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 evaluation of vibration sensation informs the clinician about the integrity of mechanoreceptors in the skin , rapidly conducting large - diameter afferent fibers in the peripheral nerves and the dorsal column - medial lemniscus pathways in the central nervous system [ 1 , 2 ] .
therefore , diminished vibration sensation is an important finding in the diagnosis of disorders affecting the dorsal column - medial lemniscal system and may also be an early sign of peripheral neuropathies .
it is known in everyday practice that patients , due to the physical properties of this sensory modality , can perceive vibration through layers of clothes .
this recently resulted in a debate during a case presentation in our clinic in which one of the authors tried to perform the examination on a clothed subject for the sake of speed .
the present study was designed under the inspiration of this dispute with the hope of providing some new insights into the characteristics of vibration sensation .
fifty healthy volunteers ( h group ; median age was 37 years , 22 male ) and 19 patients with diabetic polyneuropathy ( pnp group ; median age was 57 years , 5 male ) were included in the study ( table 1 ) .
the h group mainly consisted of volunteer relatives of patients , healthcare professionals , and medical students stratified into 4 age groups , as follows : ages 1825 ( n = 14 ) , 2640 ( n = 13 ) , 4155 ( n = 13 ) , and 55 + ( n = 10 ) .
their mean height was 168.5  9.1  cm ( range 153 to 183 ) and their mean weight was 72.2  14.6  kg ( range 49 to 110 ) . a brief neurological examination including superficial sensation , muscle strength , and tendon reflexes was made and found to be normal in all the subjects in this group .
those who had any neurological and systemic disease or who were using medications which could affect the peripheral or central nervous systems were excluded from the study .
the pnp group consisted of patients with known type 2 diabetes mellitus and the clinical diagnosis of diabetic polyneuropathy visiting the diabetic outpatient clinic for their regular controls ( median follow - up duration was 14 years ; range 126 ) .
vibration sensation was measured with the common psychophysical technique , whereby the duration of vibration sensation is dependent on each subject 's judgment .
the subjects lay supine in a comfortable quiet room with an ambient temperature of 2025c during the measurements .
a 128  hz standard tuning fork was used to assess the vibration sensation throughout the study ( riester tuning fork w / clamps , aluminum , no .
5162 , c 128  hz , california , usa ) . the socks used in this study all had the same thickness and tissue characteristics ( the same model from a certain manufacturer ; cotton , 70 denier linear mass density ) which had been purchased in bulk and were disposed of after a single use .
four sites were selected for measurements : dorsum of the interphalangeal joint of the great toe ( gt ) and the vertex of the medial malleolus ( mm ) on both sides .
the tuning fork was applied vertically to these points with gentle pressure after the prongs were maximally activated ( by tapping the prongs against the examiner 's hypothenar eminence ) for each measurement ( figure 1 ) .
two investigators took the measurements ; the first one applied the tuning fork while the second investigator measured with a stopwatch the duration of vibration sensation from the activation time of the tuning fork until the subject 's verbal indication that the sensation was over .
those who were found to have no vibration sensation at all on any of the measurement sites ( usually at gt ) were excluded from the study at this point . in the measurement phase ,
2 measurements without and 2 measurements with socks were performed on each site in the following sequence , allowing a five - minute break inserted so as not to exhaust the subjects and to help them maintain their concentration : without , with , interval , with , without .
sixteen measurements in total were taken for each subject , requiring about 20 minutes for the entire procedure .
the averages of each pair of measurements with and without socks were used as the statistical input .
the procedure was approved by the istanbul faculty of medicine ethics committee ( 2012/1244 ) and all participants provided informed consent .
all the statistical analyses were performed using the statistical package for the social sciences ( spss ) , version 17.0 , for windows ( spss , chicago , il , usa).samples were tested for their distribution with kolmogorov - smirnov test.correlations between the measurements in the same conditions ( first and second measurements on the same side without socks and with socks ) and between the measurements on both sides were tested with pearson 's r.after showing a high correlation between the items in , the results of the two measurements for each condition and the results elicited on the right and left sides were averaged to constitute the main inputs for the statistical analyses .
the difference between the mean durations of vibration sensation without and with socks in both groups was analyzed using paired samples t-test.statistically significant results elicited in   were analyzed for the effect size , using cohen 's d.in the h group , correlations of vibration sensation with age , height , and weight were assessed with pearson 's r.independent samples t - tests were performed to evaluate the difference between the vibration sensations measured at the gt and mm.differences between the results elicited in the pnp group and those found in an age - matched subgroup of h ( 13 females and 9 males , aged  40 years ( median 53 , min 40 , max 68 ) ) were analyzed with independent samples t - tests .
correlations between the measurements in the same conditions ( first and second measurements on the same side without socks and with socks ) and between the measurements on both sides were tested with pearson 's r. after showing a high correlation between the items in , the results of the two measurements for each condition and the results elicited on the right and left sides were averaged to constitute the main inputs for the statistical analyses .
the difference between the mean durations of vibration sensation without and with socks in both groups was analyzed using paired samples t - test .
statistically significant results elicited in   were analyzed for the effect size , using cohen 's d. in the h group , correlations of vibration sensation with age , height , and weight were assessed with pearson 's r. independent samples t - tests were performed to evaluate the difference between the vibration sensations measured at the gt and mm .
differences between the results elicited in the pnp group and those found in an age - matched subgroup of h ( 13 females and 9 males , aged  40 years ( median 53 , min 40 , max 68 ) ) were analyzed with independent samples t - tests .
the mean durations of vibration sensation and the differences between the results elicited without and with socks are given in table 1 .
the effect of wearing socks was found to be insignificant except that found on the mm in the h group , which was seen to have a small effect size upon further analysis with cohen 's d < 0.2  ( d = 0.17 ) .   vibration sensation was found to decline with age in the h group for two measurement points and both conditions .
pearson 's r in measurements without socks were 0.502 ( p < 0.001 ) and 0.432 ( p = 0.001 ) , and with socks were 0.467 ( p = 0.002 ) and 0.416 ( p = 0.003 ) , respectively ( figure 2 ) .
the duration of vibration sensation was shorter at the mm as compared to gt in the h group ( the mean difference was 4.3  s , p < 0.001 ) . a smaller difference in the same direction was also observed in the pnp group ( 1.5  s mean difference , p = 0.012 ) ( figure 2 ) .
the vibration sensation of only one of the 50 participants in the h group , a 68-year - old male , measured less at the gt than at the mm , whereas 3 patients in the pnp group were found to have shorter vibration durations at the gt . as compared to the age - matched subjects from the group h , the duration of vibration sensation in the pnp group had a significantly shorter vibration duration at the gt but not at the mm measurement points ( p < 0.01 and p = 0.12 , resp . ) .
the present study reveals that the mean durations of vibration sensation measured without and with socks are nearly the same ; there is practically no difference between them in normal subjects and patients with diabetic polyneuropathy .
although a statistically significant reduction with socks was found in the measurements at the mm in group h , its effect size was small and the mean difference was less than one second . since clinicians generally express the duration of vibration sensation by whole seconds , without using fractions , the size of the difference found at the mm does not seem important enough to affect the results of clinical examination .   as far as we know , this is the first study on humans to investigate the perception of vibration over clothing .
other examples of clinical studies which investigated the effect of clothing during physical examination do exist , including the auscultation of lung sounds through thin clothing   and measurement of blood pressure through sleeves using the auscultatory method .
these studies all resemble each other in that the focus of interest is sounds and vibrations and the spectrums in question are also similar .
kraman showed that lung sound perceived by stethoscope was somewhat deteriorated by one or two layers of indoor clothing but this effect can be reduced by force on the stethoscope head .
liebl et al . did not found statistically significant difference between sleeved and nonsleeved arm during manual auscultatory sphygmomanometric and automatic oscillometric blood pressure measurement .
an everyday experience was also found to be congruent with these results , that of a vibrating cell phone .
it was observed that one is easily able to perceive the vibrations of a cell phone in her / his pocket through a significant amount of clothing . with this observation in mind , we measured the frequencies of incoming call vibrations of several models of cell phones and found that the range was 116 to 250  hz .
it is not surprising that this range includes the optimum frequency range for pacinian corpuscles , namely , between 60 and 400  hz .
all these data suggest that the interference from garments on vibration energy is little . with regard to the vibration of a cell phone in vibration sensing , the use of a pager device in its vibration mode was reported to be used for clinical vibration testing in an era when cellular phones were not so common .
the tuning fork is the most  readily available  instrument in daily clinical practice for measuring vibration sensation and is sufficiently reliable when compared to other techniques of measurement [ 7 , 8 ] .
several studies report the use of the rydel - seiffer graduated 64  hz tuning fork because of its semiquantitative properties [ 79 ] .
although one was available at the installation phase of the present study , it was discarded because the semiquantitative scale of this device seemed to provide insufficient time resolution for our requirements .
the other reason for discarding this tuning fork was that its 64  hz was thought to be in the preferential frequency range of meissner 's corpuscles rather than the pacinian afferents .
the physiology of pacinian corpuscles may play a critical role in the sensation of vibration through clothing , due to their subcutaneous localization and wide field of perception [ 1 , 10 ] .
the shorter vibration durations at the mm than at the gt are an unexpected finding for clinicians familiar with axonal polyneuropathies , due to the distal to proximal progression of degeneration .
it has been concluded that substantial tissue damping affects the tuning fork while taking measurements at the mm .
this is probably caused by the solid mass of the tibia which is substantially larger than that of the toe bones beneath the gt measurement points .
we think that the shorter vibration durations at the mm can be attributed to this phenomenon , which has been analyzed in detail in the article by goldberg and lindblom .
mean vibration duration at the gt was higher than that at the mm even in the pnp group , although the difference was less . this may be due to the fact that this study involved only mild to moderate cases of diabetic pnp and excluded the more advanced cases in whom vibration sensation was measured as totally absent distally .
it might be expected that , with more advanced disease , the gt measurement would have been able to exceed the mm in shortening of vibration sensation duration due to the distal axonopathy process . in conclusion
, this study shows that no practically significant difference arises from wearing socks when measuring vibration sensation with a tuning fork ; any interference thus caused is negligibly small .
this is true for the healthy population over a wide age range and also for patients within the clinical context of a diabetic polyneuropathy .
however , this study does not aim to recommend measuring vibration sensation over socks . in the patients with chronic polyneuropathy ,
careful examination of the feet is crucial for the screening of ulcers and infections and leaving the socks in place during examination is strongly discouraged .
besides , the socks would still have to be removed in order to perform the other modalities of neurological examination . bearing these in mind , we hope that the results of the present study will be considered as a clinical clue indicating one of the remarkable properties of vibration sensation .

