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5 Dises *German - English* 1.0 crack serial keygen

5 Dises *German - English* 1.0 crack serial keygen

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5 Dises *German - English* 1.0 crack serial keygen - authoritative

The World's Longest Diagramless

Everything's bigger in Texas.

In this diagramless crossword, Acrosses and downs have been merged into a single combined clue list in order of appearance. (In other words, 1 Across and 1 Down both appear before 2 down, which appears before 3 down.)

Also, this puzzle has standard rotational symmetry as far as we've checked it (which, to be fair, isn't very far).

  • Animated brother of Wakko and Dot (5)
  • Complains (7)
  • Ed of "Daniel Boone" (4)
  • Kids' cereal (3)
  • Make bootees (4)
  • That hurt! (4)
  • Org. awarded an honorary Oscar in (3)
  • Close (6)
  • Pass receiver (3)
  • Difficulty in movement (5)
  • Very good grade (6)
  • For example (3)
  • Habit (4)
  • Boy to find in kids' books (5)
  • Tune which the Jarabe Tapat�o is danced (15)
  • Category of painkillers, such as aspirin (anagram of DINAS) (5)
  • Detained (4)
  • Prefix with natal (3)
  • Weep (3)
  • Tropical pitcher plants and such (7)
  • Reservations (6)
  • Logician's abbr. (3)
  • QB VII author (4)
  • "The King and I" lady (4)
  • Property claim (4)
  • "Physician, heal ___" (7)
  • Son of Darius I (6)
  • Containing nothing (5)
  • Japanese tipple (4)
  • Bert's TV roommate (5)
  • M*A*S*H Actor Alan (4)
  • Well-known cello player (6)
  • Informal eatery (5)
  • Hallways or highways (9)
  • Give a pink slip to (3)
  • Acapulco gold (3)
  • Invitation letters (4)
  • Raise (4)
  • Poivre's partner (3)
  • Tollway: Abbr. (3)
  • Without: Fr. (4)
  • "I can't be ___" (Brit's "I'm too lazy") (5)
  • Loner (7)
  • Designer Gernreich (4)
  • Slugger Slaughter (4)
  • Algebra or trig (4)
  • PBS science program (4)
  • Madness (6)
  • Tourney type (5)
  • Frequently (3)
  • Carpet layer's calculation (4)
  • Doll's cry (4)
  • Specks (4)
  • Relating to an ancient Germanic tribe (8)
  • "All Things Considered" network (3)
  • Grade-schooler (3)
  • Musical paces (5)
  • Dictionary's first animal (8)
  • Letting up (7)
  • Help a crook (4)
  • Leaving the throne, as King Edward did for Wallis Simpson (10)
  • Leave in the lurch (7)
  • Belittle (5)
  • Side by side (7)
  • On fire (6)
  • Ceremonial washing (8)
  • Detest (5)
  • Evil, corrupt, or deceptive usage (7)
  • Use the acronym for, for example (10)
  • "Sound of Music" setting (5)
  • Inflamed and pus-filled: Brit. (9)
  • Carry off illegally (6)
  • The wearing away of a rock or glacier (8)
  • Shorten (7)
  • Scrape (8)
  • Make embarassed (5)
  • Brusque (6)
  • Overseas, to a Scot (6)
  • Leave with the loot (7)
  • What some people are convicted in (8)
  • Not in class (6)
  • In ___ (not present) (var.) (9)
  • Body's midsection (7)
  • With skill (4)
  • Stay (5)
  • Worse than inferior (10)
  • Abolish by official means (8)
  • Unrestricted (8)
  • Not in class (6)
  • Like a sponge (9)
  • Self-recusal from voting (10)
  • Generalized model of a real-world phenomenon, e.g. (11)
  • Harebrained (6)
  • Plentiful (8)
  • Not at all nurturing (7)
  • Bridge support (8)
  • Tree of the mimosa family (6)
  • Military school (7)
  • Director's shout (6)
  • Acquiesce (6)
  • Greet obtrusively (6)
  • Regard as true (6)
  • On the far side of (6)
  • Be someone's plus one (9)
  • Farming unit (4)
  • Agreement (6)
  • Finish the job, say (10)
  • Narrative (7)
  • Increase gradually (6)
  • Add up (to) (6)
  • Bitterly hostile (11)
  • Constantly busy (6)
  • Revered (6)
  • It may give you a rush (10)
  • Praise to the skies (7)
  • Viper (5)
  • Publicly recommend (8)
  • Promote (9)
  • Unfavorable (7)
  • Wear down (6)
  • Recommendation (6)
  • Like a devil's advocate, say (11)
  • Pre-Christmas time (6)
  • Antenna (6)
  • Well-to-do (8)
  • In the future (5)
  • Fearful (6)
  • Auto club letters (3)
  • Small source of energy (10)
  • Slim battery (7)
  • At last! (4)
  • Aid from a road travel org. (6)
  • Driver entitled to free maps, perhaps (9)
  • Like the best bond investments (8)
  • Some batteries (4)
  • Strip's cry of disgust (6)
  • Four-line rhyme scheme (4)
  • Small cell (9)
  • Rhyme scheme (4)
  • Limerick rhyme scheme (5)
  • Highly rated security (6)
  • Mobile phone battery size (6)
  • Some small batteries (7)
  • German city near the Belgian border (6)
  • Popular cable channel (3)
  • WWII fliers (3)
  • E. S. Gardner pseudonym (6)
  • That hits the spot! (3)
  • Expressed pleasure (5)
  • Showed delight over (7)
  • Expressing delight (6)
  • Sounds of delight (4)
  • Egg carton spec (7)
  • She played the title character in "Queen of the Damned" (7)
  • Noted Finnish architect (5)
  • USAF weapon (3)
  • The Transmission Experts (5)
  • Part of a recovery prog. (9)
  • Willie of "Eight Is Enough" (5)
  • Winnie-the-Pooh's creator (7)
  • Cold Case Files network (5)
  • Supermarket chain (5)
  • Music scout's co. unit (5)
  • Restaurant chain known for its root beer floats (5)
  • Food giant (3)
  • Swiss river (3)
  • Cousin of a hyena (8)
  • Rhine feeder (4)
  • Stereotypical pirate's cry (5)
  • Alphabetically advanced boy (5)
  • Thomas Jefferson's first vice president (9)
  • Eleazar, for one (8)
  • Copland and Spelling (6)
  • A Few Good Men playwright (11)
  • TV producer born 4/22/ (13)
  • Tall flowering plant (9)
  • Org. for seniors (4)
  • Some batteries (3)
  • Spelling clarification (10)
  • Nonpro sports gp. (3)
  • Scholar's goal (8)
  • What honor students often have (9)
  • Org. for Johnnie Cochran (3)
  • Half of Ethiopia's capital (5)
  • Philippine fiber (5)
  • Double-platinum Genesis album of (6)
  • Early calculators (5)
  • One way to be taken (5)
  • Bahamas' Great or Little (5)
  • You can count on it (6)
  • Early adders (8)
  • Iranian city (6)
  • Toward the stern (5)
  • What the Brooklyn Cyclones play, informally (5)
  • Mother-of-pearl source (7)
  • Edible mollusks that cling to rocks (8)
  • Walked out on (9)
  • Being forsaken (11)
  • Leaves high and dry (8)
  • Final command from the bridge (11)
  • It's good to go out with one (5)
  • Arab garments (4)
  • Demeaned (6)
  • Degrader (6)
  • Bullies, often (7)
  • Lowers in esteem (6)
  • Feeling embarrassment (7)
  • Causes embarrassment to (7)
  • Embarrassing (8)
  • Degrading (7)
  • Blindness comparison (4)
  • Lessen (5)
  • Eased off (6)
  • Reductions (10)
  • One who eases off (6)
  • Soothers (7)
  • Lessens (6)
  • One is often taken in Vegas (5)
  • Barbed-wire barricade (6)
  • Barbed barricades (8)
  • Nullifier, in law (6)
  • Sources of power (10)
  • Slaughterhouse (8)
  • I Do, I Do, I Do, I Do, I Do singers (4)
  • Head monk's tenure (6)
  • Israel in the World author (8)
  • Palestinian prime minister (5)
  • Clerical title (4)
  • French clerics (5)
  • Mother superior, at times (6)
  • Mothers superior (8)
  • Late Beatles album (9)
  • Monk habitats (6)
  • 60's protest leader Hoffman (5)
  • Monastery superior (5)
  • Monastery heads (6)
  • Costello's partner (6)
  • Shortened form, in shortened form (4)
  • What this ans. is (6)
  • Etc., e.g., et al. (5)
  • Dear advice-giver (4)
  • Roseanne's network (3)
  • Multiple choice choices (4)
  • Child's ditty start (5)
  • Alphabetic beginning (6)
  • Twinkle, twinkle, little star (7)
  • Report card options (5)
  • Division responsible for "20/20" (7)
  • Unit of electricity (9)
  • Sit-up relatives (10)
  • Grade school fundamentals (4)
  • Keith Jackson's milieu (9)
  • Where "Lost" is found (5)
  • About to get a Ph.D., definitely, if not this year then sometime in the next five (3)
  • Step down (8)
  • Cedes the crown (9)
  • He's giving up (9)
  • Exercise targets (8)
  • Kind of muscle worked by sit-ups (9)
  • Kidnaps (7)
  • Paula of pop (5)
  • First king of Jordan (8)
  • Honest President (3)
  • 90 degrees from fore-and-aft (5)
  • Something very tough (5)
  • Without missing -- (smoothly) (5)
  • Former mayor of New York City (8)
  • Resting (4)
  • What you might have in your bonnet (4)
  • Son of Adam (4)
  • Heloise's main squeeze (7)
  • White poplar (5)
  • White poplars (6)
  • The Great Emancipator (10)
  • Soviet spy Rudolf and actor Walter (5)
  • Dutch explorer who lent his name to a sea and an island (10)
  • Evening, in Essen (5)
  • But: Ger. (4)
  • City on the North Sea (8)
  • Scottie, formerly (15)
  • Certain Scot (10)
  • King's successor as S.C.L.C. president (9)
  • Departure from the norm (9)
  • Deviating from the norm (8)
  • Irregularity (10)
  • Beame and Burrows (4)
  • Assistance (8)
  • Helps a perpetrator (5)
  • Helped with the heist (7)
  • Helper in crime (7)
  • Heist helpers (8)
  • Driving the getaway car for (8)
  • Friend in crime (7)
  • Phil Fish portrayer on "Barney Miller" (9)
  • Temporary suspension (8)
  • Temporarily inactive (7)
  • Popular British sitcom, for short (5)
  • Disliked (8)
  • Hates (6)
  • More than dislike (4)
  • Conformity (8)
  • Agree to (7)
  • Put up with (6)
  • Dweller (6)
  • Patient people (7)
  • Puts up with (6)
  • Standing for (7)
  • Third-largest French-speaking city in the world [hint: it's in Ivory Coast] (7)
  • His Rose was Irish (4)
  • Hair song containing Gettysburg Address phrases (8)
  • Mother of John Quincy (7)
  • Celebrity born July 4, (15)
  • Eisenhower Center city (7)
  • Competence (7)
  • From the beginning, Latin-style (8)
  • From within: Lat. (7)
  • Lacking life (7)
  • Not too much (4)
  • Slightly more than wanted (8)
  • Some (6)
  • Hopeless (6)
  • Formally renounce (6)
  • Trumpeting (6)
  • Vaporize (6)
  • Removed by eroding (7)
  • Removes by erosion (7)
  • Grammatical case (8)
  • Term for the i-a-u pattern in some verb tenses (such as sink-sank-sunk) (6)
  • Competent (4)
  • Quite healthy (10)
  • More adept (5)
  • Mariner (10)
  • Salts (10)
  • Most skilled (6)
  • Can, after "is" (6)
  • Flowering (6)
  • Keith with a daytime TV show (5)
  • Reddened (6)
  • SDI weapon (3)
  • Mil. defense systems (4)
  • Give up, as a right (8)
  • Gave up (9)
  • Uncommon blood type (10)
  • Capp character (5)
  • Yokum and Doubleday (6)
  • Comics rube (10)
  • Strange (8)
  • Blood-classification system (3)
  • On the train (6)
  • Cruising, say (10)
  • Dwelling (5)
  • Dwelling places (6)
  • Bubbling, as hot water (5)
  • Make illegal (7)
  • Made void (9)
  • Abraham Lincoln, notably (9)
  • Does away with (9)
  • Cassius's cloak (6)
  • Manhattan Project project (5)
  • Mushroom cloud producers (6)
  • Despise (9)
  • Found repugnant (10)
  • Away from the mouth (6)
  • Multiple choice options (5)
  • Native (10)
  • Earliest known inhabitant (9)
  • Scrub, NASA-style (5)
  • Scuttled a shuttle shot (7)
  • Cut short, as an attempt (8)
  • Cuts short, as a space flight (6)
  • Literally, "father" (4)
  • Arabic prename (4)
  • Teem (6)
  • Teemed (8)
  • Overflow with (8)
  • Teems (7)
  • Concerning (5)
  • Nick Hornby novel (9)
  • Reversal (9)
  • Did a (10)
  • Words after "no two ways" (7)
  • Film that garnered Jack Nicholson his 12th Oscar nomination (12)
  • Lead-in to an awkward topic (9)
  • Finally! (9)
  • On the verge of doing it (7)
  • Heavenward (5)
  • Mainly (8)
  • Without tricks (10)
  • Aloof (10)
  • Like a bogey (8)
  • Blameless (13)
  • Suspensory ligament location (14)
  • Like many a dictator (11)
  • Fiscally solvent (10)
  • Like hoped-for winter temps in the North (9)
  • From the beginning (5)
  • Life, they say (15)
  • Johnny Cash classic written by Shel Silverstein (12)
  • Universal recipient type (10)
  • Incantation start (4)
  • Magic words (11)
  • Scraped off (7)
  • Wears off (7)
  • Isaac's father (7)
  • Speaker of quote (14)
  • Man with a camera, (15)
  • The "A" in James A. Garfield (5)
  • Vietnam War commander (6)
  • Menendez defense lawyer Leslie (8)
  • Skin scrapes (9)
  • Substance used for polishing (8)
  • Grinders (9)
  • Word on amulets (7)
  • Conquers a trauma, in therapy (8)
  • Dugout (4)
  • Like many Reader's Digest articles (8)
  • Month after marzo, in Mexico (5)
  • Nearly overflowing (5)
  • Visiting Europe, e.g. (6)
  • Annuls (9)
  • Robert De Niro film (10)
  • Son of David who was slain by Joab (7)
  • Carter-era FBI bribery probe (6)
  • Dental affliction (7)
  • Jobs for dentists (9)
  • Separate normally, as a flower from a plant (7)
  • Graph coordinate (8)
  • Math coordinates (9)
  • X-coordinates, in math (9)
  • It makes the heart grow fonder (7)
  • Paul Newman/Sally Field film (15)
  • Attendance-book notations (8)
  • No-show (8)
  • They're usually counted last (15)
  • No-shows (9)
  • Without thinking (8)
  • Keeps (oneself) away (7)
  • Green liqueur (8)
  • Popular '90s workout video (10)
  • Smirnoff competitor (7)
  • Yes! (10)
  • Supreme ruler (15)
  • �F, scientifically (12)
  • Get off the hook (7)
  • Pardoned, as sins (8)
  • Soak up (6)
  • Sopped up (8)
  • Soaks up (7)
  • Auto safety feature, redundantly (9)
  • Decline to vote (7)
  • Kept it in one's pants, in a way (9)
  • Opts not to opt (8)
  • On the wagon (9)
  • Like Pollock works (8)
  • Pollock specialty (11)
  • Esoteric (8)
  • Approximately: Abbr. (3)
  • Aladdin monkey (3)
  • Largest of the United Arab Emirates (8)
  • Recent prison scandal locale (9)
  • Nigeria's capital since (5)
  • Plenty (9)
  • Mistreat (5)
  • Treated badly (6)
  • Privilege loser, often (6)
  • Candidates for rehab (7)
  • Mishandles (6)
  • Lots, lovewise (15)
  • Setting of two temples of Ramses II (9)
  • Mistreating (7)
  • Adjoin (4)
  • Lie next to (6)
  • Borders on (5)
  • Bumps against (7)
  • Act of touching (7)
  • Adjoined (7)
  • Full of activity (5)
  • Rock follower (4)
  • Deep-bottomed pit (5)
  • Hopelessly bad (7)
  • Bottomless pits (6)
  • Vast chasm (5)
  • Bottomless chasms (7)
  • Parting word, in '30s slang (9)
  • Shorthaired cat breed (10)
  • New York politician Bella (5)
  • Here, in Spain (3)
  • Small shrubs (7)
  • Mil. sch. (4)
  • College life (7)
  • College professors, e.g. (8)
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  • College awards (15)
  • College professors, e.g. (9)
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  • Hollywood prize (12)
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  • Maine national park (6)
  • Evangeline, in a Longfellow poem (7)
  • Schools for cadets: Abbr. (5)
  • Berry touted as a superfood (4)
  • Trendy "superfood" (9)
  • Without instrumentation (8)
  • Unaccompanied singing style (9)
  • Mexican seaport known for its cliff divers (8)
  • Mite (6)
  • Mites or ticks (7)
  • Gave approval (7)
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  • Take, as the throne (8)
  • Hit the gas (10)
  • Stress (6)
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  • Stress indicators (7)
  • Emphasize (10)
  • O.K. (10)
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  • Allowable (8)
  • Takes, as an offer (7)
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  • Password's kin (10)
  • Got into (8)
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  • Aptly named TV show about ENTER-tainment (15)
  • Agreement (9)
  • Way to a highway, perhaps (10)
  • Mishap (8)
  • Unplanned (10)
  • Hard to insure, maybe (13)
  • Adjusters' concerns (15)
  • Mishaps (9)
  • Welcome with joy (7)
  • Welcomes with cheering (8)
  • High praise (8)
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  • Conformity (10)
  • Bestowed (8)
  • Push my buttons! (9)
  • Popular Hondas (7)
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  • Confronts boldly (7)
  • Ledger column (15)
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  • Ghana's capital (5)
  • African capital (10)
  • Certify, as a college (8)
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  • Kind of basis in accounting (7)
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  • Used (to) (10)
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  • Company for which John Madden was once pitchman (11)
  • A pair of deuces beats it (7)
  • Secret advantage (12)
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  • Amtrak's 'bullet train' (5)
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  • The Sign band (9)
  • Gain an advantage over, in slang (6)
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  • Make sour (8)
  • Biting (7)
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  • Comment: 6 (13)
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  • When one might have a late lunch (5)
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  • Lawyers: Abbr. (5)
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  • Dawn music (6)
  • Amiens inn (7)
  • Illustrator Beardsley (6)
  • Reddish brown (6)
  • Certain hair colors (7)
  • New Zealand's most populous city (8)
  • Up-to-date (9)
  • Setting for this puzzle's theme (7)
  • Sold to the highest bidder (9)
  • Going, going, gone guy (10)
  • Place for bidding (12)
  • Sotheby's event (11)
  • Chutzpah (8)
  • The Age of Anxiety poet (5)
  • Another Time poet and family (6)
  • German auto (4)
  • Loud enough (7)
  • Quarterbacks' play changes (8)
  • Aloud (7)
  • Owner of multiple Lamborghinis, perhaps (10)
  • War hero Murphy (5)
  • Applauding group (8)
  • Theater fillers (9)
  • Sound portion (5)
  • Some commuter "reading" (9)
  • Parts of TV broadcasts (6)
  • Cassette-player need (9)
  • Book alternatives (10)
  • They help in the classroom (15)
  • German autos (5)
  • Check the accounts of (5)
  • Checked for accuracy (7)
  • Tried out (10)
  • Reviewer of books (7)
  • Play places (9)
  • C.P.A.s, at times (8)
  • Opinions about books (15)
  • Hearing-related (8)
  • I.R.S. visits (6)
  • Access history (10)
  • Six-time Tony winner McDonald (5)
  • Actress Hepburn (6)
  • 50's TV comedienne (13)
  • Birders' magazine (7)
  • The Clan of the Cave Bear author (4)
  • Violinist Leopold (4)
  • Quite familiar (6)
  • Sept. preceder (3)
  • Like some stables of myth (6)
  • Boring tool (5)
  • Carpentry bits (6)
  • Zero (5)
  • Most of 1, (6)
  • Saul Bellow title character (5)
  • Add to (7)
  • Increases (8)
  • With browned breadcrumbs and cheese (8)
  • Be an omen of (5)
  • Foretold one's future (7)
  • Soothsayers (6)
  • Divination (6)
  • Summer month (6)
  • Capital of Maine (7)
  • Eastern capital (12)
  • Like the post-Julius Caesar era (8)
  • Home of the Masters golf tournament (15)
  • Predecessor of Tiberius (8)
  • Pulitzer-winning "Fences" playwright (12)
  • French menu phrase (5)
  • Northern diving bird (3)
  • Small diving bird of the North Pacific (6)
  • Northern diving birds (4)
  • Assembly hall in Berlin (4)
  • Served with milk, in French cookery (6)
  • New Year's Eve word (4)
  • What song will be played at midnight tonight (12)
  • Candy star Ewa (5)
  • Port from which the Greeks sailed to Troy (5)
  • In the altogether (9)
  • Polly, to Tom Sawyer (4)
  • Frances Bavier's role on "The Andy Griffith Show" (7)
  • Oklahoma! role (9)
  • Relative of Dorothy (6)
  • Em or Mame (6)
  • Wizard of Oz character (8)
  • Russell film of '58 (10)
  • Mame and others (7)
  • Pancake syrup icon (10)
  • Peter Parker's guardian (7)
  • Fussy relatives, stereotypically (5)
  • Mom's sister (5)
  • Household employee (6)
  • Child-care helpers (7)
  • Way to make steak (8)
  • Atmosphere (4)
  • Surrounding glows (5)
  • Hearing-related (5)
  • Love Me Tender, originally (7)
  • How some things are sensed (7)
  • Atmospheres (5)
  • Salt containing gold (6)
  • Golden (7)
  • Saint surrounder, in art (7)
  • Encircling ring of light (7)
  • Bye! (8)
  • Goldfinger's first name (5)
  • Heart part (7)
  • The Charioteer constellation (6)
  • Ear doctor (6)
  • Dawn goddess (6)
  • Southern lights (15)
  • Atmospheric phenomena (7)
  • Dawnlike (7)
  • Sky lights (7)
  • Relating to gold (6)
  • Gold, in Latin (5)
  • From Vienna: Abbr. (3)
  • New York river (7)
  • Patronage (8)
  • Also, in Arles (5)
  • One from Down Under (6)
  • Sydney natives (7)
  • Pride and Prejudice author (6)
  • Tight, budgetwise (7)
  • Lone Star State capital (6)
  • Classic British cars (7)
  • Live Music Capital of the World (11)
  • Koala's home (9)
  • Honoree's nationality (10)
  • Swimming stroke (15)
  • Mozart's homeland (7)
  • Mozart, by birth (8)
  • Schwarzenegger nickname, with "the" (11)
  • Self- starter (3)
  • Filmmaker with style and total control (6)
  • Write (6)
  • Shout following a successful play (12)
  • Say-so (9)
  • Give the go-ahead to (9)
  • Storytellers (7)
  • Social behavior issue (6)
  • Mobile start (4)
  • High-speed roadway (8)
  • Group transport, archaically (7)
  • Event with stars and cars (8)
  • Road service provider (8)
  • Absolute ruler (8)
  • Tyrannical (10)
  • Cream puff pusher (10)
  • Robocall maker (10)
  • Accesses a stored phone number (9)
  • Went on the road (6)
  • Helicopter's predecessor (8)
  • Celebrity signature (9)
  • Stage-door waiters (15)
  • Fan's souvenirs (10)
  • Bluegrass instrument (8)
  • Help in buying a car (8)
  • They help you get rides (9)
  • Old cafeteria-style eatery (7)
  • I, Robot extras (8)
  • Computerize (8)
  • Like vending machines (9)
  • One for the money (15)
  • Spontaneous (9)
  • They're of help to some captains (15)
  • Hand-held heat (15)
  • Takeover of human activity by machines (10)
  • Unthinking worker (9)
  • Cuckoos in clocks, e.g. (10)
  • Garage employee (12)
  • Invention a British parliamentarian claimed in would not lead to a decline in riding horses (10)
  • They may be biased (15)
  • Spare tire location, perhaps (15)
  • Occurring involuntarily (9)
  • Self-directed (10)
  • Parent/teen sticking point (8)
  • Clutch, e.g. (8)
  • Fenders, taillights, etc. (9)
  • Disneyland's mini-car ride (7)
  • Cockpit device (9)
  • Job for TV's Quincy (7)
  • Grand Prix, for one (8)
  • Cassette deck feature (11)
  • Hudson, DeSoto and LaSalle (5)
  • It's typically made of leather or plush (8)
  • Where to see cars on carpets (8)
  • The "A" in Jay-Z's "D.O.A." (8)
  • French alternative (5)
  • Others, in Orl�ans (6)
  • Singing cowboy Gene (5)
  • World Series season (6)
  • September 23 event (15)
  • Richard Gere/Winona Ryder movie (15)
  • They "drift by the window," in song (12)
  • Harvest seasons (7)
  • Ingrid Bergman film (12)
  • A Gardner (3)
  • Actress once voted the world's most beautiful woman (10)
  • Benefit (5)
  • Not taken (9)
  • Amount left on a card (15)
  • Was of use (7)
  • Being useful (8)
  • Is of use (6)
  • Of grandparents (4)
  • Himalayan danger (9)
  • Himalayan dangers (10)
  • Arthurian paradise (6)
  • Frankie et al. (7)
  • Before: Fr. (5)
  • Trend-setting, perhaps (10)
  • Let's go, in Rome (6)
  • Greed (7)
  • Covetous qualities (8)
  • Actress Gardner and others (4)
  • Stop, sailor! (5)
  • Incarnation (6)
  • Blog posters' self-images (7)
  • Get thee gone! (6)
  • Extracurricular group that likely includes few jocks (6)
  • Hail, Caesar! (3)
  • Est�e Lauder subsidiary (5)
  • Photographer Richard (6)
  • Skin-care brand (6)
  • Catholic prayer (8)
  • Parts of some services (9)
  • Get retribution for (6)
  • Exacted satisfaction for (7)
  • Mrs. Peel, for one (7)
  • Ones seeking retribution (8)
  • Settles, as a score (7)
  • Exacting retribution for (8)
  • Boulevard (6)
  • Broadway musical featuring Trekkie Monster (7)
  • Most properties in Monopoly (7)
  • Chevy subcompact since (4)
  • Declare (4)
  • Batting statistic (7)
  • Peoria resident, it's said (15)
  • Generally accomplished (8)
  • Reality show: Woman chooses among ordinary suitors (10)
  • Unremarkable fellow (10)
  • Get past the highs and lows (10)
  • Sports section decimals (8)
  • Earl in the Baseball Hall of Fame (7)
  • Hellish (7)
  • Alleged as fact (7)
  • States (5)
  • Loath (to) (6)
  • With reluctance (8)
  • Against (8)
  • Intense dislike (8)
  • Causing repugnance (8)
  • Manage to avoid (5)
  • Turned aside (7)
  • Turns away (6)
  • Murphy Brown's son (5)
  • Cartoonist Tex et al. (6)
  • Rosary prayers (4)
  • Zoroastrian literature (6)
  • Thus spake Zarathustra (7)
  • Have, in Le Havre (4)
  • Dow Jones figure: Abbr. (3)
  • Cessna fuel (5)
  • Athletic shoe brand (4)
  • Birdlike (5)
  • Airline to Bogota� (7)
  • Birdhouse denizens (6)
  • Birds' homes (8)
  • Home for birds (6)
  • Popular athletic shoes (5)
  • Fly a plane (6)
  • Flew (7)
  • Flies (7)
  • Flying (8)
  • Pilot's field (8)
  • Pilot (7)
  • Amelia Earhart and others (8)
  • Amelia Earhart, and others (10)
  • Amelia Earhart, for one (8)
  • Gung-ho (4)
  • One who can't miss a game (7)
  • With gusto (6)
  • Bird life (8)
  • Province of Spain (5)
  • French plane (5)
  • Relating to flight technology (7)
  • High-tech aircraft science (8)
  • We try harder company (4)
  • Some rental cars (6)
  • Dispatch boat (5)
  • Dispatch boats (6)
  • Part of an Asian city name (4)
  • Macao coin (3)
  • Guacamole ingredient (7)
  • Craze that led to the infamous Guacamole Riots (12)
  • Guacamole base (11)
  • Large seed of the alligator pear (10)
  • Salad fruits (8)
  • Spare time activities (10)
  • Long-legged shorebird (6)
  • Long-legged shorebirds (7)
  • Italian chemist with a number named after him (8)
  • x 10^23 (15)
  • Sidestep (5)
  • Like a situation that could have been prevented (9)
  • Dodger's aim (9)
  • Steered clear of (7)
  • Nonconfrontational one (7)
  • Steering clear of (8)
  • Keeps away from (6)
  • The Bard's river (4)
  • Workers associated with ding-dongs (10)
  • Doorbell-ringing saleswoman (8)
  • Anne of Green Gables setting (7)
  • Three English rivers (5)
  • French toast (11)
  • Guarantee (6)
  • Confess (4)
  • Frank acknowledgment (6)
  • Promises (7)
  • Declared (6)
  • Declarer (6)
  • Confessors (7)
  • Promising (7)
  • Swears (5)
  • Canadian pop singer Lavigne (5)
  • Tear apart (6)
  • Genial, like a certain male relative (9)
  • Like gossiping tongues (4)
  • Lie in store for (5)
  • Was patient for (7)
  • In the wings (8)
  • Expects (6)
  • Conscious (5)
  • Stirred from sleep (6)
  • Rise and shine (6)
  • Came to (8)
  • Coming around (9)
  • De Niro film of '90 (10)
  • Rouses from sleep (7)
  • Rouses from slumber (6)
  • Greeting the day (7)
  • Obie or Edgar (5)
  • Bestowed (7)
  • Prize recipient (7)
  • Presenter's task (8)
  • Oscar and Edgar (6)
  • Cognizant (of) (5)
  • It may be heightened (9)
  • Knowing (7)
  • Flooded (5)
  • Inundated with (7)
  • On vacation (4)
  • Alee (15)
  • It isn't played at home (8)
  • Half a team's schedule (9)
  • Somewhat far (5)
  • Jackie Gleason catchphrase, with "And" (8)
  • Pretty please?! (6)
  • More than admiration (3)
  • Plenty (of) (7)
  • Tuckered out, in literature (6)
  • On the windward side (8)
  • Impressed deeply (4)
  • Not very much (7)
  • Every seven days (5)
  • Seven days before now (8)
  • Anchor position (6)
  • Oxymoronic change of pace (17)
  • Astounds (4)
  • Stunning (7)
  • Overcome with wonder (9)
  • Very bad (5)
  • Very (7)
  • Shucks! (5)
  • Shucks, you're too kind! (6)
  • For a short time (6)
  • In weeks past (9)
  • Some time in the past (10)
  • Spinning (6)
  • In the least (5)
  • Bunches and bunches (9)
  • Leaving breathless (5)
  • After "on," relying mostly on hope in desperate circumstances (15)
  • What each theme answer in this puzzle illustrates (16)
  • Parrot's cry (3)
  • All thumbs (7)
  • Early adolescence, they say (10)
  • Cobbler's tool (3)
  • Shoemaker's tools (4)
  • This is the worst! (5)
  • Grain bristle (3)
  • Bearded, as barley (5)
  • Sunshade (6)
  • Storefront shaders (7)
  • Plant appendages (4)
  • Darn it! (6)
  • Came to (5)
  • Roused from sleep (6)
  • Army no-show (4)
  • M.P.'s hunt them (5)
  • Out of kilter (4)
  • Self-effacing reply to a compliment (8)
  • How adorable! (3)
  • Lumberjack's tool (3)
  • Fired (4)
  • Ice show jump (4)
  • That synthesizer song from "Beverly Hills Cop" (5)
  • Golden Globe-nominated role for Eddie Murphy (9)
  • Medicine Nobelist Julius (7)
  • Skater's leaps (5)
  • Lumberjack (6)
  • Lumberjacks, e.g. (6)
  • Downsizer (4)
  • Managers, sometimes (5)
  • X and Y on a graph (4)
  • Grudge (10)
  • What a lumberjack holds (8)
  • Cutting part of a lumberjack's tool (6)
  • Like some symmetry (5)
  • Botanical angle (4)
  • Armpit, in anatomy class (6)
  • Armpits (7)
  • Feather under a bird's wing (7)
  • Leaf-to-branch angles (5)
  • Getting rid of (5)
  • You can believe it (5)
  • They're universally accepted (6)
  • Particle theorized in (5)
  • X or Y, on a graph (4)
  • War on terror foe (10)
  • Italy, once (9)
  • Tokyo Rose's counterpart (9)
  • Guns N' Roses frontman Rose (3)
  • Wheel rod (4)
  • Having a bar by means of which a pair of wheels rotates (5)
  • Lube job supply (10)
  • Wheel connectors (5)
  • Wheel's attachment on a horse-drawn cart (8)
  • Rocker formerly known as William Bailey (7)
  • Lumberjack (5)
  • Corporate heavies (5)
  • Cute Mexican salamander (get on this, Buzzfeed) (7)
  • Nerve cell part (4)
  • Neural impulse transmitters (5)
  • Selfish reason (9)
  • Country singer Hoyt (5)
  • Hindu nursemaid (4)
  • Memsahibs' nannies (5)
  • Bart Simpson catchphrase (9)
  • Yes, to Rob Roy (3)
  • Per annum (5)
  • Reply to the captain (6)
  • Naval yeses (7)
  • Naval assent (9)
  • Morning, to Walter Winchell (4)
  • Yesterday, to Juan (4)
  • Rock in Australia (5)
  • Thumbs-up votes (4)
  • Mohammed's favorite wife (6)
  • 'Yes, cap'n' (6)
  • Dan of "Ghostbusters" (7)
  • The Clan of the Cave Bear heroine (4)
  • Author Rand (3)
  • The Fountainhead novelist (7)
  • Author Rand et al. (4)
  • River in Scotland (3)
  • Actor Lew (5)
  • Words from Hamlet (14)
  • Showy shrub (6)
  • Showy spring flowers (7)
  • Call from the minaret (4)
  • The Simpsons voice man Hank (6)
  • Hyundai model (5)
  • Luxury Hyundai sedans (6)
  • Baku is its capital (10)
  • Nitrogen compound (5)
  • Astronomer's measurement (7)
  • Navigational measurements (8)
  • Paul of the PGA (7)
  • Comedian Ansari on "Parks and Recreation" (4)
  • Nitrogenous dye (3)
  • Dye used on recordable CDs (7)
  • Methyl red, for one (6)
  • Geologic age meaning "without life" (5)
  • Nitrogen compound (5)
  • Radio-controlled aerial bomb (4)
  • Portuguese islands (6)
  • Nitrogen (5)
  • Sea fed by the Don (4)
  • AIDS treatment drug (3)
  • Nahuatl language (5)
  • Like Montezuma (7)
  • Montezuma's people (6)
  • Multipurpose Pontiac model (5)
  • Coastal color, in Cap d'Antibes (4)
  • Sky blue (5)
  • Shades of blue (6)
  • Los Angeles suburb (5)
  • Bleat (3)
  • Words to a black sheep (6)
  • Whiffenpoof refrain (9)
  • Nursery-rhyme starter (16)
  • Sounded like sheep (5)
  • Sheep noise (6)
  • False god (4)
  • Belief in ancient Phoenicia (7)
  • False gods (5)
  • Sheep cries (4)
  • Saddam's party (5)
  • Overnight site (3)
  • Ali who said "Open sesame!" (4)
  • Liquor-soaked cake (10)
  • Nickname on "The Howard Stern Show" (9)
  • Desi Arnaz signature song (7)
  • Desi Arnaz's signature song (6)
  • Elephant of children's lit (5)
  • Rum cakes (5)
  • Saturday Night Live character who introduced herself with "Hewwo" (8)
  • English mathematician (7)
  • One who contentedly conforms to middle-class ideals (7)
  • Talk nonsensically (6)
  • Some brooks (8)
  • Prates (7)
  • Rustic stream (13)
  • Talking nonstop (10)
  • Barbara of "Dr. Quinn, Medicine Woman" (7)
  • Cute porker of film fame (4)
  • Towers of many tongues (5)
  • The Sultan of Swat (8)
  • Innocent ones (5)
  • Broadway score (11)
  • Inexperienced ones (15)
  • Judy Garland musical (15)
  • Mollycoddled (6)
  • Infants (6)
  • Yevtushenko poem (7)
  • Slavic coffee cake (5)
  • Louts (5)
  • Hindu gentleman (5)
  • Type of baboon (6)
  • Big monkeys (7)
  • Nickname for Barbara (4)
  • Hindu gentleman (4)
  • Woman's head scarf (8)
  • Blessed event (4)
  • Youngest of three porridge eaters (8)
  • Attractive eyes (9)
  • Period of increased births (8)
  • Fortysomething, say (10)
  • They may bounce (8)
  • Nursery sleepwear (11)
  • Ricki Lake TV movie (9)
  • Follower of love and marriage, in a kids' chant (12)
  • Betsy Wetsy, for one (8)
  • Jolson tune (8)
  • Gangster born Lester (14)
  • Some pudginess (7)
  • Infant's meal (8)
  • Where one might get one's first pair of overalls (7)
  • Flip my lid! (9)
  • Infantile (7)
  • Shirelles hit (10)
  • Nebuchadnezzar's realm (7)
  • Subject of a s surrogate mother custody battle (5)
  • Infant's skin moisturizer (7)
  • Gerber reports on frequent corporate changes (11)
  • Chewy Nestl� candy bar (8)
  • Watched Junior (7)
  • Mom-to-be's party (10)
  • Tend a tot (7)
  • First job, maybe (10)
  • Bowler's challenge (9)
  • Nonsensical syllables, perhaps (8)
  • Some parents keep them after they're lost (9)
  • Bogart's love (6)
  • Brand of rum (7)
  • Casino game (8)
  • Orgiastic (12)
  • God of wine and revelry (7)
  • One of the three B's (4)
  • James Buchanan, notably (8)
  • John Forsythe sitcom (14)
  • Single guy's home (11)
  • Best man's job (13)
  • Cornflower (15)
  • Major fulfillment (15)
  • Noted musical family (5)
  • Bacterium type (8)
  • Here again (4)
  • Informal "Likewise" (8)
  • Retreat (8)
  • Bottle storage spot (7)
  • Upscale section of Boston (or two words that can follow GREEN) (7)
  • Resolve (8)
  • Exhausting task (11)
  • Physically demanding (12)
  • Place for low-priority items (10)
  • Rural area (11)
  • Make retroactive, in a way (8)
  • Rear entrance (8)
  • Retreat (8)
  • Kurt Russell movie (9)
  • Scrim, perhaps (8)
  • Scene setters (9)
  • Gave support to (6)
  • Rear section (7)
  • Theatrical angel (6)
  • Angels, maybe (7)
  • Boomerang (8)
  • Part of a gymnastics routine (8)
  • Reverse springs (9)
  • Remote acreage on a ranch (9)
  • Game with a bar in the middle of the board (10)
  • Pre-employment routine (15)
  • Excavating machines (8)
  • Retro (6)
  • Working again (15)
  • First song on the Beatles' "White Album" (13)
  • Sharp reaction (8)
  • Silhouetted (7)
  • Inventory (7)
  • Lists of orders yet to be shipped (8)
  • Uh-uh! (7)
  • Hike (8)
  • Hiker with a heavy load (10)
  • Overdue salary (7)
  • Retreat (9)
  • Cops out (10)
  • Spinal support (8)
  • Rural way (8)
  • Cheap seats' site (7)
  • Massage for a person who's prone (7)
  • Supports (5)
  • Kibitzing type of driver (8)
  • Unwanted advice-givers (15)
  • Rear (8)
  • They may get spanked (9)
  • Relapse into bad habits (9)
  • Key with an arrow (9)
  • Golf-shot effect (8)
  • Betray by bad-mouthing (8)
  • Behind-the-scenes area (9)
  • Ball catcher behind a catcher (8)
  • Route far from the beaten path (10)
  • One way to swim (10)
  • Corroborates (7)
  • Sassy reply (8)
  • Bicyclist's buy (8)
  • One way to win (10)
  • Like some August sales (12)
  • Starting over (10)
  • Where you might go for a fresh start (15)
  • Michael J. Fox film of '85 (15)
  • Return over the same course (9)
  • Support or go in reverse (6)
  • It's created to prevent data loss (10)
  • Contingent arrangement (10)
  • Jim who was the voice of Mr. Magoo (6)
  • Unenlightened (8)
  • Isolated place (9)
  • Place for a barbecue (8)
  • Bit in a salad (4)
  • Part of BLT (5)
  • Breakfast pair (12)
  • Degrees of separation in a Hollywood parlor game (11)
  • Actor Kevin and kin (6)
  • Virginia uprising (15)
  • Crunchy salad toppers (5)
  • Neosporin target (8)
  • Camel variety (8)
  • Naughty (3)
  • Just like that! (8)
  • Lousy liar (8)
  • No-goodnik (8)
  • No-goodniks (9)
  • Dangerous place (7)
  • Not proficient in (5)
  • Hostile relationship (8)
  • Record label founded by Sean Combs (6)
  • Will Smith movie (7)
  • Extreme form, as of an illness (7)
  • Half an interrogative, role-playing couple (6)
  • Down time (6)
  • Offering from a sleazy negotiator (7)
  • Overdue IOU (7)
  • Certain write-offs (8)
  • More evil, so to speak (6)
  • Most mean, slangily (7)
  • Villain, slangily (6)
  • Rebuke to Rover (6)
  • Nightmare (8)
  • Villain (5)
  • Expressed, as a farewell (4)
  • No-goodnik (6)
  • No-goodniks (7)
  • Noted German spa (6)
  • When doubled, a spa site (5)
  • German resort (10)
  • Villains may come to one (6)
  • Justice Ginsburg's maiden name (5)
  • Treachery (8)
  • Mismatch (6)
  • Socially unacceptable behavior (7)
  • Cop's ID (5)
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  • Freeport's "Grand" island (6)
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  • Nassau's country (7)
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  • Nassau native (8)
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  • Sultanate island in the Persian Gulf (7)
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  • 13, to James Beard (11)
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  • Auditorium sections (9)
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  • Spot in the top tier (11)
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  • Board game with fake definitions (7)
  • Nonsense (10)
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  • Not just a fib (12)
  • Losing one's hair (7)
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  • Cueball, so to speak (8)
  • Swordsman's belt worn diagonally from shoulder to hip (7)
  • Has a need for Rogaine (5)
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  • Alec, Stephen, Billy and Daniel (15)
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  • Kirov or Bolshoi (13)
  • Sleeping Beauty and "Swan Lake" (7)
  • Ump's call (8)
  • Fenway Park action (8)
  • Much weekend TV fare (9)
  • Court employee (8)
  • Part of ICBM (9)
  • Human dynamo (10)
  • Everything, informally (9)
  • Cat's plaything, perhaps (10)
  • Umpire's call (7)
  • Kind of bike tire (7)
  • Had a rapid weight gain (9)
  • Provision for ending many a mortgage (14)
  • He tried to sell the Macy's Thanksgiving Parade route, even arranging for (15)
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  • Votes (7)
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  • Rough estimate (14)
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  • Automated device in a bowling alley (10)
  • Place for a cotillion (8)
  • Social dance areas (9)
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  • More pleasant (7)
  • Scottish castle for British royals (8)
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  • Mild, as weather (5)
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  • Debutantes' affairs (4)
  • Light wood (5)
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  • Fragrant ointments (7)
  • Light woods (6)
  • Native of Latvia (4)
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  • It borders Sweden and Poland (9)
  • Black-and-orange bird (15)
  • World Series champs* (16)
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  • French novelist (6)
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  • Wok veggies (12)
  • Hoodwink (9)
  • Betty and Barney Rubble's son (8)
  • Loud thuds (4)
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  • Eric who played 's Hulk (4)
  • George Peppard's TV detective (7)
  • Dull (5)
  • In a predictably trite way (7)
  • Tropical fruit (6)
  • Food transportation that Harry Belafonte sang about (10)
  • Pie choice (11)
  • Bar order (14)
  • Bakery offering (14)
  • Cause of a slip, perhaps (10)
  • Girl group with the #1 hit "Venus" (10)
  • Small tropical country (14)
  • Petty dictatorships (15)
  • Woody Allen film (7)
  • Kid's bike part (10)
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  • Slimy mascot of the University of California at Santa Cruz (10)
  • Ice-cream treat (11)
  • Indulgent desserts (12)
  • Judge's seat (4)
  • Safe place, in Italian (5)
  • Baccarat bet (5)
  • Bandido's targets (6)
  • The Miracle Worker star (8)
  • Judges' seats (5)
  • Narrow strip (4)
  • Cut covering (7)
  • Applied first aid (8)
  • Boo-boo protector (7)
  • Scratch hiders (8)
  • Head scarf (7)
  • Hoedown neckwear (8)
  • Weekend getaway spot, for short (5)
  • Smallish ballpark (7)
  • Prisoner restraint (9)
  • Illegal access, in perp-speak (5)
  • Headband (7)
  • Striped, as a bird's neck (6)
  • Antonio who played Zorro (8)
  • Kicked (about) (7)
  • Exchanges (7)
  • Stagecoach robber (6)
  • Mexican outlaw (7)
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  • Ricky Ricardo, e.g. (10)
  • Monopoly railroad, briefly (5)
  • Spielberg's WWII miniseries (14)
  • Sinister se�or (9)
  • McCartney .1 album of '74 (12)
  • Musical groups (5)
  • Toothed-belt machine (7)
  • Concert platform (9)
  • Join forces (12)
  • Not colorized (abbr.) (5)
  • Circus-parade vehicle (9)
  • Moe of country music (5)
  • Source of ruin (4)
  • Afflictions (5)
  • Canadian National Park (5)
  • Gun sound (4)
  • City west of Madras (9)
  • Very close, like a play at first base (8)
  • Pounded, as on the door (6)
  • Black-and-blue, as from a fight (8)
  • Sausage, in Sussex (6)
  • Sausages, in British slang (7)
  • English pub dish (14)
  • Collide with (8)
  • Asian capital (7)
  • Asian capital (15)
  • Asian nation (10)
  • Rigid bracelet (6)
  • Walk Like an Egyptian band, with "the" (7)
  • Hit loudly and repeatedly (6)
  • Maine city (6)
  • City on the Penobscot River (11)
  • Forehead-covering locks (5)
  • Rams (9)
  • Damages extensively (7)
  • If you cut your hair that way, Alice, you're goin' straight to the moon! (9)
  • Excellent, informally (6)
  • Excellent performance (9)
  • Kick out (6)
  • Expatriates (8)
  • Item that may be slid down (8)
  • Oh! Susanna instrument (5)
  • Folk music instruments (6)
  • Chase Manhattan, e.g. (4)
  • Sure to bring in money (8)
  • Depositor's holding (11)
  • Local lender (10)
  • It's swiped at a register (8)
  • Like a curve at Indy (6)
  • Treasurer (6)
  • Financial watchdog (9)
  • Business that involves checks and balances (7)
  • Heist of a sort (7)
  • Financial institution scrip (8)
  • Green (9)
  • Put one's trust in (6)
  • I won't let you down! (8)
  • Kind of crook (10)
  • Wad of dough (8)
  • Like a Chapter 11 filer (8)
  • Safe places for money (5)
  • Trusts (7)
  • Graffiti artist who didn't win a Oscar (which made the identity-reveal speculation a non-event) (6)
  • One with many bills (10)
  • Device with a time lock (9)
  • Places for valuables (10)
  • Synthetic yarn (6)
  • Prohibited (6)
  • Waking Ned Devine star Ian (6)
  • Headline (6)
  • Thin promo on a website (8)
  • Remarkable time period (9)
  • Newspaper attention-getters (15)
  • Huge headlines (7)
  • Super season (10)
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  • Partook of a feast (9)
  • Ghost in "Macbeth" (6)
  • Excommunicates (4)
  • Wailing spirit (7)
  • Wailing spirits (8)
  • Small chicken (6)
  • Miniature fowl (7)
  • Outlaw + Scottish hat + load (12)
  • Playful talk (6)
  • Traded playful barbs (8)
  • Teasing talker (8)
  • Exchanges taunts (7)
  • Anti-nuke slogan (10)
  • African language group (5)
  • Certain South African (11)
  • Zulu kinsmen (6)
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  • Monopoly deed (3)
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  • Christian denom. (3)
  • Pres. Clinton, religiously (4)
  • Immersion, for example (7)
  • Some church ceremonies (8)
  • Jesse Jackson, religiously (7)
  • Some followers of Martin Luther King (8)
  • Symbolically dunk (7)
  • Butter unit (3)
  • Actress Theda of the silents (4)
  • Criminal spared by Pilate (8)
  • Presidential candidate Obama (6)
  • Senator born in Honolulu (11)
  • Netanyahu's successor (5)
  • Local eatery (11)
  • Fishhook's end (4)
  • Caribbean island (8)
  • Honky-tonk booking (7)
  • Longtime "20/20" co-host Walters (7)
  • First family pair (15)
  • '66 Beach Boys song (10)
  • Midge in Vertigo (16)
  • California senator (12)
  • First lady who wrote "Millie's Book" (11)
  • She played Jeannie the genie (11)
  • TV's Della Street for nearly 40 years (11)
  • Country singing star (15)
  • She married George Bush in (13)
  • Star of "Double Indemnity" (15)
  • Jane Fonda sci-fi film (10)
  • Conan, for one (9)
  • Savage (8)
  • Kentucky Derby winner (7)
  • Either of two corsairs who were brothers (10)
  • North African region (7)
  • Tailless simian (10)
  • Family reunion activity (8)
  • Condiment often vinegar- and mustard-based (13)
  • Like fence wire (6)
  • Lucien B. Smith's invention: (10)
  • Weightlifter's apparatus (7)
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  • Hair stylist (6)
  • Hanna's cartooning partner (7)
  • Rossini opera, with "The" (15)
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  • Workers with poles, once (7)
  • Business that cuts locks (10)
  • Its stakes may be a beer (6)
  • Singer Benton (5)
  • Ken's friend (6)
  • Cookout food, for short (5)
  • Ms. Streisand (6)
  • Fanny Brice, in "Funny Girl" (15)
  • Rickles' repertoire (5)
  • Spanish football powerhouse, familiarly (5)
  • Commuter's watering hole (6)
  • Venetian boat song (9)
  • Where some commuters unwind (7)
  • Mixed drink servers (8)
  • Where the Dream Team debuted (9)
  • Graph with rectangular areas (8)
  • British banking name (7)
  • Scanner reading (7)
  • Supermarket scannings (8)
  • Shakespearean epithet (4)
  • Biutiful star Javier (6)
  • Of epic poetry (6)
  • Shakespeare (10)
  • Actress Brigitte (6)
  • Troubadours (5)
  • Like some necessities (4)
  • Model for an art class, say (7)
  • Riding like Lady Godiva (8)
  • Essentials (9)
  • Revealed (5)
  • Audacious (9)
  • Like a stroller at the shore, shoewise (8)
  • Fierce and unrelenting (11)
  • Wearing shorts without socks, maybe (10)
  • By the skin of one's teeth (6)
  • Least acceptable amount (11)
  • Band with the #1 hit "One Week" (15)
  • Just the essentials (15)
  • Nudity (8)
  • Scandinavian sea (7)
  • Arm of the Arctic Ocean (10)
  • Less furnished (5)
  • Exposes (5)
  • Most basic (6)
  • 's Robert Blake series (7)
  • Legal hurdle (7)
  • Oh, gross! (4)
  • Tavern frequenters (8)
  • Saloon regular (6)
  • Dog in "The Family Circus" (5)
  • Cut-rate purchase (7)
  • Frugal shopper's spot (15)
  • Place where discounted merchandise is thrown (10)
  • Tag-sale shopper, often (9)
  • Expect (10)
  • Leverage in negotiations (14)
  • Cleo's river boat (5)
  • Intruded, with "in" (6)
  • Arrived rudely (8)
  • Arrive impolitely (7)
  • Collide with (9)
  • River transports (6)
  • Enters rudely (8)
  • Nightclub employee (7)
  • Chart in many a PowerPoint presentation (8)
  • Comparitive- analysis diagrams (9)
  • Maine resort (9)
  • Go from pub to pub (6)
  • Tavern-tour activity (10)
  • Goes from tavern to tavern (7)
  • Italian port on the Adriatic (4)
  • Pertaining to element 56 (5)
  • Making public (6)
  • Coffee maker at Starbucks, e.g. (7)
  • Crooner's voice range: Abbr. (5)
  • Mineral used as a weighting agent (6)
  • Voice between bass and tenor (8)
  • Crooners, often (9)
  • Element in witherite (6)
  • Bowwow (4)
  • Speak to gruffly (6)
  • Upholstery fabric (9)
  • Made dog noises (6)
  • Cocktail maker (7)
  • Happy hour server (9)
  • Mixologists (8)
  • Carnival pitchman (6)
  • Carnival pitchmen (7)
  • Witch hazel, for one (11)
  • Pacino's "Sea of Love" costar (6)
  • Hounds' sounds (5)
  • Speaks to brusquely (7)
  • Whiskey grain (6)
  • Certain cereal grains (7)
  • Burlap bag (10)
  • Fermented foam (4)
  • It has north and south poles (9)
  • One might hand you a screwdriver (7)
  • Some tavern workers (8)
  • Mai-tai maker (6)
  • Mixers and shakers (6)
  • Certain year-old's rite of passage (10)
  • Frothy (5)
  • Farm building (4)
  • New Testament prophet (8)
  • Rudge of fiction (7)
  • Boat hanger-on (8)
  • Boat hangers-on (9)
  • One of the Seven Sisters (7)
  • Rustic social event (9)
  • Noble's partner (6)
  • Company with the stock ticker symbol BKS (14)
  • Charlie of swing (6)
  • N.B.A. All-Star Dick (7)
  • Purple kiddie pleaser (6)
  • Andy Griffith Show character (10)
  • Longtime Massachusetts congressman (11)
  • Flintstone's friend (12)
  • Including everything (7)
  • Nocturnal rodent hunter on a farm (7)
  • Hooters (8)
  • Rural activity (11)
  • Outbuildings (5)
  • Take one's show on the road (9)
  • American showman (6)
  • The Greatest Show on Earth purveyors (15)
  • Farm area (8)
  • Hen hangouts (9)
  • Fragrant cake (9)
Источник: [storycall.us]

