Infections de prothèse articulaire : aspects pratiques à l’attention du médecin de premier recours

L’infection de prothèse articulaire est une complication rare mais redoutée. Sa prise en charge nécessite une collaboration entre médecin de premier recours, orthopédiste et infectiologue. Une méconnaissance du diagnostic peut avoir pour conséquences des traitements chirurgicaux lourds. L’identification du germe responsable de l’infection est essentielle. Elle guide le choix de l’antibiothérapie et est aussi un critère décisif de la stratégie chirurgicale. Une antibiothérapie ne devrait jamais être instaurée sans prélèvement microbiologique adéquat préalable. Ici, le frottis de plaie superficielle n’est d’aucune utilité, car il reflète tout au plus la colonisation par des germes de la flore cutanée. Cette revue se veut un aperçu pratique des infections de prothèse articulaire à l’attention du médecin de premier recours.

Das Burnout-Syndrom: eine medizinische Perspektive

The burnout syndrome is a heterogeneous concept mostly understood as a complex of symptoms, primarily exhaustion, in response to prolonged emotional and interpersonal stress at work. The prevalence of burnout is considerably high in Swiss primary care physicians. In spite of its vague definition, burnout is a serious stress disease with many associated medical problems and high economic costs. Previous recommendations for the psychosomatic management of patients with functional somatic syndromes also apply to burnout treatment. These are complemented by more specific interventions targeting job stress related factors. Relapse prevention focuses on early recognition of warning signs and is an ongoing process.

Entraide judiciaire internationale en matière civile

Dans le contexte global actuel, les autorités judiciaires ou administratives sont régulièrement confrontées à des situations présentant des éléments d'extranéité pour lesquelles un acte en dehors de la juridiction saisie est souvent nécessaire. Le principe de droit international public de territorialité délimite toutefois les pouvoirs étatiques; ces limites peuvent être surmontées par le recours aux mécanismes de l'entraide. Dans la pratique, le contour des limites territoriales des activités de l'Etat pose de nombreuses questions et crée autant d'incertitudes. Cet ouvrage veut donner une réponse à ces questions, notamment par une analyse approfondie de l'article 271 CP appliqué dans le cadre d’une procédure civile internationale. L'ouvrage présente et explique en outre le fonctionnement de l'entraide internationale en matière civile, en particuliers celui des Conventions de La Haye de 1965 et de 1970. Les auteurs développent également les fondements de l'entraide internationale civile en matière de notification et d'obtention de preuves. Il s'agit ainsi d'un ouvrage qui présente tant les aspects pratiques que les aspects théoriques de l'entraide et qui s'adresse aux praticiens - avocats ou juges -, aux universitaires et aux étudiants.

Intraoperative fabrication of patient-specific moulded implants for skull reconstruction: single-centre experience of 28 cases

BACKGROUND Intraoperatively fabricated polymethylmethacrylate (PMMA) implants based on computer-designed moulds were used to improve cosmetic results after hard tissue replacement. To assess the implant's cosmetic and functional results we performed both subjective and objective assessments. METHODS This retrospective analysis was performed using a cohort of 28 patients who received PMMA implants between February 2009 and March 2012. The cosmetic and functional results were assessed using a patient questionnaire. Furthermore an objective volumetric subtraction score (0-100) was applied and implant thickness, as well as gaps and tiers, were measured. RESULTS Patients mainly judged their cosmetic result as "good". Two of the 28 patients found their cosmetic result unfavourable. The functional result and stability was mainly judged to be good. Measurements of implant thickness showed a very high correlation with the thickness of the contralateral bone. Volumetric subtraction led to a median quality of 80 on a scale from 0 to 100. Median gaps around the margins of the implant were 1.5 mm parietally, 1.7 mm frontally and 3.5 mm fronto-orbitally, and median tiers were 1.2 mm, 0 mm and 0 mm respectively. The overall rate of surgical revisions was 10.7 % (three patients). Two patients suffered from wound healing disturbances (7.1 %). The overall complication rate was comparable to other reports in the literature. CONCLUSIONS Implantation of intraoperatively fabricated patient-specific moulded implants is a cost-effective and safe technique leading to good clinical results with a low complication rate.

L’hépatite auto-immune

Autoimmune hepatitis is a systemic disease, difficult to diagnose due the high variability of the clinical presentation and some non specific histological features. The recent identification of additional autoantibodies used as serological markers, as well as simplified diagnostic criteria should help the primary care physician to advance with the diagnostic process. These progresses are crucial as undiagnosed and therefore untreated autoimmune hepatitis has a poor prognosis, whereas immunosuppressive therapy leads to remission in a majority of cases.

Steroidogenesis of the testis - new genes and pathways

Defects of androgen biosynthesis cause 46,XY disorder of sexual development (DSD). All steroids are produced from cholesterol and the early steps of steroidogenesis are common to mineralocorticoid, glucocorticoid and sex steroid production. Genetic mutations in enzymes and proteins supporting the early biosynthesis pathways cause adrenal insufficiency (AI), DSD and gonadal insufficiency. The classic androgen biosynthesis defects with AI are lipoid CAH, CYP11A1 and HSD3B2 deficiencies. Deficiency of CYP17A1 rarely causes AI, and HSD17B3 or SRD5A2 deficiencies only cause 46,XY DSD and gonadal insufficiency. All androgen biosynthesis depends on 17,20 lyase activity of CYP17A1 which is supported by P450 oxidoreductase (POR) and cytochrome b5 (CYB5). Therefore 46,XY DSD with apparent 17,20 lyase deficiency may be due to mutations in CYP17A1, POR or CYB5. Illustrated by patients harboring mutations in SRD5A2, normal development of the male external genitalia depends largely on dihydrotestosterone (DHT) which is converted from circulating testicular testosterone (T) through SRD5A2 in the genital skin. In the classic androgen biosynthetic pathway, T is produced from DHEA and androstenedione/-diol in the testis. However, recently found mutations in AKR1C2/4 genes in undervirilized 46,XY individuals have established a role for a novel, alternative, backdoor pathway for fetal testicular DHT synthesis. In this pathway, which has been first elucidated for the tammar wallaby pouch young, 17-hydroxyprogesterone is converted directly to DHT by 5α-3α reductive steps without going through the androgens of the classic pathway. Enzymes AKR1C2/4 catalyse the critical 3αHSD reductive reaction which feeds 17OH-DHP into the backdoor pathway. In conclusion, androgen production in the fetal testis seems to utilize two pathways but their exact interplay remains to be elucidated.

Loyal to the Game? Strategic Policy Representation in Mixed Electoral Systems

In Germany's compensatory mixed electoral system, alternative electoral routes lead into parliament. We study the relationship between candidates' electoral situations across both tiers and policy representation, fully accounting for candidate, party and district preferences in a multi-actor constellation and the exact electoral incentives for candidates to represent either the party or the district. The results (2009 Bundestag election data) yield evidence of an interactive effect of closeness of the district race and list safety on candidates' positioning between their party and constituency.