Can hydro-economic river basin models simulate water shadow prices under asymmetric access?

Hydro-economic river basin models (HERBM) based on mathematical programming are conventionally formulated as explicit 'aggregate optimization' problems with a single, aggregate objective function. Often unintended, this format implicitly assumes that decisions on water allocation are made via central planning or functioning markets such as to maximize social welfare. In the absence of perfect water markets, however, individually optimal decisions by water users will differ from the social optimum. Classical aggregate HERBMs cannot simulate that situation and thus might be unable to describe existing institutions governing access to water and might produce biased results for alternative ones. We propose a new solution format for HERBMs, based on the format of the mixed complementarity problem (MCP), where modified shadow price relations express spatial externalities resulting from asymmetric access to water use. This new problem format, as opposed to commonly used linear (LP) or non-linear programming (NLP) approaches, enables the simultaneous simulation of numerous 'independent optimization' decisions by multiple water users while maintaining physical interdependences based on water use and flow in the river basin. We show that the alternative problem format allows the formulation HERBMs that yield more realistic results when comparing different water management institutions.

[Skin manifestations in lupus erythematosus: clinical aspects and therapy]

Lupus erythematosus (LE) is an inflammatory autoimmune disorder, which is characterized by clinically heterogeneous manifestations of different organs. In systemic LE (SLE) the skin, the musculoskeletal system, the kidneys, the cardiovascular and central nervous systems can be involved. The skin lesions can be divided into LE-specific and LE-non-specific manifestations, the former represent the subtypes of cutaneous LE (CLE). The diagnosis is confirmed by clinical, histopathological, immunoserological and genetic features. The treatment is similar for the different subtypes of CLE; however, the therapeutic regimen should be individually defined in each patient. Antimalarials are still the first-line systemic therapy and in addition to sunscreens, glucocorticosteroids and calcineurin inhibitors have an important impact as topical agents in this disease.

Coherence and imaginary part of coherency identifies cortico-muscular and cortico-thalamic coupling

The understanding of the interaction between muscle control and cortical areas and between subcortical and cortical areas is important for the effective treatment of patients with movement disorders. The combination of coherence (COH) and the imaginary part of coherency (iCOH) is applied here to electrophysiological data from patients with a movement disorder and to data from healthy subjects performing finger movements. The COH and iCOH between magnetoencephalographic (MEG) and electromyographic (EMG) signals of the healthy subjects yields the expected result for cortico-muscular coupling. Based on this the COH and iCOH between sub-thalamic nucleus local field potentials (STN-LFP) and MEG signals are assessed for deep brain stimulation patients with externalized LFP electrodes. The results suggest interactions in the 10 to 20 Hz range. Artificially mimicking volume conduction by re-referencing the STN electrodes to a surface EEG electrode leads to large changes in the COH and iCOH. This suggests that volume conduction is not important for the analysis of interactions between MEG and bipolar STN electrodes.

Ionic mobility in Nasicon-type LiMIV2(PO4)3 materials followed by 7Li NMR spectroscopy

Lithium mobility in LiM2(PO4)3 compounds, with M= Ge, Ti, Sn, Zr and Hf, has been investigated by 7Li Nuclear Magnetic Resonance (NMR) spectroscopy in the temperature range 100-500 K. From the analysis of 7Li NMR quadrupole interactions (CQ and η parameters), Li sites occupancy and exchange processes between structural sites have been studied. Below 250K, Li ions are preferentially located at M1 sites in rhombohedral phases, but occupy M12 sites in triclinic ones. At increasing temperatures, Li mobility has been deduced from spin-spin () and spin-lattice relaxation () rates. In this analysis, the presence of two relaxation mechanisms in plots has been associated with departures of conductivity from the Arrhenius behavior. At high temperatures, residence times at M12−T11−T11−T1 and M12 sites become similar and conductivity significantly increase. This superionic state can be achieved by enlarged order-disorder transformations in rhombohedral phases, or by sharp first order transitions in triclinic ones. Results described in the LiTi2(PO4)3 sample have been compared with those obtained in rhombohedral Li1+xTi2-xAlx(PO4)3 and LiTi2-xZrx(PO4)3 series showing respectively higher and lower conductivities. In the case of Li1.2Ti1.8Al0.2(PO4)3, displaying the highest reported conductivity, NMR results are discussed in relation with those obtained by Neutron Diffraction (ND) and Impedance Spectroscopy (IS). Diffusion coefficients determined by NMR Pulse Field Gradient (PFG) technique are similar to those deduced from Impedance Spectroscopy and NMR relaxation data.

