ESCMID* guideline for the diagnosis and management of Candida diseases 2012: patients with HIV infection or AIDS.

Mucosal candidiasis is frequent in immunocompromised HIV-infected highly active antiretroviral (HAART) naive patients or those who have failed therapy. Mucosal candidiasis is a marker of progressive immune deficiency. Because of the frequently marked and prompt immune reconstitution induced by HAART, there is no recommendation for primary antifungal prophylaxis of mucosal candidiasis in the HIV setting in Europe, although it has been evidenced as effective in the pre-HAART era. Fluconazole remains the first line of therapy for both oropharyngeal candidiasis and oesophageal candidiasis and should be preferred to itraconazole oral solution (or capsules when not available) due to fewer side effects. For patients who still present with fluconazole-refractory mucosal candidiasis, oral treatment with any other azole should be preferred based on precise Candida species identification and susceptibility testing results in addition to the optimization of HAART when feasible. For vaginal candidiasis, topical therapy is preferred.

Chest pain in daily practice: occurrence, causes and management

QUESTIONS UNDER STUDY: We assessed the occurrence and aetiology of chest pain in primary care practice. These features differ between primary and emergency care settings, where most previous studies have been performed. METHODS: 59 GPs in western Switzerland recorded all consecutive cases presenting with chest pain. Clinical characteristics, laboratory tests and other investigations as well as the diagnoses remaining after 12 months of follow-up were systematically registered. RESULTS: Among 24,620 patients examined during a total duration of 300 weeks of observation, 672 (2.7%) presented with chest pain (52% female, mean age 55 +/- 19(SD)). Most cases, 442 (1.8%), presented new symptoms and in 356 (1.4%) it was the reason for consulting. Over 40 ailments were diagnosed: musculoskeletal chest pain (including chest wall syndrome) (49%), cardiovascular (16%), psychogenic (11%), respiratory (10%), digestive (8%), miscellaneous (2%) and without diagnosis (3%). The three most prevalent diseases were: chest wall syndrome (43%), coronary artery disease (12%) and anxiety (7%). Unstable angina (6), myocardial infarction (4) and pulmonary embolism (2) were uncommon (1.8%). Potentially serious conditions including cardiac, respiratory and neoplasic diseases accounted for 20% of cases. A large number of laboratory tests (42%), referral to a specialist (16%) or hospitalisation (5%) were performed. Twentyfive patients died during follow-up, of which twelve were for a reason directly associated with thoracic pain [cancer (7) and cardiac causes (5)]. CONCLUSIONS: Thoracic pain was present in 2.7% of primary care consultations. Chest wall syndrome pain was the main aetiology. Cardio - vascular emergencies were uncommon. However chest pain deserves full consideration because of the occurrence of potentially serious conditions.

Ätiologie und Management der Gicht [The etiology and management of gout].

Gout is an inflammatory arthritis caused by monosodium urate (MSU) crystal deposits in and around the joint. The formation of urinary calculi can also occur in gout, but are less common than arthritis. Gout usually presents with recurrent episodes of joint inflammation, which over time lead to tophus formation and joint destruction. In the last decade, significant advances have been made regarding not only the epidemiology and genetics of gout and hyperuricemia but also the mechanisms of inflammation and treatment of gout. In addition, knowledge concerning the key role of interleukin 1 (IL-1) has provided new therapeutic perspectives. However, the current management of gout is often suboptimal, with many Patienten either not receiving adequate treatment or being unable to tolerate existing treatments. New therapeutic agents provide interesting new options for Patienten with difficult-to-treat gouty arthritis.The English full-text version of this is available at SpringerLink (under "Supplemental").

2013 Iowa DOT Engineering Intern Development and Management Program, 13-464, 2013

The Institute for Transportation (InTrans) at Iowa State University (ISU) developed an internship mentoring program in collaboration with the Iowa Department of Transportation (DOT) to provide additional mentorship to both student interns and Iowa DOT intern managers. For the summer 2013 Iowa DOT Engineering Intern Development and Management Program, this report summarizes the following: * Mentoring activities conducted by ISU; * Results of the different intern program success assessments that were conducted; * Experiences, lessons learned, and recommendations; * Program benefits that were realized.

