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:
brachial plexus surgery using the da vinci surgical robot is a new procedure . to evaluate the advantages and the restrictions of the technique , a cadaveric study of supraclavicular and axillary approaches was conducted .
we found that the axillary approach was useful and advantageous for lower roots , particularly for thoracic outlet syndrome ( tos ) .
this report will focus on the evaluation of axillary robotic approach as the advantages and disadvantages of supraclavicular robotic intervention have been widely discussed in the literature .
a human cadaver was subjected to this experiment in paris university ecole europenne de chirurgie anatomy laboratory and da vinci robot system was used .
the left arm was tucked along the side and the right arm was placed in a semiflexed position extending toward the anesthesia location near the head , supported by foam and blankets ( figure 1 ) .
a 6  cm long incision was made at the right axillar line , lateral to the edge of the pectoralis major muscle ( figure 2 ) .
a self - retaining chung retractor was placed into the incision to elevate the pectoralis major muscle flap .
the robot was docked as a camera ; right and left robotic arm were adapted in the incision area ( figure 3 ) . a 10  mm 0 downlooking scope , maryland forceps , and a curved scissors
the working space was maintained with the self - retaining retractor , without co2 insufflation ( figure 4 ) .
the subclavian artery was seen in front of the truncus and was positioned to the posterior of the working space .
subclavian artery was dissected from the plexus and truncus of the lower plexus was exposed with blunt dissection .
the plexus was exposed thoroughly from t1 to c7 levels . in this surgical setting , the operating surgeon , who has
a wide experience in open brachial surgery of the brachial plexus , reported that lower brachial plexus exposure was easier from the axillary working area and a more wide range of motion was achieved to manipulate the robotic tools compared to the supraclavicular exposure for lower part of the brachial plexus .
the development of robotic - assisted minimally invasive techniques began in urology , general surgery , and gynecology because of the generally large working spaces available in the abdomen for these types of surgeries [ 14 ] .
since then , other surgeons have sought to use robotic devices in other areas , such as the brachial plexus [ 5 , 6 ] .
brachial plexus dysfunction can be the result of shoulder trauma [ 7 , 8 ] .
it can also occur with tos , which encompasses three separate disorders involving compression of the subclavian artery , subclavian vein , or brachial plexus in the triangular space bordered by the first rib , clavicle , and scalene muscles [ 9 , 10 ] .
compression of the vessel - nerve package at the thoracic inlet has been treated with soft - tissue ( scalene muscle ) release and/or bone ( first rib ) resection .
surgical approaches to first rib resection may be transthoracic , transaxillary , supraclavicular , infraclavicular , or thoracoscopic [ 9 , 10 ] . however , these approaches are typically associated with incomplete resection of the most medial portion of the first rib and neurovascular complications .
theoretically , a minimally invasive transthoracic approach can obviate these problems , enabling complete resection of the offending portion of the first rib without neurovascular complication .
, respectively , reported successful results of robotic en bloc first rib resection for tos treatment via transthoracic and transaxillary approaches [ 9 , 11 ] .
's techniques were only bony interventions and as being intrathoracic these need to be lung collapsed and lung complication can be waiting risk .
although liverneaux et al . reported techniques and results of upper brachial plexus injury intervention via robotic surgery with a supraclavicular approach , they described the disadvantages as a narrow working space and difficulty to expose the c7 vertebra [ 1 , 5 , 12 ] . to our knowledge , this report is the first to objectively describe robotic axillar brachial plexus exposure .
thus , we discuss the theoretical and clinical advantages and disadvantages of the axillary approach in the present report .
the development of robot - assisted surgery has revealed new perspectives in peripheral nerve microsurgery . minimally invasive
robot - assisted surgery could lead to modification of the classic algorithm for the treatment of traumatic brachial plexus lesions [ 6 , 8 ] . to date , exploration of these lesions has not been attempted less than 3 months after the traumatic event because clinical examination can not provide an accurate diagnosis or reliable prognosis in these first weeks .
early intervention may enable initial assessment of the lesion and repair of potentially graftable nerve roots .
several robotics properties are particularly adapted to microsurgery , such as high - resolution three - dimensional ( 3d ) visualization with up to 40 magnification , up to 10-fold magnification of surgical movements , elimination of physiological tremors , and the provision of ergonomic work conditions for otherwise uncomfortable surgery .
robotic surgical systems allow high - definition magnified 3d visualization of the operative field , provide significant instrument maneuverability , even within a confined space , and may overcome the shortcomings of conventional approaches [ 2 , 5 ] .
axillary ( infraclavicular ) brachial plexus intervention via robotic surgery has not been described previously .
axillary intervention was previously performed as an open procedure to expose the plexus or resect the first rib for the treatment of tos .
martinez et al . described first rib resection via robotic surgery but not to address plexus injury without transthoracic exposure , a novel minimally invasive approach to the first rib from inside of the chest .
in addition , gharagozloo et al . reported first rib resection via transthoracic robotic surgery for paget - schroetter disease .
's techniques were considered more useful for lower brachial plexus viewing and assessing according to gharagozloo et al .
the experience of the whole surgical team with robotic technology is important for the procedure . during learning curve period ,
two staff surgeons are required to participate in all procedures to ensure the safety of the program [ 5 , 9 ] .
martinez et al . reported importance of the learning curve , not only for the surgeon but also for the entire surgical team and 180 minutes for the initial 10 cases .
reported exclusion criteria include a history of previous incision in the same area and obesity , which present difficulties in robotic surgery initiation .
other drawbacks of this new surgical approach are the increased cost of surgical equipment and longer operating time , especially during the learning curve period .
however , we believe that the avoidance of a classic incision leads to significant patient satisfaction for cosmetic reasons and we believe that demand for this procedure from a select group of patients justifies the exploration of alternative ways to avoid classic brachial plexus exposure .
this report presents our initial experience with robot - assisted axillary exposure of the brachial plexus region . in our opinion
robotic surgery will be used routinely in the future for brachial plexus surgery and particularly for tos that is caused by bone and/or soft tissue . however , newer dedicated surgical instruments need to be developed and further studies should be conducted to evaluate in vivo application and results of this novel approach .

Answer:
brachial plexus surgery using the da vinci surgical robot is a new procedure .
 although the supraclavicular approach is a well known described and used procedure for robotic surgery , axillary approach was unknown for brachial plexus surgery .
 a cadaveric study was planned to evaluate the robotic axillary approach for brachial plexus surgery .
 our results showed that robotic surgery is a very useful method and should be used routinely for brachial plexus surgery and particularly for thoracic outlet syndrome .
 however , we emphasize that new instruments should be designed and further studies are needed to evaluate in vivo results .


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:
qualitative and quantitative disturbances in the function of salivary glands are detrimental to the oral environment , adversely influencing patients quality of life.1
 ,
 2 three pairs of salivary glands , namely parotid , sublingual and submandibular glands , secrete saliva into the oral cavity through specific ducts .
salivary glands are extremely susceptible to radiation injuries with parotid glands being more susceptible than others .
serous acini are more susceptible to radiation compared to mucous acini.1
 ,
 2 clinical evaluations have demonstrated that subsequent to a single radiotherapy dose , serous acini are immediately destroyed ; however , mucous acini demonstrate no acute histological changes .
therefore , immediately after radiotherapy is initiated , patients saliva becomes thicker . with the continuation of radiotherapy , mucous cells
are also affected and salivary flow rate decreases , depending on the gland that is in the path of direct radiation rays.2
 ,
 3 the severity of xerostomia depends on the gland involved , radiation dose and dose rate ( the intervals of radiations ) .

the glands that are partially exposed to radiation demonstrate higher salivation compared to the glands that are completely exposed to radiation .
radiation exposure on one side may not completely affect glands on the other side ; therefore , it may not result in severe xerostomia .
however , directing rays to the nasopharynx exposes parotid glands to radiation on both sides , leading to severe xerostomia.2
 ,
 3
 ,
 4

 xerostomia , the most common complication in patients with nasopharyngeal carcinomas following radiotherapy , makes mastication , deglutition and denture wearing difficult for patients .
in addition to its constant effect on the patient s daily life , long - term xerostomia predisposes the patient to oral candidiasis .
subsequent to radiotherapy , these patients run a higher risk of dental caries , especially root surface caries .
this higher risk is attributed to a decrease in saliva quality and quantity , a shift in the oral flora towards cariogenic microorganisms , and changes in diet .
therefore , it is critically important that dental practitioners have broad knowledge about potential oral complications following radiotherapy procedures in the head and neck region to be able to render efficacious treatment modalities and minimize or eliminate problems.2
 ,
 5

 no definitive treatment modalities or preventive measures have been introduced for xerostomia to date . in our community
no studies have been carried out about xerostomia ; therefore , we decided to evaluate xerostomia in patients under radiotherapy before engaging in an interventional study and comparing various procedures and confounding variables .
we decided to use the results of this preliminary study in the following interventional study to determine factors involved in decreasing xerostomia severity .
since , according to some studies , xerostomia and other concomitant complications of radiotherapy begin to manifest themselves approximately in the third week of the procedure we decided to compare the third week data with baseline records .

the study was carried out in the radiotherapy department of tabriz imam khomeini hospital .

all of the patients referring to the department of radiotherapy from 22 june 2005 to 21 june 2006 , who had the following inclusion criteria , were included in the study :

 nasopharyngeal carcinomas with similar stages , i.e. local and local advanced stages

 no history of surgical removal of salivary glands

 absence of any signs and symptoms of distant metastasis

 no history of saliva - reducing medications , such as anticholinergics and antidepressants

 absence of diabetes ( evaluated with fbs test before the study )

 a questionnaire was filled out for each patient .
the patients were asked to refrain form eating , drinking , brushing and smoking at least for two hours before sample collection .
in addition , they were given identical hygienic and food regimens . during the study all removable prostheses were removed so that they could not function as foreign bodies which can act as impeding factors in salivation .
all the samples were collected in one well - illuminated room while the patients were in a sitting position .

the radiotherapy of these patients was an external procedure , in which the nasopharyax and lymph nodes of the neck received cobalt 60 ( ~6mv ) radiation with two lateral fields , which consisted of an initial dose of 4400 - 4500 cgy in 25 sessions ( fractions ) , comprising 180 - 200 cgy daily .

