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:
lower urinary tract symptoms ( luts ) due to benign prostatic hyperplasia ( bph ) are one of the most common diseases in elderly males .
patients in general are prescribed an alpha - blocker first and then , if necessary , are treated by transurethral resection of the prostate ( turp ) if not enough response to the alpha - blocker is shown .
turp has been accepted as the gold standard for the surgical management of symptomatic bph . even though several excellent alpha - blockers are in use , some patients with severe luts require surgical therapy .
our county 's guidelines recommend surgical management for patients with bph with repeated urinary retention or bladder stone formation .
recently , surgical therapy has come to include methods thought to be relatively less invasive than turp .
these new methods have resulted in lower morbidity and excellent improvements in voiding and storage symptoms .
for example , holmium laser enucleation of the prostate ( holep ) has become a widespread and well - accepted treatment modality with excellent outcomes compared to other conventional treatment modalities such as turp and open prostatectomy . because this surgical procedure is comparatively new ,
surgeons tend to concentrate on the completion of the surgery , and most previous reports regarding holep have described the efficacy of the procedure for patients ' urination . as a next step , surgeons need to consider whether this procedure can be performed safely with a comparatively lower rate of adverse events than turp .
this new technique should not only be less invasive and offer better efficacy for urination but also show a lower ratio of adverse events , especially in terms of postoperative infectious diseases . in this study
, we retrospectively examined the incidence of postoperative infectious complications ( pics ) in our early experience with holep for bph with a particular focus on the kind and duration of prophylactic antibiotic administration ( paa ) .
a retrospective study was conducted in 90 patients complaining of luts who underwent holep combined with morcellation at our institute between february 2008 and march 2011 .
briefly , a modified 26-fr continuous - flow resectoscope ( karl storz gmbh & co. , tuttlingen , germany ) was used for enucleation of the prostate . a 550-m end - firing laser fiber ( slimline 550 ; lumenis inc . , yoqneam , israel )
was engaged with an 80 w holmium : yttrium - aluminum - garnet laser ( versapulse select , lumenis inc . ,
energy power was usually set at 72 to 80 w ( 1.8 to 2.4 j and 30 to 40 hz ) and at 0.2 j and 40 hz for hemostasis .
tissue morcellation was performed with a versacut morcellator ( versacut system , lumenis inc . ) through a 6-degree rectangular nephroscope ( karl storz gmbh & co. ) . during the transurethral procedure ,
the outer sheath was always in the urethra , because the resectoscope and nephroscope were exchangeable in the outer sheath .
after completion of the morcellation , a urethral catheter was inserted for continuous bladder irrigation with normal saline .
the kind and the dosing duration of paa were based on the physicians ' discretion .
pics were diagnosed according to the centers for disease control and prevention ( cdc ) guidelines ; in short , a pic was defined as a febrile ( body temperature 38 ) complication caused by a surgical procedure at a surgical site , such as urinary tract infection ( uti ) , that occurred within 30 days after surgery .
we analyzed the relationship between the emergence of pics and the kind or duration of paa .
statistical analysis was conducted with the jstat java virtual machine statistics monitoring tool with use of the chi - square test ( sun microsystems inc . , santa clara , ca , usa ) .
a retrospective study was conducted in 90 patients complaining of luts who underwent holep combined with morcellation at our institute between february 2008 and march 2011 .
briefly , a modified 26-fr continuous - flow resectoscope ( karl storz gmbh & co. , tuttlingen , germany ) was used for enucleation of the prostate . a 550-m end - firing laser fiber ( slimline 550 ; lumenis inc . ,
yoqneam , israel ) was engaged with an 80 w holmium : yttrium - aluminum - garnet laser ( versapulse select , lumenis inc . ,
energy power was usually set at 72 to 80 w ( 1.8 to 2.4 j and 30 to 40 hz ) and at 0.2 j and 40 hz for hemostasis .
tissue morcellation was performed with a versacut morcellator ( versacut system , lumenis inc . ) through a 6-degree rectangular nephroscope ( karl storz gmbh & co. ) . during the transurethral procedure ,
the outer sheath was always in the urethra , because the resectoscope and nephroscope were exchangeable in the outer sheath .
after completion of the morcellation , a urethral catheter was inserted for continuous bladder irrigation with normal saline .
the kind and the dosing duration of paa were based on the physicians ' discretion .
pics were diagnosed according to the centers for disease control and prevention ( cdc ) guidelines ; in short , a pic was defined as a febrile ( body temperature 38 ) complication caused by a surgical procedure at a surgical site , such as urinary tract infection ( uti ) , that occurred within 30 days after surgery .
we analyzed the relationship between the emergence of pics and the kind or duration of paa .
statistical analysis was conducted with the jstat java virtual machine statistics monitoring tool with use of the chi - square test ( sun microsystems inc . , santa clara , ca , usa ) .
twenty - three ( 25.6% ) had an indwelling catheter owing to urinary retention ( table 1 ) .
diabetes was seen in 19 patients ( 21.1% ) , heart disease in 17 ( 18.9% ) , and hypertension in 15 ( 16.7% ) .
urological cancer was seen in 3 patients ( 2 patients had bladder cancer and 1 renal cancer ) .
there were 18 patterns regarding the kind and duration of paa ; the details are shown in table 3 .
the most frequently used paa was sulbactam / ampicillin ( sbt / abpc ; n=32 , 35.6% ) , followed by cefazolin ( n=18 , 20.0% ) and cefotiam ( n=9 , 10.0% ) .
we examined the influence of the kind or duration of dosing of paa on pcc occurrence .
our statistical data showed that there were no significant differences between 2 or fewer days and 3 or more days of paa dosing with regard to pic occurrence .
there were also no significant differences between sbt / abpc , which was most frequently used in this study , and other antibiotics for paa with regard to pic occurrence ( tables 4 , 5 ) .
pic was diagnosed in 7 cases , and the paa of the cases was 3 sbt / abpc , 2 tazobactam / piperacillin , 1 cefazolin , and 1 cefotiam ( table 4 ) .
there were 3 cases of prostatitis , 2 cases of pyelonephritis , and 2 cases of epididymitis .
one case was diagnosed as sepsis after prostatitis caused by klebsiella pneumoniae and was cured by use of doripenem , cefazolin , and levofloxacin . in all , 2 cases of serratia marcescens , 1 case of proteus mirabilis , and 1 case of k. pneumonia were cultured , and these were quite different from the preoperative culture data shown above , which suggested that preoperative treatments might be effective ( table 6 ) .
twenty - three ( 25.6% ) had an indwelling catheter owing to urinary retention ( table 1 ) .
diabetes was seen in 19 patients ( 21.1% ) , heart disease in 17 ( 18.9% ) , and hypertension in 15 ( 16.7% ) .
urological cancer was seen in 3 patients ( 2 patients had bladder cancer and 1 renal cancer ) .
there were 18 patterns regarding the kind and duration of paa ; the details are shown in table 3 .
the most frequently used paa was sulbactam / ampicillin ( sbt / abpc ; n=32 , 35.6% ) , followed by cefazolin ( n=18 , 20.0% ) and cefotiam ( n=9 , 10.0% ) .
we examined the influence of the kind or duration of dosing of paa on pcc occurrence .
our statistical data showed that there were no significant differences between 2 or fewer days and 3 or more days of paa dosing with regard to pic occurrence .
there were also no significant differences between sbt / abpc , which was most frequently used in this study , and other antibiotics for paa with regard to pic occurrence ( tables 4 , 5 ) .
pic was diagnosed in 7 cases , and the paa of the cases was 3 sbt / abpc , 2 tazobactam / piperacillin , 1 cefazolin , and 1 cefotiam ( table 4 ) .
there were 3 cases of prostatitis , 2 cases of pyelonephritis , and 2 cases of epididymitis .
one case was diagnosed as sepsis after prostatitis caused by klebsiella pneumoniae and was cured by use of doripenem , cefazolin , and levofloxacin . in all , 2 cases of serratia marcescens , 1 case of proteus mirabilis , and 1 case of k. pneumonia were cultured , and these were quite different from the preoperative culture data shown above , which suggested that preoperative treatments might be effective ( table 6 ) .
holep for bph has become widespread in the urological field and has recently been performed at many institutions .
holep may involve less stress to patients   and should offer a lower rate of surgical site infection and postsurgical complications than open surgery or turp .
this surgery has the benefit of less extensive injury to prostatic tissue than turp ; thus , postsurgical local inflammation may not be as severe as with turp .
inflammation could be one risk factor for pics , such as prostatitis , and therefore holep may also be beneficial for suppressing pics . basically , holep is thought to cause the patients less stress in addition to having higher efficacy for luts .
however , the present study had 7 cases of pics , and this ratio may be comparatively higher than in other reports .
there are several possible reasons for this ; 1 ) our 90 cases were performed by 7 surgeons including beginners with less than 5 cases of experience with holep .
even though it is not clear whether there is a significant relationship between longer surgical time and a higher ratio of pic occurrence , beginners or less - experienced surgeons take more time to accomplish the surgery than experienced surgeons , both to finish the surgical procedures such as enucleation or tissue morcellation and to avoid surgery - related adverse events .
2 ) paa may not have included the most appropriate kind of antibiotics or duration of dosing .
this is because the cdc guidelines and japanese guidelines recommend that first - generation cephalosporins be administered every 2 to 3 hours during surgery and that penicillins , first - generation or second - generation cephalosporins , and aminoglycosides be administered within 72 hours in turp , respectively .
in addition , discrepancies may exist between paa performance and guideline recommendations in individual cases .
this is because , for instance , the japanese guideline recommends first - generation or second - generation cephalosporins , penicillins , and aminoglycosides for turp as mentioned above but has not yet established guidelines for holep .
our most often used paa is sbt / abpc and the duration of dosing is recommended to be within 72 hours .
however , our cases tended to have a longer duration of dosing with a higher ratio of pic occurrence than in other reports , even in preoperative nonpyuria cases .
our statistical data showed that pic occurrence did not depend on the kind or duration of paa , which suggests that we may be able to shorten the duration of paa , which may lead to the control of unnecessary antibiotic use . regarding causative bacteria , the pic cases included 2 cases of s. marcescens , 1 case of p. mirabilis , and 1 case of k. pneumonia .
our comparatively broader spectrum paa than recommended in guidelines or other reports , or preoperative intervention against preoperative pyuria cases , might have accounted for this difference .
this was a retrospective study and the number of cases was not enough for making definitive conclusions .
second , some of our cases were performed by surgeons who were less experienced with holep and showed a comparatively higher ratio of pic .
third , our paa duration of dosing tended to be longer and the kind of antibiotics tended to be broad spectrum , which could lead to the emergence and spread of resistant strains .
the results of this retrospective study showed that pic occurrence did not depend on the duration or the kind of paa in our early experience with holep .
further prospective study is necessary for the evaluation and establishment of prophylactic measures for pic .

