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River bank protection is vital in hydraulic river engineering to preserve natural rivers, lands, and critical constructions such as bridges. Spur dikes are erosion-protective structures that protrude outward from the river bank in different orientations to deflect the flow away from the riverbank. The present experimental study provides insight into the temporal variation in bed morphology and scours around rectangular-shaped spur dikes with different orientations, such as 60º, 90º, and 120º. Also, maximum scour depth (MSD) is developed compared to the condition when downward seepage is applied. The experiments examined the suitability of various spur dike orientation configurations and the scour development over time, specifically at intervals of 2, 12, and 24 hours, and compared with 24 hours (Seepage). Results showed that the orientation angle of 90º generated the highest scour depth, while the least scour depth was found with an orientation angle of 120º. The downward seepage intensifies the motion of sediment particles and leads to an escalated particle detachment, resulting in deeper scour depressions. The development of scour depth is initiated from the spur dike tip and reaches its maximum there. The deposition of sand particles shifted downstream, and a dune-like structure formed near the second spur dike.

In this study, we investigate the changes in flow structure at the interface of a partly vegetated section and determine whether it is better to have wholly vegetated test sections near important riverine structures. We analyze the flow behaviour at the interface using the transverse flux, turbulent kinetic energy, probability density function, and anisotropy. We observed a helical flow downstream of the partly vegetated section, indicated by a negative Reynolds shear stress. The lateral acceleration of the flow contributes to large-scale fluctuations, confirmed by a probability density function analysis and anisotropy stress tensor. The turbulent kinetic energy was higher for the wholly vegetated case due to the presence of two-dimensional stress components compared to one-dimensional stress components in the partly vegetated case, confirmed by an anisotropy invariant map. Wholly vegetated sections exhibited a highly fluctuating transverse flux, indicating a larger intermixing rather than a unidirectional movement. Based on the findings, it is recommended to opt for a wholly vegetated cover instead of a partly vegetated cover in riverbanks or near structures such as bridge piers and river training structures affected by a lateral or laterally accelerating flow. The analysis of an additional turbulence helps safer designs of critical components of river structures.

Breast cancers metastasize most commonly to the bone, brain, liver, and lungs, but rarely to the gastrointestinal tract. Although metastatic breast carcinomas in the stomach can be confused with primary gastric cancers due to their nonspecific presentation and rare incidence, it is important to differentiate the two since the treatment is different. Clinical suspicion is imperative for a prompt endoscopic evaluation and a definitive diagnosis that will lead to appropriate treatment. Therefore, it is important for clinicians to be aware of the possibility of gastric metastasis of breast cancers, especially in those with a history of invasive lobular breast carcinoma and a new onset of gastrointestinal symptoms.

Visceral artery pseudoaneurysms is a known vascular complication of pancreatitis that can lead to life-threatening hemorrhages with a high mortality rate if left untreated. We present a case of ruptured gastroduodenal artery pseudoaneurysm in a 68-year-old male with acute pancreatitis presenting with fatal gastrointestinal and retroperitoneal bleeding that was successfully managed with endovascular coil embolization of the involved vasculature. Patients with hemorrhagic pancreatitis or those presenting with unexplained retroperitoneal or gastrointestinal bleeding in the setting of pancreatitis with an unexplained drop in hematocrit or sudden expansion of pancreatic fluid collection should be screened in a timely manner for pseudoaneurysm using CT angiogram of the abdomen, which is the gold standard imaging modality to identify pseudoaneurysms. Once pseudoaneurysm is diagnosed, it should be treated immediately. Endovascular treatment options are now favored over surgical options in most cases.