then , after a two - day interval , spinal cord was removed from the radiation field and the field was tailored .
based on the case involved , the patients received a booster dose , which is a procedure called  conventional radiotherapy .

 saliva samples were collected by spitting method three times , i.e. before treatment , 3 weeks after the initiation of treatment and at the end of treatment .

 during sample collection
, the patients evacuated their saliva into a glass every 60 seconds for 2 - 5 minutes and then the volume of the sample was measured with a graduated pipette and recorded in the patients questionnaires .

one - way anova to test the significance of differences between means , paired sample t - test for the two - by - two comparison of means , independent sample t - test to compare the differences in the mean values between independent groups , and pearson s correlation coefficient to evaluate the relationship between quantitative variables were used .

 one - way anova to test the significance of differences between means , paired sample t - test for the two - by - two comparison of means , independent sample t - test to compare the differences in the mean values between independent groups , and pearson s correlation coefficient to evaluate the relationship between quantitative variables were used .

 a total of 30 subjects were studied , 63.3% being males and 36.7% females ( 19 males and 11 females ) .
mean age of the patients was 51.1715.44 ; mean age of females and males were 51.3614.88 and 51.0516.16 , respectively .
mean values of salivation before radiotherapy in the study population , and in males and females separately , were 1.320.37 ml , 1.340.41 ml , and 1.250.30 ml in 5 minutes , respectively .

mean values of salivation in the third week after the initiation of treatment in the study population , in males and females separately were 0.840.35 ml , 0.850.38 ml and 0.800.90 ml in 5 minutes , respectively .
means of salivation at the end of treatment in the study population , in males and females separately were 0.420.31 ml , 0.440.33 ml and 0.380.28 ml in 5 minutes , respectively ( table 1 & 2 ) .

salivation 1 : salivation before radiotherapy    : all the subjects

 salivation 2 : salivation 3 weeks after radiotherapy    : males    : females

 salivation 3 : salivation at the end of radiotherapy   :males compared to females

 pearson s correlation coefficient demonstrated the following : there was no statistical relationship between the decrease in salivary flow rate and all patients age ( p = 0.76 , n = 30 , r = -0.057 ) , males age ( p = 0.96 , n = 19 , r = 0.011 ) and females age ( p = 0.539 , n = 11 , r = -0.208 ) .

 despite great progress in cancer biology and radiotherapy techniques in recent decades , malfunction of salivary glands remains a major and ever - lasting problem subsequent to radiotherapy of head and neck malignancies .
the majority of patients experience severe xerostomia , which adversely influences their quality of life .
the patients salivary samples were collected by spitting at three intervals : before treatment , 3 weeks after radiotherapy was instituted , and at the end of treatment .
the results demonstrated that differences in the means of salivation 3 weeks after the initiation of radiotherapy compared to baseline data , at the end of radiotherapy compared to baseline data , and at the end of treatment compared to 3 weeks after radiotherapy was initiated , were statically significant .
however , there was no relationship between the decreases in the means of salivation and variables such as age and sex .
the results of the present study are consistent with the results of studies carried out by jen yee - min et al , 2006 ; nagler , 2002 ; moller et al , 2004.1
 ,
 3
 ,
 8

 yee - min attributed the decrease in salivary flow rate to the destruction of cells in serous acini and to the progression of an acute classic inflammatory process , which takes place 24 hours after receiving a 12.5-gy radiation dose . the histologic basis for a decrease in salivary flow rate has not been elucidated to data .
however , recent molecular evaluations have demonstrated that pro - inflammatory cytokines such as tnf- result in a decrease in the release of aquaporin 5 ( a group of membrane proteins responsible for the transportation of water through membranes ) , contributing to a decrease in the production of aqueous solution of saliva .
yee - min introduced the received radiation does as the most important factor involved in radiotherapy - induced xerostomia .

nagler reported that the complications of radiotherapy manifested in the salivary glands in the first weeks after the institution of radiotherapy are transient and secondary to oropharyngael syndrome .
the syndrome consists of a transient severe mucositis , resulting in dehydration , malnutrition and inadequate chewing of food due to intense pain .
nagler introduced cell death through apoptosis as an important factor in early radiation - induced xerostomia ; this cell death was attributed to injuries to membranes as a result of peroxidation of membrane lipids .
in addition , long - term xerostomia was attributed to the damage to dna , which can be observed during cellular mitosis , and to a decrease in mitotic rate .

moller , consistent with nagler s report , attributed the noticeable decrease in salivation to the death of cells in serous acini through apoptosis in the early stages and to cellular necrosis in the late stage .
in addition , moller believed the received dose by salivary glands was an important factor in determining the severity of xerostomia , pointing out that more than 2/3 of the baseline salivation is lost during radiotherapy .
considering the results of the above - mentioned studies and the almost identical doses used in those studies and our study ( approximately 60 - 65 gy ) , we believe similar mechanisms were involved in our subjects .
although we have been unable to find a research study , thoroughly evaluating the effects of age and sex on radiation - induced xerostomia , the results of our study in terms of the influence of age and sex on salivary flow rate are consistent with the results of studies carried out by yee - min et al , 2006 ; liu et al , 1990 ; moller et al , 2004 ; shern et al , 1993 ; bretz et al , 2001 ; and fischer , 1990 . however , our results do not coincide with the results of a study carried out by fenoll - palomanes , 2004 , who reported statistically significant relationship between sex and decrease in salivation and also between age and decrease in salivary flow rate .

percival attributes the lower rate of salivation in females compared to males , which is statistically significant , to the smaller size of salivary glands in women and hormonal differences .
postmenopausal females have a lower salivary flow rate but this lower rate can not be attributed to a decrease in estrogen secretion and further comprehensive studies are required .

fenoll - palomares believes , in addition to the smaller size of salivary glands in females , higher rate of autoimmune diseases in females compated to males is involved in the lower salivary flow rate in females since autoimmune diseases are important factors involved in xerostomia .

percival attributes the disparity between the results of his study with the results of studies carried out by ben - aryeh et al , 1984 , and heft and baun , 1984 , to differences in sample collection methods .

ben - aryeh and heft and baun did not find any statistically significant differences between males and females .
percival collected his samples in a 10-minute period ( contrary to 5-minute periods in the present study and other studies ) , which may have resulted in higher volumes of salvation and different results .
we , too , attribute lack of significant differences between males and females , in the present study , to differences in the methods employed and recommend further extensive studies to elucidate the role of gender in radiotherapy - induced xerostomia .

there is considerable controversy over the role of age in salivary flow rate and only limited studies have been carried out on the subject .
researchers have attributed the differences in results to differences in the methods used , differences in the criteria for case selection , differences in sample collection and finally inclusion of subjects who were taking medications which influence salivation .

a study by scott in 1977 demonstrated histologic changes in human submandibular salivary glands due to senescence .
some researchers believe that unstimulated salivary flow rate decreases with age , which can be attributed to the destruction of the parenchyme of the glands due to senescence . on the contrary
, some researchers such as fischer ( 1999 ) believe that healthy senile individuals have a salivary flow rate similar to healthy young people and attribute this similarity to the high reserve capacity of salivary glands , especially parotid , which has also been confirmed in the present study .

 the present study confirms that patients with nasopharyngeal carcinomas will experience severe xerostomia subsequent to radiotherapy , with no statistically significant differences between males and females .

Answer:
background and aims
 salivary glands are extremely susceptible to radiation injuries .
 the aim of this study was to evaluate radiation - induced xerostomia in patients with nasopharyngeal carcinomas , referring to tabriz imam khomeini hospital in 2005 - 2006 .

 materials and methods
 thirty patients with nasopharyngeal carcinomas , who received conventional radiotherapy , were included in the present study .
 the patients unstimulated saliva samples were collected at three intervals , i.e. before treatment , 3 weeks after the initiation of treatment and at the end of treatment by spitting , and measured with a graduated pipette .

 results
 the differences in the mean values of the patients salivary flow rates at three afore - mentioned intervals were statistically significant ( p<0.001 )
 . two - by - two comparison of the mean values of salivary flow rates of all the patients and of males and females , carried out separately , demonstrated statistically significant differences ( p<0.0025 ) .
 however , there were no statistically significant differences between males and females before treatment ( p = 0.723 ) , 3 weeks after the initiation of treatment ( p = 0.724 ) and at the end of treatment ( p = 0.595 ) .
 there were no statistically significant relationships between age and a decrease in salivary flow rate in the total sample ( p = 0.76 , r = -0.057 ) , in males ( p = 0.96 , r = 0.011 ) and in females ( p = 0.539 , r = -0.208 ) .

 conclusion conventional radiotherapy results in severe xerostomia in 3 weeks in patients with nasopharyngeal carcinomas .
 age and sex do not influence radiotherapy - induced xerostomia .


