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:
diabetes represents a challenging health issue in the 21st century with a growing incidence estimated to be 381.8 million patients globally in 2013 and high morbidity and mortality rates .
though population data are often scarce , the african continent is expected to bear the most important burden of diabetes during the next coming decades [ 13 ] . however
, a few countries have developed national strategies to contain this coming epidemic . in many cases ,
lack of data is the major barrier for setting up efficient programs for prevention and management of diabetes in disadvantaged populations . in senegal
, there is not yet available data on diabetes burden at national level but one recent survey in saint - louis city ( northern region ) reported a prevalence of 10.4% with two - thirds of patients uncontrolled .
moreover , marked disparities had been reported between urban and rural regions where lifestyle habits and access to care are different [ 24 ] .
the objective of this study was to compare prevalence and risk factors of diabetes in adult populations living in rural and urban areas in senegal .
we performed a community - based cross - sectional survey in saint - louis ( northern region of senegal ) .
all individuals aged 18 years and living in saint - louis for  3 months were eligible to participate in the study .
a two - stage cluster sampling method was used to select a representative sample of adults living in urban and rural areas of saint - louis .
we firstly selected 17 localities as clusters ( 9 urban areas and 8 rural areas ) .
then , we randomly took a number of households proportional to population size of each locality ( data available from the national agency of statistics and demography ) . from each household a maximum of two participants
considering -error of 0.05 and a power  of 80% , the required sample size was 855 individuals and we added a 20% attrition rate to get a sample of 1026 participants . finally , a total of 1056 persons were sampled to enter the study .
data were collected on site during house - to - house visits that were conducted between 7 a.m. and 12 p.m. or at the nearest health centre when patients did not live far away from this facility .
a modified version of the who stepwise questionnaire ( http://www.who.int/chp/steps/ ) was pretested and validated before its use to collect data .
researchers assisted by medical students , trained nurse practitioners , and community health workers had to fill the data collection form , to document the sociodemographic status ( age , sex , marital status , education , profession , and education ) , personal and family health history ( regarding , particularly , hypertension , diabetes , stroke , and heart and kidney disease ) , and lifestyle ( nutritional habits , physical activity , smoking , and alcohol consumption ) of each participant .
anthropometric measurements ( weight , height , waist , and hip circumference ) were performed using standard methods and calibrated devices .
blood pressure was measured twice at five minutes intervals by a semiautomatic sphygmomanometer and the mean of the two readings was calculated .
if the difference between the readings was greater than 10  mm  hg , a third measurement was performed .
hypertension was defined as a systolic blood pressure of 140  mm  hg or more , diastolic blood pressure of 90  mm  hg , any prescription of antihypertensive medication in the past two weeks , or any self - reported history of hypertension .
serum total cholesterol , ldl cholesterol , hdl cholesterol , and triglycerides were measured with colorimetric method .
fasting blood glucose ( fbg ) was measured with a glucose oxidase method , and serum total cholesterol , hdl cholesterol , and total triglycerides were measured by an enzymatic calorimetric method .
diabetes was defined as fbg  126  mg / dl or by prescription of hypoglycemic agents despite fasting plasma glucose or any self - reported history of diabetes .
physical inactivity was defined as less than 30 minutes of moderate activity per week or less than 20 minutes of vigorous activity three times per week , or the equivalent .
statistical analyses were performed with stata 12.0 ( stata corp , tx , usa ) .
comparison of proportions and means were done using pearson 's chi - square test or student 's t - test as appropriated .
the age - standardized prevalence rates were calculated with the direct method , using the results of senegalese general population census as the standard ( http://www.ansd.sn/ ) .
clinical and biochemical parameters associated with diabetes were assessed , in bivariate analysis , comparing the group with diabetes and the group without diabetes using student 's t - test or a chi - square test .
variables significantly associated with diabetes were then included in a multivariate logistic regression model with age , gender , and urbanization as forced variable .
odds ratio ( ors ) with 95% ci and p values of the final model are presented .
a total of 1056 participants were involved in the study with a response rate of 99.1% . but
21 of them were excluded from the analysis because of incomplete collected data and 1026 individuals were finally analyzed .
the crude prevalence of diabetes in our sample was 10.8% ( 95% ci : 6.9%14.2% ) .
the age - adjusted prevalence of diabetes was 7.6% ( 95% ci : 5.4%10.5% ) with a difference between men ( 6.0% ) and women ( 9.0% ) .
the mean age of diabetic patients was 46.8  13.5 years ( 1876 years ) .
the crude prevalence of diabetes in urban and rural settings was , respectively , 12.7% and 6.8% .
adjusted prevalence of diabetes was higher in urban areas ( 8.1% ) compared to rural areas ( 4.6% ) ( figure 1 ) .
also , in both settings , there was an increase in diabetes prevalence with age as shown in figure 2 .
comparing cardiovascular risk of people living in urban and in rural settings , we found similarly high prevalence of traditional cardiovascular risk factors such as hypertension , obesity , and physical inactivity contrasting with low proportion of smokers . regarding the disease awareness ,
43% of patients were diagnosed during the survey , 36% were previously declared diabetic but without any medical follow - up , and 21% were regularly treated by a physician . the presence of diabetes was associated with common risk factors like age , gender , obesity , and familial history of diabetes ( see table 2 ) .
univariate analysis showed that age 35 years ( 10% of diabetics versus 5.5% in people aged < 35 years ) , female gender ( 9.0% of diabetics versus 6.0% in males ) , family history of diabetes ( diabetes prevalence of 8.4% versus 5.1% ) , and obesity ( diabetes prevalence of 13.9% versus 8.3% ) were significantly associated with a higher chance to get diabetes .
conversely , physical activity and daily consumption of 3 fruits / vegetables were associated with lower risk of diabetes in this population ( prevalence differences of 19.5% and 4.4% , resp . ) . after adjustment for age , gender , smoking , familial history , and obesity ,
the risk of diabetes was similar in individuals living in urban area compared to those living in rural areas ( they presented a diabetes risk excess of 27% ) .
only age > 35 years ( or = 1.63 , 95% ci = [ 1.482.06 ] ) , existence of family history of diabetes ( or = 1.42 , 95% ci = [ 1.123.77 ] ) , and abdominal obesity ( or = 1.17 , 95% ci = [ 1.001.78 ] ) remained significantly associated with diabetes ( see table 3 ) .
prevalence of diabetes in sub - saharan africa is variable across countries , ethnic groups , and settings considered . reported data from community - based studies range from 2.8% in rural populations in angola   to 28.2% found in south african mixed ancestry populations living in urban areas [ 8 , 9 ] .
epidemiological studies in rural populations are scarcer but they generally show a lower prevalence [ 1012 ] compared to surveys in urban settings [ 1315 ] . in this study ,
the prevalence of diabetes in urban areas is quite twice the one in rural areas .
comparable prevalence ratios ( urban / rural ) were found in kenya   and in democratic republic of congo .
as already reported in the literature , we found an increasing prevalence with age which is a major risk factor for type 2 diabetes .
some studies found higher prevalence in men [ 10 , 11 ] and others reported the contrary [ 9 , 16 ] . in the present study , female gender , absence of school education , and living in urban setting
were associated with diabetes at univariate analysis . however , these associations were no longer significant after adjustment for true risk factors that were abdominal obesity , age , and familial history of diabetes . as underlined in many studies , we found a higher prevalence of diabetes in women compared to men and this difference was more striking among rural populations .
however , these rates are better than what was reported in rural tanzanians ( 8.3 to 13.2% ) [ 17 , 18 ] or south africans ( 15.3% )   or in a previous survey in dakar ( capital city ) where 90% of newly diagnosed diabetics were not aware of their disease .
recent forecast suggests an alarming increase of diabetes incidence in africa during the next decade in addition to other noncommunicable and infectious diseases . in the us population between 1980 and 2011 ,
the crude prevalence of diagnosed diabetes increased from 2.5% to 6.9% while age - adjusted prevalence rose in the same proportions indicating that changes in the population age structure do not explain the epidemic transition .
the true explanation of this rising burden of diabetes in both urban and rural africa is probably multifactorial . with life expectancy increase ,
the most important part might be driven by lifestyle modifications ( fast urbanization , physical inactivity , and dietary transition ) which promote obesity and insulin resistance but also environmental and genetic factors have not been well explored .
data on the changes in the -cell function and insulin resistance in the early stages of the disease process in african populations are scarce .
a few genetic studies performed in small groups from northern and western africa had identified some polymorphism associated with diabetes but epigenetic factors which should play an important role in the disease onset are still unknown [ 2224 ] . other conditions like hiv and sickle cell diseases are also incriminated in the current epidemics of diabetes in africa [ 25 , 26 ] . despite its epidemiological importance of describing diabetes face in senegalese populations
firstly , the cross - sectional design is not suitable for inferential analysis about causality or direction of association between diabetes and other cardiovascular risk factors .
secondly , incidence of diabetes could not be calculated to estimate the disease potential progression in the population .
age , familial history of diabetes , and abdominal obesity are the main risk factors identified .
prevention program targeting both urban and rural populations are urgently needed in african countries in order to reduce the morbidity and mortality due to diabetes .

Answer:
diabetes represents a challenging global health issue in the 21st century .
 data from sub - saharan african populations are scarce and are usually restricted to urban settings .
 the objective of this study was to compare prevalence and risk factors of diabetes in rural and urban areas in senegal .
 methods . in a community - based survey between january and may 2012 , we included 1027 adults aged 18 years living in northern senegal .
 sociodemographic , clinical , and biological data were collected during household visits .
 multivariate logistic regression was performed to identify factors associated with diabetes . results .
 mean age of participants was 48.0  16.9 years and 65.7% were female .
 participants from urban area represented 55.7% .
 the age - standardized prevalence of diabetes was 7.6% ( 6.0% in men versus 9.0% in women ) .
 prevalence of diabetes was higher in urban areas ( 8.1% ) compared to rural areas ( 4.6% ) .
 disease awareness rate was 43% .
 after multivariate analysis , age ( or = 1.63 , p = 0.001 ) , familial history of diabetes ( or = 1.42 , p = 0.001 ) , and abdominal obesity ( or = 1.17 , p = 0.05 ) were associated with diabetes .
 conclusion .
 diabetes is frequent in urban and rural areas in senegal .
 awareness rate is very low among populations .
 age , family history of diabetes , and abdominal obesity are the main risk factors identified .


