In this case, given the antibiotic treatment given and the severity of the diarrhea, it seems that we are dealing with a Clostridium infection. Option 2 is not very credible, in fact, as much as patients with CAP may have associated diarrhea, it is unlikely that a bacterium is sensitive to an antibiotic at the beginning of the picture and stops being so after 3 days.

In this case, given the antibiotic treatment given and the severity of the diarrhea, it seems that we are dealing with a Clostridium infection. Option 2 is [HIDDEN], in fact, as much as patients with CAP may have associated diarrhea, it is unlikely that a bacterium is sensitive to an antibiotic at the beginning of the picture and stops being so after 3 days.

A 52-year-old patient is admitted to the Hospital for severe pneumonia. With appropriate antibiotic treatment, the patient's respiratory symptoms improved. After 4 days of stay in the ward, his evolution is complicated by the appearance of a severe diarrhea. What is the most frequent microorganism responsible for this condition?

The bacterium itself causing pneumonia that has become resistant to the antibiotic.

[Etiology, diagnosis and course of infectious diarrhea in the Liestal canton hospital (5-year retrospective study)].

Between 1987 and 1991 219 patients (1.3% of all hospitalized patients) with acute infectious diarrhea were investigated retrospectively. 52% of the patients were hospitalized and 48% were outpatients. In 55% the inducing diarrhea microorganism could be identified. The most frequently detected pathogens were endemic Salmonella sp. and Campylobacter jejuni (65%). Imported diarrheas (Shigella sp. and parasites) were rare, as only 15% of the patients had a history of travel. All Clostridium difficile infections were associated with antibiotic treatment. The stool examinations for bacteria were positive in 92/160 patients (57%). Stool examinations for occult blood or fecal leukocytes were highly useful in detecting the infectious agent. In 70% of the patients with positive occult blood test or 81% of the patients with fecal leukocytes, an infectious agent in the stool was found. All patients recovered with few complications. 31% of the patients were treated by antibiotics because of septic disease or pathogenic parasites.

A 5-year study of the bacterial pathogens associated with acute diarrhoea on the island of Crete, Greece, and their resistance to antibiotics.

During a 5-year period (1995-1999) a total of 7090 stool samples obtained from patients with acute diarrhoea, mostly community-acquired, were examined for bacterial pathogens, in the Greek island of Crete. One or more enteric pathogens were isolated from 987 patients (14%). Salmonella enterica were the most commonly isolated bacteria (6%), followed by Campylobacter spp. (4.2%), and enteropathogenic Escherichia coli (EPEC) (1.8%). Yersinia enterocolitica (0.6%), Shigella spp. (0.3%), and Aeromonas hydrophila (0.04%), were less frequently isolated. Clostridium difficile was isolated from 65 out of 451 diarrhoeal specimens examined (14.4%). Toxin B was detected in all cases. No verotoxigenic E. coli strains were identified. Resistance to ampicillin was observed in 31.5% of the Salmonella, 58.3% of the Shigella and 31.5% of the EPEC isolates. Resistance to trimethoprim-sulfamethoxazole was observed in 4.4% of the Salmonella, 30.5% of the Shigella, and 18.5% of the EPEC isolates. High percentages of resistance to quinolones (44.5% to norfloxacin, and 40.5% to ciprofloxacin), were found among Campylobacter isolates, while resistance to erythromycin was observed in 14.9% of them. With the present study we continue the surveillance of bacterial pathogens associated with diarrhoeal disease on the island of Crete.

Gastroenteritis

Toxigenic Clostridium difficile is an important cause of diarrhea that occurs more often in the elderly. Infants can carry these bacteria without developing symptoms. It is a common cause of diarrhea in those who are hospitalized and is frequently associated with antibiotic use. Staphylococcus aureus infectious diarrhea may also occur in those who have used antibiotics. Acute "traveler's diarrhea" is usually a type of bacterial gastroenteritis, while the persistent form is usually parasitic. Acid-suppressing medication appears to increase the risk of significant infection after exposure to a number of organisms, including Clostridium difficile, Salmonella, and Campylobacter species. The risk is greater in those taking proton pump inhibitors than with H2 antagonists.

Empiric antimicrobial therapy and infectious diarrhea. Do we need local guidelines?

In the management of acute diarrhea, administration of antibiotics may be indicated. Appropriate antimicrobial therapy can shorten illness, reduce morbidity and can be life-saving in invasive infections. Emergence of microbial strains resistant to commonly used antibiotics means that treatment failures may become common. Because of changing patterns of resistance, knowledge of recent local patterns of susceptibility can guide the initial choice of antibiotics. A retrospective study was conducted to investigate the epidemiology of infective gastroenteritis in patients over 14years old in the region of Chania (Crete). We reviewed all positive stool cultures and susceptibilities of the pathogens recovered from patients with symptoms of acute diarrhea, from 2003 until October 2010. Out of 194 positive stool cultures, we observed 139 cases of Salmonella enterica and 48 cases of Campylobacter jejuni. During the last 3years of observation there was an increased incidence of C. jejuni, especially after the tap water outbreak that occurred in our region in 2009. In the vast majority of acute diarrhea in adults, antibiotics are of no benefit and overprescription may confer to side effects, costs and emergence of resistance. Antibiotics are initiated in cases of febrile diarrheas especially those believed to have moderate to severe disease. Considering the increased incidence of C. jejuni and the resistance of the great majority of isolated strains to quinolones as well as the sensitivity of Salmonella spp. to azithromycin, administration of azithromycin empirically for acute diarrhea, when indicated, could be appropriate in our region.

[Pneumonia caused by Haemophilus influenzae. Study in a series of 58 patients].

Haemophilus influenzae tends to form part of the usual respiratory flora in adults, especially if they have a chronic underlying disease or are smokers. Pneumonia due to H. influenzae is frequently involved in respiratory infections and its level of resistance to ampicillin has remained stable over the last five years. Most of the literature on the subject was published more than 10 years ago. In this study, we describe the clinical features and evolution of 58 adult patients admitted to hospital for pneumonia due to H. influenzae over a 2-year period, with this group accounting for 6.5% of all the patients admitted with pneumonia during this time period. The etiological diagnosis was made using a good quality sputum sample. Forty patients (69%) were male. The mean age (+/- SD) of the group was 67 (+/-16.8) years and all the patients had at least one underlying disease. The mean duration of the symptoms was 6.7 days. All patients presented an increase in the quantity or purulence of the sputum. On admittance, respiratory failure was present in 52 patients (90%). Gram-negative coccus-bacilli were observed in the direct sputum test and H. influenzae grew in the culture. In two cases, H. influenzae was recovered from the blood culture and in one from bronchial aspiration obtained through bronchoscopy. Another pathogen was identified in 28 patients (48%). In 21 it was another pyogenic bacteria (15 S. pneumoniae, 4 M. catharralis, 1 K. pneumoniae, 1 E. coli), an atypical microorganism in 5 (3 C. pneumoniae, 2 C. burnetii) and a respiratory virus in 2 (syncytial and influenza A). Atypical bacteria and respiratory virus were detected using serological techniques. The radiographic infiltrate was unilobar in 54 of the 58 patients and all showed an alveolar pattern. The empirical treatment included the administration of a third generation cephalosporin (or a fluoroquinolone in patients allergic to penicillin). The evolution was favorable in all the cases in which H. influenzae was the only pathogen or was accompanied by an atypical microorganism or a respiratory virus. Four patients with mixed bacterial pneumonia died (2 S. pneumoniae, 1 E. coli and 1 M. catharralis). The study indicates that pneumoniae due to H. influenzae affects a population with an underlying disease, preferably pulmonary, that it has a longer clinical period than that for pneumococcal pneumonia, that it is slightly bacteremic and, that, usually, it evolves benignly with a low mortality.

Salmonellosis

Signs and symptoms Enteritis After a short incubation period of a few hours to one day, the bacteria multiply in the small intestine, causing an intestinal inflammation (enteritis). Most people with salmonellosis develop diarrhea, fever, vomiting, and abdominal cramps 12 to 72 hours after infection. Diarrhea is often watery and non-bloody but may be mucoid and bloody. In most cases, the illness lasts four to seven days, and does not require treatment. In some cases, though, the diarrhea may be so severe that the patient becomes dangerously dehydrated and must be hospitalized. At the hospital, the patient may receive fluids intravenously to treat the dehydration, and may be given medications to provide symptomatic relief, such as fever reduction. In severe cases, the Salmonella infection may spread from the intestines to the blood stream, and then to other body sites, and can cause death, unless the person is treated promptly with antibiotics.

[Salmonella Bacteremia Accompanying COVID-19: The First Salmonella Co-Infection in the World Unrelated to Pakistan].