Development of quality indicators to evaluate the monitoring of SLE patients in routine clinical practice

The assessment of systemic lupus erythematosus (SLE) patients in routine clinical practice is mainly based on the experience of the treating physician. This carries the risk of unwanted variability. Variability may have an impact on the quality of care offered to SLE patients, thereby affecting outcomes. Recommendations represent systematically developed statements to help practitioners in reducing variability. However, major difficulties arise in the application of recommendations into clinical practice. In this respect, the use of quality indicators may raise the awareness among rheumatologists regarding potential deficiencies in services and improve the quality of health care. The aim of this study was to develop a set of quality indicators (QI) for SLE by translating into QIs the recently developed EULAR Recommendations for monitoring SLE patients in routine clinical practice and observational studies. Eleven QIs have been developed referring to the use of validated activity and damage indices in routine clinical practice, general evaluation of drug toxicity, evaluation of comorbidities, eye evaluation, laboratory assessment, evaluation of the presence of chronic viral infections, documentation of vaccination and of antibody testing at baseline. A disease specific set of quality assessment tools should help physicians deliver high quality of care across populations. Routine updates will be needed.

[Does cutaneous lupus erythematodes really exist?]

It should be obvious today that systemic lupus erythematosus (SLE) patients are better treated in an interdisciplinary approach. Nonetheless, the question remains as to whether cutaneous lupus erythematosus (CLE) indeed constitutes a disease entity of its own rather than the only recognized manifestation of oligosymptomatic SLE. The ACR criteria, designed for classification rather than diagnosis, are of limited value in answering this question. However, the concept of specific autoantibodies and immune complexes as inducers of various organ manifestations and analogous ideas on other autoantibody-mediated problems within and outside SLE argue for CLE as an existing entity. This is relevant for understanding the underlying immunopathogenesis, while less important for the appropriate therapy.

Treatment of cutaneous lupus erythematosus

In patients with cutaneous lupus erythematosus (CLE) and mild skin involvement, local therapy consisting of topically applied pharmacological agents, e.g., topical/intralesional steroids, may be sufficient. Recent reports have also shown efficacy of topical calcineurin inhibitors in patients with CLE, particularly on the face. Special attention receives consistent sun protection through photoresistant clothing and application of light-shielding substances with highly potent chemical or physical UVA- and UVB-protective filters. These substances should be applied in sufficient amount (ca. 2 mg/cm(2)) at least 20-30 minutes before sun exposure in order to avoid induction and exacerbation of cutaneous lesions. The mainstay of treatment for disfiguring and widespread skin manifestations in patients with CLE, irrespective of the subtype of the disease, is antimalarial agents. Our understanding of the use of combinations of antimalarials and proper dosing according to the ideal bodyweight limits problems with toxicity. Further therapies, such as methotrexate, or retinoids, dapsone, mycophenolate mofetil, and thalidomide in selected cases, can be helpful for patients with resistant disease; however, side effects need to be taken into consideration. Recent advances in biotechnology resulted in the development of novel systemic agents, but randomized controlled trials are necessary for the approval of new therapeutic strategies in CLE.

Reduction of regulatory T cells in skin lesions but not in peripheral blood of patients with systemic scleroderma

OBJECTIVE

To determine the frequency and suppressive capacity of regulatory T cells (T(reg)) and their association with clinical parameters in patients with systemic scleroderma (SSc).

METHODS

Peripheral blood from 25 patients with SSc, 15 patients with localised scleroderma (LS) and 29 healthy controls (HC) was studied. Analysis of CD4(+) forkhead box P3 (Foxp3)(+) and CD4(+)CD25(++)Foxp3(+) T(reg) subpopulations was carried out by flow cytometry and cell proliferation was quantified by (3)H-thymidine incorporation. Quantitative analysis of T(reg) was further performed in skin biopsies from 17 patients with SSc and 21 patients with LS using anti-CD4 and anti-Foxp3 monoclonal antibodies for immunohistochemistry.

