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Resumen Introduccion Las ganas de vivir, concepto central en las teorias del bienestar, representa un componente actitudinal positivo hacia la propia vida. Se ha identificado como un mediador entre la autopercepcion del envejecimiento y la longevidad y la salud. El objetivo de este estudio es caracterizar a las personas mayores que tienen elevados niveles de ganas de vivir en las principales dimensiones de la psicologia positiva. Metodo Participaron de forma voluntaria 165 adultos mayores con edades comprendidas entre 54 y 89 anos, usuarios de centros de mayores de la Comunidad de Madrid. Se evaluaron las ganas de vivir y otras dimensiones del bienestar y la salud. Se analizaron las correlaciones entre las distintas dimensiones evaluadas, se establecieron comparaciones entre ellas en funcion de distintos niveles de ganas de vivir, y se analizo que dimensiones contribuyen en mayor medida a las ganas de vivir. Resultados Las correlaciones entre variables han resultado estadisticamente significativas en su mayor parte; se ha observado una disminucion de los coeficientes al controlar el efecto de las ganas de vivir. En las comparaciones de medias, se hallaron diferencias significativas entre los 3 grupos con diferente nivel de ganas de vivir en practicamente todas las dimensiones de la psicologia positiva. Gratitud, afecto positivo y depresion son las dimensiones que mejor predicen las ganas de vivir. Conclusion Los adultos mayores que conforman el grupo con elevadas ganas de vivir se caracterizan por tener mayores niveles de optimismo, gratitud, resiliencia, afecto positivo, sentido de la vida, prosperidad psicologica, felicidad y satisfaccion con la vida y menores niveles de depresion y autopercepcion del envejecimiento negativa. Las implicaciones de estos resultados apuntan hacia la relevancia de las ganas de vivir en el envejecimiento con exito.

Resumo Objetivo Descrever a evolução dos decretos e indicadores relacionados à COVID-19 em Santa Catarina, Brasil, até agosto de 2020. Métodos Estudo ecológico que analisou indicadores epidemiológicos e decretos estaduais sobre o distanciamento social. Os decretos foram agrupados em medidas de restrição, manutenção ou flexibilização. Mortalidade, incidência e transmissibilidade constituíram os indicadores. Resultados Foram registrados 179.443 casos e 2.183 óbitos no período selecionado. A taxa de incidência passou de 20,4 casos a cada 100 mil habitantes no mês de março para 642,2/100 mil hab. em agosto. Foram emitidos 15 decretos estaduais. Em agosto, quando se observou a maior taxa de mortalidade (13,1/100 mil hab.), verificou-se que todas as categorias, à exceção de uma, haviam sido flexibilizadas. Conclusão Os decretos que flexibilizaram as medidas de distanciamento social foram emitidos precocemente, em desacordo com o contexto epidemiológico no estado. Resumen Objetivo Describir la evolución de los decretos e indicadores relacionados con la COVID-19 en Santa Catarina, Brasil, hasta agosto de 2020. Métodos Estudio ecológico que analizó indicadores epidemiológicos y decretos estatales sobre distanciamiento social. Los decretos se agruparon en: restricción; mantenimiento y flexibilización. Mortalidad, incidencia y transmisibilidad fueron los indicadores. Resultados Se registraron 179.443 casos y 2.183 defunciones. La tasa de incidencia pasó de 20,4 casos por 100.000 habitantes en marzo a 642,2 en agosto. Se emitieron 15 decretos estatales. En agosto, cuando se observó la tasa de mortalidad más alta (13,1 por 100.000 habitantes), parecía que todas las categorías, con excepción de una, se habían flexibilizado por decretos anteriores Conclusión Los decretos que flexibilizaron las medidas de distancia social se emitieron precozmente y en desacuerdo con el momento epidemiológico en el estado. Abstract Objective To describe the evolution of decrees and indicators related to COVID-19 in Santa Catarina, Brazil, up until August 2020. Methods This was an ecological study that analyzed epidemiological indicators and state decrees on social distancing. The decrees were grouped into restriction, maintenance and relaxation. The indicators were mortality, incidence and transmissibility. Results 179,443 cases and 2,183 deaths were recorded in the period. The incidence rate went from 20.4 cases per 100,000 inhabitants in March to 642.2 in August. Fifteen state decrees were issued. In August, when the highest mortality rate was observed (13.1 per 100,000 inhabitants), it was found that all decree categories, except one, had been relaxed. Conclusion The decrees that relaxed social distancing measures were issued early and in disagreement with the epidemiological context in the state.

