Intracranial Hemorrhage and Facial Fractures After Nose Blowing and Sternutation: A Case Report.

INTRODUCTION: Blowing the nose and sneezing are ubiquitous physiologic processes. While exceedingly rare, traumatic injuries have been described. We detail a case of spontaneous intracranial hemorrhage and orbital fractures sustained as a result of these two phenomena in an otherwise healthy adult without known risk factors for bleeding or intracranial hemorrhage. CASE REPORT: A 79-year-old female presented to the emergency department after blowing her nose with an episode of sneezing following mild epistaxis. She denied any history of trauma, anticoagulation use, bleeding disorders, or pain associated with her symptoms. On examination, she had notable right periorbital swelling. Computed tomography revealed multiple areas of intracranial hemorrhage along with right-sided orbital and zygomatic fractures. After consulting trauma surgery and neurosurgery, we elected to pursue conservative management with repeat imaging. The patient had an uneventful course and was discharged with outpatient follow-up two days later. CONCLUSION: To our knowledge, this is the first case described of this constellation of injuries after a relatively benign process. Despite not having increased risk factors for intracranial hemorrhage (anticoagulation use, history of trauma, history of coagulopathy), this patient had severe injuries that presented with few external symptoms. This case serves as a reminder that while physiologic processes are almost always benign, serious traumatic injuries can result. Clinicians should have a low threshold for advanced imaging when there is a high clinical suspicion of facial fractures or more ominous processes.

A Case of Neuroleptic Malignant Syndrome Presenting as Anxiety.

Neuroleptic malignant syndrome (NMS) is a rare but potentially lethal complication of dopamine antagonist use. A 34-year-old male presented to the emergency department with a chief complaint of feeling anxious for the past several days. He presented with his family who helped provide history as he had become less communicative over the preceding two days. It was revealed that the patient had a recent psychiatric hospitalization for suspected new-onset psychosis and was discharged six days prior to his presentation. It was reported that the patient was discharged with unknown psychiatric medications but stopped taking them two days prior because he felt they were increasing his anxiety. On physical examination, the patient was found to have upper extremity rigidity and appeared tremulous. A review of records revealed that the patient was discharged from inpatient psychiatric treatment on dual antipsychotic therapy. With this information, the patient met the diagnostic criteria for NMS. He was hospitalized and his symptoms resolved following treatment. Without the knowledge of antipsychotic use, the diagnosis of a serious, life-threatening condition may have been missed. Our case highlights an important but occasionally overlooked aspect of evaluating a patient in the emergency department, namely, outside chart and documentation reviewing.

Spontaneous Arterial Thrombus and Dissection Associated With Exercise and Exogenous Testosterone Use.

Spontaneous lower extremity arterial dissection has been linked to atherosclerotic and non-atherosclerotic causes. A 55-year-old male presented to the emergency department via emergency medical services for a chief complaint of right leg pain. He stated that he was performing leg exercises when he felt a sudden pop in his right leg followed by severe pain. His exam was remarkable for lack of ipsilateral distal popliteal or dorsalis pedis pulse by palpation or doppler. The patient was admitted to a three-year history of non-prescription testosterone injection use along with a history of prior portal vein thrombosis two years prior with anticoagulation noncompliance after one month of therapy. A computed tomography angiography of the lower extremity was performed which demonstrated complete acute occlusion of the right common iliac, and right external iliac, along with right femoral artery dissection. The patient was emergently taken to the operating room with vascular surgery where a thrombectomy with stent placement was performed. After three days in the surgical intensive care unit and nine days in the hospital, the patient was subsequently discharged from the hospital in good condition. A post-operative follow-up appointment three weeks after discharge revealed mild residual pain; however, no issues ambulating or residual weakness, and normal ankle-brachial indexes. This case highlights a unique presentation of acute limb ischemia associated with exogenous testosterone use.

The Impact of Chronic Obstructive Pulmonary Disease and Hospital Teaching Status on Mortality, Cost, and Length of Stay in Elective Total Hip Arthroplasty Patients.

Introduction Total hip arthroplasty (THA) is a frequently performed surgery. Chronic obstructive pulmonary disease (COPD) is one of the most prevalent diseases in the United States and has been associated with higher complications in many orthopedic surgeries. The purpose of this study was to examine the clinical and economic impacts of COPD on the mortality, cost, and length of stay of those undergoing THA and the effect of hospital teaching status on these outcomes. Methods This retrospective cohort study identified adult patients (≥18 years) utilizing information from the Healthcare Cost and Utilization Program Nationwide Inpatient Sample (NIS) from 2012 to 2014 undergoing elective THA using ICD-9 codes. Patients missing key clinical identifiers or those who did not undergo THA were excluded. Mortality, cost, and length of stay were assessed. The COPD cohort was further analyzed by hospital teaching status, including urban teaching, urban non-teaching, and rural. Results An adjusted total of 7,652 patients with COPD and 768,000 patients without COPD undergoing THA were identified. COPD was associated with higher mortality rates, longer lengths of stay, and total charges. In the COPD cohort, teaching status did affect outcomes. Between urban teaching hospitals and urban non-teaching, chronic conditions were significantly higher in urban teaching hospitals, yet total charges were lower. LOS was longer in rural hospitals, however, all other variables, including costs, were not significantly different as compared to urban teaching hospitals. Between urban non-teaching hospitals and rural hospitals, the number of chronic conditions and LOS were higher in rural hospitals, yet costs were significantly less. Age and mortality rates were not significantly different between different teaching statuses. Conclusion COPD has a significant effect on mortality, length of stay, and cost in patients undergoing THA. Additionally, teaching status seems to play an interesting role in these variables. Preoperative planning may help surgeons mitigate some of these risks associated with COPD. Further work on how LOS and costs are optimized with regards to teaching status should be done.

