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Introduction Organizing pneumonia is a rare clinico-pathological syndrome. This cryptogenic or secondary condition is of unknown origin, and may be infectious, or associated with autoimmune diseases, cancer, drugs, or radiation. Case description The case is presented of a 52-year-old patient who was diagnosed with organizing pneumonia secondary to anti-synthetase syndrome. Discussion It is intended to make known that not all pulmonary consolidative clinical pictures correspond to infectious processes. In this case, an organizing pneumonia secondary to anti-synthetase syndrome is documented. Despite being a disorder that is classified as an idiopathic inflammatory myopathy, it manifests as an interstitial lung disease with predominantly respiratory symptoms.

Summary Objective We aim to describe the supraclavicular nerve's vascular entrapment by the external jugular vein as an unreported anatomical finding. Case description In a routine cadaveric dissection, the superficial emergence of the first division of the left supraclavicular nerve emerged along a duct formed through the external jugular vein. No other vascular or neural anatomical abnormalities were found in the surrounding structures. Conclusion This unreported vascular entrapment of the supraclavicular nerve by the external jugular may harbour clinical implications for surgical and endovascular procedures on the external jugular vein and in refractory thoracic and scapular waist pain.

Background and Overview The purpose of this article is to present the variations in maxillary molar palatal root canals and provide a reference for the possible variations in root canal treatment. Case Description Five rare cases with palatal canal variation presented in this case series received nonsurgical endodontic treatment successfully. These case reports highlight that understanding and managing the different types of canal configurations in palatal roots of maxillary molars is essential to successful root canal treatment. We tried 2 methods of examining the palatal canal variation to provide examples for clinicians in diagnosing and treating similar cases. Conclusions and Practical Implications The outline form of the access cavity and the shape of the pulp chamber floor are important factors for identifying variations in root canal number. Moreover, cone-beam computed tomography can help in detecting variations in root canals.

CASE DESCRIPTION A 30-year-old person with a unilateral transtibial amputation (TTAmp) was assessed performing an Olympic-style back squat with an energy storage and return prosthetic foot. OBJECTIVE Determine joint-level movement strategies of an individual with TTAmp while performing an Olympic-style back squat. STUDY DESIGN Case study design. TREATMENT Back squat mechanics are evaluated in an individual with TTAmp by comparing the contribution of the ankle, knee, and hip joint to total positive and negative amputated and sound limb work. OUTCOMES The hip joint was the greatest contributor to total positive limb work compared with the knee and ankle, respectively, in the amputated (55.0% hip vs. 30.8% knee, P < 0.001; vs. 14.2% ankle, P = 0.001) and sound limbs (52.2% hip vs. 38.9% knee, P < 0.001; vs. 8.9% ankle, P < 0.001). The hip joint was the greatest contributor to total negative limb work compared with the ankle in both the amputated (51.0% hip vs. 15.9% ankle, P < 0.001) and sound limbs (47.3% hip vs. 10.0% ankle, P < 0.001) and the knee in the amputated limb (51.0% hip vs. 32.5% knee, P < 0.001). Ankle joint power demonstrated an atypical bimodal negative/positive/negative/positive pattern. CONCLUSION The individual with TTAmp used a hip-dominant joint strategy in both the amputated and sound limbs while demonstrating more potential to optimize the prosthetic foot's energy storage and return capabilities when performing a back squat.

Introduction We described a case of initial unsuccessful outcome of failed macular hole treated with amniotic membrane, that resolved after amniotic membrane exchange and silicone oil injection. Case Description a woman affected by a high myopic macular hole that had failed to close after multiple surgeries, had been treated using an amniotic membrane graft and 20% sulfur hexafluoride but, after the gas reabsorption, the macular hole was still open, and the amniotic membrane. A second surgery with a second amniotic membrane patch and silicone oil was carried out. Two weeks after the procedure the macular hole closed, and the final visual acuity improved from 20/400 to 20/100. Conclusions In this case, a second surgery, using a new amniotic membrane graft and a longer-lasting endotamponade, closed the hole and improved the visual acuity.

Background We present a first case report of an Actinomycosis lesion of the ventral tongue. Actinomycosis of the tongue is an uncommon finding. Case Description The 64-year-old female patient presented with a leukoplakic ventral tongue lesion. The diagnosis Actinomycosis was confirmed by histopathologic evaluation. The lesion was successfully treated with antibiotics and laser ablation therapy. Practical Implications Diagnostic and therapeutic concerns are discussed. Clinicians are alerted to considering Actinomycosis within the differential diagnosis of leukoplakic tongue lesions.

CASE DESCRIPTION A 2.5-month-old 17.5-kg female alpaca cria was presented for evaluation and treatment of severe bilateral carpal varus deformities. CLINICAL FINDINGS No lameness was evident at a walk, and neither carpal varus deformity could be corrected by means of manipulation. Radiography revealed severe varus of the left (27°) and right (21°) carpal regions. No additional conformational abnormalities were detected. TREATMENT AND OUTCOME A single 2.7-mm transphyseal cortical screw was placed in the distolateral aspect of the radius in each limb. On reexamination 8 weeks after screw placement, the left carpal varus deformity had corrected from 27° to 2.6°, and the left transphyseal screw was removed. The right carpal varus deformity had improved but was still present (18°), and hemicircumferential periosteal transection and elevation was performed on the mediodistal aspect of the right radius. Five weeks after the second surgery, the right carpal varus deformity had corrected to 2.4°, and the right transphyseal screw was removed. Six months after the second screw removal, both thoracic limbs remained straight, the cria had a normal gait, and the owner was happy with the cosmetic result. CLINICAL RELEVANCE Placement of a single transphyseal cortical screw with or without the addition of hemicircumferential periosteal transection and elevation can provide a favorable outcome in skeletally immature alpacas with severe carpal varus deformities.

