The science of clinical practice: disease diagnosis or patient prognosis? Evidence about "what is likely to happen" should shape clinical practice.

BACKGROUND: Diagnosis is the traditional basis for decision-making in clinical practice. Evidence is often lacking about future benefits and harms of these decisions for patients diagnosed with and without disease. We propose that a model of clinical practice focused on patient prognosis and predicting the likelihood of future outcomes may be more useful. DISCUSSION: Disease diagnosis can provide crucial information for clinical decisions that influence outcome in serious acute illness. However, the central role of diagnosis in clinical practice is challenged by evidence that it does not always benefit patients and that factors other than disease are important in determining patient outcome. The concept of disease as a dichotomous 'yes' or 'no' is challenged by the frequent use of diagnostic indicators with continuous distributions, such as blood sugar, which are better understood as contributing information about the probability of a patient's future outcome. Moreover, many illnesses, such as chronic fatigue, cannot usefully be labelled from a disease-diagnosis perspective. In such cases, a prognostic model provides an alternative framework for clinical practice that extends beyond disease and diagnosis and incorporates a wide range of information to predict future patient outcomes and to guide decisions to improve them. Such information embraces non-disease factors and genetic and other biomarkers which influence outcome. SUMMARY: Patient prognosis can provide the framework for modern clinical practice to integrate information from the expanding biological, social, and clinical database for more effective and efficient care

Upper extremity injuries in alpine ski and snowboard

Background: Most traumatic injuries in alpine skiing and snowboarding affect the lower extremity, especially the knee. Snowboard appeared in the 1970’s, then gained truly in popularity in the 1990’s. The most common injury in snowboarding is located around the wrist. Alpine skiing has seen a change in equipment from the year 2000 on, with the appearance of carving skis. While it generated a rise in internal knee injuries, it has yet to be proven if this had an impact on upper extremity injuries. Purpose: Determine the epidemiology of upper extremity injuries in both alpine ski and snowboard, its chronological evolution in the last two decades and the impact of carving on ski injuries. Study design: Systematic review Methods: A systematic search in Pubmed was conducted using the key words “skiing”, “snowboard”, all anatomical entities of the upper extremity and all type of injuries. Both prospective and retrospective studies were included, while case reports were excluded. Only articles focusing on alpine ski, snowboard or telemark injuries, and providing statistical data about the upper extremity were included. Exclusion criteria were other kind of winter sports, Paralympic sports, artificial or indoor slopes Results: The literature review represented a period from 1939 to 2017 with a total of 673 270 patients. The upper limb represents 23% of all ski injuries and 33% of all snowboard injuries. The most injured upper extremity segments are the shoulder (35%) and the hand (32%) for skiing and the wrist (40%) and the shoulder (31%) for snowboarding. In both sports, most fractures happen far from the elbow, meaning the proximal humerus and the distal radius and ulna. The main upper extremity dislocation is located to the glenohumeral articulation (41%) for skiing and to the elbow (48%) for snowboarding. Comparing alpine ski to snowboard, it can be noticed that hand injuries are significantly more prevalent while skiing, but the rest of upper extremity injuries are significantly more prevalent while snowboarding. The comparison between alpine ski and telemark did not show any significant difference. For skiing, the time trends from the year 2000’s on have shown a significant increase in fractures for all segments, shoulder girdle dislocations and hand sprains. The snowboard’s epidemiology did not show any significant change in the last two decades, besides an increase in elbow fractures. Conclusion: About 1 injury out of 4 for alpine ski and 1 injury out of 3 for snowboard is located to the upper extremity. The epidemiology varies significantly between skiing and snowboarding, with generally a higher prevalence in snowboarding. The time trends show that carving increased the incidence of upper extremity fracture, which can be explained by higher kinetics, bigger edge angle and the democratization of the sport. The lack of change in the snowboard’s epidemiology could be explained by the absence of significant technical modification in the material

Magic Number Pt₁₃ and Misshapen Pt₁₂ Clusters: Which One is the Better Catalyst?

A relationship between the size of metal particles and their catalytic activity has been established over a nanometer scale (2–10 nm). However, application on a subnanometer scale (0.5–2 nm) is difficult, a possible reason being that the activity no longer relies on the size but rather the geometric structure as a cluster (or superatomic) compound. We now report that the catalytic activity for the oxygen reduction reaction (ORR) significantly increased when only one atom was removed from a magic number cluster composed of 13-platinum atoms (Pt₁₃). The synthesis with an atomic-level precision was successfully achieved by using a dendrimer ligand as the macromolecular template strictly defining the number of metal atoms. It was quite surprising that the Pt₁₂ cluster exhibited more than 2-fold catalytic activity compared with that of the Pt₁₃ cluster. ESI-TOF-mass and EXAFS analyses provided information about the structures. These analyses suggested that the Pt₁₂ has a deformed coordination, while the Pt₁₃ has a well-known icosahedral atomic coordination as part of the stable cluster series. Theoretical analyses based on density functional theory (DFT) also supported this idea. The present results suggest potential activity of the metastable clusters although they have been “missing” species in conventional statistical synthesis

High fidelity simulation and ECMO in intensive care unit. A multi profesionnal training program to improve skills and self efficacy

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