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Stroke volume is a key determinate of cardiac output. It is affected by the preload, contractility and afterload of the myocardium. It is possible to gain insight into the right and left ventricular preload following the insertion of a central venous catheter and pulmonary artery catheter to measure central venous pressure and pulmonary capillary wedge pressure, respectively. Abnormal measurements can indicate a pathophysiological state and guide management.

Background This study aimed to evaluate our outcomes and complication rate following placement of self-expanding esophageal stents in children for the management of refractory esophageal strictures and comparing these to the existing literature. Methods Outcomes following placement of stents in consecutive patients under 18 years at a single center from 2003 to 2018 were reviewed. A PRISMA-guided systematic review was conducted identifying studies with 5 or more children evaluating self-expanding stents published from 1975 to 2018. Endpoints for both the retrospective and systematic reviews were the requirement for further intervention and stent-associated complications. Results 25 patients received 65 stents. There were 12 caustic injury-related strictures (48%), 9 anastomotic strictures (36%), and 4 esophagitis-related strictures (16%). Four patients were lost to follow-up. 19/21 patients (90%) required further intervention, and 8/21 (38%) had esophageal replacement. Nine studies, all case series, were included in the systematic review. 97 patients received 160 stents for esophageal strictures and/or perforation. 36 out of 69 patients (52%) with strictures required no further treatment post-stenting, and 22/29 (76%) of esophageal perforations closed with stenting. Conclusions Esophageal stents may have a role as a bridge to definitive surgery and for the management of esophageal leaks, but complete stricture resolution post-stenting is unlikely. Type of Study Treatment Study (Case Series with no Comparison Group) Level of Evidence Level IV

Summary: Background: Most claims-based frailty instruments have been designed for group stratification of older populations according to the risk of adverse health outcomes and not frailty itself. We aimed to develop and validate a tool based on one-year hospital discharge data for stratification on Fried's frailty phenotype (FP). Methods: We used a three-stage development/validation approach. First, we created a clinical knowledge-driven electronic frailty score (eFS) calculated as the number of deficient organs/systems among 18 critical ones identified from the International Statistical Classification of Diseases and Related Problems, 10th Revision (ICD-10) diagnoses coded in the year before FP assessment. Second, for eFS development and internal validation, we linked individual records from the Lc65+ cohort database to inpatient discharge data from Lausanne University Hospital (CHUV) for the period 2004-2015. The development/internal validation sample included community-dwelling, non-institutionalised residents of Lausanne (Switzerland) recruited in the Lc65+ cohort in three waves (2004, 2009, and 2014), aged 65-70 years at enrolment, and hospitalised at the CHUV at least once in the year preceding the FP assessment. Using this sample, we selected the best performing model for predicting the dichotomised FP, with the eFS or ICD-10-based variables as predictors. Third, we conducted an external validation using 2016 Swiss nationwide hospital discharge data and compared the performance of the eFS model in predicting 13 adverse outcomes to three models relying on well-designed and validated claims-based scores (Claims-based Frailty Index, Hospital Frailty Risk Score, Dr Foster Global Frailty Score). Findings: In the development/internal validation sample (n = 469), 14·3% of participants (n = 67) were frail. Among 34 models tested, the best-subsets logistic regression model with four predictors (age and sex at FP assessment, time since last hospital discharge, eFS) performed best in predicting the dichotomised FP (area under the curve=0·71; F1 score=0·39) and one-year adverse health outcomes. On the external validation sample (n = 54,815; 153 acute care hospitals), the eFS model demonstrated a similar performance to the three other claims-based scoring models. According to the eFS model, the external validation sample showed an estimated prevalence of 56·8% (n = 31,135) of frail older inpatients at admission. Interpretation: The eFS model is an inexpensive, transportable and valid tool allowing reliable group stratification and individual prioritisation for comprehensive frailty assessment and may be applied to both hospitalised and community-dwelling older adults. Funding: The study received no external funding.