CASE DESCRIPTION A 5-month-old domestic shorthair cat was presented for recurrent regurgitation and hypersalivation after eating, which had been evident since adoption 2 months earlier. CLINICAL FINDINGS Physical examination was unremarkable. Plain thoracic radiography, positive contrast esophagography, endoscopy, CT, electromyography, and blood analysis were performed. A caudal cervical esophageal diverticulum, likely congenital, was diagnosed. TREATMENT AND OUTCOME A diverticulectomy was performed with a surgical stapler while an endoscope was in the esophageal lumen. No intra- or postoperative complications were reported. Postoperative and short-term outcomes were excellent, with resolution of clinical signs and no endoscopic esophageal abnormality 3 months after surgery. The cat remained without clinical signs 8 months after surgery. CLINICAL RELEVANCE An esophageal diverticulum in a cat is rare. The cat of this report had a good outcome following surgical management of a cervical esophageal diverticulum. Surgery is worth considering for similarly affected cats, but additional cases are required to confirm the benefit of surgery versus conservative management. (J Am Vet Med Assoc 2021;259:396–400)

CASE DESCRIPTION 4 alpacas and 2 llamas (11 months to 11 years old) from 2 properties were examined for lethargy (6/6), salivation and regurgitation (4/6), and recumbency (3/6). Signs developed approximately 48 to 72 hours after accidental access to black oil sunflower seeds. CLINICAL FINDINGS 3 alpacas died suddenly prior to treatment and were necropsied. One llama survived, and 1 alpaca and 1 llama died after days of medical treatment. All 3 treated animals had systemic inflammatory signs including tachycardia, fever, and hematologic changes. Biochemical anomalies included azotemia, hyperglycemia, hyponatremia, hypochloremia, and hypoalbuminemia. Necropsy identified numerous sunflower seeds in the gastrointestinal tract of all 5 animals that died, with pulmonary congestion (5/5 animals), mild centrilobular vacuolar hepatic degeneration (4/5), and erosions of the esophagus (3/5) and first (3/5) and third (1/5) compartments of the forestomach. Renal tubular necrosis was found in the 2 animals that died on day 4 of treatment. TREATMENT AND OUTCOME One llama responded successfully to intensive medical management including supplemented IV fluid therapy, oral and partial parenteral nutrition, and administration of antimicrobials, furosemide, and insulin and was clinically normal with plasma biochemical analysis values within reference range 12 weeks later. Vitamin D, oxalates, heavy metals, and mycotoxins were excluded as the cause of clinical signs on the basis of screening of uneaten seeds and tissue samples and gastric content from the treated llama that died. CLINICAL RELEVANCE Inadvertent large volume black oil sunflower seed ingestion resulted in a high mortality rate in camelids. A specific toxic principle was not identified. Feeding this product to camelids is not recommended to avoid the risk of accidental overingestion and subsequent disease. (J Am Vet Med Assoc 2021;259:406–414)

BACKGROUND: Two patients received ocular injuries from rusted metallic projectiles at their industrial workplaces. Said injuries resulted in the loss of their eyes by evisceration surgeries to prevent fatal infections. CASE DESCRIPTION: The first case, a man in his twenties, received a stock conformer immediately after surgery and started prosthetic therapy within 2 months. The second case, a man in his forties, started prosthetic therapy after 10 years. Definitive custom ocular prostheses were fabricated and relined according to conventional protocol. RESULTS: On issue of the prosthesis, there was adequate retention, aesthetics and stability to extra-ocular movements and treatment was considered successful for both cases. However, follow-ups showed noticeable prosthetic eye movements for case 1 which, to some extent mimicked the physiologic movement of its fellow natural eye. Case 1 adjusted to his prosthesis better while case 2 was still adjusting with little to no physiologic movement. CONCLUSION: Prosthetic rehabilitation should be started as early as possible to obtain optimum rehabilitative results.

CASE DESCRIPTION A 3-year-old 17.5-kg (38.5-lb) mixed-breed dog was referred for evaluation because of nasal discharge, sneezing, and signs of nasal congestion of approximately 9 months’ duration. A diagnosis of nasopharyngeal stenosis (NPS) was made prior to referral. CLINICAL FINDINGS Sneezing, bilateral mucopurulent nasal discharge, reduced nasal airflow, stertor, and increased inspiratory effort were noted on physical examination. Results of serum biochemical analysis were within respective reference ranges. Review of CT images of the skull revealed findings consistent with severe bilateral partial osseous choanal atresia and NPS. Retrograde rhinoscopy confirmed membranous NPS. TREATMENT AND OUTCOME A ventral rhinotomy was performed; communication between the pharynx and nasal passageway was reestablished by surgical debridement of the caudal border of the palatine bone and vomerine crest and groove, followed by dissection of the membranous NPS and reconstruction of the caudal part of the nasopharynx. A covered nasopharyngeal stent was placed in the newly established nasopharynx. The dog recovered uneventfully but was presented 3 weeks later with recurrent signs; diagnostic findings were consistent with stenosis rostral to the stent. The stenosis was treated with balloon dilation, and a second covered stent was placed rostral to and overlapping the first stent, spanning the stenotic region. Eleven months after this procedure, the dog was doing well. CLINICAL RELEVANCE Results for this patient suggested that ventral rhinotomy and covered nasopharyngeal stent placement can be used successfully for the management of osseous choanal atresia in dogs; however, careful attention to preoperative planning and potential complications is necessary. (J Am Vet Med Assoc 2021;259:190–196)

Background and Overview Severely molar-incisor hypomineralization (MIH)–affected teeth are prone to develop early posteruptive enamel breakdown (PEB) and caries. A novel conservative interim approach for the prevention of this complication is presented. Case Description A 6-year-old boy with strong hypersensitivity and extensive brown opacities in the partially erupted mandibular permanent first molars (PFMs) was diagnosed with MIH. Constant hygiene and dietary counseling were followed by the application of luted orthodontic bands and glass ionomer sealants to protect PFMs from caries and PEB until the complete eruption of the teeth. After 36 months, the PFMs were completely erupted, with no caries and PEB, and the cooperation of the child increased. Conclusions and Practical Implications Temporary strategies are useful to preserve MIH-affected PFMs. With the methodology described, the hypersensitivity decreased and the patient reached a good degree of cooperation, making possible definitive rehabilitative considerations.

