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

Paper text:
the sign of leser - trelat historically has been characterized as the sudden eruption of numerous seborrheic keratoses and considered an ominous sign of internal malignancy , as it is classically described before the diagnosis of malignancy .
the seborrheic keratoses themselves are benign and , in some cases , have been reported to resolve with treatment of the underlying malignancy .
the mechanism of this phenomenon has been ascribed to secreted cytokines and growth factors from tumors ( e.g. , elevated epidermal growth factor receptor [ egf - r]-mediated signaling ) leading to development of seborrheic keratoses ( yamamoto , 2013 ) .
the malignancies classically implicated in the setting of sign of leser - trelat are gastric adenocarcinoma and other tumors of the digestive tract ; additionally , other classes of malignant tumors , such as lymphoma and breast cancers , have been cited in association with the condition ( husain et al . , 2013 ) .
rare cases of gynecologic cancers ( e.g. , uterine leiomyosarcoma and ovarian adenocarcinoma ) have been associated with the sign of leser - trelat ( abakka et al .
, 2013 , holguin et al . , 1986 ) . in general , with the exception of hypercalcemia and disseminated intravascular coagulation , paraneoplastic syndromes
are not classically associated with gynecologic cancer ( ashour et al . , 1997 ) .
this case illustrates eruptive seborrheic keratoses with atypical annular and gyrate erythema that occurred in the setting of endometrial adenocarcinoma , which resolved upon surgical removal of the malignant uterine tissue ( lacey and chia , 2009 ) .
a 61-year - old post - menopausal caucasian female presented for an initial evaluation of numerous intensely pruritic scaly spots on her trunk .
she reported that similar lesions had been diagnosed as seborrheic keratoses by another dermatologist ; however , in the month before presentation in our clinic , the number of lesions on her trunk had dramatically increased .
the patient was able to distinguish new lesions from her existing seborrheic keratoses because they were constantly pruritic and many had coalescing and concentric rings of erythema around them .
she denied any history of cancer , but upon inquiry regarding her family history , she reported that her father had died of gastric cancer .
the patient denied any constitutional symptoms or any uterine bleeding , and complete review of symptoms was significant only for depression .
her past medical history was significant for squamous cell carcinoma , uterine fibroids , dysmenorrhea , granuloma annulare ( ga ) , and benign pulmonary nodules .
total body skin examination was notable for numerous brown papules that appeared to be attached to the surface of her skin as well as plaques consistent with inflamed seborrheic keratoses with surrounding annular and gyrate erythema with scaling at edges of rings  some of which were concentric and had the appearance of targets  on the face , neck , and trunk . there were no signs of acanthosis nigricans .
biopsy of an erythematous lesions surrounding a seborrheic keratosis on her trunk revealed multifocal intraepidermal langerhans cell microabscesses with eczematous dermatitis and superficial perivascular infiltrate containing scattered histiocytes and without granulomatous inflammation .
this presentation of atypical , acute eruption of seborrheic keratoses and family history of gastric cancer , as well as the fact the patient had not yet had her age - appropriate cancer screenings , prompted concern that the eruption was a marker of internal malignancy , and screenings for malignancy were recommended . she initially declined colonoscopy and other first - line screenings and insisted that she would only accept a positron emission tomography scan , which highlighted focal intense uptake in the uterus ; based on this , transvaginal ultrasound was recommended and revealed abnormally thickened endometrium .
dilatation and curettage also revealed complex focal atypical hyperplasia , which prompted the gynecology team to perform a hysterectomy , and the postoperative diagnosis was endometrial adenocarcinoma . because of the significant , distressing pruritus associated with the lesions , the patient was treated symptomatically during the work - up period .
symptomatic treatment with cryotherapy , phototherapy , and topical steroids yielded some partial improvement ; however , the patient experienced dramatic clearance of the erythematous skin lesions and marked improvement in her pruritus after surgical removal of the abnormal uterine tissue . at present , after the hysterectomy , she has developed no new seborrheic keratoses and is asymptomatic .
although seborrheic keratoses are a common benign skin finding in elderly people , a rapid and intensely pruritic eruption warrants suspicion for occult internal malignancy .
special care should be taken for patients with first - degree relatives of gastric cancer because it is the most commonly implicated cancer in paraneoplastic dermatoses ( e.g. , the sign of leser - trelat ) .
the marked annular , gyrate , and targetoid erythema associated with seborrheic keratoses seen in our patient is not typical for the classic sign of leser - trelat .
it is possible that this unusual morphology represents two coexistant paraneoplastic dermatoses similar to those seen in cases of prostate cancer and renal angiosarcoma ( da rosa et al . , 2009 , rubegni et al . , 2014 )
the possibility that the annular erythematous plaques could be a reactive granulomatous process was also considered , given the patient s history of ga . however , upon consultation with the pathologist , it was clarified that no granulomatous inflammation was seen .
the notable presence of high numbers of langerhans cells seen on microscopy may have signified abnormal antigen presentation in these lesions , which also supports a paraneoplastic process .
it was suspected that cytokines and hormone stimuli associated with the endometrial adenocarcinoma might have triggered the paraneoplastic dermatosis . as in this patient 's case
this case demonstrates a common gynecological cancer presenting with a paraneoplastic dermatosis rather than the classical signs of uterine bleeding , and serves to raise awareness of cutaneous manifestations as markers of malignancy in a women s health issue in which early detection can affect health outcomes .
-a sudden eruption of numerous seborrheic keratoses should prompt a malignancy work - up in patients with risk factors and those who have not undergone age - appropriate cancer screenings .- although gastric adenocarcinoma is the malignancy most commonly associated with the sign of leser - trelat , the possible association of other malignancies may necessitate a thorough work - up for internal malignancy . a sudden eruption of numerous seborrheic keratoses should prompt a malignancy work - up in patients with risk factors and those who have not undergone age - appropriate cancer screenings . although gastric adenocarcinoma is the malignancy most commonly associated with the sign of leser - trelat , the possible association of other malignancies may necessitate a thorough work - up for internal malignancy .

Answer:
eruptive seborrheic keratoses have been reported as a rare paraneoplastic dermatosis in the setting of internal malignancy , particularly that of the digestive tract .
 this case illustrates a patient with a family history of gastric cancer who presented with an acute eruption of inflamed pruritic seborrheic keratoses with annular and gyrate erythema , and was found to have endometrial adenocarcinoma .
 the inflammatory cutaneous eruption resolved shortly after surgical removal of the dysplastic uterine tissue .
 this case demonstrates an example of a common gynecological malignancy presenting in an uncommon way ; in the absence of uterine bleeding , the patient s skin manifestations in the form of a paraneoplastic dermatosis prompted timely diagnosis .
 thus this case serves to raise awareness of cutaneous manifestations of a women s health issue , in which early detection can impact health outcomes .


