Surgical glues: are they really adhesive?

OBJECTIVE: The aim of this study is to create a standard test to approve the efficacy of a surgical sealant. An industrial test, the bulge-and-blister test, which is very convenient for measuring adhesion energy, is applied to the surgical field to quantify adhesion of bioadhesives. METHODS: Samples were composed of two circular layers of equine pericardium glued by the surgical sealant studied. The sample was fixed to a support with an industrial glue. The support and the bottom layer were perforated in the centre to allow injection of pressurised water. Water was progressively introduced through the hole in the support and the bottom layer to create a blister with constant radius, increasing height and internal pressure during this first step. At a critical pressure, delamination started, the radius and height of the blister increased and the pressure decreased. At this point, the adhesion energy could be determined. The experimental parameters were measured with a pressure sensor and an optical profilometry device for deflection. RESULTS: Adhesion testing was carried out in eight paired equine pericardium samples bonded with a Dermabond cyanoacrylate glue. The average value of the practical adhesion energy is 2.3 Jm(-2) with a standard deviation of 1.5 Jm(-2). CONCLUSION: Application of the bulge-and-blister test to the surgical field was achieved and allowed a quantification of adhesion of a surgical glue. Such information is essential to compare the different surgical glues presently available. The study of the impact of bonding conditions such as pressure, hygrometry or setting conditions will provide a better understanding of the characteristics of adhesion in the surgical field.

Treating high blood pressure: is reaching the target more important than the means? No, the means are important.

All major antihypertensive drug classes i.e. diuretics, beta-blockers, calcium antagonists and blockers of the renin-angiotensin system have been shown to effectively lower blood pressure and hence to reduce cardiovascular outcomes in hypertensive patients. These drugs decrease cardiovascular complications in hypertension essentially because they reduce systemic blood pressure. Nevertheless, there is growing evidence that the extent of the benefits differed between drug classes suggesting that the various classes of antihypertensive agents are not equivalent in their ability to protect against target organ damages and cardiovascular and renal endpoints. More recently, evidence has also accumulated to demonstrate that even combination therapies are not equally effective in reducing the occurrence of cardiovascular complications in hypertension. These recent observations suggest that the means to lower blood pressure are as important as the achieved target blood pressure in the management of hypertensive patients.

Multi-stage garnet in the internal Brianconnais basement (Ambin massif, Savoy): New petrological constraints on the blueschist-facies metamorphism in the Western Alps and tectonic implications

Three types of garnet have been distinguished in pelitic schists from an epidote-blueschist-facies unit of the Ambin and South Vanoise Brianconnais massifs on the basis of texture, chemical zoning and mineral inclusion characterization. Type-1 garnet cores with high Mn/Ca ratios are interpreted as pre-Alpine relicts, whereas Type-1 garnet rims, Type-2 inclusion-rich porphyroblasts and smaller Type-3 garnets are Alpine. The latter are all characterized by low Mn/Ca ratios and a coexisting mineral assemblage of blue amphibole, high-Si phengite, epidote and quartz. Prograde growth conditions during Alpine D-1 high-pressure (HP) metamorphism are recorded by a decrease in Mn and increase in Fe (+/-Ca) in the Type-2 garnets, culminating in peak P-T conditions of 14-16 kbar and 500degreesC in the deepest parts of the Ambin dome. The multistage growth history of Type-1 garnets indicates a polymetamorphic history for the Ambin and South Vanoise massifs; unfortunately, no age constraints are available. The new metamorphic constraints on the Alpine event in the massifs define a metamorphic T `gap' between them and their surrounding cover (Brianconnais and upper Schistes Lustres units), which experienced metamorphism only in the stability field of carpholite-lawsonite (T < 400degreesC). These data and supporting structural studies confirm that the Ambin and South Vanoise massifs are slices of `eclogitized' continental crust tectonically extruded within the Schistes Lustres units and Brianconnais covers. The corresponding tectonic contacts with top-to-east movement are responsible for the juxtaposition of lower-grade metamorphic units on the Ambin and South Vanoise massifs.

