Anterior Abdomen Research Articles

Relación entre la localización anatómica y el manejo selectivo no operatorio de las heridas por arma blanca penetrantes en abdomen

IntroductionThe relationship between the anatomical location of penetrating abdominal stab wounds (SW) and the rate of selective non-operative management (SNOM) based on that location is scarcely reflected in the specialized literature. Our main objective has been to assess this rate based on the anatomical location, and our results. MethodsRetrospective review of a prospective registry of abdominal trauma from April 1993 to June 2020. The two study groups considered were the Operative Management (OM), and the SNOM, including in this one the use of diagnostic laparoscopy. Penetrating SWs in the abdomen were classified according to anatomical location. ResultsWe identified 259 patients who fulfilled the inclusion criteria. SNOM was applied in 31% of the patients with a success rate of 96%, and it was more frequent in the lumbar, flank, and thoraco-abdominal regions; within the anterior abdomen it was more applicable in the RUQ, followed by the LUQ and epigastrium, respectively. An unnecessary laparotomy was done in 21% of patients, with the highest number in the epigastrium. Taking into account the unnecessary laparotomies and the rates of successful SNOM, 70,5% of lumbar, el 66,5% of epigastric, 62% of flank, and 59% of RUQ penetrating SWs could have been managed without a laparotomy. ConclusionsSNOM of penetrating SWs in the abdomen has been safer and more applicable in those located in the lumbar, flank, epigastric, and RUQ regions.

The specialized thoracic skeletomuscular system of the myrmecophile Claviger testaceus (Pselaphinae, Staphylinidae, Coleoptera)

External and internal structures of the thorax of the myrmecophile beetle Claviger testaceus (Clavigeritae, Pselaphinae) were examined and documented with state-of-the-art visualization techniques. Following a general trend in the omaliine lineage (Staphylinidae), the skeletal elements of the pro- and pterothorax in Claviger reach a maximum degree of compactness, with largely reduced inter- and intrasegmental sutures and skeletal elements linked with the flight apparatus. The musculature, especially metathoracic direct and indirect flight muscles, also shows a high degree of reduction. Two forms of wings were found among individuals of C. testaceus, both non-functional and representing an advanced stage of reduction. However, that wing vestiges are still present and the metanotum, only slightly reduced, suggests that loss of flight in this species is likely the result of a young evolutionary process. Several structures are linked with myrmecophilous habits: small body size facilitates transportation of beetles by ant workers and makes it easier to move inside nest tunnels; the remarkably compact body and mechanically robust appendages make the beetles less vulnerable to attacks by ant mandibles; the improved elytral interlocking mechanism and unusually expanded epipleura enhance the protection of vulnerable dorsal parts of the pterothorax and anterior abdomen; and glands associated with trichomes on the posterolateral elytral angle produce secretions attractive for ants. Various modifications of the thorax and anterior abdomen lead to an optimization of intimate associations with ants. The morphological syndrome enabling these beetles to cope with life in ant colonies evolved in several steps. This is suggested by an increasing solidification of the thoracic skeleton in related non-myrmecophilous groups and also by less modified related clavigerites;for instance, ant-associated tropical species are still able to fly.

18-25 Yaş arası genç bireylerdeki melanositik nevüslerin klinik ve dermatoskopik özelliklerinin incelenmesi

Background: Melanocytic nevi are common pigmented lesions of the skin. They are sometimes confused with melanoma which is most malign tumor of the skin. Malign transformation of an existing nevus is one of the most seen etiological factor for melanoma formation. Objective: Although characteristics of childhood nevi well studied, there are not much study about the nevi at 18-25 years old age group. The aim of this study is to determine the clinical and dermoscopic features of melanocytic nevi in Turkish young people with 18–25 years-old. Methods: A total of 668 young people from students of Gulhane Military Medical Academy, Military Nurse School and Military Health Sergeant School and suitable patients of outpatient clinic of Gulhane Military Medical Academy Department of Dermatology were included in the study. A medical history of including age, sex, sunblock use, and sunburn asked. On clinical examination, we evaluated number of nevi, location of nevi and skin type. Nevi that are equal or greater than 3mm were examined dermoscopically, recorded and scored by using pattern analysis, ABCD total dermoscopic score, 7 point checklist, Menzies algorithm, 3 point checklist and CASH algorithm. Results: Totally 668 young people were physically examined in this study (268 of which were women and 400 of which were men). The most common skin phototype in both sexes was type 3 (91.6% of women, 85.25% of men). In 668 cases, a total of 3663 melanocytic nevi were determined. Mean number of nevi among cases were 5,4 ± 5,24. A total of 453 nevi which are equal or greater than 3 mm were examined dermatoscopically. The most common localization of nevi was on the head and neck region (n=144; 31.8%), followed by anterior trunk and abdomen (n=128; 28.3%), back (n=122; 26.9%) and extremities (n=45; 9.9%). The most common dermatoscopic global feature was the globular pattern (n=135; 29.8%), followed by reticular pattern (n=88; 19.4%), and cobblestone pattern (n=64; 8.8%). The correlations between 5 dermoscopic algorithm scores were done statically. Except the correlation between 7-point checklist and total CASH score(p=0,052 r=0,091), all algorithms were correlated with each other. Conclusion: Different dermoscopic algorithms can be used together in routine to investigate the melanocytic nevi for valuable professional follow . This is the one of the rare studies about the characteristics of melanocytic nevi at this age group and lays the foundation for future studies that will elucidate the relationship between nevi, dermatoscopic pattern and the other factors in a population-based cohort.