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

Paper text:
the study protocol was approved by the ethics committee of the ministry of health and the school boards .
a total number of 30 clusters including 7,493 girls ( aged 620 years ) were selected .
students with a history of acute or chronic diseases or any chronic medication use were excluded . in all subjects , height , weight , and pubertal stages
general physicians determined pubertal stages under the supervision of specialists by visual inspection and palpation , using the criteria and definitions described by marshall and tanner.10 accordingly , breast stages 15 were determined by both inspection and palpation .
breast stage b2 corresponded to the breast bud stage with palpable glandular breast tissue and elevation of the papilla , stage b3 with further enlargement of the breast and areola with no separation of the contours , stage b4 where the areola and papilla form a secondary mound above the level of the breast , and stage b5 was assigned in case of the mature breast with projection of the papilla only .
the onset of puberty was measured as the age at breast development at tanner stage 2 ( b2 ) .
stage ph2 was assigned with the presence of long , slightly pigmented hair ( straight or curled ) .
participants were grouped by 1-year age intervals , which extended from the day of their birthday to the day before the next birthday . for comparison of different areas
, we used the national classification of the provinces according to their climate , ethnicity of the population , geographic locations , and socioeconomic variables .
classification of iranian provinces to regions according to climate , geographic location , ethnicity and socioeconomic status we estimated the mean of the time of men - arche , b2-b5 and ph2-ph5 stages .
statistical analysis was done using spss version 15 ( spss , chicago , il ) .
analysis of variance ( anova ) and post - hoc tests were used to compare the mean ages of menarche , pubarche , and telarche in different regions .
we estimated the mean of the time of men - arche , b2-b5 and ph2-ph5 stages .
statistical analysis was done using spss version 15 ( spss , chicago , il ) .
analysis of variance ( anova ) and post - hoc tests were used to compare the mean ages of menarche , pubarche , and telarche in different regions .
we estimated the mean of the time of men - arche , b2-b5 and ph2-ph5 stages .
statistical analysis was done using spss version 15 ( spss , chicago , il ) .
analysis of variance ( anova ) and post - hoc tests were used to compare the mean ages of menarche , pubarche , and telarche in different regions .
tehran had the lowest mean age of menarche , being 11.99  1.35 years , which was significantly lower than other 10 regions .
the second region with lowest age at menarche was fars ( 12.40  1.27 years ) .
the mean age at b2 stage of breast development was significantly lower in ghazvin - zanjan region ( 8.97  1.45 years ) followed by the region consisting of khorasan jonobi and sistan balochestan ( 10.11  1.61 years ; p = 0.003 ) , boshehr - khouzestan region ( 10.05  1.21 years ; p = 0.01 ) , tehran - relatd cities ( 10.46  1.67 years ; p < 0.0001 ) , fars ( 11.01  1.88 years ; p < 0.0001 ) and kordestan - lorestan - ilam region ( 9.94  1.25 years ; p = 0.02 ) . in fars region , the mean age at b2 stage of breast development ( 11.01  1.88 years ) was higher than other regions except for mazendran - guilan and tehran - related cities regions .
figure 2 shows the mean age at b1-b5 of breast development in different regions in iran .
mean age ( years ) at menarche in different regions mean age ( years ) at various stages of telarche in different regions in iran the mean age at ph2 stage of pubarche in kordestan - lorestan - ilam region ( 10.70  1.23 years ) was significantly higher than khorasan jonobi - sistan balochestan region ( p < 0.0001 ) , boshehr - khozestan region ( p < 0.0001 ) , tehran - relatd cities ( p < 0.0001 ) , chaharmahal - kerman - isfahan region ( p < 0.0001 ) , ghazvin - zanjan region ( p < 0.0001 ) , and boshehr - khozestan region ( p < 0.0001 ) .
the mean age at ph2-ph5 of pubic hair development in different geographic locations of iran is presented in figure 3 .
to the best of our knowledge , this is the first study of its kind to compare the pubertal stages in different geographic locations in a country .
it should be acknowledged that such comparison is not feasible in many countries with small population and no significant diversity in climate and other geographic characteristics .
we found that the mean age of menarche was significantly lower in tehran than all other regions .
tehran province , including the metropolitan city of tehran , is located in central part of the country with multiethnic population .
not only multi - ethnicity but also higher socioeconomic status and more industrialized lifestyle habits in tehran might be associated with earlier menarche age . in another study
the mean age of menarche was 12.68 years in tehran in 2004.11 in our study conducted 2 years later , this age decreased to 11.99  1.35 years . decreasing trend of menarche age
is observed in many developed and developing countries.1213 it might be attributed to changes in socioeconomic status of people14 and increasing rate of obesity.12 ethnicity is documented as a factor that describes some international varieties of puberty age.1516 in the current study , the mean age at menarche and ph2 was higher in girls with kurd ethnicity than in other ethnicities .
kurd ethnicity is the third most prevalent ethnicity in iran after persian and azeri ethnicities .
it can be suggested that the higher age of puberty in girls of this region might be attributed to their ethnicity as well as the cold climate and their high altitude mountainous region of living .
in addition to ethnicity , the geographic characteristics may influence the age of puberty . in our study , the lowest mean age at b2
was documented in zanjan - ghazvin region , with mediterranean weather and spring rains , and population of azeri ethnicity .
the earlier telarche in this region in comparison to other regions with azeri population might be attributed to environmental factors .
premature telarche is suggested to be associated with endocrine disrupting chemicals found in pesticides and plastics , with possible estrogenic and androgenic activities.1718 further investigations on environmental pollution might be necessary in this regard .
the considerably high prevalence of overweight among young iranian children19 might decrease the age of puberty in the near future .
the main limitation of this study was its cross sectional nature , and as a result , casualty can not be ascertained .
in addition , we considered the prominent ethnicity in each region ; but some participants might have other ethnicities .
we found significant differences in the age of pubertal stages of girls living in various regions with different ethnicity and geographic characteristics .
considering the impact of pubertal age on general health , more studies should be done about the lifestyle and environmental factors affecting the onset of puberty .
mem participated in the design and conducting the study ; ar participated in the design and conducting the study and helped to draft the manuscript ; rk drafted and edited the manuscript ; pm conducted the statistical analyses and helped to draft the manuscript ; ss participated in conducting the study ; ga participated in the design and conducting the study ; ha participated in conducting the study ; np participated in conducting the study ; sk in conducting the study ; pp helped to draft and edit the manuscript ; as participated in conducting the study .

Answer:
background : this study aimed to compare the timing of puberty between various geographic locations and different ethnicities.methods:this national survey was conducted in 20 provinces in iran .
 healthy iranian girls were selected from public schools using cluster random sampling .
 a total number of 30 clusters including 7493 girls , aged 6.020 years , were selected . in order to compare different areas , the national classification of the provinces based on climate , ethnicity , geographic locations , and socioeconomic variables were used .
 accordingly , there are 11 regions in iran .
 analysis of variance was used to compare the mean ages of menarche , pubarche , and thelarche in different regions.results:tehranian girls , with 11.99  1.35 years ( mean  sd ) , had the lowest age of menarche which was statistically significantly .
 the second region with lowest age at menarche was fars ( 12.40  1.27 years ) .
 the mean age at breast bud stage ( b2 ) was significantly lower in ghazvin - zanjan region ( 8.97  1.45 years ) . in fars region ,
 the mean age at b2 stage of breast development ( 11.01  1.88 years ) was higher than other regions except for mazendran - guilan and tehran - related cities .
 the mean age at public hair development at tanner stage 2 ( ph2 ) in kordestan - lorestan - ilam region ( 10.70  1.23 years ) was significantly higher than other regions.conclusions:we found significant differences in the age of pubertal stages of girls living in various regions with different ethnicity and geographic characteristics .
 considering the impact of pubertal age on general health , more studies should be done about the lifestyle and environmental factors affecting the onset of puberty .


