Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
the countermovement jump ( cmj ) is an explosive movement that is essential in many sports ,
 including basketball and volleyball1 .
cmj
 height , which is determined by measuring the jump height starting from an erect position
 followed by a downward movement before starting to push off , is an important criterion in
 athletic evaluation .
athletes spend much time and effort in various training activities to
 improve their athletic performance2 .
many
 researchers have reported the performance characteristics of the cmj and have discussed
 multiple issues related to achieving better cmj height3,4,5 .
ugrinowitsch et al.6 reported that better
 cmj height was the result of an increased vertical shift in the body s center of mass . to
 improve cmj performance , ankle flexibility4 ,
muscle strength3 , 7 , 8 ,
 initial jumping posture ( squat depth)5 ,
 and take - off velocity during vertical jump1 are required .
robertson and fleming9 investigated the contributions of the extensors in the lower limb
 and found that the greatest contributor to jump performance was the hip ( 40% ) followed by
 the ankle ( 35.8% ) and the knee ( 24.2% ) . furthermore , another study suggested that ankle
 joint flexibility contributes significantly to increasing cmj height4 . during a vertical jump , the contribution of the ankle joint
 depends on the torque produced by the plantar flexors as well as the ankle dorsiflexion
 range of motion ( df rom)10 .
toe flexor muscles ( tfm ) , which support the longitudinal arch of the foot against the
 reaction of the floor on the forefoot , also affect athletic performance11 .
previous studies reported that tfm strengthening may have
 a positive effect on athletic performance7 , 12 .
in addition , tfm strength may affect the
 use of the metatarsophalangeal joint ( mpj ) before take - off during the cmj10 . to date
, no studies on the effects of tfm
 strength on cmj height have been conducted .
therefore , this study investigated the correlations between peak tfm strength , df rom , and
 cmj height .
the results of this study may help identify the factors for improving cmj height
 in training athletes .
eighteen healthy volunteers ( age : 23.3  2.5  years , body weight : 71.9  11.2  kg , height :
 174.6  3.8  cm , df rom : 19.6  3.9 , cmj height : 46.3  10.3  cm ) participated in this study .

all participants were free of injuries , especially in the ankle joints , feet , and mpj .
the
 exclusion criteria were ( 1 ) any cardiovascular , respiratory , abdominal , neurological ,
 musculoskeletal , or other chronic disease and ( 2 ) any symptoms that could affect the
 musculoskeletal system .
the study procedure was approved by the yonsei university wonju
 campus human studies committee ( approval number : 1041849 - 201508-bm-018 - 03 ) ; all participants
 provided written informed consent before enrollment .
peak tfm strength , df rom , and cmj height were used as the variables in this
 cross - sectional study .
each participant s body weight and height were determined at the
 beginning of the test protocol .
prior to gathering data , participants performed a warm - up
 that consisted of 5 minutes of walking up and down the stairs .
three cmjs were performed by each
 participant , and the mean value ( mean cmj height ) was used for analysis .
peak tfm strength was measured using a digital dynamometer ( msc-200 , ametec inc , largo , fl ,
 usa ) . for a stable measurement setting
, the digital dynamometer was attached to a wooden
 frame consisting of a platform , a vertical board , and a footboard13 , 14 .
each
 participant was instructed to sit comfortably with his or her back supported by a chair
 backrest and to place the foot to be tested on the footboard .
the hip , knee , and ankle
 joints were positioned at 90 during the test .
the toe to be measured was inserted into a
 leather cuff that was placed on the plantar side of the proximal phalanx , and the
 participant was instructed to pull the cuff downward as hard as possible for 5 seconds .
each
 of the 5 toes ( phalanges ) was measured 3 times in the same way .
for familiarization with the
 testing procedure , participants were allowed to practice before measurement . for analysis
,
 the highest value of 3 tfm strength measurements in each toe was used .
a 3-minute rest
 period was provided between the strength measurements of each toe to minimize muscle
 fatigue . a blinded tester with experience working with a digital dynamometer read and
 recorded the strength value for each tfm on the digital display to eliminate experimental
 bias ( table 1table 1.mean (  sd ) of peak toe flexor muscle strengths by participants ( n=18)first toesecond toethird toefourth toefifth toepeak tfm strength13.1  3.93.1  1.02.8  0.83.1  1.0 4.2  1.3values are presented as the mean  sd .
tfm : toe flexor muscle the maximal df rom of the dominant leg was measured with a universal goniometer in 1
 increments with the participant lying prone with 90 knee flexion .
one lever of the
 goniometer was positioned on the proximal fibular head , while the pivot was placed on the
 lateral malleolus .
the measuring arm was positioned on the fifth metatarsal bone , and its
 position was used to determine the passive df rom15 .
participants were instructed to perform 3 maximal cmjs with the use of both arms , trying to
 cover the longest possible vertical distance .
the highest successful cmj height among the 3 attempts of each participant was chosen
 for jump height analysis7 .
two - dimensional
 ( 2d ) kinematics measurement was obtained during the procedure with regular sampling at
 25  hz .
a camera ( canon 500d , tokyo , japan ) was mounted on a tripod , which was placed 5  m
 away from the participants , to record movements in the sagittal plane .
a marker was placed on the sacrum at the
 approximate center of mass ( com ) , and the camera lens was focused on each participant s
 sacral marker in the standing position16 .

video
 sequences were digitized and examined using virtualdub software ( avery lee , version 1.5.10 ,
 cambridge , ma , usa ; http://www.virtualdub.org/ ) .
the images were then analyzed using the
 imagej computer program ( national institutes of health , bethesda , maryland usa ;
 http://rsb.info.nih.gov/nih-image ) for height comparison .
the data were analyzed using pasw version 18.0 ( chicago , il , usa ) for windows .
pearson
 correlation coefficients ( r ) were used to determine the strength and directionality of the
 relationships among the variables ( peak tfm strength , df rom , and cmj height ) .
mukaka17 suggested threshold values of 0.00.3 ,
 0.30.5 , 0.50.7 , 0.70.9 , and 0.91.0 for negligible , low , moderate , high , and very high
 correlation coefficients , respectively .
in addition , the coefficient of determination
 ( r ) was used to account for the variation among the variables . in all
 analyses ,
table 2table 2.correlation coefficients between peak tfm strength , df rom , and cmj
 heightfirst tfmsecond tfmthird tfmfourth tfmfifth tfmdf romcmj heightfirst tfm strength1.0second tfm strength0.161.0third tfm strength0.0820.7011.0fourth tfm strength0.2280.5030.7901.0fifth tfm strength0.2080.6250.6230.5851.0df rom0.7100.2190.1860.0070.0291.0cmj height0.7650.0210.2330.1020.0630.6421.0*p<0.05 ; * * p<0.001 .
cmj : countermovement jump , df rom : ankle dorsiflexion range of motion , tfm : toe
 flexor muscle shows the pearson s correlation coefficients between peak tfm strength , df
 rom , and cmj height in the participants . cmj height showed a moderate correlation with df
 rom ( r=0.642 , r=41.3% , p<0.001 ) and a high correlation with peak first tfm
 strength ( r=0.765 , r=58.5% , p<0.001 ) .
the relationships between cmj height
 and peak tfm strength of the other toes were negligible ( r=0.021 to 0.233 , p>0.05 ) . * p<0.05 ; * * p<0.001 .
cmj : countermovement jump , df rom : ankle dorsiflexion range of motion , tfm : toe
 flexor muscle
the results of this study indicate that cmj height is correlated with peak first tfm
 strength and df rom in healthy subjects .
several previous studies investigated multiple issues related to cmj and reported a
 proximal - to - distal sequence of muscle activation
hip extensors , followed by knee extensors
 and finally ankle plantar flexors3 , 18and a proximal - to - distal transfer of
 energy during jumping10 , 19 .
papaiakovou4 reported that the ankle should be a key joint in transmitting the
 energy generated by the proximal part ( hip extensor , knee extensor , and ankle plantar
 flexor ) to the ground during cmj execution .
however , the mpj is smaller than the other
 joints in the leg , but the mpj force amounts to about 86% body weight during push - off in the
 gait cycle20 .
the tfm around the mpj may
 have a profound effect on forefoot loading and force transmission21 , and improvements of tfm strength training may have a
 significant effect on athletic performance enhancement7 , 12 .
the results of this study indicate a high correlation between peak first tfm strength and
 cmj height ( r=0.765 , r=58.5% , p<0.001 ) .
cohen22 reported that the coefficient of determination could be used to
 more fully interpret the r value .
thus , 58.5% of the total variation in peak first tfm
 strength can be explained by variation in cmj height .
nihal et al.23 reported that dancers had greater hallux muscle strength
 than non - dancers ( 7  4n vs. 6  4n , respectively ; p<0.049 ) . in addition , the first tfm
 strength was twice the second tfm strength ( 9  4n vs. 4  1n , respectively ; p<0.001 ) .
 furthermore ,
tanaka et al.24 demonstrated
 that the tfm are important contributors to sustaining dynamic balance ; in particular , the
 tfm of the hallux was greater than the sum of the others combined . tfm strength may
 influence mpj stiffness before take - off during cmj performance .
stefanyshyn and nigg10 reported that increasing mpj stiffness
 would decrease the energy lost at the mpj , which would correspond to a positive effect on
 jump height .
this finding may indicate a lack in the peak first tfm strength leading to a
 large amount of energy loss and , therefore , would not adequately transmit energy via the
 lower limb extensors before take - off during a cmj .
thus , the results of this study suggest
 that the peak first tfm strength is an important factor not only in stabilization of the
 forefoot but also in the transmission of energy generated from the lower limb extensors to
 the ground , as well as in improving athletic performance ; it is a major contributor in
 performing a higher cmj .
df rom during a full squat before take - off was reported to affect cmj height25 . in this study ,
cmj height showed a
 moderate positive correlation with df rom ( r=0.642 , r=41.3% , p<0.001 ) ,
 consistent with the results of a previous study4 .
individuals with a greater df rom were reported to have the ability
 to place their heels in contact with the ground during a full squat , which causes the ankle
 plantar flexor muscles to achieve sufficient force - generating capacity for a deeper squat
 position before take - off4 .
it has been
 shown that an active muscle , when lengthened , may sustain high forces and stretch the tendon
 sufficiently so that it can store elastic energy for the late concentric phase when the
 muscle activity starts to decay26 .