Is accountability a double-edged sword? Experimental evidence on the effectiveness of internal controls to prevent fraud

Recent legislations oblige organizations to monitor the effectiveness of internal control mechanisms that are necessary to prevent fraud. However, little is known about the effectiveness of different internal controls. We investigate whether the duty to sign work results-one of the most prominent internal control mechanisms-is effective to prevent fraud under different superior instructions. We use a 2×2 between-subjects experimental design with accountability (duty to sign work results vs. no duty to sign) and superior instructions (with vs. without profit maximization cue) as independent variables. Both manipulations of superior instructions reminded people to respect accounting standards and principles but in one condition, an instruction to increase revenues was integrated as profit maximization cue. We expected this cue to trigger a profit maximization decision frame that increases the likelihood for fraudulent revenue recording. 58 managers from an executive MBA class participated in the experiment. We find that superior instructions interact with accountability. Fraudulent revenue recording was particularly observed when people received instructions to increase revenues and had to sign their work results. Consequently, fraudulent behavior can occur without pressure to commit fraud due to profit maximization cues that are communicated by a superior and despite implemented internal control mechanisms. We discuss possible implications of our results for the prevention of fraudulent behavior.

The effect of continuous positive airway pressure on total cerebral blood flow in healthy awake volunteers.

PURPOSE: Continuous positive airway pressure (CPAP) is the gold standard treatment for obstructive sleep apnea. However, the physiologic impact of CPAP on cerebral blood flow (CBF) is not well established. Ultrasound can be used to estimate CBF, but there is no widespread accepted protocol. We studied the physiologic influence of CPAP on CBF using a method integrating arterial diameter and flow velocity (FV) measurements obtained for each vessel supplying blood to the brain. METHODS: FV and lumen diameter of the left and right internal carotid, vertebral, and middle cerebral arteries were measured using duplex Doppler ultrasound with and without CPAP at 15 cm H(2)O, applied in a random order. Transcutaneous carbon dioxide (PtcCO(2)), heart rate (HR), blood pressure (BP), and oxygen saturation were monitored. Results were compared with a theoretical prediction of CBF change based on the effect of partial pressure of carbon dioxide on CBF. RESULTS: Data were obtained from 23 healthy volunteers (mean ± SD; 12 male, age 25.1 ± 2.6 years, body mass index 21.8 ± 2.0 kg/m(2)). The mean experimental and theoretical CBF decrease under CPAP was 12.5 % (p < 0.001) and 11.9 % (p < 0.001), respectively. The difference between experimental and theoretical CBF reduction was not statistically significant (3.84 ± 79 ml/min, p = 0.40). There was a significant reduction in PtcCO(2) with CPAP (p = <0.001) and a significant increase in mean BP (p = 0.0017). No significant change was observed in SaO(2) (p = 0.21) and HR (p = 0.62). CONCLUSION: Duplex Doppler ultrasound measurements of arterial diameter and FV allow for a noninvasive bedside estimation of CBF. CPAP at 15 cm H(2)O significantly decreased CBF in healthy awake volunteers. This effect appeared to be mediated predominately through the hypocapnic vasoconstriction coinciding with PCO(2) level reduction. The results suggest that CPAP should be used cautiously in patients with unstable cerebral hemodynamics.

Impact of electronic monitoring of drug adherence on blood pressure control in primary care: a cluster 12-month randomised controlled study.

BACKGROUND: Poor long-term adherence is an important cause of uncontrolled hypertension. We examined whether monitoring drug adherence with an electronic system improves long-term blood pressure (BP) control in hypertensive patients followed by general practitioners (GPs). METHODS: A pragmatic cluster randomised controlled study was conducted over one year in community pharmacists/GPs' networks randomly assigned either to usual care (UC) where drugs were dispensed as usual, or to intervention (INT) group where drug adherence could be monitored with an electronic system (Medication Event Monitoring System). No therapy change was allowed during the first 2 months in both groups. Thereafter, GPs could modify therapy and use electronic monitors freely in the INT group. The primary outcome was a target office BP<140/90 mmHg. RESULTS: Sixty-eight treated uncontrolled hypertensive patients (UC: 34; INT: 34) were enrolled. Over the 12-month period, the likelihood of reaching the target BP was higher in the INT group compared to the UC group (p<0.05). At 4 months, 38% in the INT group reached the target BP vs. 12% in the UC group (p<0.05), and 21% vs. 9% at 12 months (p: ns). Multivariate analyses, taking account of baseline characteristics, therapy modification during follow-up, and clustering effects by network, indicate that being allocated to the INT group was associated with a greater odds of reaching the target BP at 4 months (p<0.01) and at 12 months (p=0.051). CONCLUSION: GPs monitoring drug adherence in collaboration with pharmacists achieved a better BP control in hypertensive patients, although the impact of monitoring decreased with time.