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:
using water as solvent in the organic reactions is one of the most important targets to organic chemists because of the easy availability , nontoxicity , and ecofriendly nature of the water [ 17 ] . in this endeavour
, a number of chemical reactions such as diels alder , hetero diels - alder , 1,3-dipolar cycloaddition , oxidations , reductions , and others are performed successfully in water [ 13 ] .
also , it is reported that in few cases addition of the water increases the rate and the yield of a reaction and also enhances the enantioselectivity in a chiral synthesis .
but the main problems associated with water as a solvent is its poor ability to solubilise organic reactants and incapability to create anhydrous condition for moisture sensitive organic compounds and catalysts . to overcome the solubility problem , generally a surfactant is introduced to the reaction mixture .
the surfactant , due to its hydrophobic and hydrophilic nature , forms micelles with water insoluble organic compounds and promote the desired reactions to occur inside the hydrophobic ambience of the micelle core [ 9 , 10 ] .
cleavage of the c = n bonds is a very important transformation in organic synthesis as the c = n functionality is widely used to protect both the carbonyl and amines .
there are a number of methods used for the cleavage of c = n bonds which include acidic reagents [ 1113 ] , oxidizing agents , metallic salts [ 15 , 16 ] , ( phseo)2o , nahso3 , and others .
most of these methodologies suffer from serious drawbacks like involvement of strong lewis and bronsted acids , use of toxic and costly transition metals ( i.e. , cr , pd , co ) , low temperature , longer reaction time , low yield , and difficulties in isolating the products
. therefore , development of efficient , mild and environment friendly reagents are always necessary . on the other hand
, bisindoles are recently emerging as extremely important class of compounds because of their novel antibacterial and anticancer activities [ 1921 ] .
that is why a number of methodologies have also been postulated for the synthesis of bisindoles [ 2229 ] . in our previous communications
, we reported that surfactant- ( sds- ) mediated cleavage of c = n bonds could be achieved with acetic anhydride   and surfactant - i2-water can be used for the deprotection of imines to carbonyls .
we have also shown that bis- and tris ( indolyl)alkanes can be synthesized in presence of bronsted acid in water . in continuation of our research in hydrated media , herein , we wish to disclose the dual catalytic activity of the system i2-sds - h2o which behaves as a lewis acid   for the cleavage of 2,3-diaza-1,3-butadiene , 1-aza-1,3-butadienes , and oximes to produce carbonyls and amines , and the resulting reaction mixture reacts with indoles to produce bis ( indolyl)alkanes in situ at room temperature under neutral conditions .
for an initial study , molecular iodine was added to a mixture of 1,4-diphenyl-2,3-diaza-1,3-butadiene ( 1a ) ( 1  mmol ) and indole ( 2a ) ( 2  mmol ) in water .
it was presumed that the activated imine should produce carbonyl compound in the reaction mixture which might be trapped with indole .
but only a trace amount of 3,3-bis(indolyl)phenylmethane ( 3a ) was found to be formed in the reaction .
we envisioned that the poor yield of the product may be due to the insolubility of organic substrates in water .
accordingly , we added a surfactant ( sds ) to the reaction flask . to our delight ,
the reaction produced isolable amount of 3a as a brown solid but half of the 1,4-diphenyl-2,3-diaza-1,3-butadiene ( 1a ) left unreacted in the reaction mixture .
so amount of indole ( 2a ) was doubled ( 4  mmol ) and the same reaction condition successfully produced quantitative amount of 3a .
the product was filtered out and the filtrate was treated with freshly distilled benzaldehyde ( 0.05  mmol ) in ethanol which furnished 1a ( m.p .
this infers the simultaneous involvement of two c = n bonds of bis - anils , leaving behind hydrazine in the reaction mixture .
also , no self - reaction of individual starting materials leading to indole dimer   ( 4 ) or pyrrole formation   ( 5 ) were observed under the same reaction conditions ( scheme 1 ) .
optimization of the reaction conditions was undertaken by employing different catalyst loadings under various surfactant conditions .
it was found that the best result was obtained by the application of 15  mol% of i2 containing sodium dodecyl sulphate ( sds ) and water at room temperature ( entry 1 , table 1 ) . in absence of the catalyst no formation of 3a
was observed even after stirring for 24 hours ( entry 5 , table 1 ) . to study the scope and limitations of the reaction ,
i2-sds - h2o system was applied to the reaction of indole ( 2 ) and 2,3-diaza-1,3-butadiene derivatives ( table 2 , entries a
the bisindoles were formed in excellent yields under the reaction condition . it was observed that the reaction was relatively faster when an electron withdrawing substituent , for example , no2 , was present in the phenyl ring of the 2,3-diaza-1,3-butadienes ( table 2 , entry e ) in comparison to the electron donating groups , for example , ome and oh ( table 2 , entries b and f ) .
identical results were obtained when 2-methylindole ( 2a ) was used in place of indole ( 2 ) ( table 2 , entries g and h ) .
all the products were characterized by their ir , h nmr , c nmr , and mass spectral data and also by comparison with the literature report ( scheme 2 ) [ 24 , 25 ] . in order to further explore the efficiency of the i2-sds - h2o system the reaction of the oximes 6 and indoles 2 was studied . when oximes ( 1  mmol ) and indole ( 2  mmol ) were allowed to react under the same reaction condition described earlier , bis - indolylalkanes formed ( table 3 ) . the product was filtered off and the filtrate was treated with benzaldehyde in ethanol .
the resulted product was benzaldoxime , which proved the liberation of hydroxylamine during the reaction .
it was found that no michael addition product   was formed and only a trace amount of indole dimer 5   could be identified .
the system was also applied to the reaction of 1-aza-1,3-butadienes 7 with indole ( 2 ) which produced bis ( indolyl)alkanes 8 in very good yield eliminating aryl amine in the reaction mixture ( table 4 ) .
all the products were well characterized by comparison of their spectral and mass data with that of the reported value [ 24 , 25 ] .
in conclusion , we have shown the dual catalytic activity of i2-sds - h2o system which deprotects the azadienes , oximes , and azabutadienes and produces bis ( alkyl)indoles in situ when indole is present in the reaction medium .
the two - step reaction can be carried out without using acid , transition metals , and organic solvents . besides , the reaction condition is mild and can be done in water under neutral condition which contributes to the criteria of green chemistry .
h nmr spectra were recorded on avance dpx 300  mhz ft - nmr spectrometer .
chemical shifts are expressed in  units relative to tetramethylsilane ( tms ) signal as internal reference .
ir spectra were recorded on ft - ir - system-2000 perkin elmer spectrometer on kbr pellets or in chcl3 .
the solvents for chromatography were distilled before use . in a 50  ml round bottom flask
, 15  mol% of i2 was first dissolved in water ( 10  ml ) .
2,3-diaza-1,3-butadiene ( 1  mmol ) and indole ( 4  mmol ) were added and stirred in the presence of sodium dodecyl sulphate ( sds ) ( 0.02  g ) for the stipulated time .
the product formed was filtered off and washed with water , dried , and recrystallized from ethanol .
identical reaction condition was followed when 1-aza-1,3-butadienes and oximes were used as reactants . in this case , 2  mmol of indoles were used to react with 1  mmol of imines .
colorless solid ; mp : 150152c ; ftir ( kbr ) :  3418 , 3058 , 1623 , 1611 , 1445 , 1093  cm ; h nmr ( 300  mhz , cdcl3 ) :  5.95 ( s , 1h , ar
ch ) , 6.73(s , 2h ) , 7.06 ( t , 2h , j = 6.8  hz ) , 7.187.27 ( m , 3h ) , 7.317.36 ( m , 2h ) , 7.367.42 ( m , 6h ) , 7.98 ( br , s , 2h , nh ) ; c nmr ( 75  mhz , cdcl3 ) : 40.7 , 111.2 , 119.1 , 119.5 , 120.4 , 122.1 , 123.8 , 126.9 , 126.9 , 128.2 , 129.1 , 136.8 , 144.8 ; hrms calcd for c23h18n2 ( m ) : 322.2851 , found 322.2832 ; anal.calcd . : c , 85.70 ; h , 5.59 ; n , 8.69 ; found c , 85.75 ; h , 5.56 ; n , 8.56 .
pink solid ; mp : 76 - 77c ; ftir ( kbr ) :  3415 , 3060 , 1491 , 1465 , 1095  cm ; h nmr ( 300  mhz , cdcl3 ) :  5.91 ( s , 1h , ar  ch ) , 6.76 ( s , 2h ) , 7.08 ( t , 2h , j = 8.3  hz ) , 7.22 ( t , 2h , j = 7.9  hz ) , 7.287.42 ( m , 8h ) , 8.01 ( br , s , 2h , nh ) ; c nmr ( 75  mhz , cdcl3 ) : 39.8 , 111.5 , 122.6 , 123.8 , 127.1,128.4 , 129.8 , 130.1 , 130.9 , 131.0 , 131.6 , 137.2 , 143.5 ; hrms calcd for c23h17n2cl ( m ) : 356.7371 ; found 356.7324 ; anal.calcd .
: c , 77.52 ; h , 4.77 ; n , 7.86 ; found c , 77.48 ; h , 4.72 ; n , 7.80 .
brown solid ; mp : 323325c ; ftir ( kbr ) :  3420 , 1720 , 1455 , 1258  cm ; h nmr ( 300  mhz , cdcl3 ) :  5.98 ( s , 1h , ar - ch ) , 6.85 ( s , 2h ) , 7.107.55 ( m , 11h ) , 8.05 ( br , s , 2h , nh ) ,
c nmr ( 75  mhz , cdcl3 ) : 34.8 , 107.0 , 110.0 , 111.5 , 117.8 , 119.9 , 120.0 , 122.5 , 124.8 , 127.1 , 136.8 , 142.2 ; hrms calcd for c21h16n2o2 ( m ) : 312.2621 ; found 312.2611 ; anal.calcd .
c , 80.84 ; h , 5.12 ; n , 8.97 ; found c , 84.05 ; h , 5.15 ; n , 8.94 .
the spectral data of the compounds are available in the supplementary material available online at doi : 105402/2012/635835 .

Answer:
a novel catalytic system consisting of i2-sds - h2o has been developed which cleaves 2,3-diaza-1,3-butadiene , 1-aza-1,3-butadienes , oximes and in presence of indoles in the medium uses the corresponding aldehyde products to produce bis(indolyl)alkanes in situ .
 this one pot simple and mild dual catalytic system works in water at room temperature under neutral conditions .


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

Title:
Analysis of membrane binding equilibria of peripheral proteins: allowance for excluded area of bound protein

Paper sections:

The binding of peripheral proteins to membranes has been the subject of extensive study (for a recent review, see [1]). It is often the case that such proteins do not bind to discrete, specific sites on the membrane, but are electrostatically attracted to the head groups of the phospholipids that make up the membrane, so that the binding process is equivalent to physical adsorption [1]. The difference between binding to discrete sites and physical adsorption appears to have been neglected or glossed over by workers in this field (see for example, [2]). The purpose of the present note is to clarify this distinction and to demonstrate that neglect of the difference can lead to significant quantitative errors in the interpretation of binding data.

We consider the following experiment. A fixed amount of phospholipid membrane, or an equivalent phospholipid surface such as that produced by coating hydrophobic beads with phospholipid [3, 4], is equilibrated with varying amounts of peripheral protein. The amount of peripheral protein bound to the surface of the membrane or phospholipid-coated bead may be measured by a variety of techniques [2]. The quantitative analysis of the dependence of the equilibrium concentration of bound protein upon the total protein concentration proceeds as follows.

Let the total area of membrane per unit volume be given by
(1)Amem=aLcL,tot where aL denotes the average cross-sectional area of a phospholipid molecule (lipid or L) in the plane of the membrane and cL,tot denotes the molar concentration of L. The fraction of surface area occupied by a concentration cP,bound of membrane-bound protein (P) is then given by
(2)ϕ=cP,boundaPcL,totaL=cP,boundnLcL,tot where aP denotes the area of membrane "covered" by each molecule of bound protein, and nL the number of lipid molecules "covered" by each protein molecule. It may be shown via a general thermodynamic argument [5] that the equilibrium between free and membrane-bound protein is given by
(3)KcP,free=ϕγP,bound(ϕ) where K denotes the intrinsic equilibrium association constant for binding of protein to a bare membrane and γP,bound denotes the thermodynamic activity coefficient of bound protein, a measure of the interaction between bound protein molecules. It may be shown that when the protein binds to discrete equivalent and independent sites, the activity coefficient of bound protein is simply 1/(1 - ϕ) [5], and that as a result, the membrane binding isotherm may be described by the familiar Langmuir isotherm
(4)KcP,free=ϕ1−ϕ which may be combined with equation (2) to yield
(5)cP,bound=cL,totnLKcP,free1+KcP,free Equation (5) has been used to model data on the reversible binding of peripheral proteins to membranes. However, to the extent that protein does not bind to discrete and independent binding sites, equation (5) is not a correct description of the binding equilibrium, since it does not allow for the fact that bound protein excludes surface area, and hence potential locations for binding, to other proteins, leading to values of γP,bound that substantially exceed 1/(1 - ϕ) with increasing ϕ.

The dependence of γP,bound on ϕ depends upon many factors, including the size and shape of the cross-section of the bound protein in the plane of the membrane, as well as the presence and magnitude of any interactions between bound protein over and above simple steric repulsion [5]. These details are generally unknown to the experimenter in advance, but in some instances may be deduced by fitting sufficiently comprehensive data with sufficiently sophisticated models [6]. The inadequacy of the naïve Langmuir analysis of membrane binding may be demonstrated by application of the simplest model allowing for area exclusion by bound protein to the analysis of published experimental data.