however , studies have shown that people lacking df rom raised their heels off the ground ,
 had greater horizontal shift rather than vertical shift of com , and achieved a low jump
 height25 , 26 .
thus , df rom is thought to be a second contributor to achieving
 sufficient force - generating capacity and proper vertical shift of com during cmj
 performance .
first , the participants performed the experiment
 barefoot , but they wear shoes for actual athletic activities .
second , other related muscles
 that may contribute to the cmj , including the ankle plantar flexors , knee extensors , and hip
 extensors , were not investigated .
however , this
 study is the first to examine the relationship between peak tfm strength and cmj height .
 further study is needed to investigate the correlation between peak tfm strength and ankle
 plantar flexors .
second , further research will need to examine whether improvement in peak
 tfm strength and df rom can have a clinically useful impact on cmj performance .
this study was performed to investigate the correlations between df rom , peak tfm strength ,
 and cmj height .
the results of this study indicate that the peak first tfm strength and df
 rom are the main contributors to cmj performance .
measuring the strength of peak first tfm ,
 ankle plantar flexors , knee extensors , and hip extensors in the lower limb and df rom may be
 useful in clinical practice for improving jump performance in athletes such as volleyball
 and basketball players .

Answer:
[ purpose ] this study assessed the relationships between peak toe flexor muscle strength ,
 ankle dorsiflexion range of motion , and countermovement jump height . [ subjects and
 methods ] eighteen healthy volunteers participated in the study .
 each participant completed
 tests for peak toe flexor muscle strength , ankle dorsiflexion range of motion , and
 countermovement jump height .
 [ results ] the results showed ( 1 ) a moderate correlation
 between ankle dorsiflexion range of motion and countermovement jump height and ( 2 ) a high
 correlation between peak first toe flexor muscle strength and countermovement jump height .

 peak first toe flexor muscle strength and ankle dorsiflexion range of motion are the main
 contributors to countermovement jump performance .
 [ conclusion ] these findings indicate
 that the measurement of peak first toe flexor muscle strength and ankle dorsiflexion range
 of motion may be useful in clinical practice for improving jump performance in athletes
 training for sports such as volleyball and basketball .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
three fruiting bodies of t. matsutake were used to measure the number of spores produced from each fruiting body .
the samples used for the enumeration of spores were similar in size used for the investigation of spore dispersion , and their veils under each pileus had just started to open .
we cut the stem of each mushroom and set the pileus above a piece of aluminum foil for 4 days to obtain spore prints .
all of the spores on the foil were collected and measured for weight , and the numbers of spores in a serial - diluted solution were enumerated using a haemacytometer .
the experimental site was mainly composed of 65-year - old japanese red pines ( pinus densiflora s. et z. ) , although a few oaks ( quercus variabilis bl . ) occupied less than 20% .
the site had been surveyed for mushroom growth for more than 4 yr , and the locations of pine mushroom had been thoroughly documented .
only one fruiting body of t. matsutake remained within each site ; all others , including other mycorrhizal mushrooms , were thoroughly removed .
we established three sites for study , and the distances from each site were more than 50 m. we established 48 slide glasses coated with glycerin nearby each fruiting body in four directions separated by four different distance intervals at three heights .
the distances were set as 50 , 100 , 200 and 500 cm from the fruiting body . at each point
, we installed a stick containing three slide glasses that were 0 , 50 and 100 cm above the ground .
the dispersed spores were collected from the time immediately after the veils of pileus were torn out .
we installed the collecting glasses when the fruiting body was hemispherical and stopped when it became planar , a total of 4 days as described by ka et al . .
the slide glasses were installed at 10 am every day and were replaced by a new one after 24 hr .
the number of spores on each slide was enumerated by the line - transect method under a microscope ( 400 ) using an image analyzer ( leica , sasem onairtv ) .
the plate was overlapped by grids of 116 m118 m for counting , and triplicates were applied for the enumeration .
three fruiting bodies of t. matsutake were used to measure the number of spores produced from each fruiting body .
the samples used for the enumeration of spores were similar in size used for the investigation of spore dispersion , and their veils under each pileus had just started to open .
we cut the stem of each mushroom and set the pileus above a piece of aluminum foil for 4 days to obtain spore prints .
all of the spores on the foil were collected and measured for weight , and the numbers of spores in a serial - diluted solution were enumerated using a haemacytometer .
the experimental site was mainly composed of 65-year - old japanese red pines ( pinus densiflora s. et z. ) , although a few oaks ( quercus variabilis bl . ) occupied less than 20% .
the site had been surveyed for mushroom growth for more than 4 yr , and the locations of pine mushroom had been thoroughly documented .
only one fruiting body of t. matsutake remained within each site ; all others , including other mycorrhizal mushrooms , were thoroughly removed .
we established three sites for study , and the distances from each site were more than 50 m. we established 48 slide glasses coated with glycerin nearby each fruiting body in four directions separated by four different distance intervals at three heights .
the distances were set as 50 , 100 , 200 and 500 cm from the fruiting body . at each point
, we installed a stick containing three slide glasses that were 0 , 50 and 100 cm above the ground .
the dispersed spores were collected from the time immediately after the veils of pileus were torn out .
we installed the collecting glasses when the fruiting body was hemispherical and stopped when it became planar , a total of 4 days as described by ka et al . .
the slide glasses were installed at 10 am every day and were replaced by a new one after 24 hr .
the number of spores on each slide was enumerated by the line - transect method under a microscope ( 400 ) using an image analyzer ( leica , sasem onairtv ) .
the plate was overlapped by grids of 116 m118 m for counting , and triplicates were applied for the enumeration .
the fruiting bodies used for spore counting were 230  22 g in fresh weight , 12  0.3 cm in pileus diameter , 15  0.3 cm in stipe length and 3.5  0.1 cm in stipe diameter .
although the fruiting bodies were relatively larger and heavier than generally harvested mushrooms as goods , they could be considered as representative fruiting bodies of overmatured mushrooms .
the spores collected from each fruiting body reached about 150 mg in total mass and were counted as 4.5~5 billion , which varied depending on the size of the mushroom .
although we set the slide glasses at three heights ( 0 , 50 and 100 cm above the ground ) , the data collected from the slides located at 50 and 100 cm above the ground were unusable due to sparseness with large variation .
as deering et al .   showed for the airflow surrounding a simulated mushroom , the spores of t. matsutake did not fly at high elevations but instead streamed down along the forest floor .
thus , we only used the data from the slides set on the ground for the enumeration .
the number of spores increased with time but rapidly dropped as the pileus turned over ( on the fifth day ) ; 475 spores / cm on the first day , 497 spores / cm on the second day , 599 spores / cm on the third day and 836 spores / cm on the fourth day after the veils of pileus opened . ogawa   noted that the most abundant time for spore production is 3~4 days after the veil of pileus is torn down .
he noted that spores are immature if the veil is not torn down or the pileus turned over , and the amount of spores also becomes smaller .
thus , we used the cumulative numbers of spores over 4 days to compare the differences in the amount of spores among directions and/or distances .
the spores dispersed more along the slope compared to those within the slope ( table 1 ) .
although we did not measure the intensity of the wind within the forest , the intensity of the wind was stronger along the slope than that within the slope .
thus , we estimated that the difference in intensity of the wind resulted in the differences in spore dispersion .
the number of spores dispersed downward was about 1.5 times greater than that dispersed upward , which indicates that gravity was another key factor in the dispersion of spores , as noted by deering et al . .
although spores may usually spread more toward the lower part of mountains , pine mushrooms are mainly produced on the upper parts .
this implies that the decline in the productivity of pine mushroom was not due to an insufficient number of spores but actually other factors , such as unsuitable site conditions for growth .
further , the number of spores decreased exponentially as the distance increased from each fruiting body ( fig .
1 ) . more than 95% of the spores dropped within a meter of the fruiting body , with about 75% of them within 0.5 m ( table 2 ) . however , the spores dispersed over 5 m from the fruiting body could not be discounted as they numbered more than 50 million , considering that the number of spores produced by a fruiting body is about 5 billion .
the pattern of spore dispersion was also dependent upon the stand density and other micro - environmental factors ( table 3 ) .
as stand density increased , the number of dropped spores on the sampled slides decreased ( 2,605 spores / cm for dense , 2,089 spores / cm for middle and 1,670 spores / cm for sparse ) , which indicates that stand density might have affected air flow and therefore spore dispersion .
ogawa   reported that spore dispersion is largely dependent upon the climatic conditions or fructification time .
he mentioned that the amount of mature spores would be quite few if the air temperature is very high or low .
in addition , he stated that relative humidity is a key factor in spore dispersion ; for example , colonized spores are high in number after rain or fog . in some cases ,
a spore print was formed on the surface of litter , which indicates that the spores were not widely spread out .
thus , stand density and other site factors could be major factors in the dispersal of spores , but microclimatic factors such as wind are more important in spore dispersion .
the fruiting bodies used for spore counting were 230  22 g in fresh weight , 12  0.3 cm in pileus diameter , 15  0.3 cm in stipe length and 3.5  0.1 cm in stipe diameter .
although the fruiting bodies were relatively larger and heavier than generally harvested mushrooms as goods , they could be considered as representative fruiting bodies of overmatured mushrooms .
the spores collected from each fruiting body reached about 150 mg in total mass and were counted as 4.5~5 billion , which varied depending on the size of the mushroom .
although we set the slide glasses at three heights ( 0 , 50 and 100 cm above the ground ) , the data collected from the slides located at 50 and 100 cm above the ground were unusable due to sparseness with large variation .
as deering et al .   showed for the airflow surrounding a simulated mushroom , the spores of t. matsutake did not fly at high elevations but instead streamed down along the forest floor .
thus , we only used the data from the slides set on the ground for the enumeration .
the number of spores increased with time but rapidly dropped as the pileus turned over ( on the fifth day ) ; 475 spores / cm on the first day , 497 spores / cm on the second day , 599 spores / cm on the third day and 836 spores / cm on the fourth day after the veils of pileus opened . ogawa   noted that the most abundant time for spore production is 3~4 days after the veil of pileus is torn down .
he noted that spores are immature if the veil is not torn down or the pileus turned over , and the amount of spores also becomes smaller .
thus , we used the cumulative numbers of spores over 4 days to compare the differences in the amount of spores among directions and/or distances .
the spores dispersed more along the slope compared to those within the slope ( table 1 ) .
although we did not measure the intensity of the wind within the forest , the intensity of the wind was stronger along the slope than that within the slope .
thus , we estimated that the difference in intensity of the wind resulted in the differences in spore dispersion .
the number of spores dispersed downward was about 1.5 times greater than that dispersed upward , which indicates that gravity was another key factor in the dispersion of spores , as noted by deering et al . .
although spores may usually spread more toward the lower part of mountains , pine mushrooms are mainly produced on the upper parts .
this implies that the decline in the productivity of pine mushroom was not due to an insufficient number of spores but actually other factors , such as unsuitable site conditions for growth .
further , the number of spores decreased exponentially as the distance increased from each fruiting body ( fig .