Acquisitions thérapeutiques en médecine ambulatoire en 2011 [2011 findings from literature on general internal ambulatory medicine].

In 2011 several articles seemed significant for the practice of general medicine. Diagnosis of hypertension needs several measurements and may need 24-hour ambulatory blood pressure monitoring. Glycosylated hemoglobin is a reliable tool to diagnose diabetes mellitus. The ABCD2 score with neurological imaging help the triage of transient ischemic attacks. Pulmonary embolism can be treated as outpatient for low risk patients. Gluten-free diet may be tried in irritable bowel syndrome. Nitrofurantoin is a reasonable alternative for simple urinary tract infection in women, but antibiotics are not needed after drainage of an uncomplicated skin abscess. Subclinical thyroid dysfunction is a risk factor of osteoporosis in older men. Sequential use of MMSE and ACE scores is a promising approach to assess medical decision-making capacity.

Acquisitions thérapeutiques en médecine ambulatoire en 2013 [2013 literature findings in internal general medicine].

The prescribing of antibiotics for uncomplicated skin abscesses and diverticulitis has no benefit. Some antibiotics are more at risk of causing a Clostridium difficile infection. The tests used to exclude a history of a penicillin allergy are safe. A threshold of D-dimer adjusted for the age significantly improves the specificity of the test without affecting the sensitivity. The prescription of paraclinics tests is not an effective "treatment" for the patient's anxiety. In the sleep apnea syndrome, treatment with CPAP (Continuous positive airway pressure) appears to have more benefits compared to the mandibular advancement prosthesis. The work of primary care physicians can be supported by the work of advanced practice nurses. The limitation placed on the working hours of doctors in hospitals seems to affect their ability to spend time with their patients.

L'année 2014 mise en perspective par les internistes hospitaliers [What is new in 2014 for the specialist in hospital internal medicine? The point of view of university hospital chief residents].

The year 2014 was rich in significant advances in all areas of internal medicine. Many of them have an impact on our daily practice and on the way we manage one problem or another. From the use of the ultrasound for the diagnosis of pneumonia to the choice of the site of venous access and the type of line, and the increasing complexity of choosing an oral anticoagulant agent, this selection offers to the readers a brief overview of the major advances. The chief residents in the Service of internal medicine of the Lausanne University hospital are pleased to share their readings.

Liquid chromatography-tandem mass spectrometry (LC/APCI-MS/MS) methods for the quantification of captan and folpet phthalimide metabolites in human plasma and urine.

Captan and folpet are fungicides largely used in agriculture. They have similar chemical structures, except that folpet has an aromatic ring unlike captan. Their half-lives in blood are very short, given that they are readily broken down to tetrahydrophthalimide (THPI) and phthalimide (PI), respectively. Few authors measured these biomarkers in plasma or urine, and analysis was conducted either by gas chromatography coupled to mass spectrometry or liquid chromatography with UV detection. The objective of this study was thus to develop simple, sensitive and specific liquid chromatography-atmospheric pressure chemical ionization-tandem mass spectrometry (LC/APCI-MS/MS) methods to quantify both THPI and PI in human plasma and urine. Briefly, deuterated THPI was added as an internal standard and purification was performed by solid-phase extraction followed by LC/APCI-MS/MS analysis in negative ion mode for both compounds. Validation of the methods was conducted using spiked blank plasma and urine samples at concentrations ranging from 1 to 250 μg/L and 1 to 50 μg/L, respectively, along with samples of volunteers and workers exposed to captan or folpet. The methods showed a good linearity (R (2) > 0.99), recovery (on average 90% for THPI and 75% for PI), intra- and inter-day precision (RSD, <15%) and accuracy (<20%), and stability. The limit of detection was 0.58 μg/L in urine and 1.47 μg/L in plasma for THPI and 1.14 and 2.17 μg/L, respectively, for PI. The described methods proved to be accurate and suitable to determine the toxicokinetics of both metabolites in human plasma and urine.

