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:
perinatal depression is a major public health problem , affecting up to a quarter of all pregnant women in rural countries .
it is associated with profound physical and emotional changes and associated risks for the onset or exacerbation of several mental disorders such as depression .
in addition to its effects on the mother 's well - being , perinatal depression is associated with adverse outcomes of pregnancy .
relevant effective interventions are being developed , but their effectiveness in low- and middle - income countries may be limited by various factors .
exercise can provide a viable treatment options for depressed patients , whether as an alternative treatment strategy to conventional treatments or as a supplemental strategy , either in the short - term or long - term .
research to date by low numbers to support the use of exercise in some form as a positive treatment option for individuals suffering from depression .
all married women aged 1740 years with low socioeconomic status in their second trimester of pregnancy , who had depression , were considered .
women with a diagnosed medical condition , pregnancy - related illness , significant physical or intellectual disability , post par tumor other form of psychosis , and severe depressions were excluded . during the pre - intervention assessment ,
both groups were asked to attend post - intervention assessment 4 and 8 weeks following the start of the program to complete the questionnaire .
subjects in this group had 4 weeks exercise program , cycle 4 sessions a week for 4060 min / session .
the exercise in each session were including : 10 min heating with walking , stretching and flexibility , and three sets of moderate intensity cycling in 6 min with 6065% of maximum heart rate .
subjects in the control group were given a patient handout which is in gujarati explaining about the procedures to do as home based program .
the hand out consist of five criteria such as stay active , do something that you think is fun each day , spend time with people who help or support you , relaxing and set simple goals .
inter group analysis was done using wilcoxon - mann  whitney test and intra group analysis was done using one - way anova .
during the pre - intervention assessment , subjects have undergone kuppuswamy 's socioeconomic status scale and the physical health questionnaire-9 .
both groups were asked to attend post - intervention assessment 4 and 8 weeks following the start of the program to complete the questionnaire .
subjects in this group had 4 weeks exercise program , cycle 4 sessions a week for 4060 min / session .
the exercise in each session were including : 10 min heating with walking , stretching and flexibility , and three sets of moderate intensity cycling in 6 min with 6065% of maximum heart rate .
subjects in the control group were given a patient handout which is in gujarati explaining about the procedures to do as home based program .
the hand out consist of five criteria such as stay active , do something that you think is fun each day , spend time with people who help or support you , relaxing and set simple goals .
inter group analysis was done using wilcoxon - mann  whitney test and intra group analysis was done using one - way anova .
of 146 subjects , 80 ( 55% ) met the inclusion criteria and 60 ( 41% ) agreed to enroll .
four subjects were excluded from the analysis in the exercise group ( group 1 ) and 2 subjects were excluded from analysis in the control group ( group 2 ) .
no significance differences between groups were found at baseline on outcome variable such as depression level .
analysis of depression level shows significant changes within and between exercise and control group . at baseline , the mean depression score was 15.96 ( 3.09 ) and 16.23 ( 3.38 ) for the exercise group and the control group , respectively . after the 4-weeks intervention ,
the mean score fell to 6.10 ( 2.44 ) for the exercise group ( 43.54% ) and to 10.60 ( 2.74 ) for the control group ( 21.25% ) .
at the 8 weeks follow - up , the mean score was 1.34 ( 1.09 ) for the exercise group ( 72.81% ) and 5.03 ( 1.50 ) for the control group ( 42.50% ) .
exercise has been shown in a number of studies to prove beneficial in the treatment of depressive symptoms especially in perinatal and post natal conditions .
bartholomew showed that a single incidence of exercise can have a positive effect on mood . maintaining the intensity and frequency of exercise recommended by most public health agencies were sufficient to provide a significant reduction in major depressive disorder ( mdd ) symptoms .
the additional benefits of exercise to individuals suffering from depression include stress reduction , better attitude , improved outlook , self - confidence , and mental well - being .
our intervention , the  physical exercises  was developed to provide a culturally appropriate , feasible , and evidence - based physical therapy intervention for women living in very poor communities in rural india .
these results suggest that supervised physical exercise provides better improvement in depression status in perinatal subjects .

Answer:
background : perinatal depression is a major public health problem , affecting up to a quarter of all pregnant women in rural asean countries and often leads to psychologic symptoms , lower quality of life , and higher health care costs . the purpose of this study was to assess the impact of supervised physical exercise on depression level of perinatal subjects.subjects/intervention:60 subjects who fulfill the selection criteria were randomly assigned to exercise ( group-1 , n=30 ) and control group ( group-2 , n=30 ) .
 participants completed general screening form and physical health questionnaire-9 ( phq-9 ) before their intervention and again 4 weeks and 8 weeks later .
 group-1 underwent aerobic training with 60 - 65% maximum heart rate and group-2 was prescribed with handouts for 4 weeks.statistics:repeated-measures analysis of variance ( anova ) was use to analyze group differences over time while controlling for baseline differences.results:demographic and the baseline values show homogenous population ( p>0.05 ) .
 patients in both groups experienced significant reduction in depression level .
 group a showed reduction of 91.70% ( p=0.00 ) as compared to group b 69.01% ( p=0.00).conclusion : these results suggest that supervised physical exercise provides better improvement in depression status in perinatal subjects than providing handouts alone .


