Diagnosis by imaging : the case of textbooks of diseases of the nervous system (1850-1920)

Les traités scientifiques ne font que depuis peu d'années l'objet d'études en histoire des sciences. Pourtant, ces traités ont énormément à apporter car ils renseignent sur la manière de raisonner des auteurs, ainsi que sur le développement d'une discipline. Dans ce travail de doctorat, différents traités des maladies du système nerveux ont été dépouillés, notamment le traité de Sémiologie des affections du système nerveux (1914) de Jules Dejerine (1849-1917). Ce traité a été analysé de trois manières différentes. Il a tout d'abord été comparé à une édition précédente publiée sous forme de chapitre (1901), révélant un large remodelage du contenu du traité, suggérant une évolution rapide de la discipline neurologique en l'espace de quelques années. Deuxièmement, l'analyse de la Sémiologie a permis de recréer un réseau de professionnels avec qui Jules Dejerine était en contact et, en parcourant les livres publiés par ces auteurs, il a été possible de décrire de quelle manière ces auteurs se citent mutuellement. Finalement, ces livres contiennent de nombreuses illustrations, qui sont associées à la notion de « preuve » : les auteurs utilisent des images sous forme de dessins, de photographies ou de schémas qui illustrent des patients ou des pièces anatomiques pour « montrer » la maladie ou la lésion. Chaque illustration a un rôle à jouer pour décrire la lésion, montrer la progression de la maladie et elle aide le médecin à poser le diagnostic. Grâce à ces trois axes de recherche, un traité devient un outil de travail dynamique, qui évolue au fil des rééditions, influencé par les critiques et commentaires retrouvés dans d'autres traités et articles, et par les progrès accomplis dans la discipline traitée. Des, passages et certaines images de l'ouvrage circulent également de traité en traité et véhiculent l'autorité de l'auteur de ces passages et images qui en viennent à représenter la maladie. Ce transfert d'images joue également un rôle dans la standardisation du diagnostic et dans l'unification de la neurologie à travers le monde occidental au début du XXe siècle, une période charnière pour l'histoire de la médecine. -- Au début du XXe siècle, la neurologie est une jeune spécialité médicale qui se développe rapidement. Les différents médecins publient des traités, communiquent entre eux et échangent leurs données. Un traité scientifique est un outil de travail dynamique qui évolue avec les rééditions et le développement d'une discipline. Ces ouvrages recèlent toutes sortes d'informations et leur analyse ne fait que depuis peu de temps l'objet d'études en histoire des sciences. Ces traités regorgent notamment d'illustrations qui sont associées à la notion de « preuve » : les auteurs utilisent des images sous forme de dessins, de photographies ou de schémas qui représentent des patients ou des pièces anatomiques afin de « montrer » la maladie ou la lésion. Chaque illustration a un rôle à jouer pour décrire la pathologie, montrer la progression de la maladie et elle aide le médecin à poser le diagnostic. Les auteurs des traités, qui viennent d'Europe et d'Amérique du Nord, se citent mutuellement, permettant au lecteur de recréer leur réseau de professionnels au niveau international. De plus, comme ces auteurs réutilisent les observations et les illustrations des autres, celles-ci circulent de traité en traité et en viennent à représenter la maladie. Ce transfert d'images joue également un rôle dans la standardisation du diagnostic et dans l'unification de la neurologie à travers le monde occidental au début du XXe siècle, une période charnière pour l'histoire de la médecine. -- Until recently, the study of textbooks has been neglected in the history of the sciences. However, textbooks can provide fruitful sources of information regarding the way authors work and the development of a particular discipline. This dissertation reviews editions of a single textbook, the Sémiologie des affections du système nerveux (1914) by Jules Dejerine (1849-1917). This textbook enabled the description of three axes of research. Firstly, by comparing the book to a first edition published as a chapter, one can acknowledge an extensive remodeling of the content of the book, suggesting a vast increase in knowledge over time. Secondly, by looking at the authors that Dejerine quotes repeatedly, it becomes possible to recreate his professional network, to review the works of these authors and to determine how they cross-reference each other. Thirdly, these textbooks contain numerous medical illustrations, which are linked with the concept of "proof;" the authors demonstrate a willingness to "show" the lesion or the pathology by publishing an image. Drawings, schematic representations, radiographies, or photographs of patients or of anatomical preparations all have their own purpose in describing the lesion and the progression of the disease. They assist in the diagnosis of the pathology. By looking at all of these aspects, it is therefore possible to conclude that a neurological textbook is a dynamic object that evolves through re-editions, comments and references found in other textbooks and by the circulations of parts of these books, such as the images. The illustrations also carry the author's authority, since their ongoing use claims that the work by the owner of the image has been endorsed by others. At the same time, it validates the borrowers' arguments. By using medical illustrations from different authors worldwide, the authors are also making a claim to a common language, to a similar way of examining patients, and about how much they depend on medical imagery to prove their points. In that sense, by focusing upon these textbooks, one can affirm that neurology already existed as a worldwide specialty at the turn of the twentieth century. Much more than mere accompaniments to the text, images were of paramount importance to the unification of neurology.

