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To determine the prevalence of abnormal laryngeal findings during videostroboscopy in performers presenting to clinic or when having an acute vocal emergency.Retrospective study of professional singers and actors who presented for a vocal evaluation.A chart review of singers or professional actors who presented in a private otorhinolaryngology clinic between 2014 and 2016. The prevalence of laryngeal lesions noted on stroboscopy were reviewed. The RFS (reflux finding score) was calculated and the exams that presented RFS greater than or equal to seven were considered suspicious of laryngopharyngeal reflux (LPR).A total of 140 records of actors and singers were evaluated either for routine evaluation or for an acute emergency. Sulcus vocalis was the most prevalent lesion 36% (n = 33), followed by cyst 27% (n = 25) and acute laryngitis, 14% (n = 13). Thirty-seven (26.4%) performers were treated for emergence due to dysphonia, Emergency dysphonia, mostly due to viral infection, was treated with steroids and speech therapy, with improvement of symptoms after treatment. Of these professionals, 83.8% (31) presented with a structural lesion or infection in the vocal folds, while 16.2% presented with dysphonia, which required emergency care without a structural lesion in the vocal folds. (P0.05) Eighty-nine percent (33) of the professionals presenting with a voice emergency with dysphonia (37) were treated with corticosteroids. Thirty-three percent (n = 47) of the professionals presented with RFS scores ≥7. Nineteen professionals (40%) with signs of LPR were treated for emergency due to dysphonia. The professionals with signs of LPR had more emergency dysphonia than those who did not suspect LPR. (19.4%) (P = 0.008).Vocal emergencies in professionals are common in a private laryngology practice and require specialized assessment. The most prevalent lesions in the study were vocal sulcus. LPR is common in this group as noted both by findings with videostroboscopy and the RFS.

A girl born by normal vaginal delivery at 34 weeks’ gestation was noted to have a discrete midline scalp swelling from birth. This parieto-occipital lesion was non-tender, non-pulsatile and measured 10 mm in diameter. At 4 weeks of age, the lesion remained similar in size and had developed a

Functional metastatic pheochromocytoma (PCC) is a very rare tumour and cytoreductive adrenalectomy with oligo metastatectomy is recommended in cases of low tumour burden. We report a rare case of metastatic PCC with an incidentally detected suspicious nodule seen on the anterior surface of the right lobe of the liver. The adrenal and the lesion were excised and sent for histopathology which was reported as a metastasis from PCC. This lesion was not visualised preoperatively on DOTA-PET-CT, highlighting the importance of keeping a low threshold for suspicion of metastasis in abnormal lesions and taking a biopsy during surgery. Inspection of the liver and rest of the abdomen for any abnormality should be done even when operating for any apparently benign lesions.

We describe the case of a 32-year-old man from Cape Verde having headache and increasing visual loss. Clinical and radiological investigations disclosed a massive destructive lesion involving the anterior and central skull base, orbit and nasoethmoid region initially interpreted as a malignant small round cell tumour. Surgical biopsies were negative for neoplasm, showing an intense inflammatory infiltrate together with fungus, later characterised as Aspergillus flavus spp. The patient was immunocompetent with no evidence of congenital or acquired immunodeficiencies. Invasive fungal infections in immunocompetent patients are rare and can be a diagnostic challenge. The best diagnostic clues include the patient’s origin from tropical climates, imaging features and the identification of fungal hyphae on pathology specimens. Although a devastating disease in immunocompromised patients, craniocerebral aspergillosis in immunocompetent patients carries a better prognosis. Available literature supports the combined used of ‘conservative’ surgical resection and antifungal therapy as the best treatment option.

An 8-year-old girl presented with precocious puberty and an otherwise normal examination. MRI of the pituitary was normal; however, an incidental oval, non-enhancing T2 hyperintense lesion in the right temporal subcortical white matter was identified ([figure 1][1]). The neuro-radiographic

We report the case of a 10-year-old boy that presented with a palpable, painless, frontal lesion. Laboratory assessments were unremarkable and the patient was asymptomatic. Initial investigation, with a skull radiograph and unenhanced CT scan, showed a lytic midline frontal lesion involving the inner and outer tables of the skull and a large subgaleal hypodense component. MRI further depicted communication with the epidural space and contact with the superior sagittal sinus (SSS). Subsequent evaluation by Doppler ultrasound and MR angiography excluded a sinus pericranii and showed normal patency of the SSS. Surgical biopsy revealed chronic granulomatous inflammation; PCR was positive for Mycobacterium sp. One year after surgical resection and antitubercular therapy, there are no signs of recurrence. Primary calvarial involvement by tuberculosis is rare, even in developing countries. Familiarity with the expected clinical and imaging features is required to avoid diagnostic delay.

Aneurysmal bone cysts are locally aggressive benign bone tumours with a high risk of recurrence. We describe a case in a 4-year-old girl, involving the right acetabulum. A direct posterior approach was used and the lesion ablated with curettage and local adjuvants with bone grafting. The cyst resolved swiftly with an uncomplicated recovery.

Rosacea is a chronic inflammatory skin disease whose late manifestations have not yet been clearly reported in animal models. The objective of this study is to describe the skin lesions and major histopathological changes in a rosacea-like phenotype in mice induced by prolonged LL-37 administration and furthermore, to assess the potential of long-term LL-37 administration in inducing irreversible rosacea-like skin lesion models. Balb/c mice were continuously injected intradermally with LL-37 every 12 h to induce a rosacea-like phenotype. After LL-37 injections were administered for 20 consecutive days, the area of rosacea-like lesions gradually expanded in the first 13 days, then entered a stable phase. Haematoxylin and eosin (H&E) and Van Gieson’s staining showed a high degree of inflammatory cell aggregation, thickening of the epidermis and dermis, and collagen deposition in large quantities. The results of immunofluorescence staining and Western blotting showed that the expression of α-SMA, TNF-α, vimentin, and COL1 in the skin of mice was significantly upregulated. Short-term LL-37 administration induced rosacea-like lesions that only featured the aggregation of inflammatory factors and thickening of the epidermis, whereas no collagen hyperplasia was observed, and a full recovery was noticed. However, rosacea-like skin lesions induced by long-term LL-37 administration did not completely recover. Our study compares rosacea-like lesions induced by short-term versus long-term LL-37 administration, and the results suggest that irreversible rosacea-like lesions can be induced by long-term LL-37 administration.

