Teaching cardiac auscultation to trainees in internal medicine and family practice: does it work?

BACKGROUND: The general proficiency in physical diagnostic skills seems to be declining in relation to the development of new technologies. The few studies that have examined this question have invariably used recordings of cardiac events obtained from patients. However, this type of evaluation may not correlate particularly well with bedside skills. Our objectives were 1) To compare the cardiac auscultatory skills of physicians in training with those of experienced cardiologists by using real patients to test bedside diagnostic skills. 2) To evaluate the impact of a five-month bedside cardiac auscultation training program. METHODS: 1) In an academic primary care center, 20 physicians (trainees in internal medicine and family practice) and two skilled academic cardiologists listened to 33 cardiac events in 13 patients directly at bedside and identified the cardiac events by completing an open questionnaire. Heart sounds, murmurs and diagnosis were determined beforehand by an independent skilled cardiologist and were validated by echocardiography. Thirteen primary cardiologic diagnoses were possible.2) Ten of the physicians agreed to participate in a course of 45-minute sessions once a week for 5 months. After the course they listened again to the same patients (pre/post-interventional study). RESULTS: 1) The experts were the most skillful, achieving 69% recognition of heart sounds and murmurs and correct diagnoses in 62% of cases. They also heard all of the diastolic murmurs. The residents heard only 40% of the extra heart sounds and made a correct diagnosis in 24% of cases. 2) After the weekly training sessions, their mean percentage for correct diagnosis was 35% [an increase of 66% (p < 0.05)]. CONCLUSIONS: The level of bedside diagnostic skills in this relatively small group of physicians in training is indeed low, but can be improved by a course focusing on realistic bedside teaching.

Traitement des fractures de l'enfant par enclouage centro-médullaire élastique stable (ECMES) [Treatment of pediatric fractures by intramedullary stable elastic pinning]

During the past decade several new techniques for the treatment of children's fractures respecting the specificity of the growing bone have been described. The goal of all these techniques was to mechanically stabilise the fracture however to preserve a certain instability of the fracture gap itself inducing early callus formation and subsequent consolidation. The dynamic external fixation as well as the elastic stable intramedullary pinning have become accepted means in the treatment of long bone fractures in the paediatric age group. We report our experience of the last seven years with the intramedullary pinning of 105 fractures. Eighty-four were fractures of the femur, 9 of the humerus, 8 of the forearm, and a further 4 of the tibial shaft. The intramedullary elastic pinning represents a simple technique which supports or even enhances the natural process of fracture healing of the growing bone. The method is not very invasive, is cost effective, and allows short hospitalisation. Early physical activity is guaranteed due to early consolidation of the fracture. Complications are rare and the final orthopedic and cosmetic outcome is excellent.

Fracture network characterization using hydrological and geophysical data

Les décisions de gestion des eaux souterraines doivent souvent être justiffées par des modèles quantitatifs d'aquifères qui tiennent compte de l'hétérogénéité des propriétés hydrauliques. Les aquifères fracturés sont parmi les plus hétérogènes et très difficiles à étudier. Dans ceux-ci, les fractures connectées, d'ouverture millimètrique, peuvent agir comme conducteurs hydrauliques et donc créer des écoulements très localisés. Le manque général d'informations sur la distribution spatiale des fractures limite la possibilité de construire des modèles quantitatifs de flux et de transport. Les données qui conditionnent les modèles sont généralement spatialement limitées, bruitées et elles ne représentent que des mesures indirectes de propriétés physiques. Ces limitations aux données peuvent être en partie surmontées en combinant différents types de données, telles que les données hydrologiques et de radar à pénétration de sol plus commun ément appelé géoradar. L'utilisation du géoradar en forage est un outil prometteur pour identiffer les fractures individuelles jusqu'à quelques dizaines de mètres dans la formation. Dans cette thèse, je développe des approches pour combiner le géoradar avec les données hydrologiques affn d'améliorer la caractérisation des aquifères fracturés. Des investigations hydrologiques intensives ont déjà été réalisées à partir de trois forage adjacents dans un aquifère cristallin en Bretagne (France). Néanmoins, la dimension des fractures et la géométrie 3-D des fractures conductives restaient mal connue. Affn d'améliorer la caractérisation du réseau de fractures je propose dans un premier temps un traitement géoradar avancé qui permet l'imagerie des fractures individuellement. Les résultats montrent que les fractures perméables précédemment identiffées dans les forages peuvent être caractérisées géométriquement loin du forage et que les fractures qui ne croisent pas les forages peuvent aussi être identiffées. Les résultats d'une deuxième étude montrent que les données géoradar peuvent suivre le transport d'un traceur salin. Ainsi, les fractures qui font partie du réseau conductif et connecté qui dominent l'écoulement et le transport local sont identiffées. C'est la première fois que le transport d'un traceur salin a pu être imagé sur une dizaines de mètres dans des fractures individuelles. Une troisième étude conffrme ces résultats par des expériences répétées et des essais de traçage supplémentaires dans différentes parties du réseau local. En outre, la combinaison des données de surveillance hydrologique et géoradar fournit la preuve que les variations temporelles d'amplitude des signaux géoradar peuvent nous informer sur les changements relatifs de concentrations de traceurs dans la formation. Par conséquent, les données géoradar et hydrologiques sont complémentaires. Je propose ensuite une approche d'inversion stochastique pour générer des modèles 3-D de fractures discrètes qui sont conditionnés à toutes les données disponibles en respectant leurs incertitudes. La génération stochastique des modèles conditionnés par géoradar est capable de reproduire les connexions hydrauliques observées et leur contribution aux écoulements. L'ensemble des modèles conditionnés fournit des estimations quantitatives des dimensions et de l'organisation spatiale des fractures hydrauliquement importantes. Cette thèse montre clairement que l'imagerie géoradar est un outil utile pour caractériser les fractures. La combinaison de mesures géoradar avec des données hydrologiques permet de conditionner avec succès le réseau de fractures et de fournir des modèles quantitatifs. Les approches présentées peuvent être appliquées dans d'autres types de formations rocheuses fracturées où la roche est électriquement résistive.

