A leg ulcer with hard, yellow projections

Gout is a multisystem disease that may present in different ways. We report an elderly man who presented with a large ulcer of the left leg with hard yellow projections evolving for one year. Analytical study revealed a normal uric acid level, but histopathology showed a focal basophilic acellular material compatible with a gouty tophus. This tophus represents the cardinal feature of advanced gout and may present several challenges to wound care professionals. In fact, the ulcer in our patient persisted after one-year follow-up. Our aim is to alert clinicians about a rare cutaneous presentation of gout that may be increasingly diagnosed

Ethoprophos fate on soil–water interface and effects on non-target terrestrial and aquatic biota under Mediterranean crop-based scenarios

The present study aimed to assess the environmental fate of the insecticide and nematicide ethoprophos in the soil–water interface following the pesticide application in simulated maize and potato crops under Mediterranean agricultural conditions, particularly of irrigation. Focus was given to the soil–water transfer pathways (leaching and runoff), to the pesticide transport in soil between pesticide application (crop row) and non-application areas (between crop rows), as well as to toxic effects of the various matrices on terrestrial and aquatic biota. A semi-field methodology mimicking a “worst-case” ethoprophos application (twice the recommended dosage for maize and potato crops: 100% concentration v/v) in agricultural field situations was used, in order to mimic a possible misuse by the farmer under realistic conditions. A rainfall was simulated under a slope of 20° for both crop-based scenarios. Soil and water samples were collected for the analysis of pesticide residues. Ecotoxicity of soil and aquatic samples was assessed by performing lethal and sublethal bioassays with organisms from different trophic levels: the collembolan Folsomia candida, the earthworm Eisenia andrei and the cladoceran Daphnia magna. Although the majority of ethoprophos sorbed to the soil application area, pesticide concentrations were detected in all water matrices illustrating pesticide transfer pathways of water contamination between environmental compartments. Leaching to groundwater proved to be an important transfer pathway of ethoprophos under both crop-based scenarios, as it resulted in high pesticide concentration in leachates from Maize (130 µg L−1) and Potato (630 µg L−1) crop scenarios, respectively. Ethoprophos application at the Potato crop scenario caused more toxic effects on terrestrial and aquatic biota than at the Maize scenario at the recommended dosage and lower concentrations. In both crop-based scenarios, ethoprophos moved with the irrigation water flow to the soil between the crop rows where no pesticide was applied, causing toxic effects on terrestrial organisms. The two simulated agricultural crop-based scenarios had the merit to illustrate the importance of transfer pathways of pesticides from soil to groundwater through leaching and from crop rows to the surrounding soil areas in a soil–water interface environment, which is representative for irrigated agricultural crops under Mediterranean conditions.This studywaspartlysponsoredbytheEuropeanFundfor Economic andRegionalDevelopment(FEDER)throughthePro- gram OperationalFactorsofCompetitiveness(COMPETE)and National FundsthroughthePortugueseFoundationofScience and Technology(Ph.D.granttoSaraLeitão – SFRH/BD/42306/2007, Ciência 2007 – POPH andQREN,andTerbAzineBiorem – PTDC/ AAC-AMB/111317/2009)

Visceral dissemination of mucocutaneous leishmaniasis in a kidney transplant recipient

Intracellular protozoan of the genus Leishmania, endemic in the Mediterranean basin, are the cause of cutaneous (CL), mucocutaneous (MCL), and visceral leishmaniasis (VL). A 75-year-old woman was admitted nine years after a second kidney transplant (KT), due to persistent pancytopenia and fever. She presented edema and erythema of the nose in the last two years and an exophytic nodular lesion located on the left arm, with areas of peripheral necrosis and central ulceration in the last 18 months. A bone marrow biopsy revealed features compatible with Leishmania amastigotes, and polymerase chain reaction test (PCR) for Leishmania infantum was positive. Moreover, biopsy and PCR for L. infantum of the cutaneous lesion on the patient’s left arm and nose and PCR from peripheral blood were positive. Thus, a diagnosis of CL, MCL, and VL was made, and liposomal amphotericin B was initiated, but the patient had an unfavorable outcome and died. This is the first report of a KT recipient presenting with the entire spectrum of leishmaniasis. In Portugal, this infection is rare—so a high degree of clinical suspicion is required for its diagnosis, especially in endemic regions, as visceral leishmaniasis is a potentially life-threatening infection

The DSM-5 criteria, level of arousal and delirium diagnosis: Inclusiveness is safer

© 2014 European Delirium Association et al.; licensee BioMed Central Ltd. Background: Delirium is a common and serious problem among acutely unwell persons. Alhough linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity.Discussion: Altered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises 'consciousness' as 'changes in attention'. It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested.Summary: Our conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation