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:
however , studies have shown that surgery is best done during normal working hours . given the pressures on theatre use
it is important to be able to assess the retinal detachment and to ascertain the urgency of planning surgical intervention .
one of the most important features is the involvement of the macula and fovea that is macula on or macula off . in cases of macula - off retinal detachments ,
macula - on retinal detachments , however , should have their surgery expedited , the main concern being the conversion to a macula - off situation which has a much poorer visual prognosis .
the assessment of rhegmatogenous retinal detachments is multifactorial ; in an otherwise normal eye visual acuity is an easy measure of macula involvement with the 6/60 patient being macula off and 6/6 macula on .
similarly the onset of symptoms and the age of the retinal detachment is important , as chronic detachments can be more stable and surgery can be safely delayed .
also the extent of detachment and position of the retinal break can also help predict the progression of an acute macula on retinal detachment .
however , in certain situations the macula - on or macula - off question is not easily answered ; visual acuities may be misleading ; examination of the detachment may be difficult due to poor views often due to vitreous hemorrhage and chronicity may be difficult to ascertain in patients with vague histories .
high - speed spectral domain optical coherence tomography ( oct ) offers a noninvasive tool to evaluate retinal microstructural changes in a number of eye pathologies .
newer systems using spectral domain calculations have improved data acquisition speeds compared with conventional time - domain oct equipment allowing much greater axial resolution .
given the greater resolution a number of characteristic changes seen in retinal detachment have been observed . in this paper , we discuss two cases where spectral domain oct and an understanding of the histological changes have enabled a clearer diagnosis and planning of treatment .
our first case is a seventy - five - year - old gentleman who presented with a vague history of blurred vision for six weeks .
visual acuity was 6/24 and examination revealed a pseudophakic inferotemporal macula - off retinal detachment .
the reduction in visual acuity was thought to be secondary to vitreous haemorrhage as biomicroscopy assessment showed the detachment stopping inferior to the macula ( figure 1 ) . to confirm the macula status ,
contrary to the biomicroscopy examination ( figure 1 ) , this revealed a macula - off retinal detachment ( figure 2 ) .
changes seen in the oct scan were characteristic of an old retinal detachment with the presence of intraretinal cysts , undulation of outer retinal layers , and the hyper - reflectivity in the photoreceptor layer ( figure 2 ) .
secondary to these oct findings , the surgical session was deprioritised and performed five days later .
the surgical repair consisted of a three - port pars plana vitrectomy with perfluoropropane tamponade and cryotherapy .
subsequent spectralis oct one year following the retinal detachment shows restoration of normal retinal morphology with resolution of the intraretinal cysts , flattening of the retinal layers , and no hyperreflectivity seen ( figure 3 ) .
our next case was a fifty - year - old myopic female who presented on a friday with a several - month history of floaters and visual distortion described as
microstructural analysis of the macula was performed using a heidelberg spectralis oct scan which confirmed a macula - off retinal detachment ; however , the oct scan revealed that the fovea was bisected by this detachment ( figure 4 ) .
moreover , the macula microstructure seen in the oct scan showed no retinal folds or hyperreflectivity present near the fovea .
indeed , the only morphological retinal detachment changes observed which indicated any chronicity were small intraretinal cysts present peripherally away from the fovea ( figure 4 ) .
given the oct findings , she was treated as a macula - on retinal detachment patient , and surgery was expedited such that an emergency theatre session was organised within 24 hours on a saturday morning .
the surgical repair was a three - port pars plana vitrectomy using a sulphur hexaflouride tamponade and cryotherapy .
after subsequent cataract surgery , vision had returned to 6/6 with normal oct findings ( scan not shown ) .
the morphological changes seen in retinal detachment have previously been evaluated by oct and are becoming clearer with newer systems using spectral domain calculations , which have improved data acquisition speeds to ~40  000 a - scans per second allowing much greater axial resolution to approximately 3.5  m tissue resolution .
the transformations seen in retinal detachment include intraretinal cyst formation , intraretinal separation , and undulation of outer retinal layers [ 3 , 4 ] .
the disruption of the photoreceptor inner and outer segment junction in macula - off rhegmatogenous retinal detachments is also seen both preoperatively   and postoperatively [ 6 , 7 ] .
murine models comparing histology and oct confirm these findings and also highlight the hyperreflectivity in the photoreceptor layer which may represent a cellular immune infiltration or misalignment of the photoreceptor layer .
these changes were all seen in our first case ( figure 2 ) proving that the retinal detachment had been present for a period of time prior to arrival in our unit and enabling appropriate de - prioritisation within a busy vitreoretinal service . in our second case ,
in which the fovea was bisected by a retinal detachment , time of onset was in some doubt .
retinal thickness of the detached retina has been shown to be time dependent initially thickening then thinning with time [ 8 , 9 ] ; however the subfovea thickness was normal when scanned suggesting a recent event along with the absence of any intraretinal cysts , retinal undulations , and hyper reflectivity of the photoreceptor layer ( figure 4 ) .
onset of retinal detachment is of importance , as experimental retinal detachments in cats have shown that although alterations in the outer nuclear layer occur after 1 hour , progressive loss of photoreceptors continues up to 1330 days , with limited atrophy in cat retinas detached 3 to 7 days .
however , patients that have no tomographic structural changes presumably due to recent foveal involvement have better clinical prognosis .
this is most likely secondary to less atrophy and death of the photoreceptors which has histopathologically been shown to be present in prolonged detachment of the retina [ 1014 ] . finally , the height of retinal detachment , which appears to affect the formation of multiple cystic cavities in the detached inner and outer neuronal layers , correlates with poor visual outcome [ 15 , 16 ] .
all of these features when taken into account suggested a good prognostic outcome for our second patient and hence prompt surgery resulting in an excellent visual recovery ; an outcome that could have been considerably poorer if surgery had been delayed and fovea atrophy had occurred .
the morphological changes in retinal detachment seen in oct scans give prognostic factors pertaining to visual outcome and thus help anticipate surgical outcomes .
this paper has shown the two scenarios where surgical prioritisation is reversed , that is , from macula on to macula off and secondly , from macula off to macula on . in our first case ,
a chronic detachment was identified by oct and allowed planning within the department for higher priority operations to take place .
conversely , the lack of subfoveal morphological changes in our second case led to the conclusion that the detachment was recent and prognosis good , thus surgery was expedited .
we suggest that if any doubt regarding the status of the macula exists , a routine noninvasive oct should be performed to help clarify the situation prior to surgery .

Answer:
regmatogenous retinal detachments need prompt intervention particularly when macula is on .
 unfortunately this is not always easy to ascertain clinically and the chronicity of the event is often muddled in patient 's histories .
 developments in optical coherence tomography ( oct ) have allowed high - resolution axial scans which have enabled the characterisation of retinal changes in retinal detachments . in this paper
 , we show the changes in retinal morphology observed by spectral domain oct and how this can be used to plan appropriate surgical intervention .


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:
castleman 's disease is a lymphoproliferative disorder with benign hyperplastic lymph nodes characterized histologically by ( a ) follicular hyperplasia , and ( b ) capillary proliferation with endothelial hyperplasia ( 1 ) .
this disease has been classified histopathologically as hyalinevascular , plasma cell , or a mixed type variant of the two ( 2 , 3 ) .
the plasma cell and mixed types are often associated with ' multicentric castleman 's disease ' ( mcd ) , which shows various systemic manifestations , such as fever , anemia , hypergammaglobulinemia , hypoalbuminemia , and an increase in acute phase proteins ( 2 ) .
mcd is often refractory to conventional therapeutic strategies , such as corticosteroid , cytotoxic agents , and/or radiation ( 4 , 5 ) .
the frequency of mcd associated with a lung lesion among the japanese population is high ( ~70% ) ( 6 ) and such progressive lung lesions often lead to death ( 2 , 7 ) .
interleukin-6 ( il-6 ) is a pleiotropic cytokine with a wide range of biologic activities , such as hematopoiesis , regulation of immune responses , and inflammatory responses ( 4 ) .
patients with the plasma cell type castleman 's disease often generate large quantities of il-6 in the germinal centers of hyperplastic lymph nodes ( 8) . '
tocilizumab ' is a humanized anti - interleukin-6 receptor antibody that neutralizes the pleiotropic actions of il-6 .
it was approved for use in japan for the treatment of castleman 's disease in 2005 .
this report describes a case of mcd with an associated lung lesion , which responded dramatically to tocilizumab in combination with corticosteroid and tacrolimus .
a 43-yr - old female visited a nearby hospital because of abnormal shadows including multiple nodules and reticular shadows on chest radiography found at an annual medical checkup in 2005 .
they were unable to obtain a biopsy specimen from one of the nodules in s10 of the left lung because the patient had a strong bleeding tendency .
she was referred to this hospital for further examination on june 30 , 2005 . on admission ,
the laboratory data were : erythrocyte sedimentation rate , 119 mm/1 hr ; white cell count , 8,900/l ; hemoglobin , 8.4 g / dl ; platelet count , 39.410/l ; serum aspartate aminotransferase , 22 iu / l ; alanine aminotransferase , 22 ; total protein , 9.7 g / dl ; albumin 2.6 ; creatinine , 0.48 ; pt , 13.1 sec ( inr 1.45 ) ; aptt , 39.6 ( control , 10.4 ) ; fibrinogen , 750 mg / dl ; kl-6 , 277 u / ml ( reference range < 500 ) ; c - reactive protein , 11.7 mg / dl ( < 0.3 ) ; serum immunoglobulin ( ig)g , 4,570 ( 870 - 1740 ) ; iga , 491(110 - 400 ) , igm , 706 ( 35 - 220 ) , ch50 , 52.3 u / ml ( 30 - 50 ) , soluble il-2 receptor , 1,400 ; serum il-6 , 6.8 pg / ml ( < 4 ) ; rheumatoid factor ( rf ) , 1,330 iu / ml ( < 20 ) .
autoantibodies , including antinuclear antibody , anti - ds - dna , anti - sm , anti - rnp , cytoplasmic antineutrophil cytoplasmic antibody ( anca ) , and myeloperoxidase - anca were all negative .
chest ct scan disclosed a slight enlargement of the mediastinal lymph nodes , centrilobular nodules , thin - walled cysts , the thickening of the bronchovascular bundles , and ground - grass opacities , all of these findings were compatible with those of lymphocytic interstitial pneumonia ( lip ; fig .
gallium citrate scintigraphy did not reveal any evident accumulation . a lung surgeon and a thoracic physician declined to perform a lung biopsy because of her bleeding tendency ( bleeding time : 6 min 30 sec ) and poor general condition .
a biopsy of an inguinal lymph node was obtained for making a definite diagnosis ( fig .
she was diagnosed with mcd and undifferentiated arthritis based on the characteristic pathology of the specimen of the inguinal lymph node , ct findings of the bilateral lung lesions and laboratory data .
she was initially administered intravenous corticosteroid ( methylprednisolone , 500 mg / day , 3 consecutive days ) followed by oral corticosteroid ( methylprednisolone , 16 mg / day ) , and , 375 mg / m rituximab every week for 4 weeks .
the polyarthralgia instantly disappeared ; however , none of the other clinical and laboratory parameters were fully resolved .
therefore the therapeutic regimen was changed to tocilizumab ( 8 mg / kg , every 2 weeks ) , oral corticosteroid ( methylprednisolone , 16 mg / day ) on october 25 , 2005 .
the patient requested that the interval between tocilizumab to be increased to more than every two weeks .
the dose of corticosteroid in combination with tocilizumab should be kept as low as possible to avoid various side effects , such as osteoporosis , hyperglycemia , and hypertension .
both the possible merits and demerits of the drug were explained to the patient and her oral consent was obtained .
laboratory findings , including anemia , hypergammaglobulinemia , and an increase in acute phase proteins responded to this regimen ( fig .
the enlargement of mediastinal lymph nodes and abnormal shadows were also partially alleviated ( fig .
the intervals of the tocilizumab - administration sessions were extended from every 2 weeks to every 3 weeks from january 2006 .
oral corticosteroid was gradually tapered from 16 mg / day finally to 4 mg / day .
the treatment of mcd includes various therapeutic strategies such as corticosteroid , chemotherapy , rituximab , or tocilizumab .
rituximab , an immunoglobulin g1 ( igg1 )  monoclonal antibody to cd20 , has the potential for b - lymphocyte depletion via antibody - dependent cell mediated - cytotoxicity ( adcc ) , complement dependent cytotoxicity ( cdc ) , and apoptosis .
kaposi 's sarcoma - associated herpes virus ( kshv / hhv8 ) was thought to be associated with the development of castleman 's disease , especially in patients infected with human immunodeficiency virus ( hiv ) and rituximab was reported to be effective in hiv - related castleman 's disease ( 11 ) .
the effectiveness of rituximab was limited in the present case because the patient was not infected with hiv . a humanized anti - interleukin-6 receptor antibody , tocilizumab ,
was shown to be effective for the treatment of mcd in an open label trial , and has been widely used in japan ( 5 ) .
the frequency of mcd associated with a lung lesion is relatively low ( 10 - 20% ) in the united states .
in contrast , nishimoto et al . reported that 18 of 28 japanese cases ( = 64.3% ) had a lung lesion ( 6 ) .
the ct findings of intrathoracic involvement in mcd include bilateral hilar and mediastinal lymphadenopathy , centrilobular nodular opacities , thin - walled cysts , interlobular septal thickening , and ground - glass attenuation ( 9 ) .
some reports have noted that the lung lesion in mcd is compatible with lymphocytic interstitial pneumonia ( lip ) ( 5 , 9 ) .
( 12 ) reported a case of mcd with a lung lesion that responded to tocilizumab .
( 7 ) described that the administration of tocilizumab for 2 yr had no effect on the lung lesion in an mcd patient .
il-6 production by the germinal center b cells in the swollen lymph nodes of patients with mcd is remarkable ( 8) , but the roles of t cells are unknown .
if t cells do participate in the pathogenesis , immunosuppressive drugs for t cells should be useful .
in fact , mcd , which is classified as a lymphoproliferative disorder , has characteristics of an autoimmune disease , demonstrated by the production of autoantibodies .
several studies have shown that these drugs are active not only against t cells but also against other cells .
they suppress the promotion of il-6 in the rheumatoid synovium where t cells are relatively scarce ( 13 ) .
they also suppress il-6 production in monocytes , and tnf- production in b cells ( 14 , 15 ) .
pham et al . ( 16 ) reported that inhibition of nf-b and nfat activation in aggressive b - cell lymphomas by calcineurin inhibitors suppressed the cd40 ligand expression in b cells and lymphoma cell survival in an in vitro experiment .
some of these actions of tacrolimus , if not all , may be associated with the efficacy of the drug for the treatment of mcd .
( 17 ) reported that non - cytostatic immunomodulatory therapy including corticosteroid , cyclosporine a and thalidomide treatment was effective for castleman 's disease .
the long - time use of tocilizumab and corticosteroid is necessary for the treatment of mcd .
corticosteroid has various dose - related side effects , and acquisition of drug resistance possible .
p - glycoprotein ( p - gp ) plays a pivotal role in the latter .
peripheral lymphocytes in patients with autoimmune diseases could express p - gp on their cell surface .
calcineurin inhibitors have an antagonistic activity to p - gp : they may inhibit corticosteroid - resistance in peripheral lymphocytes in vivo ( 18 , 19 ) .
the dose of corticosteroid could be tapered in the current case , at least in part , due to the antagonistic activity to p - gp of tacrolimus . in conclusion , this is the first report to describe that tocilizumab , in combination with corticosteroid and tacrolimus , shows a dramatic effectiveness in the treatment of a lung lesion in an mcd patient .