For the purposes of this demonstration we represent the cross-section of bound protein in the plane of the membrane as a circular disk. It is emphasized that the footprint of an arbitrarily selected protein on a phospholipid surface may not be realistically modeled by a disk. This approximation is employed for didactic purposes only, and resulting parameter values obtained by fitting a model based upon this approximation should not be assumed to be physically realistic. The activity coefficient of the bound "circular" protein may thus be estimated using the scaled particle theory for a two-dimensional fluid of hard circular particles [7]
(6)lnγP,bound≈−ln(1−ϕ)−2+11−ϕ+1(1−ϕ)2

An expression equivalent to equation (6) may be obtained for any footprint describable as a convex polygon [5]. We note that the value of γP,bound obtained assuming a circular cross-section is the minimum value obtained for any convex hard particle of equal area at constant ϕ, so that the results shown below represent a lower bound to magnitude of excluded area effects expected for any real steric interaction between bound proteins.

Equation (2), Equation (3), and Equation (6) may be solved numerically to yield the dependence of cP,bound upon cP,tot = cP,bound + cP,free for given values of cL,tot, K and nL. This model was fit via nonlinear least squares to the published data of Cho et al [2] for the binding of phospholipase A2 to phosphatidylcholine-coated beads (cL.tot = 6 µM) to obtain best-fit values of K = 4.4 (−1.0, + 3.5) × 106 M−1 and nL = 11.2 (±2), where the indicated uncertainties correspond to one standard error of estimate. The dependence of cP,bound on cP,tot calculated according to this model with the above-given best-fit values of K and nL is plotted together with the data in Figure 1 (solid line).

For comparison, the Langmuir relation, equation (5), was fit to the same data to obtain best-fit values of K = 8.5 (−2, +2.5) × 106 M and nL = 29.1 (± 2), in agreement with best-fit values reported by Cho et al [2]. The dependence of cP,bound on cP,tot calculated according to the Langmuir model with the above-given best-fit values of K and nL is plotted together with the data in Figure 1 (dashed line).

Both models fit the data to approximately the same goodness of fit as measured by the sum of squared residuals, so the relative applicability of these two models cannot be distinguished solely on this basis. However, extrapolation of the respective best-fit curves to higher concentration, also illustrated in Figure 1, indicates that additional data obtained at significantly higher protein concentrations would enable such a distinction to be made. Additionally, if we accept the value of nL = 29.1 obtained from the Langmuir analysis, then according to equation (2), the highest amount of protein bound measured in the Cho experiment (0.175 uM) would correspond to a fractional area occupancy of around 85%. Chatelier and Minton [5] demonstrated unequivocally that in the absence of attractive interactions between adsorbed proteins leading to cluster formation, it is impossible to attain such a large fractional area occupancy at equilibrium with any experimentally attainable total protein concentration. So the Langmuir model, which does not take into account either repulsive or attractive interactions between bound ligand, cannot provide a physically reasonable interpretation of the Cho data that are treated in this MS.

The present example demonstrates that failure to take into account steric repulsion between peripheral proteins bound to a membrane may lead to significant overestimates of binding affinity and the number of lipid molecules "covered" by a protein molecule. Note that this number is not equivalent to the number of lipid molecules comprising a "binding site", since there are no specific binding sites for protein on a featureless phospholipid membrane.

The Langmuir analysis is valid only at very low levels of area occupancy by bound protein (ϕ− 1). This condition obtains in measurements such as those reported by Kim et al [8]. However, it follows from equation (5) that the apparent binding constant reported by these authors is not the actual binding constant K, but rather the quantity K/nL. In order to estimate the quantitities K and nL independently, it is necessary to measure ligand binding at sufficiently high values of ϕ to enable application of the full analysis described above, and even in this case it is necessary to make assumptions regarding the cross-sectional area of adsorbing protein and tendency of adsorbed protein to self-associate, both of which affect the dependence of γ on ϕ[6]. The values of K and nL derived from modeling the experimental data will thus be subject to more or less uncertainty depending upon the reliability of these assumptions.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Answer: When peripheral proteins bind to phospholipid membranes lacking discrete binding sites, steric repulsion between bound protein molecules may result in a reduction of the surface area available to additional bound protein by an amount significantly greater than the actual area occupied by bound protein. An approximate treatment of this effect demonstrates that neglect of area exclusion by bound protein may lead to significant errors in the evaluation of equilibrium association constants and the fractional coverage of membrane surface area.


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:
prostate cancer is a common health problem that in the majority of cases starts to develop at the age of 50 years , reaching its peak at 6070 years of age .
a variation in its incidence and prevalence exists between western , asian and arabic populations .
the highest incidence is in the usa and canada followed by european countries , then the asian population and the lowest incidence is in arabic population [ 1 , 2 ] .
the incidence of prostate cancer was reported to be about 100127/100.000 men in the usa , while only 3.1 , 3.3 and 6.5/100.000 men in saudi arabia , oman   and kuwait .
the marked difference in the incidence and prevalence of prostate cancer between western and arabic countries is very interesting and can be attributed to different explanations .
all arabic countries are actually islamic countries where muslims constitute the majority of the population .
they adopt male circumcision in the first few years of life as an obligatory event in relation to the religion of islam .
interestingly , many recent studies confirmed the association between circumcision and the lower incidence of penile viral infections .
uganda trial reported that applying male circumcision results in a reduced incidence of hsv2 infection by 25% , hpv infection by 35% and hiv infection by 5060% [ 7 , 8 ] .
morris   recently reported that male circumcision is a surgical vaccine that guards against genital and urinary bacterial and viral infection and protects against penile and prostate cancer . in a study of 20,243 men in finland , infection with hpv18
was associated with a 2.6fold increase in risk of prostate cancer ( p < 0.005 ) . for hpv16 ,
some studies reported that uncircumcised men have more than twice the incidence of prostate cancer compared with circumcised men [ 1214 ] which explains why prostate cancer is relatively rare amongst jews .
of men operated on for prostatic obstruction , 1.8% of obstructions were cancerous in jews ( circumcised ) , compared with 19% of non  jews ( uncircumcised ) .
a study in the uk in 1996 found an odds ratio for the reduction in risk of prostate cancer in circumcised men to be 0.62 .
table 1 illustrates some recent publications studying the association between male circumcision , stds and prostate cancer .

publications studying the association of circumcision with sexually transmitted diseases and prostate cancer the age  standardized incidence rate of prostate cancer is lower in asian countries than in the united states and european countries .
however , the incidence rate in asians living in the united states is substantially higher than that in those living in their homelands .
migration studies   have shown an increase in prostate cancer incidence in asian men after emigration to the united states .
this observation suggests that environmental factors and changes in lifestyles , particularly in dietary practices , can affect the aetiology of prostate cancer
. a higher intake of vegetables in the arabic population may be also a factor that contributes to the lower incidence of prostate cancer .
a recent study from egypt   confirmed higher vegetable intake to be of significant value in reduction of the risk of prostate cancer . a recent systematic
review   confirmed that a diet low in fat and meat and rich in vegetables and fruits is recommended to lower the risk for prostate cancer .
studied the difference in serum testosterone between arab and german groups of patients with diseases other than prostate cancer and was able to demonstrate a significantly lower level of testosterone in the arab population in the middle age group ( < 30 years ) , pointing out that the relatively lower level of serum testosterone in that age group may be protective in the long run . in another study ,
the same group published   the difference in levels of serum testosterone between arabs and american caucasians and reported lower levels o in arabic men in all age groups , with a higher significance in the middle age groups ( < 30 years ) .
schistosomiasis is a parasitic disease that is endemic in tropical countries with more than half of the cases located in africa and middle east .
animal studies on the effect of schistosomal infection on the testes confirmed that schistosomal infection results in a significant decrease in the level of serum testosterone [ 2427 ] .
another endemic problem that emerged in egypt , secondary to schistosomiasis , is caused by the treatment itself . in the mid20 century , the egyptian ministry of health began to conduct mass treatment in rural areas and for every suspected infection using tartar emetic intravenous injection . at that time , the dangers of exposure to human blood were n't considered and disposable needles and syringes were not available [ 28 , 29 ] .
frank et al .   reported a direct relationship between parenteral treatment of schistosomiasis and the country wide prevalence of antibodies to hepatitis c infection .
many studies [ 30 , 31 ] confirmed the association between hepatitis c infection and chronic liver disease with the occurrence of hypogonadotropic hypogonadism manifested by low serum level of gonadotropic hormones and serum testosterone .
table 2 illustrates findings in publications correlating serum testosterone in arabic and western populations .

publications correlating serum testosterone in arabic and western populations serum psa is a widely used parameter for the early detection and monitoring of prostate cancer . in western countries men with total psa < 2.5
ng / ml have a low probability of having prostate cancer , while those with psa > 10 ng / ml have > 50% chance of having prostate cancer [ 3234 ] .
a recent paper from kuwait , demonstrated that for cases with psa > 10 ng / ml , prostate cancer was still of a low probability , with the majority of cases with elevated psa only suffering from prostatitis or bph .
they could detected a psa value of > 50 ng / ml to carry 100% specificity for prostate cancer in the arabic population .
a recent paper from saudi arabia   studying the incidence of prostatic adenocarcinoma in patients admitted to king abdul
aziz university hospital showed that prostate cancer was detected in 28.5% of patients with psa > 4 ng / ml , which is considered lower than the expected incidence for their patients median age group of 68 years .
table 3 demonstrates the difference in incidence between the findings in the saudi arabia study   with a canadian   and a multi  institutional   studies .