This article considers the lives of disabled people requiring assistive technology who live in contexts of urban poverty. Provision is often constrained by a range of contextual factors which seem outside the scope of health and rehabilitation services. We critically reflect on health, rehabilitation, and capabilities approaches. We explore both rehabilitation and capabilities approaches with posture and mobility practice in an area of urban poverty in Argentina. Contrasting rehabilitation and capabilities approaches to a composite posture and mobility case provides a range of insights. Rehabilitation approaches start with the individual as the locus for intervention. Capabilities approaches reframe interventions such as posture and mobility in terms of the freedoms they offer, and highlight the barriers or capability gaps that must be addressed to achieve outcomes. We conclude that capabilities approaches give practitioners the scope to go beyond posture and mobility processes and attend to the other factors, across the ecosystem, that prevent people from realizing their freedoms. To address capability gaps, a broader scope of practice for health practitioners may include consumer empowerment strategies; partnering with the community; and systemic advocacy with duty holders able to address systemic barriers.

Inflammatory bowel disease (IBD), historically subdivided into Crohn's disease and ulcerative colitis, is a very heterogeneous condition. While the tendency in medicine is to try to reduce complexity, IBD is a disease that cannot justify a one-size-fits-all principle. Our current clinical classification tools are suboptimal and need further refinement to capture, at least in part, the variety of phenotypes encountered in daily clinical practice. Although these revised classification tools alone will not be sufficient and should be complemented by more detailed molecular subclassifications, optimized clinical phenotypes can contribute to improved trial designs, future translational research approaches, and better treatment outcomes. In the current review, we discuss key clinical features important in IBD disease heterogeneity, tackle limitations of the current classification systems, propose some potential improvements, and raise priorities for future research in this domain.

L’enseignement des sciences expérimentales a subi des changements importants sur le plan des orientations pédagogiques prescrites. Ces changements reflètent l’évolution d’un cadre international dont l’une des caractéristiques est de mettre en avant des démarches plus ouvertes fondées sur « l’investigation ». Les programmes français et colombien, sujet de cette recherche, attendent des enseignants d’une part de concevoir des problèmes pouvant conduire à la mise en place de démarches expérimentales ouvertes et, d’autre part, de motiver les élèves à participer davantage aux processus de construction du savoir. Dans cette recherche, on s’intéresse aux conditions qui favorisent la construction d’un problème scientifique. Nous avons conçu une action de formation continue d’enseignants du primaire sans formation initiale scientifique qui visait à favoriser ce processus de construction. Nous avons fait le choix d’une thématique non familière des curricula scientifiques de l’école primaire : le rebond des boules. Le cadre de la » problématisation », appliqué à l’analyse des interactions langagières des enseignants engagés dans l’activité de construction d’un problème, permet de comprendre les éléments qui bloquent ou favorisent l’émergence de problèmes pouvant donner naissance à de l’investigation fondée sur de l’expérimentation et à la construction de connaissances associées au phénomène de rebond (influence de paramètres physiques, construction de grandeurs caractéristiques, etc.). Science teaching has undergone significant transformations in terms of pedagogical orientation. These transformations reflect the evolution of an international framework highlighting more open procedures based on "inquiry". In this context, both French and Colombian science curricula require teachers to create problems leading to the implementation of inquiry-based science teaching sequences. Teachers must also motivate students to participate more actively in the process of the scientific knowledge construction. Consequently, helping teachers in the task of designing a problem appears as an essential step for inquiry-based science education to be implemented. In this research, we focus on what favors the construction of scientific problems. We designed an in-service training session for primary school teachers who have no prior specialization in scientific fields. This training session leans on the use of a scientific topic (the bouncing of the balls) that rarely appears in primary school science curricula. The training session is evaluated through the analysis of the teachers’ interactions whithin the "problematization" theoretical framework. This allows to understand which elements inhibit or favor the emergence of problems allowing (1) science inquiry (2) the construction of knowledge associated with the phenomenon of bouncing (influence of physical parameters, construction of characteristic scales, etc.).