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 need for categorization of anomalies and congenital aberrancies formed due to developmental vascular defects produce identifiable birthmarks of the skin and mucosa and a variable degree of underlying soft tissue abnormalities .
presently a surge in the knowledge of criterias to classify these various anomalies has put forth classifications purely with respect to histopathological features of the disease .
these lesions predominantly occur within the head and neck and affect approximately 1 in 22 children .
involvement of the oral cavity is common but frequently requires unconventional treatment strategies for its management .
though previously termed  angiomas  or vascular  birthmarks  , vascular anomalies are divided into two main categories : vascular tumors and vascular malformations .
infantile hemangiomas comprise the majority of vascular anomalies and are considered the predominant vascular tumor type composed of rapidly proliferating endothelial cells .
blood vessel architecture is incomplete and surrounded by hyperplastic cells in hemangiomas and other vascular tumors . in contrast , vascular malformations do not contain hyperplastic cells but consist of progressively enlarging aberrant and ectatic vessels composed of a particular vascular architecture such as veins , lymphatic vessels , venules , capillaries , arteries or mixed vessel type .
the latter comprises lymphangiomas or lymphatic malformations which are congenital collections of ectatic lymph vessels that form endothelial lined cystic spaces .
the pathogenesis of these tumors could be of importance in thoroughly understanding the mode of these varying histopathological presentations .
they represent about 6% of the total number of benign tumors of the soft tissue in patients aged less than 20 years .
regarding gender distribution of lymphangioma , it is equally divided between males and females , with about 50% of the lesions being noted at birth and 90% developing by 2 years of age .
oral lesions may occur at various sites but they form most frequently on the anterior two thirds of tongue
. they may increase in size , producing macroglossia which may lead to difficulties in mastication , deglutition , and speech ; and displacement of the teeth , with a resulting malocclusion .
they may interfere with normal breathing , particularly during sleep , produce sleep apnea , and in certain instances , produce a life - threatening upper airway compromise .
they can also be present in the palate , buccal mucosa , gingiva and lip .
the tumor is superficial in location and demonstrates a white pebbly surface that resembles a cluster of translucent vesicles . the deeper lesions could mimic various soft tissue tumors since the color which is classically used for diagnosing such tumors would seem to be irrelevant .
they appear as a nodule or masses without significant change in surface texture or color .
a 9-year - old female patient reported to the department of oral & maxillofacial pathology , i.t.s cdsr , with a complaint of a painless growth with respect to left side of tongue .
patient had given a history of trauma due to tongue bite around 3 months back and was enlarging slowly in size the swelling was initially small , peanut sized , which increased to the present size .
on examination of the swelling a growth of 2  1 cm on the anterior part of the dorsal surface of tongue .
the lesion was pale pink in color and oval in shape with well - defined margins [ figure 1 ] .
intraoral photograph showing nodular swelling resembling cluster of vesicles on the left side of dorsum of tongue an incisional biopsy was performed and the tissue was histopathologically diagnosed as lymphangioma , since large lymphatic vessels lined by flattened endothelial cells pushing into the overlying epithelium were seen [ figure 2 ] .
patient was recalled after 4 days and a total excision of the lesion was performed under local anesthesia ( la ) .
photomicrograph of incisional biopsy showing large lymphatic vessels ( h and e , 10 ) examination of gross macroscopic appearance revealed the excised tissue to be oval shaped , measuring 1.5  1 cm in size and was creamish brown in color with a pebbly surface .
microscopic examination of the excised lesion showed numerous large , dilated lymphatic channels of irregular shape , lined by flattened endothelial cells , of which some of the vessels were filled with lymph .
numerous large- to medium - sized channels with thin endothelial lining , engorged with rbcs , were also present in the deeper area of the connective tissue [ figure 3 , inset ] .
lymphangioma was first described by virchow in 1854 , and in 1872 , krester hypothesized that hygromas were derived from lymphatic tissue .
the origin of lesion is considered to be congenital abnormality of lymphatic system rather than true neoplasm .
a portion of the jugular lymphatic sac is thought to sequestrate from the primary sacs during fetal development with failure to establish communications with other lymphatic system .
the fact that most lymphangiomas manifest clinically during early childhood and develop in areas where the primitive lymph sacs occur ( neck , axilla ) provides presumptive evidence for this hypothesis . on the contrary
, it is argued that instead of being a congenital malformation , lymphangioma is a true neoplasm resulting from transformed lymphatic endothelial cells and/or stromal cells .
the classic sequence of events in embryology and development of vasculogenesis falls into three stages : the undifferentiated capillary network stage , the retiform developmental stage and the final developmental stage .
the first theory is that the lymphatic system develops from five primitive sacs arising from venous system .
concerning the head and neck , endothelial outpouchings from the jugular sacs spread centrifugally to form the lymphatic systems .
another theory proposes that the lymphatic system develops from mesenchymal clefts in the venous plexus reticulum and spreads centripetally toward the jugular sacs .
several studies have been published regarding possible lymphangiogenic growth factor involvement in the etiology of lymphatic malformations .
these factors include vascular endothelial growth factor ( vegf)-c , vascular endothelial growth factor receptor 3 ( vegfr-3 ) , and transcription factor prox-1 .
vegf - c and vegfr-3 have been shown to be upregulated in lymphatic malformed tissue , and both are involved in lymphatic tissue proliferation .
the tumor may be localized in a small area of tongue or floor of mouth or it may diffusely infiltrate these areas . if the tumor is located in a deeper area , it may present as submucosal mass .
cervical lesions in a child cause dysphagia and airway obstruction which is rare in adults .
the misunderstanding on the nosologic distinction between oral hemangiomas and vascular malformations leads to diagnostic mistakes .
hemangiomas are differentiated from vascular malformations by their clinical appearance , histopathological features , and biologic features
. the natural history of hemangiomas involves rapid proliferations for the first several months of life with subsequent spontaneous regression .
vascular malformations are often recognized at birth and grow proportionately with the child , with many becoming more prominent at puberty .
histologically , hemangiomas in the proliferating phase show endothelial hyperplasia and large number of mast cells .
in contrast , vascular malformations show normal number of mast cells , and consist of mature , often combined , capillary , arterial , venous , and lymphatic elements .
lymphatic malformations / lymphangiomas are classified microscopically into four categories : lymphangioma simplex ( lymphangioma circumscriptum ) composed of small , thin - walled lymphatics ; cavernous lymphangioma comprising dilated lymphatic vessels with surrounding adventitia ; cystic lymphangioma ( cystic hygroma ) consisting of huge , macroscopic lymphatic spaces with surrounding fibrovascular tissues and smooth muscle ; and benign lymphangioendothelioma ( acquired progressive lymphangioma ) , in which lymphatic channel dissects through dense collagen bundles .
occasionally , channels may be filled with blood , a mixed hemangiolymphangioma , an uncommon developmental anomaly with a propensity to invade underlying tissues and to recur locally , distinguishing it from the simple lymphangioma or hemangioma .
although histologically it is a benign disorder , local invasion into the muscle , bone , and underlying tissue can lead to severe deformity . in the present case ,
numerous large - sized lymphatic channels along with medium- to large - sized channels entrapped with rbcs , lined by endothelium , were seen and hence it was subcategorized as hemangiolymphangioma .
we reviewed the archival cases of lymphatic malformations in our department , the demographical information , location and histopathological features of which are shown in table 1 .
the only significant difference in the three archival cases and the present case was in the histopathological features of lymphangioma and hemangiolymphangioma .
the demographic information , location and histopathological features these anomalies present the necessity for sound discretion with regards to their approach therapeutically.although spontaneous regression of lesions is rarely encountered , the treatment seems to weigh heavily on individual assessments of the observer .
sclerosing agents are ineffective , probably as a result of the discontinuous basement membrane of the lymphatic vessels .
nd - yag laser surgery has been widely preferred because of its advantages of less bleeding and edema .
due to a rate of recurrence of nearly 21% , long - term follow - up is essential of these tumorigenic anomalies .
the vascular lesions consist of both blood vessels and lymphatic vessels . whether these can be termed as hemangiolymphangioma or just vascular malformation is still confusing .
thus through the present article we would like to highlight the complexities which can arise from the terminal categorization of the large group of tumors called vascular neoplasms when based on their histopathological representation .
further detailed analysis of a larger case series would be imperative in the correct classification and diagnosis which could enormously help to accurately ascertain prognosis and direct treatment .

Answer:
malformations of vascular nature originate as anomalies caused due to errors in vasculogenesis .
 these tumors are generally broadly classified into vascular tumors ( hemangiomas ) and vascular malformations ( venous malformations , arteriovenous malformations , lymphatic malformations ) .
 these descriptive tumors and malformations have been categorized based on the architectural assembly of vessels .
 lymphangiomas are further subclassified microscopically into capillary , cavernous , cystic and lymphangioendothelioma , depending upon their histopathological features .
 lymphatic malformations or lymphangiomas are uncommon congenital malformations of the lymphatic system , usually occurring in the head and neck region , characterized by collections of ectatic lymph vessels that form endothelial lined cystic spaces .
 advancements in the knowledge of pathogenesis of such vascular malformations are continuously changing their treatment protocols .
 early recognition is of utmost importance for initiation of proper treatment and avoiding serious complications .
 hemangiolymphangioma is a variant of lymphangioma showing vascular component .
 herewith , we present a case of vascular malformation diagnosed as hemangiolymphangioma histopathologically in a 9-year - old girl , along with a review of literature regarding its categorization .


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:
female genital tuberculosis ( fgtb ) is common in developing countries and associated with significant morbidity in the form of menstrual dysfunction , infertility , tubal block , peritubal adhesions , intrauterine adhesions , and perihepatic adhesions .
fallopian tubes are involved in about 90% of the cases with findings such as congested tubes , tubercles , or caseous nodules on them , peritubal adhesions , and tubal blockage at various levels such as cornual block , mid - tubal block , multiple tubal blocks , or fimbrial block , hydrosalpinx , pyosalpinx , and tubo - ovarian masses .
a 25-year - old woman with family history of pulmonary tb was presented to the gynecology outpatient department with primary infertility and oligomenorrhea of 3 years . on examination ,
vaginal examination demonstrated anteverted uterus with fullness and induration in both fornices . on investigations ,
hysterosalpingogram which was already performed by the referring doctor for infertility before diagnosis of fgtb was made showed bilateral tubal block .
endometrial aspirate performed in premenstrual phase showed positive polymerase chain reaction based on the amplification of the 240 bp region of the mpt 64 gene using primers mpt 1 ( 59-tccgctgccagtcgtcttcc-39 ; nt 460479 ) and mpt 2 ( 59-gtcctcgcgag tctaggcca-39 ; nt 700681 ) with equipment using amplitron thermocycler ( barnstead / thermolyne ) , it also tested positive for culture for mycobacterium tuberculosis using mycobacterium growth indicator tube-960 .
, there were findings of tb in the pelvis in the form of multiple tubercles on tubes and uterus , bilateral hydrosalpinx with beading of tubes , and few caseous nodules .
when methylene blue dye was injected in the uterus , the fallopian tubes became distended and blue colored with beading looking with alternate constrictions and dilatation looking - like  blue pythons
diagnosis of genital tb was made , and she was started on anti - tb therapy .
her postoperative period and follow - up were uneventful . left fallopian tube with distension , multiple ballooning , and blue coloration with fimbrial block showing  blue python sign
although gold standard in diagnosis of fgtb is demonstration of mycobacterium tuberculosis either on microscopy or culture of endometrial biopsy or presence of epithelioid granuloma on histopathology , they are positive in only few cases leading on to missing of diagnosis in many cases . polymerase chain reaction on endometrial biopsy is a sensitive and rapid method for detecting mycobacterium dna ( mpt 64 gene ) but can be false positive and may not be able to differentiate between infection and disease .
gene xpert has recently been introduced in both pulmonary and extra - pulmonary tb as a sensitive and specific method , but its data in fgtb are very sparse . imaging modalities such as ultrasound , computed tomography scan , magnetic resonance imaging , and positron emission tomography scan have main role in tubo - ovarian masses .
hysterosalpingography is generally avoided in a suspected case of fgtb due to risk of flare up of the disease but may demonstrate tubal block and other tubal patterns , especially in advanced case .
hysteroscopy is useful in endometrial disease and may show pale looking endometrium with endometrial cavity being partially or completely obliterated by adhesions of varying grade ( asherman 's syndrome ) which may involve ostia .
however , laparoscopy is the most reliable tool to diagnose fgtb , especially for tubal , ovarian , and peritoneal disease .
there can be tubercles on peritoneum or tubes , tubo - ovarian masses , caseous nodules , encysted ascites , various grades of pelvic adhesions , hydrosalpinx , pyosalpinx , beaded tubes , tobacco pouch appearance , and inability to see tubes due to adhesions .
other authors have also found laparoscopy very useful in diagnosis and management of genital and peritoneal tb with the advantage of avoidance of laparoscopy which is more traumatic and hazardous especially in a case of abdominopelvic tb . in a case of fgtb ,
if there is no cornual block , there is a partial or complete fimbrial block with multiple blocks at various parts of tube as is typical of fgtb , dye enters the tube but remains in various parts of tubes with alternate dilatation and constriction making the tube look like a  blue python  as happened in the present case .
the new sign case is easily diagnosed by gynecologists during routine laparotomy performed for infertility patients with suspected fgtb and can aid in its diagnosis

