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Achill Head Hotel, Castlebar
1 Reviews
1 Reviews
'The Achill Head Hotel' is one venue for clubbing. Previously owned by my parents, It's new owners are continuing the fun with dancing every weekend. In peak-seasons, you'll find it open 5 (if not more) nights a week. Doors to the club open at midnight (if I'm not mistaken) but you can 'socialize' in their bar area earlier than that. During holidays times, there is usually live entertainment in the bar, where one can stay if you are not in the dancing mood. Closes between 2am and 2:30am.
Another place to go dancing, is a new bar/club at 'Alice's Harbour Inn.' Unfortunately, I have not had the opportunity to try the place out myself, but in speaking with friends still over there, It's a hopping place!
The music is good and the atmosphere is great! Though it can get pretty crowded during the 'holiday seasons,' this only serves to increase the fun. It's a great place to meet the locals, drink good ale and spend quality time.
Dress Code: Casual..... but shirts and shoes, please!
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Potjana Jitawatanarat, Bhatraphol Tingpej and Paul Deringer
Tumefactive multiple sclerosis (MS) is a rare variant of MS. This form of MS can masquerade as neoplasm or infectious etiology. Understanding of the disease is limited to case report but it is associated with high morbidity and mortality.
Case report
A 44 year old man presented with a 2-month history of progressive right upper extremity weakness, confusion and visual change. Physical exam revealed weakness, hyperreflexia on the right side and right homonymous hemianopia. MRI of the brain showed multiple ring-enhancing lesions located in both cerebral hemispheres. CSF analysis disclosed elevated protein with positive oligoclonal bands and myelin basic protein. Stains and cultures for bacteria and mycobacteria were negative. Serologies including HIV, Toxoplasmosis, and Lyme were all negative. Patient was treated with high-dose IV corticosteroid and clinically improved. One month later, he presented with increasing confusion, aphasia and progressive weakness. Repeat MRI of the brain revealed worsening multiple ring-enhancing lesions with surrounding vasogenic edema in most lesions. High-dose corticosteroid was promptly started. There was also concern about infection, especially brain abscess; hence, intravenous ceftriaxone, vancomycin, and metronidazole were empirically given. Due to uncertainty of diagnosis, first brain biopsy at right frontal lobe lesion yielded non-specific gliosis. Repeat MRI brain showed increasing number of ring-enhancing lesions in both cerebral hemispheres. As a result, a second brain biopsy was performed, which showed an active demyelinating process consistent with multiple sclerosis. Patient experienced severe disability and was discharged to long-term facility with slowly tapered schedule of corticosteroid. He was readmitted several times and eventually family decided hospice care.
Multiple sclerosis is diagnosed by demonstrating clinical and/or radiographic evidence of dissemination of disease in time and space1. Tumefactive MS is a term used when the clinical presentation and/or MRI findings are indistinguishable from a brain tumor2. Not all case of tumefactive MS are fulminant. Marburg variant MS is an acute rare variant of MS which has a rapidly progressive course with frequent, severe relapses leading to death or severe disability within weeks to months3. The tumefactive demyelinating lesions are defined as large (>2 cm.) white matter lesions with little mass-like effect or vasogenic edema, and post-gadolinium magnetic resonance imaging (MRI) typically showing an incomplete ring enhancement2,4. The clinical and imaging characteristics of these demyelinating lesions may mimic primary and secondary brain tumors, brain abscess, tuberculoma, and other inflammatory disorders e.g. sarcoidosis, primary sjogren's syndrome5. As a result, tumefactive MS is frequently misdiagnosed. There are some MRI characteristics that are more suggestive of tumefactive demyelinating lesions than of other etiologies. These include incomplete ring enhancement, mixed T2-weighted iso-and hyperintensity of enhanced regions, absence of a mass effect and absence of cortical involvement2,6. Differential diagnosis of rapidly progressive neurological deficit with ring-enhancing lesions include brain abscess, primary brain neoplasm or brain metastasis, acute disseminated encephalomyelitis (ADEM) and tumefactive multiple sclerosis. Careful clinical history, CSF study, serial MRI evaluation and follow-up are usually sufficient to make a diagnosis. Some cases pose considerable diagnostic difficulty owing to clinical and radiographical resemblance to brain tumor, for which biopsy may be warranted. Pathologically, the lesions are characterized by massive macrophage infiltration, acute axonal injury, and necrosis. No specific histological features distinguished specimens derived from patients developing classic multiple sclerosis from those who had tumefactive form7. A limited number of cases of Marburg's variant MS have been reported in the literature whereby most patients died within a period of weeks to months. Only two cases survived after one year7,8. There is no current standard treatment for this condition. Plasma exchange and Mitoxantrone are reportedly showed some promising options9,10.
Figure A: FLAIR imaging at first presentation showed lesion in both hemisphere. Figure B: FLAIR imaging at one month later showed progression of multiple lesion in both hemisphere. Figure C: T1 Post contrast imaging showed intense ring enhancement pattern in almost all lesions with mild edema and minimal mass effect. Figure D: Showed lesion view as sagittal section.
Our patient presented somewhat like a stroke with visual field defect and right hemiparesis which is unusual in MS, but MRI and CSF exam yielded a diagnosis of probable MS. Because of his abrupt clinical deterioration and impressive worsening of his MRI, concern was raised about possibility of infection or neoplasm. Hence, he received two brain biopsies, the second of which showed active demyelination, confirming the diagnosis of severe tumefactive multiple sclerosis and can be consider as a Marburg variant multiple sclerosis.
Marburg variant multiple sclerosis carries a high morbidity and mortality. This disease notoriously mimics other conditions leading to delay diagnosis and treatment. Absence of definitive diagnosis test apart from brain biopsy makes diagnosis, prognosis and treatment decisions difficult.
1. McDonald WI, Compston A, Edan G, et al. Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the Diagnosis of multiple sclerosis. Ann Neurol.2001; 50: 121–7.2. Dagher AP, Smirniotopoulos J. Tumefactive demyelinating lesions. Neuroradiology. 1996; 38: 560–5.3. Canellas AR, Gols AR, Izquierdo JR, et al. Idiopathic inflammatory-demyelimating disease of central nervous system. Neuroradiology.2007; 49:393-409.4. Lucchinetti CF, et al. Clinical and radiographic spectrum of pathologically confirmed tumefactive multiple sclerosis. Brain.2008; 131:1759-75.5. Sanahuja J, Ordonez-Palau S, Beque R, Brieva L, Boquet D. Primary Sjogren syndrome with tumefactive central nervous system involvement. Am J Neuroradiol.2008 Nov; 29(10):1878-79.6. Kim DS, et al. Distinguishing tumefactive demyelinating lesions from glioma or central nervous system lymphoma: Added value of unenhanced CT compared with conventional contrast-enhanced MR imaging. Radiology. 2009; 251:467-75.7. Turatti M, Gajofatto A, Rossi F, et al. Long survival and clinical stability in Marburg variant multiple sclerosis. Neurol Sci. 2010; 31(6):807-11.8. Giubilei F, Sarrantonio A, Teisei P, et al. Four-year follow-up of a case of acute multiple sclerosis of the Marburg type. Ital J Neurol Sci.1997; 18:163-166.9. Jeffery DR, Lefkowitz DS, Crittenden JP. Treatment of Marburg variant multiple sclerosis with mitoxanthrone. J Neuroimaging. 2004; 14:58-6210. Rodriguez M, Karnes WE, Bartleson JD, Pineda AA Plasmapheresis in acute episodes of fulminant CNS inflammatory demyelination. Neurology.1993; 43 (6):1100-4.
Muhammad Zohaib Bawany, Zeeshan Tariq, Thomas Sodeman and Anand Mutgi
Hypertension is common, but with early detection and treatment, it is rare to see malignant hypertension. Malignant hypertension is a medical emergency with an incidence of 1% in hypertensive patients. We report on a patient who presented with signs suggestive of Thrombotic Thrombocytopenic Purpura and severe hypertension, which resolved with the treatment of hypertension.
Hypertension is common but, with early detection and treatment, it is rare to see malignant hypertension. We report a patient who presented with signs suggestive of thrombotic thrombocytopenic purpura and severe hypertension, which resolved with the treatment of hypertension.
A 34 year old African American male presented to the emergency department (ED) having experienced nausea, vomiting and diarrhoea for two days. He denied haematochezia, meleana or sick contacts at home. He complained of blurred vision without photophobia, headache and mild chest discomfort. His past medical history was unremarkable. The patient did not have any significant family history. Smoking history was significant for a pack of cigarettes daily for seven years. He reported occasional alcohol intake, and denied use of recreational drugs. On presentation, this patient's blood pressure was 201/151 mmHg, with a mean of 168 mmHg. Pulse 103 beats per minute, respirations 20 per minute and temperature 98.4F. Physical examination was otherwise unremarkable, including absence of focal neurological deficits.
Blood tests showed: Haemoglobin 12.6 g/dl, White cell count 13.9 g/dl, Platelets 67000, Sodium 136, Potassium 3.4, BUN 24, Creatinine 2.56 and LDH 556. Chest x-ray showed cardiomegaly. A non-contrast computed tomography scan of the brain did not show any sign of stroke (haemorrhage). Urinalysis was positive for proteins 4+, a large amount of blood, 0-2 white blood cells/high power field (HPF) and 0-2 red blood cells/HPF.
Figure 1
The patient's initial treatment whilst in the ER consisted of a Labetalol drip. His mean arterial pressure decreased to approximately 115 mmHg during the first hour, and his chest pain and headache improved with the control of elevated mean arterial pressure. Furthermore, over the next 24 - 48 hours, the patient's blood pressure was brought down to 138/86 mmHg and his blurred vision improved significantly. Subsequently, intravenous medications were switched to an oral regimen. Blood peripheral smear from the day of admission was significant for the schistocytes (Figure 1) suggesting ongoing haemolysis. Renal ultrasound was unremarkable. His cardiac ultrasound revealed an enlarged left ventricle, however no valvular abnormality was seen. Serum calcium and thyroid stimulating hormone levels were normal, as were urine catecholamines and vanillylmandelic acid level. On two week follow up in the outpatient clinic, the patient's platelet count and creatinine had returned back to baseline and peripheral smear did not reveal any schistocytes as the blood pressure came under better control. [Table 1]
Table 1
Malignant hypertension is a medical emergency with an incidence of 1% in hypertensive patients1and is more common in the African American population2. Depending on the clinical presentation, it must be differentiated from thrombotic thrombocytopenic purpura (TTP), disseminated intravascular coagulation (DIC), glomerulonephritis and vasculitis.