CLINICAL VIGNETTES

Clinical Vignettes

A CASE OF ACYCLOVIR-INDUCED RESPIRATORY DEPRESSION IN PATIENT WITH END-STAGE RENAL DISEASE

W. Hester1; V.T. Martin1; S. Bansil1; C.J. Fichtenbaum1. 1University of Cincinnati, Cincinnati, OH. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize the clinical setting of acyclovir-induced neurotoxicity. 2. Diagnose and manage acyclovir-induced neuroxicity.

CASE

A 46 year-old woman with AIDS (recent CD 4 + lymphocyte count per mL &#x; plasma HIV RNA level copies per mL) and ESRD on continuous ambulatory peritoneal dialysis (CAPD) presented with pain in her right thigh for three months. Doppler ultrasounds were negative for deep venous thrombosis on two different tests. She had been in stable health without recent opportunistic infections. Her past medical history was significant for a history of shingles, orolabial herpes simplex disease, pancreatitis secondary to nucleosides, Candida esophagitis, and asthma. Her physical exam revealed an edematous right thigh and a tender 3 × 5 cm irregular ecchymotic area present on her lateral thigh near a small shallow ulcer. A small vesicle has preceded the ulcer. Laboratory data included a white blood cell count of K with 74% neutrophils; blood urea nitrogen of 74 mg/dL; creatinine of mg/dL; and creatinine kinase 1, U/L. The Alveolar-arterial gradient was mmHg. Computerized Tomography of the right lower extremity with contrast and multiplanar 3D reconstructions revealed no abscess. Empiric therapy with intravenous acyclovir 5 mg/kg/day was empirically started on hospital day 2. The next day the patient developed delirium and hypoxemia. The arterial blood gas revealed a pH , PaCO2 67 mmHg, PaO2 , HCO3 27 mmol/L, O2 saturation % on % oxygen via a non-rebreathable mask. Chest radiography demonstrated pulmonary edema. Cultures of the peritoneal fluid, bronchoalveolar lavage, blood, and spinal fluid, were all negative. The skin biopsy demonstrated findings consistent with calciphylaxis and pressure necrosis and the absence of viral inclusions. Acyclovir was discontinued on the sixth hospital day and a serum acyclovir level 12 hours after stopping the acyclovir was mcg/mL (reported therapeutic peak range of &#x; mcg/mL). Twenty-four hours after stopping the acyclovir the patient became alert and was extubated within 48 hours. Given all of these findings, the patient was diagnosed with acyclovir-induced respiratory depression.

DISCUSSION

Neurotoxicities such as lethargy, confusion, and delirium have been reported with acyclovir and seem to be more prevalent in the setting of kidney dysfunction, but have been identified in otherwise healthy individuals. To our knowledge, this is the first case report of acyclovir leading to respiratory failure in a patient with chronic renal disease. As demonstrated in this case, acyclovir should be used cautiously in those with renal failure to prevent neurotoxicities.

A CASE OF AMIODARONE-INDUCED THYROTOXICOSIS

J.E. Adams1. 1University of California, San Francisco, San Francisco, CA. (Tracking ID #)

LEARNING OBJECTIVES

1. Review Amiodarone's effects on thyroid function. 2. Diagnose and treat thyrotoxic effects of Amiodarone.

CASE

62 y/o male presented to his primary medical doctor complaining of a several month history of weakness, fatigue, hand tremor, and a ten pound weight loss. The patient was started on Amiodarone 2 years ago for paroxysmal atrial fibrillation and had remained in sinus rhythm without further complications. Upon initial work-up patient was found to have an undetectable TSH, and an elevated free T4.

DISCUSSION

Up to 20% of patients on long-term therapy will develop hypothyroidism as a result of toxic effects of Amiodarone, and 3% will develop hyperthyroidism. Hypothyroidism occurs by several mechanisms, the most common being a destructive thyroiditis which is often preceded by a hyperthyroid phase. Additionally, Amiodarone decreases the peripheral conversion of T4 to T3 and acts to directly block the T3 receptor. Lastly, synthesis of thyroid hormone is inhibited by high levels of iodine in Amiodarone (Wolff-Chaikoff effect). Treatment of hypothyroidism is with replacement therapy and is rarely an indication to discontinue therapy. Hyperthyroidism secondary to Amiodarone toxicity also occurs by a variety of mechanisms. In Type 1, synthesis of T4 is increased due to iodine load in a patient with underlying autonomy secondary to a nodule or goiter. In Type 2, patients develop a destructive thyroiditis often followed by hypothyroidism. Clinically, determining the mechanism of hyperthyroidism can be challenging but can direct therapy. Detectable uptake on thyroid scan or nodules on exam suggest Type 1. Patients with Type 2 sometimes have elevated IL-6 levels. Doppler sonography to assess vascularity and diagnose small nodules is successful in classifying 80% of cases. Type 1 disease is treated with anti-thyroid drugs such as Methimazole and response may be slow. Patients with Type 2 are treated with steroids and often respond quickly. In clinical practice, patients are often treated with both, with the rapidity of response guiding further treatment. In considering stopping therapy, it is important to weigh the risks of chronic hyperthyroidism against the risk of arrhythmia. Amiodarone has a very long half-life which prevents any immediate benefit in stopping the drug, and symptoms may actually be exacerbated when the beta-blocking effects of Amiodarone are lost. In general, thyrotoxicity is not an absolute contraindication for continuation of Amiodarone and risks and benefits must be weighed carefully. In monitoring patients on long-term therapy, TSH and FT4 should be followed every six months.

A CASE OF AMNESIA RESPONSIVE TO PHLEBOTOMY

H.A. Younes1; R. Parker1. 1University of Pittsburgh, Pittsburgh, PA. (Tracking ID #)

LEARNING OBJECTIVES

1) To diagnose and recognize the different kinds of erythrocytosis and polycythemia, 2) To learn about the complications of erythrocytosis, 3) To learn about the treatment options of different kinds of erythrocytosis.

CASE

A 63 y.o. gentleman, with a past medical history significant for CAD, hypertension, and recurrent DVT's, presented to his PCP office complaining of frequent forgetfulness for 2 weeks. He reported the problem starting while he was on a plane trip from Denver to Pittsburgh where he felt some shortness of breath with mild headache. When he reached Pittsburgh, he couldn't tell where he came from, or the time of the day. He was even somewhat confused about his personal belongings. This episode was followed with several incidences of forgetfulness in his daily tasks, such as forgetting the water tap was open and forgetting his daily schedule of activities. Physical exam revealed no localized neurological deficit. An MRI of brain showed no evidence of a new ischemic or hemorrhagic stroke, although it showed an old right MCA occipital lobe infarct. A hypercoagulable workup was negative. A CBC showed a Hgb of 18 g/dL, a Hct of , and an RBC mass of × 10 to power 12 per L. WBC count was , and platelet count , A repeat CBC confirmed above values. Serum viscosity and erythropoitin level proved normal. A blood volume study showed normal RBC volume, with a low plasma volume, and a low normal total blood volume; all findings consistent with a relative polycythemia. In view of the persistent neurological findings, therapeutic phlebotomy of the patient was done, with ml removed each time. After a few sessions, the patient reported his symptoms improving significantly, with a decrease in his hemoglobin and hematocrit levels.

DISCUSSION

As opposed to absolute polycythemia (polycythemia vera or PV) where there is an absolute increase in red cell mass, &#x;relative&#x;, &#x;stress&#x;, or &#x;apparent&#x; polycythemia is defined as an increase in hematocrit with normal red cell mass. Approximately 25% of cases have reduced plasma volume. Possible causes of this relative polycythemia include dehydration, alcohol, smoking, obesity, hypoxia, acute MI, and hypertension. PV is known to cause both microvascular disturbances, such as peripheral ischemia and atypical cerebral ischemic attacks, as well as major arterial and venous thromboembolism. However, the risk of vascular occlusive episodes in relative polycythemia is not well known. A study by Schwartz et al. comparing relative polycythemia with PV revealed significantly more thromboembolic events (DVT/PE) in PV, but equal risk of cardiac and cerebrovascular events. The fact that our patient's symptoms improved after phlebotomy as his hematocrit decreased, suggests that his symptoms were atypical cerebral attacks. Although phlebotomy is not considered a typical treatment modality of relative polycythemia, it worked well with our patient.

A CASE OF CAMPYLOBACTER FETUS MENINGITIS IN A FORTY-YEAR OLD MAN

M.S. Divakaruni1; A. Hwang2. 1Stanford University, Palo Alto, CA; 2Santa Clara Valley Medical Center, San Jose, CA. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize Camplyobacter species as a potential etiology of bacterial meningitis in patients with predisposing illness, including recent or distant neurosurgery, or alcohol abuse. 2. Treat CNS infections with C. fetus with carbapenems or a third-generation cephalosporin and an aminoglycoside.

CASE

Campylobacter is an uncommon cause of bacterial meningitis in adults. We report the case of a year old Vietnamese gentleman with a prior history of partial craniotomy and alcohol abuse who was admitted with headache, fever, neck pain, and weight loss over the preceding two weeks. The patient had reported a history of a flu-like illness preceded by one day of non-bloody diarrhea, but these symptoms had resolved several days prior to admission. On admission, he was febrile to degrees centigrade and had prominent nuchal rigidity and positive Kernig's and Brudzinski's signs, but an otherwise normal neurological exam except for marked confusion. Laboratory data showed serum WBC 15,/mm3 with a left shift. Cerebrospinal fluid analysis showed WBC/mm3 with 85% neutrophils and 15% lymphocytes, glucose of 24 mg/dl, and protein of mg/dl. The fluid was India ink negative, cryptococcal antigen negative, and acid-fast bacilli negative. The patient was initially treated with intravenous vancomycin and cetriaxione. On the third hospital day, one out of four blood cultures began to grow out gram-negative rods. The subsequent day, the patient's cerebrospinal fluid grew out comma-shaped gram-negative rods suspicious for Campylobacter species. Vancomycin was discontinued, and the patient was started on gentamicin in addition to ceftriaxone. The patient responded rapidly to antibiotic therapy. Both the patient's blood and cerebrospinal fluid cultures eventually returned with a final result of Campylobacter fetus species. The patient was treated with a total of five days of parenteral gentamicin, fifteen days of parenteral ceftriaxone, and an additional seven days of oral ciprofloxacin for a total antibiotic course of twenty-one days. At the time of discharge the patient was doing well, and had no further gastointestinal or neurologic symptoms.

DISCUSSION

In this case of Campylobacter fetus meningitis, the patient had predominately extra-intestinal manifestations as is normally seen with C. fetus species, though with a one-day history of diarrheal illness not usually reported with the organism. The patient had a predisposing immunosuppressed state secondary to his alcohol abuse, as well as a prior history of neurosurgery, consistent with previously reported cases. Given the incidence of mortality reported in the case literature, and this patient's rapid response to the selected antibiotic regimen, the early and appropriate treatment of C. fetus meningitis appears to be clinically important.

A CASE OF HERPES ZOSTER ENCEPAHLITIS

S. Ramamurthy1; M. Graham2. 1Medical College of Wisconsin, Germantown, WI; 2Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #)

LEARNING OBJECTIVES

Viral pathogens can cause a variety of syndromes when affecting the central nervous system including aseptic meningitis and storycall.uslla zoster virus (VZV) is a rare cause of central nervous system syndromes. We discuss a patient who initially presented with dermatomal zoster whose clinical course was complicated by the development of VZV encephalitis with complications both from the primary disease process and the appropriate therapy.

CASE

66 yr old Caucasian female with history of rheumatoid arthritis treated with methotrexate who presented with mental status changes. Seven days prior to admission she developed an erythematous rash on back and chest confined to right side of thorax. She was treated with valacyclovir for two days and complained of pain at the site for which she was prescribed vicodin and amitryptyline. The next day she was noted to be disoriented by family and brought to ER. Physical exam revealed an erythematous vesicular rash on her chest and back confined to the T2&#x;T3 dermatome on right side. Neurological exam was within normal limits except that she had difficulty finding words. CT scan of the head on admission was normal and her labs were significant for hyponatremia ( mmol/l). Urine osmolality was mosm/kg and serum osmolality was mosm/kg consistent with SIADH. She was placed on intravenous (IV) acyclovir and fluid restriction for SIADH. Cerebrospinal fluid (CSF) analysis revealed an elevated white blood cell count (/cmm) with lymphocytic predominanace (90%) and elevated protein level ( mg/dL). CSFanalysis for VZV by PCR was positive. On day 3 her creatinine level increased and urinalysis revealed numerous crystals consistent with acyclovir induced nephropathy. The acyclovir dose was adjusted based on renal function and she was given IV fluids. On day 4 she complained of hallucinations and double vision. MRI of the head was normal. She continued to improve with IV acyclovir and hyponatremia resolved. A repeat CSF analysis was negative for VZV by PCR. Patient completed a two week course of IV acyclovir and was discharged on oral valacyclovir for an additional week and neurontin for pain.

DISCUSSION

Herpes zoster encephalitis is rare and very few cases have been storycall.us postulate that in this case her immunosuppresed state on methotrexate was the main predisposing factor. This case also highlights the complications of disease process, specifically hyponatremia (SIADH) and adverse effect of treatment (acyclovir induced nephropathy) and how to manage them astutely.

A CASE OF INTERNAL MAMMARY ARTERY STEAL SYNDROME

H.L. Korlakunta1; D. Lakkireddy1; N. Mehta1; T. Lanspa1; I. Khan1. 1Creighton University, Omaha, NE. (Tracking ID #)

LEARNING OBJECTIVES

To report a case of a patient with IMA steal syndrome after a LIMA bypass grafting to the LAD who was successfully treated with percutaneous transcatheter endovascular coiling of the anomalous lateral internal thoracic artery.

CASE

A year male presented for evaluation of recurrent exertional angina more so with upper body exercise. He had known diabetes, hypertension, hyperlipidemia, paroxysmal atrial fibrillation and coronary artery disease with a 3-vessel coronary artery bypass surgery done 4 years prior to presentation. A transradial coronary angiogram revealed total occlusion of the RCA graft with 99% stenosis of mid RCA, which was successfully treated with angioplasty and stent placement. The LCX graft was patent, LIMA was patent but appeared to be a small vessel. There was 80% stenosis of mid LAD just proximal to the LIMA insertion. During LIMA injection a parallel branch running lateral to the LIMA graft was seen giving rise to anterior intercostals and perforating branches. This fits the anatomic description of an anomalous IMA with a lateral internal mammary artery. Patient then underwent an adenosine cardiolyte stress perfusion imaging which showed mild to moderate reversible ischemia in the antero-septal and anterior walls. Patient was started on a long acting nitrate in addition to his regular dose of beta blockers, diuretic, angiotensin converting enzyme inhibitor and was advised to abstain from upper body exertional activities. He was brought back a month later and a selective catheterization followed by a coil embolization of the lateral internal thoracic artery was performed with successful closure. There was a dramatic improvement to the flow through the LIMA graft after closing the lateral branch. An exercise stress was performed with no ischemic symptoms or EKG manifestations.

DISCUSSION

The internal mammary artery (IMA) is a conduit of choice for myocardial revascularization, especially when the target vessel is the left anterior descending artery (LAD). Occasionally IMA hypo perfusion occurs when there is inadequate flow through the IMA graft to the LAD artery. The graft hypo perfusion can occur both acutely and chronically resulting in Malperfusion Syndrome and Dysfunctional Graft with persistent ischemia in the region of supply. This is a case of symptomatic LAD ischemia from a hypoperfusing IMA graft which was experiencing vaso-steal phenomenon from a persistent anomalous lateral internal thoracic artery. It was subsequently embolized with coils with improved perfusion in LAD and symptomatic improvement.

A CASE OF MONDOR's DISEASE: SUPERFICIAL THROMBOPHLEBITIS OF THE BREAST

D. Cywinski1; E. Caiola1. 1University of Rochester, Rochester, NY. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize that thrombophlebitis of superficial veins of the breast is an uncommon condition that is usually self-limited. 2. Review the potential etiologies of Mondor's disease: most commonly idiopathic, post breast surgery and uncommonly due to underlying breast cancer. 3. Review that Mondor's disease can be diagnosed with color flow Doppler examination of the breast and if no other abnormalities are detected can be followed and treated symptomatically.

CASE

A previously healthy year-old female presented with a two-day history of a painful left breast with a palpable cord. She denied a history of breast-feeding, trauma, fever or chills. She was G2P with a 2-year-old child. Depo-Provera was her only medication. She denied alcohol, tobacco or drug use. She had no previous history of thrombophlebitis or deep venous thrombosis. Family history was negative for thromboembolism or breast cancer. Physical examination was notable for an approximate cm palpable, tender venous cord over the upper outer quadrant of the left breast. There was minimal surrounding erythema and induration. There were no palpable breast masses or axillary adenopathy. There was no extension to the axillary veins and there was no arm edema or asymmetry. The remainder of the exam was non-focal. A Doppler examination demonstrated a hypoechoic tubular structure without vascular flow consistent with Mondor's thrombophlebitis. No other abnormalities were detected. The patient was treated symptomatically with warm compresses and NSAIDs and had complete resolution of her symptoms 4 weeks post presentation.

DISCUSSION

Mondor's disease is a rare condition of superficial thrombophlebitis of the breast veins. It is usually a self-limited condition that can be followed and treated supportively with NSAIDs. In most cases a cause is not found but Doppler examination and possible mammography are indicated. Mondor's disease may be a complication of breast surgery and uncommonly associated with underlying breast cancer.

A CASE OF NON-MENSTRUAL STAPHYLOCOCAL TOXIC SHOCK SYNDROME

S. Arora1. 1University of Connecticut, Farmington, CT. (Tracking ID #)

LEARNING OBJECTIVES

To recognize and manage toxic shock syndrome (TSS).

CASE

A year old previously healthy male deli worker presented with a painful, marble sized swelling posterior to right greater trochanter, high fever and vomiting for 2 days with generalized red skin rash involving the entire body for a day. He had not passed urine for 12 hours. There was no preceding history of trauma or any outdoor activity. Examination revealed tachycardia with HR of bpm, fever with temperature of oF and hypotension with BP of 80/58, pierced lower lip with lip ring, intensely red, blanchable erythema involving the entire skin and oro-pharyngeal mucous membranes. There was 2 × 2 cm tender, fluctuant swelling, mobile over underlying muscle located 5 cm posterior to right greater trochanter over the posterolateral aspect of right hip. Incision and drainage of the swelling yielded 5 ml of yellow pus which grew staphylococcus aurues sensitive to oxacillin. Investigations revealed WBC of 28,/cmm with 18% bands and 81% neutrophils, platelets: 90,/cmm, BUN/Cr: 44/ and FeNa of %, the patient was diagnosed with staphylococcal toxic shock syndrome and was treated with IV fluids, IV Vancomycin and supportive care of acute renal failure. The patient's renal function started improving by D2, he became afebrile on D4 with gradual resolution of rash subsequently. He was discharged on D4 on Dicloxacillin and recovered with no sequelae.

DISCUSSION

Staphylococcal TSS is an acute life-threatening toxin-mediated intoxication caused by TSS toxin 1 or staphylococcal enterotoxin B. Although menstruation remains the most well-known setting for TSS, 50% of TSS is non-menstrual and can complicate the use of barrier contraceptives, child birth, superinfection of various skin lesions including burns, insect bites, varicella, surgical wounds and post-influenza pneumonia. The primary site of colonization often appears entirely benign. CDC criteria for diagnosis includes presence of all of the following: hypotension or orthostatic drop in BP, temperature oF, diffuse macular erythroderma, desquamation of palms and soles 1&#x;2 weeks after onset, negative results of blood, throat or CSF cultures which may suggest an alternative diagnosis and involvement of at least three of the following organ systems: gastrointestinal (nausea and vomiting), muscular (severe myalgias or elevated CPKs, mucous membranes, renal, hepatic, hematological (thrombocytopenia ,, central nervous system (disorientation but no focal neurological signs). Treatment includes site drainage, aggressive fluid resuscitation, anti-staphylococcal antibiotics for 14 days, pressors for hypotension and correction of dyselectrolytemia. Critically ill or unstable patients benefit from intravenous immunoglobulin.

A CASE OF POLYMICROBIAL ENDOCARDITIS IN AN INTRAVENOUS DRUG ABUSER DUE TO ANAEROBES

S. Oh1; N. Hussain1; P.R. Havlen1. 1University of Texas Medical Branch at Galveston, Galveston, TX. (Tracking ID #)

LEARNING OBJECTIVES

1. Gain awareness of Infective Endocarditis (IE) due to anaerobic organisms 2. Compare IE in intravenous drug abusers (IVDA) from other cases 3. Recognize that peculiar habits of IVDA can result into unusual polymicrobial IE.

CASE

A year-old white male presented to our hospital with a two-week history of subjective fevers, chills, and rigors. He had history of intravenous drug abuse and a habit of licking the needle to the dorsum of the tongue before injection into his arm. Blood cultures grew Actinomyces odontolytica, Veillonella species, and Prevotella melaninogenica. CT of the thorax showed multiple cavitary lesions in both lungs and echocardiogram showed vegetations on the tricuspid valve. The patient was treated with a six-week course of penicillin G and metronidazole. He responded well with complete resolution of symptoms.

DISCUSSION

Endocarditis in intravenous drug users are usually right sided and of the tricuspid valve. Right-sided endocarditis presents with a syndrome of persistent fever and pulmonary symptoms due to septic emboli including cough, dyspnea, and hemoptysis. The peripheral stigmata of endocarditis are not classically found in right-sided endocarditis. Although the most common organism isolated is Staphlococcus aureus, it is important to consider other more fastidious causes of infection in this population including those of endogenous origin. Anaerobes are predominant components of normal human skin and mucous membranes and are an uncommon cause of endocarditis. Most cases are caused by anaerobic cocci, Propionibacterium acnes and Bacteroides fragilis group. Actinomyces odontolytica, Veillonella species, and Prevotella melaninogenica reside predominantly in saliva and the dorsum of the tongue as compared to other organisms. We believe that his peculiar habit of licking the needle to the dorsum of the tongue to gauge the strength of the injection, subjected our patient to infection by these particular anaerobes. Polymicrobial endocarditis is a rare entity that is found almost exclusively in intravenous drug abusers. Although uncommon, it is important to consider since it carries a mortality rate exceeding 30%. There are documented cases in which cultures from the vegetations grew more organisms than the blood cultures, further exemplifying the fastidious nature of the organisms causing endocarditis in intravenous drug users. Therefore, some authors recommend empiric coverage of both skin and oral flora when endocarditis is suspected in this population. Penicillin G or other bactericidal agents appear to be the treatment of choice for these three organisms. Metronidazole is often added due to the growing resistance of anaerobes towards penicillins.

A CASE OF POST-OBSTRUCTIVE PNEUMONIA SECONDARY TO BRONCHOLITHIASIS

S.E. Luckhaupt1; L. Coberly1. 1University of Cincinnati, Cincinnati, OH. (Tracking ID #)

LEARNING OBJECTIVES

1) Distinguish post-obstructive pneumonia from uncomplicated community acquired pneumonia 2) Recognize broncholithiasis as a cause of bronchial obstruction 3) Manage bronchial obstruction to prevent recurrent pneumonia.

CASE

A year-old male smoker with an unremarkable past medical history presented with a 2-week history of shortness of breath, cough, purulent sputum, pleuritic chest pain, and orthopnea. On exam, he had a temperature of , respirations of 28 and a pulse ox of 89% on room air. Chest exam revealed bibasilar rhonchi and intermittent wheezing over the left lung base. Initial laboratory data: WBC with 12% bands, Hb ABG on room air: pH , pCO2 36, pO2 A chest x-ray suggested left lower lobe consolidation with pleural effusion. Despite treatment with iv antibiotics, his oxygen requirement increased and serial x-rays showed increasing infiltrate and effusion. A CT on hospital day #3 revealed extensive loculated left pleural effusion with a compressed lower lobe, possibly caused by calcified left hilar lymph nodes. An ultrasound was negative for free-flowing fluid, so chest tubes were placed, and t-PA was used to assist in drainage. A repeat CT showed improvement in the effusion, but compression of the left lower lobe persisted. Bronchoscopy ultimately revealed obstructing broncholiths. The broncholiths could not safely be removed, so left lower lobectomy was performed. Pathology showed four hard tan-gray stones measuring cm to cm in diameter and lymph nodes with necrotizing granulomas, negative for neoplasia. No fungi, acid fast bacilli, or other organisms were identified in the pathology specimens or in the pleural fluid.

DISCUSSION

This patient's presentation provided several clues that he did not have a typical case of community acquired pneumonia. Despite having an unremarkable medical history, he was very ill on presentation with hypoxemia, which progressed even after treatment with antibiotics. Localized wheezing raised suspicion for bronchial obstruction and concern about the possibility of carcinoma. Broncholithiasis is a less common cause of bronchial obstruction, which usually presents with hemoptysis (from erosion of pulmonary vessels), wheezing, shortness of breath, or chronic cough. It is often associated with fungal infection, such as histoplasmosis, or tuberculosis. The cause of broncholithiasis in this case was unclear. The diagnosis can usually be confirmed by bronchoscopy, but bronchoscopic removal carries a high risk of bleeding, so surgical resection is often required to relieve obstruction.

A CASE OF RAPIDLY FATAL ASPERGILLOSIS IN AN IMMUNOCOMPETANT PATIENT

F.K. Salahuddin1; S. Chitavellue2; K. Karamchandanni3. 1University of Illinois at Peoria,SFMC., Peoria, IL; 2University of Illinois College of Medicine,@Peoria,SFMC, Peoria, IL; 3University of Illinois College Of Medicine,@Peoria, Peoria, IL. (Tracking ID #)

LEARNING OBJECTIVES

1. Diagnosis of massive hemoptysis. 2. Aspergilloma as a cause of hemoptysis. 3. Management of life threatening hemoptysis using various means.

CASE

A 60 year old male was admitted into the hospital because of pleuritic chest pain, hemoptysis, fever, lethargy and significant weight loss. He was a retired janitor in a school. At the time of presentation, he was in respiratory distress and examination revealed bilateral crackles and wheezes. Chest X-ray and CT scan showed consolidation and cavitation of right upper lobe (Figure below). He underwent diagnostic flexible bronchoscopy which confirmed the bleeding from right upper lobe without any intra-bronchial pathology. Bronchoalveolar lavage grew aspergillious. Patient was treated with Amphotericin B because of massive hemoptysis. He continued to have massive hemoptysis which required mechanical ventilatory support with double lumen endotracheal intubation. Patient was sent for an emergent bronchial arteriogram and had control of bleeding with coiling. After 24 hours patient developed another episode of maasive hemoptysis which lead to his demise. Autopsy confimed the angioinvasive aspergillosis.

DISCUSSION

Angioinvasive pulmonary aspergillosis is commonly seen as a serious complication in immunosupressed individuals such as patients with AIDS and leukemia. It is rare to encounter angioinvasive aspergillosis in immunocompetant individuals. Aspergillosis can develop as a fungal ball in preexisting pulmonary cavities causing lifethreatening massive hemoptysis. Routine surgical recection of aspergillious is not recommended but should be reserved for patients with recurrent severe refractory hemoptysis. Pleuro-pneumonectomy should be avoided. Lung necrosis can result from invasion of fungus into the vasculature, leading to vascular thrombosis and hemorrhage. Massive hemoptysis can be managed with mechanical ventilation using double lumen endotracheal tube, bronchial artery embolization and or surgery. Prognosis in immunocompetant patients is usually good with above therapies.

A CASE OF RHODOCOCCUS EQUI PNEUMONIA IN A RENAL TRANSPLANT PATIENT

T.S. Bischof1; J. Hariharan1; M. Graham1. 1Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #)

LEARNING OBJECTIVES

(1) To recognize the clinical presentation of atypical pneumonia in transplant patients. (2) To educate the clinician on the presentation, radiography, pathology, and treatment of Rhodococcus equi pneumonia.

CASE

A 48 y/o male with IgA nephropathy and 4 renal transplants presented with a one week history of nausea, vomiting, and diarrhea. He related dehydration, weakness, low-grade fevers, night sweats, and weight loss. He denied chest pain, shortness of breath or cough. The patient was taking immunosuppressive and antihypertensive medicines. Physical exam revealed an afebrile, normotensive, cachectic male in no acute distress. Exam was within normal limits, and lungs were clear. BMP was normal except for Bun/Cr of 37 mg/dL and mg/dL. WBC was , Hgb g/dL, and urinalysis revealed no proteinuria or white cells. Blood, urine and stool cultures were negative. Patient was hydrated, and CXR revealed a new opacity in the left lung. A chest CT revealed a × cm consolidation in the left lower lobe, but was negative for bony lesions and lymphadenopathy. A bronchoscopy and CT guided biopsy were done, and cultures from both subsequently grew Rhodococcus equi. On directed questioning, it was found the patient lives near a farm with routine exposures to horses and had a new dog. Therapy with moxifloxacin and azithromycin was planned until the lesion cleared on repeat CT scan.

DISCUSSION

Rhodococcus equi is a gram-positive coccobacillus that usually causes infections in grazing animals. Infection in humans is rare, but over cases have been reported. Rhodococcus is often overlooked in cultures as a non-pathogenic organism and its insidious onset often leads to delays in diagnosis. Pulmonary infection is the most common, and symptoms include fever, cough, and weight loss. On radiography, the superior lobes are mainly involved, and cavitation is frequent, as well as effusion and empyema. Diagnosis is based on positive culture. Most isolates are susceptible to erythromycin, ciprofloxacin, and aminoglycosides. Oral and parenteral combinations of the above are used for treatment for at least two months. This patient was treated for 5 months and repeat CT 3 months later showed decreased consolidation. It is well known that immunocompromised patients are more prone to atypical infections. This case represents a rare cause of a treatable bacterial infection in a transplant patient and the value of social and personal history in medical management. It is important to recognize that when patients present with vague complaints and lack of physical signs, a good history and continually pursuing identification of treatable causes is important. Rhodococcus equi pneumonia is rare but understanding the nature of its presentation is highlighted in this case.

A CASE OF UNSTABLE ANGINA IN A YOUNG MAN

B. Barmar1; G. Tabas1. 1University of Pittsburgh, Pittsburgh, PA. (Tracking ID #)

LEARNING OBJECTIVES

Learning Objectives: (1) Recognize angina in young patients. (2) Consider cardiac and noncardiac causes of chest pain in young patients.

CASE

A year-old Korean man with a history of gastritis and gastroesophageal reflux disease presented to his primary care physician's office with exertional chest pain relieved by rest. Because of his underlying gastrointestinal problems, young age, and lack of cardiac risk factors, his physician prescribed pantoprazole, obtained a complete blood count (CBC), and scheduled him for a treadmill stress test later that week. The next day, when the CBC revealed a platelet count of 2,,/uL (normal range &#x;,/uL) the patient was instructed to go to the emergency department. He reported chest pain at rest, but this resolved after 2 sessions of emergent platelet pheresis and treatment with aspirin and nitroglycerin. Cardiac enzyme levels and electrocardiographic findings were normal. Peripheral smear showed numerous platelets, and bone marrow biopsy confirmed the diagnosis of essential thrombocytosis. After the initiation of anagrelide, a platelet-reducing agent, the patient's platelet count dropped to 1,,/uL by the second hospital day. To avoid a positive stress test result attributable only to platelet sludging in the coronary arteries, the physician waited until the platelet count was below ,/uL to perform a stress test. When the test was performed, it yielded negative results for ischemia. At 8 months after diagnosis, the patient is asymptomatic and has a platelet count of about ,/uL.

DISCUSSION

In young patients, cardiac causes of chest pain can be found in about 16% of cases, noncardiac causes in 68%, and unknown causes in 16%. The common noncardiac causes include musculoskeletal problems (in 36% of cases), gastrointestinal problems (in 19%), psychological problems (in 8%), and pulmonary problems (in 5%). The noncardiac causes that are most serious and require immediate treatment are pulmonary embolus, pneumothorax, and aortic dissection. A thorough history and physical examination and focused laboratory studies usually exclude life-threatening causes of cardiac chest pain. Although the patient in this case was young, his chest pain was typical for angina, so further investigation was initiated. Investigation uncovered essential thrombocytosis, an unusual cause of angina.

A CASE OF WIDE ANION GAP NON-ACIDOSIS

E. Cichowski1; H. Sakowski1; H. Hashish1; R. Baltaro1. 1Creighton University, Omaha, NE. (Tracking ID #)

LEARNING OBJECTIVES

1) Recognize laboratory error in the measurement of serum bicarbonate. 2) Utilize the Henderson-Hasselbach equation to indentify blood gas analysis errors. 3) Identify a previously unrecognized interfering substances as potential causes of laboratory errors.

CASE

A 72 year-old male was admitted for respiratory distress and confusion, and found to have a right upper lobe lung mass and hypercalcemia. He was intubated on the second hospital day due to worsening of his respiratory status. Propofol was initiated for sedation and methylprednisolone and levofloxacin were given for a presumed post-obstructive pneumonia. His initial arterial blood gas after intubation showed a pH pCO2 38 pO2 on an Fio2 of His measured HCO3 was 26 meq/l. Over the next 4 days, his measured bicarbonate progressively dropped to 8 meq/l despite no change in his arterial blood gas (pH pCO2 36 pO2 on an FiO2 of ). His anion gap was calculated at Serum lactate was normal, and serum ketones were absent. Consultation with the pathology department revealed the patient's serum to be grossly lipemic. A review of the chart revealed the patient did receive lipid infusions with TPN 36 and 18 hours prior to this discovery. A lipid panel was obtained and revealed marked hypertriglyceridemia at 4, mg/dl. The lipid infusions were discontinued, and the propofol was weaned off. The bicarbonate level dropped to a low of 3 meq/l approximately 7 hours after the medication was discontinued. Four hours later, the bicarbonate had corrected to 21 meq/l. The serum, however, remained grossly lipemic. The patient's condition continued to decline with the development of septic shock, multi-organ failure and ventricular arrythmias. Results of a previous bronchoscopy demonstrated small cell carcinoma. The patient's family requested no further aggressive treatment and he expired later that day.

DISCUSSION

This patient developed marked derangement in his measured bicarbonate levels that did not correspond to his arterial blood gas analysis (according to the Henderson-Hasselbach equation). A laboratory error was hypothesized as the cause. Due to the finding of lipemic serum, the hypertriglyceridemia was initially suspected as the interfering substance. Upon discontinuing the propofol, the serum bicarbonate level normalized, the serum, however remained lipemic. In a review of the literature, neither propofol nor hypertriglyceridemia have been reported as potential causes of this lab error. Further testing is needed to determine the role of propafol as an interfering substance in bicarbonate laboratory analysis.

A CASE REPORT OF OXYGEN EMBOLISM FOLLOWING HYDROGEN PEROXIDE INGESTION

D. Misra1; B. Legere1. 1New Hanover Regional Medical Center, Wilmington, NC. (Tracking ID #)

LEARNING OBJECTIVES

Recognize that ingestion of concentrated solution of hydrogen peroxide can result in significant morbidity and mortality owing to venous or arterial oxygen embolization. We intend to share our experience through a case report to emphasize this fact .