Laboratory experiments have been conducted to investigate flow patterns in a sinuous curvilinear channel with flexible banks. Those experiments focused primarily on rectangular or trapezoidal cross sections with rigid banks, whereas comprehensive experiments pertaining to curved cross sections with flexible banks in a sinuous/meandering channel have not been performed. Hence, the flow characteristics in a curved sinuous channel with erodible banks are analyzed in this study. The velocity profile does not reflect the typical straight flow logarithmic profile owing to secondary flow. The velocity magnitude at the entry and exit of the bend is greater than that at the apex of the final and next bends, respectively. The magnitude of the depth-averaged velocity in the bend entry region is 40% greater than that in the bend exit section of the sinuous channel. A negative streamwise Reynolds shear stress is observed at some locations of the bend, which confirm the presence of helical flow therein. The turbulent intensities and an analysis of the turbulent kinetic energy (TKE) reveal that the magnitude of the helical flow at the inner bank is greater than that at the outer bend of the apex. The depth-averaged TKE magnitude in the inner band is higher than that at the outer bend in the apex cross section by more than 50%. This finding is opposite to that pertaining to the velocity magnitude, thus indicating that a region with a greater mean velocity does not imply greater fluctuations. Higher-order correlations show that the flux and diffusion of streamwise and vertical normal stresses are indicated in both positive and negative signs, thus indicating sediment mobility in the channel.

Clayton Goodwin's profile of Sir Lewis Hamilton is easily the best I've read so far on my all-time hero. Thank you New African, you made my month! HARISH PATEL, Bulawayo, [...]

Kikuchi-Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare, benign, focal, self-limiting disease. We report a unique case of KFD in a patient with coexisting Crohn’s disease. Our patient is a 23-year-old African American female with a past medical history significant for Crohn’s disease who presented to the clinic because of a painless lump over the right side of the neck for the past 3 weeks. On physical examination, the patient was found to have enlarged nontender right cervical lymph nodes from levels 2 to 4. An excisional biopsy of the right neck lymph node was done which revealed necrotizing histiocytic lymphadenitis, favoring a diagnosis of KFD. Over the course of the next 2 months, her lymphadenopathy got resolved. This is the first case of KFD in a patient with Crohn’s Disease. Lymphoma remains a feared adverse outcome for immunomodulatory drugs, thus necessitating their cessation upon signs of lymphadenopathy. Our case highlights the importance of a detailed workup in order to access the underlying cause of the lymphadenopathy so that the immunomodulatory drugs can be resumed in these patients.

Constipation is one of the most common functional gastrointestinal disorders and affects 20% of the general population. Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal tract that affects the large intestine and is characterized by chronic abdominal pain and altered bowel habits. We report a case of a 35-year-old African American man with a past medical history of IBS who presented to the clinic with a chief complaint of abdominal pain and bloody diarrhea for 1 week. The patient stated that he used a colon-cleansing agent because of persistent constipation. Computed tomography scan of the patient’s abdomen and pelvis with contrast was performed which showed diffuse contiguous segmental mural thickening and nodularity seen along the distal transverse, descending, and sigmoid colon. Colonoscopy showed moderate diffuse inflammation characterized by altered vascularity, erythema, and granularity from the rectum to the descending colon, and localized mild inflammation characterized by erythema was found at the ileocecal valve. The patient’s clinical condition improved with symptomatic management over 10 days. Patients with IBS should be advised to restrain from using a colon-cleansing agent without advice from their primary doctor as it can lead to various complications.

Gastrointestinal stromal tumors (GISTs) are the stromal or mesenchymal neoplasms affecting the gastrointestinal tract. Although they constitute 1% of primary gastrointestinal tumors, they are the most common nonepithelial tumors involving the gastrointestinal tract. They mostly present as overt or occult gastrointestinal bleeding. We present a case in which a 77-year-old female presented with a large abdominal mass. The origin of the mass was unclear on CT and MRI scan of the abdomen. Upper gastrointestinal endoscopic ultrasonography showed a cystic lesion in the perigastric region. A fine-needle biopsy of the lesion was performed, which was consistent with spindle type GIST. After the initial failure of imatinib therapy, the tumor was managed surgically.