Answer:
objective . to investigate the difference between the measurement of vibration sensation without and with socks .
 material and methods .
 fifty healthy volunteers ( h group ) and 19 patients with diabetic polyneuropathy ( pnp group ) were included .
 the sites of measurement were the great toe ( gt ) and medial malleolus ( mm ) .
 a standard 128  hz tuning fork was used in the measurements .
 results .
 mean duration of vibration sensations without and with socks was as follows : in the h group , 19.4  4.2 and 19.5  4.2  s at gt and 15.1  3.3 and 14.6  3.3  s at mm ; in the pnp group , 13.4  3.8 and 12.7  4.1  s at gt and 11.9  3.8 and 11.7  3.4  s at mm .
 no significant difference was found between the measurements without and with socks , except those found at the mm in group h ( p = 0.02 ) .
 this significant difference was further analyzed in terms of effect size which was concluded to be practically insignificant ( cohen 's d < 0.2 ) .
 shorter mean vibration duration was measured at mm as compared to gt that could be explained by the damping effect .
 conclusions . wearing socks of moderate thickness
 does not have any important effect on the duration of vibration sensation .
 this might be considered as a reflection of the remarkable properties of vibration sensation .


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 name  granulosa cell tumor  ( gct ) was proposed by von werdt in 1914 .
to have primarily originated retroperitoneal gct is even rarer . in medical literature in english from 1938 till today , only 12 cases have been reported .
although , the histology of ovarian adult - type granulosa cell tumors ( agcts ) is well - documented , it is rarely encountered in cytological specimens and the identification of tumor cells is very difficult . here
. per abdominal examination revealed a well - defined mass palpable in the left hypochondriac and lumbar regions . computerized tomography ( ct ) of the abdomen revealed a solid heterogeneous mass lesion measuring 11.2 cm  8 cm  12 cm , consistent with retroperitoneal hematoma [ figure 1a ] .
ultrasonography ( usg)-guided aspiration of the mass was performed and the smears were hypercellular with small , overlapping cell clusters and cells in a microfollicular pattern [ figure 1b ] .
on enquiry , she gave a history of hysterectomy with bilateral salpingo - oophorectomy 22 years ago for uterine leiomyoma .
with these cytological features and the clinical history , a diagnosis of extraovarian agct was proposed .
we received multiple dark brown and necrotic tissue fragments together measuring 10 cm  8 cm  3 cm .
the cut section of all fragments showed gray white , yellowish , and hemorrhagic areas .
( a ) ct showing a solid heterogeneous mass in the left anterior pararenal space compressing left kidney ( b ) cytology smear showing cells in microfollicular pattern ( papanicolaou , 400 ) ( c ) cells in sheets and microfollicular pattern ( h and e , 400 ) ( d ) tumor cells showing strong positivity for inhibin ( inhibin , 400 ) histologically the neoplasm was composed of small round to oval neoplastic cells with predominantly microfollicular [ figure 1c ] , diffuse , and watered - silk patterns .
immunohistochemistry ( ihc ) for inhibin and epithelial membrane antigen ( ema ) was done .
the tumor was positive for inhibin [ figure 1d ] and negative for ema . with the typical histopathological features and ihc findings , a diagnosis of primary agct of retroperitoneum was confirmed .
there are two subtypes : adult and juvenile , based on different clinical and histological features .
agct of the ovary is oftentimes a hormonally active stromal cell neoplasm that is distinguished by its ability to express aromatase and to secrete sex steroids such as estrogen .
the histogenetic origin of extraovarian agct is thought to be from the ectopic gonadal stromal tissue from the mesonephros .
the cytological smears of an agct are usually highly cellular of both single cells , syncytial aggregates , and follicular pattern
. the cells are monomorphic with scanty to moderate amount of pale cytoplasm and monomorphic round to oval nuclei having longitudinal grooves and granular chromatin .
histologically , the tumor cells resemble normal granulosa cells with uniform , round or oval nuclei having finely granular chromatin and longitudinal nuclear grooves or folds .
they show microfollicular , macrofollicular , trabecular , watered - silk , or diffuse patterns .
extraovarian gct should be differentiated from other tumors such as small - cell carcinoma , undifferentiated carcinoma , carcinoids , and lymphoma .
gct is positive for inhibin and calretinin and negative for ema whereas other tumors do not show positivity for inhibin and calretinin .
the case of primary retroperitoneal gct is reported for its rarity after excluding previous ovarian origins and to describe its relevance to the histologic origin . due to their rarity , agcts present a diagnostic challenge for cytologic preparations .
we believe that sensitive cytologic evaluation , histopathologic correlation , taking clinical history , and a positive immunohistochemical reaction with inhibin could help us in practice .
surgery is the primary treatment for these tumors , however , long - term follow - up with history , clinical examination , and tumor markers are crucial for gcts , as later relapse is a common behavior for these unique tumors .

Answer:
the most frequently occurring retroperitoneal tumors are those of the kidneys , adrenal glands , and the pancreas .
 a primary retroperitoneal tumor composed of granulosa cells and developing far away from the normal location of the ovary is less frequently observed .
 a 69-year - old female patient presented with abdominal discomfort . computerized tomography ( ct ) of the abdomen revealed a solid heterogeneous mass lesion measuring 11.2 cm  8 cm  12 cm consistent with retroperitoneal hematoma .
 ultrasonography ( usg)-guided aspiration smears revealed cytological features suggestive of adult - type granulosa cell tumor ( agct ) . as the patient had a history of hysterectomy with bilateral salpingo - oophorectomy 22 years ago for leiomyoma , a diagnosis of extraovarian agct was made .
 intraoperatively , the tumor was removed in piecemeal that showed yellowish areas with extensive necrosis and hemorrhage .
 histopathological examination of the excised mass and inhibin positivity confirmed the diagnosis .
 primary retroperitoneal extraovarian gct is a rare tumor with only 12 cases reported in medical literature in english .


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:
although global gene content and detailed sequence similarity comparisons with the previously described megaviridae members clearly classify pgv within the family ( including the partially sequenced organic lake phycodnaviruses ( olpv ) , chrysochromulina erecina virus , and phaoecystis pouchetti virus ) , the finding of a pgv - associated virophage came as a surprise .
complete virophage genomes have now been described , but only 3 correspond to identified and isolated
the pgv virophage ( pgvv ) is the third , and presumably not the last , of a rapidly growing series . except for their genome size in the 20 kb range ,
these new types of satellites viruses have little in common in terms of gene content , although they all code for a major capsid protein and one dna primase .
consistent with the fact that it was never observed in pgv - infected cultures , pgvv is the first example of a virophage lacking the information to make a capsid protein , the essential building block of a virus particle . once multiplied in the pgv virus factory , the pgvv genome is thus packaged ( in multiple copies ) alongside the pgv genome , and propagated through the pgv virion , either as an integrated or free viral  plasmid .  the precise molecular structure(s )
the finding of a virophage associated to pgv is already teaching us the important lesson that virophages are not solely associated to dna viruses with micron - sized particles and 1 mb genome sizes , but can be found with large dna viruses of more reasonable ( poxvirus - like ? ) proportion .
it is thus likely that many of such associations have been overlooked in the past , and that virophages might have played a fundamental role in the evolution of many more viruses than just the megaviridae .
if this is true , they could be ( and have been ) the main vehicle of gene transfers between eukaryotic viruses , and indirectly between these viruses and their hosts .
they may also be responsible for the sporadic occurrences of mobiles elements such as self - splicing introns , inteins , and transpovirons .
another lesson is that , like all parasites , the virophages are submitted to the irreversible phenomenon of reductive evolution , condemning them to disappear as individual biological entities , eventually saving some of their genes by integrating them into the genome of their companion virus , themselves undergoing a similar process vis -  - vis their cellular host .
the first published phylogenetic tree including mimivirus 2 and using a concatenation of 7 universally conserved protein sequences , already pointed out that :  we could now build a tentative tree of life , within which mimivirus appears to define a new branch distinct from the three other domains .  elsewhere in the same article , mimivirus was also shown to be part of the broad family of the nucleocytoplasmic large dna viruses ( ncldv ) , branching near the middle of the previously defined iridovirus , phycodnaviruses , poxviruses , and asfarviruses lineages . put together , these 2 results suggested in a subliminal way that all the large dna viruses were in fact defining a domain distinct from the 3 established cellular domains . as additional genomes of megaviridae became available ,
molecular phylogenies computed with an increasing number of universal proteins associated to basic functions ( dna clamp loaders , ribonucleotide reductases , aminoacyl - trna synthetases , dna polymerases ) kept clustering the megaviruses in their own clade , clearly separate from the cellular domains , thus contributing an additional domain rooted in between archaea and eukarya in the tree of life . despite receiving increasing support from various authors , others remain strongly opposed to this view . in agreement with the notion of a fourth domain of life anchored by the largest dna viruses , the dna polymerase of pgv nicely clusters with the other megaviridae homologs , exhibiting no affinity with any of the main cellular lineages ( fig .  1 ) .
based on the presence of a vestigial protein translation system , i previously argued that the genome of today 's giant viruses derived from an ancestral cellular organism through the irreversible process of reductive evolution experienced by all parasites .
dna viruses exhibiting a whole range of genomic complexity could have been generated through this continuous process : viruses would have lost translation first ( the ribosome ) , then transcription ( the rna polymerase ) , then dna replication ( the dna polymerase ) , following an evolutionary scenario whereby they become increasingly dependent from their host .
the vast range of size and complexity among today 's dna viruses might thus be the results of differences in their evolution rates ( the largest ones experiencing the least evolutionary pressure ) . in this context
, the lack of affinity of the giant viruses with any of today 's cellular domains , as well as the huge proportion of the viral genes without cellular homolog , would suggest that the lineage of the ancestral cellular organism that gave rise to giant viruses became extinct as a cellular life form , and only managed to survive as a parasitic  fourth domain .
 the recently described giant pandoravirus might represent an independent instance of the same scenario .
the tree was produced using the default option on the mafft server ( url : mafft.cbrc.jp ) from the multiple alignment of 25 dna polymerase b sequences ( 510 ungapped positions , excluding the inteins ) .
branches with bootstrap values < 80 are collapsed . despite infecting eukaryotic hosts from vastly divergent phyla
, the viruses do not show any phylogenetic affinity with a specific eukaryotic group , and cluster ( in red ) separately from the 3 cellular domains : eukarya ( green ) , archaea ( purple ) , and eubacteria ( blue ) .
this strongly supported topology suggests that the common ancestor of the megaviridaelargely predated the radiation of the eukaryotes .

