Major bleeding of the upper aerodigestive tract due to oral anticoagulant/antibiotic interactions

INTRODUCTION Although a well-known complication in certain medical specialties, major bleeding due to the interaction between oral anticoagulants and antibiotics has been rarely reported concerning the upper aerodigestive tract. We report three cases of life-threatening bleeding of the upper aerodigestive tract in a context of antibiotic therapy in patients treated with oral anticoagulants. CASE SERIES Three male patients under coumadin anticoagulation therapy presented major bleeding in three different contexts (epistaxis, peritonsillar abscess and postoperative course after total laryngectomy). Surgical intervention for hemostasis was required in all cases, with coagulation correction in two. Complications were severe anemia (2/3) and chronic heart failure (1/3). DISCUSSION/CONCLUSIONS Interactions between two drugs commonly used in otolaryngology can result in major bleeding. The goal of this article is to raise practitioners' awareness of a potentially fatal, although rare, complication. We also review the main preventive strategies.

Stricture of the Afferent Isoperistaltic Tubular Segment: A Late and Rare Cause of Bilateral Dilation of the Upper Urinary Tract After Ileal Bladder Substitution

OBJECTIVE To evaluate the etiology and treatment of bilateral hydronephrosis not responding to bladder substitute drainage after ileal bladder substitution using an afferent isoperistaltic tubular segment. MATERIALS AND METHODS A retrospective analysis was performed of a consecutive series of 739 patients who had undergone bladder substitution from April 1985 to August 2012. RESULTS Of the 739 ileal bladder substitute patients, 10 (1.4%) developed bilateral hydronephrosis unresponsive to complete bladder substitute drainage. The etiology was stenosis of the afferent isoperistaltic tubular segment. The median interval to presentation was 131 months (range 45-192). The incidence of afferent tubular segment stenosis was significantly higher in the 61 ileal bladder substitute patients with recurrent urinary tract infection (9 [15%]) than in the 678 without recurrent urinary tract infection (1 [0.15%]; P <.001). Urine cultures revealed mixed infections (34%), Escherichia coli (18%), Staphylococcus aureus (13%), enterococci (11%), Candida (8%), Klebsiella (8%), and others (8%). Seven patients underwent 10 endourologic interventions, only 1 of which was successful (10%). After failed endourologic treatment, 7 open surgical revisions with resection of the stricture were performed, with all 7 (100%) successful. CONCLUSION Bilateral dilation of the upper urinary tract after ileal orthotopic bladder substitution unresponsive to complete bladder substitute drainage is likely to be caused by stenosis of the afferent isoperistaltic tubular segment. The stenosis occurs almost exclusively in patients with long-lasting, recurrent urinary tract infection and can develop many years after the ileal bladder substitution. Minimally invasive endourologic treatment is usually unsuccessful; however, open surgical revision offers excellent results.

Functional Multiparametric Magnetic Resonance Imaging of the Kidneys Using Blood Oxygen Level-Dependent and Diffusion-Weighted Sequences: a Reliable Tool for Monitoring Acute Upper Urinary Tract Obstruction.

PURPOSE Little data is available on noninvasive MRI-based assessment of renal function during upper urinary tract (UUT) obstruction. In this study, we determined whether functional multiparametric kidney MRI is able to monitor treatment response in acute unilateral UUT obstruction. MATERIAL AND METHODS Between 01/2008 and 01/2010, 18 patients with acute unilateral UUT obstruction due to calculi were prospectively enrolled to undergo kidney MRI with conventional, blood oxygen level-dependent (BOLD) and diffusion-weighted (DW) sequences on emergency admission and after release of obstruction. Functional imaging parameters of the obstructed and contralateral unobstructed kidneys derived from BOLD (apparent spin relaxation rate [R2*]) and DW (total apparent diffusion coefficient [ADCT], pure diffusion coefficient [ADCD] and perfusion fraction [FP]) sequences were assessed during acute UUT obstruction and after its release. RESULTS During acute obstruction, R2* and FP values were lower in the cortex (p=0.020 and p=0.031, respectively) and medulla (p=0.012 and p=0.190, respectively) of the obstructed compared to the contralateral unobstructed kidneys. After release of obstruction, R2* and FP values increased both in the cortex (p=0.016 and p=0.004, respectively) and medulla (p=0.071 and p=0.044, respectively) of the formerly obstructed kidneys to values similar to those found in the contralateral kidneys. ADCT and ADCD values did not significantly differ between obstructed and contralateral unobstructed kidneys during or after obstruction. CONCLUSIONS In our patients with acute unilateral UUT obstruction due to calculi, functional kidney MRI using BOLD and DW sequences allowed for the monitoring of pathophysiologic changes of obstructed kidneys during obstruction and after its release.

