A Case Of Spontaneous Intercostal Artery Hemorrhage

A Case Of Spontaneous Intercostal Artery Hemorrhage Chang Lee, MD Providence Portland Medical Center – Portland, OR Additional Authors: Veronica Schims, MD; Craig Riley, MD Introduction: Spontaneous intercostal arterial bleeding is rare and usually related to trauma. We describe a patient with a history of cirrhosis and coagulopathy admitted with sepsis who spontaneously developed an expanding extrathoracic hematoma and subsequent hypovolemic shock requiring arterial embolization. Case Presentation: 50-year-old male with a past medical history of alcoholic liver disease, esophageal varices, chronic coagulopathy, type 2 diabetes and hypertension on lisinopril was admitted to hospital with decreased urine output, dizziness, poor PO intake and lower abdominal discomfort. On exam, blood pressure was 80/50 mmHg and he was encephalopathic with otherwise unremarkable physical exam. Labs showed a normal lactate, sodium 117, hemoglobin 11 g/dL, INR 1.5, elevated creatinine and severe metabolic acidosis. CT abdomen and pelvis showed nonspecific diffuse colitis but no source of infection. His decompensated cirrhosis and acute kidney injury was thought due to poor oral intake and Lisinopril use. He developed worsening renal function and acidosis. His urinary output diminished leading to volume overload. He was then transferred to the intensive care unit for placement of right-sided internal jugular temporary dialysis catheter for initiation of hemodialysis, which was without complications. On hospital day five, he developed a precipitous drop in hemoglobin from 8.7 to 6.0 g/dL and a new right back pain with swelling. A CT chest/abdomen/pelvis revealed a large hematoma along the posterior right hemithorax involving the latissimus dorsi extending from the level of the 1st to 10th rib measuring 30 cm x 5 cm. No reports of trauma and no invasive procedures occurred to explain the hematoma. The patient required multiple transfusions of red blood cells, platelets and fresh frozen plasma and the bleeding, expected to tamponade itself, continued. He underwent emergent arterial embolization with coiling of three intercostal arteries and then successful ultrasound-guided evacuation of the remaining large extrathoracic hematoma. Discussion: This is a rare case of spontaneous intercostal arterial bleeding. Literature review shows spontaneous intercostal artery hemorrhage is rare. Cases of intercostal artery hemorrhage more commonly involve trauma, and rarer still, associations with neurofibromatosis type 1 and coarctation of the aorta. There is one case report of an incident occurring after hemodialysis, which is the case in this patient. Other case reports include patients with hepatocellular carcinoma, intercostal artery aneurysm while in flight, SLE with antiphospholipid syndrome, Dengue fever, as well as causes entirely unknown. Our patient had underlying liver disease with chronic coagulopathy and mild thrombocytopenia as risk factors for spontaneous bleeding, other considerations included use of low molecular weight heparin or heparin use with hemodialysis, but no inciting factor such as trauma or surgical intervention. When active, uncontrollable bleeding is observed from intercostal arteries, early arterial embolization should be considered.https://digitalcommons.psjhealth.org/ppmc_internal/1017/thumbnail.jp

The Role of Special Operations Forces in Operations Against Theater Missiles

The U.S. military has never been able to prevent theater missiles (TMs) from being launched at U.S. and Allied or Coalition forces and citizens. Post-war analysis of interdiction efforts during World War II and the Persian Gulf War could not identify a single instance where either a German V weapon or an Iraqi SCUD missile was destroyed before launch. During the Cuban Missile Crisis, the best estimate that the Air Force could provide the National Command Authority was that ninety percent of the Soviet missiles in Cuba would be destroyed by an airstrike. To correct this deficiency, the military developed joint theater missile defense (JTMD) doctrine. This doctrine attempts to integrate synergistically all U.S. military assets and capabilities. However, this doctrine does not fully integrate Special Operations Forces (SOF) into attack operations against TMs. Additionally, the joint tactics, techniques, and procedures (JTTPs) needed to implement this doctrine have not been developed. The integration of SOF's capability to conduct pre-strike and post-strike reconnaissance, critical material recovery operations and target acquisition tasks can immediately improve JTMD capabilities.http://archive.org/details/theroleofspecial1094544388Captain, United States ArmyApproved for public release; distribution is unlimited

Ectopic synthesis of high-Mr calcitonin by the BEN lung carcinoma cell line reflects aberrant proteolytic processing