Answer:
female genital tuberculosis ( fgtb ) is an important cause of infertility in developing countries .
 various type of tb salpingitis can be endosalpingitis , exosalpingitis , interstitial tb salpingitis , and salpingitis isthmica nodosa .
 the fallopian tubes are thickened enlarged and tortuous .
 unilateral or bilateral hydrosalpinx or pyosalpinx may be formed .
 a new sign python sign is presented in which fallopian tube looks like a blue python on dye testing in fgtb .


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:
olfactory neuroblastoma or esthesioneuroblastoma is a rare malignant neoplasm of neuroectodermal origin arising from olfactory membrane of the sinonasal tract .
it was originally described in french literature by berger et al . in 1924 who coined the term
the various synonyms used for this entity are olfactory esthesio - neuroepithelioma , esthesio - neurocytoma , esthesio - neuroepithelioma , esthesio - neuroblastoma , olfactory neuroblastoma and olfactory placode tumor . the first case in american literature
this tumor has broad histologic spectrum and is often histologically confused with peripheral neural ectodermal tumors and is notorious for its wide clinical behaviors .
the common clinical symptoms include nasal obstruction , recurrent epistaxis , hyposomia , rhinorrhea , headache and visual disturbances .
here we report a rare case of esthesioneuroblastoma in a female with presenting symptom as tooth pain .
a 50-year - old female reported to the department of oral medicine with the complaint of pain in the left side of the upper jaw since seven months , which was spontaneous , dull and reduced on taking analgesics .
she visited a general dentist five months ago and maxillary left second molar was extracted as it was considered as the causative tooth for pain , however , the patient did not get relief and the pain continued .
she noticed swelling of left side of the face , which gradually increased in size and there was a concomitant decrease in size of her left eye opening and the eyeball was pushing superiorly since two months .
her medical and family history was noncontributory and upon general physical examination , all her vital signs were within normal limits .
on extraoral examination , a diffuse swelling was seen on the left maxillary area extending from infraorbital margin to mid of the cheek supero - inferiorly and ala of nose to outer canthus of eye antero - posteriorly , which was soft in consistency and tender on palpation [ figure 1a ] .
intraorally , swelling was evident on palpation extending from maxillary tuberosity to the vestibule causing vestibular obliteration till the posterior aspect , which was tender and soft in consistency on palpation [ figure 1b ] . clinical photograph showing swelling on maxillary region and decrease in the size of the left eye ( a ) .
intraorally , vestibular obliteration was evident ( b ) on the basis of history and clinical examination , a provisional diagnosis of malignant neoplasm of maxillary sinus was considered .
the coronal ct revealed a large mass originating in left maxillary sinus with destruction of its medial , superior and postero - lateral wall .
medially , this mass was extending into left nasal fossa leading to marked luminal compromise on the left side and superiorly extension into left orbit was noticed .
posteriorly it was extending into infra - temporal fossa , left masseteric space and left pterygomaxillary fissure .
partial erosion of anterior maxillary wall , hard palate and lateral pterygoid plate on left side and extension of this mass from lateral maxillary wall into left cheek was also noticed [ figure 2a and b ] .
coronal computed tomographic scan showing extension of lesion into sinus and nasal fossa incisional biopsy was performed and on histopathological examination , hematoxylin and eosin stain showed basophilic cells arranged in large lobar sheets with intertwining connective tissue septa .
cells had large round nucleus with minimal pleomorphism and a thin rim of cytoplasm . pronounced vascularity and formation of pseudorosettes ( homer - wright type ) were seen in some areas , suggestive of esthesioneuroblastoma [ figure 3a and b ] .
immunohistochemistry revealed strongly positive neuron - specific enolase among the tumor cells and s-100 showed weak association [ figure 4a and b ] .
so based on clinical examination and the investigations performed , a final diagnosis of esthesioneuroblastoma was given .
the case was referred to the oncology institute for the management and the patient was started with chemotherapy , cisplatin 50 mg ( per day ) and 5 fluorouracil 1 mg ( per day ) , and recalled after 15 days ; there was improvement in the symptoms after which the patient was lost to follow up .
photomicrograph showing cells arranged in sheets and intervening connective tissue stroma ( a ) ( h&e stain , 40 ) .
photomicrograph showing cells with large round nucleus , thin rim of cytoplasm arranged in large sheets with intertwining connective tissue septa and formation of pseudorosettes ( homer - wright type ) ( b ) ( h&e stain , 100 ) immunohistochemistry showing strongly positive neuronspecific enolase among the tumor cells ( a ) ( ihc stain , 200 ) and weak association with s-100 protein ( b ) ( ihc stain , 200 )
esthesioneuroblastoma is a rare malignant tumor arising from olfactory epithelium and its neural origin was established by trojanowaski et al . in 1982 who demonstrated the presence of neurofilament proteins ( nfp ) in the tumor cells .
though , it has been reported in patients as young as two years to 90 years , a bimodal age distribution has been noted in the second and sixth decades of life .
there are no known etiologic agents for human olfactory neuroblastoma , however , injection of diethylnitrosamine in syrian hamsters and n - nitrosopiperidine in rats has produced tumors histologically identical to human olfactory neuroblastoma .
the common symptoms associated are unilateral nasal obstruction ( 70% ) and epistaxis ( 46% ) , and less common manifestations are anosmia , headache , pain , excessive lacrimation and ocular disturbances . in the present case ,
the patient complained of pain in left maxillary molar teeth , which is a rare symptom and also , there was decrease in size of left eye , which may be due to superior extension of tumor in the left orbit .
the most common site of origin is in the upper nasal cavity in the region of the cribriform plate ; other primary sites such as maxillary sinus and nasopharynx have also been reported .
esthesioneuroblastoma is generally believed to be derived from the neurosensory receptor cells of olfactory mucosa .
other sources of origin suggested include sphenopalatine ganglion by escat , organ of jacobson , ganglion of luci by martin et al . and olfactory placode .
the tumor in the present case was seen to arise from left maxillary sinus and extended to involve nasal fossa , infra - temporal fossa , masseteric space , cheek and the left orbit .
according to this classification , stage a tumors are confined to the nasal cavity , stage b tumors have paranasal sinus extension and stage c tumors have extra - paranasal extension including the involvement of the cribriform plate , base of skull , orbit or intracranial cavity .
this classification was modified by morita et al . in 1993 who established stage d in the classification for tumors with metastasis to cervical lymph nodes or distant site .
kadish 's classification has been used by various authors and appears to correlate well with the clinical outcome .
the present case can be categorized as belonging to stage c of kadish 's classification . in evaluation of esthesioneuroblastoma ,
the extent of disease is best determined by pre- and post - contrast mr imaging in which there is intense signal in t2-weighted images with marked enhancement of t1-weighted images after gadolinium injection .
details of bone erosion ( lamina papyracea , cribriform plate and fovea ethmoidalis ) are better demonstrated by ct scan .
tumor is presented as homogenous density mass , equal or greater to the surrounding soft tissue and no tumor cysts or calcifications .
coronal images were of value in evaluating extension to the orbit and through the cribriform plate and the anterior cranial fossa .
( 2001 ) demonstrated the usefulness of technetinium-99m - ethyl cysteinate dimer ( tc - ecd ) spect in detection of olfactory neuroblastoma .
( 1960 ) stated that the characteristic histologic features of olfactory neuroblastoma are plexiform intercellular fibrils , round - to - oval - shaped nuclei with scanty cytoplasm , distinct and sharply defined chromatin , which may be coarse or fine , compartmentation of sheets of neoplastic cells into lobules by slender vascular fibrous septa , true neural rosettes ( flexner - wintersteiner type ) and pseudorosettes ( homer - wright type ) .
they concluded that if fibrils were absent , then the tumor can not be classified as neuroblastoma with certainity .
histologically neuroblastoma has been classified as olfactory neurocytoma ( pattern i of mendeloff ) , a tumor with a sheet of round small cells separated by connective tissue septa and occasionally pseudorosettes ; olfactory neuroepithelioma ( pattern ii of mendeloff ) , a tumor containing round to oval nuclei clear nuclear membrane , scant cytoplasm and rosettes ; and a tumor similar to neuroblastomas found elsewhere in the body .
immunologically , it is most reactive with neuron - specific enolase ( nse ) as seen in the reported case .
it has shown reactivity with s-100 , synaptophysin , nfp , class iii beta - tubulin and microtubule - associated protein .
light microscopy can usually establish the diagnosis , but highly undifferentiated tumors make this difficult . in case when light microscopy fails to establish diagnosis , electron microscopy is helpful .
esthesioneuroblastoma must be distinguished from lymphosarcoma , transitional cell carcinoma , plasmacytoma , reticulum cell carcinoma , small cell undifferentiated carcinoma and ewing 's sarcoma .
small cell carcinoma typically is a submucosal hypercellular proliferation growing in sheets , cords and ribbons ; the distinct lobular pattern of olfactory neuroblastoma is absent .
the cells are small and hyperchromatic with oval- to spindle - shaped nuclei , absent nucleoli and minimal cytoplasm .
although uncommon , neural - type rosettes similar to those seen in olfactory neuroblastoma can be seen in association with small cell carcinoma .
in contrast to olfactory neuroblastoma , nse reactivity in small cell carcinoma is more likely to be focal than diffusely positive and the s-100 protein staining , if present , is dispersed throughout the cellular proliferation and not limited to sustentacular cells .
ewing 's sarcoma is composed of solid sheets or masses of solid round cells with very little stroma , scanty cytoplasm and ovoid large nuclei ; necrosis is common .
the characteristic cells of plasmacytoma and so - called cylinders in cylindromas readily help in identifying these tumors .
small cell undifferentiated carcinomas does not contain fibrils and the distinct cytoplasmic borders can be seen .
the current accepted standard of treatment is craniofacial resection followed by adjuvant radiotherapy to a dose of 55 - 65 gy for kadish stages b and c. small kadish stage a disease is treated by surgery alone in some situations by some groups , but most suggest adjuvant radiotherapy for these lesions also .
neoadjuvant chemotherapy has been used in advanced disease and where complete resection is not possible , with cyclophosphamide , vincristine ifosphamide , etoposide and cisplatin combined with preoperative radiotherapy .
the overall five , 10 and 15-year survival rates have been reported to be 78% , 71% and 68% , respectively .
initial multimodality therapy is associated with five - year survival of 80% for low - grade tumors and 40% for high - grade tumors .
the most hazardous and often fatal complication is intracranial extension of tumor through destruction of cribriform plate and orbital plates and secondly due to distant metastasis .
prognosis has been correlated to clinical staging with five - year survival of 75 - 91% , 68 - 71% and 41 - 47% for stages
other factors that have been implicated in prognosis include histologic grading , proliferation rate and ploidy .
histologically lower grade tumors ( grades i and ii ) have been reported to have a better five - year survival than higher grade tumors ( grades iii and iv ) .
the tumor metastasizes widely by both hematogenous and lymphatic routes , approximately 10 - 60% will experience distant metastasis .
the most common site for metastasis spread are cervical lymph nodes , and less frequent are lungs , brain , bone , spinal column , breast and abdominal viscera .
metastasis to the central nervous system is infrequent and in spinal cord 80% of metastasis is in cauda equine .
, this tumor has been difficult to recognize and diagnose pathologically and the wide spectrum of presentation of this tumor has resulted in its frequent misdiagnosis .
thus , the diagnosis of esthesioneuroblastoma demands a specialized and experienced head and neck pathologist , especially as incidence rate is low . also , esthesioneuroblastoma may present , only as tooth pain as in the present case .
so , it may be considered as a possible differential diagnosis , though rare in cases of dento - facial pain of idiopathic cause .