Suspicion for TTP was initially high in this patient because of haemolysis, thrombocytopaenia, central nervous system (CNS) manifestations and renal insufficiency. However, TTP did not explain the presence of elevated blood pressure3,4nor the improvement in symptoms and signs with the management of this, which clearly supports our diagnosis. Rapidly progressive glomerulonephritis did not explain the CNS symptoms, and a normal prothrombin time and activated partial thromboplastin time ruled against disseminated intravascular coagulation5. The patient did not have a history of preceding diarrhoea6, which could possibly direct towards haemolytic uraemic syndrome (HUS)4. There was no history of prosthetic valves, nor clinical evidence of vasculitis. The patient's symptoms of severe hypertension, haemolysis, thrombocytopaenia and renal failure were consistent with malignant hypertension, and treating the hypertension7gradually resolved the thrombocytopaenia, haemolysis and renal failure8.
This case report highlights that malignant hypertension is a medical emergency which can present with features resembling a wide variety of diseases, including TTP and HUS. Using appropriate management to control the elevation in blood pressure can help reveal the underlying diagnosis.
1. Kitiyakara C, Guzman NJ. Malignant hypertension and hypertensive emergencies. J Am Soc Nephrol 1998;9:133-42.2. Khanna A, McCullough PA. Malignant hypertension presenting as hemolysis, thrombocytopenia, and renal failure. Rev Cardiovasc Med 2003;4:255-9.3. Patel A, Patel H. Thrombotic thrombocytopenic purpura: the masquerader. South Med J 2009;102:504-9.4. Shibagaki Y, Fujita T. Thrombotic microangiopathy in malignant hypertension and hemolytic uremic syndrome (HUS)/ thrombotic thrombocytopenic purpura (TTP): can we differentiate one from the other? Hypertens Res 2005;28:89-95.5. Kitchens CS. Thrombocytopenia and thrombosis in disseminated intravascular coagulation (DIC). Hematology Am Soc Hematol Educ Program 2009:240-6.6. Hertig A, Ridel C, Rondeau E. [Hemolytic uremic syndrome in adults]. Nephrol Ther 2010;6:258-71.7. Varon J, Marik PE. The diagnosis and management of hypertensive crises. Chest 2000;118:214-27.8. Gassanov N, Pollok M, Er F. Acute renal failure associated with malignant hypertension. Dtsch Med Wochenschr 2009;134:2224-7.
SKM Annamalai, SS Raju and VG Langkamer
We present here a 63 year old lady who had a primary total knee arthroplasty( TKA) for osteoarthritis of knee. She developed methicillin resistant staphylococcus aureus( MRSA )infection of the primary prosthesis following an intravenous(IV) cannula site infection with MRSA bacteraemia. This was complicated by Stevens-Johnson syndrome following vancomycin therapy for the infection, which was confirmed by clinical features including typical skin rashes and skin biopsy. She was treated with alternative antibiotics and was referred to a specialist orthopaedic unit where she had a two- stage revision.
In retrospect, the infection could have been avoided if the IV cannula was not left in for so long. She also unfortunately had an adverse reaction to the vancomycin which complicated the situation, making management difficult. A team consisting of orthopaedic surgeons, microbiologists, dermatologists and physiotherapists was essential for successful management of this difficult and complicated situation.
Infection of a prosthetic total knee joint is a serious complication1 and should be diagnosed promptly2 and treated aggressively. We present an interesting case of MRSA infection of a primary total knee replacement following an IV cannula infection leading to bacteremia and subsequent infection of the knee prosthesis, complicated by stevens- Johnson syndrome .
There were many challenging issue which are outlined including diagnosis and management.
Case Report
A 63-year- old lady had an elective total knee arthroplasty for severe osteoarthritis of the knee. She had a background history of well-controlled type 2 diabetes mellitus and was on warfarin for a previous pulmanory embolism. As per the hospital protocol her warfarin was stopped before surgery until her INR was <1.5 and she was heparinised with a view of
warfarinizing after the surgery. She had an uneventful knee arthoplasty, but unfortunately one of her IV cannula site became cellulitic. She was empirically started on oral flucloxacillin after taking blood cultures and sending the cannula tip for microscopic culture and sensitivity (which is routinely done has hospital protocol for infected cannula sites).
Surprisingly the tip grew MRSA and also had MRSA bacteraemia. She became systemically unwell and septic, and was treated aggressively with parentral vancomycin for MRSA bacteraemia. She had a transeosphageal echocardiogram to rule out cardiac vegetation. She gradually improved but developed typical papular rashes over her palm, dorsum of hand, extensor surface of arm and forearm and trunk and buccal mucosa (Fig 1 and 2) .
Fig 1: Rash over the dorsum hands
Fig 2: Rash over the extensor aspects of forearm
She had a severe allergic reaction to vancomycin and the skin biopsy of the lesion confirmed that she had developed Stevens-Johnson syndrome. An alternative antibiotic was started following discussion with the specialist bone infection unit. She gradually improved over the next few weeks without any problem in her prosthetic replaced knee. At about 6 weeks post- operatively she developed severe pain and hot swelling of her replaced knee with decrease range of motion. Her inflammatory markers were markedly raised and the knee aspirate confirmed MRSA infection of the total knee replacement. She was referred to a specialist bone infection unit due to the complexity of the case, where she successfully underwent two- stage revision.
Infection of a Knee replacement is a serious complication that requires significant hospital-based recourse for successful management3. The rate of infection of a primary knee replacement varies from 0.5- 12%1. Rheumatoid arthritis , previous surgery , diabetes mellitus are all associated with an increased risk of infection 4. Although there is no absolute diagnostic test for peri-prosthetic infection2 , a high index of clinical suspicion is essential. There has been a case report on MRSA cervical epidural abscess following IV cannulation 5, but to the best of our knowledge there has been no previous report of MRSA- infected knee arthroplasty following complications of IV cannulation. Stevens-Johnson syndrome involves rare but severe cutaneous adverse reactions related to a variety of medications including antibiotics6. Parenteral vancomycin is the first line treatment for MRSA bacteraemia. It is recognised that vancomycin is indicated in inducing Stevens -Johnson syndrome, mortalitiy being 30-100%7. It is vital that Stevens- Johnson syndrome is recognised early so that offending agents are stopped and supportive treatment commenced. Early dermatological consultation, skin biopsy and direct immunofluorescence7 are essential to confirm diagnosis so that effective treatment can be instituted.The diagnosis and management of this serious complication is complex and requires considerable recourse allocation by the patient, the hospital, the infectious disease specialist, and the orthopaedic surgeon1,5.
Robert Moots is Professor of Rheumatology at the University of Liverpool and Director for Research and Development at the University Hospital, Aintree. He is also a Consultant Rheumatologist at the hospital.
He graduated from St Mary's Hospital, London University in 1985 and also worked at Harvard Medical School. He became a Consultant Rheumatologist at University Hospital Aintree in 1997 and the youngest full-time professor of Rheumatology and Head of Department in 2003.
Professor Moots has published extensively in rheumatology, winning the prestigious Michael Mason prize for rheumatology research. He advises the UK Department of Health and NICE. His research interests are inflammatory rheumatic diseases, in particular innate cellular immunity in rheumatoid arthritis, immunotherapy, new therapeutic targets and clinical trials.
How long have you been working in your speciality?
I've been working as a consultant in rheumatology since1997, when I returned to the UK from the USA. Of course I was a trainee in rheumatology for a few years before then.
Which aspect of your work do you find most satisfying?
Its hard to single out any one thing. The great fun of being Professor is that no two days are the same. My job varies so much from looking after patients, to teaching, running research and also communicating and sharing research findings with other clinicians and scientists throughout the world – giving me the opportunity to visit countries, where I would not normally have visited.
What achievements are you most proud of in your medical career?
Clinically, I often deal with rare rheumatic diseases, or situations where normal treatments have failed and other doctors have said there is "no more that can be done". Each patient that I see in this situation, who then goes on to recover and have a normal happy life, gives me a great satisfaction. Academically, building up a successful research team of talented individuals in Liverpool, the first academic rheumatology unit in that city, has been a great privilege.
Which part of your job do you enjoy the least?
Trying to balance the demands of patient care with the many other calls on my time can be rather wearing. But nothing is worse than the ever expanding administration tasks and bureaucracy!
What are your views about the current status of medical training in your country and what do you think needs to change?
When I visit other countries to lecture, I always try to see how medicine runs there. I attend clinics and hospitals, see patients and learn how practice compares to the UK. I am pleased to note that the standard in the UK remains amongst the highest of all countries.
How would you encourage more medical students into entering your speciality?
Its hard to image why students and doctors could consider any specialty other than Rheumatology! Rheumatology provides the opportunity to see patients of all ages, develop a close rapport with patients as the diseases tend to be chronic and prevalent, perform cutting edge research to understand pathophysiological process underlying the diseases and access drugs that can make a revolution to lives with great outcomes.
What qualities do you think a good trainee should possess?
Be keen to learn, open, honest and bright. I also like trainees to challenge accepted wisdom – a considered critical approach is needed to move things forward and to keep us on our toes.
What is the most important advice you could offer to a new trainee?
Don't accept non-evidence based dogma. Don't learn bad habits. Be critical and try to improve things. Try to spend some time away from your unit and ideally out of your country – seeing how medicine works in other environments to get life and work in a better perspective.
What qualities do you think a good trainer should possess?
Good trainers should be excellent clinicians, inspirational leaders and listeners with patience. If you know someone like this, you should really treasure them!
Do you think doctors are over-regulated compared with other professions?
No – but I fear that we are getting there in the UK.
Is there any aspect of current health policies in your country that are de-professionalising doctors? If yes what shouldbe done to counter this trend?
With a recent change in government in the UK and major changes to the Health Service planned, it's a little too early to tell. We have to be vigilant though.
Which scientific paper/publication has influenced you the most?
For much of my working life, I was focused on the T cell as the major driver for diseases such as rheumatoid arthritis. The paper that changed that was: Edwards SW, Hallett MB. Seeing the wood for the trees: the forgotten role of neutrophils in rheumatoid arthritis. Immunol Today.1997 Jul;18(7):320-4. This crucial paper from Steve Edwards, the world leader in neutrophil biology opened my eyes to a whole new field of work. I didn't know at the time that I would eventually have the privilege of working with Steve.
What single area of medical research in your specialty should be given priority?
That's an easy one – it should be whatever my group are working on at the time.(I just wish that were the case!)
What is the most challenging area in your specialty that needs further development?