1 ) . more than 95% of the spores dropped within a meter of the fruiting body , with about 75% of them within 0.5 m
however , the spores dispersed over 5 m from the fruiting body could not be discounted as they numbered more than 50 million , considering that the number of spores produced by a fruiting body is about 5 billion . the pattern of spore dispersion was also dependent upon the stand density and other micro - environmental factors ( table 3 ) .
as stand density increased , the number of dropped spores on the sampled slides decreased ( 2,605 spores / cm for dense , 2,089 spores / cm for middle and 1,670 spores / cm for sparse ) , which indicates that stand density might have affected air flow and therefore spore dispersion .
ogawa   reported that spore dispersion is largely dependent upon the climatic conditions or fructification time .
he mentioned that the amount of mature spores would be quite few if the air temperature is very high or low .
in addition , he stated that relative humidity is a key factor in spore dispersion ; for example , colonized spores are high in number after rain or fog . in some cases ,
a spore print was formed on the surface of litter , which indicates that the spores were not widely spread out .
thus , stand density and other site factors could be major factors in the dispersal of spores , but microclimatic factors such as wind are more important in spore dispersion .

Answer:
the spore of tricholoma matsutake is considered to be the starting point of the mushroom growth cycle , but the mechanism of mycelial development from the spore stage is not yet clarified . in this study , we tried to measure how far the spores of t. matsutake disperse from a fruiting body located at a pinus densiflora stand in korea .
 we established 16 slide glasses coated with glycerin near a fruiting body in four directions separated by four different distance intervals within a mushroom productive stand after removing all other fruiting bodies from three plots .
 the number of dispersed spores increased with time from the first day ( 475 spores / cm2 ) to the fourth day ( 836 spores / cm2 ) after the pileus opened .
 the number of spores dispersed downward was about 1.5 times greater than that dispersed toward the ridge .
 the number of dispersed spores decreased exponentially as the distance from each fruiting body increased .
 more than 95% of the spores dropped within a meter from the fruiting body , with 75% dropping within 0.5 m. even so , the number of spores dispersed over 5 m from the fruiting body was more than 50 million when considering the total number of spores produced by a fruiting body is about 5 billion .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
granuloma faciale ( gf ) is an uncommon , benign , inflammatory skin disorder of unknown etiology .
it is characterized by single or multiple , grey - brown or violaceous nodules or plaques primarily occurring on the face and occasionally at extra - facial sites .
the disease is notoriously resistant to therapies and often tends to relapse when treatment is discontinued .
we present a patient with multiple lesions of gf and its response to topical tacrolimus .
a 35-year - old female presented to our department with a 5 year history of single , asymptomatic , grey - brown pigmented , nodule over the left cheek [ figure 1 ] .
it started as a pin head sized papule which gradually increased to 2.5 cm  1.5 cm in size .
two years later similar lesions appeared on the forehead , both arms and upper back .
past and personal history was unremarkable . before treatment  single , grey - brown nodule with prominent follicular orifices over left cheek .
after treatment  residual lesion after three months of tacrolimus application general physical and systemic examination was normal .
cutaneous examination revealed multiple , well - defined , grey - brown , indurated , non - tender plaques , varying in size from 0.5 cm  0.5 cm to 1.5 cm  2.5 cm , present on the left cheek , left forehead , both arms and upper back .
multiple grey - brown plaques over upper back routine hematological and biochemical investigations were normal .
skin biopsy ( 4 mm ) from plaque revealed normal epidermis with clear sub epidermal
grenz zone and pan dermal dense infiltrate comprising of neutrophils , lymphocytes , histiocytes and plasma cells .
small dermal vessels showed infiltration of neutrophils in the vessel wall along with peri - appendageal and peri - neural infiltrate in subcutaneous fat [ figure 3 ] .
( h and e , 100  ) skin biopsy with normal epidermis and dense , mixed inflammatoey infiltrate beneath a narrow grenz zone in the dermis .
infiltrate is composed of mononuclear cells with neutrophils and eosinophils she was started on intralesional triamcilone acetonide 10 mg / ml injection monthly with tab .
six sessions of cryotherapy were performed once monthly after which she developed erythema and itching over the plaques and discontinued treatment .
the lesions showed 40 - 50% improvement after 3 months of therapy [ figure 1 ] .
classically , red - brown or violaceous nodules or plaques with associated telangiectasia and follicular accentuation are seen on the face over sun - exposed sites .
differential diagnosis includes lupus pernio , lupus vulgaris , lymphoma , discoid lupus erythematosus and deep mycotic infection .
skin biopsy is characterized by a mixed inflammatory infiltrate with a predominance of neutrophils and eosinophils in the dermis , in conjunction with small vessel vasculitis .
there is a grenz zone that separates the infiltrate from the epidermis and pilosebaceous units .
the disease is notoriously resistant to therapies and often tends to relapse once the treatment is discontinued .
several medical and surgical modalities like topical and intralesional corticosteroids , cryotherapy , pulsed dye laser , puva , systemic corticosteroids , dapsone and antimalarials have been tried with variable success rates .
carbon dioxide laser has also been used in a case of recurrent gf . surgical excision has been performed with often unsatisfactory results .
ablative procedures may leave residual pigmentation and scarring , whereas long - term application of corticosteroids is associated with skin atrophy , telangiectasia and other possible adverse effects . in recent years successes with topical calcineurin inhibitors has been reported .
several authors have reported complete or near - complete resolution of lesions after application of topical tacrolimus 0.1% ointment.[48 ] treatment regimens , duration and time to resolution of lesions have varied in these case reports [ table 1 ] .
others have found time to resolution to be between 4 and 6 months . in our patient ,
treatment with tacrolimus 0.1% ointment twice daily for 3 months has resulted in improvement . reported cases of successful treatment of granuloma faciale ( gf ) with topical tacrolimus tacrolimus
inhibits t - cell proliferation , production and release of several pro - inflammatory cytokines like interleukin-2 ( il-2 ) , il-4 , tumor necrosis factor - alpha , and interferon - gamma ( ifn - gamma ) .
although the pathogenesis is still unknown , it has been suggested that gf may be an ifn - gamma mediated disease .
in addition , an increased production of il-5 , probably induced by the clonal expansion of a locally recruited t - cell population may enhance the attraction of eosinophils into the lesions of gf .
therefore , a possible mechanism of action of topical tacrolimus in this condition may be the inhibition of ifn - gamma and il-5 production and release , induced by the down - regulation of the t - cell activity , primarily involving the calcineurin binding and inactivation .
however , we did observe eosinophils in skin biopsy in our case , probably since the biopsy was taken after one year of oral dapsone .
our patient experienced a relevant improvement within 3 months of treatment with tacrolimus ointment after no response with intra lesional steroids , dapsone and cryo therapy . in conclusion
, the previous reports and our observation suggest that topical tacrolimus may be a well - tolerated , efficacious therapy for gf .

Answer:
granuloma faciale ( gf ) is a chronic condition characterized by red - brown plaques with follicular accentuation present usually on the face .
 we present a case of 35-year - old female with 5 year history of plaques over cheek and extra facial sites consistent with gf and its response to topical tacrolimus .
 this case supports previous reports of successful treatment of gf with topical tacrolimus .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
in 2008 , the greater london authority and the london health consortium , with funding provided by the big lottery , instigated a series of health interventions entitled
well london. these activities were set up in 20 of london 's most disadvantaged neighbourhoods , in an effort to promote healthier life - styles as a way of combating chronic disease ( wall et al .
an evaluation of the project was undertaken in which a series of in - depth interviews were conducted with 60 residents across three of the well london areas ; a key component of the interview was to enquire about the environment and residents perceptions of their neighbourhood . a frequent and vociferous complaint that arose unprompted concerned the prevalence of dog excrement , or to use local terminology :
dog poo. not only was the frequency of the complaint remarkable , but also its specificity and distinctive nature , making further detailed investigation necessary .
apart from an element of antipathy , there was also considerable anger expressed in relation to : who was responsible ; the lack of care demonstrated by its ongoing presence ; and fear over its risk to human health .
 dog - poo was not the only form of pollution complained about in the three areas , but it was the most frequently cited . in terms of risk to human health ,
for example , since 2000 between one and eight laboratory confirmed reports of toxocarosis have been received annually by the health protection agency ( hpa 2011 ) .
in addition , a  keep britain tidy report into litter cites a 40% drop in the incidence of dog faeces in the uk over recent years ( 2007 ) . despite this lack of evidence concerning risk or prevalence , canine faeces
continues to be a significant cause for complaint , requiring further explication in order to understand its relevance for public health . in a study of urban environmental factors that impact on health ,
kennedy ( 2000 ) cites residents complaints of dog faeces as a blight that affected their sense of wellbeing .