Answer:
esthesioneuroblastoma , also called olfactory neuroblastoma , is a rare malignant tumor originating in the olfactory epithelium in the upper nasal cavity with intracranial extension and may also be associated with secondary sinus diseases .
 esthesioneuroblastoma has been observed to cause death by distant metastasis or by invasion through the cribriform plate and secondary meningitis .
 it usually produces nasal obstruction , epistaxis and less commonly anosmia , headache and pain .
 we report a case of esthesioneuroblastoma in a 50-year - old female who reported with tooth pain as a presenting symptom .


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:
pyomyositis affects the massive skeletal muscles and is most frequently caused by staphylococcus bacteria ( 1 ) .
necrotizing fasciitis is a localized spread of infection that follows events such as trauma or surgery ( 2 ) , and which is commonly affected by group a streptococcus .
rhabdomyolysis comprehensively affects the skeletal muscle and , like pyomyositis and necrotizing faciitis , shows serum creatinine kinase elevation ; however , rhabdomyolysis occurs as a systemic disease and is not associated with the focal manifestation of abscesses ( 3 ) .
the pathogenesis of infectious rhabdomyolysis is thought to be associated with the systemic or local metabolic changes related to a systemic or local infection ( 4 ) ; however , the mechanisms underlying its pathogenesis have not been established . in addition , gram - negative bacillus rhabdomyolysis is rare , and its microbiological pathology remains to be elucidated .
we diagnosed the patient , a 64-year - old japanese man with multiple myeloma , with bacteremia caused by morganella morganii .
he was admitted to our institute due to septic shock at the sudden onset of a febrile episode .
his vital signs at admission were as follows : blood pressure , 82/60 mmhg ; heart rate , 78/min ; body temperature , 39.1 ; respiration rate , 20/min ; and spo2 , 95% ( room air ) .
the laboratory findings at the time of his diagnosis showed massive myolysis and a significantly elevated level of creatinine kinase ( ck ; 3,582 u / l ) ; thereafter , an isotype analysis of the patient 's ck confirmed that the elevated ck was derived from the patient 's skeletal muscle ( 98.8% ) .
the status of the patient 's multiple myeloma , which had been diagnosed 5 years earlier , was stage iiia , igg  type .
he had undergone treatment with a variety of chemotherapies : melphalan ( mp ; 12 mg / day for 4 days + prednisolone 60 mg / day for 6 days , repeated triweekly ) , vad ( vincristine 0.4 mg / m for 4 days as a continuous infusion + doxorubicin 10 mg / m for 4 days as a continuous infusion + dexamethasone 40 mg / day , days 1 - 4 , 9 - 12 , and 17 - 20 , repeated monthly ) , bd ( bortezomib 1.3 mg / m on days 1 , 4 , 8 , and 11 + dexamethasone 40 mg / day for 4 days , repeated monthly ) , and thalidomide ( 100 mg / day ) .
his last treatments were lenalidomide 20 mg / day , and igg gradually increased 6 months before the current infectious episode .
after the patient 's admission for sepsis caused by m. morganii , rehydration was immediately performed via central venous catheterization and a catecholamine infusion ( dopamine 3 mg / kg / h ) was administered ; at the same time , antimicrobial treatment with meropenem ( 0.5 g three times a day ) was initiated .
cervical to pelvis computed tomography ( ct ) was performed on the day of admission , but there were no clear findings explaining the patient 's massive myolysis . on day 2 of the patient 's hospitalization ,
the patient 's vital sign were as follows : blood pressure , 61/45 mmhg ; heart rate , 87/min ; and body temperature , 36.8. we started hemodialysis combined with endotoxin absorption the same day .
however , respiratory failure occurred , necessitating mechanical ventilation , on the night of day 2 .
the patient died of multi - organ failure two days after undergoing intubation . before his death , rhabdomyolysis developed day - by - day and was reflected in the remarkable elevation of the patient 's ck level .
the final ck value was 19,790 u / l ( normal range : 40 - 200 u / l ) ( figure ) .
we found that the m. morganii was sensitive to all of the broad spectrum beta - lactams , including carbapenems and cephalosporins , but only resistant to cefotiam , minomycin , and ciprofloxacin .
his muscle damage manifested as with elevated levels of ck , aspartate aminotransferase ( ast ) , alanine aminotransferase ( alt ) , and lactate dehydrogenase ( ldh ) after the onset of the disease ( day 1 ) , with increasing leukocytes and c - reactive protein ( crp ) .
the days in the x - axis indicate the days after the patient s admission .
the patient visited our outpatient clinic for a routine follow - up examination 6 days before his admission .
infectious rhabdomyolysis is caused by various pathogens including viruses , bacteria and fungi ( 3 ) .
the clinical entity of infectious rhabdomyolysis was established in 1982 ( 5 ) , and a review ( 3 ) identified the predisposing risk factors for rhabdomyolysis : alcohol ingestion , compression injury , and generalized seizures . regardless of the pathogen that causes infectious rhabdomyolysis , the underlying mechanism of the disease is metabolic .
the most frequent differential diagnosis is necrotizing fasciitis , which occurs when the infection spreads into the deep fascial layers ( 2 ) .
necrotizing fasciitis is generally caused by infection , and the initial entry site is sometimes trivial . in contrast
, rhabdomyolysis is caused by the following two critical conditions : ( 1 ) physical distress ( for example , distress due to or involving excessive exercise , seizure , muscle compression , hyperthermia , or hypothermia ) ; and ( 2 ) systemic metabolic disorders ( for example disorders due to hypoxia , acidemia , drug abuse , infection , or inflammation ) .
the localization of a soft - tissue infection can be distinguished by systemic imaging , especially by sensitive mri ( 6 ) . in the reported cases of rhabdomyolysis , the local radiological findings are faint . in the present case ,
our evaluation of the present case raised an important question : what is the microbiological mechanism underlying the development of rhabdomyolysis accompanied by systemic infection ( 3,7 ) ?
thus , rhabdomyolysis is relatively common among patients with miscellaneous bacterial infections including , but not limited to , legionella ( 4 ) , pneumococcal ( 8) , and salmonella ( 7 ) .
we underscore that patients these types of infectious rhabdomyolysis share the following common findings : 1 ) the patients were immunocompromised due to malignancy or a severe wound ; 2 ) precedent or concomitant acute renal failure were observed in the patient 's clinical course ; and 3 ) metabolic abnormalities such as dehydration or acidemia due to single / multi - organ failure existed as the underlying pathogenesis .
thus , ischemia or hypoxia caused by systemic infection are considered to be involved in the mechanism underlying the development of rhabdomyolysis .
m. morganii is rarely pathogenic in humans , but it sometimes develops into an opportunistic infection in a compromised host . although there are no reported cases of infectious rhabdomyolysis caused by m. morganii , arranz - caso et al .
the authors noted that gram - negative bacterial pyomyositis can occur in an immunocompromised case followed by enteric organism translocation .
gram - negative bacterial infection does not favor pyomyositis , which is usually raised by gram - positive bacteria .
our case suggests that infectious rhabdomyolysis may be underdiagnosed as a comorbidity of gram - negative bacterial infections , even if the causative organism is an opportunistic pathogen such as m. morganii . regarding myolysis / rhabdomyolysis complicated with a systemic bacterial infection and the accumulation of muscle damage
the non - bacteremic mechanism includes alterations of systemic metabolism ( i.e. , hypoxia , acidosis ) and an intracellular metabolism in situ ( e.g. , disturbances of glycolysis and oxidation in muscle cells ) ( 7 ) .
the non - bacteremic mechanism of rhabdomyolysis accompanied by systemic infection is similar , regardless of the pathogen that is involved ( 3,7 ) .
the common mechanisms underlying muscle damage arise from a combination of hypoxia , dehydration , and acidemia in the tissue ( 4 ) . in general , rhabdomyolysis develops during the course of systemic infection in up to 5% of bacterial and viral cases ( 7 ) .
rhabdomyolysis is a specific term describing the excess leakage of enzymes derived from muscular tissue , which can result in multi - organ failure . in our patient , the apparent infection focus was not identified by repeated systemic ct .
this negative finding caused a delay in our differentiation of the cause of the patient 's rhabdomyolysis .
we treated the patient with meropenem , to which the causative pathogen , m. morganii , is sensitive ; however , an adequate antimicrobial therapy can not always rescue a patient from advanced multiple - organ deterioration .
rhabdomyolysis should thus be recognized as a more aggressive clinical situation than local myolysis , and one that requires intensive care .
furthermore , non - specific myolysis / rhabdomyolysis can occur due to any pathogen ( 7 ) ; thus , it may be underdiagnosed during the infection .
myalgia and scant laboratory signs of myolysis / rhabdomyolysis ( usually appearing as liver damage in laboratory data ) can be misdiagnosed in patients with the overlapping leakage of transaminases due to various etiologies .
clinicians should keep in mind that abnormal liver function test results may be linked to a muscular problem .
clinicians should be aware of the possibility of systemic infection - associated myolysis / rhabdomyolysis and closely observe immunocompromised patients .
this is the first report of lethal rhabdomyolysis caused by m. morganii as a complication in a non - hiv patient .
short description : fatal rhabdomyolysis caused by m. morganii can occur in a multiple myeloma patient without hiv .

