nThe blood pressure was 112/70 mmHg, and the heart rate was 93 beats per minute. The neuromuscular monitoring device (TOF-Watch® SX, Organon, Netherlands) was attached to the ulnar nerve of the right forearm flap. Loss of consciousness was confirmed after administration of 2 mg/kg of i.v. propofol, and then 2.5 vol% of sevoflurane was administered as an inhalation anesthetic.\nAfter the loss of consciousness, stabilization and calibration were carried out to establish the initial value of the spasm height prior to the administration of rocuronium. For the calibration of the spasm reaction, a 50 Hz tetanic stimulation was conducted for 5 seconds, which was then changed to a 2 Hz TOF stimulation with 15-second intervals, and the calibration was initiated by pressing the CAL switch on the TOF-Watch®SX (CAL 2 mode). The TOF response change was within 10% 2 minutes after the calibration, and this was considered as the stabilization of the spasm response. The muscle relaxant was then administered.\nAt 180 seconds following the i.v. administration of rocuronium 0.3 mg/kg (ED95), a block of more than 80% of T1 failed; therefore, additional i.v. rocuronium 0.3 mg/kg was administered, and a 100% block of T1 was achieved at just past 300 seconds. Endotracheal intubation was then carried out. The anesthesia was maintained with 1.5-2.0 vol% of sevoflurane and 50% of N2O during the operation. The time taken to recover T1 to 25% after the administration of the second dose of the muscle relaxant was 4 minutes and 36 seconds.\nTwenty-five minutes after endotracheal intubation, T1 had recovered more than 25%; hence, an additional 7.5 mg of rocuronium was administered. With the recovery of the muscle relaxation, the time taken for T1 to recover from 25% to 75% was 9 minutes and 1 second.\nThe TOF ratio was 0.33 5 minutes after ceasing sevoflurane administration on completion of the operation. Neostigmine 0.05 mg/kg and glycopyrrolate 0.005 mg/kg were administered to antagonize the muscle relaxation.\nAt 5 minutes and 30 seconds after administration of the antagonist, T1 had recovered more than 95%, and the TOF ratio had recovered to more than 0.9. Therefore, extubation was carried out. There was no sign of respiratory depression after extubation in the recovery unit.

[[52.0, 'year']]

M

{'12067009': 1, '3752576': 1, '17222339': 1, '2858994': 1, '3057938': 1, '21878205': 1, '6048486': 1, '6614536': 1, '7901438': 1, '9768798': 1, '6499510': 1, '15023108': 1, '3527659': 1, '21372281': 1, '20560919': 1, '24624274': 2}

{}

3948444-1

noncomm/PMC003xxxxxx/PMC3948444.xml

An awake double lumen endotracheal tube intubation using the Clarus Video System in a patient with an epiglottic cyst: a case report

A 54-year-old male, 165.8 cm in height, weighing 55.6 kg was scheduled for PPPD and video-assisted thoracic surgery (VATS) due to a previously diagnosed duodenal cancer and a 1.1 cm-sized mass on the right apex of the lung, suspected to be a duodenal cancer metastasis. He had no other underlying disease but had a known large epiglottic cyst, which resulted in intubation failure and the cessation of surgery at a previous hospital. Laryngoscopic examination revealed a bulge arising from the center of the epiglottis and stretching to the glottis. It covered most of the epiglottis and occupied most of the pharyngeal space (). Despite the large size (> 2 cm) of this epiglottic cyst, the patient did not complain of any laryngeal symptoms such as dyspnea, dysphagia, hoarseness, and sleep apnea. A preoperative evaluation by an otolaryngologist concluded that the patient be kept under close observation as he did not show any symptoms. Preoperative airway assessment demonstrated excellent mouth opening and that the jaw could be thrust forward, corresponding to a class 1 Mallampati score. His temporomandibular joint activity, neck movement and thyromental distance were also normal.\nThe patient was informed at the preoperative visit about the likelihood of a difficult intubation, the procedures involved with an awake intubation, and the necessity for his cooperation with this procedure. In the operation room, we decided to perform an awake orotracheal intubation using CVS loaded with a left 37 Fr DLT (). The patient was premedicated intravenously with 0.2 mg glycopyrrolate, and 50 µg fentanyl. A superior laryngeal nerve block with 2 ml of 2% lidocaine was performed bilaterally and 10% lidocaine spray was applied to the oropharyngeal mucosal surface with direct laryngoscopic exploration. Preoxygenation was performed using a closed facemask with 100% oxygen delivery at 8 L/min over 10 minutes. The CVS loaded with a lubricated 37 Fr DLT was smoothly inserted into the posterior pharynx. After identifying the epiglottis and glottis opening, the distal tip of the CVS was carefully advanced below the mass to the glottis aperture (). The DLT was further advanced until the tracheal cuff passed through the vocal cord. After endotracheal intubation was confirmed by auscultation of the bilateral breath sound and end-tidal CO2 detection, the patient was given propofol 140 mg and vecuronium bromide 10 mg intravenously.\nThe time taken to complete awake intubation was less than 1 minute. Spontaneous breathing was maintained and no desaturation occurred during the entire procedure. General anesthesia was maintained with a 2-3 vol% of sevoflurane with 50% oxygen and medical air mixture. After the position change for VATS, the final position of the DLT was confirmed by flexible fiberoptic bronchoscopy (FOB) (Olympus LF-DP; Olympus optical Inc., Tokyo, Japan). At the completion of VATS, the patient's position was changed to supine and the PPPD preceded without an endotracheal tube change. Although the DLT is a larger tube with the potential to cause more airway trauma or edema postoperatively, we decided not to change the tube because this would have caused an even higher risk to the patient from possible cyst damage or intubation failure.\nAfter these surgical procedures were completed, the patient was fully awakened and extubated. The patient was then transferred to the general ward via a recovery room with no respiratory or hemodynamic complications.

[[54.0, 'year']]

M

{'9706954': 1, '27051377': 1, '21991744': 1, '21254990': 1, '22074080': 1, '15957729': 1, '11498322': 1, '22070595': 1, '31142177': 2, '21286452': 2, '22040447': 1, '23053462': 1, '28879281': 1, '14616594': 1, '24624275': 2}

{'3030048-1': 1, '6683921-1': 1}

3948445-1

noncomm/PMC003xxxxxx/PMC3948445.xml

Anesthetic management of a patient with obstructive prosthetic aortic valve dysfunction: a case report

A 55-year-old woman (height 153 cm, weight 59.5 kg) was scheduled for burr-hole drainage due to a subdural hematoma. Previous medical history revealed rheumatic involvement of heart valves resulting in moderate mitral stenosis and severe aortic stenosis with a preserved LV ejection fraction (EF) of 83%. Accordingly, the patient had undergone a double heart valve replacement (DVR) surgery 6 years ago with mechanical valves (Sorin®, Sorin group, Milano, Italy) #18 and #25 for the aortic and mitral valve, respectively. Echocardiography performed immediately after DVR revealed a LVEF of 60% and significant reductions in the peak and mean systolic pressure gradient (PSPG/MSPG) across the prosthetic valves. In detail, the PSPG/MSPG across the aortic valve was reduced from 122/74 mmHg to 29/12 mmHg. Follow-up echocardiography performed 2 years after DVR revealed an increased pressure gradient across the prosthetic aortic valve (PSPG/MSPG = 91/57 mmHg) due to PPM and possibly from pannus formation, with good motion of the prosthetic mitral valve and normal LVEF. Echocardiography performed a year ago revealed similar findings with persistence of the pressure gradient across the aortic valve (PSPG/MSPG = 98/50 mmHg) (). While the patient had been asymptomatic regarding obstructive PVD, her treatment plan was close medical observation.\nWarfarin 7.5 mg and olmesartan 10 mg was given orally per\nday after DVR, and warfarin was discontinued as soon as the diagnosis of a subdural hematoma was confirmed. The patient's electrocardiography (ECG) showed a sinus rhythm with first-degree AV block and other preoperative laboratory studies were all within the normal limits. As the patient was free of cardiac symptoms, an additional echocardiography was not performed before the burr-hole drainage.\nWe planned to perform general anesthesia under the assumption that her hemodynamic status was similar to a patient with severe, asymptomatic aortic stenosis. Upon arriving at the operating room, the patient was alert and standard monitoring devices were applied including 3-lead ECG, noninvasive blood pressure and pulse-oximetry. Initially assessed vital signs were as follows: arterial blood pressure of 173/72 mmHg, pulse rate of 63 beats/min, and peripheral oxygen saturation (SpO2) of 100% in room air. Glycopyrrolate 0.1 mg was given as premedication and radial artery cannulation under local anesthesia was performed for continuous monitoring of arterial blood pressure before anesthetic induction. Anesthesia was induced via the intravenous route using midazolam 3.5 mg, thiopental sodium 50 mg, and a continuous infusion of remifentanil using a target-controlled infusion device (Orchestra® infusion pump system, Fresenius vial, Brenzins, France). The effect site concentration of remifentanil was gradually increased while paying attention to the patient's vital signs. After loss of consciousness, mask ventilation was maintained with 1.5 % of sevoflurane in 100% oxygen, and 30 mg of rocuronium bromide was injected intravenously. After the effect site concentration of remifentanil reached 4.0 ng/ml, the trachea was intubated and the lungs were mechanically ventilated with 60% oxygen with air. Mechanical ventilation was performed to achieve an end-tidal carbon dioxide level between 35 and 40 mmHg. Her heart rate remained unchanged while her blood pressure was maintained between 130/70 mmHg and 140/80 mmHg during the period of anesthetic induction and tracheal intubation. For anesthesia maintenance, sevoflurane was carefully titrated to maintain a bispectral index score between 40 and 60. The effect site concentration of remifentanil was adjusted to maintain the intraoperative blood pressure and heart rate within 20% of the preoperative values. Major hemodynamic goals during the surgery were to maintain the systolic blood pressure between 130-170 mmHg, diastolic blood pressure between 60-80 mmHg, and pulse rate between 55-70 beats/min. Upon completion of the surgery, sevoflurane was discontinued, and the neuromuscular blockade was antagonized with 0.2 mg of glycopyrrolate and 1 mg of neostigmine. After confirmation of regaining adequate consciousness and spontaneous respiration, the patient was transferred to the post anesthesia recovery unit. The duration of the surgery and anesthesia was 30 and 60 min, respectively, and 200 ml of colloid solution and 300 ml of crystalloid solution were given. There were no remarkable events in the operating room and in the post anesthesia recovery unit.\nTwo days after the operation, transthoracic echocardiography was performed, and it still showed an increased aortic valvular pressure gradient (PSPG/MSPG = 100/55 mmHg), an aortic valve area (AVA) of 0.88 cm2 and an indexed effective orifice area (EOA) of 0.56 cm2. While warfarin could not be restarted immediately, a follow-up transesophageal echocardiography was performed on the tenth day after operation, which revealed a hyperechogenic fixed structure at right coronary cusp side, which seemed to be suspicious of a pannus formation or organized thrombus (). In addition, good motion of the prosthetic aortic valve with flow acceleration, partial motion limitation of the anterolateral leaflets of the prosthetic mitral valve, and moderate mitral stenosis (mid-diastolic pressure gradient = 10 mmHg) probably due to thrombus formation were also observed. Despite these findings, warfarin could not be started until 2 weeks after the surgery to prevent fatal hemorrhagic complications. Heart computer tomography on the eighteenth day after the operation showed no significant coronary artery disease, no prosthetic mitral valve dysfunction, and a well-functioning prosthetic aortic valve. Follow-up echocardiography performed upon discharge 3 weeks after the operation revealed a slightly decreased pressure gradient across the aortic valve (PSPG/MSPG = 89/50 mmHg) and a well-functioning prosthetic mitral valve with loss of the previously observed pressure gradient with a LVEF of 73%. The patient was discharged without any complications.

[[55.0, 'year']]

F

{'21160731': 1, '348341': 1, '10660178': 1, '18397904': 1, '16230487': 1, '22435901': 1, '9809956': 1, '1534335': 1, '22747790': 1, '8313552': 1, '16607051': 1, '21292606': 1, '24624276': 2}

{}

3948446-1

noncomm/PMC003xxxxxx/PMC3948446.xml

Anesthetic management of antiphospholipid syndrome patients who underwent cardiac surgery: three cases report

A 23-year-old man (192 cm, 106.4 kg) presented to the authors for pulmonary thromboembolism and was scheduled for pulmonary artery thrombectomy. He has been diagnosed with APS after the treatment of deep vein thrombosis in his right leg at another hospital four years earlier, and he had been prescribed an anticoagulant medicine. Two weeks before the patient's hospital admission, he stopped taking the medication at his discretion. Tenderness, edema, and skin ulcers occurred in both his lower extremities. During his hospital stay, the patient developed dyspnea, and pulmonary thromboembolism was diagnosed in both his descending pulmonary arteries and lower lobe segmental and subsegmental arteries via echocardiography and chest computed tomography. The result of the lung perfusion scan that was performed was also suitable for pulmonary thromboembolism. The preoperative diluted Russell's viper venom time (dRVVT) result was 112.80 s (reference: 24-37.5 s), and the silica clotting time (SCT) was prolonged to 185.6 s (reference: 23.4-39.2 s). Arterial oxygen tension was 70 mmHg under room air. The mixing test was not corrected, and the result was 112.80 s with the patient plasma, and 73.3 s with the mixed plasma. The patient was thus diagnosed with lupus anticoagulant (LA). The anticardiolipin antibodies (ACAs) IgG, and IgM were positive, the antithrombin III was 85% of the normal level, the protein C was reduced to 66%, and the protein S was reduced to 57%. Enoxaparine 120 mg was injected via the subcutaneous tissue twice a day and prednisolone was administered during the preoperative period. An abnormal coagulation profile was observed; prothrombin time/international normalized ratio (PT/INR) was 1.9, prothrombin time (PT) was 22.3 s and activated partial thromboplastin time (aPTT) was 79.1 s. Preoperative estimated pulmonary arterial systolic pressure (PASP) was 76 mmHg.\nRadial artery catheterization was performed, and midazolam (13 mg), sufentanil (150 µg), and vecuronium (10 mg) were injected for induction of anesthesia. The routine monitoring devices for cardiac surgery and intravenous anesthetics were used for maintenance of anesthesia. Initial point-of-care testing (POCT) results were the following: arterial oxygen tension was 201 mmHg under a 50% fraction of inspired oxygen (FiO2), and plasma hematocrit was 54%. The activated coagulation time (ACT) was 165 s after induction and 951 s after injection of 336 mg of heparin to begin CPB. CPB was started after insertion of the cannulas into the aorta, superior vena cava, and inferior vena cava. After the temperature was lowered to 20℃, pulmonary thrombectomy and endarterectomy were performed, following which intermittent total cardiopulmonary bypass using aortic-cross-clamp was conducted to clear the operating field. Forty minutes after the administration of heparin, the ACT was checked again and found to be 627 s. Generally, such a result would be considered acceptable for a CPB operation, but concerns about the occurrence of catastrophic APS in this case, prompted the empirical administration of 100 mg of heparin via injection. The ACT was again measured 5 min after the injection and was found to be 1200 s. After 3 hours, the ACT was found to be 629 s. An additional 80 mg of heparin was thus administered, and the ACT was found to be 1001 s 5 min after that injection. It was decided that protamine would not be administered due to worries about the occurrence of postoperative thrombotic complications. Forty minutes after the last heparin injection, weaning from CPB was successfully performed. The total injected dose of heparin was 516 mg, and the total CPB time was 248 min. At the end of the surgery, POCT was again performed. Arterial oxygen tension was 332 mmHg under 50% FiO2 and plasma hematocrit was 42%. The estimated blood loss (EBL) during surgery was 1,000 ml and urine output was 1,100 ml. 1,500 ml of crystalloid and 1,400 ml of colloid were infused during surgery. No transfusion was performed during the surgery.\nFollowing the procedure the patient was transferred to the intensive care unit (ICU) without experiencing significant bleeding. The immediate postoperative PT/INR was 1.63 and aPTT was over 180 s. The goal of the postoperative anticoagulation therapy was PT/INR 3.0 with intravenous heparin infusion during the NPO period and with oral warfarin after that. PASP was not normalized after the surgery; postoperative PASP was 74 mmHg. The patient was discharged 12 days after surgery without specific complications.

[[23.0, 'year']]

M

{'16420554': 1, '20822807': 1, '10968914': 1, '15003982': 1, '12892393': 1, '8608627': 1, '10499657': 1, '9412889': 1, '15982596': 1, '27578899': 1, '9327321': 1, '19324520': 1, '2115326': 1, '24624277': 2}

{'3948446-2': 2, '3948446-3': 2}

3948446-2

noncomm/PMC003xxxxxx/PMC3948446.xml

Anesthetic management of antiphospholipid syndrome patients who underwent cardiac surgery: three cases report

A 34-year-old man (160.5 cm, 48.9 kg) was presented to the authors for mitral valve (MV) replacement. The patient had been diagnosed with SLE and APS after being admitted to the hospital for treatment of palpitations and dyspnea ten years earlier, and he had taken an anticoagulant medication. During the outpatient clinic follow-up, 24-hr Holter monitoring revealed the increasing frequency of non-sustained atrial fibrillation. An operation was thus scheduled to reduce the risk of atrial thrombosis. The preoperative blood coagulation tests showed prolonged results. The aPTT was 57.8 s and dRVVT was 47.2 s (reference: 25.9-35.7 s). The result with patient plasma from the mixing test was 27.3 s, and the mixed plasma result was 37.6 s, while SCT was 52.1 s (reference: 22.3-42.7 s). In addition, the patient was positive for LA, negative for ACA IgG, and had borderline results for ACA IgM. Intravenous heparin and oral deflazacort tablets were used for preoperative management.\nInvasive blood pressure monitoring was conducted via the patient's radial artery. Anesthesia induction and maintenance were performed as usual, and routine cardiac anesthesia monitoring was done. The ACT level increased from 129 s to 850 s after the injection of 150 mg of heparin. After the insertion of cannulas into the aorta, superior vena cava, and inferior vena cava, CPB was started. One hour after the administration of heparin, the ACT level was found to have decreased to 524 s. Therefore, an additional 50 mg of heparin was injected. After the mitral annuloplasty, valvuloplasty was performed, and weaning from CPB was attempted. Due to the risk of thrombosis, a half dose (75 mg) of protamine was administered. Five minutes after the injection of protamine, the ACT level was found to be 220 s. The total administered dose of heparin during the surgery was 200 mg, and the total CPB time was 52 min. The EBL during surgery was 500 ml and urine output was 455 ml. 800 ml of crystalloid and 500 ml of colloid were infused during surgery. The patient did not receive any transfusion during the surgery.\nFollowing the surgery the patient was transferred to the ICU without significant bleeding. The immediate postoperative PT/INR was 1.39 and aPTT was over 180 s. Postoperative prophylactic anticoagulation was maintained with warfarin. Ten days after the operation, the patient was discharged without specific complications.