Grover’s disease: a rare bullous dermatosis spontaneously regressing

Grover's diseaseis an itchy acantholytic disorder occurring on the trunk of middle-aged men. It is a transient dermatosis of unknown cause manifesting clinically as a papular skin eruption located usually on the anterior chest and abdomen and histologically with dyskeratosis and acantholysis. This disease has occasionally been reported in patients with chronic renal failure, some infections, hematological malignancies, and many other anomalies. We report herein a new case of Grover's disease that developed in a female patient after a fever episode.

Dynamics of concentration of C-reactive protein after hernioplasty and simultaneous interventions

Were analyzed 127 case histories of patients aged (54.3±13.6) years; 44 women (34.6%) who underwent hernia plastic surgery of different localization: 26 (20.5 %) umbilical and paraumbilical; 25 (19.7%) - incisional, 68 (53.6%)-inguinal and 8 (6.3%)-hiatalhernia. 64 (50.4%) patients underwent simultaneous operations: for multiple hernias - 35 (27.6%), cholecystolithiasis I, chronic cholecystitis - 14 (11.0%), gynecological pathology - 6 (4.7%), chronic appendicitis - 3 (1.4%), or abdominoplasty due to fatty deformity of the anterior abdomen walls (fat «apron») - 6 (4.7%). The initial condition of the patient features of surgery and the dynamics of the concentration of C-reactive protein (CRP), which was determined before surgery, in the first, third and fifth days after. It was found that the initial concentration of CRP is increased in some cases in patients with overweight and obesity, as well as in the presence of chronic cholecystitis or chronic appendicitis. In the postoperative period, regardless of the location of the hernia and the method of surgery, there is an increase in the concentration of CRP, which is most pronounced in the first day after surgery and indicates the activation of systemic inflammatory responses. The increase in CRP concentration on the first day was greatest after hiatal hernia repair and after simultaneous operations, especially after abdominoplasty. In overweight and obese patients, an increase in CRP is observed up to the fifth day after surgery, indicating a prolonged activation of the inflammatory response. The concentration of CRP on the first and third days after isolated operations did not depend on the method of operation («open» alloplastic, open autoplastic or laproscopic hemioplasty), but was the lowest on the fifth day after laparoscopic hemioplasty. Keywords: hemioplasty, simultaneous operations, C-reactive protein, dynamics.

Cutaneous Elastorrhexis; A Heralding Sign of Gronblad-Strandberg Syndrome: A Case Report

Introduction: Pseudoxanthoma Elasticum (PXE), also called Gronblad-Strandberg syndrome, is an autosomal recessive disorder due to mutation in the ABCC6 allele on chromosome 16p. It is characterized by the progressive fragmentation and calcification of elastin fibers of the dermis, blood vessels, and Bruch’s membrane of the eye. In this article, the authors present a case of PXE with cutaneous elastorrhexis. Case Presentation: A 31-year-old female presented with skin changes in the form of yellowish linearly arranged papules over the lateral side of the neck and anterior abdomen since adolescence. Her retinoscopy and cardiovascular examinations were reported as normal. The molecular analysis could not be done due to financial limitations. Based on these findings, the patient was suspected of PXE according to the revised criteria for the diagnosis of PXE. Conclusions: Skin lesions are generally first to appear in adolescence. Ocular findings develop at later ages, i.e., third or fourth decades. Cardiovascular manifestations develop later in life. Hence, skin changes can aid in the early diagnosis of PXE and help clinicians to screen patients for systemic complications. Being a multisystem heritable disorder with morbidity and mortality, there is a need to formulate the clinical criteria for definitive diagnosis in resource-poor settings where molecular assays cannot be performed. The recognition of typical skin lesions can aid in the accurate diagnosis to facilitate the early detection and management of life-threatening systemic complications.

