Summary
Acrodermatitis chronica atrophicans (ACA) is the late cutaneous form of Lyme borreliosis. The early inflammatory phase manifests with a bluish‐red discoloration and doughy swelling of the ...skin. The atrophic phase represents a late‐phase process with red discoloration, and a thin and wrinkled appearance of the skin. We present a patient who exhibited a previously undescribed form of late cutaneous Lyme borreliosis (LCLB) with a foot tumour. A 64‐year‐old woman had a large tumorous lesion on the right sole. The tumour size and deformation of the feet made wearing shoes difficult. On skin histology, a granulomatous lymphohistiocytic infiltrate with plasma cells was noticed. In fact, the patient recalled tick bites 2 or 3 years before. Borrelia burgdorferi (Bb) serology was highly positive and a polymerase chain reaction analysis on the skin biopsy detected Bb sensu lato, genospecies B. afzelii. We diagnosed LCLB and antibiotics were prescribed. On the more recent examination, the tumour had totally disappeared; the skin was atrophic and dry with only few scales. We report an atypical case of European LCLB, suggesting that ACA is not the only possible presentation of LCLB. The diagnosis of ACA is often clinically missed for months or years, and may be mistaken at the inflammation phase for vascular disorders, erysipelas or bursitis/arthritis, and at the atrophic phase for lichen sclerosus atrophicus, morphoea or anetoderma. To our knowledge, no such tumorous LCLB has previously been described.
What's already known about this topic?
Late cutaneous Lyme borreliosis usually manifests with doughy swelling or atrophic lesions.
Acrodermatitis chronica atrophicans has variable clinical presentations.
Optimal treatment has not been determined.
What does this study add?
Late cutaneous Lyme borreliosis can be tumorous.
A Borrelia serology test and skin biopsy are useful in endemic areas.
Antibiotics must be given for at least 30 days but effectiveness on atrophy and neuropathy can be delayed and incomplete.
Linked Comment: Hofmann. Br J Dermatol 2017; 177:906–907.
Vascular medicine is now a clinical specialty in France. During their studies, students will acquire clinical reasoning in addition to technical skills. An Objective Structured Clinical Examination ...(OSCE) is considered as the gold standard for evaluating clinical competence. Our main objective was to evaluate the feasibility and acceptability of OSCE for the evaluation of students, secondarily their performance.
Three representative clinical cases of the specialty were developed. The OSCE consisted of a sequence of clinical situations presented in three stations of 7minutes each. The role of the simulated patient was played by medical students. At the end of the OSCE, observers and students completed the evaluation form. We compared the performances between junior and senior vascular medicine students. Written questionnaires were used to measure OSCE satisfaction.
We were able to develop and organize this examination without difficulties. Fifteen students were evaluated. All participants agreed that the clinical situations were representative of vascular medicine practice, the cases were realistic and standardized patients were convincing. The performance of senior students was statistically higher than junior students in one case.
Our study demonstrates the feasibility and acceptability of the OSCE in students in vascular medicine. The small number of stations and candidates requires further studies on a larger scale to evaluate their performance.
Abstract Background Postsurgical physiotherapy programs after total hip arthroplasty (THA) show important differences between types and numbers of treatment sessions. To increase functional recovery ...in postsurgical patients, manual therapy can be added to traditional physiotherapy programs. Fascial Manipulation (FM) has been demonstrated to be effective in decreasing pain and increasing muscular capacity. Objective To compare the effectiveness of FM when added to a standard protocol of care. Design Randomized controlled trial. Setting Rehabilitation center. Patients A total of 51 patients were recruited after total hip arthroplasty. Inclusion criteria were first THA surgery, posterior-lateral access, and onset of pain within a maximum 2 years. Exclusion criteria were previous hip or knee prosthesis, congenital hip dysplasia, elective THA secondary to trauma, real leg-length discrepancy (≥1.5 cm), cognitive impairment, concomitant rheumatic pathology in acute phase, and serious comorbidities such as cardiac, respiratory, and/or neuromuscular pathologies. Methods Patients were randomized into 2 groups; both followed a standard protocol based on 2 daily sessions of active exercises for 45 minutes. In the study group, 2 sessions were replaced by FM. Main Outcome Measures Functional outcome measures were collected before and after treatment and at the end of the rehabilitation program. The measures included the Harris Hip Score; Timed Up-and-Go test; articular range of motion in abduction, flexion, extension, and bilateral external rotation with heels together; and verbal numerical scale. Results Statistically significant differences were observed in degrees of flexion between the study and control group with 25.4 (±11.3) and 18.7 (±9.5), respectively ( P = .04); for abduction with 16.8 (±7.0) and 11.1 (±6.1), respectively ( P = .005); for extension with 16.2 (±4.9) and 9.3 (±3.8), respectively ( P = .001); for bilateral external rotation with heels together with 8.3 (±4.3) and 5.5 (±4.6), respectively ( P = .04); for the Harris Hip Score 23.3 (±8.9) and 14.5 (±8.5), respectively ( P = .002); and for verbal numerical scale score 1.1 (±2.1) and 0.5 (±1.1), respectively. Conclusions This study demonstrates that 2 FM sessions are able to significantly improve several functional outcomes in patients compared to usual treatment after THA.
