Infection and immune-mediated meningococcal-associated arthritis: combination features in the same patient

We present a case of a 16-year-old male patient with sudden-onset, rash, arthritis and meningitis by Neisseria meningitidis one week after an acute upper respiratory infection. On the 10th day of treatment followed by neurological and arthritis clinical improvement, he presented once again a tender and swollen left knee with a moderate effusion, and active and passive range of motion was severely limited secondary to pain, and when he was submitted to surgical drainage and synovial fluid analysis he showed inflammatory characteristics. A non-steroidal anti-inflammatory drug was taken for five days with complete improvement of symptoms. The case is notable for its combination of features of septic and immune-mediated arthritis, which has rarely been reported in the same patient.

Actividad física y síndrome metabólico en adultos de Canarias

Programa de doctorado: Actividad Física, Salud y Rendimiento Deportivo

Valutazione del rischio di contaminazione di corsi d'acqua da rilasci accidentali di idrocarburi.

Nella definizione di incidente rilevante presente nelle Direttive Seveso, come pure nel loro recepimento nella legislazione italiana, rientrano eventi incidentali che abbiano conseguenze gravi per il bersaglio “ambiente”, sia in concomitanza sia in assenza di effetti dannosi per l’uomo. Tuttavia, a fronte di questa attenzione al bersaglio “ambiente” citata dalle norme, si constata la mancanza di indici quantitativi per la stima del rischio di contaminazione per i diversi comparti ambientali e, conseguentemente, anche di metodologie per il loro calcolo. Misure di rischio quantitative consolidate e modelli condivisi per la loro stima riguardano esclusivamente l’uomo, con la conseguenza che la valutazione di rischio per il bersaglio “ambiente” rimane ad un livello qualitativo o, al più, semi-quantitativo. Questa lacuna metodologica non consente di dare una piena attuazione al controllo ed alla riduzione del rischio di incidente rilevante, secondo l’obiettivo che le norme stesse mirano a raggiungere. E d‘altra parte il verificarsi periodico di incidenti con significativi effetti dannosi per l’ambiente, quali, ad esempio lo sversamento di gasolio nel fiume Lambro avvenuto nel febbraio 2010, conferma come attuale e urgente il problema del controllo del rischio di contaminazione ambientale. La ricerca presentata in questo lavoro vuole rappresentare un contributo per colmare questa lacuna. L’attenzione è rivolta al comparto delle acque superficiali ed agli sversamenti di liquidi oleosi, ovvero di idrocarburi insolubili in acqua e più leggeri dell’acqua stessa. Nel caso in cui il rilascio accidentale di un liquido oleoso raggiunga un corso d’acqua superficiale, l’olio tenderà a formare una chiazza galleggiante in espansione trasportata dalla corrente e soggetta ad un complesso insieme di trasformazioni fisiche e chimiche, denominate fenomeni di “oil weathering”. Tra queste rientrano l’evaporazione della frazione più volatile dell’olio e la dispersione naturale dell’olio in acqua, ovvero la formazione di una emulsione olio-in-acqua nella colonna d’acqua al di sotto della chiazza di olio. Poiché la chiazza si muove solidale alla corrente, si può ragionevolmente ritenere che l’evaporato in atmosfera venga facilmente diluito e che quindi la concentrazione in aria dei composti evaporati non raggiunga concentrazioni pericolose esternamente alla chiazza stessa. L’effetto fisico dannoso associato allo sversamento accidentale può pertanto essere espresso in doversi modi: in termini di estensione superficiale della chiazza, di volume di olio che emulsifica nella colonna d’acqua, di volume della colonna che si presenta come emulsione olio-in-acqua, di lunghezza di costa contaminata. In funzione di questi effetti fisici è possibile definire degli indici di rischio ambientale analoghi alle curve di rischio sociale per l’uomo. Come una curva di rischio sociale per l’uomo esprime la frequenza cumulata in funzione del numero di morti, così le curve di rischio sociale ambientale riportano la frequenza cumulata in funzione dell’estensione superficiale della chiazza, ovvero la frequenza cumulata in funzione del volume di olio che emulsifica in acqua ovvero la frequenza cumulata in funzione del volume di colonna d’acqua contaminato ovvero la frequenza cumulata in funzione della lunghezza di costa contaminata. Il calcolo degli indici di rischio così definiti può essere effettuato secondo una procedura analoga al calcolo del rischio per l’uomo, ovvero secondo i seguenti passi: 1) descrizione della sorgente di rischio; 2) descrizione del corso d’acqua che può essere contaminato in caso di rilascio dalla sorgente di rischio; 3) identificazione, degli eventi di rilascio e stima della loro frequenza di accadimento; 4) stima, per ogni rilascio, degli effetti fisici in termini di area della chiazza, di volume di olio emulsificato in acqua, di volume dell’emulsione olio-in-acqua, lunghezza di costa contaminata; 5) ricomposizione, per tutti i rilasci, degli effetti fisici e delle corrispondenti frequenze di accadimento al fine di stimare gli indici di rischio sopra definiti. Al fine di validare la metodologia sopra descritta, ne è stata effettuata l’applicazione agli stabilimenti a rischio di incidente rilevante presenti nei bacini secondari che fanno parte del bacino primario del Po. E’ stato possibile calcolare gli indici di rischio per ogni stabilimento, sia in riferimento al corso d’acqua del bacino secondario a cui appartengono, sia in riferimento al Po, come pure ottenere degli indici di rischio complessivi per ogni affluente del Po e per il Po stesso. I risultati ottenuti hanno pienamente confermato la validità degli indici di rischio proposti al fine di ottenere una stima previsionale del rischio di contaminazione dei corsi d’acqua superficiali, i cui risultati possano essere utilizzati per verificare l’efficacia di diverse misure di riduzione del rischio e per effettuare una pianificazione d’emergenza che consenta, in caso di incidente, di contenere, recuperare e favorire la dispersione dell’olio sversato.

