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:
bile cast syndrome ( bcs ) is a complication of orthotopic liver transplantation ( olt ) .
we describe 2 patients with bcs who were successfully diagnosed with endoscopic retrograde cholangio pancreatography ( ercp ) and one of whom was successfully treated endoscopically .
a 65-year - old female underwent olt 6 months prior to presentation for chronic hepatitis c and hepatocellular carcinoma .
her intraoperative course during liver transplantation was complicated by a significant amount of blood loss from hepatic veins .
she had a complicated postoperative course including hemorrhagic shock , abdominal compartment syndrome and acute renal failure which required hospitalization for 2 months after the transplantation .
she developed an anastomotic bile leak which was treated with placement of a 10 fr stent . at 4 weeks and 8 weeks after initial ercp ,
the cbd stents were exchanged and secondary sclerosing cholangitis was suspected based on cholangiographic appearance .
her immunosuppression regimen included tacrolimus 9  mg bid and mycofenolic acid 180  mg bid .
laboratory data showed bilirubin of 1.1  mg / dl ( reference range : 0.2  mg / dl-1.3  mg / dl ) , alanine aminotransferase of 53  iu / l ( reference range : 13  iu / l-69  iu / l ) , aspartate aminotransferase of 60  iu / l ( reference range : 15  iu / l-46
iu / l ) , alkaline phosphatase of 257  iu / l ( reference range : 42  iu / l-140
iu / l ) , -glutamyl transferase of 466  iu / l ( reference range : 5  iu / l-55
balloon sweeps yielded a small amount of debris , but cholangiographic findings persisted that were concerning for filling defects or marked ductal irregularity in the region of the common hepatic duct and bifurcation .
cholangioscopy ( fig .  2 ) was performed with the spyglass single operator biliary visualization system ( boston scientific , natick , ma , usa ) .
a tubular biliary cast , in the shape of the bile duct , was seen in the donor bile duct extending from the anastomosis into the intrahepatic ducts .
attempts to extract the cast with a snare , basket , mechanical lithotripter , balloon , spybite(boston scientific , natick , ma , usa ) biopsy forceps , and standard egd forceps were all unsuccessful due to inability to grasp the cast and tethering of the cast to intrahepatic extension . a 10 fr 12-cm cbd stent was placed . in subsequent months ,
it appears to contain filling defects which retrospectively are related to presence of biliary cast material in the right and left main hepatic ducts .

a 58-year - old male with a history of hepatitis c and cirrhosis presented with fevers , chills , and a headache .
the patient s immunosuppression regimen included mycophenolate 360  mg bid , prednisone 5  mg daily and tacrolimus 8  mg bid .
laboratory data showed bilirubin of 2.2  mg / dl ( reference range : 0.2  mg / dl-1.3  mg / dl ) , alanine aminotransferase of 162  iu / l ( reference range : 13  iu / l-69  iu / l ) , aspartate aminotransferase of 159  iu / l ( reference range : 15  iu / l-46
iu / l ) , alkaline phosphatase of 1277  iu / l ( reference range : 42  iu / l-140  iu / l ) and white blood cell count of 8.17    10 cells / l .
the left main hepatic duct was dilated with a 4-mm dilating balloon to facilitate clearance of the filling defects .
cholangiogram prior to intervention shows diffuse stricturing of the left and right hepatic ductal system in patient 2 .
b cholangiogram after removal of the biliary cast showing a widely patent left hepatic duct in patient 2 .

subsequent to removal of the biliary cast , endoscopic treatment for the anastomotic stricture resulted in resolution of the stricture .
a 65-year - old female underwent olt 6 months prior to presentation for chronic hepatitis c and hepatocellular carcinoma .
her intraoperative course during liver transplantation was complicated by a significant amount of blood loss from hepatic veins .
she had a complicated postoperative course including hemorrhagic shock , abdominal compartment syndrome and acute renal failure which required hospitalization for 2 months after the transplantation .
she developed an anastomotic bile leak which was treated with placement of a 10 fr stent . at 4 weeks and 8 weeks after initial ercp ,
the cbd stents were exchanged and secondary sclerosing cholangitis was suspected based on cholangiographic appearance .
her immunosuppression regimen included tacrolimus 9  mg bid and mycofenolic acid 180  mg bid .
laboratory data showed bilirubin of 1.1  mg / dl ( reference range : 0.2  mg / dl-1.3  mg / dl ) , alanine aminotransferase of 53  iu / l ( reference range : 13  iu / l-69  iu / l ) , aspartate aminotransferase of 60  iu / l ( reference range : 15  iu / l-46
iu / l ) , alkaline phosphatase of 257  iu / l ( reference range : 42  iu / l-140
iu / l ) , -glutamyl transferase of 466  iu / l ( reference range : 5  iu / l-55
balloon sweeps yielded a small amount of debris , but cholangiographic findings persisted that were concerning for filling defects or marked ductal irregularity in the region of the common hepatic duct and bifurcation .
cholangioscopy ( fig .  2 ) was performed with the spyglass single operator biliary visualization system ( boston scientific , natick , ma , usa ) .
a tubular biliary cast , in the shape of the bile duct , was seen in the donor bile duct extending from the anastomosis into the intrahepatic ducts .
attempts to extract the cast with a snare , basket , mechanical lithotripter , balloon , spybite(boston scientific , natick , ma , usa ) biopsy forceps , and standard egd forceps were all unsuccessful due to inability to grasp the cast and tethering of the cast to intrahepatic extension . a 10 fr 12-cm cbd stent was placed . in subsequent months ,
it appears to contain filling defects which retrospectively are related to presence of biliary cast material in the right and left main hepatic ducts .

a 58-year - old male with a history of hepatitis c and cirrhosis presented with fevers , chills , and a headache .
he underwent deceased donor liver and kidney transplantation two months prior to his presentation . the patient
s immunosuppression regimen included mycophenolate 360  mg bid , prednisone 5  mg daily and tacrolimus 8  mg bid .
laboratory data showed bilirubin of 2.2  mg / dl ( reference range : 0.2  mg / dl-1.3  mg / dl ) , alanine aminotransferase of 162  iu / l ( reference range : 13  iu / l-69
iu / l ) , aspartate aminotransferase of 159  iu / l ( reference range : 15  iu / l-46
iu / l ) , alkaline phosphatase of 1277  iu / l ( reference range : 42
iu / l-140  iu / l ) and white blood cell count of 8.17    10 cells / l .
the left main hepatic duct was dilated with a 4-mm dilating balloon to facilitate clearance of the filling defects .
4 ) . following extraction , cholangiograms revealed a widely patent left main duct ( fig .
cholangiogram prior to intervention shows diffuse stricturing of the left and right hepatic ductal system in patient 2 .
b cholangiogram after removal of the biliary cast showing a widely patent left hepatic duct in patient 2 .

subsequent to removal of the biliary cast , endoscopic treatment for the anastomotic stricture resulted in resolution of the stricture .
bile casts occur in 4  % to 18  % of olt recipients 1 .
more than 70  % of casts are identified in the first 16 weeks after transplant 1 .
bile casts are dark and hard in appearance and formed by lithogenic material confined to the bile duct dimensions 3
 4 .
although the exact mechanism of injury is unknown , ischemic injury to the biliary epithelium is most common 5
 6
 7 .
other mechanisms including anastomotic and non - anastomotic strictures leading to accumulation of biliary sludge can lead to formation of casts 5 .
bacterial infection and stones are also predisposing factors for biliary ductal injury and cast formation 6 .
microcirculatory dysfunction is also suggested , given the higher prevalence of renal failure and need for renal replacement therapy in patients with bcs 7 .
a combination of endoscopic interventions is considered including sphincterotomy , balloon and basket extraction , lithotripsy and stent placement . in one study ,
re - transplantation and 12-month mortality rates were significantly higher with bcs ( 30  % vs. 7  % ) and bcs patients also required a longer intensive care unit stay post - olt 7 .
success rates with endoscopic therapy for bcs have been reported to be 70  % recently 7 .
previously in a large study of post - olt adverse events , biliary cast syndrome occurred in 4/260 patients and a median of 3.5 ercp treatments attempted over a median of 21 weeks achieved a success rate of 25  % 8 .
percutaneous drainage has also been advocated , especially in the setting of cholangitis or with roux - en - y choledochojejunostomy .
percutaneous transhepatic choledocoscopy via a tract created with radiographic assistance is a novel approach used for management of bcs . when there is intrahepatic biliary system involvement , management becomes even more challenging .
retransplantation is considered when complete removal is not feasible and if the patient s clinical condition deteriorates 2
 7 . a combined endoscopic and percutaneous method was able to successfully clear the casts in 60  % of patients in one study 9 .
surgical intervention including hepaticojejunostomy , choledochojejunostomy and revision of choledochocholedocostomy reportedly has had success rates above 85  % 10 .

Answer:
background and study aims  bile cast syndrome ( bcs ) is a complication of orthotopic liver transplantation ( olt ) .
 it occurs in 4  % to 18  % of olt recipients and can present as cholangitis and graft damage or loss
 . twenty - two percent of patients with bcs require repeat olt .
 the diagnosis and management of bcs can be challenging .
 our aim is to share our experience with bcs and to briefly review the diagnosis and management of the condition .


Question:
You will be shown the title of a chemistry paper, together with sections excerpted from the body of the paper. The paper sections may include HTML tags like `<p>` and `</p>`; please ignore these. Your task is to write an abstract for the paper. Your response should include the abstract and no other text.

Title:
An improved procedure for the preparation of Ru(bpz)3(PF6)2 via a high-yielding synthesis of 2,2’-bipyrazine

Paper sections:
Findings

Visible light-photoredox catalysis using transition metal chromophores is rapidly becoming recognized as an important strategy in organic synthesis [1–5]. This approach towards reaction design enables the facile generation and exploitation of odd-electron intermediates such as radicals and radical ions under exceptionally mild reaction conditions. A large number of transition metal chromophores with well-characterized photophysical and electrochemical properties are known, and the influence of ligand modification on the photoredox properties of these complexes is well understood [6–8]. As a result, a variety of Ru and Ir based chromophores spanning a range of redox potentials have recently become widely utilized in the design of new photocatalytic transformations [9].

