Ewing Sarcoma/Primitive Neuroectodermal Tumor Involving the Duodenum.

Background: Ewing sarcoma/primitive neuroectodermal tumor (ES/PNET) is a soft tissue malignancy arising from the neuroectoderm. While the locations of these extraskeletal manifestations are diverse, origin from the small bowel and small bowel mesentery is extremely rare. Intra-abdominal manifestations of ES/PNETs are nonspecific, and patients present with a wide range of symptoms, most frequently vague abdominal pain. Case Report: A 66-year-old female initially presented with vague and nonspecific symptoms of hypotension, anemia, dyspnea, and coffee-ground emesis. Imaging workup with computed tomography and fluorodeoxyglucose positron emission tomography demonstrated a metabolically active large mass involving the duodenum and measuring 10.3 × 8.8 × 12.3 cm. The mass was characterized as an ES/PNET on histopathologic diagnosis. The patient was treated with chemotherapy followed by radical resection and was disease-free at 1 year postpresentation. Conclusion: This case highlights that while ES/PNETs are rare tumors of the abdomen, they should be considered in cases of large soft tissue masses in patients presenting with nonspecific symptoms. To the best of our knowledge, this case is the fourth report in the literature of an ES/PNET involving the duodenum.

Dermatofibrosarcoma Protuberans Presenting in a Patient With Neurofibromatosis Type 1: Potential Implications on Treatment.

Dermatofibrosarcoma protuberans (DFSP) is a rare soft tissue sarcoma. Neurofibromatosis type 1 (NF1) is a neurocutaneous syndrome that affects multiple organ systems. We present the case of a 47-year-old African American male with a two-year history of a slowly enlarging right lower back lesion. Upon workup, the 3 × 2 cm mass was biopsied confirming a diagnosis of DFSP. This was identified in concert with axillary freckling, café-au-lait spots, and pedunculated plaques evaluated with biopsy. The findings were consistent with neurofibromas, leading to a new diagnosis of NF1. The patient was definitively treated with wide local excision of the DFSP lesion without tumor recurrence over six years. DFSP has a favorable prognosis when treated with wide local excision and negative surgical margins. However, lesions may recur with inadequate margins. Although deferred in our patient, treatment with imatinib mesylate, a tyrosine kinase inhibitor, may be employed in the setting of advanced disease, metastasis, positive surgical margins, or irresectable locations. Imatinib has also been used to treat NF1. Hence, we posit that the concomitant presentation of these two disease entities in our patient highlights a potentially unique treatment with imatinib mesylate. To our knowledge, this is the second reported case of both entities in the same patient.

Nerve Sheath Myxoma in the Lower Extremity: A Rare Case with Description of Magnetic Resonance Imaging and Sonographic Findings.

BACKGROUND This report is of a nerve sheath myxoma presenting as a slow-growing mass in the back of the left ankle of a 36-year-old man that was investigated by ultrasound and magnetic resonance imaging (MRI) before the diagnosis was confirmed by histopathology. CASE REPORT We report a nerve sheath myxoma of the ankle in a 36-year-old man. The palpable abnormality was falsely assumed to be a ganglion cyst prior to advanced imaging. Magnetic resonance imaging demonstrated a lobular mass with high T2 and intermediate T1 signal as well as moderate enhancement. T2 sequences also demonstrated distinctive internal septae. These internal septae were also noted on sonographic evaluation prior to biopsy. The patient was treated with surgical excision, and pathologic analysis showed myxoid nodules with loose arrangements of spindled cells separated by fibrous septae. S-100 protein and glial fibrillary acidic protein positivity by immunohistochemistry staining was demonstrated. Follow-up imaging at 12 months showed no evidence of tumor recurrence. CONCLUSIONS This case highlights that while nerve sheath myxomas are rare tumors, they should be considered in cases of cutaneous soft-tissue masses with myxoid imaging features. Ultrasound and magnetic resonance imaging features of thin internal septae may be present and correspond well with the unique histopathological characteristics of these lesions. This report shows the importance of imaging of peripheral soft-tissue masses, including ultrasound and MRI, which can identify localized and benign features and the solid, cystic, and myxoid areas, which were characteristic in this case of benign nerve sheath myxoma.

A novel method for soft tissue retraction during periapical surgery using 3D technology: a case report.