CASE

We present the case of an 82 yr old caucasian female with prior history of emphysema who had inadvertently ingested a large quantity of concentrated hydrogen peroxide solution. Following this, she vomited and developed resiratory distress which required intubation and mechanical ventilation. On examination, she was sedated, tachycardic and had hemoccult positive stool. Blood work revealed elevated white cell count and a low hematocrit. Her basic metabolic panel, urine drug screen, liver function tests were within normal limits. Chest xray showed emphysema. CT scan of abdomen/pelvis was significant for portal venous gas and pneumatosis involving duodenal and jejunal wall. Upper endoscopy revealed hemorrhagic gastritis and distal esophagitis. She was started on empiric antibiotics and followed with serial abdominal radiographs. CT scan of the abdomen obtained five days later revealed no free air or pneumatosis. On the sixth day of hospitalization, patient was extubated and at that point of time was noted to have right sided hemiparesis. MRI scan of the brain revealed multiple areas of acute/subacute non-hemorrhagic infarction. Patient was evaluated by a neurologist and it was felt that her neurologic deficits were a result of oxygen embolization. Patient gradually improved with physical and occupational therapy and currently awaits discharge to a rehabilitation facility.

DISCUSSION

Hydrogen peroxide is widely used as an oxidant/disinfectant. It is sold in health food stores also as means of improving oxygenation in people with coronary artery disease. Literature search revealed several cases of accidental hydrogen peroxide ingestion. A retrospective review of all exposures reported to a poison control center revealed that % were hydrogen peroxide related. Although exposure to diluted (3%) hydogen peroxide is benign, ingestion of the concentrated form can be dangerous. Following ingestion, hydrogen peroxide breaks up into water and oxygen in the presence of catalase. When the amount of oxygen produced exceeds the maximum blood solubility, embolization occurs. We emphasize that physicians should be alert to the possibilty of multiorgan embolization in patients presenting with accidental ingestion of concentated hydrogen peroxide.

A CASE REPORT OF RECURRENT COCCIDIOIDES MENINGITIS (CM)

S.M. Maiorano1; P. Radhakrishnan2. 1St. Joseph's Medical Center, Phoenix, Phoenix, AZ; 2Catholic Healthcare West, Phoenix, AZ. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize that CM recurrence can occur despite prolonged antifungal treatment. 2. Recognize that indwelling CFS shunt can mask the hallmark symptoms of hydrocephalus associated with CM. 3. Recognize that diagnosis of CM can be made on serum serologies without positive CSF cultures.

CASE

A 62 year old male, presented with a 2 month history of worsening diplopia, ataxia and headache. Past History-CM with obstructive hydrocephalus and VP shunt. He was treated with Amphotericin B (intrathecal and systemic) for 2 years followed by Fluconazole for 8 years. He had been off Fluconazole for the last 5 years. Physical exam&#x;He was somnolent, but arousable. Eyes-limited upward movement with downbeating nystagmus, disconjugate gaze with mild right lateral ocular deviation. Lab. data-CT head&#x;mild right encephalomalcia, enlargement of 3rd and 4th ventricles, catheter in the right lateral ventricle. CSF-(from the shunt and a lumber puncture)-including Gram stain-negative. Positive CSF Coccidioides IgG and serum IGG,IGM antibodies. Complement fixation (CF) titer Catheter tip-Coagulase negative Staphylococcus. MRI of the head&#x;ventriculomegaly, increased periventricular and meningeal enhancement. He was diagnosed with recurrent CM, shunt failure due to presumed Staphyloccal infection. He was started on Voriconazole and Vancomycin. The shunt was replaced. He improved with resolution of his neurological symptoms and signs. He was discharged with the plan to continue the Voriconazole indefinitely.

DISCUSSION

CM is a grave form of disseminated Coccidiodes infection. Of the nearly , cases per year, only percent present as meningitis. This case has several interesting aspects, the first being the recurrence of the CM after several years. Recurrences usually occur shortly after discontinuing therapy, as despite adequate antifungal penetration the fungus is not easily cleared. In this case, the patient remained symptom free for 5 years after stopping therapy. Second, the temporal association of shunt blockage and recurrence of symptoms of CM made us postulate that the patient remained symptom free due to the drainage of CSF and clearance of the fungus. Little data is available as to the incidence or common etiologies of shunt failure, but many case reports have found bacterial shunt obstruction through colonization as well as fungal biofilm occlusion. Third, the diagnosis of CM recurrence was made based on the CSFand serum studies. As CSF cultures are positive in only one third of cases, positive CSF IgG or IgM and CF antibodies are very helpful in diagnosing CM in patients with a high pre-test probability and negative cultures. While there are definitive guidelines for the duration of treatment of CM, patients who experience a relapse should be continued lifelong therapy.

A DIAGNOSIS AT BOTH ENDS: A CASE OF CELIAC DISEASE AND MICROSCOPIC COLITIS

D. Nataraj1; R. Granieri1. 1University of Pittsburgh, Pittsburgh, PA. (Tracking ID #)

LEARNING OBJECTIVES

(1) To recognize the clinical history and histopathology of celiac disease and microscopic colitis (2) To recognize an association of celiac disease with microscopic colitis (3) To manage celiac disease and microscopic colitis.

CASE

A 31 year-old female presents with 6 months of nausea, bilious emesis, abdominal cramps, watery diarrhea, and 30 lb weight loss. Diarrhea occurs 5 to 15 times daily. Physical examination reveals cachexia, tachycardia, dry mucous membranes, normal bowel sounds, and abdominal distention with mild but diffuse tenderness to palpation. Initial laboratory values demonstrate hypokalemia, contraction alkalosis, normal amylase and lipase, hypoalbuminemia, normal liver function tests, hemoglobin of 13, leukocytosis of 22,, and urinalysis suggestive of an infection. Additional studies show low iron level, increased RDW and decreased % saturation. EGD and colonoscopy are grossly normal. Colonic biopsy reveals increased intraepithelial lymphocytes. Duodenal and jejunal biopsies show villous atrophy with cryptitis, and mucosal lymphocytes and plasma cells. She is found to have antigliadin and antiendomysial antibodies. The diagnoses of both celiac sprue and microscopic colitis are made. With initiation of a gluten/lactose-free diet, prednisone, and octreotide, her symptoms improve considerably.

DISCUSSION

Iron deficiency anemia is the most common presentation of celiac disease. Abdominal discomfort and bloating, also common features, often incorrectly lead to the diagnosis of irritable bowel syndrome. Significant diarrhea is present in 50% of patients. Serologic studies including antiendomysial antibody (sensitivity 85%&#x;98%; specificity 97%&#x;%) and tissue transglutaminase antibody (sensitivity 90%&#x;98%; specificity 95%&#x;97%) have facilitated diagnosis of this disease; however, the gold standard remains small bowel biopsy. Standard therapy is dietary gluten restriction, which results in symptomatic improvement in 70% of patients within 2 weeks and a decrease in antibody titers within 6 months. Conditions associated with celiac disease include type 1 diabetes and microscopic colitis (either lymphocytic or collagenous). Lymphocytic colitis typically presents in the sixth decade as watery diarrhea. The diagnosis is made by colonic biopsy revealing increased intraepithelial lymphocytes. Medications such as lansoprazole and NSAIDS have been associated with this condition. Large randomized controlled trials regarding treatment have not been conducted. Therapy is based on case reports involving small numbers of patients and includes removal of the offending drug and addition of antidiarrheals, aminosalicylates, octreotide, prednisone, or budesonide. A prospective study of 81 patients treated with a variety of the above medications demonstrated a 70% resolution of diarrhea. Bismuth subsalicylate has been promising in small trials.

A DIFFERENT TWIST TO AN ABDOMINAL PAIN

C.E. Landaverde1; S. Dea1. 1UCLA-San Fernando Valley Program, Sylmar, CA. (Tracking ID #)

LEARNING OBJECTIVES

1) Recognize that a volvulus can have an atypical age of presentation and occur in someone with no predisposing risk factors. 2) Recognize clinical and radiological features of a volvulus.

CASE

A 39 y/o Hispanic nulliparous female presented to the emergency room with a one day history of abdominal pain, distension, nausea and vomiting. The abdominal pain was described as sudden onset, continuous, severe, crampy, lower abdominal pain worse with eating. The patient reported having explosive, watery, brown diarrhea soon after the onset of the abdominal pain for a couple of hours but since had not had a bowel movement nor passed flatus. Patient denied prior history of constipation or use of psychotropic medications or a diet high in fiber. The patient was afebrile with a blood pressure of / The abdominal exam revealed moderate distension, no bowel sounds, tympanic with tenderness to palpation in the lower abdominal quadrants, left more than the right. There was no rebound tenderness or guarding. The rest of the physical exam was unremarkable. Laboratory results were unremarkable except for a bicarbonate level of An abdominal plain film revealed a dilated, ahaustral loop of large bowel extending from the pelvis to the right upper quadrant in an inverted U appearance. A CT scan of the abdomen confirmed the diagnosis of a sigmoid volvulus with findings of a dilated sigmoid colon. A gastrograffin enema revealed a partial sigmoid volvulus, which had reduced upon the post-evacuation examination. Subsequently, the patient had a sigmoid resection with primary anatamosis performed.

DISCUSSION

Sigmoid volvulus is produced when a long redundant sigmoid twists about its mesenteric axis in either direction and forms a partial or complete loop obstruction. It occurs more commonly in the elderly, individuals with neurologic conditions, and in patients in nursing homes or mental health facilities. The common factor is chronic constipation. Other predisposing risk factors include megacolon, an excessively mobile colon, high-roughage diet, and lead poisoning. Furthermore, volvulus has been observed to occur most commonly in young patients in settings such as Crohn's disease, pregnancy, Chagas and in individuals with prior history of roundworm infestation. Patients present with abdominal pain, distension, nausea and absolute constipation with vomiting as a late sign. Findings on abdominal plain films include a markedly distended sigmoid loop, inverted U-shaped appearance, loss of colonic haustra and elevation of the sigmoid loop under one of the diaphragms. The involved bowel walls are edematous, resulting in a coffee bean&#x;shaped structure (the coffee bean sign). CT findings of ischemia in a sigmoid volvulus include the whirl sign , which represents tension on the tightly twisted mesocolon by the afferent and efferent limbs of the dilated colon.

A FATAL CASE OF VARICELLA-ZOSTER PANENCEPHALO-MENINGO-RADICULO-MYELITIS IN A PATIENT WITH AIDS.

D.B. Van Schyndel1. 1Hennepin County Medical Center Internal Medicine Dept., Minneapolis, MN. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize that varicella-zoster virus infection of the central nervous system is a sign of probable immunocompromise. 2. Recognize that the characteristic rash often seen in varicella-zoster infections may not appear in immunocompromised patients. 3. Diagnose varicella-zoster infection of the central nervous system using PCR amplification.

CASE

A 38 year old previously healthy Canadian woman presented to the emergency department with a four-day history of frontal headache and one day of lower extremity weakness and numbness. The initial exam revealed 4/5 lower extremity strength. The initial head CT was normal and a lumbar puncture was performed. CSF studies revealed increased protein and white blood cell counts. Empiric acyclovir was started. Six hours after the patient was admitted, she complained of worsening leg weakness and numbness extending to her chest. On exam she was areflexic in her lower extremities, paraplegic, and had a sensory level at T4. She became hypoxic and was intubated. Several hours later the patient was reexamined and no brain stem reflexes were present. A repeat head CT revealed brain stem swelling and leptomeningeal enhancement of the brain stem and cerebellum. The next day, the varicella-zoster PCR performed on cerebrospinal fluid was found to be positive. The patient's family reported that she had been exposed to a child with chicken pox two weeks before her admission. They did not remember the patient complaining of a rash. An HIV test was also positive. A MRI showed changes consistent with acute disseminated encephalomyelitis. Her neurologic exam was unchanged. The patient's family decided to withdraw support and the patient died approximately 72 hours after admission. An autopsy revealed lymphocytic encephalomeningoradiculomyelitis.

DISCUSSION

Zoster is not viewed as an AIDS-defining illness, but it can indicate immunodeficiency and tends to occur more often in patients with HIV. Varicella-zoster virus is likely to be associated with HIV in central and east Africa, where the positive predictive value of a history of VZV can be up to 90%. Among opportunistic CNS infections in AIDS patients, VZV accounts for 2&#x;4% of neurological disease. In one series of 11 AIDS patients with VZV encephalitis, four did not report a rash. Health care providers should therefore keep VZV on their differential in patients with HIV risk factors who present with neurologic symptoms but do not report a rash. Examination of the CSF usually reveals mild mononuclear pleocytosis, a normal or elevated level of protein, and a normal glucose level. Varicella-zoster virus cannot be cultured from cerebrospinal fluid, but the virus can be detected with PCR. The varicella-zoster PCR has a specificity of % and a sensitivity of %.

A FIRM HANDSHAKE. PRESENTATION OF AN ECTOPIC GROWTH HORMONE SECRETING TUMOR

M. Chan1; M. Ziebert1. 1Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize the importance and early diagnosis and treatment of acromegaly. 2. Recognize the importance of a good history and physical exam. 3. To develop a basic understanding of pathophysiology and current treatment modalities.

CASE

A year old Caucasian woman who presented to establish primary care was noted to have very large hands on initial introduction. Her only complaints were chronic bilateral hip and knee pain. Past medical history included hypertension, hypercholesterolemia, and scoliosis. Review of systems revealed difficulty sleeping with excessive daytime sleepiness, back pain, headaches, and polyuria. Physical exam revealed a woman with significant mandibular overgrowth and prognathism, a deep resonant voice, a large fleshy nose and very large hands. The patient was asked to bring an old ring and pictures for comparison. Laboratory studies included a basic metabolic panel, complete blood count, TSH, prolactin, FSH, LH, cortisol, ACTH, growth hormone (GH), and somatomedin C or insulin-like growth factor-1 (IGF-1). Both GH and IGF-1 were extremely elevated, up to five times the upper limit of normal. An MRI of her pituitary revealed a large cm ectopic tumor in the sphenoid sinus. The patient was referred to endocrinology, neuroophthalmology, and neurosurgery for evaluation. The patient subsequently underwent sublabial, transphenoidal resection of her tumor and pathology confirmed isolated GH producing cells. The patient currently feels like a new person . Her arthralgias, headaches, and probable obstructive sleep apnea have significantly diminished. She is currently on cabergoline or Dostinex and finishing her adjuvant radiation.

DISCUSSION

Acromegaly is a rare, chronic syndrome that is often diagnosed by the general internist. Most commonly, it is caused by excessive secretion of GH by the somatotroph adenoma of the anterior pituitary. However, very rarely, ectopic tumors may secrete GH and present in an indolent fashion. Diagnosis is usually delayed for many years resulting in significant morbidity and mortality. In the era of healthcare reform, the emphasis is on a problem focused clinical encounter. This case illustrates that a rare, debilitating disease can be diagnosed by simply shifting the focus back to the patient. A firm handshake or first impression can still be a valuable clinical tool.

A GIFT FROM THE TOOTH FAIRY

D. Blackmon1; M. Panda1. 1University of Tennessee, Chattanooga, chattanooga, TN. (Tracking ID #)

LEARNING OBJECTIVES

To recognize the similarities in clinical and radiographical presentation of pulmonary actinomycosis and neoplasms.

CASE

53 year old male with a heavy tobacco history, presented with malaise, non-productive cough and weight loss for 3 months. On exam he had normal vitals, appeared non-toxic but cachetic, with dental caries and diminished breath sounds on the left. Labs were only significant for an elevated wbc count with microcytic anemia. CXR showed opacity in left hemithorax. CT chest revealed 10 × 10 × 7 cm necrotic mass abutting the pericardium and pleural suspicious for carcinoma. Biopsy revealed no neoplastic cells. Aspirate cytology revealed filamentous sulfur granules consistent with Actinomycosis confirmed by culture. Patient was treated sucessfully with penicillin and dental extractions.

DISCUSSION

Actinomycosis is a gram-positive anaerobic filamentous bacteria. Humans are the only host. It resides in the oropharynx, GI and female genital tract and commonly causes cervicofacial infections. Aspiration of oropharyngeal secretions commonly cause pulmonary actinomycosis&#x;50% of which is associated with dental caries. These bacteria invade bony structures and cross-anatomic borders, making its appearance similar to neoplasms. Diagnosis is by identification of sulfur granules on cytology or isolation of organism on culture. Bronchoscopy, CT guided biopsy/aspiration or thoracotomy is often required for diagnosis due similarity in presentation to neoplasm. Treatment requires PCN for 12 months and extraction of dental caries when indicated. Diagnosis of Actinomycosis requires a high clinical index of suspicion and must be considered in individuals with lung masses and poor dental hygiene in order to spare the patient from unnecessary tests and invasive procedures.

A HIGHLY FUNCTIONING CASE OF DEMENTIA

G. Prakash1; P. Koneru1; R.D. Hobbs1. 1Oakwood Healthcare System, Dearborn, MI. (Tracking ID #)

LEARNING OBJECTIVES

To recognize a common error in making the diagnosis of dementia.

CASE

A year-old woman with Alzheimer's disease presented for a physical exam. She had been institutionalized in another city and had recently moved to be near her sister. Her history was significant for resection of a pituitary tumor with resultant hypopituatrism, hypogonadism, hypothyroidism and later, diabetes mellitus. She was a nurse by profession. Her husband had died two years before. Physical examination revealed a dysconjugate gaze, a dilated fixed right pupil and a visual field defect. During the exam she remarked Oh, you're checking my visual fields by direct confrontation. She then explained how these findings were chronic since She was alert and oriented, performed serial sevens accurately, interpreted proverbs abstractly, and had only minor difficulty remembering a name and address. When asked to spell world backwards she did so and then asked the examiner if he would like to hear the alphabet spelled backwards. Without an error or pause, she then accurately spelled the alphabet backwards. The examiner later remarked jokingly, This was the most highly functioning case of Alzheimer's disease that he had ever seen. Her miraculous improvement had occurred after moving closer to her sister.

DISCUSSION

Studies done during the 's showed that between 10&#x;20% of nursing home patients diagnosed with dementia were actually suffering from untreated depression. Unfortunately, since most dementia is incurable, such a diagnosis frequently labels an individual as medically untreatable and condemns them to their continued existence with scant hope of improvement. With more modern care the contribution of depression to dementia has been recognized and is now frequently treated. Our patient did not have Alzheimer's disease but was suffering from severe bereavement and isolation that improved when she moved nearer her sister. This case should serve as a cautionary tale to clinicians and underscore the point that in there are still individuals whose severe depression can mimic dementia to the point of institutionalization.

A HIP FRACTURE ALREADY?

C. Christopher1; J. Wiese2. 1Tulane Health Sciences Center, New Orleans, LA; 2Tulane University, New Orleans, LA. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize risk factors for osteoporosis in a young woman 2. Distinguish causes of secondary osteoporosis.

CASE

A 44 year-old woman was admitted following a displaced left femur fracture. She also noted four months of irregular menses and depression with poor appetite. Her body mass index was 21, and the early fracture prompted an evaluation for osteopenia. She smoked but did not consume alcohol. She noted a past history of a stomach ulcer that required surgical intervention. She had no pallor, thyromegaly, or dental caries. Her breast exam was normal. Her calcium level was mg/dL, albumin g/dL, phosphorous mg/dL, alkaline phosphatase ; her renal function and CBC were normal. An intact PTH level was 53 pg/mL (normal 8&#x;97). Her TSH was uIU/mL with a free T4 of ng/dL (normal &#x;). FSH, LH, and estradiol levels were consistent with premenopause. Her 1,dihydroxycalciferol was (&#x;); the hydroxycalciferol was (&#x;). Bone densitometry showed T-scores of &#x; (hip) and &#x; (spine). Alendronate therapy was initiated with supplemental calcium and vitamin D. An extensive past medical history revealed that the surgery for the duodenal ulcer required a Bilroth I anastomosis, later revised to a Roux-en-Y re-anastomosis.

DISCUSSION

Risk factors for osteoporosis include gender, race, tobacco use, alcohol consumption, low body weight, and nulliparity. Our patient's young age for a hip fracture prompted an evaluation of secondary etiologies of osteoporosis. These include renal or liver disease, malignancy, primary hyperparathyroidism, vitamin D deficiency, malabsorption, malnutrition, myeloma, and hyperthyroidism. In our patient, the Roux-en-Y anastamosis had led to malabsorbtion of fat-soluable vitamin D. She was started on parenteral vitamin D in addition to alendronate and calcium supplements. Diagnosis of osteoporosis is based on T-scores from bone densitometry studies that compare the patient to sex and race matched young controls. T-scores below &#x; is the recommended level for therapy in patients with risk factors, and therapy should begin at T-scores below &#x; in the absence of risk factors.

A LARGE SPLENIC CYST: INCIDENTALOCYST

A. Sequeira1; N.K. Atray1; T.J. Vachharajani1. 1Louisiana State University Medical Center at Shreveport, Shreveport, LA. (Tracking ID #)

LEARNING OBJECTIVES

To discuss the differential diagnosis of an incidental splenic cyst.

CASE

A year old type 1 diabetic male presented with a 5 day history of nausea, vomiting, diarrhea and upper abdominal pain, 2 months after a motor vehicle collision. He denied any prior symptoms of gastroparesis. Examination was remarkable for an afebrile patient with epigastric tenderness. Laboratory data: Hb g/dL, WBC 15 k/cmm, serum amylase 75 U/L, serum lipase U/L, storycall.us mg/dL, albumin mg/dL, Alk phos U/L, SGOT 12 U/L, SGPT 56 U/L, BUN 28 mg/dL, Creat mg/dL, anion gap 18, urine ketones 4 + and an ABG with pH , PaCO2 27, PaO2 , HCO3 12, SaO2 99% on liters oxygen. His symptoms of nausea, vomiting and abdominal pain persisted despite correcting his ketoacidosis. A CT abdomen showed a calcified multiseptate splenic cyst measuring 12 × 8 cm, which was compressing the stomach. The possibility of a splenic abscess precipitating ketoacidosis was entertained. His blood cultures were negative for bacteria, fungi and acid-fast bacilli. The splenic aspirate was sterile for any organisms. Subsequently, he underwent splenectomy for multiseptated cystic spleen with pressure symptoms. Pathology revealed a gm spleen measuring 16 × 13 × 8 cm. Histopathology revealed a cyst without lining cells with organized fibrin and old hemorrhages, suggestive of a posttraumatic pseudocyst.

DISCUSSION

Splenic cysts are rare, many of which are asymptomatic and incidental findings. They are classified as true or false based on the presence or absence of an epithelial lining. In the absence of an Echinococcal infection, cysts are commonly congenital or post traumatic. The above case highlights the need to suspect posttraumatic splenic cyst as a possible differential in a patient with a LUQ mass following an abdominal trauma. As in the above case, large splenic cysts may mimic the symptoms of gastroparesis in a diabetic.

A LAZY HOUSEWIFE : CASE OF LUPUS PNEUMONITIS

J.E. Cho1; D. Yick1. 1University of California, Los Angeles&#x;San Fernando Valley Program, Sylmar, CA. (Tracking ID #)

LEARNING OBJECTIVES

1) Recognize lupus pneumonitis as an etiology of pulmonary effusion 2) Describe the typical presentation of lupus pneumonitis 3) Recognize the treatment options and prognosis of lupus pneumonitis.

CASE

A previously healthy 22 year old female presented to the emergency department with acute shortness of breath. Her shortness of breath was worse with exertion and associated with pleuritic chest pain for two days. She also noted fever, non-productive cough, nausea, vomiting, and arthralgia. On presentation, she was febrile with temperature , blood pressure 88/54, pulse of beats per minute, respiratory rate of 28 and oxygen saturation of 88% on room air improved to 92% with 2 liters of supplemental oxygen. She was in moderate respiratory distress; however, she was speaking in full sentences. Physical examination revealed absent breath sounds throughout right thorax with decreased breath sounds half way up on the left thorax. There was associated egophony, decreased fremitus, and dullness to percussion on the right thorax. There was no jugular venous distension, lower extremity edema, or skin rash. Chest radiograph revealed small pleural effusion on the left side one-fourth way up in addition to the right-sided pleural effusion three-fourths way up with mediastinal shift to the left. She was admitted to the intensive care unit for acute respiratory distress. Chest CT with contrast confirmed findings of right-sided pleural effusion and small left sided effusion. Thoracentesis was performed and it showed negative culture, gram stain, and cytology with increased LDH and protein consistent with Light's criteria for exudative process. The pleural fluid was positive for ANA at ,, lupus anticoagulant, anti double stranded DNA , and anticardiolipin antibody. The diagnosis of lupus pneumonitis was made, and she improved on intravenous solumedrol, and discharged home on oral prednisone several days later.

DISCUSSION

Systemic lupus erythematosus (SLE) is a multifactorial autoimmune disorder that may affect one or multiple organ systems. Acute lupus pneumonitis is an uncommon presentation that appears in 1% to 10% of the cases, and the symptoms include severe dyspnea, tachypnea, fever, pleurisy, cough, basilar rales, hypoxia, and no apparent infection with radiographic findings of bilateral lower lobe infiltrate and atelectasis. In addition, pleural effusion is observed in up to 30% of cases. Lupus pneumonitis responds with glucocorticoids. However, intravenous pulse steroid therapy or immunosuppressive drugs may be considered if no improvement in 3 days. Lupus pneumonitis may progress to pulmonary fibrosis and eventually develop into pulmonary hypertension. The prognosis of lupus pneumonitis is poor with short-term mortality approaching as high as 50% with persistent pulmonary function abnormalities, including severe restrictive pulmonary defect.

A METABOLIC MESS: A CASE OF ETHYLENE GLYCOL POISONING

S. Khan1; B. Taqui1. 1Temple University, Philadelphia, PA. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize causes of potentially fatal alcohol intoxication. 2. Recognize clinical features of ethylene glycol poisoning. 3. Review management of ethylene glycol posioning.

CASE

A 55 year old African American female with depression, hypothyroidism, and breast cancer presented with altered mental status. She lives with her mother, but history taking was limited by the mother's Alzheimer's disease. The mother reported that the patient had been vomiting earlier in the day. In the emergency room, patient became unresponsive and was intubated. Her vitals were T F, HR 96, BP / Her exam revealed left, fixed pinpoint pupil, flaccid extremities, absent reflexes. Her labs revealed: Na , K , Cl , HCO3 7, BUN 14, Cr , glucose , anion gap Her calculated osmolarity was , measured osmolarity and osmolar gap Her lactate was and ammonia Her WBC was (no shift), Hgb , platelets Her liver function tests and TSH were normal. Her urine showd calcium oxalate crystals. ABG prior to intubation revealed pH pCO2 21 HCO3 4. Head CT and LP were negative. Her ethanol level was 31 mg/dl and ethylene glycol level was mg/dl. She received two doses of fomepizole and D5W with 3 amps of bicarbonate. She was then placed on an ethanol drip. She subsequently improved, was extubated and transferred to inpatient psychiatry after she admitted to drinking antifreeze.

DISCUSSION

Three alcohols can produce fatal intoxication: methanol, isopropanolol, and ethylene glycol. All can increase the osmolal gap, but only methanol and ethylene glycol cause an anion gap metabolic acidosis. Ethylene gylcol is a component of antifreeze and solvents. The lethal dose is ml. Clinical presentation ranges from from drunkenness to coma. Complications involve the heart, lungs and kidneys. Two types of urinary calcium oxalate crystals can be seen: needle shaped and envelope shaped. The absence of crystalluria does not preclude the diagnosis. Urine examination by Wood's light may reveal fluorescence if the patient has ingested antifreeze which commonly contains fluorescin dye. Ethylene glycol is metabolized to toxic metabolites: glycolic acid and oxalic acid. Glycolic acid falsely elevates lactate. Management consists of supportive care, prevention of drug absorption, bicarbonate, and antidotes. Fomepizole, which rapidly inhibits alcohol dehydrogenase, is the drug of choice for ethylene glycol and methanol intoxication. Ethanol can also be used, but is not as potent. Both treatments need to be initiated quickly, prior to alcohol metabolism. In severe cases, hemodialysis may be required.

A MIDDLE AGE WOMAN WITH WORSENING SHORTNESS OF BREATH

N. Latif1; G.H. Tabas1. 1University of Pittsburgh, Pittsburgh, PA. (Tracking ID #)

LEARNING OBJECTIVES

Recognize a non-embolic cause of pulmonary occlusive disease(PVOD) in hypoxemic patients.

CASE

A 55 year old white female with a history of coronary artery disease, insulin dependent diabetes mellitus and hypertension presented with a one week history of worsening shortness of breath, dry cough, wheezing and chest discomfort. She was treated with azithromycin as an outpatient but because her symptoms did not improve she presented herself to the emergency department. There, her temperature was 39 degrees C and her physical examination revealed some neck stiffness. Lumbar puncture was performed and cerebrospinal fluid examination was unremarkable. Her chest X-ray was interpreted as normal. The patient was empirically treated with intravenous levofloxacin. In the hospital her oxygen saturation decreased to 86% and a repeat chest X-ray showed bilateral pleural effusions and pulmonary edema. Computerized tomography of the chest revealed no pulmonary embolism. Because of the onset of atrial flutter, echocardiography was performed and showed an increased pulmonary artery pressure of 55 mmHg. To diagnose the cause of her pleural effusions and hypoxemia she underwent video assisted thoracoscopy and lung biopsy that revealed pulmonary veno-occlusive disease (PVOD). She was treated with prednisone and coumedin with symptomatic improvement.

DISCUSSION

PVOD is rare but important cause of hypoxemia and pulmonary hypertension. PVOD has no known etiology, can present at any age group with equal male and female distribution. The pathologic hallmark of PVOD is occlusion of small pulmonary veins by fibrous tissue; large veins are rarely affected. Pulmonary arteries may exhibit moderate to severe medial hypertrophy and alveolar capillaries may become engorged and tortous. Interstitial fibrosis may develop in the pulmonary parenchyma. There is no curative therapy and immunosuppressive agents including prednisone are of unproved benefit. Anticoagulation may improve survival but long-term prognosis is poor.

A MULTIPLE SCLEROSIS-LIKE ILLNESS ASSOCIATED WITH LEBER's HEREDITARY OPTIC NEUROPATHY

A.J. Huang1. 1University of California, San Francisco, San Francisco, CA. (Tracking ID #)

LEARNING OBJECTIVES

1. Review the clinical features of Leber's hereditary optic neuropathy (LHON). 2. Recognize LHON as a risk factor for developing multiple sclerosis. 3. Distinguish between LHON and the optic neuritis of multiple sclerosis.

CASE

A 27 year-old man with a family history of Leber's hereditary optic neuropathy (LHON) presented for physical examination before enrolling in a rehabilitation program for the visually impaired. The patient reported 2 years of progressive, bilateral central vision loss, similar to a female cousin who had been diagnosed with LHON after genetic testing confirmed the presence of a characteristic mitochondrial DNA mutation, GA. Unlike his cousin, the patient also suffered from patchy numbness and clumsiness in both hands and lower extremities, which he attributed to drinking too much alcohol (over 8 pints of beer per day). Physical exam revealed severe bilateral optic atrophy with an otherwise normal cranial nerve exam, decreased vibration and joint position sense in both feet, and a slow and wide-based gait. Routine laboratory studies, including TSH, B12, RPR, and HIV, were normal. The patient was counseled to stop drinking, but continued to have problems with coordination and ambulation after discontinuing alcohol, and returned to clinic 3 months later after a mechanical fall. Follow-up exam revealed interval development of moderate spasticity in both lower extremities, a mildly positive Romberg sign, and worsened vibration and joint position sensory defects. Electromyography was negative for lower motor neuron abnormalities. An MRI showed multiple focal areas of T2 prolongation in the periventricular white matter of the corpus collosum, brainstem, and cervical spinal cord, consistent with a demyelinating disease such as multiple sclerosis. The patient was referred to neurology for management of multiple sclerosis associated with LHON.

DISCUSSION

Leber's hereditary optic neuropathy (LHON) is a mitochondrially transmitted disease affecting young adults, with a male to female ratio of approximately 4 to 1. It is characterized by subacute, bilateral, central vision loss resulting in permanent optic atrophy, with relative sparing of peripheral vision. While a tentative diagnosis of LHON can often be made based solely on patients' clinical history, fluorescein angiography and electrophysiology studies may be helpful in confirming the diagnosis. Over 95% of patients with LHON have one of three mitochondrial DNA point mutations, GA, GA, or TC, but only 50% of men and 10% of women who harbor one of these mutations develop the optic neuropathy. A multiple sclerosis (MS)-like illness has been described in patients with LHON, especially those with mutation GA, in which MRI and CSF findings are identical to those of the MS population in general. The vision loss associated with LHON differs from the optic neuritis more commonly seen in multiple sclerosis in that it is bilateral rather than unilateral, is not accompanied by eye pain, is not associated with pupillary reflex defects, and rarely responds to corticosteroids. Screening LHON patients for MS, particularly if they have neurologic symptoms other than visual loss, may be appropriate if one accepts that immunomodulatory treatment should be started early in MS.

A NECROTIC PENIS

M. Glass1; J. Wiese2. 1Tulane Health Sciences Center, New Orleans, LA; 2Tulane University, New Orleans, LA. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize the clinical presentation of calciphylaxis. 2. Recognize the risk factors for calciphylaxis.

CASE

A year-old man with was admitted for necrosis at the tip of his penis. He had a history of diabetic renal failure, and was scheduled for dialysis following a permacath placement. He was afebrile and a systolic murmur was noted at the base and apex of the heart. His labs were notable for a phosphate of , and a calcium of An echocardiogram revealed calcified mitral and aortic valves. The necrotic area was treated with surgical debridement. The surgical pathology report described acute and chronic inflammation with extensive coagulative necrosis consistent with calciphylaxis-induced ischemia.

DISCUSSION

Calciphylaxis is the deposition of calcium-phosphate crystals in the setting of either hypercalcemia or hyperphosphatemia. Deposition in peripheral arteries can result in ischemia with subsequent peripheral necrosis. A calcium-phosphate product of greater than fifty should prompt suspicion of this complication. The diagnosis is suggested by ischemic skin lesions and is confirmed by biopsy showing arterial occlusion and calcification without vascultic changes. In this case, a diagnosis of calciphylaxis was suggested by the clinical presentation and his history of renal failure; the elevated calcium-phosphate product of 67 sufficiently increased the pre-test probability to prompt a skin biopsy. In the setting of a calcium-phophate product greater than 50, physicians should consider calciphalaxis as a potential cause of vascular insufficiency and valvular calcification.

A NOT-SO-BENIGN CASE OF PROSTATIC HYPERPLASIA

A.N. Githaiga1; P.K. Han1. 1University of Pittsburgh, Pittsburgh, PA. (Tracking ID #)

LEARNING OBJECTIVES

1) To recognize bladder diverticuli and spontaneous bladder perforation as possible complications of benign prostatic hyperplasia (BPH). 2) To identify clinical findings suggestive of bladder perforation.

CASE

A year-old man with a history of mild BPH, colonic diverticulosis and hyperlipidemia presented to his doctor's office with a two-day history of lower abdominal pain, dysuria, urinary urgency and frequency. He was treated empirically with ciprofloxacin and tamsulosin, but his symptoms progressed to include generalized abdominal pain and distension, constipation, nausea and vomiting. He presented to the emergency room two days later, in distress from pain. Vital signs were storycall.us physical examination his abdomen was distended and tympanitic with absent bowel sounds. There was severe generalized tenderness but no peritoneal signs and no masses. Rectal examination revealed an empty rectal vault and a firm, moderately enlarged and non-tender prostate gland. Four attempts were made at bladder catheterization but the catheter failed to pass through the urethra. Bladder ultrasound showed an empty bladder. Laboratory tests included WBC K, BUN 38, creatinine (baseline ), and normal serum electrolytes. Urinalysis showed 0&#x;3 WBC, 5&#x;10 RBC, and few bacteria. Plain abdominal X-ray demonstrated a dilated transverse colon with absence of gas in the distal colon. A non-contrast CT scan showed inflammatory changes around the mesentery and bladder; gastrograffin enema and renal ultrasound were normal. CT scan of the abdomen and pelvis was repeated with IV contrast, and demonstrated communication in the superior aspect of the bladder with a contrast-filled collection in the extraperitoneal space, consistent with a bladder leak. A cystogram was obtained, which demonstrated bladder perforation along with trabeculation and diverticuli, consistent with chronic bladder outlet obstruction. These findings were confirmed by cystoscopy. The patient was managed conservatively with bladder catheterization and had rapid resolution of his symptoms and renal insufficiency.

DISCUSSION

BPH is a common condition, although serious complications are unusual. Chronic bladder outlet obstruction, however, may occasionally cause urinary retention, bladder diverticuli, and, rarely, spontaneous bladder perforation, which presents with progressive abdominal pain. Intraperitoneal rupture may cause peritonitis; in this particular patient, however, the perforation was extraperitoneal, and thus there were no signs of peritoneal inflammation. The case illustrates that although bladder perforation presents dramatically, affected patients may have minimal prior symptoms of bladder outlet obstruction; therefore, clinicians should be aware of this potential complication.

A PAIN IN THE BUTT

H. Segrest1; J. Brice1. 1Tulane Health Sciences Center, New Orleans, LA. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize the criteria for diagnosing endocarditis. 2. Recognize the surgical indications in endocarditis

CASE

A year-old man presented with one week of a right buttock lesion and fevers. He denied any past medical history or IV drug use. His temperature was 37°C, pulse bt/min, respirations 32 breaths/min, blood pressure of 83/59 mmHg. With the exception of the lesion, his exam was normal. His white count was 33, with 40% bands. He was taken to the operating room for incision and drainage of the abscess and started on vancomycin and piperacillin. The wound culture grew methacillin-resistant staph aureus. On the third hospital day, he was noted to have Janeway lesions, a new murmur, and chest X-ray with fluffy infiltrates. Gentamicin was added; an echocardiogram revealed a small vegetation on the mitral valve. Blood cultures were positive for methacillin-resistant staph aureus and remained positive despite antibiotics. CT surgery was consulted, but declined to operate given his positive cultures. On the eighth hospital night he complained of headache and blurred vision. A CT of the head was performed. By the end of the CT scan, his Glasgow Coma scale had decreased to 4. The CT scan revealed a large occipital intra-cranial hemorrhage. He was pronounced brain dead the following morning.

DISCUSSION

While seemingly commonplace in urban hospitals, acute endocarditis carries a high morbidity and mortality. The indications for sugery in endocarditis include acute aortic or mitral regurgitation with heart failure, fungal infection, acute aortic regurgitation with tachycardia and early closure of the mitral valve on echocardiogram, and evidence of annular or aortic abscess. In these situations, surgery should not be delayed due to persistently positive blood cultures. One of the roles of the general internist is to advocate for the patients who cannot advocate for themselves. Internists should be fully aware of the indications for surgery in the setting of endocarditis to permit this advocacy where indicated.

A PAIN IN THE NECK

J.A. Kasher1; P.P. Balingit1; A. El-Bialy1; J. Wheat1. 1UCLA San Fernando Valley Program, Sylmar, CA. (Tracking ID #)

LEARNING OBJECTIVES

1. Appreciate the multiple possible clinical manifestations of aortic dissection.

CASE

A year-old male with history of hypertension presented with complaint of neck discomfort and increasing shortness of breath for 2 weeks. Initially, he felt a sudden severe, pressure sensation in his jaw which radiated to his chest, neck, and back of the head. In the next few days, the pain localized to the neck and he also developed progressive dyspnea and orthopnea. On examination heart rate was 96, blood pressure was /65, and breating rate was Lungs had bibasilar rales, and heart had a diastolic murmur best heard over the aortic area and S3 gallop. Distal extremities revealed normal, equal peripheral pulses and moderate edema. Serum electrolytes, CBC, and EKG were not significant. Troponin level was , but normalized later. Chest radiograph demonstrated cardiomegaly, an unfolded aorta, bilateral pleural effusions, and pulmonary vascular congestion. Subsequent trans-thoracic and trans-esophageal echocardiograms revealed a type A aortic dissection involving both the ascending and descending aorta and causing significant aortic regurgitation. The patient underwent emergent repair of aortic dissection and was discharged shortly thereafter in good condition.

DISCUSSION

Aortic dissection is a relatively uncommon but catastrophic illness classically thought to present with sudden-onset, unrelenting, tearing pain localized in the thorax and radiating posteriorly. However, clinical presentations are variable, and dependent on which areas of the aorta are involved. For instance, involvement of the coronaries could lead to acute MI. Patient could also present with severe aortic insufficiency, heart failure, cardiac tamponade. Involvement of the carotid or renal arteries may lead to cerebrovascular accident or acute renal failure, respectively. Peripheral vascular involvement may result in pulse and neurologic deficits, whereas abdominal pain may develop with involvement of the mesenteric arteries. Type A dissection can present as severe chest pain (79%), back pain (46%), abdominal pain (22%), syncope (13%), CHF (9%), or cerebrovascular accident (6%). In one case series, only 64% of patients described their pain as being sharp. Another series reports that the treating clinician fails to initially entertain the diagnosis of aortic dissection in up to 35% of cases. Many patients later found to have aortic dissection are initially suspected to have other conditions, such as acute coronary syndrome, non-dissecting aneurysms, pericarditis, pulmonary embolism, aortic stenosis, or even cholecystitis. The high mortality associated with aortic dissection makes its early diagnosis critical. This case serves as a cautionary tale for the clinician to recognize the often unusual presentations of this deadly disease, and to consider the diagnosis of aortic dissection in any patient presenting acutely with chest or abdominal pain.

A PUZZLING CASE OF HYPOGYLECEMIA: THE CLUE IN THE MEDICATION HISTORY

S. Estes1; M. Panda1. 1University of Tennessee, Chattanooga, Chattanooga, TN. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize the importance of taking a detailed history. 2. Recognize the interactions of herbal medications with prescription drugs.

CASE

A 30 year old white female with well controlled insulin dependent diabetes mellitus for thirteen years presented with 2 months of numerous hypoglycemic episodes. A decrease in her insulin regimen did not resolve the hypoglycemia. On further review of the patient's medications, the only new addition was ginseng, which she began taking 2 months ago for increased energy . Complete work-up including renal function was normal. The ginseng was discontinued and her hypoglycemia resolved. She was able to resume her previous insulin regimen.

DISCUSSION

Herbal therapy is an ancient practice that appears to be experiencing resurgence in the U.S. In numerous previous studies, the ginseng glycopeptides (GGP) from the roots of Panax ginseng had hypoglycemic activity on both normal and hyperglycemic animals. Studies in diabetic humans have also suggested that ginseng lowers blood glucose. The hypoglycemia is due to the enhancement of aerobic glycolysis. The administration of GGP decreases both the level of plasma lactic acid and the activities of plasma and liver LDH while enhancing the rate limiting enzymes in aerobic glycolysis (tricarboxylic acid cycle). The hypoglycemic action of GGP could last up to 16 hours. This case reflects the increasing frequency of herbal and alternative medication use and supports the fact that patients often neglect to tell their physicians. Direct inquiry about herbal medication use should be a routine part of history taking.

A RARE CASE OF INTRATHORACIC ECTOPIC GOITER

Q. Saleheen1; H.J. Freidman1; O. Marzouki1; S. Nizar1. 1Saint Francis Hospital, Evanston, IL. (Tracking ID #)

LEARNING OBJECTIVES

1. To emphasize the need to consider ectopic goiter in the differential of a mediastinal mass. 2. To understand that a mediastinal mass with hemorrhagic changes can cause acute stridor. 3. To think about mediastinal mass as a cause of cough especially when cough is positional.

CASE

A year-old African American woman presented with a history of dry cough for 3 weeks and shortness of breath with a loud noisy breathing for 1 day. Patient also complained of generalized fatigue but no fever, no phlegm or weight loss. Patient is a non-smoker and works as a construction worker. On examination, patient vital signs were stable with 98% O2 saturation on room air with audible stridor. There was fullness in the lower anterior neck but no well-demarcated mass, no lymphadenopathy or thyroid enlargement, and no audible bruit in the neck was appreciated. The rest of examination was unremarkable. Laboratory workup showed microcytic hypochromic anemia with Hemoglobin of TSH, FT4 and T3 were normal. Chest x-ray revealed a superior mediastinal mass with deviation of trachea towards the right side. A subsequent CT scan showed a 7 cm mediastinal mass with inhomogeneous enhancement extending from anterior to middle mediastinum with no lymphadenopathy. Patient underwent surgical resection with removal of a cystic mass arising from the chest beneath, but separate from the left inferior lobe of thyroid. Both lobes of the thyroid gland appeared normal. A preliminary post-operative diagnosis of bronchogenic cyst with tracheal compression was made. The final diagnosis was made on biopsy, which showed benign nodular thyroid tissue with involution and hemorrhagic changes. Patient subsequently discharged home without complications.