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection emerged in China at the end of 2019 and caused coronavirus disease 2019 (COVID-19). The lymphopenia seen in COVID-19 increases the incidence of susceptibility to other microorganisms and may cause co-infections. As the signs and symptoms of the diseases overlap with other infectious diseases and due to the intensity in health services, the diagnosis of co-infections becomes difficult and the treatment may be delayed. Therefore, infections accompanying COVID-19 cause an increase in morbidity and mortality.The isolation and quarantine measures taken during the COVID-19 process have reduced the number of infections transmitted from person to person. However, there was no significant decrease in diseases transmitted by food, such as salmonellosis. During the pandemic, salmonellosis continued to be a problem, especially in endemic areas such as Pakistan, and an increase in Salmonella infections associated with backyard poultry has been reported in countries such as the United States. A co-infection of COVID-19 and enteric fever associated with travel to Pakistan was reported for the first time in the literature in February 2021. In this case report, the first co-infection of COVID-19 and Salmonella in our country was presented. A 56-yearold male patient with no known systemic disease was admitted to the hospital with fever, shortness of breath, weakness and myalgia lasting for three days. SARS-CoV-2 polymerase chain reaction test was positive. The patient has been hospitalized and favipiravir, moxifloxacin, and methylprednisolone were started. Blood cultures were taken from the patient whose clinical picture worsened and fever continued despite of the medical treatment. Salmonella enterica spp. enterica was isolated and ceftriaxone treatment was started. The patient's anamnesis was deepened, but no diarrhea, abdominal pain, suspicious food consumption, travel history were determined. From the second day of the ceftriaxone treatment, the patient's fever decreased and no growth was detected in the control blood cultures. Ceftriaxone treatment was completed in 14 days and the patient was discharged on the 28th day. Approximately 87-95% of Salmonella strains isolated in our country are S.enterica spp. enterica, and S.enterica spp. enterica was also isolated in our case. Salmonella infections most commonly present as gastroenteritis, but the risk of bacteremia increases in case of immunosuppression. Although there was no additional disease in our case, it was considered that the infection in the form of bacteremia occurred due to an immunosuppression caused by COVID-19. In this context; drawing blood cultures of patients hospitalized with the diagnosis of COVID-19 is very important in terms of detecting co-infections and superinfections, and administering appropriate antibiotic therapy at appropriate treatment times. Presentation of first case of Salmonella bacteremia and simultaneous COVID-19 infection in our country was the strong side of our report. In addition, our case is also important as being the first SARS-CoV-2 and Salmonella co-infection unrelated to Pakistan in the literature. The limitation of our case was that S.enterica spp. enterica detected in the blood culture could not be subtyped and the stool culture could not be examined. However, this does not constitute a diagnostic requirement. In addition, the patient's pre-COVID-19 Salmonella carrier status was also unknown. As a result, patients become vulnerable to other infections due to the lymphopenia seen in COVID-19. Therefore, Salmonella bacteremia can be seen with SARS-CoV-2 infection without a comorbid condition. Drawing blood cultures in hospitalized patients with the diagnosis of COVID-19 is very important in terms of detecting concomitant infections in a short time. In patients whose clinical condition does not improve and fever continues despite of treatment, blood cultures should be taken, especially in the case of an advanced immunosuppresive treatment plan, and it should always be kept in mind that secondary infections and co-infections may occur.

2018 American salmonella outbreak

Treatment Treatment of salmonella infections depends on age and pre-disposition of the infected person and the severity of the symptoms. One of the side-effects from salmonella infection is dehydration, making the replacement of fluids and electrolytes the main treatment for less severe infections. In severe cases, patients are treated with antibiotics, rehydrated with intravenous (IV) fluids and hospitalized. In cases where the infection spreads from the intestines to the bloodstream, quick treatment with antibiotics is required to prevent the risk of death. Possible complications include resistances to certain antibiotics in the salmonella streaks, that might require treatment with different antibiotics than commonly prescribed antibiotics. In this case, whole-genome sequencing (WGS) analysis identified no antibiotic resistance in 112 of 127 isolates. Prevention and Structural Consequences

Acute diarrhea in under five-year-old children admitted to King Mongkut Prachomklao Hospital, Phetchaburi province.

A prospective epidemiological and clinical study of acute diarrhea in children under 5 years old was done at King Mongkut Prachomklao Hospital in order to provide baseline data for health officers to make a strategic plan to reduce the diarrheal mortality and morbidity, which is one of the mid-decade goals for children. There were 105 cases of acute diarrhea patients admitted to the Pediatric ward between May 1995 and April 1996. Seventy-six per cent of them were in the younger age group (> 1 month-2 years old) while 23.8 per cent were in the older age group (2-5 years old). Causative pathogens were identified in 64 patients (61%). Younger patients had a higher percentage of identifiable pathogens (66.7%) than older patients (44.4%). Rotavirus was the most common pathogen isolated (17.2%). The other common pathogens identified were Eschericia coli (14.1%), Campylobacter jejuni (14.1%), Shigella (12.5%), Entamoeba histolytica (7.8%) and Salmonella (3.1%). Mixed infections were reported in 31.3 per cent of these patients. Clinical presentations and stool characteristics were difficult to distinguish from most of the pathogens. However, Rotavirus was highly suspected if a younger child presented with fever, watery to loose stool with the predominant symptom of vomiting. Mucous, mucous-bloody stool gave a clue to the diagnosis of Shigella and Entamoeba histolytica. Most cases had at least mild to moderate dehydration, so oral rehydration solution (ORS) was successfully given in only 31.4 per cent of patients. Antibiotics were prescribed to 51.4 per cent of patients in this study. Healthcare personnel should emphasize to parents and caretakers about good hygienic behavior to reduce the episodes of diarrhea and the use of ORS every time when their children have diarrheal episodes to reduce the disease severity.

[Pneumonia due to Haemophilus influenzae.Study in a series of 58 patients]

Haemophilus influenzae tends to form part of the usual respiratory flora in adults, especially if they have a chronic underlying disease or are smokers. Pneumonia due to H. influenzae is frequently involved in respiratory infections and its level of resistance to ampicillin has remained stable over the last five years. Most of the literature on the subject was published more than 10 years ago. In this study, we describe the clinical features and evolution of 58 adult patients admitted to hospital for pneumonia due to H. influenzae over a 2-year period, with this group accounting for 6.5&#37; of all the patients admitted with pneumonia during this time period. The etiological diagnosis was made using a good quality sputum sample. Forty patients (69&#37;) were male. The mean age (+/- SD) of the group was 67 (+/-16.8) years and all the patients had at least one underlying disease. The mean duration of the symptoms was 6.7 days. All patients presented an increase in the quantity or purulence of the sputum. On admittance, respiratory failure was present in 52 patients (90&#37;). Gram-negative coccus-bacilli were observed in the direct sputum test and H. influenzae grew in the culture. In two cases, H. influenzae was recovered from the blood culture and in one from bronchial aspiration obtained through bronchoscopy. Another pathogen was identified in 28 patients (48&#37;). In 21 it was another pyogenic bacteria (15 S. pneumoniae, 4 M. catharralis, 1 K. pneumoniae, 1 E. coli), an atypical microorganism in 5 (3 C. pneumoniae, 2 C. burnetii) and a respiratory virus in 2 (syncytial and influenza A). Atypical bacteria and respiratory virus were detected using serological techniques. The radiographic infiltrate was unilobar in 54 of the 58 patients and all showed an alveolar pattern. The empirical treatment included the administration of a third generation cephalosporin (or a fluoroquinolone in patients allergic to penicillin). The evolution was favorable in all the cases in which H. influenzae was the only pathogen or was accompanied by an atypical microorganism or a respiratory virus. Four patients with mixed bacterial pneumonia died (2 S. pneumoniae, 1 E. coli and 1 M. catharralis). The study indicates that pneumoniae due to H. influenzae affects a population with an underlying disease, preferably pulmonary, that it has a longer clinical period than that for pneumococcal pneumonia, that it is slightly bacteremic and, that, usually, it evolves benignly with a low mortality.

[Clostridium difficile infection in a Department of Internal Medicine. A consecutive series of 45 patients].

A retrospective study of 45 patients with Clostridium difficile infection over a 4-year period in a department of Internal Medicine. Mean age was 79 years; sex-ratio (F/M)=1.5; 38% of the patients had neurological or severe psychiatric disorders; 20% had a neoplastic disease. Ninety-three percent of cases had received one or more antibiotics before onset of diarrhea, prescribed mainly for a pulmonary infection. Amoxicillin clavulanic acid and cephalosporins were the most frequently used treatments, respectively in 48% and 40% of cases. For 25 patients (56%) Clostridium difficile-associated diarrhea was considered as a nosocomial infection, and as community-acquired diarrhea in 20 cases (44%). Treatment included isolation of the patient as soon as bacteriological diagnosis was known and specific therapy was instituted by metronidazole or vancomycin for a mean of 18 days. The addition of Saccharomyces boulardii was used in of cases. The clinical course was rapidly favorable for 80% of patients. Five patients died with complications of severe colitis in 2 cases. Mean hospital stay was 49 days (annual mean of the department=10 days). Clostridium difficile diarrhea concerns above all elderly patients with one or more underlying pathologies. Amoxicillin clavulanic acid and third-generation cephalosporins are the most frequently prescribed antibiotics in these cases and have the highest correlation with this infectious complication. This medical problem requires greater knowledge as it causes significant morbidity and increases the risk of prolonged hospital stays.

Community-acquired pneumonia

Treatment CAP is treated with an antibiotic that kills the infecting microorganism; treatment also aims at managing complications. If the causative microorganism is unidentified, which is often the case, the laboratory identifies the most effective antibiotic; this may take several days. Health professionals consider a person's risk factors for various organisms when choosing an initial antibiotic. Additional consideration is given to the treatment setting; most patients are cured by oral medication, while others must be hospitalized for intravenous therapy or intensive care. Current treatment guidelines recommend a beta lactam, like amoxicillin and a macrolide, like azithromycin or clarithromycin, or a quinolone, such as levofloxacin. Doxycycline is the antibiotic of choice in the UK for atypical bacteria, due to increased clostridium difficile colitis in hospital patients linked to the increased use of clarithromycin.

