Overcrowding in the Emergency Department and Patient Safety

Emergency department (ED) overcrowding is a recognized problem worldwide. This chapter reviews the scope of the problem, manifestations, repercussions, and potential solutions to this problem

Thrombostatic Agents and Tissue Adhesives in the Emergency Department: Stopping the Bleeding, Closing the Wound, and Novel Applications

Complaints of bleeding are frequent presentations to the emergency department, and although most bleeding can be controlled with direct pressure, increased use of antiplatelet agents and anticoagulants complicates what might be otherwise simple bleeding. Industry has met the demand for hemostatic adjuncts, and a number of products are available for the emergency physician to assist in hemostatic control and wound closure. This chapter will cover the various available technologies, covering their preferred use and discussing particular bleeding scenarios and which technology may be best for each scenario

Diabète et troubles de la production de la testostérone chez l'homme

Introduction: La prévalence du diabète de type 2 augmente rapidement avec une estimation à 17% chez les hommes âgés de plus de 55 ans en Europe. Il semblerait que ces hommes diabétiques de type 2 présentent également un hypogonadisme, mécanisme expliqué par un lien bidirectionnel entre ces deux pathologies. Par ailleurs, la découverte dans la salive de stéroïdes dont la testostérone (T) permet une nouvelle méthode de dosage facile, non-invasive, peu coûteuse et sans douleur. Objectifs : Partie 1 : Analyser la prévalence d'hypogonadisme chez des patients avec un diabète mellitus de type 2 dans la région lausannoise. Rechercher des facteurs prédisposants et les effets des altérations métaboliques sur l'axe reproducteur. Partie 2 : Etudier la relation entre le dosage de la testostérone salivaire et la testostérone sanguine mesurée par LC-MS (chromatographie en phase liquide couplée à la spectrométrie de masse). Méthodologie : Etude rétrospective qui se fonde sur les données récoltées par le Service EDM du CHUV avec deux cohortes étudiées : entre 2010 et 2015 (partie 1) et entre 2005 et 2014 (partie 2). La base de données de la partie 1 contient 63 hommes diabétiques de type 2. Lorsque les dosages n'existaient pas, nous avons demandé un accord au patient afin de doser la testostérone lorsque les sérums étaient disponibles. La partie 2 contient 56 hommes et les testostérones sanguines ont été mesurées par IA (immunoassay) ou LC-MS pour les dosages les plus récents ainsi que calculées par l'algorithme de Sartorius pour avoir la testostérone libre. La testostérone salivaire a été mesurée par LC-MS. Résultats : Partie 1 : La moyenne d'âge des patients est de 62 ans avec un IMC de 31 kg/m2 et une durée moyenne du diabète de 12 ans. De ces 63 patients, 32 d'entre eux ont eu une mesure de la testostérone plasmatique. Le dosage de la testostérone n'a pas pu être effectué chez les 31 patients restants. La prévalence de l'hypogonadisme (Testostérone totale <12nmol/l) est de 53%. 15 patients disent présenter des troubles sexuels ce qui représente 24% des patients. De ces 15 patients, 8 ont une testostérone totale <12nmol/l avec des troubles sexuels. Les hommes qui souffrent de troubles sexuels ont une testostérone totale plus basse avec une durée de diabète plus longue. Avec l'âge, la testostérone totale diminue tandis que la LH, la FSH et la SHBG augmentent. Partie 2 : Les données montrent une moyenne de la testostérone salivaire de 347.18 ± 583.4. Chez les patients sans traitement elle diminue avec l'âge. Une corrélation forte est trouvée entre la testostérone salivaire et la testostérone sanguine mesurée par LC-MS (r= 0.79) chez les patients sans traitement. Conclusion: Ces données ont mis en évidence une prévalence élevée d'hommes diabétiques de type 2 qui présentent un hypogonadisme ainsi que des troubles sexuels. De plus, nos données démontrent que l'axe gonadotrope est influencé par l'âge et le BMI. Cette étude souligne l'importance d'une prise en charge globale des patients souffrant d'un diabète de type 2 et la compréhension des mécanismes en jeu entre l'axe endocrinien et le système métabolique. Nos résultats montrent une forte corrélation entre la testostérone salivaire et la testostérone totale sanguine mesurée par LC-MS