ASCITES OF THE DIAPHRAGM

SESSION TITLE: Medical Student/Resident Pediatrics Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Rhabdomyosarcoma is more common in pediatric populations, but remains rare, representing only 3 percent of pediatric cancers. It is typically diagnosed in children less than 6 years of age, and tends to occur in the head and neck, GU tract, and extremities, with different histologic subtypes having a predilection for certain areas. CASE PRESENTATION: We present a 12-year-old girl with 1.5 weeks of cramping upper abdominal pain, nonbilious, abdominal distention, non-bloody emesis, and watery diarrhea. She also reported fatigue and 10 pound weight loss. On presentation, she was afebrile and vitals were within normal limits. Exam was notable for a distended abdomen with positive fluid wave and tenderness in the upper abdomen, as well as inguinal and axillary adenopathy. Initial labs revealed hemoglobin 12.4, platelets 718, AST 48, albumin 2.3, lipase 68. Abdominal ultrasound showed a large amount of ascites. Subsequent labs showed ESR 60, CRP 13.65, LDH 666, and uric acid 6.1. Repeat CT abdomen/pelvis with intravenous and oral contrast showed malignant ascites with focal nodular soft tissue along the left hemidiaphragm as well as in the anterior abdomen, and left pleural effusion. A paracentesis was performed with 3 L of yellow, cloudy fluid obtained with ˜5000 red blood cells, 1120 white blood cells, albumin 2.1, amylase 27, glucose 70, protein 3.9, triglyceride 28. Cytology showed reactive vs neoplastic atypical cells, degenerating cells, reactive mesothelium and inflammatory cells. Quantiferon and AFB cultures were negative. Biopsy of the left hemidiaphragm soft tissue mass showed alveolar infiltrating fibrocollagenous rhabdomyosarcoma. She is currently undergoing palliative radiation and chemotherapy. DISCUSSION: Rhabdomyosarcomas are cancers that originate from rhabdomyoblasts, making them more common in children. There are 4 subtypes: embryonal (59%), alveolar (21%), anaplastic (1%), and undifferentiated (8%). Alveolar rhabdomyosarcomas typically involve large muscles of the trunk and extremities, and tend to occur in individuals ages 10-25. They grow rapidly, and require more intensive therapy. Diagphragmatic rhabdomyosarcomas are rare, with 41 cases noted from 1868 to 2005 in a review of literature. The majority of cases present with thoracic symptoms, rather than abdominal symptoms. A recent study from the Italian Soft Tissue Sarcoma Center identified 150 children over 30 years with rhabdomyosarcoma, with only 18 of those presenting with ascites. CONCLUSIONS: We present a case of alveolar diaphragmatic rhabdomyosarcoma with only 41 cases diagnosed worldwide. What makes this case more rare is the presenting complaint of abdominal symptoms. Our case highlights that these entities can present a diagnostic challenge, given their ability to affect less common areas and grow insidiously until presenting with atypical symptoms. Reference #1: Cada M, et al. Approach to diagnosis and treatment of pediatric primary tumors of the diaphragm. Journal of Pediatric Surgery. October 2006. 41(10):1722-6 Reference #2: Di Carlo, D., Ferrari, A., Toffolutti, T., Milano, G. M., Manzitti, C., Ruggiero, A., ... Bisogno, G. (2019). Prognostic role of pleural effusion or ascites in localized rhabdomyosarcoma. Pediatric Blood and Cancer, 66(11), e27932. https://doi.org/10.1002/pbc.27932 Reference #3: Raney RB, Anderson JR, et al. Soft-tissue sarcomas of the diaphragm: a report from the Intergroup Rhabdomyosarcoma Study Group from 1972 to 1997. Journal of Pediatric Hematology Oncology. 2000 Nov-Dec; 22(6):510-4 DISCLOSURES: No relevant relationships by Holly O'Brien, source=Web Response No relevant relationships by Seif Shahidain, source=Web Response

