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:
patients with cervical radiculopathy due to single - level degenerative disc disease who fail to improve with nonoperative therapy are candidates for anterior decompression and reconstruction with either an arthrodesis or arthroplasty .
both procedures require minimal hospitalization and are highly effective in relieving pain and improving neurological function .
the ability to return to work and the speed with which this occurs are important to the individual being treated and also to society .
arthrodesis and arthroplasty differ in that one treatment eliminates motion at a cervical spinal segment while the other preserves it .
this fundamental difference may impact postoperative function in terms of activity level , which ultimately could facilitate or hinder the ability to return to work .
in patients with degenerative disease of the cervical spine , does cervical artificial disc replacement lead to better work - related outcomes than fusion ? does return to work after surgery differ based on gender , age , smoking , litigation status , workers compensation status , or other sociodemographic factors ? study design : systematic review .
inclusion criteria : studies ( coe i - ii ) directly comparing cervical artificial disc replacement ( c - adr ) with discectomy and fusion ( anterior cervical discectomy and fusion [ acdf ] ) in patients with degenerative cervical disc disease ; us food and drug administration ( fda)-approved or unapproved devices in phase iii trials with 1 year of follow - up data in a peer - reviewed journal ; subanalysis data from fda investigational device exemption ( ide ) trials .
exclusion criteria : studies in patients with disc replacement or fusion in the thoracic or lumbar spine . outcomes :
proportion of patients working at follow - up ; time to return to work following surgery .
analysis : proportion of patients working and mean or median number of days until return to work were abstracted from the reports as available . pooling of data was not done due to concerns regarding heterogeneity and the lack of well - defined measures of return to work .
inclusion criteria : studies ( coe i - ii ) directly comparing cervical artificial disc replacement ( c - adr ) with discectomy and fusion ( anterior cervical discectomy and fusion [ acdf ] ) in patients with degenerative cervical disc disease ; us food and drug administration ( fda)-approved or unapproved devices in phase iii trials with 1 year of follow - up data in a peer - reviewed journal ; subanalysis data from fda investigational device exemption ( ide ) trials .
exclusion criteria : studies in patients with disc replacement or fusion in the thoracic or lumbar spine .
outcomes : proportion of patients working at follow - up ; time to return to work following surgery .
analysis : proportion of patients working and mean or median number of days until return to work were abstracted from the reports as available .
pooling of data was not done due to concerns regarding heterogeneity and the lack of well - defined measures of return to work .
we identified eight reports that met our inclusion criteria , which included information on return to work . from a total of 295 citations retrieved ,
1 ) . of these , eight met the inclusion criteria , four of which described the same study at different follow - up points ( table 1 ) .
seven article representing four randomized controlled trials ( coe ii ) and four artificial discs are critically summarized : bryan cervical disc : us1,2 and china,3 prestige st,4,5 prodisc - c,6 and kineflex|c.7 in addition , we summarized a secondary analysis of data from the u. bryan and prestige rcts that focused on a subset of patients who were covered by workers compensation.8 further details on the class of evidence rating and additional data for these studies can be found in the web appendix at www.aospine.org/ebsj .
percentage of patients working at follow - up (
 tables 2,3 ) in two studies,2,4 the overall proportion of patients who were working increased postoperatively approximately 10%12% ( from 65% preoperatively to 75% at 24 months ) .
larger improvements were evident among workers compensation patients ( from 36%63%),8 and a third study6 reported no preoperative or postoperative differences in work status . at 24 months
postoperatively , there was no significant difference in work status between disc replacement and fusion patients across three trials .
work status less than 24 months after surgery was reported in only one study,2 and suggested that disc replacement patients were more likely than fusion patients to be working 6 weeks after surgery .
this difference was more pronounced in workers compensation patients.8 patients covered by workers compensation appeared to be less likely to be working at all time points ; however , no direct statistical comparisons of these patients - to - patients with other insurance were reported .
2 ) patients who received disc replacement began working sooner after surgery than patients who received fusion with statistical significance reported in two studies .
after controlling for gender , study , and preoperative work status , the difference between treatments for median time to work return among worker s compensation participants did not reach statistical significance . among patients who were covered by workers compensation , those who were working at the time of surgery returned to work sooner than did patients in the full sample of the worker s compensation patients .
no direct comparison of workmen s compensation patients - to - other patients was reported .
differential effects of c - adr / acdf on return to work
  no studies examined differential work - related outcomes by gender , smoking status , litigation , or any characteristic other than workers compensation .
no direct comparisons of worker s compensation patients - to - patients with other insurance were possible .
the pattern of findings for workers compensation patients , however , was similar to that of patients in general : earlier return to work with disc replacement compared with fusion and no significant group differences in work status after 6 months .
one study 7 reported that the proportion of patients who rated their activity level as
rct indicates randomized controlled trial ; nr , not reported ; and n / a , not applicable .
c - adr indicates total disc replacement ; acdf , anterior cervical discectomy and fusion ; wc , workers compensation ; and nr , not reported .
c - adr indicates total disc replacement ; acdf , anterior cervical discectomy and fusion . * workers compensation patients only ; controlling for gender , study , and preoperative work status .
this analysis of the data demonstrated that patients treated with disc replacement tended to return to work more quickly than those receiving fusion , but that overall return to work in the two groups was equivalent at 2 years .
both therapies have been shown to be safe and effective ; therefore , it is expected that most patients will be able to resume normal productive lives .
the c - adr patients tended to return to work sooner than fusion patients and the reasons for this are unclear .
the first is either patient or surgeon bias since neither group was blinded . at the time of enrollment for each of the studies ,
c - adr had not been approved in the united states , and it could be presumed that the primary patient motivation to enter one of the studies was to obtain a c - adr .
this high level of interest could have led to a placebo effect in those receiving the c - adr .
additionally , surgeons may have been more willing to release patients to work if they received a c - adr .
finally , it may be that there is period during which the patient adjusts to the loss of a motion segment which is associated with increased discomfort , particularly with activity .
such an adjustment would not occur with c - adr and if real , could account for the difference in early return to work .
conclusions from this review are limited by the following : follow - up rates in the prestige study were low ; however , these low rates were due to the publication of articles before all patients had reached the follow - up window .
follow - up rates at 4 years were also fairly low ( 75% ) in the fda bryan trial ; however , in both of these studies loss to follow - up was equivalent across treatment groups .
questions about return to work were assessed with patient self - report and apparently not validated with work records .
no definition was provided of self - reported  return to work  ( eg , how the question was asked , whether part - time work was included ) .
the measures do not reflect return to work per se , as  return to work  assumes that patients were working before surgery .
the proportions of people who are working do not reflect individual change from preoperative to postoperative , only group percentages at the various time points .
these percentages were not broken down by the work status of the patient before surgery , and included patients who were working postoperatively as well as those who were not working .
therefore , this measure does not accurately reflect return to work but rather work status at the time of follow - up in the study population .
no direct comparison of patients with workers compensation versus patients with other kinds of insurance was reported in a secondary analysis of the bryan and prestige trials .
workers compensation patients comprised only about 10% of patients in those two trials , so that it is likely that the percentages reported in table 2 for the full sample would be close to the percentages for the nonworkers compensation sample .
if that is the case , then indirect comparisons of the workers compensation patients with the full sample would approximate differences between patients with and without workers compensation .
only the published articles from the bryan trial1,2 provided data on working status less than 2 years after surgery
. measures from earlier time points were collected in the prestige trial and analyzed by steinmetz et al,8 but they are not reported in the main articles from the prestige study.4,5
disc replacement patients were more likely than fusion patients to be working at 6 weeks postoperatively in one study no significant differences between treatment groups in proportion of patients working after 6 months of follow - up in three rcts earlier return to work following surgery for disc replacement than for fusion across three rcts ; statistically significant differences were seen in two studies one study reported equivalent activity levels at 24 months in both treatment groups

Answer:
study design :  comparative effectiveness review.study rationale : the ability of a patient to return to work and the speed with which this occurs are important outcome metrics for the assessment of patients undergoing spinal surgery.clinical questions :  in patients with degenerative disease of the cervical spine , does cervical artificial disc replacement ( c - adr ) lead to better work - related outcomes than fusion ? does return to work after surgery differ based on gender , age , smoking , litigation status , workers compensation status , or other sociodemographic factors?methods :  a systematic search and review of the english - language literature was undertaken to identify studies published through october 2 , 2011 .
 pubmed , cochrane , national guideline clearinghouse databases , and bibliographies of key articles were searched .
 two individuals independently reviewed articles based on inclusion and exclusion criteria , which were set a priori .
 each article was evaluated using a predefined quality - rating scheme.results :  for follow - up periods of more than 6 months , there was no significant difference in work status between disc replacement and fusion patients ; however , c - adr patients began working sooner after surgery .
 statistical significance for earlier return was not reached in all studies.conclusions :  most patients undergoing cervical decompression and fusion or c - adr return to work .
 the rates are equivalent at 6 months but patients treated with c - adr resumed work sooner .