Revue du traitement chirurgical de la pseudarthrose de la diaphyse fémorale

Ce travail consiste en l'analyse et la revue des différentes prises en charge de la pseudarthrose de la diaphyse fémorale dans un groupe nommé « Echantillon CHUV » formé par 16 patients. Les patients ont tous été opérés au Centre Hospitalier Universitaire Vaudois, CHUV, entre 2008 et 2011 pour cure de pseudarthrose. Une présentation succincte des fractures de la diaphyse fémorale ainsi que de la pseudarthrose de la diaphyse fémorale consiste en la première partie du rapport. La deuxième partie est une revue des cas des patients de l'échantillon CHUV. Des paramètres tels que le mode initial de fracture, la durée effective de la pseudarthrose, le nombre de révisions avant la consolidation ou la répartition des pseudarthroses selon leur type font partie des différents éléments caractéristiques répertoriés puis analysés dans cette revue. 25 cures de pseudarthroses sont effectuées sur les 16 patients. Les techniques de fixations les plus utilisées sont la fixation par plaque après réduction ouverte (ORIF, 64%, 16 cures sur 25) et l'enclouage centromédullaire (24%, 6 cures sur 25). L'utilisation de substituts osseux est très souvent complémentaire à la refixation mécanique lors des cures de pseudarthrose (recours à la greffe osseuse dans 72% des cures). Le taux d'union après la première cure de pseudarthrose s'établit à 63% et il monte à 100% après l'ensemble des cures. Le retour à une fonction adéquate du membre inférieur est obtenu chez 14 des 16 patients (1 patient est traité par arthrodèse du genou sur pseudarthrose du tiers distal de la diaphyse fémorale et 1 patient tétraplégique est traité par résection de la tête et du col fémoral sur pseudarthrose du tiers proximal de la diaphyse fémorale). La revue quantifie la durée de l'invalidité causée par la pseudarthrose de la diaphyse fémorale : la longueur totale du traitement avant union est d'au minimum 12 mois pour 75% des patients. 8 patients sur 16 ont un temps avant union supérieur à 20 mois. La pseudarthrose de la diaphyse fémorale doit être considérée comme une complication grave. La localisation au niveau du fémur réduit voire abolit l'autonomie de marche du patient et limite ses activités de la vie quotidienne. Elle entrave le retour au travail et réduit terriblement la qualité de vie pendant souvent plus d'une année. L'ensemble des symptômes ont un effet dévastateur sur la rééducation et peuvent parfois laisser d'importantes séquelles physiques ou psychologiques sur le long terme. Pour ces raisons, le traitement doit être adapté du mieux possible à la pseudarthrose du patient afin d'augmenter les chances de réussite de la cure.

Validation of methane measurement using headspace-GC-MS and quantification by a stable isotope-labeled internal standard generated in situ.

