Gonalgies: que faire en médecine de premier recours [Knee pain in ambulatory practice].

Knee pain is a frequent complaint in ambulatory practice. Because of its complexity, the knee is prone to trauma, arthritis and the impact of aging. Septic arthritis is an emergency and has to be suspected when important knee pain is associated with fever, an alteration of the general condition, or in a particular social context. In most cases the clinical examination can identify the type of pathology. Conservative treatment is beneficial in most cases and physiotherapy a major component of the prognosis.

Maalämpöpumpun mitoitusjärjestelmän kehittäminen

Työn tavoitteena oli kehittää maalämpöpumppujärjestelmään kuuluvien komponenttien mitoitusta. Työ tehtiin Alufer Oy nimiselle yritykselle, joka on työskennellyt jo kolme vuotta maalämpöpumppujärjestelmän tuotekehityksen parissa. Maalämpöpumppujärjestelmä tullaan suunnittelemaan mahdollisimman suorituskykyiseksi ja joustavaksi. Suunnittelun lähtökohtana on, että lämmitysjärjestelmä on ns. matalalämpö-järjestelmä, joka käytännössä usein toteutetaan lattialämmityksenä. Ensimmäiseksi työssä on selvitetty mitä maalämpö on ja mitkä ovat yleisimmät maalämpöpumppujärjestelmän lämmönkeruuputkistojen asennustavat. Tällä hetkellä käytössä on joko vaakaan (maa, vesi) tai pystyyn asennettava lämmönkeruuputkisto (porakaivo). Seuraavaksi työssä on lähdetty selvittämään maalämpöpumppumarkkinoita Suomessa sekä selvitetty kolmen suurimman valmistajan Geopro Systemsin, Suomen Lämpöpumpputekniikan ja Ekowellin tuotteita sekä tekniikkaa. Työssä selvitetään myös muutamien Eurooppalaisten maiden markkinat. Mitoitusjärjestelmässä tarkastelu on aloitettu uudisrakennuksen lämmitystehon tarpeesta ja käyttöveden lämmityksen tarvitsemasta tehosta. Tarvittavan lämmitysenergian perusteella määriteltiin lämpöpumppujärjestelmään kuuluvat komponentit. Maalämpöpumppujärjestelmä koostuu seuraavista pääkomponenteista: höyrystin, kompressori, lauhdutin ja paisuntaventtiili. Höyrystimen tehon mitoituksessa on huomioitu lämmönkeruuputkistossa kulkevan nesteen aineominaisuudet, massavirta ja lämpötilaero höyrystimen nesteen ulostulon sekä sisään menon välillä. Kompressorin teho on määritetty valitun kylmäaineen (R407C) lg p-h piirroksesta tai määritetty teoreettisesti kompressorivalmistajien omista valintaohjelmista. Lauhduttimen teho on määritelty höyrystimen sekä kompressorin tehon summasta. Samalla määräytyy myös uudisrakennuksen lämmitystehontarve. Lopuksi työssä on käsitelty maalämpöpumppujärjestelmän kehitysmahdollisuuksia. Vaihtoehtoina on huomioitu tulistin, alijäähdytin ja varaaja, joilla voidaan huomattavasti parantaa maalämpöpumpun lämpökerrointa.

Biologisen jätevedenpuhdistuksen ilmastuksen tehostaminen

Työssä tutkittiin, mikä on kustannustehokkain tapa lisätä ilmastuskapasiteettia ja selvitettiin, saostaako vesilaitokselta flotaatioaltaasta poistettava ferrisulfaattisakka jäteveden fosforia esiselkeyttimessä. Työssä määritettiin teoreettinen hapentarve ilmastusaltaassa maksimikuormituksen aikana ja hapensiirtonopeus jäteveteen olemassa olevalla laitteistolla. Hapensiirtonopeuden funktion korjauskertoimet  ja  sekä kokonaishapensiirtokerroin määritettiin laboratorio-olosuhteissa. Lisäksi laskettiin kuinka paljon nykyisten ilmastimien kautta saadaan happea jäteveteen liukenemaan ja verrattiin tätä lukua teoreettiseen hapentarpeeseen. Jälkimmäistä menettelytapaa käyttäen arvioitiin lisähapen tarve. Tulokseksi saatiin, että maksimi BOD-kuormituksen aikana happea tarvitsee saada jäteveteen liuotettua 5200 m³/d lisää. Ilmastuskapasiteetin lisäyksen kustannuslaskelmassa verrattiin neljää vaihtoehtoa: puhdasta happea liuotettuna happimattojen kautta tai OKI-ilmastimen kautta, onsite-happilaitoksen puhdasta happea liuotettuna OKI-ilmastimen kautta tai ilman happea liuotettuna jäteveteen EDI-ilmastimien kautta. Laskelmat osoittivat uusien EDI-ilmastimien hankinnan olevan edullisin vaihtoehto pitkällä aikavälillä. Vaikka EDI-ilmastimien investointikustannukset ovat korkeat, tulevat ne käyttökustannuksiltaan kaikkein edullisimmaksi. Vesilaitokselta tulevan rautasuolasakan fosforia saostavaa vaikutusta tutkittiin laboratoriossa astiakokein. Näytteet otettiin vesilaitokselta jätevesilaitokselle menevästä rautasuolasakasta sekä esiselkeyttimen kirkasteesta. Näitä eri suhteissa keskenään sekoittamalla saatiin selville, että rautasuolasakka ja sakan mukana tuleva reagoimaton rautasuola saostavat liukoista ja kokonaisfosforia esiselkeytyksessä.