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:
verruciform xanthoma ( vx ) , which has almost similar histologic features , is also a rare lesion usually found on the oral mucosa or the genital area .
it is presumably associated with the inflammatory response to mucosal damage.1 however , xanthoma and vx of the esophagus are extremely rare . since the first report by remmele and engelsing2 only 13 cases of esophageal xanthoma have been reported,1,2,3,4,5,6,7,8,9 and since the report by herrera - goepfert et al.,10 only four cases of vx of the esophagus have been reported.10,11,12,13 the etiologies of both lesions are not understood .
we describe herein a new case , including a review of all reported cases of xanthoma and vx of the esophagus .
a 70-year - old man with an unremarkable medical history was hospitalized with a complaint of epigastric pain .
serum total cholesterol , triglyceride , high density lipoprotein cholesterol , and low density lipoprotein cholesterol levels were 151 , 215 , 33 , and 102 mg / dl , respectively .
multiple shallow gastric ulcers and a duodenal ulcer were detected and suspected to be the cause of the pain .
besides the ulcers , in the upper esophagus 20 cm from the incisors , a 3-mm yellowish granular elevated mucosal lesion was found and a biopsy was performed ( fig .
1 ) . microscopically , large round cells were aggregated in the lamina propria immediately beneath the squamous epithelium .
the etiologies are different , as xanthoma is caused by hyperlipidemia and vx arises presumably as a result of an inflammatory response to continuous mucosal damage.1 however , the etiologies of the two lesions arising in the esophagus are not understood .
the characteristics of all reported cases of xanthoma and vx of the esophagus are summarized in table 1 .
fourteen cases of xanthoma and four cases of vx of the esophagus have been reported .
however , some reports loosely stratified vx into esophageal xanthoma , whereas others have excluded it.6,8 in terms of clinical data , both diseases were found predominantly in men than in women : 9 versus 3 in xanthoma and 3 versus 1 in vx .
the median age was 59 years ( range , 37 to 74 ) in xanthoma and .
the predominant location was the lower esophagus for xanthoma ( lower , 7 ; middle , 2 ; upper , 3 ) , whereas vx was not reported in the lower esophagus ( upper , 2 ; middle , 2 ) .
the median size was not different : 3 mm ( range , 2 to 10 ) for xanthoma and 4 mm ( range , 3 to 20 ) for vx .
the associated medical conditions were diverse ; however , two patients with malignant tumors were included in each group : hepatocellular carcinoma and ileocecal lymphoma in xanthoma , and gastric cancer and multifocal cancer ( cancer of the glottis , liver , and trachea ) in vx , although there was no definite association .
vx is characterized by its histologic features , including papillomatosis , acanthosis , and hyperparakeratosis.11 also , the external morphology is verrucoid .
nevertheless , findings of large round foam cells in the lamina propria under the squamous epithelium are the same as those in xanthoma .
it is difficult to differentiate between the two lesions on the basis of gross examination when they arise on the esophagus .
exophytic and verrucoid features seen in vx of the skin were not observed in the esophagus because most of the reported cases were small in size.10,12 considering that xanthoma and vx are nonneoplastic lesions , differentiating between them could be a waste of effort .
however , these lesions have to be grossly distinguished from ectopic sebaceous glands and small subepithelial tumors such as carcinoid and granular cell tumor because most of the reported esophageal xanthomas are yellowish or white mucosal elevated lesions . in terms of microscopic findings , signet ring cell carcinoma , which contains round cells with abundant cytoplasm ,
while signet ring cell carcinoma has an eccentrically located nucleus because of the intracellularly abundant mucin , xanthoma has a centrally located and small nucleus .
positive immunohistochemical staining for cd68 , which indicates a histiocytic origin , is another characteristic finding of xanthoma.5 moreover , esophageal cancer and ectopic sebaceous glands do not commonly stain with lugol 's solution ; thus , endoscopists need to be aware of these lesions for the differential diagnosis.6,14 with more case reports of esophageal xanthoma and vx of the esophagus , the characteristics of both lesions will be more clearly elucidated .

Answer:
xanthoma is an uncommon nonneoplastic lesion resulting from the accumulation of histiocytes .
 it predominantly shows cutaneous manifestations associated with dyslipidemia . however , xanthoma of the esophagus is extremely rare . to the best of our knowledge ,
 only 14 cases have been reported thus far .
 the clinical significance of this lesion has not been established .
 however , this lesion should be distinguished grossly from ectopic sebaceous glands and small subepithelial tumors such as carcinoid and granular cell tumor . moreover , signet ring cell carcinoma , which contains round cells with abundant cytoplasm and has similar histologic features to xanthoma , should be distinguished microscopically .


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:
ventricular tachycardia or fibrillation ( vt / vf ) in patients with acute myocardial infarction ( ami ) is associated with a poor prognosis.1 ) despite a better prognosis for early vt / vf compared to late vt / vf , early refractory vt / vf is a serious obstacle for the definitive treatment with primary percutaneous coronary intervention ( pci ) .
one of the recent advances in the field of critical care is the extracorporeal life support ( ecls ) system , which is portable , readily applicable and easy to maintain . before its advent ,
patients with ami complicated by refractory vf / vt before commencing primary pci would rarely survive or recover without ischemic brain damage .
such patients are among those who can derive the most benefit from ecls at present . in fact
, ecls has well demonstrated its efficacy in treating in - hospital cardiopulmonary arrest and is being used for broader indications then before.2 ) the use of ecls after prolonged cardiopulmonary resuscitation ( cpr ) , a traditional contraindication , is particularly challenging . here , we present two cases of emergency ecls after prolonged cpr for in - hospital cardiac arrest caused by refractory vf in patients with ami waiting for primary pci .
a 55-year old man visited the emergency room due to acute ch - est pain .
his vital signs were stable but his electrocardiogram ( ecg ) showed st - elevation in leads ii , iii and avf as well as q waves in leads v 1 and 2 ( fig .
1 ) . the patient had a history of repeated amis , for which he had received multiple stents in two different hospitals . despite the higher risk of recurrent cardiovascular events , his compliance seemed poor and he was still a heavy smoker .
his current medication included triple antiplatelet therapy , a lipid - lowering agent , a beta - blocker , and an angiotensin - converting enzyme inhibitor .
the pain - to - door time was about 30 minutes and the pci team was called after diagnosis of an acute inferior wall st - elevation myocardial infarction ( stemi ) . during the stay in the emergency room , the patient suddenly collapsed from vf .
cpr was initiated and repeated shocks at maximum energy were administered . throughout about 30 minutes of conventional cpr ,
, we decided to implement ecls ( capiox ebs , terumo , tokyo , japan ) .
the right femoral vessels were accessed guided by anatomical landmarks and ecls was finally implemented , about 2 hours from the initiation of cpr . with full support
, we achieved a flow rate of 4.8 l / min and mean arterial pressure of 70 mm hg , but vf persisted .
now the patient could be transferred to the catheterization room to undergo primary pci , without the need for chest compressions for his fibrillating heart . in the catheterization room
, the left femoral artery accessed also guided by anatomical landmarks and a coronary angiogram ( cag ) was performed .
the right cag revealed one stent in the proximal portion that was totally occluded by a thrombus ( fig .
the coronary flow was successfully restored after ballooning , about three hours from the onset of chest pain .
we implanted a long drug - eluting stent on the previous stent because the residual stenosis after ballooning was more than 80% ( fig .
we finished the procedure by installing an intra - aortic balloon pulsation ( iabp ) catheter to assist recovery .
the iabp and ecls could be weaned on the third day and the patient was transferred to general ward on the fourth day .
he was discharged with chest wall pain , caused by the cpr , and a large hematoma around the ecls cannula insertion site , which had required a transfusion .
vital signs were stable but his ecg showed st - elevation in leads v 1 - 4 and isolated vpc .
he had hypertension , hypercholesterolemia and acquired immunodeficiency syndrome , for which he received regular medications including anti - viral agents .
the pain - to - door time was about 60 minutes and primary pci was promptly arranged after diagnosis of an acute anterior wall stemi . during transfer to the catheterization room , one run of non - sustained vt appeared which could be suppressed with intravenous lidocane .
however , during preparation for the procedure in the catheterization room , a sustained vt developed and turned into vf .
we immediately called the ecls team and continued cpr . at about 45 minutes of continuous cpr ,
normal sinus rhythm spontaneously restored with the implementation of ecls ( capiox ebs , terumo , tokyo , japan ) via the right femoral vessels .
restoration of sinus rhythm resulted in a stable patient with a flow rate of 2.5 l / min and mean arterial pressure of 80 mm hg .
his right cag showed no significant stenosis , however , the left cag revealed a thrombotic occlusion of proximal left anterior descending coronary artery .
coronary flow was successfully restored after ballooning , about two and half hours from the onset of chest pain .
we implanted a drug - eluting stent in the culprit lesion with no further complications .
he regained full consciousness the same day , in the absence of any neurological deficit .
the ecls could be weaned the second day and the patient was transferred to general ward on the third day .
finally , he was discharged with no complications except for chest wall pain caused by the cpr .
a 55-year old man visited the emergency room due to acute ch - est pain .
his vital signs were stable but his electrocardiogram ( ecg ) showed st - elevation in leads ii , iii and avf as well as q waves in leads v 1 and 2 ( fig .
1 ) . the patient had a history of repeated amis , for which he had received multiple stents in two different hospitals . despite the higher risk of recurrent cardiovascular events , his compliance seemed poor and he was still a heavy smoker .
his current medication included triple antiplatelet therapy , a lipid - lowering agent , a beta - blocker , and an angiotensin - converting enzyme inhibitor .
the pain - to - door time was about 30 minutes and the pci team was called after diagnosis of an acute inferior wall st - elevation myocardial infarction ( stemi ) . during the stay in the emergency room , the patient suddenly collapsed from vf .
cpr was initiated and repeated shocks at maximum energy were administered . throughout about 30 minutes of conventional cpr ,
, we decided to implement ecls ( capiox ebs , terumo , tokyo , japan ) .
the right femoral vessels were accessed guided by anatomical landmarks and ecls was finally implemented , about 2 hours from the initiation of cpr . with full support
, we achieved a flow rate of 4.8 l / min and mean arterial pressure of 70 mm hg , but vf persisted .
now the patient could be transferred to the catheterization room to undergo primary pci , without the need for chest compressions for his fibrillating heart . in the catheterization room
, the left femoral artery accessed also guided by anatomical landmarks and a coronary angiogram ( cag ) was performed .
the right cag revealed one stent in the proximal portion that was totally occluded by a thrombus ( fig .
the coronary flow was successfully restored after ballooning , about three hours from the onset of chest pain .
we implanted a long drug - eluting stent on the previous stent because the residual stenosis after ballooning was more than 80% ( fig .
we finished the procedure by installing an intra - aortic balloon pulsation ( iabp ) catheter to assist recovery .
the iabp and ecls could be weaned on the third day and the patient was transferred to general ward on the fourth day .
he was discharged with chest wall pain , caused by the cpr , and a large hematoma around the ecls cannula insertion site , which had required a transfusion .
vital signs were stable but his ecg showed st - elevation in leads v 1 - 4 and isolated vpc .
he had hypertension , hypercholesterolemia and acquired immunodeficiency syndrome , for which he received regular medications including anti - viral agents .
the pain - to - door time was about 60 minutes and primary pci was promptly arranged after diagnosis of an acute anterior wall stemi . during transfer to the catheterization room ,
one run of non - sustained vt appeared which could be suppressed with intravenous lidocane .
however , during preparation for the procedure in the catheterization room , a sustained vt developed and turned into vf .
we immediately called the ecls team and continued cpr . at about 45 minutes of continuous cpr ,
normal sinus rhythm spontaneously restored with the implementation of ecls ( capiox ebs , terumo , tokyo , japan ) via the right femoral vessels .
restoration of sinus rhythm resulted in a stable patient with a flow rate of 2.5 l / min and mean arterial pressure of 80 mm hg .
his right cag showed no significant stenosis , however , the left cag revealed a thrombotic occlusion of proximal left anterior descending coronary artery .
coronary flow was successfully restored after ballooning , about two and half hours from the onset of chest pain .
we implanted a drug - eluting stent in the culprit lesion with no further complications .
he regained full consciousness the same day , in the absence of any neurological deficit .
the ecls could be weaned the second day and the patient was transferred to general ward on the third day .
finally , he was discharged with no complications except for chest wall pain caused by the cpr .
prolonged cpr ( > 30 minutes ) or unwitnessed cardiac arrest are poor prognostic markers for the implementation of ecls.3 ) according to rhee et al.4 ) the time to ecls for in - hospital arrest or shock patients was 4323 minutes in failed weaning cases versus 258 minutes in successful weaning cases in korea . with this in mind ,
although the precise impact of cpr duration on predicting survival or neurologic recovery seems to be unclear , our experiences suggest that well organized cpr can protect the major organs , including the brain , for up to 2 hours in witnessed in - hospital cardiac arrest . with advancements in ecls systems , patients with in - hospital arrest
more experience with the use of ecls will help define its most appropriate time of deployment . because primary pci ( the treatment of choice for stemi ) is readily available and highly successful in current practice , patients with refractory cardiac arrest are likely candidates for ecls .
however , conclusions from our limited experiences should not be generalized to other causes of cardiac arrest .
according to recent epidemiological study , sustained vt / vf occurred in 5.7% of acute stemi patients undergoing primary pci , which mostly happened before the end of cardiac catheterization.1 ) although the frequency of refractory cardiac arrest is not well documented , it is a potential threat in all patients with ami .
our experience of the past two years suggests refractory vf / vt accounts for about 2.5% of patients with stemi waiting for primary pci ( unpublished data ) .
the importance of chest compression during cpr is increasingly emphasized.5 - 8 ) we think the favorable results of our cases are based on the endeavored cpr , conducted with minimal interruption of chest compression .
also , the cpr in both cases was fully directed by the same experienced cardiologist . to improve the outcome of ecls ,
rapid and accurate cannulation of the ecls system is important . in one of our two cases we spent about 90 minutes on ecls implantation , mostly due to difficulty in cannulation of the pulseless vessel without interrupting chest compression
this was further complicated by formation of a large hematoma at the cannulation site , requiring a transfusion .
we hope our experiences may contribute to improving the prognosis of patients with cardiac arrest .

