Extensive Postpartum Upper and Lower Extremity Deep Vein Thrombosis in a Patient With a History of Preeclampsia.

We describe the case of a 19-year-old woman with no significant medical history who developed progressive right-sided neck pain and palpitations one month following a pregnancy complicated by preeclampsia. Family history was significant for unprovoked deep vein thrombosis (DVT) and pulmonary embolism (PE) in her father at age 44. Systemic examination revealed mild swelling of the right upper extremity with pain on palpation. Computed tomography (CT) of the thorax with contrast demonstrated extensive occlusion of right upper extremity veins and collateralization of chest wall veins. Pulmonary emboli were present bilaterally in the segmental and subsegmental branches of the lower lobe pulmonary arteries. CT of the abdomen with contrast revealed thrombi in the left common and external iliac veins. Thrombophilia screening was normal. The patient was treated with enoxaparin and ampicillin/sulbactam. Her clinical condition improved, and she was discharged with an outpatient clinic follow-up appointment.

Tortuous Carotid Arteries and Their Clinical Implications: A Report of Two Cases.

The tortuous carotid artery is a rare anatomic abnormality defined as vascular elongation leading to an altered course. It can be discovered incidentally or have clinically significant manifestations. The most common location is the internal carotid artery or, less commonly, the common carotid artery. Bilateral tortuous carotid arteries can also occur, leading to "kissing carotids" where the carotid arteries are juxtaposed. We describe two cases of carotid artery tortuosity in patients with risk factors associated with its development. One case is of a 91-year-old female presenting with a cerebrovascular accident and an incidental finding of tortuosity of the right common carotid artery mimicking the appearance of "kissing carotids." The other case concerns a 66-year-old female with a symptomatic tortuous left internal carotid artery. This report aims to inform clinicians of the differences in the anatomical features, pathogenesis, and possible clinical implications of these variants.

Acute amnesia caused by left fornix infarction: A case report of an unusual entity.

Cerebral infarction is an uncommon and unusual cause of acute amnesia. The fornix is a white matter tract bundle that plays an important function in memory. We present the case of a 60-year-old male presenting with altered mental status and acute onset amnesia with CT and MR imaging demonstrating an acute left fornix infarct. This case serves to further illuminate the findings associated with this uncommon clinical event. In addition, it highlights the importance for physicians across multiple subspecialities to maintain an index of suspicion for fornix infarct in the evaluation of acute onset amnesia.

Telephone reminders reduce no-shows: A quality initiative at a breast imaging center.

PURPOSE: To improve the workflow and productivity at a Breast Imaging Center, primarily by decreasing the no-show rate. MATERIALS AND METHODS: Mammography clinic data were recorded and analyzed for a 6-month period prior to our intervention. Personal pre-appointment phone calls were then instituted for all patients, following which data was recorded and analyzed for a 2-month period. Analyses compared pre- and post-intervention data. RESULTS: No-shows were significantly reduced (p < 0.001) from 20.99% (907/3775) pre-intervention to 7.07% (69/976) post-intervention. Calling ahead to cancel an appointment from those who either were no-shows or canceled their appointment significantly improved (p < 0.001) from only 2.81% (22/784) calling to cancel pre-intervention to 25.00% (23/92) calling to cancel post-intervention. CONCLUSIONS: Through systematic pre-appointment phone calls and documentation, we were able to achieve a very significant decrease in the no-show rate at our Breast Imaging Center. We believe that our intervention can be useful for other radiology groups to implement in their practices to reduce no-show rates.

Parkinsonism in a Patient with Human T-lymphotropic Virus 1 Myelopathy.

Human T-lymphotropic virus 1 (HTLV-1) infection is commonly associated with neurological conditions like chronic progressive myelopathy and tropical spastic paraparesis (TSP) but rarely also reported with polymyositis, multiple sclerosis, and parkinsonism. It is important to recognize that HTLV-1 infection increases the risk of these neurological conditions. We present a case of 71-year-old female with HTLV-1 associated chronic progressive myelopathy with parkinsonism which signifies that it is under-recognized and not frequently reported due to lack of expert neurological assessment in these chronically debilitated patients.

