Obvious Source Research Articles

Searching for Information on the Risks of Combined Hormonal Contraceptives on the Internet: A Qualitative Study Across Six European Countries.

BackgroundSearching for health information online is increasingly common and is an obvious source of information about oral combined hormonal contraceptives (CHCs) and their risks. However, little is known about how publicly available websites address the risks of CHCs, particularly venous thromboembolism (VTE).ObjectiveThe aim was to explore the information available to women about VTE and other risks of CHCs on websites available through commonly used search engines.MethodsA qualitative study was conducted to explore whether and how websites about CHCs in Denmark, Germany, Netherlands, Slovakia, Spain, and the United Kingdom make reference to VTE and other CHC risks. A systematic search procedure was adopted across the six countries, based on relevant keywords. The search was carried out using the Google search engine by fluent/native speakers of each language. A content analysis approach was conducted to extract information from the selected websites.ResultsA total of 357 websites were reviewed. Nearly all (343/357, 96.1%) the websites mentioned VTE as a risk of CHCs, with approximately half referring to other side effects as well. One-fifth (92/357, 25.8%) of the websites provided suggestions about the best contraceptive method to use, and only a minority (23/357, 6.4%) recommended women discuss CHCs with their health professionals. Sites were generally run by the media (110/357 30.8%) or medical services from nongovernmental organizations (140/357, 39.2%). Only a minority of websites referred to organizations such as the European Medicines Agency (11/357, 3.1%).ConclusionsDespite the large number of websites containing information about oral CHCs and their risks, particularly VTE, only a limited number referred to information from accredited health agency sources. We argue this is a missed opportunity for accredited health agencies to share high-quality information to assist women using CHCs to make informed decisions about contraception.

The carbonaceous aerosol levels still remain a challenge in the Beijing-Tianjin-Hebei region of China: Insights from continuous high temporal resolution measurements in multiple cities

Carbonaceous aerosols in high emission areas attract worldwide attention of the scientific community and the public due to their adverse impacts on the environment, human health and climate. However, long-term continuous hourly measurements are scarce on the regional scale. In this study, a one-year hourly measurement (from December 1, 2016 to November 30, 2017) of organic carbon (OC) and elemental carbon (EC) in airborne fine particles was performed using semi-continuous OC/EC analyzers in Beijing, Tianjin, Shijiazhuang and Tangshan in the Beijing-Tianjin-Hebei (BTH) region in China, which is one of high emission areas in China, even in the world. Marked spatiotemporal variations were observed. The highest concentrations of OC (22.8 ± 30.6 μg/m3) and EC (5.4 ± 6.5 μg/m3) occurred in Shijiangzhuang while the lowest concentrations of OC (11.0 ± 10.7 μg/m3) and EC (3.1 ± 3.6 μg/m3) were obtained in Beijing and Tianjin, respectively. Pronounced monthly, seasonal and diurnal variations of OC and EC were recorded. Compared to published data from the past two decades for the BTH region, our OC and EC levels were lower, implying some effect of recent measures for improving the air quality. Significant correlations of OC versus EC (p < 0.001) were found throughout the study period with high slopes and correlation coefficients in winter, but low slopes and correlation coefficients in summer. The estimated secondary OC (SOC), based on the minimum R squared (MRS) method, represented 29%, 47%, 38% and 48% of the OC for Beijing, Tianjin, Shijiazhuang and Tangshan, respectively. These percentages are larger than previous ones obtained for the BTH region in the past decade. There were obvious differences in the potential source regions of OC and EC among the four cities. Obvious prominent potential source areas of OC and EC were observed for Beijing, which were mainly located in the central and western areas of Inner Mongolia and even extended to the Mongolian regions, which is different from the findings in previous studies. For all sites, adjacent areas of the main provinces in northern China were found to be important potential source areas.