L'anticoagulation du patient âgé en fibrillation atriale: que prescrivent les cardiologues, les gériatres et les médecins généralistes [Anticoagulation in the aged patient with atrial fibrillation: What are prescribing cardiologists, geriatricians and general practitioners?].

OBJECTIVE: To assess prescribing of anticoagulants in atrial fibrillation (AF) in the elderly, both a quantitative point of view (rate of anticoagulation) and qualitative (type of anticoagulation). Determinants of prescribing and non-prescribing were also analysed. METHODS: Prospective survey of practice, based on one clinical case and questionnaire conducted in 60 practitioners (20 cardiologists [C], 20 geriatricians [G] and 20 general practitioners [GP]). RESULTS: In reading the clinical case, 88.3% of physicians would have initiated a treatment; three types of treatments would have been chosen: AVK (68.3%), ODA (20.0%) and platelet antiaggregant (11.7%). Criteria taken into account to initiate anticoagulation varied according to the specialty. Cardiologists considered more the age criteria (C: 95.0%, G: 75.0%, MG: 60.0%; P<0.05), diabetes (C: 90.0%, G: 60.0%, MG: 55.0%; P<0.05), hypertension (C: 85.0%, G: 55.0%, MG: 60.0%; P<0.05) and female gender (C: 80.0%, G: 35.0%, MG: 25.0%; P<0.05). The quality of renal function was however a more secondary criteria (C: 15.0%, G: 5.0%, MG: 0.0%; P<0.05). General practitioners considered most frequently the presence of underlying heart disease (C: 35.0%, G: 5.0%, MG: 45.0%; P<0.05) as well as usual cardiovascular risk factors (overweight, dyslipidaemia; P<0.05). Risk of bleeding, however, was observed by 76.7% of physicians in the clinical situation presented (C: 70.0%, G: 75.0%, MG: 85.0%; P<0.05). CONCLUSION: This survey confirms that the FA remains under anticoagulated in the elderly and the barriers to the prescription of oral anticoagulation are often without rational basis.

Grande fréquence des prescriptions médicamenteuses à visée cardiovasculaire potentiellement inappropriées dans la population âgée [Potentially inappropriate prescribing cardiovascular medications in the aged population: prospective study in a district hospital centre (France)].

OBJECTIVES: Cardiovascular disease is a leading cause of morbidity and mortality in the elderly population. We evaluated the adequacy of prescribing (miss and under used) with respect to STOPP-START criteria. METHODS: A sample of 100 patients hospitalized in cardiovascular specialty divisions (medicine or surgery) or in the different sectors making up the geriatric network (day-care hospital, short or rehabilitation ward, nursing home) has been considered. Drug prescriptions at the admission time were analysed. RESULTS: Eight hundred and seventy-four prescriptions were analysed. In 65% of patients, from 5 to 10 medications were prescribed and in 28% over 10. Fifty-four percent of patients had, at least, one potentially inappropriate prescription (PIP) by STOPP. Among them, 48% of PIP prescriptions contained 1, 41% 2 and 11% 3 or more. The omission of one medication according to START criteria concerned 57% of the sample. Among them, 46% had one omission, 44% 2 to 3 and 10% 4 omissions or over. The cardiovascular system is the one most concerned by the PIP. Whether 28.1% of the PIP by STOPP criteria concerned cardiovascular drugs, the omission of prescription, according to START criteria, was 41.8%. There was no significant difference between the different settings studied. There was no effect of age or sex on the impact of PIP (P>0.20) or being polymédiqué (P=0.44). According to the criteria STOPP-A, the prescription of antiplatelet (indication and dose) was highlighted. Prescribing omission also concerned antiplatelet agents but also statins in patients with atherosclerosis as well as antiplatelet and anticoagulant in patients with permanent atrial fibrillation and inhibitor of angiotensin converting enzyme (ACE) after myocardial infarction or with chronic heart failure. CONCLUSION: Potentially inappropriate prescribing medications were very common in elderly patients with cardiovascular conditions. They concerned as much as underusing of important drugs with potential benefits and prescribing commission of treatment that did not fit with patients' comorbidities and/or characteristics.