In particular, the homoleptic tris(bipyrazyl) complex 2 (Ru(bpz)32+) [10] has emerged as one of the most useful transition metal photocatalysts for oxidatively induced organic transformations (Figure 1). Due to the electron-deficient nature of its bipyrazyl ligands, the excited state redox potential of 2 is quite positive (+1.45 V vs SCE) [11]. Consequently, it is an effective photocatalyst in oxidatively induced photoredox transformations where less strongly oxidizing complexes (e.g., 1) are not successful. For instance, we have reported that 2 is uniquely capable of promoting radical cation mediated Diels–Alder cycloadditions [12], radical thiol–ene couplings [13–14], and photooxygenation reactions [15–16]. Similarly, Zheng has reported oxidatively initiated indole synthesis [17] and [3 + 2] cycloaddition [18–19] reactions using photocatalyst 2. Finally, a variety of transition metal complexes bearing bipyrazyl ligands have been prepared and investigated for a wide range of applications in inorganic and organometallic chemistry [20–25].

Influence of ligand structure on photoredox behavior.

Findings

Unfortunately, the synthesis of 2,2'-bipyrazyl (bpz) is quite challenging compared to the syntheses of other, structurally similar bidentate bisazene ligands. Various methods for the preparation of bpz have been reported [26–28], the most common of which involve transition metal-catalyzed reductive homocouplings of halopyrazine electrophiles [29–30]. However, we found these procedures to be capricious in our hands, and after a survey of known reductive dimerization protocols, the highest yields of bpz we were able to obtain resulted from a Pd-catalyzed procedure reported by Plé (Scheme 1) [31]. Using this protocol, we were able to obtain only 40% yield of the desired 2,2-bipyrazine ligand on milligram scale, accompanied by a significant degree of undesired reductive dehalogenation. Moreover, the yields on larger scales were unreliable, and work-up and purification of this inefficient coupling reaction proved difficult.

Pd-catalyzed reductive coupling of 2-chloropyrazine.

Findings

Thus, in order to accelerate our investigations of complex 2 as a strongly oxidizing photoredox catalyst, we required a robust, high-yielding, and scalable synthesis of bpz. An improved synthesis of this ligand would be useful both in the context of the growing interest in photoredox catalysis as well as other organometallic and inorganic applications of bpz-supported transition metal complexes.

Our optimization studies for the reductive coupling of 2-halopyrazines are summarized in Table 1. Initial exploratory experiments using 2-chloropyrazine as the substrate gave quite poor yields using either organic or inorganic bases (Table 1, entries 1 and 2). Speculating that oxidative addition into the aryl chloride bond might be problematic in this coupling reaction, we turned our attention towards the use of more reactive aryl iodides. A screen of solvents commonly used in Pd-catalyzed cross-coupling reactions revealed that DMF provided the highest yields (Table 1, entries 3–5). We next examined the effect of varying equivalents of the terminal reductant, and we observed that the presence of excess isopropanol had little effect (Table 1, entries 6 and 7). Finally, an evaluation of the reaction temperature revealed that the coupling proceeded sluggishly at lower temperatures (Table 1, entry 8). Optimal conditions thus called for 5 mol % Pd(OAc)2, 2 equiv of isopropanol, and 1.5 equiv of K2CO3 in DMF (0.4 M) at 100 °C; under these conditions, the reaction was complete in 2 h and afforded the desired homocoupling product in 81% isolated yield (Table 1, entry 9).

Optimization of Pd-catalyzed reductive homocoupling of 2-halopyrazines.a

aConditions: Reactions were conducted on a 0.22 mmol scale using 1 equiv 2-halopyrazine, 5 mol % Pd(OAc)2, and 1.5 equiv K2CO3 at 100 °C unless otherwise noted. bYields determined by 1H NMR analysis using an internal standard. cReaction conducted using 1.5 equiv iPr2NEt instead of K2CO3. dReaction conducted at 60 °C. eReaction conducted for 2 h. fValue in parentheses is the average isolated yield from two reproduced experiments.

Findings

Although our investigations were motivated by our specific need to access photocatalyst complex 2, we were pleased to find that the optimal conditions for the synthesis of 2,2'-bipyrazine translated smoothly to the reductive coupling of a variety of pyridyl electrophiles. Table 2 demonstrates the application of these reaction conditions to the syntheses of a number of electron-deficient bipyridyl ligands that have been used to prepare strongly photooxidizing metal–polypyridyl complexes [32–36]. In each case, the requisite aryl iodides are either commercially available or can be easily synthesized by Finkelstein displacement of the aryl chloride with NaI [37].

Pd-Catalyzed synthesis of other ligands used to support electron-deficient Ru(II) chromophores.a

aConditions: 1.0 equiv 2-iodopyrazine, 1.5 equiv K2CO3, 2 equiv isopropanol, 5% Pd(OAc)2, DMF (0.4 M), 100 °C. bIsolated yield (average of two experiments).

Findings

Finally, we explored the scalability of the optimized conditions, and found that they remained applicable on multi-gram scale (Scheme 2). Thus, exposure of 4 g of 2-iodopyrazine to the optimized conditions from Table 1 cleanly produced 1.25 g of 2,2'-bipyrazine in 81% isolated yield. A portion of this material was then carried on to synthesize 689 mg (83% yield) of Ru(bpz)3PF6, showing for the first time that we could efficiently prepare hundreds of milligrams of this important photocatalyst. Importantly, this protocol has proven to be reproducible in the hands of other researchers as well [38].

Preparative-scale synthesis of Ru(bpz)3(PF6)2.

Findings

In conclusion, we have developed an improved, Pd-catalyzed method for the synthesis of 2,2'-bipyrazine, an important ligand with growing utility in the context of visible light photocatalysis. This method is readily scalable to enable the gram-scale preparation of 2,2'-bipryazine, which facilitates the preparative synthesis of the strongly oxidizing photocatalyst Ru(bpz)3(PF6)2 [39].

Experimental section.

Answer: There has been a recent surge of interest in the use of transition metal polypyridyl complexes as visible light-absorbing photocatalysts for synthetic applications. Among the most attractive features of this approach is the availability of many known complexes with well-characterized photophysical and electrochemical properties. In particular, Ru(bpz)32+ is a powerful photooxidant that has proven to be uniquely suited for oxidatively induced photoredox transformations. We present here a straightforward and high-yielding route to Ru(bpz)3(PF6)2 that features an improved Pd-catalyzed synthesis of the 2,2’-bipyrazine ligand that is amenable to gram-scale preparations.


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:
we reviewed the medical records of patients who had l. monocytogenes isolated from blood and body fluids from sterile sites during 19962008 at the national taiwan university hospital ( ntuh ) , a 2,500-bed hospital in taiwan .
we evaluated disease severity using modified acute physiology and chronic health evaluation ii scores ( 8) .
incidence of nontyphiodal salmonella bacteremia ( ntsb ) during 20002008 in ntuh was calculated for trend comparison of the 2 foodborne illnesses .
only 1 episode was calculated during the same admission for ntsb to avoid the influence of repetitive bacteremia .
isolates from patients with fetomaternal listeriosis ( i.e. , paired isolates from mother and neonate who had listeriosis ) were considered to be the same and only 1 of them was analyzed .
all isolates were analyzed for their serotype by pcr as described , and genetic relatedness was evaluated by pulsed - field gel electrophoresis ( pfge ) by using pulsenet standardized protocols and 2 restriction enzymes ( asci and apai ) ( 2,9 ) .
strains were considered to be of the same cluster if their bands had indistinguishable restriction patterns by both enzymes .
strains with pfge patterns with > 80% similarity by asci and apai profiles were considered to be closely related .
a forward stepwise model with a p value of 0.1 was used , and p<0.05 was considered statistically significant in the multivariate cox proportional hazards model . during the study period ,
listeriosis was diagnosed in 48 patients , and 46 nonduplicated isolates were obtained for further microbiological analysis .
average annual incidence increased from 0.0287 cases per 1,000 admissions during 19962004 to 0.118 cases per 1,000 admissions during 20052008 ( figure 1 ) .
the increase in annual incidence of listeriosis was significantly correlated with years ( p = 0.0045 ) .
the average annual incidences of ntsb were 1.189 and 1.118 per 1,000 admissions during 20002004 and 20052008 , respectively ; it was not significantly correlated with years ( p = 0.50 ) .
age - specific incidence of listeriosis increased at both extremes of age , but especially among patients > 80 years ( figure 2 ) .
all of the patients with listeriosis lived in northern taiwan , and no obvious geographic correlation was observed between listeriosis patients in each year .
incidence ( cases per 1,000 admissions ) of human listeriosis and serotype distribution of all isolates , national taiwan university hospital , taipei , taiwan , 19962008 .
forty - six isolates were available for analysis , including 2 serotype 4b isolates from fetomaternal transmission in 2005 and 2006 and 1 serotype 4b from a pediatric patient ( 2005 ) .
patient distribution and incidence of human listeriosis , by age group , national taiwan university hospital , taipei , taiwan , 19962008 .
all 43 patients had underlying predisposing conditions , and 18 ( 42% ) were > 65 years of age . of the 30 patients with malignancies , 23 ( 77% )
 one female patient had coexisting non - hodgkin lymphoma and colon cancer ; 1 male patient had coexisting non - hodgkin lymphoma , gastric cancer , and bladder cancer .
initial modified acute physiology and chronic health evaluation ii score , mean  sd : 18.8  7.3 . among the 46 isolates ,
serotype 1/2b was identified most frequently ( 46% ) , followed by 1/2a ( 28% ) and 4b ( 26% ) .
all 46 isolates were susceptible to ampicillin , ertapenem , meropenem , and vancomycin ; 3 isolates were intermediately susceptible to trimethoprim / sulfamethoxazole ; and 4 isolates were nonsusceptible to linezolid ( 10 ) .
sixteen ( 37% ) patients received cephalosporin alone as initial treatment regimens and empirical treatment was effective for only 14 ( 33% ) .
the presence of solid - organ malignancies was a significant negative prognostic factor for 14-day mortality in the univariate analysis ( 95% confidence interval [ ci ] 1.16516.694 ; p = 0.029 ) but not in the multivariate analysis .
the results of the multivariate analysis for 14-day mortality showed that hepatic decompensation at disease onset was a significant negative prognostic factor ( hazard ratio 12.02 , 95% ci 1.84278.470 ; p = 0.009 ) and that the use of effective antimicrobial drugs after culture results were reported was a significant positive prognostic factor ( hazard ratio 0.014 , 95% ci 0.0020.131 ; p<0.001 ) .
log - rank tests performed to compare the difference in survival between patient groups for the 2 variables also had the same results ( p<0.001 ) .
we observed an upsurge of listeriosis beginning in 2005 in ntuh . the increase might not be attributable to common - source outbreaks because no clustering was detected .
the annual incidence of listeriosis has been on the rise in europe since 2000 ( 2,3,11 ) .
the reason is not clear because the increase could not be attributed to outbreak clusters and no increase in pregnancy - related listeriosis was observed ( 2,3 ) .
wong et al . found that l. monocytogenes was isolated in > 50% of pork samples and chicken carcasses ( 6 ) .
semiready foods ( dumplings and meatballs ) and frozen dim sum examined also carried the pathogen ( 34.0% and 4.4% , respectively ) , and > 60% of the isolates were serotype 1 or 4 ( 6 ) . if served undercooked , these foods could be potential transmission sources .
taiwan currently has no strict regulatory policy regarding listeriosis in the food industry and no disease surveillance system . in france ,
serotype 4b was the predominant serotype ( 42%56% ) , whereas serotype 1/2b was more common ( 46% ) in our study ( 2 ) .
none of the isolates were resistant to the tested agents , except for 4 isolates , which were resistant to linezolid .
the contributions of disease severity and antimicrobial drug treatment are difficult to evaluate in population - based studies ( 12 ) .
brouwer et al . reported that up to 30% of adults with l. monocytogenes meningitis did not receive initial adequate antimicrobial drug therapy , and they found no association between that variable and outcome ( 13 ) . a high proportion ( 37% ) of patients in our study
initial disease severity and initial adequate antimicrobial drug therapy was not associated with overall mortality .
we found that mortality was related to hepatic decompensation and effective antimicrobial drug therapy after culture results were reported .
therefore , the incidence of and risk factors for human listeriosis in taiwan could not be determined precisely , and potential outbreaks might have been overlooked .
the retrospective design of our study limited the possibility of identifying the potential vehicles and disease - acquiring behaviors .
an increase of listeriosis was noted since 2005 in our hospital , and all of the affected patients had predisposing factors that hampered their immunity .
dietary education and food management information should be provided to high - risk groups in taiwan .
food monitoring and human disease surveillance systems need to be established in taiwan to control this potentially fatal foodborne disease .