To describe the evolution of decrees and indicators related to COVID-19 in Santa Catarina, Brazil, up until August 2020.This was an ecological study that analyzed epidemiological indicators and state decrees on social distancing. The decrees were grouped into restriction, maintenance and relaxation. The indicators were mortality, incidence and transmissibility.179,443 cases and 2,183 deaths were recorded in the period. The incidence rate went from 20.4 cases per 100,000 inhabitants in March to 642.2 in August. Fifteen state decrees were issued. In August, when the highest mortality rate was observed (13.1 per 100,000 inhabitants), it was found that all decree categories, except one, had been relaxed.The decrees that relaxed social distancing measures were issued early and in disagreement with the epidemiological context in the state.Descrever a evolução dos decretos e indicadores relacionados à COVID-19 em Santa Catarina, Brasil, até agosto de 2020.Estudo ecológico que analisou indicadores epidemiológicos e decretos estaduais sobre o distanciamento social. Os decretos foram agrupados em medidas de restrição, manutenção ou flexibilização. Mortalidade, incidência e transmissibilidade constituíram os indicadores.Foram registrados 179.443 casos e 2.183 óbitos no período selecionado. A taxa de incidência passou de 20,4 casos a cada 100 mil habitantes no mês de março para 642,2/100 mil hab. em agosto. Foram emitidos 15 decretos estaduais. Em agosto, quando se observou a maior taxa de mortalidade (13,1/100 mil hab.), verificou-se que todas as categorias, à exceção de uma, haviam sido flexibilizadas.Os decretos que flexibilizaram as medidas de distanciamento social foram emitidos precocemente, em desacordo com o contexto epidemiológico no estado.Describir la evolución de los decretos e indicadores relacionados con la COVID-19 en Santa Catarina, Brasil, hasta agosto de 2020.Estudio ecológico que analizó indicadores epidemiológicos y decretos estatales sobre distanciamiento social. Los decretos se agruparon en: restricción; mantenimiento y flexibilización. Mortalidad, incidencia y transmisibilidad fueron los indicadores.Se registraron 179.443 casos y 2.183 defunciones. La tasa de incidencia pasó de 20,4 casos por 100.000 habitantes en marzo a 642,2 en agosto. Se emitieron 15 decretos estatales. En agosto, cuando se observó la tasa de mortalidad más alta (13,1 por 100.000 habitantes), parecía que todas las categorías, con excepción de una, se habían flexibilizado por decretos anteriores.Los decretos que flexibilizaron las medidas de distancia social se emitieron precozmente y en desacuerdo con el momento epidemiológico en el estado.

This proposal concerns a comparative analysis of the praxeologies of the refraction of light in the context of academic programs for general and vocational education. Our study is based on the Anthropological Theory of Didactics and aims to highlight the influence of the various institutions - to which teachers are subject - on their self-reported practices. We are particularly interested in the mathematical tools involved and the contextualization of knowledge objects. The results of this work reveal significant differences between the institutional praxeologies specific to general and vocationnal education, in the context of the study of refraction, but also between the personal praxeologies of teachers, the latter probably resulting from different dominant subjections according to the sector of practice., Cette proposition porte sur une analyse comparée des praxéologies de la réfaction de la lumière dans les cadres des enseignements général et professionnel. Notre étude s’appuie sur la Théorie Anthropologique du Didactique et vise à mettre en évidence l’influence des diverses institutions - auxquelles les enseignants sont assujettis - sur leurs pratiques déclarées. Nous nous intéressons plus particulièrement aux outils mathématiques mis en jeu et à la contextualisation des objets de savoirs. Les résultats de ce travail mettent à jour des différences significatives entre les praxéologies institutionnelles propres à chaque filière, dans le cadre de l’étude de la réfraction, mais également entre les praxéologies personnelles des enseignants, ces dernières résultant vraisemblablement d’assujettissements dominants différents selon la filière d’exercice.