Self-management of type 1 diabetes (T1D) is a difficult task that involves different actions and decisions and requires various types of knowledge. Nowadays, it can be done partly autonomously, using a mobile digital device that measures the level of blood glucose. The FreeStyle Libre, launched on the Swiss market in 2016, is one such device. Drawing on Science and Technology Studies and adopting a sociocultural approach to learning, the present study investigated how healthcare professionals and young people living with T1D learned to use this new device during a summer camp. Based on field observations and interviews, results showed that through the mediation of others, an appropriation space was created. Through distributed expertise involving different actors, practices and types of knowledge, the users learned technical and procedural knowledge, and much more besides. In particular, they learned to cope with uncertainty, sidestep obstacles, and trust the device, gaining knowledge about diabetes itself in the process and grasping the potential contribution of the new data provided by this device to therapeutic decisions. By drawing on an explicit theory of learning that considers learning to be a context-bound activity, the present study will inspire the development of new practices in health education.

The aim of the present work was to investigate the interaction of nanoparticles (NPs) with proteins during the digestion of selected food matrices. To accomplish this, magnetic silica NPs were added to skimmed milk powder (SMP), peanuts, and tofu, and the mixtures were subjected to in vitro digestion. The proteins and peptides present in the digesta, with and without NPs, and in the protein corona (PC) of NPs at the different digestion stages (oral, gastric, and intestinal) were characterised and identified with gel electrophoresis and mass spectrometry. Electrophoretic results revealed no differences in protein patterns between the control and NPs containing digesta at all digestion stages. At the end of simulated intestinal digestion, no intact food proteins were detectable, either in the food or on the NPs. At this stage, exclusively, digestive enzymes originating from pancreatin were present in the digesta and bound to NPs. Digestion-resistant peptides were detected in the digests of all studied food matrices, independently of NP presence. Moreover, on the PC of NPs digestion-resistant peptides, especially longer ones, were exclusively present after gastric and intestinal digestion stages from SMP and peanuts, but not from tofu, indicating that the PC composition was influenced by the food matrix., M. C. M.-H. also wishes to acknowledge the Spanish National Research Council (CSIC) and the AGL2017-87884 (MINECO/AEI/FEDER, UE) and AGL2016-75159-C2-2-R (MINECO, ES) projects.

AIM: To tested whether the efficacy of an internet-based brief intervention that included normative drinking feedback varied with estimations of the drinking of others. METHODS: This study is a secondary analysis of a randomized controlled trial showing an intervention effect on weekly drinking. Participants were males with unhealthy alcohol use (mean age [SD]=20.8 [1.1]). Before the trial, participants were asked to estimate the percentage of men their age who drink more than they do. Using their self-reported drinking data, the "perceived" percentage of people their age and gender who drink more than they do, and data from Swiss statistics, we classified participants as overestimating (>+10%), accurately (-10% to +10%) or underestimating (RESULTS: Of 734 participants with complete data, 427 overestimated, 205 accurately estimated and 102 underestimated the drinking of others. The mean (SD) number of drinks per week was 9.8 (7.9) and AUDIT score was 10.6 (4.2). In stratified negative binomial regression models predicting drinks per week, at 6months, and controlling for baseline drinks per week, the intervention was effective among those overestimating (IRR[95%CI]=0.86[0.74;0.98]), but showed no effect among those accurately estimating (IRR[95%CI]=0.83[0.66;1.03]) or underestimating IRR[95%CI]=1.21[0.92;1.60]) the drinking of others. CONCLUSIONS: Perception of drinking by others appears to be a moderator of effect of an electronic feedback intervention among hazardous drinkers. This finding is consistent with the hypothesis that correcting the perceptions of others' drinking is a potential mechanism of action in normative feedback paradigms.Copyright © 2016. Published by Elsevier Ltd. Language: en