Answer:
purposethe objective of this study was to retrospectively investigate postoperative infectious complications ( pics ) in our early experience with holmium laser enucleation of the prostate ( holep ) followed by mechanical morcellation for symptomatic benign prostatic hyperplasia.materials and methodsa retrospective review was performed of the clinical data for 90 consecutive patients who underwent holep at our institution between february 2008 and march 2011 . all patients were evaluated for the emergence of pics , including prophylactic antibiotic administration ( paa ) and the influence of the kind or duration of paa on pic .
 the details of cases with pics were also examined.resultsthe patients ' mean age was 71 years ( range , 50 to 95 years ) , and their mean prostate volume was 60 ml ( range , 2 to 250 ml ) .
 there were 7 cases ( 7.78% ) with pics ; in detail , 3 patients were diagnosed with prostatitis , 2 with pyelonephritis , and 2 with epididymitis .
 three patients had positive urine cultures : 1 had serratia marcescens / proteus mirabilis , 1 had s. marcescens , and 1 had klebsiella pneumonia ; only one case had urological sepsis .
 our statistical data showed no significant differences between 2 or fewer days and 3 or more days of paa and pic occurrence .
 there was also no significant effect on pic occurrence of sulbactam / ampicillin compared with other antibiotics.conclusionsthe results of this retrospective study showed that pic occurrence did not depend on the duration or the kind of paa .
 further prospective study is necessary for the evaluation and establishment of prophylactic measures for pics .


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:
rare fungi have recently been implicated in human infections ranging from colonisation to invasive fungal infections ( ifis ) in immunocompromised patients , accounting for < 10% of all isolated fungal pathogens.1
 pseudozyma species ( spp . )
are basidiomycetous yeast classified in the family ustilaginaceae , and its members are close relatives of ustilago maydis and other smut fungi .
infections in humans have rarely been reported after the first description as a human pathogen in 2003.3 data regarding the clinical characteristics and pathogenicity in humans remain insufficient .
recently , we experienced a case of pseudozyma aphidis fungaemia with invasive fungal pneumonia after reinduction chemotherapy for acute myeloid leukaemia ( aml ) . here , we describe this case and review the global literature .
mary 's hospital approved this case report and waived the need for patient consent ( no .
a 51yearold man who was diagnosed with aml and had not experienced remission after the first induction chemotherapy started reinduction chemotherapy with 100 mg m cytarabine for 7 days and 90 mg m daunorubicin for 3 days . on day seven after reinduction chemotherapy ( d7 ) , neutropenic fever ( up to 38.0 c ) developed as measured using an axillary thermometer .
laboratory data included a white blood cell count of 220 l ( absolute neutrophil count , 0 l ) and creactive protein level of 8.60 mg dl .
empirical antibiotic therapy with ceftazidime ( 2 g twice a day ) and isepamicin ( 400 mg once a day ) was initiated after performing blood cultures .
on d8 , the results of the blood culture revealed presumptive growth of grampositive cocci ( gpc ) .
teicoplanin ( 12 mg kg a day after loading with 12 mg kg every 12 h for three doses ) was added based on the culture results .
although the patient had no respiratory symptoms , infiltration was suspected in the right lower lung field on the chest radiograph on d9 .
lowdose computed tomography of the lung was performed , which showed consolidation with surrounding ground glass opacity at the medial segment of the right middle lobe ( rml ) ( fig .
the patient received fluconazole instead of posaconazole as the primary antifungal prophylaxis ; because he had participated in a clinical trial using a thrombopoietin receptor agonist during the same period , a drug interaction was possible .
then , the antifungal prophylaxis was empirically changed to caspofungin ( 50 mg a day after the loading dose ) for the possibility of fungal pneumonia according to the revised definition of ifi from the european organization for the research and treatment of cancer / mycoses study group ( eortc / msg).4
  low dose computed tomography of the lung .
consolidation with surrounding ground glass opacity at the medial segment of the right middle lobe .
the gpc from the blood culture was identified as vancomycinresistant enterococcus faecium ( 3 of 4 bottles ) , using vitek 2 ( biomrieux , hazelwood , mo , usa ) .
however , the neutropenic fever persisted , and yeastlike organisms were noted from central blood culture ( 1 of 2 bottles ) performed on the same day ( d11 ) .
this culture result was reported after 2 days of incubation , using bd bactec fx blood culture system ( bd diagnostics , sparks , md , usa ) .
colonies observed on the blood agar plate were white , dry or wrinkled ( fig .
the species could not be identified using either vitek 2 or api 20c ( biomrieux ) .
therefore , further identification was performed using rdna gene sequencing analysis with the following primers : internally transcribed spacer ( its)1 ( forward primer [ 5tcc gta ggt gaa cct gcg g3 ] and reverse primer [ 5gct gcg ttc atc gat3 ] ) , its2 ( forward primer [ 5gca tcg atg aag aac gca3 ] and reverse primer [ 5tcc tcc gct tat tga tat3 ] ) , and d1/d2 domain ( forward primer [ 5gca tat caa taa gcg gag3 ] and reverse primer [ 5ggt ccg tgt ttc aag acg g3]).5 the isolated gene sequence showed 100% concordance with the p. aphidis strain ( genbank accession number : kf443199.1 and kf443201.1 ) . because the fungaemia developed during the caspofungin therapy and pneumonia was aggravated with persistent neutropenic fever , caspofungin was changed to liposomal amphotericin b ( 5 mg kg per day ) on d15 .
yeastlike colonies that are dry , creamy , brightly coloured , and glabrous in texture ; ( b ) gram stain showing yeast with branching pseudohyphae ( arrow ) . the followup blood culture performed on
transbronchial lung biopsy and bronchial washing and brushing were performed at the rml bronchus to identify the pathogens of fungal pneumonia .
pathology specimens showed inflammatory changes with necrosis and dichotomous hyphae with a septum , suggestive of organising pneumonia with a fungal infection ( fig .
as the neutropenia recovered , the patient improved clinically and was discharged with itraconazole capsules ( 200 mg twice a day ) . at the outpatient clinic ,
chest radiography revealed little change in the rml consolidation despite 3 weeks of continued itraconazole .
considering the possibility of both proven invasive pulmonary aspergillosis and fungal pneumonia due to pseudozyma spp .
the patient sequentially received consolidation chemotherapy and allogeneic stem cell transplantation ( sct ) while continuing the voriconazole . during the voriconazole treatment , serum level of voriconazole was within the therapeutic range .
the pneumonia resolved after 4 months of voriconazole treatment , with complete remission of aml after successful sct .
( a ) haematoxylin and eosin stain , 100 ; ( b ) haematoxylin and eosin stain , 400 ; ( c ) silver stain , 400 .
invasive fungal infections remain a major cause of significant morbidity and mortality in immunocompromised patients , especially those with hematologic malignancies . of the ifis ,
a rare fungus is difficult to treat in the aspects of the early diagnosis and appropriate treatment , which might be related to the severity of the patient 's condition and often challenging intrinsic susceptibility pattern of the pathogens.6
 pseudozyma spp .
was first described as a possible human pathogen in 2003 , when it was identified from blood cultures from three thai patients , as p. antarctica , p. parantarctica , and p. thailandica.3 the first case of p. aphidis human infection was reported in a 7yearold girl with short gut syndrome in 2008.7