2018 American salmonella outbreak

Signs and Symptoms Salmonella is a bacterium that produces the symptoms of diarrhoea, fever and abdominal cramps in infected individuals 12-72 hours after exposure. Most people recover without treatment and the illness usually lasts for 4-7 days. Some people may need hospitalization due to severe symptoms and in rare cases, Salmonella can cause death unless the person is treated with antibiotics promptly. Those most likely to develop severe salmonella are children under the age of 5, adults over the age of 65 and people with compromised immune systems. Treatment

List of antibiotic-resistant bacteria

Gram positive Clostridium difficile Clostridium difficile is a nosocomial pathogen that causes diarrheal disease worldwide. Diarrhea caused by C. difficile can be life-threatening. Infections are most frequent in people who have had recent medical and/or antibiotic treatment. C. difficile infections commonly occur during hospitalization. According to a 2015 CDC report, C. difficile caused almost 500,000 infections in the United States over a year period. Associated with these infections were an estimated 15,000 deaths. The CDC estimates that C. difficile infection costs could amount to $3.8 billion over a 5-year span. C. difficile colitis is most strongly associated with fluoroquinolones, cephalosporins, carbapenems, and clindamycin. Some research suggests the overuse of antibiotics in the raising of livestock is contributing to outbreaks of bacterial infections such as C. difficile.[16]

[Long-term follow-up of the etiology of diarrhea with emphasis on the role of rotaviruses in hospitalized patients at the Infectious Disease Clinic of the Medical School Hospital in Plzen].

During 1986-1994 the etiological structure of diarrhoea in hospitalized patients at the Infectious Diseases Clinic, University Hospital Plzen was analyzed. In children under four years most frequently (in 26%) rotaviruses were involved, in older patients their ratio was lower and the decisive pathogenetic organism were salmonellae. In rotavirus infections the shortest hospitalization period was recorded. These infections were encountered all round the year with a maximum prevalence in the winter months.

[Unusual pathology caused by Salmonella in the Greater Hospital of Milan in the 3-year period of 1977-1979].

At the Central Laboratory of the Medical School, University of Milano, Italy, 44 Salmonella strains were isolated from morbid materials other than stools during the three-years period 1977-79 (blood 26, urine 6, pus 3, pleural fluid 4, bile 3, upper respiratory mucus 2). In the present paper, nine cases of Salmonella infections, selected for their unusual localization a/o their peculiar clinical onset, are reviewed. From most of the clinical histories it appears that, in quite a few occasions, the episode due to Salmonella has been favoured or conditioned by a preexisting disease, therefore suggesting a nosocomial-type event. It also appears that the help from the microbiologist was often requested less than promptly, and minimal requirements for its efficacy were seldom achieved.

Campylobacter jejuni

Treatment Patients with Campylobacter infection should drink plenty of fluids as long as the diarrhea lasts to maintain hydration. Patients should also get rest. If he or she cannot drink enough fluids to prevent dehydration or if the symptoms are severe, medical help is indicated. In more severe cases, certain antibiotics can be used and can shorten the duration of symptoms if given early in the illness. Moreover, maintenance of electrolyte balance, not antibiotic treatment, is the cornerstone of treatment for Campylobacter enteritis. Indeed, most patients with this infection have a self-limited illness and do not require antibiotics at all. Nevertheless, antibiotics should be used in specific clinical circumstances. These include high fevers, bloody stools, prolonged illness (symptoms that last >1 week), pregnancy, infection with HIV, and other immunocompromised states.

[Acute Gastroenteritis in hospitalized children. 14-Year evolution].

To analyze the etiology and evolution of patients with acute gastroenteritis hospitalized in our pediatric department and to study the clinical and laboratory differences between acute viral and bacterial gastroenteritis. We studied the children with a diagnosis of acute gastroenteritis, aged between 0 and 14 years, who were consecutively admitted between 1987 and 2000. Differences were considered statistically significant if p < 0.05. A total of 2,613 patients diagnosed with acute gastroenteritis were hospitalized (10.4 % of hospital admissions). The most common pathogens isolated were rotaviruses (46.5 %), followed by Salmonella (32.6 %) and Campylobacter (19.3 %). Hospital admissions due to Salmonella (p < 0.0001), other bacteria (Escherichia coli and Shigella) (p < 0.002) and adenoviruses (p < 0.01) significantly decreased. Rotaviruses were the most frequently detected pathogens in winter and in children aged less than 1 year (p < 0.0001). The incidence of Salmonella spp was greater in summer and in children older than 2 years (p < 0.0001). The incidence of hyperthermia (rectal temperature higher than 38.5 degreeC) (p < 0.0001), dehydration (p < 0.0005) and fecal blood (p < 0.0001) was higher in bacterial diarrheas. Erythrocyte sedimentation rate (p < 0.001) and leukocyte counts were higher in bacterial gastroenteritis (p < 0.01). Rotaviruses were the most frequently isolated enteropathogens. The features that best distinguished between bacterial and viral diarrhea were hyperthermia and fecal blood. Hospital admissions due to Salmonella Shigella E. coli, and adenoviruses significantly decreased.

Methicillin-resistant Staphylococcus aureus

Endocarditis and bacteremia Evaluation for the replacement of a prosthetic valve is considered. Appropriate antibiotic therapy may be administered for up to six weeks. Four to six weeks of antibiotic treatment is often recommended, and is dependent upon the extent of MRSA infection. Respiratory infections CA-MRSA in hospitalized patients pneumonia treatment begins before culture results. After the susceptibility to antibiotics is performed, the infection may be treated with vancomycin or linezolid for up to 21 days. If the pneumonia is complicated by the accumulation of pus in the pleural cavity surrounding the lungs, drainage may be done along with antibiotic therapy. People with cystic fibrosis may develop respiratory complications related to MRSA infection. The incidence of MRSA in those with cystic fibrosis increased during 2000 to 2015 by five times. Most of these infections were HA-MRSA. MRSA accounts for 26% of lung infections in those with cystic fibrosis.

Pneumonia severity index

Usage The purpose of the PSI is to classify the severity of a patient's pneumonia to determine the amount of resources to be allocated for care. Most commonly, the PSI scoring system has been used to decide whether patients with pneumonia can be treated as outpatients or as (hospitalized) inpatients. A Risk Class I or Risk Class II pneumonia patient can be sent home on oral antibiotics. A Risk Class III patient, after evaluation of other factors including home environment and follow-up, may either: be sent home with oral antibiotics be admitted for a short hospital stay with antibiotics and monitoring. Patients with Risk Class IV-V pneumonia patient should be hospitalized for treatment. Algorithm

[Bacteremia caused by ciprofloxacin-resistant Salmonella serotype Kentucky: a case report and the review of literature].

Salmonella infections can be seen in four clinical types, namely gastroenteritis, bacteremia/sepsis, enteric fever and carriage. These infections can result in uncomplicated diarrhea in most cases, but can lead to invasive disease requiring antimicrobial therapy and can be life-threatening in elderly or immunocomprimised patients. Broad-spectrum cephalosporins and fluoroquinolones are crucial options in the treatment of the invasive infections. Ciprofloxacin resistance is rarely seen in non-typhoid Salmonella enterica isolates, and only in S. Typhimurium, S. Choleraesuis and S. Schwarzengrund. In this report, we aimed to discuss a patient infected with ciprofloxacin-resistant Salmonella Kentucky under the light of data from our country and the world. A 52-year-old male patient wih acute myocardial infarction was hospitalized in intensive care unit of cardiovasculer surgery for left ventricular assist device (LVAD) implantation for the treatment of left ventricular disfunction. On the seventh day of LVAD and coronary artery bypass grafting (CABG), the patient presented high fever and productive cough. His physical examination revealed hyperemia around the insertion point of right jugular central venous catheter (CVC) and a serous discharge from the insertion point of LVAD located just below the inferior edge of sternum. Empiric IV cefoperazone/sulbactam (SCF) therapy was started with the prediagnosis of pneumonia and bloodstream infection. The blood samples taken from peripheral veins and CVC, and swabs taken from LVAD insertion point for culture when the patient was febrile, revealed the growth of bacteria with S type and lactose-negative colonies on EMB and SS media. Biochemical characteristics of the isolate were as follows: lactose fermentation negative, H<sub2</subS positive, IMVIC (-,+,-,+), urease negative, lysine/ornithine decarboxylase positive and motile. The bacteria was then identified as Salmonella enterica serotype Kentucky (8,20;i;z6) by agglutination tests. Antibiotic susceptibility tests were conducted according to CLSI guidelines and it was found as ampicillin- and ciprofloxacin-resistant. Ciprofloxacin resistance of the isolate was confirmed with E-test. Stool culture was performed to investigate the source of infection, and S. Kentucky was isolated. On the 15th day of SCF treatment, LVAD was taken out, and tissue cultures taken from the fibrillar tissues between pericardial layers during surgery, also yielded S. Kentucky growth. On the second day of SCF therapy the patient's fever returned normal and on the seventh day, CBC and CRP values were normalized. Nevertheless, the clinical situation of the patient worsened gradually and on the 40th day he was intubated due to low oxygen saturation and pleural effusion. His antibiotherapy was stopped on 42nd day as the blood cultures were negative and his clinical situation was attributed to cardiac failure. The patient died four days after the antibiotherapy has stopped due to cardiac reasons. To our knowledge, this is the first reported case infected with ciprofloxacin-resistant Salmonella Kentucky in our country.

Prophylactic Lactobacillus GG reduces antibiotic-associated diarrhea in children with respiratory infections: a randomized study.