Many rheumatic diseases such as rheumatoid arthritis can be treated extremely successfully (with patients enjoying a full remission) if they can access the right drugs at the right time. There is still much variability in time to diagnosis and in provision of appropriate medications – the challenge is to ensure that best practice can be rolled out more effectively.
Which changes would substantially improve the quality of healthcare in your country?
There needs to be a greater understanding of the importance of rheumatic diseases in the UK. These conditions are prevalent, may cause significant morbidity (and indeed mortality), cost the nation considerably in reduced productivity and in disability payments – yet many of these conditions can be treated most effectively.
Do you think doctors can make a valuable contribution to healthcare management? If so how?
Its crucial that doctors are fully engaged in management. We are in the best position to be advocates for our patients but cannot do this effectively without understanding the health care system and take the lead in ensuring this works for the best.
How has the political environment affected your work?
The consequences of the recent change in Government in the UK are likely to be considerable for the National Health Service. This will involve major changes to the work of staff at all levels. It is too early to know the full extent of this – but we all wait with trepidation
What are your interests outside of work?
With so much to do, its hard to find the time for much else apart from relaxing with my family. I travel a lot and especially enjoy taking my children with me. My 10 year old has heard me lecture so much that I suspect she can give my talk for me (and do it better). She has also taken to asking questions at the end of my lecture, which always scares the chairperson of the meeting!
If you were not a doctor, what would you do?
I'm not sure that I would be fit for anything else!
Fadi Seif and Lamia H. Ibrahim
A 73 year old lady presented for assessment of her recurrent right sided pleural effusion. She had a history of gallstones and underwent open cholecystectomy. One month after surgery the patient had recurrent pleural effusion requiring thoracocentesis on a monthly basis. On the chest x-ray, the pleural effusion was seen exclusively on the right side occupying the whole right hemithorax.
The pleural fluid was transudative on multiple occasions and there was no evidence of malignant cells. Her echocardiography revealed preserved cardiac function. An abdominal ultrasound showed findings of cirrhosis and splenomegaly consistent with portal hypertension.
Image 1
Computerised tomography (CT) of the chest and abdomen revealed a large right-sided pleural effusion and minimal ascites (Image 1). An ultrasound guided paracentesis was performed with difficulty and only 17cc of fluid.was obtained. The abdominal fluid showed similar consistency as the pleural fluid. The blood workup at the same time was unremarkable.
Image 2
Intra-peritoneal administration of 99mTc-sulphur colloid was attempted but failed in the absence of ascites. Computed tomography with three dimensional reconstruction at the diaphragmatic level revealed a defect in the posterior aspect of the right hemidiaphragm (Image 2 black arrow) and also revealed irregular contours of the liver, an indirect sign of diaphragmatic defect (Image 2 white arrow).
The patient declined any surgical intervention at that point including the option of pleurodesis. She was started on diuretics and a low salt diet with significant improvement.
Pleural effusion due to hepatic cirrhosis and ascites is well known, but hepatic hydrothorax in the absence of ascites is a rare complication. We report a case of liver cirrhosis with a large and recurring right sided pleural effusion that had an apparent abdominal source in the absence of ascites. We review the characteristics and treatment for hepatic hydrothorax in the absence of ascites.
Hepatic hydrothorax is defined as the presence of significant pleural effusion in a cirrhotic patient without primary pulmonary or cardiac disease1. Postulated mechanisms for the development of pleural effusions in patients with hepatic cirrhosis include: hypoalbuminemia and decreased oncotic pressure leakage of the plasma from the hypertensive azygos vein, lymphatic leak from the thoracic duct, passage of ascitic fluid to the pleural space by way of lymphatic channels in the diaphragm, and transfer of peritoneal fluid directly via diaphragmatic defects2.
The usual unilaterality of hepatic hydrothorax could be attributed to a congenital factor, but not to physiologic mechanisms3. The most likely explanation appears to be that ascitic fluid passes through congenital or acquired fenestrations in the diaphragm directly into the pleural space2. The description of hepatic hydrothorax in the absence of ascites is very rare1. The flow of the ascitic fluid into the pleural space equaled the rate of ascites production in patients with this entity3.
The composition of pleural fluid from hepatic hydrothorax is similar to that of ascitic fluid. Pleural effusions associated with portal hypertension are always transudative1. Nuclear scans can be performed to establish the diagnosis of hepatic hydrothorax with fairly high accuracy. Intra-peritoneal administration of 99mTc-human serum albumin or 99mTc-sulphur colloid can be used to demonstrate the communication between the peritoneal and pleural space. Recent advances in radiological imaging have enabled investigators to examine in detail the diaphragmatic defects responsible for the development of hepatic hydrothorax1.
The management is challenging and frequently associated with poor outcomes in most cases. Dietary restriction of sodium intake and the addition of diuretics is the initial approach. Thoracocentesis can be performed in patients with dyspnoea due to hepatic hydrothorax for immediate relief of symptoms. When thoracocentesis is required too frequently in patients on maximal sodium restriction and optimal diuretics, alternative treatment options must be considered1, 3.
Over the last few years, new insights into the pathogenesis of this entity have lead to improved treatment modalities such as portosystemic shunts (TIPS) and video-assisted thoracoscopy (VATS) for closure of diaphragmatic defects. Both, though temporary measures, are perhaps the best available bridging to liver transplantation in selected patients with refractory hepatic hydrothorax2, 3.
Jennifer L. Pham, Steven R Bruhl and Mujeeb Sheikh
We present an interesting case of severe dyspnea due to chronic obstructive airway disease exacerbation and upon further evaluation a diagnosis of stress cardiomyopathy was entertained. We highlight a management of this particular case and provide a brief review of stress cardiomyopathy.
Case presentation
A 52 year-old Caucasian male with a history of chronic obstructive airway disease (COPD) presented to the emergency department complaining of progressive shortness of breath. Two days prior, the patient had presented to the ED with similar complaints that resolved with aerosol treatments and the patient was discharged on a metered dose inhaler (MDI). The patient had been prescribed MDI's (metered dose inhalers) previously for management of his COPD, but due to financial constraints he had been unable to fill his prescription for the past month. Emergency medical services (EMS) suspected COPD exacerbation and administered 40 mg prednisone IV and two albuterol-ipratropriumnebulisertreatments en route to the hospital, which improved the patient's breathing symptoms.
Upon arrival to the hospital, his blood pressure was 129/90, respirations 28, pulse 127, and he had an oxygen saturation of 100% on 7L/min. Physical examination revealed increased work of breathing, and wheezes in all lung fields with prolonged expiratory phase. The cardiovascular exam was normal except for tachycardia. A Routine electrocardiogram (ECG) revealed sinus tachycardia and T wave inversions in anterior leads. Chest x-ray showed old scarring in the left lower lobe. Routine cardiac enzymes showed mild elevation with a serum troponin level of 0.68ng/ml (normal range 0.0ng/ml-0.05ng/ml). The second set of troponin peaked at 1.66 ng/ml (normal 0.0ng/ml-0.05ng/ml). In view of the elevated cardiac enzymes atransthoracicechocardiogram was performed which demonstrated multiple wall motion abnormalities and reduced left ventricular ejection fraction of 25%. Coronary angiography demonstrated normal coronary arteries. Left ventriculography revealed hypokinetc mid-anterior and apical segment with a hypercontractile base with reduced ejection fraction (EF) of around 25% (normal range EF 55-65%) (Figure 1)
Figure 1. Left ventriculography demonstrating the classic appearance of Takotsubo cardiomyopathy
In light of the systolic dysfunction not in proportion with the degree of coronary artery stenosis and the multiple areas of wall motion abnormalities seen on echocardiogram, the diagnosis of Takotsubo cardiomyopathy (TCMP) was made. The diagnosis was further supported by the presence of ECG changes, troponin elevation, and the added social stresses of being unemployed. Over the course of his stay in hospital, the patient's breathing improved with oral prednisone, inhaled tiotropium, and fluticasone/salmeterol. The patient was also treated with an angiotension converting enzyme inhibitor (ACE inhibitor), aspirin, statin, and beta-blockers. There were no adverse coronary events during the course of his hospital stay and the patient was discharged after four days. A Follow up echocardiogram after 4 weeks showed normal left ventricular systolic function.
Takotsubo cardiomyopathy (TCMP), also called stress-induced cardiomyopathy, apical ballooning syndrome, or broken heart syndrome, is a transient systolic dysfunction of the ventricles in the absence of significant coronary artery disease. Once thought to be a rare syndrome, TCMP is increasingly being identified in clinical practice, however, the prevalence and incidence are not known. It is estimated that 0.7-2.5% of patients who present with acute coronary syndrome are found to have TCMP1 .The majority of these patients are postmenopausal females, with a mean age of 62-75 years. They may present with chest pain and have a recent history of an emotional stress or severe medical illness. 1
The clinical manifestations of TCMP can mimic those of an acute myocardial infarction. Although, chest pain is a common presenting symptom, patients may also have complaints ofdyspnoeaand arrhythmias. In our casedyspnoeawas the predominant symptom and was easily confused with COPD exacerbation. Recently a few cases of concomitant stress cardiomyopathy with obstructive airway disease have been documented in literature. 2-4 While the pathophysiology of the coexistence of these two disorders is not fully understood, it is thought that both stress induced cardiac dysfunction due to exaggerated sympathetic activation and use of sympathomimetic bronchodilators instigates the myocardial stunning in such patients. Furthermore, an emotional stressor, such as death of a family member, or a physiological stressor, such as an acute medical illness, is thought to be a trigger for cardiomyopathy. 5 It is believed that the syndrome is not a result of anischemia, but there is some evidence to suggest thatoestrogenlevels may have a role in modulating the sympatho-adrenal outflow in TCMP. In mice models, chronic oestrogen supplementation seemed to have protective effects from exaggerated sympathetic outflow from the heart and brain6 . Postmenopausal women with low levels ofoestrogenmay be more vulnerable to the exaggerated catecholamine release in responses to stressors. 7
The characteristic finding in TCMP is a transient mid-ventricular or apical ballooning due to a hypokinetic portion seen on echocardiogram or on a left ventriculography. Systolic dysfunction is usually transient, inconsistent to the perfusion area of a single coronary artery, and usually resolves within 4-6 weeks. 8 Additional findings include ECG changes with ST segment deviations in precordial leads being the most common. Cardiac enzymes have been noted to have moderate elevations.9.