 pseudozyma spp .
is classified under the family ustilaginaceae , phylum basidiomycota , subphylum ustilaginomycotina , class ustilaginomycetes , and order ustilaginales.2 , 8 ustilaginales are plant pathogens that can infect corn plants to produce tumourlike galls . of the pseudozyma spp .
aphidis is known as the most common human pathogen . however , due to the rare isolation of p. aphidis in human infections , this rare fungus species can not be identified using commercial systems that are available in routine diagnostic laboratories . however
, sequencing and phylogenetic analysis can help with the direct detection of a fungus from blood or tissues because yeast taxonomy is continually evolving .
we retrospectively reviewed the global literature to identify the possible risk factors , clinical presentation , and optimal treatment strategies for pseudozyma infection ; in addition to the present case , 14 case reports were found ( table 1).3 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 since 2014 when previous literature review was reported by prakash et al .
therefore , we present a updated literature review with some modifications and adding recent cases . of the 15 cases ,
level identification , and the remaining six cases were nonaphidis pseudozyma isolates that were all different spp . from thailand .
of the nine cases with reported underlying medical conditions , three had gastrointestinal ( gi ) tract problems such as short bowel syndrome or intestinal surgery,4 , 9 , 13 and three had neutropenia7 , 14 , 15 which can damage the gut mucosa .
of the seven patients for whom the presence or absence of a central venous catheter ( cvc ) was reported , six patients had a cvc .
the risk factors are thought to be similar to those of other less common yeast infections including gi tract problems , the presence of a cvc , and neutropenia .
we could not identify the exact social history or dietary history to determine potential exposure to plants or crops .
however , crop exposure was identified in two cases : a farmer with mycetoma of the leg and a paediatric patient who had eaten corn chips.8 , 10 in the present case , the possible port of entry for the p. aphidis fungaemia is uncertain .
while the fungaemia met the definition of a catheterrelated bloodstream infection because p. aphidis was isolated only from central blood , the origin of p. aphidis is unclear .
literature review of pseudozyma species infections in human amb , amphotericin b ; aml , acute myeloid leukaemia ; cas , caspofungin ; cvc , central venous catheter ; flc , fluconazole ; itc , itraconazole ; lamb , liposomal amphotericin b ; mic , minimal inhibitory concentration ; n / a , not available ; tpn , total parenteral nutrition ; vrc , voriconazole ; 5fc , flucytosine .
histopathology of deep tissue from the foot showed grains surrounded by inflammatory cells , periodic acidschiff stain showed clustered yeastlike cells , and tissue cultures showed septate hyaline hyphae on a wet mount .
the major manifestation of pseudozyma infection is fungaemia ( 12 of 15 cases , 80% ) ; others ( n = 3 ) have been isolated from a brain abscess that developed after brain surgery , deep biopsy of mycetoma of the leg , and pleural fluid.9 , 10 , 11 in our case , we proved p. aphidis fungaemia with fungal pneumonia from lung tissue .
however , our case has a limitation , in that we could not identify the fungal pathogen from the lung tissue .
antifungal susceptibility testing was performed in 11 cases of human infections caused by pseudozyma spp .
, p. aphidis was susceptible to itraconazole , voriconazole , and amphotericin b ; had varying susceptibility to fluconazole ; and was resistant to echinocandines and flucytosine.7 , 8 , 11 , 14 , 15 nonaphidis pseudozyma spp
. seemed to have susceptibility to amphotericin b only.13 in all reported cases , pseudozyma spp .
, we described a case of a 51yearold male patient with aml who suffered from neutropenic fever during chemotherapy with a defined bacterial and fungal infection that was finally diagnosed as p. aphidis fungaemia and concurrent invasive fungal pneumonia without genus level identification .
many other fungal pathogens show subtle morphological differences between forms found in tissue and in culture
this case is worth reporting in the aspect that p. aphidis fungaemia developed during neutropenic fever with concurrent invasive fungal pneumonia in an aml patient .

Answer:
summary
 pseudozyma species rarely cause invasive diseases in humans , which are usually isolated from plants .
 there have been anecdotal reports regarding pseudozyma species infections in patients with underlying diseases or in neonates
 . however , clinical data and the pathogenicity in humans are still insufficient .
 we experienced a case of pseudozyma aphidis fungaemia with invasive fungal pneumonia that developed during reinduction chemotherapy in a 51yearold male with acute myeloid leukaemia ( aml ) .
 p. aphidis was suspected based on the morphology of the yeast isolated from the blood and was confirmed via rdna gene sequencing analysis .
 the patient successfully underwent stem cell transplantation with continuing antifungal treatment and finally completely recovered from both the aml and infectious complications . here , we report a case of p. aphidis infection that developed during neutropenia in an aml patient and review the global literature .


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:
oral hygiene habits are instilled in childhood itself irrespective of the nationality or geographic location of an individual .
the most reliable and accepted method of oral hygiene maintenance the world over are mechanical methods of tooth cleaning but adjuvants for decreasing plaque formation and maintaining oral hygiene have been sought .
presently chemotherapeutic agents are used as adjuvant agents to reduce plaque formation but they have their own disadvantages.1 kavala graha or gandoosha2 are procedures recommended for oral hygiene maintenance in ayurveda .
it is described as a procedure in which an individual takes a comfortable amount of oil / medicated oil and holds it or swishes it in the mouth .
when the oil turns thin and milky white it is spit out without swallowing.2 dr .
f. karach popularised this procedure as oil pulling.3 he claimed that oil pulling can cure several illnesses including oral diseases , but his claims were not supported by evidence .
recent studies of oil pulling therapy using sunflower oil4 and sesame oil5 were found to decrease plaque induced gingivitis . even though coconut oil is used for gargling among the people in coconut farming communities ,
no studies have been done on the benefits of oil pulling using coconut oil , to date .
coconut oil is an edible oil and is consumed as a part of the staple diet in many tropical countries .
coconut oil is different from most other dietary oils because the predominant composition of coconut oil is a medium chain fatty acid , whereas in the majority of other oils the basic building blocks are almost entirely long chain fatty acids .
human breast milk is the only other naturally occurring substance with such a high concentration of lauric acid .
lauric acid has proven anti - inflammatory effects and antimicrobial effects.678 therefore a study was conducted to assess the effect of coconut oil on plaque formation and plaque related gingivitis .
the aim of the study was to evaluate the effect of coconut oil pulling / oil swishing on plaque formation and to evaluate the effect on plaque induced gingivitis .
a total of 60 age matched subjects in the age - group of 16 - 18 years with plaque induced gingivitis were included in the study .
the use of systemic or topical antibiotics and the history of dental treatment in the past one month were set as exclusion criteria .
the study was designed to compare the baseline values and the post intervention values in a single group performing coconut oil pulling in addition to their oral hygiene routine .
a thorough history regarding the medical condition and the medication taken in the past 6 months was obtained from the subjects .
all the chosen subjects had a habit of brushing once or twice a day with toothbrush and paste .
six subjects had the habit of flossing once in the night along with brushing twice a day .
the subjects were advised to routinely perform oil pulling with coconut oil every day in the morning in addition to their oral hygiene routine .
five subjects discontinued from the study as they could not tolerate the taste of the oil and three subjects discontinued from the study because of antibiotic usage during the period .
modified gingival index9 and plaque index10 were used as the clinical measures to assess gingival inflammation and plaque formation respectively .
plaque and gingival indices were measured at baseline that is , and on days 1 , 7 , 15 , 30 after the oil pulling routine was started .
reliability of clinical examination was tested for all the days of assessment and the interexaminer reliability was found to be substantial to good .
the kappa coefficient scores were in the range of 65 - 92 [ table 1a and b ] .
the mean gingival index was 0.91 and the plaque index was 1.19 at baseline . in comparison to the baseline values both the gingival and the plaque indices substantially reduced during the period of assessment .
there was a steady decline in both the plaque index and the gingival index values from day 7 .
the average gingival index score on day 30 was down to 0.401 and the plaque index score was 0.385 [ figures 1 and 2 ] .
statistical analysis using the paired t test showed that the decrease was statistically significant [ tables 2 and 3 ] .
kappa scores for modified gingival index kappa scores for plaque index shows the mean and standard deviation of plaque index scores shows the mean and standard deviation of gingival index scores comparison of plaque index scores between baseline , 7 , 15 , and 30 days comparison of gingival index scores between baseline , 15 , 30 and 45 days
dental plaque is defined clinically as a structured , resilient substance that adheres to intraoral hard surfaces and is composed of bacteria in a matrix of salivary glycoprotein and extracellular polysaccharides .
plaque induced gingivitis is the result of an interaction between plaque and the tissues and the inflammatory response of the host .
it is associated with the subtle microbial alterations as the plaque matures.1112 oral hygiene measures using chemo mechanical procedures reduce the incidence of plaque related diseases by decreasing the plaque accumulation .
our study aimed at checking the effectiveness of oil pulling with coconut oil as an adjuvant to brushing , in decreasing the plaque accumulation and plaque induced gingivitis .
plaque index by sillness and loe10 and modified gingival index9 were used for clinical assessment in the study as they are the most widely used indices in trials for therapeutic agents.13 oil pulling with sunflower oil was found to significantly reduce plaque index and gingival index after 45 days.4 asokan et al . , found oil pulling therapy with sesame oil was equally effective as chlorhexidine in decreasing plaque induced gingivitis.5 in our study also there was a significant decrease in the plaque and the gingival index at the end of 30 days .
there are various hypotheses on the mechanisms by which oil pulling may act in decreasing the plaque and gingival index . in oil pulling , as the oil is swished in the mouth the mechanical shear forces exerted on the oil leads to its emulsification and the surface area of the oil is greatly increased .
the oil film thus formed on the surface of the teeth and the gingiva can reduce plaque adhesion and bacterial co aggregation.5 it was also proposed that the alkalis in the saliva can react with the oil leading to saponification and formation of a soap like substance [ figure 3 ] which can reduce the adhesion of plaque.514 coconut oil has a high saponification value and is one of the most commonly used oil in making soaps .
the soaps produced with coconut oil can lather well and have an increased cleansing action.15 the lauric acid in the coconut oil can easily react with sodium hydroxide in saliva during oil pulling to form sodium laureate , the main constituent of soap16 which might be responsible for the cleansing action and decreased plaque accumulation .
saponification reaction the significant reduction in gingivitis can be attributed to decreased plaque accumulation and the anti - inflammatory , emollient effect of coconut oil . in animal studies
coconut oil was found to be an effective burn wound healing agent and this was attributed to its anti - inflammatory and antiseptic properties.17 coconut oil showed moderate anti - inflammatory effects on ethyl phenylpropiolate induced ear edema in rats , and carrageenin and arachidonic acid - induced paw edema.18 it was found be effective and safe when used as an emollient and moisturiser.19 there are many commercially available mouthwashes .
listerine ( phenol compound ) and meridol ( an amine / stannous fluoride mouthwash ) were found to be less efficacious than chlorhexidine in controlling plaque induced gingivitis .
after 3 weeks of rinsing , plaque indices remained the lowest in the chlorhexidine group , while subjects using listerine or meridol the score were similar but significantly lower than that of individuals rinsing with the placebo solution .
the antimicrobial potential of chlorhexidine was found to be the highest followed by meridol.20 in our study there was a 50% decrease in the plaque and gingival index scores in 4 weeks which is comparable to the decrease produced by chlorhexidine .
chlorhexidine on long term use alters taste sensation and produces brown staining on the teeth which is very difficult to remove .
the mucous membranes and the tongue can also be affected and may be related to the precipitation of chromogenic dietary factors on to the teeth and mucous membranes.21 staining is also associated with the of long term use of phenol compound and stannous fluoride containing mouth washes.22 in the present study there were no reported alterations in the taste or noticeable staining from coconut oil at the end of 4 weeks . as an antimicrobial agent , chlorhexidine is effective against both gram positive and gram negative bacteria .
its antibacterial action is due to an increase in cellular membrane permeability followed by coagulation of the cytoplasmic macromolecules.232425 it has also been shown that chlorhexidine can reduce the adherence of porphyromonas gingivalis to epithelial cells.26 pure - culture studies of 10 oral bacteria ( eight genera ) showed that actinomyces naeslundii , veillonella dispar , prevotella nigrescens , and the streptococci were highly susceptible to chx , while lactobacillus rhamnosus , fusobacterium nucleatum , were less susceptible.27 studies show that coconut oil also has substantial antimicrobial activity .
it is shown to have significant antimicrobial activity against escherichia vulneris , enterobcater spp . ,
including c. albicans , c. glabrata , c. tropicalis , c. parapsilosis , c. stellatoidea and c. krusei728 studies also show that coconut oil is affective against s. mutans and c. albicans in an in vitro oral biofilm model.29 the antimicrobial potency of coconut oil was not tested in our study .
further studies with a have been planned to check the antimicrobial potential of coconut oil .
the fact that a control group with a proven chemotherapeutic agent was not used is the major the limitation of our study .
oil pulling has been proven to be an effective method in reducing plaque formation and plaque induced gingivitis .
this preliminary study shows that coconut oil is an easily usable , safe and cost effective agent with minimal side effects which can be used as an adjuvant in oral hygiene maintenance .
more studies on the antimicrobial potency of coconut oil on microorganisms causing oral diseases is required to authenticate the use of coconut oil as an effective oral antimicrobial agent .
further studies on coconut oil with a large number of subjects and comparative studies using various chemotherapeutic agents can improve the quality of evidence .