Antimicrobial treatment may disturb the colonization resistance of gastrointestinal microflora, which may induce clinical symptoms, most commonly diarrhea. The severity of antibiotic-associated diarrhea may range from a brief, self-limiting disease to devastating diarrhea with electrolyte disturbances, dehydration, crampy abdominal pain, pseudomembranous colitis, toxic megacolon, or even death. The incidence of diarrhea in children receiving a single antimicrobial treatment is unclear. In addition to more critical use of antimicrobials, adjunctive preventive measures to antibiotic-associated diarrhea are needed. The objective of this study was to evaluate the incidence of diarrhea after antimicrobial treatment in children with no history of antimicrobial use during the previous 3 months. Another aim of this study was to assess the preventive potential of Lactobacillus rhamnosus GG (Lactobacillus GG; American Type Culture Collection 53103), a probiotic strain with a documented safety record and a therapeutic effect in viral gastroenteritis on antibiotic-associated diarrhea. Oral antimicrobial agents were prescribed for the treatment of acute respiratory infections at the clinics of the Health Care Center of the City of Tampere or Tampere University Hospital, Finland, to 167 patients who were invited to participate in the study. Of the patients, 48 were lost to follow-up; therefore, the final study population consisted of 119 children from 2 weeks to 12. 8 years of age (mean: 4.5 years). All study subjects met the inclusion criteria: they had not received any antimicrobial medication during the previous 3 months, they did not suffer from gastrointestinal disorders, and they did not need intravenous antimicrobial treatment. The patients were randomized to receive placebo or 2 x 10(10) colony-forming units of Lactobacillus GG in capsules given twice daily during the antimicrobial treatment. Lactobacillus GG and placebo capsules were indistinguishable in appearance and taste. The parents kept a daily symptom diary and recorded stool frequency and consistency at home for 3 months. Diarrhea was defined as at least three watery or loose stools per day for a minimum of 2 consecutive days. In the case of diarrhea, viral (adenovirus, rotavirus, calicivirus and astrovirus) and bacterial (Salmonella, Shigella, Yersinia, Campylobacter, Clostridium difficile, Staphylococcus aureus, and yeasts) analyses were studied in fecal samples. The metabolic activity of the gut microflora was assessed by analysis of fecal urease, beta-glucosidase, and beta-glucuronidase activities. The primary outcome measure was diarrhea during the first 2 weeks after the beginning of the antimicrobial treatment, because this period most likely reflects the effects of antimicrobial use. Secondary outcome measures were the activities of fecal urease, beta-glucuronidase, and beta-glucosidase. On the entire follow-up, 80% of any gastrointestinal symptoms were reported during the first 2 weeks after the beginning of the antimicrobial treatment. The incidence of diarrhea was 5% in the Lactobacillus GG group and 16% in the placebo group within 2 weeks of antimicrobial therapy (chi(2) = 3.82). The treatment effect (95% confidence interval) of Lactobacillus GG was -11% (-21%-0%). In diarrheal episodes, the viral and bacterial analyses were positive for Clostridium difficile in 2 cases and for Norwalk-like calicivirus in 3 cases. The age of the patients with diarrhea was between 3 months and 5 years in 75% of cases in both groups. The severity of diarrhea was comparable in the study groups, as evidenced by similar stool frequency (mean: 5 per day; range: 3-6) and the duration of diarrhea (mean: 4 days; range: 2-8). The activities of fecal urease and beta-glucuronidase, but not beta-glucosidase, changed significantly after the beginning of the antimicrobial treatment in the Lactobacillus GG group and in the placebo group alike. (ABSTRACT TRUNCATED)

[Oral pefloxacin in the treatment of acute gastroenteritis].

In the case of travellers' diarrhoea, in order to reduce to a minimum the period of sickness and temporary invalidity, suitable therapy needs to be undertaken, involving the reintegration of fluids and electrolytes, as well as antibiotic treatment whose spectrum of action covers the most commonly isolated microorganisms. The aim of the study was to verify the rapidity of the antibacterial action of pefloxacin in the treatment of this type of gastrointestinal infection. The patients enrolled were treated for 5 days with pefloxacin in tablets containing 400 mg of the active agent, given orally. Treatment involved a first dose of 800 mg (2 tablets in a single administration), followed by 400 mg twice a day (1 tablet every 12 hours). Administration was carried out prevalently at mealtimes. At the end of treatment a two-week follow-up period was scheduled. At the beginning of the study, and after 5 days' treatment, a coproculture was carried out, with identification of the germ responsible for the infection. The study was carried out in accordance with the principles of the Helsinki declaration and its revisions, in particular each patient gave his/her informed consent to participate in the trial. Thirty patients enrolled in the study (16 males, 14 females), of mean age 48.2 years (18-82 min-max), mean weight of 66.3 kg (46-88 min-max), suffering from acute gastroenteritis. The coproculture carried out at the baseline for all patients led to the isolation in 10 patients, of 10 pefloxacin-sensitive GRAM-negative bacterial strains: Salmonella spp. in 6 cases, Shigella spp. in 2, Escherichia coli in 1 and Yersinia enterocolitica in 1. At the end of treatment and follow-up the coproculture indicated that all the germs isolated initially had been eradicated and no cases of superinfection or reinfection occurred. The number of daily evacuations gradually decreased from a mean of 6.8 at the baseline to 1.1 on the fifth day (p<0.0001). The consistency of faeces had increased in a significant fashion by the third day and at the end of treatment 93.3% of patients had well-formed faeces. In the course of treatment abdominal pain, nausea and vomiting decreased progressively and body temperature returned within normal limits by the third day. Safety was excellent in 93.3% of patients, with one case of nausea and one of erythema, which resolved spontaneously in the course of treatment. At the end of treatment with pefloxacin, the physician expressed his final judgment of efficacy, which was excellent in 86.7% of cases (26/30) and good in 13.3% (4/30), in accordance with the clinical evaluation of recovery in 93.3% of cases (28/30) and of improvement in 6.7% (2/30). In forms of acute gastroenteritis in which coproculture shows the presence of germs sensitive to pefloxacin, the use of this quinolone guarantees a high percentage of success with a short course of treatment.

Hospital-acquired infection

Types Hospital-acquired pneumonia Ventilator-associated pneumonia Urinary tract infection Gastroenteritis Puerperal fever Central line-associated blood stream infection Organisms Staphylococcus aureus Methicillin resistant Staphylococcus aureus Candida albicans Pseudomonas aeruginosa Acinetobacter baumannii' Stenotrophomonas maltophilia Clostridium difficile Escherichia coli Tuberculosis Vancomycin-resistant Enterococcus Legionnaires' disease Cause Transmission In-dwelling catheters have recently been identified with hospital acquired infections. To deal with this complication, procedures are used, called intravascular antimicrobial lock therapy that can reduce infections that are unexposed to blood-borne antibiotics. Introducing antibiotics, including ethanol, into the catheter (without flushing it into the bloodstream) reduces the formation of biofilms.

Blood in stool

Inflammatory bowel Diseases causing inflammation in the GI tract can lead to blood in the stool. Inflammation can occur anywhere along the GI tract in Crohn's disease, or in the colon if a person has ulcerative colitis. Crohn's disease Ulcerative colitis Colitis Enteritis—inflammation of the small intestine, which has many causes including autoimmune conditions (e.g. Crohn's disease), certain drugs (e.g. ibuprofen), radiation therapy, and Coeliac disease. Infectious colitis Food poisoning—the bacteria that is associated with bloody diarrhea is typically E. coli Campylobacter enteritis Shigellosis Salmonellosis (Salmonella enteritis/Salmonella enterocolitis) Bacterial gastroenteritis Campylobacter jejuni Clostridium difficile Escherichia coli enteritis—most common cause of travelers' diarrhea Salmonella enterica Shigella dysenteriae see also dysentery Staphylococcus aureus Drug-induced colitis Radiation enteritis

[Bacterial etiological factors of diarrhea in the stool of infants hospitalized in January 1987].

The results are presented of the second part of the studies conducted for monitoring of the variability of bacterial factors causing diarrhoea in the youngest children. The presently reported study comprised 42 babies aged from 7 days to 18 months treated in hospital in January 1987. The number of children with diarrhoea hospitalized in this period was relatively smaller than in January 1985, while the incidence of enteropathogenic bacteria in stools was very similar. They included mainly Klebsiella and enteropathogenic Escherichia coli strains, especially in the youngest children. In only one case Salmonella arizonae was found while in 1985 a very high number of Salmonella agona strains were cultured, especially from newborns. In both parts of the study Campylobacter jejuni and Yersinia enterocolitica were never found in stools. In both parts of the study the course of bacterial diarrhoea was mostly moderately severe, loose stools continued usually for 3-4 days, but in the second part more cases of severe diarrhoea were noted, which, however, could not have been related to the bacterial species cultured from stools or to the presence of mixed bacterial flora. The importance is stressed of the carrier state of enteropathogenic bacteria which was observed in three-fourths of patients in January 1987, while in January 1985 this was present in nearly all cases without diarrhoea.

Pneumonia

Antibiotics by mouth, rest, simple analgesics, and fluids usually suffice for complete resolution. However, those with other medical conditions, the elderly, or those with significant trouble breathing may require more advanced care. If the symptoms worsen, the pneumonia does not improve with home treatment, or complications occur, hospitalization may be required. Worldwide, approximately 7–13% of cases in children result in hospitalization, whereas in the developed world between 22 and 42% of adults with community-acquired pneumonia are admitted. The CURB-65 score is useful for determining the need for admission in adults. If the score is 0 or 1, people can typically be managed at home; if it is 2, a short hospital stay or close follow-up is needed; if it is 3–5, hospitalization is recommended. In children those with respiratory distress or oxygen saturations of less than 90% should be hospitalized. The utility of chest physiotherapy in pneumonia has not yet been determined.

Changes in the trend of shigellosis in Dhaka: family study on secondary infection, clinical manifestation and sensitivity pattern: 1980.