THE ROLE AND SIGNIFICANCE OF COSTEN’S SYNDROME IN DYSFUNCTIONAL CONDITIONS OF THE TEMPOROMANDIBULAR JOINTS

Temporomandibular joint disease (TMJ) is one of the most pressing problems of modern dentistry, on the one hand, the frequency of pathology of the temporomandibular joint, and on the other hand - the complexity of diagnosis.
 In the medical specialty "dentistry" there is no section where there would be as many debatable and unresolved issues as in the diagnosis and treatment of diseases of the temporomandibular joints.
 Aim of the research. Based on the analysis of sources of scientific and medical information to determine the role and place of "Costen's syndrome" in the pathology of the temporomandibular joints.
 Results and discussion
 The term TMJ dysfunction has up to 20 synonyms: dysfunction, muscle imbalance, myofascial pain syndrome, musculoskeletal dysfunction, occlusal-articulation syndrome, cranio-mandibular TMJ dysfunction, neuromuscular and articular dysfunction.
 Finally, in the International Classification of Diseases (ICD-10), pain dysfunction of the temporomandibular joint has taken its place under the code K0760 with the additional name "Costen's syndrome", which is given in parentheses under the same code.
 Thus, such a diagnosis as "Costen's syndrome" is not excluded in the International Classification of Diseases.
 The first clinical symptoms and signs of TMJ were systematized in 1934 by the American otorhinolaryngologist J. Costen and included in the special literature called "Costen's syndrome".
 This syndrome includes: pain in the joint, which often radiates to the neck, ear, temple, nape; clicking, crunching, squeaking sound during movements of the lower jaw; trismus; hearing loss; dull pain inside and outside the ears, noise, congestion in the ears; pain and burning of the tongue; dizziness, headache on the side of the affected joint, facial pain on the type of trigeminal neuralgia. The author emphasized the great importance of pain and even singled out "mandibular neuralgia."
 The criteria proposed by McNeill (McNeill C.) in 1997 are somewhat different from those described in ICD-10: pain in the masticatory muscles, TMJ, or in the ear area, which is aggravated by chewing; asymmetric movements of the lower jaw; pain that does not subside for at least 3 months.
 The definition of the International Headache Society is similar in content.
 Anatomical and topographic study of the corpse material suggested the presence of a structural connection between the TMJ and the middle ear. According to some data, in 68% of cases the wedge-shaped mandibular ligament reaches the scaly-tympanic fissure and the middle ear, and in 8% of cases it is attached to the hammer. In addition, several ways of spreading inflammatory mediators from the affected TMJ to the middle and inner ear, which causes otological symptoms, have been described.
 It should be noted that there are certain prerequisites for the mutual influence of the structures of the cervical apparatus, middle and inner ear and upper cervical region at different levels: embryological, anatomical and physiological.
 At the embryological level. It is confirmed that from the first gill arch develops the upper jaw, hammer and anvil, Meckel's cartilage of the lower jaw, masticatory muscles, the muscle that tenses the eardrum, the muscle that tenses the soft palate, the anterior abdomen of the digastric muscle, glands, as well as the maxillary artery and trigeminal nerve, the branches of which innervate most of these structures.
 At the anatomical level. Nerve, muscle, joint and soft tissue structures of this region are located close enough and have a direct impact on each other. The location of the stony-tympanic cleft in the medial parts of the temporomandibular fossa is important for the development of pain dysfunction.
 At the physiological level. A child who begins to hold the head, the functional activity of the extensors and flexors of the neck gradually increases synchronously with the muscles of the floor of the mouth and masticatory muscles, combining their activity around the virtual axis of the paired temporomandibular joint.
 In addition, the location of the caudal spinal nucleus of the trigeminal nerve, which is involved in the innervation of the structures of the ear, temporomandibular joint and masticatory muscles at the level of the cervical segments C1-C3 creates the possibility of switching afferent impulses from the trigeminal nerve to the upper cervical system. Innervate the outer ear, neck muscles and skin of the neck and head. Also important are the internuclear connections in the brainstem, which switch signals between the vestibular and trigeminal nuclei.
 That is why the approach to the treatment of this pathology should be only comprehensive, including clinical assessment of the disease not only by a dentist or maxillofacial surgeon, but also a neurologist, otorhinolaryngologist, chiropractor, psychotherapist with appropriate diagnostic methods and joint management of the patient.

A Pilot Trial of Topical Capsaicin Cream for Treatment of Cannabinoid Hyperemesis Syndrome.

Patients with cannabinoid hyperemesis syndrome (CHS) present frequently to the emergency department. Previous case studies suggest dramatic symptomatic improvement with topical capsaicin treatment. This exploratory study examined the potential effectiveness of topical capsaicin in patients with nausea and vomiting due to a suspected CHS exacerbation. This was a double-blind, randomized placebo-controlled pilot trial. Adults who presented with vomiting suspected to be from CHS were eligible for enrollment. We excluded pregnant women and those with resolution of symptoms. Following randomization, topical 0.1% capsaicin or placebo cream was applied to the anterior abdomen in a uniform manner. The primary outcome was the severity of nausea on a visual analog scale (VAS) of 0 to 10cm assessed at 30minutes. Secondary outcomes were adverse events, occurrence of posttreatment vomiting, nausea by VAS at 60minutes, and hospital admission. This pilot trial enrolled 30 patients, 17 in the capsaicin arm and 13 in the placebo arm. One patient in the capsaicin arm did not tolerate treatment due to skin irritation. Mean± SD nausea severity at 30minutes was 4.1±2.3cm in the capsaicin arm and 6.1±3.3cm in the placebo arm (difference=-2.0cm, 95% confidence interval [CI]=0.2 to -4.2cm). At 60minutes, mean± SD nausea severity was 3.2±3.2cm versus 6.4±2.8cm (difference=-3.2cm, 95% CI=-0.9 to -5.4cm). The percent reduction in nausea at 60minutes from baseline was 46.0% in the capsaicin arm and 24.9% in the placebo arm (difference=21.1%, 95% CI=-5.6% to 47.9%). A higher proportion of capsaicin group patients (29.4% vs. 0%) had complete resolution of nausea (relative risk=3.4, 95% CI=1.6 to 7.1). In this pilot trial, the application of topical capsaicin cream was associated with a significant reduction in nausea at 60minutes but not at 30minutes and provided more complete relief of nausea.

A comparative description of the mesosomal musculature in Sphecidae and Ampulicidae (Hymenoptera, Apoidea) using 3D techniques

Conflicting hypotheses about the relationships among the major lineages of aculeate Hymenoptera clearly show the necessity of detailed comparative morphological studies. Using micro-computed tomography and 3D reconstructions, the skeletal musculature of the meso- and metathorax and the first and second abdominal segment in Apoidea are described. Females ofSceliphron destillatorium, Sphex (Fernaldina) lucae (both Sphecidae), andAmpulex compressa(Ampulicidae) were examined. The morphological terminology provided by the Hymenoptera Anatomy Ontology is used. Up to 42 muscles were found. The three species differ in certain numerical and structural aspects. Ampulicidae differs significantly from Sphecidae in the metathorax and the anterior abdomen. The metapleural apodeme and paracoxal ridge are weakly developed in Ampulicidae, which affect some muscular structures. Furthermore, the muscles that insert on the coxae and trochanters are broader and longer in Ampulicidae. A conspicuous characteristic of Sphecidae is the absence of the metaphragma. Overall, we identified four hitherto unrecognized muscles. Our work suggests additional investigations on structures discussed in this paper.