Background: Caregivers of Indigenous cancer survivors provide critical unpaid support to survivors, yet they rarely receive information or training for this role and may themselves benefit from support services. Little is documented about the experiences of caregivers of Indigenous cancer survivors. The aim of this systematic review was to identify and aggregate qualitative research describing the experiences of caregivers of Indigenous cancer survivors in Australia, New Zealand, Canada and the United States.Methods: We systematically searched PsycINFO, PubMed, CINAHL, Embase, Scopus and Web of Science using keywords relating to Indigenous populations; caregivers; and cancer. Data were extracted from original qualitative research articles published up to March 2020.Results: From 24 full-text articles, 14 articles from 13 studies were analyzed using meta-aggregation. This highlighted key caregiver experiences relating to: the need for information about cancer and services; providing and receiving support; communication challenges and responsibilities; balancing caregiver roles and emotions; and culturally unsafe health systems and settings. Caregivers of Indigenous cancer survivors often act as mediator between Western biomedical approaches to cancer care and Indigenous peoples’ holistic and family-focused views of health and wellbeing, aiming to ensure that both health professionals and the cancer survivors understand each other's perspectives and preferences for care. Caregivers expressed preferences for family-focussed rather than patient-focussed care. Culturally unsafe health care systems created barriers to optimal care.Conclusions: The findings reveal caregivers’ unique experiences of caring for an Indigenous cancer survivor, and identifies several unmet needs which should be appropriately and systematically addressed. Caregivers should be regarded as co-clients with their own needs as well as co-workers with health professionals providing cancer care. Ultimately supporting caregivers will contribute to improving health outcomes for Indigenous cancer survivors.

Background Although the clinical hair changes that occur under treatment with epidermal growth factor receptor inhibitors (EGFRIs) are documented, their trichoscopic features have not been reported. Objective To evaluate the trichoscopic findings in scalp and facial hair, induced by EGFRI treatment. Methods Patients treated with EGFRIs at a tertiary oncodermatology clinic in 2015 through 2017 were evaluated for macroscopic and trichoscopic changes. Results The cohort included 23 patients (13 women; median age, 68 years) treated with EGFRIs for an average of 13 months (range, 2-40 months). Macroscopically, 18 patients (78%) had dry, lusterless, coarse, kinky, brittle scalp hair, and 17 (74%) had trichomegaly of the eyebrows/eyelashes. Trichoscopic findings were of hair shaft anomalies including pili torti, affecting scalp hair in 20 patients (87%), eyebrows in 6 (26%), and eyelashes in 8 (50%), and asymmetric hyperpigmented fusiform widening of hair scalp in 3 (13%), eyebrows in 10 (43%), and eyelashes in 4 (25%). Dermoscopic findings of the peri- and interfollicular skin were scale, whitish erythematous structureless areas, and branching vessels. Limitations Lack of trichoscopic-histologic correlation, lack of baseline examination. Conclusion The trichoscopic correlates of the macroscopic hair changes under EFGRI treatment include pili torti, and asymmetric hyperpigmented fusiform widening, with dermoscopic cutaneous manifestations of scale, whitish erythematous structureless areas, and branching vessels.

Will-to-live, a central concept in well-being theories, represents a positive attitudinal component towards one's own life. It has been identified as a mediator between the self-perception of aging and longevity and health. The objective of this study is to characterise elderly people with high levels of will-to-live in the main dimensions of positive psychology.The study included the voluntary participation of 165 adults, aged between 54-89 years, users of senior centres in the Community of Madrid. Will-to-live and other dimensions of well-being and health were evaluated. The correlations between the different evaluated dimensions were analysed, and comparisons made in terms of different levels of will-to-live, as well as an analysis of the dimensions that contribute most to the will-to-live.Correlations among the majority of variables were statistically significant, with a decrease in the coefficients being observed when controlling the effect of the will-to-live. When groups with different levels of will-to-live are compared with well-being and health, there are statistically significant differences in practically all of the dimensions. Gratitude, positive affect, and depression are the dimensions that best predict will-to-live.Older adults that make up the group with high will-to-live are characterised by higher levels of optimism, gratitude, positive affect, sense of life, psychological prosperity, resilience, happiness, and satisfaction with life, as well as lower levels of depression and negative self-perception of aging. The implications of these results point towards the relevance of will-to-live in successful aging.