[[34.0, 'year']]

M

{'16420554': 1, '20822807': 1, '10968914': 1, '15003982': 1, '12892393': 1, '8608627': 1, '10499657': 1, '9412889': 1, '15982596': 1, '27578899': 1, '9327321': 1, '19324520': 1, '2115326': 1, '24624277': 2}

{'3948446-1': 2, '3948446-3': 2}

3948446-3

noncomm/PMC003xxxxxx/PMC3948446.xml

Anesthetic management of antiphospholipid syndrome patients who underwent cardiac surgery: three cases report

A 65-year-old woman (153 cm, 62.9 kg) presented to the authors for MV leaflet mass excision. She already had percutaneous mitral valvuloplasty 10 years ago, MV replacement with tissue valve 8 years ago, and MV thrombectomy and MV replacement with mechanical valve 7 years ago. Since the final surgery, she had been on an anticoagulation regimen with warfarin. Recently she had gone to emergency room after experiencing sudden onset language disturbance, and had been diagnosed with left middle cerebral artery territory infarction. She also underwent routine follow-up transesophageal echocardiography (TEE) and a mobile mass was found which was attached to the prosthetic MV leaflet. To prevent an embolic event and decrease the size of the thrombus, the patient was started on heparin several days before the surgery was scheduled. Despite heparinization, however, the thrombus showed no change in size on TEE. The surgeon therefore considered that the patient might have a disease causing a hypercoagulable state and ordered laboratory examinations to investigate this possibility. The results of the tests were as follows: Protein C (-), protein S (-), antithrombin III 80 (80-120%), ACA IgM 15.5 mg/dl (<20), ACA IgG negative, LA (+), dRVVT 69.1 s (reference: 24-37.5 s), SCT 137.2 (reference: 23.4-39.2 s), mixing test with patient plasma 137.2 s, mixing test with mixed plasma (1 : 1) 99.3 s. Twelve weeks later, the LA test was performed again, and the patient was finally diagnosed with APS. Preoperative PT/INR was 1.37 and aPTT was 59.8 s.\nThe planned surgery was MV leaflet mass excision. The patient's left radial artery was cannulated under local anesthesia for invasive blood pressure monitoring. Routine induction and maintenance of anesthesia with IV anesthetics were performed. The central venous catheter was accessed and a TEE probe was inserted. The patient's basal ACT was 113 s and 180 mg of heparin was administered for vessel cannulations. The ACT level increased to 742 s and CPB was begun after insertion of cannulas into the aorta, superior vena cava and inferior vena cava. Twenty minutes after the start of CPB, the ACT level was found to be 826 s, and an additional 60 mg of heparin was administered. The target ACT level during CPB was over 800 s. After 50 min, the ACT level had decreased to 682 s, and another 100 mg of heparin was given. At the end of CPB, the ACT level was 668 s, and the surgeon decided not to administer protamine, concerned about possible postoperative thrombotic complications. One hour after the cessation of CPB, the ACT level decreased to 577 s. The total time of CPB was 99 min, and the total administered dose of heparin was 340 mg. The EBL during surgery was 600 ml and the urine output was 2,710 ml. 200 ml of crystalloid and 2,000 ml of colloid were infused during surgery. No transfusion was administered during the surgery.\nFollowing the procedure, the patient was transferred to the ICU. The immediate postoperative PT/INR was 2.93 and aPTT was over 400 s. Due to a bleeding tendency, 30 mg of protamine was administered to the patient. With that exception, there were no other specific complications. Warfarin was used for prophylactic anticoagulation and the patient was discharged 9 days after the operation.\nThe three case mentioned above are summarized in .

[[65.0, 'year']]

F

{'16420554': 1, '20822807': 1, '10968914': 1, '15003982': 1, '12892393': 1, '8608627': 1, '10499657': 1, '9412889': 1, '15982596': 1, '27578899': 1, '9327321': 1, '19324520': 1, '2115326': 1, '24624277': 2}

{'3948446-1': 2, '3948446-2': 2}

3948447-1

noncomm/PMC003xxxxxx/PMC3948447.xml

Clinical experiences of performing transforaminal balloon adhesiolysis in patients with failed back surgery syndrome: two cases report

A 62-year-old female presented at our hospital complaining of pain in the left buttock and a tingling sensation in the left L5 dermatome. Eight months prior, the patient's left leg pain did improve after undergoing discectomy at the L5-S1 level, but her pain recurred and she still had the tingling sensation in her left leg. Her visual analogue scale (VAS) score for pain was 8 out of 10 and her functional score on the Oswestry Disability Index was 56%. Examination revealed normal motor power and sensation in the lower extremities, and normal pulsation of the dorsalis pedis and tibial arteries. The results of the straight leg raise test of the left leg were negative. She complained of leg pain after walking for 20 meters, and an epidurogram performed after discectomy indicated filling defects in her left side at the L5-S1 level. She was treated with 900 mg/day of gabapentin and a transdermal fentanyl patch (25 µg/hr). We performed percutaneous epidural adhesiolysis at the left L5 level using a Navigation catheter (Epimed International, Gloversville, USA), and, for the next 2 months, the patient demonstrated reduced leg pain (VAS 3 of 10) and increased walking distance (100 meters). Three months after treatment, her symptoms worsened to a degree similar to that before the procedure, so we decided to perform transforaminal balloon adhesiolysis.\nWe obtained approval from our institutional review board and written informed consent from the patient. The patient was placed in the prone position, and a pillow was placed under her abdomen to minimize lumbar lordosis. After sterilizing the insertion site, an 18-gauge R-K needle (Epimed International, Gloversville, USA) was inserted into the left L5 intervertebral foramen. The filling defects in her left side at the L5-S1 level and the positioning of the tip in the anterior epidural space was confirmed by fluoroscopy with the aid of a contrast medium. A 3-Fr Fogarty catheter (Edward Lifescience, Irvine, CA, USA) filled with the contrast medium was introduced into the epidural space of the L5 intervertebral foramen and placed into the medial portion of the fibrotic area. Inflation of the balloon using 0.13 ml of the contrast medium followed by deflation was repeatedly performed throughout the affected region, from the lateral recess to the dural sleeve, with each inflation session lasting less than 5 seconds. If the patient complained of moderate discomfort during inflation of the balloon, the volume of the balloon was reduced. After removing the Fogarty balloon catheter, lysis of fibrosis was confirmed by fluoroscopy with the contrast medium, and 3 ml of a mixture of 0.8% lidocaine, 20 mg triamcinolone, and 1500 IU of hyaluronidase was administered (). There were no complications such as bleeding or severe pain throughout the procedure. The pain in her left leg (VAS 3 of 10) and functional status (40%) improved over the next 4 weeks and the patient reported no left leg pain (VAS 0 of 10), an improved functional status (32%), and increased claudication distance (200 meters) for the next 24 weeks.

[[62.0, 'year']]

F

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{'3948447-2': 2, '3259140-1': 1, '3259140-2': 1, '3259140-3': 1}

3948447-2

noncomm/PMC003xxxxxx/PMC3948447.xml

Clinical experiences of performing transforaminal balloon adhesiolysis in patients with failed back surgery syndrome: two cases report

A 76-year-old female patient who had undergone two lower back surgeries, a left partial laminectomy for disc herniation at the L4/5 and L5/S1 levels 4 years prior, and a discectomy at the L4/5 level 1 year and 5 months after the first operation was referred to our unit. Lower back pain and numbness in the left calf had developed about 6 months after the second operation and had gradually worsened. Her VAS score was 7 out of 10 and her Oswestry Disability Index was 48%. Examination revealed normal motor power and sensation in the lower extremities, and normal pulsation of the dorsalis pedis and tibial arteries. The straight leg raise test of her left leg was positive at 70 degrees. She complained of severe numbness and a pulling pain in her left leg after walking for more than 20 minutes. She had received various medications and treatments including transdermal fentanyl patch (12 µg/hr), Celecoxib 200 mg/day (Celebrex®, Pfizer, Inc., New York, NY, USA), repeated epidural steroid injections, and percutaneous epidural adhesiolysis using a Navigation catheter. Despite these interventions, she complained of persistent symptoms and only demonstrated a 20% improvement for 3 weeks after treatment; further, there were no improvements in her functional status or walking distance. We therefore decided to perform transforaminal balloon adhesiolysis. A filling defect in the medial side of her left L5 pedicle was confirmed by fluoroscopy using a contrast medium. A 3-Fr Fogarty catheter was introduced into the epidural space of her left L5 intervertebral foramen, followed by serial balloon decompression. After removal of the Fogarty balloon catheter, she was administered 3 ml of a mixture of 0.8% lidocaine, 20 mg triamcinolone, and 1500 IU hyaluronidase. There were no complications throughout the procedure. For the next 17 weeks, the patient reported reduced leg pain (VAS 2 of 10), an improved functional status (28%), and increased walking time (60 minutes). Eighteen weeks after treatment, her symptoms reoccurred but were more tolerable (VAS 4 of 10) than prior to treatment.

[[76.0, 'year']]

F

{'2795321': 1, '19281499': 1, '10905440': 1, '22259719': 2, '1831547': 1, '17256027': 1, '19057628': 1, '1534723': 1, '2546258': 1, '27574583': 1, '18096323': 1, '1740654': 1, '16850047': 1, '19305485': 1, '15246312': 1, '24624278': 2}

{'3948447-1': 2, '3259140-1': 1, '3259140-2': 1, '3259140-3': 1}

3948572-1

noncomm/PMC003xxxxxx/PMC3948572.xml

Endoscopic Surgery for Traumatic Acute Subdural Hematoma

An 87-year-old woman who had undergone coil embolization for a ruptured middle-cerebral artery aneurysm and placement of a ventriculoperitoneal shunt for normal pressure hydrocephalus 5 years earlier fell and hit her head. She suffered consciousness disturbance and was transported to our hospital 6 h after the fall. At the time of admission, she was confused and manifested right hemiplegia. Her Glasgow Coma Scale score was 8 (E2V2M4). A computed tomography (CT) scan showed a thick, (2 cm in diameter) left-frontotemporal ASDH and a marked midline shift (fig. ). Her pupils were isocoric and her light reflex was prompt.\nThe possibility of impending brain herniation required emergency evacuation of the ASDH. As her advanced age and poor condition rendered general anesthesia risky, we opted for endoscopic evacuation under local anesthesia. In case this proved impossible, we simultaneously prepared for performing a craniotomy under general anesthesia. With her head in a neutral position, we made a single burr hole at a site on her left forehead. We then increased the hole to 15 mm in diameter in order to obtain a wide-angle endoscopic field. As the skin incision was along a wrinkle, it raised minimal cosmetic concerns. We introduced a rigid endoscope with a tip angle of 0° (Machida Endoscope Co. Ltd., Tokyo, Japan). After incising the dura, we observed a dark red clot. There was no outer membrane associated with chronic subdural hematoma. After evacuating the clot beneath the burr hole, we used the rigid endoscope to introduce a transparent sheath (10 mm in diameter) into the hematoma cavity. Although a portion of the soft clot was hard, it could be removed easily with a suction tube (fig. ). Irrigation with artificial cerebrospinal fluid (Artcereb®, Otsuka Factory, Tokushima, Japan) yielded a clear operative field and precise manipulation was possible. Upon removing the hematoma, we noted arterial bleeding on the brain surface. We applied a suction tube to the bleeding point (fig. ) and coagulated it electrically (fig. ). After confirming the removal of the hematoma and complete hemostasis, we filled the subdural space with artificial cerebrospinal fluid. The burr hole was covered with a ceramic burr-hole button and the skin incision was sutured cosmetically. The entire procedure was completed in 47 min.\nA postoperative CT scan showed an obvious reduction of the hematoma; there was no brain shift or swelling (fig. ). Her consciousness disturbance and right hemiplegia improved immediately. She was discharged 30 days later without any neurological deficits.

[[87.0, 'year']]

F

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{'4631953-1': 1, '5649296-1': 1}

3948855-1

noncomm/PMC003xxxxxx/PMC3948855.xml

A Case of Occupational Hypersensitivity Pneumonitis Associated with Trichloroethylene

A 29-year-old man was referred to our hospital because of a severe and persistent dry cough, night sweats, and a 10 kg body weight loss over the previous two months. The dry cough and night sweats persisted for two months despite treatment at local outpatient clinic, but he did not complain of exertion-related dyspnea, malaise, or fever upon admission. He was a former smoker, but had stopped smoking five years prior. Notably, he did not have a history of asthma or pulmonary disease. He was not taking any medications or herbal medicines. He had started working in a new occupation of computer repairing 3-4 months ago, and did not use personal protective devices at workplace. Upon physical examination, there were no significant findings, and his vital signs were stable. The chest examination showed clear breath sounds without rales or wheezing, and the cardiac and abdominal examinations were also unremarkable. He had no skin rash or digital clubbing and no musculoskeletal abnormalities. We explored numerous causes for chronic cough, such as upper airway cough syndrome and gastro-esophageal reflux syndrome, but there were no specific findings.\nA chest X-ray demonstrated some reticulonodular densities on both upper lobes (). The results of a pulmonary function test were within the normal range, except for mildly reduced diffusion capacity of carbon monoxide (). A chest computed tomography (CT) scan showed tiny ill-defined centrilobular nodules prominent in both upper lobes (), which is consistent with HP. Laboratory results were as follows: complete blood count, 9,500/mm3 (neutrophil 71.6%, lymphocyte 22.6%, eosinophil 0.4%); hemoglobin, 14.6 g/dL; platelet count, 286,000/mm3; aspartate aminotransferase/alanine aminotransferase, 13/15 IU/L; total bilirubin, 0.7 mg/dL; total cholesterol, 210 mg/dL; total protein, 7.6 g/dL; blood urea nitrogen, 13.1 mg/dL; and a creatinine of 0.8 mg/dL on biochemistry test. Serum electrolytes were within the normal limits. C-Reactive protein was 0.152 mg/dL (normal range, 0-0.8 mg/dL), and the erythrocyte sedimentation rate was 9 mm/hr (normal range, 0-15 mm/hr). Urinalysis did not reveal proteinuria or glucosuria, but did show microscopic hematuria and pyuria. Serum total IgE level was slightly elevated at 125 kU/L (normal range, <100 kU/L). The panels for autoimmune markers such as antinuclear antibody, rheumatoid factor, anti-cyclic citrullinated peptide antibody, cytoplasmic anti-neutrophil cytoplasmic antibody, perinuclear anti-neutrophil cytoplasmic antibody, anti-Scl 70, anti-SS-A/Ro, and anti-SS-B/La were all within the normal limits.\nWe performed bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) in the posterior segment of the right upper lobe and in the anterior-medial segment of the right lower lobe.\nBAL revealed the presence of lymphocytes (80%), of which the ratio of CD4 and CD8 was 41.8%:50.6%. TBB showed no pathologic findings.\nAfter gathering details about his occupation, we discovered that his main role in repairing computers was to use lead welding to install capacitors on computer chip boards, and to wipe down the chip boards with TCE. His duties were performed without personal protective equipment or a proper ventilation system in the workplace. Unfortunately, we could not test his serum or urine TCE level, but his lead level in serum was 1.67 µg/L (normal range, <20 µg/L) and in urine was 6.24 µg/L (normal range, <80 µg/L), which were both within the normal range.\nWith this information, we strongly suspected that the HP was related to TCE exposure. We recommended him to change the occupation, but he could not find alternative occupation due to economic status. We started treatment with 30 mg oral prednisolone daily, and after oral prednisolone treatment, the dry cough was slightly improved, but it was not entirely resolved. For a more accurate diagnosis, he underwent surgical lung biopsy via video-associated thoracoscopy (VATS). Pathologic findings were present, which consisted of multifocal, patchy, fibroblastic proliferations, chronic inflammatory cell infiltration around the respiratory bronchiole, and associated foamy histiocytic aggregation (). With these biopsy results under the consideration of both clinical presentation and radiological findings, we reached a final diagnosis of subacute HP. After receiving the diagnosis, he returned to work, but revisited the outpatient clinic due to worsening, severe cough and anterior chest pain. Chest CT was performed and showed pneumomediastinum and slightly aggravated HP. He was exposed to TCE repeatedly after discharge from the hospital, and we think the pneumomediastinum may have been developed by aggravation of symptoms including severe cough. He was treated with high concentration oxygen and steroid pulse therapy (methylprednisolone 62.5 mg bid I.V.), but despite this, recurrent pneumothorax developed. He underwent wedge resection for two subpleural bullae at the right apex, and he underwent a thoracoscopic pleurectomy to treat the recurrent pneumothorax. After the operation, the recurrent pneumothorax resolved, but his chronic cough still remained after the steroid treatment. We recommended again strongly to change occupation, and after entering a new department, we tapered down the oral prednisolone slowly until discontinuation. After changing occupation and finishing the steroid regimen, the symptoms improved and the CT findings were almost completely resolved (, ).