P39 Treatment of scleromyxedema with intravenous immunoglobulin

Abstract Background Scleromyxedema is a rare, idiopathic, generalised mucinosis with a progressive and unpredictable course, and has both cutaneous and systemic manifestations. It typically presents with a diffuse cutaneous papular eruption causing extensive skin tightening which can be severely debilitating and is one of four diagnostic criteria for scleromyxedema. The remaining criteria being evidence of histological mucinosis, presence of an IgG lambda monoclonal gammopathy and the absence of thyroid disease. Due to its rarity and subsequent lack of controlled studies, there remains no current standardised treatment. Relevant literature consists of case studies and series trialling use of a variety of immunosuppressive therapies with varying levels of success. Intravenous immunoglobulin (IVIG) has been shown to be the most effective therapeutic option so far and we report here further success following its use. Methods A previously healthy 54-year-old Caucasian woman presented to dermatology with widespread cutaneous mucinous deposits on her entire body with sparing of the anterior chest and abdomen. She was trialled on both topical and oral steroids as well as oral and subcutaneous methotrexate, but all had negligible benefit and her modified Rodnan’s skin score (mRss), an objective assessment of skin thickness, remained significantly raised at 29/51. A punch skin biopsy showed prominent superficial histiocytic mucinosis, and serum electrophoresis revealed an IgG lambda gammopathy, consistent with a diagnosis of scleromyxedema. To complete the diagnostic criteria, she also tested negative for thyroid dysfunction. In terms of systemic manifestations, she later presented with unexplained intermittent dysphagia and occasional reflux, which have previously been reported as common symptoms in 60-90% of patients with scleromyxoedema. Monthly treatment with IVIG at a dosage of 2 gram/kg over 2 days was started. Results The IVIG showed marked clinical success and minimal side effects. After four cycles, skin thickening was reversed and her mRss dropped to zero. Mycophenolate mofetil (MMF) (2g daily) was introduced after three months, to allow six-weekly IVIG infusions. Conclusion This report further supports the growing literature that IVIG is a safe and effective treatment for scleromyxedema. The underlying mechanism of how it treats scleromyxoedema is yet to be elucidated with only proposed mechanisms so far, such as the neutralisation of pathogenic autoantibodies. It is, however, important to acknowledge that IVIG is very expensive and in limited supply and requires time-consuming administration. To combat these downfalls, we had trialled the potential use of MMF as an IVIG ‘sparing agent’ to optimise patient convenience and reduce cost, without compromising clinical care. Unfortunately, the MMF was only successful for the first few months and was subsequently stopped due to adverse effects. Nevertheless, we still anticipate this work will provide further evidence for the approval of IVIG for the future treatment of scleromyxedema. Disclosures C. Lin None. F.A.H. Cooles None. S.J. Meggitt None. B. Griffiths None.

Spinal cord stimulators and implications for anaesthesia

Spinal cord stimulators and implications for anaesthesia

Cloacal exstrophy misdiagnosed as bladder exstrophy

Abstract Cloacal exstrophy (CE) is the most serious and complex congenital ventral abdominal wall defect. It has also been reported as one of the rarest congenital anomalies. A 9-month-old boy suffering from bladder exstrophy due to the presence of a lower anterior abdomen wall defect that drains urine was referred to a paediatric surgery outpatient clinic. Magnetic resonance imaging (MRI) revealed a small urinary bladder connected to the rectum, and there is a fistula connected from the urinary bladder to the anterior abdominal wall, which was previously misinterpreted as a ureteral orifice in the abdominal wall. CE presented a wide range of pictures that varied from case to case. We reported the case referred to our hospital as a misdiagnosis of bladder exstrophy.

Dermoscopy of Pityriasis Lichenoides Chronica in an Indian Girl.