As data regarding the treatment of TCMP is limited, medical management mainly consists of symptomatic therapy with aspirin, ACE inhibitors, beta-blockers, and diuretics, also used in acute coronary syndrome.10 Patients who present acutely are treated as acute coronary syndrome and often receive emergency coronary angiography. However, less invasive imaging techniques, such as echocardiograms, should first be examined carefully. Due to the transient nature of the syndrome, the duration of treatment is unknown with some studies suggesting that there is no benefit with chronic treatment. 11 The prognosis is fairly good, with in hospital mortality rates being reported to range from 0-8%, and recovery of left ventricular function in the majority of patients. 9, 12
TCMP is difficult to distinguish from acute coronary syndrome on first presentation. Our patient had significant social stress. She presented with severedyspnoeaand was treated for COPD exacerbation. Elevation of cardiac enzymes and ECG changes lead to further evaluation and diagnosis of stress cardiomyopathy. This atypical presentation of TCMP showcases the importance ofutilisingthe routine noninvasive imaging and laboratory values to guide the diagnosis. Furthermore physicians need to maintain a high clinical suspicion for this syndrome.
1. Bybee, K.A., et al., Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med, 2004. 141(11): p. 858-65.
2. Bilan, A., et al., Dyspnea as a dominant clinical manifestation in a patient with takotsubo cardiomyopathy treated for chronic obstructive pulmonary disease and hyperthyroidism. Pol Arch Med Wewn, 2009. 119(4): p. 265-8.
3. Hernandez Lanchas, C., et al., [Tako-Tsubo syndrome in a patient with exacerbated bronchial asthma]. Rev Clin Esp, 2007. 207(6): p. 291-4.
4. Saeki, S., et al., [Case of bronchial asthma complicated with Takotsubo cardiomyopathy after frequent epinephrine medication]. Nihon Kokyuki Gakkai Zasshi, 2006. 44(10): p. 701-5.
5. Tsuchihashi, K., et al., Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll Cardiol, 2001. 38(1): p. 11-8.
6. Ueyama, T., Emotional stress-induced Tako-tsubo cardiomyopathy: animal model and molecular mechanism. Ann N Y Acad Sci, 2004. 1018: p. 437-44.
7. Ueyama, T., et al., Catecholamines and estrogen are involved in the pathogenesis of emotional stress-induced acute heart attack. Ann N Y Acad Sci, 2008. 1148: p. 479-85.
8. Nef, H.M., et al., Mechanisms of stress (Takotsubo) cardiomyopathy. Nat Rev Cardiol. 7(4): p. 187-93.
9. Banihashemi, M.R. and I.A. Khan, Acute stress-induced cardiomyopathy: a brief observation. Int J Cardiol, 2009. 134(2): p. 273-7.
10. Cocco, G. and D. Chu, Stress-induced cardiomyopathy: A review. Eur J Intern Med, 2007. 18(5): p. 369-79.
11. Fazio, G., et al., Chronic pharmacological treatment in takotsubo cardiomyopathy. Int J Cardiol, 2008. 127(1): p. 121-3.
12. Regnante, R.A., et al., Clinical characteristics and four-year outcomes of patients in the Rhode Island Takotsubo Cardiomyopathy Registry. Am J Cardiol, 2009. 103(7): p. 1015-9.
Mahesh E, Medha Y, Indumathi V A, Prithvi S Kumar, Mohammed Wasim Khan and Punith K
Background: Urinary tract infection (UTI) in the elderly poses a very serious problem. The knowledge of microbiology and antibiotic susceptibility of micro-organisms causing the disease is vital for defining the empirical treatment. There are no large-scale studies on the same from India.
Aim: To find out the common presenting symptomatology and risk factors associated with UTI and distribution of isolated uropathogens and their resistance pattern.
Settings and design: Prospective study done in a tertiary care centre in Bangalore.
Methods and material: The study included elderly patients aged 65 years and above who were admitted, or visited the outpatient departments in the hospital, and had confirmed UTI.
Results and conclusions: Fever (57/194 - 29.4%) and dysuria (52/194 - 26.8%) were the most common symptoms of UTI. Diabetes Mellitus (DM) was the most common risk factor associated with UTI. Extended Spectrum Beta-Lactamase (ESBL) producing Escherichia coli (E.coli) (93/194 - 47.94%) was the most commonly isolated pathogen. Of the total, 56.2% of the uropathogens showed ESBL positivity. Overall, the highest antibiotic resistance was recorded for Fluoroquinolones (79.9%).
Urinary tract infection (UTI) is the second most common infectious complaint in geriatric clinics overall, and the most common outpatient complaint caused by bacteria.1 The diagnosis and treatment of UTI in the elderly is not the same as treating UTI in adults. In frail elderly patients with age-associated multiple severe underlying disorders and cognitive impairment, early recognition of bacteraemic UTI and prompt, appropriate treatment are critical in reducing the mortality.2Also, the extensive and inappropriate use of antimicrobial agents has invariably resulted in the development of antibiotic resistance which, in recent years, has become a major problem worldwide.3 The diagnosis and empirical treatment of UTI in the elderly is challenging and a sound knowledge of the prevalent epidemiology of bacteria and their resistance pattern is necessary for the same. However, there is not much information on the aetiology and resistance pattern of UTI in the elderly in India. This study was done to find out the present uropathogen profile causing UTI in our centre and their antibiotic resistance patterns.
Subjects and methods
This prospective study was done at our tertiary care centre from January to December 2008. The study included all patients who were admitted or visited the outpatient departments in the hospital with symptoms of UTI during the study period and had UTI confirmed by positive urine culture reports. Only one sample from each subject was considered. Subjects with clinical symptoms of UTI but no growth on culture were excluded from final analysis. Subjects who were treated with another antimicrobial within the previous 48 hours, or within 24 hours if only a single dose and in the presence of an appropriate positive culture and ileal loops or vesicoureteral reflux were also excluded from the study. Complete data regarding demography, sex preponderance, associated symptoms, pathogenic organisms causing UTI and their antibiotic resistance were collected.
Overall, 194 subjects were included in the study (male: 116, female: 78). The mean age of the study population was 73.54±7.19 years, ranging between the ages of 65 and 96. The distribution of patients according to gender across various age groups is given in table 1. A general trend of more male subject enrolment was seen across all the age groups.
Age group
Isolation and identification of uropathogens
A clean catch midstream specimen, or suprapubic aspirate in subjects who were unable to give the former, was collected in a sterile, wide-mouth, leak-proof container to hold approximately 50ml from these subjects. Using a calibrated loop method of loop diameter 4 mm, 10 µL of the uncentrifuged specimen was transferred onto the agar plate and streak, using the modified Mayo's technique without flaming the loop for isolation, and incubated at 35- 370C for 24 hours. A specimen was considered positive for UTI if a single organism was cultured at a concentration of >105 Colony Forming Units/ml. The Gram-positive and Gram-negative organisms culture isolates were further identified by using various biochemical reactions up to genus/species level wherever applicable.
Antibiotic sensitivity testing
In the presence of any potential growth, antibiotic sensitivity testing was done by the Modified Kirby-Bauer disc diffusion method according to the Clinical and Laboratory Standards Institute (CLSI) guidelines.4 The antibiotics tested were Imepenem, Meropenem, Ciprofloxacin, Ofloxacin, Norfloxacin, Amikacin, Gentamicin, Nitrofurantoin and Cotrimoxazole (Pathoteq Labs, India).
Extended Spectrum Beta-Lactamase (ESBL) detection
The screening for ESBL was done using Cefpodoxime (<17mm), Ceftazidime (<22mm), Aztreonam (<27mm), Cefotaxime (<27mm) and Ceftriaxone (<25mm). If the organisms showed the zone of inhibition lower than the minimum for any antibiotic disc, ESBL positivity was suspected. The phenotypic confirmation was done by testing the strain against Ceftazidime (Ca) and Ceftazidime/Clavulanic Acid. A > 5mm diameter of the zone of inhibition for Ceftazidime/Clavulanic Acid in comparison to Ceftazidime was considered indicative of ESBL production. Escherichia coli (E. coli) ATCC 25922 was used as ESBL negative and Klebsiella pneumoniae (K. pneumoniae) 700603 was used as ESBL positive reference strain.4
Statistical analysis
Descriptive statistics (totals, means, percentages, and standard deviations) were conducted using the statistical software package - SPSS Version 16.0 (SPSS Inc., Chicago, USA). Age, gender, organisms causing UTI, their antibiotic sensitivity and resistance, symptomatology of these subjects, and risk factors for UTI were included in the analysis and the results presented in tables and figures.
Fever (57/194 - 29.4%) and dysuria (52/194 - 26.8%) were common symptoms of most UTI patients (Fig. 1). Diabetes mellitus (DM) and recent uro-genital instrumentation were the most common risk factors associated with UTI in the present study (Table 2). The organism profile and their antibiotic resistance profile were similar in patients with or without DM.
Figure 1. Various symptomatologies seen in patients with urinary tract infection during the initial presentation
Table 2. Frequency of various risk factors in subjects with urinary tract infection.
Risk Factor
Diabetes Mellitus
Recent history of uro-genital Instrumentation
Recurrent urinary tract infection
Renal stones
E. coli (138/194 - 71.1%) was the most commonly isolated pathogen responsible for UTI in the present study (Figure 2). 56.2% of the total infection was caused by ESBL positive organisms. The antimicrobial potency and spectrum for nine selected antimicrobial agents (Imepenem, Meropenem, Ciprofloxacin, Norfloxacin, Ofloxacin, Gentamicin, Amikacin, Nitrofurantoin and Cotrimoxazole) against the uropathogens were studied. The highest and least antibiotic resistance was noted against fluoroquinolones (79.9%) and carbapenems (3.61%) respectively (Fig. 3).
Figure 2. Frequency and distribution pattern of urinary tract infection pathogens and percentage Extended Spectrum Beta-Lactamase (ESBL) production.
Figure 3. Resistance pattern to various antibiotics of the uropathogens
While increased frequency and dysuria are usual symptoms of UTI, uncertainty looms around the same as these symptoms can be masked by catheterisation, or be common and chronic in the elderly even in the absence of UTI.5-10Fever was the most common symptom of UTI in the present study as with similar studies worldwide.11-13 Studies have found that the elderly do not lack a febrile response; that an elevated temperature was the most common initial symptom, a marker for a serious infection, and the most important clinical indicator for antibiotic treatment.14-16 Whitelaw et al17 reported that a delay in interpreting fever as a symptom of UTI led to a high mortality rate in the elderly within 24 hours of admission.
Diabetes isconsidered as an important risk factor for UTI with manyauthors having defined UTI in patients with DM as complicated when the UTI is symptomatic.18-19 However, the authors did not find that DM influenced the organism profile and their antibiotic resistance in the present study. Bonadio et al20 studied the influence of DM on the spectrum of uropathogens and antimicrobial resistance in elderly adult patients with asymptomatic UTI (mostly hospital-acquired). They found that DM per se did not seem to influence the isolation rate of different uropathogens and their susceptibility patterns to antimicrobials. These findings indicate that, although DM is a known immunomodulator, the role played by the same in altering the antibiotic resistance is minimal compared to recent invasive procedures.