incidence of prostate cancer in different recent studies another arabic study   compared age adjusted serum level of psa of the arabic population with that of usa caucasians and the japanese population .
they showed that usa whites tend to have the highest total psa , followed by japanese population and finally the lowest psa level , adjusted to age , was present in arabic population .
psa density ( psad ) is another important parameter that was introduced by benston and colleagues as a useful tool to increase specificity of the detection of prostate cancer .
different cut  off values of psad ranging from 0.1 to 0.15 was proposed by urologists aiming to increase the specificity of prostate cancer detection in the grey zone area of total psa level , and thus avoid unnecessary prostatic biopsies [ 4144 ] .
contrary to studies on the western population , a recent arabic study , trying to include psad as a mean to avoid unnecessary prostatic biopsy , concluded that in patients with total psa < 10 ng / ml , values of psad < 0.32 strongly suggest benign disease .
the aim of our work was to report the pattern of prostate cancer presentation in alexandria university that as a tertiary referral center , provides care for uro  oncology cases .
data collection for all patients diagnosed with prostate cancer at alexandria universityin egypt through the year 2012 was done .
all possible information including patients age , clinical presentation , dre findings and serum total psa and prostate volume were evaluated .
analytical analysis was done using two tailed fisher exact test and two tailed unpaired t test .
we found 950 patients diagnosed with prostate cancer in our database through the year 2012 .
mean serum total psa , prostate volume and psad were 149 ng / ml , 63 grams and 3.1 ng / ml / gm respectively .
the remaining group was presenting with luts , including 23 patients who presented initially with back pain .
patients characteristics only 7 patients were found to fulfill the criteria of low risk prostate cancer namely , psa < 10 , t1c and gleason grade < 7 .
symptomatic patients were significantly associated with finding suspicious nodules during dre ( p 0.002 ) and higher psa density ( p 0.01 ) .
psa density of 0.15 did not yield any significant difference between both symptomatic and asymptomatic groups .
the median psa density for the whole group was 0.425 . when we used that value as the cutoff value , symptomatic patients had significantly higher psa density values .
table 5 shows the analytical analysis for the studied groups .
  analytical analysis for asymptomatic and symptomatic cases
only 54 patients ( 25% ) were diagnosed through surveillance programs for prostate cancer ( annual total psa and dre ) without having any symptoms .
thirty three patients had suspicious findings on dre and 42 patients had serum total psa > 10 ng / ml . the striking features in those groups were the high psa density and that most of the cases ( 46 patients ) had a gleason grade > 6 .
irritative urinary symptoms were the main presenting complaints in our patients and the same findings of markedly higher psa density and higher gleason grade were noted . using
the suggested western psa density value of 0.15 did not give any significant difference between surveillance and symptomatic groups , as the majority of cases had a psa density > 0.15 .
we decided to use psa density value of 0.425 as the cut  off value , being as it was the median value from the all 216 cases .
the surveillance group had 65% of cases with a value < 0.425 , while the symptomatic group had 46% of patients with values < 0.425 ( p 0.01 ) .
that in the arabic population , a high psa density value up to 0.32 may present benign disease .
our study also confirms the pivotal role of dre in the diagnosis of patients with prostate cancer as 77% of our cases had a suspicious finding during examination .
it was clear that patients diagnosed with prostate cancer in egypt , regardless of their mode of presentation and whether screened or not , tend to have a high serum total psa , psa density , abnormal findings on dre and higher gleason grade , reflecting the aggressive nature of prostate cancer in the egyptian population ( using the western definitions ) .
a recent paper from nigeria   showed that abnormal dre can predict higher gleason grades .
our study shows that prostate cancer may not be a single disease throughout the world and racial , religious and life style conditions may be contributing factors that affect the nature and presentation of the disease . applying western definitions
would mean that nearly all of our cases already had a metastatic and advanced disease , while really only 11% of them had metastatic deposits .
our reports confirm that egyptian men with prostate cancer had higher psa , psa density and higher gleason grade at initial diagnosis and tailored risk stratification may be needed to allow proper management for our cases .
egyptian men with prostate cancer have a markedly high psa density and gleason grade at diagnosis .

Answer:
introductionprostate cancer is a common health problem that in the majority of cases starts to develop at the age of 50 years , reaching its peak at 6070 years of age .
 a variation in its incidence and prevalence exists between western , asian and arabic populations.the aim of our work was to report the pattern of prostate cancer presentation in alexandria university that as a tertiary referral center provides care for uro
 oncology cases.material and methodsdata collection for all patients diagnosed with prostate cancer at alexandria university in egypt through the year 2012 was done.resultsthe mean age of the patients was 67 .
 mean serum total psa , prostate volume and psad were 149 ng / ml , 63 grams and 3.1 ng / ml / gm respectively .
 25% of patients were asymptomatic diagnosed accidentally during screening for prostate cancer .
 the remaining group was presenting with luts , including 23 patients who presented initially with back pain.conclusionsegyptian men with prostate cancer have a markedly high psa density and gleason grade at diagnosis .


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:
simultaneous palmar dislocation of the scaphoid and lunate is rare [ 17 ] and has been classified into two types depending on whether or not the scapholunate ligament is intact .
ten patients with dislocation of the scaphoid and lunate as a unit have been described to date , as well as six patients with divergent dislocation [ 16 ] .
the patient described here is therefore the seventh with palmar - divergent dislocation of the scaphoid and lunate . in this patient
, the scapholunate and lunotriquetral ligaments were sutured through the dorsal approach , the anterior capsule was sutured through the palmar approach , and the scapholunate and lunotriquetral joints were fixed with kirschner wires . to our knowledge , this is the first report in which interosseous ligaments were sutured by open surgery for divergent dislocation of the scaphoid and lunate .
a 46-year - old man who fell from a height of 1.5  m onto his left hand was brought to the emergency center of our hospital and underwent a medical examination .
radiography of the wrist revealed palmar - divergent dislocation of the scaphoid and lunate ( fig .  1 ) but with no neurovascular disturbance in the hand .
seven days after the injury , open surgery was performed through the palmar and dorsal approaches .
the dorsal approach showed ruptures of the scapholunate and lunotriquetral ligaments , which were sutured with anchors .
the palmar approach showed an oblique tear of the anterior capsule , which was sutured with absorbable threads .
finally , the scapholunate and lunotriquetral joints were fixed with two kirschner wires , inserted from the scaphoid to the lunate and from the triquetrum to the lunate , respectively , and the wires were buried under the skin ( fig .  2 ) .
a short arm plaster splint was applied postoperatively ; 2 weeks later , it was changed to a removable splint and rehabilitation was started . as kirschner wires remained in the carpal bones , range of motion ( rom ) exercises of the wrist were restricted to avoid wire failure . at 7 weeks , the kirschner wires and splint were removed , and the patient was started on intensive rehabilitation for an additional 3 months . at the 1-year follow - up , the patient had returned to normal life and work and had no pain in his wrist , although wrist motion was still restricted .
measurements of wrist and forearm rom showed that right / left extension was 60/50 , flexion was 70/40 , supination was 90/80 , and pronation was 90/90. a hand dynamometer showed that grip strength in his left hand was 16  kg compared with 27  kg on the contralateral ( dominant ) side .
although we observed no evidence of dorsal or volar intercalated segment instability pattern deformity , radiography showed a break in arc ii of gilula s line between the lunate and triquetrum , as well as flexion deformity of the scaphoid ( fig .
magnetic resonance imaging showed no evidence of avascular necrosis of the scaphoid and lunate ( fig .
1radiographs at initial diagnosis showing palmar - divergent dislocation of the scaphoid and lunatefig .
the scapholunate angle was 54 and the radiolunate angle 6. gilula s line was well - regulatedfig .
the scapholunate angle was 67 and the radiolunate angle 0. dorsal intercalated segment instability ( disi ) deformity was not observed , although there was flexion of the scaphoid and a break in arc ii of gilula s line at neutral and ulnar deviationfig .
4magnetic resonance imaging at the 1-year follow - up showing no evidence of avascular necrosis of the scaphoid and lunate radiographs at initial diagnosis showing palmar - divergent dislocation of the scaphoid and lunate postoperative radiographs showing good alignment of the carpal bones .
the scapholunate angle was 54 and the radiolunate angle 6. gilula s line was well - regulated radiographs at the 1-year follow - up .
the scapholunate angle was 67 and the radiolunate angle 0. dorsal intercalated segment instability ( disi ) deformity was not observed , although there was flexion of the scaphoid and a break in arc ii of gilula s line at neutral and ulnar deviation magnetic resonance imaging at the 1-year follow - up showing no evidence of avascular necrosis of the scaphoid and lunate the patient provided written informed consent prior to inclusion in this study , which was authorized by the local ethics committee and performed in accordance with the ethical standards of the 1964 declaration of helsinki as revised in 2000 .
as palmar - divergent dislocation of the scaphoid and lunate is rare , its optimal treatment remains unclear . in previous reports ,
two patients were treated by open reduction and cast immobilization [ 1 , 2 ] , two by open reduction and percutaneous pinning of the carpal bones and cast immobilization [ 3 , 4 ] , one by open reduction and suture of the anterior capsule and cast immobilization , and one by proximal row carpectomy ( prc ) ( table  1 ) .
carpal instability is severe in divergent dislocation due to ruptures of both the scapholunate and lunotriquetral ligaments .
therefore , it is difficult to stabilize the carpal bones and still retain sufficient wrist motion.table  1review of previous patients with divergent dislocation of the scaphoid and lunateauthorfollow - up ( months)surgical procedureapproachimmobilization ( duration)k - wire removalrange of motioncomplicationscampbell 12only open reductionpalmarcastnr
ext 1/2flex 1/3 of healthy sidenonegordon 12only open reductionpalmarcast4  weeks  ext 15flex 25disikupfer 42open reduction k - wire pinning ( s - l)palmar & dorsalcast4  months4  monthsext 25flex 0crps disi an ( scaphoid , lunate)baulot 42open reduction anterior capsule suturepalmarcast6  weeksalmost fulldisikang 18open reduction k - wire pinning ( s - l / s - c)palmarcast6  weeks6  weeksalmost fullnonedomeshek 1proximal row carpectomypalmar & dorsalsplint1  month  nrnran avascular necrosis , nr not recorded , k - wire kirschner wire , s scaphoid , l lunate , t triquetrum , c capitate , disi dorsal intercalated segment instability , crps complex regional pain syndrome , ext extension , flex flexion review of previous patients with divergent dislocation of the scaphoid and lunate an avascular necrosis , nr not recorded , k - wire kirschner wire , s scaphoid , l lunate , t triquetrum , c capitate , disi dorsal intercalated segment instability , crps complex regional pain syndrome , ext extension , flex flexion among the methods recommended to repair , the anterior and posterior ligaments on both sides of the lunate are combined palmar and dorsal approaches , and open reduction and percutaneous pinning of the scapholunate and scaphocapitate joints without suture of the interosseous ligaments .
although we found that suturing of the dorsal scapholunate and lunotriquetral ligaments provided a satisfactory outcome in our patient , wrist stiffness , carpal malalignment due to a break in arc ii of gilula s line between the lunate and triquetrum , and flexion of the scaphoid still remained .
first , we should have sutured the palmar , not the dorsal , lunotriquetral ligament because the palmar ligament is stronger .
moreover , in addition to fixing the scapholunate and lunotriquetral joints with kirschner wires , we should have fixed the scaphocapitate joint to maximize anatomical carpal alignment .
thus , for reliable carpal stability , we recommend ligament repair and temporary joint fixation of the carpal bones .
subsequent wrist stiffness may be prevented by early removal of kirschner wires after surgery and starting wrist exercises .
indeed , it may be possible to remove kirschner wires earlier than 6 weeks when interosseous ligaments are sutured . the injury to our patient
prc on a patient with a scapholunate dislocation and complete scaphoid extrusion resulted in a good clinical outcome , suggesting that prc may eliminate avascular necrosis and avoid additional surgery in patients with this type of injury .
however , although prc has shown satisfactory clinical outcomes , postoperative rom and grip strength averaged 5070% and 6090% , respectively , compared with the healthy side , outcomes similar to those observed in our patient .
therefore , except when unavoidable , we recommend surgical repair , especially for active young people and manual workers , with prc considered a salvage procedure .