Distribution and Risk Assessment of Heavy Metals in Sediment from Bohai Bay, China

Sediment core and porewater samples from the Western coastal tidal flat in Bohai Bay, China, were collected for meals and physical-chemical properties analysis. The vertical distribution characteristics of eight metals along the core was investigated based on 137Cs and 210Pb radionuclide dating. The chemical fractions of six metals (Cu, Pb, Zn, Ni, Mn and Cd) were also measured based on the modified European Community Bureau of Reference (BCR) sequential extraction procedures to better understand the mobility and bioavailability of these metals in the sediment. In addition, geoaccumulation index (Igeo) and risk assessment code (RAC) are used to assess risk status of these metals in the environment. 210Pb measurement indicates a sedimentation rate of about −1.87 cm∙year−1. The metals Cu, Zn, Pb and Ni show similar vertical distributions throughout the core, while Mn and Cd show different distribution patterns. Ni, Cu, Pb and Zn are strongly associated with the residual fraction while Mn and Cd are dominant in the acid-soluble fraction. According to the estimated diffusive fluxes, the Zn ions were the most mobilized, followed by Cu, Ni, Pb, and to a lesser extent Cd. The result of Igeo shows that Ni in sediments does not reflect any pollution, and Cu, Pb and Zn are in a level from unpolluted to modest polluted throughout the core. Mn and Cd have obvious anthropogenic sources. Based on the RAC, Cd and Mn pose a high to very high risk to the local environment, respectively, due to the significant percentage of exchangeable fraction. Clay content is significantly positively correlated with Ni, Cu, Al and Fe, and Cu, Pb, Zn and Ni might originate from the same sources or be influenced by similar geochemical processes. River runoff and atmospheric deposition are important sources for heavy metals, and since 1998, domestic sewage discharge might have had an important influence on the source of heavy metals (except for Cd and Mn).

Samarium Polyarsenides Derived from Nanoscale Arsenic.

Zintl phases of arsenic and molecular compounds containing Zintl-type polyarsenide ions are of fundamental interest in basic and applied sciences. Unfortunately, the most obvious and reactive arsenic source for the preparation of defined molecular polyarsenide compounds, yellow arsenic As4 , is very inconvenient to prepare and neither storable in pure form nor easy to handle. Herein, we present the synthesis and reactivity of elemental As0 nanoparticles (As0 Nano , d=7.2±1.8 nm), which were successfully utilized as a reactive arsenic source in reductive f-element chemistry. Starting from [Cp*2 Sm] (Cp*=η5 -C5 Me5 ), the samarium polyarsenide complexes [(Cp*2 Sm)2 (μ-η2 :η2 -As2 )] and [(Cp*2 Sm)4 As8 ] were obtained from As0 nano , thereby generating the largest molecular polyarsenide of the f-elements and circumventing the use of As4 in preparative chemistry.

Locating Hidden Elements in Walls of Cultural Heritage Buildings by Using Infrared Thermography

The structure of Tvrđa and its buildings date back to the Middle Ages. Tvrđa represents the Old Town of the city of Osijek and the best-preserved and largest ensemble of Baroque buildings in Croatia. After the withdrawal of the Ottomans in 1687, during the 18th century, the Austro-Hungarian administration systematically formed a new fortification system, regulated streets and squares and built a large number of military objects. Tvrđa took its present form in the 19th century and has kept it since then. Investigating the historical development of individual buildings, in addition to archival sources and existing architectural documentation, the obvious source of information are the buildings themselves. The aim of this paper is to explore the possibilities of using infrared thermography to find structural elements and hidden openings in historic buildings in Osijek’s Tvrđa. This paper describes the exploration of the 18th century openings on the facades of the former Kostić houses. The facades were bricked into the walls in the 19th century because houses were reused and their purposes changed from commercial to residential. Infrared thermography is often a starting, nondestructive testing method (NDT) for building analyses. This paper presents thermographic analyses of two buildings. The analyses were carried out in December 2017 and January 2018. Using a steady-state thermographic analysis of a building envelope as the first step, the audit was continued with step heating (SH) of an interest point where changes in a thermal pattern were expected due to additional bricking. Heat flux was generated by the usage of a heat gun for paint removal.

Sources of thymidine and analogs fueling futile damage-repair cycles and ss-gap accumulation during thymine starvation in Escherichia coli

