Phalanx-like osseous structure posterior to the cervical vertebrae: a hitherto unreported location for a rare anomaly

Several types of abnormalities of the vertebral column have been reported. Pelvic rib or pelvic digit is a rare congenital anomaly of the spine. A 58-year-old male patient presented with a complaint of a firm mass in the neck. He had no history of trauma and had been aware of the mass for years. Physical examination showed a painless and immobile mass in the neck, measuring 4 x 1 cm. About 10 to 15 degrees of restriction was noted in neck movements, with slight pain. A plain radiograph of the cervical region showed two bony formations resembling a coccygeal segment or a phalanx, posterior to the spinous process of the C6 vertebra. They had well-defined cortices and medullae and pseudo-articulation between each other and with the spinous process. These findings were confirmed by three-dimensional computed tomography and magnetic resonance images. The patient did not accept surgery for the lesions were not associated with a significant discomfort. To our knowledge, such a digit has hitherto not been reported in the cervical region.     

Primary mixed adenocarcinoma and small cell carcinoma of the appendix: a clinicopathologic, immunohistochemical, and molecular study of a hitherto unreported tumor

Appendiceal carcinoids range from well-differentiated endocrine tumor to well-differentiated endocrine carcinoma, while poorly differentiated (small cell) carcinoma has not been described in this site. We report herein a case of mixed intestinal-type adenocarcinoma associated with a small cell carcinoma arisen in a 35-year-old woman and clinically presenting as an appendiceal abscess. The resected tumor histologically appeared as a biphasic lesion composed of a nonmucinous adenocarcinoma closely juxtaposed with a poorly differentiated (small cell) endocrine carcinoma. The subsequent right hemicolectomy was unremarkable, but one pericolic lymph node showed a metastatic deposit consisting of the adenocarcinoma only. The patient thus underwent a chemotherapeutic protocol for colorectal cancer, and she is alive and well at the 65-month follow-up. Immunohistochemically, the adenocarcinoma strongly stained for cytokeratin 20 and carcinoembryonic antigen, while the endocrine component displayed a dot-like positivity for pan-cytokeratins and chromogranin. Of note, both components did not stain with CDX2 and p53. At genotypic analysis by microsatellite instability, both components shared many microsatellite alterations as well as a normal p53 gene setup, although small cell carcinoma harbored additional alterations. Clinical and molecular findings led us to consider this lesion as a clonal tumor in which the endocrine component seems to derive from a progressive differentiation of the adenocarcinoma following a glandular-to-endocrine sequence.     

May-thurner syndrome: A previously unreported variant

Irritation of the left common iliac vein by the overlying right common iliac artery may result in intraluminal obstruction and symptomatic venous occlusion of the left lower extremity. We recently treated a 39-year-old patient with such an obstruction of the left common iliac vein as a result of compression by the left internal iliac artery. This case stresses the need to consider etiologies of external venous obstruction of the left lower extremity other than the commonly reported right common iliac artery when planning surgical intervention.     

A previously unreported late complication of Finney strictureplasty

We report the case of a 23 year old woman, treated for Crohn's disease for 11 years. She was operated on for multiple obstructing jejuno-ileal strictures using strictureplasty technique. Nine stricturoplasties of Heineke-Mikulicz type and one Finney type were performed without immediate postoperative complication. The patient received Imurel(R) and remained in remission for 15 months. Peritonitis due to a perforation of the Finney strictureplasty required re-operation; an ileostomy was performed. Such a late complication of a strictureplasty has not previously been reported in the literature. Although this complication was severe, the indication for this procedure in the surgical management of Crohn's complications should not be modified.     

A previously unreported cause of pain after total knee arthroplasty

Total knee arthroplasty achieves consistently excellent results in most patients. The most common causes of failure are loosening and infection. This article reviews the records of five patients in whom intraarticular fibrous tissue hypertrophy was the cause of pain after total knee arthroplasty. All of the patients had increasing pain and decreasing knee motion. Evaluation for loosening, malalignment, intraarticular debris, and infection gave negative results. Examination revealed a blocked range of motion and a palpable, tender, intraarticular mass. Injection of anesthetic relieved the symptoms. Surgical excision of the hypertrophic fibrous tissue relieved symptoms and increased knee range of motion. This cause of pain in the total knee arthroplasty patient is rare.     

Magnesium ammonium phosphate monohydrate — A hitherto undetected constituent of urinary calculi

Magnesium ammonium phosphate monohydrate, MgNH₄PO₄·H₂O, has been detected as a constituent of urinary calculi. The substance was identified by X-ray powder diffraction analysis, and the analysis was confirmed by comparison with synthetic material. Magnesium ammonium phosphate monohydrate may occur in secondary calculi which are formed in a strongly inflamed urinary tract. A possible mechanism of formation is discussed.     