Effects of chordwise flexibility on 2D flapping foils used as an energy extraction device

The effects of chordwise pressure- and inertia-driven deformations on the power extraction potential of a kinematically constrained oscillating thin plate that undergoes a heaving and pitching motion are investigated. 2D fully coupled fluid-structure interaction simulations are performed at a Reynolds number of 1100 with thin flexible plates having a thickness over chord ratio of 1%. Three flexibility distributions are tested: a uniformly flexible plate as well as plates with only the rear part or the front part being flexible. The results are compared with those of rigid plates operating at the same conditions. Flexible plates show very promising results as they can extract up to more than twice the power of the corresponding rigid ones. The investigation of semi-flexible foils has highlighted the fact that considering a completely flexible foil with constant chordwise mechanical properties is likely not an optimal configuration. Indeed, different mechanisms are beneficial whether the front part or the rear part of the foil is flexible: pressure-driven deformations usually increase the performances of front flexible foils while inertia-driven deformations are beneficial to rear flexible foils. In cases involving weak fluid-structure interactions (e.g.: heavy plate in a light fluid), the resonance of the first deformation mode of the plate's tail or head may appear. It is observed that this phenomenon can either deteriorate or improve the performances of the flapping plate. In this context, the dimensionless flexibility appears to be a key factor as it is involved in the resonance phenomenon that turns out to greatly influence the flow field

Punch Injuries: Insights into Intentional Closed Fist Injuries

Objectives: This study sought to investigate the patterns of injury resulting from a punch mechanism and to investigate the associated psychopathology present in patients with these injuries.Methods: Retrospective analysis of patients with hand radiographs ordered from the emergency department allowed for identification of patients with a punch mechanism. We recorded injury patterns and queried patients’ medical records for associated psychopathology.Results: 1,292 patients underwent hand radiographs during a one-year time period; 172 patients (13%) were radiographed following an intentional punch injury, identifying 76 fractures in 70 patients. Males contributed a greater proportion of patients presenting with punch injury when compared to females (80% vs. 20%). Males were more likely to sustain fracture from a punch mechanism (48% vs. 11%, OR 7 [95% CI 2.3-20.9]), but were less likely to have preexisting documented psychiatric disease (23% vs. 49%, OR 3.1 [95% CI 1.4-6.7]). Of all fractures, 61% were to the fifth metacarpal, 21% were to the remainder of the metacarpals, and the remaining were fractures to phalanges and bones of the wrist.Conclusion: Women are less likely to present with punch injury and are less likely to sustain a fracture when they do present but have more associated psychiatric disease. Both men and women presenting with punch injuries have a higher prevalence of psychiatric disease than the background incidence in the population as a whole. Although punch injuries result in a significant number of boxer fractures, a number of other injuries are associated with punch mechanisms. [West J Emerg Med. 2011;12(1):6-10.

Low-threshold calcium spike bursts in the human thalamus: Common physiopathology for sensory, motor and limbic positive symptoms