Thymine deprivation in thyA mutant E. coli causes thymineless death (TLD) and is the mode of action of popular antibacterial and anticancer drugs, yet the mechanisms of TLD are still unclear. TLD comprises three defined phases: resistance, rapid exponential death (RED) and survival, with the nature of the resistance phase and of the transition to the RED phase holding key to TLD pathology. We propose that a limited source of endogenous thymine maintains replication forks through the resistance phase. When this source ends, forks undergo futile break-repair cycle during the RED phase, eventually rendering the chromosome non-functional. Two obvious sources of the endogenous thymine are degradation of broken chromosomal DNA and recruitment of thymine from stable RNA. However, mutants that cannot degrade broken chromosomal DNA or lack ribo-thymine, instead of shortening the resistance phase, deepen the RED phase, meaning that only a small fraction of T-starved cells tap into these sources. Interestingly, the substantial chromosomal DNA accumulation during the resistance phase is negated during the RED phase, suggesting futile cycle of incorporation and excision of wrong nucleotides. We tested incorporation of dU or rU, finding some evidence for both, but DNA-dU incorporation accelerates TLD only when intracellular [dUTP] is increased by the dut mutation. In the dut ung mutant, with increased DNA-dU incorporation and no DNA-dU excision, replication is in fact rescued even without dT, but TLD still occurs, suggesting different mechanisms. Finally, we found that continuous DNA synthesis during thymine starvation makes chromosomal DNA increasingly single-stranded, and even the dut ung defect does not completely block this ss-gap accumulation. We propose that instability of single-strand gaps underlies the pathology of thymine starvation.

Oral fluid testing facilitates understanding of hepatitis A virus household transmission.

The public health response to sporadic hepatitis A virus (HAV) infection, hepatitis A, can be complex especially when the index case is a child and no obvious source is identified. Identifying an infection source may avoid mass immunisation within schools when transmission is found to have occurred within the household. Screening of asymptomatic contacts via venepuncture can be challenging and unacceptable, as a result non-invasive methods may facilitate public health intervention. Enzyme-linked immunoassays were developed to detect HAV immunoglobulin M (IgM) and immunoglobulin G (IgG) in oral fluid (ORF). A validation panel of ORF samples from 30 confirmed acute HAV infections were all reactive for HAV IgM and IgG when tested. A panel of 40 ORF samples from persons known to have been uninfected were all unreactive. Two hundred and eighty household contacts of 72 index cases were screened by ORF to identify HAV transmission within the family and factors associated with household transmission. Almost half of households (35/72) revealed evidence of recent infection, which was significantly associated with the presence of children ⩽11 years of age (odds ratio 9.84, 95% confidence interval: 2.74-35.37). These HAV IgM and IgG immunoassays are easy to perform, rapid and sensitive and have been integrated into national guidance on the management of hepatitis A cases.