The incidence of shigellosis and the death rate have increased and the resistance of shigellae to antibiotics has changed in Dhaka during our experiences. In 1980, we investigated the secondary infection and case rates, infection to case ratio, duration of illness, excretion of shigellae and antibiotic sensitivity pattern in 100 families with cases of shigellosis, culturing rectal swabs obtained by home visits for a 10-day period. Standard methods were used for culture and sensitivity tests. The over-all secondary infection rate in contacts was 27.3% and the case rate 10.7%. The rates were higher for Shigella flexneri than for Sh. dysenteriae. When the index cases were nought to four years old the secondary infection and case rates were higher than when index cases were older. Contacts aged nought to four years had highest attack rates. The average duration of excretion of Sh. flexneri was 4.5 and Sh. dysenteriae 2.6 days. Illness was one day longer for Sh. dysenteriae than for Sh. flexneri. Cases of shigellosis in hospital had higher rates of fever and blood in stool than those who were not in-patients. 40% of Sh. dysenteriae and 14% of Sh. flexneri were sensitive to tetracycline, 0 to 5% to streptomycin and 100% to sulphamethoxazole, trimethoprim and gentamicin. Incidence of Sh. flexneri had increased in 1980 but that of Sh. dysenteriae remained the same as in 1973 although Sh. dysenteriae type 1 appeared to be less infective in 1980 than in 1973.

Campylobacter coli

Treatment Campylobacteriosis is often self-limiting infection, which is treated according to the symptoms, for example with electrolyte replacement and rehydration. While extra fluid is required of an infected person for as long as the symptoms lasts, antibiotics such as azithromycin or ciprofloxacin can be used to treat risk groups, including immunocompromised patients. Due to the increased antibiotic usage in both animal agriculture and human populations, Campylobacter spp. has been reported to be progressively resistant to several antibiotics, including fluoroquinolones and macrolides. Although most patients recover from the infection, severe post-infectious complications such as Guillain-Barré syndrome, a rare autoimmune condition which causes muscle weakness as a result of the immune system damaging the peripheral nervous system, have been linked to campylobacteriosis. See also List of human flora References

[Life-threatening diarrhea in atypical course of legionellosis].

After eating a meal of poultry a 41-year-old man fell ill with severe diarrhoea, persistent high fever of around 39 degrees C, dehydration and somnolence. On admission to hospital physical examination was normal except for signs of dehydration. The blood count showed a leukocytosis (13,300/microliters) with 60% stab-form neutrophils. The erythrocyte sedimentation rate was raised to 49/82 mm. Also increased were the serum concentrations of creatinine (3.5 mg/dl), creatine kinase (179 U/l), lactate dehydrogenase (298 U/l) and C-reactive protein (16.8 mg/dl). Bacteriological and virological examinations of blood and stool were negative. A normal fluid and electrolyte balance was re-established. But as there was no improvement, ampicillin was administered, 2 g three times daily, then ciprofloxacin, 500 mg two times daily, and finally combined with metronidazole, 500 mg three times daily. Despite this treatment a chest radiograph on the tenth day revealed an infiltration in the left basal lung segment, and the legionella titre became positive at 1:2045. The antibiotic treatment was changed to 150 mg roxithromycin two times daily. The fever fell within 3 days and the diarrhoea stopped after 5 days. He was discharged free of symptoms after 24 days.

<i>Clostridium difficile</i> Colitis Leading to Reactive Arthritis: A Rare Complication Associated With a Common Disease.

The relationship between reactive arthritis and enteric infections caused by <iYersinia enterocolitica, Campylobacter jejuni</i, and <iSalmonella typhimurium</i is well documented. <iClostridium difficile</i colitis is a less recognized cause of reactive arthritis. We present a case of a 58-year-old woman with <iClostridium difficile</i colitis complicated by reactive arthritis. A 58-year-old woman with no significant past medical history presented to our hospital with complaints of nonbloody watery diarrhea, abdominal pain for the past 1 week, and right knee pain starting 1 day prior. The patient had recently used antibiotics for a respiratory tract infection. On examination, the patient had a swollen and erythematous right knee. While in the hospital the patient also developed a similarly painful and swollen left knee. The patient was found to be positive for <iC difficile</i toxin in stool. Synovial fluid analysis of both the knee joints revealed a sterile and inflammatory fluid, negative for crystals and showing no growth on gram stain. We diagnosed the patient with reactive arthritis secondary to <iC difficile</i colitis once all other causes of the bilateral knee joint symptoms were ruled out with appropriate laboratory and imaging studies. Treatment with oral vancomycin and an anti-inflammatory was initiated, and the patient had complete resolution of symptoms. This case illustrates the importance of recognizing <iC difficile</i colitis as a potential differential for reactive arthritis under the appropriate circumstances. The treatment of reactive arthritis is mainly supportive and treating the underlying cause, which happens to be <iC difficile</i in this case.

[Salmonellosis in children: study of 95 cases in the Hospital Ste-Justine, Montreal, in 1963-1964].

A retrospective study was done in children in whom salmonellosis was confirmed by laboratory findings with the aim of reviewing etiology, epidemiology, clinical manifestations and therapy. The 15 serotypes most frequently isolated from stool, and in exceptional cases from urine, are discussed. If patients with typhoid fever are excluded, only one patient (who subsequently died) had a blood culture positive for Salmonella, specifically S. enteritidis.No seasonal or other peaks of incidence were noted. Age appeared to be important; of 81 patients with gastroenteritis, 30 were less than 6 months old.Two children in the older age group developed complications; one with appendicitis required surgery.Ten strains of Salmonella out of 23 tested by the disc method showed in vitro resistance to ampicillin on primary isolation.Acquired in vitro resistance to one or more antibiotics appeared to develop with six Salmonella strains reisolated from patients after or during antibiotic treatment.In several children the stool cultures remained positive after clinical signs had disappeared. These findings strongly suggest that, even though antibiotic therapy may improve the symptoms of Salmonella infection, it does not decrease the number of carriers during the convalescent period.


With the deformity and pain in the distal radius, we expect a fracture at this level, so we mark 3. However, I see it as unquestionable, given that it could also have a concomitant fracture in the ulnar green stalk, although the main lesion is that of the radius.

With the deformity and pain in the distal radius, we expect a fracture at this level, so we mark [HIDDEN]. However, I see it as [HIDDEN], given that it could also have a concomitant fracture in the ulnar green stalk, although the main lesion is that of the radius.

A 7-year-old boy brought to the emergency department after falling off a swing onto his right hand. He has no history of interest. He presents with fork dorsum deformity of the wrist and functional impotence, with normal distal neurovascular status. What lesion would you expect to find on the urgent x-ray you request?

Distal radius fracture

Before the 18th century, distal radius fracture was believed to be due to dislocation of the carpal bones or the displacement of the distal radioulnar articulation. In the 18th century, Petit first suggested that these types of injuries might be due to fractures rather than dislocations. Another author, Pouteau, suggested the common mechanism of injury which leads to this type of fractures - injury to the wrist when a person falls on an outstretched hand with dorsal displacement of the wrist. However, he also suggested that volar displacement of the wrist was due to the ulnar fracture. His work was met with skepticism from colleagues and little recognition, since the article was published after he died. In 1814, Abraham Colles described the characteristics of distal end radius fracture. In 1841, Guilaume Dupuytren acknowledged the contributions by Petit and Pouteau, agreeing that the distal end radius fracture is indeed a fracture, not a dislocation. In 1847, Malgaigne described the

Fracture-Dislocations You Can't Afford to Miss.

Occult dislocations can accompany extremity fractures and may lead to serious complications if undetected and untreated. Physicians, therefore, need to watch for uncommon trauma like distal radius fractures with radioulnar joint disruption (Galeazzi fractures), proximal ulna fractures with radial head dislocation (Monteggia fractures), and midfoot dislocations with or without fracture (Lisfranc injuries). Injury recognition involves comparing important historical features like a fall onto an outstretched hand, physical exam findings such as the nature of the pain, and sometimes-subtle radiographic clues. Treatment is usually surgical.

Distal radius fracture

Distal radius fractures are common, and are the most common type of fractures that are seen in children. Distal radius fractures represent between 25% and 50% of all broken bones and occur most commonly in young males and older females. A year or two may be required for healing to occur. Most children with a buckle wrist fracture experience a full recovery to their previous level of wrist function and do not have an increased chance of re-fracturing the same spot or other adverse effects. Signs and symptoms People usually present with a history of falling on an outstretched hand and complaint of pain and swelling around the wrist, sometimes with deformity around the wrist. Any numbness should be asked to exclude median and ulnar nerve injuries. Any pain in the limb of the same side should also be investigated to exclude associated injuries to the same limb.

Wrist Sprain -- History and Physical

A Scapholunate ligament injury commonly presents following a fall onto a dorsally extended and ulnar deviated hand. Wrist pain is usually dorsal-radial and accompanied by an inability to bear weight with the wrist extended, such as in a push-up position. The physical exam may show tenderness over the location of the scapholunate ligament, which is palpable on the dorsum of the wrist, immediately distal to the head of the radius. A scaphoid shift test can be performed as part of the physical exam to aid in the diagnosis with a positive likelihood ratio of 2.76 and a negative likelihood ratio of 0.25. [6] Dynamic imaging with a clenched fist, as well as contralateral wrist views, can improve the sensitivity of imaging with plain films. [7]

Elbow Dislocation with Irretrievable Rotating-Rope Injury of the Forearm: Case Report and Literature Review.

Simultaneous dislocation of the elbow, radioulnar joint and proximal radius fracture with rotary noose injury to the medial ulna tubercle is extremely rare. An emergency surgery was performed to reduce it. The radial head with the backbone was reset after two hammers were fixed, then the radial capitulum safety was fixed with a locking plate. After the ulnar instability was examined, two Kirschner wires were drilled percutaneously to fix the elbow flexion at 100° under closed reduction, and two Kirschner wires were drilled percutaneously to fix the ulnar joint. Good follow-up results were achieved. To the best of our knowledge, this is the first report on this particular type of injury and on this approach to treating this type of injury. We report the case of a 36-year-old male, who extended and landed on his left hand to protect his child in right arm before felling, resulting in severe pain and deformity of his left elbow and wrist and loss of movement in these joints. X-ray examination found proximal distal radioulnar joints, a proximal radial fracture and a dislocation bowstring in the ulna nodule. For a timely diagnosis in an emergency open reduction situation, accurate judgment of this injury is highly important. After 12 months of postoperative follow-up, the patient was symptom-free, and radiographs showed fracture healing. We performed emergency reduction and internal fixation of the elbow and successfully saved elbow function, no stability decrease and movement restriction. This case also provides a new reference for the treatment of this type of elbow fracture dislocation.