Answer:
we describe a patient with palmar - divergent dislocation of the scaphoid and lunate .
 after successful closed reduction , the scapholunate and lunotriquetral ligaments were sutured through the dorsal approach , and the anterior capsule was sutured through the palmar approach .
 the scapholunate and lunotriquetral joints were fixed with kirschner wires for 7 weeks . at the 1-year follow - up ,
 magnetic resonance imaging showed no evidence of avascular necrosis of the scaphoid or lunate , and radiographs showed no evidence of the dorsal and volar intercalated segment instability patterns associated with carpal instability . however , flexion of the scaphoid and a break in gilula s line remained . to our knowledge , this is the first report showing treatment of palmar - divergent dislocation of the scaphoid and lunate by suturing the carpal interosseous ligaments .


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:
in 2007 , a 14-year - old male killer whale at a marine park in san antonio , texas , usa , died suddenly without notable premonitory signs . on gross examination , mild multifocal meningeal hyperemia and petechial parenchymal hemorrhage
focally extensive tan discoloration and fibrosis were present in the right accessory lung lobe with associated hemorrhage and congestion .
tissues fixed in 10% buffered formalin were processed routinely and stained with hematoxylin and eosin for histologic examination .
inflammatory lesions of the central nervous system were focused in gray matter of the medulla oblongata , pons , mesencephalan , and cerebellum .
blood vessels demonstrated mild to moderate acute necrosis and lymphocytic and contained plasmacytic and neutrophilic infiltrates within vascular walls .
encephalitis was characterized by perivascular lymphocytes and fewer plasma cells expanding the virchow - robbins spaces .
predominant lesions in the lungs were areas of chronic and active abscessation amid a focally extensive area of mixed inflammation and fibrosis .
they were characterized by central ulcerations with necrosis and a mixed inflammatory infiltrate surrounded by variable fibrosis and a rim of epithelial hyperplasia .
changes in spleen , lymph node , and kidney included acute edema , congestion , and vascular dilation .
conventional diagnostic assays were performed for aerobic , anaerobic , and fungal microbes in liver , lung , kidney , cerebrospinal fluid , and brain .
the final diagnosis was fulminant peracute bacteremia and septicemia secondary to a primary viral infection associated with nonsuppurative encephalitis .
published etiologic considerations for cetacean nonsuppurative encephalitis include morbillivirus and protozoal infections ( 2 ) .
a dna microarray with highly conserved sequences from > 1,000 viruses was selected to screen for known and novel viruses ( 3 ) .
total rna was extracted from brain tissue and hybridized to a microarray as described ( 4 ) .
analysis of the resulting hybridization pattern demonstrated a strong hybridization signal to many oligonucleotide probes on the microarray from the family flaviviridae , in particular to wnv .
consensus reverse transcription pcr primers ( 5 ) targeting wnv were used to confirm the microarray results .
hq610502 ) yielded a sequence with 99% nt identity and 100% aa acid identity to wnv strain ok03 ( genbank accession no .
eu155484.1 ) , a strain originally identified in oklahoma , usa . to further support a wnv diagnosis , we performed immunohistochemical staining on brain tissue .
rockville , md , usa ) with peroxidase - tagged goat antirabbit immunoglobulin g ( dakocytomation , carpinteria , ca , usa ) bridge and 3-amino-9-ethylcarbazole ( dakocytomation ) as the chromogen .
this staining demonstrated abundant wnv antigen within the cytoplasm of a small number of neurons and glial cells and in fewer macrophages in the brain tissue ( figure ) .
brain specimen from killer whale ( orcinus orca ) with west nile virus infection that died at a marine park , san antonio , texas , usa , 2007 . neurons and glial cells demonstrate abundant intracytoplasmic west nile viras antigen .
we evaluated wnv exposure within the same cohort , as well as a geographically distant cohort of whales by using serologic testing .
all testing was performed at the same laboratory by using a standard plaque - reduction neutralization test . in this assay ,
a 90% neutralization cutoff was used ( 6 ) . a 90% plaque - reduction titer
serum from the affected whale and 5 cohort killer whales from the same marine park in san antonio as well as 5 whales housed at another facility in orlando , florida , usa , were evaluated . in each facility , the animals have regular contact with each other .
the facilities are geographically separated so the animals do not have exposure to those in the other park .
all 6 animals from texas had 90% plaque - reduction titers > 10 , ranging from 40 to 80 .
these findings broaden the known host tropism of wnv to include cetaceans in addition to previously known pinnipeds .
although we can not definitively attribute the cause of death of this whale to wnv , the observed lesions are consistent with those caused by wnv in other animals .
the serologic results demonstrate that subclinical infections can occur and that exposure can be variable .
both bexar county , texas , and orange county , florida , have had wnv in wildlife since 2002 .
mosquito management practices are similar in both facilities and have been expanded since this diagnosis .
differences in wnv prevalence or mosquito numbers may have played a role in the different serologic results .
health evaluations of free - ranging and captive cetaceans should include wnv serology to assess exposure rates .
this report focuses on killer whales , but the  loafing  behavior ( stationary positioning at the water s surface ) is commonly seen in many coastal dolphins , thereby increasing the likelihood of mosquito bites and exposure to wnv .
serologic screening of bottlenose dolphins ( tursiops truncatus ) from the indian river lagoon demonstrated wnv titers ( 7 ) .
as with many species of birds and mammals , wnv infection carries a risk for zoonotic transmission .
until the implications of this infection in marine mammals are better understood , biologists and veterinarians working with cetaceans should consider this possibility .
potential viral shedding can occur through the oropharygeal cavity and feces as well as through blood and organs during necropsies .
finally , our study demonstrates the broad applicability of using panviral microarray - based diagnostics .
even though pcr diagnostics are well developed for wnv , the agent was not initially considered as a potential pathogen in this species .
panviral microarray can be used not only to identify novel viruses but also to detect unsuspected agents .

Answer:
in 2007 , nonsuppurative encephalitis was identified in a killer whale at a texas , usa , marine park .
 panviral dna microarray of brain tissue suggested west nile virus ( wnv ) ; wnv was confirmed by reverse transcription pcr and sequencing .
 immunohistochemistry demonstrated wnv antigen within neurons .
 wnv should be considered in cases of encephalitis in cetaceans .