Answer:
this report presents the case of a patient demonstrating multicentric castleman 's disease ( mcd ) with a lung lesion that was successfully treated with an anti - interleukin-6 receptor antibody , tocilizumab in combination with corticosteroid and tacrolimus .
 a 43-yr - old female with abnormal shadows on a chest x - ray was referred to the hospital for further examination .
 she was diagnosed as having mcd based on the characteristic pathology of inguinal lymph node , lung lesions , laboratory data , and undifferentiated arthritis .
 corticosteroid and rituximab therapy did not fully ameliorate the symptoms ; thus , the therapeutic regimen was changed to include tocilizumab , oral corticosteroid and tacrolimus .
 this regimen resulted in clinical remission and the dose of tocilizumab and corticosteroid could be tapered .
 tocilizumab in combination with corticosteroid and tacrolimus may therefore be a beneficial treatment regimen for lung lesions associated with mcd .


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:
organized by nei dan school , european school of taiji quan and by the  tao and science studies centre , under the aegis of the provincia di bologna and the partnership of asi ( alleanza sportiva italiana ) and luni editrice .
goodwill of the conference is to act as a starting point to develop a net of experts , doctors and scientists , who will investigate the dynamic interactions between spiritual insight and scientific analysis to come to the creation of a new paradigm of modern science .
science , philosophy , medicine and body arts of the ancient east are reunited together to create a new ecological awareness of body and mind .
modern science , which paved the way for an outlook of reality considering the universe as a whole , in which all parts and phenomena are connected among them , can be integrated to the ancient eastern wisdom for the control of the mind and to the body arts ( taiji quan , qi gong , yoga ) to develop a new ecological awareness , an awareness based on nature and on the dynamic relation among all living creatures .
the conference was divided in two sections : a gathering of experiences , of paths where science meets metaphysics to have a new language born , made of images and movement , and a panel to understand how taiji quan , the arts of movement and meditation , can prolifically meet cognitive sciences and neurosciences .
speakers during the tao and science conference were : andrea pezzi ( presenter and tv author ) ; professor edwin l. cooper professor , laboratory of comparative neuroimmunology , department of neurobiology , david geffen school of medicine , university of california los angeles , editor - in - chief , the journal : evidence based complementary and alternative medicine , oxford university press ; professor carlo ventura ( professor of molecular biology at the faculty of medicine , university of bologna ; director of the laboratory of molecular biology and stem cell bioengineering , national institute of biostructures and biosystems by the institute of cardiology of santorsola malpighi hospital in bologna ) ; professor angelo marzollo ( professor of systems theory , faculty of sciences , university of udine ; vice general secretary of the international centre for mechanical sciences ; unesco ex - person in charge for mathematics and now consultant ) ; professor giovanni sambin ( professor of logic mathematics , university of padova ) ; dottor matteo luteriani ( publisher , journalist and master of martial arts ) , dottor massimo mori ( doctor , poet and master of taiji quan ) and eng .
flavio daniele ( writer and master of taiji quan ) the following guests took part in the conference through their representatives : professor james k. gimzewski ( department of chemistry and biochemistry , university of los angeles
ucla ; director of the  pico lab  laboratory at ucla ) ; professor aldo stella ( teacher of medical psychology , university of urbino ; teacher of psychology of cognitive processes , university for foreigners of perugia ) ; professor carmelo di stefano ( teacher of teaching didactics of the adapted movement and sports activity , faculty of motor sciences , university of bologna ) .
carlo ventura , md , phd : western science has long been entangled with increasing reductionism and the development of  field restricted approaches to understand cell biology and the molecular basis of disease .
it is now becoming increasingly evident that reductionism is a remarkable bias in pursuing some of the major goals of modern biology and medicine .
complex problems , including cell growth and differentiation under normal or malignant conditions ( cancer ) , and the adaptive mechanisms of humans to multiple changes in cell signaling networks now pose the need for holistic approaches both at the molecular biology and medical levels .
such a requirement is even more urgent in spite of the emerging interest in stem cell biology , since taking a glimpse at the mechanisms underlying cell commitment and fate specification may hold promises for a revolutionary field , the so - called  regenerative medicine. while moving from reductionism to holistic approaches , the cell is studied as an integrated system , behaving as a neural network with complex and sophisticated logics .
awareness of these features has progressively led to wide - ranging strategies in the investigation of gene and protein expression .
techniques such as the dna microarray and the serial analysis of gene expression ( sage ) are now able to follow the expression of thousands of genes and signaling molecules at a time , attempting to uncover the overall plans that underlie molecular patterning and cellular decisions .
omics era ( genomics , proteomics ) and will hopefully form the scientific underpinning for moving from basic science to a clinical practice in which physicians will learn how to deal with illness rather than disease ( or even worst , diseased organs ) .
a major sign of these cultural changes is provided by the ongoing development of nanobiotechnologies . in both the philosophical and visual sense ,
 seeing is believing does not apply to nanotechnology , for there is nothing even remotely visible to create proof of existence . on the atomic and molecular scale ,
data is recorded by sensing and probing in a very abstract manner , which requires complex and approximate interpretations .
more than in any other science , visualization and creation of a narrative becomes necessary to describe what is sensed , not seen .
we have growing needs for separating the  informational content of life from its  material substrate.
information is thought to be the essence of life , as in the dna code ( james k. gimzewski , university of california at los angeles , department of chemistry and biochemistry , director of  the pico lab  at ucla ) .
edwin cooper highlighted how different alternative medicines if integrated can be useful to reclaim that holistic view of the diseased person , that an excessive specialization has made modern western medicine lose and he illustrated the work done in this direction by the biomedical journal ecam .
disease has always been of enormous concern in human society . from prayers and spells to the birth of medicine as a rational science , man has developed all sorts of medical treatments to combat different illnesses and chronic ailments : according to the chinese proverb :  life is worth more than a thousand gold pieces. the first objective in a serious approach to complementary and alternative medicine ( cam ) should be to obtain a broad understanding , with a minimum of detail , of how cam fits into the pattern of biology  of the way in which the nervous , endocrine and immune systems coevolved , their function and coordination with other body systems , and their development from the embryo onwards including aging . at the same time , such an outline should provide an adequate background for easy application of cam ideas to the detail of practical cam work in public health , clinical and medical practice , and yet not stray far away from its essence , the very biology that under girds it .
cam is organismic , considers the whole individual and is inclusive , not reductionist nor exclusive .
concerning senescence and age - associated diseases , that accompany longer living populations , substantial attention is now focused on searching for : ( i ) mechanisms of aging and ( ii ) approaches to ameliorate or lessen the effects through the use of therapies , some of which utilize natural products from aquatic and terrestrial plants and animals .
clearly there are numerous treatments to explore and to understand long past the anecdotal information that has been passed on through centuries .
there is evidence for treatment of diseases of an ever - aging society especially in developed countries .
it is of great interest that these remedies now being refined by ecam approaches derives almost entirely from primitive societies where there are minimal facilities essential for analyses by an evidence - based approach .
massimo mori said :  [  ] if the scientific research is free , the same is not valid for its technological applications , which have to serve an ecology of culture marked by wisdom , an ecology of the mind , as wrote gregory bateson , in harmony with nature ; nature , where the uncertainty principle of werner heisenberg has scientific and philosophical value ; harmony , comprising the clash and entropy of ilya prigogine as factors of transformation . a holistic view recomposing the divided self of ronald d. laing , giving deepness to the one - dimensional man of herbert marcuse. prof .
angelo marzollo highlighted the importance of combining the art of  to say with the art of  to do , i.e. , that the learned man , the intellectual is direct evidence of the ideas carried on by him , that the body does not contradict the mind , that the body - mind unit remains not only a theoretical statement .
giovanni sambin said :  although the theme is science , i can speak only about my specialization .
i am fascinated by oriental wisdom , but i know almost nothing about it because of lack of time .
i am here only because i am trying to learn tai ji quan , with master roberto benetti. mathematics is important in western science .
galilei was the first to propose that the laws of nature are written in the language of mathematics .
this has been the base for inventions characterizing industrial revolution in xixth century . by using mathematics
so mathematics is at the base of present - day western technological supremacy . in modern times , debate concerning foundations of mathematics has been most lively at the beginning of xxth century .
one of its outcomes was the invention of programmable computers , which speaks of its importance .
i am not a believer , but i find constructivism much more convincing than the now dominating theory , which is called classical and is considered by most scientists as an absolute truth .
to do modern mathematics one needs an abstract notion of concept , or set . in the classical approach , one has classical logic ( by which all propositions are either true or false , any third possibility like abstinence is excluded ) and axiomatic set theory ( all sets are there already , a static universe containing now , and ever , all possible concept - sets ) .
the mental scheme looks as something like : classical mathematics is at the base of western science , which is the reason for technological superiority , which makes western people the owners of the world .
hence it must be that western mathematics , and all what follows from it , is an absolute truth , which can be imposed on others by force .
needless to say , this view can be extremely dangerous . here and in all my life ,
my aim is to show that a different foundation of mathematics is possible , which has the same applications , but which avoids any form of fundamentalism .
a way of doing mathematics is possible , in which the will of power is replaced by harmony with nature , control is replaced by knowledge , brute external force is replaced by internal energy , the search for the
i want to emphasize that originally this was not motivated by some ethical or political principles , rather by the search for a better foundation of mathematics .