Women, Rhetoric, and Drama in Early Modern Italy by Alexandra Coller

Reviewed by: Women, Rhetoric, and Drama in Early Modern Italy by Alexandra Coller Caterina Mongiat Farina WOMEN, RHETORIC, AND DRAMA IN EARLY MODERN ITALY, by Alexandra Coller. New York: Routledge, 2017. 282 pp. $155.00 cloth; $54.95 ebook. Imagine a place where women own property and support themselves independently, speak and move freely, and can be with a person of their choice. Margherita Costa did just that with the fictional realm of Fessa in her comedy Li buffoni (1641; The Buffoons, 2018). This is only one of the masterpieces discussed in Alexandra Coller’s revisionist canon of Italian drama delineated with philological rigor and critical ingenuity in Women, Rhetoric, and Drama in Early Modern Italy. As Coller explains in the introduction, her book challenges the notion of tragicomedy as the only original genre of sixteenth- and early seventeenth-century Italian drama to argue that early modern comedy, tragedy, and pastoral tragicomedy share a claim to originality for the following reasons: their quantitative and qualitative shift in depicting female characters, their common predilection for Giovanni Boccaccio’s Decameron (c. 1351) in addition to the more obvious classical sources, and their rhetorical choices in signaling cultural and literary shifts in gender representations, which opened new creative possibilities for both male and female playwrights (pp. 1–2). The book is divided in two parts. In the first part (chapters 1–2), Coller focuses on women characters in comedies and tragedies written by men and, in the second part (chapters 3–5), on pastorals written by women. Yet the chapters in part one are felicitously complicated by codas discussing the first extant comedy authored by a woman and the first extant tragedy authored by a woman, respectively. In the first chapter, Coller identifies Ruzante’s L’Anconitana (The Woman from Ancona, 1994), for which she follows Linda Carroll’s dating of 1517–1518, as an early example in fiction of women crossdressing as men for reasons other than love. Coller unveils the ways in which the protagonist Isotta (crossdressed as Gismondo) uses her virtù (skill) in “feminine” arts like fashion together with her rhetorical prowess in speech to fend for herself and teach other women how to achieve grace: “Ruzante is putting forward a female figure who can instruct and dispute” (p. 30). In Coller’s reconstructed canon, which includes among other comedies Alessandro Piccolomini’s Alessandro (1544), Niccolò Secchi’s Gl’inganni (1547; Deceits), Luca Contile’s Cesarea Gonzaga (1550), and Giambattista Della Porta’s Cintia (1601), Ruzante’s women characters establish the originality and preeminence of his comedy. Costa’s Li buffoni joins this canon by exploring the traditionally male genre of comedy. Coller’s fascinating hypothesis is that Costa’s protagonist Marmotta, a noblewoman that leads the utopian realm of Fessa, might have been inspired by Grand Duchess Vittoria della Rovere [End Page 446] and her female-centered court of Poggio Imperiale, where fiction and history converge regarding the emancipation of women. Differing conceptions of virtù, understood in chapter two as the more traditional “moral virtue” rather than “skill,” and friendship emerge from the juxtaposition of Giambattista Giraldi Cinzio’s and Ludovico Dolce’s tragedies with Valeria Miani’s Celinda (1611) (p. 77). Collectively, the heroines Selene and Eufimia (Cinzio), Marianna and Medea (Dolce), Celinda (Miani), and their female friends argue through eloquent words and deeds that friendship (including friendship between husband and wife) rests on equality and loyalty and that men often fail at one or both of these principles. Coller, here as throughout the book, excels at integrating the complex and necessary synopses of the plays into her rhetorical and critical analysis. The extended coda on Miani’s Celinda gives Coller the opportunity to explore in detail Boccaccio’s influence on certain episodes of the protagonist’s love affair. Part two begins with an eye-opening comparison of satyr scenes in the male canon (Tasso and Battista Guarini are here joined by Agostino Beccari, Luigi Groto, Giovan Maria Avanzi, and Cesare Cremonini among others) with a diverse collection of women-authored pastorals including Isabella Andreini’s Mirtilla (1588), Maddalena Campiglia’s Flori (1588), Barbara Torelli Benedetti’s Partenia (1586), Leonora Bernardi’s Tragicomedia pastorale (Pastoral tragicomedy) written in...

Epidemiological Associations of Various Substances and Multiple Cannabinoids with Autism in USA

Introduction: Autistic Spectrum Disorder (ASD) is increasing in across USA. Paediatricians and physicians in both Colorado and Australia continue to see high caseloads however this prevalence uptick remains largely unexplained. Since drug use is an obvious potential source of developmental brain damage the present study was undertaken to study drug-ASD associations at state level. Methods: Existing datasets from the US Department of Education Individuals with Disabilities Act, the Substance Abuse and Mental Health Services Administration National Survey of Drug Use and Health, and the Drug Enforcement Agency cannabinoid concentration in seizures were re-analyzed. Results: ASD rates are high and rising fastest in Colorado, Maine, Massachusetts, Oregon, Rhode Island and New Jersey but falling in Oklahoma and Iowa. When the nine highest cannabis use states are grouped together ASD is rising significantly faster there than elsewhere (time:status interaction in quadratic mixed effects model p<0.0001). On univariate regression ASD rate was significantly positively associated with alcohol and cannabis exposure and with the cannabinoids Δ9-tetrahydrocannabinol, cannabinol, cannabichromene, cannabigerol and tetrahydrocannabivarin. These effects remained after multivariate adjustment for Δ9-tetrahydrocannabinol and cannabidiol (from p<0.0001). Cannabidiol correlated with ASD rate when a three year lag was introduced (R=0.7483, p=0.0032). Conclusion: These data show that increased cannabinoid exposure explains on bivariate and multivariate regression much of the recent rise in ASD across USA, and in the context of other reports, also at some local cluster levels. Together with numerous mechanistic reports these data argue for causality and indicate a large case-control study. ASD-like neurobehavioural toxicological syndromes likely represent the commonest form of cannabis-related teratology following peri-gestational exposure.

The Conceptual Design of a Novel Workstation for Seizure Prediction Using Machine Learning With Potential eHealth Applications.