AIM: This case report describes a new approach to isolation and soft tissue retraction during endodontic surgery using cone-beam computed tomography (CBCT), computer-aided design (CAD) and three-dimensional (3D) printing. SUMMARY: A 53-year-old patient presented for endodontic treatment of her maxillary left central incisor. It was decided to treat this tooth with a microsurgical approach. The data from the diagnostic CBCT scan were also used to make a physical model of the operative site, and CAD software was used to design a soft tissue retractor to be used during the patient's surgery. A custom retractor was then fabricated using a 3D printer. The custom-made retractor enhanced visualization and soft tissue handling during the patient's surgery. The patient was asymptomatic at a 1-year review. No abnormalities were detected during her clinical examination, and radiographic examination revealed complete healing of the surgical site. KEY LEARNING POINTS: The significance of proper soft tissue retraction in periapical microsurgery is underemphasized. Geometric data from CBCT scans may be harvested for a variety of uses, adding value to the examination. 3D printing is a promising technology that may potentially have many uses in endodontic surgery.

3D printing in dentistry.

3D printing has been hailed as a disruptive technology which will change manufacturing. Used in aerospace, defence, art and design, 3D printing is becoming a subject of great interest in surgery. The technology has a particular resonance with dentistry, and with advances in 3D imaging and modelling technologies such as cone beam computed tomography and intraoral scanning, and with the relatively long history of the use of CAD CAM technologies in dentistry, it will become of increasing importance. Uses of 3D printing include the production of drill guides for dental implants, the production of physical models for prosthodontics, orthodontics and surgery, the manufacture of dental, craniomaxillofacial and orthopaedic implants, and the fabrication of copings and frameworks for implant and dental restorations. This paper reviews the types of 3D printing technologies available and their various applications in dentistry and in maxillofacial surgery.

A review of rapid prototyped surgical guides for patient-specific total knee replacement.

Improvements in the surgical technique of total knee replacement (TKR) are continually being sought. There has recently been interest in three-dimensional (3D) pre-operative planning using magnetic resonance imaging (MRI) and CT. The 3D images are increasingly used for the production of patient-specific models, surgical guides and custom-made implants for TKR. The users of patient-specific instrumentation (PSI) claim that they allow the optimum balance of technology and conventional surgery by reducing the complexity of conventional alignment and sizing tools. In this way the advantages of accuracy and precision claimed by computer navigation techniques are achieved without the disadvantages of additional intra-operative inventory, new skills or surgical time. This review describes the terminology used in this area and debates the advantages and disadvantages of PSI.

Post-implant neuropathy of the trigeminal nerve. A case series.

BACKGROUND: The incidence of implant-related inferior alveolar nerve injuries (IANI) is steadily increasing within the UK population. AIMS: This study prospectively reviewed thirty cases (35% male; 65% female) of implant-related IANI seen in a specialist nerve injury clinic.Methods Neurosensory examinations were carried out to ascertain a quantifiable rating of the perception, pain profiling and functional difficulties. Data were analysed using SPSS software. RESULTS: Patients were aware of signing consent forms for the surgery in 11 cases and 8 of those felt they were not explicitly warned about nerve injury. Over 70% of patients were referred after six months post injury. Implant surgery planning involved intra-oral films only (30%), CBCT (10%), dental pantomograph (50%) and long cone peri-apical radiographs (48%). However, no radiographic evidence pre- or postoperatively was provided by the referring practitioner in 15% of cases. Intra-operative problems included bleeding and neurological symptoms. Proximity of the implant bed or implant to the inferior alveolar canal was evident radiographically. This showed contact with roof inferior alveolar nerve canal in 44% of cases, protrusion into the canal in 20% of cases, crossing of the canal in 20% cases and distance in one case, presumed to be due to local anaesthetic injury. All patients presented with a demonstrable neuropathy, which included neuropathic pain (50%) that interfered with speaking, kissing and socialising. CONCLUSIONS: Consent, preoperative planning and appropriate referral were inadequate in provision of mandibular implants in this patient group. Recommendations have been proposed to improve practice and possible novel strategies are suggested for the prevention and improved management of these complications.

Bovine haptoglobin as an adipokine: serum concentrations and tissue expression in dairy cows receiving a conjugated linoleic acids supplement throughout lactation.