DISCUSSION

We present here a rare case of an ectopic intrathoracic goiter (a goiter with no attachment to the cervical thyroid gland). Most of the ectopic goiters are reported in the neck but rarely in the mediastinum. On review of the literature, there were sporadic cases reported as ectopic intrathoracic goiters. A study in Germany of 61 surgically treated intra-thoracic goiters from to showed that only 2 cases were ectopic. When present as a mediastinal mass the ectopic goiter can cause compression symptoms in about 40%&#x;50% of the cases. A mediastinal goiter can cause stridor that can be gradual in onset or sudden if there are hemorrhagic changes in goiter (as in our patient). Also a mediastinal goiter can cause cough that can be positional in character. Thus it is important to consider ectopic goiter in the differential of a mediastinal mass with the evidence of airway obstruction.

A RARE CAUSE OF CIRRHOSIS IN AN EPILEPTIC

M.A. Kalpakian1; S. Dea2. 1UCLA San Fernando Valley Program, Sylmar, CA; 2University of California, Los Angeles, Sylmar, CA. (Tracking ID #)

LEARNING OBJECTIVES

1. Diagnose the etiology of cirrhosis when the cause is not obvious. 2. Review monitoring tests for patients on antiepileptic medications.

CASE

A year-old male with a history of epilepsy for over ten years presented with complaints of nausea, vomiting, and dull left upper quadrant pain developing over the past two months. His generalized tonic-clonic seizures and absence seizures have been controlled with carbamazepine for ten years and valproic acid for three years. The patient did not have diabetes or hyperlipidemia. On review of symptoms, he complained of decreased appetite with 20 lb weight loss over the past year. The patient denied tobacco, alcohol, or drug abuse. Physical exam was significant for a slender afebrile male with tenderness to palpation in the left upper quadrant and hepatosplenomegaly. There was no rebound or guarding. The patient was not jaundiced and did not have stigmata of chronic liver disease. Labs were significant for an ALT of , AST of 79, alkaline phosphatase , INR , WBC of , Hb , Hct and platelet count of Pancytopenia was thought to be a result of massive splenomegaly. An abdominal ultrasound showed a liver span of cm and the spleen was cm × cm with a patent portal vein with appropriate flow. Liver biopsy revealed cirrhosis. Hepatitis B and C serologies were all negative. Antinuclear antibody, anti-smooth muscle antibody, and antimitochondrial antibody were negative. Iron, ferritin, iron saturation and ceruloplasmin levels were normal. A comprehensive literature search showed no reported cases of carbamazepine-induced cirrhosis and a few case reports of valproic acid associated with cirrhosis. Carbamazepine and valproic acid were stopped and the patient was started on levetiracetam.

DISCUSSION

Many drugs are hepatically metabolized but drugs that induce cirrhosis are relatively rare. Valproic acid is one of these drugs and is being used by internists for many indications ranging from migraine headache prophylaxis to seizure disorders. Routine monitoring of transaminases in patients on anti-epileptics is still controversial. Some clinicians argue that since hepatic failure caused by valproic acid is an acute idiosyncratic reaction, checking transaminases in patients who have been on valproic acid for years may not prevent liver failure. However, as this case illustrates, chronic liver damage and cirrhosis can result from chronic anti-epileptic drug use. A toxic metabolite of valproic acid may be responsible for inducing non-alcoholic fatty liver disease that may progress to cirrhosis. Perhaps monitoring transaminases every 6 months in these patients could have diagnosed liver toxicity prior to the onset of cirrhosis. Monitoring may have allowed this patient to be switched to another anti-epileptic drug earlier, preventing him from developing end-stage liver disease.

A RATHER SIGNIFICANT EOSINOPHILIA

S.Y. Chien1; A.M. Fogelman2. 1University of California, Los Angeles, Sylmar, CA; 2University of California, Los Angeles, Los Angeles, CA. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize the differential diagnosis and clinical aspects of eosinophilia. 2. Distinguish between different vasculitides.

CASE

A 43 year-old female with complicated medical history was transferred to our hospital for six months of bilateral neck swelling and recent right-sided weakness. She reported several other conditions that had begun in the previous 2 years including alopecia, allergy, chronic otitis media, and whole body pruritis. She was now complaining of a new cough, dyspnea, and exertional chest pain. Previous diagnostic work-ups found pulmonary infiltrates, bilateral internal carotid artery aneurysms, and confirmed a recent stroke. Her initial CBC was particularly signifcant for a WBC of 11, with 50% eosinophils on the differential. ESR was negative. A work up of this appreciable eosinophilia ensued, with normal infectious cultures and rheumatologic tests (ANA and ANCA). Because of her history of angina, a cardiac nuclear stress perfusion scan was done, showing multiple defects with a depressed ejection fraction. Subsequent cardiac catheterization demonstrated no significant atherosclerosis, but found aneurysmal dilatation of all three main coronary arteries. Based on her carotid and coronary aneurysms and significant eosinophilia, our patient was diagnosed with a vasculitis, most likely Churg-Strauss syndrome or Takayasu's.

DISCUSSION

Eosinophilia is defined as  per microliter in the blood or tissue. Patients may have multiple end-organ dysfunction, leading to thrombosis and fibrosis. Besides parasitic or helminthic infections, other common causes are allergies, collagen vascular diseases, and malignancies. However, the etiology of this patient's eosinophilia was due to vasculitides, likely ANCA-associated small to medium-vessel disease (Churg-Strauss syndrome, microscopic polyangitis, or Wegener's granulomatosis) versus large-vessel disease (Takayasu's). It is important to realize that approximately 10% of patients with ANCA-associated vasculitis have negative assays for ANCA. Often, there is a substantial overlap among different vasculitides, such as in this patient. Churg-Strauss syndrome has a characteristic triad: allergic rhinitis and asthma, systemic granulomatous inflammation of small vessel, and virtually all patients have eosinophilia. Ofteh, it has less renal involvement. However, coronary arteritis and myocarditis are very frequent, accounting for major morbidity and mortality. On the other hand, Takayasu's arteritis (aortic arch syndrome) has a strong predilection for the aortic arch and its branches. Pulses are commonly absent, particularly if subclavian artery is involved. Although less common, inflammation can also be found in other major arteries, including carotid and coronary. The mainstay of treatment for most vasculitides includes corticosteroids with or without cytotoxic drugs such as cyclophosphamide. Combined therapy induces improvement in 90% and complete remission in 75% of patients.

A RED EYE AND VISION LOSS: NOT YOUR USUAL CONJUNCTIVITIS

T. Pestana1; M. Landry1. 1Tulane Health Sciences Center, New Orleans, LA. (Tracking ID #)

LEARNING OBJECTIVES

1) Identify ocular manifestations of fungal infections. 2) Recognize risk factors for fungal ocular infections. 3) Establish available treatments for fungal ocular infections.

CASE

A 25 year-old woman presented with left eye pain and vision loss. She noted eye injection and pain with movement. She also complained of lower back pain. She had fever, chills, night sweats, and a recent fifty-pound weight loss. Her past medical history included hepatitis C and intravenous drug abuse. Her needle-sharing companions had developed similar ocular symptoms several weeks prior. She was afebrile, and had conjunctival, scleral, and limbal injection with a hazy cornea, and clear ocular discharge. The left pupil was fixed at four millimeters; visual acuity was 20/ Direct fundoscopic exam revealed fluffy white vitreous opacities obscuring the optic disc, and retinal detachment. The L1&#x;L2 right paraspinal region was tender to palpation. MRI of the spine showed discitis, osteomyelitis, and a psoas abscess in the paraspinal region. The patient was diagnosed with retinal detachment and fungal endophthalmitis. Intravitreal and systemic amphotericin B were initiated. Cultures obtained from the psoas abscess yielded Candida albicans, confirming disseminated fungal infection.

DISCUSSION

Fungal endophthalmitis is a serious infection that can lead to visual deficits. Risk factors include intravenous drug abuse, immunosuppression, parenteral nutrition, and ophthalmologic surgery. There is no consensus on standard antifungal treatment, but amphotericin B, flucytosine, and fluconazole may be used. Vitrectomy may also be considered for vision salvage. Early diagnosis, ophthalmologic evaluation, and treatment are essential for preventing vision loss.

A RESTAURANT, AN ONION, A LIVER: A CASE OF FULMINANT HEPATIC FAILURE FROM HEPATITIS A

P.K. Nair1; B.S. Berk1. 1University of Pittsburgh, Pittsburgh, PA. (Tracking ID #)

LEARNING OBJECTIVES

1) Recognize the epidemiology of Hepatitis A (HA), 2) Diagnose Fulminant Hepatic Failure (FHF), 3) Manage FHF in HA.

CASE

A year-old male who is on prednisone for ulcerative colitis presented with elevated liver enzymes and change in mental status. He is a non-smoker who drinks about two beers per week. On October 11th, he and his wife ate at a local restaurant. On October 29th, they both developed anorexia, myalgia, and diaphoresis. The patient's wife improved, but he continued to deteriorate. On November 5th, he went to his community hospital. His labs showed the following: ALT , AST , INR , and Total Bili The next day he became poorly responsive and was transferred to our MICU. He was deeply jaundiced, had brisk reflexes, and right ankle clonus. Intracranial pressure was elevated. No stigmata of chronic liver failure was noted. Labs revealed the following: glucose 50, lactate 5, ammonia , ferritin 5,, ALT , AST , Total Bili , PTT , and non-calculable PT/INR. He was promptly transferred to the Liver Transplant ICU. Hepatitis serologies were negative for HepB, HepC, CMV, EBV, HSV, VCZ, Wilson's, and autoimmune markers. HepA IgM was positive. The next morning he underwent orthotopic liver transplantation. He was discharged one month later in stable condition.

DISCUSSION

There were confirmed cases of HA from a recent outbreak in western Pennsylvania. It was linked to a restaurant that served tainted green onions from Mexico. Four people developed FHF, and only this patient survived. In the United States, there has been a gradual decline in the number of confirmed HA cases from (29, reported cases) to (10, reported cases). On average only % to % of cases of HA progress to FHF. The risk of developing FHF from HA infection increases with advancing age and in patients with chronic liver disease, especially from hepatitis C. In FHF from HA, there is a rapid progression of severe acute liver injury with impaired synthetic function as evidenced by decreasing AST/ALT and increasing INR. Stigmata of chronic liver disease are absent. To be classified as having FHF one must have encephalopathy develop within eight weeks of onset of symptoms if they had a previously healthy liver, or within two weeks of onset of jaundice regardless of any underlying liver disease. Management of FHF from HA should involve early referral to a liver transplant center of high-risk patients. Transplantation improves survival rates in FHF by as much as 70% to 80%. Based on the King's College Criteria, referral for transplant of FHF from HA should take place if the following criteria are met: 1. PT , irrespective of the grade of encephalopathy, or 2. Any three of the following variables: age 10 or 40, duration of jaundice before onset of encephalopathy 7 days, PT 50, or Total Bili 

A SEVERE CASE OF ALCOHOLIC HEPATITIS

J.E. Guy1. 1University of California, San Francisco, San Francisco, CA. (Tracking ID #)

LEARNING OBJECTIVES

1. Review the differential diagnosis of right upper quadrant abdominal pain. 2. Recognize laboratory findings seen in alcoholic hepatitis. 3. Discuss treatment options for severe cases.

CASE

A 45 year old woman with a 23 year history of significant alcohol abuse presents to the emergency room with a several week history of nausea, nonbloody emesis, constant, nonradiating right upper quadrant pain, and jaundice. She reports intermittent subjective fevers. Her last drink was one day prior to admission, and she reports drinking 9 shots of brandy a week. On physical exam she was afebrile. She was somnolent but arousable. Asterixis was present. Her abdominal exam was distended and diffusely tender to palpation, with marked right upper quadrant pain without rebound. Her liver span was enlarged to 12 cm but there was no fluid wave or frank ascites. Skin exam was markedly jaundice but without spider angiomata or palmar erythema. Pertinent laboratory data included a WBC of K, total bilirubin , AST , ALT 14, albumin , Cr , and PT A CXR, urinalysis and blood cultures were negative. A right upper quadrant US did not reveal signs of cholecystitis, obstruction or ascites. An abdominal/pelvic CT was without evidence of cholangitis or masses. Of note, the patient was admitted to the surgical service three weeks prior to admission with similar complaints, a WBC of K, AST , ALT 20, and total bilirubin At that time a RUQ ultrasound, HIDA scan, abdominal CT, white blood cell scan, urine and blood cultures were within normal limits. The patient was diagnosed with alcoholic hepatitis and told to abstain from drinking.

DISCUSSION

This patient's clinical picture was consistent with severe alcoholic hepatitis. On two occasions an in-depth evaluation was undertaken to evaluate for cholecystitis, cholangitis, obstructing lesion, systemic infection or other explanations of right upper quadrant pain, abnormal liver function tests and leukocytosis. As this case underscores, alcoholic hepatitis manifests as an inflammatory state of the liver and can be confused for infection or obstruction. Patients often present with right upper quadrant pain, hepatomegaly, jaundice and fever. Hepatic encephalopathy is a poor prognostic indicator. The mortality of the disease is high, and can be stratified by calculating the discriminant function [formula (PT-control) + tbili]. In this patient with a discriminant function (DF) of greater than 32, her mortality at one month is 50%. A small mortality benefit at two and six months has been demonstrated with corticosteroids and at four weeks with pentoxifylline in patients with DF 32 and no evidence of infection or bleeding. This patient received pentoxifylline without significant change in her laboratory or clinical parameters after 4 weeks of treatment. She did survive the acute period, and in follow-up six months later, the patient had abstained from drinking with improvement in her physical exam and laboratory values.

A SURPRISING CAUSE OF ACUTE-ONSET ALTERED MENTAL STATUS AND HYPOXIA IN A PREVIOUSLY STABLE PATIENT

M.R. Heller1. 1University of California, San Francisco, San Francisco, CA. (Tracking ID #)

LEARNING OBJECTIVES

1) Recognize air embolus as a possible cause of respiratory distress and altered mental status in hospitalized patients. 2) Become familiar with preventative measures and treatment options.

CASE

A 58 year old man with AML was admitted to the hospital for consolidation chemotherapy. Three weeks into his hospital stay, he was found on the ground in the doorway to his room, confused and unable to get up. The patient was oriented only to person, but did not complain of any localized pain or difficulty breathing. On physical exam, his vitals were stable with the exception of his O2 saturation, which was 84% on room air, but increased to 97% on 10L face mask. He had no obvious signs of trauma, except that the cap to one of the lumens of his central line was off. The remainder of his cardiopulmonary and neurological exam was within normal limits, to the extent that he could cooperate. Labs were unremarkable. A head CT was negative, and a chest x-ray and CT did not show signs of new infection, pneumothorax, or pulmonary embolus. By the following morning, the patient's altered mental status and hypoxia had resolved. His symptoms were ascribed to an air embolus, which likely occurred during a normal tidal volume inhalation after the cap to his central line became disconnected.

DISCUSSION

Air embolus (AE) is most commonly associated with surgical procedures, penetrating chest injuries, barotrauma, and central venous catheterization. Slow infusions of small amounts of air are tolerated better than large rapid boluses &#x;it is thought that &#x; cc of air infused over a few seconds can be fatal in humans. Dyspnea is found in almost all cases of AE, and may be accompanied by tachypnea, respiratory failure, chest pain, hypotension, and tachycardia. Neurological findings are present in up to 40% of cases, and range from dizziness and a subjective sense of doom to altered mental status or focal neurological deficits. Diagnosis of AE can be difficult, as labs, chest x-rays, VQ scans, and chest CTs are most often normal. Therefore, a high index of suspicion is required in a patient undergoing a surgical procedure or with central venous access. Treatment focuses on identifying the source of air entry and preventing further air flow. Hyperbaric oxygen may be helpful in extreme cases to reduce the intravascular air bubble size. Furthermore, positioning the patient in the left lateral decubitus position may help to prevent an air bubble in the right ventricle from obstructing the pulmonary outflow tract. Finally, aspiration through the central venous catheter may be attempted if the introduction of the AE is witnessed. Emphasis should be placed on prevention &#x;patients should be in Trendelenburg position and they should be instructed to valsalva or exhale during the placement or removal of a central venous catheter.

A THORNY PROBLEM: MYCOBACTERIUM KANSASII INFECTION OF THE SKIN

K. Pachipala1; S. Naidu1; L. Adhikesavan1; R. Gotoff1; D.R. Gutknecht1. 1Geisinger Medical Center, Danville, PA. (Tracking ID #)

LEARNING OBJECTIVES

Appreciate that storycall.usii can cause water-borne skin infections.

CASE

A year-old woman developed erythema and swelling over a PIP joint of her left hand three months after cutting that finger on a thorn. Pus was aspirated but no bacteria were found on gram stain or culture. Subsequent biopsy showed a granulomatous reaction and cultures grew pigmented mycobacteria. The patient had a history of exposure to both an inground swimming pool and a hot tub and was empirically treated with Bactrim for presumed infection with storycall.usm, since that agent is the commonest pigmented mycobacterium causing skin infections. The organism was later identified as storycall.usii and the patient was given INH, rifampin and ethambutol. INH and rifampin could not be continued because of hepatotoxicity, and after consultation with a national expert, an alternative treatment regimen of clarithromycin, gatifloxacin and ethambutol was instituted and the patient improved.

DISCUSSION

storycall.usii is a slow growing, photochromogenic mycobacterium found in potable water supplies, swimming pools and sewage. Cutaneous storycall.usii infections are rare, with 44 cases so far reported in the literature. These infections are sporadic and usually due to inoculation following minimal cutaneous trauma. Most occur in patients with immunological problems, and patients may present with papules, nodules, pustules, crusted ulcers, cellulitis or sporotrichial lesions. The American Thoracic Society recommends treatment with INH, rifampin and ethambutol. In our patient the history suggested both thorn injury and water exposure as possible vectors of infection. Thorn prick is usually associated with infections with gram-negative bacteria, clostridial species or sporotrichosis. Bacteria associated with water exposure include Aeromonas sps, Edwardsiella tarda, Erysipelothrix rhusiopathiae, Vibrio vulnificus and Mycobacterium marinum. The surprise finding of storycall.usii confirmed this was a water-borne infection, and an unusual one at that.

A VERY RARE PRESENTATION OF A COMMON ILLNESS, INFLUENZA A INFECTION WITH A MASSIVE PERICARDIAL EFFUSION

S.G. Khurshid1; U. Ahmed2; P. Sherchan3. 1Saint Francis Hospital at Evanston, Evanston, IL; 2Saint Francis Hospital, Evanston, IL; 3Saint Fancis Hospital at Evanton, evanston, IL. (Tracking ID #)

LEARNING OBJECTIVES

To recognize an unusual complication of Influenza A virus.

CASE

year-old previously healthy male presented with seven days history of pleuritic chest pain and fever. Chest pain was persistent and worsened with deep breathing and lying down. Patient also described a recent upper respiratory illness associated with fever, chills and myalgias. Physical examination revealed a temperature of F, pulse rate of , BP of /65 and respiratory rate of The heart sounds were distant with a prominent pericardial rub. Decreased breath sounds and dullness were present at the left lung base. No rales were audible, liver was not enlarged and there was no peripheral edema. No jugular venous pulsation was visible and pulses paradoxus could not be detected. Lab workup revealed WBC count of with 40 percent lymphocytes. Serological screening for viruses including CMV, Coxsackie, EBV, VZV, HIV and Echovirus was negative. Rapid influenza antigen detection from nasophyrengeal swab was positive for influenza A virus. EKG revealed sinus tachycardia with no evidence of electrical alternans. CXR showed cardiomegaly with bilateral pleural effusions. CT scan of the chest showed a fluid collection in the pericardium with abnormal enhancement of the pericardial lining indicating pericardititis. Echocardiogram revealed massive pericardial effusion with no evidence of cardiac tamponade. Patient improved with NSAIDs, oseltamivir and fluid resuscitation.

DISCUSSION

Influenza A and B infections are recognized causes of pericarditis. Viral pericarditis may be associated with myocarditis and in this case, the pericardial inflammation was sufficient to cause a massive effusion. Myocarditis and pericarditis were reported in association with influenza viral infection during the &#x; pandemic; these reports were largely based on histopathologic findings, and these complications have been reported only infrequently since then. To our knowledge only a few cases of a massive pericardial effusion causing tamponade secondary to influenza have been reported but all those patients had underlying cardiac disease. This case appears to be unique in that the presence of massive pericardial effusion did not cause clinical or echocardiographic evidence of tamponade. We attribute this to the young age and normal underlying myocardium.

ACQUIRED FACTOR VIII INHIBITOR PRESENTING AS REFRACTORY GI BLEEDING

R.R. Yeldandi1; M. Peek1. 1Rush University/Rush- Presbyterian-St. Luke's Medical Center, Chicago, IL. (Tracking ID #)

LEARNING OBJECTIVES

(1) Recognize underlying coagulopathies as etiologies of refractory GI bleeding. (2) Understand the treatment options for acquired factor VIII inhibitors.

CASE

The patient is a 49 year old woman with a history of hypertension, coronary artery disease, and CHF who presented after two episodes of hematemesis; she denied hematochezia or melena. She had no history of peptic ulcer disease, dyspepsia or NSAIDs use. Nasogastric lavage yielded ccs of coffee grounds and her stool was heme positive. An emergent EGD revealed a gastric ulcer whose actively bleeding vessel was coagulated with electrocautery. She was started on Protonix. Three days later, the patient had hematochezia and hematemesis. Repeat EGDs showed an adherent clot but no active bleeding. H. pylori titers and a colonoscopy were negative. With no other source of active bleeding identified, the gastric ulcer was surgically resected, but the patient had persistent post-operative bleeding. On admission, the patient had a prolonged aPTT ( sec) which was previously normal; aPTT mixing studies were positive for a coagulation factor inhibitor. Factor VIII inhibitor levels were elevated, thus diagnosing the patient with an acquired factor VIII inhibitor coagulopathy. The patient was treated with Factor Eight Inhibitor Bypass Activator (FEIBA), recombinant activated factor VIIa, steroids and Imuran. The patient was discharged in stable condition.

DISCUSSION

Factor VIII inhibitor is an autoantibody directed against coagulation factor VIII. Patients can present with hematomas, hematuria, GI bleeding, retropharyngeal or retroperitoneal bleeding, cerebral hemorrhages and/or post-operative bleeding. Recombinant factor VIIa infusions can activate the coagulation cascade by bypassing factor VIII and control acute bleeding. Maintenance therapy with immunosupressants can lower inhibitor titers. Our patient's acute bleeding resolved with infusions of FEIBA and recombinant factor VIIa. Although she presented with a common clinical manifestation of factor VIII inhibitor, the etiology of her uncontrolled bleeding was uncommon. Our patient had a clear source of GI bleeding, but she did not respond to standard treatment. Without her underlying coagulopathy, her bleeding may have ceased with cautery. We present this case in order to bring attention to possible uncommon etiologies for common scenarios. Failure of conventional therapy for GI bleeding should prompt further evaluation for an underlying coagulopathy. Early identification of acquired coagulopathies and treatment with effective agents can reduce excessive blood loss and reduce mortality.

ACTINOMYCOSIS PRESENTING AS A SKIN ABSCESS

J. Blank1; M. Traina1. 1UCLA&#x; San Fernando Valley Program, Sylmar, CA. (Tracking ID #)

LEARNING OBJECTIVES

1) Recognize Actinomyces as a cause of skin abscess. 2) Discuss the diagnosis and management of disseminated Actinomycosis.

CASE

A 46 year old male presented to the clinic with a three month history of left shoulder pain and progressive loss of range of motion. The patient noticed a lump on his shoulder 6 weeks ago that has been increasing in size. He admits to a productive cough, dyspnea on exertion, and fatigue. The patient smokes 2 packs per day, drinks 6 beers per day, and works as a repairman, often underneath houses. Physical examination revealed a fluctuant 13 × 13 cm mass over the left scapula, poor dentition, and rhonchi over the left lung base without evidence of lymphadenopathy. Significant laboratory results included a WBC , Hemoglobin , and Folate Chest x-ray showed a nodule in the left lower lobe. CT scan of the chest revealed a 3 cm irregular soft tissue mass in the left lower lobe with apparent sinus tracts extending to the back. Fine needle aspiration of the shoulder mass was completed and Gram stain demonstrated sulfur granules consistent with Actinomyces infection. After surgical drainage of the abscess, intravenous ampicillin-sulbactam was initiated for 4 weeks followed by oral penicillin. Repeat CT scan after 4 weeks of treatment revealed a decreased lung mass size.

DISCUSSION

Actinomycosis in humans is commonly caused by Actinomyces israelii. It frequently occurs in adult males with dental infections but also can occur in patients with diabetes, immunosuppression, malnutrition and local tissue damage with neoplastic disease or irradiation. Actinomycosis generally arises from a dental source but in rare cases it can originate from the thyroid gland, thyroidectomy incision sites or lung as seen with this patient. Typically, infection spreads by direct invasion without respect to anatomical barriers including fascial planes, forming multiple abscesses. Pulmonary infections usually arise after aspiration of oropharyngeal or gastrointestinal secretions. The most common pulmonary clinical presentation is an indolent, progressing pneumonia with or without pleural involvement. Patients present with a productive cough, fever, chest pain, and weight loss. Actinomyces is difficult to culture and should be suspected when sulfur granules are seen on visual or microscopic examination. Sulfur granules which are rarely seen with Nocardiosis, are common with Actinomycosis and have a characteristic cauliflower-like appearance upon microscopic examination. Abscesses require surgical drainage and the infection is highly responsive to antibiotic treatment with long term penicillin.

ACUTE ONSET GENERALIZED LYMPHADENOPATHY IN A 58 YO MALE

B.E. Gewurz1; J. Beach2. 1Beth Israel Deaconess Medical Center, Boston, MA; 2Beth Israel Deaconess Medical Center, Brookline, MA. (Tracking ID #)

LEARNING OBJECTIVES

Distinguish between local and generalized adenopathy. Diagnose etiology of generalized lymphadenopathy. Recognize when a lymph node biopsy is indicated.

CASE

Mr. JW is a 58 yo male with no significant PMHx who presented to an urgent care visit with a chief complaint of bumps on his neck of several days duration. He denied associated symptoms, including fevers, chills, night sweats, cough, myalgia or arthralgia. He denied any recent travel, sick contacts, or unusual exposures at the supermarket that he manages. He takes no medications. He has been married for 30 years, has a remote smoking history, and denied IV drug use. He has a pet cat. Physical examination was notable for numerous 1&#x;3 cm nontender, firm, mobile lymph nodes in the preauricular, postauricular, occipital, anterior and posterior cervical, axillary and inguinal chains. There was no hepatosplenomegaly, rashes, or mucosal lesions. An extensive work-up did not reveal likely infectious causes of adenopathy: PPD was negative and serologic tests failed to show acute infection by HIV-1, CMV, EBV, toxoplasma, syphilis, borrelia, or bartonella. No HIV RNA was detected. ESR was 16 mm/hr. No acute cardiopulmonary process was evident on chest film. CBC revealed WBC of 5, cells/uL, HCT of %, and PLT of , cells/uL. Regressing adenopathy was noted at a subsequent visit, with interval onset of night sweats, low grade fever, 5-lb weight loss over two weeks, fatigue, persistent dry cough and generalized pruritis. A chest CT scan revealed striking systemic adenopathy of all major nodal groups. Submandibular biopsy revealed features consistent with angioimmunoblastic T-cell lymphoma (AILD). Bone marrow biopsy revealed AILD involvement.

DISCUSSION

Peripheral lymphadenopathy may be the only sign of an underlying systemic process. We review the importance of recognizing regional versus generalized adenopathy, their differential diagnoses, and studies that should be considered. Generalized adenopathy signifies a serious associated condition and that requires further evaluation. When should a lymph node biopsy be obtained? Although many patients with adenopathy fear a diagnosis of cancer, adenopathy often results from an infectious illness and only rarely represents malignancy in the primary care setting. The need for definitive diagnosis should be weighed against the morbidity of an invasive procedure. We discuss circumstances where an observation period is a safe alternative and review algorithms that predict the appropriateness of lymph node biopsy.

ACUTE RENAL FAILURE CAUSED BY A RARE BLEEDING COMPLICATION OF ENOXAPARIN

M. Bandara1; B.P. Sankarapandian1; S.K. Thambidorai1; S. Dhanireddy2; D. Schuller1. 1Creighton University, Omaha, NE; 2Creighton University Medical School, Omaha, NE. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize the potential for enoxaparin induced intra-abdominal bleed 2. Identify acute renal failure as a potential secondary complication of intra-abdominal bleed 3. Assess causes for post obstructive uropathy.

CASE

A year-old white female with recent history of multiple upper respiratory tract infections presents to the emergency room with dyspnea. She was found to be in atrial fibrillation with rapid ventricular response. The patient was admitted and treated with enoxaparin and diltiazem infusion. She was subsequently cardioverted to normal sinus rhythm using direct current cardioversion. During the hospitalization she developed left lower quadrant abdominal pain with associated oliguria. She rapidly progressed to anuria prior to the obtaining of urine studies. Renal ultrasound showed bi-lateral hydronephrosis. Urology performed a cystoscopy, which showed a compression of the bladder from an external source. Bi-lateral ureteral stents were placed extending from the renal pelvis into the urethra. Post operatively the patient became severely hypotensive requiring multiple transfusions and vasopressor support. Computerized tomography (CT) of the abdomen showed a massive hematoma in the pelvis surrounding and compressing the bladder. The patient remained anuric for several days requiring continuous venous-venous hemodialysis. Her renal function eventually improved and hemodialysis was discontinued.

DISCUSSION

Enoxaparin is a rare cause for intra-abdominal bleed. This patient presented with obstructive uropathy resulting in acute renal failure. The initial cause for the obstruction was not apparent. Evaluation of the renal failure led to the discovery that the patient had extrinsic bladder compression from a massive intra-pelvic hematoma. The severity of the bleeding led to a prolonged state of renal hypoperfusion, which resulted in acute tubular necrosis. In patients where the cause of obstruction is not readily apparent, one must consider other potential factors. Post-obstructive renal failure is commonly due to tumors, prostatic hypertrophy, calculi, and strictures. This case demonstrates that pelvic bleeding should also be included in the differential diagnoses of post-obstructive renal failure in patients receiving anti-coagulation therapy.

ADRENAL INCIDENTALOMA, CUSHING's SYNDROME, AND INSULIN RESISTANCE SYNDROME

M.N. Phan1; N. Mikhail1; M. Rotblatt1. 1UCLA SFVP-Olive View Medical Center Department of Internal Medicine, Sylmar, CA. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize an approach to diagnosing adrenal incidentaloma. 2. Be aware of the possibility of Cushing's syndrome in adult patients with an insulin resistance syndrome.

CASE

A 51 year old male was referred for further evaluation and management of an adrenal incidentaloma found on abdominal CT, which was originally performed to rule out nephrolithiasis. There were no kidney stones, but instead, a 3 cm left adrenal mass was reported. His PMH included hypertension for 6 years and diabetes mellitus for 3 years. The patient did not report easing bruising, headache, sweating, or palpitations. Review of systems was significant for weight gain of 50 lbs over 5 years. Family history was also positive for diabetes and hypertension. Vitals signs were T37, BP /90, P, RR16, and WT lbs. Physical exam was significant for obesity, moon facies, and supraclavicular fat pads, but no buffalo hump or abdominal striae. Cushing's syndrome was suspected, and laboratory investigation revealed an elevated hour urine cortisol of ug/24 hrs (4&#x;50), and suppressed ACTH of 5 PG/ML (15&#x;70). Serum renin and aldosterone were normal, as were urine catecholamines. The patient was diagnosed with Cushing's syndrome secondary to an adrenal mass and was subsequently referred for adrenalectomy.

DISCUSSION

The incidental discovery of an adrenal mass is not an uncommon event due to the routine use of common imaging techniques. The prevalence of adrenal incidentaloma is about % at autopsy and &#x;2% by abdominal CT scan. Hyperfunctioning develops in % of cases, and the risk is higher in patients with lesions larger than 3 cm, of which cortisol hypersecretion is the most likely disorder. Evaluation of an adrenal incidentaloma includes hormone studies to determine whether the patient has pheochromocytoma, glucocorticoid excess, primary aldosteronism, or virilizing or feminizing tumors. This is especially important if signs and symptoms of hormonal excess are present. Cortisol secreting adrenal incidentaloma has been implicated in causing obesity, glucose intolerance/type 2 diabetes, hypertension, and dyslipidemia or the insulin resistance syndrome. Screening for Cushing's syndrome in this patient population, i.e., those with larger masses and/or potential signs or symptoms of hormonal hypersecretion, can be critical. Adrenalectomy should ameliorate insulin resistance as well as the vascular risk profile of these patients.

ADULT PRESENTING WITH A PEDIATRIC DISEASE

M. Bandara1; B.P. Sankarapandian1; S.K. Thambidorai1; S. Dhanireddy2; J. Derby1. 1Creighton University, Omaha, NE; 2Creighton University Medical School, Omaha, NE. (Tracking ID #)

LEARNING OBJECTIVES

1. Identify the clinical manifestations of Henoch-Schonlein purpura. 2. Recognize the organ systems affected by the disease. 3. Demonstrate that pediatric diseases can present in adulthood.

CASE

A 21 year old white male with a 4 month history of bloody diarrhea and poly-arthritis presents to an outpatient clinic with pain, stiffness, swelling and purplish discoloration of the right ankle. These skin changes progressed to multiple purpuric lesions over the bilateral lower extremities. Erythrocyte sedimentation rate, urine analysis, rheumatoid factor, human leukocyte antigen B and radiologic studies of the ankles were all normal. Skin puncture biopsy of these lesions showed evidence of leukocytoclastic vasculitis. IgA antigen was positive on the vascular wall confirming the diagnosis of Henoch-Schonlein purpura (HSP). The patient was then started on oral prednisone therapy. He responded well to the steroids, and they were subsequently tapered.

DISCUSSION

HSP is a subtype of Leukocytoclastic vasculitis which affects multiple organ systems. Skin involvement is seen in virtually all patients, manifesting as a palpable purpura in the lower extremities and the buttocks. Polyarthralgias are also a common clinical manifestation. Gastrointestinal symptoms are characterized by colicky abdominal pain, vomiting, diarrhea, and the passage of blood. Renal involvement is seen in almost 80% of the patients and has a nephritic urine sediment and moderate proteinuria. The presence of mesangial IgA on immunofluorescence microscopy is diagnostic. Less than 10% of the patients will progress to chronic renal failure and persistent hypertension. HSP has the highest incidence in children with a median age group of 5 years. Classic skin manifestations occurring early in the disease help diagnose HSP in the pediatric age group. Our case presented with bloody diarrhea demonstrating the need for physicians to be cognizant that HSP may initially manifest in atypical organ systems in adult populations. Steroids are the first line of treatment for this disease.

ALCOHOLIC HEPATITIS&#x;A CAUSE OF FEVER OF UNKNOWN ORIGIN

M. Gaddamanugu1; F. Salahauddin1; M. Aiyer2. 1University of Illinois at Peoria, Peoria, IL; 2University of Illinois at Chicago, Peoria, IL. (Tracking ID #)

LEARNING OBJECTIVES

Identify alcoholic hepatitis as one of the causes of fever of unknown origin. Recognize the classic presentation of alcoholic hepatitis Discuss the diagnostic work up of fever in a patient presenting with alcoholic hepatitis.

CASE

A year-old female with significant history of alcohol and IV drug abuse presented with 3-week history of jaundice, fever, and malaise. Past medical history was significant for hypertension and asthma. Review of systems was remarkable only for a 30 lb weight loss. Initial evaluation revealed markedly elevated liver enzymes, and anemia. Blood cultures, urine cultures and chest radiographs were normal. The diagnosis of alcoholic hepatitis was entertained. However patient was persistently febrile even 10 days after hospital admission. Exam revealed a cachetic female with marked scleral icterus. Vital signs showed temp F, B.P 98/52, RR Abdominal exam revealed hepatosplenomegaly with minimal ascites. Patient underwent an extensive workup including CT scan of abdomen, pelvis and chest, gallium scan, bone marrow studies and temporal artery biopsy, all of which were normal. Her ANA, HIV and hepatitis panel were negative. Liver biopsy revealed alcoholic steatohepatitis. Over the course of 6 weeks of hospital stay, patient gradually deferveresed with supportive treatment and was discharged in stable condition

DISCUSSION

Malaise, fever, jaundice and tender hepatomegaly represent the classic syndrome of alcoholic hepatitis. However, the full syndrome occurs only in a minority of patients with alcoholic liver disease. In addition, the fever in alcoholic hepatitis is very modest usually less than degree Fahrenheit. High temperatures warrant a work up for alternative diagnosis. This case represents a patient who presented with the classic syndrome of alcoholic hepatitis and persistent high fever all attributed to alcoholic hepatitis. Alcoholic hepatitis can be considered as a cause for fever of unknown origin.

ALTERED MENTAL STATUS AND AN ABDOMINAL MASS

L.B. Chun1; R.V. Liddicoat1. 1Massachusetts General Hospital, Boston, MA. (Tracking ID #)

LEARNING OBJECTIVES

1) To recognize the clinical manifestations of unmanaged renal failure 2) To understand the complications of decompressing a massively distended bladder

CASE

A 59 year old male presented with three months of nausea, altered mental status, difficulty urinating, and a 30lb weight loss. Physical exam revealed a pale, cachectic man with slowed speech, fetor uremicus, and a midline 20 × 20 cm, hard, nontender abdominal mass. Labs revealed a hematocrit of 15, potassium , HCO3 , BUN , creatinine 17, phosphorus and iCa , and a reticulocyte count of His abdominal CT revealed a markedly distended bladder, severe hydronephrosis, and an enlarged prostate. A foley catheter was placed and L of blood tinged urine was drained. A renal ultrasound after bladder drainage showed a 10 × 10 cm bladder mass and moderate hydronephrosis with no significant cortical thinning. Cystoscopy revealed over 4 units of malodorous blood clot in the bladder, a normal sized prostate, and markedly friable bladder walls. The clots were removed and bilateral ureteral stents placed. The patient continued to bleed from the bladder despite the use of desmopressin acetate and required 14 units of packed red blood cells over 9 days to increase his hematocrit from 15 to Despite expedient removal of the patient's obstruction, the patient did not regain full renal function and required dialysis.

DISCUSSION

This case illustrates an unusual cause of renal failure as well as many of its complications. It also demonstrates the problems that can arise from decompression of a massively distended bladder. The electrolyte abnormalities commonly seen in untreated renal failure include uremia, hyperkalemia, metabolic acidosis, and hyperphosphatemia. Nausea, altered mental status, anorexia, and fetor uremicus are classic signs of uremia. High levels of blood urea nitrogen can also inhibit platelet action and lead to excessive bleeding. In addition, hypocalcemia and anemia can result from decreased 1, OH vitamin D and erythropoetin production. Acute decompression of the bladder can result in bleeding through re-expansion of previously compressed bladder wall veins. This is difficult to ameliorate through intermittent clamping. Reflex vasodilation occurs with bladder decompression leading to hypotension, particularly in hypovolemic patients. Although it has been suggested that more gradual bladder decompression can reduce hypotensive episodes, this is of unproven efficacy. Post-renal causes of acute renal failure account for 5&#x;15% of cases of renal failure cases, the vast majority due to BPH. Early recognition of renal failure secondary to obstruction and prompt relief of the obstruction are important in preventing permanent renal damage. Normal urine output does not rule out obstructive causes of renal failure. Most recovery of renal function occurs within 7&#x;10 days after relief of the obstruction.

AN ESSENTIAL CASE OF NON-ESSENTIAL HYPERTENSION

M. Guidry1; J. Wiese2. 1Tulane Health Sciences Center, New Orleans, LA; 2Tulane University, New Orleans, LA. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize the symptoms and signs that suggest secondary hypertension 2. Diagnose adrenal adenoma using clinical and radiographic criteria

CASE

A year-old man presented with five days of shortness of breath. His baseline dyspnea on exertion increased from shortness of breath at five blocks, to walking 30 feet. His one-pillow orthopnea increased to sleeping for minutes at a time sitting straight up in bed; he developed new onset paroxysmal nocturnal dyspnea and pedal edema. The shortness of breath was associated with a cough productive of clear sputum and fatigue. He has a past history of hypertension and systolic dysfunction. His out-patient medications included clonidine, metoprolol, and K-dur 40 meq. His blood pressure was / mmHg, pulse 80 beats/min, respiratory rate 26 breaths/min, and temperature °C. He had eight cm of JVD, an S3 gallop, and bibasilar crackles. Despite his supplementation, his potassium was mg/L. He had LVH on EKG and bilateral cephalization on chest X-ray. He was admitted with the diagnosis of a CHF exacerbation and treated with diuresis and blood pressure control. The inability to control his blood pressure despite several medications and the continuing potassium supplementation requirements in the absence of a diuretic prompted an evaluation for the diagnosis of primary hyperaldosteronism. This was confirmed with a serum aldosterone of (normal 16) and a rennin level of An abdominal/pelvic CT showed an 18 × 14 mm round adrenal mass with central attenuation.

DISCUSSION

Primary hypertension is so common as to mask the red flags of secondary hypertension. A search for secondary causes of hypertension should be initiated when faced with any of the following: hypertension in youth, hypertension requiring multiple medications, episodes of flash pulmonary edema or unexplained congestive heart failure, hypertension with unexplained electrolyte abnormalities, and any of the above coupled with an incidentaloma found on CT. The patient in this case presented was diagnosed with hypertension at the age of 26, and his blood pressure was poorly controlled while being treated with multiple medications. He required potassium supplementation despite not being on potassium-wasting medications. He was hospitalized twice for unexplained congestive heart failure and had a benign adenoma was discovered on abdominal CT. Following the removal of his adrenal adenoma, his hypertension resolved.

AN INTERESTING CASE OF HYPERTHYROIDISM IN PREGNANCY

N. Mehta1; R.O. Powrie2; L. Larson2; K. Rosene-Montella2. 1Women and Infants' Hospital, Providence, RI; 2Brown University, Providence, RI. (Tracking ID #)

LEARNING OBJECTIVES

LEARNING OBJECTIVES: 1) Correctly interpret thyroid function tests (TFTs) in pregnancy 2) Review the relevant differential diagnosis and management of hyperthyroidism in the pregnant patient.

CASE

We were asked to consult on a year-old woman at 18 weeks gestation for elevated blood pressure and abnormal TSH. She had been healthy until 3 months prior to presentation when she first noted increasing lower extremity edema. She had also noted blurry vision and headache in the preceding week. In the emergency room, she was noted to be tachycardic (/min) and hypertensive (/ mmhg). Her physical exam was unremarkable except for a fine tremor of the hands and 3+ pitting pedal edema. A urine dipstick revealed 3+ proteinuria. Lab abnormalities were consistent with preeclampsia. A TSH level was found to be U/ml. Her full thyroid function panel was consistent with hyperthyroidism. She was admitted with a diagnosis of thyrotoxicosis and severe preeclampsia at early gestational age. A fetal ultrasound revealed multiple congenital anomalies consistent with triploidy. The patient chose to terminate the pregnancy. Placental pathology was consis-tent with a partial hydatiform mole. Postpartum, the patient's tachycardia, hypertension and tremor resolved within a day. A -hCG level on the third postpartum day was still elevated at 42, u/ml. At her 6-week postpartum check, the patient was well, with normal thyroid function tests and -hCG level 5 u/ml.

DISCUSSION

Hyperthyroidism is the second most common endocrine problem encountered in pregnant women. Recent evidence has emphasized the importance of a euthyroid state in pregnancy for favorable maternal and fetal outcomes. Internists should be prepared to diagnose and manage thyroid disease in pregnancy. Changes in serum concentrations of thyroid hormones and thyroxine-binding globulin during pregnancy make the interpretation of TFTs in pregnancy difficult. The expected changes in TFTs with each trimester and their relationship to hCG levels will be dis-cussed. The pathophysiology, clinical presentation and management of hyperthyroidism in pregnancy will be discussed. Typical causes of hyperthyroidism in pregnancy, including Grave's disease and Hashimoto's thyroiditis will be reviewed and differentiated from hyperthyroidism associated with gestational trophoblastic disease and hyperemesis gravidarum.

AN OVERLOOKED DIAGNOSIS IN THE ELDERLY

C.L. Cullinane1. 1Boston Medical Center, Boston, MA. (Tracking ID #)

LEARNING OBJECTIVES

1. To enhance clinician awareness of the need for HIV testing in the elderly. 2. To recognize the importance of a complete history. 3. To recognize the need for further research on HIV prevention and treatment among the elderly.