One hundred thirty-three Clostridium difficile strains were collected from 71 patients and analyzed for the presence of C. difficile toxin B by the cell cytotoxicity neutralization assay, genes for toxin A, toxin B, binary toxin and TcdC deletion by PCR. All strains were also PCR-ribotyped and analyzed for sporulation frequency. The MICs of the isolates were determined against cadazolid and seven other antimicrobial agents by the agar dilution method. All isolates were positive for toxin B by the cell cytotoxicity neutralization assay. One hundred fourteen isolates were positive for toxin A and B and 16 isolates were positive for toxin A, toxin B and binary toxin by PCR. Three isolates were negative for toxin A but positive for toxin B. Thirty-three different ribotypes were identified. No strain of ribotype 027 was found. No differences in sporulation were noticed between the primary and recurrent isolates. All 133 isolates were sensitive to cadazolid (0.064–0.5 mg/l), fidaxomicin (0.008–0.125 mg/l), metronidazole (0.125–2 mg/l), vancomycin (0.125–1 mg/l) and tigecycline (0.032–0.25 mg/l). Three isolates were resistant to linezolid (8 mg/l), 15 isolates were resistant to moxifloxacin (8–32 mg/l) and 103 isolates were resistant to clindamycin (8–256 mg/l). No association between toxins A, B and binary toxin, ribotypes or the sporulation and the sensitivity to cadazolid could be found. Cadazolid has a potent in vitro activity against C. difficile.

Background Dermatophyte infection is almost exclusively a superficial cutaneous mycosis usually confined to the stratum corneum of nails and hairs of normal hosts. Deep cutaneous and subcutaneous infections due to dermatophytes are exceedingly rare and usually limited to immunosuppressed individuals. These infections remain chronic and persist in spite of treatment. Materials and methods We report two clinical cases of disseminated dermatophytic pseudomycetoma caused by Microsporum gypseum and Microsporum canis in immunosuppressed patients. Results Patient 1, in 2008, showed improvement with fluconazole, cephalothin, and terbinafine treatment for Microsporum gypseum. After suspension of the treatment, new lesions appeared and culture from material was positive. In 2009, she presented confluent papules and nodules forming plaques on her face and neck with the isolation of Microsporum canis. Clinical response to this treatment was poor. Patient 2 was affected by both tinea corporis due to Trichophyton rubrum and dermatophytic pseudomycetoma caused by Microsporum canis. The response to treatment was successful with oral itraconazole and local surgical excision. Conclusions It is important to recognize these atypical presentations of dermatophytic infections in immunosuppressed patients, which may warrant a more aggressive treatment in order to achieve resolution.

Background The aim of this study was to investigate the effects of chondroitin sulfate (CS) on the serum levels of Coll2-1 in patients with knee OA. Methods Seventy two patients with unilateral symptomatic knee OA were involved in a post-authorization open-label study evaluating CS (800 mg/day). The primary outcome was the % relative change in serum Coll2-1 (sColl2-1). The secondary outcomes were the evaluation of pain (VAS) and function (Lequesne’s Index). Responders and non-responders were classified according to OMERACT-OARSI recommendations. Finally, an original cut-off method was applied to categorize patients and interpret individual variations in serum levels of Coll2-1. Results Patients showed no difference in the sColl2-1 levels at baseline. When considering responders and non-responders from the ITT population, a significant difference was found for Coll2-1 at 3 months (p = 0.030) and 6 months (p = 0.038). A decrease in pain (VAS) and an improvement in function (LI) were recorded throughout the visits (p