Answer:
extracorporeal life support ( ecls ) has well demonstrated its efficacy in treating in - hospital cardiac arrest and is being used for broader indications .
 however , ecls after prolonged cardiopulmonary resuscitation ( cpr ) has been traditionally contraindicated and is now challenging . here , we introduce two cases of successful ecls after prolonged cpr , resulting in a immediate and full recovery . both these acute st elevation myocardial infarction patients waiting for primary percutaneous coronary intervention ( pci ) suddenly collapsed due to ventricular fibrillation ( vf ) , which was refractory to conventional treatment .
 after 2 hours of conventional cpr , the ecls had been implemented and primary pci could be performed .
 subsequent to successful revascularization , the vf was stopped with a single electric shock . in our second case ,
 normal sinus rhythm was spontaneously restored after ecls implementation , which was completed after 45 minutes of conventional resuscitation .
 both patients made a full neurological recovery on the day of the event and were discharged with only minor complications .


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:
laparoscopic supracervical hysterectomy ( lsh ) has continued to represent a favorable alternative to total abdominal hysterectomy ( tah ) for the treatment of benign gynecologic conditions , particularly due to the reduced complication rates , shorter surgery / hospital stay , and prompt resumption of patient daily living activities .
nevertheless , studies continue to suggest that lsh should not be used as a treatment for benign gynecological conditions , particularly cervical dysplasia .
the purpose of this commentary is to address the primary objections against lsh and further illustrate the benefits inherent in this procedure . initially , the primary impetus for removal of the cervix at the time of hysterectomy in patients with benign conditions was to prevent cervical cancer . however , the incidence of cancer in the cervical stump is extremely low and primarily preventable due to latent disease progression , pap smear technology , and hpv screening .
therefore , removing this organ solely for the purpose of preventing cervical cancer appears counterintuitive , especially considering that both at - risk patients and the general nonhysterectomized population receive the same recommended screening guidelines . since lsh involves the removal of the uterine section ostensibly related to the specific condition , the operation fixes many gynecologic problems while it conserves the patient 's anatomy and sexual function by retaining the cervix and its mucous - secreting glands .
furthermore , the cervix is not typically associated with pelvic pain or bleeding , and thus patients can thereby avoid the common complaints of vaginal dryness and dyspareunia .
studies have further indicated that removal of the normal cervix can cause untoward bladder and bowel consequences , including prolapse and urinary incontinence .
additionally , prior research has reported that lsh outcomes coincide with favorable rates of prolapse and vaginal cuff dehiscence ( vcd ) .
in particular , hur et al examined the prevalence of vcd in a large hysterectomy study , indicating that the condition has a significantly following tah compared with lsh .
randomized controlled trials and metaanalyses have documented that lsh is associated with a higher incidence of cervical stump complications ( eg , cyclical bleeding and urinary incontinence ) .
however , the cyclical bleeding with lsh is often slight and can be tolerated if the patient receives adequate preoperative counseling . in terms of stress
urinary incontinence , tah appears to be associated with more favorable outcomes compared with lsh , whereas there were no reported lower urinary tract symptom ( luts ) differences between the 2 procedures .
we contend that because vaginal suspension alters the bladder neck angle and reduces postoperative incontinence , when performing lsh , consideration for suspending both the vagina and the cervical stump may significantly mitigate stress urinary incontinence .
while there were no reported differences between tah and lsh regarding the incidence of luts , urinary tract infections , incomplete bladder emptying and voiding complications increased after tah at 1-year follow - up but decreased in the lsh patients . in an earlier surgical study ,
gimbel et al also reported a much higher incidence of serious adverse events and perioperative blood loss in patients treated with tah compared with those treated with lsh .
furthermore , the tah group exhibited more bladder / ureteral injuries , underwent longer operative times .
patients who present with recurrent cervical dysplasia should consider having their cervix removed if a total hysterectomy is warranted .
however , when a patient initially presents with cervical dysplasia , lsh may be preferable to hysterectomy particularly given the reportedly lower complication rates , reduced surgical time , and earlier recovery .
the combination of improved prevention programs , patient adherence to annual screening recommendations , and an informed community appreciation of the virus 's vaccination distribution may further render this issue inconsequential .
we suspect that the controversy surrounding the removal of the cervix is partially attributed to both insufficient lsh outcome studies and because many gynecologic surgeons are not formerly trained or experienced with this treatment option .
while we recognize that both the american college of obstetrics and gynecology and a recent cochrane analysis clearly state that tah is more beneficial than lsh in treating benign gynecologic conditions , clinicians should strongly consider the several encouraging lsh findings and emerging studies that continue to substantiate the efficacy of lsh for treating many common benign gynecologic conditions .

Answer:
recent results from metaanalyses and observational studies have suggested that total abdominal hysterectomy ( tah ) is superior to laparoscopic supracervical hysterectomy ( lsh ) for the treatment of benign gynecologic conditions .
 however , because lsh is associated with fewer intraoperative complications , shorter operative time , and preserves patient anatomy and sexual function in comparison with tah , clinicians should reconsider the benefits of lsh .


