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Examines trends and identifies efficiencies resulting from technological advances in the warehouse, distribution, and storage inventory of the United States federal government. Opportunities for improving the use of the federal government real property; Background of the establishment of the strategic warehouse inventory needs group.

Accommodation for head growth presents one of several challenges unique to pediatric cochlear implantation. Given contemporary cochlear implant device designs, an electrode cable implanted at the age of 2 years must extend 2 to 3 cm as the head grows during childhood. In an initial study we found that model lead wires with redundant loops extended effectively when they were maintained within air-containing spaces such as the mastoid cavity or middle ear space. However, when looped leads traversed soft tissues overlying the parietal bone, they became embedded in fibrous tissue and did not extend. The present study evaluated three different configurations of expansile devices that were enclosed In polytetrafluoroethylene (PTFE) envelopes to deter fibrous ingrowth. This simple strategy was designed to ensure effective cable extension over cable pathlengths by protecting the redundant leads from any mechanically significant connective tissue ingrowth. Twelve such devices were implanted across the calvaria of four newly weaned plglets. Skull growth and changes in electrode dimensions were documented by sequential computed tomographic scans. At 3 months of age, cranial circumferences had increased substantially. Animals were then killed, the model cable extension appliances examined physically, and their implantation sites examined histologically. For all experimental devices, extension of redundant lead wires was satisfactory, and there was no mechanically significant invasion of fibrous connective tissue into the PTFE envelope. This indicates that enclosure of excess lead wire within a PTFE envelope may be an effective means of inhibiting fibrous Ingrowth. This strategy should prove useful for ensuring effective electrode cable extension In cochlear implants applied in young children.

A 36-year-old primigravida female from a birthing center was referred for elevated blood pressure to the hospital two days after normal spontaneous vaginal delivery with nausea, vomiting, and diarrhea. During this two-day period, she was experiencing persistent vaginal bleeding and lower abdominal pains for which she took six doses of 600 mg ibuprofen. Further laboratory evaluation reflected leukocytosis, anemia, thrombocytopenia, elevation of liver enzymes, and renal failure with hyperkalemia requiring emergent hemodialysis once in the Medical Intensive Care Unit (MICU). She was diagnosed with HELLP syndrome with underlying preeclampsia. A week later, due to hypertension controlled with medications and nonoliguric renal failure with no active urine sediments, a renal biopsy was indicated to direct management. The renal biopsy supported the diagnosis of diffuse severe acute tubulointerstitial nephritis with hypereosinophilia and thin basement membrane nephropathy (see figures). She was subsequently treated with high-dose steroids which resulted in the normalization of blood pressures and renal function returning to baseline. We report the first case of acute tubulointerstitial nephritis in an individual with thin basement membrane nephropathy secondary to postpartum complications.

A 26-year-old African American male with a history of congenital cerebral palsy, sickle cell trait, and intellectual disability presented with abdominal pain that started four hours prior to the hospital visit. The patient denied fever, chills, diarrhea, or any localized trauma. The patient was at a party at his community center last evening and danced for 2 hours, physically exerting himself more than usual. Labs revealed blood urea nitrogen (BUN) level of 41 mg/dL and creatinine (Cr) of 2.8 mg/dL which later increased to 4.2 mg/dL while still in the emergency room. Urinalysis revealed hematuria with RBC > 50 on high power field. Imaging of the abdomen revealed no acute findings for abdominal pain. With fractional excretion of sodium (FeNa) > 3%, findings suggested nonoliguric acute tubular necrosis. Over the next couple of days, symptoms of dyspepsia resolved; however, BUN/Cr continued to rise to a maximum of 122/14 mg/dL. With these findings, along with stable electrolytes, urine output matching the intake, and prior use of proton pump inhibitors, medical decision was altered for the possibility of acute interstitial nephritis. Steroids were subsequently started and biopsy was taken. Biopsy revealed heavy deposits of myoglobin. Creatinine phosphokinase (CPK) levels drawn ten days later after the admission were found to be elevated at 334 U/dl, presuming the levels would have been much higher during admission. This favored a diagnosis of acute kidney injury (AKI) secondary to exertional rhabdomyolysis. We here describe a case of nontraumatic exertional rhabdomyolysis in a sickle cell trait (SCT) individual that was missed due to findings of microscopic hematuria masking underlying myoglobinuria and fractional excretion of sodium > 3%. As opposed to other causes of ATN, rhabdomyolysis often causes FeNa < 1%. The elevated fractional excretion of sodium in this patient was possibly due to the underlying inability of SCT positive individuals to reabsorb sodium/water and concentrate their urine. Additionally, because of their inability to concentrate urine, SCT positive individuals are prone to intravascular depletion leading to renal failure as seen in this patient. Disease was managed with continuing hydration and tapering steroids. Kidney function improved and the patient was discharged with a creatinine of 3 mg/dL. A month later, renal indices were completely normal with persistence of microscopic hematuria from SCT.