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 large increase in fusion rates for spine surgery has been observed in the last 20 years9 ) , and the frequency of revision spine surgery continues to increase .
the most common reasons for additional surgery7 ) following fusion surgery are implant complications and pseudoarthrosis .
. they may be in the shape of a male or female rectangle or hexagonal , octagonal , or star - shaped .
therefore , it is necessary to have the instrument set used during the first operation or to have an appropriate screwdriver available .
this is not always possible and in some circumstances the implant may no longer be in production . when revision surgery studies were examined5,12 ) ,
methods to remove broken screws are reported but very little information related to removing normal screws has been provided .
no previous report has described a single - piece screw remover to remove normal screws . a small part of the rod is cut and placed in the screw when a removal set is not available . after tightening the screw head , mobile screw 's head
this screw is a single piece that can be removed by hand or with pincers10 ) .
the polyaxial remover presented here requires only a cap - screw screwdriver to remove the polyaxial screws .
due to the structure of the remover and the method , existing screws can be removed with minimal dissection of surrounding soft tissue .
debridement is important to remove scars , envision the bone elements , and prepare a new fusion bed during revision surgery .
additional procedures applied to remove screws cause the surgeon to expend extra effort , which may lead to loss of time .
our tool simplifies and accelerates the screw removal process ; thus , shortening operating time .
the aim of our polyaxial screw remover design is to facilitate screw removal and thereby reduce blood loss , infection risk , cost , and effort expended by the surgeon .
the patient demographic data and reasons for primary and revision surgery are given in table 1 .
the aim when removing polyaxial screws is to stabilize the polyaxial head so the screw becomes monoaxial and can be removed by turning .
the method described by kose et al.6 ) was of benefit when we designed our instrument , which has not been described previously in the literature . in the method of kose
et al . , the screw becomes monoaxial with a rod and cap screw , whereas we used a u - shaped end section in our instrument without the need for a rod .
the polyaxial remover consists of a single - piece shaft , sleeve , and handle ( fig .
the shaft section is hollow , and the screw cap is tightened with a screwdriver .
thus , a spine screw enters easily , and the surgeon avoids damaging surrounding tissue .
the head section of a polyaxial screw was removed , and the screw was placed in the u - section ( fig .
the cap screw was tightened on the screw , and the screw was fixed in the end section of the apparatus .
the polyaxial screw that became monoaxial can be removed by turning the handles on the shaft .
this method also removes the need to clean the fibrous tissue covering the internal screws and to see the screw shape .
a total of 42 polyaxial screws were removed from five patients with the new single - piece screw remover ( fig .
the polyaxial cap screws were 4.5 hexagonal screws in four patients and star - shaped in one patient .
after removing the cap screws and rods , all of the polyaxial screws were made monoaxial with the instrument described above and were removed rapidly in a minimally invasive way with no complications .
we have described a screw removal instrument designed to overcome the problems of screw removal often encountered during revision surgery .
our clinical application shows that these screws can be removed without the need for additional materials or soft tissue debridement within or below the screw head .
the correct screwdriver for the materials used can not always be obtained to remove existing implants during revision surgery because of the different designs .
this explains why revision surgery can be a longer and more fatiguing operation with increased blood loss .
of the several known spine surgery problems , the most accepted and most widely used method for repair is pedicle screw fixation1,2,3,4,5,6,7,8,9,10,11 ) .
after fixation , the most common reasons for revision surgery7 ) are implant problems and pseudoarthrosis .
methods and instruments to remove broken screws have been described in the literature5,12 ) . however , no additional methods6,10 ) , other than the rod techniques for removing normal screws , have been described . in the u - rod technique described by kse
et al.6 ) , the cap screws are removed with an allen key , and the screw is placed in the u - shaped rod after removing the rods . after tightening the screw head , the screw with a mobile head becomes a monoblock screw . this single - structure screw can be removed by hand or with pincers .
in addition , large metal cutters are required to cut the rods , a rod bender is needed to shape , and pincers are needed to turn the rod placed on the screw head .
our screw remover design is a single piece and will not damage surrounding tissue or the pedicle ( fig .
there is no need for metal cutters or a rod bender ; thus , reducing the time and effort required .
the tool also removes the need to clean the fibrous tissue covering the internal screws to determine screw shape .
second , a polyaxial remover was used after removing the cap screws , so it was necessary to have a screwdriver suitable for the cap screws
. however , cap screws are generally hexagonal or star - shaped and there are few varieties .
these screws are generally found in sets , or the screwdriver in the revision set can be used .
another limitation was that the polyaxial remover could not be used if the cap screw is damaged or broken .
the screw removal technique using the polyaxial remover is practical and easy and requires a minimal amount of time .
the instrument described here can be used to remove all types of polyaxial and monoaxial screws used in spine surgery .
here is no requirement for additional screw removal tools or materials and unnecessary debridement is avoided .

Answer:
objectiveto present the clinical benefits of an instrument designed to facilitate removal of polyaxial screws during revision surgery.methodsall polyaxial screws can be removed without additional materials or a large amount of debridement using our newly designed instrument .
 forty - two screws were removed from five patients without any complications using this instrument.resultswe removed the cap screws and rods from the 42 polyaxial screws in five patients and made them monoaxial using the new screw removal apparatus .
 the screws and rods were removed quickly in a minimally invasive way with no complications . no damage to the pedicle or surrounding soft tissue occurred during screw removal .
 no neurogenic changes developed during revision surgery after changing the screws.conclusionthis newly designed screw removal instrument was used safely and effectively to remove all polyaxial and monoaxial pedicle screws .