RESULTS

The frequency of CD4(+)Foxp3(+) and CD4(+)CD25(++)Foxp3(+) T(reg) in peripheral blood from patients with SSc was not significantly different from that of patients with LS or HC. The suppressive capacity of CD4(+)CD25(++) T(reg) in SSc was also found to be similar to that of HC. Phenotypic and functional data revealed no significant difference between the limited or diffuse form of SSc. Moreover, therapy with bosentan showed no significant effect on the frequency of T(reg) during the course of the disease. However, the frequency of T(reg) in skin lesions from patients with SSc or LS, determined as the percentage of CD4(+) cells expressing Foxp3 in the inflammatory infiltrate, was significantly reduced compared with other inflammatory skin diseases.

CONCLUSION

These results indicate that although the authors found no defect in the frequency or function of peripheral T(reg) subpopulations, the reduction of CD4(+)Foxp3(+) T(reg) in the skin of patients with SSc may be important in the pathogenesis of the disease.

Evaluation of disease activity and damage in different subtypes of cutaneous lupus erythematosus using the CLASI

BACKGROUND

The Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) is a scoring system for patients with cutaneous lupus erythematosus (CLE) to assess disease activity and damage. Objective  The aim of this study was to evaluate whether the CLASI is a useful instrument which reflects the different subtypes of CLE comparably well in each parameter.

METHODS

A total of 50 patients (42 female, 8 male) with different subtypes of CLE, including acute CLE (ACLE), subacute CLE (SCLE), chronic CLE (CCLE) and LE tumidus (LET), from the Departments of Dermatology, University of Düsseldorf, Germany, and Danderyd Hospital, Stockholm, Sweden, were evaluated using the CLASI at one time point.

RESULTS

The total CLASI activity score was significantly lower in patients with LET compared with ACLE (P<0.05) and CCLE (P<0.001), and the total CLASI damage score was significantly lower in patients with LET than with ACLE (P<0.05), SCLE (P<0.001) and CCLE (P<0.001). The erythema score and the scale/hypertrophy score were significantly lower in LET than in ACLE (P<0.05, both) and CCLE (P<0.05 and P < 0.001, respectively). The dyspigmentation score was lowest in patients with LET, differing significantly from ACLE (P<0.05), SCLE (P<0.05) and CCLE (P<0.001). The scarring/atrophy/panniculitis score was significantly higher in patients with CCLE in contrast to SCLE and LET (P<0.05 and P<0.001, respectively).

CONCLUSION

These data characterize the CLASI as an overall useful instrument to analyse disease activity and damage in CLE. However, the CLASI does not give an accurate assessment of all disease subtypes; therefore, a revision of the CLASI with critical analysis of all parameters is recommended.

Use of methotrexate in patients with psoriasis

Psoriasis is considered to be a polygenetically influenced, immune-mediated, organ-specific disease of dysregulated inflammation that is triggered by environmental factors such as infections, medications, and physical and/or emotional stress. It is recognised as one of the most prevalent skin diseases, affecting 2% to 3% of Caucasian populations. Major advances in understanding of disease pathogenesis indicate that patients with psoriasis have an increased risk of comorbidities such as metabolic syndrome and cardiovascular disease. A wide range of systemic drugs have been developed in recent years for treatment of psoriasis and comorbidities. Low-dose methotrexate (MTX) is one of the classical agents and is still one of the most frequently used systemic treatments for psoriasis worldwide. Low-dose MTX is also effective in treatment of psoriatic arthritis. The mechanism of action is not fully understood, but MTX is suggested to act primarily as an anti-inflammatory and immunosuppressant drug. A favourable efficacy and safety profile has been established for MTX in a large number of clinical trials, as well as in common practice. This review summarises the nature of the disease and our present knowledge about MTX in the treatment of psoriasis, including combination therapies.