similarly , two separate studies by jones ( 1996 ) and cresswell ( 1992 ) report residents complaints of dog faeces in urban areas of the uk affected by poverty and environmental neglect .
therefore , the presence of dog faeces has associations and implications that can be linked with more subjective responses
. one key facet of the complaints raised by residents in the well london study was a sense of disgust evoked by
therefore , the challenge was to explore not the grievance itself ( whether  dog poo existed or its potential as a disease carrying agent ) but rather the symbolic
this article critically engages with residents explicitly focused disgust with canine faecal matter and generates understanding of its symbolic value that helps clarify what has to date , been a poorly resolved public health issue .
sixty qualitative interviews were conducted in total : 20 individuals in each of the three well london areas , which were located in the north , east and south of the city .
all three areas were characterised by high levels of unemployment , poor health , environmental neglect and a mixed indigenous and global migrant population .
quality assurance procedures were undertaken whereby three randomly selected interviews were recoded , blind to the initial coding , by two independent researchers .
the three versions of each interview were then compared to identify new codes and establish the degree of consensus in applying a particular code to similar text . a major part of the interview focused on what residents thought about the area where they lived
. recurrent and spontaneous reference was made to the prevalence of dog faeces in the area and , more subjectively , the feelings that were evoked by its presence .
dog poo ( most frequently cited among all its synonyms ) , over all other complaints . extended coding of the interviews revealed the contextual significance of these complaints .
incivility emerged as a recurrent theme : a lack of respect for the neighbourhood environment by residents and negligence by local authorities  whether the police or local council .
this meant carrying out repairs , cleaning and ensuring personal safety , especially in relation to the presence of gangs , local drug dealers and other types of criminality .
further , measurement of actual incidence of dog foul across london was undertaken : 40 areas were examined and divided into
211 were found to contain no dog faeces ; 72 had a small amount and eight had a moderate amount .
however , 117 coded references pertaining to  dog poo ( and its synonyms : dog shit / muck / litter / mess / fouling ) were found in all 60 interviews .
the disparity between high numbers of complaints and the limited presence of actual faecal matter required an alternative mode of analysis that would help locate , more specifically , residents concerns . interpreting how meaning is expressed through cultural symbols  in this instance
analysing the symbolic content and context in which the complaints occurred , highlighted compelling evidence of its link to social neglect , including criminality , dirt and the absence of cohesive community relations .
the work of social anthropologist douglas ( 1966 ) is seminal in the symbolic interpretation of matters pertaining to pollution .
also , studies by van der geest ( 1998 , 2007 , 2008 ) , stallybrass and white ( 1986 ) , laporte ( 2000 ) , enzensberger ( 1972 ) and miller ( 1997 ) offer useful theoretical perspectives on dirt and  disgust ; especially regarding bodily substances that transgress boundaries in relation to social morality , inequality and taboo .
the inherent value of examining cultural symbols shows how in this instance , they express not only fears of the transgression of boundaries , but also how
dog poo is constructed as a metonym for the disgust felt by residents about their experience of incivility .
this includes neglect of the environment , and a lack of respect by local authorities and fellow neighbours alike , as one resident implied :  and the worst thing is they just , they poo everywhere in the buildings  a month back there was dog poo in our own building .
i do n't know whose poo it is  whether it 's human or dog poo , but i seen it. another described a similar sense of repulsion :  the outside spaces , there 's dog foul .
i mean wherever you put your feet  and it 's unsafe because the poo of the dog and you put your foot
oh no! the focus on canine excrement did not exclude other complaints : of drugs , gangs , noisy neighbours and the lack of intervention by either police or local authorities .
however , complaining about  dog poo conveyed a powerful message about these neighbourhoods blighted by multiple problems , and often by unknown perpetrators : like this drug dealing problem going on , on my doorstep .
you do n't know who 's done it , or why they done it , or where did they come from .
and they 're smoking , they 've got needles there on the stairs , they wee do on the stairs , everything  we ca n't say nothing . and my lift is still broken .
( sita ) the notion of  incivility evoked through residents descriptions of their environment determined the appropriateness of symbolically linking complaints of  dog poo , with the experiences of social neglect .
as requests to improve living conditions and expressed worries about safety and cleanliness were ignored , a pervasive sense of hopelessness took over .
right , the area is dangerous , dirty , very , very unkempt and has been basically forgotten by the powers that be for the past , i 'd say , 15 years . in as much as one person who i spoke to at the local housing office who was at the time in charge of major works , did n't even know where i was living . did n't know where it was , so that 's the
it 's just been a forgotten little area and it 's been left to rot and decay .
( robert ) for stallybrass and white :  what is socially peripheral , is so frequently symbolically central ( 1986 : 5 , authors italics ) .
this resonates with the well london residents sense of social marginalisation that was marked by the absence of effective management of the neighbourhood , as explicitly articulated above .
but , when these explicit complaints were neither heard nor acted upon , they became symbolically represented by excreta , which defined their experience of marginality .
the path as you go up there , there 's always glass up there or dogs poo , always
there 's dogs poo along there and it 's , well , it 's just disgusting. van der geest ( 1998 , 2007 , 2008 ) has written extensively on attitudes towards defecation , including an historical examination of the origins of our revulsion towards bodily functions and their
management. he suggests that without the containment of bodily matter , there is nothing to prevent chaos and disorder ( 2007 ) .
therefore , if faeces , animal or human , is taken as an effective metonym that represents disorder , it follows that managing dirt has as its main function the restoration of order  primarily , social order as part of a civilising process .
dirt in its rightful place  ordered and bounded within a set of social rules of behaviour .
douglas ' ( 1966 ) work on symbolism and in particular  matter out of place , states that
dirt is defined by its place or context ; in other words , where it is found and who is responsible for it .
for example , faecal matter inside the body is less problematic than when it becomes external to it , where it is an object of revulsion .
the attitude and management of excrement , both human and animal , is linked with the state as it intervenes in the management and consequent attitudes towards dirt ; segregation of public and private means that all faecal matter is consigned to private rather than public space ( enzensberger 1972 , laporte 2000 ) .
faeces , now considered taboo in the public domain , contrasts with the pre - victorian era when horse manure covered the streets of london and running sewers were open to public senses ( pike 2005 ) .
this segregation of public and private in relation to cleanliness was also acknowledged among residents :  when we moved to this area , we saw dog poo  now it 's a little bit clean , my area is , because it 's a private area. another spoke of her annoyance at her neighbour who
pushed rubbish over to her side of the passageway , invading her private space and breaking boundaries .
but , complaints also illustrated a more extreme form : the permeability of private space that could be infiltrated by bad smells and noise : yeah , the noise .
my downstairs neighbours , they 're singing like five o'clock in the morning and it wakes you up and you just ca n't do anything .
and then they smoke marijuana and  you know this is a converted building ? so there 's lots of holes in the  you see those things ?
yeah , every time they smoke , every time they drink  if they 're vomiting in their toilet , it all comes up ( here ) .
dog poo has salience within their particular social and cultural milieu of urbanised , inner city london where neighbourhoods are unsafe , environmentally polluted and often without social cohesion .
anger and blame is placed on those who seem to ignore the boundaries i.e dog owners ,
dirty neighbours , the police , or the local authorities responsible for the management of the neighbourhood .
 dog poo is therefore a transgression of not only spatial boundaries , but also social norms of what is considered  civil behaviour ; especially when focused on personal responsibility : and that 's one thing as well , the dog fouling , they do n't pick up .
they do n't pick up their dog fouling , do you know what i mean ? and
i 'll tell you what , it would be a big sense of achievement if they actually put cameras in every direction to catch these people out , because it 's terrible . you 've got kids playing around and every time they 're playing football , they stop in dog foul .
as campkin and cox ( 2007 ) suggest theorising about dirt is  constitutive of space and social relations. here , vociferous complaints of canine faeces in the absence of actual evidence of high incidence indicated a more hidden form of distress or grievance that was better understood by examining its symbolic content , as well as its context . by taking
dog poo as a metonym for the  disgust with which residents experienced their neighbourhoods , the authorities and each other it was possible to gain deeper insight into the problem .
acknowledgement of this has implications for intractable public health problems , where not only the contextualisation of complaints is important , but also analysis of their deeper symbolic components ; especially in the face of frequent , inexplicable complaints .
conducting such an analysis uncovered the distress of residents living in some of london 's more deprived neighbourhoods where grievances were frequently ignored , leading to frustration and anger . had the issue of dog faeces
clean up operation alone , this would never have uncovered the scale of the problem or the depth of feeling in relation to the issues , which can be defined as poor social relations and inadequate or ineffective communication with local authorities .
investigations and analyses of this kind lend themselves to the development of constructive , inclusive public health policies that can improve the wellbeing of marginalised populations by understanding how people articulate their concerns .
the approach used here is effective in this , because it can : generate new insights into intractable public health problems ; offer alternative and useful methods to understand and communicate complex social issues in relation to public health ; advance theoretical knowledge ; and broaden the scope of analytic tools with which to understand well - being and society .

Answer:
during a  well london study , residents were asked about their neighbourhood and its environment . above all other complaints ,
 dog poo was mentioned as a key concern . despite low rates of infection and disease among the human population resulting from contact with canine faecal matter
 , the concerns of the public continue to rate it as a serious public health issue .
 most public health studies , therefore , seek to identify processes of transmission and disease pathology as a method of addressing the problem .
 this study approaches the issue through a contextualised analysis of residents complaints , using anthropological theory to examine the symbolic representation of
 dog poo. analysis of the interviews shows that these specific complaints were located among less easily defined or articulated experiences of social and environmental neglect , where neighbours were estranged from one another and local authorities seen as negligent .
 this approach has important implications for public health , as it provides not only a strong indicator of the level of dissatisfaction within some of london 's more disadvantaged neighbourhoods , but also identifies a need for policies that are grounded in cross - disciplinary research into the relationship between health ,  wellbeing and experiences of marginalisation among urban populations .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
written informed consent was obtained from the parents , and assent was obtained from the subjects .
the institutional review board at ut southwestern medical center approved this study , which began in august 2006 and ended in may 2008 .
participants were randomized to either the mi or sde group based on a sex - stratified schedule .
a third education session was planned ( t2 ) if a1c continued to be 9% .
three diabetes educators were assigned to the mi arm and trained on motivational interviewing at a 2-day workshop .