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:
alopecias can be broadly classified into non - scarring or non - cicatricial and scarring or cicatricial forms .
pathologically , a scar constitutes the end point of reparative fibrosis with permanent destruction of the preexisting tissue.1 scarring alopecias are further subdivided into primary and secondary types . in primary scarring alopecias ,
the hair follicle is the primary target of destruction , which is microscopically evident as  preferential destruction of follicular epithelium and/or its associated advential dermis with relative sparing of the reticular dermis.2  this group includes the following clinical entities : chronic cutaneous lupus erythematosus ( ccle ) , lichen planopilaris ( lpp ) , pseudopelade of brocq ( pb ) , folliculitis decalvans ( fd ) , dissecting cellulitis / folliculitis ( df ) . if the follicular destruction is secondary to the scarring and occurs outside the follicular unit , e.g. , the reticular dermis , epidermis , or sub cutis , it can eventually impinge upon and even eradicate the whole follicle .
the term secondary scarring alopecia implies that follicular destruction is not the primary pathologic event .
exogenous factors , such as burns , and endogenous infiltrative and inflammatory diseases , such as sarcoidosis , pemphigus vulgaris and reticular dermal sclerosis , can result in secondary alopecias . in 2001 ,
a group of hair clinicians , pathologists and researchers , under the rubric of the north american hair research society ( nahrs),3 issued a consensus opinion on the classification of primary cicatricial alopecias . the proposed classification subdivides primary scarring alopecias on the basis of the predominant type of inflammatory cell component , an approach that had already published1,4,57 and was further refined by the workshop .
in addition to the lymphocyte- and neutrophil - associated subgroups , a mixed and nonspecific group was differentiated and newly defined ( table 1 ) . in the late phase of cicatricial alopecias ,
a histopathologic diagnosis is more difficult because the main criteria of classification , i.e. , the type of inflammatory infiltrate , can not always be evaluated . in these cases , additional criteria , such as the evaluation of the perifollicular elastic sheet and the fibrosis ,
the goal of this study was to review clinical and histopathologic findings of 38 patients diagnosed with late , pauci or non - inflammatory phase of cicatricial alopecias at the dermatologic department of the hospital das clinicas , so paulo university medical school , over a six - year period in order to classify them by sub - types according to nahrs and evaluate the dermal elastic system and thickness of the epidermal basement membrane , using weigert and pas stains , respectively .
biopsy specimens obtained using 5-mm punches from patients seen between 2000 and 2005 at the dermatologic department of hospital das clinicas , so paulo university medical school with cicatricial alopecias in the late , pauci or non - inflammatory phase were reevaluted .
essential criteria included histopathologic diagnosis of cicatricial alopecia and accessibility of the patient s clinical records .
slides stained with hematoxylin and eosin , pas and stain for elastic tissues ( weigert with previous oxidation by peracetic acid ) were reviewed , evaluating the presence or absence of criteria listed in the table 2 .
a total of 38 cases with a histopathologic diagnosis of cicatricial alopecia were included in the study .
these cases had been previously diagnosed as follows : eight cases of ccle , two cases of lpp , 13 cases of pb , two cases of fd , one case of scleroderma and 13 cases of non - specific cicatricial alopecia .
twelve of 13 cases ( 92.3% ) that were initially classified as non - specific cicatricial alopecias could be specifically reclassified .
chronic cutaneous lupus erythematosus was diagnosed in 17 cases , representing 43.6% of the total number of scarring alopecias .
the female to male ratio was 4.7 : 1 ( 14 females and three males ) .
the age at onset ranged from 29 to 75 years , with a mean age of 46.5 years .
characteristic histopathologic findings of the late phase included hyperkeratosis , horn plugs , atrophy of the malpighian layer , slight vacuolar degeneration of the basal layer , and fibrous tract replacing the follicles .
a thickened basal membrane could be seen in 58.8% of the cases on pas stained sections , and an incomplete elastic sheet occurred around the fibrous tracts . in all cases on weigert- stained sections .
elastolytic foci were also found in areas of fibrosis outside the perifollicular zone ( figure 1d  f ) .
this category of cicatricial alopecia represented 10.2% of the total number of biopsies , totaling four cases .
in one case , there was a lichenoid infiltrate around the infundibuloisthmic segment of one follicle in addition to fibrous tracts replacing follicles .
in all the others , absence of inflammation , absence of sebaceous epithelium , and atrophy of the bulge area occurred , resulting in hourglass figures .
fibrous tracts replacing the follicle , with or without the presence of colloid bodies , were also observed .
the basal membrane was not thickened on pas - stained sections , and the perifollicular elastic sheet was partially destroyed , as observed with the weigert stain ( figure 1g
pseudopelade of brocq was diagnosed in 12 cases , representing 30.8% of the total number of biopsies .
age of onset ranged from 23 to 69 years , with a mean age of 54.4 years .
characteristic histopathologic findings were the absence of criteria seen in ccle and lpp and preservation of the elastic sheet around the follicles ( figure 1a  c ) .
folliculitis decalvans was diagnosed in three cases , representing 7.7% of the total number of biopsies .
the histopathologic hallmark was the presence of superficial suppurative folliculitis and fibrosis replacing the follicle and the perifollicular area , with elastolysis visible with the weigert stain ( figure 2a  c ) .
this category of cicatricial alopecia represented 2.6% of the total number of cicatrizing biopsies , totaling one case in a female 19 year - old patient . in this case , the inflammation was slight , and there was an extensive and deeper dermal fibrosis extending to the hypodermis , with elastolysis ( figure 2d  f ) .
one case of non - specific alopecia was diagnosed due to the destruction of the follicles being the only histopathologic finding .
this category of cicatricial alopecia represented 10.2% of the total number of biopsies , totaling four cases .
in one case , there was a lichenoid infiltrate around the infundibuloisthmic segment of one follicle in addition to fibrous tracts replacing follicles .
in all the others , absence of inflammation , absence of sebaceous epithelium , and atrophy of the bulge area occurred , resulting in hourglass figures .
fibrous tracts replacing the follicle , with or without the presence of colloid bodies , were also observed .
the basal membrane was not thickened on pas - stained sections , and the perifollicular elastic sheet was partially destroyed , as observed with the weigert stain ( figure 1g
pseudopelade of brocq was diagnosed in 12 cases , representing 30.8% of the total number of biopsies .
age of onset ranged from 23 to 69 years , with a mean age of 54.4 years .
characteristic histopathologic findings were the absence of criteria seen in ccle and lpp and preservation of the elastic sheet around the follicles ( figure 1a  c ) .
folliculitis decalvans was diagnosed in three cases , representing 7.7% of the total number of biopsies .
the histopathologic hallmark was the presence of superficial suppurative folliculitis and fibrosis replacing the follicle and the perifollicular area , with elastolysis visible with the weigert stain ( figure 2a  c ) .
this category of cicatricial alopecia represented 2.6% of the total number of cicatrizing biopsies , totaling one case in a female 19 year - old patient . in this case , the inflammation was slight , and there was an extensive and deeper dermal fibrosis extending to the hypodermis , with elastolysis ( figure 2d  f ) .
one case of non - specific alopecia was diagnosed due to the destruction of the follicles being the only histopathologic finding .
considering the group of primary lymphocytic cicatricial alopecias in the inflammatory phase , a differential diagnostic consideration for ccle is lpp .
the superficial and deep perivascular and periecrine patterns of inflammation further aid in differentiating ccle from lpp . in the late pauci or non - inflammatory phase , as observed in our cases of ccle , interfollicular epidermis alterations were evident ( hyperkeratosis and atrophy ) , in an area usually spared in lpp cases .
commonly , in the dermis in lpp , the only disturbance was the fibrous tract replacing the follicle , while in ccle , there was frequent extra follicular fibrosis and elastolysis ; even in this late phase , the basement membrane was thickened in 58.8% of cases .
ccle is differentiated from pb by the presence of predominately vacuolar interface changes at the level of follicular infundibulum in the former and lack of interface alterations in the latter.1 in our cases , the perifollicular elastic sheet was preserved in pb cases , while it was partially destroyed in lpp and ccle , confirming the previous findings of pinkus et al.7 some authors believe that pb is not a distinct clinical - pathologic entity but a variant of certain primary cicatricial alopecias or , alternatively , a form of end - stage alopecia caused by other scarring alopecias , such as ccle , lpp and fd.79 according to stephen ( 1993)1 and other authors , with whom we agree , pb does indeed have sufficient distinct pathologic features to merit a separate classification.5,1012 klaus and wilma ( 2006)1 believe that the close clinicopathlogic correlation in the histologic absence of significant follicular plugging , as well as the use of elastic fiber stain in addition to evaluation of conventional he - stained sections , should enable the differentiation of classic pb from late stage lesions of lpp and ccle in most cases and further justify the classification of the condition as an entity sui generis . in relation to the neutrophilic cicatricial alopecias ,
it is remarkable that even in the late phases of this disorder , it seems that the inflammatory process persists in our cases , , and a neutrophilic folliculitis can frequently be seen , which helps make the correct histopathologic diagnosis .
we could also see that the fibrotic process that is secondary to this neutrophilic folliculitis was more intense and proceeded by a granulation tissue , as is expected after a suppurative process .
sinus tracts are the histopathologic hallmark of dissecting cellulites and are not seen in either folliculitis decalvans or acne keloidalis and were not observed in our late phase cases .
bacterial or fungal folliculitis ( kerion and favus ) may have to be excluded in the group of neutrophilic cicatricial alopecias , with the use of special stains .
acne keloidalis cases were not seen in our series because they are histopathologically reported in our laboratory as a superficial and deep suppurative and giant cellular granulomatous folliculitis with extensive fibrosis compatible with acne keloidalis , not as a cicatricial alopecia .
besides , the clinical aspect of this disorder is so typical that histopathologic exam is seldom required .
a scalp biopsy is mandatory in all cases of cicatricial alopecias , representing the clinically inflammatory area .
if there is no evidence of inflammation , a biopsy at the border of the cicatricial zone should be performed .
a precise diagnosis is possible , even in the late , pauci or non - inflammatory phase of cicatricial alopecias if a systematic evaluation of a constellation of criteria is employed , using routine he , pas and a stain for elastic tissue . in our cases , this method allowed a precise diagnosis in 97.4% of cases , even in those initially considered non - specific cicatricial alopecia .

Answer: backgroundscarring alopecias are classified into primary and secondary types according to the initial site of inflammation . in primary scarring alopecias , the hair follicle is the main target of destruction ; the term secondary cicatricial alopecia implies that follicular destruction is not the primary pathologic event.aimsto review the histopathologic diagnoses of cases of cicatricial alopecia in order to classify them according to the north american hair research society.patients and methodspatients with biopsy specimens diagnosed as cicatricial alopecia seen from 2000 to 2005 at the dermatologic department of hospital das clinicas , so paulo university medical school had hematoxylin and eosin , periodic acid - schiff and weigert stained slides reevaluated and sub - typed into different primary cicatricial alopecias.resultsthirty-eight cases of primary cicatricial alopecias were reclassified as : chronic cutaneous lupus ( 17 ) , lichen planus pilaris ( 4 ) , pseudopelade of brocq ( 12 ) , folliculitis decalvans ( 3 ) , dissecting folliculitis ( 1 ) , and non - specific scarring alopecia ( 1 ) . in our cases , the methods employed allowed an accurate diagnosis in 12 of 13 cases ( 92.3% ) previously classified as non - specific cicatricial alopecias.conclusionseven in the late , pauci or non - inflammatory phases , an approach with systematic evaluation of a constellation of criteria in routine hematoxylin and eosin stain , periodic acid - schiff and weigert stain allowed for a more accurate diagnosis of cicatricial alopecias .