CASE

A 77 year old Cape Verdean-male was admitted with trigeminal zoster. Past medical history was significant for hypertension, pneumonia with sepsis, recurrent urinary tract infections, anemia of chronic disease, malnutrition, ischemic cardiomyopathy, and renal insufficiency. He was a nonsmoker and denied IVDU or prior transfusions. His wife had recently died of unknown causes. Three years prior to admission, a persistently elevated total protein prompted an evaluation for multiple myeloma. Bone marrow biopsy revealed a polyclonal gammopathy and a skeletal survey was negative. Subsequently a leukemia and lymphoma panel was unremarkable. Prior to admission he was being followed by a hematologist for Monoclonal Gammopathy of Undetermined Significance. As an inpatient with trigeminal zoster he tested positive for HIV with a CD4 count of 70 and a viral load of 38,, suggesting advanced disease. HAART therapy was instituted after discharge with suppression of his viral load. He died of an arrhythmia almost 2 years later in the setting of decompensated heart failure.

DISCUSSION

Individuals over 50 years of age account for up to 10% of AIDS cases reported to the CDC, a number that is expected to rise as a result of improved survival of patients with treated disease. Older adults are less likely to use a condom during sexual intercourse or to participate in HIV testing. Older adults with HIV infection are more likely to be diagnosed late in disease due to delayed recognition, they experience progression more quickly, and they survive for shorter periods of time than their younger counterparts. Co-morbidities often complicate management and controlled data on tolerability and responses to HAART are lacking. The possibility of HIV infection must be considered among elderly patients with clinical features of immunodeficiency in order to avoid delay in counseling and treatment. This case emphasizes the importance of conducting the sexual history, regardless of age, and it underscores the need for age-appropriate prevention and treatment strategies.

AN UNCOMMON CAUSE OF CIRRHOSIS, OR IS IT?

S. Evans1; J. Wiese2. 1Tulane Health Sciences Center, New Orleans, LA; 2Tulane University, New Orleans, LA. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize the complications of jejeunoileal bypass prior to the onset of liver failure 2. Recognize the presentation of vitamin deficiency.

CASE

A 62 year-old white woman presented with a two-year history of intermittent jaundice and a three-week history of increasing abdominal girth. She had a history of jejeunoileal bypass in for morbid obesity. She had been admitted fourteen months prior with a hemoglobin of 4 g/dl, an elevated bilirubin, and a prolonged prothrombin time. She was diagnosed with B12 deficiency and malabsorption of fat soluble vitamins. A CT at that time showed diffuse fatty infiltration of the liver. On exam she had peripheral wasting, spider angiomas, shifting dullness, jaundice, and peripheral edema. On admission, she had a prolonged prothrombin time, a normal hemoglobin, an elevated bilirubin, and low cholesterol levels. An abdominal CT revealed large volume ascites and a cirrhotic liver. Paracentesis was consistent with portal hypertension as an etiology for the ascitic fluid. A liver biopsy showed severe steatosis with cirrhosis.

DISCUSSION

Jejeunoileal bypass has been a common treatment for morbid obesity, but has rapidly lost favor due to its severe long term consequences, including arthritis, B12 deficiency, cirrhosis, and chronic diarrhea. Patients who received this procedure are now coming to the attention of physicians because of cirrhosis. Unfortunately, this patient was regularly followed in the medicine clinic but did not undergo hepatic evaluation because her symptoms were attributed to the altered physiology of bypass. The intermittent episodes of jaundice following the correction of the B12 deficiency suggested another underlying pathology. Similarly, the prolongation in the prothrombin time following replacement of vitamin K should have been a clue that there was impaired hepatic synthetic function. The CT scan of the abdomen was also potentially confusing: because of the morbid obesity, hepatic steatosis was attributed to NASH. Prompt recognition of this complication of jejeunoileal bypass is important to refer patients to a hepatologist to prevent the expected fifty percent mortality after the development of ascites. At present our patient is awaiting liver transplant.

AN UNEXPECTED CAUSE OF TREMOR AND MYOCLONUS

K. Nashar1; E. Anish1; N. Busis1. 1University of Pittsburgh, Pittsburgh, PA. (Tracking ID #)

LEARNING OBJECTIVES

1. To recognize Creutzfeldt-Jakob Disease (CJD) as a cause of tremor and myoclonus. 2. To appreciate the value of performing a brain biopsy to confirm a diagnosis of CJD.

CASE

A 70 year-old female presented with a 6-week history of abnormal motor movements. Initially, she developed an action tremor in the right arm. After 4 weeks, the left arm also became affected and she began to experience myoclonus in both arms. On physical exam, the patient appeared well-nourished and was afebrile. Her Mini-Mental Status Exam score was 30/ CNs II-XII were intact. Action-induced myoclonic jerks were noted in both arms (R  L). Strength was 5/5 in all extremities. Sensory testing was normal. DTR's were +2 and symmetric. Romberg test was negative. Cerebellar testing was normal. A brain MRI was performed revealing gyriform signal changes in the parietal-occipital region bilaterally. This raised suspicion for a diagnosis of encephalitis. As a result, a lumbar puncture was performed that showed no evidence of pleocytosis or increased protein. Over the next 4 weeks, the patient developed worsening neurological changes, including: dysarthria, ataxia, and increased myoclonus. A repeat brain MRI was unchanged. An EEG was normal. Serological studies looking for evidence of an autoimmune disease were negative. Anti-Hu and anti-Yo antibodies were negative. Since a diagnosis remained elusive and the patient's clinical condition continued to deteriorate, a brain biopsy was performed. The pathology revealed spongiform changes consistent with CJD. The patient's neurological impairment progressed, including the development of dementia, and she died 2 weeks later.

DISCUSSION

CJD is a degenerative disease of the central nervous system that is caused by infectious proteins called prions. Various forms of CJD have been recognized including: sporadic, familial, iatrogenic, and new-variant CJD. Most patients with CJD have the sporadic form and present with some degree of cognitive impairment and tend to progress rapidly to a state of dementia. A myriad of other neurological signs and symptoms may develop throughout the course of the illness with 90% of patients developing myoclonus. A typical clinical course may suggest CJD, but confirming this diagnosis can be challenging. Blood and CSF analyses can help exclude other conditions that may mimic CJD. Most patients demonstrate characteristic periodic complexes on EEG and/or abnormal signal patterns on MRI, but these findings are nonspecific. The gold standard for diagnosis remains brain biopsy. This case is unique in that cognitive impairment did not develop until extremely late in the course of the illness. It also emphasizes how an atypical clinical presentation, the absence of the more common EEG and/or MRI abnormalities, and a lack of risk factors for prion disease, can result in the delay of a diagnosis of CJD being made.

AN UNUSUAL CASE OF ACUTE SICKLE HEPATIC CRISIS

D. Zell1; E. Choe1; D. Spruill1. 1Tulane Health Sciences Center, New Orleans, LA. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize the common and uncommon abnormal laboratory findings associated with sickle cell disease. 2. Recognize hepatitis as a complication of vaso-occlusive crisis.

CASE

A 36 year-old woman presented with one week of worsening pain in her back, lower extremities, and nauseaand vomiting. She had a history of sickle cell anemia and a recent pulmonary embolism Her vital signs were normal; she had hepatomegaly and tenderness in the right upper quadrant. There was also pain in her back and lower extremities. Her alkaline phosphatase was 71, total bilirubin , AST , and ALT Her viral hepatitis panel was negative; she denied alcohol use. Her acetaminophen and salicylate were normal. She was treated for five days with intravenous fluids and pain medication, and her liver enzymes decreased with resolution of her abdominal pain. She returned ten days later; her has AST (53) and ALT (67) has both decreased.

DISCUSSION

Sickle cell disease is characterized by arterial occlusions due to micro-thrombi from the sickled cells. Peripheral vaso-occlusion is the most common since systemic vascular resistance is higher in these vessels and they are of smaller caliber. The result is the typical bone and muscle pain of a sickle cell crisis. Solid organs can also be involved, however, resulting in myocardial infarction, stroke, renal impairment and, in this case, ischemic hepatitis. Although ischemic hepatitis is seen in only ten percent of all sickle patients, physicians should be vigilant for the complication, especially in the setting of right upper quadrant pain, hepatomegaly, jaundice, and a low grade fever. The usual laboratory findings are elevated AST and ALT levels. Treatment is supportive care with IVF and pain control; hepatitis that does not resolve warrants exchange transfusions.

AN UNUSUAL CAUSE OF FEVER IN AN HIV+ PATIENT

R. Gardner1. 1University of California, San Francisco, San Francisco, CA. (Tracking ID #)

LEARNING OBJECTIVES

1. Diagnose Multicentric Castleman's Disease. 2. Recognize the association between Castleman's Disease, HHV-8, and HIV.

CASE

The patient is a 39 year-old HIV+ man (CD4 23) who presents with worsening fevers and increasing abdominal pain for 1 week. He reports onset of intermittent fevers 18 months ago; 1 week ago, the fevers began to occur daily, accompanied by abdominal pain, headaches, back pain, and nausea. The patient recalled a similar symptom constellation 7 months before that resolved spontaneously. He has Karposi's Sarcoma (KS) and takes abacavir/3TC/AZT, lopinavir, tenofovir, azithromycin, and TMP/SMX. On admission the patient was afebrile with normal vital signs. His exam was remarkable for axillary and inguinal lymphadenopathy (LAD); a soft abdomen, mildly tender to palpation diffusely; KS lesions on the left lower extremity. Laboratory studies showed anemia but were otherwise normal. While hospitalized the patient spiked daily fevers, unrelated to antiretroviral administration. Blood, urine, CSF and MAC cultures all were negative, as were an influenza panel, monospot test, and cryptococcus serology. Chest radiography and head CT were normal. Abdominal CT revealed splenomegaly and diffuse LAD. Biopsy of an axillary lymph node showed Castleman's disease (CD) and stained positive for human herpes virus 8 (HHV-8).

DISCUSSION

The differential diagnosis for fever and LAD, already extensive, is even broader in patients with advanced HIV. In this case, the leading diagnoses included disseminated TB, MAC, and non-Hodgkin's lymphoma. CD, which also manifests with fever and LAD, is a rare lymphoproliferative disorder which has received renewed interest as increasing case reports link it to HIV and HHV The unicentric form of CD is isolated, usually asymptomatic, and often discovered incidentally. Not typically associated with HHV-8, it can be cured with surgical resection. Multicentric CD (MCD), as seen in this patient, has systemic symptoms. Effective therapeutic options are limited, contributing to a poor prognosis. The disease manifests differently in patients with and without HIV and HHV HIV+ patients with MCD are universally positive for HHV-8, and are more likely to have a rapidly progressive course with a shorter survival. New studies suggest that HHV-8 may contribute more to this pattern than HIV. Patients typically die of fulminant infection or associated malignancies. Optimal treatment is unclear given the rarity of the disease, the variety of clinical presentation, and the paucity of literature. Most therapies offer a temporary response with relapse after discontinuation, but combination chemotherapy and rituximab show promise for more durable responses. Castleman's disease is a rare disorder with a clinical course shaped by the presence of HIV and HHV-8; it should considered in any HIV+ patient with KS, fevers, and lymphadenopathy.

AN UNUSUAL CAUSE OF RECURRENT RHABDOMYOLYSIS

D.L. Stern1; R. Warrier2; J. Fixley2; E. Adickes2; J. Derby3. 1Creighton University Medical Center, Omaha, NE; 2CUMC, Omaha, NE; 3Creighton University, Omaha, NE. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize that viral infections are a common cause of rhabdomyolysis. 2. Recognize that a muscle biopsy is the gold standard for diagnosis of rhabdomyolysis. 3. Realize that congenital diseases can have initial presentation in adulthood.

CASE

Case Presentation: A 23 yo AA girl with PMH of asthma was admitted to the hospital with a 3 day history of generalized muscle pain. She reported upper respiratory tract symptoms approximately one week prior to admission. She denied muscle weakness, changes in urine color or urine output. She had no history of trauma, no new meds, seizures, or extraordinary physical exertion. She had been admitted two other times with similar symptoms in the past four years. These episodes were treated as rhabdomyolysis believed to be precipitated by viral illnesses. Physical exam was unremarkable except she displayed generalized muscle tenderness without any objective muscle weakness. Her CPK was 35, with a serum myoglobin Other labs of significance included potassium of , BUN/Cr of / Phosphorus was , AST was , ALT was 64, while the remainder of her liver function tests were normal. Complete blood count was normal. A urinalysis showed a myoglobin of 32, Free carnitine, acyl carnitine, total carnitine, pyruvate and lactate were all within normal limits. A diagnostic muscle biopsy was performed which revealed Nemaline myopathy. Patient was treated for rhabdomyolysis and was asymptomatic with low levels of CPK at the time of discharge.

DISCUSSION

Discussion: Nemaline myopathy is a congenital muscle disease with a wide spectrum of phenotypes, ranging from forms with neonatal onset and fatal outcome to asymptomatic forms. Muscle biopsy reveals atrophy, variation in muscle fiber size and a lattice like appearance typical of nemaline rod bodies emanated from the Z-discs of affected muscle fibers. Adult-onset cases usually manifest with symptoms as a child. Our patient denied any problems as a child and was actually was very active in athletics. Most case reports of adult-onset cases are of patients with progressive proximal weakness or generalized weakness. These patients had either a normal or slightly elevated CPK. None of these case reports displayed such a markedly elevated CPK or recurrent rhabdomyolysis as manifested in our patient. We believe that this is the first case report of nemaline myopathy presenting as recurrent rhabdomyolysis.

AN UNUSUAL ETIOLOGY OF LEFT INGUINAL LYMPHADENOPATHY IN A 53 YEAR OLD MAN

D. Takahashi1; M.M. Schapira1; S.R. Pandit1. 1Medical College of Wisconsin, Milwaukee, WI. (Tracking ID #)

LEARNING OBJECTIVES

1. Recognize unusual etiologies of localized lymphadenopathy. 2. Recognize clinical features of Castleman's disease. 3. Determine when there is a need for biopsy in patients presenting with lymphadenopathy.

CASE

A 53 year old Caucasian male presents with left groin lump and 10 kg weight loss over a period of one month. The lump is painful to touch and has been progressively enlarging in size over the past month. The patient also complains of generalized malaise and night sweats. His past medical history is significant for essential hypertension. The physical exam reveals an ill-appearing, 72 inch, 81 kg male with stable vital signs. The general physical exam is unremarkable except for a left sided groin mass measuring 2 &#x;3 cm in size. The mass is discrete, firm and mobile with moderate tenderness to touch and not associated with erythema or induration. Laboratory exam initially reveals a normal CBC and differential and normal electrolytes. An ultrasound of the groin mass reveals clusters of enlarged inguinal lymph nodes, the largest of which measures cm. A CT scan of the chest, abdomen, and pelvis reveals no additional lymphadenopathy. An inguinal lymph node biopsy was done, with initial pathology impression being a low grade lymphoma, but a second opinion from a reference laboratory was reported as follicular hyperplasia with expanded mantle zones, atretic germinal centers and monotypic lambda expression by plasma cells (Castleman's disease like changes).

Источник: [storycall.us]

List of accidents and incidents involving military aircraft (–)

Wikipedia list article

This is a list of notable accidents and incidents involving military aircraft grouped by the year in which the accident or incident occurred. Not all of the aircraft were in operation at the time. Combat losses are not included except for a very few cases denoted by singular circumstances.

Aircraft terminology[edit]

Information on aircraft gives the type, and if available, the serial number of the operator in italics, the construction number (c/n), also known as the manufacturer's serial number, exterior codes in apostrophes, nicknames (if any) in quotation marks, flight call sign in italics, and operating units.

[edit]

On its th flight, the first prototype Cessna XTCE, 54–, c/n , first flown 12 October , becomes uncontrollable during spin tests and crashes in Kansas, Cessna test pilot Robert S. "Bob" Hagan[1] ejecting successfully.[2]
5 January
Two Boeing BE Stratojets of the 44th Bomb Wing from Lake Charles AFB, Louisiana, collide over the Gulf of Mexico during refuelling Wednesday night, causing one to crash and the other to limp home to base with damage, sans its observer who bailed out over the Gulf. Air-sea rescue teams began a search of the Gulf in an area some 30 miles (48&#;km) SE of Cameron, Louisiana, on the Gulf coast.[3] BEDT, , is lost with all three crew. Observer who bailed out is never found.[4] The pilot of the recovered bomber stated that the lost plane apparently smashed down on his aircraft from above, "leaving wheel tracks on the cabin before it spun off to crash in Gulf waters. Capt. Morris E. Shiver, 29, of Albany, Ga., said 'we never knew what hit us' as the two six-jet bombers crashed together Wednesday night about 30 miles (48 km) southeast of Cameron, La. An armada of planes and ships searched Thursday for the four airmen missing after the crash. Three of them were aboard the B47 which plunged into the Gulf, while the fourth, 1st Lt. Matthew Gemery, of Lakewood, Ohio, an observer, could have returned on his limping plane had he waited another minute before ejecting himself. They identified Maj. Sterling T. Carroll, 33, of Port Arthur, Tex., as the commander of the plane that returned, and Shiver as the pilot. The other three missing airmen were Maj. Jean S. Pierson, of Danville, Ind., aircraft commander; Capt. David O. Crump, of Albermarle, N.C. [sic], copilot, and father of six children, and 1st Lt. Rodney P. Egelston of Levelland, Tex., observer-bombardier."[5]
6 January
"BRAMAN, Okla. (AP) – A crippled B47 six-engine jet bomber barrel-rolled, crashed and exploded in a wheat field a mile east of here Thursday, killing all three crewmen aboard. The plane, from McConnell Air Force Base, Wichita, Kan., disintegrated into hundreds of pieces after the explosion in this farm area of North Central Oklahoma near the Kansas border. Maj. Lawrence Tacker of McConnell AFB identified the dead as: Capt. Wayne E. Andrew of Yellow Springs, Ohio, commander of the plane; 1st Lt. Joseph C. Cook, co-pilot, Sunland, Calif.; Capt. William C. Berry, observer, Dayton, Ohio. The wives and families of the men are living temporarily in Wichita. O. O. McMasters, who lives here, said he heard the plane coming from the north and in distress. McMasters said it suddenly barrel-rolled and crashed. A crater 10 to 12 feet deep (4 m) was left in the pasture. Bits of the crewmen's bodies and the plane were scattered for hundreds of yards. The plane landed on the Horne farm and the explosion was so great it rocked Bramen a mile away."[6] BBBW Stratojet, , of the th Flying Training Wing lost.[4][7]
6 January
A ferry pilot in a flight of three North American F Mustangs from Norton Air Force Base, California, to McClellan Air Force Base, California, bails out into the Sierra Pelona Mountains north of Los Angeles in the first snowstorm of the season after suffering engine failure. Capt. John S. Thompson, of the th Ferrying Squadron at Long Beach Air Force Base "trudged through the season's first heavy snow to a cafe at Acton in the mountains between Los Angeles' San Fernando Valley and the Mojave Desert, and called authorities. He said he had landed not far from where his F51 Mustang, crippled by a faulty propeller, crashed in the snow."[8] The airframe came down near the Southern Pacific Railroad tracks, east of Soledad Canyon Road.[9] FHNA Mustang, ,[10] wrecked.[11]
6 January
The crash of a Lockheed TA Shooting Star in the Shadow Mountains in the Mojave Desert, while en route from Perrin Air Force Base, Texas, to George Air Force Base, California, kills two crew just 18 miles short of their destination. "The plane crashed as the pilot lost radio contact with George AFB, Victorville, in a heavy snowstorm while approaching from Williams AFB, Phoenix, Thursday. A George helicopter sighted the wreckage on the east side of snow-covered Shadow Mountain, 18 miles northwest of Victorville, and a search party reached the plane later Friday. The Perrin trainer was on a routine flight. It had stopped at Williams to refuel." Perrin officials identified the dead as Capt. Donald McLaren, 30, and 2d Lt. Richard Delehanty, 24, both of Sherman, Texas.[12] Ground parties had set out from March Air Force Base, Riverside, on Thursday to search for the plane and its crew as bad weather delayed an air search.[13] Shadow Mountain, an isolated peak, is located about six miles due east of the main chain of the range. It has a peak elevation of 1, meters (4,&#;ft).[14] TALO, ,[7] was involved.[11]
6 January
"TOKYO (AP) – Two planes, presumably U. S. jets, collided high over Tokyo Bay Friday night in a blinding flash of light that startled thousands of residents. U. S. Far East Air Force headquarters said a Sabre jet fighter and a jet trainer from nearby Yokota Air Base were missing."[15] "Tokyo (AP) – The U.S. Air Force today released the names of three Air Force pilots killed Thursday night when two jet planes collided over Tokyo Bay. The pilots were identified as 2nd Lt. Kenneth E. Heeter, son of Mr. and Mrs. Floyd E. Heeter of Emlenton, PA.; 2nd Lt. William O. Edwards, son of Mrs. E.D. Edwards of Beaucoup, Ill., and Capt. Milan Mosny, son of John Mosny, Little Falls, NY. Heeter was piloting an F86 Sabre jet and Edwards and Mosny were in a T33 trainer when their planes collided during a night training mission. After the collision the planes plummeted into Tokyo Bay. Two of the bodies have been recovered and search is continuing for the third. The Air Force did not say which bodies have been recovered.[16] FDNA Sabre, , and TALO Shooting Star, , were involved.[11][17]
7 January
A pilot suffered first and second degree burns when his North American FD Sabre crashed on takeoff from Norton AFB, California, when the engine flamed out as he departed the runway at 1st Lt. Robert L. Buss, from Selfridge AFB, Mount Clemens, Michigan, reached an altitude of c. feet after leaving the west end of the east-west runway and a speed of c. knots when the engine failed. It crashed about yards from the air strip feet west of Alabama Street and south of 3rd Street, near the Santa Ana River Wash. The plane was headed for Alabama Street, which was carrying heavy north-south traffic. "Officials at Norton praised the young pilot for his courage in making a degree right turn with the dead plane to avoid crashing on the thoroughfare. Lt. Buss said he first struck a small embankment causing the fuel tank to explode before the plane began grinding to a halt yards away. One wing was ripped from the craft on impact. The pilot's clothing caught fire when the fuel tank exploded. After crawling from the blazing craft he tore off his outer garments and rolled in the sand, saving his own life." Floyd K. Smith, chief of Office for Information Services at the San Bernardino installation, said that the pilot, rushed immediately to the base hospital, was from the 13th Fighter-Interceptor Squadron at Selfridge AFB. He is single and believed a resident of that base. Smith stated that Buss was on his way to the Fresno Air Terminal and had stopped for fuel at Norton earlier in the day.[18] FDNA, ,[17] was involved.[11]
9 January
A U.S. Navy Beechcraft with three aboard goes missing while on a flight from Monterey, California, to Norton AFB, California. On board were Lt. Marshall Hand, of La Mesa Village, Monterey, pilot; Lt. Lasley K. Lacewell, Jr., of Carmel, California, copilot; and a sailor passenger, Haskel Lewis Reichbach, fireman of the USS Badoeng Strait, berthed in San Diego. Still missing by mid-week, despite the search efforts of the Air Force, Navy, Coast Guard, Civil Air Patrol and Army National Guard, "At dawn Thursday, 51 military planes coordinated by the 42nd Air Rescue Squadron at March Air Force Base will continue the search." Wreckage discovered near Corona in Silverado Canyon Wednesday turned out to be from another accident several years ago. According to CAA officials at Ontario International Airport who were the last to hear from the missing craft, the plane is believed to be down somewhere in the snow-covered San Bernardino Mountains.[19] The SNB-2 Navigator, BuNo , crashed into a ridge on Cajon Mountain above Cajon Pass in a rugged area of chaparral. All on board killed.[20][21] The crash site was discovered on 13 January at about the 5, foot level of Cajon Mountain.
13 January
Former Navy pilot, now a test pilot for Douglas Aircraft Company, James B. Verdin, 36, is killed this date when he bails out of A4D Skyhawk, BuNo , at 30, feet during a test flight near Victorville, California, and his parachute fails to open. Douglas company officials said that he radioed that he was bailing out shortly before the fighter-bomber crashed and burned. The wreckage was sighted at dusk 25 miles (40&#;km) northwest of Victorville between Haystack Butte and Highway by helicopters from Edwards AFB. Verdin's body was not in the wreckage. The Los Angeles Sheriff's Office said a parachute was reported in the northeast section of the county shortly after the crash. Search parties were dispatched to the area, which is partially snow-covered. Temperatures were near freezing.[22] The pilot's body was spotted at Friday 14 January, on the desert floor eleven miles (18&#;km) south of Kramer Junction, about a mile east of Highway It was found c. three miles (5&#;km) northeast of the aircraft wreckage by a ground party composed of personnel from Camp Irwin, Edwards AFB and George AFB. "Aiding in the widespread search by several thousand men afoot, on horseback and automobile was a posse from the San Bernardino County sheriff's office under the direction of Capt. Jack Miller of the Victorville substation." Scores of military and civilian planes were also involved. Confirmation that it was Verdin's body was made by Edwards AFB officers who landed at the scene in a helicopter a few minutes after the discovery. Verdin's helmet and part of his canopy were found about a mile south of where his body fell. Coroner R. E. Williams said that the body was removed from the scene by Air Force personnel.[23] YA4D-1 Skyhawk, BuNo , the third pre-production airframe, written off.[24] Verdin, as a Navy lieutenant commander, had set an absolute speed record of miles per hour on a three-kilometer course over the Salton Sea in an F4D Skyray on 5 October He left the service in June to take a test pilot job with Douglas.
15 January
The U.S. Air Force grounds its Fairchild C Flying Boxcars for a fleetwide engine inspection after incidents and accidents led to four forced or crashed landings within a week. A total of paratroopers and air force crew were involved in the four accidents in which two men were killed. "Thirty-five airborne infantrymen and three crewmen parachuted to safety when an engine burst into flames Tuesday shortly after a C took off from Sewart Air Force Base, Tenn. The pilot and co-pilot were killed in that crash. Just hours before the Tennessee crash, 33 paratroopers bailed out when an engine caught fire on their plane near Miles City, Montana. Pilot – Capt. T. G. Johnson, of Sewart AFB then guided the plane to the Miles City Airport without incident. Thirty-three paratroopers jumped to safety over Fairbanks, Alaska, Thursday when one engine of their plane failed. Lt. Robert Bruckner, pilot; Lt. Herbert T. Kurse, co-pilot, and six crewmen rode the plane to safety at Ladd AFB. Another C engine failed Saturday shortly after the twin-engined Flying Boxcar took off from Ellsworth AFB, South Dakota, but the pilot safely landed the plane, which was carrying 33 paratroopers and three other crew members." Officers at Anchorage said that "Exercise Snowbird" schedules on troop and other aircraft movement would not be affected by the inspection, which is relatively simple. Sixty Cs involved in the exercise arrived at Elmendorf AFB, Alaska, from Sewart AFB, and 16 more were en route. Officers said that engine inspections were being performed at stations along the way as well as at Anchorage.[25] The airframe lost in the fatal Sewart AFB incident was CG, , c/n , which crashed five miles northeast of the base.[17][26]
16 January
"EL TORO (AP) – A year-old Long Beach policeman, on weekend flying duties with the Navy, was killed Sunday when his prop-driven fighter plane crashed in a muddy field near here. The Los Alamitos Naval Air Station identified the pilot as Lt.(j.g.) Robert Everett Hagen, Rose Avenue, Long Beach. Hagen, who flew one weekend a month in a reserve squadron, had just taken off on a routine training flight in the Vought-Corsair plane. He leaves his wife, Betty, and four daughters; Mary Lou, 12, Patricia Ann, 6, and twins Jennifer Joan and Jane Margaret, 8."[27]
17 January
U.S. Navy Lockheed CJ Super Constellation, BuNo , c/n ,[28] departs Harmon AFB, Newfoundland, at for a "routine transport flight" to its home-station, NAS Patuxent River, Maryland. At , while over Prince Edward Island, two engines fail. The flight attempts to return to Harmon and a Boeing B is dispatched to escort the crippled C, rendezvousing with it at over Cabot Strait, between Newfoundland and Cape Breton Island, Nova Scotia. Twelve minutes later, the Constellation shut off its lights and other electrical equipment to facilitate the dumping of excess fuel. Within minutes the bomber lost radar contact with the transport and it vanished. The Constellation went into a stormy sea amidst clouds and fog. The B circled the area and finally spotted five life rafts and life jackets amidst wreckage at , but no survivors. The six crew and seven passengers, twelve men and one woman, were lost. The plane's pilot was identified as Lt. Cdr. L. R. Fullmer, Jr., of Little Rock, Arkansas. The woman aboard was identified as Seaman Jeanette W. Elmer, 22, of Syracuse, New York.[29]
19 January
"OXNARD (AP) – An Air Force T33 jet trainer made a successful forced landing in soft mud after its engine quit at 8, feet. Marine Maj. Edward LeFaivre, 33, Baltimore, Md., on temporary duty at Oxnard AFB, and Lt. Stanley Green, 23, Inglewood, were in the plane. Neither was injured, the Air Force said. The landing was made in a field about three miles (5 km) south of the base."[30] TALO, ,[11] was repaired and placed back in service, finally being retired to MASDC on 1 February [17]
19 January
"TRIPOLI, Libya (AP) – Lt. Stanford Nall, 28, of Meridian, Calif., was killed Wednesday when his F86F Sabre jet crashed into the Mediterranean eight miles northwest of Wheelus Field, the U.S. Air Force said Friday."[31]
19 January
"HONOLULU (AP) – The navy said Friday night the transport Fred C. Ainsworth rescued all seven survivors of a twin-engined navy amphibian forced down Wednesday night in the Central Pacific. The transport radioed that it had picked up the men at ( PST), the Hawaiian Sea Frontier said. Only a few hours before the rescue, the seven airmen had transferred from their life raft to a foot lifeboat dropped by an air force plane. The lifeboat was about miles northwest of Kwajalein, destination of the plane which developed engine trouble while flying from Johnston Island. The survivors reported by a walkie-talkie dropped to them that there were no casualties but some fever had developed. Coast Guard Lt. Martin W. Flesh was commander of the search plane which sighted the survivors. In Washington, the navy identified the seven as Lt. James Gotfray Measel, pilot, Norfolk, Va.; Ens. Harrison Bernard Nordstrom, Robert Nason Gardon, navigator, Watertown, Mass.; aviation electronics technician 2-c Robert D. Frame, Memphis, Tenn.; aviation machinists mate 2-c Edward James Nowark, Buffalo, N. Y.; aviation machinists mate 1-c William Clement Pavey, Warwick, R. I.; and aviation electronics technician 2-c Jerome Joseph Warras, Detroit, Mich."[32]
20 January
"SAN DIEGO (AP) – A Navy F9F2 Panther jet fighter crashed into a Navy Retraining Command prison area near here Thursday, killing the pilot. He was identified as Lt. Douglas Mosser, 31, of La Jolla, Calif. He is survived by his wife, Ann; a son, Bruce, 1; and his mother, Mrs. Anna S. Mosser, Chinook, Mont. Parts of the exploding craft struck a warehouse and set it afire. A wing was seen to fall from the plane as it came in for a landing at Miramar Naval Air Station, across U.S. Highway across from the Retraining Command's Camp Elliott. It rolled over and struck between the warehouse and another building, about a mile from the Miramar runway. The Navy said none of its personnel, including the Navy, Marine Corps and Coast Guard prisoners confined for various offenses, was in the immediate area of the crash."[33]

22 January

Royal Canadian Air Force B Mitchell light bomber from No. (City of Edmonton) Squadron crashed 40 km southwest of Edmonton, Alberta. Killed in the crash were: Flying Officer Douglas Merrill Ward (Pilot), Flying Officer Richard Grant Officer (Squadron Engineering Officer), and Flying Officer John Kutyn (Navigator). It is believed the B Mitchell (that was returning from a cross-country flight) developed mechanical trouble and tried to crash-land on the frozen North Saskatchewan River. Unfortunately, the plane clipped the elevated cable for the Holborn Ferry, flipped over, crashed, and burned. There were no survivors.[34][35]
27 January
"STUTTGART, Germany (UP) – A crippled U. S. Army helicopter and a second helicopter racing to its rescue both crashed in flames Thursday night, killing all six aboard, the 7th Army announced Friday. German police said one of the helicopters developed trouble over an open field and cracked up in an emergency landing shortly before midnight. It burst into flames. A second helicopter on night maneuvers dropped down to rescue the three crewmen but also piled up and caught fire."[36] These may have been either Bell H Sioux or Sikorsky H Chickasaws; Sikorsky H Choctaws were not delivered to the Army until later in
28 January
"WARNER SPRINGS, Calif. (AP) – A Navy jet fighter crashed Friday four miles north of here, killing the pilot. A second Navy man was fatally injured in a helicopter accident at the crash scene. The pilot was Ens. L. R. Nelson, 23, stationed at Miramar Naval Air Station at San Diego, 60 miles southeast of here. The second man was not immediately identified. He was an enlisted man stationed at a Navy fliers' mountain survival school near here. Nelson's F9F5 Panther jet hit the top of a knoll while making a low-level pass on routine maneuvers. The Navy said a Coast Guard helicopter called to the scene from San Diego began to roll down a slope on landing. Its tail rotor hit the ground and flew apart. A piece of the rotor struck the enlisted man."[37]
22 February
Fifth of 13 North American Xs, GM, c/n 5, on X flight number 13, out of Edwards AFB, California, has supersonic flight aborted when afterburners fail. Automated landing fails when chute deploys during radio controlled approach, causing the vehicle to plunge into the desert and be destroyed.[38]
11 March
Third of 13 North American Xs, GM, c/n 3, on X flight number 14, out of Edwards AFB, California, first flight of refitted c/n 3, the static test article. Vehicle exploded on gear retraction two seconds after lift-off – it was found that the destruct package was wired to the gear circuit instead of the engine circuit.[38]
22 March

Main article: Hawaii R6D-1 crash

A United States NavyDouglas R6D-1 Liftmaster, BuNo , c/n , of Air Transport Squadron 3 (VR-3), assigned to the Military Air Transport Service, hits a cliff on Pali Kea Peak in the Waianae Range on Oahu, 15 miles (24&#;km) northwest of Honolulu, Territory of Hawaii, United States, at , killing all 57 passengers and nine crew, making it the worst heavier-than-air disaster in U.S. naval aviation history.[39][40]
14 April
The first significant Nike Ajax missile accident occurs at Fort George G. Meade, Maryland, on a rainy afternoon this date, when, at , Battery C, 36th AAA Missile Battalion, located south of Maryland (now Route ), was "practicing Nike procedures" when the rocket booster on an Ajax which was being elevated on its launcher suddenly ignites and the missile takes off. Crewman SFC Stanley C. Kozak, standing seven feet away, is caught in the flareback from booster ignition and suffers minor burns. Initial reports stated that the missile exploded about three miles (5 km) away, "several thousand feet in the air." Later accounts state that the missile, which was not in the fully upright launch position when it unexpectedly left the rail, suffered structural damage as it took off, "coupled with rapid initial acceleration, rendered the missile aerodynamically unsound and led to the break up. The fact the crew had not removed the propulsion safety pin during the drill contributed to the failure of the sustainer motor to start. And, since the launch was unintended, the missile was not under radar control. Neither the missile nor the booster exploded in flight. The booster separated and fell onto Barber's Trailer Court more than a mile from the launch site. Fuel tank fragments fell on the Baltimore-Washington Expressway where the fuel and oxidizer caused a fire but little or no damage. The missile nose section was found yards from the launcher with the guidance assembly still attached." The Army board of inquiry isolated the cause as an electrical short caused by rain water in the junction box on the outside rear of the launcher control trailer. This condition defeated the crew's pre-launch safety checks.[41]
18 April
Second prototype Lockheed XFA Starfighter, , c/n , is lost when airframe sheds the bottom ejection seat hatch fairing during 20&#;mm gun firing causing an explosive decompression. Test pilot Herman R. "Fish" Salmon ejected as aircraft broke up, injured landing in rough country.[42]Joe Baugher cites date of 14 April for this accident.
28 April
Ten crew are "killed while flying" (KWF) when a Boeing BABN, ,[43] piloted by Victor C. Marston,[44] of the st Air Resupply Group, 20th Air Force, on a routine low-level training mission, strikes a hill on the south end of Okinawa,[45] three miles (5&#;km) from Naha Airport, as it gropes through overcast.[46] This was the st's first major accident.[45] Sp3C Lee L. Bean, Artillery, U.S. Army, on duty with the First Composite Service Unit, is awarded the Soldier's Medal for his attempts to rescue any survivors when he voluntarily enters the fiercely burning wreckage in which oxygen bottles are exploding and removes several victims with no regard for his own safety before abandoning his efforts when it becomes clear that there are none alive.[47]
3 May
Four U.S. Army personnel are killed in a nighttime crash of a helicopter on main post at Fort Benning, Georgia.[48] A Sikorsky H Chickasaw crashed and burned in a heavily wooded area half a mile from a housing development while on a routine training flight at Fort Benning. Killed were: Capt. Earl J. Scott, pilot; Capt. Robert F. Carter, pilot; SFC. Herman W. Punke; and Sgt. Horace G. Connor.[49]
5 May
A twin engine target tow plane, Douglas JD-1 Invader,[50] the U.S. Navy variant of the Air Force B, crashes six miles south of the Jackson Creek Ranch[51] in the Black Rock Desert. A McDonnell F2H Banshee cut the tow cable, the target plane went into a dive and crashed. One enlisted man bailed out and survived, three others killed. The Banshee returned to Fallon Naval Auxiliary Station with a gash in its wing.[52]
8 May
An Ohio Air National Guard pilot, Maj. Charles C. Cook, 30, of Dayton, stays with his ship in order to give other crew a chance to bail out of their Douglas CADK, , c/n ,[53][54] when it developed engine trouble en route from Friendship Airport, south of Baltimore, Maryland, to Columbus. Of the 15 aboard, 11 elect to parachute. Three others stayed with the pilot or did not have time to jump, all of whom survived the crash landing with relatively minor or no injuries when the plane came down in the Belmont County Hills near St. Clairsville. One of the men who took to the chute was killed. He is identified as Sgt. Thurl Warren Starcher, 46, New Philadelphia. Five others were admitted to the Barnesville, Ohio, General Hospital; one with serious injuries. The plane was carrying 11 members of the all-Ohio National Guard rifle team on a return flight from Friendship Airport, Air National Guard officials said.[55]
13 May
On seventh and final flight of Northrop NA test vehicle for the Northrop XSM Snark, only two of which were successful, mission was cut short when the missile collided with its TA photo plane.[56]
17 May
"PORTSMOUTH, England AP – A navy fighter plane crashed into the funnel of the 36,ton British aircraft carrier Eagle today during deck landing exercises in the English Channel. The pilot was seriously injured. The admiralty said the plane was given a signal to make another circuit as it came into land. The pilot increased speed but the engine stalled and the plane plowed into the rear of the funnel, burying the engine in the steam pipes."[57] First cruise for full-scale training exercises without operational restrictions for the Westland Wyvern S Mk. 4, deployed aboard HMS&#;Eagle with Nos. and Squadrons, begins inauspiciously when Wyvern, VZ, '/J', of Naval Air Squadron,[58] attempting a go-around after misjudged approach, strikes ship's funnel, forcing the carrier to return to Portsmouth to have Armstrong Siddeley Python turboprop engine extracted from funnel "in which it was stuck like a dart." Repairs delay cruise by a fortnight.[59] An article published in the debut issue of Air Enthusiast Quarterly, by William Green and Gordon Swanborough, with Harald Penrose, incorrectly gives the accident date as 30 September
18 May
McDonnell Aircraft Corporation engineering test pilot Robert H. Strange is killed in the crash of an F3H-1N Demon naval fighter, BuNo , after the J40 engine flamed out. He had just completed a dive from 40, feet, above Mach, to test dynamic pressure in the radar compartment under these conditions. The engine died above 25, feet. The pilot tried repeated restarts with no luck until he had descended to 5, feet,[60] at which point he radioed that he was abandoning the plane and attempted to eject. The McDonnell-designed seat failed and Strange was killed as the jet impacted a cornfield near Carrollton, Illinois, about 55 miles northeast of St. Louis, barely missing a farm home "as it plowed a foot furrow in the earth. Strange's body was about feet from the wreckage."[61] Strange was born in Sumter, South Carolina, in He joined the U.S. Navy as an aviation cadet in June , and ended up flying with Marine air, – He was awarded the Air Medal, with two gold stars, and the Distinguished Flying Cross. He graduated from Clemson Agricultural College of South Carolina with a degree in mechanical engineering in , and did engineering work for Curtiss-Wright and Frigidaire for three years. He then served with the Marines again from to Strange joined the McDonnell Corporation as a design engineer in November , becoming a test pilot in October He is survived by his wife Shirley, and four children, David, Douglas, Susan and Jeffrey.[60]
25 May
Convair BJCF Peacemaker, A, c/n , of the 6th Bomb Wing, call sign Abbott 27, on a routine training flight, crashes at c. CST, in the southwest corner of Glasscock County, Texas, on the Drannon Ranch, c. miles (&#;km) southwest of Sterling City, Texas. The aircraft had apparently disintegrated due to thunderstorm or tornadic activity, losing its outer wing panels and all tail control surfaces, and impacted in a flat attitude with little forward motion. Aircraft wreckage was found in a 25 x 3-mile (&#;km) path on a heading of 66 degrees true. None of the 15 members of crew L were able to escape the damaged bomber and all hatches and ports were found still in place. The wings and forward fuselage burned on impact, with only the rear fuselage remaining. The aircraft had been preparing to land at Walker AFB, New Mexico, when it was lost. Due to the extended period that the crash site was kept secured while crew remains were recovered and identified, and wreckage from the disintegration was searched for (almost a week), there was some question as to whether the B was armed with a nuclear weapon, but there is no evidence to support this.[62]
27 May
A Boeing BEDT Stratojet, , returning from a night navigation training mission after slightly more than two hours aloft crashes on the runway at Lincoln AFB, Nebraska, at while landing.[63] Brake parachute failed and it overran the runway – no injuries. Joe Baugher cites date of 24 May. John Kodsi, aircraft commander, and Sgt. Edward Seagraves, plus two other crew survive.[64]
3 June
The General de Brigada Aérea (Chief of Staff) of the Fuerza Aérea Boliviana, Mayor Jorge Jordán Mercado, is killed when his aircraft crashes in Tapacari in eastern Bolivia. An air force sergeant also dies in the accident.[65] The two-sentence Associated Press item announcing Mercado's death, widely printed, does not identify the type of aircraft involved. The major was one of the first graduates of the Escuela Militar de Aviación (EMA) (Military Aviation School), founded in , and became its first commander in "He was a military aviator [of] outstanding performance. He commanded the Bolivian aviation as First Commander of the Air Force campaign during the Chaco War (–). The vast escalation during the Chaco War forced the school and most of the Bolivian air force to settle at Villamontes". "He participated in operations in support of Corrales and Toledo forts He received the Military Merit in the grade of "Comendador". He later served as Director of Aviation at the Ministry of Defence. He was member of the Supreme Court of Military Justice and Chief of Aviation until his death in the plane crash in the Quebrada of Patani, Cochabamba," this date.[66]Grupo Aéreo de Caza 31 – "Gral. Jorge Jordán Mercado", Bolivian Aerial Fighter Group "31" (GAC) is named for the late officer.[67]
4 June
A Royal Air ForceShort Sunderland sank on landing off Eastbourne, East Sussex with the loss of three of her thirteen crew. Survivors were rescued by RAF launches and the Eastbourne Lifeboat Beryl Tollemache.[68][69]
22 June
While approaching USS Oriskany (CV) for a night landing in the Sea of Japan, U.S. naval aviator John R. C. Mitchell's McDonnell F2H Banshee begins to sink. Mitchell turns but fails to clear the ship and crashes into the ship's fantail. The rear half of the airplane falls into the ocean in flames, but Mitchell sustains only minor injuries. Five sailors sleeping on the fantail are injured. When Mitchell calls the ship's ready room to report his status, the officers to whom he speaks initially refuse to believe that he is still alive. The incident will be immortalized in The Right Stuff by Tom Wolfe, which refers to Mitchell by the alias of "accident-prone Mitch Johnson".[70][71]
5 July
Sole prototype Supermarine Type , VX, crashes while flying out of Boscombe Down, this date.[72] Aircraft entered a spin at 10,&#;ft which deteriorated into a flat spin from which the pilot, Lt. Cdr. Rickell, could not recover. Late ejection due to problems with jettisoning the canopy and operating the ejector seat – the seat did not have time to separate, nor did the parachute have time to fully deploy – Pilot killed on impact with the ground. The aircraft was completely destroyed.[73]
Ramp strike of a VF F7U-3 on the USS&#;Hancockon 14 July resulting in the deaths of the pilot, two boatswain's mates and a photographers mate. LSOTed Reilly manages to sprint across fantail and gets clear. Photo by PH2 James Binkley.[74]
14 July
Vought F7U-3 Cutlass, BuNo , 'D ', of VF, suffers ramp strike on landing aboard USS&#;Hancock during carrier qualifications off the California coast,[75] disintegrating airframe spins off portside; pilot LCDR Jay Alkire, USNR, executive officer of VF, killed when airframe sinks, still strapped into ejection seat; also killed are two boatswain's mates, one photographer's mate, in port catwalk by burning fuel.[citation needed] Dramatic footage shot from port catwalk exists showing burning fighter going over the side. Footage: storycall.us?v=9CTdAzfo
4 August
Avro AshtonWB is damaged beyond repair at RAF Pershore, Worcestershire, United Kingdom, when a fire in the undercarriage causes severe damage to a main spar in one of the wings. The aircraft is Struck Off Charge on 30 November.[76]
8 August
Internal explosion aboard Bell X-1A, , while being carried aloft by Boeing B mothership, forces NACA pilot Joseph Albert Walker to exit aircraft back into the Superfortress, which is then jettisoned due to the full fuel load it carries, the rocket-powered testcraft coming down on the Edwards AFB, California bombing range.[77]
11 August

