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Focal linear elastosis (FLE) is a benign skin findingcharacterized by hypertrophic linear plaques withabnormal elastic fibers on histology. We present aunique case in which focal linear elastosis occurredin the setting of joint hypermobility syndrome(JHS). Our patient, a 20-year-old man with a medicalhistory significant for symptoms consistent with JHS,had been followed by the rheumatology clinic formany months. He was referred to the dermatologydepartment for further evaluation of asymptomaticlongitudinal bands on his back that had been presentfor many years. He denied trauma but endorsed ahistory of 'stretch marks.' On examination there werenumerous horizontally oriented, firm, linear, yellowto flesh colored bands, all non-tender to palpation.Punch biopsies were performed of involved anduninvolved skin. Histopathology of normal skinrevealed no significant abnormalities whereasinvolved skin demonstrated broadened collagenbundles in the deep dermis. The elastic fiber stain,Verhoeff-Van Gieson, revealed a gross increase in thenumber of elastic fibers, fragmented fibers, fiberswith "paintbrush" or widened-ends, fibers of varyingthickness, and clumped fibers. This combination ofhistopathologic and clinical features was consistent with FLE.

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Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder of unknown etiology characterized by spiking fever, arthritis or arthralgia, rash, and leukocytosis. The nonspecific findings and epidemiology of the disease can complicate the diagnosis among deployed U.S. personnel, because they are exposed to infectious etiologies that can present in a similar fashion. We present a case of 19-year-old U.S. Army soldier who was deployed to Afghanistan and eventually medevaced to Walter Reed National Military Medical Center complaining of arthralgia, diffuse myalgia, daily spiking fever, and laboratory abnormalities including leukocytosis and elevated liver-associated enzymes. After an initial concern for an infectious etiology, the patient met Yamaguchi criteria for the diagnosis for AOSD. The patient's clinical course, pertinent laboratory, and pathology data are reviewed in the context of approaching the diagnosis and treatment of AOSD. This case highlights that providers need to maintain a high clinical suspicion for less common conditions such as AOSD in the setting of unresolving nonspecific findings such as fever, rash, and leukocytosis.

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INTRODUCTION: Best oxygenation index on day 1 (BOId1) had been shown to predict survival in congenital diaphragmatic hernia (CDH). Serial oxygenation index (OI) may enable better assessment of response to cardiorespiratory support than BOId1. METHODS: All antenatally diagnosed CDH from one tertiary neonatal unit were retrospectively reviewed. Oxygenation index at 6, 12, 24, and 48 hours from birth, as well as BOId1, were compared between survivors and nonsurvivors. The area under the curve and receiver operating characteristic (ROC) curves were used to compare serial OI within the first 24 hours and BOId1 between survivors and nonsurvivors. Statistical significance was set at P < .05. RESULTS: Twenty-four patients with CDH (13 survivors, 11 nonsurvivors) were included. Both groups were comparable in demographics and variables that could affect outcome. In terms of nonsurvival, ROC curve analysis demonstrated a sensitivity of 78% for serial OI greater than 252 and 56% for BOId1 greater than 8.5, both having a specificity of 100%. The area under the ROC curve for serial OI and BOId1 were 0.96 and 0.85, respectively. The positive predictive value of serial OI (>252) and BOId1 (>11) for nonsurvival were both 100%, with an negative predictive value of 87% and 76%, respectively. CONCLUSIONS: Our preliminary study showed that serial OI in the first 24 hours of life is a good predictor of survival. It is simple to use and has the added advantage of assessing response to medical support in CDH. The results support the need for a large prospective study exploring the potential of serial OI to guide management and prognosis.

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Nitrofurantoin is a commonly used antibiotic for the prophylaxis and treatment of urinary tract infections. We report the first case of nitrofurantoin-induced systemic inflammatory response syndrome, an important adverse drug reaction in the setting of what was initially believed to be a recurrent infection.

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An anaerobic filter was used to examine the treatability of wastewater formulated to simulate that from the manufacture of detergents. The detergent element was a mixture (1:1:1 v/v) of concentrated washing up liquid, a non-biological hand washing detergent and a fabric softener and, thus contained a combination of cationic surfactants, anionic surfactants, non-ionic surfactants and amphoteric surfactants. A concentration of 2 ml/l caused a deterioration in the performance of the digester which was pronounced after 7 days. When the packing of the filter was modified to include two layers of granular activated carbon, 320 g in total, the reactor was capable of treating a feed containing 10 ml/l. The amount of detergent removed during this second trial was greater than the Langmuir monolayer capacity of the carbon, indicating that both adsorption and degradation were occurring. The results also showed that, at detergent concentrations greater than 1 ml/l, the theoretical COD removal was lower than the actual COD removal. This was compatible with there being an element of adsorption by the activated carbon.

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As part of a larger project to examine the causes of bulking in activated sludge plants treating wastewaters from paper mills, two laboratory-scale activated sludge plants were run in parallel. This was to evaluate the impact of variable environmental and operational parameters on the sludge ecology, and in particular, on the filamentous bacteria in the sludge. A survey of paper mills in the UK showed that there was a significant difference between the activated sludge plants at the paper mills using virgin fibre and those using recycled fibre. An examination of samples from activated sludge plants at the paper mills showed that there did not appear to be any significant correlation between filament abundance and the settlement characteristics as measured by stirred specific volume index (SSVI). The surface charge carried by the sludge particles was also measured and it was found that this parameter was better related to the SSVI. Similar results were found for samples from the laboratory plants. Seven different sets of operational conditions were applied to the laboratory-scale plants. These were aimed at simulating the conditions noted for the full-scale plants during the mill survey. The effects of low dissolved oxygen and low organic loading rates were examined. The effect of inorganic sulphur compounds and volatile fatty acids was studied. A change in raw material from virgin fibre to recycled fibre (corrugated paper) caused an immediate and continuous deterioration in settlement. Divalent cations, calcium and magnesium, were found to be successful in controlling settlement in the final clarifier.

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