Limited Cutaneous Leishmaniasis as Ulcerated Verrucous Plaque on Leg, Tucson, Arizona, USA1.

We report a 34-year-old man who had a nonhealing, verrucous plaque with central ulceration on the lower leg. This case-patient is a rare example of endemic limited cutaneous leishmaniasis in Tucson, Arizona, USA. Clinicians should be aware of this disease because its manifestations can vary for individual patients.

Delays in Coccidioidomycosis Diagnosis and Associated Healthcare Utilization, Tucson, Arizona, USA.

Tucson, Arizona, USA, is a highly coccidioidomycosis-endemic area. We conducted a retrospective review of 815 patients in Tucson over 2.7 years. Of 276 patients with coccidioidomycosis, 246 had a delay in diagnosis; median delay was 23 days. Diagnosis delay was associated with coccidioidomycosis-related costs totaling $589,053 and included extensive antibacterial drug use.

ULF Pre-Seismic Geomagnetic Anomalous Signal Related to Mw8.1 Offshore Chiapas Earthquake, Mexico on 8 September 2017.

In the last decade, the real time ground-based geomagnetic observations realized in correlation with the Vrancea seismicity in Romania, together with supplementary studies related to some earthquakes (Mw9.0 Tohoku, Japan on 11 March 2011 and Mw8.3 Coquimbo, Chile on 16 September 2015), enlarged our knowledge about the relationship between the pre-seismic anomalous phenomena and the final stage of the earthquake nucleation. To identify possible ultra-low-frequency (ULF) geomagnetic signals prior to the onset of an Mw8.1 earthquake, we retroactively analyzed the data collected on the interval 1 August-16 September 2017 at the Geomagnetic Observatories in Teoloyucan (TEO), Mexico and Tucson (TUC) USA, with the last taken as a reference. Daily mean distributions of the polarization parameter BPOL (geomagnetic polarization parameter) and standard deviation are obtained for both observatories using a fast Fourier transform (FFT) band-pass filtering in the ULF range (0.001-0.083 Hz). Further on, we investigated the singularity of the pre-seismic signal associated with an Mw8.1 earthquake and applied a statistical analysis based on a standardized random variable equation; results are presented as BPOL* time series on the interval 1-26 September. Finally, the hourly mean distribution, obtained as difference BPOL (TUC-TEO) on the interval 7-9 September emphasizes an anomalous signal with five hours before the onset of the Mw8.1 earthquake.

Limitation of medical care: an ethnographic analysis.

This ethnographic study has shown how one attempt to apply ethical principles through a routine procedure failed to fit the clinical context and, in the two cases studied, served to counteract the very foundation these principles were based on--that patients or their families have the right to determine life-and-death decisions regarding code status. The results suggest that the use of well-meaning forms that are intended to facilitate decision making can, in the absence of appropriate guidelines, routinize the doctor-patient discourse to meet bureaucratic needs, narrowing rather than expanding understanding and communication. Bioethical principles implemented in abstraction, apart from the complex intricacies of the doctor-patient-family relationship and the sociocultural influences upon which this relationship is dependent, may be counter-productive to patient interests. As bioethicists and clinicians work to implement the demands of the Patient Self-Determination Act, they will undoubtedly try to forestall legal problems, assure ethical consistency, facilitate auditing, and promote documentation by creating forms. They may look to create inventories, such as the Limitation of Medical Care form described here, or turn to other, less explicit, means of documentation. This study suggests that, in these efforts, genuine attention should be given to patient concerns, not just to the ethical or institutional needs of medicine. This shift in focus from outcome to process can enhance patient and clinician satisfaction, help resolve difficulties in reaching consensus between involved decision makers, and return the power in DNR decision making to patients and families.