[[29.0, 'year']]

M

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{}

3948856-1

noncomm/PMC003xxxxxx/PMC3948856.xml

A Case on Streptococcal Pneumonia Associated with Leptomeningitis, Osteomyelitis and Epidural Abscess in a Patient with AIDS

A 53-year-old male presented with cough, sputum, and headache for 2 weeks.\nFive years previously, he had been diagnosed with HIV. He noted the onset of cough, sputum, and headache. The cough worsened, his sputum turned more yellowish and headaches accompanied by neck stiffness were related to coughing.\nOver the first five years following the diagnosis of HIV, he was treated with antiretroviral medications (lamivudine and zidovudine; Combivir, Ritonavir; Norvir, atazanavir sulfate; Reyataz).\nVital signs were as follows: temperature, 38.0℃; blood pressure, 110/70 mm Hg; pulse rate, 90/min; respiratory rate, 20/min. He was alert mentally. Auscultation revealed rales in the right lower lung field. A Brudzinski-Kernig test was positive.\nComplete blood count results were white blood cell 18.43×103/µL (neutrophils 91.3%, lymphocytes 3.5%), hemoglobin 14.0 g/dL, hematocrit 40.3%, and platelets 290×103/µL. Serum chemistry showed blood urea nitrogen 14 mg/dL, creatinine 0.66 mg/dL, aspartate aminotransferase 25 IU/L, alanine aminotransferase 23 IU/L, total bilirubin 1.92 mg/dL, and C-reactive protein 38.51 mg/dL. Cerebral spinal fluid (CSF) showed a white blood cell count of 108/µL, red blood cell count 0/µL, glucose 53 mg/dL, and protein 123 mg/dL. CSF and sputum bacterial cultures were negative. A CD4 T-cell count of 139/µL and HIV RNA of 20.7 copies/mL were recorded.\nPlain chest radiography showed ground glass opacity and consolidation in both lung fields (especially the right lower) (). Contrast-enhanced chest computed tomography showed multiple irregular nodular infiltration in both lungs and patchy consolidation with ground glass opacity of the right middle and lower lung (). Contrast-enhanced cervical spine magnetic resonance imaging (MRI) showed a posterior epidural abscess: a peripheral rim-enhancing lesion at the posterior C2-3 epidural space (); osteomyelitis; mild scanning enhancement of the clivus and cervical spine; early leptomeningitis; and prominent leptomeningeal enhancement ().\nThe patient was administered vancomycin (1 g q 12 hr IV), ceftriaxone (2 g q 24 hr), clindamycin (600 mg q 12 hr) and fluconazole (400 mg q 24 hr). The patient's fever reduced 3 days following admission. His epidural abscess was discussed with the neurosurgeon in our hospital. There were no neurological symptoms, no surgical treatment was performed and antibiotic therapy was maintained. At follow-up 5 days after admission, a plain chest radiograph showed improvement, and S. pneumoniae was detected in two blood cultures that showed sensitivity to most antibiotics. The patient was thus switched from vancomycin plus ceftriaxone to ampicillin (2 g) plus sulbactam (1 g q 6 hr IV). Fifteen days after admission, neck stiffness had improved and cough and sputum production reduced. A plain chest X-ray showed decrease in both ground glass opacity and consolidation in both lung fields (). Twenty-six days after admission, laboratory analysis was as follows: white blood cell count 5.42×103/µL, neutrophils 55.9%, lymphocytes 25.9%, and C-reactive protein 0.26 mg/dL. The patient wished to be discharged, so antibiotic therapy was switched from intravenous to oral (amoxicillin/clavulanate 625 mg PO tid). Since discharge, no recurrence of symptoms or evidence of pneumonia according to plain chest radiography have been observed. One year after discharge, there is no abnormal finding on cervical MRI ().

[[53.0, 'year']]

M

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{}

3948857-1

noncomm/PMC003xxxxxx/PMC3948857.xml

Pandemic Influenza (H1N1) and Mycobacterium tuberculosis Co-infection

A previously healthy 20-year-old woman was admitted on December, 2009 because of abdominal pain, fever and 10 kg of weight loss during the previous two months. The physical examination upon admission revealed a high body temperature (39.3℃). Laboratory findings were as follows: white blood cells (WBC), 4,110/mm3; neutrophils, 76.4%; lymphocytes, 480/mm3 (11.7%); hemoglobin, 10.2 g/dL; C-reactive protein (CRP), 34.9 mg/L; and erythrocyte sedimentation rate, 62 mm/hr, and a stool occult blood test was positive. A chest X-ray showed granular opacity in the bilateral apical area. Repetitive sputum acid fast bacilli (AFB) fluorescent smear studies were negative. A computed tomographic (CT) scan of the abdomen and pelvis revealed diffuse swelling of the liver, gallbladder, distal small bowel and ascending colon. Considering the influenza pandemic period and opacities in the chest X-ray, a reverse transcriptase polymerase chain reaction (RT-PCR) for pH1N1 via nasopharyngeal swab specimen was performed, and pH1N1 infection was confirmed on hospital day (HOD) 2. The conventional dose of oral oseltamivir (75 mg b.i.d.) was prescribed to the patient. On the same day, the patient complained of hematochezia, and then sigmoidoscopic evaluation revealed several polypous and aphthous lesions on the cecum and rectum with erythema, edema, granularity and telangiectasia, while pathologic evaluation of the biopsy specimen revealed acute colitis. Fever and respiratory symptom improved after three days of treatment with oseltamivir, but hematochezia had been continued, and after 5 afebrile days, fever started to spike again with higher degree up to 39.7℃. An interferon-gamma releasing assay (QuantiFERONTB Gold; Cellestis Ltd., Carnegie, Australia) was positive, and the pathology result of colonoscopy done for further evaluation of hematochezia revealed a chronic granulomatous inflammation consistent with intestinal tuberculosis, and a Ziehl-Neelsen stain revealed acid-fast bacilli. On the next day of pathology report, a MTB complex-specific PCR of sputum revealed positive results, and the administration of isoniazid, rifampin, ethambutol and pyrazinamide was initiated (HOD 16). Symptoms of fever, abdominal pain and hematochezia gradually improved within 5 days of treatment with anti-tuberculosis mediation, and the growth of MTB was confirmed in the sputum specimens after three weeks of collection.

[[20.0, 'year']]

F

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{'3948857-2': 2, '3948857-3': 2, '3948857-4': 2}

3948857-2

noncomm/PMC003xxxxxx/PMC3948857.xml

Pandemic Influenza (H1N1) and Mycobacterium tuberculosis Co-infection

A previously healthy 47-year-old man was referred to the emergency department (ED) on December, 2009 for dyspnea and documentation of pneumonic consolidation in chest X-rays from another primary care clinic. He complained of two weeks of cough, sputum, and rhinorrhea. Dyspnea upon exertion had developed since the day before he visited the ED. Laboratory findings were as follows: WBC, 8,260/mm3; neutrophils, 80.2%; lymphocytes, 1,050/mm3 (11.7%); and CRP, 79.6 mg/L. His chest X-ray image revealed heterogenous ground glass opacities in bilateral lung fields. For further evaluation of the pulmonary lesions, a chest CT was performed, and multisegmental involvement of centrilobular nodules with a tree-in-bud appearance and multiple small cavitary lesions were observed, suggesting active pulmonary tuberculosis. In addition, RT-PCR for pH1N1 via nasopharyngeal swab was positive, and a serum glucose test registered 404 mg/dL. Admission was recommended for proper management of pH1N1 and active pulmonary tuberculosis as well as previously unknown diabetes mellitus. However, the patient refused admission and was discharged with medications such as oseltamivir, isoniazid, rifampin, ethambutol, and pyrazinamide. An AFB smear reported to be 4+ next day, and improvement of symptoms and pulmonary consolidation in chest X-ray were observed upon out-patient department follow-up visit after 5 days. Later, growth of MTB was confirmed in respiratory specimens. It took about 6 months for the lung lesions of heterogenous ground glass opacities and consolidations to nearly resolve.

[[47.0, 'year']]

M

{'21751659': 1, '17142743': 1, '14417946': 1, '23260033': 1, '19883549': 1, '16558116': 1, '32586885': 1, '31035651': 1, '20943443': 1, '8721043': 1, '19871671': 1, '19444150': 1, '28824877': 1, '4858301': 1, '27516082': 1, '20219780': 1, '33887214': 1, '24624218': 2}

{'3948857-1': 2, '3948857-3': 2, '3948857-4': 2}

3948857-3

noncomm/PMC003xxxxxx/PMC3948857.xml

Pandemic Influenza (H1N1) and Mycobacterium tuberculosis Co-infection

A 45-year-old man visited the ED on December, 2009 because of fever and cough for one day and one incident of hemoptysis estimated at about 400 mL. He had a history of pulmonary tuberculosis diagnosed in 2007 and reported a complete recovery after treatment. A physical examination upon admission revealed a high body temperature (38.1℃) and increased pulse rate (105/min), while his breath sounds were clear. Oxygen saturation was 97% under an oxygen supply of 2 L/min via nasal cannula. Laboratory findings were as follows: WBC, 7,110/mm3; neutrophils, 80.8%; lymphocytes, 650/mm3 (9.1%); and CRP, 6.69 mg/L. A chest X-ray showed multiple small nodules and patchy consolidation predominantly in the left lung field, and chest CT revealed a cavitary nodule and tree-in-bud appearance on the left upper lung and left lingular segment, with ground glass opacities due to aspirated blood on the left lower lung suggesting tuberculosis reactivation (). However, pH1N1 RT-PCR was positive for a nasopharyngeal swab specimen, and a conventional dose of oral oseltamivir was prescribed. Fever spiking was improved after starting oseltamivir, but it remained to lower degree for 4 days. Repetitive sputum AFB smears were negative, while MTB complex-specific PCR was positive. Due to suspected active pulmonary tuberculosis, isoniazid, rifampin, ethambutol and pyrazinamide were prescribed on HOD 4. Fever subsided from the next day of starting anti-tuberculosis medication, and respiratory symptoms gradually improved, so the patient was discharged on HOD 6. Three weeks after collection, a sputum culture revealed growth of MTB.

[[45.0, 'year']]

M

{'21751659': 1, '17142743': 1, '14417946': 1, '23260033': 1, '19883549': 1, '16558116': 1, '32586885': 1, '31035651': 1, '20943443': 1, '8721043': 1, '19871671': 1, '19444150': 1, '28824877': 1, '4858301': 1, '27516082': 1, '20219780': 1, '33887214': 1, '24624218': 2}

{'3948857-1': 2, '3948857-2': 2, '3948857-4': 2}

3948857-4

noncomm/PMC003xxxxxx/PMC3948857.xml

Pandemic Influenza (H1N1) and Mycobacterium tuberculosis Co-infection

An 88-year-old woman was transferred to the ED on January, 2010 for suspected panperitonitis. She had been diagnosed with pneumonia during a prior hospital admission and reported that related symptoms improved after 14 days of intravenous ceftriaxone and metronidazole administration. Upon arrival, the patient complained abdominal pain, mild dyspnea, and sputum. The physical examination revealed no significant findings except for diffuse tenderness in her whole abdomen. Laboratory findings were as follows: WBC, 12,810/mm3; neutrophils, 89.2%; lymphocytes, 760/mm3 (6.0%); and CRP, 182 mg/L. Chest X-ray revealed a mass-like lesion in the left upper lung field, and subsequent chest CT revealed left bronchial wall narrowing and obstruction with distal consolidation. However, pH1N1 RT-PCR revealed a positive result in a nasopharyngeal specimen, and a conventional dose of oseltamivir was administered as along with piperacillin/tazobactam. The patient was thought to also have pseudomembranous colitis according to clinical presentation and abdomen CT finding, and abdominal pain was improved after administration of oral vancomycin.\nDespite administration of both anti-bacterial and anti-viral agents, pulmonary consolidation did not improve while dyspnea and sputum had been improving. After repetitive negative results of sputum AFB smear studies, growth of MTB was identified from the initial respiratory specimens on HOD 15. After administration of isoniazid, rifampin, ethambutol, and pyrazinamide, pulmonary infiltration observed via chest X-ray improved, and the patient was discharged without significant sequelae.

[[88.0, 'year']]

F

{'21751659': 1, '17142743': 1, '14417946': 1, '23260033': 1, '19883549': 1, '16558116': 1, '32586885': 1, '31035651': 1, '20943443': 1, '8721043': 1, '19871671': 1, '19444150': 1, '28824877': 1, '4858301': 1, '27516082': 1, '20219780': 1, '33887214': 1, '24624218': 2}

{'3948857-1': 2, '3948857-2': 2, '3948857-3': 2}

3948858-1

noncomm/PMC003xxxxxx/PMC3948858.xml

Non-infected and Infected Bronchogenic Cyst: The Correlation of Image Findings with Cyst Content

A 51-year-old woman without a significant medical history presented to our hospital complaining of chest pain lasting 2 months. She was a non-smoker. Chest CT revealed a rounded lesion, 2.3 cm in maximum diameter, with homogeneous soft-tissue attenuation density. The lesion was located at the right lower paraesophageal space (). The physical examination and results of routine laboratory tests were normal. We performed bronchoscopic US (CP-EBUS, BF-UC260F-OL8; Olympus, Tokyo, Japan) via the transesophageal route to characterize the lesion. A dedicated ultrasound scanner (EU-C2000; Olympus) was used as the image processor. US depicted a 2.3-cm, round, hypoechoic lesion with some fine homogenous internal echoes and the absence of a Doppler flow signal (). To rule out a malignant lymphadenopathy, transesophageal fine-needle aspiration (FNA) biopsy was performed with a 22-gauge needle (Olympus NA-202C, 4 passes) under bronchoscopic US guidance. Whitish jelly-milk-like content was aspirated (), fluid cytology showed no evidence of malignancy and Gram staining and cultures of the mucous content showed no organisms. Fever, chest pain, and dysphagia developed within a few days thereafter, and leukocytosis was noted. Cystic infection was suspected, but to rule out other serious complications such as mediastinitis, chest MRI was performed and intravenous administration of antibiotics (ampicillin/sulbactam, 3 g q 8 hr) was begun. The cystic lesion increased in maximum diameter from 2.3 cm to 2.6 cm. Upon contrast-enhanced MRI, a T1WI showed low signal intensity, and a T2WI showed heterogeneous high signal intensity, no enhancement of the cyst contents, but enhancement of the thickened cystic wall (). The patient underwent video-assisted thoracic surgery (VATS) 14 days after the FNA. The cystic mass was completely removed, and the aspirate was yellowish and turbid (). The resection specimen consisted of a benign cyst with a respiratory-type epithelial lining, smooth muscle, and epithelial denudation with infiltration of neutrophils and lymphocytes. The findings favored a diagnosis of bronchogenic cyst with active inflammation (). The MRI findings, the change in the cyst contents, and the pathology findings suggested that a secondary infection occurred after the FNA. Cultures of the aspirate were negative, probably because VATS was performed after 12 days of antibiotic therapy. The postoperative course was unremarkable. The patient's symptoms improved within a few days after the surgery, and no recurrence was seen upon follow-up chest CT at 8 months.

[[51.0, 'year']]

F

{'32257658': 1, '8020324': 1, '17859095': 1, '2069465': 1, '2778135': 1, '14528209': 1, '4058048': 1, '20868780': 1, '12929034': 1, '11058643': 1, '12376602': 1, '19648532': 1, '23678359': 2, '9097990': 1, '15368318': 1, '18027836': 1, '24624219': 2}

{'3651928-1': 1}

3948969-1

noncomm/PMC003xxxxxx/PMC3948969.xml

A Five (5) chamber heart (Cor Triatriatum) in Infancy: A rare congenital heart defect

A female baby seen on the second day of life was delivered by a 25-year-old primiparous Youth Corper. The mother attended antenatal clinic in Federal Medical Centre Owerri from the 16th week of gestation. However, during the 8th week of pregnancy, the mother had threatened abortion for which some drugs were given (injections and tablets names unknown) at a hospital in Lagos. She also had some liquid herbal preparation at 8 months of gestation; other drugs she took were essentially haematinics. She denied a history of alcohol, coffee and cigarette use. The pregnancy was carried to term. She went into spontaneous labour with an 18-h history of rupture of membrane. Delivery was spontaneous, vertex and supervised by medical personnel. She gave birth to a 3.6-kg baby girl who cried immediately after, and breastfeeding commenced. The child was transferred to the Special Care Baby Unit from the postnatal ward on account of history of fever on day 2 of life.\nExamination revealed a full-term newborn, febrile (38.1©) with a respiratory rate of 100 cycles per minute, acyanotic, heart rate of 110 beats/min heart sound- I and II only no murmur heard. A diagnosis of probable neonatal sepsis was made. Investigations carried out included blood culture that did not yield any growth. However, the child completed a course of antibiotics (Ampicillin–Sulbactam and Gentacin) and, with clinical improvement, was discharged home.\nAt follow-up at the 2nd week of life, the child weighed 3.5 kg, heart rate was 130 beat/min and a grade 3 pansystolic murmur was heard, following which a chest radiograph and electrocardiograph (ECG) was requested.\nAt 1 month of life, a review of ECG showed:\nheart rate: 128 beats/min,\nRR: 468 mS,\nP: 70 mS,\nPR: 94 mS,\nQRS: 54 mS,\nQT: 290 mS,\nQTc: 426 mS,\nAxis P-39©,\nQRS-147© and\nT-18, which suggested supraventricular arrhythmia, abnormal right superior axis deviation.\nChest radiograph showed perihilar mottling on both the lung fields. Heart and thoracic cavity were within normal limits. An impression of bronchopneumonia was made by the Consultant Radiologist.\nMurmur was still grade 3/6, pansystolic maximal at the left-lower sternal edge.\nEchocardiograph was subsequently requested and the result showed that a 2D echocardiogram was done [] with the following results:\nSitus solitus\nSeparate left atrium with dividing membranous running in the direction of long axis of left atrium close to the lateral wall.\nNo evidence of flow across the septum. Mitral valve draining the larger, more medial chamber, normal atrio-ventriculo-arterial connection. Normal relationship of aortic root to the pulmonary trunk.\nSupravalvular pulmonary membrane causing stenosis noted. High velocity turbulent flow in the main artery noted (PA Vmax = 335 cm/s PG = 45 mm).\nSecundum atrial septal defect about 1.2 mm noted with left to right shunt.\nNormal wall motion and thickness, good global left ventricular contractility.\nNormal pericadium.\nConclusion\nCor Triatrietum.\nSupravalvular pulmonary stenosis.\nSecundum atrial septal defect []\nThe child is presently being followed-up regularly. During her last visit, at 7 months of age, she weighed 9.6 kg, length was 73 cm, occipito-frontal circumference was 47 cm and mid-upper-arm circumference was 15 cm (all within normal for age).\nCardiovascular examination revealed a child with heart rate of 120 beats/min, apex beat located at the 4th left intercostals space, with a grade 3/6 systolic murmur heard loudest at the upper left sternal edge. The respiratory rate was 42 cycles/min and no organs palpably enlarged on digestive system examination.