Microturbinas a gás são maquinas utilizadas para gerar energia elétrica em sistemas de geração distribuída, sistemas de geração de emergência ou de suprimento adicional para horário pico. Entre as vantagens que apresentam estas maquinas, pode-se mencionar o fato de serem unidades compactas com dimensões reduzidas, flexibilidade em quanto ao uso de combustíveis, alta confiabilidade e pequena necessidade de manutenção, níveis aceitáveis de emissões de poluentes, etc. Na atualidade com o aumento da sua utilização, surge a necessidade de fazer estudos para melhorar tanto a eficiência como a potencia útil do ciclo. A proposta desta dissertação é realizar uma análise termoeconômica de um ciclo Brayton com resfriamento por nebulização de etanol na entrada do compressor de uma microturbina a gás de 30 kW. A nebulização de etanol na entrada resfriará o ar de admissão no compressor e diminuirá o trabalho consumido por este componente. Para a nebulização e injeção do etanol na admissão, é utilizado um mecanismo qual o fluido de resfriamento é convertido em névoa através de bicos de alta pressão de operação. A evaporação da névoa gerada em contato com o ar quente diminui a temperatura do ar na entrada do ciclo. Portanto, a eficiência e potência do ciclo são incrementadas, além de diminuir o consumo do gás natural, poupando o custo da produção da eletricidade e retornando o investimento a amortizações menores em comparação ao ciclo convencional. A metodologia utilizada para a análise termoeconômica é o método de contabilidade de custos, também conhecida como a teoria de custos exergéticos, mediante a construção do diagrama funcional termoeconômico e determinação das expressões das funções exergéticas. Os resultados mostram que a maior irreversibilidade encontra-se na câmara de combustão sendo 90 kW e a análise de viabilidade econômica indica que o preço ótimo de venda da eletricidade seja de 0,391 U$S/kWh para obter um retorno do investimento aproximado de 2 anos.

Evolution of function (LI). (DOCX 12Â kb)

Evolution of pain measured (VAS). (DOCX 12Â kb)

The aim of this study was to evaluate the impact of glucose levels on admission and High Risk Ventricular Tachyarrhythmia (HRVT) in hospital mortality in patients with Acute Myocardial Infarction (AMI).We studied 1.258 consecutive patients admitted to the Coronary Care Unit with a diagnosis of AMI. Ventricular Fibrillation, sustained and nonsustained Ventricular Tachycardia were considered as HRVT. Association between admission glucose, in-hospital mortality and HRVT was assessed with Cox regression analysis.The overall incidence of in-hospital HRVT was 20% (254/1258 patients) and in-hospital mortality (115/1.258) was higher in patients with HRVT (20% vs 6%) (p0.001). Diabetes Mellitus (DM) was present in 441 patients (35%). Optimal threshold level of glycemia admission to predict ventricular arrhythmia was 180 mg/dl (AUC = 0.716; 0.66- 0.76)(p0.001). Patients with euglycemia on admission (120 mg/dL) had lowest prevalence of HRVT (13%)(OR=0.6;0.46-0.78) in contrast to non DM patients who presented glucose 180 mg/dL that exhibited 2-fold increase of in-hospital HRVT (36%; OR=2.2; 1.6-3)(p0.001). Multivariate risk adjusted hazard ratio (HR) analysis showed that, blood pressure100 mmHg (HR=2.4; 1.6-3.6)(p0.001), White Blood Count (WBC)10.000 cell count (HR=1.44;1.02-2)(p=0.04) and admission glycemia 180 mg/dL (HR=1.5; 1.04-2.3)( p=0.03) had a significantly increased risk in in-hospital HRTV only in NDM patients.The higher glycemia on admission the higher prevalence of life-threatening arrhythmia and mortality regardless diabetes status in patients presenting with AMI. Elevated initial glucose level and WBC count considered along with other clinical data can assist in life-threatening ventricular arrhythmia in non diabetic patients.

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Here's a helpful review of what goes right and what can go wrong in the female and male breast, with emphasis on dermatologic and developmental disorders. New issues are demanding the clinician's attention, including the cosmetic effects of nipple piercing and tattooing.