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:
mosquitoes were collected from june to september 2003 at the ejido francisco villa , municipality of pesqueria , state of nuevo leon ( 2547n , 10003w ) , with cdc - type light traps baited with dry ice and mechanical aspiration from resting sites on vegetation and in houses .
the area is located 40 km northeast of monterrey and consists of mixed suburban housing and agriculture .
average annual rainfall in the region is 550 mm ; the mean annual temperature is 28c .
after collection , the mosquitoes were placed on dry ice for transport back to the medical entomology laboratory , faculty of biological sciences , autonomous university of nuevo leon , monterrey , where they were separated into pools of 10 insects each , based on species , date , and method of collection ( table 1 ) .
the mosquitoes were stored in a mechanical freezer at 70c and later transported on dry ice to the university of texas medical branch ( utmb ) to be processed for virus isolation .
a total of 2,297 mosquitoes , representing 4 genera and 11 species , were tested in 238 pools ( table 1 ) .
individual mosquito pools were titrated manually in sterile , ten broeck tissue grinders containing 1.0 ml of phosphate - buffered saline , ph 7.4 , containing 30% fetal bovine serum and antimicrobial agents ( penicillin , streptomycin , and amphotericin ) .
the resultant suspension was centrifuged at 12,000 rpm for 5 min ; then 200 l of the supernatant was injected into a flask culture of vero cells .
after the solution was absorbed for 1 h at 37c , maintenance medium ( 9 ) was added ; cultures were maintained in an incubator at 37c and examined daily for evidence of viral cytopathic effect ( cpe ) for 14 days . a single pool of cx .
quinquefasciatus yielded a virus isolate , designated nl-54 , which produced cpe on approximately day 7 .
the isolate was identified as wnv by immunofluorescence , hemagglutination - inhibition ( hi ) test , complement - fixation test , vectest wnv / sle antigen assay ( medical analysis systems , camarillo , ca , usa ) , and reverse transcription  polymerase chain reaction ( rt - pcr ) ( 9,10 ) .
the wnv human isolate was from a 62-year - old mexican woman living in the municipality of etchojoa ( near ciudad obregon ) in sonora state .
she visited a local hospital in july 2004 with symptoms of fever , headache , vomiting , arthralgias , and myalgia .
an acute - phase blood sample was obtained , and a presumptive diagnosis of dengue fever was made .
the patient was sent home and subsequently completely recovered . when rt - pcr using dengue primers was negative on the acute - phase serum , a culture was performed .
wnv was isolated from the sample at the state public health laboratory in sonora and at utmb , upon culture in vero cells .
hi tests conducted on the acute - phase serum at utmb with west nile , st .
louis encephalitis , yellow fever , dengue 1 , and dengue 2 viral antigens were negative , which indicated that the patient had no preexisting flavivirus antibodies .
an immunoglobulin ( ig ) m enzyme - linked immunosorbent assay ( 11 ) , performed on the acute - phase specimen and a 30-day convalescent - phase serum specimen in sonora , demonstrated seroconversion and the presence of wnv - reactive igm antibodies in the convalescent - phase serum sample .
viral rna was extracted from the 2 wnv strains after a single vero cell passage directly from 140 l of the infected cell culture supernatants , using the qiaamp viral rna extraction kit ( 12 ) .
rt - pcr was performed by using 3 primer pairs to amplify the entire prm - e genes of each wnv isolate as previously described ( 12 ) .
pcr products were gel purified with the qiaquick kit ( qiagen , valencia , ca , usa ) according to the manufacturer 's protocol , and the resulting template was directly sequenced with the amplifying primers .
analysis and assembly of sequencing data were performed with the vector nti suite software package ( informax , frederick , md , usa ) .
nucleotide and deduced amino acid sequences of the 2004-nucleotide region representing the prm - e genes from each isolate were aligned with the alignx program in the vector nti suite and compared to sequences of selected north american wnv isolates for which the prm - e genes were available in genbank .
phylogenetic trees were constructed by bayesian analysis with the program mrbayes , version 2.0 ( 13 ) , with the metropolis - coupled , markov chain , monte carlo algorithm run with 4 chains over 150,000 generations under a general time - reversible model with a burn - in time of 50,000 generations .
the bayesian consensus tree was compared to trees generated by neighbor - joining , maximum parsimony , and maximum likelihood analyses using paup , version 4.0b10 ( 14 ) , and each method generated trees with the same overall topology .
the consensus phylogram of the 40 wnv isolates generated by bayesian analysis ( 13 ) is shown in the figure , with confidence values at relevant nodes to demonstrate statistical support for each clade .
phylogram of 2 west nile viruses ( wnv ) isolated from a mosquito pool and human serum in mexico ( shown in bold ) .
the phylogenetic tree was generated by bayesian analysis of a 2004-nucleotide region of the prm and e genes of 40 wnv isolates rooted by the most closely related old world strain , israel 1998 .
ay963774 ) , to the prototypical north american wnv isolate , wn - ny99 ( genbank accession no .
ay371271 ) ( 2 ) , and an isolate collected in harris county , texas , in 2002 ( genbank accession no .
ay185906 ) ( 15 ) indicated nucleotide and deduced amino acid differences and similarities among each of the isolates .
both the mexican mosquito and human isolates reported herein shared a nucleotide mutation at position 660 ( c to u ) of the prm gene and 2 mutations at positions 1442 ( u to c ) and 2466 ( c to u ) of the e gene .
each of these 3 mutations was shared with a 2003 horse strain from nuevo leon ( mexnl-03 ) ( 7 ) and a 2002 bird isolate from harris county , texas ( tx-1 ) ( 15 ) .
the mutation at nucleotide 1442 also represented a deduced amino acid substitution in the envelope protein ( v159a ) .
the mexican mosquito and human isolates reported herein shared a unique mutation at genomic position 1320 ( a to g ) in the e gene .
the human isolate also had 3 additional mutations in the e gene at positions 1074 ( g to a ) , 1656 ( u to c ) , and 1974 ( c to u ) .
the nucleotide mutations at nucleotide positions 660 , 1442 , and 2466 have also been described in most wnv isolates sequenced from texas , illinois , and colorado in 2002 ( 12 ) .
this finding suggests that isolates obtained from northern states of mexico ( i.e. , nuevo leon and sonora ) were derived from wnv strains circulating in the western united states .
only a single mutation at position nucleotide 2466 was shared by these 2 isolates and a 2003 bird isolate from tabasco state ( tm171 - 03 ) .
this finding supports results from earlier studies that suggest separate introductions of wnv into mexico ( 2,7 ) .
phylogenetic trees generated by a number of methods indicate that the recent mexican mosquito and human isolates belong to the clade comprised of wnv isolates collected outside the northeastern united states after 2001 , with the exception of isolates collected along the southeast coast of texas .
( those isolates constitute a separate , sister clade relative to all other north american wnv isolates sequenced to date [ figure ] . ) . because of a shared mutation between the recent mexican mosquito and human isolates ,
these 2 virus strains constitute a distinct subclade within the larger us 2002 clade that is supported by strong bayesian confidence values ( 94% ) .
the accumulation of 3 additional nucleotide mutations in the 2004 mexican human isolate is illustrated by longer branch lengths in comparison to the 2003 mosquito pool isolate nl-54 , which suggests the continued microevolution of wnv in mexico from year to year .
* nucleotide numbers correspond to wn - ny99 ; amino acid substitutions are in brackets .  genbank accession number .
our patient represents the first reported autochthonous human case of confirmed wnv infection in mexico .
the paucity of human cases reported to date from mexico is curious for several reasons : 1 ) a large number of cases are reported from the united states , 2 ) available evidence indicates that wnv is now widely distributed in mexico ( 17 ) , 3 ) most of the wnv virus strains circulating in the republic are genetically similar to those in the united states ( figure ) .
one explanation for this difference could be the failure of local health personnel to recognize the various clinical forms of wnv infection .
as illustrated by our patient , west nile fever can easily be mistaken for dengue fever
. a second reason may be the difficulty of making a serologic diagnosis of wnv infection among persons living in geographic regions where several different flaviviruses circulate , and people have multiple flavivirus infections ( 11 ) .
a third and related possibility is that wnv infection may be less severe in persons with preexisting heterologous flavivirus antibodies ( 11 ) .

Answer:
west nile virus has been isolated for the first time in mexico , from a sick person and from mosquitoes ( culex quinquefasciatus ) . partial sequencing and analysis of the 2 isolates
 indicate that they are genetically similar to other recent isolates from northern mexico and the western united states .