Photosensitivity, phototesting, and photoprotection in cutaneous lupus erythematosus

Cutaneous lupus erythematosus (CLE) is a heterogeneous autoimmune disease involving well-defined skin lesions that can be categorized as acute CLE (ACLE), subacute CLE (SCLE), chronic CLE (CCLE), or intermittent CLE (ICLE). It is commonly accepted that ultraviolet (UV) exposure can induce and exacerbate skin lesions in patients with certain subtypes of CLE. Phototesting with UVA and UVB irradiation using a standardized protocol has proven to be a reliable model to study photosensitivity in CLE and to analyse the underlying pathomechanisms of the disease. In addition to UV-mediated induction of apoptosis, the molecular and cellular factors that may underlie the abnormal long-lasting photoreactivity in CLE include mediators of inflammation such as cytokines and chemokines, inducible nitric oxide (NO) synthase (iNOS), and cellular adhesion molecules. The photosensitivity associated with CLE requires education of the patient about avoidance of excessive sun exposure, continuous photoprotection through physical measures such as protective clothing, and daily application of broad-spectrum sunscreens. Novel approaches to UV-protection, such as alpha-MSH or thymidine dinucleotides, might also have an impact on photosensitivity in patients with CLE. In this review, we summarize the current knowledge about photosensitivity in patients with CLE, including an overview of standardized phototesting procedures, possible molecular pathomechanisms, and photoprotection. Lupus (2010) 19, 1036—1046.

The impact of the EUSCLE core set questionnaire for the assessment of cutaneous lupus erythematosus

Epidemiological data and standard European guidelines for the diagnosis and treatment of cutaneous lupus erythematosus (CLE) are lacking in the current literature. In order to provide a standardized tool for an extensive consistent data collection, a study group of the European Society of Cutaneous Lupus Erythematosus (EUSCLE) recently developed a Core Set Questionnaire for the assessment of patients with different subtypes of CLE. The EUSCLE Core Set Questionnaire includes six sections on patient data, diagnosis, skin involvement, activity and damage of disease, laboratory analysis, and treatment. An instrument like the EUSCLE Core Set Questionnaire is essential to gain a broad and comparable data collection of patients with CLE from different European centres and to achieve consensus concerning clinical standards for the disease. The data will also be important for further characterization of the different CLE subtypes and the evaluation of therapeutic strategies; moreover, the EUSCLE Core Set Questionnaire might also be useful for the comparison of data in clinical trials. In this review, the impact of the EUSCLE Core Set Questionnaire is discussed in detail with regard to clinical and serological features as well as therapeutic modalities in CLE. Lupus (2010) 19, 1144—1152.

Plasmid Transfer into the Homoacetogen Acetobacterium woodii by Electroporation and Conjugation

Shuttle vectors (pMS3 and pMS4) which replicated in Escherichia coli and in gram-positive Acetobacterium woodii were constructed by ligating the replication origin of plasmid pAMbeta1 with the E. coli cloning vector pUC19 and the tetM gene of streptococcal transposon Tn916. Electrotransformation of A. woodii was achieved at frequencies of 4.5 x 10 transformants per mug of plasmid DNA. For conjugal plasmid transfer, the mobilizable shuttle vector pKV12 was constructed by cloning the tetM gene into pAT187. Mating of E. coli containing pKV12 with A. woodii resulted in transfer frequencies of 3 x 10 to 7 x 10 per donor or recipient.

Characteristics of joint involvement and relationships with systemic inflammation in systemic sclerosis: results from the EULAR Scleroderma Trial and Research Group (EUSTAR) database

OBJECTIVE

To determine the prevalence of and independent factors associated with joint involvement in a large population of patients with systemic sclerosis (SSc).

METHODS

This study was cross-sectional, based on data collected on patients included in the European League Against Rheumatism (EULAR) Scleroderma Trials and Research (EUSTAR) registry. We queried this database to extract data regarding global evaluation of patients with SSc and the presence of any clinical articular involvement: synovitis (tender and swollen joints), tendon friction rubs (rubbing sensation detected as the tendon was moved), and joint contracture (stiffness of the joints that decreased their range of motion). Overall joint involvement was defined by the occurrence of synovitis and/or joint contracture and/or tendon friction rubs.