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:
pectus excavatum ( pe ) , characterized by posterior displacement of the sternum and cartilaginous - rib attachments , is one of the most common congenital chest wall deformities.1)2 ) the physiological impact of pe varies .
symptomatic patients frequently complain of dyspnea with exertion , progressive loss of endurance , tachycardia , palpitations and chest discomfort.3 - 5 ) in a critical location , even small depressions of the chest can create significant cardiac dysfunction when the right heart and pulmonary outflow tract are compressed to varying degrees by the depressed sternum.5 - 7 ) an index of severity can be calculated by measuring the inner width of the chest ( at the lowest level of the pectus defect ) and dividing it by the distance between the posterior surface of the sternum ( at the lowest part of the defect ) and the anterior surface of the spine ( with normal being approximately 2.52).2)3 ) in general , an index of 3.2 or greater is considered severe however symptoms do not necessarily correlate with severity of index.2 - 4 ) echocardiography plays a significant role in the evaluation of patients with pe .
the degree of right heart compression however is often difficult to assess by transthoracic echo ( tte ) especially with severe deformities that prevent the operator from obtaining the normal transthoracic views.7 - 9 )
a 32-year - old woman presented to out - patient clinic for further evaluation of a 1-year history of progressive chest pain , fatigue , dizziness , paroxysmal tachycardia and dyspnea with exertion . with even mild exertional effort she experienced sharp , " stabbing " chest pain along the left lower and mid - sternum .
a 12-lead electrocardiogram demonstrated a right - bundle branch block with left posterior fascicular block .
she had a history of severe pe ( index of > 4 ) for which she had undergone operative repair 18 months prior by an open resection of cartilage attachments and sternal " flip " as described by hawkins & colleagues.10 ) prior to her first correction , she had some dyspnea with exertion , however , cardiac work - up , including echocardiogram had been reported to not show any abnormalities .
she noted onset of her current symptoms approximately 6 months after her pe repair . a subsequent operation with superficial anterior remodeling of the chest wall cartilage on the left side of the sternum had failed to relieve her progression of pain and symptoms .
she exhibited post - operative abnormal remodeling of the chest wall with residual as well as some recurrent pe .
the sternum protruded anterior with bilateral depression of the costal - sternal attachments creating a " wave - like " appearance ( fig .
close attention to the anteroposterior planes ( best seen from the apical four - chamber views ) clearly demonstrated extrinsic compression and deformation of the lower mid - right ventricle ( rv ) by the chest wall which is more obvious during diastole ( fig .
3b ) . biplane and live 3-d images of the preoperative transesophageal echocardiogram ( tee ) improved the visualization and localization of extrinsic compression of the right ventricle ( fig .
tricuspid valve prolapse is seen likely due to partial compression of the rv resulting in distortion of the tricuspid annulus ( fig .
open revision of her chest wall deformity was performed with placement of two stainless steel support bars ( lorentz surgical , jacksonville , fl , usa ) and a trabecular metal implant ( zimmer , inc . ,
minneapolis , mn , usa ) which elevated the sternum and depressed regions 3 - 4 centimeters anterior to the rv with good cosmetic results ( fig .
symptomatic pe patients often present for cardiovascular evaluation with tte being the most commonly utilized diagnostic modality .
documenting the effects of a depressed chest wall on the right heart and outflow tract as well as any associated interference with diastolic filling is critical for decision making in patient treatment and the need for potential surgical intervention .
modifying standard views such as biplane transthoracic and transesophageal views may be necessary in some patients due to limitations from the abnormal anatomy of the deformed anterior chest wall . in some cases , rv compression is often difficult to assess by tte especially with severe deformities that prevent the operator from obtaining the normal transthoracic window views .
technical tips for assessment of the rv include 1 ) narrowing the 2-d sector width to optimize only rv structures ; 2 ) use of harmonic imaging and adjustment of gain and compression for good contrast and endocrinal edge detection ; 3 ) making all measurements at end - diastole or the frame demonstrating the largest chamber dimension ; and 4 ) for 2-d measurements , obtain all acquisitions during quiet respiration or full - expiration .
apical four - chamber views when seen clearly can usually visualize any extrinsic compression to the rv of the heart .
use of all three possible traditional acoustic windows ( parasternal short - axis , apical and subcostal ) may be necessary . in an effort to minimize foreshortening of the rv , the transducer can be positioned down an intercostal space and laterally until the rv apex is clearly seen . in some patients
a transesophageal and transgastric view may be necessary to better evaluate the right heart chambers and rv outflow obstruction .
many patients with pe have associated alterations in rv morphology and function . assessment for localized sacculation of the rv wall , global dilation of the ventricle , prominent trabeculae , and/or hypertrophy of the moderator band is important . identifying abnormalities , including mitral valve prolapse and aortic root measurements are especially critical in suspected or confirmed cases of marfan syndrome .
resolution of mitral valve prolapse with release of the chest wall entrapment is seen in more than half of patients after pe correction.7)11)12 ) more importantly , many patients improve their symptoms such as exertional dyspnea and chest pain which may be related to extrinsic compression of the rv and reduced preload.4)5)7 ) further studies are needed to better understand the pathophyiology of symptoms in relation to cardiac and chest wall function in patients with pe . in conclusion ,
echocardiographic evaluation is critical in patients with symptomatic pe to assess the degree of rv compression .
we presented a case of a pe in a patient with symptoms including severe chest pain with exertion that was diagnosed with the expertise of echocardiography and subsequently surgically corrected .
subtle abnormalities in cardiac structure and chest wall compression may result in debilitating symptoms in a small population of patients.2 - 4 ) when astutely performed , echocardiography can accurately provide clinically relevant information about cardiac size and any hemodynamic compromise in patients with pe .

Answer:
pectus excavatum exists as varying anatomic deformities and compression of the right heart by the chest wall can lead to patient symptoms including dyspnea and chest pain with exertion .
 echocardiography can be difficult but is critical to the evaluation and diagnosis of this patient population .
 modifying standard views such as biplane transthoracic and 3-d transesophageal views may be necessary in some patients due to limitations from the abnormal anatomy of the deformed anterior chest wall .
 apical four - chamber views when seen clearly can usually visualize any extrinsic compression to the right ventricle of the heart .


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:
nsclc is the most common type of lung cancer and the most common malignant neoplasm worldwide ( 1 ) . during past decades
, various studies have attempted to identify molecular biomarkers to predict the prognosis of nsclc ( 2 , 3 ) .
numerous promising biomarkers have been evaluated but none of these have been effective for clinical use ( 2 , 3 ) .
the main cell population in anti - cancer immune response is the population of cytotoxic t lymphocytes ( ctls ) ( 4 ) .
the ctls population is represented by cd8 + lymphocytes , cd4 + lymphocytes , natural killer cells ( nk ) , natural killer t cells ( nkt ) and lymphocytes b ( 5 , 6 ) .
cancer cells are killed by induction of apoptosis by cytolytic reaction or membrane - receptor induction of programmed death .
the successful cytotoxic attack needs an effective antigen presentation by tumor cells and antigen presenting cells ( apc ) .
anti - cancer defense is ineffective in clinically detectable cancers and the greater is the size of a tumor mass , the less effective anti - cancer response is ( 8) .
lung cancer cells hide against cytotoxic attack by low antigen presentation and low co - stimulatory molecule expression .
the lung cancer antigens are unstable and badly defined as a result of multiple genetic and epigenetic alterations during oncogenesis ( 9 ) .
hepatitis b ( 10 ) and inflammatory bowel disease ( 11 ) are examples , leading to hepatocellular and colorectal cancer
. neutrophils , as a key component in inflammation , may play a crucial role in inflammation driven tumorigenesis ( 12 ) .
neutrophils support angiogenesis via secretion of proangiogenic factors or by proteolytic activation of proangiogenic factors .
neutrophils are implicated in tumor growth through the proteolytic release of egf - epidermal growth factor , tgf1-transforming growth factor
1 , and pdgf  platelet derived growth factors from the extracellular matrix ( ecm ) ( 13 ) .
immature neutrophils or g - mdsc ( granulocytic myeloid derived suppressor cells ) are implicated in the establishment of an immunosuppressive tumor microenvironment .
neutrophils kill tumor cells through direct or antibody dependent cell cytotoxicity ( adcc ) ( 13 ) .
they accumulate in large numbers in premetastatic organs and have a positive effect on tumor cell seeding ( 14 - 17 ) .
also , it has been shown that neutrophils limit metastatic seeding by killing tumor cells ( 14 , 16 ) .
neutrophils do not affect the growth of the metastatic nodules ( 14 , 16 ) .
there is a  polarization  of neutrophils in tumor promoting and antitumor phenotype which is mediated via cytokines in the tumor microenvironment ( i.e. tgf1 and ifns ) .
neutrophil abundance correlates with a better prognosis in some studies and a worse prognosis in others ( 18 ) .
platelets play a significant role in cancer growth , progression and metastasis ( 19 , 20 ) .
significant attention has been given to the association between malignancies and coagulation ( 19 , 20 ) .
a hypercoagulability is one of the signs of a more aggressive disease and thromboembolism is one of the major causes of mortality in cancer ( 21 ) .
a prognostic significance between the platelet count and lung cancer has been identified but not fully elucidated ( 22 - 27 ) .
platelets release some growth factors such as platelet - derived growth factor , platelet factor 4 , and thrombospondin which promote hematogenous tumor spread , tumor cell adhesion , invasion and angiogenesis and play an important role in tumor progression ( 22 , 25 - 27 ) .
platelets contain many active molecules and , as they adhere to sites of tumor activated or injured endothelium ; many of these molecules are released into the local microenvironment leading to platelet - mediated effects on vascular tone and neo - angiogenesis ( 22 - 27 ) .
platelets play important roles in the tumor microenvironment that may be thought of as  a wound that never heals  ( 28 ) .
objective of this study is to compare neutrophil / lymphocyte ratio ( nlr ) and platelet / lymphocyte ratio ( plr ) in patients with nsclc ( non- small- cell lung cancer ) with and without metastases at the time of diagnosis to find out if there is the importance of these cell ratios in the assessment of severity nsclc .
this is the retrospective analysis of nrl and prl in patients with nsclc at the time of the diagnosis of disease before any anti tumor treatment ( chemotherapy , radiotherapy , surgery ) .
x 10 / l ) , calculated nlr and plr in every patient and compared obtained values in patients with metastases and patients without metastases .
in 57 patients there were 15 males ( 26% ) mean aged 68 , 64 with metastases , 28 males ( 49% ) mean aged 64,63 years without metastases , 8 females ( 14% ) mean aged 61,63 with metastases and 6 females ( 11% ) mean aged 63,33 years without metastases .
there were 23 patients with nsclc ( 40% ) with metastases and 34 patients ( 60% ) without metastases .
the values of nlr in 34 patients without metastases were : 5,15 ; 8,57 ; 1,81 ; 1,45 ; 1,69 ; 3,77 ; 1,35 ; 1,83 ; 1,77 ; 2,11 ; 1,65 ; 2,26 ; 2,78 ; 4,25 ; 3,52 ; 1,92 ; 1,37 ; 1,77 ; 3,52 ; 1,22 ; 3,92 ; 3,28 ; 1,47 ; 3,74 ; 3,74 ; 1,82 ; 3,68 ; 2,39 ; 2,39 ; 2,67 ; 1,88 ; 1,70 ; 4,14 ; 2,84 .
the values of nlr in 23 patients with metastases were : 1,51 ; 13,3 ; 0,58 ; 2,25 ; 1,71 ; 3,94 ; 2,47 ; 2,97 ; 2,58 ; 2,35 ; 2,35 ; 2,01 ; 4,46 ; 4,47 ; 3,23 ; 0,78 ; 2,79 ; 2,39 ; 3,67 ; 2,23 ; 2,25 ; 6,54 ; 1,56 ; ( figure 2 ) nsclc with and without metastases in males and females nrl in patients with nsclc nlr in patients without metastases = 2.32 ( 1.75 to 3.69 ) , in patients with metastases= 2.39 ( 2,01- 3.67 ) .
the values of plr in 34 patients without metastases were : 221,85 ; 261,0 ; 115,34 ; 69,8 ; 130,0 ; 166,9 ; 78,93 ; 50,29 ; 105,98 ; 137,99 ; 70,77 ; 106,9 ; 178,78 ; 168,4 ; 123,7 ; 72,5 ; 150,54 ; 83,02 ; 156,46 ; 76,12 ; 184,62 ; 156,46 ; 93,85 ; 225,78 ; 225,78 ; 68,09 ; 281,58 ; 105,56 ; 105,56 ; 116,94 ; 68,46 ; 92,71 ; 328,79 ; 107,69 .
the values of plr in 23 patients with metastases were : 82,49 ; 402,56 ; 172,07 ; 167,60 ; 104,96 ; 220,53 ; 220,81 ; 201,15 ; 168 ; 171,65 ; 171,85 ; 133,09 ; 225,78 ; 307,84 ; 131,80 ; 204,90 ; 143,30 ; 128 ; 142,67 ; 110,90 ; 100,30 ; 124,60 ; 49,83 .
plr in patients without metastases = 116.14 ( 81.99 to 170.99 ) , in patients with metastases=167.60 ( 124 , 60- 204.90 ) . since there was no regularity in the distribution of obtained values of nlr and plr we made the mann - whitney u test .
mean values are not presented using the x and sd , but with a median and interquartile percentiles .
the nlr in patients with nsclc without metastases amounted to 2.32 ( 1.75 to 3.69 ) and was not significantly different from the nlr in patients with metastases 2.39 ( 2,01- 3.67 ) ( p=0.614 ; p = ns ) .
the plr in patients with nsclc without metastases amounted to 116.14 ( 81.99 to 170.99 ) and was not significantly different from the plr in patients with metastases 167.60 ( 124 , 60- 204.90 ) ( p = 0.068 ; p = ns ) .
various studies have attempted to identify molecular biomarkers to predict the prognosis of nsclc ( 2 , 3 ) .
lymphocytes , macrophages and granulocytes are involved in the anti - cancer battle ( 1 - 8 ) .
the main cell population in anti - cancer immune response is the population of cytotoxic t lymphocytes ( ctls ) ( 4 ) .
neutrophil abundance correlates with a better prognosis in some studies but a worse prognosis in others ( 18 ) .
platelets release some tumor growth factors which play a significant role in cancer growth , progression and metastasizing ( 19 , 20 , 22 , 25 - 28 ) .
elevated pretreatment nlr , plr and mean platelet volume ( mpv ) in peripheral blood were identified as independent prognostic factors associated with poor survival with various cancers including nsclc ( 29 ) . in 81 patients with lung cancer nlr and plr values
were significantly higher compared to the healthy subjects ( nlr : 4.42 vs 2.45 p=0.001 , plr : 245.1 vs 148.2 p=0.002 ) .
no significant relationship was determined between these markers and histopathology or tnm stages ( 29 ) .
pretreatment high nlr and plr were associated with significantly shorter disease - free and survival rates in study worked on 94 patients with nsclc ; there was not impact on the response to chemoradiotherapy ( 30 ) . in 149 patients with nsclc
nonlocal failure rates were 11% for patients with plr less than 250 and 58% for plr
. patients with high pretreatment plr had shorter survival after stereotactic radiatiotherapy ( 31 ) .
some studies indicated that the combination of nlr and plr could be a better prognostic factor . in study on 366 patients in iii and iv stage of nsclc
, patients could be divided into three prognostic groups prior to treatment : poor : nlr > 2.68 ; moderate : nlr  2.68 and plr > 119.50 ; and good : nlr  2.68 and plr  119.50 ( 32 ) .
a high pretreatment plr ( 33 ) and nlr ( 34 ) might be a predictive factor of poor prognosis in nsclc  a shorter survival after treatment . some authors ( 35 )
failed to find the prognostic significance of nlr in nsclc and some ( 36 ) did not find correlation between plr and prognosis of nscl .
we compared nlr and plr in patients with nsclc without and with metastases at the time of the diagnosis of diseases .
nrl in patients without metastases was 2.32 and plr 116.14 ; in patients with metastases nlr was 2.39 and plr 167.60 .
although there was not statistical significance these results show that nlr and plr could be useful in preliminary assessment of nsclc before any treatment
. they can be useful predictors for worse prognosis but we still do not know reference values . if our sample were grater we might be given statistical significant results .
immune cells and their ratio influence prognosis and that could be clinically applied in nsclc .
more investigations will improve the understanding of the lung cancer and may develop novel therapeutic opportunities .