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

Paper text:
a 3.09 kg , 33-day - old boy with pierre robin syndrome was admitted to our hospital for a glossopexy .
the patient was born at 39 weeks by c - section and was diagnosed with the syndrome during pregnancy . after birth , the patient showed a micrognathia , retrognathia , and a large tongue .
the patient also showed moderate chest retraction with coarse breathing sounds presenting difficulty in maintaining patent upper airway .
he was kept in a prone / lateral position under 5 l / min of o2 hood at nicu until the operation . in the operating room
intraoperative monitoring devices such as an ecg , an automatic blood pressure cuff , and a pulse oximeter were applied to the patient .
the initial oxygen saturation was 98% in room air and other vital signs ( bp : 96/27 mmhg , pr : 161/min , rr : 42/min ) were in normal ranges .
a mask was applied before induction and the manual ventilation was well maintained with patient 's spontaneous ventilation .
premedication with 0.004 mg / kg of glycopyrrolate was given intravenously and anesthesia was induced with gradual increment of sevoflurane concentrations from 2% to 4% with oxygen by mask while also maintaining spontaneous respiration .
brief direct laryngoscopic examination with a curved mcintosh blade ( # 1 ) was performed and only the hypopharynx was seen .
classical reusable laryngeal mask airway ( lma ) # 1 , in which two vertically placed bars were removed , was inserted and effective ventilation was assured by chest expansion , auscultation , and etco2 monitoring . while pausing the ventilation , ultrathin fiberoptic bronchoscope ( fob ) ( olympus enf type xp , 1.8 mm od , length : 530 mm , tokyo , japan ) was passed through the lumen of the lma and the vocal cords were well visualized .
under the visualization of the vocal cords by the fob , we passed the cook airway exchange catheter ( caec ) ( 1.6 mm i d , 2.7 mm od ) ( cook medical incorporated , bloomington , in , usa ) through the lma into the vocal cords .
however , passing the caec into the vocal cords under the guidance of the fob repeatedly failed because the caec frequently flexed backwards toward the esophagus . at that time , we recognized that the length of an uncuffed i d 3.0 mm endotracheal tube ( length : 16 cm ) was longer than that of lma#1 ( length : 11 cm ) .
therefore , through the lma , the tracheal tube was mounted on the fob and introduced into the trachea .
successful ventilation was verified by manual ventilation . to prepare for any accidental removal of the tracheal tube while removing the lma , we inserted the caec into the lumen of the tracheal tube . after placing the caec in the midtrachea ,
lma was carefully removed while tightly holding both the caec and tracheal tube simultaneously . despite this , the endotracheal tube was displaced out of the vocal cords while removing the lma . by holding the caec firmly inside the trachea , the displaced endotracheal tube
after intubation , endotracheal tube position was verified again by auscultation of equal bilateral breathing sounds and etco2 . during the procedure
, anesthesia was maintained with intermittent sevoflurane administration in oxygen ( o2 : 1 l / min , air : 1 l / min ) through the lma to prevent awakening and desaturation of the patient .
the maximum time allowed for the procedure was until the spo2 decreased lower than 95% .
atracurium 1.5 mg was given intravenously for muscle relaxation and mechanical ventilation was maintained during the operation .
the extubation was carried out when the patient was in a completely alert state and the spontaneous ventilation was well maintained without any chest retraction following the extubation .
the patient was then transferred to nicu in the supine position under 5 l / min of o2 mask .
patients with pierre robin syndrome may create difficulties during intubation and airway control is a major concern for anesthesiologists .
ventilation using a face - mask in the presence of a markedly recessed mandible may be difficult and patient 's supine position frequently leads to a total obstruction of the airway .
visualization of the larynx is almost impossible once the patient is anesthetized . in a recent survey conducted amongst pediatric anesthetists in canada
, 73% stated that they first attempted a direct laryngoscopy and , in the case of a failure , 51% would choose laryngeal mask airway - guided fiberoptic intubation .
when fob is chosen to be used for intubation , most anesthesiologists generally tend to use lma as a conduit for the bronchoscope , indicating that this technique is now firmly established in an approach to the difficult pediatric airway .
although this approach seems to be very successful , one problem is that the endotracheal tube can be easily withdrawn from the trachea during the removal of the lma . in order to prevent this , selim et al
therefore , it was possible to keep the intubated tube patent inside the trachea while lma was being removed , but instability of an elongated tube has still been a problem .
in addition to this , some authors   used a long guide wire inserted into the suction port of the fiberscope , which was then placed inside the trachea under direct vision . having the guidewire left in the trachea ,
the fiberscope and lma were withdrawn , and the tracheal tube was railroaded over the guidewire .
a disadvantage of this method was that the guidewire can be easily bent and flipped out of the trachea .
osses et al .   introduced a method of using an adult intubating stylet attached to the end of the tracheal tube so that lma would be removed while pushing the stylet inward . as an alternative approach , we used the caec under the guidance of the fiberscope to ease the insertion of the endotracheal tube into the trachea . however , when this catheter was passed down through the lma , it frequently emerged from the posterior aspect of the mask aperture of the lma and resulted in an esophageal intubation even though vocal cords were well - visualized with the ultrathin fob . despite many trials using a caec , it was very difficult to approach the vocal cords with the tip of the catheter .
brimacombe and berry   have reported that the success rate of blind placement of the caec via the lma in adults was only 30% despite good lma positioning .
therefore , this indicates that , even when the lma is perfectly positioned , blind tracheal intubation can not always be performed successfully . in children , perfect positioning of the lma
was observed in 44% , 29% , and 49%   of all cases , which also indicates that there may have been some impediment to blind passage of the endotracheal tube , a bougie or introducer when this technique is attempted . to correctly place the caec into the trachea ,
after the guidewire passed through the suction channel of the fob , a stiffening device such as the caec or ureteral dilator railroaded over the guide wire through the lma might be helpful in placing the caec or dilator correctly in the trachea .
in addition to this , we suggest another method for successful placement of the caec . as shown in fig .
1 , a fishing line is passed through the lumen of a caec and form a guide - loop like the one of arndt endobronchial blocker ( cook medical incorporated , bloominton , in , usa ) at the distal end of the caec and a tight knot is made at the proximal end of the catheter , making sure that it does not come loose .
then , the fob and lma were removed while keeping the catheter in midtrachea and the endotracheal tube is mounted on the caec , followed by railroading over the caec . in a pediatric patient , weighing 7.5 kg , thomas and parry   also used a caec through which a fob was inserted and the tip of the fob was extended from the distal aperture of the caec . following introduction of caec with the enclosed fiberscope into the trachea , the fob was removed leaving the caec within the trachea .
although this is an interesting approach , considering that they used an olympus lf - p fiberscope ( proximal od 2.2 mm and distal od 1.8 mm ) and a caec ( 2.3 mm i d for use with tracheal tubes of i d 4 mm or larger ) , it can not be used in a smaller pediatric patient because the olympus enf type xp or lf - p fiberscope can not pass through the lumen of the caec ( 1.6 mm i d for use with tracheal tubes of 3 mm or larger ) which we used .
another problem with this approach is that the caec has to be cut to an adequate length to ensure that the fob tip extends from the distal aperture of the caec . in our case ,
an uncuffed 3.0 mm i d endotracheal tube ( length : 16 cm ) was longer than that of lma#1 ( length : 11 cm ) .
however , in pediatric difficult airway cases in which the endotracheal tube length is similar to or shorter than the lma , the proximal end of the tracheal tube tends to disappear into the lma once the tracheal tube has passed through the vocal cords . in this situation
, it might be helpful to insert a caec first through the lma using the suggested methods by walker , thomas and parry 's   methods , or our method in order to facilitate easy insertion of the caec into the trachea . in summary
first , it can provide a more stable passage for the endotracheal tube since the diameter of the caec which we used ( 1.6 mm i d ) is larger than the guide wire previously used to pass through the suction port .
second , it is much safer to attempt repeated intubation in the case of accidental tube displacement out of the trachea during removal of the lma .

Answer:
the case of a 33-day - old boy with pierre robin syndrome using a cook airway exchange catheter in laryngeal mask airway - guided fiberoptic intubation is presented .
 after induction with sevoflurane , classical reusable laryngeal mask airway ( lma ) # 1 was inserted and ultrathin fiberoptic bronchoscope ( fob ) was passed through . a cook airway exchange catheter ( 1.6 mm i d , 2.7 mm od ) was passed through the lma under the guidance of the fob but failed to enter the trachea despite many trials .
 then , an endotracheal tube ( 3.0 mm i d ) was mounted on the fob and railroaded over the fob . after successful intubation
 , the cook airway exchange catheter was placed in the midtrachea through the lumen of the endotracheal tube .
 even though the tracheal tube was accidentally displaced out of the trachea during lma removal , the endotracheal tube could be easily railroaded over the airway exchange catheter .