Answer:
background : oil pulling or oil swishing therapy is a traditional procedure in which the practitioners rinse or swish oil in their mouth .
 it is supposed to cure oral and systemic diseases but the evidence is minimal .
 oil pulling with sesame oil and sunflower oil was found to reduce plaque related gingivitis .
 coconut oil is an easily available edible oil .
 it is unique because it contains predominantly medium chain fatty acids of which 45 - 50 percent is lauric acid .
 lauric acid has proven anti inflammatory and antimicrobial effects .
 no studies have been done on the benefits of oil pulling using coconut oil to date .
 so a pilot study was planned to assess the effect of coconut oil pulling on plaque induced gingivitis.materials and methods : the aim of the study was to evaluate the effect of coconut oil pulling / oil swishing on plaque formation and plaque induced gingivitis .
 a prospective interventional study was carried out .
 60 age matched adolescent boys and girls in the age - group of 16 - 18 years with plaque induced gingivitis were included in the study and oil pulling was included in their oral hygiene routine .
 the study period was 30 days .
 plaque and gingival indices of the subjects were assessed at baseline days 1,7,15 and 30 .
 the data was analyzed using paired t test.results:a statistically significant decrease in the plaque and gingival indices was noticed from day 7 and the scores continued to decrease during the period of study.conclusion:oil pulling using coconut oil could be an effective adjuvant procedure in decreasing plaque formation and plaque induced gingivitis .


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:
endoscopic ultrasound ( eus)-guided tissue acquisition is the diagnostic procedure of choice in many diseases of the gastrointestinal tract and adjacent structures .
this procedure is well known for its high accuracy and low complication rate ; however , its outcome closely relies on several factors .
the location and characteristics of the lesion , endosonographer 's experience , needle size and type , sampling technique , sample preparation , presence of a cytopathologist for rapid on - site examination ( rose ) , and cytologist 's expertise are considered some of the important factors.1,2 issues related to needle selection will be discussed here .
currently , there are three different sizes of commercially available eus fine - needle aspiration ( eus - fna ) needles : 19 , 22 , and 25 gauge ( g ) .
the size of the needle should be chosen consciously because it can directly affect the quality of the procured sample . generally speaking ,
larger needles may render bigger tissue for diagnosis ; however , samples tend to be bloodier , which might hinder the cytologic interpretation .
as a 19 g conventional needle is stiff and has limitation in the transduodenal approach , a new flexible 19 g nitinol needle ( expect 19 g flex ; boston scientific , natick , ma , usa ) has been introduced.3 recently , a new side - port needle has been developed by olympus ( tokyo , japan ) , and it is expected to allow better cellular acquisition.4 the spring - loaded 19 g biopsy needle trucut ( cook medical , winston - salem , nc , usa ) has been designed for the procurement of tissue core samples;5 however , it is not feasible to use with the transduodenal approach and has been reported to result in technical failures . the newly developed procore needle ( cook medical ) , which incorporates reverse bevel technology , has various available sizes and enables the transduodenal approach.6
currently , there are three different sizes of commercially available eus fine - needle aspiration ( eus - fna ) needles : 19 , 22 , and 25 gauge ( g ) .
the size of the needle should be chosen consciously because it can directly affect the quality of the procured sample . generally speaking ,
larger needles may render bigger tissue for diagnosis ; however , samples tend to be bloodier , which might hinder the cytologic interpretation .
as a 19 g conventional needle is stiff and has limitation in the transduodenal approach , a new flexible 19 g nitinol needle ( expect 19 g flex ; boston scientific , natick , ma , usa ) has been introduced.3 recently , a new side - port needle has been developed by olympus ( tokyo , japan ) , and it is expected to allow better cellular acquisition.4
the spring - loaded 19 g biopsy needle trucut ( cook medical , winston - salem , nc , usa ) has been designed for the procurement of tissue core samples;5 however , it is not feasible to use with the transduodenal approach and has been reported to result in technical failures .
the newly developed procore needle ( cook medical ) , which incorporates reverse bevel technology , has various available sizes and enables the transduodenal approach.6
the advantage of eus - guided tissue acquisition is its high accuracy and safety . according to a meta - analysis ,
the pooled diagnostic sensitivity and specificity of eus - fna in the diagnosis of solid pancreatic masses were 86.8% ( 95% confidence interval [ ci ] , 85.5 to 87.9 ) and 95.8% ( 95% ci , 94.6 to 96.7 ) , respectively.7 however , there is no consensus on the number of passes to achieve the highest diagnostic accuracy . increased number of passes may yield a higher diagnostic accuracy with a theoretically higher complication rate .
the average numbers of passes to obtain an adequate diagnostic sample for a solid lesion are known to be five to seven passes for the conventional fna needle .
however , the mean number of passes required for diagnosis with the new olympus 22 g side - port needle was only 1.7 in a prospective multicenter study ; however , the number of enrolled cases in that study was small.8 the procore needle seems to be able to obtain enough tissue for diagnosis with only a few passes . when single and multiple ( two to four ) passes of the 25 g procore needle were compared in the diagnosis of solid pancreatic lesions , the sensitivity , specificity , and accuracy were 85% vs. 96% , 100% vs. 100% , and 86% vs. 96% , respectively.9 in a prospective study , the diagnostic accuracy of eus - guided trucut needle core biopsy was 61% , with a mean value of 1.4 needle passes.10 the transduodenal approach was possible only in 40% of the patients . when subgroup analysis was done on technically successful cases only , the diagnostic accuracy was 87.5% . in a multicenter , pooled , cohort study ,
the overall diagnostic accuracy of the 19 g procore needle was 85%.6 during transduodenal procedures , sampling was done in 94% ; however , there were some technical difficulties .
the combination of eus - fna / fine - needle biopsy ( fnb ) techniques revealed the highest diagnostic accuracy of 91% compared with 77% for eus - fna alone and 73% for eus - fnb alone ( p=0.008).11 another study showed an 84% diagnostic accuracy with eus - guided trucut needle biopsy and suggested the additional use of eus - fna as a rescue diagnostic tool.12 eus - fnb is useful in obtaining core tissue with a few passes
. rose is critical for the high diagnostic accuracy of eus - fna;13 however , if an endosonographer can obtain visible tissue core with an fnb needle , the outcome may not be dependent on rose , which is not always readily available for many institutions .
aspiration of core tissue with preserved architecture is beneficial for the diagnosis of some specific diseases such as submucosal masses,14 lymphomas,15 and autoimmune pancreatitis.16 as molecular profiling and personalized oncologic therapy are becoming important concepts nowadays , a histologic core biopsy sample is necessary for ancillary testing.17 tissue core can be obtained with a conventional aspiration needle or a specialized fnb needle .
a study reported that satisfactory histologic specimens were procured in 94.7% and tissue acquisition for cytological assessment was successful in 100% , including the transduodenal route , when an expect 19 g flex aspiration needle was used.3 the high tissue acquisition rate is partially because of the high elasticity of the needle , which facilitates the transduodenal pass .
small pancreatic lesions ( < 2 cm ) and nueroendocrine tumors are related to a higher complication rate ; however , no definite relation was proven with patient 's age , location of lesion , needle size , and number of needle passes.18 the type of needle does not seem to pose a big difference in the complication rate .
many studies reported that there was no significant difference in diagnostic outcome and needle size .
a study reported that the diagnostic accuracy of the 19 g needle for solid pancreatic and peripancreatic masses was 86.7% and that of the 22 g needle was 78.9% ( p=0.268).19 a 19 g aspiration needle could render a higher amount of tissue ; however , technical failure was more frequent when the mass was located in the head of the pancreas .
when technical failures were excluded , the diagnostic accuracy of the 19 g needle was 94.5% .
it can be easily bent in a perpendicular direction and also has a wider puncture range .
therefore , the 25 g needle is better for targeting pancreatic head and uncinate lesions through the transduodenal route .
the obtained sample size may be smaller , but it might result in minimal blood contamination . in a prospective , randomized trial comparing 22 and 25 g needles for solid pancreatic masses , the tissue samples provided positive diagnosis in 87.5% in the 22 g group and 95.5% in the 25 g group ( p=0.18).20 according to a meta - analysis , the pooled sensitivity of the 22 and 25 g needles was 0.85 ( 95% ci , 0.82 to 0.88 ) and 0.93 ( 95% ci , 0.91 to 0.96 ) , respectively .
the pooled specificity of the 22 and 25 g needle was 1 ( 95% ci , 0.98 to 1.00 ) and 0.97 ( 95% ci , 0.93 to 0.99 ) , respectively .
the 25 g needle showed a higher sensitivity ( p=0.0003 ) but comparable specificity to ( p=0.97 ) the 22 g needle.21 another study showed that the overall accuracy of the 25 and 22 g eus - fna needles and the 19 g trucut needle was 91.7% , 79.7% , and 54.1% , respectively , in the diagnosis of solid pancreatic masses.22 for head and uncinate lesions , the 25 g fna needle was technically more successful and had significantly superior overall diagnostic accuracy than the other needles .
a study compared same - sized fna and fnb needles for the diagnosis of solid pancreatic neoplasms and reported a striking result.23 when five passes of the 22 g echotip ultra needle and two passes of the 22 g echotip procore needle were performed for same lesion alternately for 32 cases , the ability to achieve a diagnosis was 93.8% for fna and 28.1% for fnb . during the fnb procedure ,
when the echoendoscope was positioned within the duodenum , fnb could not be performed because of technical reasons .
the authors did not explain the details of tissue processing failures but noted that the " procore needle failed to obtain enough tissue to survive processing as a regular core biopsy for histology ( tissue attrition during processing ) .
" however , a previous randomized trial that compared a 22 g fna needle ( expect ; boston scientific ) and a 22 g fnb needle ( echotip procore ; cook endoscopy , bloomington , in , usa ) for solid pancreatic masses reported different results.24 the diagnostic sufficiency was 100% and 89.3% ( p=0.24 ) for the fna and fnb needle , respectively .
the 22 g biopsy needle procured both cytologic and histologic specimen ( 89.3% and 80% , respectively ) , with a 3.6% technical failure rate .
according to a meta - analysis , needle size confers only a limited effect on the overall outcomes in eus - fna for solid pancreatic masses.25 a study compared 22 g eus - fna without rose and 19 g trucut biopsy.26 the overall accuracy was 76% for both procedures , whereas the combination of the two procedures rendered a 95% diagnostic accuracy .
thus , eus - fnb showed a similar diagnostic accuracy to eus - fna without rose , with fewer passes .
the authors reported that they can obtain a positive report with eus - fnb when eus - fna was negative in cases of gastrointestinal stromal tumors , pancreatic adenocarcinoma , lung cancer , metastatic mediastinal node , retroperitoneal lymphoma , and mediastinal lymphoma.26
usually , a cytological sample is enough to establish a diagnosis ; however , histologic assessment may be useful in some cases such as pancreatic tumors other than pancreatic adenocarcinoma , tumors surrounded by chronic pancreatitis , submucosal and intramural gastrointestinal tumors , and for the biopsy of lesions or lymph nodes in which lymphoma is suspected.17 certain diseases such as autoimmune pancreatitis , well - differentiated adenocarcinoma , and highly desmoplastic pancreatic neoplasm may also require tissue core samples for a definitive diagnosis .
histological samples can often be obtained with a standard fna needle , and addition of cell block examination can provide good information that is comparable to an fnb sample.27 therefore , eus - fnb can be a recommendable supplementary technique when additional tissue and histologic section are necessary for an accurate diagnosis and if molecular characterization of tumors is required.8,17 the stiffness of the needle is a large obstacle to overcome in harvesting core tissues with the transduodenal approach .
the needle size and type can be some of the factors that influence the diagnostic yield of eus - guided tissue acquisition .
there are no convincing data showing any significant advantage between the three commonly used fna needle sizes . the smaller 25 g needle , which yields at least comparable results to the 22 and 19 g needles , may be easier to maneuver .
large - bore needles can procure more tissue ; however , the sample tends to be bloodier and technical failure may occur .
the yield of an fnb needle is higher with fewer passes and ancillary testing is usually possible .
needle selection is a complex process and should be made on the basis of many aspects , such as the location and physical characteristics of the lesion , availability of rose , and clinical needs considering the suspected diagnosis.29