[[25.0, 'year']]

F

{'11235744': 1, '895180': 1, '18549152': 1, '17519397': 1, '2407998': 1, '19037984': 1, '24665161': 2}

{}

3948997-1

noncomm/PMC003xxxxxx/PMC3948997.xml

Intramuscular Sparganosis in the Gastrocnemius Muscle: A Case Report

A 77-year-old man was referred to our clinic from a private clinic because of a suspected soft tissue tumor. The patient had a 6-month history of a mass over the right posteromedial aspect of the proximal tibia. Physical examination revealed a 3 cm×1 cm, soft, non-tender mass at the posteromedial aspect of the right proximal tibia, and the mass was freely mobile and easily compressed. Another mass was found at the posterior aspect of the right proximal tibia. He had pulmonary tuberculosis when he was 30 years old, for which he was treated and believed to have been cured. He also had the history of lobectomy because of a lung cancer in the left lower lobe at the age of 47 years and received a total gastrectomy due to an advanced gastric cancer at the age of 71 years.\nRoutine laboratory test results were unremarkable, and no eosinophilia was noted. Plain radiographs of the right leg revealed multiple calcifications extending from the medial part of the knee to the calf. Ultrasonography revealed a heterogeneous, hyperechoic mass with a hypoechoic tubular lesion in the gastrocnemius muscle (), and MRI revealed multiple tubular and cystic lesions in the gastrocnemius muscle. The lesions showed high signal intensity on T2-weighted images and multilobulated, peripheral enhancing low signal intensity on T1-weighted images (). The patient was a farmer, and he had occasionally ingested raw snake meat when he was young. Preoperative serodiagnosis of human sparganosis by using a monoclonal antibody-based competitive ELISA was positive (3.79 in OD value) (negative < 1.00).\nAfter preoperative ultrasound-guided marking for suspected cystic lesions, a longitudinal incision was made on the posterior aspect of the proximal tibia. A white, shiny, synovium-like piece of tissue emerged from the incision, and this was identified as a sparganum that measured 30 cm in length and 0.5 cm in width and was wriggling after removal from the patient (). The calcified foci near the calf were also removed, and these tracts possibly represented the pathway along which the larvae had passed.\nSixteen months after the operation, the patient revisited our hospital because of pain and paresthesia of the right thigh and a mass at the posterior aspect of the right distal thigh. Physical examination revealed generalized pain and a tingling sensation on the right thigh and multiple soft, mobile, non-tender masses at the posterior aspect of the right proximal tibia. MRI revealed a 1.8 cm-sized, well-circumscribed round mass arising at the right distal sciatic nerve. The lesion showed heterogeneous high signal intensity on T2-weighted images and intermediate signal intensity on T1-weighted images with a target sign or a fascicular sign, and a benign neurogenic tumor, such as a schwannoma or neurofibroma, was suspected (). Multifocal tubular and cystic lesions were also detected around the mass, showing high signal intensity on T2-weighted images and low signal intensity on T1-weighted images ().\nAn excisional biopsy was performed, and a histologic analysis revealed a schwannoma showing spindle tumor cells in a palisading pattern (). In the operative field, approximately 1 cm near the mass, several spargana worms were detected and removed at the same time.

[[77.0, 'year']]

M

{'11410706': 1, '29692513': 2, '21234233': 2, '34195062': 1, '8009896': 1, '23911107': 1, '3748393': 1, '2945847': 1, '12913468': 1, '21519938': 1, '3659374': 1, '24623885': 2}

{'5894292-1': 1, '3018580-1': 1}

3949001-1

noncomm/PMC003xxxxxx/PMC3949001.xml

First Report of Myiasis Caused by Cochliomyia hominivorax (Diptera: Calliphoridae) in a Diabetic Foot Ulcer Patient in Argentina

A male patient aged 54 years, who is now living in Monteros City, Tucuman Province, Argentina, checked into the Angel C. Padilla Hospital in San Miguel de Tucuman for a consultation due to an ulcerous lesion in his right foot with a sanious bottom and fetid odour (). The clinical examination revealed that the ulcer contained fly larvae (n=5) with an evolution of approximately 2 days.\nThe lesion had a circular shape with a diameter of approximately 4 cm; the edge showed signs of inflammation, and the content consisted of foul-smelling necrotic tissues with a sanious bottom that corresponded to the deep aponeurosis of the wound ().\nThe patient was diagnosed with grade II diabetes (under treatment with oral hypoglycemic drugs) with a disease of over 10 years of evolution, in which the neuropathic compromise predominated with an important loss of sensibility in the area (no pain), which was the reason for delayed consultation. However, the presence of peripheral pulses was determined, which indicates that the blood flow in the compromised limb was preserved. The first surgical debridement was performed in the hospital emergency services unit. During this operation, the larvae were mechanically extracted using a sulphuric ether solution (). Tissue samples were extracted for culturing, germ identification, and antibiogram tests.\nThe patient received treatment considering his basic disease (diabetes) with broad-spectrum antibiotics until the results of the cultures were obtained. Additionally, periodic cleaning of the wound and dressing changes were conducted every other day with gauze wetted in a physiological solution. The wound, as well as the patient's metabolic values, exhibited a favourable evolution. He was discharged from the hospital after 15 days, during which time surgical debridement was performed twice. The larval specimens were taken to the laboratory of the Instituto Superior de Entomologia "Dr. Abraham Willink", Facultad de Ciencias Naturales e Instituto Miguel Lillo (Universidad Nacional de Tucuman), where they were identified and later raised individually in flasks and fed beef liver ().\nThe collected larvae belong to the species C. hominivorax with the following external morphological characters: cylindri cal, segmented, white yellow-coloured body, and tracheas with strong pigmentation that was visible until the third or fourth larval segment immediately preceding the end portion of the body [].\nAfter 2 days, the larvae reached the pupal stage and were transferred to plastic cups containing vermiculite. The cups were covered with mosquito netting. The humidity was controlled by spraying water, and the temperature was maintained at 27℃. After 12 days, the adult insects emerged. The adults were then killed, mounted, and identified using the guidelines described by Mariluis and Schnack []. The adults were also identified as C. hominivorax, which is a species that had not been previously reported in Tucuman Province, Argentina []. The morphological characters that defined the adult species were as follows: setose basal vein in the upper surface of the wing, denuded lower surface of the wing, short and reduced palps, and parafrontalia with black hairs outside the front row of setae ().

[[54.0, 'year']]

M

{'29848939': 1, '29165211': 1, '12694705': 1, '22350677': 1, '30783861': 1, '32039212': 1, '7709854': 1, '17934629': 1, '30456490': 1, '26450595': 1, '24623889': 2}

{}

3949340-1

noncomm/PMC003xxxxxx/PMC3949340.xml

A case of sine scleroderma with parenchymal lung disease

A 38-year-old, house keeper woman was admitted in Alzahra hospital because of chills, fever, and generalized malaise. She also complained about exertional dyspnea and nonproductive cough of 2 years duration and had a history of Raynaud's phenomenon that started 8 months prior to admission. She was a nonsmoker with no documented lung disease and denied any other symptom. Physical examination revealed Velcro-like rales at the bases of both the lungs, but no sign of skin nail involvement or heart failure. Tuberculosis and other infections were ruled out. Laboratory tests showed a high positive titer of anti-nuclear antibody, erythrocyte sedimentation rate of 73, and C-reactive protein of 3 + and a normocytic normochromic anemia, whereas test for anti-Scl70 antibody and anti-centromere antibody was negative [].\nComputed tomography scan showed bilateral ground-glass pattern suggestive of ILD []. Spirometry was done, which showed a moderate restrictive pattern.\nShe was treated with prednisolone (1 mg/kg) and pulse of cyclophosphamide (1 g/month) for 6 months, and then put on Cellcept for another 6 months, but ILD did not improve. Thus, the patient was treated with rituximab 2 g (1 gram every 14 days) and showed gradual improvement, then she was subsequently treated with 100 mg of azathioprine daily, prednisolone 5 mg bid, and calcium plus vitamin-D. She has been followed up for 2 years and has not shown any other manifestation.

[[38.0, 'year']]

F

{'19487217': 1, '1516994': 1, '15331183': 1, '10693887': 1, '19247661': 1, '15331191': 1, '17035427': 1, '24627847': 2}

{}

3949341-1

noncomm/PMC003xxxxxx/PMC3949341.xml

Supraglottic paraganglioma originated from superior laryngeal nerve

A 64-year-old woman presented to our clinic with intermittent dysphagia to solid foods and dyspnea on effort from 2 months. She had history of goiter and gastroesophageal reflux; and was treated with Levothyroxin and Omeprazole.\nIndirect laryngoscopy revealed a left mass lesion at the level of supraglottis. Direct laryngoscopy and biopsy of mass was done. Biopsy revealed polypoid tissue lined by stratified squamous epithelium; acanthosis was seen; Exocytosis of lymphocytes and neutrophils in surface epithelium was present. The underlying stroma was edematous and had congested vessels. No evidence of malignancy was seen.\nIn neck sonography, a solid hypoechoic hypervascular mass (34 × 27 mm) was seen in the left paramedian, between left common carotid artery and larynx. There were two hypoechoic thyroid nodules (7 mm diameter in inferior pole and 4 mm in superior pole).\nSpiral neck CT scan with contrast revealed a large hypervascular mass which extended from epiglottis to the left vocal cord. It filled the left pyriform sinus, and narrowed airway tract with erosion to superior part of thyroid cartilage [].\nBiopsy from intraluminal space of hypopharynx was not diagnostic, so excision biopsy of mass was done.\nWith classic neck incision and exploration of carotid artery and vagus nerve, we found the tumor originated from superior laryngeal nerve, extending to supraglottic area. With preservation of superior laryngeal nerve, the tumor was dissected from supraglottic mucosa and excised completely. Because of edema of airway, prophylactic tracheostomy was done. Three days after the surgery, tracheostomy removed. Microscopic examination revealed the tumor as carotid body tumor (paraganglioma).\nAfter surgery, the patient suffered from dysphonia as a result of superior laryngeal nerve paresis that improved 3 months later.

[[64.0, 'year']]

F

{'16044742': 1, '21171315': 1, '18298303': 1, '11346434': 1, '21086280': 1, '1653927': 1, '26351506': 1, '18049441': 1, '20822766': 1, '21262948': 1, '3734607': 1, '21187865': 1, '17683703': 1, '21557244': 1, '24627854': 2}

{}

3949488-1

noncomm/PMC003xxxxxx/PMC3949488.xml

Familial tooth bone graft for ridge and sinus augmentation: a report of two cases

A 45-year-old male patient was transferred from another dental clinic for maxillary anterior horizontal ridge augmentation. The dentist planned to insert a 6-unit fixed prosthesis after implant placement in the #13 and #23 areas. The condition of the #13 and #23 areas involved an alveolar ridge of insufficient width.() The decision was made to extract the lower right 3rd molar (#48) of the patient and to treat this tissue as autogenous tooth bone graft material. The dentist planned to extract two impacted 3rd molars from the patient's daughter, prepare them as blocks and powder, and use them as graft materials.(, ) On April 10th, 2010, the lower right 3rd molar of the patient was extracted and prepared as powder-type graft material. On the same day, the impacted 3rd molars of the daughter were extracted, prepared as block and powder graft materials, and stored. On April 26th, 2010, in the maxillary anterior edentulous area (#13-#23), a flap was elevated by crestal incision. Block graft materials were grafted to the labial side of the maxillary canine area (#13 and #23 labial area), and additionally, powder graft materials were grafted to the vicinity with tissue adhesive (Greenplast; Green Cross Corp., Yongin, Korea).(-) The area was covered with an absorbable collagen membrane (Ossix Plus; OraPharma Inc., Louis Drive Warminster, PA, USA), and the wound was sutured. Good bone healing without special complications was observed, and the patient was returned to the referred dental clinic for implant placement.() Eight months after the surgery, implantation was performed at a local clinic. The condition of horizontal ridge augmentation was good, and thus 4 implants were placed in the #13, #12, #22, and #23 areas. After 1 week, a temporary prosthesis was installed.(, ) The final prosthesis was carried out in local clinic successfully, further follow up was not performed.

[[45.0, 'year']]

M

{'6951529': 1, '6459442': 1, '15626319': 1, '33922832': 1, '6798187': 1, '20060336': 1, '7233533': 1, '299142': 1, '24627842': 2}

{'3949488-2': 2}

3949488-2

noncomm/PMC003xxxxxx/PMC3949488.xml

Familial tooth bone graft for ridge and sinus augmentation: a report of two cases

A 49-year-old male patient visited our clinic for pain in the maxillary left 2nd premolar (#25) and the treatment of implants in the 1st and 2nd molar areas (#26-#27). After diagnosis of an abscess in the #25 root apex, tooth extraction was decided upon. The patient was scheduled to undergo extraction of the mandibular right impacted 3rd molar (#48 impacted molar). This tooth and an impacted tooth from his son were prepared as graft materials, and maxillary bone graft was performed in the #26-#27 areas. Delayed implant placement was planned.(, ) On April 22nd, 2010, the #48 was extracted, and the left impacted 3rd molar of the patient's 22-year-old son was extracted. These teeth were prepared as powder bone-graft materials. On May 7th, 2010, the prosthesis between the #24-#25 area was cut, and the #25 was extracted. A flap was elevated by performing crestal incision on the #25-#27 area, and maxillary sinus bone graft was performed by lateral approach. Autogenous and familial tooth bone graft in powder form were used as bone-graft materials. On August 3rd, 2010, implants (Osstem TS III SA; Osstem, Seoul, Korea, #25: 4 diameter/11.5 length, #27: 5 diameter/11.5 length) were placed in the #25 and #27 area, in a non-submerged type. The primary stability value measured by the Osstell mentor (Integration Diagnostics AB, Savedalen, Sweden) was shown to be #25: 67 implant stability quotient (ISQ) and #27: 71 ISQ, respectively.() Prior to implant placement, a bony specimen was harvested from the #27 area using a 2.0 mm diameter trephine bur. A healing abutment was connected, and the wound was sutured. On December 30, 2010, a final prosthesis was installed (Prosthetic treatment was performed by Dr. Yangjin Yi).()\nThe bone tissue specimens collected after 3 months were examined under light microscope. It was confirmed that in the sinus bone graft area, new bone had formed actively in the vicinity of graft materials. New bones formed along the border of the graft material were woven bones, and some bones had already formed short trabecular patterns. In some areas, they formed loose anastomosis with other trabecular new bones formed along the border of other graft materials. The more developed new trabecular bones were connected to the residual alveolar bone in a pattern that was more densely anastomosed.(, )

[[49.0, 'year']]

M

{'6951529': 1, '6459442': 1, '15626319': 1, '33922832': 1, '6798187': 1, '20060336': 1, '7233533': 1, '299142': 1, '24627842': 2}

{'3949488-1': 2}

3949489-1

noncomm/PMC003xxxxxx/PMC3949489.xml

Esthetic neck dissection using an endoscope via retroauricular incision: a report of two cases

A 63-year-old male patient visited the Department of Oral and Maxillofacial Surgery at Dental Hospital of Yonsei University of College of Dentistry in Korea. His chief complaint was an unhealed oral ulceration which appeared 8 months prior. Incisional biopsy had been performed by another hospital, which revealed invasive squamous cell carcinoma. The patient also had hypertension, for which he was receiving medication. He smoked two cigarettes a day for more than 30 years. The ulcerative lesion was present on the lingual side of #36, #37 and was 3.0×2.0 cm in size. The lesion had an irregular margin without bleeding tendency. Additional diagnostic imaging, including magnetic resonance imaging (MRI) and positron-emission tomography (PET), were performed to determine extent of surgery. There was no mandibular or metastatic lymph node invasion, nor were there metastatic lesions on any other organs (cT2N0M0, stage II). Thus, wide excision with marginal mandibulectomy, selective neck dissection (SND) (I-III) via endoscope, and repair of the soft tissue defect with Megaderm (L&C Bio, Seongnam, Korea) were performed.\nIt took almost 5 hours to complete endoscope-assisted SND (I-III), with 450 cc of blood loss during the operation. The final diagnosis confirmed the initial clinical staging (pT2N0M0, stage II). There was mild marginal mandibular branch weakness, which might also have arisen in conventional ND. The patient was discharged 13 days after surgery without any other complications.