Answer:
the viral nature of the first  giant virus ,  mimivirus , was realized in 2003 , 10 y after its initial isolation from the water of a cooling tower in bradford , uk .
 soon after its genome was sequenced , the mining of the global ocean sampling environmental sequence database revealed that the closest relatives of mimivirus , only known to infect acanthamoeba , were to be found in the sea .
 these predicted marine mimivirus relatives remained elusive until 2010 , with the first genomic characterization of a virus infecting a heterotrophic unicellular eukaryote , the microflagellate grazer cafeteria roenbergensis .
 the genome analysis of a virus ( pgv ) infecting the common unicellular algae phaeocystis globosa now shows that it is a bona fide member of the mimivirus family ( i.e. , the megaviridae ) , extending the realm of these giant viruses to abundant blooming phytoplankton species . despite its smaller genome size ( 460 kb encoding 434 proteins )
 , pgv exhibits the most intriguing feature of the previously characterized megaviridae : an associated virophage .
 however , the 19-kb virophage genome , devoid of a capsid gene , is packaged in the pgv particle and propagated as a  viral plasmid ,  the first ever described .
 the pgv genome also exhibits the duplication of  core genes ,  normally present as single copies and a putative new type of mobile element .
 in a dna polymerase phylogeny including representatives of the three cellular domains , pgv and the other megaviridae cluster into their own clade deeply branching between domains archaea and eukarya domains , thus exhibiting the topology of a fourth domain in the tree of life .


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 use of robotic - assisted laparoscopic surgery in minimally invasive gynecology has been rapidly increasing since the da vinci robotic platform ( intuitive surgical inc , sunnyvale , ca , usa ) was approved for this purpose by the food and drug administration in 2005 .
the rate of robotic hysterectomy is estimated to have increased from as low as 0.5% in 2005 to as high as 22% in 2010 .
this technology addresses the ergonomic challenges of traditional laparoscopy by providing a 3-dimensional view , wristed instruments , and diminished tremor for more precise movements , and potentially offers more patients the benefits of laparoscopy , including shorter hospital stays , decreased intraoperative blood loss , faster recovery , and decreased wound infections . as robotics represents an increasing percentage of minimally invasive procedures in gynecology , the debate over the relative benefits of robotic vs conventional laparoscopic surgery is driven by questions of cost , safety , credentialing , and medicolegal issues .
robotic surgery presents surgical teams with a radical departure from the operating room ( or ) culture of open surgery and even conventional laparoscopy .
the large footprint of the platform and its complexity changes the demands on the or team and may adversely affect efficiency .
team members are separated in space and lack face - to - face communication . teamwork and communication have been highlighted as 2 essential components of or safety . to date , few studies have investigated the inherent communication challenges in robotic surgery .
the purpose of this study was to evaluate the association between the quality of communication and surgical outcomes , specifically operative time , blood loss , and perioperative complications .
we conducted a prospective questionnaire - based pilot study from march 1 through may 31 , 2013 , at a university - affiliated tertiary care medical center .
surgeons , circulating nurses , and surgical technicians involved in robotic gynecologic surgery were invited to participate .
the anesthesia team was excluded because of frequent personnel turnover during case assignments , precluding adequate study participation .
all participants signed an informed consent and were assigned a study identification number by the study administrator to maintain anonymity .
circulating nurses and surgical technicians assigned to those cases were core members of the robotic surgical team .
minimally invasive surgery fellows and obstetrics and gynecology residents were also involved in the study .
all robotic gynecologic surgeries for benign indications during the study period were included . at the end of each surgery
the survey was based on 2 validated questionnaires : the safety attitudes questionnaire and the psychometric testing of interpersonal communication skills questionnaire .
we focused on the following aspects : individual communication skills , teamwork , efficiency , and provider satisfaction .
in addition , participants were asked to identify the major factors affecting communication during the case : noise level in the or , console - to - bedside communication problems , lack of nurse availability , lack of instrument availability , lack of participant familiarity with the procedure , other , or none .
in addition , operative details and outcomes were gathered , including estimated blood loss ( ebl ) , operative time , and perioperative complications .
statistical analysis was performed using sas 9.3 ( sas institute , inc . , cary , nc , usa ) .
in addition , to assess the overall perception of the quality of communication , we subjected the 13 survey questions to a principal component analysis , creating a composite quality of communication ( cqoc ) score .
multivariate linear regression models were used to assess the relationship of cqoc to surgical outcomes . in the absence of prior similar studies , a sample size could not be determined a priori .
thirty - two or team members participated in the study , and 108 surveys were completed .
the average response rate was 60% ( 105/174 ) , with a lower rate in fellows ( 9/22 ; 41% ) and a higher rate in circulating nurses ( 34/43 , 79% ; p = .025 ) .
response rates stratified by professional category n , total number of participants per professional category . significance attributed to the difference in response rate between fellows and circulators only .
a total of 24 hysterectomies , 11 robotic myomectomies , 3 sacrocolpopexies with or without hysterectomy , 1 advanced endometriosis resection , and 1 trachelectomy were included in the study .
spearman correlation between individual quality - of - communication survey items and surgical outcomes showed few significant associations .
higher quality - of - communication scores on the item , others misunderstood me because they misinterpreted my words or actions , correlated with a longer room - in  to  room - out time ( p < .01 ) .
similarly , higher scores on the item , i asked others to repeat themselves because i did n't understand / hear their message the first time , correlated with a greater ebl ( p < .05 ) .
analysis of the cqoc score showed an association between the quality of communication in the or and both cut - to - close time and ebl , when controlling for body mass index , prior abdominal surgery , type of procedure , and uterine weight in separate multivariate linear regression models .
a higher cqoc score was significantly associated with a greater ebl ( p = .010 ) and a longer operative time ( p = .045 ) .
the coefficients presented in table 3 demonstrate that for every 1-sd increase in the perceived deficit in quality of communication , there was an additional 51-ml of ebl and a 31-min increase in operative time .
correlation between quality of communication and surgical outcomes nonstandardized coefficients of correlation . controlled for body mass index , prior major abdominal surgery , and uterine weight .
we compared how the different team members judged the quality of communication in the or , and we found that , for most questions , surgeons rated communication to be worse than did circulating nurses and surgical technicians . for example , surgeons agreed with the statement , steps took longer than necessary because i or others had to repeat / clarify what they were saying , at significantly higher rates than did nurses and surgical technicians ( mean 1.4 , sd 0.6 vs. 0.8 , sd 0.8 ; p < .001 ) . despite a difference in mean cqoc scores between surgeons vs. circulating nurses and surgical technicians
, both groups ' responses showed that higher cqoc scores were associated with a longer operative time and a greater ebl .
the most commonly reported factors that negatively affected the quality of communication were the following : the noise level in the or ( 28/36 ; 78% ) , console microphone / console - to - bedside communication ( 23/36 ; 64% ) ; and the lack of familiarity of participants with the procedure ( 22/36 ; 61% ) ( table 4 ) .
there was no significant difference between team members ' report of factors that negatively affect the quality of communication .
there were a total of 5 perioperative complications : 1 cystotomy , 1 conversion to laparotomy , 1 suspected postoperative transient ischemic attack , and 2 readmissions for postoperative abscesses .
however , we did not find any associations via logistic regression between cqoc and perioperative complications , ( p > .999 ) .
factors affecting communication at least 1 participant reported the issue as occurring in each case .
we present an evaluation of the association between the quality of communication and surgical outcomes in robotic surgery .
our study demonstrated that poor quality of communication is associated with a longer operative time and a higher ebl .
our survey was based on 2 validated questionnaires including both experienced and inexperienced team members .
our results illustrate the complexity of communication in the robotic or and demonstrate for the first time the differences encountered in the perception of communication between team members stratified by their role .
robotic surgery has introduced unique and novel challenges to the workflow of a surgical team that have never been experienced before . the surgeon and surgical assistants
more specifically , surgeons operate while sitting at the surgeon 's console , and their field of vision focuses on the 3-dimensional viewer . several meters away from the surgeon 's console ,
the large robotic patient cart ( the platform that attaches to the patient and holds the operating instruments ) often obscures the surgeon 's view of their assistants at the patient 's bedside . the physical distance and obstacles
create an auditory , visual , and physical barrier between team members , potentially hampering efficient communication .
surgical teams have traditionally heavily relied on a multitude of nonverbal communication tools , such as body language and eye contact , to anticipate the next step in the workflow of a given surgery .
it is not until surgeons encounter auditory , visual , and physical barriers that they realize how much they have been relying on those cues for efficient communication .
cao and taylor reported that the complexity of the robotic setup causes a communications breakdown in the robotics or and potentially deleterious effects on team function , decision - making , and flow of information .
they demonstrated that group tasks were executed with greater efficiency and accuracy in a simulated robotic cholecystectomy in which subjects used scripted speech patterns to communicate with team members .
webster and cao concluded that facilitated team communication can ease adaptation to new technologies that disrupt customary workflow .
our data indicate that decreased quality of communication is attributable to modifiable factors : a high level of noise in the or , problems with console microphone and console - to - bedside communication , and lack of familiarity of participants with the procedure .
the high level of noise in the room may result from both the substantial background noise generated by the vision console and team members speaking loudly to communicate across significant distances .
the current built - in da vinci audio system available may not address properly the communication challenges experienced by team members .
engineering solutions to these communication barriers may decrease provider mental load and improve surgical outcomes .
our data suggest a direct relationship between the team members ' experience and quality of communication .
when nurses and trainees who are inexperienced in robotic procedures participate in these cases , it may negatively affect team functioning .
adoption of systematic approaches to integrating new team members into the robotic or may avoid deleterious consequences caused by poor team dynamics .
there is an expanding body of literature on evaluating the effect of these modifiable factors on teamwork , communication , and provider mental load based on the assumption that suboptimal working environment may affect surgical outcome .
the current study demonstrated that this assumption has merit . recognizing the importance of further defining this relationship , randell and colleagues are undertaking a large - scale study to understand and improve communication and teamwork in robotic surgeries .
finally , our study showed that , not only did both surgeons and nurses share the same perception regarding teamwork , but surgeons were more critical of team performance .
prior studies evaluating attitudes regarding patient safety in the or have shown that nurses tend to be more critical than physicians and that physicians have a tendency to have limited insight regarding their team members ' perception of performance , safety , and teamwork .
the finding in our study that surgeons are more critical or concerned than nurses regarding team integration may reflect a loss of sense of control experienced by the robotic surgeon , located distant from the patient and the rest of the team .
it was 1 institution 's experience and had a small sample size , thus limiting the generalizability of the data .
whereas response rate differed by type of participant and may represent response bias , there were no significant differences in the perception of communication , stratified by role .
although we can not determine a cause - and - effect relationship , this study does establish a clear relationship between the complexity of surgery and poor communication in robotic gynecologic surgery and provides a rationale for further comprehensive study .
more objective methods of assessing communication effectiveness , such as videotaped analysis , can be employed in addition to subjective assessment in future studies .
our study demonstrated that the diminished quality of communication reported by or team members is associated with more adverse metrics of patient outcomes .
ambient noise , audio clarity , and team members ' inexperience , all contributed to lower communication scores . overcoming the communication and teamwork obstacles introduced by robotic surgery may increase patient safety .
future studies are needed to assess interventions for improvement in communication and teamwork in the robotics or .