Electron-Mediated Aminyl and Iminyl Radicals from C5 Azido-Modified Pyrimidine Nucleosides Augment Radiation Damage to Cancer Cells.

Two classes of azido-modified pyrimidine nucleosides were synthesized as potential radiosensitizers; one class is 5-azidomethyl-2'-deoxyuridine (AmdU) and cytidine (AmdC), while the second class is 5-(1-azidovinyl)-2'-deoxyuridine (AvdU) and cytidine (AvdC). The addition of radiation-produced electrons to C5-azido nucleosides leads to the formation of π-aminyl radicals followed by facile conversion to σ-iminyl radicals either via a bimolecular reaction involving intermediate α-azidoalkyl radicals in AmdU/AmdC or by tautomerization in AvdU/AvdC. AmdU demonstrates effective radiosensitization in EMT6 tumor cells.

Idiopathic Charcot Arthropathy of the Knee Presenting as a Bicondylar Tibial Plateau Fracture.

Charcot arthropathy is an infrequent condition that primarily involves the foot and ankle; rarely, it has been reported to affect the knee. Risk factors for Charcot arthropathy are well described with diabetes being the most common cause. Idiopathic Charcot arthropathy without a secondary etiology is extremely rare, with only a few cases described involving the foot and shoulder. Clinically, idiopathic Charcot arthropathy presents a notable challenge because delayed diagnosis can lead to surgical complications and advancement of joint destruction. We report idiopathic Charcot arthropathy of the knee presenting as a bicondylar tibial plateau fracture successfully managed with total knee arthroplasty after failed open reduction internal fixation. We diagnosed the patient when the clinical/surgical presentation was indicative of Charcot arthropathy and after excluding all other diagnoses. This previously unreported case describes the complexity of idiopathic Charcot arthropathy with subsequent fractures and highlights the importance of patient history, presentation, and surgical intervention.

Non-invasive repair of an iatrogenic tibial artery branch pseudoaneurysm after intramedullary nailing.

Tibial fractures are a commonly seen injury in orthopedic surgery. Intramedullary nailing is considered the standard of care, as complications are rare. Those of a vascular nature, including iatrogenically induced pseudoaneurysms of the tibial artery have been previously described in the literature, however each reported case has required surgical repair. In the current case, we describe a repair of a tibial artery branch pseudoaneurysm, after direct contact with an interlocking screw from tibial intramedullary nailing, via ultrasound-guided thrombin injection. To the authors' knowledge, this is the first reported case of a tibial artery pseudoaneurysm repaired non-surgically. This adds support to the promising literature on non-invasive repair of orthopedically related pseudoaneurysms.

Modulating the Catalytic Activity of Cerium Oxide Nanoparticles with the Anion of the Precursor Salt.

In this work, we tested our hypothesis that surface chemistry and antioxidant properties of cerium nanoparticles (CNPs) are affected by presence of counterions. We first employed various precursor cerium (III) (Ce(III)) salts with different counterions (acetate, nitrate, chloride, sulfate) to synthesize CNPs following the same wet chemical methodology. Electron spin resonance (ESR) studies provided evidence for the formation of radicals from counterions (e.g., NO3•2- from reduction of NO3- in CNPs synthesized from Ce(III) nitrate). Physicochemical properties of these CNPs, e.g., dispersion stability, hydrodynamic size, signature surface chemistry, SOD-mimetic activity, and oxidation potentials were found to be significantly affected by the anions of the precursor salts. CNPs synthesized from Ce(III) nitrate and Ce(III) chloride exhibited higher extent of SOD-mimetic activities. Therefore, these CNPs were studied extensively employing in-situ UV-Visible spectroelectrochemistry and changing the counterion concentrations affected the oxidation potentials of these CNPs. Thus, the physicochemical and antioxidant properties of CNPs can be modulated by anions of the precursor. Furthermore, our ESR studies present evidence of the formation of guanine cation radical (G•+) in 5'-dGMP via UV-photoionization at 77 K in the presence of CNPs synthesized from Ce(III) nitrate and chloride and CNPs act as the scavenger of radiation-produced electrons.

Ethmoid malformation associated with pediatric nasal polyposis and allergic fungal sinusitis.