[[63.0, 'year']]

M

{'23728878': 1, '15322830': 1, '24326866': 1, '28944219': 2, '21134554': 1, '33299277': 1, '28546725': 1, '29974878': 1, '16935172': 1, '26632411': 1, '8696772': 1, '22644516': 1, '10958509': 1, '24627840': 2}

{'3949489-2': 2, '5583136-1': 1}

3949489-2

noncomm/PMC003xxxxxx/PMC3949489.xml

Esthetic neck dissection using an endoscope via retroauricular incision: a report of two cases

A 56-year-old male was referred from a local clinic for evaluation of a tongue mass. It appeared 3 months prior and gradually increased in size. It was erosive and ulcerative with induration and bleeding tendency. He had no specific medical history. The patient had smoked 10 cigarettes a day for 15 years. An incisional biopsy was performed and confirmed a diagnosis of invasive squamous cell carcinoma. MRI and PET demonstrated no regional or distant metastasis (cT2N0M0, stage II). Consequently, wide excision with endoscopic ND, reconstruction of the surgical defect with a radial forearm free flap, and repair of the resulting forearm defect with Megaderm were performed.\nIt took almost 3.5 hours to complete endoscope-assisted SND (I-III), with 200 cc of blood loss during the operation. The final diagnosis confirmed the clinical staging (pT2N0M0, stage II). Unlike in case 1, no postoperative facial nerve weakness was observed. The patient was discharged 16 days after surgery without any complications.

[[56.0, 'year']]

M

{'23728878': 1, '15322830': 1, '24326866': 1, '28944219': 2, '21134554': 1, '33299277': 1, '28546725': 1, '29974878': 1, '16935172': 1, '26632411': 1, '8696772': 1, '22644516': 1, '10958509': 1, '24627840': 2}

{'3949489-1': 2, '5583136-1': 1}

3949720-1

noncomm/PMC003xxxxxx/PMC3949720.xml

Pseudomyxoma peritonei: a clinical case of this poorly understood condition

A 76-year-old woman presented to our emergency department (Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal) with dyspnea, increased abdominal girth, and peripheral edema for 2 weeks. Her medical history included diabetes mellitus type 2, hypertension, and dyslipidemia. She was medicated with ramipril, furosemide, aspirin, simvastatin, rabeprazole, and lorazepam.\nThe physical examination revealed tachypnea, a blood pressure of 144/82 mmHg, a pulse rate of 83 beats per minute (bpm), and apyrexia. Expiratory time was increased, and there were rales at the base of the lungs. The cardiovascular system did not reveal any remarkable changes. There was collateral venous circulation on the abdomen wall, the wall was slightly depressible, and percussion revealed tympanic resonance in the center of the abdomen and dullness in both lumbar regions. There was no palpable organomegaly or lymphadenopathy. Peripheral edema was present.\nLaboratory investigations showed an absence of leukocytosis (8,400 leukocytes/μL) with neutrophilia (6,100 neutrophils/μL) and a C-reactive protein value of 6.21 mg/dL. The patient’s erythrocyte sedimentation rate was 88 mm, her carcinoembryonic antigen level was 177 ng/mL (0–3 ng/mL), her cancer antigen 15–3 level was 55 U/mL (0–30 U/mL), her cancer antigen 125 level was 57.5 U/mL (0–35 U/mL), and her cancer antigen 19.9 level was lower than 2.5 U/mL (0–37 U/mL).\nParacentesis was attempted but was unsuccessful. Abdomen ultrasonography and computed tomography showed images that were suggestive of pseudomyxoma and moderate, multiseptate ascites ().\nThe patient was submitted to laparotomy with right oophorectomy, omentectomy, and pseudomyxoma debulking (). At surgery, 6,200 g yellow-orange gelatinous material () was removed. The histological examination of biopsies (from small intestine, ovary, peritoneum, and epiploon) revealed mucinous neoplastic cells and diffuse intra-abdominal mucin, characteristics that allowed the diagnosis of PMP.\nThe morphological () and immunophenotypic (cytokeratin 7 focally positive [], cytokeratin 20 diffusedly positive [], and p16 negative []) patterns were compatible with colorectal/appendicular origin.\nIn the postoperative course, the patient had hemodynamic instability that reverted with fluid replacement and amines for a short period.\nShe was discharged in a satisfactory condition with follow-up at the oncology division. Because of her functional status, the patient has not received chemotherapy. The treatment is being based on symptomatic relief.\nTwo years and 8 months later, she has referred occasionally with postprandial fullness and moderate ascites. Her carcinoembryonic antigen and cancer antigen 125 levels are 133 ng/mL and 139 U/mL, respectively. The last image exam (abdomen ultrasonography) showed a small volume of perihepatic, perisplenic, and interloop fluid with peritoneal leaflets thickening. It was possible to identify a mass with 58 × 30 mm in the left parietocolic groove, indicative of peritoneal carcinomatosis (). Enlarged ganglia were also seen, the biggest of which was at the hepatic hilum, at 32 mm ().

[[76.0, 'year']]

F

{'25767403': 1, '21160816': 1, '21209766': 2, '15650641': 1, '17182192': 1, '11443613': 1, '23720095': 1, '21359034': 1, '23490141': 1, '16532086': 1, '15685704': 1, '21263209': 1, '16945158': 2, '8129481': 1, '34616812': 2, '7503361': 1, '23532601': 1, '21159590': 1, '23235753': 1, '18248391': 1, '12163380': 1, '23714507': 1, '24623987': 2}

{'2970936-1': 1, '8464479-1': 1, '1574320-1': 1, '1574320-2': 1}

3949721-1

noncomm/PMC003xxxxxx/PMC3949721.xml

Rare case of pneumorrhachis, pneumomediastinum, pneumothorax, and surgical emphysema secondary to bronchial asthma

An 18-year-old female Arab, a known asthmatic, presented to the emergency department of our hospital with complaints of chest pain and a nonproductive cough of 1-hour duration. She was conscious and well-oriented to the surroundings but had mild dyspnea. There was no history of receiving assisted mechanical ventilation. There was no previous history of pulmonary tuberculosis, recent trauma, surgery, or other intervention.\nVital parameters were stable, and body temperature was normal. There was subcutaneous emphysema involving the right side of the neck. Auscultation of the chest did not reveal any significant abnormality. A chest radiograph was obtained, which revealed surgical emphysema along the upper part of the right lateral chest wall and the right side of the neck. Minimal pneumomediastinum was also noted with air within the superior mediastinum on the right. A loss of volume of the right lung was noted with a shift of mediastinum to the right and elevated right diaphragmatic dome (). No lung consolidation, pneumothorax, or pleural collection was noted. The patient collapsed immediately after the chest radiograph was obtained. She was intubated and given intravenous fluids and vasopressors to control the hypotension. Her condition stabilized after 2 hours. The portable bedside chest radiograph revealed increased severity of pneumomediastinum, surgical emphysema, right lung collapse, and mediastinal shift to the right ().\nComputed tomography (CT) imaging of the thorax was also performed, which confirmed the dissection of air into the mediastinal and subcutaneous spaces (). A CT scan also revealed air within the posterior spinal extradural space in the thoracic spine ( and ), minimal pneumothorax on the right, and obstruction of the segmental right upper lobe bronchus by mucus plugs ().\nShe was hospitalized and treated with antibiotics, bronchodilators, oxygen inhalation, and other conservative measures. A bronchoscopic removal of mucus plugs and thick secretions was also performed. After only 5 days, clinical findings got better. The chest radiograph revealed resolution of the pneumomediastinum and surgical emphysema and a significant improvement of the right lung collapse and mediastinal shift to the right (). She improved rapidly during her stay in the hospital and was discharged after 7 days.

[[18.0, 'year']]

F

{'34955642': 2, '21442175': 1, '22194136': 1, '23569528': 1, '15965224': 1, '23362075': 1, '19641647': 2, '32307638': 1, '20930996': 1, '16950703': 1, '9646625': 1, '24044086': 2, '20542355': 1, '23079853': 1, '24623994': 2}

{'8694274-1': 1, '3772292-1': 1, '2714570-1': 1}

3949723-1

noncomm/PMC003xxxxxx/PMC3949723.xml

Herpes simplex virus type 2-associated recurrent aseptic (Mollaret’s) meningitis in genitourinary medicine clinic: a case report

A 40-year-old man was referred to our genitourinary medicine clinic with chronic recurrent herpetic genital ulcers. His first attack occurred 8 years earlier following unprotected vaginal sexual intercourse. Swabs taken from these initial lesions tested positive for HSV-2 and negative for HSV type 1 (HSV-1). Treponema enzyme immunoassay (EIA) and Neisseria gonorrhea culture were also negative. The patient had a past medical history of migraines that started in adulthood as unilateral headaches and were controlled by triptans and simple analgesics.\nOne year after his first genital infection, the patient started to develop severe holocranial headaches with distinct characteristics, which failed to respond to usual migraine therapy. The headaches were associated with neck stiffness, mild photophobia, and bilateral pedal paresthesia, but there was no fever, vomiting, or other cranial or radicular neuropathy symptoms. The patient went to the emergency department many times, but his biochemical markers and a computed tomography brain scan were normal. The patient repeatedly refused diagnostic lumbar puncture, but serologic assays (HSV-1, CMV [cytomegalovirus], VZV [varicella-zoster virus], and human immunodeficiency virus) were negative apart from a positive HSV-2 immunoglobulin G titer.\nHe was clinically diagnosed with meningitis and commenced on empirical parenteral ceftriaxone and acyclovir, to which he responded very well. His attacks often recurred two to three times per month and were usually self-limiting in 3–5 days, regardless of their severity, with no residual functional impairment. The attacks were often triggered by emotional stress or heat and were sometimes preceded by genital herpetic eruptions, for which he was referred to our clinic. The distinctive correlation between his meningitic recurrent headaches and recurrent genital lesions as well as his normal previous diagnostic tests raised our suspicion of a possible Mollaret’s meningitis diagnosis. We placed the patient on a continuous suppressive oral acyclovir therapy regimen (400 mg twice daily), which reduced the frequency of his headaches to one to two attacks every 2–3 months, each lasting 1–3 days. He has been on this regimen for 9 years. Attempts to reduce the total daily dose to 400 mg or 600 mg have led to a remarkable increase in the severity and frequency of his acute relapses, so the total daily dose of 800 mg is being sustained indefinitely with regular follow-up in our clinic.

[[40.0, 'year']]

M

{'17852910': 1, '19624935': 1, '15302190': 1, '14016408': 1, '15172776': 1, '21680663': 1, '30262533': 2, '6277234': 1, '7212652': 1, '10817900': 1, '32211261': 2, '18832846': 1, '15243021': 1, '20718190': 1, '24623993': 2}

{'7081958-1': 1, '6169622-1': 1}

3950226-1

noncomm/PMC003xxxxxx/PMC3950226.xml

Severe Hypernatremia by Excessive Bamboo Salt Ingestion in Healthy Young Woman

The patient was a 20-year-old previously healthy woman. She was a university student. Her height and body weight were 168.1 cm and 52.2 kg, respectively. She ingested bamboo salt (about 150 grams ) in a day for the purpose of digestion and weight reduction. After that, she had more than ten episodes of vomiting and diarrhea for 2-3 hours. On arrival at our emergency department, vital signs were blood pressure of 128/81mmHg, heart rate of 75 beat/min, respiration rate of 20/min, and body temperature of 37.3℃. Her consciousness was clear but she complained of generalized weakness. The complete blood counts showed hemoglobin 11.3 g/dL, WBC 10,000 cells/µL, and platelet 196,000/µL. The results of her blood chemistry were as follows: Aspartate transaminase 11 IU/L, Alanine transaminase 9 IU/L, total protein 6.4 g/dL, albumin 4.5 g/dL, blood urea nitrogen 5.2mg/dL, and creatinine 0.57mg/dL. Serum osmolarity was 348mosm/kg. Serum sodium, potassium and chloride were 174mEql/L, 3.6mEq/L and 135mEq/L respectively. Urine sodium, potassium, chloride and osmolarity were 440mEq/L, 125.7 mEq/L, 314mEq/L and 841mosm/kg, respectively. On arterial blood gas analysis, pH was 7.32, PaCO2 36mmHg, bicarbonate 18.5mEq/L, PaO2 93mmHg and O2 saturation 97%. On the 1st day, total input and urine output was 3,700ml and 2,100ml, respectively. Her symptoms such as nausea, vomiting and diarrhea improved rapidly with 0.45% saline infusion and supportive care. On the 2nd day, her serum sodium concentration dropped to 152 mEq/L and urine output was 2,200ml/day. On the 3rd day, serum sodium concentration returned to normal range (). She recovered completely without any sequelae in 3 days.

[[20.0, 'year']]

F

{'14677797': 1, '3619220': 1, '2264581': 1, '32832094': 2, '2255221': 1, '7088630': 1, '10189662': 1, '8503665': 1, '10069018': 1, '847976': 1, '15554954': 1, '25060430': 1, '13998848': 1, '15556015': 1, '24627705': 2}

{'7438811-1': 1}

3950227-1

noncomm/PMC003xxxxxx/PMC3950227.xml

Severe Hyponatremia Associated with the Use of Angiotensin II Receptor Blocker/thiazide Combinations

A 73-year-old Asian woman presented with progressive general weakness after switching to a different antihypertensive regimen at a local hospital 1 month before. She had been diagnosed with hypertension 20 years previously and diabetes mellitus 10 years later, for which she was taking oral medications consisting of olmesartan medoxomil 40mg qd, aspirin 100mg qd, vildagliptin 50mg qd and atorvastatin 10mg qd; the antihypertensive agent was changed to olmesartan/hydrochlorothiazide 20/12.5 mg qd 1 month before presentation.\nOn arrival, the patient's vital signs were stable, and physical, neurological and radiological examinations were within normal limits with the exception of a decrease in skin turgor. Initial laboratory results were as follows: WBC 6,160/mm3, Hb 12.3 g/dL, Hct 35.6%, and Platelet 302,000/mm3; Na 115 mmol/L, K 3.9 mmol/L, Cl 83 mmol/L, uric acid 10.0 mg/dL, BUN 15 mg/dL, creatinine 0.5 mg/dL, and serum osmolality 247 mOsm/kg H2O; and urine creatinine 65 mg/dL, urine urea nitrogen 620 mg/dL, urine Na 74 mmol/L, and urine osmolarity 596 mOsm/kg H2O. The patient's blood sugar was 118 mg/dL, and the HbA1c level was 7.6%. Thyroid function test and rapid ACTH stimulation test results were within normal range.\nInitial blood tests revealed the presence of hyponatremia with a Na level of 115 mmol/L; blood sugar was 118 mg/dL with serum and urine osmolality at 247 mOsm/kg H2O and 596 mOsm/kg H2O, respectively, upon which the possibility of hyperglycemia-induced pseudohyponatremia and hyponatremia caused by polydipsia was ruled out. The hypovolemic state and a high urine sodium concentration of 74 mmol/L implied the presence of sodium loss through the kidneys. Endocrine test results revealed no evidence of hypoaldosteronism. The absence of recent vomiting led to the diagnosis of drug-induced hyponatremia.\nWe initiated treatment for hyponatremia with alteration of the current antihypertensive regimen to olmesartan medoxomil 40 mg qd, in addition to a continuous intravenous infusion of 0.9% NaCl. On the following day, the patient's laboratory test results improved to Na 125 mmol/L, serum osmolality 270 mOsm/kg H2O, urine osmolality 352 mOsm/kg H2O, and urine Na 39 mmol/L. On the second day of admission, 0.9% NaCl infusion was discontinued as we continued observation of the patient. By simply adjusting the antihypertensive regimen, the serum Na level improved substantially to 135 mmol/L, while the patient's blood pressure continued to be under control at 120/80 mmHg. The patient's symptoms improved remarkably, and she was discharged.

[[73.0, 'year']]

F

{'15631534': 1, '1735925': 1, '14656957': 1, '15001200': 1, '17341994': 1, '11451212': 1, '9634263': 1, '15901205': 1, '26313793': 1, '8566137': 1, '11110230': 1, '4944156': 1, '7520210': 1, '2491733': 1, '20974655': 1, '14508180': 1, '11171802': 1, '20486869': 1, '26816476': 2, '12214259': 1, '11334767': 1, '24627706': 2}

{'3950227-2': 2, '4714391-1': 1}

3950227-2

noncomm/PMC003xxxxxx/PMC3950227.xml

Severe Hyponatremia Associated with the Use of Angiotensin II Receptor Blocker/thiazide Combinations

An 86-year-old Asian woman presented with general weakness which began on the day of presentation. She had been suffering from nausea while working in the fields in hot weather for 1 week prior to admission. The patient had been on losartan potassium/hydrochlorothiazide 50/12.5 mg qd, amlodipine 5mg qd, and aspirin 100 mg for hypertension which had been diagnosed 4 years before.\nOn arrival, the patient's vital signs were stable, and physical, neurological and radiological examinations were within normal limits. Initial laboratory results were as follows: WBC 8,240/mm3, Hb 12.4 g/dL, Hct 33.5%, and Platelet 488,000/mm3; Na 102 mmol/L, K 3.5 mmol/L, Cl 67 mmol/L, BUN 10 mg/dL, creatinine 0.4 mg/dL, and serum osmolality 223 mOsm/kg H2O; and urine creatinine 79 mg/dL, urine urea nitrogen 309 mg/dL, urine Na 79 mmol/L, and urine osmolality 398 mOsm/kg H2O. The patient's blood sugar was 142 mg/dL, and the HbA1c level was 5.6%. Thyroid function test and rapid ACTH stimulation test results were within normal range.\nInitial blood tests revealed the presence of hyponatremia with a Na level of 102 mmol/L, and serum osmolality was also low at 223 mOsm/kg H2O. Urine osmolality was 398 mOsm/kg H2O, upon which primary polydipsia was ruled out; the patient was hypovolemic, in combination with endocrine test results, implied that the possibility of hypothyroidism, adrenal cortex dysfunction, or SIADH was low. An increased urine Na level of 79 mmol/L and normal aldosterone levels, with no history of vomiting, led to the diagnosis of diuretic-induced hyponatremia.\nWe changed the patient's antihypertensive medication to a single-drug regimen of amlodipine 5mg qd. Hyponatremia was corrected with continuous intravenous infusion of 0.9% NaCl. On the following day, the serum Na level improved to 110 mmol/L; on the second day, it further improved to Na 121 mmol/L, at which point 0.9% NaCl infusion was discontinued.\nOn the fourth day of admission, the serum Na level and osmolality were substantially recovered to 130 mmol/L and 271 mOsm/kg H2O respectively, with urine osmolality of 207 mOsm/kg H2O and urine Na of 14 mmol/L. Blood pressure was stable at 120/80 mmHg. The patients' symptoms showed recovery and she was discharged.