master flavio daniele emphasized as most advanced research of the last decades of the past century in the field of cognitive sciences and neurosciences led to a new theory , revolutionizing the traditional cartesian concept of mind .
this theory , known as the santiago theory of cognition , claims that mind can no longer be regarded as a thing but as a process .
process , which is cognition to which belong perceptions , emotions and actions , the language , the conceptual thought and all the attributes of conscience , which is peculiar to man .
this view , perfectly in line with the eastern traditional thought , entails that mind with its cognitive processes goes beyond the rational aspect as it includes the whole process of life .
a further implication of this theory , which will show its vast potential , when it will be absorbed at the general cultural level , is that mind and matter are no longer regarded as separated dimensions , but as complementary aspects of the sole phenomenon of life : the process ( the mind ) and the structure ( the brain ) .
mind and matter , process and structure are indivisibly connected at all levels of life : from the simplest cell to the most complex organism .
this connection is so deep , as most recent studies in the field of cognitive sciences has demonstrated , that we can state ,  conceptual thought , on the whole , is physically incarnated in the body and in the brain. this goes beyond the simple consideration that to think we need a brain and leads to state that  human reason does not transcend body , but it is structurally shaped by our physicality and body experience. a further discovery of cognitive sciences , consequent to it that : ( 1 ) mind is deeply incarnated in the body , and the other that , ( 2 ) thought is mainly unconscious , is that ( 3 )  abstract concepts are to a large extent metaphorical. for the time being , present researchers have not explained in detail the neurophysiological dynamics underlying the formation of abstract concepts ; however , the scientists lakoff and johnson state that  the neural and cognitive mechanisms enabling us to sense and move are the same to create also our conceptual structures and our ways of reasoning. this statement that conceptual structures and ways of reasoning come from the same neural and cognitive structures of perception and movement , is extremely important for the practitioners of the arts of movement ( taiji quan , yoga , sacred dances , ritual gestures or mudra ) , as it demonstrates and confirms the creative power of movement , which no longer acts as simple instrument at the service of mind , to play the fundamental role of shaper of the cognitive capabilities ( conceptual thought , speech , conscience ) of the human mind . by paraphrasing maturana and varela
cognition , the process of knowledge , and it is identical to the process of life self . nevertheless , beyond the dialectics coming from the differences , it is more and more important to reintroduce a principle , acting as basis for the man universally , a principle which is internal and unconventional , an equal able to give the equal to all psycho - biological behaviors of the human being . in italy
this kind of research has always taken place , and in recent years has made its way into the experimental evidence of a psychology able to touch this dimension .

Answer:
the conference was organized and supported by : nei dan school ( european school of internal martial arts ) , nib ( laboratory of molecular biology and stem cell bioengineering , national institute of biostructures and biosystems , institute of cardiology , s.orsola-malpighi hospital , bologna ) , wacima ( worldwide association chinese internal martial arts ) , arti doriente ( magazine of eastern culture and traditions ) , nuovo orizzonte ( taiji quan school in florence ) , samurai ( journal on martial arts ) , and pinus ( first national institute for the unification of medical strategies ) .
 nei dan school ( www.taichineidan.com , neidan@libero.it ) was in charge of the organization .
 future meetings of the centro studi  tao and science will take place in spring 2007 in firenze and in october 2007 in bologna . for information :
 e - mail : neidan@libero.it ; web site : www.taichineidan.com , www.taoandscience.com


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:
bilateral ectopic pregnancy is a rare condition and is divided in two subgroups , primary and secondary , based on history of assisted reproductive technology .
a 30 year old primigravid woman with history of infertility and ovulation induction presented to a hospital in kashan in year 2013 .
she had vaginal bleeding , abdominal pain and ultrasound findings suggested early pregnancy . due to high titer of -hcg , gestational trophoblastic disease was proposed and d8c was done in referral and admission to gyneco - oncology ward in tehran .
repeat sonography suggested ectopic pregnancy in left side and repeat -hcg level showed an increase of 19435 miu / ml .
bilateral ectopic gestation should be considered as a rare differential diagnosis for ectopic pregnancy . in this study ,
the implantation and development of fertilized ovum outside the uterine cavity is observed in approximately 2% of all pregnancies . over 95% of ectopic pregnancies
because of the increase in incidence of sexually transmitted diseases , tubal surgery and more frequent use of ovulation induction and assisted reproductive technologies ( art ) , the incidence of ectopic pregnancies has grown in the last 30 years according to many reports from developed countries .
ectopic pregnancy is still the leading cause of pregnancy - related deaths in developed countries ( 1 ) .
however , bilateral tubal pregnancy is a rare clinical condition which occurs in only 1 per 200,000 pregnancies .
this condition is divided in two subgroups , primary and secondary , and because of different physiopathological mechanisms , these two entities should be studied separately .
however , as studies have shown , the cause of bilateral ectopic pregnancy after art is clearly different from spontaneous cases .
clinical and paraclinical findings of this condition are the same as unilateral ectopic pregnancy so the distinct diagnosis is difficult ( 2 ) . in the present article , a case of bilateral tubal pregnancy
a 30 year old primigravid woman has been hospitalized in kashan in year 2013 due to minimal vaginal bleeding and low abdominal pain .
she had been under different treatments including sequential treatment with clomiphene , fsh and hmg in previous cycle .
her last menstrual period was 8 weeks ago . in admission , vital signs were normal .
the first transvaginal ultrasound revealed a suspicious gestational sac without yolk sac in uterus and normal adnexal area was reported .
due to high level of -hcg ( 16000 miu / ml ) , without normal viable intrauterine pregnancy , dilatation and curettage had been done to clarify existence of intrauterine pregnancy or its complications or ep .
due to high level of -hcg , gestational trophoblastic neoplasm was considered in differential diagnosis besides ectopic pregnancy and it resulted in gyneco - oncology consultation .
the rise of -hcg level to 21770 miu / ml , 9 days after operation resulted in referral and admission of patients to gynecology - oncology ward of our center in tehran .
positive findings in this admission to gynecooncology ward in tehran were low abdominal pain , minimal vaginal bleeding with stable vital signs similar to the ones observed in previous admission . through
re - checking the -hcg level , titer of 19435 miu / ml was observed .
the next ultrasound reported a normal uterus with endometrial thickening up to 11 mm , a heterogeneous mass measuring 49 mm in left adnex , suspicious to ectopic pregnancy and two simple cysts , 69 mm in left ovary and 50 mm in right ovary .
there was no free fluid in the pelvic cavity . because of persistently high level of -hcg , surgical intervention was done . atypical findings and diagnosis of gtn besides fp led to choice of laparatomy instead of laparascopy .
surgical findings were two bluish , 5 cm in left side and 2 cm in right side , swelling in both ampullary parts of fallopian tubes with minimal bleeding from fimbria .
two simple cysts , about 5 cm in right ovary and 4 cm in left ovary were seen .
bilateral salpingostomy was performed and some trophoblastic - like tissue was extracted and sent for pathologic evaluation separately .
the patient received 50 mg / m intramuscular methotrexate due to bipateral fp and non - radical approach .
secondary bilateral ectopic pregnancy is a condition with localization of trophoblastic tissue in both tubes , following a kind of manipulation in physiology such as through the use of art drugs .
the classic triad of pain , vaginal bleeding and missed period was present , similar to unilateral ectopic pregnancy . in a study , 19 secondary bilateral tubal pregnancy cases were reviewed in an attempt to examine the symptoms and signs .
diagnosis in this group was done due to discrepancy between sonography and -hcg level . in 6 out of 19 ( 31.6% ) cases ,
due to involvement of both fallopian tubes , probability of rupture is higher in comparison to unilateral ectopic gestation ( 2 ) . in the case of the present study , as a secondary bilateral ectopic gestation , high level of -hcg without intrauterine pregnancy suggested ectopic gestation and atypical high titer of hcg resulted in referral to a tertiary gyneco - oncology ward . in review of studies , mean gestational age at the time of diagnosis was about 6.7 weeks ( 5 - 9 weeks ) after the last menstruation ( 2 ) .
sonographic findings and -hcg level , usually , do n't lead to a correct diagnosis of bilateral ectopic pregnancy . due to ample amount of -hcg during normal gestation , its level is not diagnostic ( 13 ) . in a review of hcg level in 16 cases of secondary bilateral tubal pregnancy ,
mean level of -hcg was 20878 miu / ml with a wide range of 27 - 226768 miu / ml .
three cases out of 16 revealed -hcg titers of 13296 , 62520 and 226768 miu / ml ( 2 , 47 ) . in unilateral ectopic pregnancy , there is lower level of -hcg .
in contrast to normal pregnancy with predictable range of -hcg in each week of gestation , in ectopic pregnancy it is more variable ( 2 , 3 ) . in our case ,
empty uterus coexisting with high level of -hcg suggested gestational trophoblastic disease ( gtn ) and ectopic pregnancy was less probable due to high atypical titer 21770 miu / ml hcg . high level of -hcg titer in bilateral ectopic gestation , such as above 10,000 in 3 case reports and our case and even 226768 miu / ml in a case report , proposed gtn as a reasonable differential diagnosis .
however , pre - operative diagnosis of secondary bilateral ectopic pregnancy was made just in 10% of patients ( 2 ) . in our case ,
bilateral rupture of tubes was rare . in 5 out of 19 cases in a review of secondary bilateral ectopic pregnancy , unilateral tubal rupture in operative field
bilateral unruptured tubal pregnancy in ampulary portion of tubes was seen . in our case ,
left tube was more distended , about 5 cm and right tube was 2 cm . in the review of bilateral tubal gestation in literature including primary and secondary cases , left tubal pregnancy was larger and more prone to rupture in comparison to right one .
an attempt was made to review cases of medical literature which the side and size of rupture in bilateral tubal gestation was defined ( table 1 ) . medical treatment of these patients is not fully studied when pre - operative diagnosis is made .
there are three surgical approaches for ectopic pregnancy : salpingotomy , salpingostomy and radical salpingectomy . regarding the future plan of fertility procedures , conservation or resection of fallopian tubes
might be planned in the operation field ( 1 , 2 , 810 ) . in this case ,
size of right and left tube distention according to surgical findings in cases with bilateral ectopic pregnancy
bilateral ectopic gestation , although rare , should be regarded as the differential diagnosis for ectopic pregnancy , especially in assisted reproductive technology cases and high titers of -hcg ( more than 100000 ) .
left tubal side of bilateral tubal pregnancy was more probable to rupture and it revealed bigger size in review of cases .