Answer:
during 19962008 , a total of 48 patients with listeriosis were identified at a taiwan hospital .
 average annual incidence increased from 0.029 to 0.118 cases per 1,000 admissions before and after january 2005 .
 serotype 1/2b predominated ; serotype 4b emerged since 2004 .
 food monitoring and disease surveillance systems could help control listeriosis in taiwan .


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 potential use of the affected upper extremity of children with hemiplegia often fails due to  learned non - use phenomenon  .
constraint - induced movement therapy ( cimt ) is one of the treatment strategies which utilizes the principles of neural plasticity to help acquire motor skills of the affected upper extremity.[27 ] this therapeutic approach involves constraining of the unaffected upper extremity using sling , plaster cast , mitt or splints and intensive training of the affected upper extremity with task - specific , goal - oriented activities by reinforcement ( shaping technique ) .
a five - year - old female child presented with right hemiplegia with the history of delayed motor milestones and limited motor skills of the right upper extremity since birth .
the objective details of the cause of hemiplegia could not be established as there were no medical records available .
presently , she has achieved the highest level of functional independence ( able to walk and run independently ) .
she displayed no voluntary effort to initiate any motor skills of the right upper extremity unless verbally prompted , even otherwise initiating only minimal response suggesting learned non - use phenomenon .
the following criteria were considered for use of cimt in this child ( adapted from cochrane review study ) .
 observed learned non - use of affected upper extremity.a possible movement of at least 10 extension at metacarpophalangeal and inter - phalangeal joints and 20 extension at wrist of the affected upper extremity.no cognitive impairment and shall cooperate with treatment .
  observed learned non - use of affected upper extremity .
a possible movement of at least 10 extension at metacarpophalangeal and inter - phalangeal joints and 20 extension at wrist of the affected upper extremity . no cognitive impairment and shall cooperate with treatment .
the quality of upper extremity skills test ( quest ) is a criterion - referenced measure that evaluates the quality of upper extremity function in four domains : dissociated movements ( 19 items with one level of response for each item ) , grasps ( six items with three to five levels of response for each item ) , weight - bearing ( five items with six levels of response for each item ) and protective extension ( three items with six levels of response for each item ) .
it is designed to be used with children who exhibit neuromotor dysfunction with spasticity and has been validated with children 18 months to eight years of age .
the data collected during the neuro developmental therapy / casting study by law et al . , were used to analyze the validity and responsiveness of the quest .
the parents of the child were counseled for the treatment approach that could improve the motor skills of the affected right upper extremity .
the parents were interested and were keen in subjecting their child to this treatment approach and gave informed consent .
the pre - intervention assessments of the right upper extremity motor skills were measured using quest .
the unaffected left upper extremity was constrained with posterior slab plaster cast extending above the elbow to the interphalangeal joints of fingers and supported with a sling .
the affected right upper extremity was then subjected to task - specific goal - oriented activities that aimed to improve reaching , grasps , manipulation and release of the object using the arm and hand .
the activities were encouraged using play way method and reinforcements using visual ( postural mirror ) and verbal feedback .
the therapy session usually lasted for one hour a day for five days a week .
the parents were instructed to constantly encourage the same activities that were carried out during the treatment session in daily activities . at the end of the two - week period , post - intervention assessment of the right upper extremity was done using quest . as there was an incremental response in the outcome measure ,
the investigators convinced the parent to continue the treatment for another week . at the end of three weeks , once again post - intervention assessment was done .
the quality of upper extremity skills test ( quest ) is a criterion - referenced measure that evaluates the quality of upper extremity function in four domains : dissociated movements ( 19 items with one level of response for each item ) , grasps ( six items with three to five levels of response for each item ) , weight - bearing ( five items with six levels of response for each item ) and protective extension ( three items with six levels of response for each item ) .
it is designed to be used with children who exhibit neuromotor dysfunction with spasticity and has been validated with children 18 months to eight years of age .
the data collected during the neuro developmental therapy / casting study by law et al . , were used to analyze the validity and responsiveness of the quest .
the parents of the child were counseled for the treatment approach that could improve the motor skills of the affected right upper extremity .
the parents were interested and were keen in subjecting their child to this treatment approach and gave informed consent .
the pre - intervention assessments of the right upper extremity motor skills were measured using quest .
the unaffected left upper extremity was constrained with posterior slab plaster cast extending above the elbow to the interphalangeal joints of fingers and supported with a sling .
the affected right upper extremity was then subjected to task - specific goal - oriented activities that aimed to improve reaching , grasps , manipulation and release of the object using the arm and hand .
the activities were encouraged using play way method and reinforcements using visual ( postural mirror ) and verbal feedback .
the therapy session usually lasted for one hour a day for five days a week .
the parents were instructed to constantly encourage the same activities that were carried out during the treatment session in daily activities . at the end of the two - week period , post - intervention assessment of the right upper extremity was done using quest . as there was an incremental response in the outcome measure
, the investigators convinced the parent to continue the treatment for another week . at the end of three weeks
as the quest measure analyzes the quality of motor skills of both the right and left extremity , it may be noted that the pre - intervention percentage score was 53.04% indicating full percentage score of unaffected left upper extremity and marginal percentage score of affected right upper extremity [ table 1 ] . following intervention , increments in percentage score by 26.79% and 07.51%
were observed at the end of two weeks and three weeks respectively which should be attributed to the improvements in the quality of motor skills of the affected right upper extremity .
it may also be noted that the grasp percentage score was greater than other domains indicating better improvement in fine motor skills than gross motor skills .
the main concern for the parents in the use of cimt for improving the motor skills of the affected upper extremity in infantile hemiplegia was the fact that it restricts the use of the unaffected extremity .
the success of the use of cimt in infantile hemiplegia depends on the parents , their proper understanding of the concept of the approach and their deep motivation in carrying out home exercises .
the increments in percentage scores observed in this case report are attributed to the increased demands for the use of the affected upper extremity while constraining the unaffected upper extremity through task - specific goal - oriented activities that were reinforced with visual and verbal feedback .
the observation of this case report indicates that the use of cimt could reverse the learned non - use phenomenon of the affected upper extremity in infantile hemiplegia and thus reduce disability to greater extent .

Answer:
infantile hemiplegia is one of the clinical forms of cerebral palsy that refers to impaired motor function of one half of the body owing to contralateral brain damage due to prenatal , perinatal and postnatal causes amongst which vascular lesion is the most common causative factor .
 we report here the effects of constraint - induced movement therapy in a five - year - old female child with infantile hemiplegia on improvement of upper extremity motor skills .


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 baff / april axis plays an important role in the pathogenesis of various autoimmune diseases including sle ; inhibitors of this axis are therefore useful in treatment of these disordersresults from bliss-52 and bliss-76 trials have shown belimumab to be efficacious in treating patients with sleserious adverse effects noted with belimumab such as progressive multifocal leukoencephalopathy , depression , suicidal tendency , and malignancy are to be watched for .

the baff / april axis plays an important role in the pathogenesis of various autoimmune diseases including sle ; inhibitors of this axis are therefore useful in treatment of these disorders results from bliss-52 and bliss-76 trials have shown belimumab to be efficacious in treating patients with sle serious adverse effects noted with belimumab such as progressive multifocal leukoencephalopathy , depression , suicidal tendency , and malignancy are to be watched for .
.
 the baff / april axis plays an important role in the pathogenesis of various autoimmune diseases including sle ; inhibitors of this axis are therefore useful in treatment of these disordersresults from bliss-52 and bliss-76 trials have shown belimumab to be efficacious in treating patients with sleserious adverse effects noted with belimumab such as progressive multifocal leukoencephalopathy , depression , suicidal tendency , and malignancy are to be watched for .

the baff / april axis plays an important role in the pathogenesis of various autoimmune diseases including sle ; inhibitors of this axis are therefore useful in treatment of these disorders results from bliss-52 and bliss-76 trials have shown belimumab to be efficacious in treating patients with sle serious adverse effects noted with belimumab such as progressive multifocal leukoencephalopathy , depression , suicidal tendency , and malignancy are to be watched for .