Radiation-induced sarcoma (RIS) of the central nervous system is an uncommon late complication of radiation therapy. We report a case of a 47-year-old male patient who underwent surgery followed by irradiation and chemotherapy with temozolomide for a frontal lobe gliosarcoma and presented 43 months later with a recurrent tumor in the same location with interval growth in the size of the lesion. Histology from surgical resection of the recurrent tumor revealed embryonal rhabdomyosarcoma (RMS). Adjacent brain parenchyma showed radiation-induced changes. There was no evidence of gliosarcoma at recurrence. In addition to the rarity of sarcomas arising following irradiation for glial tumors, this case represents one of the first reports of an intracerebral RMS arising in this setting.

The localization and segmentation of the novel coronavirus disease of 2019 (COVID-19) lesions from computerized tomography (CT) scans are of great significance for developing an efficient computer-aided diagnosis system. Deep learning (DL) has emerged as one of the best choices for developing such a system. However, several challenges limit the efficiency of DL approaches, including data heterogeneity, considerable variety in the shape and size of the lesions, lesion imbalance, and scarce annotation. In this article, a novel multitask regression network for segmenting COVID-19 lesions is proposed to address these challenges. We name the framework MT-nCov-Net. We formulate lesion segmentation as a multitask shape regression problem that enables partaking the poor-, intermediate-, and high-quality features between various tasks. A multiscale feature learning (MFL) module is presented to capture the multiscale semantic information, which helps to efficiently learn small and large lesion features while reducing the semantic gap between different scale representations. In addition, a fine-grained lesion localization (FLL) module is introduced to detect infection lesions using an adaptive dual-attention mechanism. The generated location map and the fused multiscale representations are subsequently passed to the lesion regression (LR) module to segment the infection lesions. MT-nCov-Net enables learning complete lesion properties to accurately segment the COVID-19 lesion by regressing its shape. MT-nCov-Net is experimentally evaluated on two public multisource datasets, and the overall performance validates its superiority over the current cutting-edge approaches and demonstrates its effectiveness in tackling the problems facing the diagnosis of COVID-19.

PURPOSE To report a case of paracentral acute middle maculopathy (PAMM) in an otherwise healthy young, multiparous woman in her second trimester of pregnancy. METHODS Case report RESULTS:: A 38-year-old woman in her twentieth week of pregnancy presented with a four-day history of an acute paracentral scotoma in her left eye. Fundoscopic examination of the left eye was significant for a white-gray lesion inferonasal to the fovea which corresponded with spectral domain-optical coherence tomography (SD-OCT) hyperreflectivity at the outer plexiform layer-inner nuclear layer junction and optical coherence tomography angiography (OCTA) non-perfusion. A diagnosis of paracentral acute middle maculopathy was made. The patient was sent for a hypercoagulability work-up that revealed elevated factor VIII activity, which has been associated with increased risk of complications during pregnancy. CONCLUSION PAMM in pregnancy may be secondary to an underlying hypercoaguable condition. We recommend systemic evaluation and referral to a high-risk pregnancy specialist if PAMM is diagnosed during pregnancy. Additionally, OCTA in PAMM may demonstrate reperfusion of the affected vessels.

Schwannoma is an uncommon benign tumor in the oral and maxillofacial region, and development of schwannoma in the lower lip is rare. Herein, we present the case of a 68-year-old woman who visited Nihon University Itabashi Hospital complaining of a painless mass in the lower lip. The lesion was surgically resected under local anesthesia. On histopathological examination, the resected specimen was a mixture of Antoni types A and B schwannoma. No recurrence has been seen over a postoperative follow-up period of 58 months. In the schwannoma of the lower lip, the mean tumor volume was compared for type A and the mixed type, which tended to be larger in the mixed type. No previous reports have described the relationship between the size of schwannoma in the lower lip and Antoni classification. Therefore, this report discusses the possibility of a relationship between tumor size and Antoni classification for schwannomas in the lower lip.

We present a case of solitary chondrosarcoma arising from the proximal phalanx of the ring finger in an elderly man. The chondrosarcoma developed over a period of 14 years, during which the phalanx became progressively more deformed. Several radiographic investigations were carried out, but the patient declined further suggested diagnostic examinations (computed tomography, magnetic resonance imaging, biopsy). Eventually, the lesion became significantly enlarged, and radiographs showed osteolytic lesions in the phalangeal bone. Ray amputation of the finger was required to establish a wide resection of the chondrosarcoma. Most osteochondral tumors arising from the phalanges are benign tumors such as enchondromas, but primary chondrogenic malignant bone tumors (chondrosarcomas) occasionally occur. Chondrosarcoma of the phalanx is difficult to distinguish from enchondroma of the phalanx, because histological investigations of the two neoplasms often produce similar findings. Even with a combination of clinical, biopsy, and imaging findings, differentiating these neoplasms is still challenging, because the characteristic clinical and radiological features of chondrosarcoma do not appear until it becomes aggressive and starts to cause destructive changes. Once that happens, radical expanded resection of the tumor is essential. Therefore, longstanding enchondroma-like lesions should be actively treated in elderly patients, even if a definite diagnosis of chondrosarcoma cannot be made.