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:
unilateral neglect ( un ) refers to the neuropsychological condition in which patients
 experience reduced orientation and concentration and response to stimuli on the
 contralesional side owing to behavioral problems that occur after brain injury , although
 these patients having sensorimotor abilities1 .
un is caused by various forms of brain damage and has an especially
 high incidence in patients with stroke in the right inferior parietal lobe2 .
it is
 negatively associated with the rehabilitation period because patients with un show
 relatively poor functional recovery compared with those without un3 .
in addition , these patients experience difficulties in
 activities of daily living ( adl ) , including maintaining personal hygiene , eating , and
 dressing , and also are at increased risk of falling because of gait disturbance4 . therefore , having an appropriate treatment
 and strategy are important while treating this condition because it is essential to reduce
 un to achieve effective rehabilitation in these patients .
we proposed a new treatment method for un by modifying current treatment methods and
 combining them with mental practice and electromyogram - triggered electrical stimulation
 ( mp - emg es ) .
mp - emg es is a new , state - of - the - art rehabilitation treatment technology based
 on neurologic theories .
mp - emg es involves only repetitive mental practice ( for example ,
 imagination of intense movement of the upper limbs on the neglected side ) , not voluntary
 muscular contraction . when the generated electric potential reaches a preset threshold , an
 electric stimulus is generated , resulting in actual muscular contraction and cortical
 activation5 .
in other words , mp - emg es
 can produce a synergistic effect by combining two treatments ( mental practice plus
 electrical stimulation ) with proven efficacy in the alleviation of neglect .
the purpose of
 this study was to identify the effects of this novel training method
mp combined with emg
 es  over a 6-week period of daily training in patients showing right brain damage with
 un .
the participants for this study were recruited from the rehabilitation center of a local
 university hospital .
the inclusion criteria for participation were : ( 1 ) onset duration of
 > 6 months , ( 2 ) right hemisphere stroke with un , ( 3 ) mini - mental status
 examination score > 24 , ( 4 ) ability to imagine ( average score on the
 vividness of movement imagery questionnaire < 3 ) , and ( 5 ) active wrist muscle strength
 > 2 on the medical research council ( mrc ) scale .
exclusion criteria were : ( 1 ) an implanted
 cardiac pacemaker , ( 2 ) skin lesion on the affected side or hypersensitivity at the electrode
 site , ( 3 ) a history of seizure or epilepsy , and ( 4 ) unstable medical conditions . in total ,
 thirty - three stroke patients with neglect were eligible for this study .
all participants
 provided written informed consent , and this study was approved by the inje university
 institution review board .
this study was designed as a single - blind randomized control study and was scheduled to
 last for a total 6 weeks .
eligible participants were randomly allocated to the two groups by
 block randomization using opaque envelopes containing a code specifying the group .
the
 experimental group ( n=16 ) received mp - emg es in addition to conventional rehabilitation
 therapy ( crt : physical therapy and occupational therapy ) , whereas the control group ( n=17 )
 received cyclic es in addition to the same crt .
mentamove ( mentamove deutschland gmbh ,
 munich , germany ) was used to apply mp - emg es in the experimental group .
surface electrodes
 were attached to the wrist extensor muscle and a reference electrode was attached at the
 lateral side of the forearm .
the site of electrode placement was marked using a permanent
 marker throughout the intervention . during motor imagery training ,
when the potentials reached
 a preset threshold , the induced electrical stimulation would contract the targeted
 muscle .
the mentamove process consisted of three stages : ( 1 ) motor imagery ( approximately 12  s ) ,
 ( 2 ) electrical stimulation ( approximately 6  s ) , and ( 3 ) relaxation ( approximately 12  s ) .
the
 motor imagery used in this study was a vigorous waving of the affected whole arm .
this
 imagery was selected because the emg was not able to detect electrical stimulation induced
 by motor imagery of simple extension of the wrist or elbow .
the emg pick - up threshold was
 set afresh for each subject in every session .
if the subject repeatedly reached the
 threshold during the mp - emges , the threshold was automatically increased slightly .
imagine that your left
 arm moves rapidly and intensely when you see  motor imagery  in the tool window .
if your
 performance is successful , you will experience an electrical stimulation in your forearm .
cyclic es ( mendel gmbh , germany ) without the emg function was used to apply electrical
 stimulation in the control group .
electrodes also were attached to the wrist extensor
 muscle . in either instrument , biphasic pulses with a frequency of 35  hz and pulse width of

200 s were applied for 12 s. stimulation intensity led to a clear extension of the wrist
 ( average 2030 ma ) . over a period of 6 weeks , both groups were treated 30 times in two
 30-min sessions . the line bisection test ( lbt ) , star cancellation test ( sct ) , and catherine bergego scale
 ( cbs ) were used to quantify the severity of un .
twenty lines were drawn on an
 a4 sheet parallel to the long axis , and 18 of these lines were organized into 3 set of 6 : 1
 set lay primarily on the left , 1 at the center , and 1 on the right side of the sheet .
the
 evaluator initially demonstrated the procedure by marking the 2,150-mm lines at the top and
 bottom of the sheet .
patients were asked to mark the center points of each of the 18 lines
 in order .
distances from the left of each line to patient s marks and to true line centers
 were measured .
deviations were measured using the formula : percent deviation ( % ) = [ ( marked
 left side distance - true half length)/true half length ]  100 . in sct ,
the left and right halves
 of the sheet each contained 27 stars , and patients were asked to mark all of the stars .
the
 scores range from 0 to 27 , with lower scores indicating more severe un .
assessment using cbs
 involved evaluating the performance of patients by directly observing them perform
 activities ( e.g. , dressing , grooming ) in real - life situations , and consisted of 10 items .

each item was scored on a four - point scale as follows : 0 : no neglect 110 : mild neglect ,
 1120 : moderate neglect , and 2130 : severe neglect7 .
participant characteristics were analyzed using a statistical software program ( spss
 statistics 20 ) and descriptive statistics were presented as mean  sd . the shapiro - wilk test
 was used to check normality of the outcome variables . to evaluate the intervention effects ,
 measures before and after the intervention in each group
an independent t - test was used to compare changes in outcome measures between the
 two groups .
all demographic and clinical characteristics of the participants were comparable and are
 summarized in table 1table 1.baseline characteristics of the subjects included in the studyexperimental group ( n=16)control group ( n=17)gendermale10 8 female69age ( years)67.510.362.210.2time post stroke ( months)3.31.33.51.6stroke typehemorrhage45infarction1212 .
the experimental group showed a significant improvement in the lbt ( p<0.01 ) , cbs , and sct
 ( p<0.05 ) scores after the intervention compared with the values obtained before the
 intervention ( table
 2table 2.clinical parameters before and after the treatment ( n=33)experimental group control groupbeforeafterbeforeaftercbs12.14.210.14.612.63.811.24.1lbt30.58.924.110.332.69.127.710.6sct10.65.213.05.5 9.25.211.04.6the values are mean  standard deviation .
cbs : catherine bergego scale , lbt : line
 bisection test , sct : star cancellation test .
* p<0.05 by paired t test between the
 initial and final scores in the group .
on the other hand , no significant difference was observed in the control
 group , except in the lbt score ( p<0.05 ) .
no significant differences were observed in the
 lbt , cbs , and sct scores between the two groups after treatment .
cbs : catherine bergego scale , lbt : line
 bisection test , sct : star cancellation test .
* p<0.05 by paired t test between the
 initial and final scores in the group .
mp - emg es is a recently developed method that produces tiny electrical signals in the brain
 through mental practice , rather than through actual physical movements , and this method is
 used to induce muscle contraction in the upper extremity ( u / e ) on the neglected side . in
 other words ,
the aim of mp - emg es is to form sensorimotor circuits for movement through a
 repeated cycle of brain signal  transmission  muscle movement , which can be used to
 produce functional changes in the central nervous system and the body .
the continual
 activation of these circuits helps reorganize the damaged areas of the cerebral cortex8 .
it is thought that mp - emg es works by
 inducing neural and peripheral changes through activation of the cerebral cortex via mental
 practice and afferent stimulation of the neglected u / e via electrical stimulation .
hong et al.5 reported mp - emg es is more
 effective than cyclic es for improving motor function on the affected side and improves
 cerebral glucose metabolism in supplementary motor , precentral and postcentral gyri on the
 contralesional side .
however , there is little evidence about the effects of this treatment
 in cases of un . in this study
, we investigated the effects of mp - emg es on neglect in
 comparison with those of cyclic es .
cbs , lbt and sct scores significantly improved after
 treatment in the experimental group .
the control group received various crt interventions
 that were the same as the experimental group .
this control treatment was important because
 cyclic es has been proven to alleviate neglect to some extent by applying afferent
 stimulation to the neglected side .
therefore , while the control group only showed a
 significant improvement in lbt , they also showed a slight improvement in scores for cbs and
 sct , and as a result , no significant differences were demonstrated between the two groups in
 any assessments .
some studies
 reported that mental practice is effective for rehabilitation in patients with
 contralesional neglect , but it is difficult to verify whether patients imagine the specific
 movement well9 .
mp - emg es seems to remedy
 the deficiencies of mental practice alone . in this study , patients were instructed to imagine a large and powerful movement of the
 neglected u / e during the mental practice stage of mp - emg es treatment . when imagining the
 movement of the neglected u / e , the muscles in the u / e show dynamic regulation and
 changes5 .
in this regard , when a
 participant imagined a complex and powerful movement instead of a simple movement , the
 motor - evoked potential and the excitation in the corticospinal tract increased10 .
this study showed that mp - emg es is an effective method for reducing unilateral neglect in
 stroke patients .
however , several factors need to be considered when applying this method .
 because mp - emg es requires the patient to be capable of imaging movement of the body on the
 neglect side

Answer:
[ purpose ] the aim of this study was to investigate the effect of mental practice combined
 with electromyogram - triggered electrical stimulation on neglect and activities of daily
 living in stroke patients with unilateral neglect . [ subjects and methods ] thirty - three
 stroke patients with unilateral neglect were recruited from a local university hospital ,
 and were divided into two groups .
 the experimental group received an intervention
 consisting of mental practice combined with electromyogram - triggered electrical
 stimulation on the neglected side , while the control group received cyclic electrical
 stimulation at the same site .
 in addition , both groups received an identical intervention
 of conventional occupational and physical therapy .
 [ results ] after the intervention , the
 experimental group showed a statistically significant improvement in the line bisection
 test result , star cancellation test result , and catherine bergego scale scores .
 the
 control group showed a significant improvement only in the line bisection test result .

 [ conclusion ] these data suggest that mental practice combined with
 electromyogram - triggered electrical stimulation is an effective , novel treatment for
 reducing unilateral neglect in stroke patients .