The occurrence of tuberculosis (TB) is exceedingly rare in the United States (US), and incidence has steadily declined since 1993, but the pace of decline has slowed in recent years. The US TB rate during 2019 declined to 2.7 cases per 100,000 persons, the lowest level on record. The abdominal form is the sixth leading cause of extrapulmonary TB, after lymphatic, genitourinary, osteoarticular, miliary, and meningeal. Abdominal TB can infect any part of the gastrointestinal tract, including the peritoneum and the pancreaticobiliary system. We present a case of persistently elevated adenosine deaminase in peritoneal ascites of a young, healthy female with new-onset ascites. An extended diagnostic evaluation was performed to reach the diagnosis.

Introduction. The occurrence of acute respiratory failure as a result of esophageal bezoars is a rare phenomenon. We present a patient who failed initial endoscopic intervention. Successful resolution was achieved through a novel approach involving a combination of Creon and Coca-Cola. Subsequently, the patient was diagnosed with achalasia, a condition that potentially contributed to the formation of the esophageal bezoar. Case Description. An 82-year-old man presented with respiratory distress, necessitating endotracheal intubation for airway protection. A chest computed tomogram (CT) showed pneumonia and a distended esophagus compressing the trachea, raising the possibility of an esophageal food bolus. Endoscopy revealed a severely dilated esophagus containing a significant amount of food and a phytobezoar in the lower esophagus. He failed various endoscopic techniques to remove the obstruction. Given the patient’s poor surgical candidacy, he was started in a thrice-daily regimen of Creon dissolved in 165?mL of Coca-Cola, over a 4-day period. A subsequent endoscopy revealed no discernible evidence of food or bezoar. The patient was weaned from mechanical ventilation. A high-resolution esophageal manometry identified type 1 achalasia. Conclusion. Esophageal food impaction leading to respiratory failure is rare. Endoscopy remains the mainstay approach. Surgical interventions carry significant risks. This case emphasizes the potential for noninvasive management in patients with esophageal bezoars and also underscores the significance of contemplating esophageal pathologies when addressing cases of respiratory failure. The use of Coca-Cola and Creon emerges as a safe, effective, and cost-efficient treatment, providing a feasible option when endoscopy proves unsuccessful before considering more aggressive interventions.

•By using appropriate amount of nano aluminum oxide performance of diesel engine could be improved.•Nano aluminum oxide helps to improve the efficiency when it is running with biodiesel mixed diesel.•Maximum brake power and maximum Brake thermal efficiency are observed, when 0.5 g/l of n-Al2O3is added to B20.•Optimal value of concentration of the nano-particles is calculated as 0.4592 g/l into B20.•Addition of 0.4592 g/l of n-Al2O3into the biodiesel blended diesel has been recommended.

The fracture toughness properties, in terms of stress intensity factor KIcand strain energy release rate GIc, of hemp fibre mat-reinforced sheet moulding compound (H-SMC) are measured using the compact tension (CT) method and compared with those of glass fibre-reinforced SMC (G-SMC). Three material parameters were considered for composite optimisation: fibre volume fraction, CaCO3filler content and hemp fibre surface treatments using either alkaline, silane or a combination of these two treatments. The highest fracture toughness for H-SMC composites was obtained at a fibre loading of around 30 vol.-%, while it was also shown that the fracture toughness properties of H-SMC are sensitive to mineral filler content. Surface treatment of the hemp fibres using a combined alkaline-silane treatment resulted in a significant improvement in fracture toughness of H-SMC composites. Optimised H-SMC composites exhibited fracture toughness properties similar to those of G-SMC at fibre contents of 20 vol.-%, with KIcvalues of around 6 MPa.m-1/2.

Multiple myeloma (MM) is a neoplastic proliferation of plasma cells with overproduction of monoclonal immunoglobulins and infiltration into the bone and other organs. Ascites can develop in patients with lymphoproliferative and solid malignancies involving the peritoneum. However, ascites is unusual in MM and rarely the initial presenting sign or symptom. The development of ascites can be due to peritoneal infiltration or secondary to hepatic involvement, heart failure, or kidney failure. Ascites in MM reflects a more aggressive stage, and the reported prognosis is poor, with a median survival of 1–2 months. Here we present a rare case of immunoglobulin A lambda MM presenting with massive myelomatous ascites.

