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11/841. Gustatory otalgia and wet ear syndrome: a possible cross-innervation after ear surgery.

    HYPOTHESIS: The chorda tympani and Arnold's nerves have close approximation to each other and their cross-innervation is possible after ear surgery. STUDY DESIGN: A retrospective study was performed with a temporal bone pathology case and two clinical cases as representatives of such a possibility. patients had severe otalgia and wet ear during gustatory stimulation. methods: A temporal bone pathology case was studied under a light microscope. earache and/or wet ear were provoked during gustatory stimulation. Wet ear was tested with iodine-starch reaction after the subject tasted lemon juice. RESULTS: The temporal bone specimen has clusters of regenerated fibers in the tympanic cavity in the area of the chorda tympani and Arnold's nerves, suggesting a possibility of mixing. There are regenerated fibers in the iter chordae anterius, showing successful bridging of the chorda tympani nerves across a long gap. Detachment of the skin over the operated mastoid bowl obscured signs in one clinical case. Another clinical case of gustatory wet ear showed objective evidence of cross-innervation with iodine-starch reaction. CONCLUSION: The detachment procedure and iodine-starch reaction were the proofs that the signs were related to regenerated fibers. This is the first report of gustatory otalgia and wet ear after ear surgery.
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12/841. femur osteomyelitis due to a mixed fungal infection in a previously healthy man.

    We describe a previously healthy, 22-year-old man who, after a closed fracture of the femur and subsequent operation, developed chronic osteomyelitis. Within a few days, infected bone fragments, bone, and wound drainage repeatedly yielded three different filamentous fungi: aspergillus fumigatus, aspergillus flavus, and Chalara ellisii. Histologic examination of the bone revealed septate hyphae. After sequential necrotomies of the femur and irrigation-suction drainage with added antimycotic therapy, the infection ceased and the fracture healed. This case is unique in that it is the only known instance in which a long bone was affected in an immunocompetent individual, with no evidence of any systemic infection, by a mixed population of two different Aspergillus spp. and the rare filamentous fungus C. ellisii. Environmental factors that could potentiate the infection include blood and edema fluid resulting from the surgical procedure and the presence of the osteosynthetic plate.
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13/841. Post transplant CD8 gammadelta T-cell lymphoma associated with human herpes virus-6 infection.

    Gammadelta T-cell lymphoma is a rare T-cell lymphoproliferative disorder that has been reported in both immunocompetent and immunocompromised persons. This report describes a forty eight year old patient who developed gammadelta T-cell lymphoma four years after undergoing living-related kidney transplantation. The lymphoma expressed CD2, CD3, CD7, CD8 and CD56, and the gammadelta T-cell receptor and did not express CD5, CD4 and the alphabeta T-cell receptor. In addition, HHV-6 was cultured from the patient's bone marrow, marking the first time that this virus has been associated with gammadelta T-cell lymphoma. Since all patients with gammadelta T-cell lymphoma described to date have responded poorly to standard combination chemotherapies, the patient was treated with the purine analogue 2-chlorodeoxyadenosine. While he responded transiently to treatment, long term remission was not achieved indicating that additional therapeutic approches still need to be developed, for the management of this disorder.
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14/841. Tibial and pretibial cyst formation after anterior cruciate ligament reconstruction with bioabsorbable interference screw fixation.

    We report a case of an osteolytic tibial enlargement in association with a pretibial cyst formation 8 months after successful anterior cruciate ligament reconstruction with autologous bone-patellar tendon-bone graft and tibial graft fixation with a bioabsorbable interference screw. No joint inflammatory reaction or graft insufficiency was detected. The patient underwent cyst excision and curettage of the tibial tunnel with full recovery and return to preinjury level of activity 2 months after the revision surgery. To our knowledge, the reported complication is the first obvious adverse reaction to a poly-D,L-lactide interference screw in anterior cruciate ligament surgery.
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15/841. Laparoscopic retroperitoneal repair of recurrent postoperative lumbar hernia.

    A patient who previously underwent an attempt at open mesh repair of a lumbar hernia that occurred following iliac crest bone harvesting was managed successfully by laparoscopic retroperitoneal fixation of the prosthetic material to the iliac crest using bone screws. A review of the literature supports the use of such a novel approach to manage this often vexing problem.
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16/841. Differential bone scanning.

    This is a preliminary report of eleven patients with painful total joint arthroplasties. In their evaluation the difficulty in the differential diagnosis between the loose and the infected total joint becomes apparent. We have found the use of differential bone scans an accurate method to identify the infected total joint. Further study along these lines is indicated with a larger series and generalization to other types of implants.
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17/841. Early occurrence of an adenocarcinoma after allogeneic bone marrow transplantation in a patient with AML.