Recent attempts to predict refractory epileptic seizures using machine learning algorithms to process electroencephalograms (EEGs) have shown great promise. However, research in this area requires a specialized workstation. Commercial solutions are unsustainably expensive, can be unavailable in most countries, and are not designed specifically for seizure prediction research. On the other hand, building the optimal workstation is a complex task, and system instability can arise from the least obvious sources imaginable. Therefore, the absence of a template for a dedicated seizure prediction workstation in today’s literature is a formidable obstacle to seizure prediction research. To increase the number of researchers working on this problem, a template for a dedicated seizure prediction workstation needs to become available. This paper proposes a novel dedicated system capable of machine learning-based seizure prediction and training for under U.S. $1000, which is significantly less expensive (U.S. $700 or more) than comparable commercial solutions. This powerful workstation will be capable of training sophisticated machine learning algorithms that can be deployed to lightweight wearable devices, which enables the creation of wearable EEG-based seizure early warning systems.

“Hidden fluid” in the critically ill patient: A wake-up call

Background and Aim: Fluid overload and unfavorable outcomes in critically ill patients have been demonstrated in many clinical settings, such as acute lung injury/acute respiratory distress syndrome, septic patients, and those with acute kidney injury. Fluid overload has been reported in up to 70% of patients admitted to the intensive care unit (ICU). Fluid optimization strategies are often used to prevent fluid overload. Less obvious sources of fluid intake are often overlooked. The aim of this study was to determine the contribution of intravenous medications to daily fluid intake and balance in our ICU. Methodology: We conducted a retrospective study on adult patients admitted to the ICU of the University College Hospital, Ibadan, from January to December 2015. Daily ICU record charts were reviewed to determine the sources and volumes of various fluids for the study patients. Fluid other than intravenous fluid, enteral feeds, and blood/blood products were categorized as hidden fluid. These were mainly intravenous medications. Data were analyzed using the Statistical Package for the Scientific Solutions Version 20. Results: A total of 286 patients were admitted during the study year. There were 26 nonadults (≤16 years) excluded, and the records of 74 patients were not available. The mean daily volume of drug solutions (473.4 ml) was about 16% of the mean daily intake (2846.1 ml). The percentage of hidden fluid was highest in the neurology group (26.7%). No group had

Mallory-Weiss Syndrome complicating pregnancy – A rare near miss

Mallory-Weiss syndrome (MWS) rarely occurs during pregnancy and can lead to massive bleed if occurring in the third trimester. Unrecognized MWS may lead to life threatening hemorrhage and shock affecting maternal and fetal well-being. We describe a rare case of MWS in a pregnant patient at 36 weeks of gestation with underlying pre-eclampsia, acute kidney injury, and hemodynamic instability. The possibility of mucosal tears should be kept in mind in the absence of an obvious source of bleeding.

Bonded, Grounded, and Burned to a Crisp: Electrostatic Ignition of Flammable Gases

Ignition by electrostatic discharge of clean flammable gas, such as natural gas, being released to the atmosphere during blowdown operations is unlikely. However, the presence of foreign material in the form of solid particles or liquid droplets changes the risk level significantly. The discharge of a flammable gas stream with a cloud of foreign material poses a potential electrostatic hazard, even if the piping system and associated equipment is otherwise bonded and grounded. The foreign material may be capable of accumulating sufficient electrostatic potential to ignite the flammable gas. There have been several documented incidents where ignition has occurred during a flammable gas blowdown. In some instances, gas lines were being cleaned, while in others, the blowdown was completed as a safety measure for another process. This article will focus on a case study where a stream of flammable gas was ignited during a blowdown and an obvious ignition source (other than electrostatic discharge) was not present, but foreign material was observed. © 2018 American Institute of Chemical Engineers Process Saf Prog 38: e12024, 2019

The adherence to guidelines for preventing CVC-related infections: a survey among Italian health-care workers