Treatment of cancer with oral drugs: a position statement by the Spanish Society of Medical Oncology

Cancer treatment involves the participation of multiple medical specialties and, as our knowledge of the disease increases, this fact becomes even more apparent. The degree of multidisciplinarity is determined by several factors, which include the severity and type of disease, the increasing diversity in the available pharmacological and non-pharmacological therapies, and the range of specialists involved in cancer therapy, such as medical oncologists, radiotherapists, gynecologists, gastroenterologists, urologists, surgeons, and pneumologists, among others. Across Europe, the situation of cancer care can be variable due to the diversity of health systems, differences in drug reimbursement, and the degree of establishment of Medical Oncology as a medical specialty in the European Union states.

Contribuições recentes da reação de hidroformilação na síntese de produtos farmacêuticos: parte II

The hydroformylation reaction represents one of the most important C1-chemistry area in the chemical industry. This catalytic process, which has been developed up to now mainly to the production of commodities chemicals, has shown a remarkable potential for the preparation of several categories of specialty chemicals and in particular pharmaceutical compounds. Arylpropanoic acids, various amines containing aryl groups, and intermediates for the preparation of vitamins, carbocyclic and heterocyclic compounds and many other classes of organic molecules endowed with pharmacological activity are currently accessible in good-to-high yields through hydroformylation of selected olefinic substrates. The asymmetric hydroformylation is going to reach the stage of maturity and hence to contribute in solving many troublesome synthetic problems connected with the preparation of pharmacologically active compounds with very high enantiomeric purity. The present survey emphasizes the usefulness of synthesis gas as a starting material in fine chemistry, which is expected to be important for industry.

1,3-propanodiol: produção, aplicações e potencial biotecnológico

1,3-propanediol is a high-value specialty chemical which has many industrial applications. Its main use is the production of the polymer polypropylene terephthalate, a thermoplastic used in the textile and automobile industries. The interest in 1,3-propanediol production from glycerol bio-conversion has increased after the employment of biodiesel by various countries, being produced by chemical synthesis from petroleum intermediates or biotechnologically by microbial fermentation. Glycerol is an abundant low-cost byproduct from biodiesel refineries, and it is the only substrate that can be naturally or enzymatically converted to 1,3-propanediol by microbial fermentation. In this review, information on 1,3-propanediol's importance, production and purification are presented, along with results from recent research on glycerol microbial conversion to 1,3-propanediol. The bio-production of this intermediate compound from glycerol is very attractive both economically and environmentally, since it allows the replacement of fossil fuels by renewable resources.

Aplicações de enzimas na síntese e na modificação de polímeros

Enzymes are biological catalysts that offer great potential for use in the synthesis and modification of polymers, being more specific and greener than chemical catalysts. In this work, enzymes from the classes of hydrolases (lipase, cutinase and protease) and of oxidoreductases (horseradish peroxidase, manganese peroxidase and laccase) were identified as the main biocatalysts responsible for the synthesis of polymers. Biocatalysis can potentially be part of the life cycle of several polymers, including polyesters, polyurethanes, polycarbonates, polyamides, functionalized polysaccharides and polystyrene, allowing the synthesis of specialty macromolecules for fine applications and with higher added-value than commodity polymers.