Although the uropathogen profile of the present study resembles similar studies worldwide, the antibiotic resistance of these organisms was unusually high.2, 21 Cotrimoxazole is the recommended drug for treating UTI. However, more than one third of the study subjects were resistant to the first-line drug. 79.9% of the uropathogens were resistant to fluoroquinolones, which are considered as the second-line drug. As prior fluoroquinolone use is a known risk factor for fluoroquinolone-resistantE. coli infection, it is plausible that frequent fluoroquinolone prescriptions may be contributing to the observed resistance.22-23 Aypak et al 24 found that treatment durations were statistically longer than the recommended three-day course when patients were empirically treated with fluoroquinolones due to increased resistance rates, and suggested to discourage the empirical use of fluoroquinolones in UTI.
The most troublesome finding of the present study is that ESBL-positive organisms accounted for 56.2% of the total infection. Not much information on ESBL-producing organisms causing UTI is available from India and most of these reports are from the younger population. The prevalence of ESBL-positive UTI in these studies varied between 26.6% and 48.3%.25-26 To the best of our knowledge, this is the highest ever reported prevalence of ESBL-positive UTI in the elderly worldwide. ESBL-producing organisms are frequently resistant to many of the antimicrobial agents usually recommended for the treatment. As lesser new antibiotics are available for their management, we need to be concerned of this issue in years to come especially in tertiary care centres. A unified antibiotic protocol is necessary to limit the morbidity and mortality associated with inappropriate and under-treatment of UTI.
The limitations of the present study were that altered mental status was not considered as one of the clinical manifestations of UTI in the elderly, which could have mitigated the total number of study subjects included in the study. In addition, the phenotypic confirmation of ESBL-positive organisms was done using only Ceftazidime/Clavulanic Acid and not Cefotaxime/Clavulanic Acid as per the latest CLSI guidelines. As a result, there may be under-reporting of the incidence of ESBL organisms in the present study.
In conclusion, we report a significantly high resistance to common antibiotics among the uropathogens in the present study. Furthermore, the very high rate of ESBL-positive UTI is of concern, and monitoring for the same is necessary to prevent treatment failure and increased morbidity and mortality with UTI.
Fadi Hammoudeh, Muhammad K. Perwaiz, Setu Patolia, Frances M. Schmidt, Narayan Neupane,Neerja Gulati, Danilo Enriquez, Joseph Quist, Mehjabeen Zahir and Eneh Kennedy
Patients with Wegner's Granulomatosis often present with diffuse alveolar haemorrhage alongside the classical triad of haemoptysis, anaemia and progressive dyspnoea. The diagnosis is confirmed by bronchoalveolar lavage with serial aspirated aliquots of fluid revealing persistently bloody returns. Lung biopsy is very helpful if it shows granulomatous inflammation and vasculitis however it lacks sensitivity and specificity. Studies suggest that the detection of antineutrophilcytoplasmic antibodies (ANCA) along with Proteinase-3 can substitute for biopsy for the diagnosis of Wegner's Granulomatosis in patients who present with diffuse alveolar haemorrhage.
1. Specks U. Diffuse alveolar haemorrhage syndromes. Curr Opin Rheumatol 2001; 13:12-17.2. Travis W. Colby T. Lombard C, et al: A clinicopathologic study of 34 cases of diffuse pulmonary haemorrhage with lung biopsy confirmation. Am J Surg Pathol 1990 ;14:11123. D. R. Thickett, A. G. Richter, N. Nathani, G. D. Perkins and L. HarperPulmonary manifestations of anti-neutrophil cytoplasmic antibody (ANCA)-positive vasculitis. Rheumatology 2006;45:261–2684. Travis WD, Hoffman GS, Leavitt RY et al. Surgical pathology of the lung in Wegener's granulomatosis. Review of 87 open lung biopsies from 67 patients. Am J Surg Pathol. 1991;15(4):315-335. J F Cordier, D Valeyre, L Guillevin, R Loire and J M Brechot Pulmonary Wegener's granulomatosis. A clinical and imaging study of 77 cases. Chest 1990; 97: 906-9126. S J HAWORTH, C 0 S SAVAGE, D CARR, J M B HUGHES, A J REES Pulmonary haemorrhage complicating Wegener's granulomatosis and microscopic polyarteritis British Medical Journal. 1985;290(15);1775-17787. Aine Burns Pulmonary Vasculitis Thorax 1998; 53:220–2278. Octavian C. Ioachimescu. Diffuse alveolar haemorrhage: Diagnosing it and finding the cause. Cleveland Clinic Journal of Medicine .2008;75(4): 258-2809. U. Schönermarck, P. Lamprecht, E. Csernok, W. L. Gross. Prevalence and spectrum of rheumatic diseases associated with proteinase 3-antineutrophil cytoplasmic antibodies (ANCA) and myeloperoxidase-ANCA. Rheumatology 2001;40:178-18410. Langford CA. Wegener granulomatosis. Am J Med Sci 2001;321:76-82.11. Falk RJ, Jennette JC. ANCA small-vessel vasculitis. J Am Soc Nephrol 1997; 8:314-22.12. Hagen EC, Daha MR, Hermans J et al. Diagnostic value of standardized assays for anti neutrophil cytoplasmic antibodies in idiopathic systemic vasculitis. EC/BCR Project for ANCA Assay Standardization Kidney Int. 1998;53(3):743–53.13. Moosig F, Lamprecht P, Gross WL. Wegener's Granulomatosis: the current view. Clin Rev Allergy Immunol. 2008;35(1-2):19-2114. Bosch X, Guilabert A, Espinosa G, et al. Treatment of antineutrophil cytoplasmic antibody associated vasculitis: a systematic review. JAMA. 2007; 298(6):655–6915. Mar EJ, Matsubara O, Nelia S. Tan-Liu et al. The pulmonary biopsy in the early diagnosis of Wegener's (pathergic) granulomatosis: A study based on 35 open lung biopsies. Hum Pathol. 1988;19(9):1065-7116. Hoffman GS, Kerr GS, Leavitt RY, et al. Wegener's granulomatosis: an analysis of 158 patients. Ann InternMed 1992;116:488–9817. Stephen K. Frankel, Gregory P. Cosgrove, Aryeh Fischer, Richard T. Meehan and Kevin K. Brown Update in the Diagnosis and Management of Pulmonary Vasculitis Chest 2006;129;452-46518. SL Hogan, PH Nachman, AS Wilkman, JC Jennette and RJ Falk Prognostic markers in patients with antineutrophil cytoplasmic autoantibody-associated microscopic polyangiitis and glomerulonephritis Journal of the American Society of Nephrology.1996;7:23-3219. Gisele Zandman-Goddard MD Diffuse Alveolar Haemorrhage in Autoimmune Diseases. IMAJ 2002;4:461-46220. Lin Y, Zheng W, Tian X, Zhang X, Zhang F, Dong Y. Antineutrophil cytoplasmic antibody-associated vasculitis complicated with diffuse alveolar haemorrhage: a study of 12 cases. J Clin Rheumatol. 2009;15(7):341-4.21. Chen GX, Dong Y, Ju ZB . A clinical analysis of 32 patients with diffuse alveolar haemorrhage in diffuse connective tissue diseases. Zhonghua Nei Ke Za Zhi. 2008;47(5):362-5
Usman Ali, Wai Hang Cheung and Ashis Banerjee
A 44 year old man, previously in good health, presented with congestive heart failure, the onset of which was probably four weeks previously. A diagnostic label of community acquired pneumonia led to delay in the diagnosis of type A aortic dissection.
This required surgical management which resulted in a good outcome. The absence of chest pain may have contributed to the delay in diagnosis. Aortic dissection should form part of the differential diagnosis of unexplained acute congestive heart failure.
Case History
1. Hirst AE, Johns VJ, Kime SW, Dissecting aneurysm of the aorta. A review of 505 cases. Medicine 1958; 37:217-279
2. Harris PD, Malm JR, The management of acute dissection of the thoracic aorta. Am Heart J 1969; 78: 419-422
3. Link MS, Pletrzak MP, Aortic dissection presenting as superior vena cava syndrome. Am J Emerg Med 1994; 12:326-328
4. Januzzi, JL, Eagle KA, Cooper JV, Fang J, Sechtem U, Mymel T, Evangelista A, Oh JK, Llovet A, O'Gara PT, Nienaber CA, Isselbacher EM: Acute aortic dissection presenting with congestive heart failure: results from the International Registry of Acute Aortic Dissection. J AM Coll Cardiol. 2005,46:733-735
5. Sakamoto, H, Watanabe, Y, Sugimori, H, Heart failure due to severe supravalvular aortic stenosis in painless type A aortic dissection. Ann Thorac Surg, 2008, 85: 1441-1443
6. Spier, LN, Hall, MH, Nelson, RL, et al. Aortic dissection: rupture into right ventricle and right pulmonary artery. Ann Thorac Surg,1995, 59: 1017-1019
John Agens
In anticipation of new recommendations from the Institute of Medicine and others, it behooves physicians and healthcare providers to review their knowledge base concerning adequate vitamin D intake for fall and fracture prevention in the elderly. There is enough new data for the Institute of Medicine to consider a new Dietary Reference Intake, or DRI, for vitamin D.1 A recent review by Bischoff-Ferrari et al, of numerous randomized controlled trials of vitamin D supplementation in older persons, concluded that both falls and fractures could be prevented. In addition, a dose-response relationship suggested that the optimal supplementation dose is 700 IU to 1000 IU per day.2 Epidemiologic associations between low vitamin D status and various cancers has led some to recommend balancing risk and benefit of moderate ultraviolet light (UV) exposure against complete UV protection for prevention of skin cancer.3 Others have reviewed the epidemiologic evidence for vitamin D supplementation in treatment of hypertension and prevention of cardiovascular disease.4 These epidemiologic studies are tantalizing, yet the evidence is not sufficient to support a causal relationship in making decisions about vitamin D supplementation for the prevention of cancer and cardiovascular disease. I will limit my editorial comments to preventing falls and fractures.
1. Yetley EA, Brulé D, Cheney MC et al. Dietary reference intakes for vitamin D: justification for a review of the 1997 values. The Am J Clin Nutr. 2009 Mar;89(3):719-727.