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:
they may occur at any point and age along the line of the repaired cleft .
reported recurrence range , after surgical correction of cleft palate , varies between a wide range of 10% and 30% depending on the technique used and age at the time of primary repair .
small fistulas may be asymptomatic but patients commonly complain of regurgitation of liquids into the nose , and food may become impacted with resultant malodor .
palatal fistulas can be variedly located in reconstructed palate starting from alveolar margin to anterior third , middle third , or posterior one - third of palate .
the probable cause for occurrence of anterior palatal fistulas ( apfs ) is anatomically shorter lesser segment , wide palatal cleft defect with thin palatal shelves , improper reflection of subperiosteal flap , and improper closure .
this study is a retrospective record review of patients diagnosed with apf in 3.5 years ( which reported in our unit between january 2010 and july 2013 ) .
a total number of 91 patients with anterior palate fistula were operated in this duration .
there were forty cases of unilateral apf which were treated with one or another technique surgically depending on various factors influencing the choice of surgical technique .
patients were categorized in the study depending on the procedure followed for the apf closure .
analysis of preoperative , immediate postoperative , and 1-month follow - up pictures was done to check for the site of occurrence , type of cleft , evaluation of adjacent tissue , size of fistula , postoperative healing , and closure with various techniques to compare and evaluate the results and outcome along with complication if any . out of the forty patients included in the study ,
primary palate closure of ten patients was done in our unit ( bhagawan mahaveer jain hospital , bengaluru , india ) , whereas thirty were treated elsewhere for repair of cleft palate primarily . in the study ,
unilateral apfs were evaluated depending on their site of occurrence , type of cleft , evaluation of adjacent tissue , and the size of fistulae .
depending on the site of occurrence , apf were categorized into three locations : alveolar fistulae , alveolar fistulae extending to hard palate , and fistulae in hard palate [ figure 1 ] .
( c ) fistula in hard palate all the palatal fistulas were evaluated for the adjacent tissue in which the quality of tissue was assessed if it is a normal anatomical tissue or secondary mucolized tissue postpalatoplasty .
( b ) normal anatomical tissue techniques adopted for closure of apf were anterior palate redo with bardach 's principle [ figure 3 ] , closure with rotation of island flap [ figure 4 ] , closure with crevicular flap , closure with buccal advancement flap , and closure with tongue flap and vomer flap . ( a ) unrepaired anterior palatal fistula .
as shown in table 1 , forty cases were split for surgical correction into various options depending on their size , site , and quality of the tissue .
most of the cases were operated with a bardach 's redo for fistula closure ( n = 16 ) ( 40% ) and crevicular flap technique ( n = 13 ) ( 32.5% ) .
our overall success ( satisfactory results ) was 77.5% as observed in 31 out of 40 cases with individual success rates for bardach 's and crevicular being 75% and 77% , respectively . there was reduction in size of fistula in three cases ( 7.5% ) and a remnant pinpoint hole in four cases ( 10% ) among all the operated cases .
we observed just two breakdowns of repair in forty cases . during evaluation of all the three cases managed with vomer flap ,
results were considered satisfactory in case of the absence of any symptomatic or asymptomatic fistula , no particular complaints by patient or nasal regurgitation . indicating the split up of 40 cases into various surgical techniques adapted for apf closure and comparison of result
even today , cleft palate and its associated surgical repair are rated among the greatest challenges in reconstructive surgery . a successful treatment outcome expected after repair of cleft palate includes achieving normal speech without increasing maxillofacial growth disturbances .
factors predisposing to development of postoperative dehiscence or fistula include width of the palatal cleft , amount of deficiency of palatal segment , misplacement , and distortion of the cleft segment .
other extrinsic variables considered for the fistula formation are the timing of repair , sex of the patient , surgical procedures , and the operating surgeon .
early dehiscence and fistulas are primarily caused by errors in technique such as inadequate mobilization , closure under tension , injury at reintubation , poor handling of the tissue , failure to achieve a layered closure , and postoperative bleeding and infection .
denny and amm proposed closure of palatal fistula with anterior palate redo with bardach 's principle .
they documented the technique of total palatal elevation to be a safe and reproducible technique for closure of hard palate fistulas using local palatal flaps .
the authors were of the opinion that this technique possesses added advantage of allowing direct visualization of all the elements essential for a successful repair .
our results held resemblance to this concept since we were able to achieve a successful treatment outcome in 75% of the cases .
henderson discussed the use of advancement island flap for the closure of apf and named it as the  tadpole flap .
although lesser number of defects were repaired in the current case series with island flap , but almost all of them showed satisfactory healing outcome .
carstens in his study put forward the sequential cleft management with sliding sulcus technique and alveolar extension palatoplasty .
he stated that conventional methods of cleft lip repair deprive the anterior ( buccolingual ) alveolar mucoperiosteum of blood supply from the facial - internal maxillary arcade .
after 6 months , while performing palatoplasty , the lingual incisions permanently isolate the lingual mucoperiosteum from vascular supply which is the greater palatine artery , thereby transforming the osteogenic alveolar mucoperiosteum from a richly supplied boundary zone between the two angiosomes into an isolated tissue surviving primarily on osseous backflow .
subperiosteal techniques that preserve the blood supply to this tissue is considered in a sequential plan of cleft management .
the authors were able to perform apf repair in 13 cases through this technique in our study with a predictable healing result in 77% cases .
another approach utilized by jackson for the management of small- and moderate - sized fistulae involved a combination of buccal and palatal flaps along with bone grafting .
however , such an intervention was performed in fewer number of patients in this study .
another attempt made by the surgeons to repair apfs with secondary mucolized tissue involved creating a vomer flap in small figure of three which was associated with significantly improved healing outcome in all the cases .
perhaps , an exclusive study on fate of vomer flap would provide more precise details regarding the predictability of this technique .
henceforth , the authors have made an effort to put forward treatment options for apf depending on their location by means of a simplified algorithm [ figure 5 ] .
for an apf , exclusively in alveolus buccal flap or crevicular flap can be used if patients ' age is over 11 years , whereas for patients ' younger than this secondary alveolar bone grafting with or without prior orthodontics or buccal flap appear to be more suitable . during management of fistulas extending to hard palate or into the hard palate , selection of the treatment modality depends on a major extent on the tissue quality . in case of normal palatine tissue ,
whereas in cases with secondary mucolised tissue , if it is present over greater segment , a vomer flap is advocated ; if it is bilateral , tongue flap is advised ; and in case of lesser segment , rotation of the greater segment is recommended .
the current study was based on a stringent protocol regarding the selection of a surgical treatment plan based on anatomical location of fistula and the quality of surrounding tissue .
postoperative follow - up of maximum number of cases revealed minimal complication or recurrence rate .
additional factors that could be included in future studies for similar clinical cases include speech , etiology of fistula , and width of palate at the time of primary closure .
furthermore , we believe that a long - term follow - up of at least 6 months would be better to provide more reliable result

Answer:
aim : aim of this retrospective study was to access the various surgical treatment options available for repair of anterior palatal fistula depending upon their size and presenting age , and also to anticipate the treatment outcome.materials and methods : the series include study report of forty patients with secondary anterior palatal fistula post cleft palate repair , reported in a single unit during a duration of 3 years .
 all the cases were managed surgically under general anesthesia .
 the patients were classified depending upon the location of anterior palatal fistula ( apf ) , the quality of tissue and age of patients to chalk out a justified treatment option outlay.results:forty cases were split for surgical correction into various options depending on their size , site , and quality of the tissue .
 most of the cases were operated with a bardach 's redo for fistula closure ( n = 16 ) ( 40% ) and crevicular flap technique ( n = 13 ) ( 32.5% ) .
 our overall success ( satisfactory results ) was 77.5% as observed in 31 out of 40 cases with individual success rates for bardach 's and crevicular being 75% and 77% , respectively .
 there was reduction in size of fistula in three cases ( 7.5% ) and a remnant pinpoint hole in four cases ( 10% ) among all the operated cases.conclusion:management of post palatoplasty fistulas of the hard palate presents a challenging situation for a clinician following the surgical correction of cleft palate .
 current paper describes the diagnosis and clinical management of forty cases reporting with unilateral apf following cleft palate surgery , over 3 years .
 authors have attempted to propose different treatment modalities for surgical management of unilateral apf .
 it was concluded in the primary review that the size of fistula was irrelevant in determining the clinical outcome .
 instead , the quality and condition of the adjacent tissue appear to be the major governing factors for selecting treatment modality as well as the surgical consequences .