Acute hemorrhagic edema of young children: a concise narrative review

Acute hemorrhagic edema of young children is an uncommon but likely underestimated cutaneous leukocytoclastic vasculitis. The condition typically affects infants 6-24 months of age with a history of recent respiratory illness with or without course of antibiotics. The diagnosis is made in children, mostly nontoxic in appearance, presenting with nonpruritic, large, round, red to purpuric plaques predominantly over the cheeks, ears, and extremities, with relative sparing of the trunk, often with a target-like appearance, and edema of the distal extremities, ears, and face that is mostly non-pitting, indurative, and tender. In boys, the lesions sometimes involve the scrotum and, more rarely, the penis. Fever, typically of low grade, is often present. Involvement of body systems other than skin is uncommon, and spontaneous recovery usually occurs within 6-21 days without sequelae. In this condition, laboratory tests are non-contributory: total blood cell count is often normal, although leukocytosis and thrombocytosis are sometimes found, clotting studies are normal, erythrocyte sedimentation rate and C-reactive protein test are normal or slightly elevated, complement level is normal, autoantibodies are absent, and urinalysis is usually normal. Experienced physicians rapidly consider the possible diagnosis of acute hemorrhagic edema when presented with a nontoxic young child having large targetoid purpuric lesions and indurative swelling, which is non-pitting in character, and make the diagnosis either on the basis of clinical findings alone or supported by a skin biopsy study.

[A young child with acute abdomen and iron deficiency anemia]

The case of a 20 month-old girl that was admitted to the emergency ward because of worsening of her general condition in the setting of acute non-bloody gastroenteritis is reported. The clinical examination revealed signs of severe dehydration and a prominent tender abdomen. Laboratory evaluation showed leucocytosis, elevated C-reactive protein and severe hypochromic microcytic anemia. Abdominal X-ray revealed diffuse meteorism. The child underwent laparascopic evaluation. A perforated Meckel's diverticulum was found. Perforation and anemia due to occult bleeding are unusual presentations of Meckel's diverticulum. The differential diagnosis of children presenting with an acute abdomen with special focus on Meckel's diverticulum is discussed.

Ultrasound-guided blocks for the treatment of chronic pain

Ultrasound (US) is an emerging imaging technique in interventional pain management. The main advantages are the identification of soft tissues, vessels, and nerves, without exposing patients and personnel to radiation, the possibility to perform continuous imaging, and the visualization of the fluid injected in a real-time fashion. Possible applications are nerve blocks of the cervical and lumbar zygapophysial joints, stellate ganglion block, intercostal nerve blocks, occipital nerve blocks, blocks of the inguinal nerves, peripheral nerve blocks of the extremities, blocks of painful stump neuromas, caudal epidural injections, and injections of tender points. US may also be used for destructive procedures, such as cryoanalgesia, radiofrequency lesions, or chemical neurolysis. The increasing published data available suggest that US has a potential usefulness in interventional pain management, but also limitations. There is still a need for clinical trials investigating efficacy and safety of US-guided pain procedures. Until these studies are made, fluoroscopy or computed tomography remain the gold standard for most interventional pain procedures.