Background The presence of osteoclast-like giant cells (OGC) in hepatocellular carcinoma (HCC) is rare and literature on this topic is scarce. In this article, we report on a case of a 77-year-old male patient with HCC with OGC and provide an overview of the current literature. Methods We conducted a systematic search to find all available literature on OGC in HCC. The electronic databases PubMed, Web of Science, Embase and CENTRAL were searched from inception until October 2020. Results Thirteen articles on this topic were identified and were included in this review. Data on 14 patients were available, described in twelve case reports, one patient in a patient series and the present case. Median age of included patients was 68 years. Two patients underwent neoadjuvant therapy prior to surgery. Of the 14 cases, eight tumours with OGC arose in a cirrhotic liver. Oncological outcome in this series was unfavourable, even after surgical resection, with a median disease-free survival of 75 d. Conclusions The presence of OGC in HCC is rare. Current literature is scarce, and suggests an unfavourable outcome in regard to overall survival of HCC.

CASE DESCRIPTION A 2-month-old 12.0-kg (26.4-lb) sexually intact male alpaca was evaluated for a 1-week history of progressive forelimb lameness with no known history of trauma. CLINICAL FINDINGS The cria had toe-touching lameness in the right forelimb with a firm swelling at the distal dorsomedial metacarpal region. Signs of pain were elicited on palpation of the swollen region. There was no associated wound or draining tract. Radiographic examination revealed soft tissue swelling and osteomyelitis of the distal portion of the third metacarpal bone with a possible medial cortical sequestrum. TREATMENT AND OUTCOME The cria was hospitalized and treated with meloxicam (1 mg/kg [0.45 mg/lb], PO, q 72 h) and ceftiofur sodium administered SC (2.2 mg/kg [1 mg/lb], q 12 h for 8 days) and by means of regional limb perfusion (1.25 mg/kg [0.57 mg/lb], IV, q 48 h for 8 days). Lameness and swelling improved, and the cria was discharged from the hospital with meloxicam (1 mg/kg, PO, q 72 h for 2 weeks) and ceftiofur crystalline free acid (1.5 mg/kg [0.68 mg/kg], SC, q 5 d for 2 weeks). At a recheck examination 17 days later, there was radiographic evidence of a well-defined 3.4 × 0.3-cm osseous sequestrum in the distal aspect of the affected third metacarpal bone. The owner declined further treatment and elected to monitor the cria at home. One year later, radiographic examination revealed nearly complete resolution of the sequestrum. CLINICAL RELEVANCE Results for this patient suggested that osseous sequestra in some camelids may resolve following medical treatment without surgical intervention.

Women hospitalized on an antepartum unit can benefit from an open studio art therapy group. A case description follows six women over five group sessions. Several common experiences that occurred t...

CASE DESCRIPTION A 12-year-old Friesian stallion was examined because of a 1-year history of preputial injury and urination through a urethrocutaneous fistula located at the midbody of the ventral aspect of the penis. CLINICAL FINDINGS Physical examination revealed an opening with a clearly apparent mucocutaneous junction 12 cm from the distal opening of the urethra on the ventral left side of the penis. Endoscopic examination of the distal portion of the urethra confirmed a blind pouch with no communication with the fistula or proximal portion of the urethra. TREATMENT AND OUTCOME A temporary perineal urethrostomy was performed with sedation and local anesthesia, with the stallion standing, to divert urine from the urethral reconstruction site. Fistulectomy and urethral resection and anastomosis were performed under general anesthesia with the stallion in dorsal recumbency. At 15 days after surgery, endoscopic examination of the urethra revealed distortion of the urethral lumen at the fistulectomy site. Under sedation, the urethra was dilated for 5 minutes every 12 hours for 3 days. At 22 days after surgery, endoscopic examination of the urethra revealed a healed anastomosis site and a large urethral luminal diameter. At 36 months after surgery, the owner reported that the stallion had normal micturition and had sired multiple foals by live cover matings. CLINICAL RELEVANCE Severe preputial or penile trauma in horses is most commonly treated with amputation because of concerns of postoperative urethral stricture and occlusion. To the authors' knowledge, this case represented the first time that a successful end-to-end anastomosis of the distal portion of the urethra has been performed in a stallion.

CASE DESCRIPTION 2 male and 3 female adult bearded dragons (Pogona vitticeps) were evaluated at the North Carolina State University College of Veterinary Medicine's Exotic Animal Medicine Service between September 2018 and October 2019 because of severe lymphocytosis. CLINICAL FINDINGS All 5 bearded dragons had nonspecific clinical signs, including lethargy, poor appetite, ocular discharge, and weight loss. Clinicopathologic testing revealed extremely high lymphocyte counts with morphological findings consistent with lymphocytic leukemia. TREATMENT AND OUTCOME All 5 patients were treated with lomustine, prednisolone, and antimicrobials. In addition, 1 or 2 doses of L-asparaginase were administered when the drug was available. Partial remission was achieved in all 5 patients. One patient, after disease progression was documented, was treated with cyclophosphamide and achieved a second partial remission. One of the 5 patients was still alive and continuing to receive chemotherapy at the time of final follow-up 244 days after the initial diagnosis. Survival times (ie, times from initial diagnosis to euthanasia) for the other 4 patients were 57, 157, 330, and 416 days. CLINICAL RELEVANCE The present report represented the first description of lomustine as a primary chemotherapeutic agent for the treatment of lymphocytic leukemia in bearded dragons and provided information on response to treatment, adverse effects, and survival times.