( 3 ) , journal articles ( 4 ) , and guidance from the mi trainer and psychologist .
the remaining six educators were assigned to the sde arm and did not receive additional training .
educators used a comprehensive checklist compiled using core content recommended by the american diabetes association ( ada ) on medication , monitoring , acute complications , and lifestyle ( 5 ) .
all audiotapes were coded using the motivational interviewing treatment integrity 3.0 ( miti 3.0 ) coding system ( 6 ) .
the coder attended a 2-day workshop on miti 3.0 and was blinded to the treatment groups .
a1c ( measured via a dca vantage analyzer ) and psychosocial measures were collected at baseline and at 3 , 6 , and 9 months ( t3 ) .
psychosocial measures included the center for epidemiologic studies depression scale ( ces - d ) ( 7 ) , the epidemiology of diabetes interventions and complications quality of life questionnaire ( edic - qol ) ( 8) , and the summary of diabetes self - care activities ( 9 ) .
the mixed - model procedures of proc mixed in sas version 9.2 ( sas institute , cary , nc ) were used for the primary analysis .
baseline values of a1c and each baseline psychological measure were included as covariates in the respective analyses .
the main effect of treatment group and the treatment group  time period interaction effect were examined .
cohen 's d was interpreted as the effect size estimator for the between - subject treatment group effect .
a1c ( measured via a dca vantage analyzer ) and psychosocial measures were collected at baseline and at 3 , 6 , and 9 months ( t3 ) .
psychosocial measures included the center for epidemiologic studies depression scale ( ces - d ) ( 7 ) , the epidemiology of diabetes interventions and complications quality of life questionnaire ( edic - qol ) ( 8) , and the summary of diabetes self - care activities ( 9 ) .
the mixed - model procedures of proc mixed in sas version 9.2 ( sas institute , cary , nc ) were used for the primary analysis .
baseline values of a1c and each baseline psychological measure were included as covariates in the respective analyses .
the main effect of treatment group and the treatment group  time period interaction effect were examined .
cohen 's d was interpreted as the effect size estimator for the between - subject treatment group effect .
a total of 26 participants were randomized to the mi group and 28 to the sde group .
six - month data ( t2 ) were available on 21 and 23 patients in the mi and sde groups , respectively ( table 1 ) .
four patients each in the mi and sde groups had a third education session at t2 .
baseline characteristics , a1c , psychosocial measures , and miti 3.0 least squares ( ls ) means are adjusted for each respective baseline measure .
f statistic was used to test for omnibus mean difference on each measure between the two treatment groups over 6 months of follow - up . * children 's health insurance program ( chip)/children with special health care needs ( chscn ) .
primary outcome variable , least squares means for a1c , adjusted for baseline over 6 months of follow - up .
overall competence of the clinician in using mi based on a global rating scale of 15 , where 1 is low spirit and 5 is high spirit .
the score for beginning proficiency and competency are 3.5 and 4 , respectively . # giving information , education , providing opinion without advising .
fidelity to mi would correspond to lower scores on this variable . * * asking permission before giving advice , affirming , emphasizing control , and supporting the participant . number is based on frequency of occurrences .
fidelity to mi would correspond to higher scores on this variable . after adjusting for baseline a1c , the pattern of omnibus least squares ( ls ) mean a1c values differed between groups ( f = 4.84 , df = 1 , 42.1 , p = 0.03 ) over the 6 months of follow - up ; the sde group had lower a1c ( least squares mean 10.31 , se 0.32 ) than the mi group ( least squares mean 11.35 , se 0.34 ) ( d = 0.66 , medium effect size ) .
no overall time period effect emerged ( f = 0.33 , df = 2 , 34.8 , p = 0.72 ) and no treatment group  time interaction effect was found ( f = 0.20 , df = 2 , 34.8 , p = 0.81 ) ( table 1 ) . after controlling for baseline , there were no differences between the groups on any psychosocial outcome , none of which improved in either group ( table 1 ) .
there were 21 subjects in the mi group and 22 in the sde group with interpretable tapes and miti scores .
the groups differed on all indicators of fidelity to mi in the expected direction ( p < 0.001 , repeated - measures anova ) ( table 1 ) .
after adjusting for baseline a1c , the pattern of omnibus least squares ( ls ) mean a1c values differed between groups ( f = 4.84 , df = 1 , 42.1 , p = 0.03 ) over the 6 months of follow - up ; the sde group had lower a1c ( least squares mean 10.31 , se 0.32 ) than the mi group ( least squares mean 11.35 , se 0.34 ) ( d = 0.66 , medium effect size ) .
no overall time period effect emerged ( f = 0.33 , df = 2 , 34.8 , p = 0.72 ) and no treatment group  time interaction effect was found ( f = 0.20 , df = 2 , 34.8 , p = 0.81 ) ( table 1 ) .
after controlling for baseline , there were no differences between the groups on any psychosocial outcome , none of which improved in either group ( table 1 ) .
there were 21 subjects in the mi group and 22 in the sde group with interpretable tapes and miti scores .
the groups differed on all indicators of fidelity to mi in the expected direction ( p < 0.001 , repeated - measures anova ) ( table 1 ) .
although we hypothesized that lack of motivation more than poor knowledge impedes good metabolic control , we found that one brief intervention followed by a short education session could decrease mean a1c levels by 1% .
subsequent sessions did not further affect the a1c , and the positive effect was maintained at 9 months .
we should have assessed knowledge of diabetes pre- and posteducation to show that improved knowledge played a role in our results .
however , we did find a higher amount of  given information  in the sde group compared with the mi group by miti scoring .
the lack of efficacy of mi in our study is consistent with a recent trial in adult patients with poorly controlled type 1 diabetes ( 10 ) .
in contrast , mi improved both metabolic control and psychosocial measures over a 12-month period in teens with diabetes ( 11 ) , but this study had more interventions over a longer period than ours .
this was a small study that detected a treatment effect in the direction opposite to that hypothesized .
perhaps the educators in the mi group were not proficient in mi compared with other studies ( 1113 ) , but the miti demonstrated good fidelity of our intervention to mi principles . in conclusion , brief motivational interviewing - based counseling with no pre - established level of educational content does not lead to improved metabolic control , whereas ongoing education is important for teens with poorly controlled diabetes .
we did show that we could train diabetes educators in mi with adequate proficiency . before translating research to clinical practice
future studies should compare structured diabetes education and sde plus motivation in a multicenter setting for a longer follow - up period .

Answer:
objectiveto compare motivational interviewing  based education ( mi ) and structured diabetes education ( sde ) for improving a1c and psychosocial measures in adolescents with type 1 diabetes.research design and
 methodsthis study was a 9-month randomized controlled trial comparing mi ( n = 21 ) to sde ( n = 23 ) .
 interventions were at baseline ( t0 ) and 3 months ( t1 ) , with a1c and psychosocial measures obtained at 6 months ( t2 ) and 9 months ( t3).resultsover the 6 months of follow - up , the sde group had lower adjusted mean a1c value ( least squares mean 10.31 , se 0.32 ) than the mi group ( least squares mean 11.35 , se 0.34 ) ( p = 0.03 , d = 0.66 ) . there were no differences on any of the psychosocial measures.conclusionssde is effective at improving metabolic control in adolescents with type 1 diabetes .
 diabetes educators were proficient in learning mi .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
intractable nausea and vomiting are very rare symptoms of medullary compression and there are approximately less than 10 cases reported in the literature of the aforementioned symptomatology mostly due to tumors .
there is one reported case where vertebral artery compression of the medulla led to intractable nausea and vomiting .
a 69-year - old woman presented with a 10-month history of intractable nausea and vomiting resulting in a 50 pound weight loss .
she had an extensive medical workup at multiple outside hospitals including a comprehensive gastrointestinal workup which was significant for celiac disease .
her pertinent past medical history includes a history of breast cancer , mastectomy , and cholecystectomy . during her evaluation by the gastroenterologists at our hospital ,
the diagnosis of celiac disease was confirmed , and she was also noted to have a duodenal ulcer .
hematologic and biochemical workup was only significant for anemia attributable to her ulcer and celiac disease .
magnetic resonance imaging / angiography ( mri / mra ) of the brain and neck , and diagnostic four vessels cerebral angiogram were obtained to further evaluate her dizziness and double vision .
the left vertebral artery angiogram revealed a tortuous left vertebral artery with a 9.6  5.6 mm dissecting aneurysm in the v3 segment .
this , along with dolichoectasia of the vertebro - basilar arteries , resulted in compression of the medulla oblongata , which was also confirmed in the contrasted mri / mra of the brain and neck [ figure 1 ] . computed tomography angiography ( cta ) also confirmed that the vertebral artery was pushing the medulla medially [ figure 2 ] .
the patient was offered a microvascular decompression ( mvd ) of the vertebral artery to attempt to decompress the brainstem and alleviate her intractable nausea and vomiting .
preoperative magnetic resonance imaging ( mri ) t2 sequenceshowing compression of the medulla by the vertebral artery preoperative computed tomography angiography ( cta ) showing a tortuous left vertebral artery crossing the midline a left retrosigmoid craniotomy was completed to approach the vertebral artery and lower brainstem . the elongated , ectatic vertebral artery
additionally , indentation of the lower part of the medulla by the vertebral artery was also recognized .
apericranial graft was used as a sling and tacked to the dura , to decompress the brainstem .
the postoperative course was uneventful , and the patient was kept in the hospital to transition her from gastrostomy tube feedings to regular oral feeding .
postoperative cta demonstrated that the vertebral artery had been mobilized [ figure 3 ] away from the medulla .
postoperative cta showing left vertebral artery away from the medulla the patient was discharged from the hospital without any antiemetic medication and was documented to have started gaining weight . at her 2-year postoperative visit , the patient had a nonfocal neurologic exam without recurrence of her prior nausea or vomiting .
patients with central lesions often wait months or years and undergo countless tests before a central etiology is added to the differential diagnosis because most cases do not present with localizing neurological deficits
. sustained hiccups with vomiting or isolated spontaneous vomiting with negative gastrointestinal symptoms should prompt further workup , including neuroimaging , to search for a central cause .
the patient in our case was incidentally found to have dizziness and diplopia during the initial workup , but was not demonstrating positional vomiting or headaches , which would have prompted a neurological workup sooner . the tortuous vertebral artery in this case
was found on the diagnostic mri / mra of the head and neck obtained secondary to her history of breast cancer and new onset symptoms of diplopia and dizziness . without a proper neurological examination
this patient 's celiac disease and gastrointestinal reflux would have continued to mask the true cause of her symptoms . while compression of the medulla by a dilated vertebral artery is much less common than other brainstem compression syndromes such as trigeminal and glossopharyngeal neuralgias ; it is still significant .
vascular compression of the medulla can cause disabling positional vertigo , hypertension , and hemifacial spasm ; but there are only a few reports of intractable nausea and vomiting as a symptom of an ectatic vertebral artery .
less than 10 cases of nausea and vomiting due to vertebral artery compression have been reported in the literature .
of the 20 cases of vertebral artery compression of the medulla reported in a meta - analysis by savitz et al .