Answer:
a 64-year - old japanese man with multiple myeloma was admitted to our institute due to fever and hypotension .
 he had received multiple courses of chemotherapy just before his febrile episode .
 blood culturing detected morganella morganii . at the time of the diagnosis ,
 his laboratory findings revealed massive rhabdomyolysis with a significantly increased creatinine kinase level ( ck ; 3,582 u / l ) ; 98.8% of which corresponded to the ck - mb isotype .
 we diagnosed the patient with sepsis caused by m. morganii , complicated with severe rhabdomyolysis .
 he died of multi - organ failure 2 days later .
 clinicians should closely observe patients with possible systemic infection - associated rhabdomyolysis .


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 study group comprised 15 patients of both sexes , with age ranging from 13 to 65 years , attending the outpatient department . only those periapical lesions which appeared as radiolucent on the radiographs were included in the study group .
those periapical lesions which appeared as radiopaque on the radiographs were eliminated from the study group .
all the subjects underwent ultrasonographic examination using ge logic 400 mr3 color doppler machine having multifrequency linear transducer using 711 mhz frequency at sheethal diagnostics , davangere , india .
all the examinations including real - time and color doppler imaging were performed in the periapical area extraorally .
the ultrasonographic images were analyzed based on the following principles :
 cystic lesion : a hypoechoic well - contoured cavity surrounded by reinforced bone walls , filled with fluid , and with no evidence of internal vascularization on color doppler examination.granuloma : a poorly defined hypoechoic area , showing rich vascular supply on color doppler examination.mixed lesion : predominantly hypoechoic area with focal anechoic area , showing vascularity in some areas on color doppler examination .

cystic lesion : a hypoechoic well - contoured cavity surrounded by reinforced bone walls , filled with fluid , and with no evidence of internal vascularization on color doppler examination .
granuloma : a poorly defined hypoechoic area , showing rich vascular supply on color doppler examination .
mixed lesion : predominantly hypoechoic area with focal anechoic area , showing vascularity in some areas on color doppler examination .
the results of ultrasound were correlated with radiographic and histological findings and were statistically analyzed .
all the subjects underwent ultrasonographic examination using ge logic 400 mr3 color doppler machine having multifrequency linear transducer using 711 mhz frequency at sheethal diagnostics , davangere , india .
all the examinations including real - time and color doppler imaging were performed in the periapical area extraorally .
the ultrasonographic images were analyzed based on the following principles :
 cystic lesion : a hypoechoic well - contoured cavity surrounded by reinforced bone walls , filled with fluid , and with no evidence of internal vascularization on color doppler examination.granuloma : a poorly defined hypoechoic area , showing rich vascular supply on color doppler examination.mixed lesion : predominantly hypoechoic area with focal anechoic area , showing vascularity in some areas on color doppler examination .