This study aimed to compare complete revascularization (CR) guided by angiography with a fractional flow reserve (FFR)-guided strategy in patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD). CR is preferred to culprit-only revascularization for patients with STEMI and MVD. However, whether FFR-guided CR is superior to angiography-guided CR is unclear in patients presenting with STEMI who have MVD. Randomized controlled trials comparing CR with an FFR- or angiography-guided strategy to culprit-only revascularization in patients with STEMI and MVD were systematically identified. A random-effects network meta-analysis was performed comparing clinical outcomes in the 3 arms. A total of 13 studies with a total of 8,927 patients were included in our analysis. Compared with culprit-only revascularization, angiography-guided CR was associated with a significantly decreased risk of myocardial infarction (MI) (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.37 to 0.82), all-cause death (HR 0.69, 95% CI 0.49 to 0.97), and cardiovascular death (HR 0.54, 95% CI 0.34 to 0.85) but FFR-guided CR was not (MI: HR 0.77, 95% CI 0.53 to 1.12; cardiovascular death: HR 0.89, 95% CI 0.64 to 1.24; all-cause death: HR 0.93, 95% CI 0.72 to 1.18). The network meta-analysis comparison of angiography- versus FFR-guided CR showed an HR of 0.75 (95% CI 0.50 to 1.11) for all-cause death and an HR of 0.71 (95% CI 0.54 to 1.17) for MI. In conclusion, for patients with MVD presenting with STEMI, angiography-guided CR may provide additional benefits compared with FFR-guided CR.

Introduction The proximal femur (PF) is one of the most common locations of benign cystic lesions. A fracture after bone biopsy is a rare but severe complication. However, the risk of fracture after biopsy of this lesion has not been well-studied. Computed tomography (CT)-based finite element (FE) modeling estimates the elastic modulus and compressive strength enables fracture prediction. This study investigated strength of PF after biopsy by CT-FE modeling and determined the optimum biopsy level and size. Materials and methods Six male bone tumor patients’ (15–38 years) total femur CT data (slice thickness, 0.8–1.0 mm) of the healthy side were obtained. Three different cylindrical bone defect (BD) diameters (10, 15, and 20 mm) were set on the lateral surface of PF at the following levels: level 1, insertion of the gluteus minimums; level 2, lower end of the greater trochanter (GT); level 3, origin of the vastus lateralis; level 4, center of the lesser trochanter (LT); and level 5, lower end of LT using Mechanical Finder software (version 8.0). Virtual loads were applied with incremental increases of 100 N until fracture occurred and the fracture load (FL) was evaluated. Results For BD with a diameter of 15 and 20 mm, there was a significant difference in the decrease of the mean FL, with an average of 22% at level 4 and 5, and 33%–44% at levels 3 to 5, respectively. At level 1 and 2, no significant decrease in the mean FL was observed regardless of the diameter of BD. Conclusion Biopsies at level 1 and 2 showed no significant decrease in bone strength. However, biopsy at level 1 may contaminate the GT bursas. Therefore, biopsy at level 2 (lower end of GT) can avoid contamination and minimize the effect on bone strength.

The WHO classification of tumors of the CNS in 2016 defined “diffuse midline glioma, H3 K27M-mutant” as a new tumor entity locating in the CNS midline. However, the H3 K27M-mutation in “non-midline” glioblastoma are rare and their characteristics have been rarely reported. A 16-year-old girl presented a hyper-intense lesion at her left temporal stem on T2WI, FLAIR and DWI. Biopsy was performed and molecular pathological diagnosis was glioblastoma with H3 K27M-mutant. Accordingly, the possibility of H3 K27M-mutant should be examined not only for diffuse glioma without IDH mutation that develops at a midline location, but also in non-midline locations.

PURPOSE To describe four eyes of three patients with presumed acute fovealitis to expand the clinical variants of this recently described disorder. METHOD The patients underwent a comprehensive ophthalmic examination, including multimodal imaging and electrophysiological tests. RESULTS Three female patients aged from 18 to 24 years presented sudden central visual disturbances in one or both eyes. The visual acuity ranged from 20/25 to 20/70 in the affected eyes. All of them showed a subtle yellowish lesion in the foveola. Fundus autofluorescence and fluorescein angiography were unremarkable. Optical coherence tomography disclosed focal disarrangement of the outer retinal layers restricted to the fovea and hyperrefective lesions above the external limiting membrane. Multifocal electroretinography responses were attenuated. The electrooculogram response was normal. All patients recovered normal visual acuity and the outer retinal layers. CONCLUSION Attenuated multifocal electroretinography foveal response and normal electrooculogram are newly described clinical findings in patients with acute fovealitis.

Purpose To describe the clinical findings and outcome of an unusual case of subfoveal yellowish deposits associated with excessive doses of phosphodiesterase type 5 inhibitors intake. Methods Single retrospective case report. Results A 50-year-old South American man with a personal history of multiple orally administered phosphodiesterase type 5 inhibitors drugs to treat a chronic erectile dysfunction complained of dyschromatopsia, photophobia and a three-months history of blurred vision. The fundus examination revealed a symmetrical yellowish lesion in both eyes with a subfoveal hyperreflective signal on the spectral domain optical coherence tomography at the level of the ellipsoid zone. Dysregulation of the blue-yellow axis was noticed in the color vision test and the electroretinogram demonstrated a tiny decrease in the b-wave amplitude. The use of phosphodiesterase type 5 inhibitors was discontinued and the patient was examined three months later. Optical coherence tomography revealed complete disappearance of the deposit in both eyes and the associated symptoms resolved rapidly with discontinuation of the drug. Conclusions A bilateral ellipsoid zone subfoveal focal thickening may be related to a yellowish symmetrical spot on the fovea in patients with a history of phosphodiesterase type 5 inhibitors overdose intake. Functional and structural findings are reversible in a short-term period after discontinuing the oral treatment.