Passiivisten turvallisuusjärjestelmien luontaiset virhetoiminnot ydinvoimalaitoksessa

Uusissa ydinvoimalaitostyypeissä aiotaan käyttää aiempaa enemmän passiivisia turvallisuusjärjestelmiä. Näistä järjestelmistä on vielä vähän käyttökokemusta aktiivisiin turvallisuusjärjestelmiin verrattuna. Työssä tarkastellaan passiivisten turvallisuusjärjestelmien toimintaa sekä etsitään niiden mahdollisia luontaisia vikatilanteita. Luontaisten vikatilanteiden seurauksia järjestelmän suorituskykyyn arvioitiin yksinkertaisilla laskuilla ja mallintamalla RELAP5/MOD3.2.2 beta -termohydrauliikkaohjelmalla. Tarkastelu rajattiin kahden erityyppisen ydinvoimalaitoksen passiivisiin turvallisuusjärjestelmiin. Turvallisuusjärjestelmien suuntaa antavat mitat ja käyttötilanteiden parametrit saatiin laitosvalmistajien laitoskuvauksista. Osoittautui, että vikatilanteissa passiivisissa turvallisuusjärjestelmissä geometrialla on merkittävä vaikutus järjestelmän kapasiteettiin. Tarkasteluissa saatiin myös selville, että laitosmittakaavassa painovoimaisen hätälisävesijärjestelmän turvallisuustoiminto voi toteutua vaikka esiintyisi lyhytaikaisia toimintahäiriöitä, kuten lauhtumista hätälisävesisäiliössä. Sen sijaan lämmönsiirtopiirin virtausreittien tukkeutuminen voi olla fysikaalisesti merkittävä toimintaa haittaava tekijä.

Postmortem serum protein growth arrest-specific 6 levels in sepsis-related deaths.

Growth arrest-specific 6 (Gas6) is widely expressed in leukocytes, platelets, endothelial cells, and monocytes. It regulates various processes including granulocyte adhesion to the endothelium, cell migration, thrombus stabilization, and cytokine release. In humans, increased plasma Gas6 levels have been described in patients with sepsis and septic shock. In this study, Gas6 concentrations were measured in postmortem serum from femoral blood in a series of sepsis-related fatalities and control cases. The aims were twofold: first, to determine whether Gas6 can be reliably determined in postmortem serum; and second, to assess its diagnostic potential in identifying sepsis-related deaths. Two study groups were prospectively formed, a sepsis-related fatalities group (24 cases) and a control group (24 cases) including cases of deep vein thrombosis and fatal pulmonary embolism, cases of systemic inflammatory response syndrome in severe trauma, cases of end-stage renal failure, and cases of hanging (non-septic, non-SIRS, non-end stage renal failure cases). The preliminary results of this study seem to indicate that Gas6 can be effectively measured in postmortem serum. However, Gas6 levels in sepsis-related fatalities do not appear to be clearly distinguishable from concentrations in pulmonary embolism, severe trauma, and end-stage renal failure cases. These findings tend to support previous reports that indicated that Gas6 behaves as an acute phase reactant and can be considered a general marker of inflammation rather than a specific biomarker of sepsis.

Local perception and use of the multifunctionality of water tanks in two villages of Tamil Nadu, South India

Using data from free listings and a survey in two villages of Tamil Nadu, India, we discuss local perceptions and uses of water tanks, a traditional irrigation infrastructure. We hypothesize that both farmers and nonfarmers perceive and use water tanks for purposes other than irrigation. We found that informants recognized the importance of water tanks for irrigation, but also acknowledged other socioeconomic uses and ecological functions. Marginal sectors (i.e., Scheduled Castes) use tank resources in more diverse ways than other sectors of the population. Findings are relevant for development. International organizations working on the revival of water tanks aim to transfer water management to farmers for the purpose of irrigation. By recognizing that tanks benefit people other than farmers and in ways other than providing irrigation water, organizations working on tank rejuvenation could achieve a more equitable management of tank resources.

Epidemiology and outcome of fungemia in a cancer Cohort of the Infectious Diseases Group (IDG) of the European Organization for Research and Treatment of Cancer (EORTC 65031).