The cervical spine can be cleared without MRI after blunt trauma:A retrospective review of a single level 1 trauma center experience over 8 years.

BACKGROUND: The newest CT scanners provide resolution comparable to MRIs leading many to question when and whether cervical spine MRIs are warranted. METHODS: An 8 year retrospective review identified 241 patients who underwent CT scan and MRI of the cervical spine. The initial clinical examination, cervical spine CT scan, and cervical spine MRI were compared to identify cervical spine injuries that would have been missed had the MRI not been performed. RESULTS: The CT scans were normal in 153 patients, and abnormal in 88. Of the 88 abnormal CT scans, the MRIs were abnormal in 65, and normal in the other 23. The indications for MRI in patients with normal CT scans were neck pain, an abnormal neurologic examination, and/or altered mental status. Of the 13 patients with abnormal MRIs, none were pain free with a normal clinical examination. CONCLUSION: In the absence of focal signs of neurologic injury, the cervical spine can be cleared without a clinical exam or MRI if the cervical CT scan does not demonstrate injury or abnormality.

Influence of Modern Stormwater Management Practices on Transport of Road Salt to Surface Waters.

Application of road salts in regions with colder climates is leading to ground and surface water contamination. However, we know little about how modern stormwater management practices affect the movement of road salt through urban watersheds. We investigated groundwater contamination and transport of road salts at two stormwater ponds in Baltimore County, Maryland. In association with the ponds, we documented a plume of contaminated groundwater that resulted in Cl- loadings to the adjacent stream of 6574 to 40 008 kg Cl- per winter, depending on winter snowfall. We also monitored Na+ and Cl- ion concentrations and the temporal dynamics of conductivity at a range of stream sites in watersheds with and without stormwater management ponds. Streams draining watersheds with stormwater ponds had consistently higher conductivities and Cl- concentrations during base flow conditions and often exhibited greater peaks in Cl- and conductivity associated with winter storms and subsequent melting events, despite the degree of watershed development. Our results indicate that modern stormwater management practices are not protecting surface waters from road salt contamination and suggest they create contaminated plumes of groundwater that deliver Cl- and Na+ to streams throughout the year.

Bioretention storm water control measures decrease the toxicity of copper roof runoff.

The present study evaluated the ability of 2 different bioretention storm water control measures (SCMs), planter boxes and swales, to decrease the toxicity of sheet copper (Cu) roofing runoff to Daphnia magna. The present study quantified changes in storm water chemistry as it passed through the bioretention systems and utilized the biotic ligand model (BLM) to assess whether the observed D. magna toxicity could be predicted by variations found in water chemistry. Laboratory toxicity tests were performed using select storm samples with D. magna cultured under low ionic strength conditions that were appropriate for the low ionic strength of the storm water samples being tested. The SCMs decreased toxicity of Cu roof runoff in both the BLM results and the storm water bioassays. Water exiting the SCMs was substantially higher than influent runoff in pH, ions, alkalinity, and dissolved organic carbon and substantially lower in total and dissolved Cu. Daphnids experienced complete mortality in untreated runoff from the Cu roof (the SCM influent); however, for planter and swale effluents, survival averaged 86% and 95%, respectively. The present study demonstrated that conventional bioretention practices, including planter boxes and swales, are capable of decreasing the risk of adverse effects from sheet Cu roof runoff to receiving systems, even before considering dilution of effluents in those receiving systems and associated further reductions in copper bioavailability. Environ Toxicol Chem 2017;36:1680-1688. © 2016 SETAC.

Attenuation of copper in runoff from copper roofing materials by two stormwater control measures.