Main article: Altensteig mid-air collision

Two United States Air ForceFairchild C Flying Boxcar transports of the 10th Troop Carrier Squadron, 60th Troop Carrier Group, collide over Edelweiler, Germany, near Stuttgart, shortly after takeoff for training mission from Stuttgart Army Airfield near Echterdingen. CG, , c/n , piloted by Robert T. Asher, and CG, , c/n , piloted by Eugene L. Pesci, both crash.[78] In all, 66 died, 47 on one Fairchild C Flying Boxcar, and 19 on the other. Troops aboard were of the Army's th Engineering Battalion.[79][80]
19 August
Sixth of 13 North American Xs, GM, c/n 6, on Navaho X flight number 16, out of Edwards AFB, California, demonstrates planned automated landing on first AFMTC flight, but drag chute does not deploy after landing. The vehicle overruns the skid strip, the nosewheel collapses in the sand in the overrun, the tanks rupture, and the vehicle burns.[38][81]
25 August
Vought F7U-3 Cutlass, BuNo , of VF, suffers collapsed starboard main landing gear during a hard landing aboard USS&#;Hancock while she was operating in the vicinity of Hawaii.[82]
30 August
Vought F7U-3 Cutlass, BuNo , of VF, misses all the wires during a landing aboard USS&#;Hancock, operating off of Hawaii, and hits the barrier. "Although reported to have suffered only slight damage, it was struck off charge and never flew again."[82]
8 September
Boeing BA, , from Kadena AB, Okinawa, Japan crashed into the water approximately miles south-west of Okinawa after eight hours of flying on a routine low-level round robin training flight from Kadena, AB. Rescuers found an oil slick in the water along with life rafts and equipment from the aircraft, but unfortunately, they found no survivors or remains. Lost in the crash were: Pilots 1st Lt Wendell Von Bobber, Capt Walter Prolisco, and Maj Hubert Karcher, AOB 1st Lt Frank Mills, Navigators 2d Lt Robert George and Capt Richard Jones, VO 1st Lt Joseph Jelinek, FE's Maj Robert McConnell and TSgt LeRoy Nelson, Radio Operators SSgt Harold Matheis and A1C Bernard Hurteau, and Aerial Gunners A1C Maurice O'Shea and SSgt Thomas Steele. The cause of the crash remains unknown.
9 September
Douglas B Destroyer, from Hurlburt Field crashed near Alvin, Texas. Three crew members aboard the plane bailed out after their plane developed trouble at 37, feet. Capt. Arthur J. Manzo, radar observer-navigator, was critically injured and died of his injuries 11 September Other crew members included 1st Lt. David E. Moore, pilot, and S/Sgt. Robert J. Newland, gunner.[83]
13 September
Six people were killed when a North American B suffered engine failure on takeoff from Mitchel AFB, New York, and crashed into Greenfield Cemetery, Hempstead, New York, five minutes after departure. Three of the victims were crew members, and three were passengers. The names of the dead were withheld pending notification of next of kin.[84] BJ/NC, , modified to TBN, then to VBN,[85] was piloted by James D. Judy.[86]
14 September
USAFDouglas ABDL Invader, , loses starboard engine on take off from 5,foot-long runway 12/30, Mitchel AFB, New York, runs through perimeter fence on southeast side of field, comes to rest on the Hempstead Turnpike. Port undercarriage leg collapses, port prop blades bent. No injuries.[87] Another source identifies this airframe as ABDL, , and the pilot as John E. Mervyn.[86]
6 October
McDonnell Aircraft company test pilot George Shirley Mills bails out of McDonnell F3H-2N Demon, BuNo ,[88] over Carrollton, Illinois near St. Louis, Missouri after what appears to be a massive systems failure, including the J40 engine. Instead of crashing, fighter circles over two states for more than an hour sans canopy, ejection seat and pilot. It eventually impacts in cornfield near Monticello, Iowa, miles (&#;km) from ejection.[89] Mills will pass away on 25 May [90] The whole J40 project, upon which Westinghouse had staked their engine division's future, suffered developmental delays and never lived up to the performance expectations anticipated, and the engine was considered unusable due to reliability problems, especially in the development of a functional afterburner. The J40 project was cancelled entirely in , and aircraft designed to use it were either cancelled outright, like the Grumman XF10F Jaguar, downgraded in performance expectations like the F3H Demon (six airframes and four pilots lost out of the initial production run), with Time Magazine calling the Navy's grounding of all Westinghouse-powered F3H-1 Demons a "fiasco", with 21 unflyable planes that could be used only for Navy ground training at a loss of $ million.[91] The A3D Skywarrior and F4D Skyray had been designed to permit replacement powerplants of a larger diameter and length and were subsequently fitted with the Pratt & Whitney J57 in lieu of the troubled J40, but the F3H required an enlarged fuselage and revised wing to accommodate an Allison J71, the only viable substitute, but even this combination was underpowered. The Westinghouse Aviation Gas Turbine Division would shut down shortly thereafter.
13 October
A Boeing BBBW Stratojet, , of the th Bombardment Wing,[92] crashes while taking off from March Air Force Base, California, coming down in what is now the Sycamore Canyon Wilderness Park, northwest of the base. Capt. Edward Anthony O'Brien Jr., pilot, Capt. David James Clare, co-pilot, Major Thomas Francis Mulligan, navigator, and Capt. Joseph M. Graeber, chaplain, are all killed.[93] Crew chief Albert Meyer, of Westchester, California, was not flying with his aircraft that day because he had already exceeded his flight hours. In the accident report, Col. Frederic Huish, investigation board president, concluded the primary cause of the accident was unknown, due to lack of positive evidence.[94][95]
14 October
A Strategic Air CommandBoeing BEBW Stratojet, 52–,[96] crashes while attempting landing on 3,foot (1,&#;m) runway 27 at NAS Atlanta, Georgia, shearing off tail and coming to rest beside runway. This facility is now DeKalb-Peachtree Airport.[97]
15 October
A Lockheed TALO Shooting Star trainer, , crashes into Santa Monica Bay.[98] Pilot Richard Martin Theiler, 28, and co-pilot Paul Dale Smith departed Los Angeles International Airport at PST aboard the TA, bound for Yuma, Arizona. This was an IFR departure, with instructions to report 2, feet (&#;m) on top of overcast. The Los Angeles weather at the time was 1, feet (&#;m) overcast, 4 miles (&#;km) visibility, in haze and smoke. After they were given clearance for takeoff they were never seen nor heard from again.[99] Plane was found in [] by aviation archaeologist G. Pat Macha and a group of volunteers, in feet of water.[93]
24 October
Eleventh of 13 North American Xs, GM, c/n 11, on Navaho X flight number 17, out of Cape Canaveral, Florida, an engine problem results in a mission abort. After autolanding the nose wheel develops a shimmy, the vehicle runs off the skid strip, catches fire, and is destroyed.[38]
25 October
Boeing WBABN Superfortress, , c/n , of the 53rd Weather Reconnaissance Squadron, out of RAF Burtonwood, experiences multiple problems including failed fuel feed pump, head winds, while returning from "Falcon" mission to polar region; pilot orders bail out of crew shortly before midnight as fuel exhaustion becomes critical, all eleven survive, with only one minor injury. Aircraft comes down near Kirkby Lonsdale, Lancashire, England, burns, only rear fuselage and tail remaining intact.[][]
2 November
Air Force Douglas BCDT Invader, , crashed into houses on Barbara Drive in East Meadow, Long Island, New York. An aerial photograph of the crash scene, "Bomber Crashes in Street", by George Mattson, of the New York Daily News, earned him, and 25 of his newspaper colleagues, the Pulitzer Prize Photography Award.[] KWF are Captain Clayton Elwood and Sergeant Charles Slater.[]
4 November
While operating in the Pacific with the 7th Fleet, USS Hancock flies aboard Vought F7U-3 Cutlass, BuNo , 'D',[] of VF, but tailhook floats over all wires, jet hits barrier, and ejection seat is jarred into firing when nose gear collapses.[][] Pilot LTJG George Barrett Milliard,[] in his seat, is thrown feet down the deck and suffers fatal injuries when he strikes the tail of an AD Skyraider. Airframe written off.
17 November
Douglas MCM Skymaster, A, c/n /DO, tail number O, built as a CEDO and later converted to an MCM, attached to the 57th Air Transport Squadron, th Air Transport Group, of the Military Air Transport Service, at Kelly AFB, Texas, piloted by 1st Lt. George Manuel Pappas, Jr., 27, and co-piloted by 2d Lt. Paul E. Winham, 24, crashes into Mount Charleston,[] c. 20 miles (32 km) WNW of Las Vegas, Nevada, at c. , while on a routine flight with technical personnel from the Lockheed "Skunk Works" at Burbank, California, where it had picked up passengers after departing Norton Air Force Base, California.[] Aboard were a mixture of military staffers and civilian subcontractors, engineers and technicians. It was en route to Groom Lake, Nevada, the secret Area 51, when it was blown off course by a severe storm, killing all 14 on board, nine civilians and five military.[] A knot crosswind had pushed the C into a canyon towards the mountain. The aircraft was climbing, using rated military power, with 10–15 degrees of flaps to get on top of the overcast, when it impacted, skipped about 60 feet, and slid another 20 feet before partially burning, coming to rest almost at the crest of the ridge.[] Because of the secrecy involved with the Lockheed U-2 project, the C crew was never in contact with Air Traffic Control, and, off course and lost in clouds, an error in plotting the position of the Skymaster in relation to the Spring Mountains range resulted in the crash only 50 feet below the crest of an 11,foot ridge leading to the peak of Mount Charleston. Military guards prevented newsmen from approaching the crash area, and a cover story was issued that this was a business flight to the Atomic Energy Commission's Nevada Test Site.[] Lockheed subsequently assumes responsibility for the flights to "Watertown", using a company-owned C[] Pappas had logged 1, hours flying Cs, and co-pilot Paul Winham, hours. Pappas was posthumously promoted to the grade of Captain, USAF, effective 15 September , as announced in Department of the Air Force Letter Orders dated 2 December [] Also KWF were Flight Engineer Tech S/Sgt. Clayton D. Farris, 26; and Flight Attendant Guy R. Fasolas, and ten others: S/Sgt. John Hamilton Gaines, USAF, th Air Intelligence Service Group, 23; Harold Silent, 59, of the Hycon Manufacturing Company that produced the U-2 camera; Fred Hanks, USAF, 35, of Hycon Mfg. Co.; Rodney Kreimendahl, 38, Lockheed Company; Richard Hruda, 37, Lockheed; James Francis Bray, 48, of the Central Intelligence Agency; Terence O’Donnell, 22, CIA Security Officer; James William Brown, 23, CIA Security Officer; Edwin Urolatis, 27, CIA Security Officer; and William Henderson "Bill" Marr, 37, CIA Security Officer.[]
17 November
One of the pilots of two USMCGrumman F9F Panther fighters (of VMA&#;?) that collided over the Mojave Desert near Lancaster, California, was killed this date. The dead pilot was identified as Lt. Donald R. Roland, formerly of Itasca, Illinois. The pilot of the other plane, Lt. Robert F. Heinecken, of Riverside, California, made an emergency landing and was uninjured. The planes were from MCAS El Toro, California.[]
29 November
Royal Air ForceGloster Javelin FAW.1, XA, on flight out of RAF Boscombe Down, entered spiral at 39, feet (12,&#;m) from which the pilot could not recover. He ejected and the aircraft came down, largely intact, at Ashey, Isle of Wight.[]
30 November
B crash occurred just after Thanksgiving Barksdale B tail No. of the st Bomb Wing, commanded by Major Robert Slane, was deep into an ORI (operational readiness inspection) mission, flying over Canada and preparing to refuel, when the airplane experienced aileron power unit problems and went into an uncontrollable spin. Slane ordered a bailout and survived, but the other crew members – pilot 2nd Lt. Richard J. Martin, copilot 2nd Lt. Donald S. Petty and observer 1st Lt. Max Workman – perished. The plane crashed near Seagull lake about 45 miles north of Port Arthur now Thunder Bay. Slane was recovering 19 further south at Ray Lake the morning after the crash.
December
Second Sud-Aviation, SNCASO SO Trident II -, short-range interceptor, is destroyed on its first flight.[]
7 December
First prototype Martin XP6M-1 Seamaster, BuNo , c/n XP-1, first flown July 14, , disintegrates in flight at 5, feet (1,&#;m) due to horizontal tail going to full up in control malfunction, subjecting airframe to 9 G stress as it began an outside loop, crashing into Potomac River near junction of St. Mary's River, killing four crew, pilot Navy Lieutenant Commander Utgoff, and Martin employees, Morris Bernhard, assistant pilot, Herbert Scudder, flight engineer, and H.B. Coulon, flight test engineer.[]
9 December
A USAFRepublic FFRE Thunderstreak, ,[] based at RAF Sculthorpe, suffers flame-out and after several failed attempts at a relight, the pilot, Lt. Roy G. Evans, 24, ejects at 3, feet. The fighter comes down on the Lodge Moor Infectious Diseases Hospital on the outskirts of Sheffield at , striking two wards, killing one patient, Mrs. Elsie Murdock, 46, of South Road, Sheffield, and injuring seven others. Fires are under control by [][]
15 December
An RAF Bristol Sycamore helicopter, XG, crewed by Flight Sergeant P. A. Beart and Sergeant E. F. Hall, departed from RAF Leuchars, Scotland at to perform a sea winching exercise at the Bell Rock lighthouse. At approximately , the helicopter's tail rotor struck the anemometer on the top of the lighthouse, and as a result, the aircraft crashed into the sea. The incident was witnessed by a second helicopter which immediately transmitted a distress call and flew to the scene of the crash. In response to the distress signal, four aircraft, a further two Sycamore helicopters, an RAF rescue launch and three lifeboats searched the area, recovering the body of XG's navigator. The body of the pilot was not recovered. The lighthouse was damaged, including the loss of its light, but its keepers remained uninjured. Due to bad weather, the lighthouse could not be repaired until after 20 December, when conditions permitted delivery of supplies.[]
16 December
Republic YFARE Thunderchief, , the first prototype, crash lands at Edwards AFB, California. Republic test pilot Russell M. "Rusty" Roth was forced to make an emergency landing after the right main landing gear had been torn away after having been inadvertently extended during high speed flight. Pilot uninjured. Although the airframe was returned to the factory, it was deemed too costly to repair.[][][]

[edit]

5 January
Sole Piasecki YHA Turbo Transporter helicopter prototype, , breaks up in flight at c. [] and crashes near Swedesboro, New Jersey, near the Delaware River, while returning to Philadelphia, Pennsylvania, from a test flight over New Jersey. The cause of the crash was later determined to be the aft slip ring, which carried flight data from the instrumented rotor blades to the data recorders in the cabin. The slip ring bearings seized, and the resultant torque load severed the instrumentation standpipe inside the aft rotor shaft. A segment of this steel standpipe tilted over and came into contact with the interior of the aluminum rotor shaft, scribing a deepening groove into it. The rotor shaft eventually failed in flight, which in turn led to the aft blades and forward blades desynchronizing and colliding. The aircraft was a total loss, the two test pilots, Harold Peterson and George Callaghan, were killed. This led to the cancellation not only of the YH, but also the planned sixty-nine-passenger YHB version.[]
10 January
The most notorious incident of aircraft pitch-up known as the "Sabre dance" was the loss of brand new North American FCNA Super Sabre, , flown by Lt. Barty R. Brooks, a native of Martha, Oklahoma, and a Texas A&M graduate, of the th Ferrying Wing, Detachment 12, Kelly AFB, Texas, during an attempted emergency landing at Edwards AFB, California, which was caught by film cameras set up for an unrelated test. The aircraft was one of three being delivered from North American's Palmdale plant to George AFB, California, but the nose gear pivot pin worked loose, allowing the wheel to swivel at random, so he diverted to Edwards which had a longer runway.[] The pilot fought to retain control as he rode the edge of the flight envelope, but fell off on one wing, hit the ground, and exploded with fatal results. These scenes were inserted in the movie The Hunters, starring Robert Mitchum and Robert Wagner.[][] The incident was also commemorated in the fighter pilot song "Give Me Operations" (set to the tune of the California Gold Rush song "What Was Your Name in the States?"):[]
"Don't give me a One-Double-Oh
To fight against friendly or foe
That old Sabre Dance made me
crap in my pants
Don't give me a One-Double-Oh."[][][]
Reports that the pilot was asphyxiated by throwing up into his mask are untrue. His helmet and oxygen mask were not on his head when rescuers found him. Both were found in the wreckage. Lt. Brooks was interred in Round Grove Cemetery, Lewisville, Texas. Film of this accident has been used as a training aid by both the Air Force and the Navy.[] Footage: storycall.us?v=mZL0x-gEDM8Archived at the Wayback Machine
20 January
Gloster Meteor NF 12WS of the Royal Air Force clipped a tree and crashed into buildings at Wadhurst, East Sussex, United Kingdom. Both crew were killed, as were two people on the ground.[]
26 January
“ENID, Okla. (UP) – Three officers from Vance Air Force Base were killed Thursday when a B25 bomber disintegrated in air and crashed in a field southwest of here. The Air Force identified the victims as 1st Lt. Peter F. Schermerhorn, Piedmont, Calif., as instructor, and 2nd Lt. James Fuller Glass, Durham, N.C., and 2nd Lt. Donald Russell Zynda, Detroit, student pilots.”[]
27 January
“TOKYO (AP) – Five U.S. Sabre Jets crashed in the Far East Friday – four after they ran out of fuel near Okinawa and one in Japan. The pilots escaped unhurt. The loss, running to about two million dollars, was the costliest single day’s toll of Sabres in the Far East since the Korean War. An Air Force spokesman said four Sabres were returning to Okinawa from a brief training flight when they changed course to skirt bad weather and ran out of fuel. The fifth bounced into a field of radishes on takeoff and started to burn. The four F86Fs of the 44th Fighter-Bomber Squadron based at Kadena, Okinawa, were on a ‘routine training mission,’ the Air Force said. It said one pilot landed on Okinawa near Okuma and three others were rescued from the East China Sea, which is between Okinawa and Red China. The pilots were identified as Lt. George E. Tims, Wyandotte, Mich.; Lt. Walter H. Fears, Crewe, Va.; Lt. Leonard M. Weeks Jr., Milwaukee, Wis.; and Lt. John Bradick III, Flossmore, [sic] Ill.”[]
30 January
"PORTERVILLE (UP) – A Navy guided missile launched from the Mojave Desert in Southern California broke away from its guiding aircraft Monday and crashed into an orange grove yards from a farm house near here. Fragments of the craft, which plowed a furrow 25 feet long and 10 feet deep through the grove, were scattered over a yard area. There were no reports of injuries or property damage. A piloted control plane, probably a jet, was flying a ‘close wing position’ to the craft when it got away due to bad weather conditions encountered 'during a routine training mission or a test', the navy said. Navy spokesmen said the craft carried no explosives. They would not immediately release an exact description of the craft, saying it was classified information. But they said it was considered to be a radio-controlled ‘drone’ aircraft. Spokesmen said the pilot of the control craft ‘did all he could’ to control the drone before it crashed.”[]
31 January
USAF North American TBN Mitchell, , "converted for passengers", on cross country flight from Nellis AFB, Nevada to Olmsted AFB, Pennsylvania, after departing Selfridge AFB, Michigan suffers fuel starvation northeast of Pittsburgh, Pennsylvania in mid-afternoon, attempts to divert to Greater Pittsburgh Airport, ditches in the Monongahela River at the mile (&#;km) marker, west of the Homestead High-Level Bridge, drifts c. miles (&#;km) downstream in 8–10 knots current, remaining afloat for 10–15 minutes. All six crew evacuate but two are lost in the 35&#;°F (2&#;°C) water before rescue. "Police, a heroic truck driver and rivermen combined to pull the four survivors from the stream, swollen by recent rains and melting snow. None of the survivors suffered serious injury. 'I felt like a block of ice when I was brought into shore,' said storycall.us Alfred J. Alleman, 36, of Las Vegas, Nev. 'I was hanging on a log with the others but it couldn't support all of us and I set out for shore because I guess I'm an above-average swimmer. I'm sure glad I was. That river was mighty chilly and the current (about 15 miles an hour) was strong.'" The other survivors were Maj. William L. Dotson, 33, pilot, of San Antonio, Texas, commander of the Nellis AFB Weather Office; Capt. John F. Hamieson, 32, Mechanicsburg, Pennsylvania; and Airman 2d Class Charles L. Smith, 18, Philadelphia. storycall.us Walter E. Soocey, 32, of Palmer, Alaska, was listed as missing, along with an unidentified passenger whose name was withheld pending notification of next of kin.[] Search for sunken bomber suspended 14 February with no success – aircraft is thought to have possibly settled in submerged gravel pit area in 32 feet (&#;m) of water, c. feet (46&#;m) from shore, possibly now covered by 10–15 feet of silt. This crash remains one of the Pittsburgh region's unsolved mysteries.[]
1 February
Vought F8U-1 Crusader, BuNo , crashes north of Edwards AFB, California, Vought test pilot Harry T. Brackett killed.[]
8 February
A flight of eight Royal Air ForceHawker Hunter F1s was redirected to another airfield due to inclement weather. With low visibility over the alternative airfield and little fuel left, six aircraft ran out of fuel and crashed, with one pilot killed.[]
14 February
US Army de Havilland Canada U-1A Otter, , c/n 93, encountered wake turbulence. The aircraft broke up in mid-air and crashed in Toronto, Canada. 4 killed.[]
16 February
First crash of a Boeing B Stratofortress when B, 53–,[] of the 93rd Bomb Wing, Castle Air Force Base, suffered an explosion of an electrical power panel located on the alternator deck blowing off the cover and causing a fire. The cover jammed the regulator valve of the left hand forward alternator disabling the over speed protection and resulting in an over speed failure. Wreckage comes down near Sacramento, California. Four crew eject, four killed. The failure mode was determined later when another B experienced a similar incident that blew off the rear right hand electrical power shield cover but did not cause a fire and Boeing pilot, Ed Hartz, landed safely at Boeing Field in Seattle.
17 February
Douglas R5D-2 Skymaster, BuNo , 'WC ', on flight from MCAS El Toro, California to NAS Alameda, in low overcast and drizzle, strikes Sunol Ridge on ranch c. miles (&#;km) north of Niles, California at Aircraft broke up and burned, killing 35, all but one of them Marines.[]
24 February
USAF Douglas CC Globemaster II, , en route from Goose Bay, Labrador, to Upper Heyford in the United Kingdom, lost power in number one and four engines (port and starboard outer). Restricted data cargo was jettisoned over the North Atlantic, including nuclear weapon firing and maintenance sets from an altitude of 8, to 9, feet (2,&#;m). The Air Force assumed that the cargo packaging ruptured and sank after impact with the sea. Impact area searched, nothing recovered. On its return flight to Robins AFB, Warner Robins, Georgia, in the U.S. on 2 March, the aircraft crashed in the Atlantic c. &#;nmi (&#;km) southwest of Keflavik, Iceland. The aircraft and 17 crew were lost in 3, feet (&#;m) of water.[] "The plane ran into difficulty on the northbound trip when two motors failed and it was thought that the ship would have to be ditched. However, it was shepherded into a safe landing with the assistance of the air-sea rescue planes from Keflavik base in Iceland. The two motors were replaced and the ship thoroughly inspected before starting the return trip. Just after midnight of Friday the plane radioed three of its four engines were dead and it was losing altitude rapidly. Then the radio went dead. Later Saturday morning [3 March] search planes found only two bits of wreckage – a flame-scarred oxygen bottle and a shattered piece of plywood – picked up near the position from which the final message had been radioed." One of the victims was T/Sgt. Joseph Kaltner, 32, of Crestview, Florida, a year veteran of the Air Force who had seen action as a gunner in WW II and in the Korean campaign. He was assigned at Robins Air Force Base, Georgia. He is survived by his widow, the former Roslyn Clary, of Crestview; one child, Keitha, 1; his mother, Mrs. Anna Kaltner, and two sisters, Mrs. Theresa Lampman and Mrs. Anna Sapp, all of Trenton, New Jersey, Sgt. Kaltner's home prior to his marriage.[]
2 March
Two FD Scorpions, and , of the st Fighter-Interceptor Squadron, th Fighter Group, 25th Air Division, out of Paine AFB, Washington, crash into Sheer Rock-Granite Spires on Whitehorse Mountain, near Darrington in an attempt to 'thread the needle' while flying advanced maneuvers in mountainous terrain. All four airmen perish high on a rocky cliff and deep in the wilderness.[] Killed in , the last of fifty block DNO Scorpions built, is 1st Lt. Hal Nathan Williams, although no second crewman is listed in the accident report. Killed in , the sixth of 25 block DNO Scorpions built, are 1st Lts. Wilford H. Taylor and Norman Dean Petersen.[][]
3 March
"TACOMA, Wash., March 3 (AP) – A huge, crippled refueling aerial tanker was nursed in to a safe landing by its pilot today after 10 other members of the crew parachuted to safety. The plane was a KC96 [sic] Boeing Stratocruiser converted to feed fuel aloft to big jet bombers. The tanker was flying near McChord Air Force Base south of here when the crew leaped to safety. McChord officials said all 10 men had been accounted for."[]
4 March
"HALSINGBORD, Sweden, March 4, (AP) – Four Swedish jet fighters flying in close formation crashed on a fog-shrouded hill near here today and exploded. The air force said all four pilots perished. A spokesman said the three trailing jets in the formation apparently followed the leader into the foot hill. The spokesman blamed a failure of instruments in the leading plane. The four (J 28) Vampire jets were engaged in a local maneuver."[] The J28B aircraft, all of F14, on a local flight out of Halmstad, departing there at local time, were flying over the waters of Skälderviken in foggy conditions when, due to an incorrect scale in reading maps, they struck the north side of Kullabergsvägen, near Kullaberg, scattering wreckage and body parts over a x meter area. Some parts hung from trees and one engine was found on the other side of the mountain, having been thrown more than a kilometer. The flight impacted Gregers Hill, a high point of Eastern Kullaberg with three peaks of which the northernmost is the highest. With its meters above sea level, it is also Kullaberg's second highest point after Håkull.[] Post-crash fires were extinguished by the snow cover. "The last radio contact with the planes was when they passed Bjärehalvön, they reported an altitude of about meters when they announced that the weather had cleared up slightly."[] Captain Nils Ahlqvist left a widow and two daughters, but the other three pilots (identities not yet found in the archives) were younger and unmarried.[][][][] The original mission plan called for 12 Svenska Flygvapnet J28s from Halstad to participate in this exercise in southern Sweden but the foggy conditions caused that to be cut back to just the four Vampires lost in this accident, considered to be one of Swedish aviation history's worst tragedies.[]
10 March

Main article: B disappearance

One of four United States Air Force Boeing BE Stratojet bombers of the th Bomb Squadron, th Bomb Wing (M), out of MacDill AFB, Florida, en route non-stop to Ben Guerir Air Base, Morocco, BEBW, 52–, Inkspot 59, misses tanker meet over the Mediterranean. Extensive search never turns up plane, crew, or two DE nuclear capsules.[] Lost are Captain Robert H. Hodgin, Aircraft Commander, 31; Captain Gordon M. Insley, Observer, 32; and 2nd Lt. Ronald L. Kurtz, Copilot, []
13 March
An AFJS Fury jet carrier fighter crashes near Rantoul, Kansas during a training flight, killing the pilot, United States naval aviator and Olympic diving gold medalist David "Skippy" Browning. Browning was training for the Summer Olympics at the time of his death.[]
21 March
"WACO, Tex. (AP) – A B25 missing overnight from Connally Air Force Base was found wrecked in a pasture about 50 miles (80 km) southeast of here Thursday. Highway patrolmen said the six airmen aboard were killed. There was a possibility turbulent weather figured in the crash. Winds with gusts to 35 miles per hour (56&#;km/h) an hour and some tornadoes lashed through central Texas Wednesday night. None of the victims was from California."[]
22 March
Douglas AD-5N Skyraider, BuNo , '95', one of a pair on a low-level navigational flight out of NAS North Island, San Diego, California, crashes into Martinez Mountain in the Santa Rosa Mountains, possibly due to a fuel management problem, killing all 3 Navy crew members from Squadron VC[][] "SAN DIEGO (AP) – The Navy said one of its AD5 Skyraider planes crashed and burned Thursday 12 miles southeast of Palm Springs. There was no evidence the pilot survived, the pilot of another Skyraider that was flying wing to the formation reported. The flight was from San Diego Naval Air Station. A ground rescue party was dispatched to the scene, in rugged terrain at the 5, foot level on the side of a mountain. Identity of the pilot was withheld, pending notice to relatives. Capt. Henry Erwin, of the 42nd Air Rescue Squadron of March Air Force Base, Riverside, reported sighting smoking wreckage from the air at a level of about 5,&#;ft (1,&#;m). The country is too rough for dropping parachutists. The Riverside County sheriff's office at Indio started a posse to the scene and four men of the 42nd left March AFB for the area. A Palm Desert woman, Leah Jones, who was out gathering cactus, reported she saw the two planes, then saw smoke rising from the side of a mountain."[] "RIVERSIDE (AP) – A search party, after a five-hour hike Friday through barren desert mountains, reached the wreckage of a crashed Navy attack bomber and reported finding three bodies. The Navy identified the dead as Lt. (j.g.) Richard H. Haffner, the pilot, whose widow, Jane, lives in San Diego; Donald D. Leeper, 36, aviation machinist 2.C, whose widow, Elizabeth Marie, lives in San Diego; John M. Cooper, 20, aviation electronics man 3.C, unmarried, whose father, John T. Cooper, lives in Jacksonville, Fla. The AD5 from San Diego Naval Air Station crashed Thursday on the slope of a steep canyon at the 4,foot level in the remote Santa Rosa Mountains. The scene is about 60 miles (97&#;km) southeast of here, with the closest town the desert resort of La Quinta. A sheriff's posse radioed the news of finding the bodies. The terrain is so rugged, the report said, that helicopters probably will be required to remove the bodies. The downed plane was flying with another out of San Diego when the crash occurred."[]
22 March
NACABoeing P2B-1S Superfortress, BuNo , (built as BBW, ), "Fertile Myrtle",[] with seven crew aboard, carrying the second Douglas D Skyrocket, BuNo , NACA , for airdrop from 30,&#;ft (&#;km), experiences runaway starboard outer propeller while climbing over Palmdale. Pilot Stanley P. Butchart immediately noses over and releases the rocket plane early, pilot John B. "Jack" McKay dumps rocket propellants before landing on Rogers Dry Lake, whereupon the number four prop disintegrates, throwing blades into the starboard inner engine, through the fuselage, and into the port inner engine. "Butchart's aileron controls were useless. Copilot Neil A. Armstrong nursed the bomber home on the other three engines and made a perfect landing. All of the fliers are NACA personnel based at nearby Lancaster."[]
23 March
On 1 February , an Escondidio, California, rancher filed suit against the government for damages caused by the crash of a Navy jet plane on this date. "His Federal Court complaint, asking $6,, said as a result of the crash, his hens stopped laying, his crops were trampled and a fissure in his well caused it to dry up."[]
25 March
First prototype Martin XB, , crashes in sand dunes near Biggs AFB, El Paso, Texas, killing both crew. Pilot was Maj. James O. Rudolph, 36, who was dragged from the crash site with severe burns and conveyed to Brook Army Hospital at San Antonio where he succumbed to his injuries 16 April Eddie Wilkerson, a high school tennis coach, whose car was narrowly missed by the bomber, stopped and pulled the pilot from the wreckage.[] The flight engineer was S/Sgt. Wilbur R. Savage, 28, of Rte. 3, Dawsonville, Georgia.[77] The aircraft was staging to Eglin AFB, Florida at the time of its crash for filming of scenes for the motion picture Toward the Unknown.[] After stopping for refuelling, the bomber began its take-off run at , but smashed through the fence at the end of the southwest runway and then began to disintegrate, spreading wreckage along a yard trail. There was some initial confusion about the aircraft type as rescuers found the "Gilbert XF" name applied to the airframe for the film on the wreckage.[][][]
26 March
"MASONTOWN, Pa. (AP) – A twin-engine Navy plane carrying a crew of three crashed Monday into the Monongahela River. State police said there was no sign of any survivors."[]
26 March
"PENSACOLA, Fla. (AP) – Three fliers were killed and a fourth is missing in a fiery collision of two naval trainer planes over Baldwin County, Alabama, Monday. The planes were from Saufley Field, an auxiliary of the Naval Air Station."[]
Pre March
"SAN DIEGO (UP) – Ryan Aeronautical Co. spokesmen Tuesday disclosed three company employes [sic] were burned when fire damaged a secret vertical-takeoff jet aircraft. The fire occurred in a hangar at Edwards Air Force Base, the spokesmen said. Those burned were Walter Kirby, Cardiff, John Howard, San Diego, and Howard Bianchi, Escondido."[] This was the Ryan X Vertijet.
28 March
A Boeing BBBW Stratojet, , of the th FTW, McConnell AFB, Kansas, suffers explosion in bomb bay fuel tank and sheds its wings over East Wichita, Kansas,[64] crashing four miles (6&#;km) northeast of the city, killing three crew. The office of information services at McConnell Air Force Base, said the explosion occurred after takeoff, probably at about 2, feet (&#;m) altitude. Lt. Maurice Boyack, pilot of a Navy Lockheed P2V Neptune bomber, out of Naval Air Station Hutchinson, Kansas, said the explosion occurred in a climbing turn. He flew his bomber to a point where he could see the wings rip off the B He said it appeared there was a fire in the midsection, followed by the explosion. Firefighters battled the blaze at the crash scene for more than an hour. The plane crashed within 1, feet (&#;m) of two large suburban houses. Officials at McConnell AFB identified the pilot and instructor as Capt. William C. Craggs of Wichita. He is survived by his widow and two sons. The students were Lt. Col. William H. Dames, 39, of Oconomowoc, Wisconsin whose wife and two sons are reported to be living in Milwaukee; and 1st Lt. John C. Leysath, 24, of North, South Carolina.[]
28 March
A McDonnell F Voodoo crashes on the Mojave Desert just north of Edwards Air Force Base, California, after civilian test pilot William Ross successfully bails out.[] FAMC, , written off.[]
28 March
The ton motorship Motul suffers an engine room explosion and fire while c. 60 miles off the coast of Yucatán in the Bay of Campeche early this date. A Mexican NavyConsolidated PBY Catalina responds, and takes aboard some of the 35 survivors of the sunk Motul who took to life rafts, but as it attempts takeoff one of its propellers breaks, disabling it. The following day, the lost ship's 14 crew, 21 passengers, and three naval aviators are all rescued by the Mexican coast guard cutter Virgilio Uribe, which also takes the PBY in tow as it makes its way to Progreso, Mexico.[]
30 March
Three crew are killed and two seriously injured as a Norton AFB, California,-based Beechcraft C Expeditor on a training flight to McNary Field, Salem, Oregon, rams a rocky hilltop in squally weather on Friday night and catches fire seven miles south of Klamath Falls, Oregon. The survivors who were thrown clear of the wreckage, PFC Leroy D. Wigglesworth, of Gladstone, Oregon, and A2C Virginia F. Bowman, of Portland, Oregon, were taken to a hospital suffering from shock, burns and broken bones. It took rescuers 2 1/2 hours to work their way up a steep hillside to reach the wreckage. They reported three bodies were burnt. The air force withheld the identities of the dead pending notification of next of kin.[] CH, . The plane was coming in for a refueling stop when it struck the 4,foot high ridge. The three victims were: Lt. Col. Frank Loughary, of 5th Street, San Bernardino, chief of military personnel division for the San Bernardino Air Materiel Area, survived by a brother in South America; Lt. Col. Mabry Simmons, who was taking graduate studies at Norton related to his Air Force post at University of Southern California, survived by his widow at Morado Place, Altadena; and S/Sgt. Ray Matzinger, unmarried, his mother Velma Govera lives Eldridge Street, San Fernando, California. A2C Bowman was catching a ride home from Eglin AFB, Florida, where she is stationed, as was PFC Wigglesworth, stationed at Fort Ord, California.[]
3 April
A Boeing B Superfortress departs Randolph AFB, San Antonio, Texas, and heads northwest on a training mission. Shortly thereafter, at , it strikes the WOAI-AM radio mast, knocking it down, and crashing into a cornfield north of the tower. Five of six crew survive.[][]
3 April
USAF Fairchild C Flying Boxcar with five aboard goes missing on a flight between Tachikawa Air Base and Ashiya Air Base, Japan. Wreckage sighted on 5 April at the 6, foot level of a 6,foot peak on Shikoku Island, 20 miles (32&#;km) south of Saijo, and more than miles southwest of Tokyo. "An attempt will be made Friday to reach it with a rescue team dropped by parachute."[]
5 April
Grumman test pilot Ernie von der Heyden bails out over EdwardsFlight Test Center, California, when his Grumman F11F Tiger develops trouble of an undisclosed nature while on a routine test flight. "He landed at the edge of a dry lake in uninhabited desert country 10 miles (16 km) from Edwards Air Force Base. He was picked up by helicopter and taken to the Edwards hospital for treatment of what the Air Force called non critical injuries. The plane crashed in the lake bed." Von der Heyden lives in Lancaster with his wife and three children.[] F11F-1, BuNo , lost due to engine failure, loss of control.[]
6 April
A Boeing BEBW Stratojet, , c/n ,[] of the th Bomb Wing departs Lincoln AFB, Nebraska, at c. on a northern heading. Approximately 15 minutes later, it exploded and burst into flames at c. 2, feet (&#;m) altitude, crashing three miles (5&#;km) south and 3/4 miles east of Ceresco, Nebraska. The crew of four, one over the normal crew complement, was killed.[63]
6 April
A USAF Douglas CC-DL Globemaster II, , c/n , of the st Air Transport Wing, crashes just after takeoff from Travis AFB, California, killing three of the seven crew on board. Aircraft stalled at feet (30 m), dropped one wing and plunged to the ground just southwest of the base. Airframe splits into three sections, burns. The cause is attributed to incorrect assembly of the elevator and aileron control cables.[][]
6 April
A Northrop FC Scorpion crashes in flames between Great Falls, Montana, and Malmstrom Air Force Base, just after a takeoff from that base, killing both crew. The navigator was identified as 2d Lt. Alton A. Nelson, 22, of West Sacramento, California. He had been assigned to the th Ferrying Wing, Detachment 1, at McClellan AFB, California. The name of the pilot was withheld. The plane was being ferried to a base in Alaska.[]
19 April
A U.S. Navy Grumman F9F-6 Cougar,[] out of NAS Glenview, Illinois, loses control at 19,&#;ft (10&#;km) over Lake Michigan. Reserve pilot ejects but his chute apparently fails to deploy. The plane falls into shallow water about a half mile off of Fort Sheridan and the canopy from the aircraft is recovered by personnel at the fort but there was no sign of Lt. Cmdr. Gordon Arthur Stanley (13 July – 19 April ),[] 35, assigned to the staff of the chief of naval air reserve training. Stanley, formerly of Oakridge, Oregon, lived with his wife and three children in Arlington Heights. "Officials at Glenview said the plane was one of two on a training flight. The flyer who returned reported that a few seconds after the planes went into clouds at 19, feet, Stanley reported by radio that he was 'losing control'. Glenview sent out a helicopter and flying boat PBY air-sea rescue unit, and within a few minutes both reported seeing the lost plane in shallow water half a mile off the fort. Neither saw any trace of the pilot." Navy officials said that the accident occurred at and that they were notified by phone from Fort Sheridan within five minutes. The rescue units were airborne at [] Stanley was an ace, having scored eight victories with VF[] while flying from the USS Princeton.[][]
19 April
A Lockheed TV-2 Shooting Star from an auxiliary field of Naval Air Station Corpus Christi, Texas, with one aboard, and a twin-engine Beechcraft from NAS Corpus Christi, with three aboard, collide over the outskirts of Corpus Christi, killing all four, and scattering wreckage over an area of a square mile. There was only minor property damage on the ground and no injuries reported. All the bodies are recovered.[]
22 April
A Royal Canadian NavyMcDonnell F2H-3 Banshee, BuNo , flown by Lt. D.A. "Duke" Wardrop of test squadron VX, inexplicably descends into dense clouds and disappears over the Atlantic Ocean off Yarmouth, Nova Scotia during a ferry flight from Naval Air Station Quonset Point, Rhode Island, US, to naval air station HMCS Shearwater, Nova Scotia, Canada. The pilot of a second Banshee accompanying Wardrop's aircraft attempts to contact him by radio, but no response is heard, and no traces of the missing pilot or aircraft are ever found, despite an extensive search effort by the RCN and the United States Navy. Equipment failure and hypoxia are suspected causes.[]
24 April
Ninth of 13 North American Xs, GM, c/n 9, on Navaho X flight number 21, out of Cape Canaveral, Florida, ground control system failure results in missile crashing at sea at Mach &#;km from the Cape.[38]
2 May
A USAF Boeing BEBW Stratojet, , c/n ,[] of the 98th Bomb Wing (also reported as of the d Bomb Squadron, th Bomb Wing), crashes short of runway, Lincoln AFB, Nebraska. One account states that it was on instrument approach. Another states that it came down "three miles short of the Northwest runway after departing on an evening training mission. Eyewitnesses said the plane appeared to be trying to belly in for a landing, crashed, then exploded and burned. The crash site was on farmland owned by Edmund Nelson, ½ mile west of 79 Hi-way and 2 ½ miles north of U.S. "[] KWF are Captain Marion J. Perdue, aircraft commander, 33, San Antonio, Texas; 2nd Lieutenant Linwood M. McIntosh, co-pilot, 22, Dallas, Texas; Captain Charles H. Stonesifer, navigator/bombardier, 35, Maricopa, California; and Staff Sergeant William F. Rockholt, crew chief, 24, Fellows, California. All crew were from the th Bomb Squadron.[64]
8 May
A USAF Martin BC-MA Canberra, , crashes on the Ship Shole island bombing range near Langley AFB, Virginia, killing both crew. From the accident report: "Cause of accident – Undetermined: The aircraft was observed to be flying in a northeasterly direction at an estimated feet altitude and traveling at a high rate of speed. It was probable that the speed was knots indicated, because this was the prebriefed airspeed since the aircraft was on the run-in route on the LABS bombing range. Witnesses observing the aircraft reported that everything appeared to be normal. The aircraft was then seen to abruptly dive and disappear; this was followed by an immediate explosion. The instructor pilot and the pilot of this dual control BC received fatal injuries."[]
15 May
A RCAFAvro CF Mk. IVB Canuck, , of Squadron, out of CFB Uplands, falling from 33, feet (10,&#;m) crashed into Villa St. Louis, a convent of the Grey Nuns of the Cross in Orleans, Ontario, Canada between roughly and (reports vary). "[T]he million dollar brick buildingwas demolished."[] 15 people were killed; both crewmen of the aircraft, a priest, 11 nuns and one other woman.[][] "Mrs. Marie Flora, who lives nearby, said the plane swooped over her home in flames and crashed into the three-story convent building between the second and top floors. There was a big explosion. 'They never had a chance,' she said."[]
15 May
Fifth Lockheed U-2A, Article , 56–, delivered to the CIA on 16 December , crashes at Groom Lake, Nevada, killing Agency pilot Wilburn S. "Billy" Rose. Aircraft had just departed Groom with a full fuel load, but an underwing pogo hung up. Pilot attempted to return to try to shake it loose, but let angle of bank increase too much and fully fuelled starboard wing kept dropping.[]
5 June
A USAF Northrop FDNO Scorpion fighter jet, ,[] of the 18th Fighter-Interceptor Squadron armed with live rockets, strikes an automobile during an aborted take-off at Wold-Chamberlain Field, Minneapolis, Minnesota, United States, killing three of the five occupants of the vehicle; both F crew members survive.[]
9 June
A Grumman F9F-4 Panther, BuNo ,[] of VMF, flown by a USMC Reserve pilot crashes into a row of houses near Wold-Chamberlain Field, striking the home at 46th Avenue South, Minneapolis, Minnesota, United States. In addition to killing the pilot, Maj. George E. Armstrong, the crash kills five and injures twelve on the ground, most of whom are young children. This is the second time in five days that a military jet operating from this airport crashes and kills multiple civilians on the ground.[]
9 June
Shorts chief test pilot, New Zealand-born, ex-RNZAF, RAF, and ETPS-trained Squadron Leader Walter J. "Wally" Runciman, flying Short SB.6 Seamew, XE, the fourth Seamew prototype, in a demonstration at the Sydenham Air Display, Sydenham Airport, Belfast, Northern Ireland, is killed when the exhibition "went wrong" and the aircraft crashed.[] The aircraft entered a slow roll. The nose fell and the pilot seemed to be trying to finish with a half loop, but with insufficient height, the aircraft struck the runway nose first, with fatal result.[] This airframe had been flown by Runciman for a series of sales tours in to Italy (March), Yugoslavia (April) and West Germany (May).
16 June
A USAF MATSDouglas CA Globemaster II, , inbound to Enewetak Atoll, Pacific Ocean, carrying nuclear test device components (possibly for the EGG device fired during the Operation RedwingMohawk test) crashed feet (&#;m) short of, and eight feet below, the runway at Enewetak Island, shearing off its landing gear and coming to rest 2, feet (&#;m) from the southeast end of the runway. Fire ensued, extinguished within three hours. No loss of life – most of the cargo, although damaged by water and foam, was recovered. The runway was cleared of wreckage and reopened to normal traffic before noon on 17 June:. Salvage of certain aircraft components was accomplished by a team from Hickam AFB, Hawaii.[]
26 June
A USAFBoeing KC of the th Air Refueling Squadron, th Bomb Wing, crashes shortly after an take off from Walker AFB, New Mexico, coming down in an open field 10 miles (16&#;km) south of the base near Roswell, killing all eleven crew. The tanker caught fire shortly after departure on what the Air Force described as a training flight. Observers on the base flight line said that it spun into the ground and exploded. "Word of the crash was not released by the Air Force until more than three and a half hours after the flaming tragedy, on orders of Col. George W. Porter, the base commander."[]
28 June
An Argentine Air ForceVickers VC.1 VikingT-5 crashed at Resistencia, Argentina.[]
6 July
"ST. JOHN'S, Nfld. (UP)-A U.S. Air Force Stratotanker exploded and crashed in flames Friday in a desolate mountain area 45 miles east of Goose Bay air base in Labrador. All six crew members apparently were killed. Helicopters braved dangerous winds to hover over the crash scene. Only scattered wreckage was seen from the air. The pilot of an accompanying Stratotanker said he did not see any parachutes after the four-engined KC97 exploded and fell. The Air Force said the plane was one of four Stratotankers from Lake Charles Air Force Base on temporary duty at Goose Bay."[]
6 July
"HONOLULU (AP)-A Marine helicopter rescue team Friday identified from the air the wreckage of a two-engine Marine plane which crashed in rugged Oahu mountains with four men aboard. The Navy said the rescue team, which apparently was unable to land near the wreckage immediately, reported 'the tail section is still smouldering.' There were no reports of whether anyone is alive the Navy said."[]
7 July
A USAFAir Training CommandLockheed TALO Shooting Star, , c/n ,[92] of the th FMS, based out of Lackland AFB, Texas, crashes into side of Pleasant Mountain, four miles north-northwest of Denmark, Maine, killing Capt. Gordon L. Draheim.[] Cause determined to be disorientation and fuel exhaustion.[][]
7 July
"EL SEGUNDO (AP)-Test pilot Raleigh Guynes of Douglas Aircraft Co. bailed out safely from an F4D1 Skyray which went into a spin and crashed into the Pacific Ocean".[]
8 July
The pilot of a North American FF Sabre out of Norton AFB, California, is killed when he crashes in San Dimas, California, on Sunday afternoon, on W. Allen Street, digging a hole six feet deep and 30 feet wide. The aircraft, which one witness said came across San Dimas in a southeasterly direction, passed over a park and narrowly missed a group of Little League players picnicking there before striking power and telephone lines and exploding in the street where it ruptured a gas main and set fire to trees in the yard of Mr. and Mrs. Arnold Bayer. Several grass fires were extinguished as well. Air Force officials withheld the pilot's identity pending notification of the next of kin. His body was not immediately recovered.[]The Daily Sun, San Bernardino, California, reported on 10 July that the pilot was identified as Lt. Oliver L. Dillingham, 23, from Williams AFB, Arizona. He entered the Air Force in and saw service in Korea in The story also adds that the explosion after the crash set a house alight and slightly burned two girls.[]
13 July
USAF Douglas CA Liftmaster, , c/n , encountered windshear after takeoff at c. from McGuire Air Force Base, lost altitude and crashed in pine-wooded swamp near Fort Dix, New Jersey, 46 killed, 20 survivors.[] The aircraft broke into several pieces as it landed on its belly but did not burn. The aircraft, carrying 10 crew, 41 enlisted men, nine officers and six civilians, was bound for Burtonwood, England, and was taking servicemen and military dependents to foreign posts. Weather was described as rain and a hail storm. "Capt. Tom Hamrick, information officer at Dix, said the pilot apparently tried to level off and crash land. The plane cut a swath through the brush and pines for yards."[]
13 July
A USAF Boeing BEBW Stratojet, ,[17] of the 40th Bomb Wing[4] crashes and explodes at the end of the runway on take off from Smoky Hill Air Force Base, Kansas, killing all four crew. "Witnesses said the plane just got off the runway and cleared a fence before crashing and bursting into flames. The explosion followed."[]
13 July
Two North American F Sabres, of the 82d Fighter Squadron, collide in mid-air c. eight miles east of Dixon, California, and crash in an open field, the California Highway Patrol reports. Both pilots eject and parachute safely and are recovered by state officers, a patrolman said. The pilot of Gov. Goodwin J. Knight's plane, flying in the vicinity, spotted the chutes and radioed their position and then served as an observer until the CHP located the pilots. They were found to have suffered only minor injuries. "A spokesman at Travis Air Force Base identified the pilots as 1st Lt. Albert C. Mitchell and 1st Lt. Albert F. Crews of the 82nd Fighter Squadron at Travis."[]
13 July
"EL CENTRO (AP)-The pilot of an AD6 Skyraider was killed Friday when his plane crashed on the desert 25 miles (40 km) northwest of here during a practice dive bombing mission. The Navy said he was attached to a fleet air gunnery unit at the El Centro Naval Auxiliary Air Station. His name was withheld pending notification of the family."[]
13 July
"Belington, W. Va., July 13, UP – A navy Fury jet fighter plane en route from Patuxent, Md. naval air test center to Columbus, O., crashed, exploded and burned on a farm north of here today, killing the pilot Lt. Cmdr. Horatio Gates Sickel Jr."[] Aircraft was FJ-3, BuNo .[]
15 July
"CLAREMORE, Okla. (UP)-An Air Force pilot, with both engines gone, 'deadsticked' his C45 transport to a perfect landing between two underpasses on an uncompleted toll highway near here Sunday. The pilot, Capt. Charles Bixel, 38, Riverside, Calif., and his sole passenger, A-2C Josef Grafues, St. Louis, were not hurt. The plane was undamaged."[]
16 July
Test pilot Andrey G. Kochetkov attempts first flight in first of three flying prototypes of the ultra long-range, high-altitude single-seat super interceptor Lavochkin La, but encounters an unexpectedly rapid roll moment and loses control.[] Pilot survives.
17 July
"FALLON, Nev. (AP)-The runway arresting gear, plus his own sprinting ability, saved Navy jet pilot Stanley A. Roitz of Trinidad, Colo., from death or serious injury Tuesday. Roitz, 22, who just made lieutenant junior grade Monday, was taking off in an FJ3 fury [sic] jet when it suffered a sudden power failure before leaving the runway, at the Fallon Naval Auxiliary Air Station. The craft plunged into the net-like arresting gear at the end of the runway and came to a halt as it tumbled over the gear. Roitz dived out head first, somersaulted to land on his feet and took off running. The plane's fuel tanks exploded a moment later, setting a fire that consumed the craft. Roitz is regularly stationed at Moffett Field, Calif., but was here with his squadron for aerial gunnery practice."[] FJ-3, BuNo . upgraded to FJ-3M. with VF in , written off this date.[]
27 July
A USAF Boeing BEBW Stratojet, , of the th Bomb Wing from Lincoln AFB, Nebraska, crashes while making touch-and-goes at RAF Lakenheath, skidding off runway and into nuclear weapons storage igloo holding three Mark 6nuclear bombs, burns. No weapons in the facility go off and all are later repaired. Stratojet was unarmed.[] One of the most common myths about this accident is that the weapons, if they had detonated, would have "turned southeast England into a desert." The three Mark 6 bombs were in storage, and therefore no nuclear capsules were installed, nor stored in the building (the nuclear capsule was manually installed in the Mk 6, and only when airborne and just prior to strike). Each Mk 6 did contain at least 5, pounds of high explosives, and depleted uranium. Even if the weapons had detonated because of fire, there would not have been a nuclear reaction (U is not fissionable through high explosive compression or fire).[]
31 July
In a high-speed flight, prototype Folland Gnat, G, suffers tailplane flutter which breaks away. Folland test pilot bails out and descends safely, becoming first person to use the Folland/Saabejection seat in action.[citation needed]
2 August
U.S. Navy F2H-3 Banshee, BuNo , of VF, out of NAS Alameda, California, crashes at at the c. 11, foot level on Mt. Pinchot[] in the Eastern Sierra Nevadas near Bishop while on a practice strafing run,[] pilot LTJG Tulane Oden Phillips[] killed.[]
6 August
Spanish Air ForceNorth American FF Sabre, C.5–4 crashes.[]
16 August
The Battle of Palmdale was the attempted shoot-down of a runaway Grumman F6F-5K Hellcat drone by United States Air Force interceptors in the skies over Southern California. The drone was launched at PDT from Point Mugu Naval Air Station and soon went out of control. Northrop FD Scorpion interceptor aircraft of the th Fighter-Interceptor Squadron took off from Oxnard Air Force Base and caught up to the drone, but were ultimately unable to bring it down, in spite of expending all of their rockets. After it ran out of fuel, the unmanned aircraft crashed in a sparsely populated tract of desert.[] During the incident over acres were scorched and a substantial amount of property was damaged or destroyed.[]
27 August
Eighth of 13 North American Xs, GM, c/n 8, on Navaho X flight number 24, out of Cape Canaveral, Florida, a full-range test with final dive maneuver. Final flight of vehicle eight after three successful recovered missions. During takeoff the vehicle goes aloft, then settles back to the runway with its brakes locked. The tires burst, the gear fails, the gear doors come in contact with the runway, carving grooves in the pavement as they retract. Then, astonishingly, the vehicle rises from the runway, completes a successful full-range supersonic flight with terminal dive into the waters off Grand Bahamas.[38]
31 August
Fourteenth Lockheed U-2A, , Article , delivered to the Central Intelligence Agency 27 July Crashed at Groom Lake, Nevada, this date during a night training flight, killing pilot Frank G. Grace, Jr.[] Pilot became disoriented by lights near the end of the runway and flew into a telephone pole.[]
31 August
Boeing WBD Superfortress, 49–, c/n , "The Golden Heart", (built as a BDBO), of the 58th Weather Reconnaissance Squadron, out of Eielson AFB, Alaska,[] crashed early in the morning this date on a sandy island in the Susitna River, 50 miles (80&#;km) northwest of Anchorage, Alaska, killing all 11 crew. The flight was last heard from at local time, when it was over Talkeetna, a check-in station 50 miles north of the ten-mile-long island. The wreckage was found about 5 1/2 hours later by a member of the 71st Air Rescue Squadron. "All that remained when helicopters landed at the crash scene was a smoking pile of rubble."[]
10 September
During first flight of North American FA at Edwards AFB, California, prototype, , experiences problem with engine gearbox differential pressure during a dive, North American test pilot Bob Baker lands on dry lakebed at just under knots (&#;km/h), after rolling about a mile, aircraft hits a depression in the lakebed, nose gear collapses. Jet slides c. three-tenths of a mile on its nose, but suffers limited damage, no fire. Total landing roll was 22, feet (6,&#;m). Airframe repaired in under two weeks.[]
10 September
Boeing BBBO Superfortress, 47–, c/n ,[] modified as RBG with additional radar and BD-type nose, of the st Reconnaissance Squadron, out of Yokota Air Base, Japan, disappears over Sea of Japan. Probably went down in Typhoon Emma.[]
17 September
Boeing BB Stratofortress, 53–, of the 93d Bombardment Wing (Heavy), crashes after an in-flight fire while returning to Castle AFB, California. Lost wing in subsequent dive, crashing near Highway 99, nine miles SE of Madera, California. Five crew killed, two bailed out safely.[][]
17 September
Sixth Lockheed U-2A, Article , 56–, delivered to the CIA on 13 January , crashes during climb-out from Wiesbaden Air Base, Germany, when the aircraft of Detachment A, stalls at 35, feet (11,&#;m), killing Agency pilot Howard Carey. Cause of accident never satisfactorily determined.[]
21 September
Grumman company test pilot Tom Attridge shoots himself down in a Grumman F11F Tiger, BuNo , during a Mach 20 degree dive from 22, feet (6,&#;m) to 7, feet (2,&#;m). He fires two bursts from the fighter's 20&#;mm cannon during the descent and as he reaches 7, feet (2,&#;m) the jet is struck multiple times, including one shell that is ingested by the engine, shredding the compressor blades. He limps the airframe back towards the Grumman airfield but comes down at almost the same spot where the first prototype impacted on 19 October: Pilot gets clear before jet burns, suffers only minor injuries – investigation shows that he had overtaken and passed through his own gunfire.[]
27 September
Test pilot Mel Apt is killed on the 17th flight of the Bell X-2, 46–, out of Edwards Air Force Base
Источник: [storycall.us]