Radial Head Fractures -- History and Physical

The fracture occurs when a patient has direct traumatic to the elbow or falls with the wrist and the hand in extension. The usual signs are pain and functional impotence, there may be blockages in the elbow.

Ulna fracture

Nightstick fracture is a fracture of the middle portion of the ulna without other fractures. Distal ulna fractures typically occur along with distal radius fractures. Hume fracture - a fracture of the olecranon with an associated anterior dislocation of the radial head. Monteggia fracture - a fracture of the near to elbow end of the ulna with the dislocation of the head of the radius at the elbow joint. Galeazzi fracture - not a fracture of the ulna but a displaced fracture of the radius accompanied by a dislocation of the ulna at the wrist, where the radius and ulna come together.

Radius (bone)

Essex-Lopresti fracture – a fracture of the radial head with concomitant dislocation of the distal radio-ulnar joint with disruption of the interosseous membrane. Radial shaft fracture Distal radius fracture Galeazzi fracture – a fracture of the radius with dislocation of the distal radioulnar joint Colles' fracture – a distal fracture of the radius with dorsal (posterior) displacement of the wrist and hand Smith's fracture – a distal fracture of the radius with volar (ventral) displacement of the wrist and hand Barton's fracture – an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint. History The word radius is Latin for "ray". In the context of the radius bone, a ray can be thought of rotating around an axis line extending diagonally from center of capitulum to the center of distal ulna. While the ulna is the major contributor to the elbow joint, the radius primarily contributes to the wrist joint.

Fractures of the distal end of the radius. An historical account.

From the time of Hippocrates to the beginning of the nineteenth century, fractures of the distal end of the radius were mistaken for dislocations of the wrist. Clinical observations, anatomic dissections, and experiments on cadavers dispelled this error. It was not, however, until after the discovery of roentgenograms that the variety and complexity of these common injuries could be appreciated. From the large group of fractures of the distal end of the radius, three distinct varieties can be distinguished rather easily, and to them the eponyms of Colles (Pouteau-Colles), Smith, and Barton have been applied. The remainder, which consist of a substantial number, do not fit into any specific category and must be described individually.

An Extremely Rare Combination of Monteggia Equivalent Type 1 Lesion (diaphyseal Ulna and Radial Neck Fractures Without Dislocation) with Ipsilateral Radius Shaft and Distal Radius Fractures in a Child.

We report an extremely rare combination of Monteggia equivalent Type 1 lesion (diaphyseal ulna and radial neck fractures without dislocation) with ipsilateral radius shaft and distal radius fractures in a 13-year-old boy. There are only a few cases of Monteggia or Monteggia equivalent injury with ipsilateral forearm fractures in children, and injury pattern being reported by us is not only rare but also the only case reported, thus far to the best of our knowledge. A 13-year-old, right-hand dominant boy presented in casualty with a history of fall 1 day back with pain, swelling and deformity in the left forearm with bleeding from the left forearm, and restriction of movement of fingers and thumb of the left hand. On examination, there was a wound of size 1.5 cm on the upper third-forearm over the ulnar aspect. No neurovascular deficit was present. X-rays were performed, which suggested Type I Monteggia fracture equivalent lesion (diaphyseal ulna and radial neck fractures without dislocation) with ipsilateral distal radius and radial shaft fractures. The patient was operated with toileting, debridement, and close reduction of proximal ulnar fracture with titanium elastic nail (TENS) Distal radius was managed by percutaneous fixation with two K-wires under the guidance of image intensifier, while the shaft of radius fracture was managed by close reduction and internal fixation with elastic TENS nail with a lateral entry point and radial neck fracture was managed by the Metaizeau technique. Follow-up of the patient showed subsequent union of all fractures with good functional outcome. We have highlighted an extremely rare combination of injuries. Early recognition and prompt surgical intervention can lead to a satisfactory outcome, even in these complex injuries.

List of Ashes to Ashes characters

He is reported missing by Donna. Days later, on 8 November 1982 his body is discovered floating in the canal by DCI Gene Hunt on the day he was to have flown to Turkey. The coroner opines that the low volume of water in his lungs suggests that he was killed on dry land, and notes the blunt force trauma to his right frontal lobe. The two facts suggesting murder to DI Alex Drake; while Hunt agrees with the possibility, he offers the alternative theory that Mitchell was drunk, fell, hit his head and fell in the river. Drake and the coroner agree that the scabbing on Mitchell's wrist wounds suggest they were received at the same time as the head wound.

[Wrist pain following radial head fracture caused by a tear in the interosseous membrane (Essex-Lopresti lesion)].

A 44-year-old multiple injured patient presented with several fractures including a dislocated, comminuted radial head fracture after a 4 meter fall from a ladder. He was treated with radial head resection. However, at routine follow-up he indicated pain and loss of function of his wrist due to a distal radio-ulnar dislocation with a high position of the ulna, causing loss of pronation and supination. This is also known as the Essex-Lopresti lesion. Operative treatment included reduction and fixation of the distal radio-ulnar joint after resection osteotomy of the distal ulnar shaft according to Sauvé and Kapandji.

History of head trauma in a 6-year-old boy: maybe more than meets the eye (and head).

It is spring and you are meeting for the first time, Eddie, a recently turned 6-year-old boy who moved to the area in September of the previous year and is here for his 6-year-old health maintenance visit. Eddie's mother is concerned that although he is "only" in kindergarten, he is not retaining any information at school. His mother reports he knew some of his letters before kindergarten. Currently, when he is trying to write a word, for example, "daddy" he will need to ask his mother: "what letter is the letter D?" Before kindergarten, he knew his numbers 1 to 10. At times now, Eddie will forget these numbers. For example, "if he is counting he will forget what comes after 4 and what comes after 9." Mother reports he will start crying for no apparent reason and if she asks why, he will say "I don't know why." Mother is worried that Eddie is sad, although she denies suicidal ideation. She reports he used to like making noise with other kids, and now he cannot stand when the children are noisy. Eddie will comment he does not want to go to school because the kids make lots of noise and his head hurts. He complains of headaches as often as 2 to 3 times a month. She next states, "This was not an issue before his head trauma." At this point, she reveals to you that in August, before the family relocated, Eddie fell from a 7-foot deck onto concrete while playing. He struck his head on the left side and lost consciousness for several seconds until shaken awake. He was nauseous and disoriented initially but without emesis or incontinence. He was taken to the local emergency department where he was admitted for 1 day and diagnosed with closed head injury, left frontal epidural hematoma, and question of postconcussive syndrome. Eddie has gone back to see the neurosurgeon twice over the last 6 months for scheduled visits and since the accident has had no further treatment.Eddie's mother reports that before the accident, if she read him a story from a book, he could remember the details from the story. Currently, he does not have good memory recall. Before the trauma, he did not attend a preschool program but stayed home with his mother full time. Eddie's first formal schooling has been kindergarten this year. When they moved, the neurosurgeon recommended he start school at the end of September given his head trauma in August. He had a recent computed tomography completed 3 months ago showing the epidural hematoma had completely resolved and the study was otherwise normal. His mother reports he had an evaluation the spring before the accident for a kindergarten screening test and was reported as "excellent." Eddie's birth and medical history are otherwise unremarkable except for some seasonal allergies. He has not had a loss in language skill, although his mother reports he did not speak during his hospitalization. He would just stare and nod his head if someone would ask him a question. No family history of any learning or behavioral difficulties on either side of the family. Eddie has 2 older brothers, 10 and 7 years of age, with no learning issues.What would you do next?

Judgment Day (2002)

With his feud with Triple H now over, Chris Jericho decided to enter the King of the Ring tournament, with the winner to receive a WWE Undisputed Championship match on August 25 at SummerSlam. Jericho was scheduled to compete against Edge in the first round tournament, but Edge forfeited his match to Jericho due to a legitimate shoulder injury. Jericho advanced as far as the semi-finals, losing to Rob Van Dam. On the May 30 episode of SmackDown!, The Undertaker defeated Randy Orton to retain the WWE Undisputed Championship. Afterward, Triple H assaulted The Undertaker and demanded a title shot. During Triple H's match against Test, The Undertaker interfered, enabling Test to nail Triple H with a big boot for the pin. Afterwards, The Undertaker nailed Triple H with multiple chair shots to his elbow. On the June 6 episode of SmackDown!, Triple H became the number one contender to the WWE Undisputed Championship by defeating Hollywood Hulk Hogan. Triple H faced The Undertaker for the

Ipsilateral Plastic Deformation Monteggia and Galeazzi-Type Fracture in a Child: A Case Report.

A 7-year-old boy attended the emergency department after falling from a climbing frame onto his outstretched left wrist. On examination, there was mild swelling to the left elbow and tenderness to the antecubital fossa. There was also tenderness diffusely to the distal ulnar and radius. There was no neurovascular deficit. Radiographs revealed a plastic deformation fracture of the left radius and ulna, with dislocations of the ipsilateral radiocapitellar joint and distal radioulnar joint. A diagnosis of combined Monteggia and Galeazzi-type fractures of the left forearm was made. It is rare to find cases of combined Monteggia and Galeazzi fractures to the same forearm. Furthermore, to our knowledge, ipsilateral plastic deformation Monteggia and Galeazzi-type fractures in children have not been reported in the literature.

