Lorsqu'un dossier est à l'AI, il est souvent déjà trop tard! Réponse et complément à la discussion lancée par R. Conne sur la capacité de travail et l'assurance invalidité

L'article «Capacité de travail et assurance invalidité » [1] décrit le malaise actuel concernant la réhabilitation à la place de travail. Cette problématique n'est toutefois pas uniquement valable pour des incapacités de travail liées à des raisons psychiques, mais aussi pour des incapacités de travail dues à des troubles musculo-squelettiques. De plus, les difficultés de réhabilitation à la place de travail ne doivent pas être imputées uniquement à l'assurance invalidité. En effet, elles sont dues d'une part à des données structurelles de la Suisse (comme une faible implantation de la médecine du travail dans les entreprises et un accès peu développé à la médecine de réhabilitation) et d'autre part, à un manque de définition claire de répartition des coûts ou des responsabilités. Dans son article R. Conne décrit de façon pertinente le malaise existant en Suisse en ce qui concerne la question de la réhabilitation à la place de travail ou de la récupération de sa capacité de travail. Toutefois, cet article se base principalement sur des incapacités de travail dues à des causes psychiques. En temps que médecin du travail et médecin en réhabilitation, nous souhaitons nous emparer de la discussion et l'élargir. Cet élargissement comprend d'une part la prise en compte d'incapacités de travail pour des causes non psychiques et d'autre part, la situation générale des assurances en Suisse. En effet, plutôt que de se focaliser uniquement sur le problème de l'assurance invalidité, il nous semble utile d'étendre le débat à la situation générale des assurances. [Auteurs]

Superior venous drainage in the "LifeBox": a portable extracorporeal oxygenator with a self-expanding venous cannula.

BACKGROUND: In an experimental setting, the performance of the LifeBox, a new portable extracorporeal membrane oxygenator (ECMO) system suitable for patient transport, is presented. Standard rectilinear percutaneous cannulae are normally employed for this purpose, but have limited flow and pressure delivery due to their rigid structure. Therefore, we aimed to determine the potential for flow increase by using self-expanding venous cannulae. METHODS: Veno-arterial bypass was established in three pigs (40.6+/-5.1 kg). The venous line of the cardiopulmonary bypass was established by cannulation of the external jugular vein. The arterial side of the circulation was secured by cannulation of the common carotid artery. Two different venous cannulae (SmartCanula 18/36F 430mm and Biomedicus 19F) were examined for their functional integrity when used in conjunction with the centrifugal pump (500-3000 RPM) of the LifeBox system. RESULTS: At 1500, 2000, 2500, and 3000 RPM, the blood flow increased steadily for each cannula, but remained higher in the self-expanding cannula. That is, the 19F rectilinear cannula achieved a blood flow of 0.93+/-0.14, 1.47+/-0.37, 1.9+/-0.68, and 1.5+/-0.9 l/min, respectively, and the 18/36F self-expanding cannula achieved 1.1+/-0.1, 1.9+/-0.33, 2.8+/-0.39 and 3.66+/-0.52 l/min. However, when tested for venous line pressure, the standard venous cannula achieved -29+/-10.7mmHg while the self-expanding cannula achieved -13.6 +/-4.3mmHg at 1500 RMP. As the RPM increased from 2500 to 3000, the venous line pressure accounted for -141.9+/-20 and -98+/-7.3mmHg for the 19F rectilinear cannula and -30.6+/-6.4 and -45+/-11.6mmHg for the self-expanding cannula. CONCLUSION: The self-expanding cannula exhibited superior venous drainage ability when compared to the performance of the standard rectilinear cannula with the use of the LifeBox. The flow rate achieved was approximately 40% greater than the standard drainage device, with a maximal pump flow recorded at 4.3l/min.