CASE DESCRIPTION An 8-month-old 41.2-kg (90.6-lb) sexually intact male Dogue de Bordeaux with urinary incontinence and signs of nausea was referred for further evaluation and treatment of bilateral hydronephrosis, hydroureter, and ectopic ureters. CLINICAL FINDINGS Clinicopathologic analyses revealed urine specific gravity and serum concentrations of urea nitrogen and creatinine within reference limits. Abdominal ultrasonography and CT revealed unilateral abdominal cryptorchidism, ureters that bilaterally passed dorsal to and appeared compressed by the external iliac arteries (retroiliac ureters), and bilateral hydronephrosis, hydroureter, and ectopic ureters. On CT, minimal uptake of contrast medium by the right kidney indicated either a lack of renal function or ureteral obstruction. TREATMENT AND OUTCOME The dog underwent exploratory laparotomy, right ureteronephrectomy, left neoureterocystostomy, bilateral castration, and incisional gastropexy without complication and was discharged 2 days postoperatively. Eleven days after surgery, the dog had improved but continued urinary incontinence, improved left hydronephrosis and hydroureter, and serum concentrations of urea nitrogen and creatinine within reference limits. At 24 months after surgery, the dog was reportedly clinically normal, other than having persistent urinary incontinence. CLINICAL RELEVANCE To our knowledge, this was the first report of a dog with retroiliac ureters and compression-induced ureteral obstruction with secondary hydroureter and hydronephrosis. Retroiliac ureters should be considered as a differential diagnosis in young dogs with ureteral obstruction. Our findings indicated that a good outcome was possible for a dog with retroiliac ureters treated surgically; however, the presence of additional congenital anomalies should be considered and may alter the prognosis in dogs with retroiliac ureters.

Background Spinal schwannomas are commonly presented with minor symptoms, including radicular pain, sensory deficits, and minor neurologic deficit. Acute neurologic deterioration is uncommon. Case Description In this study, a case of cauda equina schwannoma presented with acute neurologic deficit after movement of spinal schwannoma is presented. Conclusions It is noted that movement of spinal schwannoma and resultant acute neurologic deterioration should be considered during the follow-up.

Split notochord syndrome (SNS) is a rare congenital defect of the central nervous system and has been associated with several anomalies affecting multiple organ systems. One association has been communication with the gastrointestinal tract and the spine, previously identified as a neuroenteric fistula (NEF). Here, the authors describe the unique case of a female infant with SNS and NEF treated with a multistage surgical repair. The three-stage operative plan included a two-stage repair of the defect and temporary subgaleal shunting followed by delayed ventriculoperitoneal shunt placement. The infant recovered well postsurgery and over a 5-year follow-up. A case description, surgical techniques, and rationale are reported. Additionally, a systematic review of the literature utilizing the MEDLINE database was performed.Treatment of SNS with NEF using a multidisciplinary multistaged approach to repair the intestinal defect, close the neural elements, and divert cerebrospinal fluid to the peritoneum is shown to be a safe and viable option for future cases.

CASE DESCRIPTION As a result of vehicular trauma, a 3-year-old neutered male domestic shorthair cat sustained luxation of the sacrocaudal joint and a urethral tear. CLINICAL FINDINGS Retrograde contrast urethrocystography revealed a urethral tear at the level of the ischiatic tuberosity. Conservative treatment for 7 days with a urethral catheter was unsuccessful. TREATMENT AND OUTCOME An approach for a perineal urethrostomy was performed and revealed a large urethral tear (4 mm in length in a craniocaudal orientation and encompassing approx 50% of the urethral circumference) proximal to the bulbourethral glands. Urethroplasty was performed with a graft of a rectangular section of single-layer porcine small intestinal submucosa. Perineal urethrostomy was then completed routinely, and a urethral catheter was left in place for 5 days. Two days after removal of the urethral catheter, stranguria was noted. Retrograde contrast urethrocystography revealed a urethral stricture. Balloon dilation of the urethral stricture was performed, and the cat's stranguria improved. Ten weeks following balloon dilation, the cat developed hematuria, and a urinary tract infection and urethral stricture were diagnosed. Balloon dilation was repeated with instillation of triamcinolone solution at the stricture site. Eighteen months later (approx 21 months after the initial surgery), the cat was urinating normally. CLINICAL RELEVANCE The outcome for the cat of this report indicated that porcine small intestinal submucosa may be used to successfully augment urethroplasty for treatment of traumatic urethral tears in cats. Urethral balloon dilation with triamcinolone instillation may be used to treat postoperative urethral strictures.

Background and objectives The thoracolumbar junction syndrome or Maigne's syndrome is one of the causes of low back pain, for which no comprehensive treatment has yet been proposed. This case report aims to assess the effectiveness of a global physiotherapy approach, such as the Mezieres method, to reduce pain and improve posture and mobility in a patient with thoracolumbar junction syndrome (TLJS). Case description A 42-year-old woman patient presented a chronic nonspecific low back pain associated with severe pain in the right inguinal fold which has disabled her for two years. She described her pain as deep and intermittent. She complained of difficulties performing tasks that involved on long walks and bending forward lumbar flexion. Outcomes After ten sessions the pain completely disappeared (numeric rating scale-NRS improved from 6 to 0). A slight improvement in certain morphostatic parameters in the frontal and sagittal planes was reported, analyzed by ADiBAS software. Six months after the final session, the patient was asymptomatic, with improved bodily awareness and muscular extensibility. Conclusion The TLJS patient responded well to the Mezieres Method, whose global physiotherapy approach resulted in a lessening of nociceptive pain, and also improved posture and functionality.

Background Extracranial metastases from atypical meningioma are not usually found; they are sometimes found in lung, bone or scalp, but atypical meningioma in the liver is extremely rare. Case Description We report a case of a 55-year-old patient with atypical meningioma, treated with surgical resection in 2005, who accepted a second surgical resection in 2015 by the same surgeon, caused by a liver metastasis 4 years after the second surgical resection. Conclusions We have analyzed the cytological findings of a metastastic meningioma with particular focus on pathological and immunohistochemical assessment. These results could improve the knowledge of surgeons about meningioma types and guide them to solve clinical incidents.

Background: Although decongestive physiotherapy combined with diuretics may be efficient in limb edemas, no such therapy has been described in the context of anasarca. Case Description: A bedbound ...