Laparoscopic cholecystectomy (LC) can be technically challenging in the obese. The primary aim of the trial was to establish whether following a Very Low Calorie Diet (VLCD) for two weeks pre-operatively reduces operation time. Secondary outcomes included perceived operative difficulty and length of hospital stay.A single-blinded, randomized controlled trial of consecutive patients with symptomatic gallstones and BMI30 kg/m(2) 46 patients were randomized to a VLCD or normal diet for two weeks prior to LC. Food diaries were used to document dietary intake. The primary outcome measure was operation time. Secondary outcomes were length of stay, weight change operative complications, day case rates and perceived difficulty of operation.The VLCD was well tolerated and had significantly greater preoperative weight loss (3.48 kg vs. 0.98 kg; p 0.0001). Median operative time was significantly reduced by 6 min in the VLCD group (25 vs. 31 min; p = 0.0096). There were no differences in post-operative complications, length of stay, or day case rates between the groups. Dissection of Calot's triangle was deemed significantly easier in the VLCD group.A two week VLCD prior to elective laparoscopic cholecystectomy in obese patients is safe, well tolerated and was shown to significantly reduce pre-operative weight and operative time.61630192. http://www.isrctn.com/ISRCTN61630192 Trial registration.

Summary Introduction The association of high-grade vesico-ureteral reflux (VUR) with renal dysplasia and/or scarring is well-established, and the combination of these factors has been shown to decrease the likelihood of VUR resolution. Other VUR parameters have similarly been shown to be associated with VUR non-resolution, including VUR grade and timing at cystography, associated urinary tract anatomical abnormalities, and bladder dysfunction. Objective To establish independent risk factors that can predict symptomatic persistence of VUR. Design This was a single-centre study (2011–2017) including consecutive prospectively collected patients with primary VUR on voiding cystourethrogram (VCUG). Patients with dilating VUR also underwent renography (dimercaptosuccinic acid [DMSA] or 99m-technetium mercaptoacetyltriglycine [99mTc-MAG3]). All patients were initially managed medically with antibiotic prophylaxis. Primary outcome was febrile culture-positive breakthrough urinary tract infection (BT-UTI). Demographic parameters, as well as VUR grade, VUR timing at cystography, presence of ureteral anomaly, VUR index (VURx), and differential renal function (DRF) or scarring were analysed to determine independent predictors. Results A total of 61 patients (41 male, of whom 7 circumcised at presentation) were studied. VUR was diagnosed following investigation of prenatal hydronephrosis in 37 patients (62%) and following a febrile UTI in 22 (37%). Median [range] follow-up period was 38 [12–84] months. Data from a total of 77 refluxing renal units (RUs) were used for analysis. Analysis of VCUG data demonstrated that high VURx might be a potential significant predictor of breakthrough UTI (RR: 1.7, 95% CI: 1.1–2.7, p Discussion Multiple factors have been shown to be significant predictors of radiological VUR resolution. Univariate analysis of these factors suggests that only scarring on DMSA and VURx are significant predictors of symptomatic non-resolution. On multivariate analysis, scarring on DMSA was the only significant predictive variable. This information will be useful in targeting investigation and treatment in susceptible patients and when counselling families. Conclusion Renal scarring is the most significant risk factor for breakthrough UTI in primary VUR patients and could be used to determine those at risk of symptomatic VUR persistence. Download : Download high-res image (121KB) Download : Download full-size image Summary Figure . Urinary tract infection (UTI)-free survival in vesico-ureteral reflux (VUR) patients with (green/+) or without (red/-) renal scarring/dysplasia. ∗p