Answer:
belimumab is the only approved biological agent for the treatment of systemic lupus erythematosus ( sle ) .
 it is a fully humanized igg1 monoclonal antibody directed against soluble b lymphocyte stimulator ( blys ) .
 it is indicated as an add - on therapy for the treatment of adult patients with active , autoantibody - positive sle , who are receiving standard therapy .
 belimumab is generally well - tolerated , common adverse effects include infections , infusion reactions , hypersensitivity , headache , nausea , and fatigue . psychiatric events including suicidal tendency , progressive multifocal leukoencephalopathy and malignancies too have been reported .
 apart from sle , the drug is also being tried for other autoimmune disorders .


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 most commonly used materials for bone implants are metals ( such as titanium , ti ) and polymers ( such as ultra high molecular weight polyethylene ) .
numerous problems exist with these implants such as ( i ) insufficient prolonged bonding between the implanted material and juxtaposed bone ( kaplan et al 1994a , 1994b ; buser et al 1999 ; webster 2001 ) , ( ii ) different mechanical properties between bone and the implant leading to stress shielding ( kaplan et al 1994a , 1994b ; webster 2001 ) , and ( iii ) wear debris generated at articulating surfaces of orthopedic implants that may lead to cell death ( kaplan et al 1994a , 1994b ) .
it has been speculated that nano - structured materials can increase orthopedic implant efficacy since it is well known that the nanometer scale is the length scale that most of the body s natural materials possess .
for example , hydroxyapatite , the major inorganic component of bone , exists predominantly as platelet - or rod - shape crystals about 25 nm in width and 50 nm in length .
type i collagen , the major organic component of bone , has fibrils 300 nm in length , 0.5 nm in width , and has a periodicity of 67 nm ( park and lakes 1992 ) .
therefore , it is reasonable to consider that osteoblasts ( or bone - forming cells ) will be more accustomed to nano - structured surfaces compared to currently used nano - smooth implant surfaces .
such problems with promoting new bone growth next to implant surfaces are made only more complex for patients with bone cancer ( both primary bone cancer and metastasized bone cancers ) .
for example , it is estimated that 2,380 people will be diagnosed with bone and joint cancers and 1,470 people will die from primary bone and joint cancers in 2008 in the us ( american cancer society 2008 ) .
primary bone cancer is rare but bone cancer as a result of the metastasis from other organs ( such as the lungs , breasts and the prostate ) is very common ( miller and webster 2007 ) .
thus , the number of patients affiliated with bone cancer is much higher when considering the statistics of cancer metastasis . for these reasons ,
the main goal of this study was to introduce a new biomaterial naturally found in the human body that has chemopreventive properties for orthopedic implants : elemental selenium .
the first goal in this effort was to create nano - structured roughness on such materials and to determine bone cell responses on such nano - structured selenium materials .
selenium shots ( amorphous , metals basis , spherical and/or semi - spherical 24 mm in diameter ; alfa asear , ward hill , ma ) were pressed into cylindrical compacts ( 0.635 cm radius and 0.2 cm thickness ) at 1000 psi for 2 minutes using a uniaxial compacting hydraulic press ( carver , inc . ,
the compacts were then chemically treated with 1n naoh for either 10 or 30 min . after etching
, selenium compacts were washed with excessive deionized water to remove the naoh that remained on the selenium compacts .
surfaces of untreated selenium compacts as well as selenium compacts treated with 1n naoh for 10 and 30 min were visualized ( without a conductive coating ) using a scanning electron microscope ( sem , leo 1530vp fe-4800 ) with an accelerating voltage from 3 to 10 kv .
energy dispersive x - ray spectroscopy ( eds , leo 1530 ) was used to determine the surface chemistry of the compacts . to investigate osteoblast adhesion on selenium compacts , human osteoblast - like cells ( bone - forming cells ; crl-11372 american type of culture collection , population numbers 1415 ) in dulbecco s modified eagle media supplemented with 10% fetal bovine serum ( hyclone ) and 1% penicillin / streptomycin ( hyclone )
were seeded at a density of 3500 cells / cm and placed in an incubator under standard cell culture conditions ( 37c , 5% co2 , 95% humidified air ) for 24 h. importantly , this is an immortalized cell line which has been used widely in experiments involving orthopedic applications since previous studies have demonstrated that when cultured under similar conditions as described in the present study , these cells secrete bone - related proteins and deposit calcium containing mineral ( miller and webster 2007 ) .
louis , mo ) , stained with 4,6-diamidino-2-phenylindole ( dapi ) ( sigma ) and counted under fluorescence microscopy ( zeiss axiovert 200 m light microscope ) in five random fields which were averaged for each compact .
data were collected and statistical comparisons were assessed using a one - tailed student t - test .
the sem images of the selenium compacts ( untreated and treated with naoh for different time periods ) revealed various surface roughness .
untreated surfaces ( figure 1 image a ) possessed mostly micron rough surface features while those treated with 1n naoh for different time periods created submicron ( figure 1 image b ) and nano - rough ( figure 1 image c ) surface features on selenium . in particular , biologically inspired surface roughness increased with increasing naoh treatment time periods . as the etchant , naoh is believed to dissolve the oxide layer on the surface of the selenium compacts creating submicron and nanometer features at increasing times .
chemical etching is a very common , inexpensive , and simple method used to modify the surface properties ( eg , topography , chemistry , roughness , wettability , etc . ) of biomaterials .
chemical etching can be used for a wide range of biomaterials from metals , ceramics , to polymers .
for example , etching titanium with hcl followed by naoh has led to the formation of uniform micrometer featured surfaces that increased the formation of hydroxycarbonated apatite when exposed to a simulated body fluid ( jonasova et al 2004 ) .
moreover , etching poly ( lactic - co - glycolic acid ) ( plga ) films using naoh has created biologically inspired nanometer surface feature dimensions to promote the functions of numerous cells .
for example , this nanometer plga structured surface was shown to promote bladder smooth muscle cell functions compared to conventional , micrometer - structured plga after 1 , 3 , and 5 days of culture ( thapa et al 2003 ) .
in addition , feldspathic porcelain etched in 5% hydrofluoric acid was shown to promote the bonding strength between orthodontic brackets and ceramic crowns when compared to those treated by mechanical roughening with fine diamond burs or sandblasting ( schmage et al 2003 ) .
clearly , chemical etching can be an inexpensive effective way to transform nano - smooth surfaces into nano - rough surfaces for a wide range of materials to promote their biological performance .
importantly , eds profiles of the compacts used in the present study revealed that the chemistry of the selenium compacts remained unaffected after treatment in 1n naoh ( figure 2 )
. moreover , table 1 lists the weight percentages of selenium and sodium for each compact .
the results showed trace amounts of sodium on the surfaces of selenium compacts treated with 1n naoh .
this indicated that chemical etching ( ie , using 1n naoh for up to 30 min ) only changed the surface roughness , not the surface chemistry of the selenium compacts . the ability to change an implant s surface roughness and/or topography without altering
its chemistry is of great interest since , when fabricating implant materials , it is crucial not to induce any potential harmful chemistry changes . in this study ,
selenium compact chemistry remained unaltered after treatment with 1n naoh for up to 30 min . when these substrates were used as substrates for culturing osteoblasts , after 1 day , significantly increased cell densities were observed on the increasing nano - rough surfaces ( ie , compacts treated with 1n naoh for 10 and 30 min ) ( figures 3 , 4 ) .
especially , the compacts treated with 1n naoh for 30 min , which had the largest amount of nanometer surface features , had the highest osteoblast density . however , although closer , these selenium compacts ( ie , compacts treated with 1n naoh for 30 min ) had osteoblast densities lower than that of titanium .
future studies will need to utilize greater times and/or concentrations of naoh etching to determine if osteoblast adhesion can be matched between selenium and titanium .
moreover , future studies will need to examine primary osteoblast cells ( since that was not accomplished here ) as well as the multitude of cancerous cells that can cause bone cancer .
it has been shown that increased nanometer surface roughness promotes osteoblast functions ( from adhesion to the deposition of calcium containing mineral ) ( webster et al 1999 , 2000a , 2000b ; webster 2001 ; webster and ejiofor 2004 ) .
the results of this study showed a similar trend of increased healthy osteoblast densities after 1 day of culture on selenium with increased nanometer surface roughness .
the significance of these results is also the introduction of a new chemistry to the orthopedic community particularly geared at inhibiting bone cancer regrowth : selenium .
selenium has been shown to have chemo - preventive effects in numerous reports ( combs and combs 1986 ; clark et al 1991 , 1998 ; combs and gray 1998 ; navarro - alarcon and lopez - martinez 2000 ; zhuo et al 2004 ; wei et al 2004 ) .
however , the mechanisms of selenium - based chemoprevention are complex and incompletely understood ( combs 2001 ) . by imparting nano features onto selenium compacts ,
the objective of this study was to create a material that promotes healthy osteoblast functions since evidence has already been provided concerning its role in inhibiting cancer growth . in the present study ,
healthy osteoblast adhesion was shown to be enhanced on nano - rough selenium compacts when compared to micro - rough selenium compacts .
however , it has been shown that nano - roughness effectively increased the initial absorption of proteins ( such as fibronectin and vitronectin ) which mediate subsequent cell adhesion ( webster et al 2000b , 2001 ; khang et al 2007 ) . in particular ,
particle boundaries on other material ( ti , ti6al4v , and cocrmo ) surfaces were shown to be active regions for such protein adsorption ( webster and ejiofor 2004 ) .
nano - structured surfaces clearly offer more particle boundaries when compared to micron - structured surfaces for promoting initial protein adsorption events . in another recent study
, elemental selenium nanoclusters were coated on conventional titanium substrates to create nano - structured surfaces .
these surfaces were shown to promote healthy osteoblast functions after 1 day of culture and , importantly , inhibit cancerous osteoblast cell functions after 3 days of culture ( sarin et al 2008 ) . in the present study ,
nano - structured selenium surfaces were created by a different method : chemically etching selenium bulk compacts .
the approach used in this study is simpler than the coating method used ( which involved selenium chemical precipitation ) and can eliminate the influence of titanium in the interaction with osteoblasts since selenium coatings in that previous study did not completely cover the underlying titanium .
however , considering the toxicity of selenium at high levels ( whanger et al 1996 ) , the use of selenium compacts may be problematic concerning how much selenium is exposed to the body leading to possible toxic effects .
future studies need to clearly investigate this possible toxicity as well as cancerous bone cell functions on these selenium compacts .
this study provided techniques to create nano - structured roughness without altering chemistry on selenium compacts for anti - cancer orthopedic applications .
since previous studies have shown greater osteoblast functions on nano - structured compared to conventional ceramics , metals , polymers , and composites , the ability to create nano - structured roughness on selenium compacts is promising for increasing bone cell functions , while inhibiting the return of bone cancer .