The present study aimed to characterize serum haptoglobin (Hp) concentrations throughout an entire lactation period in both primi- and multiparous cows and to compare them to the Hp mRNA expression in liver and - in view of Hp being potentially an adipokine - also in different subcutaneous (s.c.) and visceral fat depots. In addition, potential anti-inflammatory effects of long-term supplementation with conjugated linoleic acids (CLA) were evaluated by assessing Hp. Trial 1 comprised 33 cows and 16 Holstein heifers from day 21 ante partum until day 252 postpartum. The animals received 100 or 50 g/day CLA or a control fat supplement. Blood samples and biopsy (tail head fat and liver) samples were collected. Trial 2 included 25 Holstein heifers, 5 animals were slaughtered on the day of parturition, the remaining animals were allocated to either CLA (100 g/day, n=10) or control fat supplement (n=10) and slaughtered on days 42 and 105 postpartum, respectively. At slaughter, fat samples were collected from 3 different visceral depots, 3 s.c. depots and from liver tissue. Results indicated no effects of CLA on serum Hp and liver Hp mRNA for both trials and on Hp mRNA in biopsies from s.c. tail head fat. In omental and s.c. withers fat from trial 2, CLA reduced Hp mRNA on both day 42 and day 105. Hp mRNA was detectable in fat tissues from both trials with abundance values being significantly lower than in liver. The Hp mRNA abundance in the s.c. fat depots was generally higher than in the visceral depots. Haptoglobin mRNA abundance in the different tissues from trial 2 was correlated whereby all s.c. depots were interrelated. The evidence of Hp mRNA expression in adipose tissues and the presence of Hp-immune staining in histological fat sections confirm that Hp can be classified as a bovine adipokine. The lack of an evident relationship between circulating Hp concentrations and normal body fat portions in dairy cattle demonstrates that varying degrees of adiposity are not confounding factors when using Hp as inflammatory marker. The physiological changes in serum Hp concentration seem to be limited to parity and parturition. In view of the lack of effects of CLA on serum Hp concentrations, the observed reaction in two out of six different fat depots seems of marginal importance for the organisms as an entity.

Optimization of cone beam CT exposure for pre-surgical evaluation of the implant site.

OBJECTIVES: The aim of this study was to investigate the possibility of reducing patient X-ray dose in the course of implant site evaluation. METHODS: Retrospective practice-based study using a Morita F170 Accuitomo cone beam CT (CBCT) scanner with variable exposure parameters and operating a small cylindrical field of view of 4 cm diameter and 4 cm height. 6 experienced dental surgeons scored the image quality of dental scans on a 5-point scale for adequacy in providing the required information in 2 categories: bone height from alveolar crest to the relevant anatomical structure and bone width. RESULTS: Lower-dose protocols only marginally affected the preference of the reviewers of the resulting images. CONCLUSIONS: There is potential to reduce patient dose very significantly in CBCT examinations for implant site evaluation.

Microtechnologies in implant and restorative dentistry: a stroll through a digital dental landscape.

This is an explanatory article introducing the combination of various technologies used in implant and restorative dentistry. The aim of the article is to provide an overview of some of the techniques supporting the restorative treatment plan at various stages to provide contemporary, state-of-the-art bridgework based on dental implants. It is a discussion of the way existing technologies used in fields of engineering and medicine are brought together to form a complete process.

Cone beam CT in dental practice.

Cone Beam Computed Tomography is a relatively new three-dimensional imaging technology, which has been specifically developed for imaging of the teeth and jaws. The aim of this paper is to acquaint the dental team with various forms of this technology and its potential applications. An understanding of the underlying principles will allow the users of this technology to tailor the imaging protocol to the patient's individual needs to achieve appropriate imaging at the lowest radiation dose.

Immediate implant supported bridgework simultaneous with jaw reconstruction for a patient with mandibular osteosarcoma.

A patient with mandibular osteosarcoma underwent full immediate dental rehabilitation including insertion of dental implants and immediately loaded implant bridgework in the same operation as surgical resection of the tumour and scapular composite free flap reconstruction. Planning and pre-production of the titanium reconstruction plate, drill guides and bridgework using a 3D stereolithographic model of the patient's jaw is described. The advantage of this immediate full rehabilitation of an oncology patient is compared with the potential disadvantages.

Balloon angioplasty for native aortic coarctation in different anatomic variants.