Cutaneous benign mixed tumor (chondroid syringoma) of the eyelid: clinical presentation and management.

PURPOSE: To describe the clinical presentation of cutaneous benign mixed tumor of the eyelid and its management options. METHODS: Periocular cases of cutaneous benign mixed tumor were gathered from members of an oculoplastics specialty Internet discussion group. A total of 9 patients are described in this retrospective, interventional case series. The clinical presentation, histopathology, and management of these lesions is reviewed. RESULTS: Patients were typically asymptomatic, presenting with a slowly enlarging, nontender nodule of 2 to 8 years' duration. The lesions ranged from 4 mm to 17 mm in greatest dimension. Four of the lesions were on the eyelid margin, three in the sub-brow area of the upper eyelid, and two in the central lids. All six cases not involving the brow were fixed to the tarsus; one brow lesion was believed to be adherent to the skin. None of the lesions was associated with significant changes of the overlying epidermis, although one lesion showed overlying pigmentation. All patients underwent excisional biopsy for diagnostic or cosmetic reasons. On histopathologic examination, the tumors were biphasic, with an epithelial component exhibiting apocrine or hair follicle differentiation and a myxoid, adipocytic, chondroid, and/or fibrous stroma. The pathologic diagnoses were all consistent with cutaneous benign mixed tumor (chondroid syringoma, pleomorphic adenoma). Follow-up ranged from 2 weeks to 12 months, although several patients failed to keep scheduled follow-up appointments. No clinical recurrences were identified. CONCLUSIONS: Cutaneous benign mixed tumor may occur in the eyelid, and, although uncommon, should be included in the differential diagnosis of firm, nodular eyelid tumors. The histopathologic features are similar to those seen in this tumor type arising in other areas of the body. Preoperative consideration of this diagnostic possibility may allow the surgeon to plan for complete excision, thereby reducing the possibility of recurrence or malignant transformation.

Réplication cérébrale du VIH malgré une thérapie antirétrovirale efficace: impact clinique et prise en charge [Intracerebral HIV replication despite an efficient antiretroviral treatment: clinical impact and management].

Various neurological and neuropsychological manifestations are still relatively frequently reported in HIV infected patients in the highly active antiretroviral therapy era. A fraction of them could be related to HIV replication in the central nervous system (CNS) despite adequate peripheral viral suppression. This hypothesis is supported by numerous reports of detectable HIV RNA in the cerebrospinal fluid in the context of a low or undetectable viremia in association with neurological or neuropsychological complaints. In addition, some antiviral molecules may not achieve adequate levels in the CNS, thus potentially favoring intracerebral HIV replication and even antiretroviral resistance. Neurologic manifestations in the presence of CNS HIV replication often decrease after antiretroviral treatment CNS penetration optimization.

Diagnosis and management of blunt great vessel trauma.

Traditionally, thoracic aortic rupture, suspected after blunt thoracic trauma, is characterized by a chest radiograph showing a widened mediastinum. The diagnostic machinery consecutively activated still depends heavily on the pressure as additional traumatic lesions. A patient with additional cranio-cerebral trauma would typically undergo contrast-enhanced computed tomography or magnetic resonance imaging of head, chest, and other regions. In a number of patients these analyses would confirm the presence of blood in the mediastinum without formal proof of an aortic disruption. This is because mediastinal hematomas may be caused not only by an aortic rupture, but also by numerous other blood sources including fractures of the spine and other macro- and microvascular lesions providing similar images. Therefore, aortic angiography became our preferred diagnostic tool to identify or rule out acute traumatic lesions of not only the aorta but with great vessels. However recently, a number of traumatic aortic transsections have been identified by transoesophageal echocardiography (TEE). TEE has the additional advantage of being a bed-side procedure providing additional information about cardiac function. The latter analysis allows for identification and quantification of cardiac contusions, post-traumatic myocardial infarctions, and valvar lesions which are of prime importance to develop an adequate surgical strategy and to assess the risk of the numerous emergency procedures required in patients with polytrauma. The standard approach for repair of isthmic aortic rupture is through a lateral thoracotomy. Distal and proximal control of the aorta can be achieved in a substantial number of cases before complete aortic rupture occurs and a higher proportion of direct suture repair can be achieved under such circumstances. Most proximal descending aortic procedures are performed without cardiopulmonary bypass (clamp and go) but paraplegia may occur before, during, or after the procedure. Ascending aortic lesions and disruption of the aortic arch, the supra-aortic vessels, the main pulmonary arteries, the great veins as well as cardiac lesions are best approached through a sternotomy, which may have to be extended. Cardiopulmonary bypass allowing for deep hypothermia and circulatory arrest is often required and carries its own complications. It is not clear whether the increasing proportion of ascending aortic and cardiac lesions which are observed nowadays are due to a change in trauma mechanics (i.e., speed limits, seat belts, air-bags), an improvement of the diagnostic tools or both.