Background Meniscal ramp lesion (RL) is the peripheral lesion of the posterior horn of the medial meniscus (PHMM) associated with anterior cruciate ligament (ACL) tear. The purpose of this study was to evaluate the accuracy of pre-operative magnetic resonance imaging (MRI) evaluation in diagnosing RL and to identify whether the difficulty in diagnosis differs depending on the location of RL. Methods ACL-injured patients undergoing ACL reconstruction from January 2017 to January 2019 were enrolled. A methodical arthroscopic exploration to identify RL was conducted intra-operatively using three steps, namely, the anterior visualization step, the inter-condylar visualization step, and the posteromedial step. The location of the RLs was evaluated and classified into two types as follows: Red-red zone (RR) - a meniscal tear of the red-red zone of the PHMM. Menisco-capsular junction (MCJ) - a lesion at the menisco-capsular junction of the PHMM, which is more peripheral than RR. Furthermore, the accuracy of 1.5-T MRI evaluation to diagnose RL by two testers using sagittal proton-density fat-saturated images was calculated. Results Of the 81 patients enrolled, 11 had RL: 5 cases each were at the MCJ and RR, and 1 case was at both locations. The sensitivity of MRI for detecting RL was 27.3–45.5%, whereas the specificity was 84.3–95.7% in total. The sensitivity of MRI in detecting RL at the RR and MCJ was 40.0–80.0%, 0–20.0%, respectively. The intra-observer reliability of the MRI evaluation was moderate (κ coefficient: 0.40–0.46), while the inter-observer reliability was fair to moderate (κ coefficient: 0.27–0.41). Conclusions A low sensitivity of the MRI in detecting RL at the MCJ was observed, and the reliability of the MRI evaluation for diagnosis of RL was not high. Therefore, methodical arthroscopic exploration is essential to diagnose RL even when it is not suspected on pre-operative MRI.

To describe a case of choroidal nevus with intralesional cavitations detected with enhanced depth imaging optical coherence tomography and to show its changes during an 8-year follow-up.A case report.A 55-year-old male patient was found to have a pigmented lesion at the posterior pole of his right eye, just temporal to the fovea. A complete multiimaging examination was obtained and showed a lesion of about 4 mm of diameter with a small amount of subretinal fluid and chronic changes in the retina overlying the lesion. Based on clinical examination, a diagnosis of choroidal nevus was made, but interestingly the enhanced depth imaging optical coherence tomography revealed the presence of intralesional cavitations. Close follow-up with no intervention was planned, and over 8 years of observation, the lesion remained stable in size, with a gradual increase of the central necrosis.Benign pigmented choroidal lesions can show internal cavitations likely secondary to internal necrosis. This feature does not represent a sign of malignancy of the lesion. Enhanced depth imaging optical coherence tomography is a feasible imaging tool for the visualization of the internal cavitations and to follow their evolution over time.

Odontogenic choristomas are a rare and recently classified entity, defined as neoplasms containing tissues of odontogenic derivation, found in abnormal locations and usually diagnosed in the early age. The authors report a unique case of a 79-year-old patient who presented to our attention for a skin lesion in the right cheek with no history of trauma or recent dental procedures, that underneath presented an indolent tooth-like structure inside the soft tissue of the right cheek, which at the histological study resulted to be an odontogenic choristoma. This rare histopathological diagnosis should be considered when a hard lesion is present in the head and neck region.

Mucormycosis is a very commonly encountered disease in the sinonasal region in patients with diabetes and immunocompromised status specially in the northern part of the Indian continent. Due to its fulminant nature and involvement in the rhino-orbital-cerebral region, prognosis is poor even after extensive debridement and amphotericin-B therapy. We present a case with diagnosis of sarcoidosis being treated with systemic steroids who developed sudden-onset ptosis and left lateral rectus palsy. On radiological evaluation with MRI, a heterogenously peripherally enhancing lesion was seen in the nasopharynx suggestive of nasopharyngeal abscess. The patient was taken up for emergency surgery; a necrotic lesion with destruction of sphenoid bone, pterygoids and clivus was seen originating in the nasopharynx. The lesion on fungal staining came out to be broad aseptate hyphae suggestive of mucormycosis.

Sweet’s syndrome (acute febrile neutrophilic dermatosis) consists of acute onset of painful cutaneous erythematous lesions, mostly found in the upper extremities followed by the head and neck region, particularly in patients with underlying malignancies. We describe the case of a woman in her mid-30s, who was treated for acute myeloid leukaemia and presented with a severe painful and progressive erythematous lesion of the retroauricular skin. Clinical features, laboratory tests, blood cultures and histological biopsy yielded a diagnosis of Sweet’s syndrome. The treatment consisted of oral and topical corticosteroids and her signs and symptoms resolved within 1 week. Although Sweet’s syndrome is uncommon, awareness among otolaryngologists is crucial to ensure a prompt diagnosis, cure and referral to an oncologist (if not already involved) for patients with Sweet’s syndrome in the head and neck area.

The standard endovascular treatment for ruptured dissecting aneurysm is a parent artery occlusion. However, this treatment is unsuitable when the artery of the lesion gives off perforating vessels that supply blood to critical regions or when the collateral flow cannot be expected due to the sacrifice of the parent artery. Here, we present an infrequent case of ruptured dissecting aneurysm on P1 segment of the posterior cerebral artery. The aneurysm had little sac for coiling and the artery of the lesion had some perforator branches; thus, we selected the monotherapy with three overlapping low-profile visualised intraluminal support stents as radical treatment, which resulted in prompt obliteration of the aneurysm. The patient was fully recovered at 3 months after the procedure. Previous studies have reported the effectiveness of multiple stents alone for dissecting aneurysms, whereas this case showed that overlapping stents may also be effective on the P1 segment.

A Dieulafoy’s lesion is a rare cause of massive gastrointestinal (GI) bleeding. It represents an abnormally dilated submucosal artery that erodes the overlying epithelium in the absence of a primary ulcer. These lesions are usually located in the stomach, nevertheless, they have been found in all areas of the GI tract, including the oesophagus, duodenum and colon. Bleeding episodes are often self-limited, although bleeding can be recurrent and profuse. The case describes a 50-year-old woman who developed haemorrhagic shock secondary to a rectal Dieulafoy’s lesion and discusses the diagnostic and therapeutic approaches.