RESULTS

We recruited 7286 patients with SSc; their mean age was 56 +/- 14 years, disease duration 10 +/- 9 years, and 4210 (58%) had a limited cutaneous disease subset. Frequencies of synovitis, tendon friction rubs, and joint contractures were 16%, 11%, and 31%, respectively. Synovitis, tendon friction rubs, and joint contracture were more prevalent in patients with the diffuse cutaneous subset and were associated together and with severe vascular, muscular, renal, and interstitial lung involvement. Moreover, synovitis had the highest strength of association with elevated acute-phase reactants taken as the dependent variable.

CONCLUSION

Our results highlight the striking level of articular involvement in SSc, as evaluated by systematic examination in a large cohort of patients with SSc. Our data also show that synovitis, joint contracture, and tendon friction rubs are associated with a more severe disease and with systemic inflammation.

Revised Cutaneous Lupus Erythematosus Disease Area and Severity Index (RCLASI): a modified outcome instrument for cutaneous lupus erythematosus

BACKGROUND

In 2005, a scoring system (CLASI, Cutaneous Lupus Erythematosus Disease Area and Severity Index) was developed for patients with cutaneous lupus erythematosus (CLE) to assess disease 'activity' and 'damage'. However, the CLASI does not give an accurate assessment of the severity in all disease subtypes.

OBJECTIVES

The main objective of this study was to analyse critically the included parameters of the CLASI and to revise the activity and damage score taking into account various clinical features of the different subtypes of CLE. The revised CLASI (RCLASI) was also validated for use in clinical trials. Patients and methods A RCLASI was designed with regard to the anatomical region (i.e. face, chest, arms) and morphological aspects (i.e. erythema, scaling/hyperkeratosis, oedema/infiltration, scarring/atrophy) of skin lesions and evaluated by nine dermatologists who scored 12 patients with different subtypes of CLE to estimate inter- and intrarater reliability.

RESULTS

Reliability studies demonstrated an intraclass correlation coefficient (ICC) for an inter-rater reliability of 0.89 for the activity score [95% confidence interval (CI) 0.79-0.96] and of 0.79 for the damage score (95% CI 0.62-0.92). The ICC for intrarater reliability for the activity score was 0.92 (95% CI 0.89-0.95) and the ICC for the damage score was 0.95 (95% CI 0.92-0.98).

CONCLUSIONS

In the present study, a RCLASI was developed by experts, and reliability studies supported the validity and applicability of the revised scoring instrument for CLE. Thus, the RCLASI is a valuable instrument in multicentre studies and for the clinical evaluation of activity and damage in different disease subtypes.

Suspicious axillary lymph nodes in patients with unremarkable imaging of the breast

OBJECTIVE

The aim of this study was to evaluate the pathological findings and the method of tissue harvesting in those patients who have both suspicious axillary lymph nodes and normal imaging of the breast.

STUDY DESIGN

From January 2005 to June 2008 all female patients who underwent opportunistic screening mammography and ultrasound examination of the breast and the axilla, and who were found to have suspicious axillary lymph nodes seen on ultrasound examination, were retrospectively analysed. Tissue harvesting was done by fine needle aspiration, core needle biopsy, or open biopsy.

RESULTS

Out of approximately 7500 screened patients, 51 were found to have suspicious axillary lymph nodes on ultrasound with unremarkable breast ultrasound and mammography. Histopathology and/or cytology of these lymph nodes showed 33 benign and 18 malignant results. Of the malignant results only 1 case was an occult invasive lobular breast carcinoma detected afterwards on breast magnetic resonance imaging. Eleven cases were non-Hodgkin lymphomas, 4 were malignant melanomas, and 2 were metastases from the lower genital tract. Diffuse cortical thickening and complete loss of echo texture were the only features on ultrasound predicting malignancy. Palpation and mean size of the evaluated lymph nodes had no predictive value for malignancy. In the 33 cases of non-malignant pathology 9 patients showed patterns of specific infectious disease, including 4 patients with tuberculosis.

CONCLUSION

Suspicious lymph nodes of the axilla seen on ultrasound rarely indicate occult breast cancer but show a variety of other malignancies and generalised infectious disease requiring further treatment. Fine needle aspiration and/or core needle biopsy are both sufficient methods for clarification in the majority of cases.