Monitorage hémodynamique invasif aux soins intensifs lors de chocs septiques ou cardiogènes Indications et préférences des médecins quant à la Swan-Ganz ou au PiCCO

L'investigation hémodynamique est cruciale chez les patients critiques en soins intensifs. Le cathétérisme cardiaque droit (Swan-Ganz) et la mesure du débit cardiaque en continu par analyse de pouls (PiCCO ou Pulse Contour Continuous Cardiac Output) sont fréquemment utilisés. Ces méthodes requièrent des compétences spécifiques quant à la précision des mesures, l'interprétation des données physiologiques et physiopathologiques, et leur signification clinique. Les connaissances de leurs limites, complications et spécificités font également partie des compétences. L'émergence de l'échocardiographie va certainement encore modifier la place de ces techniques dans la pratique de la médecine intensive. Dans la présente étude, observationnelle et prospective, nous avons cherché à déterminer les préférences des médecins quant à la Swan-Ganz ou au PiCCO, lors de prise en charge de patients avec choc cardiogène et choc septique. Nous avons inclus 117 patients sur une période de 5 mois, 42 chocs cardiogènes et 75 chocs septiques, parmi lesquels 57 ont été équipés d'un monitoring. Les chocs cardiogènes sont plus fréquemment monitorés que les chocs septiques (64% versus 40 %, p = 0.005. Les médecins privilégient la SG lors du CC plutôt que le PI (24 SG vs 5 PI), alors que l'inverse est observé lors de CS, avec 23 PI vs 7 SG (p < 0.001). L'emploi de la Swan-Ganz, au vu des mesures relevées dans le dossier du patient, apparaît moins bon que l'usage du PiCCO, ce qui soulève des questions quant aux compétences des utilisateurs. La mortalité du choc cardiogène est plus élevée que celle du choc septique (p = 0.05), sans mise en évidence d'un effet du monitoring sur cette dernière. Un profil d'hypervolémie et d'hypercinétisme dans le choc septique impliquerait un mauvais pronostic, résultat à confirmer vu le petit collectif de notre étude. De manière attendue, des indices de gravité de l'état de choc en phase initiale, telles que hypotension artérielle, hyperlactatémie et doses de Noradrénaline administrées sont prédictifs d'une mortalité accrue. Durant cette période d'observation, il y a eu une consommation toute aussi importante de Swan-Ganz et PiCCO pour d'autres pathologies, avec 106 patients monitorés. L'aide au diagnostic et au monitoring par ces techniques est bien ancrée dans la pratique de la médecine intensive. En conclusion, dans le service de médecine intensive adulte du CHUV, en 2014, le choc cardiogène est plus souvent l'objet d'un monitoring invasif et la préférence est la Swan-Ganz en comparaison avec le choc septique. Le monitoring invasif n'est pas systématique dans ces pathologies, représentant un peu moins de 50% des chocs cardiogènes et septiques. Il n'apparaît pas avoir d'influence sur la mortalité dans notre collectif

Medical record: systematic centralization versus secure on demand aggregation

<p>Abstract</p> <p>Background</p> <p>As patients often see the data of their medical histories scattered among various medical records hosted in several health-care establishments, the purpose of our multidisciplinary study was to define a pragmatic and secure on-demand based system able to gather this information, with no risk of breaching confidentiality, and to relay it to a medical professional who asked for the information via a specific search engine.</p> <p>Methods</p> <p>Scattered data are often heterogeneous, which makes the task of gathering information very hard. Two methods can be compared: trying to solve the problem by standardizing and centralizing all the information about every patient in a single Medical Record system or trying to use the data "as is" and find a way to obtain the most complete and the most accurate information. Given the failure of the first approach, due to the lack of standardization or privacy and security problems, for example, we propose an alternative that relies on the current state of affairs: an on-demand system, using a specific search engine that is able to retrieve information from the different medical records of a single patient.</p> <p>Results</p> <p>We describe the function of Medical Record Search Engines (MRSE), which are able to retrieve all the available information regarding a patient who has been hospitalized in different hospitals and to provide this information to health professionals upon request. MRSEs use pseudonymized patient identities and thus never have access to the patient's identity. However, though the system would be easy to implement as it by-passes many of the difficulties associated with a centralized architecture, the health professional would have to validate the information, i.e. read all of the information and create his own synthesis and possibly reject extra data, which could be a drawback. We thus propose various feasible improvements, based on the implementation of several tools in our on-demand based system.</p> <p>Conclusions</p> <p>A system that gathers all of the currently available information regarding a patient on the request of health-care professionals could be of great interest. This low-cost pragmatic alternative to centralized medical records could be developed quickly and easily. It could also be designed to include extra features and should thus be considered by health authorities.</p