Copyright © 2009 BJMP.org

subset: commoncrawl


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184 posts · 64,566 views
Comments on neurobiology, neuroimaging, and psychiatry from a skeptical neuroscientist.
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by Neuroskeptic in Neuroskeptic_Discover
A new paper examines how the brain keeps track of positive and negative outcomes: No unified reward prediction error in local field potentials from the human nucleus accumbens
The authors, London-based neuroscientists Max-Philipp Stenner and colleagues, recorded electrical local field potentials (LFP) using electrodes implanted into the nucleus accumbens (NAcc) in six patients. The patients all suffered from epilepsy and the electrodes were being implanted to treat the disease. The author... Read more »
Stenner MP, Rutledge RB, Zaehle T, Schmitt FC, Kopitzki K, Kowski AB, Voges J, Heinze HJ, & Dolan RJ. (2015) No unified reward prediction error in local field potentials from the human nucleus accumbens: evidence from epilepsy patients. Journal of neurophysiology. PMID: 26019312
by Neuroskeptic in Neuroskeptic_Discover
An amusing editorial in the neuroscience journal Cortex discusses the excuses scientists use to explain why they didn't submit their peer reviews on time:
Following our nagging for late reviews, we learned that one reviewer had to take their cat to the vet, another was busy buying Christmas presents, one was planning their holidays, an unfortunate one had their office broken into [...] others agreed to review whereas indeed they really intended to withdraw, or were just too busy to reply.
Th... Read more »
Della Sala, S. (2015) Author/reviewer: A case of split personality. Cortex. DOI: 10.1016/j.cortex.2015.04.012
by Neuroskeptic in Neuroskeptic_Discover
Last year I blogged about the creepy phenomenon of cyranoids. A cyranoid is a person who speaks the words of another person. With the help of a hidden earpiece, a 'source' whispers words into the ear of a 'shadower' , who repeats them. In research published last year, British psychologists Kevin Corti and Alex Gillespie showed that cyranoids are hard to spot: if you were speaking to one, you probably wouldn't know it, even if the source was an adult and the shadower a child, or vice versa.
... Read more »
Corti, K., & Gillespie, A. (2015) A truly human interface: interacting face-to-face with someone whose words are determined by a computer program. Frontiers in Psychology. DOI: 10.3389/fpsyg.2015.00634
by Neuroskeptic in Neuroskeptic_Discover
Neuroscientists might need to rethink much of what's known about the amygdala, a small brain region that's been the focus of a lot of research. That's according to a new paper just published in Scientific Reports: fMRI measurements of amygdala activation are confounded by stimulus correlated signal fluctuation in nearby veins draining distant brain regions.
The amygdala is believed to be involved in emotion, especially negative emotions such as fear. Much of the evidence for this comes fr... Read more »
Boubela RN, Kalcher K, Huf W, Seidel EM, Derntl B, Pezawas L, Našel C, & Moser E. (2015) fMRI measurements of amygdala activation are confounded by stimulus correlated signal fluctuation in nearby veins draining distant brain regions. Scientific reports, 10499. PMID: 25994551
by Neuroskeptic in Neuroskeptic_Discover
A provocative paper says that neuroscientists who research mental health problems ought to listen to the views of people who have experienced those conditions.
The piece, from Australian authors Anthony Stratford and colleagues, is published in The Psychiatric Quarterly.
Here are some highlights:
Traditionally, mental health consumer [i.e. patient] involvement in research activities has largely been as "subjects"... the passive recipients of research activity... This approach does lit... Read more »
Stratford A, Brophy L, Castle D, Harvey C, Robertson J, Corlett P, Davidson L, & Everall I. (2015) Embedding a Recovery Orientation into Neuroscience Research: Involving People with a Lived Experience in Research Activity. The Psychiatric Quarterly. PMID: 25969424
by Neuroskeptic in Neuroskeptic_Discover
A new study claims that Functional Connectivity in MRI Is Driven by Spontaneous BOLD Events
The researchers, Thomas Allan and colleagues from the University of Nottingham (one of the birthplaces of MRI), say that their results challenge the assumption that correlations in neural activity between 'networks' of brain regions reflect slow, steady low frequency oscillations within those networks. Instead, they report that the network connectivity is the result of occasional 'spikes' of coordinate... Read more »
Allan TW, Francis ST, Caballero-Gaudes C, Morris PG, Liddle EB, Liddle PF, Brookes MJ, & Gowland PA. (2015) Functional Connectivity in MRI Is Driven by Spontaneous BOLD Events. PloS one, 10(4). PMID: 25922945
by Neuroskeptic in Neuroskeptic_Discover
This week has seen a flurry of alarming headlines suggesting that thinking can make brain cancer grow quicker. For example:
HuffPo: Thinking Can Fuel The Growth Of Brain Tumors, Study Finds
Daily Mail: How your THOUGHTS can fuel brain tumours
Nation (Pakistan): Cancer 'hijacks' process of thinking
Well, whoever wrote these headlines is safe, then. The research in question in fact wasn't about thinking. It actually showed that the growth of tumours called gliomas could be increased... Read more »
Venkatesh, H., Johung, T., Caretti, V., Noll, A., Tang, Y., Nagaraja, S., Gibson, E., Mount, C., Polepalli, J., Mitra, S.... (2015) Neuronal Activity Promotes Glioma Growth through Neuroligin-3 Secretion. Cell. DOI: 10.1016/j.cell.2015.04.012
by Neuroskeptic in Neuroskeptic_Discover
After the fall of Nazi Germany, the victorious Allies sought to bring the leaders of the Third Reich to justice in the form of the well-known Nuremberg Trials. Less famous are the attempts by psychologists to understand the Nazi mind in the form of psychological evaluations of the Nuremberg defendants.
A new paper by Joel E. Dimsdale of the University of California San Diego looks at one of the stranger episodes in the aftermath of WW2 - the use of the Rorschach "Inkblot" Test on Nazi de... Read more »
Dimsdale, J. (2015) Use of Rorschach tests at the Nuremberg war crimes trial: A forgotten chapter in history of medicine. Journal of Psychosomatic Research. DOI: 10.1016/j.jpsychores.2015.04.001
by Neuroskeptic in Neuroskeptic_Discover
In a provocative review paper just published, French neuroscientists Jean-Michel Hupé and Michel Dojat question the assumption that synesthesia is a neurological disorder.
In synesthesia, certain sensory stimuli involuntarily trigger other sensations. For example, in one common form of synesthesia, known as 'grapheme-color', certain letters are perceived as allied with, certain colors. In other cases, musical notes are associated with colors, or smells.
The cause of synesthesia is obsc... Read more »
Hupé JM, & Dojat M. (2015) A critical review of the neuroimaging literature on synesthesia. Frontiers in human neuroscience, 103. PMID: 25873873
by Neuroskeptic in Neuroskeptic_Discover
A new paper in Neuroimage suggests that methods for removing head motion and physiological noise from fMRI data might be inadvertently excluding real signal as well.
The authors, Molly G. Bright and Kevin Murphy of Cardiff, studied the technique called nuisance regression. It's a popular approach for removing fMRI noise. Noise reduction is important because factors such as head movement, the heart beat, and breathing, can contaminate the fMRI signal and lead to biased results. Nuisance regres... Read more »
Bright MG, & Murphy K. (2015) Is fMRI "noise" really noise? Resting state nuisance regressors remove variance with network structure. NeuroImage. PMID: 25862264
by Neuroskeptic in Neuroskeptic_Discover
According to a large study just published in the Journal of Autism and Developmental Disorders, there's no correlation between brain anatomy and self-reported autistic traits.
Dutch researchers P. Cedric M. P. Koolschijn and colleagues looked at two samples of young Dutch adults: an 'exploration' sample of 204, and a separate 'validation' group of 304 individuals.
Most of the participants did not have autism. The researchers looked for associations between various aspects of brain ... Read more »
Koolschijn PC, Geurts HM, van der Leij AR, & Scholte HS. (2015) Are Autistic Traits in the General Population Related to Global and Regional Brain Differences?. Journal of autism and developmental disorders. PMID: 25847757
by Neuroskeptic in Neuroskeptic_Discover
A new study published in the journal Neurocase made headlines this week. Headlines like: "Sarcasm Center Found In Brain's White Matter". The paper reports that damage to a particular white matter pathway in the brain, the right sagittal stratum, is associated with difficulty in perceiving a sarcastic tone of voice.
The authors, studied 24 patients who had suffered white matter damage after a stroke. In some cases, the lesions included the sagittal stratum in the right hemisphere, and... Read more »
Davis CL, Oishi K, Faria AV, Hsu J, Gomez Y, Mori S, & Hillis AE. (2015) White matter tracts critical for recognition of sarcasm. Neurocase, 1-8. PMID: 25805326
by Neuroskeptic in Neuroskeptic_Discover
A psychiatry journal, the Journal of Nervous and Mental Disease (JNMD), has just published a remarkable attack on another journal, Frontiers in Psychology. Here's the piece: it's by the JNMD's own Statistics Editor. In it, he writes that:
To be perfectly candid, the reader needs to be informed that the journal that published the Lakens (2013) article, Frontiers in Psychology, is one of an increasing number of journals that charge exorbitant publication fees in exchange for free open access to p... Read more »
Cicchetti DV. (2015) Cognitive Behavioral Techniques for Psychosis: A Biostatistician's Perspective. The Journal of nervous and mental disease, 203(4), 304-5. PMID: 25816048
by Neuroskeptic in Neuroskeptic_Discover
Who discovered autism? Traditionally, the priority has been ascribed to two psychiatrists, Leo Kanner and Hans Asperger, who both published independent but remarkably similar descriptions of the syndrome in 1943 - 44 (although Asperger had released a preliminary description in 1938.)
But according to a new paper in the Nordic Journal of Psychiatry, both Kanner and Asperger were scooped by nearly two decades - by a Soviet child psychiatrist, Grunya Efimovna Sukhareva. She described a syn... Read more »
Manouilenko I, & Bejerot S. (2015) Sukhareva - Prior to Asperger and Kanner. Nordic Journal of Psychiatry, 1-4. PMID: 25826582
by Neuroskeptic in Neuroskeptic_Discover
In the Journal of Personality, a new study reports on the uniformity of human experience around the globe: The World at 7: Comparing the Experience of Situations Across 20 Countries
The research was an online survey of a total of 5447 people. Each participant was asked to think about what happened the previous evening at 7 pm. Then they were asked to describe the 7 pm scene by means of 89 statements (descriptors), which included things like: "Rational thinking is called for.", "Situation ra... Read more »
Guillaume E, Baranski E, Todd E, Bastian B, Bronin I, Ivanova C, Cheng JT, de Kock FS, Denissen JJ, Gallardo-Pujol D.... (2015) The World at 7: Comparing the experience of situations across 20 countries. Journal of personality. PMID: 25808415
by Neuroskeptic in Neuroskeptic_Discover
Modern winemakers may have erred when they switched to producing high alcohol wines. According to a new paper, from Spanish neuroscientists Ram Frost and colleagues, a low alcohol content wine actually produces more brain activity in 'taste processing' areas than more alcoholic varieties do.