Background: A 16-year-old girl presented with multiple dusky red to brown-colored papules with centrally adherent scales scattered over the trunk and extremities (with sparing of the face), interspersed with multiple faint hypopigmented macules [Figure 1]. The lesions had started appearing three years back with gradual progression. The self-healing lesions had left the hypopigmented macules with no varioliform scars. Occasional itching was the only symptom. There was no history of eruption of crops of vesicular/hemorrhagic/crusted papules, fever, painful lymphadenopathy, or systemic symptoms.Figure 1: Clinical image of the anterior abdomen of a 16-year-old Indian girl showing scattered brown papules with adherent scales, interspersed with faint ill-defined hypopigmented areasPolarized dermoscopic examination (Escope videodermoscope, ×20) from the truncal lesions revealed yellowish-orange to light brown-colored structureless areas, with focal superficial scales, and multiple scattered dark brown-black colored granules, globules, and clods. Only a few scattered dotted and nondotted vessels could be appreciated. Focal areas of hypopigmentation were seen in the lesional periphery [Figure 2]. A clinicodermoscopic diagnosis of pityriasis lichenoides chronica (PLC) was confirmed on histopathology that revealed small mounds of parakeratosis and epidermal infiltration by lymphocytes and red blood cells (RBCs). The dermoepidermal junction showed occasional necrotic keratinocytes. Focal interface vacuolar change and sparse superficial perivascular lymphocytic infiltrate with extravasation of RBCs were seen in the papillary dermis [Figure 3]. Focal melanophages were also seen in the papillary and mid-dermis.Figure 2: Dermoscopic image from a lesion on the anterior abdomen revealing yellowish-orange to light brown-colored structureless area with focal scales, and focal areas of hypopigmentation in the lesional periphery (blue arrows). Note the paucity of vascular structures – only a few focal vessels can be appreciated. Additionally, note the multiple scattered dark brown-black granules, globules, and clods, possibly suggestive of postinflammatory hyperpigmentation, typical of darker skin types [Escope videodermoscope, polarized, ×20]Figure 3: Histopathology confirming the diagnosis of pityriasis lichenoides chronica (PLC) showing small mounds of parakeratosis and epidermal infiltration by lymphocytes and red blood cells (RBCs). The dermoepidermal junction shows occasional necrotic keratinocytes. Focal interface vacuolar change and sparse superficial perivascular lymphocytic infiltrate with extravasation of RBCs can be seen in the papillary dermis. Focal melanophages in the mid-to-upper dermis are also seen [hematoxylin and eosin, ×400]Pityriasis lichenoides (PL) constitutes a spectrum of skin disorders with acute (pityriasis lichenoides et varioliformis acuta [PLEVA]) and chronic (PLC) forms. Approximately 20% of cases occur in children.[1] The etiology of PL remains uncertain. Although inflammatory response triggered by an infection has been proposed by many, the possibility of PL representing a T-cell lymphoproliferative disorder has not been ruled out. PLEVA and PLC represent a continuous spectrum with overlap in presentation.[2] In contrast to the abrupt crops of vesicular to necrotic erythematous macules and papules accompanied with systemic symptoms are archetypical of PLEVA, lesions of PLC are milder, have a gradual onset, and heal with postinflammatory hypo- (PIHy) or hyperpigmentation (PIH). The varioliform scarring of PLEVA is, however, not seen in PLC. Dermoscopy of PLC has been detailed by Errichetti et al. in seven Caucasian patients, the most common finding being orange-yellowish structureless areas, followed by focally distributed nondotted and dotted vessels, and scattered hypopigmented areas.[3] In contrast with the dermoscopic findings of PLC seen in white skin, we observed an add-on brownish hue over the yellowish-orange areas, only a few vessels but multiple scattered dark-brown-black granules, globules, and clods. Although conjectural, we believe that these additional pigmented structures suggest post inflammatory hyperpigmention, a specific dermoscopic finding described commonly in inflammatory dermatoses in the darker skin types.[4] The difficulty in observing vascular structures may also be attributable to the predominant pigmented background. Errichetti et al. have histologically correlated the orange-yellowish structureless areas of PLC to the presence of hemosiderin degradation products stemming from extravasated RBCs, and the vascular components to dilatation of superficial dermal vessels.[3] The dermoscopic differentiation of PLC from some of its close differentials is given in Table 1.Table 1: Dermoscopic differentiation of pityriasis lichenoides chronica from important clinical differentialsDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Subcutaneous phycomycosis involving the anterior abdominal wall in an immunocompetent boy successfully treated with potassium iodide

Subcutaneous phycomycosis is a chronic deep fungal infection caused by Basidiobolus ranarum, which usually occurs in children, predominantly affecting males. Herein, we report subcutaneous phycomycosis in a 3-year-old boy who presented with a gradually progressive painless swelling over the anterior abdomen of 20-day duration. Lesional biopsy confirmed the diagnosis of subcutaneous phycomycosis which revealed multiple well-defined granulomas composed of histiocytes, epithelioid cells, and multinucleate giant cells with broad nonseptate hyphae stained with Gomori methenamine silver stain. The child was managed with a saturated solution of potassium iodide which completely melted the swelling.