Positive symptoms arise after lesions of the nervous system. They include neurogenic pain, tinnitus, abnormal movements, epilepsy and certain neuropsychiatric disorders. Stereotactic medial thalamotomies were performed on 104 patients with chronic therapy-resistant positive symptoms. Peroperative recordings of 2012 single units revealed an overwhelming unresponsiveness (99%) to sensory stimuli or motor activation. Among these unresponsive cells, 45.1% presented a rhythmic or random bursting activity. Rhythmic bursting activities had an average interburst interval of 263±46 ms corresponding to a frequency of 3.8±0.7 Hz. Frequency variations among the different symptoms were not statistically different. Intraburst characteristics such as the highest frequency encountered in the burst (480±80 Hz) or the mean frequency of the burst (206±44 Hz) were also similar in all patients. All bursts, rhythmic or random, fulfilled the extracellular criteria of low-threshold calcium spike (LTS) bursts. After medial thalamotomy and depending on the symptom, 43-67% of the patients reached a 50-100% relief, with sparing of all neurological functions. On the basis of these electrophysiological and clinical results, we propose a unified concept for all positive symptoms centred on a self-perpetuating thalamic cell membrane hyperpolarization, similar to the one seen in slow-wave slee

Correlations between EEG and clinical outcome in chronic neuropathic pain: surgical effects and treatment resistance

Chronic neuropathic pain may require a neurosurgical treatment, but for reasons that have not been fully explored yet, a significant number of patients do not benefit from the intervention. We compared the resting EEG of 15 healthy controls to the EEG of 23 chronic neuropathic pain patients before and 12months after treatment by the central lateral thalamotomy (CLT). A patient subgroup had a high (n = 14, pain relief (PR) ≥ 50%) and another subgroup a low (n = 9, PR < 50%) postoperative PR. EEG spectral power and source localization of the high PR patients were normalized postoperatively. In contrast, low PR patients showed postoperative maintenance of insular, cingulate and prefrontal overactivities, and their frustration values were positively correlated with cingulate and prefrontal activity. These findings demonstrate a normalizing effect of CLT on cortical activity and suggest that treatment resistance is associated with a frustration-based dynamic

Qualification of Sub-atmospheric Pressure Sensors for the Cryomagnet Bayonet Heat Exchangers of the Large Hadron Collider

The superconducting magnets of the Large Hadron Collider (LHC) will be cooled at 1.9 K by distributed cooling loops working with saturated two-phase superfluid helium flowing in 107 m long bayonet heat exchangers [1] located in each magnet cold-mass cell. The temperature of the magnets could be difficult to control because of the large dynamic heat load variations. Therefore, it is foreseen to measure the heat exchangers pressure to feed the regulation loops with the corresponding saturation temperature. The required uncertainty of the sub-atmospheric saturation pressure measurement shall be of the same order of the one associated to the magnet thermometers, in pressure it translates as ±5 Pa at 1.6 kPa. The transducers shall be radiation hard as they will endure, in the worst case, doses up to 10 kGy and 10**15 neutrons·cm**-2 over 10 years. The sensors under evaluation were installed underground in the dump section of the SPS accelerator with a radiation environment close to the one expected for the LHC. The monitoring equipment was installed in a remote radiation protected area. This paper presents the results of the radiation qualification campaign with emphasis on the reliability and accuracy of the pressure sensors under the test conditions

Typification of the name Senecio pygmaeus (Asteraceae), with some additional taxonomic and phytogeographic remarks

A thorough research on the scientific activity of Guglielmo Gasparrini, Giovanni Gussone and Augustin Pyramus De Candolle allowed the authors to address a research in several European herbaria looking for the type of the name Senecio pygmaeus DC. The original specimen sent by Gussone and mentioned in the protologue by Candolle is still kept at G-DC and is designated as the lectotype, whilst three other herbarium sheets, preserved at NAP-GUSS, PAL and PAV herbaria respectively, in all probability belong to the same gathering, and are considered as isolectotypes. The authors provide an updated description of this taxon in order to better point out its diagnostic characters. However, further biosystematic and phytogeographic surveys are needed to ascertain the taxonomic value and the distribution range of S.pygmaeus. Indeed, it might represent just a dwarfed, salt-tolerant ecotype of S.leucanthemifolius Poir. or S.vulgarisL., hence be more widespread than previously reported, counting numerous scattered populations along the rocky shores of central and eastern Mediterranean countries