[[86.0, 'year']]

F

{'15631534': 1, '1735925': 1, '14656957': 1, '15001200': 1, '17341994': 1, '11451212': 1, '9634263': 1, '15901205': 1, '26313793': 1, '8566137': 1, '11110230': 1, '4944156': 1, '7520210': 1, '2491733': 1, '20974655': 1, '14508180': 1, '11171802': 1, '20486869': 1, '26816476': 2, '12214259': 1, '11334767': 1, '24627706': 2}

{'3950227-1': 2, '4714391-1': 1}

3950235-1

noncomm/PMC003xxxxxx/PMC3950235.xml

Large Cell Calcifying Sertoli Cell Tumor of the Testis: A Case Study and Review of the Literature

A 24-year-old man was admitted to The Armed Forces Capital Hospital to investigate a left testicular mass, which had been incidentally detected in a plain radiograph taken for lower back pain (). There were no clinical signs of CNC or PJS. A left orchiectomy was performed, whereupon the testis was found to contain a 1.1-cm, well-demarcated, stony hard mass. On a cut section, this lesion had a grey-brown area with, whitish calcific changes and was confined to the testis ().\nMicroscopically, the tumor was composed of neoplastic cells, fibrotic stroma, and laminated or irregularly shaped calcific bodies, containing focal ossification. The tumor cells had abundant eosinophilic or clear cytoplasm, and were arranged in cords, trabeculae, clusters, and diffuse sheets (). An intratubular growth pattern was also apparent, along with thickening of the basal lamina of these tubules, and intratubular microcalcification (IMC) at the periphery (). The nuclei were round with one or two conspicuous nucleoli, and showed moderate degree of nuclear pleomorphism. No mitotic figures, necrosis, Reinke crystalloids, or lipofuscin pigment were present, and the fibrotic stroma appeared benign.\nImmunohistochemically, neoplastic cells were diffusely positive for S-100 protein (ready-to-use, anti-S-100 polyclonal antibody, Dako, Glostrup, Denmark), vimentin (ready-to-use, anti-vimentin monoclonal antibody, clone VIM 3B4, Dako), focally and weakly positive for inhibin alpha (ready-to-use, anti-inhibin alpha monoclonal antibody, clone R1, Dako) () but negative for cytokeratin (ready-to-use, anti-cytokeratin monoclonal antibody, clone AE1/AE3, Dako), CD10 (ready-to-use, anti-CD10 monoclonal antibody, clone 56C6, Dako), and Melan-A (ready-to-use, anti-melan-A monoclonal antibody, clone A103, Dako).

[[24.0, 'year']]

M

{'22732638': 1, '11688457': 1, '12409718': 1, '11979368': 1, '28050378': 1, '12747474': 1, '20004940': 1, '9719297': 1, '28357779': 1, '17509353': 1, '7446466': 1, '15943795': 1, '24627695': 2}

{}

3950236-1

noncomm/PMC003xxxxxx/PMC3950236.xml

Primary Myxoid Leiomyoma of the Liver

A 60-year-old woman complained of upper abdominal fullness. She was taking hypertension and diabetes medications and had undergone a thyroid lobectomy for thyroid papillary carcinoma 4 years earlier. She was discovered to have a low-echogenic mass in the right lobe of the liver on an ultrasound scan. Computed tomography of the abdomen revealed an 8-cm enhancing mass in segment 7 and 8 of the liver (). Liver function tests were unremarkable. Blood tumor markers, including carcinoembryonic antigen, α-fetoprotein, and carbohydrate antigen 19-9 were within normal ranges. The patient was not a hepatitis B carrier and her human immunodeficiency virus serology was nonreactive.\nResults from a further magnetic resonance study suggested metastatic carcinoma from the thyroid. The gastrointestinal and gynecologic tracts were examined and no other lesions were detected. The patient underwent a right hepatectomy to remove the tumor. Grossly, there was an 8×5×4.5 cm, well-demarcated, unencapsulated and soft mass in the liver. The cut surface was yellow-to-tan, myxoid, and rubbery (). Histologically, the tumor was uniformly hypocellular and consisted of scattered, oval-to-spindle tumor cells and variable sized vessels. The stroma was myxoid and edematous (). The spindled tumor cells had slightly eosinophilic cytoplasm. The nuclei of the spindle cells were cigar-shaped, blunt-ended, and showed vesicular chromatin. The nucleoli were inconspicuous. No cellular atypia or mitosis was observed (). Inflammatory cells, especially mast cell and lymphocytes, were easily found.\nImmunohistochemically, the spindle cells stained positively for smooth muscle actin (SMA) () and desmin, but were negative for anaplastic lymphoma kinase (ALK), S-100 protein, human melanoma black 45 (HMB45), c-kit, CD21, CD31, and CD34. Only a few tumor cells were labeled with ki-67. Estrogen receptor and progesterone receptor studies demonstrated negative staining. Thus, the histomorphological and immunophenotype findings were consistent with myxoid leiomyoma of the liver. The patient's postoperative course was uneventful and she has had no sign of recurrence to date.

[[60.0, 'year']]

F

{'20959979': 1, '9870862': 1, '32999907': 1, '8918643': 1, '11063198': 1, '2252034': 1, '6269445': 1, '7396072': 1, '7812519': 1, '1309411': 1, '8233708': 1, '12493419': 1, '2487073': 1, '4165872': 1, '25992372': 1, '1551357': 1, '16794799': 1, '3755029': 1, '8273640': 1, '18333008': 1, '24627696': 2}

{}

3950237-1

noncomm/PMC003xxxxxx/PMC3950237.xml

Primary Sigmoid Adenocarcinoma Metastasis to the Breast in a 28-Year-Old Female: A Case Study and a Review of Literature

A 28-year-old Caucasian female presented to her general practitioner after she noticed a lump in her right breast for two weeks' duration. It was gradually increasing in size with no pain or nipple discharge. She had no previous breast problems or family history of breast cancer. On examination, a 2-cm firm lump was noted in the upper inner quadrant of her right breast, which was clinically benign. No lymph nodes were palpable. The ultrasound examination demonstrated a hypoechoic solid area with some calcification, consistent with a benign lesion (). A mammogram showed a partially well-defined nodule with intermediate type microcalcifications, which suggested suspicious morphology corresponding to the site of the primary carcinoma. Fine needle aspiration cytology showed low-grade atypia of probable benign nature set in a background of numerous polymorphs. Core biopsies were taken, and the histological examination revealed a malignant tumor made of cells showing prominent nuclear pleomorphism, significant mitotic activity, glandular structures with epithelial stratification, and focal cribriform formations. Some of the glands were dilated and contained necrotic debris within the lumen, or 'comedo-like necrosis.' These findings were consistent with a well to moderately differentiated adenocarcinoma ().\nThe main differential diagnosis included primary breast ductal carcinoma of nonspecific type and metastatic adenocarcinoma from other primary sites, including the colon, lung, upper gastrointestinal tract, hepato-pancreatobiliary sites, endometrium, and ovary. An immunohistochemical profile was performed, and the tumor was found to be strongly positive for CDX2 () and cytokeratin (CK) 20 (). CK5/6 (myoepithelial marker) showed a patchy reaction, which suggested partial maintenance of the myoepithelial cells, findings that can mimic ductal carcinoma in situ (DCIS) of comedo type. The tumor cells were negative for CK7 (), HER2, gross cystic disease fluid protein 15, estrogen receptor, and progesterone receptor. The abovementioned immunoprofile confirmed the diagnosis of metastatic adenocarcinoma from a colorectal primary source. These findings excluded other primary tumors from the breast, lung, stomach, esophagus, endometrium, and ovary, which are usually positive for CK7 and negative for CK20 and CDX2. A detailed review of previous medical records was carried out and revealed that only ten days before presenting to the Breast Clinic, the patient underwent an urgent colonoscopy after she complained of severe weight loss, poor appetite, and diarrhea with blood and mucous. There was no family history of any bowel cancers. In addition, computed tomography scan exhibited a 3.6-cm metastatic deposit in the liver and a mass lesion in the recto-sigmoid junction with no evidence of lung deposits or enlarged lymph nodes. Histology of the colonic biopsies showed a moderately differentiated adenocarcinoma. This finding helped to reach a final diagnosis of metastatic adenocarcinoma to the breast from a primary sigmoid tumor.\nTreatment options for the patient were discussed at several multidisciplinary team (MDT) meetings, including breast, colorectal, and hepatobillary MDT meetings. The patient underwent anterior resection of the rectum. The primary lesion was revealed to be a perforated adenocarcinoma, with advanced clinical disease of pT4N2M1 and Dukes C1. The patient subsequently received chemotherapy; however, the breast and hepatic lesions were not removed due to the multi-focality nature of the disease.

[[28.0, 'year']]

F

{'22319737': 2, '21619688': 2, '21738536': 1, '31860952': 2, '9414946': 1, '21264761': 1, '25883818': 2, '31482523': 1, '15019699': 1, '10663337': 1, '15230671': 1, '20160374': 1, '15695089': 1, '30662213': 2, '33074138': 1, '18791504': 1, '18461602': 1, '28693131': 1, '22125523': 1, '33743246': 1, '24627697': 2}

{'3267064-1': 1, '3128842-1': 1, '6319108-1': 1, '6319108-2': 1, '6319108-3': 1, '6319108-4': 1, '6319108-5': 1, '6319108-6': 1, '6940129-1': 1, '4390182-1': 1, '4390182-2': 1}

3950238-1

noncomm/PMC003xxxxxx/PMC3950238.xml

Adenocarcinoma Arising in a Colonic Duplication Cyst: A Case Report and Review of the Literature

A 23-year-old female patient was admitted with a palpable abdominal mass. The mass had been noted three years previously. On physical examination, a nontender and movable mass measuring approximately 7 cm was observed at the right lower quadrant.\nThe patient's serum carcinoembryonic antigen (CEA) level was 6.51 ng/mL (normal range, <5.0 ng/mL), and that of cancer antigen 19-9 was 47.71 U/mL (normal range, <37 U/mL).\nUltrasonography disclosed a hypoechoic cystic mass with an internal echogenic dot in the right lower quadrant. The echogenic dot was thought to be either an intraluminal secretion or necrotic debris (). Computed tomography (CT) revealed a nonenhancing cystic mass measuring 7 cm, with linear calcification located adjacent to the medial side of the ascending colon (). No enlarged regional lymph nodes, ascites, or other abnormalities were observed.\nA laparoscopic excision of the mass was performed. During the operation, the mass was observed to be attached to the ascending colon mesentery, having the blood supply by the right colic artery.\nOn gross examination, the cystic mass measured 8.6×6.4×2.9 cm, and its outer surface was smooth; mesenteric fat adhered to the outer surface. The maximum thickness of the cystic wall was 1.5 cm, and focal calcification was noted within the wall. The cyst contained brownish-colored mucoid material ().\nMicroscopically, the cyst was found to have two well-organized layers of smooth muscle with an infiltrating adenocarcinoma forming irregular tubules (). The tumor had invaded the pericystic mesenteric soft tissue and metastasized to eight of 16 mesenteric lymph nodes. Perineural and lymphovascular invasions were noted. Non-neoplastic glandular epithelium was not found; instead, a focal area of atypical columnar epithelium, which was compatible with low-grade dysplasia, was observed (). On immunohistochemical study, tumor cells were positive for cytokeratin 7 (1:100, OV-TL 12/30, Dako, Glostrup, Denmark), cytokeratin 20 (1:100, KS20.8, Dako), CEA (prediluted, II-7, Dako), CDX2 (1:50, AMT 28, Novocastra, Newcastle upon Tyne, UK), and p53 (1:100, DO-7, Dako). The dysplastic epithelium was also positive for p53 ().\nPositron emission tomography-CT was performed after surgery and revealed no hypermetabolic areas other than the previous operation site. Two months after surgery, the patient started adjuvant chemotherapy.

[[23.0, 'year']]

F

{'2920632': 1, '29388059': 1, '20812340': 1, '22403508': 2, '4764750': 1, '9516499': 1, '17912582': 1, '33392316': 2, '16133984': 1, '1131505': 1, '32874984': 2, '34307222': 2, '210081': 1, '6019822': 1, '24627698': 2}

{'8214887-1': 1, '3295976-1': 1, '7760449-1': 1, '7441256-1': 1}

3950239-1

noncomm/PMC003xxxxxx/PMC3950239.xml

A Rare Case of Pulmonary Papillary Adenoma in Old Aged Woman: A Brief Case Report

A 68-year-old female, who was undergoing preoperative evaluation for known rectal cancer, received percutaneous needle biopsy for a pulmonary nodule () and endobronchial sono-guided biopsy for enlarged mediastinal lymph nodes, which showed no evidence of metastasis. However, the core of the pulmonary nodule was composed of bland papillae-like structures lined with a single layer of uniform cuboidal cells, suspicious for carcinoid or low-grade epithelial neoplasm. On consideration of double primary pulmonary neoplasm, she received combined laparoscopic low anterior resection of the rectum and wedge resection of the left lobe of the lung.\nThe resected specimen of lung contained a 2.5×1.5-cm-sized, peripherally located mass with a granular cut surface. At low power view, it is well demarcated without necrosis or hemorrhage (). Microscopically, it showed dominant papillary architecture and focal microcystic area (). The papillae contained prominent or delicate fibrovascular cores and were lined by monotonous cuboidal cells (). The epithelial cells had moderate or small amount of cytoplasm and round, centrally located nuclei with inconspicuous nucleoli, and no nuclear atypia or mitosis was found (). The chromatin was relatively uniformly distributed and finely granular, suspicious for neuroendocrine tumor. The microcystic area were lined with same epithelial cells and filled with amorphous eosinophilic material, similar to colloid or amyloid.\nFor the differential diagnoses with papillary adenoma of lung, metastatic follicular or medullary carcinoma of thyroid gland and less likely metastatic adenocarcinoma of rectum, immunohistochemical staining was performed. The tumor cells showed negativity for chromogranin (1:400, DAK-A3, Dako, Glostrup, Denmark), thyroglobulin (1:500, DAK-Tg6, Dako), calcitonin (1:4,000, Dako) and CDX-2 (1:50, AMT28, Novocastra, Newcastle upon Tyne, UK) and positivity for thyroid transcription factor-1 (1:100, 8G7G3/1, Dako) (, inset). The eosinophilic material was negative by Congo-red stain and polarizing microscopy.\nThe patient was confirmed to have primary papillary adenoma of the lung and adenocarcinoma of the rectum (pT3N0Mx), and was discharged without any complications.

[[68.0, 'year']]

F

{'26474555': 2, '18708941': 1, '7357529': 1, '33126399': 1, '8290804': 1, '1543163': 1, '31934202': 1, '32355529': 1, '21790862': 1, '10782889': 1, '24627699': 2}

{'4609042-1': 1}

3950240-1

noncomm/PMC003xxxxxx/PMC3950240.xml

Malignant Fat-Forming Solitary Fibrous Tumor of the Thigh

An 84-year-old man visited our hospital complaining of a palpable mass in his left thigh. Eighteen years prior, he underwent radical cystectomy for urothelial carcinoma. Magnetic resonance imaging (MRI) revealed an 11-cm-sized soft tissue mass at the deep aspect of the proximal thigh with infiltration to the surrounding muscle. The tumor exhibited low signal intensity and no obvious intra-tumoral fat component could be identified on T1-weighted MRI (). The tumor demonstrated high signal intensity on T2-weighted MRI, and showed peripheral enhancement with extensive necrosis and hemorrhage on contrast-enhanced T1-weighted MRI with fat suppression. Wide excision was performed due to the suspicion of malignancy. Grossly, the tumor was relatively well circumscribed and had a yellowish-tan appearance with a glistering surface, extensive necrosis, and cystic degeneration (). Microscopically, the tumor was encapsulated and had a partially infiltrative margin. The tumor demonstrated a SFT component characterized by a patternless architecture of oval to spindle cells surrounding the ectatic thin-walled branching vessels admixed with mature adipose tissue. The tumor had alternating hypercellular and hypocellular areas with extensive necrosis and hemorrhage. The tumor cells in the cellular area were pleomorphic and had numerous mitotic figures (up to 25 mitoses per 10 high power fields [HPF] and atypical mitosis) (). The adipocytic components were located at the periphery of the tumor within the capsule, and comprised approximately 5% of the tumor. Fat lobules or scattered individual adipocytes were intermingled with pleomorphic stromal cells. Adipocytes had a clear cytoplasm with a flat nucleus located at the periphery of the cells (). No lipoblasts were observed in the adipocytic component. Immunohistochemical staining demonstrated that the neoplastic cells were positive for CD34, CD99, and bcl-2, but were negative for S-100 protein, keratin, epithelial membrane antigen, CD31, desmin, and CD68. Mature adipose tissue between SFT components was positive for S-100 protein (). Based on these histologic and immunohistochemical findings, the tumor was diagnosed as a malignant fat-forming SFT of the thigh. The patient was followed postoperatively for 14 months, and there was no evidence of recurrence or metastasis.