Answer:
background and objectives : robotic surgery has introduced unique challenges to surgical workflow .
 the association between quality of communication in robotic - assisted laparoscopic surgery and surgical outcomes was evaluated.methods:after each gynecologic robotic surgery , the team members involved in the surgery completed a survey regarding the quality of communication .
 a composite quality - of - communication score was developed using principal component analysis .
 a higher composite quality - of - communication score signified poor communication.objective parameters , such as operative time and estimated blood loss ( ebl ) , were gathered from the patient 's medical record and correlated with the composite quality - of - communication scores.results:forty robotic cases from march through may 2013 were included .
 thirty - two participants including surgeons , circulating nurses , and surgical technicians participated in the study . a higher composite quality - of - communication score
 was associated with greater ebl ( p = .010 ) and longer operative time ( p = .045 ) , after adjustment for body mass index , prior major abdominal surgery , and uterine weight .
 specifically , for every 1-sd increase in the perceived lack of communication , there was an additional 51 ml ebl and a 31-min increase in operative time .
 the most common reasons reported for poor communication in the operating room were noise level ( 28/36 , 78% ) and console - to - bedside communication problems ( 23/36 , 64%).conclusion : our study demonstrates a significant association between poor intraoperative team communication and worse surgical outcomes in robotic gynecologic surgery . employing strategies to decrease extraneous room noise ,
 improve console - to - bedside communication and team training may have a positive impact on communication and related surgical outcomes .