Morphogenetic characteristics and management of Tanzania grass

The objective of this work was to evaluate the effect of grazing interval and period of evaluation over tissue turnover in Tanzania grass pastures (Panicum maximum cv. Tanzania) and to ascertain if herbage accumulation rate can be used as a criterion to establish a defoliation schedule for this grass in Southeast of Brazil. A randomized block design with a split-plot arrangement was used. The effect of three grazing intervals was evaluated within seven periods between October 1995 and September 1996. Responses monitored were leaf and stem elongation rates, leaf senescence rate, stem length, and tiller density. Net herbage accumulation rate was calculated using tissue turnover data. The grazing intervals for Tanzania grass should be around 38 days between October and April (spring and early autumn) and 28 days during the reproductive phase of the grass (April/May). Between May and September (late autumn and winter), grazing interval should be around 48 days. Herbage accumulation rate is not a good criterion to establish defoliation time for Tanzania grass. Studies on the effects of stem production in grazing efficiency, animal intake and forage quality are needed to improve Tanzania grass management.

Social structure emerges via the interaction between local ecology and individual behaviour.

1. The formation of groups is a fundamental aspect of social organization, but there are still many questions regarding how social structure emerges from individuals making non-random associations. 2. Although food distribution and individual phenotypic traits are known to separately influence social organization, this is the first study, to our knowledge, experimentally linking them to demonstrate the importance of their interaction in the emergence of social structure. 3. Using an experimental design in which food distribution was either clumped or dispersed, in combination with individuals that varied in exploratory behaviour, our results show that social structure can be induced in the otherwise non-social European shore crab (Carcinus maenas). 4. Regardless of food distribution, individuals with relatively high exploratory behaviour played an important role in connecting otherwise poorly connected individuals. In comparison, low exploratory individuals aggregated into cohesive, stable subgroups (moving together even when not foraging), but only in tanks where resources were clumped. No such non-foraging subgroups formed in environments where food was evenly dispersed. 5. Body size did not accurately explain an individual's role within the network for either type of food distribution. 6. Because of their synchronized movements and potential to gain social information, groups of low exploratory crabs were more effective than singletons at finding food. 7. Because social structure affects selection, and social structure is shown to be sensitive to the interaction between ecological and behavioural differences among individuals, local selective pressures are likely to reflect this interaction.

Risk factor profile and management of cerebrovascular patients in the REACH Registry.

BACKGROUND: Cerebrovascular disease (CVD) is a global public health problem. CVD patients are at high risk of recurrent stroke and other atherothrombotic events. Prevalence of risk factors, comorbidities, utilization of secondary prevention therapies and adherence to guidelines all influence the recurrent event rate. We assessed these factors in 18,992 CVD patients within a worldwide registry of stable outpatients. METHODS: The Reduction of Atherothrombosis for Continued Health Registry recruited >68,000 outpatients (44 countries). The subjects were mainly recruited by general practitioners (44%) and internists (29%) if they had symptomatic CVD, coronary artery disease, peripheral arterial disease (PAD) and/or >or=3 atherothrombotic risk factors. RESULTS: The 18,992 CVD patients suffered a stroke (53.7%), transient ischemic attack (TIA) (27.7%) or both (18.5%); 40% had symptomatic atherothrombotic disease in >or=1 additional vascular beds: 36% coronary artery disease; 10% PAD and 6% both. The prevalence of risk factors at baseline was higher in the TIA subgroup than in the stroke group: treated hypertension (83.5/82.0%; p = 0.02), body mass index >or=30 (26.7/20.8%; p < 0.0001), hypercholesterolemia (65.1/52.1%; p < 0.0001), atrial fibrillation (14.7/11.9%; p < 0.0001) and carotid artery disease (42.3/29.7%; p < 0.0001). CVD patients received antiplatelet agents (81.7%), oral anticoagulants (17.3%), lipid-lowering agents (61.2%) and antihypertensives (87.9%), but guideline treatment targets were frequently not achieved (54.5% had elevated blood pressure at baseline, while 4.5% had untreated diabetes). CONCLUSIONS: A high percentage of CVD patients have additional atherothrombotic disease manifestations. The risk profile puts CVD patients, especially the TIA subgroup, at high risk for future atherothrombotic events. Undertreatment is common worldwide and adherence to guidelines needs to be enforced.