The fast response of volcano-seismic activity to intense precipitation: Triggering of primary volcanic activity by rainfall at Soufrière Hills Volcano, Montserrat

One-minute resolution time series of rainfall and seismic data from the Soufriere Hills Volcano, Montserrat are analysed to explore the mechanism of external forcing of volcanic eruptions by rainfall over three years of activity. The real-time seismic amplitude (RSAM) shows a narrow, statistically significant, peak within 30 min after the start of intense rainfall events, and a much broader peak with a lag of 6?40 h. The classified seismic events indicate that the volcanic response to rainfall begins at the surface and gradually penetrates deeper into the dome, as there is an increase in the pseudo-magnitude of: surface rockfall events (including pyroclastic flows) with lags from the first 30 min to 40 h, long-period rockfalls (from shallow degassing) at lags of 4 and 14 h, and long-period and hybrid events (source depth approximately 1 km) with lags at 14 and 24 h after the start of rainfall events. There was no rainfall-related change in deeper, volcano-tectonic activity. There was no change in the frequency of any type of classified event, indicating that the rainfall acts to modulate existing, internal processes, rather than generating new events itself. These robust results are due to many (229) different rainfall events, and not just to a few, large magnitude cases. The rainfalltriggered volcanic activity examined here is consistent with a model of fast, shallow interactions with rainfall at the dome surface, after which, a deeper dome collapse follows

Meyer's surgical procedure for the treatment of lip carcinoma.

Lip carcinomas are generally treated by surgery. A reconstruction is often required if the resected segment exceeds one-third of the lip. Meyer's plasty is an alternate way of reconstructing the lower or upper lip. The aim of this study is to describe the technique, its indications and results. A retrospective review of all patients who underwent a Meyer's plasty in our institution is presented. Twenty-four consecutive patients were treated in Lausanne for T1 and T2 lip carcinomas between 1983 and 2001. Primary surgery associated with Meyer's plasty was performed in all cases. Data were collected from the medical records, and eight patients were recalled for clinical evaluation. The oncological, functional and aesthetic results were analyzed. The 5-year local control was 100%. Three patients developed metachronous lymph node metastasis. No patient died from the disease. A hindering microstomy was found in three cases, and two patients suffered from temporary oral leakage. No speech difficulty was encountered. The aesthetics was described as satisfying or good in 87% of the patients. Meyer's plasty following lip surgery of the upper or lower lip allows an aesthetic and functional one-stage reconstruction without compromising the oncological outcome

Mmf1p, a novel yeast mitochondrial protein conserved throughout evolution and involved in maintenance of the mitochondrial genome

A novel protein family (p14.5, or YERO57c/YJGFc) highly conserved throughout evolution has recently been identified. The biological role of these proteins is not yet well characterized. Two members of the p14.5 family are present in the yeast Saccharomyces cerevisiae. In this study, we have characterized some of the biological functions of the two yeast proteins. Mmf1p is a mitochondrial matrix factor, and homologous Mmf1p factor (Hmf1p) copurifies with the soluble cytoplasmic fraction. Δmmf1 cells lose mitochondrial DNA (mtDNA) and have a decreased growth rate, while Δhmf1 cells do not display any visible phenotype. Furthermore, we demonstrate by genetic analysis that Mmf1p does not play a direct role in replication and segregation of the mtDNA. rho(+) Δmmf1 haploid cells can be obtained when tetrads are directly dissected on medium containing a nonfermentable carbon source. Our data also indicate that Mmf1p and Hmf1p have similar biological functions in different subcellular compartments. Hmf1p, when fused with the Mmf1p leader peptide, is transported into mitochondria and is able to functionally replace Mmf1p. Moreover, we show that homologous mammalian proteins are functionally related to Mmf1p. Human p14.5 localizes in yeast mitochondria and rescues the Δmmf1-associated phenotypes. In addition, fractionation of rat liver mitochondria showed that rat p14.5, like Mmf1p, is a soluble protein of the matrix. Our study identifies a biological function for Mmf1p and furthermore indicates that this function is conserved between members of the p14.5 family