A 55-year-old woman presented with a 4-month history of right-sided non-specific loin pain and 6 kg weight loss. A CT scan of the abdomen and pelvis showed an incidental 4.5 cm right-sided adrenal lesion which was not typical of an adrenal adenoma. This was further confirmed on MRI of the adrenals. Biochemical investigations to investigate for a functional adrenal lesion included serum catecholamines and metanephrines, an aldosterone to renin ratio and an overnight dexamethasone suppression test. These were all negative. A laparoscopic adrenalectomy was performed in view of the large size of the lesion. Histology was consistent with a phaeochromocytoma, which confirmed the diagnosis of a non-secreting phaeochromocytoma. Non-secreting phaeochromocytomas are rare and usually found in patients with known genetic mutations. Adrenal lesions not related to any mutations similar to our case are even rarer and reported even less in the literature.

Solitary fibrous tumours (SFTs) are rare neoplasms derived from mesenchymal cell lines. They are often asymptomatic, follow an indolent growth pattern and are more often benign than malignant. Here, we present a case of a very large, asymptomatic mediastinal SFT in an otherwise healthy man. A 67-year-old Irish man was referred for workup of an asymptomatic murmur. Auscultation of the lung fields revealed diminished breath sounds on the right side. Chest X-ray identified a 20 cm mass localised within the thorax. CT of the thorax confirmed a pleural based, solid lesion with no local invasion. CT-guided core biopsies were reported as consistent with SFT. Primary excision of the lesion was undertaken via median sternotomy. Histological examination confirmed a diagnosis of SFT. The patient remains well at this time. Primary excisive surgery is a safe and effective treatment modality for SFTs.

The purpose of this report is to highlight the early clinical signs and management of ocular surface neoplasia following penetrating keratoplasty in xeroderma pigmentosa. A 14-year-old girl reported increased conjunctival hyperemia, tearing, photophobia in the right eye at 6 months after penetrating keratoplasty that worsened rapidly over the subsequent 2 weeks. Slit lamp examination showed increased vascularity, epithelial haze and raised whitish lesions at the graft–host junction. Alcohol keratoepithelectomy was performed for confirming the diagnosis. Histology of the sample revealed severe dysplasia. The lesion resolved after surface plaque brachytherapy. The graft clarity was restored and maintained until the last follow-up of 15 months following brachytherapy. Exacerbated symptoms and clinical signs of increased vascularisation and epithelial lesions should arouse the suspicion of ocular surface neoplasia in grafted eyes. Early diagnosis and management can salvage the graft clarity.

A 69-year-old man was referred to the hepatobiliary surgeons for mild enlargement of an asymptomatic cystic liver lesion found on routine screening in 2017 that measured 3.7×3.6×4.3 cm. Work-up with MRI revealed a complex multilocular cyst that had enlarged to 6.6×5.5×4.6 cm. Other work-up was unremarkable. He had a Eastern Cooperative Oncology Group score of 1; therefore, a surgical excision was planned due to the possibility for malignancy. A robotic approach with enucleation of the lesion was undertaken, with plans for return for a wider resection if pathological examination revealed malignancy. The lesion was noted to be a biliary adenofibroma, an exceptionally rare lesion that is thought to be benign, but requires excision due to potential malignant degeneration. The patient was discharged home the following day and has had minimal pain in his postoperative course.

We present two 85-year-old men, with a similar history of prostate cancer treated more than 10 years ago with radiotherapy, who were in remission, but sought medical care at a time, due to alarm sign and symptoms. Case 2 resulted in a locally advanced secondary radiation-induced sarcoma of the penile base. Case 1 suffered from a round, 2 cm soft-tissue lesion with spiculated borders at the ureterovesical junction responsible for ipsilateral iliac vein compression and urinary obstruction without proven biochemical prostate cancer relapse, raising concerns about recurrence or secondary tumour. Both patients followed an oncological geriatric assessment and were ‘vulnerable’ at their presentation. Hence, we describe the effort to perform medical care adequacy regarding patient’s frailty and the anatomic locations within the prior radiation field. In case 2, we got a pathological diagnose and followed sequential multimodal treatments without success. But in case 1, minimal intervention resulted in improvement.

Isolated occipital condyle lesions are commonly treated with empirical radiation, with the sole aim of relieving symptoms. Patients rarely undergo surgical biopsy, considering the morbidity associated with open surgery approaches and the importance of surrounding structures limiting the application of computed tomography (CT) scan or fluoroscopic percutaneous needle biopsies. We describe the case of a 66-year-old woman who was admitted on an emergency basis. Her clinical presentation included unilateral occipital headache and ipsilateral hypoglossal nerve palsy. Imaging revealed findings consistent with an isolated right occipital condyle lesion. In order to pursue a tissue diagnosis, essential to dictate medical management accurately, a minimally invasive biopsy of the occipital condyle through the trans-oral route was performed. Combined fluoroscopy, cone-bean CT and angiography allowed safe access to the lesion.

Chronic total occlusions are considered the most complex coronary lesion in interventional cardiology. The absence of visible lumen on angiography obscures the vessel course and makes vessel wiring unlikely with conventional techniques. Often a source of severe ischemia, chronic occlusions are also markers of advanced atherosclerosis that brings other complex features including lesion length, bifurcations, calcification, adverse vessel remodelling, distal disease, and anatomic distortion from previous bypass grafting. Often advanced atherosclerosis is associated with patient characteristics like left ventricular dysfunction, previous coronary bypass surgery, or multivessel disease that increase procedural demands and hazards. To accommodate these challenges new techniques and dedicated technologies have been developed. When applied to appropriate patients, these advances have improved procedural success, safety, and outcomes. Our aim is to provide the general cardiologist with an overview of these advances that can serve as a basis for counselling patients considered for revascularization.

Background: Some reports have described intraosseous arteriovenous fistulas showing osteolytic changes, but an osseous arteriovenous fistula (AVF) at the jugular bulb showing extensive bone destruction is a very rare disease. Case description: A 60-year-old man presented with pulsatile tinnitus and right facial nerve palsy. Radiological imaging showed a large homogenously enhanced osteolytic lesion at the right jugular foramen. A cerebral angiogram showed a high-flow vascular lesion of the jugular bulb associated with retrograde sinus reflux, resulting in venous congestion of the deep venous system. These findings led us to misdiagnose this lesion as a glomus jugular tumor. However, combined arterial and venous angiography after transarterial embolization revealed the precise angioarchitecture, and we finally diagnosed this lesion as a high-flow osseous AVF at the jugular bulb. We performed transvenous embolization using a triple catheter technique. The lesion was successfully obliterated, and the 6-months angiogram showed no recurrence. Conclusion: A rare case of high flow osseous AVF at the jugular bulb associated with osteolytic changes in the surrounding bony structure is reported. Although many hypervascular lesions at the jugular bulb are glomus tumors, bone destructive osseous AVF at the jugular bulb should be considered.