Potential Effects of a Statutory Minimum Wage on the Gender Pay Gap A Simulation-Based Study for Germany

In a simulation-based study with data from the German Socio-Economic Panel Study (SOEP), we analyze the effects of the newly introduced statutory minimum wage of 8.50 Euro per working hour in Germany on the gender wage gap. In our first scenario where we abstain from employment effects, the pay differential is reduced by 2.5 percentage points from 19.6 % to 17.1 %, due to a reduction of the sticky-floor effect at the bottom of the wage distribution. In more realistic scenarios where we incorporate minimum wage effects on labor demand, a further reduction of the pay gap by 0.2 pp (1.2 pp) in case of a monopsonistic (neoclassical) labor market is achieved. However, this comes at the cost of job losses by which women are more strongly affected than men. The magnitude of job losses ranges between 0.2 % and 3.0 % of all employees. It is higher in a neoclassical market setting and positively related to the assumed wage elasticity

Evaluating early administration of the hydroxymethylglutaryl-CoA reductase inhibitor simvastatin in the prevention and treatment of delirium in critically ill ventilated patients (MoDUS trial): Study protocol for a randomized controlled trial

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Abstract Background The incidence of delirium in ventilated patients is estimated at up to 82%, and it is associated with longer intensive care and hospital stays, and long-term cognitive impairment and mortality. The pathophysiology of delirium has been linked with inflammation and neuronal apoptosis. Simvastatin has pleiotropic properties; it penetrates the brain and, as well as reducing cholesterol, reduces inflammation when used at clinically relevant doses over the short term. This is a single centre randomised, controlled trial which aims to test the hypothesis that treatment with simvastatin will modify delirium incidence and outcomes. Methods/Design The ongoing study will include 142 adults admitted to the Watford General Hospital Intensive Care Unit who require mechanical ventilation in the first 72 hours of admission. The primary outcome is the number of delirium- and coma-free days in the first 14 days. Secondary outcomes include incidence of delirium, delirium- and coma-free days in the first 28 days, days in delirium and in coma at 14 and 28 days, number of ventilator-free days at 28 days, length of critical care and hospital stay, mortality, cognitive decline and healthcare resource use. Informed consent will be taken from patient’s consultee before randomisation to receive either simvastatin (80 mg) or placebo once daily. Daily data will be recorded until day 28 after randomisation or until discharge from the ICU if sooner. Surviving patients will be followed up on at six months from discharge. Plasma and urine samples will be taken to investigate the biological effect of simvastatin on systemic markers of inflammation, as related to the number of delirium- and coma-free days, and the potential of cholinesterase activity and beta-amyloid as predictors of the risk of delirium and long-term cognitive impairment. Discussion This trial will test the efficacy of simvastatin on reducing delirium in the critically ill. If patients receiving the statin show a reduced number of days in delirium compared with the placebo group, the inflammatory theory implicated in the pathogenesis of delirium will be strengthened. Trial registration The trial was registered with the International Standard Randomised Controlled Trial Registry (ISRCTN89079989) on 26 March 2013.Peer reviewe

Preoperative cerebrospinal fluid cytokine levels and the risk of postoperative delirium in elderly hip fracture patients

Aging and neurodegenerative disease predispose to delirium and are both associated with increased activity of the innate immune system resulting in an imbalance between pro- and anti-inflammatory mediators in the brain. We examined whether hip fracture patients who develop postoperative delirium have altered levels of inflammatory mediators in cerebrospinal fluid (CSF) prior to surgery. Patients were 75 years and older and admitted for surgical repair of an acute hip fracture. CSF samples were collected preoperatively. In an exploratory study, we measured 42 cytokines and chemokines by multiplex analysis. We compared CSF levels between patients with and without postoperative delirium and examined the association between CSF cytokine levels and delirium severity. Delirium was diagnosed with the Confusion Assessment Method; severity of delirium was measured with the Delirium Rating Scale Revised-98. Mann-Whitney U tests or Student t-tests were used for between-group comparisons and the Spearman correlation coefficient was used for correlation analyses. Sixty-one patients were included, of whom 23 patients (37.7%) developed postsurgical delirium. Concentrations of Fms-like tyrosine kinase-3 (P=0.021), Interleukin-1 receptor antagonist (P=0.032) and Interleukin-6 (P=0.005) were significantly lower in patients who developed delirium postoperatively. Our findings fit the hypothesis that delirium after surgery results from a dysfunctional neuroinflammatory response: stressing the role of reduced levels of anti-inflammatory mediators in this process. The Effect of Taurine on Morbidity and Mortality in the Elderly Hip Fracture Patient.Registration number: NCT00497978. Local ethical protocol number: NL16222.094.0