Bmi1 loss produces an increase in astroglial cells and a decrease in neural stem cell population and proliferation

The polycomb transcriptional repressor Bmi1 promotes cell cycle progression, controls cell senescence, and is implicated in brain development. Loss of Bmi1 leads to a decreased brain size and causes progressive ataxia and epilepsy. Recently, Bmi1 was shown to control neural stem cell (NSC) renewal. However, the effect of Bmi1 loss on neural cell fate in vivo and the question whether the action of Bmi1 was intrinsic to the NSCs remained to be investigated. Here, we show that Bmi1 is expressed in the germinal zone in vivo and in NSCs as well as in progenitors proliferating in vitro, but not in differentiated cells. Loss of Bmi1 led to a decrease in proliferation in zones known to contain progenitors: the newborn cortex and the newborn and adult subventricular zone. This decrease was accentuated in vitro, where we observed a drastic reduction in NSC proliferation and renewal because of NSC-intrinsic effects of Bmi1 as shown by the means of RNA interference. Bmi1(-/-) mice also presented more astrocytes at birth, and a generalized gliosis at postnatal day 30. At both stages, colocalization of bromodeoxyuridine and GFAP demonstrated that Bmi1 loss did not prevent astrocyte precursor proliferation. Supporting these observations, Bmi1(-/-) neurospheres generate preferentially astrocytes probably attributable to a different responsiveness to environmental factors. Bmi1 is therefore necessary for NSC renewal in a cell-intrinsic mode, whereas the altered cell pattern of the Bmi1(-/-) brain shows that in vivo astrocyte precursors can proliferate in the absence of Bmi1

The gas temperature in flaring disks around pre-main sequence stars

A model is presented which calculates the gas temperature and chemistry in the surface layers of flaring circumstellar disks using a code developed for photon-dominated regions. Special attention is given to the influence of dust settling. It is found that the gas temperature exceeds the dust temperature by up to several hundreds of Kelvins in the part of the disk that is optically thin to ultraviolet radiation, indicating that the common assumption that Tgas=Tdust is not valid throughout the disk. In the optically thick part, gas and dust are strongly coupled and the gas temperature equals the dust temperature. Dust settling has little effect on the chemistry in the disk, but increases the amount of hot gas deeper in the disk. The effects of the higher gas temperature on several emission lines arising in the surface layer are examined. The higher gas temperatures increase the intensities of molecular and fine-structure lines by up to an order of magnitude, and can also have an important effect on the line shapes.Comment: 14 pages, 10 figures, accepted for publication in A&

Pkd1 Regulates Lymphatic Vascular Morphogenesis during Development.

Lymphatic vessels arise during development through sprouting of precursor cells from veins, which is regulated by known signaling and transcriptional mechanisms. The ongoing elaboration of vessels to form a network is less well understood. This involves cell polarization, coordinated migration, adhesion, mixing, regression, and shape rearrangements. We identified a zebrafish mutant, lymphatic and cardiac defects 1 (lyc1), with reduced lymphatic vessel development. A mutation in polycystic kidney disease 1a was responsible for the phenotype. PKD1 is the most frequently mutated gene in autosomal dominant polycystic kidney disease (ADPKD). Initial lymphatic precursor sprouting is normal in lyc1 mutants, but ongoing migration fails. Loss of Pkd1 in mice has no effect on precursor sprouting but leads to failed morphogenesis of the subcutaneous lymphatic network. Individual lymphatic endothelial cells display defective polarity, elongation, and adherens junctions. This work identifies a highly selective and unexpected role for Pkd1 in lymphatic vessel morphogenesis during development

Grand Challenges: Improving HIV Treatment Outcomes by Integrating Interventions for Co-Morbid Mental Illness.

In the fourth article of a five-part series providing a global perspective on integrating mental health, Sylvia Kaaya and colleagues discuss the importance of integrating mental health interventions into HIV prevention and treatment platforms. Please see later in the article for the Editors' Summary