Rethinking study and management of agricultural systems for policy design

There is a concern that agriculture will no longer be able to meet, on a global scale, the growing demand for food. Facing such a challenge requires new patterns of thinking in the context of complexity and sustainability sciences. This paper, focused on the social dimension of the study and management of agricultural systems, suggests that rethinking the study of agricultural systems entails analyzing them as complex socio-ecological systems, as well as considering the differing thinking patterns of diverse stakeholders. The intersubjective nature of knowledge, as studied by different philosophical schools, needs to be better integrated into the study and management of agricultural systems than it is done so far, forcing us to accept that there are no simplistic solutions, and to seek a better understanding of the social dimension of agriculture. Different agriculture related problems require different policy and institutional approaches. Finally, the intersubjective nature of knowledge asks for the visualization of different framings and the power relations taking place in the decision-making process. Rethinking management of agricultural systems implies that policy making should be shaped by different principles: learning, flexibility, adaptation, scale-matching, participation, diversity enhancement and precaution hold the promise to significantly improve current standard management procedures.

Optimization and Management of Materials in Earthwork Construction, TR-501, 2010

As a result of forensic investigations of problems across Iowa, a research study was developed aimed at providing solutions to identified problems through better management and optimization of the available pavement geotechnical materials and through ground improvement, soil reinforcement, and other soil treatment techniques. The overall goal was worked out through simple laboratory experiments, such as particle size analysis, plasticity tests, compaction tests, permeability tests, and strength tests. A review of the problems suggested three areas of study: pavement cracking due to improper management of pavement geotechnical materials, permeability of mixed-subgrade soils, and settlement of soil above the pipe due to improper compaction of the backfill. This resulted in the following three areas of study: (1) The optimization and management of earthwork materials through general soil mixing of various select and unsuitable soils and a specific example of optimization of materials in earthwork construction by soil mixing; (2) An investigation of the saturated permeability of compacted glacial till in relation to validation and prediction with the Enhanced Integrated Climatic Model (EICM); and (3) A field investigation and numerical modeling of culvert settlement. For each area of study, a literature review was conducted, research data were collected and analyzed, and important findings and conclusions were drawn. It was found that optimum mixtures of select and unsuitable soils can be defined that allow the use of unsuitable materials in embankment and subgrade locations. An improved model of saturated hydraulic conductivity was proposed for use with glacial soils from Iowa. The use of proper trench backfill compaction or the use of flowable mortar will reduce the potential for developing a bump above culverts.

Ecology and life history affect different aspects of the population structure of 27 high-alpine plants.

A plant species' genetic population structure is the result of a complex combination of its life history, ecological preferences, position in the ecosystem and historical factors. As a result, many different statistical methods exist that measure different aspects of species' genetic structure. However, little is known about how these methods are interrelated and how they are related to a species' ecology and life history. In this study, we used the IntraBioDiv amplified fragment length polymorphisms data set from 27 high-alpine species to calculate eight genetic summary statistics that we jointly correlate to a set of six ecological and life-history traits. We found that there is a large amount of redundancy among the calculated summary statistics and that there is a significant association with the matrix of species traits. In a multivariate analysis, two main aspects of population structure were visible among the 27 species. The first aspect is related to the species' dispersal capacities and the second is most likely related to the species' postglacial recolonization of the Alps. Furthermore, we found that some summary statistics, most importantly Mantel's r and Jost's D, show different behaviour than expected based on theory. We therefore advise caution in drawing too strong conclusions from these statistics.