Answer:
endoscopic ultrasound ( eus)-guided tissue acquisition is an indispensable technique for the diagnosis of many diseases of the gastrointestinal tract and adjacent structures .
 eus - guided fine - needle aspiration ( eus - fna ) is known for its high accuracy and low complication rate . however , the outcome of eus - fna highly depends on several factors such as the location and characteristics of the lesion , endosonographer 's experience , technique of sampling and sample preparation , type and size of the needle used , and presence of a cytopathologist for rapid on - site examination .
 eus - guided fine - needle biopsy is useful to obtain core tissue samples with relatively fewer passes .
 aspiration of core tissue with preserved architecture is beneficial for the diagnosis of certain diseases and the performance of ancillary testing such as tumor molecular profiling .
 issues related to needle size , type , and their acquired samples for cytologic and histologic evaluation are discussed here .


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:
saudi arabia ( sa ) is a large country with an area of about 2.2 million square kilometers and total population exceeding 27 million , of which 69% are saudis .
less than one quarter of cancer patients in sa present with localized disease . indeed , most cancer patients present with advanced disease with regional or distant extension .
the crude and age standardized cancer incidence rates in 2007 were 52.3 and 82.1 per 100,000 populations , respectively .
the five most common cancers , in descending order , are colorectal , non - hodgkin lymphoma , leukemia , lung , and liver in males ; and breast , thyroid , colorectal , non - hodgkin lymphoma , and leukemia in females .
the palliative care ( pc ) program at king faisal specialist hospital and research center ( kfshrc ) , riyadh , was established more than 20 years ago as the first program of its kind in the country .
the program delivers services for inpatients , outpatients , as well as for those at home through a home health care service .
the program has also established a structured postgraduate fellowship for physicians pursuing subspecialty in palliative medicine .
awareness of symptomatology pattern in cancer patients enables health care professionals to place appropriate emphasis on various challenges in a prioritized manner
. prioritization process may include patient care plans , professional education plans , and the needs of health care services .
furthermore , the quality of life of patients with advanced cancer could be significantly improved if specialized palliative care teams were involved in addressing the variety of symptoms that are common among these patients .
therefore , impeccable identification and management of symptoms are two crucial aspects of palliative care . a recent report from 11 european countries
suggests that there are variations between countries in the number of inadequately treated cancer - related symptoms . to the best of our knowledge ,
no previous report has described the prevalence and severity of nonpain symptomatology among patients with advanced cancer in saudi arabia ( sa ) .
this paper aims at determining the prevalence and severity of 10 nonpain symptoms in cancer patients visiting the pc outpatient clinic at kfshrc , riyadh , sa .
this is a cross - sectional survey exploring the pattern of 10 common nonpain symptoms in an outpatient palliative care clinic .
the research advisory council ( rac ) of kfshrc have approved the research project ( rac number 2101053 ) based on the approval of the research ethics committee .
adult cancer patients who were oriented to person , place , and time were consecutively included in the study .
the 10 nonpain symptoms included tiredness , nausea / vomiting , anxiety , depression , shortness of breath , drowsiness , insomnia , dry mouth , loss of appetite , and confusion .
the intensity of each symptom at the time of the encounter in the clinic was determined by each patient based on a 010 numerical scoring system where zero means the absence of respective symptom and 10 means the greatest severity a person could possibly imagine .
the performance status was determined using the palliative performance scale ( pps ) , which is a reliable and valid observer - rated tool for measuring performance status in pc patients .
the pps consists of five domains ( on a scale of 0%100% , with increments of 10% ) , namely ambulation , self - care , activity level / evidence of disease , intake , and conscious level .
all interviews were conducted by one of the authors ( oa ) to avoid the potential of inter - rater variability .
data analysis was conducted using the software package sas version 9.2 ( statistical analysis system , sas institute inc . ,
the student 's t test for independent samples was used to compare means between two groups , such as those related to gender , age group , encounter type , and performance status .
one - way analysis of variance was used for comparing the means among more than two groups such as in the case of grouping according to cancer type . a value of p less than 0.05 was considered significant .
a total of 124 patients were interviewed , with a median age of 56 years and dominance of female gender ( 59% ) .
one third of the patients were seen on follow - up basis and the rest were new to the palliative care outpatient clinic .
all patients had advanced incurable cancer , with the majority ( 102 ; 82.3% ) diagnosed with metastatic disease . for patients who were still receiving anticancer treatment ,
the most frequently encountered cancer types were female breast ( 27.4% ) , head and neck ( 15.3% ) , and genitourinary ( 12.9% ) .
only one patient denied any nonpain symptom while all other patients had from 1 to 10 nonpain symptoms per patient , with a mean number of symptoms of 5.1  2.2 .
the majority of patients ( 93 ; 75% ) had more than 3 nonpain symptoms each .
the mean number of symptoms was higher in patients with pps of less than 70% ( 5.9  1.9 ) as compared with those who had better performance status ( 4.6  2.3 ) ( p = 0.002 ) .
however , the mean number of symptoms did not show any statistically significant difference between groups of patients based on age , gender , cancer type , or the type of outpatient encounter .
the most frequently reported symptoms were tiredness ( 79.8% ) , loss of appetite ( 71.8% ) , dry mouth ( 69.4% ) , and anxiety ( 60.5% ) , whereas the least prevalent symptoms were nausea and confusion ( 22.6% each ) [ table 2 ] . for symptomatic patients ,
the mean severity scores were highest for tiredness ( 5.1 ) and loss of appetite ( 5 ) and lowest for nausea and confusion ( 3.4 each ) as shown in table 2 .
older patients ( above the median age , 56 years ) had lower mean anxiety score compared with younger patients , 1.9 and 3.2 , respectively ( p = 0.003 ) .
females had higher mean severity scores than males in 4 symptoms , namely , tiredness ( 4.6 vs 3.5 ; p = 0.04 ) , nausea / vomiting ( 1.0 vs 0.4 ; p = 0.02 ) , anxiety ( 3.2 vs 1.7 ; p = 0.001 ) , and loss of appetite ( 4.2 vs 2.7 ; p = 0.003 ) .
patients with lower pps tended to have significantly higher severity scores for tiredness , shortness of breath , drowsiness , dry mouth , and loss of appetite , see table 2 .
the mean severity scores of symptoms did not significantly differ between patients according to their cancer type or the nature of outpatient visit ( new vs follow - up ) .
however , when patients with primary or secondary lung or pleural disease were pooled in one group , they had higher mean severity scores of shortness of breath compared with other patients , 2.4 and 1.2 , respectively ( p = 0.01 ) . symptom prevalence and severity
the participation of all approached patients in our study was not unexpected because the questions were all focused on the presence and severity of symptoms known to be fairly common among cancer patients .
the median age of our study population agrees with the findings of a previous report on a larger group of advanced cancer patients in sa and appears generally younger than the median age of the palliative care population in western countries.[911 ] this might be explained by the fact that more than 97% of the saudi population represents those younger than 65 years .
the finding that metastatic or locally advanced disease is the rule in the studied population may be explained by the trend of delayed diagnosis of cancer in sa as well as the common practice of delayed referrals to palliative care in kfshrc .
symptom prevalence studies on patients with advanced cancer have mostly targeted inpatients rather than outpatients . furthermore , most reports have major variations in demographics of surveyed populations and in methodologies implemented , which obviously make comparisons between the findings of various reports less meaningful .
that being said , our findings have shown higher prevalence of nonpain symptoms among patients with advanced cancer compared with what other researchers have reported .
for instance , grond and colleagues have reported that cancer patients attending an outpatient pain clinic were having on average 3.3 nonpain symptoms the most prevalent of which were insomnia ( 59% ) and loss of appetite ( 48% ) . according to several reports , it seems that the more symptoms are actively assessed the more symptoms will likely be reported.[1517 ] similar to our results , there is a common finding among various reports that tiredness ( also reported as fatigue or weakness in some studies ) is often on the top of the list of prevalent nonpain symptoms among patients with advanced cancer.[1620 ] potter and coauthors have reported nonpain symptoms in patients seen at an outpatient pc clinic in the uk , with the most prevalent symptoms being tiredness and nausea ( 18% each ) and loss of appetite ( 17% ) .
a recent report from lebanon has shown high prevalence of fatigue ( 88.4% ) , dyspnea ( 65.1% ) , depression ( 53.5% ) , and confusion ( 37.2% ) among inpatients with advanced cancer .
alshemmari et al . from kuwait have studied cancer patients who were largely having advanced incurable disease and found the most common nonpain symptoms to be fatigue ( 80% ) , anorexia ( 67% ) , weight loss ( 49% ) , and dyspnea ( 42% ) .
overall , the severity of symptoms reported by our patients was generally more than what has been reported elsewhere on a group of cancer patients hospitalized for palliative reasons .
our findings have supported previous reports suggesting that poorer performance status may be associated with higher symptom burden .
in addition , we have found that some symptoms might be associated with higher severity scores in patients with poor performance status .
have found , our data failed to show an association between symptom prevalence and age or gender of patients .
however , younger patients in our study had higher severity scores of anxiety than older patients . also , females reported higher severity scores as compared with males in few symptoms including anxiety .
our finding that patients with primary or secondary lung or pleural cancer were having severe shortness of breath supports what has been suggested by kirkova et al . that some symptoms may vary in prevalence or severity ( or both ) based on cancer site . in the pc outpatient clinic at kfshrc
, it is common for patients relatives to attend follow - up clinics on behalf of patients for the sake of medication refill , hence the lower proportion of follow - up patients as compared with new patients in our study .
however , one reason could be the fact that many patients reside outside riyadh and , like most saudis , have widely extended families with good chances of having relatives living in riyadh who would be happy to visit the clinic on behalf of the patients .
although air fares for health care - related travel are usually covered by the government , some patients may find it difficult to attend the clinic in person due to poor performance status .
however , we are under the impression that a good number of patients who prefer to send relatives to attend the clinic on their behalf might be having symptoms that are fairly controlled .
this could partially explain the high prevalence and severity of symptom burden in our sample as well as the finding that symptom prevalence and severity in our study was similar in patients new to the pc clinic and those returning to the clinic for follow - up .
limitations of our study include the relatively small number of participants and the cross - sectional nature of the study design .
a longitudinal design with sequential assessments of a larger group of patients from different centers could have generated more generalizable data .
a much longer list of nonpain symptoms could have been better representatives of symptom burden among this group of patients .
future multicenter research on the same lines may be focused on longitudinally assessing symptom burden in such patients , with emphasis on exploring the efficiency and effectiveness of symptom management strategies in pc outpatient settings .
despite the wide variation in reports that explored symptom pattern and prevalence in patients with advanced cancer , it is clear that they all agree upon the fact that patients with advanced cancer are polysymptomatic .
the significant prevalence and severity of nonpain symptoms among new and follow - up cancer patients seen in a pc outpatient clinic emphasizes the need for comprehensive assessment and routinely audited symptom management plans .