BackgroundSince correct maintenance of intravascular catheters is an effective strategy for preventing central-line infections, the aim of this study was to assess the level of adherence to guidelines for CVC maintenance amongst Italian HCWs.MethodsFrom July 2016 thru January 2017, a cross sectional survey was carried out in a random sample of 549 HCWs working in different hospitals of Campania region (Italy).ResultsThe 68.9% of interviewees returned the questionnaire. Overall, respondents’ level of knowledge about CDC guidelines was low, with only the 20.7% of HCWs acknowledging guidelines main recommendations: the nurse stuff, the availability of hospital internal protocols, the use of guidelines themselves as source of information, and higher number of years of practice were significantly associated with a higher level of knowledge. An extremely positive attitude towards the utility of guidelines for preventing CVC-related infections was shown, with a linear regression model indicating a stronger attitude in physicians, in who knew the CDC main recommendations and correct use of antibiotic ointments, as well as in HCWs needing additional information on the prevention of CVC-related infections. Regarding the behaviors, physicians were more likely to be adherent about recommended evidence-based practices. Two more multivariate logistic and ordinal logistic regression models were built to investigate characteristics associated with correct behavior regarding the removal of catheter dressing if patients have tenderness at insertion site or fever without an obvious source, respectively.ConclusionsThis study reflected an important lack of evidence-based knowledge and practices regarding the CVC management, highlighting the baseline role of education and training programs, as well as pointing out the role of organizational interventions to address the adherence to best practices for the reduction of CLABSIs.

On the phonemic status of nasalized /h̃/ in Modern Zuberoan Basque

AbstractModern eastern Basque dialects have several conservative features, including the maintenance of historical /h/, which is lost in other dialects. Zuberoan, the easternmost dialect of Basque still spoken today, shows both this /h/ as well as a phonetically nasalized segment [h̃] which is a reflex of intervocalic *n. In this paper I argue that these two segments contrast in Zuberoan. Evidence for the contrast comes from both a newly described process of assimilation of /h/ to /h̃/ in nasal environments which then serves as a basis of the analogical extension of the nasalized aspirate in a context where it cannot be phonologically derived, and from neighboring Mixean Low Navarrese where the nasalized [h̃] has no other obvious source. Since a contrast between oral and nasalized aspirates is rare crosslinguistically, the Zuberoan and Mixean sound patterns discussed here should be of interest to typologists and phonologists alike.

Hemorrhagic Pancreatic Pseudocyst

Bleeding from pancreatic pseudocyst is an extremely rare complication, however it is a common finding in patients with history of pancreatitis and alcohol abuse. Pseudoaneurysm complicating pseudocyst is a rare occurrence and is reported in 10% of patients with chronic pancreatitis. 1 We report a 34 year old man with a hemorrhagic pseudocyst due to splenic artery pseudoaneurysm. 34 year old man with ongoing ETOH abuse and history of acute pancreatitis presents with 4-5 days of dark stools and 2 months of left sided abdominal pain. On physical exam, patient appeared comfortable and was hemodynamically stable, but had mild epigastric tenderness. EGD showed submucosal bulging (Image 1 and 2) in fundus/ body that prompted cross sectional imaging. The CT A/P with contrast (Image 3) showed a large mass highly concerning for a hemorrhagic pseudocyst w/ a 1.0 cm hyperdense focus within the supero-lateral portion of the hemorrhagic collection concerning for active extravasation from a suspected pseudo-aneurysm of the splenic artery. Patient was immediately taken for an angiography with IR and no extravasation was noted that afternoon; however, a repeat angiography the next day showed active extravasation of the distal branch of the splenic artery. A coil embolization was performed immediately. Patient was transferred to MICU for further monitoring and remained hemodynamically stable until discharge. While any splanchnic vessel can be source of bleeding, the splenic artery is most commonly involved in pseudo-aneurysm formation. Bleeding should be suspected in patients with a pseudocyst if a) no obvious bleeding source can be found on endoscopy b) sudden drop in hematocrit c) increase in pseudocyst size d) bruit heard on auscultation over pseudocyst. Angiography is the gold standard for examination. Current practice entails contrast enhanced CT, which guides the need for angiography and further embolization or surgery.2 As demonstrated in our case, a high index of suspicion is important in the management of pancreatic pseudocysts as our patient (with history of alcoholism) was hemodynamically stable and having only mild abdominal pain. 1. Bretagne JF, et al. Pseudo aneurysms and bleeding pseudocysts in chronic pancreatitis: radiological findings and contributions to diagnosis in 8 cases. Gastrointest Radiol. 1990. 2. Hsin-Hui Chiu, et al. Pancreatic pseudocyst bleeding associated with massive intraperitoneal hemorrhage. The American Journal of Surgery. 2006.1376_A.tif Figure 1: No Caption available.1376_B.tif Figure 2: No Caption available.1376_C.tif Figure 3: No Caption available.