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  • Источник: [storycall.us]
    • Presented to Parliament as a return to an order of the House of Commons
    • Ordered by the House of Commons to be printed 11 March
    • HC number
    • © Crown Copyright
    • ISBN

    Executive Summary

    The Budget takes place against the backdrop of the global outbreak of COVID The fundamentals of the UK economy are strong and the government is well prepared to protect people’s health and support their economic security throughout this period of temporary economic disruption. The Budget sets out a plan to support public services, individuals and businesses that may be affected by COVID

    While the economy continues to face challenges, the government’s careful management of the public finances means that it is able to support the economy in the short term, while investing in the future. The Budget announces investments in the roads, railways and digital networks that will underpin growth over the coming decade, as well as the world-class hospitals, schools, colleges and police forces that people rely on every day.

    The Budget supports the government’s ambition for a fair and sustainable tax system that helps people and families with the cost of living, funds the first class public services they expect and creates an environment for business to succeed. The government will build on this across the Parliament, creating a tax system fit for the challenges and opportunities of the 21st century.

    The Budget also sets out a plan to invest in research and development (R&D) and cutting-edge technologies. It provides support for people in every nation and region of the UK to gain the skills that they will need as the economy evolves, so that the nation can seize the opportunities of the next decade and fulfil its potential.

    In the year that the UK hosts the COP26 UN climate summit, the Budget takes steps to decarbonise the economy and protect the UK’s natural habitats, ensuring that every part of the UK economy is ready for the challenges of decarbonisation, and ready to capitalise on the opportunities to become leaders in the green markets of the future.

    This is the first Budget of a new government, the first of a new decade, and the first since the UK’s departure from the European Union (EU). It is a Budget that lays the foundations of the UK’s future prosperity and delivers on the government’s promises to the British people.

    Economic context

    The UK economy has many strengths. It has a globally competitive tax system, it is home to many highly innovative firms, has a world-beating science and research base, and has sound, independent macroeconomic institutions. Employment growth remains strong – the employment rate reached a record high in the three months to December – and earnings growth remains above inflation.

    The recent COVID outbreak is creating short-term uncertainty. The Office for Budget Responsibility’s (OBR) economy and fiscal forecast does not reflect the now global spread of COVID nor an outbreak in the UK. The OBR notes that the spread and impact of a COVID outbreak clearly represents a downside risk to the forecast, but the scale is highly uncertain and the economic impact is likely to be temporary.

    Looking further ahead, the UK also faces challenges in the medium to long term. Productivity remains low compared to other countries and unevenly distributed across the country. And, in common with other advanced economies, the transition to a net zero emissions economy by will require radical changes in every sector. The Budget lays the foundations to address these challenges.

    Outlook for the public finances

    Over the past decade, the government has taken action to restore the public finances to health, reducing the deficit by four fifths. This, and the historically low cost of borrowing, mean that the government can support the economy in the short term, while providing significantly more investment in public services and infrastructure to support growth in the long term.

    The Budget launches the Comprehensive Spending Review (CSR), setting out the overall level of public spending within which the CSR will be delivered. The CSR will conclude in July and will set out detailed spending plans for public services and investment, covering resource budgets for three years from to and capital budgets up to

    The CSR will prioritise improving public services, levelling up economic opportunity across all nations and regions, strengthening the UK’s place in the world and supporting the government’s ambitions to reach net zero carbon emissions by It will focus on linking departments’ spending proposals to the real-world outcomes they seek to achieve, and delivering value for money for taxpayers.

    The policy changes set out in the Budget, including the spending totals that have been set for the CSR, have been delivered while ensuring the current budget is in surplus, public sector net investment does not exceed 3% of GDP and debt is kept under control.

    HM Treasury will review the fiscal framework ahead of Autumn Budget to ensure it remains appropriate for the macroeconomic context, while ensuring the sustainability of the public finances.

    Responding to COVID

    Public safety is the government’s top priority in its response to COVID and it is taking firm and comprehensive action, consistent with the best scientific evidence.

    As well as being focused on safety and the public health response to the outbreak, the government recognises that people will be concerned about the effect it will have on their livelihood, and business will be concerned about reduced demand, potential disruptions to supply chains and export markets, and to their workforce during this temporary period.

    The Budget announces a £12 billion plan to provide support for public services, individuals and businesses, whose finances are affected by COVID This includes a £5 billion COVID response fund to ensure the NHS and other public services receive the funding they need to respond to the outbreak as the situation develops, and recover and return to normal afterwards.

    For individuals it includes extending Statutory Sick Pay (SSP) for those advised to self-isolate, and those caring for others who self-isolate, and support through the welfare system for those who cannot claim SSP, as well as a hardship fund.

    Finally, the government will support businesses that experience increased costs or disruptions to their cashflow. This includes expanded Business Rates reliefs, a Coronavirus Business Interruption Loan Scheme to support up to a further £1 billion lending to SMEs, a £ billion grant scheme for small businesses, and a dedicated helpline for those who need a deferral period on their tax liabilities.

    Tackling COVID is a global challenge, and to complement our domestic response the Budget sets out steps the UK is taking to lead a swift and effective global response to deal with the impacts of the virus.

    The measures set out in the Budget to support health and other public services, protect people and families and support businesses will be reflected in the public finances at Autumn Budget

    Funding excellent public services

    The people of the UK are rightly proud of its world-class public services. The NHS, schools and police provide the security and support that allow the British people to lead safe, prosperous and healthy lives. The government is committed to providing the funding that public services need and ensuring that excellent services are available in every nation and region of the UK.

    Total departmental spending is set to grow twice as fast as the economy over the CSR period. Day-to-day departmental spending is set to grow at the fastest rate over a spending review period since Spending Review

    Within this, the government will increase funding for its number one spending priority: the NHS. Compared to , NHS England will receive a cash increase of £34 billion a year by In addition, the Budget commits over £6 billion of new funding over this Parliament, including to create 50 million more GP surgery appointments per year, ensure there are 50, more nurses, and fund wider commitments on hospital car parking and support for people with learning disabilities and autism. The Budget also sets out action to ensure that pensions tax rules do not deter doctors from taking on additional shifts.

    The government will invest in the security of everyone in the UK with additional funding for counter-terrorism policing and the UK intelligence community. The government will keep people safe with strengthened community sentences and increased victim support.

    Spending Round committed to a £ billion cash increase in funding for schools by The Budget builds on this by providing £29 million per year by to support primary school PE teaching and help schools make the best use of their sports facilities, as well as £90 million per year to introduce an Arts Premium from September to help schools provide high-quality arts programmes and extracurricular activities for pupils.

    Levelling up and getting Britain building

    The government is committed to levelling up across the UK by raising productivity and growth in all nations and regions, creating opportunity for everyone, and addressing disparities in economic and social outcomes.

    For too long the UK has under-invested in infrastructure, leaving many people stuck with delays and poor service.

    By the end of the parliament, public sector net investment will be triple the average over the last 40 years in real terms. In total, around £ billion of gross capital investment will be provided for roads, railways, communications, schools, hospitals and power networks across the UK by The government will publish a National Infrastructure Strategy later in the spring, and the CSR will provide full departmental spending plans. The Budget announces:

    • the largest ever investment in English strategic roads, with over £27 billion between and , enough funding to fill in around 50 million potholes across the country, and unprecedented investment in urban transport, with £ billion for five-year, integrated transport settlements for eight city regions on top of £1 billion allocated to shovel-ready transport schemes

    • funding for the Shared Rural Network agreement to radically improve mobile coverage in rural areas, and a record £5 billion investment in gigabit broadband rollout in the hardest-to-reach areas of England, Scotland, Wales and Northern Ireland

    • record funding of £ billion for flood defences between and , offering better protection from flooding for , homes and non-residential properties. Additional funding of £ million will help communities most at risk of flooding recover faster in cases where they are affected by flood damage

    • a £ billion increase in housing investment to support the commitment to build at least 1 million new homes by the end of the Parliament, and an average of , homes a year by the mids

    • the government will invest £ billion (£ billion including indicative Barnett consequentials) over five years in capital spending to refurbish further education colleges, and has committed to a new £ billion National Skills Fund to improve adult skills (£3 billion including indicative Barnett consequentials). It will also boost science, technology, engineering and maths teaching with capital investment for up to eight new Institutes of Technology and 11 maths schools. The government is committed to giving everyone the opportunity to fulfil their potential, regardless of where they are from.

    The government is also taking action to review the Green Book, which sets out how decisions on major investment programmes are appraised in order to make sure that government investment spreads opportunity across the UK.

    The Budget reaffirms the government’s commitment to strengthening the ties that bind the Union. As well as taking action that will support people and businesses in every nation of the UK, and targeted support to each nation, it sets out the funding the government will make available through Barnett consequentials for the devolved administrations to fund public services, infrastructure and other priorities.

    Supporting people and families

    The government is committed to taking action to help with the cost of living for everyone across the UK and ensure that the most vulnerable in society get the support they need.

    Alongside the Budget, the government is formally announcing a new, ambitious target for the National Living Wage (NLW) to reach two-thirds of median earnings and be extended to workers aged 21 and over by , provided economic conditions allow. Based on the latest OBR forecast, this means the NLW is expected to be over £ in

    This builds on the % increase of the NLW to £ an hour that takes effect from this April, meaning the government is on track to meet its current target of 60% of median earnings by Since the NLW’s introduction in real wages have grown fastest for the lowest paid full-time workers.

    As people earn more, the government is committed to reducing taxes on their wages. The Budget confirms a tax cut for 31 million working people with the increase in the National Insurance contributions (NICs) thresholds for employees and the self-employed, saving the typical employee around £ and a typical self-employed person around £78 in Taken together with increases to the NLW and to the Personal Allowance, an employee working full-time on the NLW anywhere in the UK will be over £5, better off compared to April

    The government is investing a further £ billion in the Affordable Homes Programme which in total will allocate £ billion of grant funding from to support the creation of affordable homes across England.

    The government is also helping people with the cost of living by freezing fuel duty for the tenth consecutive year, freezing all alcohol duties, applying a zero rate of VAT to e-publications, abolishing the tampon tax, and making it easier for parents of up to , school-age children to access Tax-Free Childcare.

    The Budget confirms the end of the benefits freeze and continues the rollout of Universal Credit to support the most vulnerable in society, with extra help for parents of sick or premature babies, carers and victims of domestic violence.

    The government will invest an additional £1 billion to remove unsafe cladding from residential buildings above 18 metres to ensure people feel safe in their homes.

    The Budget also includes action to reduce rough sleeping, providing £ million for accommodation and support services to help people off the streets.

    Backing business

    From the largest UK-headquartered multinationals to the smallest family-owned firm, businesses are the lifeblood of the UK economy. They have created 3 million new jobs since , giving more people the chance to succeed in life and provide for their families.

    The UK is one of the best places in the world to do business and the most attractive country for inward investment in Europe. The government is committed to unleashing businesses’ potential, and the Budget supports the development of the high-tech, high-skill jobs of the future.

    The government wants to ensure that the United Kingdom continues to be attractive to investment and remains a dynamic environment to start and grow a business. To cut the cost of taking on staff the government is increasing the NICs Employment Allowance to £4,, benefiting , businesses. At 19% the UK’s Corporation Tax rate remains the lowest in the G7 and G The government is reforming Entrepreneurs’ Relief, while continuing to support the vast majority of entrepreneurs and increasing tax incentives for businesses investing in structures and buildings, and R&D.

    The Budget also announces the launch of a fundamental review of business rates, due to report in the autumn.

    The Budget will help businesses to take advantage of opportunities for the UK outside the EU, for example through new financial support for British exporters and by investing in additional business support for SMEs through Growth Hubs. The government will also extend the Start-Up Loans Programme to ensure would-be entrepreneurs can access the finance they need.

    To ensure that the UK remains a dynamic and competitive regulatory environment, the government is launching a Reforming Regulation Initiative to collect ideas for regulatory reform, as well as implementing the recommendations of the Furman Review of digital competition, publishing further detail on the Financial Services Bill which will ensure that the UK maintains its world-leading regulatory standards and openess to international markets.

    Investing in innovation

    The UK’s success in the global economy will be rooted in innovation and cutting-edge technology. By driving technological change, the government will create the high quality, highly paid jobs of the future, the Budget sets out plans to increase public R&D investment to £22 billion per year by The government will invest that money in the people, ideas and industries that will cement the UK’s world-leading position in science and technologies ranging from nuclear fusion to electric vehicles and life sciences.

    This landmark investment is the largest and fastest ever expansion in support of researchers and innovative businesses, taking direct support for R&D to % of GDP and placing the UK among the top quarter of OECD nations – ahead of the USA, Japan, France and China.

    Achieving the government’s ambitions on R&D will require investment from the private sector. To boost that investment the government will increase the rate of R&D tax credits and consult on widening the definition of qualifying expenditure to include data and cloud computing.

    In life sciences, the government will provide the British Business Bank with additional resources to launch a dedicated £ million investment programme which is expected to enable £ million of investment, helping to ensure the UK remains a world leader in life sciences innovation.

    Growing a greener economy

    The UK has already cut carbon emissions by more than any other G7 country and in was the first major economy to legislate for a target of net zero greenhouse gas emissions by As the UK prepares to host this year’s COP26 UN climate summit, the Budget announces a range of policies to reduce emissions, ensure our environment is protected and resilient to climate change, and generate green economic opportunities across the nations and regions of the UK.

    Increasing the UK’s use of clean energy is a vital part of reducing carbon emissions and putting the nation at the forefront of new innovative industries. The Budget announces a Carbon Capture and Storage (CCS) Infrastructure Fund to establish CCS in at least two UK sites, one by the mids, a second by To encourage more environmentally-friendly ways of heating homes and other buildings, the government will also introduce a Green Gas Levy to help fund the use of greener fuels, increase the Climate Change Levy that businesses pay on gas, and reopen and extend the Climate Change Agreement scheme by two years.

    Road transport is responsible for 91% of domestic transport emissions, and around a fifth of overall UK emissions. To support drivers to move away from polluting vehicles, the Budget announces investment in electric vehicle charging infrastructure, which will ensure that drivers are never more than 30 miles from a rapid charging station, provides £ million for consumer incentives for ultra-low emission vehicles, and reduces taxes on zero emission vehicles.

    In addition, the government will promote air quality improvement by removing the entitlement to use red diesel except for agriculture, fish farming, rail and non-commercial heating. The government will tackle air pollution by providing £ million to help local authorities reduce nitrogen dioxide emissions and improve air quality.

    The government will also invest in the natural environment, planting enough trees to cover an area the size of Birmingham, restoring peatlands, and providing more funding to protect the UK’s unique plants and animals. The government will also go further to tackle the scourge of plastic waste by introducing a Plastic Packaging Tax, as well as providing further funding to encourage producers to make their packaging more recyclable.

    Budget decisions

    A summary of the fiscal impact of the Budget policy decisions is set out in Table 1. Chapter 2 provides further information on the fiscal impact of the Budget.

    Table 1: Budget policy decisions (£ million) (1)

    Total spending policy decisions,,,,,
    Total tax policy decisions++1,+3,+7,+7,+7,
    Total policy decisions+,,,,,
    1 Costings reflect the OBR's latest economic and fiscal determinants.

    Government spending and revenue

    Chart 1 shows public spending by main function. Total Managed Expenditure (TME) is expected to be around £ billion in

    Chart 1: Public sector spending

    Chart 1: Public sector spending

    Chart 2 shows the different sources of government revenue. Public sector current receipts are expected to be about £ billion in

    Chart 2: Public sector current receipts

    Chart 2: Public sector current receipts

    1. Budget Report

    Economy and Public Finances

    The UK economy has many strengths: a globally competitive tax system, some of the best universities in the world, is home to many highly innovative firms, and its economic prospects are underpinned by a strong macroeconomic framework. Since , the economy has grown faster than France, Italy and Japan. Employment is at a record high and the unemployment rate is the joint-lowest since In common with other advanced economies, the UK faces economic challenges. In the near term, the outbreak of COVID is expected to have a significant but temporary effect on the economic outlook. Productivity remains weak and is distributed unevenly across the country; and the transition to a net zero economy by will require radical changes in every sector.

    The Budget announces a plan to support the economy over the short term in response to the COVID outbreak. This includes measures to support public services, individuals and businesses.

    The Budget builds on the UK’s economic strengths and takes steps to address the UK’s long-standing structural challenges. The government is committed to levelling up across the UK in order to raise productivity and growth in all nations and regions, creating opportunity for everyone and addressing disparities in economic and social outcomes.

    Since , the government has restored the public finances to health after inheriting debt that had nearly doubled in two years. The deficit has been reduced by four fifths from a post‑war peak of %[footnote 1] of GDP in to % of GDP in

    With historically low borrowing costs and the public finances in a more secure position, the government can now increase borrowing for investment without compromising fiscal sustainability. The Budget provides significant levels of funding for public services to meet the economic challenges and priorities of today, and to address the long-term challenge of low productivity growth.

    This increase in spending, which provides the envelope for the upcoming CSR, has been delivered while meeting a set of fiscal rules that ensures the government is only borrowing to invest over the medium term, with the current budget in surplus, and that limits public sector net investment to an average of 3% of GDP, to keep control of borrowing and debt. To ensure the fiscal framework remains appropriate for the current macroeconomic environment HM Treasury will undertake a review over the summer and announce any changes by Autumn Budget

    Economic context

    The OBR’s economy forecast was closed for new data when the spread of COVID was at a much earlier stage. As such, the OBR’s forecast includes an estimate of the impact on global growth, based on the assumption that the spread of the virus would be relatively limited. The forecast does not reflect the now global spread of COVID or an outbreak in the UK.

    Global economy

    The International Monetary Fund (IMF) estimates that the global economy grew by % in , down from % in , and the slowest growth since the financial crisis (Chart 1). The COVID outbreak is expected to reduce global growth this year. The OBR forecasts that annual global GDP growth will be % in , down from % in its Spring Statement forecast. This includes an assumption that the outbreak would be “relatively limited” and its impact on the forecast “largely confined to a modestly weaker outlook for growth in world trade and the UK’s export markets.” The OBR notes that, since closing its global forecast to new data, “it has become clear that the spread of coronavirus will be far wider than assumed in our baseline forecast, pointing to a deeper – and possibly more prolonged – slowdown.”[footnote 2]

    There have already been clear signs that activity in China, where the outbreak began, has slowed. In its most recent economic assessment published on 2 March , the Organisation for Economic Co-operation and Development (OECD) downgraded its forecast for Chinese growth in by percentage points, to %.

    Highly integrated just-in-time manufacturing processes across the globe mean that disruption to Chinese output is likely to affect production globally. Lower Chinese growth will affect global demand. There will also be spillovers through financial markets and potential hits to business and consumer confidence.

    The OECD has produced two scenarios. In the ‘baseline’ scenario it assumes the virus is contained largely in China and revised down expectations of global growth in from % to %. In a second scenario, assuming broader contagion, the OECD suggests that global growth could be reduced more significantly in , to %.

    Chart Global GDP growth

    Chart Global GDP growth

    UK economy

    The OBR closed its forecast before the spread of COVID in the UK, noting that this means “the precise forecasts for the economy … can no longer be regarded as central.”[footnote 3] As an open economy, the UK will be affected because of the wider impacts the outbreak is having on the global economy. The OBR’s estimate of the impact on global growth, based on the spread of the virus being relatively limited, reduces UK GDP growth by percentage points this year.

    The impact of a wider spread outbreak of COVID on the UK economy is highly uncertain. The drivers of any economic impact are health-related factors, including how many people get infected, the persistence of an outbreak and measures put in place to protect public health and prevent the spread. There will likely be significant, temporary disruption to the economy. Disruption could include temporary absences from work and interruptions to global supply chains, both of which would constrain the UK’s productive capacity for a temporary period. In addition, the economy could be affected by a reduction in consumer spending and lower business investment, largely reflecting the response to measures to contain the outbreak, and weaker demand for UK exports.

    Growth

    The Office for National Statistics (ONS) estimates that the UK economy grew by % in , percentage points higher than in Delays to the UK’s departure from the EU affected the profile of economic activity throughout , leading to volatility in quarterly growth over the year.

    Growth is distributed unevenly across the UK. England has historically had the highest GDP growth, averaging % between and Over the same period, Wales grew at an average rate of %, while Scotland and Northern Ireland both grew at an average rate of %. Growth is also uneven at a regional level – London has seen the fastest growth of all regions, averaging % between and , while the North East of England had an average growth rate of %, the slowest of all regions.

    Over the forecast, the OBR has revised down its forecast for cumulative GDP growth by percentage points, largely reflecting downward revisions to potential productivity and net migration. The OBR expects GDP growth of % in , revised down from % in its Spring Statement forecast, with weaker contributions from both consumption and business investment growth. The OBR expects annual consumption growth to be % and for there to be no growth in business investment in (Chart ). GDP growth is then expected to increase to % in before slowing slightly, reaching % in

    Chart UK GDP – contributions to annual GDP growth

    Chart UK GDP – contributions to annual GDP growth

    The labour market and earnings

    Employment is at a record high. The number of people aged 16 years and over in paid work was million in and was at a record high of million in the three months to December The employment rate – the proportion of people aged 16 to 64 who are in paid work – also reached a record high of % in the same period (Chart ). The OBR expects the employment level to increase further over the forecast period, reaching million in

    Chart UK employment and unemployment rates since (1,2)

    Chart UK employment and unemployment rates since ,2

    The unemployment rate – the proportion of the economically active population (those in work plus those seeking and available to work) who are unemployed – was % in the three months to December , the joint-lowest in over 40 years. The OBR expects the annual unemployment rate to remain at % in and , before rising to % by

    Every nation and region of the UK has higher employment and lower unemployment than in Wales has seen the largest reduction in its unemployment rate since , of  percentage points. There are million more people in work than in , with over 60% of the increase taking place in UK nations and regions outside London and the South East. Table  gives national and regional labour market statistics for the three months to December 

    Earnings growth remains above inflation. Nominal wage growth (including bonuses) and regular nominal wage growth (excluding bonuses) were % and % respectively in the final quarter of Over the same period, real total pay growth was % and real regular pay growth was %. The OBR forecasts average earnings to grow by % in and rise to % in [footnote 4] It then expects growth to fall back to % by

    Rising real wages have helped to support the growth of real household disposable income (RHDI) per head, a measure of living standards. RHDI per head grew by % in the year to Q3 , down from % in the year to Q2 The OBR expects annual growth in RHDI per head of % in , before reaching % by [footnote 5]

    Table National and regional employment and unemployment rates (3 months to December )

    Employment rateUnemployment rate
    Actual (1)Difference from UK average (3)Actual (2)Difference from UK average (3)
    North East
    North West
    Yorkshire & the Humber
    East Midlands
    West Midlands
    East of England
    London
    South East
    South West
    Wales
    Scotland
    Northern Ireland
    United Kingdom
    1 Employed people as a percentage of the population (aged ).
    2 Unemployed people as a percentage of the economically active population (aged 16+).
    3 Percentage points.
    Source: Office for National Statistics

    Productivity

    UK labour productivity (measured as output per hour) did not grow at all in , following subdued growth of % in This weakness has partly contributed to the OBR’s judgement to revise down potential productivity growth – the underlying rate that determines how quickly productivity can grow sustainably – by an average of percentage points per year across the forecast.[footnote 6] The OBR does note that “the significant planned increase in public investment potentially boosts productivity by raising the public capital stock, but we have assumed that the effect is likely to be felt mainly beyond our forecast horizon.”[footnote 7]

    The UK’s level of productivity has been lower than that of other advanced economies since the s. The UK’s level of productivity is more than 20% lower than other major advanced economies such as the US, France and Germany (Chart ). In addition, UK productivity growth has slowed more since the financial crisis than other advanced economies. UK productivity growth has averaged % since , slowing from % in the decade prior. By comparison, growth across the G7 has averaged % since , compared to % in the decade prior.

    Chart Comparison of productivity levels relative to US

    Chart Comparison of productivity levels relative to US

    There is wide variation in productivity within the UK. As measured by output per hour, the only two areas with average levels of productivity above the UK average in were London (% higher than the UK average) and the South East (% higher than average). Productivity can vary significantly within each of the nations and regions as well as between them (Chart ).

    In the long term, higher productivity remains the only path to sustainable economic growth and rising living standards. Investing in skills and infrastructure to improve productivity across the UK permits growth by enabling firms to pay higher wages, offer goods and services at lower prices, and increase their profits. Productivity improvements, by enhancing economic growth, are also a fundamental source of long-run growth in tax receipts and the government’s ability to fund public services. A low average level of productivity – as well as significant variation between and within regions – are signs of untapped economic potential. The government is committed to levelling up investment across nations and regions to improve living standards nationally, as well as to address disparities in economic and social outcomes.

    Chart Spread of productivity across the UK, (1,2,3,4)

    Chart Spread of productivity across the UK, ,2,3,4

    Prices

    The annual rate of Consumer Prices Index (CPI) inflation was % in , down from % in Inflation fell through much of , reaching % in the final quarter of the year, before increasing to % in January The ONS’s headline measure of inflation, the Consumer Prices Index including owner occupiers’ housing costs (CPIH), was also % in January [footnote 8] The OBR forecasts CPI inflation to be % in , gradually rising to % in and , and settling at % by

    Alongside the Budget, the government and UK Statistics Authority (UKSA) are launching a consultation, announced on 4 September ,[footnote 9] on UKSA’s proposal to address the shortcomings of the Retail Prices Index (RPI) measure of inflation. The consultation will cover, among other things, the issue of timing, including whether the UKSA’s proposal might be implemented at a date other than , and if so, when between and , and issues on technical matters concerning the implementation of its proposal. The consultation will be open for a period of six weeks, closing on 22 April The government and UKSA will respond to the consultation before the Parliamentary summer recess.

    Current Account

    The current account measures the flow of goods, services, income and transfers between the UK and the rest of the world. In , the current account balance widened to a deficit of % of GDP from % in This was driven by a widening of both the trade and income deficits. The current account deficit averaged % of GDP in the first three quarters of The OBR expects the current account deficit for the whole of to be %. It is then forecast to remain close to % of GDP throughout the forecast period.

    Monetary Policy

    The Monetary Policy Committee (MPC) of the Bank of England has operational independence to set monetary policy to meet its primary objective of price stability and, subject to that, to support the economic policy of the government, including its objectives for growth and employment.

    Independent monetary policy is a critical element of the UK’s macroeconomic framework, alongside sustainable public finances and a resilient financial system. Low and stable inflation supports living standards and provides certainty for households and businesses, helping them make decisions about saving, investment and spending.

    The Chancellor is responsible for setting the MPC’s remit. In the Budget, the Chancellor reaffirms the symmetric inflation target of 2% for the month increase in the CPI measure of inflation. This target applies at all times.[footnote 10] The Chancellor also confirms that the Asset Purchase Facility (APF) will remain in place for the financial year

    Table Summary of the OBR’s central economic forecast (percentage change on year earlier, unless otherwise stated) (1)

    Forecast
    GDP growth
    GDP growth per capita
    Main components of GDP
     Household consumption (2)
     General government consumption
     Fixed investment
       Business investment
       General government
       Private dwellings (3)
     Change in inventories (4)
     Net trade (4)
    CPI inflation
    Employment (millions)
    Unemployment (% rate)
    Productivity per hour
    1 All figures in this table are rounded to the nearest decimal place. This is not intended to convey a degree of unwarranted accuracy. Components may not sum to total due to rounding and the statistical discrepancy.
    2 Includes households and non-profit institutions serving households.
    3 Includes transfer costs of non-produced assets.
    4 Contribution to GDP growth, percentage points.
    Source: Office for National Statistics and Office for Budget Responsibility.

    Public finances

    Since , the government has restored the public finances to health after inheriting a deficit at a post-war high and debt that had nearly doubled in two years. The deficit has been reduced by four-fifths from a peak of % of GDP in to % of GDP in [footnote 11] As Chart and show the cost of government debt as a share of government revenues is now at a post-war low, due to historically low interest rates on government borrowing.

    With low borrowing costs and the public finances in a more secure position, the government can support the economy and fund the response to COVID in the short-term and take action over the medium-term to drive growth and improve public services, without compromising fiscal sustainability. In addition to short-term support for the COVID response, the Budget provides for a significant medium-term increase in day-to-day spending on public services. With historically low borrowing costs, it is right that the government borrows to invest in the country’s future and address challenges. The government is therefore borrowing to fund a new set of growth-enhancing policies focused on delivering a step-change in infrastructure investment, which aims to raise the UK’s productivity growth in the long-run.

    Chart Debt interest to revenue ratio from to

    Chart Debt interest to revenue ratio from to

    Chart Historical quarterly year gilt yields from to

    Chart Historical quarterly year gilt yields from to

    The fiscal framework

    This Budget has been delivered to meet the following fiscal rules:

    • to have the current budget at least in balance by the third year of the rolling five-year forecast period

    • to ensure that public sector net investment (PSNI) does not exceed 3% of GDP on average over the rolling five-year forecast period

    • if the debt interest to revenue ratio is forecast to remain over 6% for a sustained period, the government will take action to ensure the debt-to-GDP ratio is falling

    The Budget also sets the spending envelope for the upcoming CSR within these rules, which allow for significant investment in growth-enhancing infrastructure while maintaining control of day-to-day spending. They allow policy to meet the economic demands of today while ensuring that borrowing and debt remain under control. Chart shows that public sector net debt has stabilised after the sharp rise driven by the financial crisis and is expected to be broadly stable across the forecast period. The rules also provide the flexibility to respond fully to near-term shocks to the economy and public finances such as from COVID

    Chart Public sector net debt from to

    Chart Public sector net debt from to

    Interest rates are expected to remain at very low levels for an extended period. This has prompted an international debate around the implications of this environment for fiscal sustainability and the role of fiscal policy. In this context, the Chancellor has announced that HM Treasury will conduct a review of the UK’s fiscal framework, to:

    • ensure that it remains appropriate for the current macroeconomic environment

    • support the ambitious new policy agenda of the government to invest in and level up every part of the country

    • keep the United Kingdom at the leading edge of international best practice in macroeconomic policy

    The review will report back by Autumn Budget , to allow the government to confirm its fiscal objectives for the Parliament. It will be undertaken by HM Treasury and will involve broad consultation with external experts from across the UK and internationally. The review will be guided by the following principles:

    • fiscal policy should support the government’s economic objectives, while maintaining the sustainability of the public finances by keeping control over borrowing and debt

    • low and stable inflation should be supported, as an essential pre-requisite to deliver the government’s economic objectives

    • the UK’s existing institutional strengths in fiscal policy making – the independent Office for National Statistics (ONS) producing official economic and fiscal statistics, and the independent OBR producing the official economic and fiscal forecasts and assessing the government’s performance against its fiscal objectives – should be preserved and built on

    The review will consider the following areas:

    • The low interest rate environment: It has been argued that, given persistently very low interest rates, there is further fiscal space to borrow for investment. This needs to be weighed against the risks posed by high levels of public debt, for example from rapid changes in economic conditions and from longer-term fiscal pressures. The review will look at how to balance the opportunities and risks within the fiscal framework.