Background The insidious nature of BCG-osteomyelitis makes it challenging for clinicians to detect it early on. Methods This 12-year retrospective analysis was conducted at a single tertiary hospital in central Taiwan. Electronic medical records of pediatric patients treated for BCG-osteomyelitis were reviewed. Demographics, clinical features, and laboratory findings were compared with patients diagnosed with culture-proven pyogenic osteomyelitis. Results In total, eight patients fulfilled our inclusion criteria. Their median age was 16 months, and no obvious gender prevalence was found. Six of the eight patients had lesions involving the lower extremities. When compared with the pyogenic osteomyelitis group, age of disease onset was found to be significantly younger in the BCG osteomyelitis group (p=0.038). Absence of fever and pain in the BCG osteomyelitis group was found to be statistically significant when compared with the pyogenic group (p=0.002 and p=0.026 respectively). CRP and ESR were found to be significantly higher in the pyogenic osteomyelitis group (p=0.000 and p=0.004 respectively). Conclusion BCG-related osteomyelitis must be considered when evaluating an afebrile child presenting with an unexplainable swelling or limp, and especially when the lesion is located on a lower limb. Laboratory studies may reveal normal WBC and CRP, with a normal to modest elevation of ESR. Imaging studies, including plain radiographs, magnetic resonance imaging (MRI), or computed tomography (CT) should be employed to rule out BCG-related osteomyelitis. Early diagnosis help minimize inappropriate antibiotics use, and may lead to a better outcome.

Retrospective cross-sectional case series.Lesions of the triangular fibrocartilage complex (TFCC) can result in pain during axial load and unstable distal radioulnar joint (DRUJ). Conventional wrist orthoses decrease initial pain sufficiently but also prevent any movement during recovery and do not contribute to the stabilization of the DRUJ.In this retrospective analysis, we tested if the weight-bearing capacity of patients with lesions of the triangular fibrocartilage complex was increased by wearing a brace that stabilizes the distal radioulnar joint.Twenty-three patients had an arthroscopically confirmed TFCC lesion. We compared preoperative dynamic weight-bearing capacity of both hands with and without a commercially available wrist brace (WristWidget). Subgroup analysis was performed for stability of the distal radioulnar joint and etiology of the TFCC lesion. The dynamic ulnar variance was measured in a modified weight bearing test. We used parametric tests for normally distributed values.The weight-bearing capacity of the hand with TFCC lesion was significantly lower than of the control hand (16 verus 36 kg; p0.001). The relative load of the affected hand compared to the unaffected hand increased from 48 % (CI 37-60, SD 27) to 59 % (CI 47-72, SD 29 with a brace. The device had no effect on the control hand. Twelve patients with unstable DRUJ had a lower weight-bearing capacity compared to the eleven with stable joint. The percentage improvement with bracing was higher for those with unstable joints (versus stable) and traumatic lesions (versus degenrative).The use of a wrist brace significantly increases the weight-bearing capacity and therefore the maximum tolerated axial load of patients with a lesion of the TFCC. Patients with traumatic lesion or unstable DRUJ tend to show lower values than with degenerative lesions or stable joints.

Purpose To report a novel case of dark without pressure in a patient with a choroidal osteoma. To our knowledge this association has not been previously reported. Methods Observational case report. Review of clinical examination and multi-modal imaging findings in a patient with a choroidal osteoma and dark without pressure. Results A 21-year-old African American female with no significant past medical history presented with a large, unilateral, juxtapapillary, subretinal, orange-colored, ovoid shaped lesion with macular involvement. An overlying area of mottled pigmentary changes, fibrosis, and atrophy were present. Adjacent to and surrounding the osteoma was an annular band of hyperpigmented mid-peripheral retina with a sharply demarcated scalloped border that abruptly changed to normal-appearing peripheral retina. Multi-modal imaging including wide-field fluorescein angiography, optical coherence tomography, and ophthalmic B-scan were performed. The funduscopic and imaging findings were consistent with a diagnosis of choroidal osteoma and dark without pressure. Conclusion The examination and imaging findings in this patient suggest a unique association between two relatively uncommon lesions, choroidal osteoma and dark without pressure. Though these two lesions may simply be coinciding in the same eye, there may be an association with space- occupying lesions causing a change in photoreceptor structure.

AIM No flow-limiting dissection after drug-coated balloon (DCB) treatment for femoropopliteal (FP) lesions is considered as one of the endpoints, but it has not investigated the difference between each vessel dissection. This study aimed to clarify whether there is a difference between no dissection and type C dissection without flow-limiting dissection for 3 months by peak systolic velocity ratio (PSVR) based on duplex ultrasonography. METHODS Between February 2020 and April 2021, 44 consecutive de novo FP diseases that underwent endovascular therapy (EVT) with DCB were enrolled in this study. 65.9% of the patients had intermittent claudication, and mean lesion lengths were 194±107 mm. The chronic total occlusion was 38.6%. After DCB treatment, vessel dissection pattern was categorized by angiography. The minimum lumen area (MLA) identified by intravascular ultrasound was serially evaluated with PSVRs at 1 day, 1 month, and 3 months after EVT. RESULT All lesions were treated with DCB without provisional stents. The vessel dissection pattern after DCB treatment showed that types D, E, and F were not observed, 9% were no dissection, 27% were type A, 32% were type B, and 32% were type C. In all cases, the PSVR values of MLA site were less than 2.6 at 3 months, and there were no significant differences between no dissection and type C dissection. CONCLUSION Up to dissection pattern "C" is considered acceptable as one of the endpoints to determine the need for provisional stenting after DCB treatment.