CASE DESCRIPTION A 7-year-old 35-kg (77-lb) neutered male Labrador Retriever was evaluated because of a 1-month history of a rapidly growing mass associated with the right caudal aspect of the thoracic wall. CLINICAL FINDINGS CT examination revealed an aggressive, osteolytic mass lesion centered around the ventral aspect of the right ninth rib with osteolysis of that rib and focal invasion into the right external abdominal oblique muscle. Preoperative cytologic and histologic findings were most consistent with a chondrosarcoma. TREATMENT AND OUTCOME The mass and the eighth, ninth, and tenth ribs were resected, and thoracic wall reconstruction was performed with a novel surgical technique involving lateralization of the diaphragm. The dog recovered rapidly and without complications other than a small seroma; no paradoxical chest movement developed, and the cosmetic outcome was good. An excellent quality of life was reported after surgery until the dog was euthanized because of underlying disease progression 6 months later. CLINICAL RELEVANCE Diaphragmatic lateralization was a simple method of caudal thoracic wall reconstruction that had good clinical results in this case. Research is needed to further assess the safety, reliability, and potential complications of this procedure in dogs.

CASE DESCRIPTION A 12-year-old neutered male domestic shorthair cat with chronic anterior uveitis and secondary glaucoma of the right eye was examined for persistent blepharospasm 2 weeks after corneal debridement and grid keratotomy for nonhealing superficial ulcerative keratitis. CLINICAL FINDINGS Examination of the right eye revealed a central superficial corneal ulcer associated with corneal epithelial and subepithelial infiltrates and mild aqueous flare. Structures consistent with amoeboid cysts and trophozoites were detected in the cornea by in vivo confocal microscopy. Suppurative keratitis was identified cytologically. An Acanthamoeba spp was isolated through culture and identified by a PCR assay of corneal specimens. TREATMENT AND OUTCOME Symptomatic and antiamoebic (polyhexamethylene biguanide 0.02% ophthalmic solution) treatments were instituted. Over the following 6 weeks, the cat lost vision in the affected eye and lesions progressed to nonulcerative stromal keratitis associated with a dense paracentral corneal stroma ring infiltrate and anterior lens luxation. The globe was enucleated, and lymphoplasmacytic sclerokeratitis, anterior uveitis, and retinal detachment were noted. Acanthamoeba organisms were detected within the corneal stroma and anterior sclera with histologic and immunohistochemical stains. The amoebae were classified to the Acanthamoeba T4 genotype by DNA sequencing. The cat had no medical problems attributed to Acanthamoeba infection over 36 months after enucleation, until the cat was lost to follow-up. CLINICAL RELEVANCE Naturally acquired Acanthamoeba sclerokeratitis is described in a cat for the first time. Acanthamoeba infection should be considered for cats with superficial corneal disease refractory to appropriate treatments and especially occurring after ocular trauma, including keratotomy.

Background Musculoskeletal and neural alterations secondary to chronic atlantoaxial instability are evaluated. Case Description An 11-year-old girl presented with major symptoms of progressively worsening dorsal kyphoscoliosis (spinal kyphoscoliosis [SKS]). In addition to dorsal SKS, investigations revealed multiple craniovertebral and cervical spinal musculoskeletal abnormalities, Chiari formation, and syringomyelia. Dynamic imaging revealed atlantoaxial instability. Atlantoaxial stabilization resulted in rapid improvement in SKS, regression of tonsillar herniation, and resolution of syrinx. Conclusions The experience with the case showcases wide ranged spinal consequences as a result of chronic atlantoaxial instability.

CASE DESCRIPTION A 6-month-old sexually intact male Clumber Spaniel was evaluated because of small stature, recurrent dermatitis of the head, and progressive pigmentary hepatopathy. CLINICAL FINDINGS Clinicopathologic findings included nonanemic hypochromic microcytosis, hypocholesterolemia, persistently high serum liver enzyme activities, and anicteric hyperbilirubinemia. Histologic examination of liver biopsy specimens collected when the dog was 6 months and 2 years of age revealed expansion and bridging of portal tracts, occasional centrilobular parenchymal collapse, scattered lymphoplasmacytic infiltrates, and dark red to brown pigment within large aggregates of macrophages, engorged bile canaliculi, and hepatocytes. The pigment failed to stain for the presence of iron, copper, bile, and glycoprotein and, when examined with polarized microscopy, emitted a yellow to green birefringence with occasional Maltese cross configurations. Further analyses confirmed marked porphyrin accumulation in blood, urine, feces, and liver tissue; protoporphyrin accumulation in RBCs and liver tissue; and a signature porphyrin profile and fluorescence peak consistent with erythropoietic protoporphyria. Advanced protoporphyric hepatopathy was diagnosed. The chronic dermatopathy was presumed to reflect protoporphyric photosensitivity. TREATMENT AND OUTCOME Management was focused on avoiding conditions known to induce heme synthesis and catabolism, administrating ursodeoxycholic acid and antioxidants S-adenosylmethionine and vitamin E, and avoiding sunlight exposure. At follow-up at 4 years of age, the dog was stable without evidence of jaundice but with probable persistent erythropoietic protoporphyria–related solar dermatopathy. CLINICAL RELEVANCE Clinical and histologic features of congenital erythropoietic protoporphyria and resultant protoporphyric hepatopathy, the diagnosis, and the successful management of a dog with these conditions over 4 years were described. Veterinarians should consider porphyric syndromes when unusual pigmentary hepatopathies are encountered.