Cuticular and Suberin Polymers of Edible Plants. Analysis by Gas Chromatographic-Mass Spectrometric and Solid State Spectroscopic Methods

Cutin and suberin are structural and protective polymers of plant surfaces. The epidermal cells of the aerial parts of plants are covered with an extracellular cuticular layer, which consists of polyester cutin, highly resistant cutan, cuticular waxes and polysaccharides which link the layer to the epidermal cells. A similar protective layer is formed by a polyaromatic-polyaliphatic biopolymer suberin, which is present particularly in the cell walls of the phellem layer of periderm of the underground parts of plants (e.g. roots and tubers) and the bark of trees. In addition, suberization is also a major factor in wound healing and wound periderm formation regardless of the plants’ tissue. Knowledge of the composition and functions of cuticular and suberin polymers is important for understanding the physiological properties for the plants and for nutritional quality when these plants are consumed as foods. The aims of the practical work were to assess the chemical composition of cuticular polymers of several northern berries and seeds and suberin of two varieties of potatoes. Cutin and suberin were studied as isolated polymers and further after depolymerization as soluble monomers and solid residues. Chemical and enzymatic depolymerization techniques were compared and a new chemical depolymerization method was developed. Gas chromatographic analysis with mass spectrometric detection (GC-MS) was used to assess the monomer compositions. Polymer investigations were conducted with solid state carbon-13 cross polarization magic angle spinning nuclear magnetic resonance spectroscopy (13C CP-MAS NMR), Fourier transform infrared spectroscopy (FTIR) and microscopic analysis. Furthermore, the development of suberin over one year of post-harvest storage was investigated and the cuticular layers from berries grown in the North and South of Finland were compared. The results show that the amounts of isolated cuticular layers and cutin monomers, as well as monomeric compositions vary greatly between the berries. The monomer composition of seeds was found to differ from the corresponding berry peel monomers. The berry cutin monomers were composed mostly of long-chain aliphatic ω-hydroxy acids, with various mid-chain functionalities (double-bonds, epoxy, hydroxy and keto groups). Substituted α,ω-diacids predominated over ω-hydroxy acids in potato suberin monomers and slight differences were found between the varieties. The newly-developed closed tube chemical method was found to be suitable for cutin and suberin analysis and preferred over the solvent-consuming and laborious reflux method. Enzymatic hydrolysis with cutinase was less effective than chemical methanolysis and showed specificity towards α,ω-diacid bonds. According to ₁₃C CP-MAS NMR and FTIR, the depolymerization residues contained significant amounts of aromatic structures, polysaccharides and possible cutan-type aliphatic moieties. Cultivation location seems to have effect on cuticular composition. The materials studied contained significant amounts of different types of biopolymers that could be utilized for several purposes with or without further processing. The importance of the so-called waste material from industrial processes of berries and potatoes as a source of either dietary fiber or specialty chemicals should be further investigated in detail. The evident impact of cuticular and suberin polymers, among other fiber components, on human health should be investigated in clinical trials. These by-product materials may be used as value-added fiber fractions in the food industry and as raw materials for specialty chemicals such as lubricants and emulsifiers, or as building blocks for novel polymers.

Tuottavuuden mittaaminen ja johtaminen Etelä-Karjalan keskussairaalassa

Tutkimuksen tavoitteena oli arvioida, miten tuottavuustietoa voidaan hyödyntää johtamisen tukena ja kuinka tuottavuustietoa tällä hetkellä hyödynnetään Etelä-Karjalan keskussairaalassa (EKKS). Tuottavuuden mittaamisessa hyödynnetään Terveyden- ja hyvinvoinnin laitoksen (THL) vuosittain julkaisemassa Hoito-toiminnan tuottavuus -tilastossa käytettävää tuottavuuden mittaamismenetelmää, jossa panoksina ovat sairaalan tai erikoisalan hoitotoiminnasta aiheutuneet kustannukset ja tuotoksina NordDRG-ryhmittelijän avulla painotetut hoitojaksot ja käynnit. Tutkimuksessa arvioitiin tuottavuuden mittaamiseen liittyvien mahdollisten virhetekijöiden vaikutusta sairaalan tuottavuuteen EKKS:n tapauksessa ja tämän perusteella tunnistettiin, miten THL:n julkaisemaa tuottavuustilastoa ja sisäistä tuottavuustietoa voidaan hyödyntää sairaalan johtamisen tukena. Pääasiallisena aineistona työssä käytettiin EKKS:n henkilöstön haastatteluja ja sairaalan taloudellisia raportteja sekä THL:n julkista ja julkaisematonta aineistoa. THL:n kehittämän hoitotoiminnan tuottavuuden mittaamismenetelmän havaittiin soveltuvan yksittäisen sairaalan käyttöön tietyin muutoksin. Vaadittavien muutosten lisäksi tutkimuksessa tunnistettiin taustatekijät, jotka THL:n tuottavuustilaston ja sisäisen tuottavuustiedon tulkitsijan tulee ottaa huomioon. EKKS:n tuottavuustietojen keruussa havaittiin kehittämiskohteita, joita paran-tamalla tuottavuustiedon luotettavuutta ja hyödynnettävyyttä voidaan edelleen kehittää. Tuottavuustiedon hyödyntämistä voidaan niin ikään edelleen kehittää EKKS:ssa.