, only one patient experienced nausea and vomiting as a symptom . the majority of patients presented with hemiparesis and cranial nerve dysfunction .
mvd was the choice of treatment for 17 of the patients , including the patient with symptoms of nausea , and it was shown to relieve symptoms in 16 patients .
medullary compression can produce a wide spectrum of signs and symptoms from very few to several .
regardless of the etiology , compressive forces on the neuronal tracts and nuclei that lie within the medulla can produce a number of clinical scenarios .
when the etiology is vascular in origin , ischemic injury can produce symptoms such as headache , transient ischemic attacks ( tias ) , or infracts depending on the location of the compression . at the floor of the rhomboid fossa
it contains specialized cells consisting of ependymal cells and tanycytes that allow for direct communication of cerebro spinal fluid and blood because it lacks an intact blood brain barrier . as a circumventricular organ ,
the area postrema is able to detect toxins and drugs in the blood as well as hormones and other humoral signals to help maintain autonomic homeostasis .
stimulation of the area postrema by vagal afferents from the nucleus ambiguous and gastrointestinal system or from emetogenic drugs and cytokines in the blood may trigger vomiting .
the nucleus tractus solitarius ( nts ) lies adjacent to the area postrema , serves as a relay center to collect all afferent signals and activate the appropriate visceral nuclei to coordinate the action of vomiting .
efferent pathways from the area postrema and nts project to the central pattern generator , ventral medulla , and hypothalamus .
the central pattern generator is proposed to coordinate the activation of these nuclei within the medulla .
the efferent signals stimulate the appropriate parasympathetic and sympathetic neurons , which produce the different phases of vomiting .
the signal also diffuses through the brain via microglial messengers and cytokines such as substance p to allow for the cognitive recognition of emesis . a lesion to any of the afferent relay tracts or emetic reflex center proper may produce an abnormal emetic reflex and could produce intractable nausea and vomiting , as was observed in our case . on the preoperative mri ,
the vertebral artery was seen to be compressing the medulla , where the area postrema is located , and nts at the inferior and posterior limit of the fourth ventricle .
the potential disruption of the area postrema in this case may have caused an overstimulation of the emetic reflex .
the first mvd was performed in 1966 by dr peter jannetta to relieve the facial pain in a patient with a compressed trigeminal nerve .
it is now used to treat compression of the facial and glossopharyngeal nerves , as well as vascular abnormalities .
the indications of mvd could potentially be expanded to treat compressive symptomology ; including , for example , intractable vomiting due to vascular compression of the medulla as demonstrated in this case report .
this case demonstrated the importance of neurological investigations in the isolated intractable vomiting patient without a clear evidence of peripheral cause and including a central nervous system etiology on the differential , and the role of mvd in achieving cure .

Answer:
vertebral artery compressing the medulla and causing intractable vomiting has only been reported once previously .
 we report a case of a 69-year - old woman with intractable nausea and vomiting causing a 50 pound weight loss and who failed medical management and whose symptoms were completely reversed following microvascular decompression ( mvd ) .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
thoracic injury can result in a wide range of clinical manifestations depending on the structures involved like chest wall , diaphragm , mediastinum , trachea , lungs parenchyma etc .
the non penetrating trauma to the lungs manifests as contusions , lacerations of pulmonary parenchyma , pneumatocele formation , hematomas , and fractures of trachea and bronchi .
while pulmonary contusion is commonly associated with blunt thoracic trauma , appearance of cavitary lesions variably described as traumatic pulmonary pesudocysts , ( tpp ) , traumatic pneumatoceles , traumatic lung cysts are rare , developing in less than 3% of patients with pulmonary parenchymal injuries .
a 26 year old unmarried male was referred to us with history of left sided chest pain for two days .
he had consulted at local hospital immediately after trauma . a skiagram chest taken there [ figure 1 ] showed non homogenous opacity with central lucency in the region of left hilum . on examination ,
the patient gave history of trauma - a tractor wheel hitting him on the anterior chest wall , while he was lying down ; following which he developed the pain .
there was no history of breathlessness , fever , cough , hemoptysis , cough or expectoration .
there was no history suggestive of bronchial asthma or exposure to pets at home or work place .
the margins of the lesion were now thinned out and smooth [ figure 2 ] .
chest radiograph on day 1 - pa view showing non homogenous opacity with central translucency near left hilum day 3 - chest radiograph pa view showing multiple cavities near left hilum his sputum for afb was negative .
other lab investigation revealed haemoglobin 14.4 , leukocyte count 7900 , and differential count of 78 % polymorphs and 19% lymphocytes .
his serum was non reactive for hiv antibodies . a ct scan of thorax done on 03 - 09 - 2011 showed a single smooth walled cavity abutting left chest wall with surrounding areas of ground glass haziness , probably suggestive of lung contusion [ figure 3 ] . computed tomogram of chest showing smooth walled cavity in left upper lobe with surrounding ground glass opacity of lung contusion fibre optic bronchoscopy
was performed to achieve a microbiological diagnosis and to inspect the trachea - bronchial tree in view of previous reports being inconclusive .
bronchoscopy revealed a bleeding spot in left main bronchus , but no active bleeding was seen .
bronchial brushings taken from left upper lobe were negative for malignant cells and afb , and the lavage fluid also was sterile .
in view of the patient 's history of ancedent recent trauma , negative past and present history for any infectious process , and negative microbiological reports , a diagnosis of post traumatic pulmonary pseudo cyst ( tpp ) was made .
serial follow up chest skiagram showed rapid resolution of the cavities [ figure 4 ] without any antibiotics , thus confirming our diagnosis of tpp .
among the various names given to the cavitary appearance of pulmonary lacerations , the term traumatic pulmonary pseudo cysts ( tpp ) appears to be the best nomenclature because the wall of these lesions are formed by the inter lobar interstitial connective tissue and shows no epithelial lining or bronchial wall elements .
the rarity of the entity can be estimated by the fact that there have been only around 10 large case series with 8 or more patients published since 1967 .
tpp following blunt or non penetrating trauma develops through a mechanism that allows transmission of high compressive forces to the lung parenchyma .
retraction of normal lung elastic tissue from contusion induced cavities permits the escape of air and fluid into it .
laceration of pulmonary parenchyma and appearance of cavity may also occur if there is closure of the glottis at the moment of injury which may prevent fast exit of the air from compressed lung segment .
the parenchyma and/or interstitium get lacerated in a bursting manner resulting in a cavity formation .
resolution of a pulmonary hematoma or drainage into a bronchus may result in development of tpp at a later stage and it is called secondary tpp .
tpp can occur at any age , but they are more often seen in children and young adults , probably because of greater compliance of chest wall which permits a larger transmission of force of impact to the parenchyma .
sorsdahl and powell reported that 85% of the patients with tpp were under the age of 30 years with male predominance .
impact velocity and degree of chest wall displacement may play an important role in the development of tpp after blunt trauma to the chest .
a high velocity impact causes peripheral tpps while a low velocity high displacement impact produces central parenchymal and major bronchial disruption .
tpp is a clinical entity that manifests itself with minor clinical and major radiological signs .
the usual clinical manifestations include hemoptysis , occurring in about half of the cases , cough , dyspnoea , chest pain , fever and leucocytosis .
tpps may appear immediately or within a few hours after injury and their sizes range from 2 to 14 cm in diameter tpp can be differentiated from cavitating hematomas on the basis of radiographic appearance of air within the tpp 's within 48 hours .
tpps may be identifiable on chest radiography but ct scans are superior for detecting them .
unlike other cystic lesions and cavities , the size , shape , and nature of wall of tpps change relatively quickly . therefore
, serial skiagrams of chest , done over several days can help to differentiate pseudo cysts from other lesions .
found a greater resolution time in blood filled tpps and those with > 2 cm in size .
they may be seen on the site of injury or on the opposite side secondary to countre coup effects .
the majority of tpps are found in the lower lobes , the ct appearance of single or multiple thin walled cystic lesions with air space consolidation of the surrounding lung parenchyma in the backdrop of antecedent trauma is diagnostic .
differential diagnosis includes ruptured oesophagus , or herniation of viscera , post pneumonia pneumatocele , tuberculosis cavity , cavitating bronchial carcinoma , lung abscess , bronchogenic cysts , and pulmonary sequestration .
a history of trauma , rapid sequential changes over days on chest skiagram , and presence of contusion on the base of lesion usually delineates any confusion . if the cavitary lesion does not decrease with time other aetiology must be considered .
conservative management is recommended as long as evidence of a decrease in size of the lesion occurs within 6 weeks after trauma in adults and 3 - 4 months in children .