Concerns have been raised over diffuse and non-point sources of metals including releases from copper (Cu) roofs during storm events. A picnic shelter with a partitioned Cu roof was constructed with two types of stormwater control measures (SCMs), bioretention planter boxes and biofiltration swales, to evaluate the ability of the SCMs to attenuate Cu in stormwater runoff from the roof. Cu was measured as it entered the SCMs from the roof as influent as well as after it left the SCMs as effluent. Samples from twenty-six storms were collected with flow-weighted composite sampling. Samples from seven storms were collected with discrete sampling. Total Cu in composite samples of the influent waters ranged from 306 to 2863 µg L(-1) and had a median concentration of 1087 µg L(-1). Total Cu in the effluent from the planter boxes ranged from 28 to 141 µg L(-1), with a median of 66 µg L(-1). Total Cu in effluent from the swales ranged from 7 to 51 µg L(-1) with a median of 28 µg L(-1). Attenuation in the planter boxes ranged from 85 to 99% with a median of 94% by concentration and in the swales ranged from 93 to 99% with a median of 99%. As the roof aged, discrete storm events showed a pronounced first-flush effect of Cu in SCM influent but this was less pronounced in the planter outlets. Stormwater retention time in the media varied with antecedent conditions, stormwater intensity and volume with median values from 6.6 to 73.5 min. Based on local conditions, a previously-published Cu weathering model gave a predicted Cu runoff rate of 2.02 g m(-2) yr(-1). The measured rate based on stormwater sampling was 2.16 g m(-2) yr(-1). Overall, both SCMs were highly successful at retaining and preventing offsite transport of Cu from Cu roof runoff.

Case 209: Disseminated coccidioidal spondylodiskitis.

History A 46-year-old Hispanic man with a medical history of diabetes and hepatitis C and an unclear history of prior infectious disease presented to the emergency department of a community medical center in the northeastern United States with a 3-month history of back pain. The patient was originally from Mexico and had been living in the United States for approximately 1 year. Physical examination at the time of admission was noncontributory. Pertinent hematologic laboratory test results were as follows: white blood cell count, 11.2 ×10(9)/L (normal range, [4.5-11.0] ×10(9)/L); neutrophil level, 81.3% (0.81) (normal range, 38.9%-75.1% [0.39-0.75]); hemoglobin level, 7.9 g/dL (normal range, 13.5-18.0 g/dL); hematocrit level, 23.2% (0.23) (normal range, 40.0%-54.0% [0.40-0.54]); and calcium level, 8.3 mg/dL (2.07 mmol/L) (normal range, 8.4-10.4 mg/dL [2.1-2.6 mmol/L]). Protein electrophoresis revealed hypergammaglobulinemia consistent with chronic inflammation. Relevant radiologic studies included computed tomography (CT) and magnetic resonance (MR) imaging of the spine.

STAT--how to make every minute count.

Several years ago, our community teaching hospital identified a need to improve patient care by streamlining the study performance workflow and hastening communication of critical study results to clinicians. "STAT" studies are a carefully selected subset of imaging studies that are prioritized due to their utility in assessing for emergent conditions including cerebrovascular accidents, pneumoperitoneum, and cardiac arrest. We describe the multiyear process of data collection, analysis, and departmental and hospital-wide system changes that significantly improved result times. Relatively simple policy changes, such as the distribution of STAT beepers to the team members and creating color-coded worklists, drastically reduced delays.

An enriched stable isotope technique to estimate the availability of soil zinc to Lumbricus terrestris (L.) across a salinization gradient.