Answer:
metallic bone implants possess numerous problems limiting their long - term efficacy , such as poor prolonged osseointegration , stress shielding , and corrosion under in vivo environments . such problems are compounded for bone cancer patients since numerous patients receive orthopedic implants after cancerous bone resection . unfortunately , current orthopedic materials were not originally developed to simultaneously increase healthy bone growth ( as in traditional orthopedic implant applications ) while inhibiting cancerous bone growth .
 the long - term objective of the present research is to investigate the use of nano - rough selenium to prevent bone cancer from re - occurring while promoting healthy bone growth for this select group of cancer patients .
 selenium is a well known anti - cancer chemical .
 however , what is not known is how healthy bone cells interact with selenium . to determine this , selenium , spherical or semispherical shots , were pressed into cylindrical compacts and these compacts were then etched using 1n naoh to obtain various surface structures ranging from the micron , submicron to nano scales .
 changes in surface chemistry were also analyzed . through these etching techniques
 , results of this study showed that biologically inspired surface roughness values were created on selenium compacts to match that of natural bone roughness .
 moreover , results showed that healthy bone cell adhesion increased with greater nanometer selenium roughness ( more closely matching that of titanium ) . in this manner
 , this study suggests that nano - rough selenium should be further tested for orthopedic applications involving bone cancer treatment .


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:
anti - neutrophil cytoplasmic antibodies ( ancas ) correlate well with a wide spectrum of vasculitis manifestations , including wegener 's granulomatosis , microscopic polyangiitis , and churg - strauss syndrome , all of which are commonly referred to as anca - associated vasculitis ( 1 ) .
several infections , particularly infective endocarditis , have been reported to show positive findings on anca tests ; furthermore , their clinical features have been acknowledged to mimic anca - associated vasculitis , which may lead to a misdiagnosis and inappropriate treatment ( 2,3 ) .
however , to our knowledge , infected aortic aneurysms have not been reported to show positive findings on anca tests .
we herein report a patient with an infected thoracic aortic aneurysm mimicking anti - proteinase 3-antineutrophil cytoplasmic antibody ( pr3-anca)-associated vasculitis .
vegetations in the descending aorta , which were detected using transesophageal echocardiography , contributed to the diagnosis in this case .
a woman in her 60s was admitted to the nagoya city university hospital complaining of a fever , which had persisted for three weeks , along with a loss of appetite , proteinuria , hematuria , and renal dysfunction .
her renal function test values had been in the normal range three months prior to the admission .
she also had a history of orbital mucosa - associated lymphoid tissue lymphoma , which was in remission after treatment with only radiation therapy .
a physical examination at the time of admission revealed a body temperature of 38.1 , pulse rate 109 beats / min , and blood pressure 104/53 mmhg .
the laboratory tests revealed a white blood cell count of 18,900/mm , hemoglobin 6.6 g / dl , blood urea nitrogen 30.8 mg / dl , serum creatinine 2.24 mg / dl , and c - reactive protein ( crp ) 9.44 mg / dl ( table ) .
the pr3-anca titer was 47.4 iu / ml ( normal range < 10 iu / ml ) , although her myeloperoxidase - antineutrophil cytoplasmic antibody ( mpo - anca ) titer was not elevated .
a urinalysis gave results of 2 + for protein and 3 + for occult blood in a dipstick examination , and a microscopic examination detected more than 100 red blood cells per high - power field .
alt : alanine aminotransferase , ana : antinuclear antibodies , ast : aspartate transaminase , c3 : compliment 3 , c4 : compliment 4 , ch50 : 50% hemolytic unit of complement , crp : c - reactive protein , dna : deoxyribonucleic acid , ldh : lactate dehydrogenase , mpo - anca : myeloperoxidase - antineutrophil cytoplasmic antibody , rf : rheumatic factor , pr3-anca : anti - proteinase 3-antineutrophil cytoplasmic antibody she was initially diagnosed with pr3-anca - associated vasculitis and was thereafter treated with methylprednisolone pulse therapy ( 500 mg / day ) for three days ( fig .
however , streptococcus sanguis was serially detected in blood cultures ; therefore , the administration of steroids was stopped .
transesophageal echocardiography also revealed no vegetation in the heart ; however , it showed many oscillating masses attached to the intima in the descending aorta ( fig .
2 ) . contrast - enhanced computed tomography ( ct ) revealed a new descending aortic aneurysm ( fig .
effects of antibiotics on fever and c - reactive protein during hospitalization . the patient finally became afebrile and has c - reactive protein levels within the normal range after receiving antibiotics .
crp : c - reactive protein , dap : daptomycin , pcg : penicillin g , taz / pipc : tazobactam / piperacillin , tx : therapy transesophageal echocardiographic images of the descending aorta , with sectioning planes at 90 ( a ) and 0 ( b ) .
many oscillating masses attached to the intima were seen in the lumen of the descending aorta .
contrast - enhanced computed tomographic images in the axial ( a ) and frontal ( b ) sections .
these images show a descending aortic pseudoaneurysm and a contrast defect ( arrow ) beside the aneurysm that is compatible with echo - documented vegetation .
based on the results of microbiological testing , antibiotic treatment with intravenous penicillin g ( 24,000,000 unit / day ) was started , after which she became afebrile .
we added intravenous daptomycin ( 300 mg every 24 hours ) and tazobactam / piperacillin ( 2.25 g every 6 hours ) to the penicillin g because recurrent fever was observed two weeks later .
this additional antibiotic treatment made her afebrile again , and her renal function was recovered ( fig .
, she developed a janeway lesion , which was confirmed by the pathological finding of a skin biopsy specimen ( fig .
4 ) . transesophageal echocardiography finally demonstrated that the vegetation had disappeared after the antibiotic treatment ( fig .
5 ) , but contrast - enhanced ct revealed that the aneurysm remained unchanged in form . a nontender hemorrhagic macular on the sole of the foot ( a ) .
photomicrograph of the macular lesion shows microembolization with fibrin and infiltration of neutrophilic cells hematoxylin and eosin staining ( b , c ) .
a transesophageal echocardiographic image of the descending aorta after the antibiotic treatment , with the sectioning plane at 90. many oscillating masses have disappeared . on the 54th hospital day , she underwent endovascular aortic repair ( evar ) of the aneurysm ( fig .
6 ) after confirmation that her crp level was in the normal range and once blood cultures were consistently negative .
one year after the procedure , she continues to take oral antibiotics ; no complications related to stent - graft deployment or recurrent infections have been encountered .
her pr3-anca titer has normalized . a contrast - enhanced computed tomographic image after endovascular stent graft repair .
in this case , an infected aortic aneurysm exhibited elevated the patient 's pr3-anca level , and its clinical course mimicked pr3-anca - associated vasculitis .
the detection of ancas is highly specific for a diagnosis of anca - associated vasculitis ( 4 ) ; however , a number of infections can result in a positive anca test .
there are several reports of infective endocarditis with the presence of ancas that mimic the clinical manifestations of an anca - associated vasculitis such as glomerulonephritis ( 2,3 ) . in the present case , based on the finding of positive blood cultures
, we suspected that the patient was experiencing not anca - associated vasculitis but infective endocarditis .
however , no vegetations were detected in the cardiac chambers using transthoracic echocardiography or transesophageal echocardiography .
instead , contrast - enhanced ct revealed a pseudoaneurysm in the descending aorta , which suggested that the patient had an infected aneurysm .
her renal dysfunction and elevated pr3-anca levels normalized with clinical resolution of the infected aneurysm after the administration of appropriate antibiotic therapy and evar .
the patient has remained free of any evidence of systemic vasculitis during follow - up .
the presence of pr3-anca may have been falsely positive in the present patient . to our knowledge , this is the first report of an infected aortic aneurysm with a positive pr3-anca test and clinical features mimicking anca - associated vasculitis .
the presence of vegetations in the heart is one of the most characteristic findings of infective endocarditis .
these vegetations are composed of bacteria , platelets , and inflammatory cells interspersed with fibrin mesh , either on damaged endocardium , including native cardiac valves , or prosthetic valves ( 5 ) . in the present case ,
because these masses disappeared after antibiotic treatment , they were considered to be vegetations . a pathological examination of the macular hemorrhages on the patient 's sole indicated not a cholesterol embolization but rather a janeway lesion , which was the consequence of septic embolic events .
we therefore suspected that these masses were not mobile plaques but bacterial vegetations . to our knowledge ,
few cases of infected native aortic aneurysm manifesting vegetations in the aneurysm have been reported ( 6 - 8 ) .
several mechanisms have been proposed regarding how ancas are formed during the course of infection , such as autoantigen complementarity , molecular mimicry , epigenetics , neutrophil extracellular traps , and microbial - sensing proteins called toll - like receptors ( 9 ) . there may be a great degree of overlap in the clinical and laboratory manifestations between anca - associated vasculitis and anca - positive infected aortic aneurysm , potentially leading to a misdiagnosis .
it is important to correctly diagnose these cases in order to avoid administering inappropriate therapy , such as immunosuppressive treatment , which might have life - threatening consequences in a patient with an infected aortic aneurysm .
positive blood cultures and imaging findings , such as a pseudoaneurysm and/or vegetations in the aorta , suggest the presence of an infected aortic aneurysm . a combination of conventional surgical treatment with resection of the aneurysm , extensive local debridement , and revascularization by in situ reconstruction or extra - anatomic bypass may be the gold standard , but such a treatment strategy is accompanied by a high mortality and morbidity . in the present case ,
it was recently reported that evar of an infected aortic aneurysm is feasible and , for most patients , a durable treatment option ( 10 ) .
given that the continuous administration of antibiotics for the infected aneurysm should prevent a recurrence of local infection , we continued using antibiotics until the infection was controlled and carefully monitored the shape of the pseudoaneurysm on contrast - enhanced ct .
we were ready to perform an emergency surgical correction at any point during this patient 's treatment course . in conclusion
, we herein reported an unusual case of infected descending aortic pseudoaneurysm with luminal pathognomonic oscillating vegetation and with serological findings and clinical features mimicking pr3-anca - associated vasculitis .