CASE DESCRIPTION A 7.5-year-old 37.8-kg (83.2-lb) sexually intact male German Shepherd Dog (dog 1) and a 2.6-year-old 28.2-kg (62.0-lb) sexually intact male Dutch Shepherd (dog 2), both apprehension police dogs, were admitted for evaluation of left and right thoracic limb lameness, respectively. CLINICAL FINDINGS In both dogs, signs of pain were elicited on palpation of the shoulder joint in the affected limb, and a distinct popping of the biceps brachii tendon (BT) was palpable on the craniomedial aspect of the affected joint on flexion and extension and was associated with moderate signs of pain. Biceps brachii tendon luxation (BTL) was diagnosed with dynamic musculoskeletal ultrasonography (both dogs) and MRI (dog 1). TREATMENT AND OUTCOME Arthroscopic BT release by tenotomy was performed in both dogs. Lameness appeared to have resolved by 8 weeks after surgery and had not recurred by the last follow-up communications at 36 and 9 months after surgery for dogs 1 and 2, respectively. Both dogs successfully returned to their level of work performed before their injury. CLINICAL RELEVANCE Our findings for the dogs of the present report suggested that arthroscopic BT release could be considered a viable treatment option for BTL in dogs, including police dogs or other high-performance athletic dogs. Although our findings provided encouraging results, further research, best conducted with a multicenter prospective randomized study, would be needed to establish the most reliable treatment of BTL in high-performance athletic or working dogs.

What is known and objective Invasive fungal infections often occur in patients with comorbidities that complicate oral administration. Serum concentrations of isavuconazole were characterized after enteral tube administration. Case description Thirteen of 14 isavuconazole concentrations were >1 mg/dl (median 1.6 mg/dl) among those receiving enteral tube administration, which was comparable to intravenous (median 1.9 mg/dl). Higher concentrations were observed during oral administration (median 3 mg/dl). What is new and conclusion Administration of isavuconazole via tube resulted in concentrations comparable to FDA-approved routes of administration. This route may be feasible and appropriate for select patients.

Stakeholder management is an important task of project managers in housing renovation. Compared with new construction project, a great challenge that a housing renovation project manager faces, is managing the tenants that living before or during the renovation. This paper is a teaching case based on a real housing renovation project, which confronted difficult stakeholder management problems, of a Swedish real estate company between 2009 to 2016. It provides teaching materials that can be used by instructors for helping students to analyse and summarise the lessons learned from a troublesome stakeholder management process and to come up with suggestions that will ensure a smooth implementation of the housing renovation project. The case contains two main parts, namely the case description and teaching notes. It can be used by teachers and trainers, as well as university bachelor students and industrial practitioners in courses and training programs about housing renovation project management.

Background Brain arteriovenous malformations (AVMs) are dynamic lesions. Unlike the recruitment of additional vessels and the growth of the nidus over time, which are well reported in the literature, spontaneous regression is much less frequent. Only a handful of cases reporting recanalization of spontaneously regressed AVMs have been published. AVMs that undergo spontaneous regression typically share structural and historical features, including previous hemorrhage, a small nidus, superficial venous drainage, and a single draining vein. Structural features and hemodynamic changes may predispose brain AVMs to spontaneous regression, and angiogenic processes are hypothesized to contribute to recanalization and hemorrhage. Case Description We present the case of a 37-year-old female who had been diagnosed 12 years ago with an unruptured Spetzler-Martin grade 3 AVM in the left medial occipital lobe after a history of progressively worsening migraines. The AVM was monitored for 1 year, but the patient was lost to follow-up until 11 years later, when the AVM nidus was found to be significantly smaller in size. One month later, the patient presented with acute intraparenchymal hemorrhage due to rupture of the AVM, which was then surgically resected. Conclusions Our case is the second reported case of rupture of a spontaneously regressed AVM and the first reported case of this outcome with no history of previous hemorrhage. Close monitoring of brain AVMs may be warranted for longer periods of time than previously recommended.

Background Cowden syndrome (CS) is an autosomal dominant genodermatosis with a predisposition for the development of multiple cancers, benign hamartomas, and extracranial vascular malformations. Rarely, intracranial lesions like meningiomas and vascular malformations can also be present with CS. These vascular malformations include developmental venous anomalies, arteriovenous fistulae and cavernomas. Most cases of cavernomas are thought to be congenital, although in recent literature they have been shown to occur de novo with other conditions (e.g., other vascular malformations, trauma, postcranial surgery, viral infection, and genetic disorders). Case Description We present a 29-year-old woman who was diagnosed with Lhermitte-Duclos disease after episodes of persistent generalized headaches. She underwent a foramen magnum decompression and was subsequently diagnosed with CS. Ten years, later she was also diagnosed with 2 cerebral cavernomas that were not present on her prior monitoring scans. Conclusions We present a case of a patient with CS and LDD who had de novo cavernoma development several years after the initial diagnosis, as well as a review of the literature. We highlight the need of surveillance neuroimaging for patients with CS, as there is the risk of new development of vascular abnormalities (particularly cavernomas).

Background This case series describes the use of the Medtronic Micro Vascular Plug (MVP) system in the treatment of acute massive orofacial hemorrhages in patients with cancer and trauma, resulting in successful hemostasis in these emergent cases. Case Description The first case describes a patient who presented with life-threatening oropharyngeal hemorrhage after a motor vehicle accident. In the second case, a patient with oropharyngeal cancer presented with life-threatening bleeding from an ulcerated tumor. Patients were successfully treated with a combination of MVP and coils. Immediate postprocedural imaging confirmed that homeostasis was achieved. Conclusions These cases demonstrate that the MVP as an embolic device is a valuable transarterial embolic treatment option in cases of acute orofacial bleeding where rapid, effective hemostasis is required.

CASE DESCRIPTION A 9-month-old miniature Hereford heifer was evaluated for a mass on the right inferior eyelid that had progressed in size over 3 months. CLINICAL FINDINGS Physical examination revealed a firm, ulcerated, pedunculated mass on the right inferior eyelid that extended from the medial quarter to beyond the lateral canthus of the eye. The base of the mass measured 7.4 × 6.7 cm, and the dorsal margin of the base of the mass was approximately 3 mm ventral to the inferior eyelid margin. Histologic evaluation of incisional biopsy specimens from the mass was consistent with fibrosarcoma. TREATMENT AND OUTCOME The mass was surgically resected with care taken to preserve the eyelid margin. The resulting 10 × 8.5-cm surgical wound was treated with adjunct CO2 laser therapy and closed by primary closure at its medial and central aspects and placement of a 4.6 × 2.6-cm lyophilized equine amnion multilayer graft and 2 sheets of 4-ply porcine small intestinal submucosa at its lateral aspect. The grafts were kept moist by alternating topical antimicrobial and artificial tear ointments for 3 weeks. The wound healed without complications, resulting in a functional and aesthetically pleasing outcome despite the development of moderate ectropion at the lateral aspect of the inferior eyelid. CLINICAL RELEVANCE Results suggested that a combination of extracellular matrix scaffolds may be an alternative to extensive skin flaps for management of large dermal wounds, particularly wounds resulting from blepharoplasty where preservation of an eyelid margin is desired.