Answer:
backgroundbilateral ectopic pregnancy is a rare condition and is divided in two subgroups , primary and secondary , based on history of assisted reproductive technology.case presentationa 30 year old primigravid woman with history of infertility and ovulation induction presented to a hospital in kashan in year 2013 .
 she had vaginal bleeding , abdominal pain and ultrasound findings suggested early pregnancy . due to high titer of -hcg , gestational trophoblastic disease was proposed and d8c was done in referral and admission to gyneco - oncology ward in tehran .
 repeat sonography suggested ectopic pregnancy in left side and repeat -hcg level showed an increase of 19435 miu / ml .
 laparotomy findings revealed bilateral ampullary ectopic pregnancy .
 bilateral salpingostomy followed by one course of methotrexate was prescribed.conclusionbilateral ectopic gestation should be considered as a rare differential diagnosis for ectopic pregnancy . in this study ,
 bigger size and rupture in left side was observed .


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 prevalence of
 newborns with hyperthyrotropinemia was 1 in 8,000 live births at the beginning of neonatal screening in 1979
 ( 1 ) , and it is now 1 in 2,500 births ( 2 ) in japan . due to the increase in the prevalence of screening - positive newborns ,
the number of
 newborns diagnosed as having transient hypothyroidism or transient hyperthyrotropinemia has increased .
it has
 been reported that about 30% of screening - positive newborns with anatomically normal thyroids have transient
 forms of the disorder ( 3 ) .
the causes of transient hypothyroidism or
 transient hyperthyrotropinemia include prematurity , maternal thyroid disease and excess or lack of maternal
 iodine intake ( 4 ) . on the other hand
, it has been reported that
 subclinical hypothyroidism persists in late childhood in about 30% of children found to be false - positive during
 neonatal screening ( 5 ) .
it is unclear whether transient thyroid dysfunction and subclinical hypothyroidism represent true clinical
 conditions .
the aim of this study was to determine whether transient thyroid dysfunction and subclinical
 hypothyroidism detected during neonatal screening are influenced by genetic background .
the tsh receptor ( tshr ) ,
 thyroid peroxidase ( tpo ) and dual oxidase 2 ( duox2 ) genes , for which it has been reported heterozygous defects
 cause neonatal transient thyroid dysfunction , were analyzed in children with transient thyroid dysfunction or
 subclinical hypothyroidism detected during neonatal screening .
we recruited nine screening - positive children who had not received levothyroxine ( l - t4 ) replacement or had been
 able to stop l - t4 replacement after re - evaluation of thyroid function .
subjects with known underlying causes of
 transient thyroid dysfunction , such as prematurity , down syndrome , maternal thyroid disease and excessive
 maternal iodine intake , were excluded .
they were continuously observed at toho university omori medical center
 or ibaraki children s hospital .
the study was performed with the approval of the institutional review boards of the toho university school of
 medicine and ibaraki children s hospital , and informed consent for participation in this study was obtained from
 all the subjects parents .
all exons of the tshr
 gene , tpo gene and duox2 gene were amplified by polymerase chain reaction ( pcr ) using primers described in
 previous reports ( 6,7,8,9 ) .
the purified pcr products were
 sequenced directly by an automated dna sequence analyzer ( abi 310 autosequencer , applied biosystems , foster
 city , ca , usa ) .
basal tsh levels above 5 u / ml were considered elevated ( 5 ) , and peak tsh
 levels after trh stimulation above 35 u / ml in infants and above 2530 u / ml in children were considered
 exaggerated responses ( 10 , 11 ) .
the serum tsh level was 24.3  11.2 u / ml ( n=8 ) during neonatal screening .
the serum tsh and free t4 levels
 during the first visit to the hospital at 27  16 d of life were 14.3  8.0 u / ml ( n=9 ) and 1.52  0.25 ng / dl
 ( n=8 ) , respectively ( table 1 ) .
four children had not
 received l - t4 replacement , but their thyroid functions had been evaluated every 6 to 12 mo .
although subject 8
 showed normal serum tsh and t4 levels ( 4.19 u / ml and 10.9 g / dl , respectively ) during her first visit to the
 hospital at 56 d of life , her serum thyroglobulin ( tg ) level ( 120 ng / ml ) was slightly high .
the remaining five children started l - t4 replacement during the neonatal
 period and stopped it after re - evaluation of thyroid function at the age of 5.5  2.2 yr .
after the cessation of
 l - t4 replacement , their thyroid functions were evaluated every 6 mo .
the initial dose of l - t4 replacement was
 3.2  0.5 g / kg / d , and the dose of l - t4 replacement at cessation was 1.0  0.2 g / kg / d ( table 2 ) .
no
 patients had a family history of thyroid diseases.table 1   subjects initial thyroid function resultssubjectsexserum tsh level at screening ( u / ml)at first visit to the hospitalinitial dose of levothyroxine ( l - t4 )
 ( g / kg / d)age ( d)basal tsh level ( u / ml)ft4 ( ng / ml)tsh peak after trh stimulation ( u / ml)1f42.01217.961.7190.713.42f15.41711.881.5948.762.63f14.5545.51.2nano treatment4f26.11832.781.75na3.05m14.51214.321.0952.913.86m43.41119.051.8546.623.07m20.33811.581.42nano treatment8fna564.19nanano treatment9m17.92011.81.2nano treatmentna : not available .
 table 2   subjects follow - up thyroid function resultssubjectagegenetic defectbasal tsh level under no treatment
 ( u / ml)at re - evaluationagetsh peak after trh ( u / ml)dose of l - t4 ( g / kg / d)16yr , 5moa single tshr mutation ( r450h)3.206.004yr , 0mo43.71.028yr , 4mond1.402.806yr , 6mo21.70.938yr , 4mond2.98nano treatment48yr , 6mond2.502.607yr , 2mo18.41.359yr , 3mond2.106.605yr , 6mo29.10.8610yr , 4mond1.401.909yr , 0mo20.71.0714yr , 1mond1.206.550yr , 8mo26.9no treatment814yr , 3moa single tpo mutation ( p883s)3.016.1110yr , 8mo30.2no treatment915yr , 0mond1.305.001yr , 5mo22.5no treatmentnd : not detected , na : not available . nd : not detected , na : not available .
ultimately , subjects 1 , 5 , 7 and 8 were diagnosed as having subclinical hypothyroidism because of fluctuating
 basal tsh levels during the no treatment period and/or exaggerated tsh responses to trh simulation at
 re - evaluation . all subjects with subclinical hypothyroidism were negative for anti - tpo and anti - tg antibodies .