2387 Desmoplastic Tumor: Rare and Advanced Presentation

INTRODUCTION: Desmoplastic small round cell tumors (DSRCT) are a rare and aggressive variant of soft-tissue sarcomas. Data suggest that occurs as a consequence of a translocation of (11;22) (p13; q12) resulting in a fusion of EWS/WT1 genes. The incidence of DSRCT is more common in young Caucasian males between the ages of 15 and 25 [6,7]. CASE DESCRIPTION/METHODS: A 26-year-old male with no past medical history complaining of shortness of breath, anorexia, unintentional weight loss of 20 pounds and increased abdominal girth associated with pain starting two months prior to presentation. Physical exam was remarkable for cachexia, mild diffuse tenderness to palpation, protuberant abdomen without a distinct mass. Initial workup showed the following abnormality; normocytic anemia with hemoglobin of 12.6, ALP 189, AST 58, ALT 73 and HIV negative. Abdominopelvic CT scan revealed a large mass measuring 20 × 10 × 10 cm in the left upper quadrant, nodular deposits in the anterior abdomen concerning for carcinomatosis and multiple liver metastases, largest measuring 10 × 8 cm (Figure 1). Mesenteric lymph node biopsy showed findings consistent with desmoplastic fibromyxoid stroma and immunohistochemically positive for AE1/AE3, EMA, vimentin, desmin, synaptophysin, and CD99 (Figures 2–3). DISCUSSION: DSRCT's are aggressive soft tissue sarcomas that are extremely rare. They predominantly involve the pelvis, retroperitoneum, and mesentery. Upon diagnosis, it is crucial to exclude desmoid tumors and Ewing sarcomas, since, these malignancies that can be confused with DSRCT. Accumulating data suggest that is more prevalent in young adults, making the diagnosis challenging at the early stages, since, it can be potentially confused with less aggressive conditions such as gastritis, dyspepsia or gastroesophageal reflux disease. Prognosis is frequently poor given a late presentation of disease; five-year survival is estimated at 15 to 30% [2]. The exact mechanism of DSRCT is not well understood, but research suggest it arises from a translocation. Some promising therapies are undergoing phase trials as surgical interventions and hyperthermic intraperitoneal chemotherapy [2]. Systemic chemotherapy with aggressive surgical resection has shown improved outcomes [6]. Nonetheless, systemic therapy tends to be very toxic, requiring frequent admissions to control potential adverse events. Further research is needed to characterize the exact pathogenesis and treatment of this uncommon malignancy.

Two new species of Notodasus Fauchald, 1972 (Annelida: Capitellidae) from the Central Indo-Pacific region.

Notodasus Fauchald, 1972 is a small genus of the polychaete family Capitellidae, including 10 described species worldwide. The genus is unusual in the Central Indo-Pacific, and there is no taxonomic record of Notodasus in this region. In this study, two new species of Notodasus are described and illustrated, namely Notodasus celebensis sp. nov. and N. chinensis sp. nov. The former species, collected from the mixed-species seagrass beds in the Indonesian island of Sulawesi, is mainly characterized by the longitudinally striated epithelium on thoracic segments and the completely separated notopodial lobes. The latter species, obtained from coastal waters off southern China, differs from its congeners with the following characters: tessellated epithelium present on anterior thorax as well as on the dorsum of chaetigers 11 and 12, notopodial lobes fused and chaetal fascicles almost touching each other on anterior abdomen, and branchial pores evident from anterior abdomen. Comparisons are made with closely related species in this paper, and a revised key is provided to all described Notodasus species. The descriptions of the two new species represent the first record of Notodasus in this region and expand the geographical distribution of the genus.

Transversus abdominis plan bloğu için ultrason eşliğinde farklı bölgelerden yapılan ölçümler

Amaç: Analjeziklerin yetersiz veya yüksek doz kullanımı giderek önem kazanmaktadır; bu yüzden analjezi yöntemleri her gün geçtikçe gelişmektedir. Transversus abdominis plan (TAP) bloğu ultrason eşliğinde batın cerrahilerinde ağrı kontrolü için yapılan bir yöntemdir. Çalışmamızda Ultrason eşliğinde farklı bölgelerden ölçümler alarak TAP bloğunun hangi bölgeden uygulanması gerektiğini araştırmayı amaçladık.Materyal ve Metot: Çalışmaya 18-65 yaş arası 30 hasta çalışmaya alındı. Ön karın bölgesinden ultrason’nun lineer probu subkostal bölgeden ve krista iliyakanın üstünden anterior aksiler bölge ve mediyal aksiler hatta denk gelecek bölgeden internal oblık kas, eksternal oblik kas, ve transversus abdominal plan kılıf genişliği kaydedildi. Yine bu bölgelerin görüntü netliği (kötü, iyi ve çok iyi olarak ) değerlendirilip kaydedildi.Bulgular: Krista iliyaka üzerinden anterior aksiler hattın (A1) median aksiler hat (A2) ile karşılaştırılmasında alınan ölçümlerde internal oblik kas, eksternal oblik kas, transversus abdominus kası genişlikleri ve transversus abdominus fasiya daha düşük çıkmış ve istatistiksel olarak olarak anlamlı bulunmuştur (P<0,05). Kostal kenar altından anterior aksiler hattın (B1) median aksiler hat (B2) ile karşılaştırılmasında alınan ölçümlerde internal oblık kas ile transversus abdominus fasiya daha düşük çıkmış ve istatistiksel olarak anlamlı bulunmuştur (P<0,05).Sonuç: Medial aksiler hatta anterior aksiler hatta göre ölçümlerin daha yüksek çıkması ve görüntü netliğinin daha iyi olması nedeniyle TAP blok uygulanırken probun mediyal aksiler hat üzerinden yapılması gerektiği kanatindeyiz. Anahtar Kelimeler: Transversus abdominis plan bloğu, Ultrason, Analjezi.