[[84.0, 'year']]

M

{'10506450': 1, '21716088': 1, '11920476': 1, '26339447': 1, '11014579': 1, '11231493': 1, '23705040': 1, '7793472': 1, '24627700': 2}

{}

3950241-1

noncomm/PMC003xxxxxx/PMC3950241.xml

Benign Indolent CD56-Positive NK-Cell Lymphoproliferative Lesion Involving Gastrointestinal Tract in an Adolescent

A fourteen-year-old boy was admitted to our hospital due to chronic recurrent vomiting and abdominal discomfort, which began several months previously and intensified to occurrence of vomiting once a day. He also had intermittent diarrhea without severe abdominal pain or fever. His height and weight were both estimated to place him in the lowest 3% of the growth curve for his age. There was no remarkable family history except for hyperthyroidism in his farther. Initially, under the impression of eosinophilic gastroenteritis, prednisolone therapy was administered. However after short-term improvement of symptoms, vomiting recurred. After colonoscopic biopsy, he was presumptively diagnosed with EATL. He was readmitted to our hospital for further workup and nutritional therapy. Endoscopic examinations including capsule endoscopy revealed multiple small lesions with mucosal nodularity and hyperemic change in esophagus, stomach, duodenum, small intestine, and colon with several erosions of the intestine (). Computed tomography scan revealed diffuse thickening of the distal esophageal wall, stomach, duodenum and small intestine, slightly enlarged mesenteric lymph nodes and borderline-sized (10 cm) splenomegaly. On positron emission tomography scan, the only notable finding was mild fluorodeoxyglucose uptake in GI tract, suggestive of physiologic change. Laboratory tests showed mild leukocytosis (white blood cell count, 12,540/µL) with a differential count within normal range, anemia (hemoglobin, 7.4 g/dL), hypoferritinemia (3.88 ng/mL), hypocalcemia (5.5 mg/dL), hypoproteinemia (total protein 3.3 g/dL), and hypoalbuminemia (1.7 g/dL). Lactate dehydrogenase (LDH) was elevated up to 372 IU/L. The presumptive diagnosis of EATL led physicians to perform serologic tests to rule out celiac disease. Anti-tissue transglutaminase antibody was negative, and the patient was positive for HLA-DQ5 and DQ6, which made the possibility of underlying celiac disease less likely. A test for food allergies was also unremarkable.\nMultiple endoscopic biopsies were taken from the esophagus to the colon, which all exhibited similar histological features. The lamina propria was expanded by infiltration of atypical monomorphic lymphoid cells. The infiltrate was vaguely demarcated from the adjacent relatively unaffected mucosa in the colon. The atypical lymphoid cells were medium-sized with slightly irregular nuclei, inconspicuous nucleoli and finely clumped chromatin. They had a moderate amount of pale to eosinophilic cytoplasm (). Mitotic figures were occasionally observed. Necrosis, apoptosis, and angiocentricity were absent. Some scattered eosinophils were noted in the lamina propria. Enteropathy features including villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis were not observed. On immunohistochemistry, the lymphoid cells were positive for cytoplasmic CD3, CD56, CD8, and T-cell-restricted intracellular antigen-1, and negative for CD4, CD20, and TCRβF1 (clone 8A3, Thermo Scientific, Rockford, IL, USA) (). This immunophenotype suggested an NK-cell or γδ T-cell origin. The proliferation rate as determined by Ki-67 was low, up to 19.8%. EBV was not detected by in situ hybridization using an EBV-encoded RNA 1/2 probe. Molecular analysis for TCRγ gene rearrangement using BIOMED-2 multiplex PCR for TCRG: V-J; TCRG: V-J (InVivo-Scribe Technologies, San Diego, CA, USA) on formalin-fixed paraffin-embedded tissue showed no evidence of T-cell monoclonality. Later immunohistochemistry for TCRG (1:20, γ3.20, Endogen, Rockford, IL, USA) was carried out, which was negative.\nDespite a presumptive pathologic diagnosis of intestinal γδT-cell or NK-cell lymphoma, no chemotherapy was administered due to low clinical suspicion of malignancy and the poor nutritional status of the patient. He instead has been closely followed with regular clinical evaluation. Gastroduodenoscopy six months later demonstrated persistent mucosal nodularity in the duodenum, but biopsy revealed mild lymphoplasma cell infiltration with only a few scattered CD3(+) cells and no CD56(+) cells. The patient's symptoms and LDH level waxed and waned, while anemia and hypoalbuminemia have been persistent. However, 40 months later, GI symptoms were aggravated and multifocal ulcerations were observed in colon and stomach. The result of endoscopic biopsy proved recurrence of disease.

[[14.0, 'year']]

M

{'21753698': 1, '25588634': 2, '20829373': 1, '32696224': 2, '21566094': 1, '21941294': 1, '17509985': 1, '30968266': 2, '20966166': 1, '21921780': 1, '22641357': 1, '24627701': 2}

{'8203537-1': 1, '6763404-1': 1, '4284489-1': 1}

3950242-1

noncomm/PMC003xxxxxx/PMC3950242.xml

Crush Cytology of Microcystic Meningioma with Extensive Sclerosis

A 63-year-old female patient presented with a three-month history of dysarthria and motor weakness of the right arm. Enhanced brain T2-weighted magnetic resonance (MR) images showed a mass measuring approximately 5.4 cm in the left frontal convexity with strong enhancement (). Intraoperatively, the subdural mass showed marked adhesion to the underlying brain parenchyma and dura, and the lesion had a large feeding artery and high vascularity. Near total removal was performed.\nIntraoperative crush preparations stained with hematoxylineosin showed paucicellular smears composed of a few noncohesive spindle-to-ovoid cells, fragmented collagenous materials, and rare cohesive whorls of round to polygonal eosinophilic cells with a background of bluish mucin (). Scattered polygonal-to-spindle cells contained abundant vacuolated, clear bubbly cytoplasm (, left). Rare intracytoplasmic microcysts were observed (, right). Nuclear hyperchromasia was frequently found. There were a few clusters of tumor cells having indistinct cell borders and lacy eosinophilic cytoplasm, consistent with whorl-like structures (). Some scattered polygonal cells had vacuolated cytoplasm within a collagenous material (). In that portion, the tumor cells had eosinophilic cytoplasm with a well-defined border and a refractile, thick hyaline nature, rather than a lacy or fibrillary one (). There were collagen nodules and calcific materials (). No nuclear pseudoinclusions were found. Neither mitosis nor necrosis was found.\nThe near totally removed mass was composed of a microcystic area and a markedly sclerotic area occupying approximately 80% of the mass. Scattered stellate, vacuolated cells and foam cells were observed within the intercellular microcystic area (). Pleomorphic cells with enlarged hyperchromatic nuclei were occasionally found in both sclerosing and microcystic areas. The fibrotic area was composed of fibrous nodules and collagen bundles as well as markedly hyalinized vessels with focal foci of round-to-oval shaped cells in the fibrotic nodule (). In the fibrotic collagenous portion, some spindle shaped tumor cells were found in collagenous nodules and thick hyalinized vessels (). Psammoma bodies were frequently noted. Neither mitosis nor necrosis was found. These findings were reminiscent of microcystic meningioma. Both the spindle cells in the fibrotic area and the meningothelial cells in the cellular portion of typical microcystic meningioma demonstrated positivity for vimentin (prediluted, V9, Dako, Glostrup, Denmark) and negativity for glial fibrillary acidic protein (prediluted, polyclonal, Dako) and S-100 protein (prediluted, polyclonal, Dako). Only meningothelial cells showed focal cytoplasmic reactivity for epithelial membrane antigen (prediluted, E29, Dako). Masson-Trichrome staining highlighted the thick fibrotic collagenous changes of the mass. The edematous fluid in the microcysts was not stained with periodic-acid Schiff or mucicarmine, and was weakly positive for Alcian blue and toluidine blue. The tumor was diagnosed as a microcystic meningioma with extensive sclerosis, World Health Organization grade 1.\nAfter the operation, the patient demonstrated good recovery.

[[63.0, 'year']]

F

{'21187881': 1, '30636391': 1, '18335550': 1, '9068701': 1, '34582442': 1, '32601263': 2, '18418856': 1, '16837627': 1, '11002371': 1, '12722124': 1, '16901012': 1, '26605274': 2, '30887206': 1, '24627702': 2}

{'7674761-1': 1, '4656894-1': 1}

3950435-1

noncomm/PMC003xxxxxx/PMC3950435.xml

Delayed Horner's syndrome following ultrasound- guided interscalene brachial plexus block

A healthy 29-year-old man (weight 75 kg, height 169 cm, American Society of Anesthesiologists class 1) was scheduled for elective arthroscopic repair of a left shoulder Bankart lesion. Aside from the orthopedic injury, the patient's history, physical examination, and laboratory data were normal. He was given 2 mg of lorazepam orally 2 h before arriving in the operating room. On arrival to the operating room, an 18-gauge venous cannula was inserted and the patient was connected to standard monitoring equipment, an oxygen face mask (5l/min) and was intravenously given 2 mg of midazolam. The patient was positioned supine with his neck extended to the contra-lateral side to facilitate performance of an ultrasound (US) interscalene brachial plexus block (ISBPB). After skin preparation with povidone-iodine and infiltration with lidocaine 1%, US-ISBPB was performed. An 18-gauge, 2-inch insulated needle (B. Braun Medical Inc., Bethlehem, PA, USA) was inserted into the middle scalene muscle immediately superior to and out of the plane with the L38 × 10−5 MHz transducer linear array. A 9 cm scan depth probe was used to visualize the brachial plexus using an M-Turbo US machine (SonoSite, Bothell, WA, USA). In the middle portion of the scalene muscle, the needle was redirected anteriorly and advanced toward the interscalene space. Normal saline (1-2 ml) was injected in increments into the anterior border of the middle scalene muscle to expand the fascial plane between the brachial plexus and the middle scalene muscle. While intermittently aspirating under direct US visualization, 10 ml of 0.25% bupivacaine was injected into the interscalene space. A 20-gauge catheter was then inserted into the skin through the thin-walled needle to a depth of 10 cm. To locate the catheter position before placement of a clear adhesive dressing, 0.5 ml of air was injected after negative aspiration while imaging the interscalene space. The US image clearly demonstrated echogenic contrast entering the interscalene space, thereby confirming appropriate positioning of the catheter. The surgical procedure was performed under general anesthesia using the propofol, fentanyl, and cis-atracurium with the patient in a beach chair position. Following an uneventful two-hour surgery, the patient was extubated and moved to the recovery room. Analgesia was maintained with a top-up of 0.2% bupivacaine every 8 h through the interscalene catheter. Free from pain and resting comfortably, the patient was discharged from the recovery room. Eight hours after the initial bolus (visual analog pain scale 1-2 at rest), the patient received 10 ml 0.2% bupivacaine, which was administered through the interscalene catheter by the on call team. One hour later, the patient developed Horner's syndrome on the ipsilateral side, including meiosis, ptosis, enophthalmia, anhydrosis, and conjunctival hyperemia. No swelling around the site of catheter insertion was noted. The catheter was withdrawn immediately and symptoms of Horner's syndrome disappeared approximately 2 h later. Analgesia was then changed to paracetamol and non-steroidal anti-inflammatory drugs.

[[29.0, 'year']]

M

{'5124750': 1, '1363053': 1, '8024148': 1, '5534420': 1, '11575560': 1, '11149455': 1, '7324828': 1, '12883417': 1, '1859023': 1, '9416719': 1, '20652841': 1, '8067575': 1, '18292456': 1, '16368845': 1, '25987922': 2, '24665252': 2}

{'4427219-1': 1}

3950436-1

noncomm/PMC003xxxxxx/PMC3950436.xml

Anesthesia for tracheostomy for huge maxillofacial tumor

A 19-year-old female patient, weighted 40 kg, with a huge craniofacial tumor was scheduled for elective tracheostomy due to airway compromization. The tumor invaded the hypo and oropharynx causing displacement of the eyes, nasal obstruction with limited mouth opening and neck extension []. The patient had obstructive sleep apnea, shortness of breath, visual impairment and dysphagia for which gastrostomy was inserted for enteral feeding. The patient had a recurrence of the tumor after surgical intervention and multiple courses of chemo and radiotherapy. The patient absolutely refused any trial to insert an intravenous (IV) cannula as she had a low threshold for pain and on examination, her veins were apparently exhausted and sclerosed from chemotherapy and no vein could not be chosen to apply, EMLA cream. The patient was categorized as impossible to both intubate and ventilate due to severely distorted airway anatomy in uncooperative patient. Communication with the patient was challenging due to dysphonia. With the help of her mother, she reported that her daughter is absolutely refusing IV cannulation and she expressed her fear of pain perception during the tracheostomy procedure. Consent was taken from the patient to take a photo for her. In the high dependency unit, 2 h before surgery, sedation was initiated under full monitoring with baseline non-invasive blood pressure (BP) 111/74 mmHg, heart rate (HR) 92/min, oxygen hemoglobin saturation 98% and respiratory rate (RR) 17/min.\nKetamine (Tekam, Hikma, Jordan) with a dose of 120 mg (3 mg/kg) diluted in 10 ml normal saline was administered through the gastrostomy tube. That was followed by administration of 80 mcg (2 mcg/kg) dexmedetomidine (Precedex; Hospira, Inc., Lake Forest, IL, USA) diluted in 10 ml normal saline. EMLA 5 g cream 5% (Astra Pharma, Inc., Mississauga, Ontario, Canada) was applied over the planned tracheostomy site about 10 cm2 and covered by transparent film dressing (Tegaderm Film, 3M Health-Care, USA).\nIn OR, the patient was sedated yet awake with eye opening to verbal commands. Non-invasive monitoring was applied for the patient (BP, electrocardiogram, pulse oximetry). BP was 105/70 mmHg, HR: 89/min, RR: 16/min and O2 Sat: 98%. A 24G IV cannula was inserted in the left antecubital vein guided by ultrasound without complaint. 5 ml lidocaine 1% + adrenaline 1/200,000 were infiltrated over tracheostomy site by the surgeon after IV was secured with full cooperation by the patient. Cuffed tracheostomy tube size 6.0 mm tube was easily inserted. No changes in vital signs were observed during the procedure. On the following day, the cuffed tracheostomy tube was replaced by a fenestrated one; to allow the patient to speak. The mother informed the team that her daughter was highly satisfied and had no recall of the procedure.

[[19.0, 'year']]

F

{'1350888': 1, '7489470': 1, '7691503': 1, '10833550': 1, '8958493': 1, '14616431': 1, '16238552': 1, '7850366': 1, '12826556': 1, '6496911': 1, '7818623': 1, '7272143': 1, '11046225': 1, '1729932': 1, '18586315': 1, '1408506': 1, '9110906': 1, '10594409': 1, '12553389': 1, '14633551': 1, '24665253': 2}

{}

3950437-1

noncomm/PMC003xxxxxx/PMC3950437.xml

Airway management in a patient with Le Fort III Fracture

A 27-year-old male was brought to the operating room with severe blunt injury isolated to the face. He was scheduled for open reduction and fixation of facial fractures under general anesthesia.\nThe patient was in the sitting position, head slightly bent down, conscious and oriented. He exhibited a dish-face deformity with periorbital edema, multiple lacerations and dropped upper jaw. He had profuse bleeding from the nose and the mouth []. Both nares were obstructed with no flow of air and the patient was breathing from his mouth with difficulty. When asked to lie down in the supine position, the patient started suffocating and desaturated. The airway assessment revealed the inability to open the mouth. Monitoring included electrocardiogram, pulse oxymeter and non-invasive blood pressure. The laboratory investigations revealed a normal hemogram and coagulation profile.\nRadiological 3 dimensional computed tomography scan examination revealed fractures of bilateral maxilla, mandibular symphisis, left infraorbital region and nose. The skull base and the cervical spine were intact [].\nTracheostomy under local anesthesia was suggested prior to anesthesia and surgery to secure the airway because of the impossibility to perform the standard oral intubation and the contraindicated nasal intubation. The ear, nose, and throat surgeon refused to do the awake tracheostomy because of the unsuitable surgical position (sitting and head bent down). The discussion with the surgeon led to the following strategy: With the index behind the soft palate, the surgeon reduced manually the maxillary fracture by pulling the maxilla forward and upward resulting in clearing the airway and creating an inter-incisor space []. While the surgeon kept his finger in place, topical lidocaine 5% was sprayed into the mouth and the oropharynx. The fiber optic bronchoscope was advanced into the oropharynx through the vocal cords up to the carina. A 7, 5 endotracheal tube mounted on the bronchoscope was threaded into the larynx. Correct tube placement was confirmed clinically and by capnography. Then the patient lied down on the operating table and general anesthesia was induced. Tracheostomy was then performed to allow surgical access and repair of the maxillo-facial fractures. The surgery went uneventfully. The patient was awakened at the end of surgery with tracheostomy kept to ensure safe post-operative care.