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:
cardiovascular disease accounted for 30  % of an estimated 58 million deaths globally from all causes in 2005 .
it is important to recognise that a substantial proportion of these deaths ( 46  % ) occurred in individuals under 70  years of age , in their productive years of life ; in fact , 79  % of the disease burden attributed to cardiovascular disease is in this age group .
moreover , between 2006 and 2015 , deaths due to non - communicable diseases ( half of which are due to cardiovascular disease ) are expected to increase by 17  % .
this projected increase is most prominent in asia due to a very large , ageing population , increasing exposure to a westernised diet , and rapidly increasing rates of diabetes mellitus .
early detection of patients at risk and early institution of effective treatment may help to ease the mortality and morbidity burden of cardiovascular disease . to achieve this ,
improved early diagnosis in patients with chest pain in or before the emergency department would reduce the burden on the hospitals .
furthermore , in an ageing population with improved outcome after myocardial infarction , the number of patients with an elevated risk for a second cardiovascular event is increasing but identification of patients at high risk of recurrent events remains difficult .
increasing survival following acute coronary events also leads to more patients living to develop heart failure ( hf ) .
hf , the final common pathway of cardiac insults , is a serious syndrome due to inability of the heart to provide adequate circulation for the body s needs or only able to do so at increased cardiac filling pressures .
it is the cardiovascular syndrome projected to increase most   in the usa with the largest attendant loss of productivity and increase in direct medical cost in the next 20  years .
europe and asia show similar data [ 5 , 6 ] , with a rapid increase in disease burden on society .
evidence - based therapy of proven efficacy has been introduced over the last 25  years but mortality and readmission rates remain high .
these vesicles are important in cell to cell communication in a variety of processes including coagulation , antigen presentation   and tissue damage .
plasma extracellular vesicles can be easily isolated from frozen plasma or serum and contain protein , mirna and rna depending on source and stimulus .
extracellular vesicles that play a role in the initiation of thrombus formation are of major interest in cardiovascular disease pathogenesis , since thrombosis is the major underlying cause of cardiovascular events . in this process ,
tissue factor ( tf ) , as an important initiator of thrombosis , was found in vesicles that are positive for the monocyte marker cd14 ( fig .  1 ) .
in vitro studies using endothelial cells ( ec ) showed that these tf - containing vesicles do not only initiate thrombosis but also adhere to the ec that results in increased ec thrombogenicity via elevation of tf activity in the ec and decrease of tissue factor pathway inhibitor and thrombomodulin .
this procoagulant activity , with monocyte - derived circulating tf as its main source , was associated with coronary artery disease   and in stent thrombosis .fig .
subpopulations of extracellular vesicles ( evs ) in the plasma involved in coagulation are thought to have three origins : monocyte - derived evs ( blue ) , platelet - derived evs ( red ) and endothelial cell - derived evs ( green ) as outlined in the enlarged ev 3-colour pie chart .
for coagulation tf is the key initiator of the coagulation cascade and forms a complex with factor viia ( fviia ) .
the activated factor x ( fxa ) further cleaves prothrombin into thrombin that converts fibrinogen into fibrin to form clot . for fibrinolysis
, the plasmin inhibitors serping1 and serpinf2 have been identified in evs and inhibit the breakdown of a fibrin via fibrinolysis .
abbreviations : ev , extracellular vesicle ; tf , tissue factor ; psgl-1 , p - selectin glycoprotein ligand-1 ; ps , phosphatidylserine ; p - sel , p - selectin ; e - sel , e - selectin diagram showing an overview of the potential plasma extracellular vesicle procoagulant activity .
subpopulations of extracellular vesicles ( evs ) in the plasma involved in coagulation are thought to have three origins : monocyte - derived evs ( blue ) , platelet - derived evs ( red ) and endothelial cell - derived evs ( green ) as outlined in the enlarged ev 3-colour pie chart .
for coagulation tf is the key initiator of the coagulation cascade and forms a complex with factor viia ( fviia ) .
the activated factor x ( fxa ) further cleaves prothrombin into thrombin that converts fibrinogen into fibrin to form clot .
for fibrinolysis , the plasmin inhibitors serping1 and serpinf2 have been identified in evs and inhibit the breakdown of a fibrin via fibrinolysis .
abbreviations : ev , extracellular vesicle ; tf , tissue factor ; psgl-1 , p - selectin glycoprotein ligand-1 ; ps , phosphatidylserine ; p - sel , p - selectin ; e - sel , e - selectin if extracellular vesicle proteins are involved in cardiovascular events , then plasma vesicle protein content might be an important biomarker source for prognosis and prediction of cardiovascular events .
circulating mirnas are , at least partly , derived from extracellular vesicles and have been used in the diagnosis of acute coronary syndrome ( acs , ) .
extracellular vesicle protein levels , however , have only recently been described to carry information in the presence of acs . following a proteomics discovery approach
, we demonstrated in a chest pain cohort of 471 patients that pigr , cystatin c ( cst3 ) , c5a and total vesicle protein concentration are associated with the presence of acs .
comparisons of this association between male and female patients reveal these markers to be highly associated with acs in males but not with acs in females .
this striking difference is in agreement with an increasing body of evidence that women tend to have lower rates of coronary artery occlusions and have a more preserved left ventricular function .
women , however , also have a higher mortality and a worse prognosis following mi compared with men .
the established difference in extracellular vesicle protein levels associated with acs identifies vesicles as an excellent biomarker source for gender - specific diagnosis and prognosis of acs .
furthermore , this might help in understanding the underlying gender differences in the pathophysiology of acs .
the number of survivors of a first cardiovascular event is on the rise globally with a rapid increase in asia .
these patients are at high risk for a second cardiovascular event even after adequate control of risk factors .
the number and type of extracellular vesicles that are cd31/annexin v positive were associated with an increased risk for secondary events consisting of myocardial infarction , percutaneous coronary intervention ( pci ) , coronary artery bypass graft ( cabg ) , stroke and vascular mortality .
for the first time , the protein content of all plasma extracellular vesicles and its association with secondary cardiovascular events were studied in a large clinical cohort . comparing plasma extracellular vesicles of patients with a secondary cardiovascular event to gender- and age - matched patients without a second cardiovascular event
these vesicle proteins were cystatin c , serping1 , serpinf2 and cd14 and were validated in the smart cohort .
this revealed that three of these vesicle proteins ( cystatin c , serpinf2 and cd14 ) were associated with future cardiovascular events after correction of risk factors such as age , gender , smoking and egfr .
for this , measurement of plasma extracellular vesicle protein levels has the potential to stratify patients at risk for secondary events on top of risk factors .
there is much uncertainty over the relative contribution of platelets to the overall circulating extracellular vesicle population .
platelets are a key intermediary in the blood extracellular vesicle landscape because their function is readily and rapidly modified by platelet - directed medications .
the ongoing stratifying risk with metabolomics and platelet reactivity testing in acute coronary syndrome ( smart - acs ) study , initiated in singapore , includes platelet reactivity testing of more than 1000 patients undergoing invasive management of acs , using impedance aggregometry ( multiple electrode aggregometry , roche diagnostics , indianapolis , in ) and follow up for secondary cardiovascular events .
this will allow us to investigate how platelet - directed medications may potentially modify the content of the plasma extracellular vesicle population and its association with secondary events .
the identification and validation of new biomarkers is highly dependent on the availability of patient cohorts with detailed phenotypic characterisation .
important ethnic differences have been described in the susceptibility , risk factors , and outcomes with cardiovascular disease .
for example : indian men in the uk have an adjusted hazard ratio of 1.45 ( ci : 1.29 to 1.63 ) for cardiovascular disease while chinese men in the uk have an adjusted hazard ratio of 0.51 ( ci : 0.32 to 0.83 ) compared with caucasian men . among southeast asian patients with hf in singapore , indians and malays have been shown to suffer worse outcomes than chinese   although the reasons remain unclear .
the adhere - asia pacific registry showed that compared with other multicentre registries in the us and europe , asian patients hospitalised with hf were younger and had more severe clinical features .
for this , we initiated the ( ongoing ) biobanking efforts in both singapore and the netherlands ( fig .  2 ) . in 2008 , the design of the atheroexpress   collecting tissue , plasma and blood cells with a follow - up for secondary cardiovascular events was used to start up the singapore atheroexpress at the national university heart center singapore ( nuhcs ) .
this singapore biobank is collecting , besides atherectomy samples , also aortic punctures during cabg next to plasma and blood cells , and follows patients up for secondary cardiovascular events .
aortic punctures and plasma are now also collected at the umc utrecht in pegasus using the same design.fig .
red boxes indicate matched biobank studies , green boxes indicate work in progress of matching singapore and dutch biobank studies , numbers indicate patients included ~ june 2013 overview of ongoing cardiovascular biobanking in singapore and the netherlands .
red boxes indicate matched biobank studies , green boxes indicate work in progress of matching singapore and dutch biobank studies , numbers indicate patients included ~ june 2013 singapore initiated the collection of plasma of patients undergoing a pci with follow - up for secondary cardiovascular events .
a year later , the umc utrecht  mirror biobank of pci patients was initiated , a collective effort that now includes over 1000 patients a year .
work is in progress to match patients with chest pain in the emergency department of the meander hospital in amersfoort ( minerva biobank cohort ) with chest pain cohorts at nuhcs and singapore general hospital as well as the extensive hf cohort initiatives in singapore   and asia   with dutch heart failure cohorts . a key advantage of these mirrored cohorts is the implementation of common data and tissue collection and storage protocols across sites in both countries .
this facilitates comparisons of biomarker profiles between dutch and singapore populations ; such an effort is currently ongoing , with measurement of high sensitivity troponin t , high sensitivity c - reactive protein , von willebrand factor , myeloperoxidase and cystatin c in 1200 dutch and 1000 singaporean patients who have undergone elective coronary angiography .
plasma extracellular vesicle proteins are still in the early stage of study , mostly aiming to identify and to characterise the proteomes .
although relatively unexplored due to technical challenges , vesicle proteins hold promise as mass spectrometry - based proteomic technology is rapidly emerging for identification and quantification of extremely low abundant proteins in a sample .
this has already resulted in identification of vesicle proteins for the diagnosis of acs   and prognosis of secondary cardiovascular events   in clinical cohorts .
isolation of plasma extracellular vesicle subpopulations is expected to lead to new and better cardiovascular vesicle protein biomarkers in a new sample set .
this rapidly growing vesicle technology will hold , in combination with the maturation of the biobanks ( inclusion of patients and secondary events ) in the netherlands and asia , great promise for new diagnostic and prognostic biomarkers that take ethnicity and gender into account .

Answer:
cardiovascular disease is a major public health problem worldwide .
 its growing burden is particularly ominous in asia , due to increasing rates of major risk factors such as diabetes , obesity and smoking .
 there is an urgent need for early identification and treatment of individuals at risk of adverse cardiovascular events .
 plasma extracellular vesicle proteins are novel biomarkers that have been shown to be useful in the diagnosis , risk stratification and prognostication of patients with cardiovascular disease .
 ongoing parallel biobank initiatives in european ( the netherlands ) and asian ( singapore ) populations offer a unique opportunity to validate these biomarkers in diverse ethnic groups .


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:
a 28-year - old healthy male was seen in our clinic complaining of vision loss in his right eye ( od ) .
best - corrected visual acuity ( bcva ) was od : 20/200 and left eye ( os ) : 20/20 .
mild vascular abnormalities were detected in the temporal aspect of right optic nerve , but no conclusive information was obtained .
oct using the stratus oct 3 model ( carl zeiss meditec , jena , germany ) was indicated for the evaluation of the macular areas , rnfl thicknesses , and optic nerves .
the fast macular protocol revealed subtle macular thickness beyond normal in the superior and nasal quadrants of both maculae .
no visible alterations in the internal microarchitecture of the retina were observed using several retinal lines and optic disc protocols .
a slight incremental thickening of the rnfl was observed in the superior and nasal quadrants of the os . in order to evaluate the patient 's visual field ( vf ) and retinal sensitivities ,
a frequency doubling technology perimetry ( fdt ) , using the commercially available ( matrix ) device , was performed in both eyes .
the threshold 30 - 2 strategy revealed the presence of junctional scotoma composed by a central scotoma in od associated with superior temporal quadrantanopia in the fellow eye . the pattern detected in the vf suggested the presence of an expansive mass at the level of the optic chiasm [ fig . 1 ] . magnetic resonance imaging ( mri )
was performed which disclosed the presence of a tumor , compatible with the diagnosis of pituitary adenoma [ fig . 2 ] . after a complete neurological evaluation , medical treatment with cabergoline ( a dopamine agonist ) ,
after 8 months , a significant reduction of tumor volume was achieved . moreover , the patient experienced a full recovery of bcva and vf [ fig . 3 ] .
right : superior temporal quadrantanopia in os central nervous system mri . left : pituitary dependent macroadenoma .
visual loss associated with a junctional scotoma is a well - known clinical sign related with the presence of a compressive mass in the chiasmal area .
monteiro described a generalized reduction of the rnfl thickness in the retinas of patients with band atrophy secondary to pituitary tumors .
lederer and colleagues reported on the usefulness of the macular map thickness , while studying patients with glaucomatous optic nerve alterations . due to a relative incremental change in the ganglion cells axonal concentration within the macular area
interestingly , the patient described here showed a thickening in the nasal and superior and nasal aspects of both maculae .
this tomographic sign , not visible on the biomicroscopic fundus examination and in the fa , was interpreted as an early retinal manifestation produced by the presence of the tumor .
the physiopathology of this localized , incremental thickness is merely speculative , but could be produced by an alteration in the axonal transport in ganglion cells .
after obstruction of the axoplasmic flow , an early enlargement ( intracellular edema ) of the nerve fibers followed by a chronic atrophy could occur . though no direct evidence exists corroborating this phenomenon ,
at least three indirect clinical issues support this theory : ( 1 ) the retinal thickness increment was revealed anatomically by the oct , but no evidence of dye leakage was seen in the fa .
( 2 ) the presence of a topographic correlation between the junction scotoma and the macular thickening . ( 3 ) the visual loss was ipsilateral to the main tumor location .
furthermore , the macular thickness enlargement was symmetric while the visual alteration was roughly asymmetric .
this most likely could be indicative of the potential for intracellular edema preceding the visual function alteration and this thickening could be an early sign that could be detected before consolidated fiber atrophy occurs .
frequency doubling technology perimetry ( matrix  fdt ) has shown to be a suitable method for studying and detecting abnormalities in patients with neurological visual field deficits . during the functional evaluation of this patient , the fdt revealed the presence of a junctional scotoma compatible with the tumor location .
even with an asymmetric vf defect , the oct was able to show symmetric involvement , with respect to macular thickness .
we speculate that the anatomical alteration revealed by the oct precedes the functional deficit found in the vf .
thus , we propose that detection of bi - superonasal macular edema ( me ) could be an early sign of chiasmal pathology . with an early diagnosis and subsequent treatment ,
a complete restoration of visual function was achieved in this case , stressing the importance of early recognition of the disease .
we are unaware of previous reports regarding localized bi - superonasal me secondary to a pituitary adenoma and could find no references to it in the medical literature .
studies including a cohort of patients are warranted for the evaluation of these tomographic findings . in conclusion
, it is important to suspect pituitary adenoma in cases of vf deficit and oct macular alterations .