Introduction La Suisse et la France ne contribuent pas aux comparaisons internationales de l’OCDE sur la securite des arthroplasties de hanche (PTH) et de genou (PTG) utilisant les taux standardises de thromboses veineuses profondes (TVP) ou d’embolies pulmonaires (EP) a 30 jours. L’objectif principal de cette etude etait d’estimer et de comparer les taux hospitaliers standardises d’evenements indesirables (TSEI) thromboemboliques et hemorragiques survenant apres une PTH/PTG primaire programmee chez les patients âges hospitalises en Suisse et en France. Methodes Nous avons mene deux etudes transversales basees sur des donnees medico-administratives nationales chainees (periode 2011–2014) de participants (≥ 65 ans) hospitalises entre le 01/01/2012 et le 30/11/2014 pour PTH/PTG. Les evenements indesirables (EI) ont inclus les TVP et EP, les hemorragies, et les EI thromboemboliques arteriels (ETEA). Pour chaque pays et hopital, nous avons mesure les taux observes d’EI intra-hospitaliers a 30 jours, puis estime les TSEI au moyen de modeles logistiques hierarchiques ajustees sur des scores de risque specifiques, et enfin compare les distributions des TSEI hospitaliers entre Suisse et France. Resultats Entre 2011 et 2015, 45 817 et 373 671 sejours pour PTH ou PTG ont ete realises dans 128 et 1053 hopitaux suisses et francais, respectivement. En Suisse, les TSEI medians a 30 jours apres PTH/PTG simple etaient de 0,43 %/0,93 % pour les TVP, 0,32 %/0,45 % pour les EP, 4,17 %/4,30 % pour les hemorragies, 1,06 %/1,45 % pour les hemorragies severes, et 0,67 %/0,56 % pour les ETEA. Ces taux etaient tous plus faibles en France sauf pour la TVP : 1,12 %/3,54 % pour les TVP, 0,19 %/0,35 % pour les EP, 3,52 %/3,84 % pour les hemorragies, 0,21 %/0,38 % pour les hemorragies severes, et 0,44 %/0,40 % pour les ETEA. La variabilite inter-hopitaux etait plus elevee en France qu’en Suisse. Discussion/Conclusion La Suisse et la France pourraient contribuer aux indicateurs OCDE mesurant les taux de TVP et EP a 30 jours apres PTH/PTG. La comparabilite internationale devrait aussi etre amelioree par une meilleure prise en compte des profils de risque individuels des patients.

Background Information about the impact of cancer treatments on patients' quality of life (QoL) is of paramount importance to patients and treating oncologists. Cancer trials that do not specify QoL as an outcome or fail to report collected QoL data, omit crucial information for decision making. To estimate the magnitude of these problems, we investigated how frequently QoL outcomes were specified in protocols of cancer trials and subsequently reported. Design Retrospective cohort study of RCT protocols approved by six research ethics committees in Switzerland, Germany, and Canada between 2000 and 2003. We compared protocols to corresponding publications, which were identified through literature searches and investigator surveys. Results Of the 173 cancer trials, 90 (52%) specified QoL outcomes in their protocol, 2 (1%) as primary and 88 (51%) as secondary outcome. Of the 173 trials, 35 (20%) reported QoL outcomes in a corresponding publication (4 modified from the protocol), 18 (10%) were published but failed to report QoL outcomes in the primary or a secondary publication, and 37 (21%) were not published at all. Of the 83 (48%) trials that did not specify QoL outcomes in their protocol, none subsequently reported QoL outcomes. Failure to report pre-specified QoL outcomes was not associated with industry sponsorship (versus non-industry), sample size, and multicentre (versus single centre) status but possibly with trial discontinuation. Conclusions About half of cancer trials specified QoL outcomes in their protocols. However, only 20% reported any QoL data in associated publications. Highly relevant information for decision making is often unavailable to patients, oncologists, and health policymakers.

Surface functionalization of superparamagnetic iron oxide nanoparticles (SPIONs) remains indispensable in promoting colloidal stability and biocompatibility. We propose a well-defined and characterized synthesis of a new catechol-functionalized RAFT (reversible addition–fragmentation chain transfer) poly(vinyl alcohol) polymer, which can be anchored onto hydrophobic SPIONs via a one-pot emulsion ligand exchange process. Both single and clustered nanoparticles are obtained and can be separated from each other. As clustered SPIONs are receiving increasing attention, this new macroligand might be of considerable interest for both basic and applied sciences.