Answer:
we herein report an unusual case of an infected descending aortic pseudoaneurysm with luminal pathognomonic oscillating vegetation with serological findings and clinical features mimicking anti - proteinase 3-antineutrophil cytoplasmic antibody - associated vasculitis . the positive blood cultures and imaging findings , including a pseudoaneurysm and vegetations in the aorta , suggested the presence of an infected aortic aneurysm .
 the patient was successfully treated with antibiotics and endovascular aortic repair .
 a precise diagnosis is crucial in order to avoid inappropriate therapy such as immunosuppressive treatment , which could result in life - threatening consequences in a patient with an infected aortic aneurysm .


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:
amisulpride came into the indian market a few years back with hypes and hopes in the management of schizophrenia .
its broad spectrum effectiveness with lower chances of extrapyramidal symptoms ( eps ) and metabolic syndrome did help psychiatrists to treat schizophrenia and related disorders more effectively .
although this antipsychotic does not block serotonin receptors at all , it is a high - affinity and highly selective d3/d2 receptor antagonist with atypical properties .
its selective affinity for dopamine receptors in the limbic structures , but not in the striatum , leads to a low risk of extrapyramidal side effects .
all available reports suggest that chance of eps is very less with amisulpride at doses < 400 mg / day .
however , there are sporadic reports of drug - induced eps including dystonia and akathisia even in patients receiving low doses of amisulpride . here
a 30-year - old male with schizophrenia for the past 10 years now presented with predominantly negative symptoms .
he was on olanzapine 15 mg / day for more than 6 months without much improvement .
hence , amisulpride was instituted with a starting dose of 50 mg / day with a gradual increment up to 300 mg / day within 14 days .
the patient came after 14 days to the casualty with features of parkinsonian syndrome such as slowed gait , mild rigidity , salivation , and bradykinesia .
he was hospitalized , amisulpride was immediately stopped , and trihexyphenidyl 4 mg / day was given to manage the side effect .
his eps gradually subsided and for negative symptoms , clozapine was introduced at a small dose of 25 mg / day and gradually increased to 200 mg / day over a period of 10 days . at the time of discharge , on the 14 day , he was free from parkinsonian symptoms .
subsequent follow - up showed no parkinsonian symptoms and he had modest improvement in negative symptoms . a 48-year - old male with schizophrenia for the last 20 years
was treated with various antipsychotics without much improvement . since the last 6 months , he was on olanzapine 15 mg / day .
as there was no significant improvement , his olanzapine dose was gradually tapered and stopped over a period of 14 days and was started on amisulpride 100 mg / day and was increased to 200 mg / day over a period of 3 weeks .
the patient returned on the 24 day with severe parkinsonian symptoms . in this patient also , there was no prior history of parkinsonism .
we managed him with injection promethazine 25 mg intramuscular bid first 3 days along with trihexyphenidyl 2 mg bid after stopping amisulpride .
after 7 days , parkinsonian symptoms improved considerably and clozapine was introduced at a dose of 25 mg / day which was subsequently increased to 100 mg / day on the 10 day and the patient was discharged .
since the discovery that clozapine induces fewer eps and is more effective for negative symptoms than conventional antipsychotics for the treatment of schizophrenia , psychopharmacological research has focused on the development of drugs that block central 5-ht2 receptors more than d2 receptors .
combined 5-ht2/d2 receptor antagonism is the most current explanation for the so - called  atypical  profile of some antipsychotics .
amisulpride at low doses binds selectively to dopamine d2 , d3 autoreceptors , thereby enhancing dopaminergic transmission and thus might be effective for negative symptoms .
it has no affinity for d1 , d4 , and d5 receptor subtypes . at higher doses
, it blocks postsynaptic receptors , thus inhibiting dopaminergic hyperactivity . at the same time , amisulpride has greater specificity for the limbic system and thus has low incidence of eps .
amisulpride binds more loosely than dopamine to the dopamine d2 receptor and is rapidly dissociated from the dopamine d2 receptor .
low - dose therapy with amisulpride is associated with a significantly lower blockade of striatal dopamine d2 receptors than is seen during high - dose treatment . however , a significant striatal d2 blockade was demonstrated at therapeutically effective dose ranges , and a good relationship between the degree of striatal dopamine d2 receptor occupancy and the amisulpride plasma concentration or the administered dose was shown . in general , asians are slow metabolizers .
low body weight and slow metabolism may increase the plasma concentration of drugs causing side effects .
reported a low postsynaptic d2 occupancy in the striatum at low doses of amisulpride ( 50100 mg / day ) .
it has also been suggested that extrastriatal binding could mediate the effect on negative symptoms .
the probable causes of eps with low doses of amisulpride could be that it blocks postsynaptic d2 receptors significantly in striatum without much effect in the mesolimbic pathway .
, the lower incidence of eps which is claimed by western researchers as well as pharmaceutical companies should be studied well in the indian context .
we should at least keep this side effect in our minds while starting or increasing the doses .

Answer:
amisulpride , recently introduced atypical antipsychotic , is well - known for its broad spectrum effectiveness and lower profile for extrapyramidal side effects ( eps ) .
 its selective affinity for dopamine receptors in the limbic structures , but not in the striatum , leads to a low risk of extrapyramidal side effects . here
 , we report two cases of eps associated with lower dose of amisulpride .
 the proposed mechanism for its causation is also discussed .
 authors invite more studies , specifically from the indian context to find out the incidence of eps and other associated side effects .


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:
wandering spleen , also known as ectopic spleen , is an uncommon clinical entity characterized by hypermobility of the spleen due to laxity or absence of the normal ligaments that attach the spleen to the left upper quadrant .
this allows the spleen to essentially drop to the lower abdomen by the force of gravity attached only to its abnormally elongated vascular pedicle .
common complications of a wandering spleen include torsion of its pedicle , compression of another organ by the spleen or the pedicle , and susceptibility of the spleen to trauma .
symptoms are most commonly attributed to complications related to irreducible torsion which produces venous congestion , arterial infraction , strangulation and rupture of the spleen .
treatment of choice is splenopexy for an uncomplicated or complicated but viable wandering spleen and splenectomy for a non - viable spleen .
herein , we present a case of a patient with progressive torsion of a pelvic spleen causing recurrent abdominal pain and eventually spleen strangulation and rupture .
a 46-year - old male was admitted to the emergency department complaining of constant left lower quadrant abdominal pain of increasing severity for the last 6 days . direct questioning revealed a history of mild , intermittent lower abdominal pain for the past 65 days .
the patient was febrile ( 38.8  c ) , had tachycardia ( 118  beats / min ) and blood pressure of 90/50  mmhg .
physical examination revealed abdominal distention , predominantly in the hypogastric region due to a tender mass causing dullness on percussion suprapubicly .
pelvic mass or pelvic peritonitis arised from a variety of causes were included in the differential diagnosis .
abdominal x - rays revealed increased pelvic radio - opaqueness , few dilated loops of small intestine , and displacement of the splenic flexure in the normal spleen position .
emergency ct revealed absence of the spleen in its normal position , a homogeneous pelvic mass with no contrast enhancement pushing aside the sigmoid colon , free blood in the peritoneal cavity around the mass , and a normal urinary tract .
the absence of the spleen in its normal position and the non - enhancement of the pelvic mass made the diagnosis of an ectopic strangulated spleen undeniable .
the spleen was enlarged ( 23  cm    18  cm    12  cm ) , located inside the pelvis , attached to an abnormally elongated torted pedicle ( 19  cm ) , and adhered to the greater omentum and intestine ( none of splenic ligaments were present ) ( fig .
the spleen was strangulated due to the 760 clockwise twists of its pedicle ( fig .
2 ) , and ruptured at its lower pole ( 2  cm in depth , not evolving a trabecular vessel grade ii laceration ) .
3 ) ; however , the organ continued to appear non - viable and total splenectomy was performed .
thorough investigation revealed no evidence of accessory spleens in the left upper quadrant , the bowel mesentery , the greater omentum and the pelvis . during exploration
histology revealed acute thrombotic changes in arteries and veins of the splenic hilum , with diffuse hemorrhagic and ischemic infarcts of the spleen .
the postoperative course was uneventful and the patient was discharged on the fifth postoperative day without any complication .
wandering spleen is a rarely diagnosed clinical entity . according to our knowledge less than 500 cases of patients with recurrent abdominal pain or abdominal emergency caused by a wandering spleen
moreover , splenectomy for treatment of a wandering spleen account for less than 0.25% of splenectomies in reported series .
wandering spleen is 7 times more common in females than males after age 10 and 2.5 times more common in males than females under the age of 1 year .
the most common age of presentation is childhood especially under 1 year of age followed by the third decade of life , and is more frequently seen in females of reproductive age . wandering spleen occurs because of either extreme laxity or absence of the normal ligaments that attach the spleen to its fixed position in the left upper quadrant .
three of these ligaments are virtually always present ( except in the condition of the wandering spleen ) , and two may be present to variable extents .
the three ligaments , that are constantly present , are the splenogastric ligament , the splenorenal ligament and the splenocolic ligament .
the two ligaments , that are variably present , are the splenoomental and the splenophrenic ligament .
absence or laxity of the above mentioned ligaments allows the spleen to essentially drop to the lower abdomen in either the right or the left lower quadrant by the force of gravity attached by its elongated vascular pedicle .
it occurs most probably as a result of congenital anomalies in the development of the dorsal mesogastrium and the absence or malformation of the normal splenic suspensory ligaments .
conditions associated with wandering spleen include enlargement or absence of a kidney , splenomegaly and previous pregnancy .
splenomegaly and pregnancy are thought to contribute to the laxity of the supporting structure by direct effect of gravity and estrogen respectively .
symptoms may remain limited or absent for long periods of time , but complications related to torsion , compression of another organ by the spleen or its pedicle and susceptibility of the spleen to trauma are quite common .
initially , irreducible torsion produces venous congestion as a result of which the spleen becomes edematous and enlarged . eventually , progressive torsion results in infraction of the arterial supply , acute ischemia , strangulation , necrosis and rupture of the congested and gangrenous spleen .
more frequently , patients are admitted due to a non specific chronic pelvic pain related to splenomegaly or pressure on adjacent organs .
the most common physical finding is a palpable lower abdominal mass representing the abnormally enlarged torted spleen .
laboratory tests are usually nonspecific , but may occasionally reveal evidence of hypersplenism or functional asplenia .
ultrasonography , nuclear scintigraphy , ct and mri can prove useful in revealing the nature of a pelvic mass of unknown entity and confirm the diagnosis of an ectopic spleen .
operative management is the treatment of choice in uncomplicated and complicated cases because conservative treatment of an asymptomatic wandering spleen is associated with a complication rate of 65% .
the wandering spleen is ideally for laparoscopic splenectomy because it is generally free from attachments and other organs .
the treatment for a wandering spleen as an incidental finding at laparotomy or if the torsion can be corrected and the spleen appears to be viable is splenopexy .
splenopexy has been successful in preventing complications of wandering spleen while preserving the splenic function .
they applied open or laparoscopic techniques with or without using a mesh and peritoneal flaps .
as the torsion involves the vascular pedicle , partial splenectomy or splenic implantation of the totally strangulated spleen is usually unattainable .
however , partial infraction of a wandering spleen necessitating partial splenectomy and splenopexy or splenectomy and splenic implantation has been reported in the literature .
the present report was referred to a patient with progressive torsion of a pelvic spleen causing recurrent abdominal pain and eventually spleen strangulation and rupture . the patient exhibited a period of vague intermittent lower abdominal pain lasted 65 days followed by a period of constant left lower quadrant pain of increasing severity lasted 6 days .
on the first 65 days , vague pain was attributed to progressive torsion which resulted in venous congestion and enlargement of the spleen . on the last 6 days ,
exacerbation of pain was attributed to irreducible torsion , infraction of the arterial supply , acute ischemia , strangulation , necrosis and rupture of the congested and gangrenous spleen .
although the presence of the ectopic spleen could be easily identifiable on serial physical examinations since childhood , it was diagnosed in adulthood due to manifestation of complications .
written informed consent was obtained from the patient for publication of this case report and accompanying images .
konstantinos boulas , salpigktidis i and barettas n equally contributed to the writing of this paper .
konstantinos blouhos , anestis hatzigeorgiadis and konstantinos boulas performed the operation.key learning pointsthe presence of an ectopic spleen can be easily identified on serial physical examinations since childhood.however it is commonly misdiagnosed until the manifestation of complications in adulthood . the
presence of an ectopic spleen can be easily identified on serial physical examinations since childhood.however it is commonly misdiagnosed until the manifestation of complications in adulthood .
the presence of an ectopic spleen can be easily identified on serial physical examinations since childhood .