Acute hemorrhagic edema of young children (cockade purpura and edema): a case series and systematic review

BACKGROUND: Acute hemorrhagic edema is an uncommon leukocytoclastic small-vessel vasculitis of young children. OBJECTIVE: To determine clinical features and outcome of acute hemorrhagic edema of young children. METHODS: Seven new cases are reported. A search of the literature revealed 287 published cases. RESULTS: The 294 children (boys, 67%) ranged in age between 2 and 60 months (median, 11 months) and were in good general condition. In 195 children the disease developed after a simple acute infection. The exanthemata included large, round, red to purpuric plaques predominantly over the cheeks, ears, and extremities and mostly tender edema of the distal extremities, ears, and face. Involvement of body systems other than skin was rare. The children recovered spontaneously without sequelae. LIMITATIONS: Results of this review must be viewed with an understanding of the limitations of the analysis process, which incorporated data exclusively from single case reports or case series. CONCLUSIONS: Acute hemorrhagic edema of young children is a very benign vasculitis. Physicians might rapidly develop the skills necessary to diagnose this condition.

Advanced Lemierre syndrome requiring surgery

A 38-year-old homeless man was admitted with a 2-week history of a sore throat, increasing shortness of breath, and high fever. Clinical examination showed enlarged and tender submandibular and anterior cervical lymph nodes and a pronounced enlargement of the left peritonsillar region (Figure 1a). CT scan of the throat and the chest showed left peritonsillar abscess formation, occlusion of the left internal jugular vein with inflammatory wall thickening and perijugular soft tissue infiltration, pulmonary abscesses, and bilateral pleural effusions (Figures 1b-e, arrowed). Anaerobe blood cultures grew Fusobacterium necrophorum, leading to the diagnosis of Lemierre's syndrome. Treatment with high-dose amoxicillin and clavulanic acid improved the oropharyngeal condition, but the patient's general status declined further, marked by dyspnea and tachypnea. Repeated CT scans showed progressive lung abscesses and bilateral pleural empyema. Bilateral tonsillectomy, ligation of the left internal jugular vein, and staged decortication of bilateral empyema were performed. Total antibiotic therapy duration was 9 weeks, including a change to peroral clindamycin. Clinical and laboratory findings had returned to normal 12 weeks after surgery.The patient's history and the clinical and radiological findings are characteristic for Lemierre's syndrome. CT scans of the neck and the chest are the diagnostic methods of choice. F. necrophorum is found in over 80% of cases of Lemierre's syndrome and confirms the diagnosis. Prolonged antibiotic therapy is usually sufficient, but in selected patients, a surgical intervention may be necessary. Reported mortality rates are high, but in surviving patients, the recovery of pulmonary function is usually good.

Stud.IP and ILIAS in an EU-Funded Project for the Middle East

In autumn 2005 InWEnt (Internationale Weiterbildung und Entwicklung/Capacity Building International gGmbH) on behalf of the EU invited to tender for three web based trainings (WBT). The precondition: either the open-source-platform Stud.IP or ILIAS should be used. The company data-quest decided not to offer the use of either Stud.IP or ILIAS, but both in combination - and won the contract. Several month later, the new learning environment with the combined powers of Stud.IP and ILIAS was ready to serve WBT-participants from all over the world. The following text describes the EU-Project "Efficient Management of Wastewater, its Treatment and Reuse in the Mediterranean Countries" (EMWater), the WBT concept and the experiences with the new Stud.IP-ILIAS-interface.

GRASP with Hybrid Path Relinking for Bi-Objective Winner Determination in Combinatorial Transportation Auctions

The procurement of transportation services via large-scale combinatorial auctions involves a couple of complex decisions whose outcome highly influences the performance of the tender process. This paper examines the shipper's task of selecting a subset of the submitted bids which efficiently trades off total procurement cost against expected carrier performance. To solve this bi-objective winner determination problem, we propose a Pareto-based greedy randomized adaptive search procedure (GRASP). As a post-optimizer we use a path relinking procedure which is hybridized with branch-and-bound. Several variants of this algorithm are evaluated by means of artificial test instances which comply with important real-world characteristics. The two best variants prove superior to a previously published Pareto-based evolutionary algorithm.

Corporate acquisitions by listed firms: the experience of a comprehensive sample

The sample used includes tender offers, mergers, acquisitions of privately held corporations, and comprehensive acquisitions of other firms' assets. According to the results, the majority of bid announcements prompt significant stock price increases, especially when controlling for partial anticipation problems and relative acquisition size. Furthermore, there is little evidence that firms that engage in "bad" acquisitions are more likely to be taken over.