Association of ECG abnormalities and incident heart failure events

Background: With the aging of the population, the heart failure (HF) incidence and prevalence trends are expected to significantly worsen unless concentrated prevention efforts are undertaken. ECG abnormalities are common in the elderly but data are limited for their association with HF risk. Objective: To assess whether baseline ECG abnormalities or dynamic changes are associated with an increased risk of HF. Method: A prospective cohort study of 2915 participants aged 70 to 79 years without a preexisting HF followed for a median period of 11.4 (IQR 7.0-11.7) years from the Health Aging and Body Composition study. The Minnesota Code was used to define major and minor ECG abnormalities at baseline and at 4-year. Main outcome measure was adjudicated incident HF events. Using Cox models, the (1) the association between ECG abnormalities and incident HF and (2) incremental value of adding ECG to the Health ABC HF Risk Score, was assessed. Results: At baseline, 380 participants (13.0%) had minor and 620 (21.3%) had major ECG abnormalities. During follow-up, 485 (16.6%) participants developed incident HF. After adjusting for the eight clinical variables in the Health ABC HF Risk Score, the hazard ratio (HR) was 1.27 (95% confidence interval [CI] 0.96-1.68) for minor and 1.99 (CI 1.61-2.44) for major ECG abnormalities (P for trend <0.001) compared to no ECG abnormalities. The association did not change according to presence of baseline CHD. At 4-year, 263 participants developed new and 549 had persistent abnormalities and both were associated with increased HF risk (HR = 1.94, CI 1.38-2.72 for new and HR=2.35, CI 1.82-3.02 for persistent compared to no ECG abnormalities). Baseline ECG correctly reclassified 10.6% of overall participants across the categories of the Health ABC HF Risk Score. Conclusion: Among older adults, baseline ECG abnormalities and changes in them over time are common; both are associated with an increased risk of HF. Whether ECG should be incorporated in routine screening of older adults should be evaluated in randomized controlled trials.

Viral genotype-specific role of PNPLA3, PPARG, MTTP, and IL28B in hepatitis C virus-associated steatosis.

BACKGROUND & AIMS: Steatosis is a prominent feature of hepatitis C, especially in patients infected with genotype 3. The analysis of genetic polymorphisms influencing steatosis in chronic hepatitis C has been limited by the studies' small sample size, and important single nucleotide polymorphisms (SNPs), such as those in the patatin-like phospholipase family 3 protein (PNPLA3), were never evaluated. METHODS: We analyzed the role of SNPs, from 19 systematically selected candidate genes, on steatosis in 626 Caucasian hepatitis C virus (HCV) infected patients. SNPs were extracted from a genome-wide association-generated dataset. Associations of alleles with the presence and/or different severity of steatosis were evaluated by univariate and multivariate logistic regression, accounting for all relevant covariates. RESULTS: The risk of steatosis was increased by carriage of I148M in PNPLA3, but only in patients with HCV genotypes non-3 (odds ratio [OR]=1.9, 95% confidence interval [CI]=1.6-2.3, p<0.001) and similar, albeit weaker associations were found for SNPs in peroxisome proliferator-activated receptor-γ (PPARG) and interleukin-28B (IL28B). Carriage of a SNP in the microsomal triglyceride transfer protein (MTTP) increased the risk of steatosis, but only in patients with HCV genotype 3 (rs1800803, OR=3.4, 95% CI=2.4-4.9, p=0.001). CONCLUSIONS: The rs738409 SNP in PNPLA3 is associated with an increased risk of steatosis in patients infected with HCV genotypes non-3. Host genes affect steatosis depending on the infecting HCV genotype, suggesting their interaction with viral factors.

Funções e ordem da razão dos nutrientes no estabelecimento de normas DRIS em laranjeira 'Valência'

O sistema integrado de diagnose e recomendação DRIS (Diagnosis and Recommendation Integrated System) tem sido uma boa alternativa para a avaliação do estado nutricional de diversas culturas. O objetivo deste trabalho foi calcular índices DRIS mediante o uso de três métodos (Beaufils, Elwali & Gascho e Jones) de cálculo das funções das razões dos nutrientes e de dois critérios (Letzch e Nick) para a escolha da ordem da razão dos nutrientes, em pomares comerciais irrigados de laranjeira 'Valência'. Informações sobre a produtividade, porta-enxerto e teor de N, P, K, Ca, Mg, S, Fe, Mn, Cu, Zn e B em folhas de ramos não-frutíferos de cada talhão foram processadas nos anos de 1994 a 1998. O índice de balanço nutricional (IBN) foi calculado pela média da soma dos valores em módulo dos índices nutricionais e do índice de matéria seca. Os índices DRIS e IBN foram calculados e os valores de r² (produtividade em função de IBN) foram obtidos para cada método. O método Jones para cálculo do DRIS apresentou melhor correlação com a produtividade, e o critério Nick mostrou-se mais eficiente na escolha da ordem da razão dos nutrientes. Populações específicas, com pequeno número de observações, padronizadas quanto ao porta-enxerto e referentes a um ou dois anos de amostragem foliar e produção foram bancos de dados eficientes para a obtenção das normas DRIS.