Answer:
objective : to compare neutrophil / lymphocyte ratio ( nlr ) and platelet / lymphocyte ratio ( plr ) in patients with nsclc ( non- small- cell lung cancer ) : with and without metastases at the time of diagnosis to find out if there is the importance of these cell ratios in the assessment of severity nsclc.material and methods : this is the retrospective analysis of nrl and prl in patients with nsclc at the time of the diagnosis of disease before any anti tumor treatment ( chemotherapy , radiotherapy , surgery ) .
 57 of patients with nsclc treated in the first three months of 2016 .
 year were chosen at random regardless of sex and age .
 we examined full blood count cells ( fbc ) , calculated nlr and plr in every patient and compared obtained values in patients with and patients without metastases.results:in 57 patients with nsclc there were 15 males with metastases , 28 without metastases , and 8 females with metastases , 6 without metastases . since there was no regularity in the distribution of obtained values of nlr and plr we made the mann - whitney u test .
 mean values are presented with a median and interquartile percentiles .
 there was no significant difference in nlr between patients without and with metastases ( p = 0.614 ; p = ns ) as well as in plr ( p=0,068 ; p = ns).conclusion : there must be a link between the immune status of the organism and lung cancer development .
 immune cells have become of interest in recent years and much work has been done to study their role in the genesis of cancer but it did not give satisfactory results .
 further clinical studies on large number of patients and further laboratory examination of the role of immune cells in cancer development and suppression are required .