Answer:
a 28-year - old healthy male complaining of vision loss in his right eye was discovered to have localized bi - nasal macular edema in the presence of a pituitary adenoma .
 the presence of a junctional scotoma composed by a central scotoma in the right eye associated with superior temporal quadrantanopia in the fellow eye was seen .
 the pattern detected in the visual field suggested the presence of an expansive mass at the level of the optic chiasm .
 optical coherence tomography findings also revealed subtle macular thickness beyond normal in the superior and nasal quadrants of both maculae .
 this report illustrates the importance of suspecting a pituitary adenoma in the light of uncharacteristic retinal alterations .


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:
approximately 24 per cent of small bowel obstructions ( sbos ) are caused by bezoars .
in addition , presentation with features of acute surgical abdomen is extremely rare , accounting for only 1% of the patients .
a bezoar is a concretion of indigestible material found in the gastrointestinal tract , which usually forms in the stomach and passes into the small bowel , where it can cause sbo .
it can be classified into one of four major types : trichobezoar , pharmacobezoar , lactobezoar and phytobezoar .
trichobezoars are composed of hair and are most commonly associated with patients who have a psychiatric disorder .
phytobezoars are composed of undigested fiber from vegetables or fruits and are the most common form of bezoar encountered as a postoperative complication after gastric bypass .
a 63-year - old syrian male presented to the emergency department with a 2-day history of generalized colicky abdominal pain associated with repeated vomiting and absolute constipation .
there was no associated history of alteration of bowel habit , rectal bleeding , fever or dysuria .
his past medical history was significant for a laparotomy in 1979 due to a peptic ulcer - related complication , but he was unaware of the details .
he was also recently diagnosed with diabetes mellitus for which he was using herbal treatment consisting of boiled olive tree leaves ( olea europaea ) . on physical examination
there was a midline laparotomy scar with a reducible incisional hernia in the epigastric area .
he had mild lower abdominal tenderness with no muscle guarding and his bowel sounds were exaggerated .
rectal examination revealed no abnormalities and there was a small amount of stool in the rectum .
routine blood investigation and abdominal x - rays were obtained . apart from leukocytosis , they were unremarkable .
a contrast - enhanced ct scan was arranged and it showed features of sbo with collapse of the terminal ileum .
there was evidence of a previous gastrojejunostomy with suspected foreign bodies in the stomach and proximal ileum .
( figs  1 and 2 )
 figure  1:contrast - enhanced abdominal ct scan in coronal view showing evidence of gastrojejunostomy and visible foreign body in the stomach and features of small bowel obstruction .

figure  2:sagittal ct scan view showing foreign bodies in the stomach and the ileum with transition point in the small bowel .. contrast - enhanced abdominal ct scan in coronal view showing evidence of gastrojejunostomy and visible foreign body in the stomach and features of small bowel obstruction .
sagittal ct scan view showing foreign bodies in the stomach and the ileum with transition point in the small bowel . at laparotomy
an obstructing hard foreign body was palpable in the ileum with dilatation of the proximal small bowel loops .
3 ) both foreign bodies were removed through an enterotomy and gastrotomy , respectively , and the bowel was decompressed .
after limited adhesiolysis , the abdomen was closed en mass repairing the midline hernia defect .
 figure  3:retrieved phytobezoars . retrieved phytobezoars .
postoperative recovery was unremarkable except for a short duration of ileus , after which the patient made a steady recovery .
he was referred to the diabetology department and dietician during admission and was discharged with outpatient clinic follow - up .
a follow - up upper gi endoscopy was done and it showed evidence of a hiatus hernia with gastrooesophageal reflux disease .
the incidence of bezoar formation after gastric surgery ranges from 5 to 12 per cent .
the main pathogenesis of bezoar formation is believed to be the result of gastric dysmotility and decreased gastric secretions , which is very common after any gastric surgery [ 3 , 4 ] .
diospyrobezoars , formed after persimmon ingestion , are a distinct type of phytobezoars characterized by their hard consistency .
coca - cola ingestion combined with endoscopic techniques has been used effectively to treat gastric phytobezoars and avoid surgery .
phytobezoar should be considered in patients with previous gastric outlet surgery who present with bowel obstruction and features of acute surgical abdomen .
the presence of a well - defined intraluminal mass with a mottled gas pattern on emergency ct scan is suggestive of an intestinal phytobezoar .
guidelines include proper chewing of food , plenty of liquids with meals and avoidance of a high - fiber diet .

Answer:
approximately 24 per cent of small bowel obstructions ( sbo ) are caused by bezoars .
 in addition , presentation with features of acute surgical abdomen is extremely rare , accounting for only 1% of the patients .
 a bezoar is a concretion of indigestible material found in the gastrointestinal tract , which usually forms in the stomach and passes into the small bowel , where it can cause sbo .
 we present the case of a 63-year - old male who presented with sbo following ingestion of boiled olive leaves as herbal treatment for diabetes mellitus .