Introduction The Pentoxifylline, Tocopherol and Clodronate protocol (PENTOCLO) showed promising results for jaw osteoradionecrosis (ORN) management. However, the clinical and radiological improvements are often delayed, leading to unwanted long-term treatment, with potential loss of opportunity for more radical surgical treatments. Our objective was to assess the diagnosis performance of 18F-FDG PET/CT to early predict ORN response to the PENTOCLO protocol. Materials and methods All patients from our center who were treated with the PENTOCLO protocol and with a 18F-FDG PET/CT performed at diagnosis and three months after the end of antibiotherapy were retrospectively included. The PENTOCLO protocol was always combined with prior appropriate antibiotherapy for six weeks. The healing endpoint was divided into healing, stability or worsening, according to the combination of clinical and radiological assessments at the date of last follow-up. For each patient, the difference between the maximal standardized uptake value (ΔSUVmax) of the ORN lesion at three months and baseline were computed. Diagnostic performance of 18F-FDG PET/CT was evaluated by sensitivity, specificity and the area under the receiver operating characteristic curve (ROC-AUC) of ΔSUVmax. Results 24 patients were included with an average follow-up of 29.3 months. The healing, stability and worsening rate were 25%, 62.5% and 12.5% respectively. The AUC for discriminating worsening vs stability or healing was 0.92 (IC95 [0.81-1.00]). A ΔSUVmax greater than or equal to 0 was predictive of a worsening with a sensitivity and specificity of 84 and 66% respectively. Conclusion 18F-FDG PET/CT imaging could be useful for early prediction of PENTOCLO treatment resistance with appropriate antibiotherapy.

A case of spontaneous regression of malignant lymphoma of the maxillary gingiva following a biopsy is reported. An 84-year-old man was referred to the hospital with chief complaints of swelling of the anterior maxillary gingiva. A non-tender swelling with an ulcer was observed. There was no abnormal bone resorption in the anterior maxillary region and no swelling of the cervical lymph nodes. A biopsy was performed, and the patient was diagnosed with diffuse large B-cell lymphoma. The lesion regressed spontaneously 3 weeks after the initial biopsy. Two years have passed since the spontaneous regression and no recurrence has been observed. If malignant lymphoma regresses on biopsy, observation is considered to be sufficient.

The parasitic infection caused by miteSarcoptes scabiei, scabies, is widely known as one of the world's highest morbidity of skin infections. WHO classified scabies as one of the Neglected-Tropical-Disease. Scabies has several risk factors, and one of them is malnutrition. This study aimed to know the scabies infection profile and the nutritional status of patients in pediatric dermatology division, general hospital Dr. Soetomo Surabaya. This is a retrospective study from secondary data collected by evaluating medical records from pediatric patient aged 0 – 60 months. The data were analyzed using the descriptive methodology to measure the frequency and percentage of each variable. The results showed that most of the patients are male, below 1 year old, and had good nutritional status (31.6%)measured using the weight-height index from WHO. Furthermore, most of the samples had upper extremity as the common region with scabies lesion, and papule is the most common lesion found on patients.

Background Risk for infection and potential malignant degeneration are the most common arguments for resecting asymptomatic Congenital Pulmonary Airway Malformations (CPAM). We aimed to investigate if CT- imaging characteristics can be used to predict histopathological features, by using an objective quantitative CT scoring method. Methods Archival CPAM tissue samples were histologically re-assessed and patients who had a pre-operative volumetric CT-scan were included. Lung disease was quantified using the newly-developed congenital lung abnormality quantification(CLAQ) scoring method and obtained percentages were used to predict histopathological signs of inflammation and presence of mucinous proliferation (MP). Because MP is presumed a precursor for mucinous adenocarcinoma in situ (AIS) this method was also used to compare CT-scans of patients with AIS to those with only CPAM. Results Thirty-three CPAM patients were included of which 13(39%) had histological signs of inflammation and 8(24%) had a MP. Patients with inflammation had a significantly smaller lesion (14% vs 38%) while those with MP had more extensive disease (54%vs17%). Patients with AIS had a significantly smaller lesion compared to CPAM patients (5%vs29%). Significant predictors for inflammation were smaller lesion size and percentage hypodensity within lesions while a larger lesion size and percentage parenchymal hyperdensity (solid lung tissue components) were predictors for MP as well as AIS. Conclusions Smaller CPAM lesions may be more susceptible to inflammation while larger lesions may be associated with the presence of MP. Parenchymal hyperdensity is found as a predictor for MP as well as AIS and should therefore elicit more extensive gross sampling. Level of evidence Level III.

Rationale and objectives Prostate MRI improves detection of clinically significant prostate cancer; however, its diagnostic performance has wide variation. Artificial intelligence (AI) has the potential to assist radiologists in the detection and classification of prostatic lesions. Herein, we aimed to develop and test a cascaded deep learning detection and classification system trained on biparametric prostate MRI using PI-RADS for assisting radiologists during prostate MRI read out. Materials and Methods T2-weighted, diffusion-weighted (ADC maps, high b value DWI) MRI scans obtained at 3 Tesla from two institutions (n = 1043 in-house and n = 347 Prostate-X, respectively) acquired between 2015 to 2019 were used for model training, validation, testing. All scans were retrospectively reevaluated by one radiologist. Suspicious lesions were contoured and assigned a PI-RADS category. A 3D U-Net-based deep neural network was used to train an algorithm for automated detection and segmentation of prostate MRI lesions. Two 3D residual neural network were used for a 4-class classification task to predict PI-RADS categories 2 to 5 and BPH. Training and validation used 89% (n = 1290 scans) of the data using 5 fold cross-validation, the remaining 11% (n = 150 scans) were used for independent testing. Algorithm performance at lesion level was assessed using sensitivities, positive predictive values (PPV), false discovery rates (FDR), classification accuracy, Dice similarity coefficient (DSC). Additional analysis was conducted to compare AI algorithm's lesion detection performance with targeted biopsy results. Results Median age was 66 years (IQR = 60-71), PSA 6.7 ng/ml (IQR = 4.7-9.9) from in-house cohort. In the independent test set, algorithm correctly detected 111 of 198 lesions leading to 56.1% (49.3%-62.6%) sensitivity. PPV was 62.7% (95% CI 54.7%-70.7%) with FDR of 37.3% (95% CI 29.3%-45.3%). Of 79 true positive lesions, 82.3% were tumor positive at targeted biopsy, whereas of 57 false negative lesions, 50.9% were benign at targeted biopsy. Median DSC for lesion segmentation was 0.359. Overall PI-RADS classification accuracy was 30.8% (95% CI 24.6%-37.8%). Conclusion Our cascaded U-Net, residual network architecture can detect, classify cancer suspicious lesions at prostate MRI with good detection, reasonable classification performance metrics.