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:
focal segmental glomerulosclerosis ( fsgs ) is a pathological term to indicate glomerular lesion associated with various etiological factors . in native kidneys ,
, fsgs can be classified as recurrent disease or fsgs associated with chronic transplant glomerulopathy , calcineurin inhibitor ( cni ) toxicity and in long - standing grafts with hyperfiltration injury .
the incidence of recurrent fsgs is approximately 30% and secondary disease occurs in 10 - 20% of the cases .
the distinction between these various types is difficult because of lack of pretransplant diagnosis and overlapping morphological features .
we analyzed 24 graft biopsies with fsgs and tried to etiologically classify them basing on the accompanying morphological features on the graft biopsies and clinical features .
it is important to diagnose the condition adequately and promptly to protect the graft and inhibit the progression of the disease .
out of 363 allograft biopsies received between january 2012 and december 2013 , 24 diagnosed as fsgs were included in the study .
three routine stains were done in all biopsies , which included hematoxylin and eosin , periodic acid - schiff 's , and masson 's trichrome .
immunofluorescence with immunoglobulin ( ig ) g , igm , iga , c3c and c1q was done .
criteria to diagnose fsgs included segmental sclerosis , hyalinosis and or lipid deposition , focal or segmental collapse of the tuft with prominence of podocytes of variable degree depending on the histological type of lesion diagnosed .
mean serum creatinine level was 2.7 mg / dl and mean 24 h urinary protein was 3.2 g. secondary fsgs was reported in 18 cases ( 75% ) .
causes included chronic humoral rejection in seven cases ( 38% ) , cni ( cyclosporine and tacrolimus ) toxicity in six cases ( 33% ) , and in long - standing grafts with hypertensive nephron loss and hyperfiltration injury in five cases ( 29% ) .
the type of donor , biochemical parameters and pretransplant diagnosis for various categories are given in table 1 .
recurrent and new - onset primary diseases seven cases with chronic glomerular and tubulointerstitial changes with positive c4d were classified as chronic humoral rejection .
glomerular changes included thickening and duplication of basement membrane , increase in mesangial matrix and cellularity , and focal segmental sclerosis [ figure 1 ] .
c4d was given as positive when 10 - 50% of capillaries ( c4d2 ) or more than 50% of capillaries ( c4d3 ) showed linear circumferential staining .
positive c4d and segmental lesion in chronic humoral rejection ( 200 ) chronic humoral rejection mean serum creatinine level was 2.7 mg / dl and 24 h urinary protein was 2.8 g. six lesions were classified as cni toxicity .
histological features included striped fibrosis in interstitium and nodular hyaline arteriolar sclerosis ( ah2 and ah3 ) in vessels [ figure 2 ] .
nodular hyaline arteriolar sclerosis ( periodic acid - schiff , 200 ) calcineurin inhibitor toxicity mean serum creatinine level was 2.1 mg / dl and mean 24 h urinary protein was 800 mg .
hyperfiltration injury was diagnosed in five cases where hypertensive glomerular changes such as thickening and wrinkling of basement membrane , ischemic collapse of the tuft , and widening of bowman 's space and fsgs was seen .
vessels showed marked subintimal fibrosis with > 50% narrowing of lumen and associated with chronic tubulointerstitial changes .
mean serum creatinine level was 2.1 mg / dl and mean 24 h urinary protein was 300 mg . clinical and morphological details are given in table 4 .
focal segmental glomerulosclerosis is a pathological term to indicate glomerular lesion associated with various clinical situations in renal allografts .
fsgs is a common cause of end - stage disease and recurrence in grafts is approximately 30% .
we classified fsgs in renal grafts as recurrent disease , new - onset primary fsgs in cases where the native diagnosis was not fsgs , and secondary fsgs when associated with drug toxicity , chronic rejection or hypertension , depending on the clinical features and in correlation with various morphological features that are associated with fsgs .
this number does not indicate the exact incidence , as native biopsy diagnosis is not available in many cases .
risk of recurrence includes young age of the patient , presence of mesangial proliferation , and rapid progression to end - stage disease and pretransplant bilateral nephrectomy .
recurrence occurs in renal grafts in early post - transplant period . these patients present with heavy proteinuria usually of nephrotic range .
this criterion and an available diagnosis of native disease are helpful in diagnosing recurrent disease . in our series , all the four cases had a biopsy diagnosis of fsgs .
the type of fsgs in native kidney was available in three cases , and recurrence disease had a similar pattern to native disease .
recurrence can be classified as recurrence of same variant ( 51% ) , recurrence of same variant preceded by minimal change disease ( 19% ) and recurrence with a different variant of fsgs ( 19% ) .
graft survival is poor and progression to end - stage renal disease is rapid and is as high as 50% . it is therefore important to diagnose and differentiate this entity from other causes of fsgs . ( a ) collapsing glomerulopathy ( jones , 200 ) .
( b ) focal segmental glomerulosclerosis - not otherwise specified ( h and e , 200 ) chronic transplant glomerulopathy and chronic humoral rejection are other conditions in which fsgs can occur .
the mechanism for this is chronic immunological glomerular endothelial and podocyte injury , which is resulting in fsgs .
this particular lesion is relatively easy to diagnose as associated features of chronic graft damage are seen , and c4d is positive .
these patients presented in late post - transplant period mostly after 3 years and presentation is due to the rise in creatinine and mild proteinuria .
these lesions are purely based on pathology diagnosis as serum levels do not correlate with the extent of renal damage and clinical features are not specific .
glomerular changes include glomerular hypertrophy , capillary collapse , focal segmental or focal global sclerosis .
fsgs results from hyperfiltration injury due to loss of functioning nephrons rather than direct toxic effects on podocytes .
presence of hyaline arteriopathy , stripped fibrosis , [ figure 4 ] tubular atrophy with or without isometric vacuolation , and absence of heavy proteinuria help to diagnose this particular entity .
striped fibrosis ( masson 's trichrome , 100 ) the true incidence of glomerulonephritis in grafts is not exactly known and ranges from 4% to 20% .
membranous nephropathy and fsgs are most common of the glomerulonephropathies that can be seen in grafts with an incidence of 1 - 9% .
we diagnosed two cases of new - onset fsgs in patients presenting with nephrotic range proteinuria .
histologically , there were no features of hypertension or cni toxicity and c4d was negative .
new - onset fsgs has favorable clinical course when compared with recurrent disease and hence it is important to identify this lesion . in long - standing grafts with nephron loss and chronic tubulointerstitial changes
we described this entity separately when arterial changes are predominant and tell - tale signs of cni toxicity are absent .
an attempt was made to etiologically classify these lesions as there is a difference in treatment and prognosis .
it is important to make a diagnosis carefully using clinical information and pathology when a decision about second transplant has to be made .

Answer:
recurrence of fsgs in renal allo grafts is a major cause of graft loss . in this context
 , we tried to diagnose and classify fsgs in renal allografts .
 indications for biopsy included graft dysfunction and/or proteinuria .
 three hundred and sixty - three graft biopsies were studied over a period of 2 years .
 we classified fsgs into recurrent fsgs , new - onset primary fsgs and fsgs secondary to chronic humoral rejection , calcineurin inhibitor toxicity , and nephron loss and hyperfiltration injury .
 twenty - four cases were diagnosed as fsgs , constituting 6.6% .
 secondary fsgs was the most common fsgs in grafts in our study .
 incidence of recurrent fsgs may not be accurate as pretransplant biopsy is available in very few cases .


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

Title:
Sex-Specific Effects of Arsenic Exposure on the Trajectory and Function of the Gut Microbiome

Paper sections:

Arsenic exposure is a global public health issue, with more than 100 million people being exposed primarily from drinking water.1 Arsenic exposure has been linked to a series of human diseases, including cancers, diabetes, and cardiovascular disorders.2–4 Different molecular mechanisms and modes of action are associated with arsenic toxicity. For example, arsenic activates inflammatory signaling and alters DNA methylation and gene expression.5–7 Recently, the role of the gut microbiome in arsenic metabolism and toxicity has been demonstrated in different model systems.8–10 The gut microbiome is a very complex dynamic system which contains trillions of bacteria and 100-fold more unique genes than the human genome.11 The gut microbiome is deeply involved in host metabolism and can be readily perturbed by external factors, raising the possibility that arsenic exposure could alter the gut microbiome and its functions.12,13 Our previous research clearly demonstrated that the gut microbiome interplays with arsenic exposure: arsenic can perturb the gut microbiome community structures and its metabolic profile;13 the gut microbiome phenotypes/variations alter the biotransformation of inorganic arsenic.9,14 Likewise, a recent study by Dheer et al. demonstrated that arsenic at environmentally relevant doses altered the gut microbiome and microbiome/host functions.15

The establishment of the gut microflora is a temporal and sensitive process occurring after birth.16 The colonization of gut microbiome during early life is highly sex-dependent.17,18 Meanwhile, sex-specific effects of arsenic metabolism and toxicity have been reported, although with little of the molecular mechanism being identified.19 For example, previous studies have revealed that arsenic methylation is more efficient in females than in males.19 Likewise, males are more susceptible than females to develop skin lesions when exposed to arsenic.20 Taken together, sex is an important factor to be considered when exploring the complex interaction among host, gut microbiome, and arsenic toxicity. However, it remains unclear whether sex influences the gut microbiome response to arsenic exposure. In this study, we employed 16S rRNA gene sequencing and metagenomics to address this intriguing question. Our results reveal that arsenic exposure altered the trajectories (i.e., time-dependent changes of gut microbiome compositions) and functional metagenome of the gut microbiome in a sex-specific manner.

The experimental design and workflow are described in the Supporting Information and Figure S1. Briefly, we divided 20 female mice and 20 male mice into four groups: Group A, 10 female mice as controls; Group B, 10 female mice treated with 10 ppm arsenic as previously described;13 Group C, 10 male mice as controls; and Group D, 10 male mice treated with 10 ppm arsenic. Then, we collected the fecal pellets from individual animals at two different time-points (day 0 baseline and 4 weeks after arsenic treatment) and applied 16S rRNA sequencing technology to determine the fecal microbiome compositions (Figure 1). Finally, the changes of functional metagenome and pathways induced by arsenic exposure were determined by metagenomics sequencing (Figure 2).

16S rRNA sequencing results reveal that there is a remarkable difference of gut microbiome between male and female mice, as shown in Figure 1A and Figure S2. After a 4-week arsenic treatment, the gut microbiome changed in both male and female mice. According to the principal coordinate analysis (PCoA) of beta diversity (Figure 1B), the difference of gut microbiome community structures in arsenic-treated female mice is more significant than that in male mice when compared to corresponding controls. These results reflect that gut microbiome phenotypes driven by host sex have different sensitivity to arsenic exposure. Meanwhile, time plays a role in shaping the gut microbiome profiles regardless of treatment, as shown in Figure 1B and Figure S2B, raising the possibility that arsenic exposure may perturb the normal trajectory of the gut microbiome. To further examine this, we compared the gut microbiome profiles over time for both controls and treated animals. Figure 1C and D summarizes the fold changes of a few representative genera that were statistically different between day 0 and 4 weeks. Evidently, the change patterns of the gut microbiome were different for controls and treated animals, indicating that arsenic exposure affected the trajectory of the gut microbiome. Moreover, a strong sex-specific response was observed. For example, Dorea decreased in female mice after a 4-week exposure, while it significantly increased in treated males. Likewise, Akkermansia had an ~7000-fold increase in the female arsenic-treated group; however, this genus did not show any significant change in males after arsenic exposure (Figure 1C and D). More detailed information on gut bacteria alterations from arsenic treatment is listed in Tables S1 and S2. Taken together, arsenic exposure altered the trajectory of the gut microbiome in a sex-selective manner.

We next used metagenomics to examine whether arsenic exposure also perturbed the functional metagenome in a sex-specific way, as the functional impact is more relevant to the gut microbiome and host. Figure 2 shows that a number of metabolic pathways were significantly altered by arsenic exposure. Similar to the changes of the microbiome profiles, the functional pathways were also differentially perturbed by arsenic in male and female mice. For example, arsenic treatment up-regulated many functional pathways in females, with several of them being related to metal resistance (such as mercury resistance operon, zinc resistance, and the mdtABCD multidrug resistance cluster) and the cell transport system (such as glutathione-regulated potassium-efflux system, ATP-dependent efflux pump transporter Ybh, general secretion pathway, and iron acquisition in Streptococcus). In arsenic-treated males, the pathways of nitrogen, carbon, and sulfate metabolism were significantly affected. For example, the hexose phosphate uptake system and phospholipid and fatty acid biosynthesis were remarkably down-regulated in arsenic-treated males, whereas functional pathways like ammonia conversion, denitrification, and cluster Ytf and the putative sugar transporter were significantly increased in treated males. Interestingly, the previous study by Dheer et al. found elevated tissue nitrite in hosts, highlighting the potential role of host–microbiome interaction in mediating nitrogen metabolism.15 In summary, arsenic has different effects on the functional metagenome in male and female mice.