The results of some laboratory experiments are reported concerning the distribution of boundary shear stresses in smooth closed ducts of a rectangular cross section for aspect ratios between 1 and 10. The distributions are shown to be influenced by the number and shape of the secondary flow cells, which, in turn, depend primarily upon the aspect ratio. For a square cross section with 8 symmetrically disposed secondary flow cells, a double peak in the distribution of the boundary shear stress along each wall is shown to displace the maximum shear stress away from the center position towards each corner. For rectangular cross sections, the number of secondary flow cells increases from 8 by increments of 4 as the aspect ratio increases, causing alternate perturbations in the boundary shear stress distributions at positions where there are adjacent contrarotating flow cells. Equations are presented for the maximum, center line, and mean boundary shear stresses on the duct walls in terms of the aspect ratio.

Extragonadal germ cell tumors (EGCTs) in the lung are extremely rare and their pathogenesis is poorly understood. We report a case in a 48-year-old female which was very aggressive and stained positive for primoridial germ cell markers. Interestingly, there was chromosome 3 polysomy noted. To our knowledge this is the first chromosomal aberration noted in a primary germ cell tumor of the lung.

AbstractWe report the case of a 52-year-old man with HIV-AIDS, non-complaint with highly active antiretroviral therapy, who presented with long-standing dysphagia. He was treated for three episodes of severe Candida esophagitis with fluconazole and later caspofungin due to poor response. In spite of the prolonged treatment courses the patient did not report an improvement in his symptoms. He was also concomitantly being treated for other opportunistic infections including cytomegalovirus (CMV) retinitis with i.v. foscarnet for almost 2 months prior to the index presentation. Upper esophagogastroduodenoscopy revealed multiple superficial ulcers with stricturing. Bougie dilatation was attempted but failed. The biopsy specimens revealed multiple intracellular inclusion bodies pathognomonic of CMV infection. We aim to highlight the increasing resistance of CMV to conventional first-line antiviral agents such as foscarnet.Copyright © 2013 S. Karger AG, Basel

No Abstract

The catalyst prepared by supporting in situ 1,4-bis(2,6-diisopropylphenyl)acenaphthenediiminenickel(II) dichloride (1) on silica–methylaluminoxane (SMAO) has high activity for ethylene polymerization, although it is less active than the unsupported system 1/MAO. No external alkylaluminum cocatalyst needs to be added to the in situ supported system. Short chain branches are produced without addition of α-olefin comonomer, due to the chain-walking mechanism. Ethylene pressure and polymerization temperature affect the degree of short chain branch formation. At constant ethylene pressure, when the polymerization temperature rises, the short chain branch content also increases. For a given ethylene pressure, there is a threshold polymerization temperature above which polymer particle agglomeration starts to occur. For the conditions investigated herein, from 30 to 50°C the morphology of the polymer particles replicates that of the support. At 55°C, polyethylene starts to become soluble in the reaction medium, and therefore morphological control is gradually lost. Above 70°C, only soluble polymer is produced. Similar results are observed by keeping the temperature constant and changing the ethylene pressure.

Drug carriers such as liposomes are not readily transported across cellular barriers that constitute epithelia. However, certain epithelia (rabbit yolk sac endoderm and enterocytes of suckling rat gut proximal small intestine) are well known to transcytose maternal IgG by Fc receptor‐mediated endocytic events. We have shown that coating liposomes with appropriate IgG enhances their transport across these epithelia, as measured both by radioactivity indicative of liposomal membrane or entrapped 125I‐PVP and [3H]inulin, and by the hypoglycemic effect of entrapped insulin. It is suggested that these transported liposomes follow a pathway of transcytosis in clathrin‐coated vesicles, thus escaping lysosomal degradation.