Structural development accounting

We construct and estimate a unified model combining three of the main sources ofcross-country income disparities: differences in factor endowments, barriers to technologyadoption and the inappropriateness of frontier technologies to local conditions. The keycomponents are different types of workers, distortions to capital accumulation, directedtechnical change, costly adoption and spillovers from the world technology frontier. Despiteits parsimonious parametrization, our empirical model provides a good fit of GDP data forup to 86 countries in 1970 and 122 countries in 2000. Removing barriers to technologyadoption would increase the output per worker of the average non-OECD country relativeto the US from 0.19 to 0.61, while increasing skill premia in all countries. Removing barriersto trade in goods amplifies income disparities, induces skill-biased technology adoptionand increases skill premia in the majority of countries. These results are reverted if tradeliberalization is coupled with international IPR protection.

Tableaux de bord et de suivi : conception détaillée

Le présent cahier définit les modalités pratiques du suivi des performances. I1 est avant tout destiné aux responsables d'unités cliniques des Hospices qui rencontreraient des problèmes d'interprétation. Le dispositif s'appuie aujourd'hui sur les éléments suivants : - un tableau de bord ; - un tableau synoptique ; - des tableaux de suivi des patients ; - des tableaux de suivi des activités ; - des tableaux de suivi des ressources ; - des tableaux de suivi des effets. [P. 3]

Identification of myxobacteria-derived HIV inhibitors by a high-throughput two-step infectivity assay

Drug-resistance and therapy failure due to drug-drug interactions are the main challenges in current treatment against Human Immunodeficiency Virus (HIV) infection. As such, there is a continuous need for the development of new and more potent anti-HIV drugs. Here we established a high-throughput screen based on the highly permissive TZM-bl cell line to identify novel HIV inhibitors. The assay allows discriminating compounds acting on early and/or late steps of the HIV replication cycle. The platform was used to screen a unique library of secondary metabolites derived from myxobacteria. Several hits with good anti-HIV profiles were identified. Five of the initial hits were tested for their antiviral potency. Four myxobacterial compounds, sulfangolid C, soraphen F, epothilon D and spirangien B, showed EC50 values in the nM range with SI > 15. Interestingly, we found a high amount of overlapping hits compared with a previous screen for Hepatitis C Virus (HCV) using the same library. The unique structures and mode-of-actions of these natural compounds make myxobacteria an attractive source of chemicals for the development of broad-spectrum antivirals. Further biological and structural studies of our initial hits might help recognize smaller drug-like derivatives that in turn could be synthesized and further optimized.

Changes in the use of broad-spectrum antibiotics after cefepime shortage: a time series analysis.

The original cefepime product was withdrawn from the Swiss market in January 2007, and replaced by a generic 10 months later. The goals of the study were to assess the impact of this cefepime shortage on the use and costs of alternative broad-spectrum antibiotics, on antibiotic policy, and on resistance of Pseudomonas aeruginosa towards carbapenems, ceftazidime and piperacillin-tazobactam. A generalized regression-based interrupted time series model assessed how much the shortage changed the monthly use and costs of cefepime and of selected alternative broad-spectrum antibiotics (ceftazidime, imipenem-cilastatin, meropenem, piperacillin-tazobactam) in 15 Swiss acute care hospitals from January 2005 to December 2008. Resistance of P. aeruginosa was compared before and after the cefepime shortage. There was a statistically significant increase in the consumption of piperacillin-tazobactam in hospitals with definitive interruption of cefepime supply, and of meropenem in hospitals with transient interruption of cefepime supply. Consumption of each alternative antibiotic tended to increase during the cefepime shortage and to decrease when the cefepime generic was released. These shifts were associated with significantly higher overall costs. There was no significant change in hospitals with uninterrupted cefepime supply. The alternative antibiotics for which an increase in consumption showed the strongest association with a progression of resistance were the carbapenems. The use of alternative antibiotics after cefepime withdrawal was associated with a significant increase in piperacillin-tazobactam and meropenem use and in overall costs, and with a decrease in susceptibility of P. aeruginosa in hospitals. This warrants caution with regard to shortages and withdrawals of antibiotics.