Answer:
background : epidemiology of cancer - related nonpain symptoms receives less attention in literature as compared with cancer pain.objective:this paper aims at exploring the prevalence and severity of nonpain symptoms in cancer patients attending a palliative care ( pc ) outpatient clinic.materials and methods : over a 5 months period , consecutive adult cancer patients attending pc outpatient clinic at a tertiary hospital were evaluated for the presence and severity of 10 nonpain symptoms .
 patients were grouped to new or follow - up cases and were also grouped according to performance status and cancer type .
 prevalence and severity of symptoms were compared between groups using t test or analysis of variance as appropriate.results:fifty-one males and 73 females were interviewed .
 the most common cancer is female breast ( 27.4% ) followed by head and neck ( 15.3% ) .
 majority of patients ( 67% ) were new to pc clinic .
 patients had 5.1 nonpain symptoms on average , with most common symptoms being tiredness ( 79.8% ) , loss of appetite ( 71.8% ) , dry mouth ( 69.4% ) , anxiety ( 60.5% ) , and depression ( 50.8% ) .
 the least common symptoms were confusion and nausea ( 22.6% each ) .
 the median scores of severity were highest for tiredness , loss of appetite , dry mouth , and insomnia ( 5 points each ) .
 symptoms were fewer among patients with good performance status ( p = 0.002 ) , whereas age , gender , cancer type , and encounter type were not associated with difference in symptom prevalence .
 younger patients , females and those with poor performance status have shown a tendency toward higher severity scores for several symptoms.conclusion:the significant prevalence and severity of nonpain symptoms among new and follow - up cancer patients seen in a pc outpatient clinic emphasizes the need for comprehensive assessment and routinely audited symptom management plans .