Bone stress. A hitherto neglected factor in hip endoprosthesis design

Growing interest in hip endoprostheses is giving rise to new ideas on form and materials, although it is not precisely known what forces the proximal femur is subject to. To find out more about these forces, we made computerized analyses of the stresses on some different types of prostheses in an artificial standardized femur. The E-module amounts to about 14,000 N/mm. Following measurements in tension-optic trials, we inserted Student gages (EA-13-060LZ-120) at 16 points around the proximal femur; these transmitted the pressure, tensile and torsion stresses to a multipoint measuring instrument (UPM 60) and on-line to a computer. The quality of implantation was monitored by X-ray. With loads varying from 0 to 1.5 kN in 250-N steps we made five readings to reproduce the measurements, without having any material failure. To ensure an absolutely reproducible outcome we used an artificial standardized femur (KNF by Mecron), which without prostheses shows the typical and well-known (Pauwels, Perren) pressure tensions medially and tensile stresses laterally, without crossing the zero line. A distinctly reduced stress profile was seen for pressure and tensile stresses with the ribbed system prosthesis, which might be due to the anchor and collar. Nevertheless, the torsion tensions should be noted. As expected, the shaft systems without anchor and collar show a lesser degree of stiffness. The Mecroblock MR system produces preponderantly pressure stresses, while the CLS (Spotorno) prosthesis sets up more torsion tensions in different directions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Previously unreported high-grade complications of adrenalectomy

Background  Serious complications of adrenalectomy are rare but the incidence may be underestimated if they occur outside major referral centers. We report five cases of high-grade complications after adrenalectomy that have not been previously described. Methods  The records of five cases of adrenalectomy performed at outside hospitals were reviewed. Four cases were referred for management of complications and one for medical-legal review. The nature of the adrenal lesion, operative approach, complication(s), and subsequent clinical course and complication management were assessed. Both open adrenalectomy (OA) and laparoscopic adrenalectomy (LA) cases were included. Results  Operative indications were pheochromocytoma (N = 3), aldosteronoma (N = 1), and a nonfunctioning 6-cm hypervascular mass (N = 1). Complications of adrenalectomy included: case 1—complete transection of the porta hepatitis during right LA resulting in hepatic failure requiring emergent liver transplantation; case 2—ligation of the hepatic artery during right OA resulting in recurrent cholangitis and bile duct sclerosis requiring liver transplantation; case 3—ligation of the left ureter during LA resulting in postoperative hydronephrosis and loss of renal function; case 4—loss of left kidney function after OA, likely secondary to renal artery ligation ultimately requiring laparoscopic nephrectomy; case 5—LA of a normal adrenal gland for a 6-cm hypervascular mass thought to be arising from the adrenal gland. Three-month postoperative imaging demonstrated a persistent mass and the patient underwent hand-assisted laparoscopic nephrectomy for a left upper pole renal cell carcinoma that was missed at the time of LA. Conclusion  Despite the generally low morbidity of adrenalectomy, serious and potentially life-threatening complications can occur. Surgeon inexperience may be a factor in the occurrence of some of these complications which have not been previously described.     

A hybrid modified grey wolf optimization-sine cosine algorithm-based power system stabilizer parameter tuning in a multimachine power system

Damping of low-frequency oscillations due to the unpredictable perturbations of a power network has always been a challenging task. In an interconnected power network, power system stabilizers (PSSs) are in practice to damp out these low-frequency oscillations by providing a necessary control signal to the automatic voltage regulator unit based on the deviation in generator speed/power output. This article proposes a novel approach of hybrid modified grey wolf optimization-sine cosine algorithm for tuning the parameters of PSS of an interconnected multimachine power system. The optimal parameter tuning of PSS with the proposed algorithm is achieved by considering a multiobjective function comprises of improving the damping and eigenvalue characteristics of the consolidated multimachine system. A benchmark model of two area four machine system is adopted to investigate the performance achieved with the proposed algorithm in the simultaneous damping of the local and interarea mode of oscillations in a multimachine power system. The system study has been carried out under a self-clearing fault condition, and the detailed analysis is presented by analyzing the eigenvalues, and their corresponding natural frequencies, damping ratios. The damping nature achieved for the system states under system uncertainties with the proposed algorithm is also presented. The performance obtained from the proposed hybrid algorithm has been compared with the standalone and state-of-the-art optimization methods.     

Interruption of the ascending aorta: a hitherto undescribed lesion

We are describing a most unusual variant of aortic arch interruption. The ascending aorta was atretic above the sinutubular junction forming a blind-ending pouch. The coronary arteries were the only vessels arising from the aortic trunk. All the brachiocephalic vessels were perfused in retrograde fashion through the arterial duct. The aortic valve itself was dysplastic, stenotic, and permitted severe regurgitation. There was no subaortic obstruction. A modified first stage Norwood palliation was performed. Due to myocardial insufficiency transthoracic extracorporeal membrane oxygenation had to be commenced at the end of surgery. Unfortunately the child died due to severe intracranial hemorrhage.     

Neural correlates of human virtue judgment

Neuroimaging studies have demonstrated that the brain regions implicated in moral cognition. However, those studies have focused exclusively on violation of social norms and negative moral emotions, and very little effort has been expended on the investigation of positive reactions to moral excellence. It remains unclear whether the brain regions implicated in moral cognition have specific roles in processing moral violation or, more generally, process human morality per se. Using functional magnetic resonance imaging, brain activations during evaluation of moral beauty and depravity were investigated. Praiseworthiness for moral beauty was associated with activation in the orbitofrontal cortex, whereas blameworthiness for moral depravity was related to the posterior superior temporal sulcus. Humans might have developed different neurocognitive systems for evaluating blameworthiness and praiseworthiness. The central process of moral beauty evaluation might be related to that of aesthetic evaluation. Our finding might contribute to a better understanding of human morality.