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:
primary infection involves eyes , ears , larynx , lungs , and sinuses , followed by liver , spleen , bone , and meninges .
worldwide , aspergillus fumigatus is the most common species , followed by aspergillus niger and aspergillus flavus , whereas a. flavus is the most common species in india .
predisposing factors that promote fungal infections in the sinuses include polyps and stagnant secretions besides other factors like neutropenia , inappropriate use of antibiotics , immunosuppressive drugs , corticosteroids , uncontrolled diabetes mellitus ( dm ) , human immunodeficiency virus ( hiv ) infection , trauma , burns , and radiation therapy . in immunocompromised patients
, aspergillus leads to highly destructive lesions ; however , literature search shows invasive aspergillosis in non - neutropenic patients also .
clinico - radiological findings can be misleading as the lesions are locally destructive and mimic a neoplasm .
invasive fungal sinusitis ( ifs ) responds to conservative medical management and debridement ; hence , an early diagnosis by fine needle aspiration cytology ( fnac ) is mandatory to prevent undue surgery .
we report two patients presenting with swelling and pain in the maxillary region who were clinico - radiologically suspected of malignancy ; however , fnac in both the cases revealed fungal sinusitis ( fs ) .
fnac was performed in both cases using 22-gauge needle ; aspirate was whitish fluid ( case 1 ) and blood mixed ( case 2 ) .
the aspirates were processed as air - dried giemsa - stained smears ; cytomorphological features were suggestive of aspergillosis .
periodic - acid - schiff ( pas ) and silver methanamine ( sm ) stains were performed on the aspirate smears for further typing of fungus . however , considering the clinico - radiological suspicion of neoplasm , a biopsy was advised that confirmed fungus in both the cases . a 45-year - old female presented to the ear , nose and throat ( ent ) department with complaints of a painful swelling in the left maxillary region for 6 months .
there was no history suggestive of nasal obstruction , fever , recurrent infections or diabetes .
clinically , there was a tender swelling in the left maxillary region near the medial canthus .
computed tomography ( ct ) scan showed expansion of the maxillary sinus with bone erosion , suggestive of a malignancy . a 42-year - old male presented with complaints of headache , nasal discharge and swelling in right maxillary region for 8 months .
a bony hard swelling measuring 8  8 cm was palpated in the right maxilla reaching up to the infraorbital region .
ct scan showed an enhancing soft tissue density in the right maxillary sinus , suggestive of a proliferative lesion .
microscopic examination of aspirate smears revealed predominantly hemorrhagic background with many multinucleated foreign body giant cells ( gcs ) , and few inflammatory cells comprising eosinophils , plasma cells and lymphocytes . interspersed amongst these and within the gcs ,
based on the ct and cytological features , a diagnosis of ifs caused by aspergillus was suggested .
( a ) smear shows septate , fungal hyphae branching at acute angle in an acute inflammatory background ( giemsa , 250 ) and ( b ) a hyphae within the giant cell ( giemsa , 400 ) histopathological examination of biopsies from the maxillary sinus in both the cases showed abundant septate fungal hyphae , granulomatous inflammation , gcs and eosinophils ; pas and sm stains confirmed the type of fungus as aspergillus [ figure 2 ] .
culture from the serous material from sinusitis showed greenish white cotton wool growth at 37c on sabouraud 's dextrose agar ( sda ) , thus confirming the species as a. flavus .
sections show ( a ) aspergillus in necrotic background ( h and e , 250 ) , ( b ) fungal hyphae in giant cell ( h and e , 400 ) , ( c ) many eosinophils and hyphae ( h and e , 250 ) , special stains highlighting the fungal morphology ( d ; pas , 250 ) and ( e ; silver methanamine , 250 ) the former patient was treated initially with intravenous amphotericin - b and endoscopic debridement , followed by oral itraconazole ; further , she had to undergo partial maxillectomy in view of frequent recurrences and bone involvement .
a 45-year - old female presented to the ear , nose and throat ( ent ) department with complaints of a painful swelling in the left maxillary region for 6 months .
there was no history suggestive of nasal obstruction , fever , recurrent infections or diabetes .
clinically , there was a tender swelling in the left maxillary region near the medial canthus .
computed tomography ( ct ) scan showed expansion of the maxillary sinus with bone erosion , suggestive of a malignancy .
a 42-year - old male presented with complaints of headache , nasal discharge and swelling in right maxillary region for 8 months .
a bony hard swelling measuring 8  8 cm was palpated in the right maxilla reaching up to the infraorbital region .
ct scan showed an enhancing soft tissue density in the right maxillary sinus , suggestive of a proliferative lesion .
microscopic examination of aspirate smears revealed predominantly hemorrhagic background with many multinucleated foreign body giant cells ( gcs ) , and few inflammatory cells comprising eosinophils , plasma cells and lymphocytes . interspersed amongst these and within the gcs ,
based on the ct and cytological features , a diagnosis of ifs caused by aspergillus was suggested .
( a ) smear shows septate , fungal hyphae branching at acute angle in an acute inflammatory background ( giemsa , 250 ) and ( b ) a hyphae within the giant cell ( giemsa , 400 )
histopathological examination of biopsies from the maxillary sinus in both the cases showed abundant septate fungal hyphae , granulomatous inflammation , gcs and eosinophils ; pas and sm stains confirmed the type of fungus as aspergillus [ figure 2 ] .
culture from the serous material from sinusitis showed greenish white cotton wool growth at 37c on sabouraud 's dextrose agar ( sda ) , thus confirming the species as a. flavus .
sections show ( a ) aspergillus in necrotic background ( h and e , 250 ) , ( b ) fungal hyphae in giant cell ( h and e , 400 ) , ( c ) many eosinophils and hyphae ( h and e , 250 ) , special stains highlighting the fungal morphology ( d ; pas , 250 ) and ( e ; silver methanamine , 250 ) the former patient was treated initially with intravenous amphotericin - b and endoscopic debridement , followed by oral itraconazole ; further , she had to undergo partial maxillectomy in view of frequent recurrences and bone involvement .
fungal sinusitis constitutes 69% of all the rhinosinusitis.[68 ] clinically , it presents as either an acute fulminant sinusitis or chronic invasive sinusitis .
the former is largely attributed to mucor and the latter is mainly due to aspergillus .
the acute form is a life - threatening condition , usually seen in immunocompromised patients with severe neutropenia or dm , and is associated with significant visual and neurological impairments in survivors , and sometimes mortality .
clinically , these patients may present with rhinorrhea , headache , nasal obstruction , proptosis , facial and periorbital pain mimicking infections ( mucor , tuberculosis , osteomyelitis ) , inflammatory lesions ( rhinoscleroma , wegener 's granulomatosis ) and malignant tumors of the nose and paranasal sinuses .
non - invasive fs includes allergic and fungal ball and does not need extensive surgery , while most of the ifs patients are unresponsive to conservative management and require appropriate antifungals with local debridement .
early and definitive diagnosis of ifs is mandatory that will rule out other differential diagnoses , especially neoplasm , and will help clinicians for appropriate management and in the follow - up of patients .
both magnetic resonance imaging ( mri ) and ct can help establish a diagnosis of ifs .
bone involvement and erosion is more delineated on ct , while soft tissue extensions , vascular invasion and cavernous sinus involvement are more appreciated on mri . both the imaging techniques , however , are not definitive and often fail to differentiate an infectious process from a neoplastic one . definite diagnosis of fs depends upon the demonstration of the fungus on aspirate smears or a biopsy .
fungal culture is complimentary to morphology and required for species identification ; but samples submitted for culture may not be representative , and not all the fungi grow on culture media .
aspergillus can be easily differentiated from mucor on morphology , as the latter is characterised by broad , non - septate hyphae branching at right angle . in the present cases ,
both the patients were immunocompetent , middle aged and clinico - radiologically suspected of malignancy ; however , they were diagnosed on fnac as fungal sinusitis and prevented from undue surgery .
species identification is not much relevant in patients management , but is of epidemiogical significance , since it depends upon various geographical locations , thus aiding diagnosis in difficult cases .
this report emphasizes on the early diagnosis of ifs , which can be managed conservatively preventing the morbidity and mortality in these patients .
cytology , being an easily available , minimally invasive and inexpensive procedure , can be used as initial diagnostic modality in cases of ifs .

Answer:
fungi have emerged as important etiological agents for chronic sinusitis .
 invasive aspergillosis has been reported in immunocompromised individuals or diabetics ; however , it is uncommonly seen in immunocompetent patients .
 definitive diagnosis of these lesions is based on histological examination and fungal culture .
 we report two cases of invasive maxillary lesions in immunocompetent patients , clinically suspected of malignancy ; however , fine needle aspiration cytology showed fungal hyphae , morphologically suggestive of aspergillus , which was later confirmed on histopathology .
 aspiration cytology thus plays a crucial role in the early and definitive diagnosis of fungal sinusitis in cases clinico - radiologically suspected of malignancy .
 an early diagnosis will help the clinician for early and appropriate management and follow - up in order to decrease the high morbidity and mortality associated with it .


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:
childhood constipation is a common complaint accounting for 3% of visits to pediatricians and 10 - 25% of visits to pediatric gastroenterologist[13 ] .
commonly there is no underlying organic cause and the constipation is indentified as functional or idiopathic[4 , 5 ] .
functional constipation is identified by rome iii criteria in children over 4 years old and adolescents having two months of at least 2 or more of the following conditions : 2 defecations in the toilet per week , 1 episode of fecal incontinence per week , history of retentive posturing or excessive volitional stool retention , history of painful or hard bowel movements , presence of a large fecal mass in the rectum , history of large diameter stools that may obstruct the toilet .
children usually are treated with a combination of toilet training , running a bowel diary , and oral laxatives such as paraffin oil . in many patients
there are many articles on the efficacy of probiotics in organic and functional gastrointestinal disorders .
probiotics are live microbial food ingredients which are reported to be effective in the treatment of many forms of gastrointestinal disorders[812 ] .
prebiotic is a selectively fermented ingredient that changes the composition and/or activity of the intestinal microflora and has shown beneficial effects in host 's health .
, we aimed to determine the therapeutic effect of synbiotics ( combination of probiotics containing strains of l. casei , l. rhamnosus , s. thermophilus , b. breve , l. acidophilus , b. infantis , and fructooligo - saccharide as prebiotic ) on childhood constipation .
the study was performed at children 's medical center in tehran , iran , from january to december 2009 .
children with constipation were referred to the pediatric gastroenterology clinic for evaluation and treatment of constipation .
one - hundred two children aged 412 years with chronic functional constipation enrolled in this study , were divided into 3 groups by simple randomization method .
exclusion criteria were organic causes for constipation such as hirschsprung 's disease , spina bifida occulta , hypothyroidism , cystic fibrosis , neurologic abnormalities and intestinal pseudo - obstruction .
these patients were excluded from the study by history and physical examination and rome iii criteria of childhood constipation .
the research protocol was approved by the medical ethics committee of tehran university of medical sciences .
label of drugs was replaced by a new label indicating drug a or b. contents of sachets or bottles were not known to the physicians or nurses involved in the study .
group a received 1.5 ml / kg / day oral liquid paraffin plus placebo , group b received 1 sachet synbiotic per day ( restore 1x10 cfu/1 sachet , protexin co , uk ) .
synbiotic combination consisted of probiotic strains containing l. casei , l. rhamnosus , s. thermophilus , b. breve , l. acidophilus , b. infantis , fructooligosaccharide as prebiotic , and placebo .
group c received 1.5 ml / kg / day oral liquid paraffin and 1 sachet synbiotic per day .
all patients in the 3 groups received drugs in bottles and sachets with similar shape , taste and color .
frequency of bms , stool consistency , number of fecal incontinence , episodes of abdominal pain , painful defecation per week and side effects were determined in each patient before and after treatment .
success treatment was defined as 3 bms per week , 2 incontinence per month and no abdominal pain .
study design : from seven days prior to study and during the treatment period all children were requested to record frequency of bms , number of fecal incontinence episodes , stool consistency , abdominal pain , painful defecation and effects such as vomiting , diarrhea and oil seepage in a bowel diary . before starting treatment ,
all children were examined and patients with fecal impaction received rectal enema ( paraffin oil 1530ml / year ) once daily for three days in order to accomplish rectal disimpaction .
toilet training consisted of sitting on the toilet 3 times per day for 5 minutes after each meal .
patients were not allowed to use any other kind of medication for constipation during the study period .
clinical efficacy was recorded , patients were seen at the end of 4 weeks , and their charts were reviewed .
outcome measures : primary outcome measures were frequency of bms per week , stool consistency , fecal incontinence episodes per week , presence of abdominal pain , and painful defecation ; secondary outcomes were success treatment and incidence of adverse effects such as vomiting , diarrhea and seepage .
stool consistency was rated by the patients as hard , normal or watery . statistical analysis : data of baseline information were analyzed with the spss ( ver .
continuous variables were expressed as mean ( sd ) , and categorical data were shown as frequency and percent .
number of bms and fecal incontinence episodes in baseline information were analyzed by kruskal - wallis test .
change of frequency of bms and fecal incontinence episodes were analyzed by non - parametric paired wilcoxon test . for assessment changes of stool consistency and abdominal pain between baseline and after treatment , the mcnemar test was used .
totally , 102 children ( aged 412 years ) with chronic functional constipation enrolled in this study and were divided into 3 groups .
five patients were lost to follow - up and remaining 97 patients consisted of 47.4% males and 52.6% females with a mean age of 6.32.1 years .
as shown in table 1 , no significant differences were found with respect to demographic data and recorded baseline characteristics between the three treatment groups .
characteristics of the patients and the main outcomes are summarized in table 1 and 2 . as shown in table 2 ,
the frequency of bms per week increased in all groups , the highest rise occurring in group c ( p=0.03 ) .
improvement in stool consistency and decrease in number of fecal incontinence episodes happened in all groups ( p=0.2 , p=0.3 respectively ) without any statistically significant difference .
also , abdominal pain and painful defecation per week decreased ( p=0.6 , p=0.9 respectively ) similarly and there was no statistically significant difference between groups .
no side effects were reported in group b but in group a 18 patients and in group c 21 patients had seepage ( p<0.001 ) .
treatment success in group a was 24/29 ( 82.8% ) , in group b 22/31 ( 71.0% ) and in group c 28/37 ( 75.7% ) without statistically significant difference between them ( p=0.6 ) .