Acrodermatitis chronica atrophicans (ACA) is the late cutaneous form of Lyme borreliosis. The early inflammatory phase manifests with a bluish-red discoloration and doughy swelling of the skin. The ...atrophic phase represents a late-phase process with red discoloration, and a thin and wrinkled appearance of the skin. We present a patient who exhibited a previously undescribed form of late cutaneous Lyme borreliosis (LCLB) with a foot tumour. A 64-year-old woman had a large tumorous lesion on the right sole. The tumour size and deformation of the feet made wearing shoes difficult. On skin histology, a granulomatous lymphohistiocytic infiltrate with plasma cells was noticed. In fact, the patient recalled tick bites 2 or 3 years before. Borrelia burgdorferi (Bb) serology was highly positive and a polymerase chain reaction analysis on the skin biopsy detected Bb sensu lato, genospecies B. afzelii. We diagnosed LCLB and antibiotics were prescribed. On the more recent examination, the tumour had totally disappeared; the skin was atrophic and dry with only few scales. We report an atypical case of European LCLB, suggesting that ACA is not the only possible presentation of LCLB. The diagnosis of ACA is often clinically missed for months or years, and may be mistaken at the inflammation phase for vascular disorders, erysipelas or bursitis/arthritis, and at the atrophic phase for lichen sclerosus atrophicus, morphoea or anetoderma. To our knowledge, no such tumorous LCLB has previously been described.
Extended resections do play a definite role in the surgical approach to advanced gastric malignancy. Local extension of distant spread of the tumor is no longer to be considered as a contraindication ...to aggressive surgery based on the evidence that even for palliation, extensive operations, when feasible, have proved to be beneficial in preventing complications related to the natural history of the disease. Over a nine-year period 105 patients with gastric cancer were surgically treated. Out of the 88 patients undergoing tumor excision, 53 were submitted to total gastrectomy (there were 35 males and 18 females, mean age 63 years). This procedure was considered potentially curative in 37 cases and palliative in 16. In 8 of the patients treated with palliation. An extensive procedure, including splenectomy in 7 cases (1 of which with concomitant distal pancreatic resection) and a colonic resection in 1 case, was undertaken. Alimentary continuity following total gastrectomy was restored by jejunal interposition (Mouchet-type reconstruction) in 3 cases, Roux-en-Y esophagojejunostomy in 7 and simple: end-to-side esophagojejunostomy (Sweet and Allen-type) in 6. No postoperative complications have occurred and mean survival time was 8 months with a maximum of 20 months in a patient with a good nutritional status and quality of life (Karnofsky index 78%) who developed no complications related to tumor recurrence.
A wide range of lesions may occurs after accidental or voluntary ingestion of caustic substances including mild epithelial injury to whole thickness necrosis of the involved organs. The type of ...management varies according to the severity of the damage, medical therapy being indicated in the less severe cases while surgery is required in life threatering lesins or alternatively as elective treatment of trighly desabling sequelae last complications such as. From 1981 to 1989 we observed 20 patients with acute hastro-oesophageal lesions due to ingestion caustic substances 19 of then were successfully treated with medical therapy. Only 1 patient underwent surgery and died of oesophagus cardiac fistula with right atrium perforation (24 days following total gastrectomy). Based on either our own experience and the data reported in the literature we believe that the most adequate management of patients with lesions of the E.G. due to caustic agents tract must include: vital functions control maintenance intensive care treatment of shock endoscopic monitoring of E.G. lesions emergency surgical treatment where needed.
Vulnerability has garnered an increasing attention from academia, international community and industry. Nonetheless, formal definition, mainstreaming, and measurement of vulnerability are still ...flawed in the economic literature. Energy vulnerability, intended as the exposure of an energy system to adverse events and change, often overlaps with other energy policy concepts such as resilience, security, poverty, justice, and sustainability. This paper improves understanding of vulnerability in economics, energy, and sustainability studies by: i) constructing a dataset on energy vulnerability made of 180.000 observations; ii) formally defining energy vulnerability, while considering the regulatory framework and development agenda; iii) building a composite indicator on energy vulnerability; iv) analyzing and ranking the energy vulnerability of a vast number of OECD and non-OECD countries; v) testing for robustness checks. The analysis suggests that GDP is not necessarily a leading driver for energy vulnerability, whilst resource embedment is, since fossil and renewable energy producers are less vulnerable. Eventually, the paper validates that green countries are less vulnerable, differently from cold, heavily-industrialized, and highly-consuming countries.
•GDP is not a strong driver for energy vulnerability.•Green, scarcely consuming, warm, non-industrial countries perform better.•Resource endowment and electricity access matter.•Fossil and renewable energy exporters display a lower vulnerability.•Rankings for the single energy vulnerability pillars vary widely.
Carabus clatratus
is currently known as highly threatened and/or extinct at a European level due to the loss of its habitat, represented by wetlands, to which it is closely linked. In southern ...Europe, this is much more serious due to the effective adult predation by the alien and invasive crustacean
Procambarus clarkii
, introduced from the United States of America since the 1980s and now rapidly expanding its range. In an extreme attempt to preserve the Italian native populations of the subspecies
C. clatratus antonellii
, an effective mass rearing method was developed in 2009. This method, that allowed to record new important data on the biology of the species, is described in detail. Contrary to what is reported in the literature,
C. clatratus
showed a very high reproductive potential, with an average of 82.8 eggs laid by each female per season. The low prolificacy erroneously attributed to it was wrongly considered a contributing cause of the rarefaction and/or extinction of some of its populations, while the new findings make us focus on other causes. The knowledge of the effective reproductive potential is also important for a better implementation of mass rearings and introduction programs as a function of potential offspring. The duration of the various stages of pre-imaginal development of
C. clatratus
, from the hatching of the larva to the emergence and appearance of the adults on the ground, is compared with that of another congeneric species living in an extremely unstable habitat (
C. stenocephalus susicus
) resulting, however, surprisingly even shorter. I hope that other entomologists and conservation biologists will also try their hand at rearing this species (where still present) in an attempt to save it from extinction.
Implications for insect conservation
The new data obtained on the biology and fecundity of
C. clatratus
, as well as the issues encountered after its release, can be exploited for future initiatives for the species conservation.
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