In accordance with the finding of our in vivo experiments reported earlier [(1983) Biochim. Biophys. Acta 761, 142–157 (1986) Biochim. Biophys. Acta 888, 184–190], the results of in vitro experiments show that Kupffer cells avidly take up cholesterol-poor but not cholesterol-rich liposomes, whereas splenic phagocytic cells take up preferentially cholesterol-rich rather than cholesterol-poor liposomes in the presence of serum. Evidence presented here suggests that serum contains opsonins specific for hepatic and splenic phagocytic cells and these opsonins have different affinities for cholesterol-rich and cholesterol-poor liposomes.

Our understanding of bullous skin disorders has increased enormously since the beginning of the century, when a patient with generalized blisters was firmly diagnosed as having pemphigus vulgaris only on his demise. Those fortunate patients that survived obviously did not have true pemphigus vulgaris, but likely had "pemphigus of the aged" or "bullous dermatitis herpetiformis." The key observations that defined these diseases more precisely were the careful histopathologic studies of Lever and the immunofluorescence microscopy studies of Beutner and Jordon2 and Jordon et al.3 The autoantibodies in pemphigus vulgaris and bullous pemphigoid (BP) that can be detected both bound in and around lesions and circulating in the serum samples of patients have proved to be not only crucial for the accurate diagnosis of these conditions, but appear to be of primary importance in the pathogenesis of the diseases as well. There is now substantial evidence that pemphigus autoantibodies

Conclusions A number of different processes clear peptides from the circulation. These will be described and illustrated using examples from a range of peptide hormones and analogues.

Endodermal sinus tumor, also called yolk sac tumor, is a kind of nonseminomatous germ cell tumor. It is thought to be derived from differentiation of malignant germ cells along the extraembryonic yolk sac lineage. Extragonadal nonseminomatous germ cell tumor should be considered in the differential diagnosis of histologically poorly differentiated cancer and of neoplasms of an unknown primary site in young men with midline disease. We report a case of endodermal sinus tumor manifesting as rapidly growing bilateral lung masses in a 48-year-old woman.

Hyperkalemia is one of the most common electrolyte abnormalities encountered in clinical practice. The treatment of hyperkalemia includes removal of excess potassium from the body using cation exchange resins, e.g., sodium polystyrene sulfonate (Kayexalate) is one of the most practiced modalities in clinical medicine. Colonic mucosal necrosis and perforation are the serious gastrointestinal side effects associated with sodium polystyrene sulfonate (SPS) use, which have been reported with or without concomitant use of sorbitol. However, the catastrophic bleeding esophageal ulcer has been rarely described in our literature search. Due to the risk of colonic necrosis, the FDA has issued a warning to avoid concomitant sorbitol use with Kayexalate. We present an individual with acute hematemesis due to bleeding esophageal ulcer immediately after treatment with Kayexalate therapy. Though the exact mechanism by which Kayexalate causes esophageal ulcer to be elucidated, nonetheless it is worthwhile to be vigilant about its potential adverse effects. Our case highlights the rare but certainly the life-threatening complication of Kayexalate therapy.

Gastrointestinal symptoms, especially diarrhea, are common with novel coronavirus SARS-CoV-2 infection. Angiotensin-converting enzyme-2 (ACE-2) receptors are heavily expressed in enterocytes and serve as entry receptors for SARS-CoV-2. ACE-2 receptors may also be responsible for pancreatic injury in patients infected with SARS-CoV-2. Diarrhea associated with SARS-CoV-2 is usually believed to be due to viral invasion of enterocytes. However, exocrine pancreatic insufficiency resulting from SARS-CoV-2 is another plausible mechanism leading to diarrhea in such patients. We present a case series of three SARS-CoV-2-infected patients with predominant respiratory symptoms at presentation who developed diarrhea, and further fecal analysis revealed exocrine pancreatic insufficiency as the underlying mechanism.