What is known and objective Our objective is to report on a case of posterior reversible encephalopathy syndrome associated with pazopanib. Case description A 64-year-old patient with uterine sarcoma developed PRES 3 days after pazopanib was initiated. After the discontinuation of pazopanib, the symptoms of PRES improved. What is new and conclusion The first report worldwide to describe a patient with uterine sarcoma experiencing PRES caused by pazopanib. Patients with uterine sarcoma may experience PRES, even in the early phase of pazopanib therapy.

Background and Case Description We report a case of an 18-year-old patient who presented with late progressive deterioration of neurologic condition 8 weeks after a penetrating injury to the back. Investigations revealed a dorsally located post-traumatic spinal cord herniation. Urgent exploration, decompression, and repair were performed. We reviewed the literature and found only 19 similar cases previously reported. Pathophysiology and presentations were variable and even poorly understood. Conclusions Late-onset post-traumatic spinal cord herniation is a potentially curable cause of neurologic deterioration after spinal trauma and should be considered in all cases with late neurologic deterioration after spinal trauma.

Background Tension pneumoventricle (TPV) is a subtype of tension pneumocephalus in which the air is trapped inside the ventricles through a one-way osteodural defect, causing an increase in intracranial pressure. TPV secondary to cutaneous-ventricular fistula has been reported only twice in the literature. Case Description Herein, we report the third case in a 53-year-old woman who developed TPV with decreased level of consciousness after removal of a posterior fossa meningioma while she was on external ventricular drainage. There was no identifiable bony defect on neuroimaging. The drain was changed urgently, and the fistula located at the drain tunneling site was sealed. Conclusions This case report highlights the importance of suspecting and treating cutaneous-ventricular fistulas in TPV urgently in patients without skull base defects or those who showed no improvements with external ventricular drainage.

CASE DESCRIPTION A 4-year-old 55.0-kg (121-lb) spayed female Vietnamese potbellied pig was examined for right forelimb lameness of 2 months’ duration that had not resolved following rest and treatment with meloxicam. CLINICAL FINDINGS The only abnormality identified during physical examination was non–weight-bearing lameness of the right forelimb. Radiographic and CT examinations revealed that the right humerus was displaced laterally and slightly cranial to the glenoid cavity of the scapula with moderate evidence of osteoarthritis. Chronic craniolateral luxation of the right humeral (shoulder) joint was diagnosed. TREATMENT AND OUTCOME Arthrodesis of the right shoulder joint was performed surgically by a lateral approach. The humeral head was replaced in the glenoid cavity. The joint was immobilized at a 115° angle with two 3.5-mm string-of-pearls orthopedic plates and a 4.5-mm cortical bone screw placed across the joint in lag fashion. The pig recovered from surgery without any complications. At 6 weeks and 5 months after surgery, the pig had the expected mechanical lameness of the right forelimb owing to immobilization of the shoulder joint and radiographic evidence of progressive arthrodesis of that joint. The pig had resumed its usual activities and had only mechanical lameness present 1 year after surgery. CLINICAL RELEVANCE This report described successful treatment of chronic shoulder joint luxation in an adult Vietnamese potbellied pig by surgical arthrodesis of the affected joint. The described procedure might also be useful for treatment of other debilitating conditions of the shoulder joint, such as severe osteoarthritis or intra-articular fractures, in pigs.

Background Forehead reconstruction is challenging. Reconstruction of the innate curvature of the forehead is difficult, and the forehead is an esthetically important part of the face. Although synthetic implants and autologous split bone grafts are useful, these cannot be used in infants. Case Description A 4-month-old girl was presented with a right frontal bone Ewing sarcoma. The tumor was removed, and the defect was reconstructed with an autologous contralateral parietal bone graft. The parietal bone defect was repaired with a bioabsorbable hydroxyapatite and collagen complex. Good reconstruction of the forehead and ossification of the donor site was achieved within 3 years after surgery. Conclusions After removal of an extensive frontal bone tumor in an infant, exchange cranioplasty with an autograft using a bioabsorbable hydroxyapatite and collagen complex at the donor site yielded good results.