Renal sodium handling and nighttime blood pressure.

Blood pressure follows a circadian rhythm with a physiologic 10% to 20% decrease during the night. There is now increasing evidence that a blunted decrease or an increase in nighttime blood pressure is associated with a greater prevalence of target organ damage and a faster disease progression in patients with chronic kidney diseases. Several factors contribute to the changes in nighttime blood pressure including changes in hormonal profiles such as variations in the activity of the renin-angiotensin and the sympathetic nervous systems. Recently, it was hypothesized that the absence of a blood pressure decrease during the nighttime (nondipping) is in fact a pressure-natriuresis mechanism enabling subjects with an impaired capacity to excrete sodium to remain in sodium balance. In this article, we review the clinical and epidemiologic data that tend to support this hypothesis. Moreover, we show that most, if not all, clinical conditions associated with an impaired dipping profile are diseases associated either with a low glomerular filtration rate and/or an impaired ability to excrete sodium. These observations would suggest that renal function, and most importantly the ability to eliminate sodium during the day, is indeed a key determinant of the circadian rhythm of blood pressure.

Metoprolol prevents sodium retention induced by lower body negative pressure in healthy men.

BACKGROUND: Lower body negative pressure (LBNP) has been shown to induce a progressive activation of neurohormonal systems, and a renal tubular and hemodynamic response that mimics the renal adaptation observed in congestive heart failure (CHF). As beta-blockers play an important role in the management of CHF patients, the effects of metoprolol on the renal response were examined in healthy subjects during sustained LBNP. METHODS: Twenty healthy male subjects were randomized in this double blind, placebo versus metoprolol 200 mg once daily, study. After 10 days of treatment, each subject was exposed to 3 levels of LBNP (0, -10, and -20 mbar) for 1 hour, each level of LBNP being separated by 2 days. Neurohormonal profiles, systemic and renal hemodynamics, as well as renal sodium handling were measured before, during, and after LBNP. RESULTS: Blood pressure and heart rate were significantly lower in the metoprolol group throughout the study (P < 0.01). GFR and RPF were similar in both groups at baseline, and no change in renal hemodynamic values was detected at any level of LBNP. However, a reduction in sodium excretion was observed in the placebo group at -20 mbar, whereas no change was detected in the metoprolol group. An increase in plasma renin activity was also observed at -20 mbar in the placebo group that was not observed with metoprolol. CONCLUSION: The beta-blocker metoprolol prevents the sodium retention induced by lower body negative pressure in healthy subjects despite a lower blood pressure. The prevention of sodium retention may be due to a blunting of the neurohormonal response. These effects of metoprolol on the renal response to LBNP may in part explain the beneficial effects of this agent in heart failure patients.

Ambulatory blood pressure monitoring in adolescent untreated hypertensive patients.

Ambulatory blood pressure profiles were obtained with the portable semi-automatic blood pressure recorder Remler M2000 in groups of 20 adolescents, 20 young and 20 middle-aged adults and 20 elderly untreated patients, all considered by their physician to be hypertensive. It was found that adolescents who are hypertensive when seeing their physician are more often normotensive outside the physician's office than adult and elderly patients under similar conditions. The increased heart rate variability which was detected in adolescents was not associated with an enhanced blood pressure variability.

Bradykinin in blood and cerebrospinal fluid after acute cerebral lesions: correlations with cerebral edema and intracranial pressure.