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:
dyschromatosis is a rare genodermatosis which is characterized by hyper and hypo pigmented macules of variable shape and size .
case one was a 30-year - old male patient who presented with asymptomatic multiple hypopigmented , and hyperpigmented skin lesions all over the body [ figure 1a and b ] since the age of 10 years . the initial lesions started in the chest and then spread to the entire body in 2 years .
there was no history of photosensitivity or handling of any chemical or any history of drug intake .
skin biopsy from the hyperpigmented macules showed the increased melanin pigmentation [ figure 2a ] , and the hypopigmented macules showed a marked decrease in the epidermal basal melanin [ figure 2b ] .
based on these findings , a diagnosis of dyschromatosis universalis hereditaria ( duh ) was made .
( a and b ) case one with multiple hypopigmented and hyperpigmented macules all over the body photomicrograph depicting marked increase in the epidermal basal melanin from the hyperpigmented macules ( a ) and decrease in the epidermal basal melanin from the hypopigmented macules ( b ) of all the five cases ( h and e , 400 ) case two was a 22-year - old male presenting to our outpatient department with asymptomatic multiple hypo and hyperpigmented macules all over the body [ figure 3 ] since 12 years .
case two with multiple hypopigmented and hyperpigmented macules all over the body case three was a 14-year - old boy who presented with similar lesions all over the body [ figure 4a and b ] since the age of 2 years .
he also had multiple verucca vulgaris over the left arm and dorsum of hands [ figure 4c ] .
case three with similar reticulate pigmentation all over the body ( a and b ) ; broad nasal bridge , long philtrum ( a ) with verucca vulgaris on the dorsum of right hand ( c ) depicts case three and case four with palms showing similar mottled pigmentation case four was the 9-year - old sibling of the 14-year - old boy who revealed similar lesions all over the body [ figure 6 ] since 9 months of age .
he had recurrent pyodermas [ figure 6a ] since birth . on examination , he had molluscum contagiosum lesions [ figure 6b ] on the face . both the siblings also had a broad nasal bridge , long philtrum , and high arched palate . the possibility of primary immunodeficiency was kept and baseline immunodeficiency workup was done .
his serum immunoglobulin assay was normal and human immunodeficiency virus one and two tests ( elisa ) were negative .
both the brothers had hypopigmented , and hyper pigmented macules of varying sizes all over the body .
case four with similar reticulate pigmentation all over the body , abscess over the forehead , molluscum contagiosum ; broad nasal bridge , long philtrum based on these findings , a diagnosis of duh was made in all the four cases .
the other differential diagnosis in all these four cases included xeroderma pigmentosum , dyschromatosis symmetrica hereditaria , dyschromic amyloidosis , and disorders due to chemical exposure such as diphenylcyclopropenone , and monobenzyl ether of hydroquinone .
absence of photosensitivity , atrophy , telangiectasia , eye involvement and benign nature of the condition makes xeroderma pigmentosum unlikely .
these lesions were differentiated from dsh in which the lesions occur in a more acral distribution .
the disorder was also differentiated from dyschromic amyloidosis by the absence of predominant lesions in the sun exposed areas and absence of amyloid deposits in the papillary dermis .
case five was a 21-year - old male who presented with asymptomatic multiple hypo and hyperpigmented skin lesions over the extremities [ figure 7 ] since the age of 1-year .
biopsy from the hypopigmented macules showed decreased melanin pigmentation whereas biopsy from the hyperpigmented macules showed increased focal melanin in the basal layer .
other possibilities such as duh , and reticulate acropigmentation of kitamura were included in the differentials .
duh was ruled out as it is characterized by more extensive lesions including the non acral / unexposed areas of the body .
further , the disease is differentiated from reticulate acropigmentation of kitamura by the absence of atrophic macules , palmar pits or breaks in the epidermal ridge pattern .
case five with similar lesions over the extremities the features of all these five cases have been summarized in table 1 .
reticulate pigmentary dermatoses ( rpd ) comprise a rare group of disorders , characterized by hyperpigmented and hypopigmented macules coalescing to form a reticular pattern .
the various acral rpd includes reticulate acropigmentation of kitamura , acropigmentation of dohi , acromelanosis heterochromia extremitarium , and dyschromatosis symmetrica hereditaria ( dsh ) .
the differential diagnoses of generalized rpd are duh , dermatopathia pigmentoreticularis , naegeli - franceschetti - jadassohn syndrome , and dyskeratosis congenita ( dkc ) .
dyschromatosis is a spectrum of disease which includes duh , dyschromatosis symmetrica hereditaria ( dsh ) or acropigmentation of dohi and a segmental form called unilateral dermatomal pigmentary dermatosis .
duh , a rare autosomal dominant genodermatosis was first described by ichikawa and hiraga in 1933 .
duh is characterized by the presence of both hyperpigmented and hypopigmented , small , irregular macules distributed symmetrically all over the body .
these cases usually do not progress or worsen as age advances , once well established .
theses macules are usually smaller ( 15 mm ) , but larger macules measuring up to 15 cm have been reported . the trunk and the extremities are commonly involved .
the face is generally not involved , and there is sparing of the palms , soles , and mucous membranes .
various systemic associations including small stature and high - tone deafness , dowling - degos disease , x - linked ocular albinism , tuberous sclerosis have been described .
many other associated conditions have been reported , such as ocular abnormalities , photosensitivity , learning difficulties , mental retardation , epilepsy , insulin - dependent diabetes mellitus , and erythrocyte , platelet and tryptophan metabolism abnormalities .
duh is thought to occur secondary to the interference with the neural - melanocytic interaction in early embryonic life in those who are genetically susceptible .
the gene responsible for duh has been mapped to 6q24.2-q25.2 ( omim 127500 ) . because the exact biochemical basis of the gene defect is unknown , the diagnosis generally relies on the external phenotype . here
one case was associated with mental and growth retardation , recurrent respiratory tract infection , verucca vulgaris ; and his younger brother had recurrent pyoderma with molluscum contagiosum .
both the brothers had characteristic facies of high arched palate , broad nasal root , and long philtrum .
we also report one case of dyschromatosis symmetrica hereditaria in a 21-year - old male patient presenting with similar macules over the extremities .
patients with dyschromatosis symmetrica hereditaria ( reticulate acropigmentation of dohi ) present with hyperpigmented and hypopigmented macules on the face and the dorsal aspects of the extremities .
skin lesions remain localized on extremities in nearly half of the patients and involve face and extremities in the remaining half .
most cases of dsh are inherited as autosomal dominant , although an autosomal recessive variant of dhs has been reported .
later , novel mutations in the adra1 were reported in chinese families confirming that this gene is responsible for dsh in the different ethnic group .
more recently , suzuki et al . reported 16 novel mutations in the adra1 without identifying such mutations in patients with duh .
in a recent ultra - structural skin investigation , nuber et al . indicated that duh is a disorder of melanosome synthesis rate or melanocyte activity and not a disorder of melanocyte number .
dyschromatosis is a benign condition which is usually not associated with systemic involvement which has to be differentiated from conditions like xeroderma pigmentosum , dkc .
we report these cases because of their rare occurrence and characteristic facies of high arched palate , broad nasal root , and long philtrum ; recurrent respiratory tract infections , verucca vulgaris , molluscum contagiosum , and pyodermas as an association of duh has not been reported to the best of our knowledge .
duh and dsh can present without a family history of similar complaints which has been rarely reportedduh can be associated with characteristic facies of high arched palate , broad nasal root and long philtrum , recurrent respiratory tract infections , verucca vulgaris , molluscum contagiosum , and pyodermas .

duh and dsh can present without a family history of similar complaints which has been rarely reported duh can be associated with characteristic facies of high arched palate , broad nasal root and long philtrum , recurrent respiratory tract infections , verucca vulgaris , molluscum contagiosum , and pyodermas .
duh and dsh can present without a family history of similar complaints which has been rarely reportedduh can be associated with characteristic facies of high arched palate , broad nasal root and long philtrum , recurrent respiratory tract infections , verucca vulgaris , molluscum contagiosum , and pyodermas .

duh and dsh can present without a family history of similar complaints which has been rarely reported duh can be associated with characteristic facies of high arched palate , broad nasal root and long philtrum , recurrent respiratory tract infections , verucca vulgaris , molluscum contagiosum , and pyodermas .
duh and dsh can present without a family history of similar complaints which has been rarely reportedduh can be associated with characteristic facies of high arched palate , broad nasal root and long philtrum , recurrent respiratory tract infections , verucca vulgaris , molluscum contagiosum , and pyodermas .

duh and dsh can present without a family history of similar complaints which has been rarely reported duh can be associated with characteristic facies of high arched palate , broad nasal root and long philtrum , recurrent respiratory tract infections , verucca vulgaris , molluscum contagiosum , and pyodermas .

Answer:
dyschromatosis is a pigmentary genodermatosis which presents with hyper and hypopigmented skin lesions giving a mottled appearance .
 it is a rare entity in india reported mainly in the east asian population .
 classically , two forms have been described ; dyschromatosis universalis hereditaria ( duh ) and dyschromatosis symmetrica hereditaria . here
 we report four cases of duh and one case of dyschromatosis symmetrica hereditaria from india .