Answer:
introductionectopic spleen is an uncommon clinical entity as splenectomy for treatment of ectopic spleens accounts for less than 0.25% of splenectomies .
 the most common age of presentation is childhood especially under 1 year of age followed by the third decade of life.presentation of casethe present report refers to a patient with torsion of a pelvic spleen treated with splenectomy .
 the patient exhibited a period of vague intermittent lower abdominal pain lasted 65 days followed by a period of constant left lower quadrant pain of increasing severity lasted 6 days .
 on the first 65 days , vague pain was attributed to progressive torsion of the spleen which resulted in venous congestion . on the last 6 days ,
 exacerbation of pain was attributed to irreducible torsion , infraction of the arterial supply , acute ischemia , strangulation and rupture of the gangrenous spleen .
 diagnosis was made by ct which revealed absence of the spleen in its normal position , a homogeneous pelvic mass with no contrast enhancement , free blood in the peritoneal cavity , and confirmed by laparotomy.discussionclinical manifestations of ectopic spleen vary from asymptomatic to abdominal emergency .
 symptoms are most commonly attributed to complications related to torsion .
 operative management , including splenopexy or splenectomy , is the treatment of choice in uncomplicated and complicated cases because conservative treatment of an asymptomatic ectopic spleen is associated with a complication rate of 65%.conclusionalthough an ectopic spleen can be easily identified on clinical examination , it is commonly misdiagnosed until the manifestation of complications in adulthood .


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:
palisaded encapsulated neuromas clinically manifest as solitary , firm , non - pigmented , dome - shaped nodules on the face of adult patients . palisaded encapsulated neuroma is known as a benign tumor of the facial skin , and is rarely found in the oral mucosa .
microscopically , the tumors are characterized by moderately cellular , fascicular proliferation of spindle cells that show some areas of parallel nuclei .
a bundle of nerves interposed between the schwann cells typically aggregates in palisades and is identified by s-100 protein immunohistochemical stain .
an alternate designation i.e. solitary circumscribed neuroma ( scn ) was proposed by fletcher in 1989 .
irrespective of the nomenclature , pen / scns are considered as reactive hyperplastic processes . in 2010 ,
koutlas and scheithauer considered pen / scns as relatively common true neuromas of the skin or mucosa . as a peripheral nerve sheath tumor , pen accounts for only 0.04 to 0.05% of oral biopsy specimens .
other peripheral nerve sheath tumors are neurofibroma , schwannoma ( neurilemmoma ) , mucosal neuroma associated with multiple endocrine neoplasia iii , nerve sheath myxoma and granular cell tumor . in the mouth , pen is mostly found on the hard palate and maxillary labial mucosa as a small , superficial and usually painless nodule .
the lesion is frequently diagnosed between the 5 and 7 decades of life , with equal sex predilection .
a preferred treatment for pen is conservative local surgical excision ; although gross total resection has been recently claimed to be the treatment of choice .
a 48-year - old man was referred to the oral medicine department of babol dental school , complaining of a tongue mass persisting for one year .
physical examination revealed an exophytic sessile mass measuring 0.3 0.4 cm with rubbery consistency on the anterior one - third of the dorsal surface of the tongue ( fig .
clinically , the overlying mucosa was depapillated and had increased vascularity . under the impression of a pg , excision of the mass was done and no recurrence was reported at 12 months postoperatively .
histopathological sections showed an encapsulated mass within the connective tissue , composed of interlacing fascicles of spindle cells that were consistent with schwann cells .
the nuclei , showing a parallel orientation within the fascicles , were characteristically wavy and pointed , with no significant pleomorphism or mitotic activity .
the overlying epithelium was atrophic and no rete ridges were seen ( figs . 3 and 4 ) .
giemsa special stain revealed no mast cells within the stroma , ruling out the differential diagnosis of neurofibroma .
photomicrograph showing an encapsulated proliferation of neoplastic cells ( hematoxylin and eosin staining ; original magnification 40 ) .
no evidence of malignancy is observed ( hematoxylin and eosin staining ; original magnification 400 ) .
mucosal neuroma can be distinguished histologically from other neurogenic tumors such as neurofibroma , neurilemmoma and pen .
briefly , mucosal neuroma is not encapsulated and does not have palisading nuclei ; whereas neurofibroma and pen are encapsulated .
mucosal neuromas are usually associated with the multiple endocrine neoplasia syndrome iii ( men iii ) , a rare syndrome with potentially fatal consequences such as medullary carcinoma of the thyroid .
other clinical signs of the patients with men iii can be considered in the diagnosis of oral lesions such as a mucosal neuroma . however
, when oral lesions are present in absence of other diagnostic signs , histopathological evaluation can be helpful .
the microscopic examination of the mucosal neuroma shows nerve bundles in various sizes surrounded by normal connective tissue , which are not usually seen in pen .
a traumatic neuroma is not a true tumor , yet it develops as a proliferation of neural tissue that is caused by injury to a peripheral nerve .
traumatic neuromas are usually associated with pain , ranging from pain on palpation to a constant severe pain .
these include the presence of perineural cells surrounding individual microfascicles , the greater abundance of interstitial collagen , mucoid matrix and myelin components , and the more orderly parallel arrangement of axons in traumatic neuroma .
antoni a , organized spindle cells in palisaded whorls , and antoni b , haphazardly distributed neoplastic cells , are two common patterns which are often found during histopathological examination of schwannomas .
other microscopic criteria include verocay bodies and the more definite palisading in the nuclei than that in pen .
contrary to the latter , it is extremely difficult to microscopically differentiate neurofibroma from pen , especially when an incisional biopsy has been performed .
the absence of marked fibrous capsule and the irregular arrangement of the neoplastic cells are the main differential clues seen in neurofibroma compared with pen .
the significant presence of mast cells , usually observed among tumoral cells of the neurofibroma , is also detectable using histochemical or immunohistochemical staining methods . as regezi and colleagues stated ,
pen / scn may be misdiagnosed clinically once identified somewhere in the mouth other than the palate .
this may be an obvious clinical impression since intraoral pen / scns are mostly found on the hard palate .
conversely , the tongue involvement comprises less than 8% of pen / scn cases . as for this case
, the pen resembled a pg on the dorsal surface of the tongue ( a common site for neurilemmoma and neurofibroma , but not for pen ) .
an erythematous lesion in a less commonly affected site rarely happens to be a pen . besides , the tongue is a potential site for pg .
have reported that pg is most commonly seen on the attached gingivae , tongue , lower lip and buccal mucosa .
the age of patient may be an important clinical parameter when the list of differential diagnoses of a lesion is formulated .
our patient was 48 years old , which was close to the recently reported average age for pg patients ( 52 years ) .
pyogenic granuloma usually occurs in patients older than 39 years , with equal gender distribution .
soft tissue enlargements of the oral cavity often present a diagnostic challenge because a diverse group of pathological processes can produce such lesions .
pyogenic granuloma can manifest as a painless smooth or lobulated mass with a surface that bleeds quite easily .
because of their high level of vascularity , young pgs are red , whereas older lesions are more collagenized and appear pink or normal colored .
clinically , oral pg occurs as an exophytic lesion manifesting as small , erythematous papule on a pedunculated or sometimes sessile base .
pyogenic granuloma arises in response to various stimuli such as chronic low - grade irritation , traumatic injury and hormonal factors .
however , the effect of female hormones on oral pg was questioned by bhaskar and jacoway since they found lesions both in males and females with no sex predilection .
palisaded encapsulated neuromas may be misdiagnosed clinically once they appear somewhere in the oral cavity other than the palate .
a pen arising on the dorsum of the tongue may mimic a pg with similar clinical morphology . even the patient s age may be misleading . on the other hand ,
peripheral nerve sheath tumors must therefore be included in the list of differential diagnoses for a pg - like lesion on the tongue .