Anaemia may add information to standardised disease activity assessment to predict radiographic damage in rheumatoid arthritis: a prospective cohort study

OBJECTIVE: Anaemia in rheumatoid arthritis (RA) is prototypical of the chronic disease type and is often neglected in clinical practice. We studied anaemia in relation to disease activity, medications and radiographic progression. METHODS: Data were collected between 1996 and 2007 over a mean follow-up of 2.2 years. Anaemia was defined according to WHO (♀ haemoglobin<12 g/dl, ♂: haemoglobin<13 g/dl), or alternative criteria. Anaemia prevalence was studied in relation to disease parameters and pharmacological therapy. Radiographic progression was analysed in 9731 radiograph sets from 2681 patients in crude longitudinal regression models and after adjusting for potential confounding factors, including the clinical disease activity score with the 28-joint count for tender and swollen joints and erythrocyte sedimentation rate (DAS28ESR) or the clinical disease activity index (cDAI), synthetic antirheumatic drugs and antitumour necrosis factor (TNF) therapy. RESULTS: Anaemia prevalence decreased from more than 24% in years before 2001 to 15% in 2007. Erosions progressed significantly faster in patients with anaemia (p<0.001). Adjusted models showed these effects independently of clinical disease activity and other indicators of disease severity. Radiographic damage progression rates were increasing with severity of anaemia, suggesting a 'dose-response effect'. The effect of anaemia on damage progression was maintained in subgroups of patients treated with TNF blockade or corticosteroids, and without non-selective nonsteroidal anti-inflammatory drugs (NSAIDs). CONCLUSIONS: Anaemia in RA appears to capture disease processes that remain unmeasured by established disease activity measures in patients with or without TNF blockade, and may help to identify patients with more rapid erosive disease.

Protecting Tropical Forests through Public Procurement of Emission Reductions

The rate of destruction of tropical forests continues to accelerate at an alarming rate contributing to an important fraction of overall greenhouse gas emissions. In recent years, much hope has been vested in the emerging REDD+ framework under the UN Framework Convention on Climate Change (UNFCCC), which aims at creating an international incentive system to reduce emissions from deforestation and forest degradation. This paper argues that in the absence of an international consensus on the design of results-based payments, “bottom-up” initiatives should take the lead and explore new avenues. It suggests that a call for tender for REDD+ credits might both assist in leveraging private investments and spending scarce public funds in a cost-efficient manner. The paper discusses the pros and cons of results-based approaches, provides an overview of the goals and principles that govern public procurement and discusses their relevance for the purchase of REDD+ credits, in particular within the ambit of the European Union.

Eculizumab hepatotoxicity in pediatric aHUS.

BACKGROUND Eculizumab is a humanized anti-C5 antibody approved for the treatment of atypical hemolytic uremic syndrome (aHUS). Its use is increasing in children following reports of its safety and efficacy. METHODS We reviewed biochemical and clinical data related to possible drug-induced liver injury in 11 children treated with eculizumab for aHUS in a single center. RESULTS Elevated aminotransferases were observed in 7 children aged 6 to 11 years following eculizumab treatment for aHUS. Internationally accepted liver enzyme thresholds for drug-induced liver injury were exceeded in 5 cases. In all cases, liver injury was classified as mixed hepatocellular and cholestatic. Infectious and other causes were excluded in each case. One patient with no pre-existing liver disease developed tender hepatomegaly and liver enzyme derangement exceeding 20 times the upper limit of normal following initiation of eculizumab. Recurrent liver injury following re-challenge with eculizumab necessitated its discontinuation and transition to plasma therapy. CONCLUSIONS Hepatotoxicity in association with eculizumab is a potentially important yet previously unreported adverse event. We recommend monitoring liver enzymes in all patients receiving eculizumab. Further research is required to clarify the impact of this adverse event, to characterize the mechanism of potential hepatotoxicity, and to identify which patients are most at risk.

Acute hemorrhagic edema of young children: a prospective case series.

Acute hemorrhagic edema of young children is a rare leukocytoclastic vasculitis that has been reported exclusively in small retrospective cases series, case reports, or quizzes. Considering that retrospective experience deserves confirmation in at least one observational prospective study, we present our experience with 16 children (12 boys and 4 girls, 5-28 months of age) affected by acute hemorrhagic edema. The patients were in good general conditions and with a low-grade or even absent fever. They presented with non-itching red to purpuric targetoid lesions not changing location within hours, with non-pitting and sometimes tender indurative swelling, and without mucous membrane involvement or scratch marks. Signs for articular, abdominal, or kidney involvement were absent. Antinuclear or antineutrophil cytoplasmic autoantibodies were never detected. The cases were managed symptomatically as outpatients and fully resolved within 4 weeks or less. No recurrence or familiarity was noted. CONCLUSION This is the first prospective evaluation of hemorrhagic edema. Our findings emphasize its distinctive tetrad: a well-appearing child; targetoid lesions that do not change location within hours; non-pitting, sometimes tender edema; complete resolution without recurrence. What is known • Acute hemorrhagic edema of young children is considered a benign vasculitis. • There have been ≈100 cases reported in small retrospective case series. What is new • The first prospective evaluation of this condition emphasizes its features: febrile prodrome; well-appearing child; targetoid lesions not changing location within hours; non-pitting, sometimes tender indurative edema; absent extracutaneous involvement; resolution within 3 weeks. • Antineutrophil cytoplasmic autoantibodies do not play a pathogenic role.