subjects 2 , 4 and 6 were diagnosed as having neonatal transient hypothyroidism because they showed normal tsh
 responses to trh stimulation at re - evaluation and their basal tsh levels had been normal after cessation of l - t4
 replacement .
subjects 3 and 9 were diagnosed as having transient hyperthyrotropinemia because they had not
 received l - t4 replacement and their basal tsh levels had been normal since the early infantile period .
subject 1 was heterozygous for a tshr gene mutation ( r450h ) , and subject 8 was heterozygous for a tpo gene
 mutation ( p883s ; fig .
1 sequence analysis of a tshr gene in subject 1
 ( a ) and a tpo gene in subject 8 ( b ) . (
a ) the mutant site ( g to a ) is indicated by the arrow .
( b ) the mutant site ( c to t ) is indicated by the arrow .

sequence analysis of a tshr gene in subject 1
 ( a ) and a tpo gene in subject 8 ( b ) .
( a ) the mutant site ( g to a ) is indicated by the arrow .
( b ) the mutant site ( c to t ) is indicated by the arrow .

one group
 consists of genes causing thyroid dysgenesis , and the other group consists of genes causing thyroid
 dyshormonogenesis ( 12 ) . among them , tshr , sodium iodine symporter ( nis ) ,
 tg , tpo and duox2 gene defects have been occasionally reported to cause mild hypothyroidism .
subjects who are
 heterozygous for tshr gene mutations have been reported to show various phenotypes , from euthyroid to mild
 hypothyroidism ( 13,14,15,16 ) .
some subjects with
 heterozygous tshr gene mutations were identified during neonatal screening , and the others were identified in
 the course of evaluation for common nonspecific symptoms .
subjects with biallelic inactivating mutations of the
 nis gene and tg gene have also been reported to show various phenotypes , from euthyroid to severe hypothyroidism
 ( 17,18,19,20 ) .
reported that the
 heterozygous carrier rate for tpo gene mutations is significantly higher in babies with neonatal transient
 hypothyroidism than in normal babies and suggested that the presence of heterozygous tpo gene mutations
 contributes to development of neonatal transient hypothyroidism ( 21 ) .

several reports suggest that biallelic inactivating mutations in the duox2 gene are associated with severe and
 permanent congenital hypothyroidism and that heterozygous mutations of duox2 gene are associated with neonatal
 transient hypothyroidism ( 9 , 22 ) .

however , maruo et al . reported that subjects with compound heterozygous duox2 mutations
 detected during neonatal screening also showed transient hypothyroidism ( 23 ) . in the present study , the tshr , tpo and duox2 genes were analyzed because monoallelic mutations of these genes
 might cause transient neonatal thyroid dysfunction .
two of nine children with transient thyroid dysfunction or
 subclinical hypothyroidism detected during neonatal screening had heterozygous gene mutations , one for a tshr
 gene ( r450h ) and one for a tpo gene ( p883s ) .
the r450h mutation of the tshr gene is common in japan ( 15 ) , and the p883s mutation of the tpo gene has been reported in japanese
 patients ( 24 ) . since nis and tg genes were not analyzed in the present
 study , some of the remaining seven children may have had mutations of these two genes .
although further
 examinations are necessary , genetic background may contribute to development of the transient thyroid
 dysfunction and subclinical hypothyroidism detected during neonatal screening .
thyroid function is influenced by several factors , such as general condition , age and amount of iodine intake .

it is well known that patients with subclinical hypothyroidism can develop overt hypothyroidism during puberty
 and pregnancy due to the increase in thyroid hormone requirement .
however , large amounts of iodine intake have been reported to cover the development of
 hypothyroidism in patients with biallelic inactivating mutations of the nis and duox2 genes ( 17 , 25 ) .
moreover , it has been
 reported that , if left untreated , goiters caused by elevated tsh stimulation in patients with defects of the tpo
 gene and tg gene are prone to development into thyroid cancer ( 26 , 27 ) .
therefore , it is important to continue long - term follow - up of children
 with transient thyroid dysfunction and subclinical hypothyroidism detected during neonatal screening to avoid
 missing the development of overt hypothyroidism and goiters , given that they may have background gene
 defects . in conclusion ,
two of the nine screening - positive children who had not received l - t4 replacement or had been
 able to stop the treatment had genetic mutations .
it is possible that genetic background contributes to the
 development of transient thyroid dysfunction and subclinical hypothyroidism detected during neonatal screening .

therefore , long - term follow - up of screening - positive children is required .

Answer:
about 30% of children with elevated tsh levels during neonatal screening have a transient form of disorder .
 on the other hand , it has been reported that subclinical hypothyroidism persists in late childhood in about
 30% of children found to be false - positive during neonatal screening .
 the aim of this study was to determine
 whether transient thyroid dysfunction and subclinical hypothyroidism detected during neonatal screening are
 influenced by genetic background .
 the tsh receptor ( tshr ) , thyroid peroxidase ( tpo ) and dual oxidase 2 ( duox2 )
 genes , for which it has been reported that heterozygous defects cause neonatal transient thyroid dysfunction ,
 were analyzed .
 nine children with transient thyroid dysfunction or subclinical hypothyroidism detected during
 neonatal screening were studied .
 one child was heterozygous for a tshr gene mutation ( r450h ) , and another
 child was heterozygous for a tpo gene mutation ( p883s ) .
 no children with mutation of the duox2 gene were
 identified .
 genetic background may contribute to development of transient thyroid dysfunction and subclinical
 hypothyroidism detected during neonatal screening .


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 transversus abdominis plane ( tap ) block provides effective post - operative analgesia after abdominal surgery .
rafi first described tap block , who injected local anesthetic through the ilio - lumbar triangle of petit within the tap between the internal oblique muscle and transversus abdominis muscle utilizing the double - loss of resistance technique .
virtually , the ultrasound - guided tap block is highly effective and easy technique for rendering analgesia for post anterior abdominal incision as supported by literature ; however , it can also be used as a sole anesthetic technique for abdominal surgeries where the autonomic innervation is partly or not involved .
a 67-year - old woman , 55 kg was admitted to hospital with a 3-day history of abdominal pain , nausea and vomiting .
she was diagnosed to have chronic obstructive pulmonary disease ( copd ) 5 years ago and had four episodes of prior hospitalization secondary to acute exacerbation .
she often required nebulisers and had an exercise tolerance of approximately 100 yards . in the week prior to admission she had received oral antibiotics and steroids for an infective exacerbation of copd . on admission to the hospital she had signs of peritonitis and her abdomen
examination revealed reduced bi - basal air entry with crepitations all over the chest and chest x - ray showed consolidation of the right middle and lower lobe .
her arterial blood gas revealed type i respiratory failure ( fio2 0.60 , ph 7.37 , po258 mmhg , pco245 mmhg ) .
intravenous acetaminophen was administered for pain relief , but despite this she could not cough or take deep inspiration due to ongoing pain .
she was categorized as american society of anesthesiologists ( asa ) physical status grade iv / e and was planned for emergency laparotomy .
we planned to avoid general , epidural or spinal anesthesia , so we opted for tap block under ultrasound guidance as a sole anesthetic technique .
after proper explanation to the patient about the technique of tap block , she was taken to operation theatre table and monitors attached .
hence oxygen supplementation was carried out with venturi mask with oxygen flow at 6 l / min .
saturation improved to 92% . after securing an iv access with 18 g ( gauge ) needle on the right dorsum of the hand ,
she was sedated with intravenous dexmedetomidine infusion at 4 mcg / kg / min to make her comfortable , cooperative , and pain free for performing the block .
then she was laid supine with the anterolateral abdominal wall exposed bilaterally from the iliac crest to the sub - costal margins and scrubbed aseptically .
the block was performed using an aseptic ultrasound guided in - plane technique ( s - nerve sonosite , hfl38 ( company brand name of the 6.0 to 13.0 mhz linear probe ) probe , 100 mm sonoplex needle ) . when the needle tip position is within the tap neuro - fascial plane a mixture of 20 ml of 0.25% bupivacaine , 20 ml of 1% lidocaine and 0.2 mg adrenaline
a remarkably good clinical effect was achieved within 30 min with almost complete resolution of pain .
she made a slow post - operative recovery to be discharged from hospital 14 days after admission .
the use of tap blocks for control of post - operative analgesia has been described following a variety of abdominal operations such as appendectomy , hernia repair , caesarean section , abdominal hysterectomy , and prostatectomy etc .
bilateral blocks can be given for midline incisions or laparoscopic surgery with careful safe dosing .
to our knowledge , the use of ultrasound - guided bilateral tap for a sole anesthetic technique for upper abdominal surgery in a very high - risk patient has been rarely reported . the skin , muscles and parietal peritoneum of the anterior abdominal wall are innervated by the lower six thoracic nerves and the first lumbar nerve .
after leaving the respective intervertebral foramina the anterior rami ( sensory afferents ) of these nerves course around the transverse process , then pierce the musculature of the lateral abdominal wall to course through a muscle neurovascular plane superficial to the transversus abdominis . in the midaxillary line ,
the sensory afferents branch out as a lateral cutaneous branch and continue within the tap to perforate anteriorly supplying the skin as far as the midline .
the tap plane thus provides a space into which the local anesthetic can be deposited to achieve myocutaneous sensory blockade .
whilst early studies showed a t7 to l1 spread with a single posterior injection making the block suitable for midline abdominal incisions , other studies , however , failed to demonstrate a spread cephalad to t10 making it more suited for lower abdominal surgery . in a small cadaveric study , t11 , t12 , and l1 were most consistently present in the tap while t10 was present in 50% of the cases .
however , augmentation with a subcostal injection will help attain a higher block up to t7 which is a modification of the original technique in which the ultrasound probe is placed just beneath the costal margin and parallel to it .
the needle is then introduced from the lateral side of the rectus muscle in the plane of the ultrasound beam and 10 ml of local injected into the tap to extend the analgesia provided by the posterior tap block above the umbilicus . in our patient bilateral ,
sub - costal tap block under ultrasound guidance resulted in highly effective myocutaneous sensory blockade .
as the patient was categorized as asa iv / e general anesthesia or central neuraxial blockade for the emergency operation for such a high - risk case would have resulted in untoward and fatal complications both intra - operatively and postoperatively .
the abdominal wall sensory afferents , which course through the tap plane could be blocked successfully and effectively by abdominal field blocks or tap block under ultrasound guidance then the abdominal incision and operation could be carried out without patient 's discomfort .
pain caused by visceral stimulation of the celiac plexus may still challenge intraabdominal surgical success which is a major limitation .
when the surgeons manipulated the intestine , the patient complained of pain due to stimulation of autonomic nervous system through celiac plexus ( vagus ) , but dexmedetomidine infusion helped in relieving the pain or retching sensation .
anatomically , sympathetic and somatic innervation are closely related near the neuraxis , but become separated peripherally .
thus , spinal , epidural or paravertebral blocks will cause significant sympathetic block , resulting in major cardiovascular changes and other physiological effects . on the other hand ,
if complete denervation of viscera is required , vagal afferents have to be blocked by celiac plexus block .
the extent and spread of the local anesthetic solution in the tap affecting anterior abdominal wall sensory afferents depend on time factor .
it seems that the full effect of analgesia takes at least 20 - 25 min after injection of local anesthetic solution .
mcdonnell et al . suggest that local anesthetic spreads within the tap plane progressively over the several hours and an early assessment of the extensive tap block may be missed .
as ultrasound - guided bilateral transversus abdominais neurofascial plane block is quite simple , quick , safe , and effective especially for a very high - risk patient with multi - medical problems and geriatric patients needing an elective or emergency abdominal surgery , the surgeons and anesthesiologists should encourage this technique , even in this advanced era , when it is deemed suitable .