[[27.0, 'year']]

M

{'10697080': 1, '10077202': 1, '2242459': 1, '2039650': 1, '8934006': 1, '24665254': 2}

{}

3950440-1

noncomm/PMC003xxxxxx/PMC3950440.xml

Anesthetic management of a 2-day-old with complete congenital heart block

A 2-day-old-male baby, weighing 3 kg, born at full term by normal vaginal delivery presented to our facility with complaints of absent anorectal opening, abdominal distention, drooling of saliva and tachypnoea. On examination, he was found to have bradycardia with a heart rate (HR) of 65-75 beats/min. The electrocardiogram (ECG) performed for evaluation of bradycardia revealed CHB []. On the evaluation of the mother, she was diagnosed to have syphilis, which was considered as the probable cause of the congenital heart block.\nClinical examination revealed a lethargic neonate with abdominal distention and drooling from the mouth. The child was maintaining saturation of 85% on room air. On auscultation, the new born was found to have a HR of 50-55 beats/min with bilateral crepitations in the chest. The respiratory rate was 65/min. He was intubated with 3.5 mm internal diameter endotracheal tube using the midazolam 0.3 mg and mechanically ventilated. There was no hypothermia. The lab investigations revealed a hematocrit of 50%, platelet count of 3.2 lakh, total leukocyte count of 13,500, potassium 5.2 meq/L, creatinine of 1 mg/dL, bicarb of 20.5 meq/L, urea 30, Ca 4.5 meq/L, glucose of 80 mg/dL. An ECG was done, which showed wide QRS complexes and complete dissociation between the p-waves and QRS complexes. The echocardiography revealed a structurally normal heart with a small patent ductus arteriosus. The pediatric cardiologist diagnosed the new born to have a congenital CHB, advised to start dopamine (at 5 μg/kg/min) and isoprenaline (at 2 μg/kg/min) infusions were started to maintain the cardiac output. This increased the HR to about 75-80/min. No signs of cardiac failure were present in this neonate at this time.\nThe child was shifted to the operating room and attached to the ventilator. Oxygen and air were started. All the routine monitors were applied []. Isoprenaline and dopamine were continued. Adult size external adhesive pacemaker pads were applied antero-posteriorly and pacing was started in VOO mode with the pacing rate set to100 beats/min. The current was increased until a capture beat was detected. The threshold current was 60 mAmp. The patient was induced with fentanyl 4 μg, sevoflurane and atracurium 1.5 mg. The endotracheal tube was replaced with a rigid bronchoscope []. The TEF was identified and fogarty catheter was used to exclude the fistula. This was followed by palliative gastrostomy and sigmoid colostomy to relieve the intestinal obstruction. The vitals remained stable throughout the surgery with SpO2 fluctuating between 85% and 92%.

[[2.0, 'day']]

M

{'4273004': 1, '11755298': 1, '22368629': 1, '15937969': 1, '21976879': 1, '2446273': 1, '9243231': 1, '16943897': 1, '2408004': 1, '12427427': 1, '9599532': 1, '17045907': 1, '21327015': 1, '24665257': 2}

{}

3950843-1

noncomm/PMC003xxxxxx/PMC3950843.xml

Ewing's sarcoma in mandibular similar to dental abscess

The patient was a 16-year-old girl who visited a dentist complaining of toothache in the summer 2010.\nWhile dealing with the tooth, a prominent lesion was detected and removed along with the tooth. The pain did not subside, and the patient returned with pain and swelling in the mandibular angle accompanied by numbness of lower lip. She was diagnosed with abscess and was admitted to the Ear, Nose and Throat (ENT) department of a hospital where the abscess was drained. Even after the drainage, the pain still persisted; therefore, part of the tissue was removed with incisional biopsy and sent to the oral and maxillofacial department at Faculty of Dentistry. It is noteworthy that bone destruction was not observed in panoramic radiography [].\nIn the horizontal and vertical computed tomography (CT) scan, a clear reduction in trabeculation with indistinct boundary was observed in the mandible posterior to the first molar region [].\nAccording to the images, the differential diagnosis of indistinct osteolitic lesions comprises histiocytosis X, Ewing's sarcoma, lymphoma, and osteomyelitis.\nThe sample contained several pieces of yellowish cream tissue, irregularly shaped with a rubbery texture. Histopathological figure has been shown colonies of proliferation of cells with dysplastic changes such as extensive cytoplasm and large nuclei, prominent small nucleolus, mitotic figures, and polymorphism in stromal connective tissue with wide areas of necrosis [].\nAccordingly, round cell tumors including Ewing's sarcoma, lymphoma (comprising anaplastic large cell lymphoma, and diffuse large cell lymphoma), metastatic carcinoma, muscular tumors (including rhabdomyosarcoma), and neuroblastoma were included in the differential diagnosis. In order to make differential diagnosis using immunohistochemical (IHC) techniques, the following indicators were assessed and results obtained were []:\nCytokeratin (CK) = -, Desmin = -, S100 = +\nLeukocyte Common Antigen (LCA) = -, Vimentin = +, CD99 = strongly +\nMetastatic carcinoma, muscular tumors, and a variety of lymphomas were ruled out due to negative CK, Desmin, and LCA, respectively. Also, due to positive CD99, neuroblastoma was ruled out too, and with strongly positive CD99 and Vimentin, the diagnosis of Ewing's sarcoma was confirmed.\nWith this diagnosis, the patient began to undergo combination chemotherapy (Vincristine, Cyclophosphmide, Adriamycin, Iphosphamide, Etoposide) to reduce lesion's size, and then she underwent mandibulectomy by an oral and maxillofacial surgeon to remove lesions. The lesion, mandibular nerve, and sub-mandibular lymph nodes were sent to the pathology department of the oral and maxillofacial department of the dentistry faculty for the final assessment.\nIn the macroscopic view, there was a piece of bone including the right half of mandible from premolar region to the end of ascending ramus containing posterior tooth and inferior alveolar nerve and sub-mandibular lymph node [].\nIn the histopathological figure, serial sections have been shown areas of bone trabecules along with normal bone marrow spaces full of hematopoietic cells, fat cells, and areas of necrosis, and hemorrhage. In addition, in slides of the medial section of lower ramus and mandibular medial angle, only a remnant of tumoral cells, including some colonies of proliferation of cells with expansive cytoplasm, unclear boundary, and large nuclei, were seen. The diagnosis of Ewing's sarcoma was established based on these and initial IHC panel, CT scan, and radiography findings. Also, nerve sample and tumor-free lymph nodes were observed []. It appears that tumor has responded to chemotherapy, and after follow-up, mandibulectomy, chemotherapy, and CT scan of the bone, systemic condition of the patient has improved.

[[16.0, 'year']]

F

{'17634731': 1, '14586861': 1, '14561368': 1, '28438883': 1, '32064289': 2, '20464325': 1, '18245927': 1, '16096383': 1, '21503005': 1, '19421061': 1, '18983686': 1, '25409851': 1, '16327573': 1, '26679553': 1, '7614177': 1, '11402290': 1, '24627870': 2}

{'6994780-1': 1}

3951960-1

noncomm/PMC003xxxxxx/PMC3951960.xml

Clinically mild encephalitis/encephalopathy with a reversible splenial lesion associated with febrile urinary tract infection

A 15-year-old Japanese girl was admitted to the hospital with severe periorbital and pedal edema. She also had a butterfly shadow, oral ulcer, and joint pain. A peripheral blood examination showed thrombocytopenia (platelets, 66 × 109/l), hypoproteinemia (serum total protein, 33 g/l), hypoalbuminemia (serum albumin, 6 g/l), and hypercholesterolemia (total cholesterol, 13 mmol/l). Her serum creatinine level was normal (41.5 μmol/l). Immunological studies were positive for anti-nuclear antibody with a titer of 1:640 in a peripheral pattern, anti-smooth muscle antibody of 0.22 U/l (normal range, 0.0–0.0059 U/l), anti-U1 ribonucleic protein antibody of 0.15 U/l (normal range, 0.0–0.012 U/l), and anti-single-stranded DNA antibody of 0.035 U/l (normal range, 0–0.025 U/l). Serum complement levels were low, with C3 of 0.49 g/l (normal range, 0.86–1.6 g/l), C4 of 0.1 g/l (normal range, 0.17–0.45 g/l), and CH50 of 22.3 kU/l (normal range, 31.5–48.4 kU/l). Sediment contained 20–29 red blood cells and cellular casts per high-power field, and urinalysis showed proteinuria at a concentration of 34,010 g/l and urinary protein to creatinine ratio of 27 g/gCr. Based on these findings, she was diagnosed with systemic lupus erythematosus (SLE) with nephrotic syndrome. Renal biopsy findings showed a minor glomerular abnormality under light microscopy. By immunofluorescence study, granular depositions of IgG and C3 along the peripheral capillaries were observed, and electron microscopy showed subepithelial deposits. With prednisolone and tacrolimus, she achieved complete remission after 8 months.\nAt the age of 16 years, the patient had fever, headache, vomiting, and right back pain. One day later, she had chills and delirious behavior followed by consciousness disturbance. On admission, the patient was awake but appeared severely ill owing to malaise and dehydration. Her blood pressure was 87/45 mmHg, pulse was 89 beats per minute, temperature was 39.5 °C, and oxygen saturation was 98 % while she was breathing ambient air. Her abdominal pain was localized to the right back region, and costovertebral angle tenderness was positive. Peripheral blood analysis showed leukocytosis (white blood cell count, 18 × 109/l), an elevated C-reactive protein level of 0.17 g/l (normal range, 0.0–0.0039 g/l), and serum creatinine level of 78.6 μmol/l. Complement levels were normal. Urinary sediments contained 10–19 white cells, and urinary culture was positive for Klebsiella pneumoniae. Cerebrospinal fluid (CSF) examination showed no abnormalities, and cultures of blood and CSF were negative. In addition, brain single-photon emission computed tomography showed no abnormalities. Therefore, it was thought that flaring of lupus was unlikely, and she was diagnosed with febrile urinary tract infection. Further examinations, including a voiding cystourethrogram (VCUG) and 99mTc-dimercaptosuccinic acid (DMSA) renal scintigraphy, were performed. VCUG showed right vesicoureteral reflux (grade II), and 99mTc-DMSA scintigraphy showed right cortical defects. These results were compatible with right pyelonephritis. Thereafter, treatment with intravenous antibiotics gradually improved signs and symptoms, such as fever, laboratory findings, and right back pain, but she had prolonged headaches, nausea, and vomiting. Therefore, further examinations were performed. As a result, T2-weighted, diffusion-weighted, and fluid attenuated inversion recovery images in brain MRI showed high intensity lesions in the splenium of the corpus callosum on the third hospital day, which completely disappeared 1 week later (Fig. ). At the same time, headaches, nausea, and vomiting also gradually improved. These typical findings of MRI and clinical features were compatible with MERS.\nAt the age of 17 years, the patient has not had recurrence of MERS with sustained remission of lupus.

[[15.0, 'year']]

F

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{'4880818-1': 1, '4880818-2': 1, '5854845-1': 1, '4835842-1': 1, '4835842-2': 1}

3952249-1

noncomm/PMC003xxxxxx/PMC3952249.xml

Ictal Neuropsychological Assessment in a Patient with Transient Global Amnesia

A 62-year-old man was brought to the hospital with sudden memory loss and abnormal behaviors. He remembered having breakfast with his family members at 8 am on that day but didn’t what food he ate. He continuously asked questions about where he was while calling with his wife at noon, what he was doing and what clothes he wore. And as he couldn’t remember what happened in the morning, he was brought to the hospital with his family members. On the way into the hospital, he repeatedly asked why they were going to hospital, and why they were together with him.\nWhen hospitalized, he couldn’t remember the route between the hospital and his house or the accompanying persons, and how to get to the hospital. He didn’t have any diseases such as hypertension, diabetes mellitus, hyperlipidemia or migraine and didn’t drink or smoke. He had had no history of any external wound or infection. His vital signs were normal and there was nothing wrong in his physical examination. Following the neurological examination, his consciousness was proved clear. There were no problems in motor system, sensory system and cranial nervous.\nFour hours after the onset of the disease, Korean version of mini-mental state examination (K-MMSE) and Seoul Neuropsychological Screening Battery (SNSB) tests were carried out. He has master’s degree. He got 27 score in K-MMSE losing each point in time orientation, place orientation and delayed recall test.\nSNSB showed the low score in the immediate recall, delayed recall and recognition of verbal and visual memory. And it showed that there were problems in semantic word fluency and color word stroop test (). Diffusion-weighted MRI performed on the day of the onset of the disease showed the high signal abnormalities in the bilateral hippocampus (). The next day he remembered he was hospitalized but didn’t remember the fact that he went through the neuropsychological tests and brain MRI.

[[62.0, 'year']]

M

{'7468160': 1, '25868986': 1, '10935233': 1, '2341849': 1, '6747643': 1, '2286654': 1, '20129169': 1, '2731023': 1, '8229038': 1, '15963447': 1, '24649478': 2}

{}

3952250-1

noncomm/PMC003xxxxxx/PMC3952250.xml

A Case with Dopamine-Antagonist Responsive Repetitive Head Punching as Rhythmic Movement Disorder during Sleep

A 17-year-old male presented with recurrent rhythmic movement since the age of five. He repetitively tapped his brow or chin with the right fist only during sleep. The duration of this rhythmic movement ranged from 10 seconds to five minutes. Sometimes he repetitively punched the brow hard enough to render skin reddish discoloration. This behavior recurred almost every day. Upon admission, video-EEG monitoring demonstrated that the patient struck his brow with the right fist for one minute during the light sleep. The frequency of tapping during the monitoring was 2 Hz. There was no EEG change. Previously, under the impression of frontal lobe complex partial seizure, various ant-epileptic drugs including oxcarbazepine, zonisamide, levetiracetam and clobazam had been administered to control this symptom without any significant improvement. With the diagnosis of the rhythmic movement during sleep, clonazepam was prescribed before night time sleep. The dose of clonazepam was increased up to three mg per day. Clonazepam could not alter the symptom and induced only daytime drowsiness as an adverse event. Levodopa 250 mg plus carbidopa 25 mg were administered as a therapeutic challenge. Surprisingly this rhythmic movement increased dramatically in intensity and duration. The patient more or less violently punched his brow for four or five hours every night. With the hint of aggravating symptom by dopamine-agonist, haloperidol was chosen. One mg of haloperidol could markedly suppress the symptom to one-tenth degree in the intensity and duration compared with the symptom of the initial presentation. To avoid long-term adverse events, haloperidol was switched to pimozide two mg just before the night time sleep. After five days of administration, the rhythmic movement was completely disappeared for the following two months. The symptom reappeared after two months. However, the intensity was very mild and the duration was very short, which the parents could not notice the movement without careful observation for a whole night.

[[17.0, 'year']]

M

{'11104233': 1, '17309770': 1, '18036973': 1, '3970998': 1, '4114973': 1, '21056234': 1, '16124665': 1, '22893771': 1, '9406333': 1, '7212117': 1, '16541454': 1, '8776793': 1, '24649477': 2}

{}

3952252-1

noncomm/PMC003xxxxxx/PMC3952252.xml

Hashimoto’s Encephalopathy Presenting with Acute Cognitive Dysfunction and Convulsion

A 65-year-old man visited the hospital due to a sudden onset of cognitive decline. Two weeks prior to visiting to the hospital, the patient caught a cold for one week. He couldn’t remember where the razor was and was unable to find the bathroom. He confirmed that he indeed brushed his teeth when asked in case certainly he didn’t brush his teeth and didn’t use toothpaste when brushing his teeth. At work, he was unable to find the office keys nor able to recognize his co-workers. As well, he was unable to recall the road he routinely walked along, where he parked his car and if he owned a car. He didn’t give the hospital staff proper attitude while saying there was something when he saw the electric light turned on. Besides, he showed the nervousness as serious as being restless and after that he presented urinary incontinence. He collapsed turning his body around to the left as neurological examination were performed and lost consciousness with the convulsion to move his head to the right for about 20 seconds when he visited the hospital. His medical records reported hypertension without thyroid disease or dementia.\nWhen he visited to the hospital, his vital signs showed a blood pressure of 135/80 mmHg, respiration rate of 22 times per minute, pulse of 80 times per minute and a body temperature of 36.5°C. His physical check-up showed no hair loss, edema, goiter, and etc. Neurological examination showed a clear consciousness with disorientation to time and place. Korean version of Mini-Mental State Examination (K-MMSE) showed a 2/5 point in time orientation, 4/5 in place orientation, 0/3 in the three word recall and 4/5 point in serial seven substraction test. The total score was 22. There were no abnormal results among complete blood count, serum chemistry and electrolytes, serum tumor markers, paraneoplastic syndrome antibodies, and autoimmune disease and connective tissue disease test. Erythrocyte sedimentation rate and C-reactive protein level were also normal. Thyroid function test confirmed the asymptomatic hypothyroidism; the level of triiodothyronine was 62.98 ng/dL (reference value: 65–150), that of thyroxine 0.88 ng/dL (reference value: 0.78–1.54), that of thyroid stimulating hormone 5.85 μIU/mL (reference value: 0.55–4.78 μIU/mL). The level of thyrotropin-releasing hormone was normal. According to the thyroid autoantibody tests, the level of anti-thyroglobulin antibody was 77 IU/mL (reference value: 0–60) and that of anti-thyroid microsomal antibody was >1,300 IU/mL (reference value: 0–60). The cerebrospinal fluid (CSF) showed a slightly increased level of protein (58 mg/dL) and the normal level of white blood cells. And there were no abnormalities in virus including herpes simplex, bacteria and Mycobacterium tuberculosis tests. CSF 14-3-3 protein was negative.\nSeoul Neuropsychological Screening Battery (SNSB) carried out 4 days after he was hospitalized revealed a decrease in language and visual memory and language fluency, but there were no abnormalities in the concentration and time and place orientation. Electroencephalography (EEG) during awake revealed inter mittent diffuse slow waves (). There was no abnormal signal in brain MRI (). Single photon emission computed tomography (SPECT) showed decreased in perfusion in the bilateral temporal lobes (). Ultrasonography demonstrated an increased vascularity and irregular echoing in the bilateral thyroid lobes. Chest and abdomen CT showed no abnormality. It was diagnosed as Hashimoto’s encephalopathy based on the clinical features and test results. After oral steroids (prednisolone 60 mg/day) and anticonvulsant (Levetiracetam 1,000 mg/day) administration, he showed a gradual recovery of cognitive function. Therefore, on the 14th day after he was hospitalized, the score of K-MMSE became normal to 30/30. Since then, the patient’s cognitive dysfunction gradually improved and showed no suffering from any convulsions.

[[65.0, 'year']]

M

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