The interaction among host, gut microbiome, and xenobiotics is a very complex dynamic process. Previously, we have demonstrated that gut microbiome phenotypes driven by host genetics and bacterial infection largely influence the biotransformation of arsenic in the host.9,14 Here, we show that that host sex also serves as an important factor to influence the gut microbiome compositions and could further affect the gut microbiome response to arsenic exposure. It was previously documented that the female is more resistant to arsenic exposure than males.19–21 It is interesting to notice that gut bacteria in arsenic-treated female mice but not male animals have significantly increased heavy metal resistance and cell-efflux capability, which may partially contribute to the different sex susceptibilities to arsenic exposure. Future studies are needed to further elucidate this intriguing question.

In summary, our results show that arsenic exposure significantly altered the trajectory of the gut microbiome over a 4-week dosing period, with multiple components of gut bacteria being significantly changed in a sex-selective fashion. Consistent to this, metagenomics data also revealed that the functional metagenome was differentially perturbed in male and female mice. Taken together, this study provides strong evidence for the first time that host sex plays a role in the gut microbiome responses to environmental toxicants, such as arsenic. Several limitations are associated with this study, including the high arsenic dose, short exposure time, and the use of fecal microbiome to infer changes of gut microbiome. In particular, the impact of arsenic on the host functions was not assessed in this study, which may largely drive the microbiome changes. Further study is warranted to shed light on these aspects.

Answer: The gut microbiome is deeply involved in numerous aspects of human health; however, it can be readily perturbed by environmental toxicants, such as arsenic. Meanwhile, the interaction among host, gut microbiome, and xenobiotics is a very complex dynamic process. Previously, we have demonstrated that gut microbiome phenotypes driven by host genetics and bacterial infection affect the responses to arsenic exposure. The role of host sex in shaping the gut microbiome raises the question whether sex plays a role in exposure-induced microbiome responses. To examine this, we used 16S rRNA sequencing and metagenomics sequencing to analyze the changes of the gut microbiome and its associated functional metagenome in both female and male C57/BL6 mice. Our results clearly demonstrated that arsenic exposure perturbed the trajectory and function of the gut microbiome in a sex-specific manner.


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:
zika and chikungunya viruses are both transmitted by aedes aegypti mosquitoes and are associated with an abrupt onset of fever , arthralgia , myalgia and rash . in brazil , acute exanthematous outbreaks related to zika ( zikv ) and chikungunya viruses ( chikv ) have been reported in many regions and sometimes as co - infections , , , .
acute chikungunya infection generally leads to prominent joint symptoms with moderate to severe arthralgia and arthritis that may persist for months and even years .
rarely , encephalitis and other neurological involvements may also complicate chkv infection such as recently reported a neonatal encephalitis in brazil with similar lesions on brain scan as those previously described in the la runion islands , , .
in all these situations , a rapid diagnosis is of importance for epidemiological purposes and clinical management . in zikv infections ,
the molecular diagnosis in serum is generally possible until the first six days of symptoms onset and , later on , urine or saliva is used , .
zika detection in urine may help in ascertaining the diagnosis after the initial period of viremia in areas with co - circulation of zikv and dengue virus ( denv ) , where serologic cross - reactions may occur , but evidence for that associated with chikv infection has not been shown .
an expanded window for diagnosis in chikv is also needed since igm seropositivity may persist for months after the initial acute infection .
many other viruses have been detected in semen , such as ebola , hiv , hbv , hpv , hsv-1 , hsv-2 , marburg , but there has been no published data so far on the presence of chikv in semen , , , , .
we report the presence of chikv rna for a prolonged period of time in the urine and semen of an adult with a dual infection with dengue virus type 3 for a prolonged period of time .
a 25-year - old man from salvador , brazil presented with a 6  days of high fever , arthralgia , myalgia , headache and photophobia .
he also reported a burning sensation on his eyes and a non - pruritic rash in the trunk and upper limbs on the first 3  days , and complained of pain involving the ankles , knees , shoulders , wrists , lower back , and neck .
of note , he also reported a transient burning sensation in the urethra and genital region that started 3  days before the onset of symptoms and resolved spontaneously . on examination
the patient was febrile with a temperature of 38.3c , had a maculopapular erythematous diffuse rash , joint enlargement with mild inflammatory signs affecting the wrists , the metacarpophalangeal and metatarsophalangeal joints as well as the ankles .
the patient was not able to raise his arms on command because of shoulder pain and was eating with difficulty because of pain involving his temporomandibular joint .
blood samples were drawn for viral workup , semen was also requested due to the complaint of dysuria , and the possibility for zika diagnosis since the patient could not provide a urine sample at that time .
blood , urine and semen were collected again after 30  days of symptoms onset and were further processed .
serum and semen samples were submitted to viral rna extraction using a maxwell total viral nucleic acid 16 purication kit ( promega , usa ) regarding that the semen sample , the incubation time of the lysis step was extended to 30  min .
urine sample was submitted to viral rna extraction using qiamp viral rna purification ( qiagen , usa ) .
subsequent to viral rna extraction , all samples were submitted to rt  pcr technique ( accessquick system , promega , usa ) to screen for chikv , zikv and denv using conventional techniques , , .
serum and semen specimens were positive for chikv rna in the first collected samples ; semen and urine specimens were positive for chikv rna after 30  days of symptoms onset , with negative results in serum .
denv-3 rna was positive in serum specimen when first collected 6  days after the initiation of symptoms and was not tested thereafter .
table 1 presents the clinical findings and molecular results during the time frame of infection .
the patient made use of prednisone starting on the 2nd day of symptoms onset with 40  mg qd for 10  days , tapering to 20  mg qd for the next 10  days , and 10  mg qd for the last 8  days , with an uneventful course and no clinical findings after 30  days .
ebola rna ( ebo - rna ) can be detected in up to 290  days after clinical manifestations and ebola infectious particles in up to 70  days .
transmission of ebola virus ( ebov ) from a male survivor to a female has been documented 179  days after illness in liberia . in another study ,
persistence of ebo - rna could be found in semen specimens at least 9 months after the onset of symptoms with important consequences related to sexual transmission .
many papers have reinforced the sexual transmission of zikv since foy et al . have suggested its relationship , , , .
this report , besides describing a patient with classical signs of zikv , drew attention to symptoms of prostatitis with hematospermia .
our patient reported a burning sensation in the urethra and the genital region and may also have had a transient prostatic involvement with detection of chikv rna in semen .
zika rna has been detected in semen for up to 6 months after the onset of symptoms and is involved in male - to - female as well as in female - to - male transmission , .
studying human papilloma virus ( hpv ) have found a high prevalence of this virus in semen
27.2% of healthy adults in amsterdam  and using fluorescence in situ hybridization ( fish ) for hpv - dna and immunocytochemistry for the hpv - l1 and hpv - e4 proteins , the authors detected hpv - dna , hpv - e4 and hpv - l1 in exfoliated keratinocytes present in some hpv16-positive semen samples , indicating the presence of hpv viral particles .
even though alphavirus envelope glycoproteins function as the attachment point to cells , no human cell surface receptor has been implicated in cell entry so far .
primary peripheral blood cells such as cd4 + t lymphocytes , primary cd14 + monocytes and dendritic cells were reported to be refractory to chikv binding and infection .
macrophages , on the other hand , are highly sensitive to chikv and showed cytopathic effect following chikv infection , .
mononuclear cell infiltration and viral replication in the muscles ( particularly skeletal muscle progenitor cells , not muscle fibers ) and joints are associated with myalgia and arthralgia and synovial macrophages have been shown to contain viral rna months after infection .
it may be postulated that an inflammatory infiltration with macrophages in the genital tract may be the source of the chikv , leading to mild symptoms and an unknown persistence time in semen .
the detection of chikv in semen has many important implications , including the possibility of sexual transmission .
even though we did not perform cytopathic assays for chikv , this finding must be further investigated .
we did not find any other study showing evidence of chikv in semen and , specially , for such a long period since the onset of symptoms .
another unique finding in our study was the detection of chikv in urine after 30  days of the initial symptoms contrasting with recent findings in literature showing no detection of chikv in urine after the first week of symptoms onset .
this could provide an expanded window for the diagnosis of a recent infection with chikv .
the use of prednisolone may have contributed to the prolonged viral shedding and another factor that may , in part , have added to that was the possible interaction between chikungunya and dengue type 3 . with the ongoing circulation of denv , chikv and zikv in brazil , such a finding of dual infections will be increasingly seen and reported , as we recently published for chikv and zikv . in india ,
an estimate of co - infection with chikv and denv using serological markers estimated point prevalences on the range of 5.79.5% . in 1964
myers and carey reported that seven patients out of 332 patients ( 2.1% ) from south india had a simultaneous increase in antibody to both chikv and denv virus and that these patients had also an unremarkable clinical course and an expected development of antibodies to both agents , indicating that the host response was not altered by the dual infection . during an outbreak of both chikv and denv-1 in toamasina , madagascar , in 2006 ,
10 out of 55 patients sampled ( 18.2% ) were shown to be co - infected with both virus with no complications recorded .
however , chahar et al . reported that during the 2006 dengue outbreak in delhi six patients were co - infected with chikv and denv ( with denv-3 in 5 out of 6 ) , 2 of these patients had dengue hemorrhagic fever with central nervous system ( cns ) involvement and one patient died .
more recently , villamil - gomez et al . reported a 49-year - old male from colombia with a febrile illness , bilateral conjunctivitis and a pruritic rash that was diagnosed with zikv , chikv and denv and had an uneventful course .
the true extent of chikv - denv co - infection has been hampered by current diagnosis largely based on clinical grounds with unavailability of molecular methods in many parts of the world , .
this work was supported by the ministry of education  coordenao de aperfeioamento de pessoal de nvel superior ( capes )  zika fastrack number 88887116628/2016 .
written informed consent was obtained from the patient for publication of this case report and accompanying images .
a copy of the written consent is available for review by the editor - in - chief of this journal on request .