A 17-year-old female with allergic fungal sinusitis and nasal polyposis presented with epistaxis in the emergency room. On examination, right-sided proptosis and irregular nasal obstruction were observed in the right nasal cavity. CT imaging revealed massive right-sided polyposis and significant ipsilateral malformation with boney architecture preservation of the ethmoidal labyrinth and lamina papyracea. The patient was treated surgically with symptomatic improvement. These findings indicate a unique malformation of the ethmoid while the patient was in development. To the authors' knowledge, this anatomical malformation has not been previously described in the literature. Physicians should implement diagnostic procedures early if nasal polyposis and allergic fungal sinusitis is suspected in pediatric patients, especially with periocular involvement, to mitigate the risk of boney malformations of the sinuses.

Thermal Energy Produced by Medium Velocity Pistol Projectiles and the Effects on Peripheral Nerve Tissue.

CONTEXT: Sidearm pistols are more frequently involved in violent crimes due to their relatively small size and ability to be concealed. The extent to which the thermal energy released from such medium velocity pistol projectiles contributes to peripheral nerve injury requires further testing. The purpose of this paper is to describe a method to quantify how much thermal energy is released during impact of medium velocity pistol projectiles and report how thermal energy contributes to peripheral nerve injury. METHODS: Eleven seven-centimeter segments of radial, median, and ulnar nerves were dissected from a thawed fresh frozen cadaver. The nerve segments were placed in a 10% ballistics gel block, one centimeter from the end of the block nearest the shooter. A series of 115-grain 9 mm. NATO-classified ammunitions were fired through the nerve and ballistics gel construct with a pistol. The impacts were recorded with a high-speed infrared camera and nerve samples were sent for histologic analysis by two board-certified pathologists. RESULTS: The average velocity of the projectiles were 391m/s, 95% CI [387-395 m/s], with an average kinetic energy of 572.0 J, 95% CI [560.0-583.0J]. The average observable temperature of the ballistics gel/nerve prior to impact was 28.8°C±0.6ºC, 95% CI [26.4-30.3°C]. Average observable temperature of the surrounding ballistics gel/nerve during projectile impact was 55.1°C±2.4ºC, 95% CI [51.3- 62.1°C], yielding an average observable increase of 26.4°C±3.2ºC, 95% CI [20.2- 35.4°C]. An adjusted temperature increase was also surprisingly high 63.4°C ± 3.2, 95% CI [57.2 - 72.4ºC]. Histology reports of the impacted nerve tissue failed to show any sign of thermal or even crush injury. CONCLUSIONS: Medium velocity handgun projectiles release a significant amount of heat energy when impacting a substance similar to human tissue. The authors' temperature data points were greater than those previously reported to cause thermal injury to peripheral nerves. The authors' findings suggest that nerve injury after collision with pistol projectiles may be secondary to thermal injury in addition to the classic model of concussion and penetration given our documented levels of heat generated during impact.

5-Thiocyanato-2'-deoxyuridine as a possible radiosensitizer: electron-induced formation of uracil-C5-thiyl radical and its dimerization.

In this work, we have synthesized 5-thiocyanato-2'-deoxyuridine (SCNdU) along with the C6-deuterated nucleobase 5-thiocyanatouracil (6-D-SCNU) and studied their reactions with radiation-produced electrons. ESR spectra in γ-irradiated nitrogen-saturated frozen homogeneous solutions (7.5 M LiCl in H2O or D2O) of these compounds show that electron-induced S-CN bond cleavage occurs to form a thiyl radical (dU-5-S˙ or 6-D-U-5-S˙) and CN(-)via the initial π-anion radical (SCNdU˙(-)) intermediate in which the excess electron is on the uracil base. HPLC and LC-MS/MS studies of γ-irradiated N2-saturated aqueous solutions of SCNdU in the presence of sodium formate as a OH-radical scavenger at ambient temperature show the formation of the dU-5S-5S-dU dimer in preference to dU by about 10 to 1 ratio. This shows that both possible routes of electron-induced bond cleavage (dUC5-SCN and S-CN) in SCNdU˙(-) and dU-5-S˙ formation are preferred for the production of the σ-type uracilyl radical (dU˙) by 10 fold. DFT/M06-2x/6-31++G(d,p) calculations employing the polarizable continuum model (PCM) for aqueous solutions show that dU-5-S˙ and CN(-) formation was thermodynamically favored by over 15 kcal mol(-1) (ΔG) compared to dU˙ and SCN(-) production. The activation barriers for C5-S and S-CN bond cleavage in SCNdU˙(-) amount to 8.7 and 4.0 kcal mol(-1), respectively, favoring dU-5-S˙ and CN(-) formation. These results support the experimental observation of S-CN bond cleavage by electron addition to SCNdU that results in the formation of dU-5-S˙ and the subsequent dU-5S-5S-dU dimer. This establishes SCNdU as a potential radiosensitizer that could cause intra- and inter-strand crosslinking as well as DNA-protein crosslinking via S-S dimer formation.