But what does the brain really have to say about Beaujolais? Can scanning help us pick a Sauvignon? Will neuroimaging reveal the secret to a good... er... Nero d'Avola?
In their paper, publishe... Read more »
Frost R, Quiñones I, Veldhuizen M, Alava JI, Small D, & Carreiras M. (2015) What Can the Brain Teach Us about Winemaking? An fMRI Study of Alcohol Level Preferences. PloS one, 10(3). PMID: 25785844
by Neuroskeptic in Neuroskeptic_Discover
According to a new study from Chinese neuroscientists Fan Xu and colleagues, some monkeys can experience depression in a similar way to humans.
The researchers studied cynomolgus monkeys, also known as crab-eating macaques (Macaca fascicularis), a species native to Southeast Asia. Cynomolgus monkeys are highly social animals. Xu et al. previously showed that isolating a monkey from its companions caused it to develop depression-like behaviors. In their new paper, the authors say that they'v... Read more »
Xu F, Wu Q, Xie L, Gong W, Zhang J, Zheng P, Zhou Q, Ji Y, Wang T, Li X.... (2015) Macaques exhibit a naturally-occurring depression similar to humans. Scientific reports, 9220. PMID: 25783476
by Neuroskeptic in Neuroskeptic_Discover
When should scientists apply for grants? Does spending more time writing applications pay off in the long run? A paper published in PLoS ONE this week examined the eternal question: To apply or not to apply?
The authors, Ted and Courtney von Hippel, start out by noting that most major grant awards are highly competitive - with success rates of just 20% in the case of US federal NIH and NSF awards. What's more, although decisions are made by a panel of expert judges, the evidence is th... Read more »
von Hippel T, & von Hippel C. (2015) To apply or not to apply: a survey analysis of grant writing costs and benefits. PloS one, 10(3). PMID: 25738742
by Neuroskeptic in Neuroskeptic_Discover
According to a new paper, one of neuroscience's most famous case-studies came about as a result of a serious medical blunder.
Henry Molaison (1926 - 2008), better known as HM, was an American man who developed a dramatic form of amnesia after receiving surgery that removed part of the temporal lobes of his brain. The 1953 operation was intended to treat HM's epilepsy, but it had the side effect of leaving him unable to form new memories.
The consequences of HM's surgery are well known ... Read more »
Mauguière F, & Corkin S. (2015) H.M. never again! An analysis of H.M.'s epilepsy and treatment. Revue neurologique. PMID: 25726355
by Neuroskeptic in Neuroskeptic_Discover
Multi-voxel pattern analysis (MVPA) is an increasingly popular approach for analyzing the results of fMRI scanning experiments that measure brain activity. MVPA searches for patterns of activation that correlate with a particular mental state. This is called 'decoding' neural activity.
Now a new paper in the Journal of Neuroscience from Caltech neuroscientists Julien Dubois et al. reports that MVPA is unable to decode certain kinds of information, even though single-unit recordings confirm th... Read more »
Dubois J, de Berker AO, & Tsao DY. (2015) Single-Unit Recordings in the Macaque Face Patch System Reveal Limitations of fMRI MVPA. The Journal of neuroscience : the official journal of the Society for Neuroscience, 35(6), 2791-802. PMID: 25673866
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Content type:
Stage 1&2
Stage 2&3
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Stage 4&5
Challenge level:
Explore when it is possible to construct a circle which just
touches all four sides of a quadrilateral.
Which has the greatest area, a circle or a square inscribed in an
isosceles, right angle triangle?
What is the same and what is different about these circle
questions? What connections can you make?
The area of a square inscribed in a circle with a unit radius is,
satisfyingly, 2. What is the area of a regular hexagon inscribed in
a circle with a unit radius?
A circle is inscribed in a triangle which has side lengths of 8, 15
and 17 cm. What is the radius of the circle?
If the hypotenuse (base) length is 100cm and if an extra line
splits the base into 36cm and 64cm parts, what were the side
lengths for the original right-angled triangle?
A square of area 40 square cms is inscribed in a semicircle. Find
the area of the square that could be inscribed in a circle of the
same radius.
Can you maximise the area available to a grazing goat?
A spider is sitting in the middle of one of the smallest walls in a
room and a fly is resting beside the window. What is the shortest
distance the spider would have to crawl to catch the fly?
A napkin is folded so that a corner coincides with the midpoint of
an opposite edge . Investigate the three triangles formed .
Can you find rectangles where the value of the area is the same as the value of the perimeter?
My two digit number is special because adding the sum of its digits to the product of its digits gives me my original number. What could my number be?
If it takes four men one day to build a wall, how long does it take
60,000 men to build a similar wall?
Start with two numbers. This is the start of a sequence. The next
number is the average of the last two numbers. Continue the
sequence. What will happen if you carry on for ever?
The diagonals of a trapezium divide it into four parts. Can you
create a trapezium where three of those parts are equal in area?
Two ladders are propped up against facing walls. The end of the
first ladder is 10 metres above the foot of the first wall. The end
of the second ladder is 5 metres above the foot of the second. . . .
Can you see how to build a harmonic triangle? Can you work out the next two rows?
Imagine a large cube made from small red cubes being dropped into a
pot of yellow paint. How many of the small cubes will have yellow
paint on their faces?
If you have only 40 metres of fencing available, what is the maximum area of land you can fence off?
Square numbers can be represented as the sum of consecutive odd
numbers. What is the sum of 1 + 3 + ..... + 149 + 151 + 153?
Have a go at creating these images based on circles. What do you notice about the areas of the different sections?
Triangle ABC is isosceles while triangle DEF is equilateral. Find
one angle in terms of the other two.
There are four children in a family, two girls, Kate and Sally, and
two boys, Tom and Ben. How old are the children?
Five children went into the sweet shop after school. There were
choco bars, chews, mini eggs and lollypops, all costing under 50p.
Suggest a way in which Nathan could spend all his money.
A 2 by 3 rectangle contains 8 squares and a 3 by 4 rectangle
contains 20 squares. What size rectangle(s) contain(s) exactly 100
squares? Can you find them all?
Different combinations of the weights available allow you to make different totals. Which totals can you make?
Can you find an efficient method to work out how many handshakes
there would be if hundreds of people met?
Two motorboats travelling up and down a lake at constant speeds
leave opposite ends A and B at the same instant, passing each
other, for the first time 600 metres from A, and on their return,
400. . . .
Imagine you have a large supply of 3kg and 8kg weights. How many of each weight would you need for the average (mean) of the weights to be 6kg? What other averages could you have?
This shape comprises four semi-circles. What is the relationship
between the area of the shaded region and the area of the circle on
AB as diameter?
Can you find the area of a parallelogram defined by two vectors?
Can all unit fractions be written as the sum of two unit fractions?
A country has decided to have just two different coins, 3z and 5z
coins. Which totals can be made? Is there a largest total that
cannot be made? How do you know?
Why does this fold create an angle of sixty degrees?
In a three-dimensional version of noughts and crosses, how many winning lines can you make?
Manufacturers need to minimise the amount of material used to make
their product. What is the best cross-section for a gutter?
It is known that the area of the largest equilateral triangular
section of a cube is 140sq cm. What is the side length of the cube?
The distances between the centres of two adjacent faces of. . . .
Explore the effect of combining enlargements.
Explore the effect of reflecting in two parallel mirror lines.
Sissa cleverly asked the King for a reward that sounded quite modest but turned out to be rather large...
A 1 metre cube has one face on the ground and one face against a
wall. A 4 metre ladder leans against the wall and just touches the
cube. How high is the top of the ladder above the ground?
Can you find six numbers to go in the Daisy from which you can make all the numbers from 1 to a number bigger than 25?
Many numbers can be expressed as the sum of two or more consecutive integers. For example, 15=7+8 and 10=1+2+3+4. Can you say which numbers can be expressed in this way?
What size square corners should be cut from a square piece of paper to make a box with the largest possible volume?
Do you notice anything about the solutions when you add and/or
subtract consecutive negative numbers?
Four bags contain a large number of 1s, 3s, 5s and 7s. Pick any ten
numbers from the bags above so that their total is 37.
Is it always possible to combine two paints made up in the ratios
1:x and 1:y and turn them into paint made up in the ratio a:b ? Can
you find an efficent way of doing this?
A decorator can buy pink paint from two manufacturers. What is the
least number he would need of each type in order to produce
different shades of pink.
A game for 2 or more people, based on the traditional card game
Rummy. Players aim to make two `tricks', where each trick has to
consist of a picture of a shape, a name that describes that shape,
and. . . .
Can you describe this route to infinity? Where will the arrows take you next?


text:
* Platform: Android
* Genre: Puzzle
Smart Ball is a logic and strategic video game in which the ball has to reach the end of the path. In order to do that, you should strategically place the pieces in each level. The videogame has 21 different pieces, 100 levels with raising difficulty and 5 worlds. Moreover, you have a scenario editor where you can create your own levels and play it, save in your device or share them with others and see if they can beat your level.
* 5 Worlds
* 100 Levels
* 6 Diferent Scenarios
* 21 Diferent Pieces
* HD Game
* Nice Music
* Full Level Editor
Edited by DevioGames, 12 February 2012 - 02:44 PM.