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 plays several important physiological and pathological roles in not only reproductive system but also other systems .
estrogen disorder results in various diseases , such as endometrial diseases , skeletal diseases , and reproductive system tumors .
increasing attention has been paid to revealing of the functions of estrogen in physiological and pathological conditions .
estrogen receptors ( er )  and  , the two well established nuclear estrogen receptors , have different physiological functions depending upon their various distributions .
lots of evidences show that estrogen induces the proliferation of cancer cells in breast , uterus , and ovarian cancer through er. on the contrary , activation of er can reverse this effect .
notably , a novel transmembrane estrogen receptor , known as g - couple estrogen receptor ( gper ) , was found .
er are involved in the initiation , migration , and progression of estrogen - related multiorgan cancers , such as breast cancer , ovarian cancer , prostate cancer , testicular cancer , liver cancer , and lung cancer as well .
although increasing studied are focused on the roles of gper-1 in different types of cancers , the functions of gper-1 in cancers remain unclear yet .
characteristics and functions of reproductive system cancer will be summarized and discussed in the present review .
g - protein - coupled estrogen receptor-1 ( gper-1 ) , a seven - transmembrane - domain receptor localized in cell surface , was first identified in 1996 .
gper-1 is detected broadly in numerous human tissues , such as breast , prostate , ovary , placenta , subcutaneous adipose , visceral adipose , arteries , vessels , heart , liver , lung and intestine tissues .
gper-1 is a member of gpcr superfamily , which is structurally unrelated to the classical er and er. there are four transcriptional variants encoding 375 amino acids composing seven transmembrane proteins .
but gper-1 binding domain exists inside the plasma membranes and the endoplasmic reticulum [ 58 ] .
estradiol , the major type of estrogen , binds to gper-1 with a high affinity to gper-1 while the other two isoforms , estrone and estriol , have very low binding affinities [ 5 , 9 ] .
furthermore , numbers of environmental estrogen bind to gper-1 and activate the downstream signaling pathways , such as bisphenol a , genistein , and nonylphenol .
gper-1-specific compound 1 ( g-1 ) is a specific agonist of gper-1 , which has no function of er and er and was identified using virtual and biomolecular screening in 2006 .
g-1 has been widely used as a target tool to evaluate the function of gper-1 in different cells and disease models .
gper-1 mediates both genomic and nongenomic response with its ligands . to date , gper-1 signaling pathways have not been fully elucidated yet .
the binding ligands of gper-1 , such as estrogen , g-1 , tamoxifen , and ici182,780 , cross the plasma membrane and bind to the gper-1 on endoplasmic reticulum where they activate its  and  subunits and subsequently activate both src and adenylyl cyclase ( ac ) leading to the intracellular camp production .
the phosphorylation of src induces matrix metalloproteinase ( mmp ) production , which cleaves pro - heparan - bound epidermal growth factor ( pro - hb - egf ) releasing free hb - egf .
hb - egf binds to the egfr leading to activation of multiple molecules such as ras , pi3k , akt , and erk1/2 .
the downstream signal of pi3k and akt results in several nuclear receptors activation which is closely related the proliferation and migration of cancer cell .
gper-1 also binds to the g - couple protein  subunit and activates the phospholipase c ( plc ) , ac , and camp .
activated plc results in inositol triphosphate ( ip3 ) production , which further binds to its receptor and leads to intracellular calcium mobilization .
breast cancer is generally classified into estrogen receptor positive ( er+ ) and er negative ( er ) . in clinical practices ,
the endocrine treatments such as tamoxifen and aromatase are recommended in the er positive breast cancers , while there is no benefit in the er negative cancers .
gper-1 is widely expressed in both of these breast cancer types and the primary breast cancers .
recent clinical study results showed that the expression of gper-1 might correlate with clinical and pathological poor outcome biomarkers .
other results also showed that the expression of gper-1 was inversely correlated with the er expression .
coexpression of gper-1 and er was found in almost 24% patients with inflammatory breast cancer , while 19% only express er and 46% only express gper-1 .
the gper-1 mrna levels were significant higher in er positive breast cancer cells compared to er negative cancer cells , and the expression of gper-1 depends on er mrna level .
interestingly , gper-1 preformed a different proliferation manner in er positive mcf-7 breast cancer cell line .
g-1 enhanced migration of mcf-7 breast cancer cells by activating erk1/2 and egfr signaling pathway , which is tremendously attenuated by g15 .
the other evidences also approved that gper-1 is an initiator of tamoxifen resistance in breast cancers [ 1921 ] .
the promotion roles of gper-1 in cancer cells proliferation and migration may be correlated with the autolysis of calpain 1 , cleavage of cyclin e , or the expression of target gene .
there are also some studies which found that gper-1 inhibits the growth of er positive mcf-7 cells , which is probably through g - couple  and  subunits activating without camp signal activation [ 2124 ] . however , combination treatment with g-1 and her2 antibody trastuzumab exerted an additive growth inhibitory effect on breast cancer cells .
thus , gper-1 inhibits er positive breast cancers proliferation which is a potential target for er positive breast cancers and drug - resistant breast cancer .
deficiency of er in breast cancer is correlated with poor response to endocrine therapy . in er negative breast cancers , gper-1 stimulates the erk1/2 through the egfr / mapk signal cascade , inducing target gene like c - fos expression , which is involved in the progressing of breast malignancies [ 2729 ] .
estrogen and antiestrogens can also promote the production of the early growth response-1 ( egr-1 ) , connective tissue growth factor ( ctgf ) , and insulin - like growth factor 1 ( igf-1 ) through the gper-1 [ 28 , 30 , 31 ] .
grp30 activation stimulated breast cancer cells migration through ctgh , cxc receptor ( cxcr1 ) , and notch pathways . furthermore , gper-1 agonist g-1 promoted inflammation in breast cancers .
gper-1 was reported to affect the deformation of breast glandular structure inducing the malignant transformation of breast tissue .
gper-1 can also induce expression of cancer - associated fibroblasts ( cafs ) in tumor microenvironment [ 34 , 35 ] . on the contrary
, a recent study showed that activation of gper-1 by g-1 resulted in g2/m - phase arrest and induction of mitochondrial - related apoptosis .
the other studies also proved that g-1 treatment suppressed the growth of skbr3 cancer cells and increased the survival rate by inducing the erk1/2 signal activation [ 36 , 37 ] .
1520% of breast cancers are included in triple negative breast cancers ( tnbc ) , characterized by lack of er , progesterone receptor ( pr ) , and egfr2 ( her-2 )
. a higher rate of recurrence and aggressive biological features were found in younger females [ 38 , 39 ] .
gper-1 expression was found in majority of tnbcs patients . in the gper knockdown mice model , the proliferation of tnbcs ,
these findings suggest that gper plays a key role in putative mechanism for tnbcs and gper might be a therapeutic target for tnbcs .
snps of gper-1 , histone acetylation , and transcription factor recruitment were significantly associated with tumor size and histological grading [ 42 , 43 ] .
gper rna as well as gper-1 protein presents in both primary and malignant ovarian tumor tissues . the expression of gper-1 was significantly increased in ovarian carcinomas compared to pericarcinomatous tissues impendent with the expression of egfr , er , and er .
estrogen and g-1 induce ovarian cancer cell growth responses via egfr - mapk signaling pathways .
furthermore , gper-1 promoted the migration and invasion of ovarian cancer cells ovcar5 which is characterized by negative er and positive gper by increasing the expression mmp-9 [ 48 , 49 ] .
atrazine , one of the most common pesticide contaminants , promoted ovarian cancer cells proliferation via induction of erk and expression of estrogen target gene through gper-1 pathway .
but other studies results showed that g-1 suppressed proliferation and induced apoptosis of human ovarian cancer cells probably through inhibition of cell cycle progression in g2/m - phase in ovarian carcinomas [ 51 , 52 ] .

gper-1 has been shown to be involved in a variety of hormone - dependent cancers .
it is well understood that estrogens play a critical role in pathological germ cell proliferation in testicular germ cell tumors .
gper-1 seems to be involved in modulating the growth of estrogen dependent testicular cancer cells .
estrogen induces the high expression of gper-1 correlated with low levels of er in human testicular carcinoma in situ and seminomas [ 53 , 54 ] .
bisphenol a , a common environmental estrogen , can also promote the proliferation of testicular seminomas cells through gper-1 .
the above findings suggested that gper-1 may be a potential therapeutic target [ 56 , 57 ] .
estrogen has an efficacy for advanced prostate cancer ( pc ) via the mediation of the classical estrogen receptors .
the effects of er on pc growth and metastases have different mechanisms in different cellular microenvironments .
the expression of gper-1 is higher in the preneoplastic lesions and normal areas of benign prostate than the basal epithelial cells .
g-1 , the selectively activating gper-1 , inhibited the growth of multiple pc cells in vitro and in vivo through erk1/2 and c - jun / c - fos signaling pathways , which indicates that the g-1 may be a new option for pc through targeting gper-1 .
g-1 inhibited castration - resistant phase but had no effect on androgen - sensitive tumors .
the antitumor effect of g-1 on cr tumors was related to necrosis ( approximately 65% ) accompanied with neutrophils infiltration .
g-1 can also upregulate neutrophil - related chemokines and inflammation - mediated cytokines in the cr tumors . in one word
there are other studies which proved that gper-1 induced proliferation , differentiation , and drug resistance of lung cancers [ 63 , 64 ] , thyroid cancers , bladder cancers , and oral squamous carcinomas .
more studies to reveal the functions and mechanisms of gper-1 in the other system cancers are warranted .
majority of the study results addressed that activation of gper-1 by estrogen and g-1 results in the downstream signals and target genes activation , which promotes the proliferation , migration , and invasion of cancer cells . and
this effect is in nonclassical er expression dependent manner in most cancers except for ovarian cancers .
it is interesting that several other studies showed that g-1 , the special agonist of gper-1 , promoted the expression of gper-1 and inhibited the proliferation of er negative breast cancer cells , ovarian cancer cells , and prostate cancer cells .
the opposite effects of gper-1 in cancer cells may be associated with the epigenetic of gper-1 , such as the snps and histone acetylation .
the different cell types , tumor microenvironment , and hormonal level may also affect the functions of gper-1
. controversies still exist on the gper-1 localization and related signaling pathways , in particular the potential action as proapoptotic mediator . since the function and mechanisms of gper-1 are still unclear , more researches and clinical studies are strongly warranted to clarify the different function and mechanisms in different cancer types and conditions .

Answer:
the g - protein - coupled estrogen receptor-1 ( gper-1 ) , also known as gpr30 , is a novel estrogen receptor mediating estrogen receptor signaling in multiple cell types .
 the progress of estrogen - related cancer is promoted by gper-1 activation through mitogen - activated protein kinases ( mapk ) , phosphoinositide 3-kinase ( pi3k ) , and phospholipase c ( plc ) signaling pathways . however ,
 this promoting effect of gper-1 is nonclassic estrogen receptor ( er ) dependent manner .
 in addition , clinical evidences revealed that gper-1 is associated with estrogen resistance in estrogen - related cancer patients .
 these give a hint that gper-1 may be a novel therapeutic target for the estrogen - related cancers .
 however , preclinical studies also found that gper-1 activation of its special agonist g-1 inhibits cancer cell proliferation .
 this review aims to summarize the characteristics and complex functions of gper-1 in cancers .