new investigations have shown that gut bacterial colonization has an important role in health and disease .
there are several hypotheses about the effectiveness of this microbial flora in treatment of constipation . according to some
investigations gut microbial flora in chronic constipation is different from that in healthy persons[17 , 18 ] .
short chain fatty acids produced by probiotics reduce colon ph and by this mechanism enhance colon motility and finally transit time will decrease .
there are a few rcts about probiotics in the treatment of constipation in children . in rcts study by banaszkiewicz and szajewska
it was concluded that l. rhamnosus
 gg was not an effective adjunct to lactulose in treating constipation in children .
bu et al evaluated the effect of l. casei rhamnosus
 lcr35 compared to magnesium oxide(mg0).comparisons of the frequency of defecation , consistency of stool and the use of lactulose or enema during the period of treatment were made among the groups .
the patients who received mgo or probiotics had a higher defecation frequency , percentage of treatment success ( defined as 3 spontaneous defecations per week with no episodes of fecal soiling ) and less hard stool .
there is no statistically significant difference in efficacy between mgo and lcr35 , but less abdominal pain occurred when using lcr35 . in a study by coccorullo et al
the beneficial effects of l. reuteri ( dsm 17938 ) in infants with functional chronic constipation was evaluated .
administration of l. reuteri had a positive effect on bowel frequency , even when there was no improvement in stool consistency and episodes of inconsolable crying episodes .
for example , in children with constipation defined according to the rome iii criteria , administration of bifidobacteria ( b. bifidum , b. infantis , b. longum ) and lactobacilli ( l. casei , l. plantarum , l. rhamnosus ) to 20 children aged 416 years resulted in an increased frequency of bowel movements , a decreased number of fecal incontinence episodes , and reduced abdominal pain , although there was no change in stool consistency .
it seems that our study is the first rct study which investigates the synbiotics effects in childhood constipation . according to our study , mixtures of different strains of probiotics and their specialized prebiotics are more effective than each of them alone and this combination augments their efficacy in all parameters of study , but in previous researches improvement had been seen only in some of symptoms and signs .
also adjunctive therapy of synbiotic and liquid paraffin could be more effective to improve bms than any of them alone .
according to this rct , synbiotic have got beneficial effects on symptoms of childhood constipation similar to liquid paraffin without any side effects and synbiotic is an effective adjunct to liquid paraffin to improve bms .

Answer:
objectiveconstipation is a common problem in children .
 there is some clinical evidence for the role of probiotics and prebiotics in the treatment of constipated children .
 this is the first study on the therapeutic effect of synbiotics ( combination of probiotics and prebiotic ) in treatment of childhood constipation.methodsin a double - blind randomized placebo controlled study 102 children aged 412 years with functional constipation were assessed according to rome iii criteria for 4 weeks .
 they were divided into 3 groups : group a , received 1.5 ml / kg / day oral liquid paraffin plus placebo , group b , 1 sachet synbiotic per day plus placebo and group c , 1.5 ml / kg / day oral liquid paraffin plus 1 sachet synbiotic per day .
 frequency of bowel movements ( bms ) , stool consistency , number of fecal incontinence episodes , abdominal pain , painful defecation per week , success of treatment and side effects were determined in each group before and after treatment.findingsthe frequency of bms per week increased in all groups ( p<0.001 ) , but it differed between groups and was higher in group c ( p=0.03 ) .
 stool consistency increased and number of fecal incontinence episodes , abdominal pain and painful defecation per week decreased in all groups similarly and there was statistically no difference between them .
 no side effects were reported in group b ; the main side effect in group a and c was seepage of oil ( p<0.001 ) .
 treatment success was similar in all groups without any significant difference between them ( p=0.6).conclusionthis study showed that synbiotics have positive effects on symptoms of childhood constipation without any 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:
the interventions for carotid artery stenosis , vein graft and acute myocardial infarction could embolize a large amount of plaque debris , especially unstable , ulcerative , and thrombus containing lesions ( 1 ) . distal protection devices such as filterwire ex
have been widely used in carotid artery stenting to prevent distal embolization of plaque debris ( 2 ) .
the large amount of atherothrombotic debris entrapped in the filter could reduce or stop antegrade flow and may be shown as no reflow phenomenon in case using filter type distal protection device .
we present a case of pseudo no - reflow phenomenon after postdilatation of the stent in severe carotid artery stenosis and successful recovery with aspiration thrombectomy using export aspiration catheter .
a 70-yr - old man was diagnosed with asymptomatic carotid artery stenosis during preoperative risk assessments .
he had been treated in our hospital for congestive heart failure and stable angina for 2 yr .
carotid angiogram showed no significant stenosis in the left carotid artery and a 90% stenosis in the right internal carotid artery ( fig .
shuttle sheath ( 7f , cook medical , bloomington , in , u.s.a . ) was positioned to right common carotid artery via right femoral artery . to prevent distal embolization of plaque debris during angioplasty ,
filterwire ex ( boston scientific , natick , ma , u.s.a . ) was positioned in the right cervical internal carotid artery distal to stenotic lesion .
after predilation with 4.0 mm balloon , 8 mm self - expanding wall stent ( boston scientific ) was positioned across the lesion and was deployed in stenotic lesion .
after postdilation of the stent with 6.0 mm balloon , carotid angiogram showed abrupt complete flow interruption ( fig .
we decided to perform aspiration thrombectomy using export aspiration catheter ( medtronic ave , santa rosa , ca , u.s.a . ) ( fig .
after several passes of export aspiration catheter into the basket ( over the filterwire ex ) , antegrade flow was fully restored ( fig .
3 ) . after retrieval of filterwire ex , whitish debris was noted within the basket ( fig .
the patient complained of slight speech disturbance and this neurological abnormality was completely recovered within 24 hr after stenting .
obstructive carotid artery lesions are known to contain friable , ulcerated and thrombolic material that have the potential to embolize during intervention and may be responsible for the majority of the neurologic events during carotid artery stenting ( 1 ) .
a number of " distal protection " strategies , designed to capture embolic debris released during carotid intervention , have been evaluated for their efficacy in minimizing the risk of embolic neurologic events .
the intravascular filter type distal protection device offers the advantage of a constant cerebral perfusion during carotid artery stenting and allows more time for careful and precise intervention ( 2 ) . during carotid artery stenting using filter type distal protection device , microscopic particles larger than the size of the filter pores ( 80 to 130 m ) could be captured .
( 3 ) reported that carotid artery stenting with filter type distal protection device experienced flow impairment due to filter obstruction in 7.9% of procedures , which was resolved in all cases after filter removal . in our case ,
we suspected this pseudo - no - reflow phenomenon was induced by obliteration of filter pore by massive atherosclerotic debris .
we considered to remove filter by retrieval catheter , however , this process may cause entrapment of filter device to retrieval catheter and embolize massive amount of atherosclerotic debris . therefore , we choose aspiration thrombectomy using export aspiration catheter . after aspiration thrombectomy , flow interruption in the right internal carotid artery
was completely restored , therefore , we confirmed this phenomenon as pseudo - no - reflow phenomenon instead of true no - reflow phenomenon .
yadav ( 4 ) recommended practically in his review paper if there is no forward blood flow during carotid angioplasty with filter type distal protection device , this should be aspirated before the filter is collapsed .
our case is the first case report of pseudo - no - reflow phenomenon in carotid artery stenting using filter type distal protection device and successful recovery of this phenomenon by aspiration thrombectomy using export aspiration catheter .
( 5 ) recently reported that successful management of pseudo - no - reflow phenomenon by the export aspiration catheter in ostial saphenous vein graft intervention using filterwire ex protection . in conclusion
, the large amount of atherothrombotic debris entrapped in the filter during carotid intervention could stop antegrade flow .
this phenomenon is pseudo - no - reflow phenomenon instead of true no - reflow phenomenon .

Answer:
distal protection devices such as filterwire ex have been widely used in carotid artery stenting , however , the large amount of atherothrombotic debris entrapped in the filter could reduce or stop antegrade flow .
 we present a case of pseudo - no - reflow phenomenon after postdilatation of the stent in a patient with asymptomatic carotid artery stenosis .
 after several passes using an export aspiration catheter , normal flow in the internal carotid artery was restored .
 aspiration thrombectomy can successfully recover pseudo - no - reflow phenomenon .