    Several reports have showed an increased risk of secondary malignancies after bone marrow transplantation (BMT), especially after total body irradiation (TBI). We report on a 39-year-old female who underwent BMT with a matched unrelated donor because of acute myeloid leukemia in second complete remission. Previously, the patient received chemotherapy for induction, consolidation, maintenance and reinduction after diagnosis of relapse. Conditioning regimen consisted of cyclophosphamide and TBI. MTX and CSA was administered for GvHD prophylaxis. Engraftment was confirmed on day 28. Within 6 months following BMT, no complication occurred. Continuous complete remission was demonstrated by repeated bone marrow smears. On day 300 the patient complained of chest pain and dyspnea. X-ray and CT-scan showed thickening of the pleura and pleural effusion. A pleuracarcinosis was diagnosed by cytologic examination of a pleural aspirate. By an open thoracotomy a disseminated inoperable disease became apparent. diagnosis of an adenocarcinoma was confirmed by histologic examination. The patient died 2 months later due to disseminated tumour in complete remission of AML. Solid tumours are rare as secondary malignancies after BMT. Usually the neoplasmas are late events occurring more than 10 years after BMT. In this case predisposing factors such as genetic disposition, long-term smoking, intensive pretransplant chemotherapy, TBI and immunosuppression may have lead to the early secondary malignancy.
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18/841. Endogenous CD8 T cell expansion during regression of monoclonal EBV-associated posttransplant lymphoproliferative disorder.

    There are experimental data which suggest that the primary immune effector cell responsible for maintaining immune surveillance against the outgrowth of EBV-transformed B cells in humans is the CTL, but in vivo proof of this is lacking. In this study we perform a series of cellular and molecular assays to characterize an autologous, endogenous immune response against a transplantation-associated, monoclonal, EBV posttransplant lymphoproliferative disorder (PTLD). Following allogeneic bone marrow transplantation, a patient developed a monoclonal PTLD of donor B cell origin. With a decrease in immune suppression, we document the emergence of endogenous, donor-derived CD3 CD8 CTLs, followed by regression of the PTLD. The TCR Vbeta repertoire went from a polyclonal pattern prior to the development of PTLD to a restricted TCR Vbeta pattern during the outgrowth and regression of PTLD. Donor-derived CD3 CD8 T lymphocytes displayed MHC class I-restricted cytolytic activity against the autologous EBV B cells ex vivo without additional in vitro sensitization. The striking temporal relationship between the endogenous expansion of a TCR Vbeta-restricted, CD3 CD8 population of MHC class I-restricted CTL, and the regression of an autologous monoclonal PTLD, provides direct evidence in humans that endogenous CD3 CD8 CTLs can be responsible for effective immune surveillance against malignant transformation of EBV B cells.
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19/841. Inappropriate elevation of intact PTH in the presence of normocalcemia after successful surgery for primary hyperparathyroidism.

    We describe here a patient with primary hyperparathyroidism who had high serum intact PTH levels for over 16 months after parathyroidectomy without signs of recurrence or persistence of the disease. The patient was a 48-year-old female who appeared well nourished (body mass index, 23.7). She was received subtotal gastrectomy as treatment for a duodenal ulcer at 44 years and 5 months old and had reached menopaused at 46 years of age. hypercalcemia and a high serum intact PTH level were pointed out three months before admission to our institute. A bone densitometric study revealed that the bone mass of the lumbar spine was extremely reduced (0.636 g/cm2, Z score, -2.17) preoperatively and had not increased 29.5 months after parathyroidal adenomectomy (0.656 g/cm2, Z score, -1.97). hyperparathyroidism, menopause and gastrectomy may have together contributed to the reduced bone mass. The postoperative persistently increased PTH levels in our patient suggest that the remaining parathyroid glands could have been altered during hypercalcemia, causing an increase in the set-point of PTH secretion by serum calcium or a decrease in the renal responsiveness to PTH during the disease.
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20/841. Serratus anterior free fascial flap for dorsal hand coverage.

    Reconstruction of the dorsal surface of hand defects requires thin, pliable, well-vascularized tissue with a gliding surface for the extensor tendon course. Fasciocutaneous or fascial flaps are the two surgical options. Fascial flaps present the advantages of thinness and low donor site morbidity. The authors present 4 cases of serratus anterior free fascial flap (SAFFF) used to cover the dorsum of the hand. The SAFFF with skin graft has many advantages for a fascial flap: long, constant vascular pedicle; very thin, well-vascularized tissue; low donor site morbidity; and the possibility of simultaneous donor and recipient site dissection. Furthermore, it can be associated with other flaps of the subscapular system for complex reconstructions. Of the 4 observations described, 2 used associated flaps, 1 used the SAFFF with a latissimus dorsi flap, and 1 used a scapular bone flap with the SAFFF. One flap was lost due to an electrical lesion to the forearm vessels.
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