Answer:
although transversus abdominis plane ( tap ) block is an effective way of providing analgesia in post - operative abdominal surgery patients ; however , it can be considered as an anesthetic technique in high - risk cases for surgery .
 we report a case of a geriatric female with chronic obstructive pulmonary disease in the respiratory failure , hypotension , posted in an emergency with old perforation leading to peritonitis .
 the surgery was successfully conducted under bilateral tap block , which was used as a sole anesthetic technique .
 tap block can be considered as an anesthetic technique for abdominal surgery in moribund patients .


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:
though rare , it can lead to neurological sequelae such as bowel and bladder dysfunction , sexual dysfunction , saddle anesthesia , sciatica , and motor weakness .
hematoma is a good culture medium for bacteria ; therefore , reducing hematoma is advantageous in reducing infection .
many surgeons consider that a surgical drain increases the postoperative infection rate2561821 ) . as a foreign body
is inserted into a patient , it can lead to local inflammatory responses and can activate host defense system ; alternatively , it can act as an inlet of infection .
therefore , there is a controversy about usefulness of surgical drain in single - level lumbar disc surgery and that bleeding is not much . in this study
we studied 70 patients who had undergone single - level lumbar discectomy from april 2011 to march 2012 .
the patients who had undergone multilevel surgery , fusion surgery , and/or previous lumbar surgery were not included in this study .
this study was based on retrospective analysis of the patients ' medical records that included their age , sex , diagnosis , level of surgery , mean operation time , length of stay after surgery , past history ( hypertension and diabetes ) , and smoking or not , levels of c - reactive protein ( crp ) , and scores of visual analogue scale ( vas ) .
the patients were divided into 2 groups : one that received the surgical drain and the other that did not .
there were 42 patients who received the drain that included 21 men and 21 women with mean age of 49.93 years , and there were 28 patients who did not receive the drain that included 13 men and 15 women with mean age of 43.86 years .
both groups received prophylactic antibiotics ( 1st generation cephalosporin ) intravenously for 7 to 8 days .
we checked the levels of crp on postoperative days 1 , 3 , and 5 .
the amounts of surgical drainage collected for 24 hours were checked daily at the same time . in drainage group ,
proximal tip culture of surgical drain was conducted when removed . between postoperative days 7 and 8 ,
we compared the rates of infection , the levels of crp , and the scores of vas in preoperative , postoperative , and the first postoperative follow - up phases at the outpatients department .
the demographics of the 2 groups were compared using t - test and fisher exact test .
the mean duration of the surgical drain and the mean of total amounts of drainage were 2.88 days and 71.57ml , respectively .
the daily amounts of drainage on the postoperative days 1 , 2 , and 3 were 35.4 , 20.8 , and 14.27ml , respectively ( fig .
the differences in the levels of crp between the 2 groups were not significant ( p>0.05 ) ( fig .
2 ) . the mean level of crp in drainage group on postoperative days 1 , 2 , and 3 were 4.17 , 3.76 , and 2.41mg / l and in nondrainage groups mean level of crp were 4.89 , 5.2 , and
the differences in the scores of vas in preoperative , postoperative , and follow - up phases were not significant between the 2 groups ( p>0.05 ) ( fig .
3 ) . the mean scores of vas in the drainage group in preoperative , postoperative , and follow - up phase were 7.5 , 2.64 , and 0.64 and mean scores of vas in the nondrainage groups were 7.28 , 2.1 , and 0.76 .
the mean length of hospital stay after surgery was 9.68 days ; further , it was 8.68 days in the drainage group and 9.87 days in the nondrainage group .
the mean operation time of the drainage group was longer than the nondrainage group ( 150.2 minutes vs. 130.8 minutes ) .
but there was no significant difference between the 2 groups ( p>0.05 ) . in the group that did not receive surgical drain ,
the mean operation time of infected patients was 100 minutes and that of no infection patients was 144.5 minutes .
the operation time of infected patients was shorter than no infection patients , but there was no significance ( p>0.05 ) .
there was no statistically significant difference between the 2 groups ( p=0.157 ) ( tables 1 , 2 ) .
one of the 2 infected patients in the group that did not receive surgical drain was a 39-year - old woman who had undergone left l5-s1discectomy .
after 13 days of operation , she had fever and pus - like discharge at the operated site .
she underwent a repeated surgery on postoperative day 14 and received antibiotics treatment for 6 weeks ( fig .
the other patient was a 53-year - old woman who had undergone right l4-l5 discectomy .
the lumbar magnetic resonance imaging ( mri ) revealed fluid collection with rim enhancement at the operated site and adjacent soft tissue enhancement was also observed .
she underwent a repeated surgery on postoperative day 13 and received antibiotics treatment for 6 weeks .
the intraoperative pus culture grew methicillin - resistant and coagulase - negative staphylococcus ( fig .
the incidence of symptomatic epidural hematoma is rare ; however , the overall incidence rates of epidural hematomas on the first postoperative day of lumbar decompression surgery were reported using mri to be as frequent as 86%12 ) .
postoperative surgical drain can not only reduce the incidence and severity of hematoma formation but can also reduce the postoperative fibrosis14 ) .
the incidence of postoperative infection can be less than 1% after decompressive operation and more than 10% after fusions15 ) . in this study
, we analyzed the relation between the surgical drainage and postoperative infection in 70 patients who had undergone single - level lumbar disc surgery .
there were 2 cases of postoperative infection and both of them did not receive surgical drains ; however , there was no statistical significance . additionally , there was no significant difference in the outcomes of surgery ( pain and length of hospital stay after surgery ) .
additionally , from the financial perspective , there was no significant increase in the length of hospital stay because of surgical drain .
the difference in the infection rates of the 2 groups ( one that received the surgical drains and the other that did not ) was not statistically significant .
although many surgeons consider that surgical drain insertions increase infection rate , many studies have also shown no increase in the infection rate of surgical drains34816 ) .
kanayama et al.8 ) studied drain use after single - level lumbar decompression surgery and found " wound infection was not influenced by use of a drain . " more recently , poorman et al.17 ) studied drain use in cervical surgery and concluded " no differences in incidence of complications . " ho et al.7 ) reported significant increase the incidence of delayed postoperative infection in patients who did not received surgical drains .
though it may not always be correct , the tip cultures of surgical drains can allow us to detect postoperative infection at an early stage , and it can lead to faster initiation of antibiotics treatment10111920 ) .
positive tip culture predicts wound infection in 50% and a negative culture virtually excludes the possibility of a deep infection .
kobayashi et al.11 ) studied the efficacy of use of drain tip culture and conclude " rain tip culture is useful for early detection of surgical site infection caused by methicillin resistant bacteria . " in their series , there were 34 cases of positive tip culture and there were 19 surgical site infections .
drain tip culture had a sensitivity of 52% , specificity of 92% and the association between positive tip culture and wound infection was significant ( p<0.05 ) . in our study , the patients who underwent postoperative infection may have an opportunity to detect it earlier if they received drain tip culture .
surgical drains can reduce the risk of hematoma formation and can detect postoperative infection early by conducting drain tip culture .
however , even though simple , inserting surgical drain require additional effort of medical worker , time , cost of material , postoperative care and patient 's discomfort .
the decision to use or not a surgical drain is left to the surgeon 's discretion but using surgical drain can be considered in patient who has bleeding tendency and who has susceptibility to infection .
although many surgeons are apprehensive about postoperative infection by surgical drainage , no increase in infection rate and no difference in wound healing or postoperative neurological deficit have been observed .
the tip cultures of surgical drains can be an effective means of detection of the postoperative infection

Answer:
objectivesurgical drains are commonly used after the spine surgeries for minimizing hematoma formation , which can delay wound healing and may become a source of fibrosis , infection , and pain .
 the drain , however , may provide a direct route for infection if it is contaminated .
 our objective was to survey the relationship between surgical drains and infection.methodsthe 70 patients who had undergone single - level lumbar discectomy from april 2011 to march 2012 were retrospectively analyzed .
 each patient 's medical chart and magnetic resonance image were thoroughly reviewed after all the patients had been divided into the drainage and the nondrainage groups .
 the amounts and durations of the surgical drains in the drainage group were analyzed .
 additionally , the levels of c - reactive protein , rates of infection , scores of preoperative and postoperative visual analog scale ( vas ) , and lengths of hospital stay after operation were compared between the 2 groups.resultsin this study , 70 patients were retrospectively analyzed ; out of which , 42 and 28 patients were included in the drainage and the nondrainage groups , respectively .
 two of the postoperative infection cases in the nondrainage group required to undergo repeated operations .
 the frequency of the postoperative infection cases was higher in the nondrainage group than in the drainage group ; however , there was no significant statistical difference between the 2 groups ( p=0.157).conclusionsurgical drains did not elevate postoperative infection .
 furthermore , drain tip cultures allowed us to detect postoperative infection at an early stage , and it led to faster initiation of antibiotics treatment .