Natural fibre composites are of interest for a wide range of semi-structural applications in the building, construction and automotive sector. For a number of these applications, the evaluation of performance degradation after impact is of some relevance. The present work focused on the influence of fibre volume fraction and fibre surface treatment on the residual load-bearing capability of hemp fibre-reinforced sheet moulding compound (H-SMC) after non-penetrating impacts. Post-impact flexural strength and stiffness of H-SMC decreased linearly with increasing impact energy. At higher impact energy levels, the residual flexural strength of H-SMC improved with increasing fibre volume fraction. However, for the same amount of absorbed energy, the residual strength or damage tolerance capability of glass fibre-reinforced sheet moulding compound was about twice that of H-SMC. Composites based on surface treated hemp fibres showed a slight improvement in residual flexural strength, particularly for systems based on hemp fibres treated with a combined alkaline and silane surface treatment. Surface treated systems showed improved levels of adhesion and increased levels of energy absorption through potential mechanisms such as debonding, pull-out or fibre fibrillation.

Maternal and fetal morbidity and mortality associated with varicella pneumonia in the peripartum period are increased further with multiple complications.

Introduction. Sarcoidosis is a common multisystem chronic inflammatory disease of an unidentified inciting etiology. The most common initial manifestations of this disease involve the pulmonary system, and involvement of the gastrointestinal tract is rare. Sarcoidosis of the gastrointestinal tract occurs in an oral-anal gradient, with the esophagus and stomach being the most commonly involved sites, while colonic involvement remains extremely rare. Case Presentation. We present a case of a 24-year-old African American man who was evaluated for persistent abdominal pain, chronic diarrhea, and weight loss. Workup for infectious etiologies and celiac disease was unrevealing. An inflammatory mass in the hepatic flexure was found during colonoscopy, and a computed tomography (CT) scan of the abdomen was significant for circumferential thickening of the cecum and ascending colon, along with nodular thickening of the peritoneum without enhancement. Malignancy and inflammatory bowel disease were the initial differentials. A peritoneal biopsy was also performed. Pathology of the colon and peritoneal biopsy was significant for the presence of noncaseating granulomas and confluent granulomatous inflammation. The patient was diagnosed with colonic sarcoidosis, and treatment with corticosteroids was initiated. Symptoms resolved with treatment, and a follow-up colonoscopy five months later showed interval healing. Conclusion. Although rare, colonic sarcoidosis should be considered as one of the differential diagnoses when evaluating a patient with chronic diarrhea and a mass on colonoscopy. Histopathology is the key to diagnosis as it distinguishes malignancy from sarcoidosis. Corticosteroids remain as an option for treating colonic sarcoidosis.

Bacterial endocarditis is commonly encountered in clinical practice. Many bacterial species have been implicated; however, Streptococcus gallolyticus species (formerly “bovis”) has driven attention given a historical association with colon cancer. Colonoscopy is recommended in an individual with S. gallolyticus endocarditis or bacteremia to evaluate the possibility of high-grade adenoma or colon cancer. There has been no firm recommendation for prophylactic antibiotics to prevent bacterial endocarditis for patients undergoing endoscopic procedures and postcolonoscopy bacteremia in an individual with an endoscopic procedure indicated for S. gallolyticus bacteremia has not been reported. Studies have been aimed at understanding the association between colon cancer and this bacterial pathogen. There are suggestions that the systemic manifestation of S. gallolyticus, a commensal in the colon premalignant cells, may be further predisposed by patient’s immunocompromised status. We present a case of the 72-year-old man with the newly diagnosed multiple myeloma presented with aortic valve endocarditis and S. gallolyticus bacteremia. Colonoscopy revealed colon cancer and high-grade adenoma; few hours after procedure, he presented with Streptococcus mitis bacteremia. In conclusion, our case realigns association of S. gallolyticus to colon cancer, especially in an individual with altered immunity, and is novel to demonstrate the rare association of two distinct bacteria of Streptococcus species associated with cancer. Preendoscopic antibiotics use, though not standard of care, can be considered in the high-risk individual. Altered immunity can be considered the “missing link” inciting bacteremia in individuals with S. gallolyticus-associated colon cancer.