cystic lesion : a hypoechoic well - contoured cavity surrounded by reinforced bone walls , filled with fluid , and with no evidence of internal vascularization on color doppler examination .
granuloma : a poorly defined hypoechoic area , showing rich vascular supply on color doppler examination .
mixed lesion : predominantly hypoechoic area with focal anechoic area , showing vascularity in some areas on color doppler examination .
the results of ultrasound were correlated with radiographic and histological findings and were statistically analyzed .
out of the 15 subjects , 12 ( 80% ) were diagnosed as periapical cyst ultrasonographically , whereas 14 ( 93.3% ) were diagnosed as periapical cyst histopathologically and the correlation between ultrasonographic and histopathologic diagnoses was found to be in 12 ( 85.7% ) subjects [ table 1 and graph 1 ] .
correlation of histologic features with ultrasonographic findings correlation of histologic features with ultrasonographic findings out of the 15 subjects , 2 ( 13.3% ) were diagnosed as periapical granuloma ultrasonographically , whereas 1 ( 6.7% ) was diagnosed as periapical granuloma histopathologically and the correlation between ultrasonographic and histopathologic diagnoses was found to be in 1 ( 50% ) subject . out of the 15 subjects , 1 ( 6.7% ) was diagnosed as periapical abscess ultrasonographically , whereas no subjects were diagnosed as periapical abscess histopathologically and there was no correlation between ultrasonographic and histopathologic diagnoses in this subject .
the correlation between histopathologic and ultrasonographic diagnoses was found to be in 13 ( 86.7% ) subjects . comparing the results of ultrasonography with the histopathologic features , the sensitivity , specificity , positive predictive value , and negative predictive value of ultrasonography to diagnose periapical lesions were calculated . in our study
, tp denotes true positive = 12 subjects , tn denotes true negative = 1 subject , fp refers to false positive = 2 subjects , fn is false negative = 0 subjects , and n is total number of patients = 15 subjects [ table 2 and graph 2 ] .
out of the 15 subjects , 12 ( 80% ) were diagnosed as periapical cyst ultrasonographically , whereas 14 ( 93.3% ) were diagnosed as periapical cyst histopathologically and the correlation between ultrasonographic and histopathologic diagnoses was found to be in 12 ( 85.7% ) subjects [ table 1 and graph 1 ] .
correlation of histologic features with ultrasonographic findings correlation of histologic features with ultrasonographic findings out of the 15 subjects , 2 ( 13.3% ) were diagnosed as periapical granuloma ultrasonographically , whereas 1 ( 6.7% ) was diagnosed as periapical granuloma histopathologically and the correlation between ultrasonographic and histopathologic diagnoses was found to be in 1 ( 50% ) subject . out of the 15 subjects , 1 ( 6.7% ) was diagnosed as periapical abscess ultrasonographically , whereas no subjects were diagnosed as periapical abscess histopathologically and there was no correlation between ultrasonographic and histopathologic diagnoses in this subject .
the correlation between histopathologic and ultrasonographic diagnoses was found to be in 13 ( 86.7% ) subjects .
comparing the results of ultrasonography with the histopathologic features , the sensitivity , specificity , positive predictive value , and negative predictive value of ultrasonography to diagnose periapical lesions were calculated . in our study , tp denotes true positive = 12 subjects , tn denotes true negative = 1 subject , fp refers to false positive = 2 subjects , fn is false negative = 0 subjects , and n is total number of patients = 15 subjects [ table 2 and graph 2 ] . diagnostic validity of ultrasonography diagnostic validity of ultrasonography
out of the 15 subjects in the present study , ultrasonographic examination showed 12 ( 80% ) periapical cysts whereas histopathologic diagnosis revealed 14 ( 93.3% ) periapical cysts .
one of the periapical cysts ( 2 subject ) was misdiagnosed ultrasonographically as periapical granuloma .
this misinterpretation was because of the content of the lesion which showed high density equivalent to a solid lesion , even though with lack of vascular supply on color doppler examination .
one of the periapical cysts ( 11 subject ) was misdiagnosed ultrasonographically as periapical abscess [ figure 1 ] .
this lesion showed both hypoechoic and anechoic regions , i.e. , mixed echogenic patterns with numerous scattered internal echoes and varying density values within the lesion suggestive of periapical abscess .
similar to our observations , dib et al . in their study of 72 intraosseous lesions of the jaw
the reason for this could be due to the presence of thick cortical bone covering the lesion , the occurrence of infected cysts and solid areas within the cystic lesion .
the cystic lesions on the ultrasound imaging appeared as anechoic lesion in six cases , turbid fluid in one case , scattered internal echoes in one case , and posterior enhancement in three cases [ figures 2 and 3 ] .
ultrasonograph showing well - defined hypoechoic lesion with vascularity ultrasonograph showing well - defined anechoic lesion ultrasonograph showing well - defined anechoic lesion the internal echoes present in infected cysts and odontogenic keratocyst could be due to dense particles ( cholesterol clefts in the infected cysts ) in the cystic fluid and keratin in odontogenic keratocyst .
the density values varied within the lesion in case of infected cysts and odontogenic keratocyst , indicative of difference in the contents within the lesion , which reflects the disease process . out of the 15 subjects in the present study ,
ultrasonographic examination showed 2 ( 13.3% ) periapical granuloma among which 1 ( 50% ) was diagnosed histopathologically as periapical granuloma and the other as periapical cyst .
this observation is similar to the observations made by cotti et al . and gundappa et al , where they had accurately diagnosed all the periapical granulomas ( 100% ) ultrasonographically .
thus , the observations from the present study infer that the diagnostic validity of ultrasonography is similar to that made by dib et al , where they have reported 92.8% accuracy and less compared to that made by cotti et al , and gundappa et al . where they have reported 100% accuracy . in all the subjects ,
it pictorially represents the anatomic location of the periapical lesion in relation to the particular involved tooth and it provides size of the lesion [ figures 5 and 6 ] , whereas ultrasound was able to accurately identify the underlying disease process reasonably accurately and the size measurements in three dimensions using the ultrasound software .
panoramic radiograph showing unilocular radiolucent lesion occlusal radiograph showing unilocular radiolucent lesion intraoral periapical radiograph showing radiolucent lesion a major concern over the performance of ultrasonography was the difficulty in attributing the lesions to a specific area of the maxillary bone because the dental landmarks ( i.e. roots ) were not specifically visualized .
this made it difficult to orient the lesion in the different regions of the mouth without using a reference radiograph .
out of the 15 subjects in the present study , ultrasonographic examination showed 12 ( 80% ) periapical cysts whereas histopathologic diagnosis revealed 14 ( 93.3% ) periapical cysts .
one of the periapical cysts ( 2 subject ) was misdiagnosed ultrasonographically as periapical granuloma .
this misinterpretation was because of the content of the lesion which showed high density equivalent to a solid lesion , even though with lack of vascular supply on color doppler examination .
one of the periapical cysts ( 11 subject ) was misdiagnosed ultrasonographically as periapical abscess [ figure 1 ] .
this lesion showed both hypoechoic and anechoic regions , i.e. , mixed echogenic patterns with numerous scattered internal echoes and varying density values within the lesion suggestive of periapical abscess .
similar to our observations , dib et al . in their study of 72 intraosseous lesions of the jaw
the reason for this could be due to the presence of thick cortical bone covering the lesion , the occurrence of infected cysts and solid areas within the cystic lesion .
the cystic lesions on the ultrasound imaging appeared as anechoic lesion in six cases , turbid fluid in one case , scattered internal echoes in one case , and posterior enhancement in three cases [ figures 2 and 3 ] .
ultrasonograph showing well - defined hypoechoic lesion with vascularity ultrasonograph showing well - defined anechoic lesion ultrasonograph showing well - defined anechoic lesion the internal echoes present in infected cysts and odontogenic keratocyst could be due to dense particles ( cholesterol clefts in the infected cysts ) in the cystic fluid and keratin in odontogenic keratocyst .
the density values varied within the lesion in case of infected cysts and odontogenic keratocyst , indicative of difference in the contents within the lesion , which reflects the disease process . out of the 15 subjects in the present study ,
ultrasonographic examination showed 2 ( 13.3% ) periapical granuloma among which 1 ( 50% ) was diagnosed histopathologically as periapical granuloma and the other as periapical cyst .
this observation is similar to the observations made by cotti et al . and gundappa et al , where they had accurately diagnosed all the periapical granulomas ( 100% ) ultrasonographically .
thus , the observations from the present study infer that the diagnostic validity of ultrasonography is similar to that made by dib et al , where they have reported 92.8% accuracy and less compared to that made by cotti et al , and gundappa et al . where they have reported 100% accuracy .
in all the subjects , conventional radiography provided the preliminary information about the lesion [ figure 4 ] .
it pictorially represents the anatomic location of the periapical lesion in relation to the particular involved tooth and it provides size of the lesion [ figures 5 and 6 ] , whereas ultrasound was able to accurately identify the underlying disease process reasonably accurately and the size measurements in three dimensions using the ultrasound software .
panoramic radiograph showing unilocular radiolucent lesion occlusal radiograph showing unilocular radiolucent lesion intraoral periapical radiograph showing radiolucent lesion a major concern over the performance of ultrasonography was the difficulty in attributing the lesions to a specific area of the maxillary bone because the dental landmarks ( i.e. roots ) were not specifically visualized .
this made it difficult to orient the lesion in the different regions of the mouth without using a reference radiograph .
with its potential usefulness to differentiate the periapical lesions , ultrasonography can be considered as a better imaging modality with improved efficacy when compared to conventional radiography . in comparision to histopathologic diagnosis ,
ultrasonography showed less accuracy and thus can be considered to be a supplementary tool in the differential diagnosis of periapical lesions .
further research can be directed in larger samples and in different types of periapical lesions to assess the diagnostic validity of ultrasonography .

Answer:
background and objectives : to assess the diagnostic capability of real - time ultrasound imaging , together with the application of color power doppler in the identification and differential diagnosis of the periapical lesions.materials and methods : fifteen patients with periapical lesions of pulpal origin , diagnosed with clinical and conventional radiographic examination , were examined further using ultrasonography .
 the results from the biopsies of the lesions were compared and statistically analyzed.results:the differential diagnosis between periapical granulomas and cystic lesions , which were based on the ultrasonographic findings , were confirmed by the results of the histopathologic examination in 13 ( 86.7% ) of 15 cases , one being granuloma and 14 being cystic lesion.interpretation and conclusion : ultrasound real - time imaging is a technique that may help make a differential diagnosis between cysts and granulomas by revealing the nature of the content of a bony lesion .
 this technique may have further applications in the study of other lesions of the jaws .


