Streptococcus gallolyticus subspecies (subsp.) gallolyticus (formerly bovis biotype I) bacteremia has been associated with colonic adenocarcinoma. The bovis species underwent reclassification in 2003. Subtypes of gallolyticus are associated with colonic malignancy but are less frequent, resulting in less awareness. A 71-year-old male admitted with worsening lower back pain and fevers. Initial vital signs and laboratory data were within normal limits. MRI revealed lumbosacral osteomyelitis and antibiotics were initiated. Blood cultures showed Streptococcus species, prompting a transesophageal echocardiogram (TEE) revealing vegetations on the mitral and aortic valves. The etiology for his endocarditis was unclear. A colonoscopy was suggested, but his clinical instability made such a procedure intolerable. Final cultures revealed Streptococcus gallolyticus subsp. pasteurianus (previously bovis biotype II). After antibiotic completion he underwent aortic grafting with valve replacements. Later, he was readmitted for Streptococcus bacteremia. After a negative TEE, colonoscopy revealed a 2.5 × 3 cm cecal tubulovillous adenoma with high-grade dysplasia suspicious for his origin of infection. Clinicians understand the link between Streptococcus gallolyticus subsp. gallolyticus (bovis type I) and malignancy, but the new speciation may be unfamiliar. There are no guidelines for managing S. gallolyticus subsp. pasteurianus bacteremia; therefore a colonoscopy should be considered when no source is identified.
Eight millimetre diameter angioplasty balloon catheters of both the Gruntzig and Olbert types from five manufacturers have been tested in vitro to establish bursting pressures and the changes in maximum and deflated diameters following repeated inflations, both when free and within a restraining sleeve. Maximum inflated diameters were within 10% of that stated and all types of balloon except one burst at a pressure greater than the recommended value. Deflated diameters were approximately 1 mm greater than insertion diameters, which are much smaller in the Olbert type. All balloons became a little larger with each of the first few distensions, and became stiffer. The maximum diameter was reached and remained constant after 10-15 distensions. Distension within a latex sleeve did not change bursting pressures, and it is considered that results from unconstrained testing can be extrapolated to behaviour in vivo. Computer modelling and calculation of maximum stress resultants also showed that calculated longitudinal and circumferential stresses are unaffected by applied restrictions. It is concluded that balloon technology is steadily improving and it is suggested that British Standards should be established for dilatation balloon catheters. Amongst other factors these Standards should include maximum recommended inflation pressures that are at least 2 atm less than bursting pressures, whilst the stated maximum diameter should be for fully extended balloons, and should have a tolerance of more than +/- 10%.
New anticoagulation agents are now widely used for many indications. Post-marketing surveillance is intended to discover rare medication events that did not occur in clinical trials. The literature cites few reported cases of spontaneous neck hemorrhage while on anticoagulation. We report a case of an 86-year-old female with chronic atrial fibrillation who presented with spontaneous neck hematoma in the area of the parathyroid glands resulting in hyperparathyroidism and hypercalcemia while taking rivaroxaban. The hematoma spanned the anterior aspects of the neck and was confirmed via CT. The patient's anticoagulation therapy was discontinued and required intubation for airway protection. The parathyroid hormone (PTH) peaked to 176 mg/dL (upper limit of normal 65 pg/mL) followed by close to normalization of PTH and corrected calcium after appropriate treatment and stabilization of the hematoma, which did not require surgical evacuation.
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