A 43-year-old male patient with past medical history of diabetes mellitus (DM), end stage renal disease (ESRD) on hemodialysis (HD), congestive heart failure (CHF), obstructive sleep apnea (OSA), and chronic anemia presented with complaints of left thigh pain. A computerized tomogram (CT) of the thigh revealed evidence of edema with no evidence of a focal collection or gas formation noted. The patient’s clinical symptoms persisted and he underwent magnetic resonance imaging (MRI) of his thigh which was reported to show small areas of muscle necrosis with fluid collection. These findings in the acute setting concerned necrotizing fasciitis. After careful discussion following a multidisciplinary approach, a decision was made to perform a fasciotomy with tissue debridement. The patient was treated with IV antibiotics and discharged with a vacuum assisted wound drain. The surgical pathology revealed evidence of muscle edema with necrosis. Seven weeks later the patient presented with similar complaints on the other thigh (right thigh). MRI of the thighs revealed worsening edema with features suggestive of myositis and possible muscle infarction. A CT guided biopsy of the right quadriceps muscle revealed fibrotic interstitial connective tissue and no evidence of necrosis. This favored a diagnosis of diabetic muscle infarction. The disease was managed with pain control, strict diabetes management, and aggressive dialysis.

A 53-year-old Egyptian female with end stage renal disease, one month after start of hemodialysis via an internal jugular catheter, presented with fever and shortness of breath. She developed desquamating vesiculobullous lesions, widespread on her body. She was in profound septic shock and broad spectrum antibiotics were started with appropriate fluid replenishment. An echocardiogram revealed bulky leaflets of the mitral valve with a highly mobile vegetation about 2.3 cm long attached to the anterior leaflet. CT scan of the chest, abdomen, and pelvis showed bilateral pleural effusions in the chest, with triangular opacities in the lungs suggestive of infarcts. There was splenomegaly with triangular hypodensities consistent with splenic infarcts. Blood cultures repeatedly grew Candida albicans. Despite parenteral antifungal therapy, the patient deteriorated over the course of 5 days. She died due to a subsequent cardiac arrest. Systemic review of literature revealed that the rate of infection varies amongst the various types of accesses, and it is well documented that AV fistulas have a much less rate of infection in comparison to temporary catheters. All dialysis units should strive to make a multidisciplinary effort to have a referral process early on, for access creation, and to avoid catheters associated morbidity.

A 42-year-old high risk pregnant female presented with hyponatremia from multiple causes and was treated with total parenteral nutrition. She developed acute hypernatremia due to the stage of pregnancy and other comorbidities. All the mechanisms of hyponatremia and hypernatremia were summarized here in our case report. This case has picture (graph) representation of parameters that led to changes in serum sodium and radiological findings of central pontine myelinolysis on MRI. In conclusion we present a complicated case serum sodium changes during pregnancy and pathophysiological effects on serum sodium changes during pregnancy.