The awake craniotomy is an important technique used for brain tumour excision from eloquent cortex, epilepsy surgery, and deep brain stimulation surgery. It has been used, less commonly, in the management of mycotic aneurysms and arteriovenous malformations near critical brain areas. The benefits are considered to be of increased lesion removal, with growing evidence of improved survival benefit, whilst minimizing damage to eloquent cortex and resulting postoperative neurological dysfunction. Other advantages include a shorter hospitalization time, hence reduced cost of care, and a decreased incidence of postoperative complications such as nausea and vomiting. The concept of an awake craniotomy predates the existence of anaesthesia and in ancient times, trephining of the skull was used to get rid of ‘evil air’. It is a procedure that has gained in popularity because of advances in diagnosis, intra-operative functional neurosurgical technology, developments in anaesthetic agents and monitoring, and the patient’s expectations. The term ‘awake craniotomy’ is misleading as the patient is not fully awake for the entirety of the procedure. The more surgically stimulating parts of the procedure require varying levels of sedation, or anaesthesia. The patient is fully awake during the mapping procedure during which lesion resection takes place. The common anaesthetic techniques used are sedation only or general anaesthesia, and awaking the patient for cortical mapping and resection, with the option of re-anaesthetizing for closure. The patient has a scalp block inserted for pain relief usually for all anaesthetic approaches. Occasionally the anaesthetic technique of awake with a scalp block alone is utilized, this can be useful in elderly patients. The anaesthetic considerations for an awake craniotomy can make it challenging, and this article will consider the issues involved.

Problem theory points to an a priori relation between six key problems of living, to which people have adapted through evolution. Children are guided through the problems one by one, learning to switch between them automatically and unawares. The first problem of raising hope of certainty (about the environment), is dealt with in the right hemisphere (RH). The second of raising hope of freedom (or power to control), is dealt with in the left hemisphere (LH). Here adventurousness and ignoring the goodness of outcomes potentially create recklessness. When uncertainty rises the RH activates a backup with an override that substitutes immobility, takes over sensory inputs, but allows obedience to parental commands, and a cut-out that stops new work on the freedom problem. Support for the use of the backup by infants is found in the immobility that precedes the crying in strange conditions, and in childhood EEGs. The hypothesis that the backup is active in deep hypnosis imposes accord on findings that appear contradictory. For example it accounts for why observations during deep hypnosis emphasize the activity of the RH, but observations of responsive people not under hypnosis emphasize the activity of the LH. The hypothesis that the backup is active in post-traumatic stress disorder (PTSD) is supported by (a) fMRI observations that could reflect the cut-out, in that part of the precuneus has low metabolism, (b) the recall of motionlessness at the time of the trauma, (c) an argument that playing dead as a defence against predators is illogical, (d) the ease of hypnosis. With dissociative identity disorder (DID), the theory is consistent with up to six alters that have executive control and one trauma identity state where childhood traumas are re-experienced. Support for the cut-out affecting the trauma identity state comes from suppression of part of the precuneus and other parts of the parietal lobe when the trauma identity state is salient and a general script about a trauma is listened to. Support also comes from the ease of hypnosis. The cut-out acts independently of the override. It is linked to low metabolism at the same point in the left precuneus by evidence from all three conditions, hypnosis, PTSD and DID. The concept of dissociation is not required with any of the hypotheses.

Aims To explore, both among patients with diabetes and healthcare professionals, opinions on current diabetes care and the development of the “Regional Diabetes Program”. Methods We employed qualitative methods (focus groups – FG) and used purposive sampling strategy to recruit patients with diabetes and healthcare professionals. We conducted one diabetic and one professional FG in each of the four health regions of the canton of Vaud/Switzerland. The eight FGs were audio-taped and transcribed verbatim. Thematic analysis was then undertaken. Results Results showed variability in the perception of the quality of diabetes care, pointed to insufficient information regarding diabetes, and lack of collaboration. Participants also evoked patients’ difficulties for self-management, as well as professionals’ and patients’ financial concerns. Proposed solutions included reinforcing existing structures, developing self-management education, and focusing on comprehensive and coordinated care, communication and teamwork. Patients and professionals were in favour of a “Regional Diabetes Program” tailored to the actors’ needs, and viewed it as a means to reinforce existing care delivery. Conclusions Patients and professionals pointed out similar problems and solutions but explored them differently. Combined with coming quantitative data, these results should help to further develop, adapt and implement the “Regional Diabetes Program”.