Answer:
absractwe report the presence of chikungunya ( chikv ) rna in the blood , urine and semen during the acute phase of the disease in an adult with a dual infection with dengue virus type 3 .
 the patient , a 25 yr - old man from salvador , brazil , reported a 6-day duration of high fever , arthralgia , myalgia , headache and photophobia.blood and semen specimens were positive for chikv in the first collected samples ; semen and urine specimens were positive for chikv after 30 days of symptoms onset .
 denv-3 rna was positive in blood specimen when first collected 6 days after the initiation of symptoms.we describe for the first time the presence of chikv rna in urine and semen for an extended period of time and we address the possible implications of these findings for diagnosis and transmission dynamics .


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:
it could be an incidental diagnosis in adulthood or could present with obstructive symptoms from the herniated viscera .
surgical treatment consists of direct closure or mesh placement for the diaphragmatic defect , or suturing by transabdominal or transthoracic access .
we report a patient with morgagni hernia who underwent a laparoscopic mesh placement with reduced port surgery ( rps ) .
an 85-year - old female presented in er with a 2-day history of upper abdominal discomfort and loss of appetite .
she had never experienced the same symptoms previously , and she denied any history of abdominal trauma .
physical examination revealed no palpable mass in the upper abdomen , and local tenderness on upper abdomen was shown without any peritoneal inflammatory signs .
serum blood test showed a hyperlipidemia and mild elevation of urea nitrogen ( total cholesterol , 250  mg / dl ; urea nitrogen , 22.5  mg / dl ) .
a ct scan showed a huge diaphragmatic anterior hernia with a segment of transverse colon and fat tissue migration ( fig .
the diagnosis of morgagni hernia was made and the patient was considered for repair of the diaphragmatic defect by the laparoscopic approach . under general anesthesia in the lithotomy position , the sils port ( covidien , tokyo , japan ) was inserted into a 2.5-cm umbilical incision vertically .
after inspection of the visceral space , a second port , 12  mm in size , was inserted into the left lower abdomen .
the herniated bowel and fat tissues were gently pulled down with grasping forceps and placed entirely into the abdominal cavity ( fig .
the defect was ovoid and approximately 5  cm in size , and difficult to close by the suturing technique ; therefore we performed mesh placement with gore - tex dual mesh ( gore inc .
operation time and operative blood loss were 157  min and 5  ml , respectively .
the patient started to eat a soft meal on day 1 after surgery and was discharged from our hospital on day 8 after surgery without any symptoms .
after 6-month , 12-month , and 24-month follow - ups , the patient had no sign of recurrence of the morgagni hernia ( figs . 4 and 5 ) .
giovanni - battista morgagni first described this type of hernia in 1769 . at present ,
it could be an incidental diagnosis in adulthood or could present with obstructive symptoms of the herniated viscera .
surgical treatment is required to relive current symptoms or to prevent possible future complications such as strangulation ileus or incarceration .
originally , direct closure of the hernia site or mesh placement was used as the surgical options by laparotomy or thoracotomy .
recently , the laparoscopic procedure has become available to treat this type of hernia and has bought a number of advantages such as reduced pain , shorter recovery time , and cosmetic benefits .
in addition , recent trends in laparoscopic procedures have been toward minimizing the number of incisions to achieve less invasiveness .
examples of such approaches are single incision laparoscopic surgery ( sils ) and reduced port surgery ( rps ) .
only one report previously described morgagni hernia repair using single port access and closing the hernia site by non - absorbable suturing into extra - abdominal region .
this report was very successful , however postoperative pain might be occurred because of suturing tension by lifting the interrupted sutures to close the hernia site .
some technical problems associated with sils have been reported : restriction of the working field and interference of surgical instrument .
the sils technique does not rely on triangulation , which is one of the core principles of conventional laparoscopic surgery , allowing adequate operative exposure while maintaining an ergonomic position for the surgeon and assistant .
consequently , the inherent technical challenge that arises from the sils technique is that of a compromised view and locomotive field . therefore unfavorite outcomes such as longer operative time and possibly higher complication rate have been reported in early period of sils operation .
a small additional port or a reduced number of ports as with rps are modifications that may overcome these problems . in combination with the sils port and the additional port
enable the performance of dual - port surgery , even for complex operation such as laparoscopic gastrectomy .
this type of repair is technically easy and should have a high probability of success because of the  tension free  condition .
also , less postoperative pain is also expected , compared to the external knot tying technique .
thoracoscopic approach is also other option for this type of hernia as a less invasive treatment , although the benefits over conventional laparoscopic approach have not been cleared .
although the benefits of sils or rps over conventional laparoscopic surgery have not been established , either sils or rps could be the first choice for symptomatic morgagni hernia repair because of the acceptable operation time , blood loss , and clinical outcome .
basically , cosmetic benefits and less operative pain are also expected as advantages of sils or rps originating from fewer incisions . in addition , tissue trauma and port - related complications such as organ damage , adhesions , bleeding , wound infections and hernias could be decreased . for the future direction , additional
this approach is safe and can be the good indication for this kind of hernia .
written informed consent was obtained from the patient for publication of this case report and accompanying images .

Answer: highlightsmorgagni hernia is a rare diaphragmatic hernia and standard therapy has not been established.the laparoscopic repair of a rare diaphragmatic morgagni hernia in an elder patient using the reduced port approach is described.this reduced port approach is a good indication for this type of hernia because of less invasive ness , cosmetics and safety .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
papillary thyroid carcinoma ( ptc ) is the most frequent type of thyroid malignancy , and the usual metastasis sites include the locoregional lymph nodes .
distant metastasis of ptc is rare and usually involves the lungs , liver , bones and brain .
the skin metastasis of ptc is a very rare condition , and the scalp is the most frequent cutaneous area which is involved .
other cutaneous areas that are involved with less frequency are the cheeks , shoulders , arms , abdomen and thighs .
a 64 year - old female with past medical history of metastatic papillary thyroid carcinoma ( ptc ) with both liver and lung metastasis presented with a 2.5  3 cm erythematous tender nodule in right parietal scalp of two months duration .
she had a past medical history of total thyroidectomy and also had received repeated doses of radioactive iodine ( rai ) therapy in the past two years .
her last dose of rai131 ( 200 mci ) was three weeks prior to the time of presentation .
she also had a history of subglottic mass as a result of thyroidal carcinoma involvement with severe tracheal stenosis , and had undergone tumoral resection and tracheal anastomosis and partial hemilaryngectomy two years ago because of subglottic involvement by thyroidal carcinoma .
high resolution computed tomography ( hrct ) demonstrated multiple metastatic nodules in both lungs and loculated left side pleural effusion consistent with advanced metastatic involvement .
a differential diagnosis of pillar cyst and metastasis was given by dermatologist for scalp lesion .
histopathologic examination of the lesion revealed skin tissue with tumoral involvement of the dermis composed of numerous follicles ( likely thyroid follicles ) , lined by relatively large cuboidal epithelial cells with round nuclei , fine chromatin pattern , little granular cytoplasm and eosinophilic colloidal material within some of follicles , and mitosis , which was consistent with metastatic thyroidal carcinoma [ figures 1 and 2 ] .
she was discharged with suppressive therapy with levothyroxine and referred to oncology clinic for continuation of the treatment plan .
scalp lesion biopsy showing skin tissue with tumoral infiltration of dermis by numerous follicles ( likely thyroid follicle ) , consistent with metastatic thyroidal carcinoma ( h and e , 40 ) scalp metastasis of thyroidal carcinoma composed of numerous follicles lined by relatively large cuboidal epithelial cells with round nuclei , fine chromatin , little granular cytoplasm and eosinophilic colloid material within some of follicles with mitotic division ( h and e , 400 )
the skin metastasis of ptc is mostly associated with aggressive and disseminated disease and shows a poor outcome .
some authors suggested that the average patient survival time after discovering of skin metastasis is 19 months .
here , we have reported a case of scalp metastasis of ptc in a patient with metastatic pulmonary and liver involvement .
metastasis of thyroid cancer should be considered in the differential diagnosis of scalp tumors in any patient with a history of thyroidal carcinoma ; and , excisional skin biopsy is necessary for confirming the diagnosis .

Answer:
the skin metastasis of papillary thyroid carcinoma ( ptc ) is a rare condition and the lesions should be differentiated from primary skin tumors .
 the scalp is the most frequent site which is involved in skin metastasis of ptc .
 it shows the poor outcome and aggressive nature of disease . in this report
 , we aim to present a case report of a 64 year - old female with scalp metastasis of ptc in the context of disseminated pulmonary and liver metastasis .