    • Macroeconomic stabilisation: The review will consider the case for a more active role for fiscal policy in stabilising the economy, especially if there is reduced space for monetary policy due to low interest rates. This will be judged alongside consideration of the extent to which active fiscal policy can provide timely and effective demand management, and the implications for wider policy objectives and fiscal sustainability. The review will look at how to reflect these trade-offs within the fiscal framework.

    • Incentives for value for money prioritisation: The fiscal framework should support the prioritisation of public investments which most enhance growth. The review will consider whether some well-evidenced spending, beyond what the current international frameworks class as capital investment, is currently disincentivised. This will include an assessment of the practical challenges in evolving the framework: including measurement issues, consistency with internationally recognised statistical and accounting frameworks, how other countries have approached these issues, and the need to balance fiscal sustainability objectives.

    • Developments in the management and measurement of the balance sheet: Completion of HM Treasury’s Balance Sheet Review discussed in Box 1.A in the summer provides an opportunity to consider its conclusions and options to improve the management of loans, guarantees, contingent liabilities, and wider balance sheet transactions. The review will also consider the strengths and limitations of using broader balance sheet measures to assess fiscal sustainability.

    • Mitigating fiscal risks and pressures: The review will consider how to further support the effective management of fiscal pressures and risks, through a framework which can provide operationally-effective controls on the short and medium-term fiscal position, and can address and mitigate the challenge of longer-run pressures on fiscal sustainability, including from the ageing population and the actions needed to achieve net zero by 

    • Building on the strength of the UK’s world class institutions: The review will consider options to support and strengthen the practices and institutions that deliver the UK’s fiscal framework, including the independent OBR and ONS, and advisory bodies such as the National Infrastructure Commission. The review will also consider the case for strengthening the legislative underpinning for the UK’s system of public financial management.

    When the review is concluded, HM Treasury will lay before Parliament a new Charter for Budget Responsibility; the Autumn Charter therefore remains in force at the current time.[footnote 12] The Budget has been delivered within the fiscal rules set out above in section The Chancellor wrote to the OBR ahead of the Budget to ask it to assess the government against these rules, in addition to those set out in the Autumn Charter.[footnote 13]

    Box 1.A: Balance Sheet Review

    The government manages assets worth £2 trillion alongside £ trillion of liabilities on behalf of citizens.[footnote 14] The Balance Sheet Review (BSR) was launched in to identify opportunities to dispose of assets that no longer serve a policy purpose, improve returns on retained assets, and reduce the risk and cost of liabilities. This work aims to put the UK at the forefront of the international drive to reduce waste and deliver improvements in the cost-effective management of public wealth, as recognised by the IMF in its October Fiscal Monitor. The BSR will conclude and report at this year’s Comprehensive Spending Review. 

    Strengthening the assessment of balance sheet transactions

    The BSR has highlighted the importance of considering the impacts on the government’s balance sheet, as well as on income flows over the longer term, when deciding to buy or sell assets and settle or incur liabilities. The government is therefore considering a new framework to evaluate the case for proceeding with significant balance sheet transactions. This will take into account impacts across a range of fiscal metrics, including Public Sector Net Debt (PSND), Public Sector Net Financial Liabilities (PSNFL) and Public Sector Net Worth (PSNW). The government will work with the ONS and OBR to further develop statistics and forecasts for PSNW and depreciation in the public sector finances, as well as assessing how these reconcile with the Whole of Government Accounts (WGA). This will inform the fiscal framework review set out in section

    Managing risk from contingent liabilities

    The government is exposed to £ billion of contingent liabilities, including guarantees and insurance provided to the private sector.[footnote 15] The BSR has developed proposals to improve the management of these liabilities and address a key balance sheet risk recognised by the OBR in its July Fiscal Risk Report.[footnote 16] The government is publishing a report alongside Budget: ‘Government as insurer of last resort’ providing more detail on the policy approach. 

    Knowledge assets

    To improve social, economic and financial returns from its c.£ billion[footnote 17] of knowledge assets in the public sector, and following publication of a report at Budget ,[footnote 18] the government will establish a new unit and fund to develop knowledge assets. 

    The fiscal outlook

    Borrowing this year is forecast to be £ billion, £ billion lower than the OBR’s restated March forecast. Underlying receipts are forecast to be £ billion higher, driven by a combination of stronger National Insurance contributions (NICs), capital gains tax and onshore corporation tax receipts. The strength in receipts is offset by higher spending, which is forecast to be £ billion higher and is largely due to an increase in local and public corporations’ capital expenditure, an increase in company tax credits and lower than expected underspends by government departments. Policy decisions made by the government at Spending Round and at Budget, and described in Chapter 2, decrease borrowing by £ billion in [footnote 19]

    Across the rest of the forecast, compared to the OBR’s restated March forecast, the underlying forecast for borrowing is expected to be higher by £ billion on average from onwards. The changes in the underlying fiscal outlook are due to a combination of the following factors:

    • A downward revision to underlying receipts from onwards that is predominantly driven by downward revisions to growth in GDP and its components. Excluding a fiscally neutral switch that means that customs duty revenues previously remitted to the EU are now recognised in both receipts and spending, receipts are lower by an average of £ billion a year from onwards. Lower wage growth, consumer spending and profits, and an adjustment to fuel efficiency assumptions have downward effects on income tax and NICs, VAT, corporation tax and fuel duty receipts respectively. Lower interest rates reduce the interest received from government assets.

    • Underlying spending (excluding debt interest expenditure) is forecast to be higher in every year from onwards. Excluding the fiscally neutral change to the treatment of customs duties, non-interest spending is higher by an average of £ billion. Higher expenditure on welfare, company tax credits, capital transfers associated with new student loans, and capital spending by local government are the main reasons for this increase.

    • However, underlying debt interest expenditure has been revised down by £ billion on average from onwards. This is due to downward revisions in the forecasts for RPI inflation and interest rates.

    The most significant changes to the forecast since restated March are the decisions taken by the government in the Budget and described in Chapter 2, which increase borrowing across the forecast. On average they increase borrowing by £21 billion from onwards. The direct cost of the measures is partly offset by the positive short-term impact on the fiscal position of the higher economic growth that is generated as a result of the Budget package. Higher growth in the short term, and a medium-term increase in nominal GDP leads to increased tax revenues. This is partly offset by the effect of higher borrowing, interest rates and inflation which increase debt interest and welfare spending.

    In the usual way, the OBR have incorporated Budget policy decisions (set out in Table ) into their final post-measures forecast. The government has not asked the OBR to incorporate the fiscal and economic impacts of the government’s plan to tackle the economic impact of COVID into their final forecast. This reflects that the OBR’s baseline forecast does not incorporate the most recent estimate of the likely economic and fiscal impacts of a spread of COVID and to do so would have introduced an inconsistency between the baseline forecast and the policy package. Moreover, given the fast-developing situation, the government will continue to adapt its policy to best respond to the latest circumstances. The OBR has said that, relative to their Budget forecast, COVID is likely to put upward pressure on borrowing in the short term but expect limited impact over the medium and longer term.

    The government will therefore reflect the costs of its response to COVID at a future fiscal event alongside an updated OBR forecast. The current fiscal framework provides the near‑term flexibility to respond fully to the challenge of COVID, and the government has built headroom against the medium-term rules should it be needed.

    Table Changes to the OBRʼs forecast for public sector net borrowing since restated March forecast (£ billion)

    Restated March
    Total underlying forecast changes since restated March (1)
    of which
     Receipts forecast (2)
     Debt interest forecast
     Other spending forecast (2)
    Total effect of government decisions since March (1)
    of which
     Direct effects
     Indirect effects
    Total changes since restated March
    Budget
    Figures may not sum due to rounding.
    1 Equivalent to lines from Table of the OBR (March ) ʽEconomic and fiscal outlookʼ; full references available in ʽBudget data sourcesʼ.
    2 Excludes a fiscally neutral change to the treatment of customs duty revenues previously remitted to the EU.
    Source: Office for Budget Responsibility and HM Treasury calculations.

    Compared to the restated March forecast, borrowing is lower in , but higher in every other year of the forecast. It rises over the forecast period from % of GDP in to % of GDP in , before falling to % in

    Table Overview of the OBRʼs borrowing forecast as a percentage of GDP

    OutturnForecast
    Public sector net borrowing
    Cyclically-adjusted public sector net borrowing
    General government net borrowing (1)
    Memo: Output gap (2)
    1 Consistent with Manual on Government Deficit and Debt, Eurostat,
    2 Output gap measured as a percentage of potential GDP.
    Source: Office for National Statistics and Office for Budget Responsibility.

    Compared with the restated March forecast, debt is lower in , it is then higher in all the remaining years of the Budget forecast as a share of GDP, largely as a result of higher borrowing. Public sector net debt is expected to continue to fall over the forecast, from % in , to a low of % in before rising slightly to % in Public sector net debt ex Bank of England is broadly stable across the forecast.

    Table Overview of the OBRʼs debt forecast as a percentage of GDP

    OutturnForecast
    Public sector net debt (1)
    Public sector net debt ex Bank of England (1)
    Public sector net financial liabilities (1)
    General government gross debt (2)
    1 Debt and liabilities at end of March; GDP centred on end of March.
    2 Consistent with Manual on Government Deficit and Debt, Eurostat,
    Source: Office for National Statistics and Office for Budget Responsibility.

    Table Changes to the OBRʼs forecast for public sector net debt since restated March forecast as a percentage of GDP

    Restated March
    Total forecast changes since restated March (1)
    of which
     Change in nominal GDP (2)
     Change in cash level of net debt
    Budget
    Figures may not sum due to rounding
    1 Equivalent to lines from Table of the OBR (March ) ʽEconomic and fiscal outlookʼ; full references available in ʽBudget data sourcesʼ.
    2 Non-seasonally adjusted GDP centred on end of March.
    Source: Office for Budget Responsibility.

    The OBR’s ‘Economic and Fiscal Outlook’ shows that the government is forecast to meet the fiscal rules set out above in section There is a current budget surplus of £ billion in , providing headroom against this rule. Net investment is expected to average % of GDP over to – below the 3% target – while the debt interest to revenue ratio remains below 6%.

    Table Metrics used for fiscal rules

    Forecast
    Current budget deficit (% of GDP)
    Public sector net investment (% of GDP)
    Debt interest to revenue ratio (1)
    1 The debt interest to revenue ratio is defined as public sector net interest paid (gross interest paid less interest received) as a proportion of non-interest receipts.
    Source: Office for Budget Responsibility.

    Public spending

    The government’s significant progress in restoring the public finances to health over the last decade means it can now afford to support the economy in the short term while investing to support long-term growth. The new fiscal framework allows for a significant increase in growth-enhancing infrastructure investment, while maintaining control of day-to-day spending and the commitment to long-term fiscal sustainability.

    At Spending Round , the government increased departmental spending by % in real terms between and , delivering the fastest planned growth in day-to-day departmental spending in 15 years.[footnote 20] Spending Round funded vital public services: high‑quality, readily accessible healthcare; schools and colleges that ensure every child receives a superb education; and action to cut crime and help keep our streets safe.

    Individual budgets for all departments have been set until for both departmental capital totals (CDEL) and departmental resource totals (RDEL). Longer-term settlements have already been announced for the NHS and schools, which have confirmed budgets until and respectively.

    Table Departmental Capital Budgets in and (Capital DEL, in £ billion)

    Capital DEL
    Health and Social Care
    Education
    Home Office
    Justice
    Law Officers' Departments
    Defence
    Single Intelligence Account
    Foreign and Commonwealth Office
    International Development (1)
    MHCLG Housing and Communities (2)
    MHCLG Local Government
    Transport (3)
    Business, Energy and Industrial Strategy (4)
    Digital, Culture, Media and Sport
    Environment, Food and Rural Affairs
    International Trade
    Work and Pensions
    HM Revenue and Customs
    HM Treasury
    Cabinet Office
    Scotland
    Wales (5)
    Northern Ireland (6)
    Small and Independent Bodies
    Reserves (7)
    Adjustment for Budget Exchange (8)
    Total Capital DEL
    Remove CDEL not in PSGI (9)
    Allowance for shortfall (10)
    Public Sector Gross Investment in CDEL
    1 Figures for do not reflect all transfers which will be made from DfID to other government departments.
    2 MHCLG's CDEL budget in includes technical adjustments along with Budget announcements since Budget
    3 DfT's CDEL budget in includes a net reduction due to business rates retention pilots.
    4 BEIS and other government departments' CDEL budgets increased in to account for the reclassification of R&D in the National Accounts.
    5 This includes the 5% needs-based Barnett formula uplift.
    6 This includes the % VAT abatement.
    7 adjusted to account for a change in the accounting treatment of leases. This money will be allocated to departments through the Estimates process.
    8 Departmental budgets in include amounts carried forward from through Budget Exchange, which will be voted at Main Estimates. These increases will be offset at Supplementary Estimates in future years so are excluded from spending totals.
    9 Capital DEL that does not form part of public sector gross investment, including financial transactions in Capital DEL.
    10 The OBR's forecast of underspends in Capital DEL budgets.

    Table Departmental Resource Budgets in and (Resource DEL excluding depreciation, £ billion)

    Resource DEL excluding depreciation (1)
    Health and Social Care
     of which: NHS England
    Education
     of which: Schools
    Home Office
    Justice
    Law Officers' Departments
    Defence
    Single Intelligence Account
    Foreign and Commonwealth Office (2)
    International Development (2)
    MHCLG Housing and Communities (3)
    MHCLG Local Government (3)
    Transport
    Business, Energy and Industrial Strategy
    Digital, Culture, Media and Sport
    Environment, Food and Rural Affairs (4)
    International Trade
    Work and Pensions
    HM Revenue and Customs
    HM Treasury
    Cabinet Office
    Scotland (5)
    Wales (5),(6)
    Northern Ireland (7)
    Small and Independent Bodies
    Reserves
    Adjustment for Budget Exchange (8)
    Total Resource DEL excluding depreciation
    OBR allowance for shortfall (9)
    OBR resource DEL excluding depreciation forecast
    1 Resource DEL excluding depreciation is the Treasury's primary control total within resource budgets and the basis on which Spending Round settlements were made.
    2 Figures for do not reflect all transfers which will be made from DfID to FCO and other government departments.
    3 MHCLG Housing and Communities DEL in excludes the New Homes Bonus, reflecting a transfer to Local Government (LG) DEL. LG DEL increase in /21 is also driven by the ending of the /20 75% Business Rates Retention pilots.
    4 DEFRA's RDEL ex budget in increases due to the domestic replacement of Common Agricultural Policy spending.
    5 Block grant adjustments have been agreed with the Scottish Government for tax and welfare devolution and with the Welsh Government for tax devolution as part of their respective fiscal frameworks.
    6 This includes the 5% needs-based Barnett formula uplift.
    7 This includes the % VAT abatement.
    8 Departmental budgets in include amounts carried forward from through Budget Exchange, which will be voted at Main Estimates. These increases will be offset at Supplementary Estimates in future years so are excluded from spending totals.
    9 The OBR's forecast of underspends in Resource DEL budgets.

    The Spending Envelope and Comprehensive Spending Review

    The Budget marks the start of an ambitious programme of investment in communities across the country, many of whom feel left behind. The Budget launches the CSR, which will conclude in July.[footnote 21]

    Path of Public Spending

    The Comprehensive Spending Review envelope

    The CSR will set Resource DEL budgets for three years to inclusive and Capital DEL funding for departments to The CSR will be delivered within the fiscal rules set out in section The Budget sets the overall spending envelope for resource and capital spending within which the CSR will be delivered. Total departmental spending is set to grow twice as fast as the economy over the CSR period. Day-to-day departmental spending is set to grow at the fastest rate over a spending review period since Spending Review

    Having left the EU, from the UK will no longer contribute to the EU budget as a Member State, leaving only payments due as part of Financial Settlement obligations. The government has accounted for this when setting its spending plans, allowing it to determine how an additional £ billion[footnote 22] of spending by can be allocated to its domestic priorities, rather than be sent in contributions to the EU. The implementation period (IP) will end on 31 December The baseline scenario is that the UK will exit the IP at this time without a future relationship being agreed with the EU. HM Treasury will ensure that all necessary funding is made available to prepare for this outcome at the end of

    Table Total departmental budgets (Total DEL); Resource DEL excluding depreciation and Capital DEL from to (1), (2), (3) (£ billion, unless otherwise stated)

    AARG to (4),(5),(6)
    Total Resource DEL excluding depreciation%
    OBR allowance for shortfall
    OBR resource DEL excluding depreciation forecast
    Total Capital DEL%
    OBR allowance for shortfall
    OBR capital DEL forecast
    Total departmental spending (Total DEL)%
    1 Budgeting totals are shown including the Office for Budget Responsibility (OBR) forecast Allowance for Shortfall.
    2 Resource DEL excluding ring-fenced depreciation is the Treasury's primary control within resource budgets and is the basis on which departmental Spending Review settlements are agreed. The OBR publishes Public Sector Current Expenditure (PSCE) in DEL and AME. A reconciliation is published by the OBR.
    3 Capital DEL is the Treasury's primary control within capital budgets and is the basis on which departmental Spending Review settlements are agreed. The OBR publishes Public Sector Gross Investment (PSGI) in DEL and AME. A reconciliation is published by the OBR.
    4 DEL in and is reduced by Business Rates Retention pilots that switched spending into AME. To ensure consistency, growth rates for Resource DEL and Capital DEL have been adjusted to reverse this DEL-AME switch.
    5 Resource DEL from onwards is increased by the devolution of areas of welfare spending to the Scottish Government which has caused a decrease in the Block Grant Adjustment and subsequent increase in Resource DEL. To ensure consistency, growth rates for Resource DEL and Capital DEL have been adjusted to reverse this switch.
    6 Capital DEL from onwards includes a provision for the impact of the IFRS16 reclassification of leases on departmental capital budgets. To ensure consistency, growth rates have been adjusted to reverse this provision.

    Resource

    The CSR will see an increase in day-to-day spending from £ billion in to £ billion by Overall Resource DEL spending will increase by % per year on average in real terms over the CSR period. Over the Parliament, it will grow by % on average in real terms. Chart shows the real terms growth in day-to-day departmental spending over the forecast period.

    Chart Resource DEL excluding depreciation growth from to (1,2,3,4)

    Chart Resource DEL excluding depreciation growth from to , 2, 3, 4

    Capital

    Over the next five years the public sector will invest £ billion, as set out in Table This significant increase in spending means that by , public sector net investment will be triple the average investment over the last 40 years in real terms, as shown in Chart

    This spending will provide world-class infrastructure and public services, delivering value for money and focussing on efficient delivery. The CSR will allocate capital funding for projects across the UK to drive growth, level up economic opportunity, decarbonise the economy, and maintain and build high quality public infrastructure, including schools and hospitals. The Budget sets out plans to increase public R&D investment to £22 billion per year by , taking public spending on R&D to % of GDP.

    These allocations will be informed by early findings from the review of HM Treasury’s Green Book, which will consider how the design and use of project appraisal affects the ability of all areas to achieve their economic potential. The review will enhance the strategic development and assessment of projects, consider how to assess and present local impacts and look to develop new analytical methods for transformative or place-based interventions. It will also consider how project approval decisions are being made and provide clearer guidance and support to practitioners. The government will work with users, academics and others, and a revised Green Book will be published alongside the CSR.

    Chart Public sector net investment from to

    Chart Public sector net investment from to

    Total managed expenditure

    These firm decisions on the Departmental Expenditure Limits (DEL) envelope for the CSR mean that the average annual real growth of Total Managed Expenditure (TME), the total amount of money that the government spends through departments, local authorities, other public bodies and social security, will be % between and Table sets out planned TME, public sector current expenditure (PSCE) and public sector gross investment (PSGI) up to Chart which shows the change in government spending as a share of GDP over time, shows that tough decisions made in the aftermath of the financial crisis have restored the public finances to health and the government can now afford to invest more in public services and growing the economy.

    Government spending is now set to be % of GDP in TME as a percentage of GDP has also increased because of classification and methodology changes that have impacted underlying spending, in particular those relating to student loans, public sector pensions and depreciation.[footnote 23] These are technical revisions that have been applied to the entire time series of data to ensure comparison to other years can be done on an equal basis.

    Table Total Managed Expenditure(1) from to (£ billion, unless otherwise stated)

    Current expenditure
    Resource AME
    Resource DEL excluding depreciation
    Ring-fenced depreciation
    Total public sector current expenditure
    Capital expenditure
    Capital AME
    Capital DEL excluding financial transactions
    Total public sector gross investment
    Total managed expenditure
    Total managed expenditure % of GDP%%%%%%
    1 Budgeting totals are shown including the Office for Budget Responsibility (OBR) forecast Allowance for Shortfall. Resource DEL excluding ring-fenced depreciation is the Treasury's primary control within resource budgets and is the basis on which departmental Spending Review settlements are agreed. The OBR publishes Public Sector Current Expenditure (PSCE) in DEL and AME, and PSGI in DEL and AME. A reconciliation is published by the OBR.

    Chart Total Managed Expenditure (% GDP) from to

    Chart Total Managed Expenditure (% GDP) from to

    Allocations for the Comprehensive Spending Review

    Chapter 2 of this document sets out further detail on the allocations made at the Budget. The overall allocations of total resource and capital funding over the CSR period will be determined at the CSR in July.

    The CSR will prioritise:

    • levelling up economic opportunity across all nations and regions of the country by investing in infrastructure, innovation and people, to drive productivity and spread opportunity

    • improving outcomes in public services, including supporting the NHS and taking steps to cut crime and ensure every young person receives a superb education

    • strengthening the UK’s place in the world

    • reducing carbon emissions and improving the natural environment

    All new spending will be accompanied by a rigorous new focus on outcomes. To support this the government is conducting an exercise across departments to identify savings and projects that do not provide value for money or support these priorities. The government will redirect this spending through the CSR to help achieve its priorities. The CSR will also set out plans to improve the use of data, science and technology across the public sector, and to ensure all programmes are supported by robust implementation and evaluation plans.

    In conducting the CSR, the government will also build on the lessons of previous spending reviews and ensure that policy issues are considered across departmental boundaries to maximise the effectiveness and value for money of government spending. The Budget announces the first allocation from the Shared Outcomes Fund to pilot improved approaches to supporting adults with complex needs. This fund was established at Spending Round to pilot new programmes to build an evidence base and test new ways of working collaboratively across the public sector. Further details on this bid can be found in Chapter 2.

    The CSR will be informed by the Integrated Security, Defence, Development and Diplomacy Review (Integrated Review). The government intends to publish the main conclusions of the Integrated Review alongside the CSR.

    At the CSR the government will set out funding to meet commitments to replace the Common Agricultural Policy and EU structural funds. The government may also choose to participate in certain EU programmes, where it is in UK interests and the contributions are fair and appropriate.

    Improving public services

    Priority outcomes and evaluation

    The government’s spending plans provide for significant real increases in spending on public services. It is crucial that increased government funding leads to real-world improvements that make a difference to people’s lives. At the CSR, the government will establish a new approach to link departments’ spending proposals to the outcomes they intend to achieve as part of a new Public Value Framework (PVF).[footnote 24]

    The government is developing the medium- to long-term priority outcomes that it is seeking to deliver for priorities such as levelling up, as well as the metrics that will be used to measure and improve performance against these outcomes. Assessment of spending’s impact on these priority outcomes will be central to making spending decisions at the CSR. These priority outcomes and metrics will be published as part of the CSR and will include cross-cutting outcomes in areas where closer working between departments could help achieve better results.

    In order to ensure government programmes deliver for the public, it is crucial that spending decisions are based on robust evidence and evaluation of their impact. At the CSR, the government will assess the state of evaluation across all departmental spending programmes and require every department to produce plans to improve evaluation of its work. This will lead to more evidence-based allocation of public funding and better outcomes in the long term.

    These reforms will ensure that spending decisions are based on the delivery of outcomes and will put the UK at the forefront of international approaches to driving public value. This will help the government provide world-class public services and the best value for taxpayers’ money.

    Public representations

    Throughout the CSR the government will engage with all regions and nations of the UK to ensure that its policies level up and spread opportunity. The government has started this engagement at Budget by launching a process for individuals and organisations to submit written CSR representations to HM Treasury.

    Financial transactions

    Some policy measures do not directly affect PSNB in the same way as conventional spending or taxation. These include financial transactions, which predominantly affect the central government net cash requirement (CGNCR) and public sector net debt (PSND). Table shows the effect of the financial transactions announced since Budget on CGNCR. Details on the policy decisions made at the Budget can be found in Chapter 2.

    Table Financial transactions from to (£ million)(1),(2)

    Ending student loan sales programme-2,-1,-1,-1,1,1,
    UKAR pension scheme0000
    VAT: cash flow impact of postponed accounting0-3,
    Freezing the maximum tuition fee cap: freeze0
    Entitlement to part-time maintenance loans90
    Nurse maintenance grants: student finance implication0
    Removing student finance residence requirement for domestic abuse victims0neg-5-5-5-5
    Increase to UK Export Finance Direct Lending Facility0
    Help to Buy: policy definition000
    Universal Credit: extending advances repayment period and reducing maximum debt deductions00
    British Business Bank: Start Up Loans00252520
    British Business Bank: Life Sciences Investment Programme0
    British Business Bank: growth capital for innovative business0
    National Security Strategic Investment Fund00000
    Heat Networks Investment Project00000
    Nature for Climate Fund00000
    Total policy decisions-2,-5,-1,2,2,
    Note: This table details new financial transactions scored at this Budget
    1 Costings reflect the Office for Budget Responsibility's latest economic and fiscal determinants, and are presented on a UK basis.
    2 Negative numbers in the table represent a cost to the Exchequer.

    Devolved administrations

    The application of the Barnett formula to spending decisions taken by the UK government at the Budget will provide each of the devolved administrations with additional funding to be allocated according to its own priorities. To reflect the additional powers devolved to the Scottish and Welsh Governments their block grants will be adjusted as set out in their respective fiscal frameworks. This includes a substantial increase in the Scottish Government’s block grant to reflect the additional welfare responsibilities being devolved from April The Scottish and Welsh Governments have already set provisional budgets for using block grant adjustments based on previous OBR forecasts. They have been given the choice of taking on the updated block grant adjustments following the UK Budget or waiting for the outturn reconciliation processes that will take place after the end of

    While all block grant funding remains in DEL, the Scottish Government now has such substantial self-funding powers (from taxation, borrowing and reserves) that its spending is recorded in Annually Managed Expenditure (AME).

    Welfare cap

    The welfare cap was introduced in to limit the amount spent on certain social security benefits and tax credits. It improves Parliamentary accountability for welfare spending and supports the government’s aim of ensuring the welfare system is sustainable.

    The cap was last reset at Autumn Budget , following the OBR’s judgement that the government had successfully met the terms of the welfare cap set at Autumn Statement The cap applies to spending within its scope in , with a 3% margin of flexibility to manage unavoidable fluctuations in spending.

    In accordance with the Charter for Budget Responsibility, as is mandated for the first fiscal event of the Parliament, the OBR has formally assessed spending against the welfare cap in its ‘Economic and fiscal outlook’. Total relevant spending is forecast to be within the welfare cap and margin, and so the fiscal rule is judged to have been met with £ billion of headroom.

    The government is now required to reset the welfare cap for the new Parliament. The cap will be based on the OBR’s Budget forecast of the benefits and tax credits in scope, as set out in Annex B, and will apply to spending in In the interim years, progress towards the cap will be managed internally, based on monitoring by HM Treasury and the Department for Work and Pensions (DWP) of the OBR’s welfare spending forecasts. As before, there will be a margin rising to 3% above the forecast to manage unavoidable fluctuations in spending. The cap will be breached if spending exceeds the cap plus the margin at the point of assessment. Performance against the cap will be formally assessed by the OBR at the first fiscal event of the next Parliament. This will avoid the government having to make short-term responses to changes in the welfare forecast, while ensuring welfare spending remains sustainable in the medium term.

    Table New welfare cap (in £ billion, unless otherwise stated)

    Cap-----
    Interim pathway-
    Margin (%)
    Cap, pathway and margin

    Debt and reserves management

    The government’s financing plans for are summarised in Annex A. They are set out in full in the ‘Debt management report ’, published alongside the Budget.

    Supporting those affected by COVID

    Since emerging in China in December , COVID has spread widely, with a significant number of cases reported worldwide, including an increasing number in the UK. 

    The impact of the outbreak of COVID on the UK economy is highly uncertain, and while the effect could prove significant, it is expected to be temporary. 

    As an open economy, the UK will be affected because of the wider impacts the outbreak is having on the global economy. In a domestic outbreak, there could also be direct economic impacts in the UK driven by health-related factors, including how many people are infected and the persistence of any outbreak. Disruption could include temporary absences from work and interruptions to global supply chains, both of which would constrain the UK’s productive capacity for a temporary period. In addition, the economy could be affected by demand-side impacts through a reduction in consumer spending, and lower business investment and exports. The government’s Action Plan on Coronavirus sets out the potential scale of these effects in the event of a severe outbreak. 

    The government recognises that people will be concerned about the impact COVID could have on their lives, and some businesses will be concerned about reduced demand, potential disruptions to supply chains and export markets, and to their workforce during this temporary period. Therefore, the Budget announces a three-point plan to provide support for:

    • public services

    • individuals

    • businesses

    The plan includes a range of timely, targeted and temporary measures to deliver support when and where it is needed, at a total cost of £12 billion. The wider Budget policy decisions set out in Table represent £18 billion of additional government spending, which will provide support to the economy. Together, the government is taking £30 billion of policy action in ‑21, equivalent to approximately % of GDP. 

    In addition to the measures set out here, the government will continue to monitor the situation and stands ready to provide further support, should it be needed. Support will be available for as long as it is needed, based on the latest scientific evidence. HM Treasury will continue to work closely with the Bank of England to coordinate the response of the UK authorities to ensure it is as effective as possible.

    The government is working closely with the devolved administrations on this issue and it stands ready to provide further support. Where measures do not apply UK-wide, the devolved administrations will receive a share of any additional funding for support in devolved areas through the Barnett Formula. As set out in the Statement of Funding Policy the devolved administrations can also access the Reserve where they are unable to manage any disproportionate costs from their own resources.

    The government welcomes the statement by UK Finance on behalf of the sector which announced that banks, building societies and credit card providers are ready and able to offer support to consumers, including offering or increasing an overdraft or allowing repayment relief for loan or mortgage repayments. Banks and other providers of SME finance will also provide support for businesses that are facing cash flow disruption and stand ready to help when needed. 

    Tackling COVID is a global challenge. To complement its domestic response, the UK is leading the way to ensure a swift and effective global response, including by working closely with all our international partners and supporting the most vulnerable countries to deal with the impacts of the virus, including cooperating closely with counterparts in the G7 and G 

    The Chancellor will continue to co-operate closely with his counterparts in the G7 and G G20 Finance Ministers last week committed to monitoring the evolution of COVID including its impact on markets and economic conditions, and highlighted their readiness to take further actions to aid in the response to the virus, support the economy and maintain the resilience of the financial system.

    Support for public services

    Public safety is the government’s top priority in its response to COVID The government will ensure that public services receive the funding they need to respond to the outbreak as the situation develops. This includes continuing to ensure our health services have the resources they need to respond.

    COVID response fund – HM Treasury is creating an emergency response fund, set aside to ensure the National Health Service (NHS) and other public services have the resources they need to tackle the impacts of COVID Initially set at £5 billion, it will fund pressures in the NHS, support local authorities to manage pressures on social care and support vulnerable people, and help deal with pressures on other public services. The size of the fund will be reviewed as the situation develops, to ensure all necessary resources are made available. 

    Funding for research and development – The government is providing the National Institute for Health Research with £30 million of new funding to enable further rapid research into the disease. Research is essential in order to understand COVID, and it will inform how the NHS frontline service approach tackling the virus. The funding could also allow rapid screening of potential therapeutics and support clinical trials to inform treatment and improve patient outcomes.

    Funding for diagnostic testing – The government will increase the capacity and capability of diagnostic testing and surveillance facilitated by Public Health England to support the NHS, by providing an additional £10 million of new funding to DHSC.

    Support for individuals

    The Budget announces measures to support people who are unable to work because of COVID

    Eligibility for Statutory Sick Pay (SSP) – The Prime Minister has already announced that the forthcoming COVID Bill will temporarily allow SSP to be paid from the first day of sickness absence, rather than the fourth day, for people who have COVID or have to self‑isolate, in accordance with government guidelines. The Budget sets out a further package to widen the scope of SSP and make it more accessible. The government will temporarily extend SSP to cover:

    • individuals who are unable to work because they have been advised to self-isolate

    • people caring for those within the same household who display COVID symptoms and have been told to self-isolate

    Medical Evidence for SSP – The government has already issued guidance to employers, advising them to use their discretion not to require a GP fit note for COVID related absences. This Budget announces that the government and the NHS will bring forward a temporary alternative to the fit note in the coming weeks which can be used for the duration of the COVID outbreak. This system will enable people who are advised to self-isolate to obtain a notification via NHS which they can use as evidence for absence from work, where necessary. This notification would meet employers’ need for evidence, whilst taking pressure away from General Practices.

    Support for those ineligible for SSP – The government recognises that self-employed people and employees below the Lower Earnings Limit are not entitled to SSP. The best system of financial support for these people is the welfare system and, in particular, ‘new style’ Employment and Support Allowance and Universal Credit. The government is committed to supporting these groups, and the Budget announces further support by making it quicker and easier to receive benefits:

    • ‘New style’ Employment and Support Allowance will be payable for people directly affected by COVID or self-isolating according to government advice for from the first day of sickness, rather than the eighth day 

    • people will be able to claim Universal Credit and access advance payments where they are directly affected by COVID (or self-isolating), without the current requirement to attend a jobcentre

    • for the duration of the outbreak, the requirements of the minimum income floor in Universal Credit will be temporarily relaxed for those directly affected by COVID or self-isolating according to government advice for duration of the outbreak, ensuring self‑employed claimants will be compensated for losses in income

    Hardship Fund – The government will provide Local Authorities in England with £ million of new grant funding to support economically vulnerable people and households in their local area. The government expects most of this funding to be used to provide more council tax relief, either through existing Local Council Tax Support schemes, or through complementary reliefs. 

    Support for businesses

    Some businesses may experience increased costs or disruptions to their cash flow as a result of COVID The Budget announces a set of measures to provide support to businesses during this temporary period by either reducing their costs or bridging cashflow problems arising from the outbreak, and to protect people’s jobs. 

    Statutory Sick Pay – The government will support small and medium-sized businesses and employers to cope with the extra costs of paying COVID related SSP by refunding eligible SSP costs. The eligibility criteria for the scheme are as follows:

    • this refund will be limited to two weeks per employee

    • employers with fewer than employees will be eligible. The size of an employer will be determined by the number of people they employed as of 28 February

    • employers will be able to reclaim expenditure for any employee who has claimed SSP (according to the new eligibility criteria) as a result of COVID

    • employers should maintain records of staff absences, but should not require employees to provide a GP fit note

    • the eligible period for the scheme will commence from the day on which the regulations extending SSP to self-isolators come into force

    • while existing systems are not designed to facilitate such employer refunds for SSP, the government will work with employers over the coming months to set up a repayment mechanism for employers as soon as possible

    Business Rates Reliefs – The government has already announced the Business Rates retail discount will be increased to 50% in To support small businesses affected by COVID the government is increasing it further to % for The relief will also be expanded to the leisure and hospitality sectors. These temporary measures, taken together with existing Small Business Rates Relief, mean that around , properties, or 45% of all properties in England, will receive % business rates relief in The government has also already announced the introduction of a £1, Business Rates discount for pubs with a rateable value below £, in England for one year from 1 April To support pubs in response to COVID the discount will be increased to £5, Local authorities will be fully compensated for these Business Rates measures.

    Small business grant funding – The government recognises that many small businesses pay little or no business rates because of Small Business Rate Relief (SBRR). To support those businesses, the government will provide £ billion of funding for Local authorities in England. This will provide £3, to around , business currently eligible for SBRR or Rural Rate Relief, to help meet their ongoing business costs. For a property with a rateable value of £12,, this is one quarter of their rateable value, or comparable to 3 months of rent. Most properties that are eligible for SBRR will have a lower rateable value, and so this will represent an even greater proportion of their annual rent.

    Time to Pay – The government will ensure that businesses and self-employed individuals in financial distress and with outstanding tax liabilities receive support with their tax affairs. Her Majesty’s Revenue and Customs (HMRC) has set up a dedicated COVID helpline to help those in need, and they may be able to agree a bespoke Time to Pay arrangement. Time to Pay was successfully used in response to flooding and the financial crisis, giving businesses a time-limited deferral period on HMRC liabilities owed and a pre-agreed time period to pay these back. These tailored arrangements will give a business the time it needs to pay HMRC to support their recovery while operating through any temporary financial challenges that occur. To ensure ongoing support, HMRC have made a further 2, experienced call handlers available to support firms when needed. HMRC will also waive late payment penalties and interest where a business experiences administrative difficulties contacting HMRC or paying taxes due to COVID 

    Coronavirus Business Interruption Loan Scheme – The government will launch a new, temporary Coronavirus Business Interruption Loan Scheme, delivered by the British Business Bank, to support businesses to access bank lending and overdrafts. The government will provide lenders with a guarantee of 80% on each loan (subject to a per lender cap on claims) to give lenders further confidence in continuing to provide finance to SMEs. The government will not charge businesses or banks for this guarantee, and the Scheme will support loans of up to £ million in value. This new guarantee will initially support up to £1 billion of lending on top of current support offered through the British Business Bank.

    International response

    The government has already committed £91 million to the international response. The Budget makes available £ million from the UK’s ODA budget to the International Monetary Fund’s Catastrophe Containment and Relief Trust (CCRT), of which £75 million is an immediate commitment. This demonstrates that the UK can use its ODA budget to directly support our national interest. The government stands ready to provide further support as the situation develops, playing our full part in a well-coordinated global response.

    Alongside the Budget, the government has published information about the support available to individuals and businesses whose finances are affected by COVID This information, which will be regularly updated as the situation develops, can be found at: storycall.us 

    Investing in excellent public services

    The government is delivering world-class public services for hard-working people across the UK. The Budget builds on the significant investment in public services made at Spending Round , with action to make the UK a safer, healthier place to live.

    Investing in the NHS

    The NHS is the government’s number one spending priority. The NHS settlement, confirmed in January , provided the largest cash increase in public services since the Second World War – an additional £34 billion per year by [footnote 25] Spending Round confirmed the government’s commitment to the NHS, with £ billion for health budgets in ‑[footnote 26] The Budget provides over £6 billion of further funding to strengthen the NHS in England and pay for vital services that will improve people’s health, reaffirming the government’s commitment to health and social care. 

    The government will invest to increase staffing, making sure that the NHS has the people it needs. This will include a significant funding package to improve the recruitment, training and retention of nurses in England, ensuring there are 50, more in the NHS; and for the recruitment, training and retention of up to 6, more GPs and 6, more primary care professionals in England, such as physiotherapists and pharmacists. This will create 50 million more GP surgery appointments a year. The government will also change pensions tax rules to ensure that NHS staff across the UK, including senior doctors, whose income is less than £, can work additional hours for the NHS without their annual allowance being reduced. (7)

    The government will invest in our hospitals, including over £ million in ‑21 to make progress on 40 new hospital projects, as part of a long-term programme of investment in health infrastructure to ensure the NHS has world-class facilities for patients.[footnote 27] This will be accompanied by an increase in DHSC’s capital budget of £ million in the financial year to protect the level of NHS operational capital investment. This will allow Trusts to continue to invest in important capital projects such as estate refurbishments and building maintenance. (5)

    To ensure that new arrivals to the UK contribute to the funding of the NHS, the Immigration Health Surcharge will be increased to £ The government will also introduce a new discounted rate of £ for children in recognition of the increased financial impact on family groups. (6)

    The government is committed to long-term reform of adult social care and the Secretary of State for Health and Social Care has written to parliamentarians to begin building cross-party consensus on reform. Ahead of those discussions, the government will invest £1 billion of additional funding for social care next year, as announced at Spending Round The Budget confirms that this additional funding will continue for every year of the current Parliament to continue to stabilise the system.

    Supporting schools and young people 

    At Spending Round , the government committed to a £ billion cash increase in funding for schools in England by , compared to budgets. This funding settlement included an increase to minimum per-pupil funding levels, a commitment now enshrined in law.[footnote 28] The minimum per pupil amount will increase to £3, for primary schools and £5, for secondary schools in , with the primary schools minimum then rising to £4, in [footnote 29] The settlement also provides for £ million extra in to support children and young people with special educational needs, to ensure all can reach their potential.

    On average, schools will see an increase of over 4% in funding per pupil compared to ‑20 budgets.[footnote 30] The three-year settlement will also allow the government to raise starting salaries for teachers to £30, by September  

    This funding settlement reflects the government’s commitment to high quality education for all school children. The Budget sets out new steps the government is taking to support children to have the opportunity of an active and enriching school experience.

    To ensure that children get an active start in life, the government will bring forward an updated School Sport and Activity Action Plan following the Comprehensive Spending Review. Ahead of that, the Budget provides £29 million a year by to support primary school PE teaching and help schools make best use of their sports facilities. The funding will support high quality teacher training and professional development for PE, informed by best practice PE teaching. 

    The government also believes in the benefits of participating in the arts and the essential role it plays in all children’s education. The Budget provides £90 million a year to introduce an Arts Premium from September , averaging out as an extra £25, a year per secondary school for three years.[footnote 31] The funding will help schools to provide high quality arts programmes and extracurricular activities for pupils, including those delivered in partnership with arts organisations, as well as supporting teachers to deliver engaging and creative lessons in the arts. 

    Ensuring people’s safety and security

    Protecting people and keeping them safe from crime and other threats is a principal responsibility of any government. The government announced an extra £ million of funding at the Spending Round to begin the recruitment of 20, additional police officers, with the first 6, officers to be recruited by March The Budget makes further important investments in the police, security services and justice system.

    In addition, the Budget will include £ million in for counter-terrorism, to maintain capability and officer numbers in the face of a changing terrorist threat. This includes an extra £83 million for counter-terrorism policing, in addition to the government’s police recruitment commitment, and £31 million for the UK Intelligence Community. The government will also provide an additional £67 million for the UK Intelligence Community which will enable them to develop further their world‑leading technological capabilities to protect the UK’s security and help keep the country safe. (9)

    The government is committed to increasing support for victims of crime in their experience of the criminal justice system. The government will provide an additional £15 million to improve our offer to victims. This will boost the support available to victims of rape and create a new digital hub to make the criminal justice process in England and Wales easier to understand. The government will also provide an additional £5 million to begin a trial of domestic abuse courts in England and Wales, allowing criminal and family matters to be considered together. To protect victims of severe domestic abuse and their children and reduce the number of serial perpetrators, the government will provide £10 million for innovative new approaches to preventing domestic abuse, working with Police and Crime Commissioners to expand projects like the “Drive” prevention programme. 

    The Budget contains an additional £5 million for the Youth Endowment Fund to support the creation of a Centre of Excellence for Tackling Youth Violence. This will create a single evidence hub on what works to divert young people away from criminal activity and improve the effectiveness of our wider investments in crime reduction, including the work of the Youth Endowment Fund and violence reduction units. The Budget will also provide £ million to toughen community sentences, including by increasing the number of offenders who are required to wear an electronic tag. 

    The government will also provide £20 million for Fire and Rescue Services to enable them to increase fire inspection and enforcement capability and to build capacity to respond to the Grenfell Tower Inquiry’s findings, by investing in training, equipment and a stronger strategic centre for the fire service. 

    Improving local services and infrastructure

    The government is committed to supporting the work of local authorities, in delivering high quality local services in communities across the country. The local government finance settlement enables a % nominal increase in councils’ Core Spending Power.[footnote 32]

    Local authorities also invest billions of pounds of capital finance every year in their communities. The government supports this activity, in part, by offering low cost loans through the Public Works Loan Board (PWLB). However, in recent years a minority of councils have used this cheap finance to buy very significant amounts of commercial property for rental income, which reduces the availability of PWLB finance for core local authority activities. To address this the government will consult on revising the terms of PWLB lending to ensure LAs continue to invest in housing, infrastructure and front-line services. To further enable high quality investment by local authorities, the government is cutting the interest rates for investment in social housing by 1 percentage point, and making an extra £ billion of discounted loans available for local infrastructure projects. (11)

    Further details and additional announcements relating to public services can be found in Chapter 2.

    Levelling up and getting Britain building

    The Budget sets out the next stage of the government’s comprehensive plan to level up opportunity and share prosperity across the UK. The only sustainable way to drive economic growth and improve living standards in every corner of the country is to boost productivity. The government is therefore investing in people and places – by taking the first steps in its plan to level up skills across the country, ahead of setting out further details at the CSR, and by committing record levels of investment to infrastructure that will directly support productivity. These actions will boost national growth as well as addressing economic and social disparities and restoring the fabric of our towns and cities. 

    Infrastructure

    Источник: [storycall.us]
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