A cell spot microarray method for high-throughput biology

High-throughput screening of cellular effects of RNA interference (RNAi) libraries is now being increasingly applied to explore the role of genes in specific cell biological processes and disease states. However, the technology is still limited to specialty laboratories, due to the requirements for robotic infrastructure, access to expensive reagent libraries, expertise in high-throughput screening assay development, standardization, data analysis and applications. In the future, alternative screening platforms will be required to expand functional large-scale experiments to include more RNAi constructs, allow combinatorial loss-of-function analyses (e.g. genegene or gene-drug interaction), gain-of-function screens, multi-parametric phenotypic readouts or comparative analysis of many different cell types. Such comprehensive perturbation of gene networks in cells will require a major increase in the flexibility of the screening platforms, throughput and reduction of costs. As an alternative for the conventional multi-well based high-throughput screening -platforms, here the development of a novel cell spot microarray method for production of high density siRNA reverse transfection arrays is described. The cell spot microarray platform is distinguished from the majority of other transfection cell microarray techniques by the spatially confined array layout that allow highly parallel screening of large-scale RNAi reagent libraries with assays otherwise difficult or not applicable to high-throughput screening. This study depicts the development of the cell spot microarray method along with biological application examples of high-content immunofluorescence and phenotype based cancer cell biological analyses focusing on the regulation of prostate cancer cell growth, maintenance of genomic integrity in breast cancer cells, and functional analysis of integrin protein-protein interactions in situ.

Abordagem fisioterapêutica na dor pós-operatória: a eletroestimulação nervosa transcutânea (ENT)

This study provides an update on the use of Transcutaneous Eletric Nerve Stimulation (TENS) as a non-pharmacological resource of postoperative pain relief. National and international references regarding the use of TENS for the relief of postoperative pain had been selected, highlighting its mechanism of action, parameters of application, contraindications, side-effect and results. TENS is a non-pharmacological resource that has its mechanism of action based on the gate theory. It consists of a device that emits electric impulses in the skin through electrodes. It is a low cost technique, easily applicable, presents few collateral effects, good effectiveness related to the reduction of the painful perception, allowing early mobilization and reduced pharmacological analgesic consumption. TENS represents another option in the control of postoperative pain and should be inserted in a multiprofessional context.

The impact of a chest tube management protocol on the outcome of trauma patients with tube thoracostomy

ABSTRACTObjective:to investigate the effect of standardized interventions in the management of tube thoracostomy patients and to assess the independent effect of each intervention.Methods:A chest tube management protocol was assessed in a retrospective cohort study. The tube thoracostomy protocol (TTP) was implemented in August 2012, and consisted of: antimicrobial prophylaxis, chest tube insertion in the operating room (OR), admission post chest tube thoracostomy (CTT) in a hospital floor separate from the emergency department (ED), and daily respiratory therapy (RT) sessions post-CTT. The inclusion criteria were, hemodynamic stability, patients between the ages of 15 and 59 years, and injury severity score (ISS) < 17. All patients had isolated injuries to the chest wall, lung, and pleura. During the study period 92 patients were managed according to the standardized protocol. The outcomes of those patients were compared to 99 patients treated before the TTP. Multivariate logistic regression analysis was performed to assess the independent effect of each variable of the protocol on selected outcomes.Results:Demographics, injury severity, and trauma mechanisms were similar among the groups. As expected, protocol compliance increased after the implementation of the TTP. There was a significant reduction (p<0.05) in the incidence of retained hemothoraces, empyemas, pneumonias, surgical site infections, post-procedural complications, hospital length of stay, and number of chest tube days. Respiratory therapy was independently linked to significant reduction (p<0.05) in the incidence of seven out of eight undesired outcomes after CTT. Antimicrobial prophylaxis was linked to a significant decrease (p<0.05) in retained hemothoraces, despite no significant (p<0.10) reductions in empyema and surgical site infections. Conversely, OR chest tube insertion was associated with significant (p<0.05) reduction of both complications, and also significantly decreased the incidence of pneumonias.Conclusion:Implementation of a TTP effectively reduced complications after CTT in trauma patients.