Balloon angioplasty for native coarctation of the aorta in infants and children is gaining acceptance as an alternative to surgery in discrete membranous obstruction. The aim of this study was to assess the immediate and intermediate-term effectiveness and safety of balloon angioplasty in infants and children with discrete membranous obstruction and mild complex arch anomalies. We performed a retrospective study evaluating the immediate and intermediate-term results of balloon angioplasty in 46 consecutive patients with native coarctation of the aorta done between March 1998 and June 2003. Isolated discrete fibromembranous obstruction occurred in 32 patients, and 14 patients had mild complex arch anomalies. Follow-up was obtained in 40 patients. There was no early mortality. The procedure was initially successful in 43 patients (93%). There were three immediate failures. Of the 40 patients who were followed, 32 (80%) had maintained a cuff pressure gradient of 20 mmHg across the dilated area. Four patients developed restenosis, which was successfully treated by repeated balloon angioplasty. The other four patients continued to have mild gradient (20-22 mmHg) with systolic hypertension and without angiographic evidence of restenosis but with isthmus hypoplasia; they received atenolol and captopril. Serial echocardiographic measurement of left ventricular dimension and function revealed significant improvement after balloon angioplasty of aortic coarctation in patients with the echocardiographic picture of hypertensive cardiomyopathy. Balloon angioplasty may be considered as a tool in the armamentarium of management of aortic coarctation in different anatomic variants, taking into consideration the clinical presentation and patient age.

The potential applications of cone beam computed tomography in the management of endodontic problems.

AIM: To provide core information on cone beam computed tomography (CBCT) technology and its potential applications in endodontic practice. SUMMARY: CBCT has been specifically designed to produce undistorted three-dimensional information of the maxillofacial skeleton as well as three-dimensional images of the teeth and their surrounding tissues. This is usually achieved with a substantially lower effective dose compared with conventional medical computed tomography (CT). Periapical disease may be detected sooner using CBCT compared with periapical views, and the true size, extent, nature and position of periapical and resorptive lesions can be assessed. Root fractures, root canal anatomy and the true nature of the alveolar bone topography around teeth may be assessed. CBCT scans are desirable to assess posterior teeth prior to periapical surgery, as the thickness of the cortical and cancellous bone can be accurately determined as can the inclination of roots in relation to the surrounding jaw. The relationship of anatomical structures such as the maxillary sinus and inferior dental nerve to the root apices may also be clearly visualized. KEY LEARNING POINTS: CBCT has a low effective dose in the same order of magnitude as conventional dental radiographs. CBCT has numerous potential applications in the management of endodontic problems.

Environmental exposure of the pediatric age groups in Cairo City and its suburbs to cadmium pollution.

In a trial to assess the exposure of subjects in the pediatric age group to cadmium (Cd) pollution, serum Cd was estimated by atomic absorption spectrometry in 405 subjects, birth-18 years old, from Cairo City and its suburbs. Serum Cd mean concentrations were: 0.92 microg/l in 32 neonates (birth-4 weeks); 1.33 microg/l in 70 infants (4 weeks-2 years); 1.11 microg/l in 100 children in the preschool period (2-6 years); 1.34 microg/l in 103 primary school children (6-12 years); and 1.24 microg/l in 100 adolescents (12-18 years). In neonates, serum Cd was higher in babies with weights and heights that remained below the 5th percentile for age. Breast-fed infants had a serum Cd geometric mean level (1.25 microg/l) that was not in accordance to that of their mothers' milk (0.52 microg/l, P < 0.001), suggesting alternative routes of exposure. Environmental tobacco-smoke exposure was the most important determinant of Cd status in the school-aged children, the geometric mean being 1.42 microg/l in passive smokers vs. 1.2 microg/l in non-exposed children (P < 0.05). Moreover, adolescents who were active smokers had a significantly higher serum Cd level (1.7 microg/l) as compared to non-smokers (1.2 microg/l). Gender did influence the Cd status in adolescents, being higher among males, probably related to smoking, or to the difference in lifestyle of adolescents according to gender in the community. Alpha-1-microglobulinuria was accompanied by a higher serum Cd concentration in the group of adolescents only, suggesting a subclinical renal effect after several years of cumulative exposure. The residential classification, whether urban or suburban, did not influence the serum Cd status; neither did the present or past history of bronchial asthma. These findings certainly justify further evaluation of the problem of Cd pollution among Cairene individuals, knowing the long-term consequences of exposure to it. Systematic efforts for the proper disposal of Cd wastes and prevention of smoking in public places are recommended.

Laparoscopic versus open high ligation of the testicular veins for the treatment of varicocele.