Distal Radius Fractures -- History and Physical

Patients with distal radial fractures will often complain of post-traumatic distal upper extremity pain. DR fractures can also be present as part of a larger multiple trauma presentation. In either case, it is vital not to fixate on an obvious DR injury, and to do a complete evaluation for other possible life-threatening injuries or problems. A systematic approach in trauma situations will prevent a provider from missing occult injuries. Children are also diagnostically difficult as their presentations are often subtle. Children can suffer unwitnessed falls or trauma, and they are often unable to verbalize their symptoms. They can appear well and favoring the uninjured arm may be the only sign of an underlying fracture. [10] [8]

A Very Rare Presentation of Type 1 Monteggia Equivalent Fracture with Ipsilateral Fracture of Distal Forearm-approach with Outcome: Case Report.

We report a case of Type 1 Monteggia equivalent injury with intact radio-capitellar congruity, associated with epiphyseal fracture of distal radius and distal ulna shaft in an 11-year-old boy. There are only a few cases of Monteggia or Monteggia equivalent injury with ipsilateral forearm fractures in children, and injury pattern being reported by us is not only rare but also the only case reported thus far to the best of our knowledge, Sood et al. described Type 1 equivalent with epiphyseal injuries of both radius and ulna Osada et al. also described injury pattern same as Sood et al. with epiphyseal separation in both distal radius and ulna. Our case was slightly different than above two in that distally, there was ulna shaft fracture with Salter Harris Type 2 epiphyseal separation in the radius. An 11-year-old, right-hand dominant boy presented in casualty with a history of fall one day back with pain, swelling and deformity in the left forearm with bleeding from left forearm and loss of movement of fingers and thumb of the left hand. On examination, there was a wound of size one centimeter on mid-forearm over the ulnar aspect. Extension of fingers and thumb at metacarpophalangeal joints was lost with intact sensations suggestive of posterior interosseus nerve involvement. No vascular was deficit was present. X-rays were performed which suggested type two epiphyseal separation proximal radius with fracture shaft ulna with lateral angulation in elbow and proximal forearm. Radiocapitellar joint congruity was maintained in the views performed. X-rays of wrist suggested fracture both bones distal forearm epiphysis in distal radius and distal shaft in ulna. The patient was operated with toileting, debridement, and open reduction of proximal ulnar fracture with K-wire. Proximal radius epiphyseal separation was approached by Kocher approach and fixed with two K-wires, while for distal radius epiphyseal separation open reduction and internal fixation was performed. Follow-up of the patient showed posterior interosseus nerve recovery and subsequent union of all fractures with good functional outcome. This type of lesion is rare in children probably because the annular ligament is relatively lax and the radial head dislocates more easily anteriorly, rather than occurrence of fracture as seen in our case, and associated fracture of distal forearm is a very rare injury.

Occult distal radial fractures.

The radiological diagnosis of distal radial fractures is usually easy, but some fractures without displacement cannot be detected at the first examination. In this retrospective study of 626 wrist injuries diagnosed as "wrist sprain" we found 39 distal radial fractures which were discovered only after repeated examinations. The incidence of distal radial fractures was much higher than other wrist fractures that were diagnosed after repeated examinations. Repeat standard four-view X-ray examination, as well as other imaging methods, are necessary to diagnose these fractures.

Distal radius fracture

Diagnosis Diagnosis may be evident clinically when the distal radius is deformed, but should be confirmed by X-ray. The differential diagnosis includes scaphoid fractures and wrist dislocations, which can also co-exist with a distal radius fracture. Occasionally, fractures may not be seen on X-rays immediately after the injury. Delayed X-rays, X-ray computed tomography (CT scan), or Magnetic resonance imaging (MRI) can confirm the diagnosis. Medical imaging X-ray of the affected wrist is required if a fracture is suspected. Posteroanterior, lateral, and oblique views can be used together to describe the fracture. X-ray of the uninjured wrist should also be taken to determine if any normal anatomic variations exist before surgery. A CT scan is often performed to further investigate the articular anatomy of the fracture, especially for fracture and displacement within the distal radio-ulnar joint. Various kinds of information can be obtained from X-rays of the wrist:

[Who shot Erik XIV?].

Though Sweden was still at war with Denmark a revolution took place in 1568 and King Erik XIV was dethroned by his brothers Johan (John) and Karl (Charles). The situation was chaotic and the brothers didn't know how to dispose of the King. To execute or to expatriate him was far too dangerous, consequently remained to keep him imprisoned. This solution to the problem was not without hazards since Erik had many friends who repeatedly tried to free him. The former king, however, also had many enemies, one of whom was Olof Gustafsson Stenbock a man who was responsible for the guarding of Erik. Olof Gustafsson had himself been sentenced to death by King Erik but been reprieved. His brother Abraham Gustafsson Stenbock was on the other hand executed on the order of the King. On the 19th September 1569 Olof Gustafsson visited the imprisoned king, who rushed to his feet, attacking Olof Gustafsson. Olof retreated, took out his gun and shot the King in his left forearm. The King survived 8 years with a badly wounded arm which probably was of no use to him. In this article I have tried to put together all pieces of evidence to prove that the King really was shot. This includes old tales as well as written evidence and facts brought to light during the latest examination of King Erik's remains. This investigation was done in 1958 by professor Carl-Herman Hjortsjö and his collaborators. At the opening of the sarcophagi a defect healed fracture on the left humerus was still clearly visible. Many facts in this article originate from works by L.-I. Jönsson who in a very thorough and accurate way tried to reconstruct this interesting and exciting historical crime.

Diagnosis and treatment of a closed and inverted metacarpal head fracture.

This case report documents a rare inversion of a closed metacarpal head fracture in the setting of polytrauma. Although rare, hemispherical articular bones can fracture and rotate 180°. Because of the symmetry of the bone and the rarity of an inverted, metacarpal head fracture, a delay in diagnosis and subsequent treatment can occur, which can lead to a poor outcome. This is particularly true in the setting of polytrauma. A 38-year-old male, polytrauma patient presented to the emergency department (ED) after falling off a bridge and being struck by an oncoming vehicle. He presented with multiple surgical fractures of the upper and lower extremities as well as his pelvis. Three days after he was brought to the ED, x-rays were performed of his painful left hand, which revealed an extra-articular third metacarpal head fracture, for which he underwent open reduction of the closed fracture. Both collateral ligaments were intact and the head fragment had inverted within the constraints of these ligaments. Some of the ligament and capsular tissue remained attached to the head fragment along the radial and ulnar margins but was otherwise entirely covered with cartilage. The reduction maneuver was difficult but after the reduction was achieved, the fracture appeared stable and no internal fixation was used. Post reduction, the injury was splinted for 2 weeks and then early motion was allowed. The fracture has since healed, and the patient has attained near-full function of the finger and joint.

EFX (show)

As with Tommy Tune, Rick Springfield initially signed a one-year contract. Despite becoming the newest victim in EFX long history of performance-related accidents, fracturing his arm and spraining his wrist early on in his run, Springfield renewed his full contract and stayed with the show until it closed permanently on December 31, 2002. The final performances of EFX Alive! were shot with several cameras. The result was a complete DVD video of EFX Alive! (compiling footage from multiple performances) released exclusively by Springfield's Gomer Records as part of a three-disc limited edition of his 2005 studio album, The Day After Yesterday and available only through the official Rick Springfield merchandise site. An original cast album of the Springfield version of EFX was not released. References

Ulnar fracture with late radial head dislocation: delayed Monteggia fracture.

Monteggia fractures are rare but commonly discussed lesions, with increasing complications due to late diagnosis. This article describes a case of a Monteggia fracture with delayed dislocation of the radial head. Previous radiographs of a 2-year 8-month-old boy show complete fracture of the distal ulna, with no radial head dislocation. The radial head remained well positioned after 4 weeks. Seven years later, he sustained another arm injury. He was diagnosed with a hematoma but was later believed to have nursemaid's elbow. He presented to our institution 5 weeks after the injury, and the radial head was found to be chronically dislocated, indicating a displacement occurring sometime during the past 7 years. After failing conservative treatment, the patient underwent surgical repair. The annular ligament was reconstructed using a harvested triceps fascia band, and an ulnar osteotomy was performed. A review of the literature found few reports of delayed Monteggia fractures, which accounted the delayed dislocations to ulnar angulation. However, our patient showed minimal ulnar angular deformity. We propose that the initial fracture disrupted the annular ligament and the radial head spontaneously relocated prior to being seen, which put the radial head at risk for later dislocation. We present an alternative hypothesis of dislocation after fracture healing and report the longest known period of delay between fracture and dislocation.

Brachial artery laceration with closed posterior elbow dislocation in an eight year old.

Elbow dislocations are relatively uncommon in children. Rupture of the brachial artery associated with closed elbow dislocations in children is rare. This is a report of an 8-year-old boy, the youngest patient ever to be reported to have a closed posterior dislocation of the elbow associated with a brachial artery laceration. The boy incurred a closed elbow dislocation after a fall onto his outstretched arm. On physical examination, both radial and ulnar (ulnar) pulses were absent. Radiographs showed a posterolateral dislocation of the right elbow and distal fractures of the radius and ulna. Operative exploration of the antecubital fossa showed complete transection of the brachial artery. Repair of the vessel was performed using an interposition vein graft. The distal forearm fractures were managed by closed reduction. At the two-year postoperative follow-up examination, the patient had a normal neurovascular examination with full range of motion of his elbow and wrist. Surgical treatment should include exploration of the antecubital fossa and reconstruction of the injured vessels.

Reginald Dixon

On 3 July 1958, The Bulletin newspaper reported that Dixon was to have an operation that Sunday, quoting him as saying "A nerve in my right elbow is affecting the hand". It was "the result of an injury received in a motorcycle smash when I was a youth." The Bulletin reported that "He wanted to postpone the operation until the end of the season, but doctors have warned him that delay might mean losing the use of the hand". He returned to the ballroom and its Wurlitzer later in the same month, having made over 2,000 broadcasts.