text:
News from WTOP
News from the AP
Mike Causey
Shows & Panels
Shows & Panels
- Agency of the Month
- Business of Government Hour
- The CFO Agenda: Delivering value from financial transparency and audit efforts in the public and private sector
- Cloud-Driven Data Insights in Government
- CXO Surveys
- Disaster Resilience for America
- Federal News Countdown
- Government Perspectives on Mobility and the Cloud
- Reducing Risk in the Cloud
- Reimagining the Next Generation of Government
Shows & Panels
- AFCEA Answers
- American Readiness: Renewable Power and Efficiency Technologies
- Ask the CIO
- The Business Case for Cloud Computing in Government
- Cloud-Driven Data Insights in Government
- Connecting the Dots: Digital Authentication in Government
- Cybersecurity Game Changer: Real-Time Event Processing in Government
- Data-Centric Approaches to Government in the Cloud
- Delivering the Digital Government Mission
- Federal Executive Forum
- Federal News Radio's National Cyber Security Awareness Month Special Panel Discussion
- Federal Tech Talk
- The Future of Government Data Centers
- Government Perspectives on Mobility and the Cloud
- Industrialized, Interoperable and Insight-driven Federal Health Panel
- Innovation and Tech Superiority through Acquisition Reform
- Mitigating Insider Threats in Virtual & Cloud Environments
- Moving Agency Applications to the Cloud with PaaS
- Reducing Risk in the Cloud
- Security in the Age of Targeted Attacks
- Air Traffic Management Transformation Report
- The Business of Cloud
- Cloud First Report
- Data Driven Cloud Series
- Disaster Resilience for America
- General Dynamics IT Enterprise Center
- Gov Cloud Minute
- Government in Technology Series
- Homeland Security Cybersecurity Market Report
- The Intersection: Where Technology Meets Transformation
- Modern Mission Critical Series
- National Cybersecurity Awareness Month
- The New IP for Federal IT
- The Social Platform Solution for the Department of Veterans Affairs
- Technology Insights
- The Cyber Security Report
- The Next Generation Cyber Security Experts
Shows & Panels
- Cloud-Driven Data Insights in Government
- Disaster Resilience for America
- F-35 Lightning II Program
- Government Perspectives on Mobility and the Cloud
- On DoD
- Pentagon Solutions
- Reducing Risk in the Cloud
- Reimagining the Next Generation of Government
- Transforming Business Operations at the Defense Department
150 Years at GPO
March 4, 1861 was a day of two inaugurations - Abraham Lincoln took office and the Government Printing Office opened for business. In our special report, 150 Years at GPO, Federal News Radio examines GPO's technological evolution over the years. We also take a multimedia tour inside GPO's plant operations where the agency prints the Congressional Record and Federal Register.
GPO exhibit features draft of Emancipation Proclamation
Wednesday - 6/15/2011, 5:40pm EDT
By Jolie Lee
Federal News Radio
An exhibit opening June 22 to the public features 150 years of work by the Government Printing Office, including an original preliminary copy of the Emancipation Proclamation.
The copy was printed by GPO in September 1862 and bears faint penciled corrections. Most likely the marks were made by GPO proofreaders. Those corrections were incorporated into the final Proclamation, issued in January 1863.
The preliminary Proclamation is on loan from the Library of Congress through the end of the year.
GPO had printed 15,000 preliminary versions for the War Department, which were distributed to commanders, troops and diplomats.
The exhibit - entitled "Keeping America Informed: United States Government Printing Office: 150 Years of Service to the Nation" - coincides with the printing of a retrospective book detailing the agency's history.
According to the book, the significance of the document was evident in a letter then-Public Printer John Defrees wrote to President Abraham Lincoln's secretary, "Only a few events stand out prominently on the page of the history of each century ... The proposed proclamation of the President will be that one of this century."
Check out the rest of the 150 Years at GPO series.
- Inside GPO's printing plant [Audio slideshow included]
- GPO evolves from printing press to digital platform [Photo gallery included]
- Timeline of GPO's history [Interactive timeline]
- Making of the Congressional Record [Graphic]


text:
Limar 747 Helmet
|(2 Reviews)
Product DescriptionOur design department developed a fantastically shaped structure to keep it strong enough for tough MTB riding, but yet very compact to look stylish on the head. With a panache that could only come from Italy, our designers have integrated the front peak within the overall design. The close fit and the super system make sure it sits firmly and lots of vents from different angles keep your head cool.
Review Options: Sorted by Latest Review | Sort by Best Rating
|Reviews 1 - 2 (2 Reviews Total)
User Reviews
Date Reviewed: June 29, 2009
Strengths: Very confortable(no pinch chin strap)all cushions have felt, Quick sizing dial adjuster, very light weight, 24 vents are acceptable for air flow on hot days(tested). Outpreforms the Giro's Indicator and is better looking.
Weaknesses: Non-multi impact helmet. Limited helmet colors.
Bottom Line:
Expand full review >>
Duration Product Used: 6 months
Price Paid: $39.00
Purchased At: ebay
Similar Products Used: Giro Indicator
Bike Setup: Schwinn Mesa GS 2007
Date Reviewed: February 24, 2009
Strengths: Comfortable, breathable, tough, nice look
Weaknesses: Forehead pad acts like a sponge to soak up sweat but unleashes all over your face when compressed
Bottom Line:
Expand full review >>
Duration Product Used: 3 months
Price Paid: $35.00
Purchased At: Ebay
Similar Products Used: None
Bike Setup: 08 Fisher Wahoo Disc - stock
|Reviews 1 - 2 (2 Reviews Total)
Review Options: Sorted by Latest Review | Sort by Best Rating
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text:
Andrew Shaw's hit on Mike Smith(suspended 3 games)
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Originally Posted by
69.4 Contact Outside the Goal Crease - If an attacking player initiates any contact with a goalkeeper, other than incidental contact, while the goalkeeper is outside his goal crease, and a goal is scored, the goal will be disallowed.
A goalkeeper is not fair game just because he is outside the goal crease. The appropriate penalty should be assessed in every case where an attacking player makes unnecessary contact with the goalkeeper. However, incidental contact will be permitted when the goalkeeper is in the act of playing the puck outside his goal crease provided the attacking player has made a reasonable effort to avoid such unnecessary contact.
~~ Two elements here: 1) Initiating contact, 2) Unnecessary contact. Shaw did not initiate contact, the contact was incidental. Both Smith and Shaw were in the act of make a play on/or for the puck. The question then becomes was the contact unnecessary? Well in what sense? Shaw has the right to make a play for the puck, Smith is in the act of completing a pass and his stick is coming up... Shaw is not braced to intentionally hit Smith and flinches up as Smith's stick is coming through, as would any player. Now from the strong side view, yes I would agree it is shoulder to chin but when I look at the other views, particularly an overhead view it looks like helmet to helmet. There is no shoulder thrust into Smith, no elbow and Shaw is not bracing or focusing on Smith. Shaw has every right to make a play for the puck. It's an interesting situation which is complicated by the fact that Smith finished the game. Again, I would seriously question the leadership and medical staff of the Coyotes if they left him in knowing he was injured. Folks, anyone that's been concussed knows that it is very difficult to do basic motor skills tasks after having your brain slammed into your skull. There's headaches, nausea, vomiting, balance issues. He could not have gone on to have the game he did if he was concussed. Even if the argument was that it takes time for the symptons to develop. No way. He played 40+ mins after that of professional level hockey. His lateral movement was un-affected, his positioning was solid and he made some key saves requiring quick reflex. If it is a neck strain or something along those lines, yes perhaps he could play through that. A concussion, no and shame on the staff for not protecting their player if he was exhibiting concussion "like" symptons.
Unless you are a doctor I doubt your opinion on concussions and how soon symptoms set in is worth anything to be honest.
I honestly don't care though. If it means anything to you I will call on a public shaming to the Coyote medical crew.
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text:
We have some quick questions that we hope someone here can answer for us. Does Hexagon 2.5 have a tool that is the equivalent of a Bevel Tool? If so, what would it be? And also, is there a "Split" tool, or something that is similar? We're still learning the tools in this program but haven't been able to decipher what these would be.
Any help would be greatly appreciated. Thanks in advance.


text:
US, African scientists seek biotech answer to hunger
By Carey Gillam
KANSAS CITY, Missouri (Reuters) – As he pores over plant tissue and petri dishes in a biotech seed lab in Johnston, Iowa, Luke Mehlo is half a world away from his home in South Africa.
But though the corn fields of Iowa bear little resemblance to the arid plains of Africa, the research center where Mehlo toils has become home to a unique joint venture that is merging African agricultural interests with U.S. money and technology.
The goal is to turn sorghum — a common U.S. row crop used in animal feed, cereals and industrial products — into a plant that can not only weather devastating drought but also yield a rich blend of vitamins and minerals. Researchers believe such a combination could help combat the hunger and malnutrition ravaging parts of Africa.
"A lot of people have died on the African continent, quite unnecessarily," said Mehlo, a molecular biotechnologist who came to Iowa from South Africa in October. "We seek to have a crop that will enable us to survive during disasters and food shortages."
Mehlo is one of a team of African scientists who will be working in Iowa over the next three years, tinkering with the genes of sorghum seeds.
An estimated 300 million people in arid regions of Africa rely on sorghum as a food source along with other crops. But while conventional sorghum is already known to do well in drought conditions, it lacks certain key nutrients.
By taking genes from other crops as well as manipulating genes within the sorghum plant itself, scientists believe they can remake sorghum into a more easily digestible crop richer in vitamins A and E, iron, zinc and amino acids and protein.
Pioneer Hybrid International, a subsidiary of Dupont, is a key U.S. partner and the sole commercial player in the endeavor. Pioneer has donated $4.8 million in gene technology, and is lending manpower and facilities for visiting African scientists at its Johnston headquarters.
"Africa is a place where biotechnology is necessary," said Dean Oestreich, President of Pioneer Hi-Bred International Inc. "It would be a big step to take and make a food crop more nutritious for people in Africa."
The patented technology donated by Pioneer has already shown feasibility in corn seeds, making successful genetic changes in sorghum likely as well, according to Paul Anderson, a Pioneer grain manager and a member of the oversight committee for the "African Biofortified Sorghum" project.
Still, it is expected to take eight years and a second round of funding before a specialized seed is ready for market.
Pioneer will have no rights to revenues from the biotech sorghum once it is developed and commercialized, said Anderson. But the company, already locked into tight competition in the commercial seeds market, hopes that success with biotech sorghum might help open doors for other biotech crops in countries currently skeptical of genetically altered crops.
Chief funding for the project comes from the Bill & Melinda Gates Foundation in partnership with the National Institutes of Health. The foundation last summer awarded a $16.9 million grant for the project, making it the largest of four grants handed out by the foundation for the improvement of food through technology.
"Sorghum is a huge staple throughout the world, particularly in Africa where people suffer from some of the worst conditions," said Carol Dahl, director of the foundation's global health technologies group.
Indeed, millions of people in Africa are currently suffering starvation and malnutrition as extended drought and baking heat strip them of food and water.
Along with the sorghum project, the Gates group is funding projects aimed at creating more nutritious bananas, cassava and rice as part of a total of $450 million in grants for improved nutrition, disease prevention and treatment, Dahl said.
Biotech sorghum and other crops are not expected to eradicate the devastation caused by drought, but they could partly ease the pain, researchers believe.
"We have to wait… until we have a complete story," said Mehlo. "But we are already ahead of schedule and we have materials that are very very promising. There is so much light at the end of the tunnel."