AbstractCloning and nucleotide sequence analysis of the human calcitonin mRNA from the BEN lung carcinoma cell line, a cell line known to secrete high-Mr forms of calcitonin, showed no difference in the Coding region at the nucleotide level compared with calcitonin mRNA isolated from medullary thyroid carcinoma which secretes calcitonin monomer. Therefore, the secretion of high-Mr forms of calcitonin reflects the absence or limited activity of proteolytic processing enzymes within the secretory pathway of this cell line. In all other respects, as judged by RNA blotting and S1 mapping, calcitonin/α-CGRP expression was identical to that found in medullary thyroid carcinoma, including the differential use of an alternative splice donor site within intron 1. The BEN cell line also produces low levels of α-CGRP mRNA and secretes CGRP antigenic determinants. Analysis of plasma CGRP levels in 12 patients with anaplastic lung carcinoma showed elevated levels in 11 of these, suggesting that CGRP may be an important diagnostic marker for this disease

Management of the Great Salt Lake: A Research Plan and Strategy

The primary purposes of this report are to indicate the following two research items in connection with the management of the water resource system of the Great Salt Lake:\ 1. Research needs and priorities. 2. A research coordination strategy. Research needs are identified by the report in terms of (1) various management, or use, categories (such as lake industries), and (2) the need to understand the physical characteristics of the lake system itself. The research needs are identified in each category as information (including data) or understanding gaps, in cases where there seems to be sufficient information, a research need is assumed not to exist. In the case of the Great Salt Lake system, the development of a management plan is still in the early stages, so that research needs are not prioritized in terms of a specific plan. However, the various research needs are grouped into four broad categories in terms of priority levels for pro viding planners with the needed information to proceed logically with the development of a management plan which of necessity will by dynamic in terms of changing social needs and priorities. In order for research to develop information about the lake system in accordance with management needs and priorities, a research coordination procedure is proposed. The objective of this procedure is to coordinate research between carious funding sources and research organizations and groups

Draft Genome Sequence of a Community-Associated Methicillin- Resistant Panton-Valentine Leukocidin-Positive Staphylococcus aureus Sequence Type 30 Isolate from a Pediatric Patient with a Lung Infection in Brazil

The sequence of methicillin-resistant Staphylococcus aureus strain B6 (sequence type 30 [ST30], spa type t433, staphylococcal chromosomal cassette mec element [SCCmec] type IVc, Panton-Valentine leukocidin [PVL] positive), isolated from a pediatric patient with a lung infection in Niterói, Rio de Janeiro, Brazil, is described here. The draft genome sequence includes a 2.8-Mb chromosome, accompanied by a 20-kb plasmid containing blaZ and two small cryptic plasmids

Novice Lifters Exhibit A More Kyphotic Lifting Posture Than Experienced Lifters In Straight-Leg Lifting

As torso flexion and repetitive lifting are known risk factors for low back pain and injury, it is important to investigate lifting techniques that might reduce injury during repetitive lifting. By normalizing lumbar posture to a subject’s range of motion (ROM), as a function of torso flexion, this research examined when subjects approached their range of motion limits during dynamic lifting tasks. For this study, it was hypothesized that experienced lifters would maintain a more neutral lumbar angle relative to their range of motion, while novice lifters would approach the limits of their lumbar ROM during the extension phase of a straight-leg lift. The results show a statistically significant difference in lifting patterns for these two groups supporting this hypothesis. The novice group maintained a much more kyphotic lumbar angle for both the flexion (74% of the lumbar angle ROM) and extension phases (86% of the lumbar angle ROM) of the lifting cycle, while the experienced group retained a more neutral curvature throughout the entire lifting cycle (37% of lumbar angle ROM in flexion and 48% of lumbar angle ROM in extension). By approaching the limits of their range of motion, the novice lifters could be at greater risk of injury by placing greater loads on the supporting soft tissues of the spine. Future research should examine whether training subjects to assume more neutral postures during lifting could indeed lower injury risks

A Preliminary Model of the Hydrologic-Sociologic Flow System of an Urban Area

This report describes the first phase of a larger study which is directed toward the development of a general technique for analyzing and solving urban metropolitan hydrologic problems through a joint consideration of both the physical and social dimensions. This report is limited to the preliminary work of identification of social variables, the first steps in assigning mathematical values to them, and developing a mathematical format for these variables. In addition, the physical-hydrologic system is identified for purposes of clarifying the elements in that system. The ultimate objective of the entire study is directed toward discovering a theoretical and generally applicable mathematical model of both the physical and social dimensions involved in metropolitan flooding problems

Complete Genome Sequences of Four Escherichia coli ST95 Isolates from Bloodstream Infections

Finished genome sequences are presented for four Escherichia coli strains isolated from bloodstream infections at San Francisco General Hospital. These strains provide reference sequences for four major fimH-identified sublineages within the multilocus sequence type (MLST) ST95 group, and provide insights into pathogenicity and differential antimicrobial susceptibility within this group