A previous study has shown the possibility to identify methane (CH4 ) using headspace-GC-MS and quantify it with a stable isotope as internal standard. The main drawback of the GC-MS methods discussed in literature for CH4 measurement is the absence of a specific internal standard necessary to perform quantification. However, it becomes essential to develop a safer method to limit the manipulation of gaseous CH4 and to precisely control the injected amount of gas for spiking and calibration by comparison with external calibration. To avoid the manipulation of a stable isotope-labeled gas, we have chosen to generate a labeled gas as an internal standard in a vial on the basis of the formation of CH4 by the reaction of Grignard reagent methylmagnesium chloride with deuterated water. This method allows precise measurement of CH4 concentrations in gaseous sample as well as in a solid or a liquid sample after a thermodesorption step in a headspace vial. A full accuracy profile validation of this method is then presented.

The effect of treatment with calcitonin on vertebral fracture rate in osteoporosis.

The efficacy of treatments for osteoporosis does not become evident when evaluated by fracture incidence (FI). Vertebral FI decreased in all controlled studies on calcitonin, but not significantly. Small sample sizes and short periods of treatment may have masked a possible therapeutic benefit, but longer, controlled studies with sodium fluoride or etidronate in larger groups of patients also failed to show a decrease in FI. The present analysis of nine published, therapeutic studies which indicate the FI per year and the initial prevalence of vertebral fractures, examines the question of whether the initial prevalence of fractures has an effect on the subsequent incidence of new fractures and whether the therapeutic effects have to be evaluated as a function of the initial prevalence of fractures. Bearing in mind the differences in roentgenological evaluation and in the size and quality of the various studies, the analysis revealed (1) that in the control groups there was a higher FI in patients with more than three vertebral fractures at baseline (estimated odds ratio (OR) = 49, p = 0.011); (2) that a similar trend, although not statistically significant, was observed in treated patients; (3) that the groups of control patients treated for more than 1 year showed in general an increase in FI beyond the first year and that the reverse was true in treated patients. In conclusion, failure to allow for the initial prevalence of vertebral fractures at the individual level in therapeutic trials of calcitonin to treat osteoporosis and prevent new fractures might have contributed to the absence of a demonstrable benefit of the treatment in those studies.

Evolution in heterogeneous populations: from migration models to fixation probabilities.

Although dispersal is recognized as a key issue in several fields of population biology (such as behavioral ecology, population genetics, metapopulation dynamics or evolutionary modeling), these disciplines focus on different aspects of the concept and often make different implicit assumptions regarding migration models. Using simulations, we investigate how such assumptions translate into effective gene flow and fixation probability of selected alleles. Assumptions regarding migration type (e.g. source-sink, resident pre-emption, or balanced dispersal) and patterns (e.g. stepping-stone versus island dispersal) have large impacts when demes differ in sizes or selective pressures. The effects of fragmentation, as well as the spatial localization of newly arising mutations, also strongly depend on migration type and patterns. Migration rate also matters: depending on the migration type, fixation probabilities at an intermediate migration rate may lie outside the range defined by the low- and high-migration limits when demes differ in sizes. Given the extreme sensitivity of fixation probability to characteristics of dispersal, we underline the importance of making explicit (and documenting empirically) the crucial ecological/ behavioral assumptions underlying migration models.

(Young Investigator Award) Trabecular Bone Score Helps Classifying Women At Risk Of Fracture Prospectively In The Ofely Study

Introduction: To determine the metabolic effect of teriparatide (TPTD) on bone, 99mTc-MDP skeletal plasma clearance was measured in postmenopausal women with osteoporosis treated with TPTD 20 μg/day. Methods: Ten postmenopausal women with osteoporosis had radionuclide bone scans at baseline, 3, and 18 months after starting TPTD 20 μg/day and after 6 months off therapy. Participants were injected with 600 MBq 99mTc- MDP and whole body bone scans acquired at 10 min, 1, 2, 3, and 4 h. Multiple blood samples were taken between 5 min and 4 h and free 99mTc-MDP measured using ultrafiltration. 99mTc-MDP plasma clearance (Kbone) was evaluated using the Patlak plot method. Regional differences in Kbone were studied by measuring the whole skeleton and subregions. Serum procollagen type I Nterminal propeptide (PINP), bone-specific alkaline phosphatase (BSAP), and urinary N-terminal telopeptide (NTX) were measured at each visit.Discussion: The median increase from baseline in whole skeleton Kbone was 22% (P=0.004) at 3 months and 34% (P= 0.002) at 18 months, decreasing to 0.7% after 6 months off therapy. In subregions, Kbone value increases were statistically significant at 3 months and in all subregions except the pelvis at 18 months. After 6 months off therapy, subregional Kbone values also returned toward baseline. Bone markers increases from baseline were statistically significant at 3 and 18 months (BSAP, 15% and 36%; PINP, 137% and 192%; NTX, 109% and 125%). After 6 months off therapy, PINP and NTX values had declined, though remained above baseline (BSAP, −3%; PINP, 43%; NTX, 56%). Increased Kbone values in the whole body and lower extremities were correlated with increases in most bone markers at 3 and 18 months. Increased skeletal uptake of 99mTc-MDP during treatment with TPTD is indicative of increased bone formation and is supported by increases in bone turnover markers.Conclusion: Changes in Kbone and skeletal uptake measured by radionuclide bone scans in patients taking TPTD are the result of metabolic activity of the drug. These data may provide physicians with useful insights when interpreting bone scan results in this population.