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 current research on human diseases primarily focuses on the molecular , microbiological , immunological , and pathological influences .
the mechanical basis of disease is now often being explored to decipher any direct contributions toward the physiological response [ 1 , 2 ] . in functionally loaded tissues such as cartilage and bone , cells ( chondrocytes and osteocytes ) experience multiaxial forces ( hydrostatic , compressive , tensile , and shear ) , which play a significant role in modulating the biological function through maintenance of the phenotype and production of a neotissue .
conversely , abnormal mechanical forces ( either static or dynamic ) can lead to altered cell behavior resulting in pathological matrix synthesis , increased catabolic activity ( degradation ) , and ultimately osteoarthritis or osteoporosis ( apoptosis ) .
our previous investigations have indicated that chondrocytes and likely other cell types respond to their stress - strain environments in a temporal and spatial manner .
it has also just been shown that individual cellular mechanical properties may indicate the regenerative potential of mesenchymal stem cells .
investigations of the biomechanics at the cellular level have also identified the biomarkers of disease .
cytoskeletal stiffness of metastatic cancer cells was reported as more than 70% softer than the benign cells that line the body cavity in patients with suspected lung , breast , and pancreatic cancer .
these approaches highlight the utility of single - cell biomechanics as a critical component of advancing microscale therapeutics .
advancements in laser technology and microfluidics now allow the use of optical tweezers or traps and fluid mechanics to manipulate isolated single cells [ 8 , 9 ] .
isolated loads can be applied experimentally to single cells in culture to quantify cellular and cytoskeletal biomechanics .
one can then apply forces and displacements as small as pico - newtons and nanometers , respectively [ 1012 ] .
the local microenvironment can therefore be precisely manipulated to facilitate biomechanical test sequences on individual biological cells and molecular structures .   in order to explore the connection between external mechanical stimulation and cellular regeneration or degeneration
, we developed a three - dimensional , multiphysics computational model to fully characterize a unique micromechanical environment .
the applied stress state within our custom - fabricated optical and hydrodynamic ( optohydrodynamic ) trap have been mathematically developed from the fundamental equations describing microfluidic creeping flows past a suspended sphere .
the objective described in the following paper is to explore the full - field cellular strain response to a range of applied stresses and cellular moduli .
the described computational framework will now allow us to develop more realistic cellular models , whose intracellular structures are distinctly identified .
living non - adhered , suspended osteoblasts , chondrocytes , fibroblasts , and myoblasts have recently been isolated and mechanically manipulated [ 12 , 16 ] .
primary cultures of chondrogenic and osteogenic tissues were generated directly from rat long bones , while muscle cells were acquired from the mouse - derived myoblast c2c12 cell line ( atcc , crl-1772 , manassas , va , usa ) .
all cells were tested at room temperature experiments ( ~20.5c ) in a flow media consisting of a physiological buffer resulting in a media viscosity of ~1  mpa  s. this single cell biomechanical manipulation was made available by combining optical trapping with microfluidics to create the optohydrodynamic trap .
this work was facilitated by an instrument , which integrates two laser - based techniques for the mechanical characterization of cellular and biomolecular structures [ 8 , 12 ] .
the optical tweezers or the trap component of the device utilizes an infrared laser (  = 1,064  nm ) to suspend micron - sized objects with nanometer position control and pico - newton constraining forces . in the mie regime , where objects are larger in dimension than the wavelength of the trapping laser ( here biological cells ) ,
a ray optics description indicates the transfer of refracted light and the associated momentum into trapping forces ( figure 1 ) .
micron - particle image velocimetry can be engaged by incorporating two frequency - doubled lasers (  = 532  nm ) aligned through the same optical path as the ot for full - field flow velocity characterization .
however , the nanoparticles associated with velocity imaging have proven deleterious to cellular health , but provide useful experimental validation of flows around synthetic micron - sized particles
.   the hydrodynamic component of this approach is facilitated through a microfluidic chip design configured in the form of a cross - junction channel ( figure 2 ) .
this geometry creates an extensional flow environment and a stagnation point at the channel 's geometric center .
cells are positioned at the centroid with the optical trap and manipulated with microfluidics , thus creating the optohydrodynamic trap .
the cell experiences a total drag force equal to zero , confirmed by integrating the stress tensor as defined by the normal ( form drag ) and shear ( friction drag ) stresses ( figure 3 ) .
this reflects the mechanical stability or the saddle - point nature of the optohydrodynamic trap .
previous studies describe chip fabrication in detail including the control of the gravity - driven flow initially associated with microfluidic manipulation .
the two- and three - dimensional stress states were previously developed as applied to the surface of a nonrotating spheroid cell of radius a , within the optohydrodynamic trap [ 2 , 12 , 14 , 15 ] .
briefly , the full - field fluid velocity vector u was constructed from the constitutive equations describing a non - rotating sphere suspended in a general linear flow with viscosity  and pressure distribution p . in the polar - spherical components ( r-- magnitudes and er - e-e vectors ) , the generalized flow field produces the individual velocity components :
 ( 1)u = u(ra52(ar)2 + 32(ar)4)sin2cos2er+u(ra(ar)4)sincoscos2e+u(ra(ar)4)sincos2e
 including the pressure distribution
 ( 2)p = p5ua(ar)3sin2cos2. the velocity gradients can be converted into the applied fluid stresses by applying the constitutive equation for an incompressible , newtonian fluid :
 ( 3)t=pi+2e ,
 where t is the stress tensor and i is the identity matrix associated with the local isotropic ( hydrostatic ) pressure distribution p. the strain rate tensor e can be characterized by the flow velocity gradient tensor and its transpose :
 ( 4)e=(12)[u+ut ] . by incorporating the velocity and pressure fields into the gradient analysis and then in turn into the constitutive equation ,
the fluidic stress tensor can be fully defined as
 ( 5)trr=p+ua(2 + 15(ar)312(ar)5)sin2cos2er , tr=ua(25(ar)3 + 8(ar)5)sincoscos2e,tr=ua(25(ar)3 + 8(ar)5)sinsin2e. defining the stress tensor at the cellular surface , r = a , produces the volumetric fluidic stress state applied to the cell :
 ( 6)tr = ter=rrer+re+re ,
 where the full - field stress state can then be defined in terms of distinct normal , rr , and shear , r and r , stress components , respectively , in polar spherical coordinates :
 ( 7)rr=p+5uasin2cos2,r=5uasincoscos2,r=5uasinsin2.
 a three - dimensional presentation of the stresses was developed ( matlab , mathworks , inc . , natick , ma ) for demonstration of the site - specific nature of the stress distributions ( figure 4 ) .
the six deviatoric stresses were combined as an effective stress value , eff , as a means to model the three - dimensional stress state :
 ( 8)eff=12[(xy)2+(yz)2+(zx)2  + 6(xy2+yz2+zx2)]1/2 .
 here
, the maximum polar coordinate derived stresses were converted to the cartesian coordinate stresses such that the maximum normal stresses are located along the x - y - z axes and the maximum shear stresses are defined along the 45 orientation off - axis locations .
volumetric strain , e , based on the strain invariants , ii , was defined to encompass the full - field deformation response of the cell within the multiaxial fluidic loading environment and does not apply the small - displacement theory assumption .
the cartesian axes associated with the maximum normal strains were determined from a mohr 's circle analysis [ 12 , 20 ] :
 ( 9)e = i1+i2+i3=x+y+z+xy+yz+zx+xyz .   the experimental approach described earlier is a planar - wise measurement technique ; thus the optical depth strain value , z , can be determined through a transposition of the planar loading scenario , again through a mohr 's circle analysis :
 ( 10)z=1(x+y ) .
 however , in this modeling presentation here , the full - field stress state and the corresponding strains are fully characterized .
the optohydrodynamic deviatoric stress state was applied to an isotropic , homogenous biological cell ( 20  m in diameter ) within a multiphysics computational environment ( comsol v4.0 , palo alto , ca , usa ) in order to determine the individual principal strains and in turn the volumetric strains .
  in this work , we continue to examine the cellular biomechanics induced within a controlled micromechanical environment .
three - dimensional cellular strains were computationally modeled in silico with multiphysics software applying the analytically defined stress state ( figure 5 ) .
volumetric stress and strain relationships indicated both the nonlinear response of the spherical cellular structure as well as the logarithmic increase in strain with subsequently softer cellular moduli ( figure 6 ) .
this relationship is further explored when examining the direct relationship of strain with elastic moduli ( figure 7 ) .
the extreme strain response induced in diseased cells indicates their further vulnerability when passively or actively resisting applied stresses .
  we explored the full - field cellular strain response to a range of applied hydrodynamic stresses and cellular moduli , representing various degrees of functional loading and health / disease , respectively .
the computational framework now allows us to develop more realistic cellular models with intracellular and membranous structures , distinct in spatial , elastic , and active transport characteristics .
the mechanical properties of a single cell are often formulated using either macroscopic or microscopic approaches .
macroscopic approaches , as partially described in this work , homogenize every cellular component to produce an isotropic or anisotropic yet homogeneous continuum model so that the mechanical properties of cells can be formulated using temporal and spatially continuous partial differential equations .
future efforts will incorporate a more microscopic approach , which regards the cell as a biocomposite material consisting of randomly or uniformly spaced anisotropic reinforcement cytoskeletal materials within an isotropic medium .
the microscopic approach generally obtains the biomechanical response of a single cell by applying the mechanical boundary conditions at the individual fiber and matrix level , scaling  up  to the cellular level .
microscopic approaches often provide much more detail into the subtle interaction between the cytoskeletal fibers and matrix , which potentially leads to a more accurate model of the cellular behavior , such as characterizing the irreversible deformation of the cellular skeleton .
unfortunately , refined microscopic models suffer from inhibitory computational and storage costs [ 26 , 27 ] .
when interpreting the potential geometric changes in cellular shape associated with mechanical loading , the cell may experience some interesting membrane transitions triggering unique biologic cues . under suspension and hydrostatic loading , the cell 's volume ( v ) can be defined as a sphere , v = 3/4abc , with radii a = b = c. as seen here during the hydrodynamic extensional loading state , the isotropic , homogenous cell model deformed into a scalene ellipsoid ( a  b  c ) with equal and opposite tensile and compressive strains in the horizontal plane .
however , with the future inclusion of intracellular structures and organelles as well as nonlinear elastic properties assigned to the membrane and cytoskeleton , cellular models may also deform into either an oblate spheroid ( formed when an ellipse is rotated about its minor axis , a = b > c ) or a prolate spheroid ( formed when an ellipse is rotated about its major axis , a = b < c ) .
the resulting shape here replicated a scalene ellipsoid likely due to different maximum stresses applied in the three orthogonal axes .
ongoing experiments and modeling will continue to explore multiaxial single - cell biomechanics as well as the biologic triggers associated with geometric shape - shifting .
the described multiphysics computational framework will facilitate more realistic cytoskeletal model interpretations , whose intracellular structures can be distinctly defined , including the cellular membrane substructures , nucleus , and organelles .
future results will provide mathematical outcomes supporting the ongoing investigations in tissue and cellular engineering .

Answer:
controlled external chemomechanical stimuli have been shown to influence cellular and tissue regeneration / degeneration , especially with regards to distinct disease sequelae or health maintenance .
 recently , a unique three - dimensional stress state was mathematically derived to describe the experimental stresses applied to isolated living cells suspended in an optohydrodynamic trap ( optical tweezers combined with microfluidics ) .
 these formulae were previously developed in two and three dimensions from the fundamental equations describing creeping flows past a suspended sphere .
 the objective of the current study is to determine the full - field cellular strain response due to the applied three - dimensional stress environment through a multiphysics computational simulation . in this investigation ,
 the multiscale cytoskeletal structures are modeled as homogeneous , isotropic , and linearly elastic .
 the resulting computational biophysics can be directly compared with experimental strain measurements , other modeling interpretations of cellular mechanics including the liquid drop theory , and biokinetic models of biomolecule dynamics .
 the described multiphysics computational framework will facilitate more realistic cytoskeletal model interpretations , whose intracellular structures can be distinctly defined , including the cellular membrane substructures , nucleus , and organelles .