Buccal Mucosa Grafts for Reconstruction in Patients With Female Genital Mutilation

AIM: Reconstruction after female genital mutilation is a relatively new concept in the United States aimed to improve pain and sexual function and to restore a normal physical appearance. The buccal mucosa has been described as a donor-site option for reconstruction of eyelids, cheeks, larynx, urethra, and more recently the vagina. Here we present the novel use of buccal mucosal grafts in the reconstruction of external female genitalia after female genital mutilation. METHODS: 1. Mouth is irrigated with Peridex solution and throat pack is placed. 2. Rectangular piece of thin buccal mucosa is harvested using a #15 blade with care to avoid important structures such as buccal fat pads, buccinator muscle, and Stensen’s duct. Incisions are closed in a single running layer with 4-0 chromic suture. 3. Anterior abdomen fat harvesting is performed using standard Coleman technique. Fat is processed via Telfa rolling on back table. 4. Clitoral scar is incised or excised with careful attention to avoid injury to deeper nerves. 5. A flap harvested from the superior aspect of clitoral skin is rotated inferiorly to cover the superior aspect of the clitoral hood. The remainder of the hood is resurfaced using shaped portions of the buccal mucosa sutured with 4-0 chromic. 6. Flaps from the labia majora are rotated laterally and imbricated to the periosteum with interrupted 4-0 chromic. Medial flaps designed to become the new labia minora are subsequently covered with buccal mucosal grafts on their lateral aspects. 7. Buccal mucosal grafts were dressed with xeroform and antibiotic bolsters. 8. Fat subsequently grafted into bilateral labia majora inferiorly and superiorly into the vulvar region to encourage regeneration of the surgical site. RESULTS: The authors have observed excellent cosmetic outcomes at 6 months postoperatively with well-incorporated tissue. Patients report significantly improved functional outcomes with postoperative clitoral retraining therapy. CONCLUSIONS: Benefits of using the buccal mucosa as a donor site are similar to those reported previously. Namely, these include an inconspicuous donor site scar, primary closure of the donor site, and a decreased need for local tissue rearrangement and distortion of anatomy due to a distant donor site.1,2 As with any new technique, further investigation is needed to examine the long-term functional and cosmetic outcomes, including patient satisfaction and sexual function. Exposure of this technique to plastic surgeons will enable the therapeutic benefits to this greatly underserved population. REFERENCES: 1. Cohen SD, Armenakas NA, Light DM, et al. Single-surgeon experience of 87 buccal mucosal graft harvests. Plast Reconstr Surg. 2012;130:101–104. 2. Simman R, Jackson IT, Andrus L. Prefabricated buccal mucosa-lined flap in an animal model that could be used for vaginal reconstruction. Plast Reconstr Surg. 2002;109:1044–1049.

After Lightening Strikes: A Case Of Anoxic Encephalopathy In A 30 Year Old Soccer Player

HISTORY: A 30 year old male with a past medical history of hypothyroidism was out playing soccer when he was struck by lightening. After the lightening strike, the patient experienced cardiac arrest, and CPR was performed. Spontaneous circulation was achieved after a 17 minutes of CPR, and the patient was admitted to a burn unit for partial thickness burns of his left anterior chest, abdomen, and right medial lower calf. During the patient’s stay on the burn unit, he was noted to have severe cognitive deficits secondary to an anoxic brain injury sustained during his cardiac arrest, and also had a PEG tube placed after developing aspiration pneumonia. Following the burn unit, the patient was transferred to an acute rehab facility to address the severe cognitive deficits he had developed. Upon arrival at the acute rehabilitation facility, the patient was a Rancho Los Amigos level three. PHYSICAL EXAM: The patient was lying comfortably in bed. He was able to mimic behavior, but was unable to follow commands consistently. On ocular exam, the patient had a left pupil that was fixed and dilated, and sub-conjunctival hemorrhages. Abdominal exam was significant for an in-place PEG tube. Integumentary was significant for partial thickness wounds on his anterior chest and right lower extremity. The patient demonstrated full active range of motion of his upper and lower extremities. DIFFERENTIAL DIAGNOSIS: Anoxic encephalopathy Encephalopathy secondary to electrocution Toxic metabolic encephalopathy TESTS AND RESULTS: -Labs on admission were significant for the following: White blood cell count of 5.0; hemoglobin of 10.3; blood urea nitrogen of 55; AST of 42 and ALT of 70. -CT head on admission showed no evidence of intracranial hemorrhage, lobar infarct, hydrocephalus, or midline shift. FINAL DIAGNOSIS: Anoxic encephalopathy secondary to lightening strike TREATMENT AND OUTCOMES: The patient was started on amantadine to stimulate increased attention and wakefulness, and seroquel and trazadone to help address the patients nocturnal agitation and promote sleep. At the end of his 5 week stay on the acute rehabilitation unit, the patient had advanced to a Ranchos Los Amigos level eight. He was fully oriented to his environment, tolerating an oral diet, engaging in appropriate conversation, and ambulating with a walker.