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 mucopolysaccharidoses ( mps ) are a family of genetic disorders characterized by changes in an individual s ability to metabolize mucopolysaccharides , which are complex sugar molecules found in the connective tissue , mucosal fluids , synovial fluid , and other cells throughout the body .
there are six types of mps , with some types having several subtypes . according to brown ( 1999 ) ,
epidemiological data are problematic to report , but range from 1 in 100 000 live births to 1 in 600 000 live births .
this dysfunction in metabolism may result in a variety of distinct physical features , such as short stature , contracture of joints , claw - like hands , abnormal spine curvature , and hydrocephalus ( neufeld and muenzer 1995 ) .
treatment options vary , but hematopoietic cell transplantation seems to offer the best long - term quality of life improvement and decreased mortality and morbidity options for children with some of the more severe forms of mps ( grewal et al 2002 ) .
one subtype of mps is mps i , which includes hurler , scheie , and hurler - scheie syndromes .
each of these disorders within mps i is caused by a deficiency of alpha - l - iduronidase .
within mps i , hurler syndrome is generally associated with more severe features and poorer prognosis than either scheie or hurler - scheie syndromes ( brown 1999 ) . in most cases of hurler syndrome ,
motor skills are limited by age 18 months , and developmental regression occurs , including progressive loss of neurocognitive functioning , resulting in mental retardation . with hurler - scheie syndrome
, these declines usually appear between 3 and 8 years of age , with milder neurocognitive losses and a low risk for early mortality .
these neurocognitive losses typically include progressive dementia resulting from hydrocephalus and increasing deposits of nonmetabolized mucopolysaccharides ( shapiro et al 1995 ) .
language and memory deficits after a period of initial developmental slowing have been associated with the more severe forms of mps i ( guffon et al 1998 ) . while neurocognitive deficits have been associated with mps , to date
there are few neurocognitive reports of children with this disorder and no longitudinal studies , resulting in scant knowledge regarding appropriate assessment and intervention ( brown 1999 )
. many studies report cross - sectional assessments of these children at different stages . in this case report
, we have the opportunity to follow a young lady with hurler - scheie syndrome over the course of 10 years , documenting the quantity and quality of neurocognitive effects associated with this disease .
this represents a rare chance to longitudinally track the effects of hurler - scheie in a young person and allows recommendations to be made to health care professionals regarding potential neurocognitive and psychological care for children with this disorder .
researchers are currently engaging in novel therapies designed to reduce and perhaps reverse the effects of hurler - scheie .
however , while these therapies may have a beneficial effect on orthopedic , skeletal , or ophthalamic problems , their effect on neurocognitive functioning is not clearly understood .
thus , we are in a position to begin documenting both the physiological and neurocognitive effects of these new treatments .
the focus of this case report is to describe long - term neurocognitive changes in a young female with hurler - scheie syndrome that was treated using enzyme replacement therapy . to our knowledge , this is the first longitudinal case report of a patient receiving enzyme replacement therapy for hurler - scheie syndrome .
the following information was collected with the approval of the institutional review board at the university of mississippi medical center .
we report the case of a now 15-year - old female diagnosed with mps - i , specifically hurler - scheie syndrome , alpha ( not her real name ) .
alpha s mother gave consent for her child to serve as a subject in this investigation , and alpha gave assent .
her mother reported alpha grew well at first , but then seemed to  slow down .
her mother also noted alpha could not raise her arms over her head , even as an infant . at age 3.5 years , alpha complained of wrist pain , and was seen by her primary care physician .
alpha began taking gymnastics class as part of her 4-year - old preschool ; her instructor noted that alpha could not touch her toes or raise her arms .
alpha was then referred to a local orthopedic clinic and x - rays were obtained . according to alpha s mother ,
the clinic noted  something wrong  on the x - ray films , and referred alpha to a pediatric orthopedic surgeon for further evaluation .
alpha could not actively abduct her shoulders beyond 90 degrees and passive abduction was limited to 130 degrees .
she was noted to have good finger function and grip , and a full range of motion in her neck , hips , knees , ankles , and elbows , with no appreciable organomegaly .
however , after reviewing the x - rays and noting atypical features such as broad ribs with some notching at the medial metaphyseal ends , and smaller than usual femoral heads bilaterally , the orthopedic surgeon suspected alpha had scheie syndrome , one of the mps i syndromes .
alpha was referred to a geneticist to conduct urine and blood tests and was diagnosed with hurler - scheie syndrome . by age 8 , alpha remained a very happy , bright young lady who was active in theatre camp and swimming ( she used her own , special technique according to her mother ) . she could actively abduct her shoulders 80 degrees and had about 50% range of motion in her neck .
she was wearing glasses , was an avid reader , and was doing very well in school . by age 10 in 1999 , alpha was 50 inches ( 124 cm ) tall and weighed 71 pounds ( 32 kg ) .
she had restricted range of motion in her hips and knees , and was beginning to complain of neck pain . in 2000 , at the age of 12 , alpha was admitted for the placement of a vp shunt secondary to increasing hydrocephalus .
she also began enzyme replacement therapy in 2000 on a pharmaceutical study at the age of 12 , as well as outpatient physical therapy to encourage range of motion in her extremities .
tanner staging was noted as appropriate for her age ; in general , hurler - scheie and scheie patients have normal puberty and reproductive abilities .
her neurocognitive functioning was assessed three times , in june 1994 when she was 5 years 11 months old , in june 2002 when she was 13 years 11 months old , and in july 2003 , when she was 15 years old .
the initial assessment at age 511 was not conducted by the authors , but took place at another location . however ,
this assessment was done by a licensed clinical psychologist who used age - appropriate , valid measures .
copies of the report from that assessment were reviewed from the patient s medical chart .
given her young age ( 511 ) at her initial assessment , the patient was administered the stanford - binet intelligence scale , fourth edition , and the wide range achievement test , third edition ( see table 1 ) .
these measures assess for intelligence ( iq ) and achievement , respectively . at the time
, the patient had just completed kindergarten , had no behavior problems , and was considered by her teachers to be ready for the first grade .
her mother likewise thought the patient was doing well academically , but was concerned that the patient could perhaps have been showing signs of mild forgetfulness .
overall , the scores on these measures range from the average to the highly superior range , as she scored at or above the 90th percentile in most areas . at that time , it was clear that alpha was functioning in the average to superior range intellectually and academically , and had no significant behavioral or emotional problems .
alpha s parents were aware of the impressive nature of these findings , but were also aware of the usual course of this disease , including gradual neurocognitive decline .
they began both systematic and non - specific interventions designed to challenge alpha intellectually and stimulate her already significant cognitive abilities .
alpha was enrolled in a school that stressed academic excellence , and her mother reported that alpha did well through the seventh grade .
alpha was home - schooled for the second half of the seventh grade , as she was travelling frequently to receive treatment for her condition .
when she began eighth grade back at her same school , her grades began to fall from consistent as up through the seventh grade to bs and cs in the eighth grade .
this prompted alpha s parents to seek another neurocognitive evaluation . at the time of the second assessment , the patient was 13 years and 11 months , and
this second battery consisted of parts of the wechsler intelligence scale for children  third edition ( wisc - iii ) , woodcock - johnson tests of cognitive ability  third edition ( wj - iii ) , the wide range assessment of memory and learning ( wraml ) , the california verbal learning test
children s version ( cvlt - c ) , the stroop color and word test , the rey - osterrieth complex figure test ( rocf ) , the child behavior checklist ( cbcl - parent report ) , the youth self report ( ysr ) , the children s depression inventory ( cdi ) , and the revised children s anxiety and depression scale ( rcads ) .
this battery is designed to be a comprehensive measure of intelligence , neurocognitive functioning , and behavioral and emotional adjustment .
it should be noted that though different batteries of measures were used between neurocognitive assessments , the results from both assessments are comparable .
specifically , overall intelligence quotient ( iq ) scores between the stanford - binet and the woodcock - johnson show good correlation ( sattler 1992 ) . results from this second assessment indicate a significant decline in overall abilities from alpha s initial level of functioning . her abilities were now within the average range of functioning ; however , she again demonstrated no significant behavioral or emotional problems .
alpha s parents began implementing suggested interventions , including after school tutoring and structuring alpha s study time so that she studied for short blocks of time with frequent breaks . at the time of this report
, alpha s mother described alpha as doing better in school ( generally bs and cs , a few as ) , and continuing to be emotionally and socially well - adjusted .
she completed the same battery as the one she completed at age 1311 ( see table 3 ) .
while declines in neurocognitive functioning are generally expected in children with mps , this case report of a young lady with hurler - scheie demonstrates that declines may proceed at different rates and are likely influenced by premorbid neurocognitive functioning and environmental  behavioral vectors . in other words ,
alpha s current level of  average  neurocognitive functioning is probably the result of impressive capabilities prior to the onset of hurler s syndrome as well as the degree of intervention and cognitive expectations that characterize her family system .
the idea of cognitive reserve as a protective factor in individuals who have some sort of neurological insult has been assumed in children with traumatic brain injury and brain tumors .
thus , it could be that since alpha had such a high premorbid level of functioning , she had more to  spare  during the course of her illness and treatment ( taylor 2004 ) .
it should be noted that many children with hurler - scheie show some degree of cognitive sparing , in comparison with other types of mps .
it should be noted that alpha has been diagnosed with a milder form of mps , hurler - scheie , and that this subtype of mps has been shown to involve relative neurocognitive sparing ( brown 1999 ) .
however , this report is the first of its kind to our knowledge to document longitudinal changes in a youngster .
the issue of alpha s current level of neurocognitive functioning can not be fully addressed in this report .
her initial decline is undoubtedly related to her diagnosis of hurler - scheie syndrome . however , the amount of decline and conversely the degree of neurocognitive sparing attributable to her premorbid functioning and behavioral interventions by her parents is indeterminable .
the differences in her test performance may be attributable to regression to the mean , a common result of multiple assessments conducted on a single individual .
consequently , we can not estimate the amount of variance accounted for by alpha s premorbid intellectual capabilities , hurler - scheie syndrome , and her parents level of cognitive and intellectual interventions .
it should also be noted that the measured decline in iq might be related to progressive motor dysfunction , as this might affect some of the subtests on the neurocognitive measures .
there are no reports of the possible neurocognitive - sparing or improving effects of enzyme replacement therapy , which alpha received .
weaknesses of this case report include the use of different measures of intelligence and neurocognitive functioning .
however , all measures used to assess this patient are well - established , well - validated measures , and hence should be interpreted as adequately reflecting her level of neurocognitive functioning at the time they were administered .
this case represents a unique opportunity to study a genetic disorder with neurocognitive effects , in the light of apparently strong biological and environmental protective factors .
children with hurler - scheie syndrome should be followed regularly with neurocognitive assessments in order both to document expected intellectual declines and to target areas for cognitive and behavioral interventions that might slow the decline associated with this disease .
the strong behavioral and environmental support that alpha received from her parents can not be discounted .
alpha s parents proactively began working with her in light of her diagnosis , and then followed through with a neurocognitive rehabilitation plan suggested by the first author ( tde ) .
this neurocognitive rehabilitation plan was tailored to address the specific levels of functioning that alpha evidenced from her assessments .
we strongly recommend neurocognitive assessment and intervention for these patients , alongside newer medical interventions .
the lack of continued neurocognitive decline from age 1311 to age 150 may be attributable to ( 1 ) the milder form of mps with which alpha was diagnosed , ( 2 ) the newer treatments initiated by the team of physicians ( jm ) , ( 3 ) the fact that alpha probably began life with a higher - than - average neurocognitive capacity , or ( 4 ) the supportive and appropriately challenging environment of social support that alpha enjoyed .
however , neurocognitive assessment adds a low burden to an overall treatment plan , and can help with behavioral interventions designed to improve long - term neurocognitive functioning .