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:
neurofibromatosis type-1 ( nf-1 ) is a multisystem , autosomal dominant disorder of peripheral nerves affecting nearly 1/3000 individuals worldwide.1 it was first described by a german pathologist , friedrich daniel von recklinghausen .
inherited or spontaneous mutation of the neurofibromin gene located on chromosome 17 is responsible for this diverse disorder .
common skeletal manifestations of nf-1 include spinal deformities , congenital tibial dysplasia ( congenital bowing and pseudarthrosis ) , sphenoidal dysplasia and cystic lesions in bones . pathological fracture of the acetabulum with anterior dislocation of hip secondary to osseous involvement of the acetabulum , femoral head , and pubic rami has never been documented in a case of nf-1 .
a 16-year - old boy presented with the complaints of pain in the left hip associated with the inability to bear weight following a trivial fall . on examination , the affected limb was 1.5 cm short , abducted and externally rotated .
on general examination , patient had 8 caf au lait spots over the body , bilateral axillary freckles and multiple palpable neurofibromas in the subcutaneous tissues of forearm , thighs and back [ figure 1 ] .
patient met three out of seven criteria described for the diagnosis of nf-1 [ table 1].2 plain radiograph and computed tomography scan of pelvis revealed an ill - defined lytic lesion causing pathological fracture - dislocation of the left hip [ figure 2 ] .
magnetic resonance imaging ( mri ) showed additional soft tissue involvement and joint effusion [ figure 3 ] .
ultrasound guided fine - needle aspiration cytology showed scanty cellularity with round to oval cells having minimal pleomorphism ; hyperchromatic nucleus and moderate cytoplasm with spindle cells and osteoblasts .
clinical photograph showing skin lesions - caf au lait spots ( black arrows ) and axillary freckling ( white arrow ) criteria for diagnosis of nf-1 ( at least 2 or more features ) preoperative radiograph anteroposterior view ( a ) and computed tomography scan ( b ) of pelvis showing an ill - defined lytic lesion destroying anterior column of acetabulum , pubic rami and part of the femoral head coronal ( a ) and axial ( b ) sections of magnetic resonance imaging of pelvis showing expansile lytic lesion of acetabulum and pubic rami with soft tissue involvement and joint effusion a wide local excision followed by arthrodesis of the joint was planned .
considering the extent of bony and soft tissue involvement , we used a modification of the ilioinguinal and iliofemoral approach to have a wide exposure .
we used the conventional ilioinguinal incision and combined it with femoral part of the iliofemoral incision [ figure 4a ] .
on exposing the pelvis , anatomy was distorted . the deformed femur head and acetabulum with deficient pubic rami
there was extensive soft tissue involvement adjacent to the acetabulum and lower part of the ilium .
the entire acetabulum with 2 - 3 cm clear margin of the ilium was resected along with the abnormal soft tissue .
iliofemoral arthrodesis was done using a 14 hole stainless steel dynamic compression plate [ figures 4c  d , and 5 ] .
intraoperative photographs showing ( a ) skin incision ( b ) deformed femoral head ( c ) 14 hole dcp ( d ) iliofemoral arthrodesis postoperative radiograph after tumor resection and iliofemoral arthrodesis histopathology revealed dense collagenous tissue cores with spindle cells having blunt nuclei with minimal atypia and no mitosis or necrosis [ figure 6a ] . on immunohistochemistry , cells were s-100 positive and of neural origin [ figure 6b ] .
partial weight bearing was allowed at 6 weeks and full weight bearing at 10 weeks . at 1-year followup ,
the patient was comfortable , pain free , able to ambulate unassisted , stand on one limb , sit and climb stairs without any difficulty [ figure 7 ] .
( a ) histopathological photomicrograph showing dense collagenous tissue cores and spindle cells with blunt nuclei .
( b ) immunohistochemistry showing neural marker s-100 positivity clinical photographs showing functional outcome at 1-year followup
type 1 neurofibromatosis or von recklinghausen disease , is a multisystem disorder that primarily affects the cell growth of neural tissue and characterized by involvement of skin , peripheral nerves , subcutaneous tissue , eyes , and skeletal system .
although involvement of the musculoskeletal system is common , there have been only a few cases of subluxation / dislocation of hip in patients with nf [ table 3].34567891011121314 on reviewing the literature , the etiology of hip instability leading to pathological subluxation / dislocation in patients with nf-1 can be classified as local and remote .
most of the cases are secondary to local ( intra and peri - articular ) neurofibromas , which can result in mass effect , bony erosions ( ilium , acetabulum , and femoral neck ) , acetabular dysplasia , narrowing of the femoral neck , coxa valga , increased femoral neck offset , capsuloligamentous laxity , and synovial membrane proliferation.3458101113 remote causes of hip instability include intra spinal neurofibromas / schwannomas leading to motor deficit ( hip abductor weakness ) or sensory deficit ( charcot 's neuropathic arthropathy ) , limb length discrepancies secondary to hemi - hypertrophy of lower limb and abnormal biomechanical alteration in the spinopelvic alignment due to scoliosis.6791011 endo et al . described anterior subluxation of hip secondary to decreased femoral head coverage resulting from decreased lumbosacral lordosis and posterior pelvic inclination following scoliosis correction.11 until date , there has been no case of nf-1 reported in the literature with pathological fracture of the acetabulum with anterior dislocation of hip attributable to a neurofibroma involving the acetabulum , pubic rami and femoral head .
orthopedic manifestations of nf-1 comprehensive literature review on published cases of hip dislocation / subluxation in nf-1 the various treatment options described for pathological hip dislocations in nf-1 include closed reduction , open reduction , shelf operation with fascia lata tenorraphy , rotational acetabular osteotomy with femoral varus osteotomy , girdle stone resection , total hip replacement with the trochanteric distalisation.791114 the rate of re dislocation is very high in most of the cases , subsequently requiring a secondary surgical procedure for stabilization . since only a handful of cases have been described in the literature , it is difficult to comment upon the best line of management . in our case ,
arthrodesis was the best possible option since the bone stock after tumor resection was so inadequate that none of the above mentioned procedures could be tried .
moreover , the fear of redislocation , which might necessitate repeated surgeries , was negated .
a combination of ilioinguinal and iliofemoral approach was employed to have a better exposure of the hip joint .
the neurofibromatous tumors associated with nf-1 are usually benign ; however , there is a 2 - 5% chance of malignant transformation , especially with plexiform neurofibromas.15 plexiform neurofibromas are diffuse , poorly defined nerve sheath tumors arising from multiple nerve fascicles and surrounding tissues .
they are more prone for hemorrhage , dysfunction , pain , disfigurement , and malignant transformation.16 there was no clinical or radiological evidence of recurrence or malignant transformation in our patient at 1-year followup .
subtle clinical signs such as skin patches , axillary freckling , and subcutaneous neurofibromas can be easily missed .
orthopedic surgeons must be aware about the various management options available and tailor them as per the needs of their patient .
iliofemoral arthrodesis offered a good functional outcome with improved quality of life in our case .

Answer:
skeletal neurofibromatosis ( nf ) commonly manifests as scoliosis and tibial dysplasias .
 nf affecting the pelvic girdle is extremely rare .
 pathological fracture of the acetabulum leading to anterior hip dislocation in a patient with nf-1 has never been reported in the literature .
 the paper presents the clinical symptomatology , the course of management and the successful outcome of such a rare case of nf-1 .
 histopathological and immunohistochemistry studies showing abundant spindle cells , which are s-100 positive and of neural origin are the classical hallmarks of neurofibromatous lesions .
 tumor resection and iliofemoral arthrodesis can be considered as a valid option in young patients with pathological fracture dislocation of the acetabulum .


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:
bacteria of the genus actinomyces are gram - positive bacilli which generally colonize mouth , colon and vagina .
, if actinomycosis occurs , it often presents as an indolent , slowly progressive infection characterized by abscess formation , which can progress across tissue boundaries , can present with mass like features which simulate malignancy , can develop into a sinus tract and/or develop clinically into a refractory or relapsing infection after a short course of therapy .
a 43-year old woman with no significant medical history presented with complaints of an unilateral slowly growing painful mass in the left breast .
mammography ( fig . 1 ) and ultrasonography were conducted and showed a small abscess - like density retroareolarly.fig .
. 1 mammography of the left breast showing a confined density in the retroareolar area .
species identification was performed using matrix - assisted laser desorption ionization - time - of - flight mass spectrometry ( maldi - tof ms ; bruker ) .
susceptibility testing for a. neuii was performed using e - tests ( biomerieux ) . at the time that culture findings became available ,
therefore , the cultured actinomyces was considered as skin commensals and a wait and see policy was installed .
after several months , the patient returned to the outward clinic with complaints of pain in the breast .
psychical examination of the breast showed mild erythema and ultrasonography showed a minimal increase of the lesion .
the abscess was surgically drained and new purulent fluid from the abscess was sent to the laboratory . the material was processed as described above .
in contrast to initial culture findings , determination by the maldi - tof ms showed peptostreptococcus magnus ( score value 2.056 ) . after four days there was also growth observed in the brewer thioglycollate medium .
the isolate was shown to be susceptible to penicillin , amoxicillin , clindamycin , meropenem and vancomycin .
histopathological examination of the obtained tissue showed abscess formation in an infection with a sinus tract .
subsequently , the patient was treated for six weeks of intravenous penicillin followed by six months of oral amoxicillin successfully .
secondly , a 73-year old woman with a history of bilateral breast cancer was seen at with severe pain and swelling of the left breast ten days after her ablation which was complicated by a large hamatoma treated conservatively .
gram strain showed many leukocytes , some gram - positive cocci and many gram - positive rods .
determination using maldi - tof ms identified a staphylococcus aureus after 2  days there were colonies visible on the anaerobically incubated schaedler agar .
determination by the maldi - tof ms revealed an a. neuii susceptibility testing was performed using e - tests .
unfortunately , patient returned four days after discharge with a relapse of the hematoma which was surgically evacuated . a month later at the outward clinic she showed full recovery.fig .
other isolates that have been identified as pathogens causing primary breast actinomycosis include actinomyces viscosus , actinomyces turincensis and actinomyces radingae
 .
it differs from the other actinomyces species because of its aerobic growth and its microscopic morphology without branching .
we were able to retrieve only three former cases of a. neuii causing primary actinomycosis .
in the first case , treatment with antibacterials was unsuccessful and the lesion had to be surgically removed . in the second case ,
patient was successfully treated with amoxicillin for 21  days . in the third case ,
actinomycosis , regardless of species , should be treated with high doses of antibacterials for a prolonged period of time although therapy needs to be individualized .
current guidelines recommend high dose of penicillin intravenously for two to six weeks , followed by oral therapy with penicillin or amoxicillin for 6 to 12 months .
alternative antibacterial treatments include doxycycline , erythromycin or clindamycin . if actinomycosis presents with well - defined abscess then surgical drainage followed by long - term antibacterial therapy is indicated .
we describe this combination of treatment in our cases . in the first case initial cultures showed islolated a. neuii . because signs of infection had decreased this finding was interpreted as skin flora and not as a pathogen . therefore medical treatment was considered unnecessary .
in retrospect , if antibacterial therapy had been given at first presentation recurrence of the infection might have been prevented .
actinomyces species morphologically resemble diphtheroids and could be dismissed as skin commensals , even when isolated from an abscess sample . in both of our presented cases we found different organisms in the culture additional to a. neuii . in
the first case we found p. magnus and in the second case s. aureus was present .
although a. neuii infection is known for its chronicity , the influence of these mixed organisms on the severity of infections remains unclear .
further research on the effect of mixed organism on the severity of an a. neuii infection is required .

Answer:
actinomycosis is a slowly progressive infection caused by anaerobic bacteria , primarily from the genus actinomyces .
 primary actinomycosis of the breast is rare and presents as a mass like density which can mimic malignancy .
 mammography , ultrasonography and histopathologic examination is required for diagnosis .
 treatment should consist of high doses of antibacterials for a prolonged period of time and possibly surgical drainage .
 primary actinomycosis infections are commonly caused by a. israelii .
 actinomyces neuii is a less common cause of classical actinomycosis .
 we present two cases of primary actinomycosis of the breast in two female patients caused by a. neuii .