A logical relationship exists among six general problems that people face in life. Using hope about something for its subjective probability, its expected likelihood, the problems form a series where the method of assessing hope changes in a simple manner from one problem to the next. The central hypothesis is that human beings exploit this. Brain structures and predispositions have evolved accordingly, leading to the hemispheres having different predispositions. The hemispheres are effectively joined at 5 months. Infants will then find that they engage in two unrelated activities. Typical infants label the activities in detail, using visual images, as part of gaining control over them. Hypotheses are: (a) autistic children fail labelling at the start, and hence they encounter uncontrolled competition between the hemispheres; (b) with some, serotonin abnormality impairs sensory information processing and hence the labelling; (c) with some, a delay in myelination from autoimmune effects disrupts labelling; (d) the likelihood of this 'delay autism' is reduced by long chain omega oils; (e) self-pressuring, which underlies taking on challenges and play like Hide and Seek, brings relief from the competition by raising the influence of one side; (f) the same left-right competition occurs in confused episodes and schizophrenia in vulnerable people who encounter pressures to use both hemispheres at the same time; (g) some symptoms raise the influence on one side ideationally. This leads to coherent theories of autism and schizophrenia. In both competition between the hemispheres is relieved primarily by self-pressuring, which raises influence on one side.

Background In the United States, the Agency for Healthcare Research and Quality (AHRQ) has developed 20 Patient Safety Indicators (PSIs) to measure the occurrence of hospital adverse events from medico-administrative data coded according to the ninth revision of the international classification of disease (ICD-9-CM). The adaptation of these PSIs to the WHO version of ICD-10 was carried out by an international consortium. Methods Two independent teams transcoded ICD-9-CM diagnosis codes proposed by the AHRQ into ICD-10-WHO. Using a Delphi process, experts from six countries evaluated each code independently, stating whether it was “included”, “excluded” or “uncertain”. During a two-day meeting, the experts then discussed the codes that had not obtained a consensus, and the additional codes proposed. Results Fifteen PSIs were adapted. Among the 2569 proposed diagnosis codes, 1775 were unanimously adopted straightaway. The 794 remaining codes and 2541 additional codes were discussed. Three documents were prepared: (1) a list of ICD-10-WHO codes for the 15 adapted PSIs; (2) recommendations to the AHRQ for the improvement of the nosological frame and the coding of PSI with ICD-9-CM; (3) recommendations to the WHO to improve ICD-10. Conclusions This work allows international comparisons of PSIs among the countries using ICD-10. Nevertheless, these PSIs must still be evaluated further before being broadly used.

This study investigated whether crisis intervention (CI) at the General Hospital is a suitable management strategy among borderline patients referred to the emergency room (ER) for deliberate self-harm. Two patient cohorts (n=200) meeting DSM-IV Borderline Personality Disorder criteria, were prospectively assessed for repeated deliberate self-harm and service consumption. At ER discharge, 100 subjects received CI, while 100 comparison subjects (recruited before the implementation of CI) were assigned to treatment as usual (TAU). At 3-month follow-up, a high proportion of repeated deliberate self-harm and hospitalization in the global study sample was found. However rates were lower in the CI group: 8% repeated deliberate self-harm and 8% psychiatric hospitalization, versus 17% and 56% in the TAU group. The global expenditure for psychiatric hospitalization was 728,840 Swiss Francs (CHF) for CI and 914,340 for TAU. This study indicates that associated with mean hospitalization/relapse rates, CI may be a suitable management strategy for acutely suicidal borderline patients.