Educational Expansion and Persistent Inequalities of Education: Utilizing the Subjective Expected Utility Theory to Explain the Increasing Participation Rates in Upper Secondary School in the Federal Republic Of Germany

This investigation attempts to answer the question why more and more parents have chosen the Gymnasium for their children's secondary school education in post‐war West Germany. Based on the theory of subjective expected utility, the crucial mechanisms of parental educational decisions have been emphasized. From this perspective it is assumed that increasing educational motivation coupled with changes in the subjective evaluation of the cost–benefit of education were important conditions for an increasing participation in upper secondary schools. These were, however, in turn, the result of educational expansion. The empirical analyses for three time‐periods in the 1960s, 1970s, and 1980s confirm these assumptions to a large degree. Additionally, empirical evidence was found to suggest that in addition to the intentions of parents and the educational career of their children, structural moments of educational expansion and their own inertia played an important role in the pupils' transition from one educational level to the next. Finally, evidence was found that persistent class‐specific educational inequality stems from a constant balance in the relative cost–benefit advantages between social classes as well as from an increasing difference of primary origin effect between social classes in the realization of their educational choice.

Core formation and mantle differentiation on Mars

Geochemical investigation of Martian meteorites (SNC meteorites) yields important constraints on the chemical and geodynamical evolution of Mars. These samples may not be representative of the whole of Mars; however, they provide constraints on the early differentiation processes on Mars. The bulk composition of Martian samples implies the presence of a metallic core that formed concurrently as the planet accreted. The strong depletion of highly siderophile elements in the Martian mantle is only possible if Mars had a large scale magma ocean early in its history allowing efficient separation of a metallic melt from molten silicate. The solidification of the magma ocean created chemical heterogeneities whose ancient origin is manifested in the heterogeneous 142Nd and 182W abundances observed in different meteorite groups derived from Mars. The isotope anomalies measured in SNC meteorites imply major chemical fractionation within the Martian mantle during the life time of the short-lived isotopes 146Sm and 182Hf. The Hf-W data are consistent with very rapid accretion of Mars within a few million years or, alternatively, a more protracted accretion history involving several large impacts and incomplete metal-silicate equilibration during core formation. In contrast to Earth early-formed chemical heterogeneities are still preserved on Mars, albeit slightly modified by mixing processes. The preservation of such ancient chemical differences is only possible if Mars did not undergo efficient whole mantle convection or vigorous plate tectonic style processes after the first few tens of millions of years of its history.

Petrogenesis of rift-related tephrites, phonolites and trachytes (Central European Volcanic Province, Rhon, FRG): Constraints from Sr, Nd, Pb and O isotopes

The volcanic rocks of the Rhön area (Central European Volcanic Province, Germany) belong to a moderately alkali basaltic suite that is associated with minor tephriphonolites, phonotephrites, tephrites, phonolites and trachytes. Based on isotope sytematics (87Sr/86Sr: 0.7033–0.7042; 143Nd/144Nd: 0.51279–0.51287; 206Pb/204Pb: 19.1–19.5), the inferred parental magmas formed by variable degrees of partial melting of a common asthenospheric mantle source (EAR: European Asthenospheric Reservoir of Cebriá and Wilson, 1995). Tephrites, tephriphonolites, phonotephrites, phonolites and trachytes show depletions and enrichments in some trace elements (Sr, Ba, Nb, Zr, Y) indicating that they were generated by broadly similar differentiation processes that were dominated by fractionation of olivine, clinopyroxene, amphibole, apatite and titaniferous magnetite ± plagioclase ± alkalifeldspar. The fractionated samples seem to have evolved by two distinct processes. One is characterized by pure fractional crystallization indicated by increasing Nb (and other incompatible trace element) concentrations at virtually constant 143Nd/144Nd ~ 0.51280 and 87Sr/86Sr ~ 0.7035. The other process involved an assimilation–fractional crystallization (AFC) process where moderate assimilation to crystallization rates produced evolved magmas characterized by higher Nb concentrations at slightly lower 143Nd/144Nd down to 0.51275. Literature data for some of the evolved rocks show more variable 87Sr/86Sr ranging from 0.7037 to 0.7089 at constant 143Nd/144Nd ~ 0.51280. These features may result from assimilation of upper crustal rocks by highly differentiated low-Sr (< 100 ppm Sr) lavas. However, based on the displacement of the differentiated rocks from this study towards lower 143Nd/144Nd ratios and modeled AFC processes in 143Nd/144Nd vs. 87Sr/86Sr and 207Pb/204Pb vs. 143Nd/144Nd space assimilation of lower crustal rocks seems more likely. The view that assimilation of lower crustal rocks played a role is confirmed by high-precision double-spike Pb isotope data that reveal higher 207Pb/204Pb ratios (15.62–15.63) in the differentiated rocks than in the primitive basanites (15.58–15.61). This is compatible with incorporation of radiogenic Pb from lower crustal xenoliths (207Pb/204Pb: 15.63–15.69) into the melt. However, 206Pb/204Pb ratios are similar for the differentiated rocks (19.13–19.35) and the primitive basanites (19.12–19.55) implying that assimilation involved an ancient crustal end member with a higher U/Pb ratio than the mantle source of the basanites. In addition, alteration-corrected δ18O values of the differentiated rocks range from c. 5 to 7‰ which is the same range as observed in the primitive alkaline rocks. This study confirms previous interpretations that highlighted the role of AFC processes in the evolution of alkaline volcanic rocks in the Rhön area of the Central European Volcanic Province.