Answer:
an adolescent with hurler - scheie syndrome is reported .
 this now 15 year - old - young woman was initially diagnosed at age 4 .
 she was assessed for neurocognitive functioning at ages 5 , 13 , and 15 years .
 results show a significant decline in intellectual functioning from the superior range to the average range from age 5 to age 13 , and then no change from age 13 to age 15 .
 the relationship between hurler - scheie syndrome , premorbid intellectual functioning , and cognitive  behavioral interventions are discussed in light of the longitudinal neurocognitive effects of this disease .


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:
transesophageal echocardiogram ( tee ) has been introduced to the operating room over 30 years ago .
we report a case of esophageal perforation caused by tee during an aortic valve replacement operation , treated successfully with a new endoscopic clip . to the best of our knowledge ,
this is the first case of post - tee esophageal perforation treated endoscopically with this new clip device .
a 72-year - old female was admitted to the operating theater for aortic valve replacement . during the operation and in the first hours in the intensive care unit ( icu )
the patient had to undergo tee in order to assess postoperative left ventricle performance status .
a deep 2  1.5 cm ulcer covered with blood thrombus was found approximately 2 cm above the gastroesophageal junction .
the rest of the endoscopy was unremarkable . within the next 48 h , thoracic and
only a few blood clots were found in the area between the stomach and the left liver hilum , but no signs of mediastinitis or free intra - abdominal air .
four days later , as the patient became febrile , a second gastroscopy was performed .
a 2  1.5 cm perforation was seen at the same site of ulcer with no bleeding ( fig .
due to the patient 's clinical condition and the size of the gap , an endoscopic intervention was decided . a new 12-mm clip ( otsc ; ovesco endoscopy , tbingen , germany ) was engaged .
the clip is made of nitinol and approximates large perforation margins like a surgical clamp .
the edges of the perforation were approximated by using a specific endoscopic double grasping forceps and applying suction through the cap .
thus , the tissue was pulled into the cap and the clip was released by rotating the wheel attached to the shaft of the endoscope .
a nasogastric levin tube was uneventfully left in the stomach under direct vision for long - term enteral feeding .
further , the patient was offered two intra - abdominal drainage catheters in the operating theater so that intra - abdominal air and blood clots be drained and high fever get under control .
all intra - abdominal and peripheral blood cultures were sterile . the patient was kept on intravenous antibiotics , proton pump inhibitors and parenteral nutrition over the next 10 days followed by enteral feeding through the levin tube .
two weeks later she was transferred to the clinical ward , experiencing no dysphagia , and was discharged fully recovered 3 months after the operation .
tee has safely been applied in patients undergoing cardiac surgery and in icu departments for diagnostic purposes and monitoring over 30 years .
factors that may determine the way of intervention following esophageal perforation are age , clinical condition , location and size of the perforation , cost of intervention and elapsed time since the injury .
the time since perforation has occurred is crucial . a diagnosis delayed for more than 36
h is associated with high mortality ( 50% ) , despite surgical intervention . up to date , there have been no randomized controlled trials comparing surgical to endoscopic intervention regarding patient outcome . in our case ,
the tee performed in the operating theater and the icu led to esophageal perforation due to the patient 's esophagus anatomy .
the delayed diagnosis of perforation is attributed to the blood thrombus on top of the ulcer seen in the first endoscopy that behaved as a sealant .
our patient 's serious clinical condition precluded major surgical intervention , and it was decided to provide her with endoscopic therapy .
additionally , due to the size of perforation and cost , a single clip that could seal the gap was very appealing .
last , by leaving this clip in place for a long time , longer than common clips , could possibly guarantee safe sealing of this perforation . according to clip manufacturers ,
the clip may remain in place for over 6 months and is magnetic resonance imaging - safe .
esophageal perforations closed endoscopically range from 3 to 25 mm in size . due to the new device technology ( twin grasper and the cap at the tip of endoscope ) , a single clip is enough and able to create a full - thickness closure of perforations up to 3 cm in diameter .
this new clip provides a secure and successful esophageal perforation closure rate , up to 100% in perforations diagnosed within the first 24 h . according to this study , the clip remains in place for over 6 months and
the mean repairing time of an esophageal perforation after successful multiple clipping is 18 days ( interquartile range 626 ) .
most importantly , chronicity of perforation ( > 10 days ) was the only independent predictive factor for successful perforation closure in univariate and multivariate analysis .
however , esophageal perforation as a complication of this clip during patient intubation has been reported in up to 3% of patients , but probably this can be attributed to the learning curve .
indeed , in another study with 94 patients regarding the use of the otsc clip to narrow the pouch in patients who underwent gastric bypass surgery , no esophageal perforation occurred . in conclusion
, although tee is a safe procedure , it may be complicated by esophageal perforation .
we clearly showed and strongly suggest that esophageal perforation of 5 days can safely and successfully be treated endoscopically by applying this new otsc clip device .

Answer:
esophageal perforation due to transesophageal echocardiogram ( tee ) during cardiac surgery is rare .
 a 72-year - old female underwent tee during an operation for aortic valve replacement .
 further , the patient presented hematemesis .
 gastroscopy revealed an esophageal bleeding ulcer .
 endoscopic therapy was successful .
 although a ct scan excluded perforation , the patient became febrile , and a second gastroscopy revealed a big perforation at the site of ulcer .
 the patient 's clinical condition required endoscopic intervention with a new otsc clip ( ovesco endoscopy , tbingen , germany ) . the perforation was successfully sealed .
 the patient remained on intravenous antibiotics , proton pump inhibitors and parenteral nutrition for few days , followed by enteral feeding .
 she was discharged fully recovered 3 months later .
 we clearly demonstrate an effective , less invasive treatment of an esophageal perforation with a new endoscopic clip .