The purpose of this study is to determine the relative advantages of laparoscopic varicocelectomy compared to the conventional open high ligation of Palomo. We studied 193 patients who presented with varicocele. While 65 patients were treated by open high ligation of the testicular veins, 128 patients had laparoscopic varicocelectomy. In addition to varicocele ligation, 14 patients (11%) had laparoscopy-assisted right orchidopexy, and 5 patients (4%) had laparoscopic repair of concomitant right inguinal hernia. The mean hospital stay was 3.5 days and 1.3 days, respectively, and the recurrence rates were 10.8% and 3.9%, respectively. Return to normal activity was significantly earlier in Group II (mean 4.5 days) compared to Group I (mean 8.9 days). There was no incidence of testicular atrophy in any case in the study, regardless of whether the testicular artery was ligated or preserved during surgery. We conclude that laparoscopic varicocelectomy is safe, effective and minimally invasive. In addition to its better cosmetic results and advantage in case of bilateral disease, it allows excellent exposure and control of the affected vessels. Furthermore, the shorter hospital stay and the earlier return to normal activities are very important advantages in recommending this technique as an efficient alternative to the open surgical method.

The modified rectal bladder in children: long-term follow-up.

The criteria for evaluation of urinary diversion procedures in children must be strict since their life expectancy is long. Our experience with the modified rectal bladder in children with considerable follow-up periods is reported herein. All patients were continent by day and night. Urography studies revealed a normal upper tract in all cases. Three early complications were encountered among patients who had a submucous tunnel reimplantation. Reflux to the proximal colon or the kidneys was not demonstrated. The metabolic status and growth-rate patterns of these patients were within normal limits without alkaline therapy. All urine samples aspirated from the renal pelves were sterile. We conclude that a modified rectal bladder with a second ileal intussusception valve is the operation of choice whenever urinary diversion in children is indicated.

Evaluation of adenosine deaminase activity and antibody to Mycobacterium tuberculosis antigen 5 in cerebrospinal fluid and the radioactive bromide partition test for the early diagnosis of tuberculosis meningitis.

A number of different biochemical and serological tests have been described recently for the early and accurate diagnosis of tuberculous meningitis. None of these tests has yet gained widespread acceptance in clinical medicine or in microbiology laboratories. To investigate this problem we evaluated adenosine deaminase activity (ADA), an enzyme linked immunosorbent assay (ELISA) that detects antibody to antigen 5 of Mycobacterium tuberculosis, and the radioactive bromide partition test (BPT) in the cerebrospinal fluid (CSF). Cerebrospinal fluid specimens from children with tuberculous, pyogenic, and viral meningitis as well as from patients with pulmonary tuberculosis without meningitis and from controls with normal CSFs were included inn the study. In addition, we estimated ADAs in serum samples from selected children in these groups. The sensitivity and specificity of the three tests evaluated in the CSF were: ADA assay 73% and 71%; BPT 92% and 92%; and ELISA for antibody to antigen 5, 53% and 90%, 40% and 94%, and 27% and 100%, respectively, at tires of more than or equal to 1:20, 1:40, and 1:80. The serum ADA was lower (11.0 +/- 6.15 IU/l) in children with tuberculous meningitis when compared with those with pulmonary tuberculosis alone (25.8 +/- 20.9 IU/l). The BPT was found to be the most reliable test in the early differentiation of tuberculous from other causes of meningitis and remained abnormal for a period of up to five months after the beginning of treatment. Accordingly, we believe that the BPT should be used in conjunction with bacterial and fungal antigen detection systems for the initial differentiation of clinically suspicious tuberculous meningitis from Gram or culture negative cases, or both, of bacterial and fungal meningitis.

Weaver's syndrome--primordial excessive growth velocity. A case report.

We report on a black child with the Weaver syndrome of primordial overgrowth, the seventh and largest case thereof yet recorded. His birth weight was 10 200 g and he has continued to grow at an excessive velocity. At the age of 14 months his weight was 30 kg, his height 105 cm and his radiological bone age between 6 and 7 years. Other features which conform to previous reports are a peculiar face with a long philtrum, protuberant lower lip, relative micrognathia, large dysplastic ears, excessive loose skin folds around the scalp, neck and trunk, large hands with camptodactyly, varus deformities of the feet and a hoarse, low-pitched voice. A significant feature in this patient is lumbar kyphosis due to hypoplasia of the second and third lumbar vertebrae. Biochemical and endocrinological tests did not reveal an abnormality.