Background. Chronic cough is often associated with gastroesophageal reflux disease (GERD). The role of gastroenterologist in the management of the chronic cough is to identify and manage GERD. Ineffective esophageal motility is often associated with GERD induced cough. Chronic cough is often refractory to medical and surgical management despite adequate acid control. Unresponsiveness warrants a thorough pulmonary evaluation. The pathophysiology of refractory cough in these patients is poorly understood, and hence management is often challenging. Case Presentation. A 75-year-old woman from Ghana was evaluated for GERD associated chronic cough. A 48-hour ambulatory pH study revealed acid exposure of 4.9% and high-resolution manometry showed decreased lower esophageal sphincter pressure, an inadequate response to medical and surgical management of GERD. Postfundoplication ambulatory pH testing demonstrated well-controlled acid reflux but her cough still persisted. Repeat manometry showed an ineffective motility disorder (IEM). Taking frequent sips of water eventually resolved her chronic cough. Conclusion. Frequent sips of water can be used in the management of the gastroesophageal reflux and ineffective motility induced cough. It results in increased esophageal clearance of acid, nonacid reflux, and ingested pharyngeal secretions, thus breaking the cycle of cough generated increased intra-abdominal pressure with reflux and more cough.

A healthy male infant had been first noted to have blisters at age 36 hours. He had been the product of a full-term, uncomplicated pregnancy and vaginal delivery. His mother claimed that she had no history of herpes simplex infection, and there was no family history of blistering or other skin diseases.At age 8 days, the patient was examined in the outpatient Dermatology Clinic and was noted to have flaccid bullae with erythematous bases on both hips (Fig 1), the lower back, the left thumb, and the lower lip. Erosions were present on the hard palate, on the left leg, and in the periungual regions of all his fingers (Fig 2). No other mucocutaneous or general medical abnormalities were noted. Bacterial cultures of the blister fluid were negative.A biopsy specimen was taken from skin adjacent to a blister on the right flank; routine histopathologic examination disclosed a separation

Gastrocolic fistulae have been described for benign conditions including penetrating peptic ulcer and complicated pancreatitis. Malignant etiology can arise from gastric or colon cancer and is a rare and late complication with an incidence of 0.3-0.4%. Usual presentation is the classic triad of weight loss, diarrhea, and feculent vomiting. Barium enema has been shown to have the highest diagnostic accuracy but endoscopy offers additional advantage of biopsy to aid in diagnosis of malignant etiology; the role of computed tomography (CT) scan is controversial. Treatment by one-stage en bloc surgical approach is the current acceptable standard of care with variable recurrence and survival rates. Adjuvant chemotherapy would be based on lymph node involvement and patient discussion.

REPORT OF A CASE A 23-year-old woman was admitted to The Johns Hopkins Hospital, Baltimore, for evaluation of fever, polyarthralgias, and a skin rash. She had been well until four weeks before admission, when she developed pain in multiple small and large joints. After initial evaluation at an outside hospital two weeks before the present admission, she had been placed on a regimen of hydroxychloroquine sulfate (200 mg/d), indomethacin (75 mg/d), enteric-coated aspirin (1 g three times a day), and ampicillin (250 mg four times a day) for cough. Her symptoms progressed and she developed pleuritic chest pain, malaise, fever, headache, and a vesiculobullous eruption that prompted admission to our hospital.On physical examination, the patient had tense vesicles and bullae on a nonerythematous base scattered over her head and the upper aspect of her trunk; most of the lesions were concentrated on the lips, postauricular area, and axilla (Figs

X-Ray reflection has been used to study the nucleation and growth of thin films of a silica–surfactant mesophase (MCM-41) at the air/water interface in the presence and absence of an insoluble lipid monolayer of phosphatidylcholine; the rate of self-assembly and structural order of films comprising up to four micellar layers were enhanced under the lipid monolayer.