An enriched stable isotope approach was developed to evaluate Zn bioavailability to Lumbricus terrestris. The decrease in (68)Zn/(66) Zn in organ tissues was used to assess the relative magnitude of the bioavailable soil Zn pool. This tool was then used to specifically evaluate bioavailability as a function of soil cation distribution. Storm-water pond soils were modified using two treatment regimens whereby H(2)O-extractable Zn was varied either by different ZnCl(2) amendments or by constant ZnCl(2) amendment followed by varying the soil cation distribution through salt amendments (NaCl or CaCl(2)). Earthworms previously equilibrated in (68) Zn-spiked soil were introduced to experimental soils, and after 2 d, removed for analysis of isotopic ratios in specific tissues. Despite a wide range of H(2)O-extractable Zn values produced by the salt treatments (0.007-24.3 mg/kg), a significant relationship between Zn turnover rate in earthworm tissues and H(2)O-extractable Zn in the salt-treated soils was not observed. Rather, considering both treatment regimens, turnover rate better correlated with Zn present in broader pools, such as that extracted by 6M HNO(3). The bioavailability of trace metals to earthworms may be poorly characterized by loosely bound fractions such as the pore water. Additionally, the turnover rate of (68)Zn in anterior organ tissues may be an effective tool to evaluate the relative magnitude of the bioavailable soil Zn pool.

Effects of zinc exposure on earthworms, Lumbricus terrestris, in an artificial soil.

Earthworms have the potential to act as trophic links for pollutants that accumulate in urban soils. However, many pollutants may act as micronutrients at low concentrations and toxins at higher concentration. When pollutants are also micronutrients, bioaccumulations may initially increase trophic transfer as pollutant concentration increase, but at higher levels toxic effects may limit population size and the potential for trophic transfer. We found support for this model among earthworms exposed to a range of soil Zn levels. Worms showed increasing bioaccumulation of Zn with increasing Zn soil concentrations, but at higher Zn levels worm growth rates decreased.

Chemical fractionation of Cu and Zn in stormwater, roadway dust and stormwater pond sediments.

This study evaluated the chemical fractionation of Cu and Zn from source to deposition in a stormwater system. Cu and Zn concentrations and chemical fractionation were determined for roadway dust, roadway runoff and pond sediments. Stormwater Cu and Zn concentrations were used to generate cumulative frequency distributions to characterize potential exposure to pond-dwelling organisms. Dissolved stormwater Zn exceeded USEPA acute and chronic water quality criteria in approximately 20% of storm samples and 20% of the storm duration sampled. Dissolved Cu exceeded the previously published chronic criterion in 75% of storm samples and duration and exceeded the acute criterion in 45% of samples and duration. The majority of sediment Cu (92-98%) occurred in the most recalcitrant phase, suggesting low bioavailability; Zn was substantially more available (39-62% recalcitrant). Most sediment concentrations for Cu and Zn exceeded published threshold effect concentrations and Zn often exceeded probable effect concentrations in surface sediments.

Impacts of weathered tire debris on the development of Rana sylvatica larvae.

Highway runoff has the potential to negatively impact receiving systems including stormwater retention ponds where highway particulate matter can accumulate following runoff events. Tire wear particles, which contain about 1% Zn by mass, make up approximately one-third of the vehicle derived particulates in highway runoff and therefore may serve as a stressor to organisms utilizing retention ponds as habitat. In this study, we focused on the potential contribution of tire debris to Zn accumulation by Rana sylvatica larvae and possible lethal or sublethal impacts resulting from exposure to weathered tire debris during development. Eggs and larvae were exposed to aged sediments (containing either ZnCl2 or tire particulate matter, both providing nominal concentrations of 1000 mg Zn kg(-1)) through metamorphosis. Water column Zn was elevated in both the ZnCl2 and tire treatments relative to the control treatment, indicating that aging allowed Zn leaching from tire debris to occur. Tissue Zn was also elevated for the ZnCl2 and tire treatments indicating that Zn in the treatments was available for uptake by the amphibians. Exposure to both ZnCl2 and tire treatments increased the time for larvae to complete metamorphosis in comparison with controls. We also observed that the longer the organisms took to complete metamorphosis, the smaller their mass at metamorphosis. Our results indicate that Zn leached from aged tire debris is bioavailable to developing R. sylvatica larvae and that exposure to tire debris amended sediments can result in measurable physiological outcomes to wood frogs that may influence population dynamics.