Answer:
palisaded encapsulated ( solitary circumscribed ) neuromas ( pens ) are relatively common intraoral neurogenic tumors , which occur most frequently on the hard palate .
 herein , we describe the clinicopathological characteristics of a palisaded encapsulated neuroma of the tongue .
 this tumor was an exophytic sessile mass measuring 0.3 0.4 cm with rubbery consistency on the anterior one - third of the dorsum of the tongue .
 the tumor was excised under the impression of a pyogenic granuloma ( pg ) .
 no recurrence was reported at 12 months postoperatively .
 histopathological examination showed a well - circumscribed mass that composed of interlacing fascicles of spindle cells .
 the cells were s-100 positive .
 the nuclei , showing parallel orientation within the fascicles , were wavy and pointed and showed no sign of mitotic activity .
 giemsa staining revealed no mast cells within the stroma .


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:
myxoma is a benign neoplasm of mesenchymal origin composed of undifferentiated stellate cells in a myxoid stroma , which were differentiated into altered fibroblasts and lost their ability to produce normal collagen18 ) .
myxoma can arise in a variety of locations ; heart , subcutaneous and aponeurotic tissues , bone , genitourinary tract and skin , etc .
the most frequent site for myxoma is the heart , and bony myxoma is almost exclusively limited to the jaws and palate , representing 40 - 50% of all head and neck myxomas216 ) .
the soft tissue myxoma is rare , and occurs mostly in the large skeletal muscles .
the myxomas that arise in the skeletal muscles are generally called intramuscular myxomas ( ims ) .
the most of ims are detected in the fourth to sixth decades of life with slight female predominance16 ) .
i m accounts for about 3 - 17% of the all myxomas , and the incidence is about 1 case per million population per a year51823 ) . to our knowledge ,
we report the eighth case of a myxoma developed within the lumbosacral paraspinal muscle ( including thoracolumbar paraspinal muscle ) , which had some different characteristics from the typical i m , and brief review of the literature will be followed .
a 62-year - old female was referred to our hospital for mass - like lesion detected on magnetic resonance imaging ( mri ) of her spine .
she presented with low - back pain just for 3 months without radiating leg pain , and the symptom was slowly progressive .
but , interestingly , she had the previous history of bone harvest on the right posterior superior iliac spine ( psis ) for the cervical fusion operation 15 years ago in the other hospital . physical examination revealed a large palpable mass on the right paraspinal area in the lumbosacral region , but there was no associated tenderness in this region .
her neurologic examination at the time of admission was fully normal , and there was no abnormal finding on the laboratory tests and the electrophysiological studies such as electromyography ( emg ) and somatosensory evoked potential ( ssep ) .
mri demonstrated a multi - lobulated mass in the right lumbosacral paraspinal muscles in contact with the posterior elements of the l4 and l5 vertebra ( fig .
this well - circumscribed mass was measured approximately 4.03.56.5 cm in size , and the lesion was hypointense on t1-weighted image ( t1wi ) and hyperintense on t2-weighted image ( t2wi ) .
there were heterogenously enhancing foci inside the mass with peripheral and septal enhancement on the post - contrast t1wi . on computed tomography ( ct )
scan of the lumbosacral region , this mass had low density and some calcification particularly on the inferior portion of the mass ( fig .
there was no bony destruction or invasion around the mass . in the process of a full diagnostic workup
, we found her previous abdominal ct images in picture archiving computer system ( pacs ) , which had been performed for evaluation of her abdominal pain 4 months ago ( fig . 2c ,
d ) . in the previous abdominal ct , although it was slightly smaller than the mass of recent lumbar ct , the hypodense lesion was also seen at the same area .
it was notable that calcification inside the mass was not detected on the previous abdominal ct .
we planned to conduct the complete excision , instead of simple biopsy ( for example , ct - guided biopsy ) , because the tumor was not only symptomatic , but also the operation had fairly limited risk to the patient .
the tumor was encapsulated and lobulated with grayish white surface , and there was no evidence of the infiltration or invasion into the surrounding bony structures .
3 ) . according to the frozen biopsy during the operation , the mass was revealed to myxoid tumor , and the final histopathological findings were consistent with intramuscular myxoma .
this mass was composed of prominent myxoid stroma with a distinct presence of spindle and stellate cells , and while pyknotic nuclei and karyorrhectic nuclei were also seen ( fig .
numerous micro - calcifications were also found , especially in the peripheral capsular area of the tumor .
the patient was neurologically free and experienced complete relief of her low - back pain postoperatively .
since stout et al18 ) . outlined the diagnostic criteria and defined myxoma at 1948 , the intramuscular myxoma has been known as the most rare sub - type in these tumor category .
ims have been reported at the various locations such as thighs , buttocks , upper limbs , shoulders , and paravertebral area . of those ims ,
paraspinal regions are the most uncommon site , and so far , only 14 cases of paraspinal ims have been reported .
and to the best of our knowledge , this report is just the eighth case of paraspinal i m in the lumbosacral area including one case of thoracolumbar lesion , and the first case in asian population ( table 1)891114151720 ) .
ims usually appear as well - circumscribed homogeneous low - density lesions within the skeletal muscle on ct scan , and have low - signal intensity on t1wi and high - signal intensity on t2wi .
bancroft el al.1 ) described that the peri - tumoral fat rind on t1wi and increased signal in the adjacent muscle on t2wi are the most reliable radiologic features for distinguishing intramuscular myxoma from other myxoid tumor .
but in this case , this finding was not definite on the mri . on gross inspection , the tumor has usually oval shape and shows well - circumscribed appearance , however its fibrous tissue often has incomplete pseudocapsule to result in infiltration of adjacent musculature510 ) . and
in general the tumor has a glistering gray - white appearance and contains gelatinous material and cyst filled with fluid inside the mass .
histologically , ims are composed of well - localized myxomatous connective tissue surrounded by a collagenous fibrous connective tissue22 ) .
ims are often confused with other pathologic conditions such as ganglion or neurofibroma , and furthermore , with other mucoid sarcomas such as liposarcomas , chondrosarcomas , low - grade fibromyxoid sarcoma and malignant histiocytomas , because these sarcomas are also accompanied by the myxomatous degeneration .
however , several critical clues had been presented , which help to distinguish ims from other myxoid lesions .
first , ims have poor vascularization and a paucity of cells ( lipoblasts or chondroblasts ) , in contrast to myxoid liposarcoma which has a rich , delicate , plexiform capillary vascular network . secondly , ims lack nuclear atypia , necrosis , and prominent mitotic activity .
in addition , on the enhanced mri , soft tissue sarcomas showed heterogeneity , intense enhancement , septation , ill - defined margins and invasion of adjacent structure against the ims .
moreover , ims often do not have a true capsule , and therefore could infiltrate to the adjacent striated muscle , resulting in muscle atrophy which appear as a peri - tumoral fat rind on t1wi .
additionally , doyle et al.4 ) presented the muc4 protein as a specific marker for distinguishing from low - grade fibromyxoid sarcroma .
ims usually present as a solitary slow growing painless mass , however multiple myxomas can occur on rare specific condition , for example , mazabraud 's syndrome .
the clinical manifestations of ims generally are non - specific , but rather presenting symptoms depend on the affected locations . in our case ,
the patient also presented with ambiguous low back pain and this symptom was resolved after total resection of the tumor . in general , ims are known as slowly growing and painless tumors , whereas there are some differences from typical natures of ims in this case .
first , it had been just asymptomatic mass , but it developed to symptomatic lesion in a very short time ( about 3 months ) .
there was demonstrable difference in size of the tumor ; widthlengthheight=3.03.05.4 cm to 4.03.56.5 cm .
in addition , a new calcification inside the mass was accompanied with tumor growth , while there is no internal calcification in most cases of i m .
third , the location of i m was adjacent to the previous operation site ( iliac bone harvest site ) .
although the pathogenesis of ims remains obscure , there are several theories for explaining the pathogenesis . according to one of the theories ,
stellate cells may be altered fibroblasts that fail to produce mature collagen5 ) . by glazunov and puckov , " viral origin "
wirth et al.24 ) proposed the fibrous dysplasia as another theory for the pathogenesis of ims , and fibrous dysplasia usually precedes the ims by several years .
we assumed that interruption of paraspinal muscles by previous operation could induce fibrous dysplasia to arise i m .
though there was no report about the prevalence by race due to the rarity of the incidence of ims , previous many reports were almost confined to the western population .
our case is the first case of i m in asian people , which developed in the lumbosacral paraspinal musculature .
the clinical course of ims is known to be nearly benign , and the treatment for ims is the total surgical resection . there is no report of metastasis or malignant change , but occasionally local recurrence resulting from incomplete resection has been reported6913 ) .
therefore , if possible , wide excision with clean margins is recommended to avoid local recurrence , since ims have an infiltrative tendency to surrounding muscles .
we report the first case of the paraspinal intramuscular myxoma developed in the lumbosacral area in asian population .
intramuscular myxomas are uncommon benign tumors , especially in the paraspinal area , and moreover it is difficult to make a diagnosis before operation because of the lack of characteristic clinical history and radiographic findings , however , neurosurgeons should be aware of this entity .

Answer:
intramuscular myxoma ( i m ) is a benign neoplasm of mesenchymal origin .
 we report a rare case of i m which was located in the lumbosacral paraspinal muscles .
 a 62-year - old female patient presented with progressive low back pain for 2 months , and the radiologic findings showed a large mass ( 4.03.56.5 cm ) in the right lumbosacral paraspinal area .
 total resection of the tumor was performed and the symptom was nearly resolved after surgery . although the immuno - histopathological analysis was consistent with i m , there were some different findings from typical pathological characteristics of i m in this case .
 firstly , the symptomatic change of the mass took relatively short time ( less than 3 months ) , and this change was accompanied by partial calcification inside the mass .
 moreover , iatrogenic interruption of paravertebral muscle by the other previous operation might be the promoting factor of the fibrous dysplasia , which can explain the pathogenesis of i m .
 to our knowledge , this is the eighth case of the lumbar paraspinal myxoma reported in the literatures and the first case in asian population .