Isolated Radial Shaft Fracture with Unreducable Posterior Dislocation of the Radial Head in Adult: A Case Report.

Isolated fracture of the radial diaphysis with dislocation of the radial head is a rare injury, which requires careful evaluation. Combined injuries associated with forearm shaft fractures and elbow dislocations are well recognized. A 35-year-old male presented to our emergency department with a history of fall in ditch under influence of alcohol with swelling of her right elbow and deformity of right upper limb. Roentgenograms showed oblique fracture of the radial shaft and dislocation of radial head posteriorly. He underwent open reduction and internal fixation of fracture with limited contact dynamic compression plate and reduction of radial head and fixing with radiocapitellar wire. After 4 months, the fracture healed fully and he had complete full range of elbow movements. Ipsilateral radial head dislocation and radial shaft fracture are extremely rare injury in a child. A good outcome can be achieved by applying principles of the management of proximal forearm fracture-dislocation. Ipsilateral radial head dislocation and radial shaft fracture is extremely rare injury in a child. A good outcome can be achieved by applying principles of management of proximal forearm fracture-dislocation.

Frank Reys

Trainer Trainer Ray Hutchins stood by Frank Reys after a horrible two years in which he had suffered a broken shoulder, two pelvis fractures, a broken cheek bone and a broken ankle, and earned himself the nickname "Autumn Leaves". Despite these injuries Hutchins entrusted Reys with the ride on the four-year-old gelding Gala Supreme in the 1973 Caulfield Cup, in which Gala Supreme ran second. Hutchins had long before mapped out the Melbourne Cup as his mission, and after the Caulfield Cup second he prepared Gala Supreme for the Cup.

Combined Monteggia and Galeazzi fractures in a child: a case report and review of the literature.

We present an unusual case in which a combination of Monteggia and Galeazzi fractures occurred in the same forearm. The patient was a 10-year-old male who climbed up the pole of a basketball net, caught hold of the net, then lost his grip, and fell onto his right hand. On physical examination, a complete paralysis of the radial ulnar and median nerves was recognized. X-rays showed an olecranon fracture and lateral dislocation of the radial head in the elbow joint, a dorsal dislocation of the distal bone fragments due to a fracture of the distal third of the radius, and a palmar dislocation of the distal end of the ulna at the wrist joint. The injuries were diagnosed as a combination of a Bado type III Monteggia fracture and a palmar-type Galeazzi fracture of the same arm. Manual reduction and immobilization in a plaster cast were performed. Three years after the injury, both the distal and proximal radioulnar joints were maintained in the reduction position. Range of motion was reduced minimally in extension at the patient's elbow, and there was complete recovery of all three nerves. A combination of Monteggia and Galeazzi fractures in the same arm has been reported in only two pediatric patients worldwide and in eight cases total when adult patients are included, indicating that this is an extremely rare trauma.

Rhun ab Arthgal

It is uncertain when Rhun's reign and life ended. One possibility is that Rhun died in 876, when Causantín seems to have been slain by Vikings. Causantín's death is dated to 876 by the Annals of Ulster. The Chronicle of the Kings of Alba appears to locate his fall in Atholl, whilst several king-lists locate his demise to a place variously called , an otherwise uncertain location that could refer to Inverdovat in Fife. If Causantín indeed enjoyed overlordship of Strathclyde at this date, Rhun could have fallen alongside him as a supporting vassal. It is likewise unknown who succeeded to the kingship of Strathclyde. If Rhun and Causantín both died in 876, Eochaid could well have inherited the British kingship in their absence. Certainly, Causantín's brother, Áed mac Cináeda, succeeded as King of the Picts, and ruled as such upon his death two years later. Whilst it is possible that the Pictish kingship was then assumed by a certain Giric, another possibility is that Eochaid succeeded to

Teasing out specific language impairment from an autism spectrum disorder.

Marcus is a handsome, sweet, 7½-year-old boy with a significant history of delayed development, specifically in speech and language skills, as well as difficulties with social interactions that have led other specialists to be concerned about a diagnosis of an autism spectrum disorder.He has been seen in our primary care practice since birth. He was born full-term after vaginal delivery weighing 6 pounds, 6 ounces. There were no pregnancy or delivery complications noted. Genetic testing revealed normal chromosomes, fragile X, and microarray testing. Marcus was a picky eater and good sleeper and had delays in toilet training.There is no family history of attention-deficit hyperactivity disorder (ADHD), autism, or substance abuse. Maternal grandmother and mother have a history of learning difficulties, and his father and a paternal uncle have a history of depression and anxiety. Marcus lives in a supportive environment with his mother, father, and sister.Marcus was noted to have significantly delayed language, stuttering, and immediate echolalia as a toddler. Gross and fine motor milestones were met on time, but he did not talk or follow directions until 4 to 5 years old. As a younger child, he would pretend to talk on the phone or mow the grass with a pretend lawn mower, but other household activities were not of interest to Marcus.Currently, he enjoys puzzles, reading, and board games. He likes to play with other children and can interact with familiar adults. Marcus is reported to initiate social interactions, although he has difficulty in understanding personal space. Imaginative play is preferred over other types. He seeks out adult attention and will bring objects over to an adult especially to share his perceived accomplishment. Marcus has difficulty in playing cooperatively with his sister.He is independent with activities of daily living. Marcus is noted to have auditory defensiveness including covering his ears to loud noises and becoming distressed. Parents feel he is immature and inattentive for his age. Marcus responds well when a routine is followed.Previous testing about 2 years ago revealed significant language deficits on the Clinical Evaluation of Language Functioning with average scores on the Woodcock Johnson Achievement Testing and Test of Nonverbal Intelligence Version 3. Marcus was not referred for early intervention and he did not attend preschool. In a regular education Kindergarten, he received speech and occupational therapy along with reading and math support.Comments from teachers or evaluator include the following: Marcus looked to his peers for clues about what he should be doing. Marcus has great difficulty in understanding requests but seems to be interested in pleasing his teacher and others. Marcus' language difficulty makes socialization with his peers problematic; however, he is interested in interacting with them and they seem to accept him willingly. Marcus has intent to communicate with others but relies on visual support to decipher social situations. Marcus has difficulty in attending to details and moves from activity to activity quickly. His short attention span is likely impacting not only learning but also his ability to socially interact with peers.On the day you see him for his 7-year-old checkup, he brought many toys over to show his father and interrupted your conversation to get your attention intermittently throughout the examination. He immediately pointed out a lit ceiling tile with Nemo illuminated to show his father. Marcus does not have any notable or significant repetitive motor mannerisms or stereotypies reported or observed. Marcus' gesture use was appropriate for age and included both symbolic (directing eye gaze and pointing) and concrete (hands up to be picked up and touching an item rather than pointing to it) gestures. Play observed today, although immature for age, was novel, imaginative, and functional. Answers to questions did not always match the question posed. He had a difficult time waiting for his turn before interrupting a conversation. Visual cues were helpful in understanding what was expected of him and what was going on socially.Marcus' speech is notable for persistent stuttering and difficulty in turn-taking in conversation. He gets frustrated easily and has a hard time being understood. He continues to confuse pronouns and makes some grammatical errors. He is able to follow simple directions but has a hard time following complex or multistep directions with accuracy. Nonverbal communication includes pointing to objects of interest in order to share the experience ("Look mom!"). He will point to identify an object and can follow a point across the room. He is able to use his eye contact to direct yours to moderate social interactions.Marcus has a special interest in Thomas the Tank Engine Train and Disney movies but is able to move away from those topics to engage in other play interests. Repetitive behaviors are not noted. Toe walking, hand flapping, or spinning, or unusual hand motions or observation of objects were not observed.Difficulties noted today include delays in his receptive and expressive language, poor intelligibility, dysfluency, and impaired motor planning. He recently underwent an audiogram which was normal. You decide to refer to a specialist for further evaluation.

Fred Olen Ray

Evil Toons (1992) was a comedy-horror, then he co-directed another with Wynorski, Dinosaur Island (1994). Witch Academy (1994) was the last of his "scream queen" movies. After Attack of the 60 Foot Centerfold (1995), he made Fugitive Rage (1996), Friend of the Family II (1996), Inferno (1997), Hybrid (1997), and The Shooter, which has been referred to as Ray's best film. Dear Santa (1998) was a family film and Billy Frankenstein (1998) a comedy. 2000s to present In 2001 he made the film Critical Mass. He later said he was a "Critical Mass kind of guy. I like to shoot things and blow stuff up. I also like comedies. Don't like erotic thrillers." He established a DVD company called Retromedia. Ray made a film called Bikini Airways "on a lark and it did really well", said Ray. This led to a series of Bikini films. In 2007 he reflected on his career:

Bone fracture

Rib fracture Sternal fracture Shoulder fracture Clavicle fracture Scapular fracture Arm fracture Humerus fracture (fracture of upper arm) Supracondylar fracture Holstein-Lewis fracture – a fracture of the distal third of the humerus resulting in entrapment of the radial nerve Forearm fracture Ulnar fracture Monteggia fracture – a fracture of the proximal third of the ulna with the dislocation of the head of the radius Hume fracture – a fracture of the olecranon with an associated anterior dislocation of the radial head Radius fracture Essex-Lopresti fracture – a fracture of the radial head with concomitant dislocation of the distal radio-ulnar joint with disruption of the interosseous membrane Distal radius fracture Galeazzi fracture – a fracture of the radius with dislocation of the distal radioulnar joint Colles' fracture – a distal fracture of the radius with dorsal (posterior) displacement of the wrist and hand