Abstract Bradykinin (BK) was shown to stimulate the production of physiologically active metabolites, blood-brain barrier disruption, and brain edema. The aim of this prospective study was to measure BK concentrations in blood and cerebrospinal fluid (CSF) of patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and ischemic stroke and to correlate BK levels with the extent of cerebral edema and intracranial pressure (ICP). Blood and CSF samples of 29 patients suffering from acute cerebral lesions (TBI, 7; SAH,: 10; ICH, 8; ischemic stroke, 4) were collected for up to 8 days after insult. Seven patients with lumbar drainage were used as controls. Edema (5-point scale), ICP, and the GCS (Glasgow Coma Score) at the time of sample withdrawal were correlated with BK concentrations. Though all plasma-BK samples were not significantly elevated, CSF-BK levels of all patients were significantly elevated in overall (n=73) and early (≤72 h) measurements (n=55; 4.3±6.9 and 5.6±8.9 fmol/mL), compared to 1.2±0.7 fmol/mL of controls (p=0.05 and 0.006). Within 72 h after ictus, patients suffering from TBI (p=0.01), ICH (p=0.001), and ischemic stroke (p=0.02) showed significant increases. CSF-BK concentrations correlated with extent of edema formation (r=0.53; p<0.001) and with ICP (r=0.49; p<0.001). Our results demonstrate that acute cerebral lesions are associated with increased CSF-BK levels. Especially after TBI, subarachnoid and intracerebral hemorrhage CSF-BK levels correlate with extent of edema evolution and ICP. BK-blocking agents may turn out to be effective remedies in brain injuries.

The tectonically controlled emplacement of a vertically sheeted gabbro-pyroxenite intrusion: Feeder-zone of an ocean-island volcano (Fuerteventura, Canary Islands)

The Miocene PX1 gabbro-pyroxenite pluton, Fuerteventura, Canary Islands, is a 3.5 x 5.5 km shallow-level intrusion (0.15-0.2 GPa and 1100-1120 degrees C), interpreted as the feeder-zone to an ocean-island volcano. It displays a vertical magmatic banding expressed in five 50 to 100 metre-wide NNE-SSW trending alkaline gabbro sequences alternating with pyroxenites. This emplacement geometry was controlled by brittle to ductile shear zones, generated by a regional E-W extensional tectonic setting that affected Fuerteventura during the Miocene. At a smaller scale, the PX1 gabbro and pyroxenite bands consist of metre-thick differentiation units, which suggest emplacement by periodic injection of magma pulses as vertical dykes that amalgamated, similarly to a sub-volcanic sheeted dyke complex. Individual dykes underwent internal differentiation following a solidification front parallel to the dyke edges. This solidification front may have been favoured by a significant lateral/horizontal thermal gradient, expressed by the vertical banding in the gabbros, the fractionation asymmetry within individual dykes and the migmatisation of the wall rocks. Pyroxenitic layers result from the fractionation and accumulation of clinopyroxene +/- olivine +/- plagioclase crystals from a mildly alkaline basaltic liquid. They are interpreted as truncated differentiation sequences, from which residual melts were extracted at various stages of their chemical evolution by subsequent dyke intrusions, either next to or within the crystallising unit. Compaction and squeezing of the crystal mush is ascribed to the incoming and inflating magma pulses. The expelled interstitial liquid was likely collected and erupted along with the magma flowing through the newly injected dykes. Clinopyroxene mineral orientation - as evidenced by EBSD and micro X-ray tomography investigations - displays a marked pure-shear component, supporting the interpretation of the role of compaction in the generation of the pyroxenites. Conversely, gabbro sequences underwent minor melt extraction and are believed to represent crystallised coalesced magma batches emplaced at lower rates at the end of eruptive cycles. Clinopyroxene orientations in gabbros record a simple shear component suggesting syn-magmatic deformation parallel to observed NNE-SSW trending shear zones induced by the regional tensional stress field. This emplacement model implies a crystallisation time of 1 to 5 years for individual dykes, consistent with PX1 emplacement over less than 0.5 My. A minimum amount of approximately 150 km(3) of magma is needed to generate the pluton, part of it having been erupted through the Central Volcanic Centre of Fuerteventura. If the regional extensional tectonic regime controls the PX1 feeder-zone initiation and overall geometry, rates and volumes of magma depend on other, source-related factors. High injection rates are likely to induce intrusion growth rates larger than could be accommodated by the regional extension. In this case, dyke intrusion by propagation of a weak tip, combined with the inability of magma to circulate through previously emplaced and crystallised dykes could result in an increase of non-lithostatic pressure on previously emplaced mushy dyke walls; thus generating strong pure-shear compaction within the pluton feeder-zone and interstitial melt expulsion. These compaction-dominated processes are recorded by the cumulitic pyroxenite bands. (C) 2010 Elsevier B.V. All rights reserved.