espanolIntroduccion: La infeccion por coronavirus favorece el desarrollo de alteraciones respiratorias. En trasplantados renales el pronostico de la neumonia por SARS-CoV-2 puede ser diferente al resto de la poblacion. Muchos pacientes trasplantados tienen de base linfopenia inducida por farmacos, por lo que la deteccion y el tratamiento precoz son determinantes en este grupo de poblacion. Presentacion del caso: Varon de 50 anos con ERC no filiada, trasplantado renal en 2016 que acudio a urgencias por fiebre de 38oC, tos, rinorrea, diarrea con perdida de peso y molestia en injerto renal en fosa iliaca derecha. Se diagnostico de COVID-19 positivo tras realizacion de placa de torax y PCR SARS-CoV-2. Ingreso en nuestra unidad de trasplante renal. Plan de cuidados: Se realizo una valoracion inicial mediante los patrones funcionales de Gordon. Posteriormente identificamos Diagnosticos de Enfermeria segun la taxonomia NANDA con sus correspondientes criterios de resultados e intervenciones. Evaluacion del plan: Tras la realizacion de las intervenciones y la evaluacion de los indicadores de resultados observamos una disminucion de la temperatura corporal y de la dificultad respiratoria con mejoria en el patron respiratorio. En cuanto a la funcion renal, no se ha visto significativamente alterada a pesar de la retirada temporal de la inmunosupresion. Conclusion: El paciente se fue de alta con una funcion renal similar a la previa y con la inmunosupresion reintroducida. Se lograron los objetivos planteados dejando patente que el papel de enfermeria ha sido fundamental en el proceso de recuperacion y afrontamiento de la enfermedad EnglishIntroduction: Coronavirus infection favours the development of respiratory disorders. In kidney transplant patients, the prognosis of SARS-CoV-2 pneumonia may be different from the rest of the population. Many transplant patients have drug-induced lymphopenia, so early detection and treatment are crucial in this population group. Case description: A 50-year-old man with unknown CKD and a kidney transplant in 2016 who came to the emergency room due to fever of 38oC, cough, rhinorrhea, diarrhea with weight loss and discomfort in a kidney graft in the right iliac fossa. He was diagnosed with COVID-19 positive after performing a chest X-ray and SARS-CoV-2 PCR. He was admitted to our kidney transplant unit. Description of the care plan: An initial assessment was made using Gordon's functional patterns. Subsequently, we identify Nursing Diagnoses according to the NANDA taxonomy with their corresponding outcome and intervention criteria. Evaluation of the care plan: After carrying out the interventions and evaluating the outcome indicators, we observed a decrease in body temperature and respiratory distress with improvement in the respiratory pattern. Regarding renal function, it has not been significantly altered despite the temporary withdrawal of immunosuppression. Conclusion: The patient is discharged with a renal function similar to the previous one and with reintroduced immunosuppression. The objectives set were achieved, making it clear that the role of nursing has been vital in the process of recovery and coping with the disease

CASE DESCRIPTION A 2-year-old spayed female domestic shorthair cat was evaluated for recurring estrous behavior after ovariohysterectomy and 2 subsequent exploratory laparotomies. CLINICAL FINDINGS Physical examination revealed no abnormalities. A serum sample tested positive for anti-Müllerian hormone and had a progesterone concentration consistent with the presence of an ovarian remnant. Results of abdominal ultrasonographic examination suggested presence of a slightly hyperechoic mass caudal to the left kidney. TREATMENT AND OUTCOME Exploratory laparotomy was performed when the cat was showing estrous behavior. Tissues at the right and left ovarian pedicles and the uterine stump appeared grossly normal but were excised and submitted for histologic examination. Two small nodules associated with the omentum were removed, and histologic examination results for one of these nodules indicated ovarian tissue with secondary and graafian follicles. Clinical signs of estrus resolved after surgery, and hormonal assay results were within ranges expected for an ovariectomized cat. CLINICAL RELEVANCE To the authors’ knowledge, the present case represented the first clinical report of ovarian remnant syndrome in a cat or dog in which persistent ovarian tissue was not found at the site of an ovarian pedicle. Our findings emphasized the importance of exploring the entire abdominal cavity when evaluating a patient for possible ovarian remnant tissue and confirming the excision of ovarian remnant tissue by histologic assessment.

What is known and objective The blood concentration of tacrolimus can be affected by co-administrated drugs. The objective is to draw more attention to herb-drug interactions in China, where herbal medicines are commonly used. Case description The blood concentration of tacrolimus in a girl with refractory nephrotic syndrome decreased nearly a half despite no change in dose. Nebulizer therapy, cyclophosphamide and a compound Chinese herbal medicine were the only additional treatments than usual. What is new and conclusion The most possible cause of the decrease in tacrolimus concentration was the administration of Radix Astragali among compound Chinese herbal medicine granules.

CASE DESCRIPTION A 6-month-old male Miniature Dachshund was referred for examination and correction of a unilateral pes varus deformity. CLINICAL FINDINGS Clinical examination and diagnostic imaging revealed varus, procurvatum, and internal torsion of the distal aspect of the left tibia causing intermittent lameness. TREATMENT AND OUTCOME True spherical osteotomy performed with a dome-shaped saw allowed correction of the deformity in 3-D, and orthogonal internal plate fixation provided stabilization. No intraoperative or immediate postoperative complications developed. Outcome as judged by the clinician and the owners was satisfactory 2 weeks after surgery and excellent at each subsequent assessment. The patient remained free of clinical signs at the last follow-up 30 months after surgery. CLINICAL RELEVANCE To the authors’ knowledge, this case represented the first time a true spherical osteotomy was used to correct a pes varus deformity in a canine patient.

Osseointegration is a relatively new technique for prosthetic limb attachment that offers various improvements for patients with amputation and facilitates joint preservation. We present a case of implant loosening during rehabilitation in a patient with transtibial amputation that was successfully managed through a combination of measures, aiming to promote re-osseointegration of the implant.Not much is known about structured management of adverse events after osseointegration. Septic or aseptic loosening is currently regarded as implant failure, prompting removal and possible re-implantation at a later stage. The objective of this case report was to evaluate the feasibility of salvaging a loosened implant.Case report.A novel treatment approach was employed to enable renewed osseointegration of the implant. First, the bone-implant interface was disrupted and renewed through axial rotation and distal repositioning of the implant. Afterwards, extracorporal shockwave therapy and antibiotic treatment were administered. Prosthetic rehabilitation was then started anew. Regular follow-up x-rays and clinical evaluations were conducted, including standardized outcome tests.These combined measures led to a successful re-osseointegration of the implant. In a 21-month follow-up, the patient regained a stable and secure gait pattern, using his prosthesis every day for 15 hours and scoring above average on standardized outcome measures.This represents the first report of implant salvage after failed primary osseointegration. As the associated risks of this novel treatment are very low, investigations are warranted to evaluate this approach on a larger scale.

Background To add to the confusion in the debate on pathogenesis of os-odontoideum, an additional report of its occurrence in two members of the same family is reported. Case Description This is a report of a rare coincidence wherein both father (51 years old) and daughter (25 years old) were diagnosed to have os odontoideum and presented with crippling neurologic deficits. Conclusions Following atlantoaxial fixation, both recovered in their symptoms. Investigations revealed no genetic abnormality. Literature on the subject is briefly reviewed.