Introduction La fragilite est frequente et constitue un predicteur important de mortalite et de morbidite dans la population âgee. Elle est egalement associee a une augmentation de la consommation de soins hospitaliers et ambulatoires. Il apparait donc primordial de monitorer la population fragile ou a risque de fragilite dans un objectif de planification sanitaire et medico-sociale. Methodes Les donnees de la cohorte lausannoise des personnes âgees de 65 ans et plus (Lc65 + ) ont ete chainees aux donnees medico-administratives du Centre hospitalier universitaire Vaudois (CHUV) pour la periode 2004–2015. Ces donnees ont permis de : (1) construire un score de fragilite (score Lc65 + ) base sur les codes diagnostiques des sejours des 12 mois precedant l’evaluation du phenotype de fragilite de Fried (PFF) ; (2) developper et valider un algorithme predictif de la fragilite (score PFF ≥ 3) par modeles de regression et algorithmes d’apprentissage supervise (« Supervised machine learning »). Resultats Les 1648 participants a la cohorte ont donne lieu a 3497 mesures de PFF : 55,3 % concernaient des femmes, l’âge moyen etait de 71 ans et la prevalence de la fragilite etait de 5,5 %. Le score Lc65 + variait entre 0 et 9, sa moyenne etait de 2,1. Le modele optimal pour predire la fragilite etait le modele de regression logistique mixte avec l’âge, le sexe, le nombre d’hospitalisations dans les 12 mois precedents et le score Lc65 + comme predicteurs. Pour ce modele, l’aire sous la courbe ROC estime par bootstrap etait de 0,71 et la sensibilite et la specificite etaient maximales (0,54 et 0,79) pour un seuil de probabilite predite de fragilite de 0,2. Le modele predisait significativement la mortalite, le nombre d’hospitalisations a 12 mois, la duree de sejour, et l’institutionnalisation. Discussion/Conclusion Les donnees medico-administratives hospitalieres peuvent etre utilisees pour identifier les personnes fragiles et estimer leur prevalence dans la population suisse. Notre modele predictif montre cependant des performances limitees et pourrait etre ameliore par l’utilisation de donnees cliniques du dossier patient electronique.

SummaryBackgroundIf carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA.MethodsBetween 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3–2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6–11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392.Findings1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7% versus 4·8% at 1 year (and 92·1% vs 16·5% at 5 years). Perioperative risk of stroke or death within 30 days was 3·0% (95% CI 2·4–3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1% versus 10·0% at 5 years (gain 5·9%, 95% CI 4·0–7·8) and 10·8% versus 16·9% at 10 years (gain 6·1%, 2·7–9·4); ratio of stroke incidence rates 0·54, 95% CI 0·43–0·68, p

Cardiovascular haemodynamics is the study of how blood flows through the cardiovascular system. The physical factors that determine blood flow include the blood pressure and the resistance to this flow. The resistance is determined by vessel length and radius, blood viscosity and the arrangement of these vessels. The arterioles account for more than 60% of the resistance in the cardiovascular system and control local blood flow through organs. In shock states, where there is inadequate tissue perfusion, autonomic outflow to the heart and vessels can be modified by various cardiovascular reflexes to control heart rate, cardiac contractility, vascular tone and blood pressure. It is important to have an understanding of the haemodynamics of the cardiovascular system in order to monitor the circulation and administer fluids and vasoactive drugs in a sensible manner when managing the critically ill patient.

It is now clear that the monocyte/macrophage has a crucial role in the development of atherosclerosis. This cell appears to be involved in all stages of atherosclerotic plaque development and is increasingly seen as a candidate for therapeutic intervention and as a potential biomarker of disease progression and response to therapy. The main mechanisms related to the activity of the monocyte/macrophage that have been targeted for therapy are those that facilitate recruitment, cholesterol metabolism, inflammatory activity and oxidative stress. There is also increasing evidence that there is heterogeneity within the monocyte/macrophage population, which may have important implications for plaque development and regression. A better insight into how specific phenotypes may influence plaque progression should facilitate the development of novel methods of imaging and more refined treatments.

SummaryBackgroundAlthough there is no strong evidence of benefit, chest physiotherapy (CP) seems to be commonly used in simple pneumonia. CP requires equipment and frequently involves the assistance of a respiratory therapist, engendering a significant medical workload and cost.AimTo measure and compare the efficacy of two modalities of chest physiotherapy (CP) guideline implementation on the appropriateness of CP prescription among patients hospitalised for community-acquired pneumonia (CAP).Patients and methodsWe measured the CP prescription rate and duration in all consecutive CAP inpatients admitted in a division of general internal medicine at an urban teaching community hospital during three consecutive one-year time periods: (1) before any guideline implementation; (2) after a passive implementation by medical grand rounds and guideline diffusion through mailing; (3) after adding a one-page reminder in the CAP patient's medical chart highlighting our recommendations. Death and recurrent hospitalisation rates within one year after hospitalisation were recorded to assess whether CP prescription reduction, if any, impaired patient outcomes.ResultsDuring the three successive phases, 127, 157, and 147 patients with similar characteristics were included. Among all CAP inpatients, the CP prescription rate decreased from 68% (86/127) to 51% (80/157), and to 48% (71/147), respectively (P for trend