A 54-year-old man of Persian origin presented to our department with a 1-year history of ulcers on the right leg that had been unresponsive to numerous topical treatments, accompanied by lymphedema of the right leg. Medical history included hypergonadotropic hypogonadism, which had not been further investigated. He was treated for 20 years with testosterone IM once monthly, which he stopped a year before the current hospitalization for unclear reasons. The patient reported no congenital lymphedema. Physical examination revealed two deep skin ulcers (Figure 1) on the right leg measuring 10 cm in diameter with raised irregular inflammatory borders and a boggy, necrotic base discharging a purulent hemorrhagic exudate. Bilateral leg pitting edema and right lymphangitis with lymphadenitis were noted. He had low head hair implantment, sparse hair on the body and head, hyperpigmentation on both legs, onychodystrophia of the toenails (mainly the large toe and less prominent on the other toes), which was atrophic lichen-planus-like in appearance and needed no trimming (Figure 2), normal hand nails, oral thrush, and angular cheilitis. Other physical findings were gynecomastia, pectus excavatum, small and firm testicles, long extremities, asymmetrical goiter, systolic murmur 2/6 in left sternal border, and slow and inappropriate behavior. The patient's temperature on admission was 39 degrees C. Blood cultures were negative for bacterial growth. Results of laboratory investigations included hemoglobin (11.2 g/dL), hematocrit (26.8%), normal mean corpuscular volume and mean corpuscular hemoglobin volume, and red blood cell distribution width (16%). Blood smear showed spherocytes, slight hypochromia, anisocytosis, macrocytosis, and microcytosis. Blood chemistry values were taken for iron (4 micro g/dL [normal range 40-150 micro g/dL]), transferrin (193 mg/dL [normal range 220-400 mg/dL]), ferritin (1128 ng/mL [normal range 14-160 ng/mL]), transferrin saturation (1.5% [normal range 20%-55%]), serum folate (within normal limits), and vitamin B12 (within normal limits). Direct Coombs' test equaled positive 2 + IgG. All these values indicated anemia of chronic diseases combined with hemolytic anemia. Further blood work-up tested antinuclear antibody (positive1:80 homogeneous pattern), rheumatoid factors (143 IU/mL [positive8.5 IU/mL]), C-reactive protein (286 mg/L [normal range 0-5 mg/L]), anticardiolipin IgM antibody (9.0 monophosphoryl lipid U/mL [normal range 0-7.00 MPL U/mL]) and antithrombin III activity (135% [normal range 74%-114%]). Results of other blood tests were within normal limits or negative, including lupus anticoagulant, beta2 glycoprotein, anticardiolipin IgG Ab, anti-ss DNA Ab, C3, C4, anti-RO, anti-LA, anti-SC-70, anti-SM Ab, P-ANCA, C-ANCA, TSH, FT4, anti-T microsomal, antithyroglobulin, protein C activity, protein S free, cryoglobulins, serum immunoelectrophoresis, VDRL, hepatitis C antibodies, hepatitis B antigen, and human immunodeficiency virus. Endocrinological work-up examined luteinizing hormone (22.9 mIU/mL [normal range for adult men 0.8-6 mIU/mL]), follicle stimulating hormone (49.7 mIU/mL [normal range for adult men 1-11 mIU/mL]), testosterone (0.24 ng/mL [normal range for adult men 2.5-8.0 ng/mL]), bioavailable testosterone (0.02 ng/mL [normal range for adult men0.6 ng/mL]), and percent bioavailable test (8.1% [normal value20%]). These results indicate hypergonadotropic hypogonadism. Plasminogen activator inhibitor 1 was 6 U (normal value 5-20 U/mL). Karyotyping performed by G-banding technique revealed a 47 XXY karyotype, which is diagnostic of Klinefelter's syndrome. Doppler ultrasound of the leg ulcers disclosed partial thrombus in the distal right femoral vein. X-rays and bone scan displayed osteomyelitis along the right tibia. Histological examination of a 4-mm punch biopsy from the ulcer border revealed hyperkeratosis, acanthosis, hypergranulosis, and mixed inflammatory infiltrate containing eosinophils compatible with chronic ulcer. Multiple vessels were seen, compatible with a healing process. Direct immunofluorescence of the biopsy revealed granular IgM in the dermo-epidermal junction. Indirect immunofluorescence was negative. Thyroid function tests showed normal thyroid stimulating hormone and free throxine4. Multinodular goiter was seen on thyroid scan and ultrasound. Thyroid fine needle aspiration was compatible with multinodular goiter (normal follicular cells, free colloid, macrophages with pigment). IV treatment with amoxicillin-clavulanic acid 1 g t.i.d. was administered for 2 weeks, with a decrease in temperature and normalization of the leukocyte level. Oral antibiotic treatment with amoxicillin-clavulanic acid was continued for 10 more days, followed by 25 days of ciprofloxacin for the osteomyelitis. Local treatment included saline soakings followed by application of Promogran (JohnsonJohnson, New Brunswick, NJ) and Kaltostat (ConvaTec Ltd., a Bristol-Myers Squibb Company, New York, NY) with slight improvement. At the same time, the patient was treated with warfarin sodium due to deep vein thrombosis under international normalized ratio 2-3. The patient was treated with IM testosterone once monthly for 1 year, which resulted in a reduction in the diameter and depth of the leg ulcers (Figure 3). Blood tests were not performed for follow-up of the immune state.