Weathering geochemistry and Sr-Nd fingerprints of equatorial upper Nile and Congo muds

This study investigates processes of sediment generation in equatorial central Africa. An original, complete and integrated mineralogical-geochemical database on silt-sized sediments derived from different parent rocks (basalt, granite, gneiss, metapsammite, sandstone) along the East African Rift from 5°S in Tanzania to 5°N in Sudan is presented and used to assess the incidence of diverse factors controlling sediment composition (source-rock lithology, geomorphology, hydraulic sorting, grain size, recycling), with particular emphasis on chemical weathering.

High-resolution sequence stratigraphic correlation in the Upper Jurassic (Kimmeridgian)–Upper Cretaceous (Cenomanian) peritidal carbonate deposits (Western Taurides, Turkey)

Upper Jurassic (Kimmeridgian)±Upper Cretaceous (Cenomanian) inner platform carbonates in the Western Taurides are composed of metre-scale upward-shallowing cyclic deposits (parasequences) and important karstic surfaces capping some of the cycles. Peritidal cycles (shallow subtidal facies capped by tidal-¯at laminites or fenestrate limestones) are regressive- and transgressive-prone (upward-deepening followed by upward-shallowing facies trends). Subtidal cycles are of two types and indicate incomplete shallowing. Submerged subtidal cycles are composed of deeper subtidal facies overlain by shallow subtidal facies. Exposed subtidal cycles consist of deeper subtidal facies overlain by shallow subtidal facies that are capped by features indicative of prolonged subaerial exposure. Subtidal facies occur characteristically in the Jurassic, while peritidal cycles are typical for the Lower Cretaceous of the region. Within the foraminiferal and dasyclad algal biostratigraphic framework, four karst breccia levels are recognized as the boundaries of major second-order cycles, introduced for the ®rst time in this study. These levels correspond to the Kimmeridgian±Portlandian boundary, mid-Early Valanginian, mid-Early Aptian and mid-Cenomanian and represent important sea level falls which affected the distribution of foraminiferal fauna and dasyclad ¯ora of the Taurus carbonate platform. Within the Kimmeridgian±Cenomanian interval 26 third-order sequences (types 1 and 2) are recognized. These sequences are the records of eustatic sea level ¯uctuations rather than the records of local tectonic events because the boundaries of the sequences representing 1±4 Ma intervals are correlative with global sea level falls. Third-order sequences and metre-scale cyclic deposits are the major units used for long-distance, high-resolution sequence stratigraphic correlation in the Western Taurides. Metre-scale cyclic deposits (parasequences) in the Cretaceous show genetical stacking patterns within third-order sequences and correspond to fourth-order sequences representing 100±200 ka. These cycles are possibly the E2 signal (126 ka) of the orbital eccentricity cycles of the Milankovitch band. The slight deviation of values, calculated for parasequences, from the mean value of eccentricity cycles can be explained by the currently imprecise geochronology established in the Cretaceous and missed sea level oscillations when the platform lay above fluctuating sea level.