the use of antibiotics is controversial and may be used more to provide simple reassurance that the pseudo cyst wo nt get infected .
tpp 's can be complicated and may require surgery . they may rupture and cause a secondary pneumothorax that may require tube thoracostomy .
the indications for diagnostic and therapeutic bronchoscopy are endobronchial bleeding , thick sputum , large air leak , mediastinal emphysema and lobar collapse .
the approach to an infected pseudo cyst is similar to that for a lung abscess .
if an infected pseudo cyst is larger than 2 cm , or there are unremitting signs of sepsis after 72 hours of antibiotics , the pseudo cysts may be drained percutaneously .
early lobectomy may be considered for complex tpp 's with extensive lung abscess surrounded by necrotic parenchyma , failure of bronchoscopic treatment of massive airway bleeding , infected pseudo cyst more than 6 cm in size , or no response to more conservative treatment .
video assisted thoracoscopic surgery ( vats ) may be considered for managing a persistent air leak , hemothorax due to pseudo cyst rupture , failure of lung expansion , progressive enlargement of pseudo cyst and compression of lung parenchyma .
late thoracotomy has been reported ( lobectomy , cystotomy , capitonnage ) up to 6 months after trauma because of pneumonic infiltration and persistent cavitary size .
our patient presented with few abrasions on anterior chest wall and history of blunt trauma to chest wall of one day duration .
there was no previous history of any respiratory illness or unconsciousness during or after trauma .
the immediate chest skiagram revealed an area of consolidation with central area of lucency around left hilar region .
there was no associated cough , fever , expectoration , hemoptysis or breathlessness which clinically ruled out an infective process .
serial skiagrams over next 24 hours showed a rapid development of a cavity which regressed spontaneously and significantly over next 7 days without any antibiotics .
ct thorax done was also suggestive of tpp , in view of a cavity adjacent to anterior chest wall with surrounding contusion .
exclusion of other infectious diseases like tuberculosis , lung abscess , by absence of relevant clinical history , sputum negativity on zn staining , sterile pyogenic culture , negative mantoux test , negative microbiology of bal , and cytology of bronchial brushing led us to the diagnosis of tpp which was well supported by the available literature .
it is generally a self limiting benign condition , diagnosed by excluding other conditions which may present with similar radiological manifestations .
a typical history of blunt trauma to chest , rapid radiological changes of the cavity and exclusion of other cavitary pulmonary diseases by adequate laboratory work helps in diagnosing this rare condition .
the disease at times might become complicated and becomes life threatening ; hence , should be closely monitored and followed up .

Answer:
blunt thoracic trauma manifests in various ways , depending on the structures injured and type of injury . commonly manifested as parenchymal contusion , at times , pseudacavitation may also been seen on the chest x ray .
 they are to be differentiated from other causes of pulmonary cavitations which are often done based on history .
 the so called pulmonary pseudo cysts usually have a benign course and needs only observation .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
flurodeoxyglucose ( f - fdg ) positron emission tomography / computed tomography ( pet / ct ) has become the imaging modality of choice for initial staging , follow - up and treatment response assessment in patients with hodgkin 's lymphoma and has proved superior to contrast enhanced ct ( cect ) in these settings .
f - fdg pet / ct has accuracy of almost 100% in diagnosing primary splenic involvement during initial staging of lymphoma . however , in the post - therapy setting its role for evaluation of secondary splenic involvement is limited .
one of the pattern of splenic activity that help to detect splenic involvement on pet / ct is diffusely increased f - fdg uptake greater than that in the liver and bone marrow with or without corresponding ct lesions . in this context , we report a case of a patient with hodgkin 's lymphoma in remission presenting with f - fdg avid splenomegaly .
the present case report is about a 22-year - old male patient who presented with enlarged right cervical lymph node .
f - fdg pet / cect performed for staging revealed metabolically active lymph nodes on either side of the diaphragm [ figure 1a , broken arrows ] , enlarged spleen with multiple hypodense hypermetabolic , lesions [ figure 1a , arrow ] ( suvmax= 9.4 ; spleen suvmax / liver suvmax ratio = 3.76 ) and bone lesion .
he was then given 6 cycles of chemotherapy and f - fdg pet / cect was done for response evaluation .
pet / ct showed complete metabolic response , with normal spleen uptake [ figure 1b , arrow ] ( spleen suvmax= 2.5 , liver suvmax= 2.6 s / l ratio = 0.96 ) . at 1-year
later routine follow - up the patient complained of mild fever , lethargy and listlessness . in view of previous history of hodgkin 's lymphoma ,
pet / ct revealed enlarged spleen with diffusely increased fdg uptake [ figure 2a  c , arrow ] ( suvmax= 5.3 ; liver suvmax= 2.3 s / l ratio = 2.30 ) .
the first differential in the given clinical scenario was splenic relapse of lymphoma , however , a second differential diagnosis of some infective / inflammatory process was considered .
on further evaluation , peripheral smear showed evidence of malaria parasite infection ( plasmodium vivax ) .
follow - up pet / ct after 7 months revealed normalization of size and f - fdg uptake of spleen [ figure 2d , arrow ] ( suvmax= 3.0 ; liver suvmax= 2.7 s / l ratio = 1.1 ) .
hence , malaria and other relevant ( endemic ) infective possibilities ( kala - azar etc . ) should be considered and further investigation , if warranted , should be advised .
f - flurodeoxyglucose ( f - fdg ) positron emission tomography/ computed tomography ( pet / ct ) done for staging and response evaluation .
( a ) staging maximum intensity projection ( mip ) pet image showing multiple metabolically active lymph nodes in thorax , abdomen and pelvis ( broken arrows ) with splenic ( arrow ) and bone lesion ( left femur ) .
( b ) mip pet image done for response evaluation demonstrates complete metabolic response with normal splenic fdg uptake ( arrow ) .
physiological gastric fdg uptake noted ( bent arrow ) f - flurodeoxyglucose ( f - fdg ) positron emission tomography / computed tomography ( pet / ct ) done for recurrence detection and follow - up .
( a - c ) follow - up pet / ct performed 1 year after chemotherapy showing enlarged spleen with diffusely increased fdg uptake ( arrow ) .
( d ) maximum intensity projection pet image performed after anti - malarial therapy , showing normalization of size and fdg uptake of spleen ( arrow ) . ( a and d )
focal fdg uptake noted in the pelvis is due to urinary fdg activity in the left ureter ( curved arrows )
pet / ct is a useful modality for staging and restaging of hodgkin 's lymphoma with high sensitivity and specificity .
furthermore , it is a sensitive modality for early detection of relapse in asymptomatic patients making surveillance f - fdg pet / ct clinically important .
splenic uptake on f - fdg pet can be due to a wide variety of causes such as lymphoma , anemia , granulocyte colony stimulating factor treatment , beta - thalassemia , inflammation and infections .
splenic uptake , greater than hepatic uptake , is a relatively reliable indicator of lymphomatous involvement of the spleen , in the absence of recent cytokine administration . in early stage hiv infection , diffusely increased splenic uptake is noted due to reactive stimulation of b - cells in the spleen .
post - therapeutic reactive splenic uptake is also noted after administration of granulocyte colony - stimulating factor for myelosuppression or high - dose interferon - alpha-2b adjuvant therapy for melanoma . until date , only a single report by liu et al . have demonstrated f - fdg uptake in spleen in case of malaria .

Answer:
18flurodeoxyglucose ( 18f - fdg ) positron emission tomography / computed tomography ( pet / ct ) is nowadays routinely used in management of lymphoma patients .
 we here present a case of hodgkin 's lymphoma which showed 18f - fdg avid splenomegaly on pet / ct done for clinically suspected relapse .
 further evaluation by peripheral smear examination revealed malaria .
 the patient was then started on anti - malarial medications and follow - up pet / ct revealed resolution of hypermetabolic splenomegaly .
 this report highlights that in endemic regions malaria can cause 18f - fdg avid splenomegaly and might mimic relapse of lymphoma .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
subependymoma , first described by scheinker in 1945 , is a rare central nervous system tumor . since its first description in the spinal cord by boykin et al in 1954 ,
32 involved the cervical cord . in the spinal region , these lesions are predominantly subpial in location , with exophytic components .
the location of these lesions in the spinal cord suggest a subpial glial progenitor origin rather than its proposed origin from subependymal progenitor cells.[14 ]
a 37-year - old lady presented to us with complaints of neck pain and gait disturbances of 1 year duration with severe progressive weakness of her right upper limb since 3 months .
mri revealed a long - segment t2 hyperintense intramedullary lesion opposite to the c3 to d4 vertebral levels with mild heterogeneous enhancement on the post contrast study [ figure 1 ] .
( a ) sagittal t2 and ( b ) post contrast t1-weighted mr images showing a long segment t2 hyperintense and mild hetrogenous enhancing lesions in the cervical cord , showing cord expansion .
intraoperatively , the lesion was firm , with a poor plane of demarcation from the normal cord , and was seen intermingling with posterior and anterior nerve rootlets .
it was eccentric in location , involving more of the left hemicord , with exophytic components [ figure 2 ] .
surgical finding : typical exophytic subpial lesions , with lesion on either sides of the dorsal nerve roots .
all of the resected tissue submitted for histopathological analysis was processed and embedded in three paraffin blocks .
histopathological examination [ figure 3 ] revealed characteristic features of a subependymoma ( who grade 1 ) with small monomorphic cells arranged in a lobular pattern against a finely fibrillary background , with occasional rosette like pattern .
features of pleomorphism , mitotic activity , endothelial cell proliferation , and necrosis were not seen .
the mib-1 proliferative index was low ( < 1% of tumor cells ) ( ) . immunohistochemistry revealed diffuse positivity for glial fibrillary acidic protein ( gfap ) , whereas tumor cells failed to express epithelial membrane antigen ( ema ) .
histopathology : ( a ) h and e staining shows lobular pattern arrangement of monomorphic nuclei in fibrillary pattern ( 400 ) .