There is increasing evidence that modified phospholipid products of low density lipoprotein (LDL) oxidation mediate inflammatory processes within vulnerable atherosclerotic lesions. Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) is present in vulnerable plaque regions where it acts on phospholipid oxidation products to generate the pro-inflammatory lysophsopholipids and oxidized non-esterified fatty acids. This association together with identification of circulating Lp-PLA(2) levels as an independent predictor of cardiovascular disease provides a rationale for development of Lp-PLA(2) inhibitors as therapy for atherosclerosis. Here we report a systematic analysis of the effects of in vitro oxidation in the absence and presence of an Lp-PLA(2) inhibitor on the phosphatidylcholine (PC) composition of human LDL. Mass spectrometry identifies three classes of PC whose concentration is significantly enhanced during LDL oxidation. Of these, a series of molecules, represented by peaks in the m/z range 594-666 and identified as truncated PC oxidation products by accurate mass measurements using an LTQ Orbitrap mass spectrometer, are the predominant substrates for Lp-PLA(2). A second series of oxidation products, represented by peaks in the m/z range 746-830 and identified by LTQ Orbitrap analysis as non-truncated oxidized PCs, are quantitatively more abundant but are less efficient Lp-PLA(2) substrates. The major PC products of Lp-PLA(2), saturated and mono-unsaturated lyso-PC, constitute the third class. Mass spectrometric analysis confirms the presence of many of these PCs within human atherosclerotic lesions, suggesting that they could potentially be used as in vivo markers of atherosclerotic disease progression and response to Lp-PLA(2) inhibitor therapy.

Summary Evidence suggests that platinum-based regimens confer a better survival in patients with non-small cell lung carcinoma (NSCLC). However, evidence is lacking regarding the specific effects of cisplatin or carboplatin when compared to non-platinum-based doublets. Methods Meta-analysis of all randomized trials comparing non-platinum-based with platinum-based doublet regimens given as first-line treatment for NSCLC. Relative risks were calculated for all outcomes ascertained. Sensitivity analysis, using methodological quality of the trials and different measures of effect, was undertaken. Results Seventeen trials, comprising 4920 patients were included. The use of platinum-based doublet regimens was associated with a slightly higher survival at 1 year (RR = 1.08, 95% CI 1.01–1.16, p = 0.03), better partial response (RR = 1.11, 95% CI 1.02–1.21, p = 0.02), with a higher risk of anemia, nausea, and neurotoxicity. Cisplatin-based doublet regimens improved survival at 1 year (RR = 1.16, 95% CI 1.06–1.27, p = 0.001), complete response (RR = 2.29, 95% CI 1.08–4.88, p = 0.03), partial response (RR = 1.19, 95% CI 1.07–1.32, p = 0.002) with an increased risk of anemia, neutropenia, neurotoxicity and nausea. Conversely, carboplatin-based doublet regimens did not increase survival rate at 1 year (RR = 0.95, 95% CI 0.85–1.07, p = 0.43). There was a statistically significant difference between the effect of cisplatin compared to carboplatin (p = 0.05). Carboplatin-based doublet regimen included a higher risk of anemia and thrombocytopenia, but no increased nausea and/or vomiting, contrarily to cisplatin. Sensitivity analyses showed that the results were robust to the exclusion of lesser quality trials and the choice of the measure of effect. Conclusion We provide additional evidence that cisplatin, but not carboplatin-based doublet regimens are associated with a slightly better survival compared to non-platinum-based doublet regimens. Side effects of cisplatin- and carboplatin-based regimens differ between each other and when compared to non-platinum doublets. Although this analysis has limitations, it may provide valuable information to clinicians when choosing the appropriate regimen for patients with non-small cell lung cancer.