small and middle-sized neoplastic B cells with a follicular pattern. They rarely express Bcl-2 and are not associated with the t(14;18) translocation, in contrast to nodal follicular lymphomas.Risk factors for the development of B-cell lymphomas are poorly understood. Briefly, there are reports of B-cell lymphoproliferative diseases with the presence of EBV, mainly in patients treated with immunosuppressive drugs such as methotrexate, and in patients with human immunodeficiency virus. 1 However, in these cases, the pathology was different as these were not follicular proliferations, but rather diffuse infiltration of large B cells. Rarely, B. burgdorferi has been associated with the development of FCCL. 2 We report a unique case of low-grade B-cell lymphoma that developed at the precise site of brachytherapy plus externalbeam radiotherapy for breast cancer. Oncogenic transformations due to the carcinogenetic effects of ionizing radiation are known complications of irradiated skin, but usually lead to carcinoma and sarcoma. 5 Although a fortuitous association cannot be ruled out, the development of a rare condition-namely FCCL-on the precise site of an event known to be able to promote oncogenesis of other cell types suggests that radiation may be a risk factor for cutaneous lymphoma. Interestingly, a small number of single case reports of primary lymphoma involving the brain or the heart after radiation therapy have been described. 6,7 The role of genetic alterations in Pten and p53 pathways in radiation-induced lymphoma development is suggested by some authors. 8 In conclusion, a prolonged clinical surveillance of irradiated skin especially in patients with breast cancer is mandatory in order to establish an early diagnosis of carcinoma and sarcoma but perhaps also primary cutaneous lymphoma. References 1 Wilkins K, Turner R, Dolev JC et al. Cutaneous malignancy and human immunodeficiency virus disease. J Am Acad Dermatol 2006; 54:189-206. 2 Bogle MA, Riddle CC, Triana EM et al. Primary cutaneous B-cell lymphoma. J Am Acad Dermatol 2005; 53:479-84. 3 Willemze R, Jaffe ES, Burg G et al. WHO-EORTC classification for cutaneous lymphomas. Blood 2005; 105:3768-85. 4 Bergman R, Kurtin PJ, Gibson LE et al. Clinicopathologic, immunophenotypic, and molecular characterization of primary cutaneous follicular B-cell lymphoma. Arch Dermatol 2001; 137:432-9. 5 Brenn T, Fletcher CDM. Radiation-associated cutaneous atypical vascular lesions and angiosarcoma. Clinicopathologic analysis of 42 cases. Am J Surg Pathol 2005; 29:983-96. 6 Stein M, Haim N, Kuten A et al. Primary brain lymphoma after X-ray irradiation to the scalp for tinea capitis in childhood. J Surg Oncol 1992; 50:270-3. 7 Yukiiri K, Mizushige K, Ueda T, Kohno M. Second primary cardiac B-cell lymphoma after radiation therapy and chemotherapy. Angiology 2001; 52:563-5. 8 Mao JH, Wu D, Perez-Losada J et al. Genetic interactions between Pten and p53 in radiation-induced lymphoma development. Oncogene 2003; 22:8379-85.SIR, We read with interest the paper by Zaballos e...

The Abernethy malformation consists of a congenital extrahepatic portosystemic shunt and is believed to be extremely rare in humans. The potential implications of abnormal portovenous shunting and decreased hepatic portal flow are numerous and potentially serious. Although congenital extrahepatic portosystemic shunts are increasingly suspected and diagnosed in specialized centres, much of their clinical presentation and natural history is not fully understood. Symptoms of portosystemic shunt are mainly caused by increased levels of ammonia, which lead to signs of encephalopathy. Therapeutic options depend on the type of shunt and its clinical course, so the classification of the congenital portosystemic shunt is a key finding in these patients.

ObjectivesIdentifying the prevalence of palliative care (PC) needs among patients who die at the emergency department (ED) and to assess symptom control and aggressiveness of care.MethodsWe conducted a decedent cohort study of adults deceased at the ED of a Portuguese teaching hospital in 2016. PC needs were identified using the National Hospice Organization terminality criteria and comorbidities measurement by the Charlson’s Index.Results384 adults died at the ED (median age 82 (IQR 72–89) years) and 78.4% (95% CI 73.9% to 82.2%) presented PC needs. Only 3.0% (n=9) were referred to the hospital PC team. 64.5%, 38.9% and 57.5% experienced dyspnoea, pain and confusion, respectively. Dyspnoea was commonly medicated (92%), against 56% for pain and 8% for confusion. Only 6.3% of the patients were spared from aggressive interventions, namely blood collection (86.0%) or intravenous fluid therapy (63.5%). The burden of aggressive interventions was similar between those with or without withhold cardiopulmonary resuscitation order (median 3 (2–4) vs 3 (2–5)), p=0.082.ConclusionsNearly four out of five adults who died at the ED had PC needs at the time of admission. Most experienced poor symptom control and care aggressiveness in their last hours of life and were mostly unknown to the PC team. The findings urge improvements in the care provided to patients with PC needs at the ED, focusing on patient well-being and increased PC referral.

The main aim is to evaluate the cyclic fatigue resistance of blue heat-treated instruments with different kinematics. Twenty-four endodontic instruments of the same brand were used for each of three experimental groups: VB (Vortex Blue 40/0.04), RB (RECIPROC Blue 40/0.06), and XB (X1 Blue 40/0.06). The instruments were randomly distributed and subjected to temperatures of 20°C and 37°C. The fatigue test was performed using a stainless steel device. Data were analysed using the Shapiro–Wilk test, Student’s t-test, the F test, and Tukey’s and Tamhane tests at significance level P = 0.05 . The instruments’ cyclic fatigue resistance at both temperatures differed significantly for each instrument type ( P < 0.001 ). The RB instruments displayed greater cyclic fatigue resistance at the tested temperatures compared with the VB and XB instruments ( P < 0.001 ). Reciprocating kinematics positively influenced cyclic fatigue resistance. Blue heat-treated instruments showed decreased cyclic fatigue resistance as the temperature increased ( P < 0.001 ).

Aim:This study aims to investigate the influence of temperatures of 20 °C and 37 °C on the resistance to cyclic fatigue of NiTi instruments with different heat treatments, as tested in severely curved simulated canals. Materials and methods: Seventy-two instruments were distributed according to the temperature used (20 °C and 37 °C): XP-endo Shaper (30/0.01), ProDesign Logic (30/0.05), and iRaCe (30/0.04). The instruments were rotated freely until the occurrence of fracture inside an artificial severely curved stainless steel canal, which had a 90° angle of curvature and a curvature radius of 5 mm. Kolmogorov-Smirnov, Wilcoxon, ANOVA, and Kruskal-Wallis tests were performed. A p value of <0.05 was considered statistically significant. Results: XP-endo Shaper instruments presented higher NCF values and time to failure compared with ProDesign Logic and iRaCe instruments at 20 °C and 37 °C (p < 0.001). Conclusion:Within the limitations of this study, the results show that the body temperature (37 °C) significantly lowers the resistance to cyclic fatigue of all instruments compared with 20 °C. Clinical significance: Body temperature is an important factor in the results of cyclic fatigue tests.