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.

Facteurs de risque fracturaire, nouveaux traitements: comment evolue la prise en charge de l'ostéoporose de la personne agée [Fracture risk, new treatments: how does the management of the osteoporosis of elderly change?]

Osteoporosis of elderly is a growing medical, economic and health-care problem. It is due to the increase of the life expectancy and the number of osteoporotic fractures. With the new Swiss-specific tool FRAX and the development of inpatients fracture trajectory, we can better identify patients with high risk of fracture. An appropriate treatment can be proposed more quickly. The follow-up of bone markers increases the treatment efficiency. With a better identification, treatment and follow-up of osteoporosis of elderly patients, we can ameliorate the patient's quality of life and decrease the number of osteoporotic fractures with a good cost-effectiveness ratio.

A new species of Homalocerus Schoenherr from the Atlantic coast of the State of São Paulo, Brazil (Coleoptera, Belidae, Belinae), with notes on color pattern and on the sclerites of the internal sac

A new species of Homalocerus Schoenherr from the Atlantic coast of the State of São Paulo, Brazil (Coleoptera, Belidae, Belinae), with notes on color pattern and on the sclerites of the internal sac. Homalocerus bimaculatus sp. nov. (type locality: Brazil, São Paulo) is described and illustrated, and comments on the sclerites of the internal sac of aedeagus and on color pattern are provided. The new species is compared to other similar species of the genus, being distinguished by having three clusters of carmine pubescence on pronotum and two lateral whitish oval spots located slightly before the middle of each elytron. Six species of Homalocerus, including the new one, are known from the State of São Paulo. The previously published identification key for species of Homalocerus is updated to include H. bimaculatus.

The fixation of locally beneficial alleles in a metapopulation.

Extinction, recolonization, and local adaptation are common in natural spatially structured populations. Understanding their effect upon genetic variation is important for systems such as genetically modified organism management or avoidance of drug resistance. Theoretical studies on the effect of extinction and recolonization upon genetic variance started appearing in the 1970s, but the role of local adaptation still has no good theoretical basis. Here we develop a model of a haploid species in a metapopulation in which a locally adapted beneficial allele is introduced. We study the effect of different spatial patterns of local adaptation, and different metapopulation dynamics, upon the fixation probability of the beneficial allele. Controlling for the average selection pressure, we find that a small area of positive selection can significantly increase the global probability of fixation. However, local adaptation becomes less important as extinction rate increases. Deme extinction and recolonization have a spatial smoothing effect that effectively reduces spatial variation in fitness.

Hip fracture incidence in the canton of Vaud, Switzerland, 1986-1991.

The objective of this study was to estimate the incidence of hip fracture in the canton of Vaud, Switzerland (total population 584 000), for the period 1986-1991 using routine hospital discharge data collected by the Cantonal Service of Statistical Research and Information (SCRIS). For the survey period, the estimated average annual crude incidence rate of hip fractures was 167 per 100 000 persons aged 20 or older (241 for women and 84 for men). For the population aged 50 years or older, the crude incidence rate was 388 per 100 000 persons (546 for women and 185 for men). The average annual age-specific rates rose exponentially by successive 5-year age groups. The median age of patients at the time of the fracture was 82 years in women and 74 years in men. There was no significant difference between the total number of cervical and trochanteric fractures. Between the ages of 20 and 84 years, the cumulative risk for a woman to be admitted to hospital with a hip fracture was twice that of a man (15.8% vs 7.8%). From 1986 to 1991, the age- and sex-adjusted incidence, like the ratio of cervical to trochanteric fractures, did not show any significant trend, although it was consistent with an increase in men (p=0.09). However, the annual number of fractures rose from 644 to 776, particularly among very aged men. The mean length of stay in the acute care hospital fell from 38 days in 1986 to 25 days in 1991. Finally, the comparison of these results with those obtained in 1986 for the same population from more exhaustive sources has confirmed the provision of a consistent, although overestimated, assessment of hip fracture incidence by means of these routine hospital statistics in the canton of Vaud, Switzerland.