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:
papillary and follicular carcinomas of the thyroid gland , commonly referred to together as differentiated thyroid carcinoma ( dtc ) , are characterized by a slowly progressive course , and a 10-year survival rate as high as 80 - 95% .
distant metastases are seen in a minority of the patients and the reported rates of occurrence range from 4% to 15% .
the most common site of distant metastases is the lung , followed by the bone .
we present a case of asymptomatic radioiodine - avid renal and brain metastases presenting 20 years after hemi - thyroidectomy for adenomatous goiter and identified with i - whole body scintigraphy ( wbs ) and i single photon emission computed tomography / computed tomography ( i - spect / ct ) .
a 65-year - old man , investigated at a different hospital for intermittent cough and white - colored expectoration for 4 months , was found to have multiple bilateral nodular lesions on a chest x - ray [ figure 1a ] and a hyperdense lesion ( arrow ) in the right posterior parietal lobe of the brain on ct [ figure 1b ] .
he had undergone left hemi - thyroidectomy 20 years previously , reportedly for adenomatous goiter .
since serum thyroglobulin ( tg ) was > 3000 ng / ml , a provisional diagnosis of metastatic dtc was made .
however , abdominal ultrasonography ( usg ) showed multiple echogenic round lesions with areas of necrosis and internal vascularity in both kidneys .
( a ) chest x - ray showing multiple nodular lesions in both lungs and ( b ) computerized tomography of the brain showing a hyperdense lesion ( arrow ) in the right posterior parietal lobe i wbs [ figure 2a ] and spect / ct [ figure 2b and c ] performed 48 h after oral administration of 2 mci i showed tracer uptake in the head , neck ( residual thyroid ) , bilateral hilar lymph nodes , right third and fourth ribs with lytic changes , lung nodules , s1/s2 spinal canal , right femur , acetabulum and humerus , and multiple exophytic renal nodules .
usg - guided biopsy of a left renal nodule revealed only thyroid follicular cells ( positive for tg immunostaining ) with no pathological evidence of malignancy .
postoperative investigations after 6 weeks showed tg > 3000 ng / ml , anti - tg 30.1 iu / ml , and thyroid stimulating hormone 14.28 iu / ml .
he was treated with 207 mci of i under steroid cover ( prednisolone 40 mg / day ) .
i whole body scan ( a ) 48 h after administration of 2 mci 131i showing increased tracer uptake at multiple sites in the neck , chest , abdomen , pelvis and right thigh .
a small focus of radioiodine uptake is seen on the right side of the head posteriorly ( arrow ) , adjacent to a known focus of tracer contamination ( arrowhead ) .
single photon emission computed tomography / computed tomography of the neck and chest ; ( b ) localizes tracer uptake to residual thyroid , bilateral hilar lymph nodes , right 3rd and 4 ribs with lytic changes and multiple lung nodules .
single photon emission computed tomography / computed tomography of the abdomen ; ( c ) shows tracer uptake in multiple exophytic renal nodules a fifth - day posttherapy whole body planar and spect / ct scan [ figure 3a and b ] confirmed metastasis in the brain ( arrow ) and other sites seen in the pretherapy scan . after an uneventful hospital stay ,
he was discharged on a suppressive dose of thyroxin ( 225 g / day ) .
whole body planar ( a ) and single photon emission computed tomography / computed tomography ( b ) scans 5 days after 207 mci 131i showing increased tracer uptake in the brain ( arrow ) , d11 vertebra , sacrum , and right acetabulum , in addition to residual thyroid and lungs
distant metastases from dtc may present after a latent period of many years . around 10% of the patients with dtc present with multiple sites of distant metastases other than lung , bone , and lymph nodes ,
50% of which involve the brain , 25% the liver , and 25% other sites .
the reported incidence of renal involvement from a primary thyroid malignancy is very rare , being only about 4.5 - 5.9% , whereas of all secondary metastases to the kidneys from all cancers , thyroid cancer constitutes only about 2.5 - 2.7% . so far ,
most of the subjects were female and older than 45 years of age , whereas our patient was an elderly male .
renal metastasis usually appears in the setting of multifocal metastases , as in the present case .
however , in our patient , no pathological evidence of malignancy was identified in any of the surgically resected thyroid specimens .
it is possible that malignancy ( most likely follicular thyroid carcinoma ) might have escaped detection in the left hemi - thyroidectomy specimen 20 years earlier ; a similar case has been reported previously .
apart from a recent onset of cough , our patient was asymptomatic in the presence of renal as well as bone and brain metastases .
metastases from dtc may develop several years ( occasionally decades ) after the removal of the primary thyroid malignancy .
furthermore , they may remain undetected for a long time if no radioiodine intervention is done .
since multiple iodine avid lesions were seen throughout the body on planar scintigraphy , a whole body spect / ct scan was performed for lesion localization .
this helped in precisely localizing abnormal radioiodine uptake in the hilar nodes , lung nodules , kidneys , bone , spine , and brain .
. however , our patient showed radioiodine uptake in the brain metastasis in the presence of radioiodine - avid residual thyroid , renal , and other metastases , which is extremely uncommon .
metastases to the brain are observed in only about 1% of the thyroid carcinomas and , in one study , 23% of the brain metastases were discovered only at autopsy .
the median interval between the diagnosis of dtc and that of brain metastasis was 6.5 years . however , the actual number of reported cases of brain metastases from thyroid carcinoma remains small , and there has been little evidence of benefit from any specific mode of therapy .
the median disease - specific survival from diagnosis of brain metastases was 16.7 months for patients who underwent local excision of one or more brain metastases , compared with 3.4 months for those who did not ( p < 0.05 ) .
our patient had metastatic involvement in multiple organs , which were not amenable to surgery .
the patient 's condition improved symptomatically with absence of any cough during the 2 months following iodine treatment ; he is currently doing well under regular follow - up . to conclude ,
metastatic dtc should be suspected in asymptomatic patients with incidentally detected lesions , raised serum tg and history of thyroid lesions .

Answer:
a 65-year - old patient , with a history of left hemi - thyroidectomy for adenomatous goiter 20 years previously , was found to have pulmonary lesions on chest x - ray , a brain lesion on computerized tomography ( ct ) , and elevated serum thyroglobulin ( tg ) . while completion thyroidectomy revealed that no pathological evidence of thyroid malignancy , radioiodine - avid pulmonary , brain , and renal and bone lesions were identified on diagnostic as well as posttherapy whole body planar scintigraphy and single photon emission computed tomography - ct .
 subsequent ultrasonography - guided biopsy of a renal nodule showed thyroid follicular cells .
 this case suggests that metastatic differentiated thyroid carcinoma should be suspected in asymptomatic patients with incidentally detected lesions , raised serum tg , and history of thyroid lesions .


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 epstein  barr virus ( ebv ) infects b cells . in most cases , ebv - positive patients develop a severe form of infectious mononucleosis which typically manifests with fever , tonsillopharyngitis , lymphadenopathy and hepatosplenomegaly .
deficiencies may be characterized by abnormal activity of lymphocyte function leading to hemophagocytosis and multi - organ failure .
although ebv - associated hlh carries a high mortality rate , quick diagnosis and appropriate treatment can subside the disease .
we describe here a patient who developed hepatosplenomegaly and pancytopenia at 2 years of age but achieved automatic recovery .
, there was a clinical suspicion of ebv - induced hlh and the patient was given the option of treatment with rituximab .
she received antibiotic treatment due to fever and chills . during the hospitalization period , the patient recovered and developed hemophagocytosis with pancytopenia as well as sores on the lip .
the patient underwent bma and nothing abnormal was found . in spite of treatment , the disease did not subside and she developed fever , abdominal distention and edema in her lower extremities .
physical examination showed that the patient had decreased deep - tendon reflexes ( dtr ) and was unable to walk .
clindamycin , ceftazidime , dexamethasone , ivig ( intravenous immunoglobulin ) and g - csf were administered .
since the patient did not achieve full recovery , she was transferred to our center .
based on clinical symptoms and lab tests ( table 1 ) , bma was performed once again and the result raised suspicion of ebv - induced secondary hlh .
rituximab was injected once and the patient developed a blood ebv load of zero within one week . in order to control abnormal stimulation of the immune system ,
the patient was investigated for mutations in il-2-inducible t cell kinase ( itk ) and negative test results were received .
( the patient was negative for mutations in il-2-inducible t cell kinase ( itk ) ) .
she is now considered to be an acceptable candidate for transplantation from an hla matched sibling donor .

hlh can be divided into two subgroups : primary or familial hlh and secondary hlh .
the primary form is an inflammatory disease which is similar to secondary one on the basis of symptoms .
primary hlh usually arises in young children less than one year old ( 70% cases ) ; however , in rare cases it can also occur in adults ( perforin gene mutations have been identified in patients with primary hlh ) .
for example , type 2 is caused by mutations in genes 21 - 22 and type 5 is due to mutations in the munc18 - 20 that may be accompanied by hypogammaglobulinemia .
hypogammaglobulinemia was not confirmed in the patient because it was not possible to check mutation ( the related tests were sent to germany to examine the type 5 disease ) .
ebv may also be accompanied by hypogammaglobulinemia for a certain period secondary hlh is associated with immunologic stimulation caused by malignancies and bacterial or congenital infections .
the most common causes of secondary hlh are viral infections by ebv , cmv , prob19 and hiv .
however , it may also be seen in patients with immune system defects . , 4 secondary hlh is a known complication of ebv infection , particularly in patients with x - linked lymphoproliferative disease .
the incidence of x - linked lymphoproliferative syndrome is 1 in 1,000,000 male infants .

diagnostic criteria for hlh disease diagnosis of hlh requires the presence of all 5 major criteria .
if the patient meets only 4criteria but the clinical suspicion for hlh is high , one should initiate treatment , because delays may be fatal .
alternative criteria 1 or a combination of 2 and 3 may substitute for 1 major criterion . adapted from henter ji , elinder g , ost a.semin oncol . 1991 ; 18:29 - 33 .
it means that ebv - infected b cells stimulate cytotoxic t lymphocytes leading to hypercytokinemia and stimulation of histolytic cells .
more recently , it has been found that chronic stimulation by ebv may cause chronic hlh in the patient . on the other hand
, ebv causes stimulation , generation and uncontrolled secretion of t - and nk- cells , as well as generation of il2 , infa and il6 .
there is another mechanism by which ebv stimulates membrane protein ( lmp-1 ) in cells .
similar to xlp , lmp-1 may cause acquired immune deficiency , leading to hlh accordingly .

treatment follows two goals : first , to suppress immune response using ivig , steroid and hlh protocol .
second , to inhibit undesirable influence of immune response and cytokine - stimulated cell activation using immunochemotherapy . in cases with neurological symptoms
the level of viral dna which is measured by quantitative pcr may be useful to demonstrate treatment response predicting mortality .
the dna level reached zero in our patient . using ivig prior to start of protocol 2004
it has also been recommended in the treatment of ebv - induced secondary hlh monthly .

decrease of b cells , which have been contaminated by ebv , actually causes decrease of viruses , as it may be useful for our patient as well .
finally , treatment - refractory patients , transplant candidates , patients with familial type of hlh , or recurrent disease undergo chemotherapy for 8 weeks .
patients who respond favorably to treatment do not undergo transplantation but those who experience relapse and exhibit neurological symptoms are considered for transplantation .
severe infection of ebv is not associated with life - threatening condition , but our case study needs urgent treatment . in patients with long - term ebv infection , pancytopenia , coagulopathy and hepatosplenomegaly ,
bma will be performed and the serum ferritin level will be measured as well . for patients with secondary hlh ,
rituximab can be used when hlh is associated with ebv to inhibit the immune response .
thus , the main aim of treatment is to reduce the rate of mortality in patients with hlh .

Answer:
hemophagocytic lymphohistiocytosis ( hlh ) is one of the complications of epstein - barr virus ( ebv ) infection .
 although the patients who have developed hlh following ebv have normal immune system , there are a few patients with ebv - induced immune deficiency who develop hlh as well . here
 , we describe the case of a 10-year - old girl with neurological complications caused by ebv - induced hlh .
 the patient received rituximab , leading to weakening inflammation associated with ebv infection and suppression of disease through quick treatment .