Use of raw Euphorbia tirucalli extract for inhibition of ascitic Ehrlich tumor

Objective: to evaluate the effect of the Euphorbia tirucalli hydroalcoholic extract (ETHE) on the development of Ehrlich Tumor, in its ascitic form. Methods: we intraperitoneally inoculated 15 Swiss mice with 10.44 x 107 cells of Ehrlich Tumor and divided them in two groups one day after: ETHE Group (eight mice), treated with a dosage of 125 mg/kg/day of EHTE for five days; and Control Group (seven mice), treated only with 0.9% isotonic saline solution over the same period. The treatment was done by gavage. Ten days after inoculation, four mice from each group were sacrificed for quantification of tumor cell number, ascitic fluid volume and bone marrow cell number. The remaining animals were maintained to evaluate survival. Results: The ascitic fluid volume and the tumor cell number were decreased in the ETHE group when compared with the control group, but with no statistical significance. On the other hand, survival was higher in the ETHE group, as well as the number of bone marrow cells. Conclusion: Treatment with ETHE after inoculation of Ehrlich Tumor decreases its development and increases survival and the bone marrow cellularity, thus reducing the myelosuppression present in the Ehrlich Tumor bearing mice.

The analysis of knowledge retention mechanisms for leaving experts

The goal of this thesis is studying knowledge retention mechanisms used in cases of single experts’ leaving in the case company, analyzing the reason for the mechanisms choice and successfulness of knowledge retention process depending of that choice. The theoretical part discusses the origins of knowledge retention processes in the theoretical studies, the existing knowledge retention mechanisms and practical issues of their implementation. The empirical part of the study is designed as employees’ interview with later discussion of the findings. The empirical findings indicate the following reasons for knowledge retention mechanisms choice: type of knowledge retained, specialty of leaving experts and time and distance issues of a particular case. The following factors influenced the success of a retention process: choice of knowledge retention mechanisms, usage of combination of mechanisms and creation of knowledge retention plans. The results might be useful for those interested in factors influencing knowledge retention processes in cases of experts’ departure.

VVER-440 Thermal Hydraulics as a Computer Code Validation Challenge

This thesis concentrates on the validation of a generic thermal hydraulic computer code TRACE under the challenges of the VVER-440 reactor type. The code capability to model the VVER-440 geometry and thermal hydraulic phenomena specific to this reactor design has been examined and demonstrated acceptable. The main challenge in VVER-440 thermal hydraulics appeared in the modelling of the horizontal steam generator. The major challenge here is not in the code physics or numerics but in the formulation of a representative nodalization structure. Another VVER-440 specialty, the hot leg loop seals, challenges the system codes functionally in general, but proved readily representable. Computer code models have to be validated against experiments to achieve confidence in code models. When new computer code is to be used for nuclear power plant safety analysis, it must first be validated against a large variety of different experiments. The validation process has to cover both the code itself and the code input. Uncertainties of different nature are identified in the different phases of the validation procedure and can even be quantified. This thesis presents a novel approach to the input model validation and uncertainty evaluation in the different stages of the computer code validation procedure. This thesis also demonstrates that in the safety analysis, there are inevitably significant uncertainties that are not statistically quantifiable; they need to be and can be addressed by other, less simplistic means, ultimately relying on the competence of the analysts and the capability of the community to support the experimental verification of analytical assumptions. This method completes essentially the commonly used uncertainty assessment methods, which are usually conducted using only statistical methods.