Rationale and Objectives To date, no clinically useful classification system has been developed for reliably differentiating mucinous cystic neoplasm (MCN) from a benign hepatic cyst (BHC) in the liver. The objective was to use machine learning and a multi-center study design to develop and assess the performance of a novel classification system for predicting whether a hepatic cystic lesion represents MCN or BHC. Materials and Methods A multi-center cohort study identified 154 surgically resected hepatic cystic lesions in 154 subjects which were pathologic confirmed as MCN (43) or BHC (111). Readers at each institution recorded seven pre-determined imaging features previously identified as potential differentiating features from prior publications. The contribution of each of these features to differentiating MCN from BHC was assessed by machine learning to develop an optimal classification system. Results Although several of the assessed imaging features demonstrated statistical significance, only 3 imaging features were found by machine learning to significantly contribute to a potential classification system: (1) solid enhancing nodule (2) all septations arising from an external macro-lobulation (3) whether the lesion was solitary or one of multiple cystic liver lesions. The optimal classification system had only four categories and correctly identified 144/154 lesion (93.5%). Conclusion This multi-center follow-up study was able to use machine learning to develop a highly accurate classification system for differentiation of hepatic MCN from BHC, which could be readily applied to clinical practice.

Background (1) To evaluate patient-reported outcomes and revision surgeries after various operative interventions for osteochondral lesions of the talus (OLT) in a prospective single center series over 10 years, and (2) to identify predicting factors related to subjective ankle status and quality of life pre- and postoperatively. Methods Ninety-nine patients underwent operative treatment due to primary or recurrent OLT, with an average follow up 3.5 (1.8) years. Treatment outcome was followed clinically (FAOS, EQ-5D, Tegner activity scale) and by pursuing any serious adverse events or graft failures. Results There were 80 responding patients (81%) for the study. The mean lesion size was 2.0 (1.1) cm2. All FAOS values increased from preoperative to final follow-up values (Symptoms 60–68, Pain 58–69, ADL 71–80, Sport 36–54, QoL 30–45). EQ-5D increased from 0.49 to 0.62, while Tegner activity scale change from 3.2 to 3.4. There were 19 (24%) serious adverse events recorded; 13 (16%) of them were graft-related. Graft survival rates were 100% at 1 year, 94% (males)/93% (females) at 2 years, and 77% (males)/47% (females) at 5 years. Female gender, higher BMI, and higher Kellgren-Lawrence ankle OA score were negative predictors for preoperative patient-reported ankle joint status. The foremost improvement after operative intervention was observed in patients with large osteochondral lesions without postoperative adverse events. Conclusion Various operative interventions for OLT significantly improved patients’ ankle status and quality of life. High graft survival rates were demonstrated over first two years, but notable decline was confirmed thereafter, especially in female patients.

Primary lymphoma of the visual pathway is rare, especially at the chiasm. Very few cases have been reported. The lesion is frequently confused with an optic–hypothalamic glioma. A 55-year-old man was found disoriented at his home by a friend and evaluated with a brain MRI which demonstrated an expansile mass located at the optic chiasm and hypothalamus level. The principal differential was a high-grade hypothalamic glioma due to the contrast enhancement. A biopsy of the chiasmal lesion was performed. Histological diagnosis of the lesion was compatible with a diffuse large B cell lymphoma. He was started on methotrexate and rituximab; however, his clinical course kept deteriorating, and he died 64 days after his presentation. All prior cases of primary lymphoma of the chiasm are reviewed.

A 57-year-old man was incidentally diagnosed with a 7 cm left-sided retroperitoneal mass. The mass was presumed to be arising from the left adrenal gland on a CT scan of the adrenal glands. Thus, a thorough workup ensued, looking into the possible functionality of the lesion. All investigations resulted in the negative. Subsequently, the patient was referred for surgery to fully characterise the tumour. Histology proved that the lesion was a benign retroperitoneal schwannoma with no relation to the adrenal gland.

A 45-year-old man presented with right upper abdominal pain and low-grade fever for 2 weeks. Laboratory investigations showed polymorphonuclear leukocytosis with normal liver function tests. Ultrasound scan showed a heteroechoic lesion in the right lobe of the liver with mobile echogenic foci

Management of Sclerotinia stem rot (SSR) disease in Brassica napus is heavily reliant on prophylactic fungicide applications at flowering, which often provides inconsistent control depending on timing of ascospore release in the field and environmental conditions. Understanding host response to Sclerotinia sclerotiorum infection is essential for sustainable disease management in the future. This study determined host response of nine B. napus varieties to four aggressive S. sclerotiorum isolates across two years by measuring four disease variables: area under the disease progress stairs (AUDPS), seed production, sclerotia number and average sclerotia weight. Brassica napus varieties varied greatly in their response to the four measured variables, with varieties producing the highest AUDPS not being the same varieties that had the lowest seed production, the highest numbers of sclerotia or heaviest sclerotia. Repeating the experiment over two years using the same varieties and isolates identified the impact of environment on measured disease variables as the most influential factor, highlighting the complexity of disease responses to diverse isolates and host genotypes under different environments. It was recommended that both long-term (such as inoculum production) and short-term (such as seed production) disease outcomes be combined with lesion length measurement (i.e., AUDPS) for future host screening studies.