Midgut Volvulus as Presentation of Intestinal Malrotation in an Elderly Patient

Congenital intestinal malrotation is an incomplete rotation and fixation of the midgut during embryogenesis. Most commonly diagnosed during infancy, it is rarely reported in adults with an estimated incidence of 0.0001 and 0.2%. A 77 year old man presented to the ED with symptoms of gastrointestinal(GI) bleeding, including, anemia and melena. At prior hospitlizations the patient had several upper and lower endoscopies showing multiple AVMs in the stomach and duodenum. Patient was admitted and subsequently underwent a push enteroscopy that did not reveal any obvious source of bleeding. Six hours post-procedure, he developed diffuse severe abdominal pain with abdominal distention and tenderness over the RUQ. CT abdomen demonstrated a “mesenteric swirl” concerning for mid-gut volvulus. He underwent emergent exploration and was found to have a complete malrotation of the small and large bowel with classic Ladd's bands adhesions and the appendix in the LLQ. Mid-gut volvulus was reduced, the congenital adhesions divided and the appendix removed. The early post-op period was complicated by high-grade small bowel obstruction warranting re-operation on POD#7. Abdominal re-exploration revealed multiple adhesions of the small bowel, which were lysed as well as a severe kink at the 4th portion of the duodenum which was to the right of the SMA. Patient had a complicated, prolonged hospital course requiring TPN and was discharged on POD# 37. Unlike infant population, adult patients with intestinal malrotation present with more vague and chronic symptoms like recurrent abdominal pain associated with nausea, vomiting, frequent diarrhea, bloating, early satiety and upper or lower gastrointestinal bleeding. Acute volvulus can be the initial presentation in 10-15% of adults. CT abdomen with oral and IV contrast is the imaging of choice for diagnosis. The classic “whirl” sign, consisting of mesentery and superior mesenteric vein around the superior mesenteric artery, is highly suggestive of midgut volvulus. Surgical management typically involves counterclockwise detorsion of bowel, lysis of Ladd's bands and appendectomy to prevent morbidity of future diagnostic delay. Non-operative management of asymptomatic patients is reasonable. We present this case to increase awareness of malrotation as a possible cause of chronic abdominal pain and acute volvulus in the adult population.1468_A Figure 1. CT abdomen showing Intestinal malrotation with suspected midgut volvulus1468_B Figure 2. CT abdomen: showing whirlpool sign at coronal view1468_C Figure 3. Findings at exploratory laparotomy

Thermal-conductivity measurement by time-domain thermoreflectance

Abstract

Evaluation of Prolonged and Recurrent Unexplained Fevers.

Fever is a common symptom in children. Some children may present to their primary care physician with undifferentiated fever; that is, fever for which there is no obvious source from the history or physical examination. Undifferentiated fevers may be prolonged or recurrent. Distinguishing between the two is helpful for narrowing the differential diagnosis, which can be broad and include infections and inflammatory diseases and, rarely, malignancies and autoinflammatory disorders. The evaluation of such children requires a step-wise approach. Taking a detailed history, performing a thorough physical examination, and reviewing a fever and symptom diary is crucial in recognizing clues that may ultimately lead to a diagnosis. Some children who look good and whose fever disappears may never have a diagnosis, whereas referral to a specialist may be prudent for others. [Pediatr Ann. 2018;47(9):e347-e353.].

Sources of Antibiotic Resistance Genes in a Rural River System.

The increasing prevalence of antibiotic resistance genes (ARGs) in the environment is problematic due to the risk of horizontal gene transfer and development of antibiotic resistant pathogenic bacteria. Using a suite of monitoring tools, this study aimed to investigate the sources of ARGs in a rural river system in Nova Scotia, Canada. The monitoring program specifically focused on the relative contribution of ARGs from a single tertiary-level wastewater treatment plant (WWTP) in comparison to contributions from the upgradient rural, sparsely developed, watershed. The overall gene concentration significantly ( < 0.05) increased downstream from the WWTP, suggesting that tertiary-level treatment still contributes ARGs to the environment. As a general trend, ARG concentrations upstream were found to decrease as proximity to human-impacted areas decreased; however, many ARGs remained above detection limits in headwater river samples, which suggested their ubiquitous presence in this watershed in the absence of obvious pollution sources. Significant correlations with ARGs were found for human fecal marker, and some antibiotics, suggesting that these markers may be useful for prediction and understanding of ARG levels and sources in rural rivers.