( b ) mib-1 labeling index is less than 1% of tumor cells ( not shown in figure ) ( 400 ) .
immunohistochemistry for ( c ) gfap highlights diffusely positive tumor cells in a fibrillary background ( 400 ) ( d ) tumor cells are negative for ema ( 400 ) she did not receive any adjuvant treatment and has been on follow up for 6 months with periodic mr imaging .
subependymomas are rare central nervous system tumors accounting for 0.7% of all intracranial neoplasms and 8.3% of all ependymal tumors .
they are located most frequently in the fourth ventricle ( 5060% of cases ) followed by the lateral ventricles ( 3040% ) .
so far , only 47 cases have been reported in the english literature in the spinal cord ; of which 32 cases were located in the cervical , cervico - medullary , and cervico - thoracic locations .
most are intramedullary in location , with few subarachnoid and extramedullary variants mentioned in the literature .
the symptomatic subependymoma generally occur after 40 years of age and are rare in childhood.[13 ] the salient features 33 in cases of cervical subependymomas they have a mean age of presentation of about 44 years with a strong male preponderance [ table 2 ] .
epidemiology of spinal subependymomas ( including our case).[16 , 814 ] histopathologically these tumors are low grade ( who grade 1 ) , characterized by homogenous cells with sparse cellularity showing clustering of nuclei over a fibrillary background formed by cell processes and occasional occurrence of microcysts .
the tendency to form pseudorosettes and the cells being round with hyperchromatic nuclei are reminiscent of ependymomas .
immunohistochemical characteristics are however identical to that of astrocytic neoplasms with diffuse gfap and s-100 protein positivity . in contrast to ependymomas ,
the former is evidenced by the processes containing intermediate filaments and the latter by microlumens , cilia , microvilli , and intercellular junctions .
the histogenesis of these tumors has been much debated . due to their ultrastructural similarities with ependymal cells
, they were initially thought to arise from ependymal cells , with reactive astrocytic proliferation .
since immunohistochemical profile favors a glial origin , they were grouped with low - grade glial tumors .
tanycytes were also proposed as source of origin , due to the presence of ultrastructural features of glial as well as ependymal components .
however , the presence of round cells rather than spindle - shaped cells differentiates these lesions from tanycytic ependymomas .
the identification of cells similar to subependymal glial precursor cells suggested alternate cell of origin .
subependymal zone glial precursor cell origin can not explain the predominant peripheral and exophytic location of these lesions in spinal cord unlike their intracranial counterparts .
the current concept seems to suggest that these progenitor cells exist throughout the spinal cord white matter as well as the root entry zones .
they are more localized in the outer subpial white matter than the medial zones , especially at the dorsal and ventral spinocerebellar tracts .
they tend to proliferate within their template zones and do not possess trans - zonal migratory ability .
the tumor origin from these cells better explains the eccentric , subpial , and exophytic locations of spinal subependymomas .
the progenitor cells origin postulated by horner et al is an alternative to the conventional old postnatal theory [ type 1 , figure 4 ] where the progenitor cells migrate from the subependymal zone to the outer zones .
there are two alternative postulates : one where the stem cell divides asymmetrically and the daughter cell migrates to the outer white matter where it remains as a glial progenitor cell and multiplies [ type 2 , figure 4 ] , and the second which postulates that the stem cells exist separately in the outer zone where tracts are constantly proliferating even postnatally and these give rise progenitor glial cells [ type 3 , figure 4 ] .
( a ) post natal theory : where the subependymal stem cells give rise to glial progenitor cells which then migrate to the periphery .
( b and c ) alternate new theories where the stem cells themselves migrate to the periphery and become glial progenitor cells ( b ) or the stem cells already existing in the periphery of the cord become glial progenitor cells ( c ) .
irrespective of their origin the subpial spinal white matter progenitor cells may be the origin of the spinal subependymoma .
the subependymomas reported are more commonly located in the cervical cord and the cervico - thoracic cord followed by the pure thoracic and lumbar segments .
one rare case occurring in the filum teminale has also been reported [ table 2 ] .
radiologically , these lesions are located eccentrically within the cord , with iso or hypointense on t1-weighted images and mild hyperintensity on t2-weighted images .
there is minimal diffuse or no enhancement on contrast.[148 ] these lesions can usually be excised totally .
only three cases have been reported with recurrence of the tumor after initial total excision .
all of them had a resurgery and were not subjected to adjuvant radiation or chemotherapy despite recurrence .
the chances of recurrence after total excision are low ; hence , a total excision should always be attempted [ tables 1 and 2 ] . however , as with our case , the size of the lesion and its extensive intermingling with the nerve roots made it sometimes necessary to settle for a subtotal excision .
there have been instances of postoperative radiation following subtotal excision , but it is generally not recommended .
residual or recurrent tumor on follow up after gross total resection should be strongly considered for a re - excision rather than adjuvant therapy.[268 ]

Answer:
subependymomas are extremely rare lesions of the spinal cord .
 only 33 cases including ours have been reported in the cervical cord .
 these are typically benign slow growing tumors occurring eccentrically within the cord , producing minimal neurological deficits .
 the clinical , radiological , and histopathological aspects of this unusual lesion have been reviewed in detail .
 as the histogenesis of this tumor is much debated , we propose an alternate origin for the same .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
metastasis of transitional cell carcinoma ( tcc ) of the renal pelvis to the eye is a very rare event and has only been reported in one case in the literature .
once diagnosed , these cases usually show widespread metastases and carry a very poor prognosis .
we present a case report of a male patient with unilateral choroidal metastasis secondary to tcc of the renal pelvis .
review of the relevant literature will be addressed to highlight the involvement of the choroid in cases of metastatic disease , the unusual presentation of tcc , diagnostic methods , and the various therapeutic modalities used to treat these cases .
a 61-year - old male , who has a history of congestive heart failure , is a nonsmoker , and has no significant family history of malignancies , presented to the ophthalmology clinic with sudden - onset loss of vision of the left eye associated with intermittent left eye pain , relieved by analgesics
. ophthalmic evaluation revealed a visual acuity of 20/40 in the right eye and 20/400 in the left eye .
funduscopic examination of the left eye showed an amelanotic macular choroidal lesion associated with inferior exudative retinal detachment ( fig 1a ) .
a b - scan ocular ultrasound showed a dome - shaped , 2.8-mm choroid thickening with variable internal reflectivity , associated with inferior exudative retinal detachment ( fig 1b ) .
fluorescein fundus angiography revealed early choroid blockage ( fig 1c ) and late leakage associated with hot spots at tumor margin .
all of these clinical features are suggestive of the clinical diagnosis of left choroidal metastasis .
physical examination of the patient also revealed multiple suspicious chest wall nodules . in search for a primary malignancy ,
imaging studies were done , which revealed multiple pulmonary and liver metastasis , subcutaneous metastasis , multiple lymphadenopathies , and left renal upper pole mass ( fig 2 ) .
ct - guided left renal mass biopsy and ultrasound - guided biopsy of the left chest wall subcutaneous mass were performed .
they are negative for ck20 , pax2 , ttf-1 , synaphopysin , and s100 ( fig 3 ) .
external beam radiation therapy ( ebrt ) is a common mode of treatment   and will be considered if there is no improvement of visual symptoms with chemotherapy .
choroidal metastasis is the most common intraocular malignancy , due to its rich vascular supply and high oxygen concentration [ 4 , 5 ] .
less common primary cancers include the thyroid , prostate , kidney , testicles , pancreas , ovary , and liver .
rarely is it seen in cases of tcc , as there have only been 5 previous reports in the literature involving choroidal metastasis , 3 from tumors involving the bladder , and 2 from other parts of the urinary tract .
choroidal metastasis is commonly associated with disseminated disease and , unfortunately , carries a very poor prognosis .
tcc usually metastasizes to the regional lymph nodes ( 78% ) , liver ( 38% ) , lung ( 36% ) , bone ( 27% ) , adrenal gland ( 21% ) , and intestine ( 13% ) .
the heart , brain , kidney , spleen , pancreas , meninges , uterus , ovaries , prostate , and testes have been reported as unusual sites of presentation of tcc .
other less common clinical presentations include flashes ( 5% ) and floaters ( 5% ) .
diagnosis is based on clinical findings , which are typically seen as yellow , plateau - shaped lesions associated with subretinal detachment .
a - scan and b - scan ultrasonography show irregular internal reflectivity and a solid plateau - shaped mass , respectively .
fluorescein fundus angiography typically shows mottled hypofluorescence in early stage and leakage in late stage .
the treatment of choroidal metastasis should be individually tailored , taking into consideration the patient 's systemic state , disease activity , and the presence of visual symptoms .
its aim is palliation , to improve the quality of life of the patient and to restore or maintain visual function .
local therapeutic regimens include ebrt , plaque radiotherapy , and complete enucleation for painful , blind eyes [ 13 , 14 ] .
ebrt delivered at a dose of 40 gy over 20 fractions was effective in improving and maintaining vision in patients with choroidal metastasis [ 15 , 16 ] . in cases of widespread metastases , systemic chemotherapy alone or in combination with local therapy is an accepted therapeutic option . in patients with choroidal metastasis alone ,
local therapy has been reported to be safe , maintaining visual functions without the systemic side effects of chemotherapy .
choroidal metastasis related to tcc of the renal pelvis is an extremely rare event and is associated with widespread disease and a very poor prognosis
. systemic chemotherapy with carboplatin and gemcitabine is a palliative treatment option for this patient .
ebrt offers local palliation and will be considered according to the patient 's visual response to chemotherapy .

Answer:
metastases of transitional cell carcinoma ( tcc ) of the renal pelvis to the eye is a very rare event , as only one previous case has been described in the literature .
 we present a patient with choroidal metastasis secondary to tcc of the renal pelvis , with a review of the relevant literature . a 61-year - old male presented with sudden - onset loss of vision of the left eye . upon evaluation and assessment ,
 the patient was found to have unilateral choroidal metastasis secondary to tcc of the renal pelvis .
 he is currently on palliative chemotherapy with carboplatin and gemcitabine .
 external beam radiation therapy is a common mode of treatment and will be considered accordingly .