Erythema nodosum and pyoderma gangrenosum are common skin manifestations in inflammatory bowel diseases. Curiously, these two cutaneous features have seldom been reported to occur simultaneously. We present three patients affected with inflammatory bowel disease with concomitant erythema nodosum and pyoderma gangrenosum.

Dermatophyte infection is almost exclusively a superficial cutaneous mycosis usually confined to the stratum corneum of nails and hairs of normal hosts. Deep cutaneous and subcutaneous infections due to dermatophytes are exceedingly rare and usually limited to immunosuppressed individuals. These infections remain chronic and persist in spite of treatment.We report two clinical cases of disseminated dermatophytic pseudomycetoma caused by Microsporum gypseum and Microsporum canis in immunosuppressed patients.Patient 1, in 2008, showed improvement with fluconazole, cephalothin, and terbinafine treatment for Microsporum gypseum. After suspension of the treatment, new lesions appeared and culture from material was positive. In 2009, she presented confluent papules and nodules forming plaques on her face and neck with the isolation of Microsporum canis. Clinical response to this treatment was poor. Patient 2 was affected by both tinea corporis due to Trichophyton rubrum and dermatophytic pseudomycetoma caused by Microsporum canis. The response to treatment was successful with oral itraconazole and local surgical excision.It is important to recognize these atypical presentations of dermatophytic infections in immunosuppressed patients, which may warrant a more aggressive treatment in order to achieve resolution.

Introduction and objectives: In patients with acute myocardial infarction, elevation of plasma glucose levels is associated with worse outcomes. The aim of this study was to evaluate the association between stress hyperglycemia and in-hospital mortality in patients with acute myocardial infarction with STsegment elevation (STEMI). Methods: We analyzed 834 consecutive patients admitted for STEMI to the Coronary Care Unit of our center. Association between admission glucose and mortality was assessed with Cox regression analysis. Discriminative accuracy of the multivariate model was assessed by Harrell’s C statistic. Results: Eighty-nine (10.7%) patients died during hospitalization. Optimal threshold glycemia level of 140 mg/dl on admission to predict mortality was obtained by ROC curves. Those who presented glucose 140 mg/dl showed higher rates of malignant ventricular tachyarrhythmias (28% vs. 18%, P = .001), complicative bundle branch block (5% vs. 2%, P = .005), new atrioventricular block (9% vs. 5%, P = .05) and in-hospital mortality (15% vs. 5%, P < .001). Multivariate analysis showed that those with glycemia 140 mg/dl exhibited a 2-fold increase of in-hospital mortality risk (95% CI: 1.2-3.5, P = .008) irrespective of diabetes mellitus status (P-value for interaction = 0.487 and 0.653, respectively). Conclusions: Stress hyperglycemia on admission is a predictor of mortality and arrhythmias in patients with STEMI and could be used in the stratification of risk in these patients.