BACKGROUND: Anti-cancer treatment and the cancer population have evolved since the last European Organisation for Research and Treatment of Cancer (EORTC) fungemia survey, and there are few recent large epidemiological studies. METHODS: This was a prospective cohort study including 145 030 admissions of patients with cancer from 13 EORTC centers. Incidence, clinical characteristics, and outcome of fungemia were analyzed. RESULTS: Fungemia occurred in 333 (0.23%; 95% confidence interval [CI], .21-.26) patients, ranging from 0.15% in patients with solid tumors to 1.55% in hematopoietic stem cell transplantation recipients. In 297 evaluable patients age ranged from 17 to 88 years (median 56 years), 144 (48%) patients were female, 165 (56%) had solid tumors, and 140 (47%) had hematological malignancies. Fungemia including polymicrobial infection was due to: Candida spp. in 267 (90%), C. albicans in 128 (48%), and other Candida spp. in 145 (54%) patients. Favorable overall response was achieved in 113 (46.5%) patients by week 2. After 4 weeks, the survival rate was 64% (95% CI, 59%-70%) and was not significantly different between Candida spp. Multivariable logistic regression identified baseline septic shock (odds ratio [OR] 3.04, 95% CI, 1.22-7.58) and tachypnoea as poor prognostic factors (OR 2.95, 95% CI, 1.66-5.24), while antifungal prophylaxis prior to fungemia (OR 0.20, 95% CI, .06-.62) and remission of underlying cancer (OR, 0.18; 95% CI, .06-.50) were protective. CONCLUSIONS: Fungemia, mostly due to Candida spp., was rare in cancer patients from EORTC centers but was associated with substantial mortality. Antifungal prophylaxis and remission of cancer predicted better survival.

A prospective evaluation of ultrasound as a diagnostic tool in acute microcrystalline arthritis.

INTRODUCTION: The performance of ultrasound (US) in the diagnosis of acute gouty (MSU) arthritis and calcium pyrophosphate (CPP) arthritis is not yet well defined. Most studies evaluated US as the basis for diagnosing crystal arthritis in already diagnosed cases of gout and few prospective studies have been performed. METHODS: One hundred nine consecutive patients who presented an acute arthritis of suspected microcrystalline arthritis were prospectively included. All underwent an US of the symptomatic joints(s) and of knees, ankles and 1(st) metatarsopalangeal (MTP) joints by a rheumatologist "blinded" to the clinical history. 92 also had standard X-rays. Crystal identification was the gold standard. RESULTS: Fifty-one patients had MSU, 28 CPP and 9 had both crystals by microscopic analysis. No crystals were detected in 21. One had septic arthritis. Based on US signs in the symptomatic joint, the sensitivity of US for both gout and CPP was low (60 % for both). In gout, the presence of US signs in the symptomatic joint was highly predictive of the diagnosis (PPV = 92 %). When US diagnosis was based on an examination of multiple joints, the sensitivity for both gout and CPP rose significantly but the specificity and the PPV decreased. In the absence of US signs in all the joints studied, CPP arthritis was unlikely (NPV = 87 %) particularly in patients with no previous crisis (NPV = 94 %). X-ray of the symptomatic joints was confirmed to be not useful in diagnosing gout and was equally sensitive or specific as US in CPP arthritis. CONCLUSIONS: Arthrocenthesis remains the key investigation for the diagnosis of microcrystalline acute arthritis. Although US can help in the diagnostic process, its diagnostic performance is only moderate. US should not be limited to the symptomatic joint. Examination of multiple joints gives a better diagnostic sensitivity but lower specificity.

Equilibrium of the simultaneous etherification ofisobutene and isoamylenes with ethanol inliquid-phase

The simultaneous etherification of isobutene and isoamylenes with ethanol has been studied using macroreticu-lar acid ion-exchange resins as catalyst. Most of the experiments were carried out over Amberlyst-35. In addition,Amberlyst-15 and Purolite CT-275 were also tested. Chemical equilibrium of four chemical reactions was studied:ethyl tert-butyl ether formation, tert-amyl ethyl ether formation from isoamylenes (2-methyl-1-butene and 2-methyl-2-butene) and isomerization reaction between both isoamylenes. Equilibrium data were obtained in a batchwisestirred tank reactor operated at 2.0 MPa and within the temperature range from 323 to 353 K. Experimental molarstandard enthalpy and entropy changes of reaction were determined for each reaction. From these data, the molarenthalpy change of formation of ethyl tert-butyl ether and tert-amyl ethyl ether were estimated. Besides, the chemical equilibrium between both diisobutene dimers, 2,4,4-trimethyl-1-pentene and 2,4,4-trimethyl-2-pentene, wasevaluated. A good agreement between thermodynamic results for the simultaneous etherification carried out in thiswork and those obtained for the isolated ethyl tert-butyl ether and tert-amyl ethyl ether systems was obtained.

Sanitary quality of edible bivalve mollusks in Southeastern Brazil using an UV based depuration system

The increase in seafood production, especially in mariculture worldwide, has brought out the need of continued monitoring of shellfish production areas in order to ensure safety to human consumption. The purpose of this research was to evaluate pathogenic protozoa, viruses and bacteria contamination in oysters before and after UV depuration procedure, in brackish waters at all stages of cultivation and treatment steps and to enumerate microbiological indicators of fecal contamination from production site up to depuration site in an oyster cooperative located at the Southeastern estuarine area of Brazil. Oysters and brackish water were collected monthly from September 2009 to November 2010. Four sampling sites were selected for enteropathogens analysis: site 1- oyster growth, site 2- catchment water (before UV depuration procedure), site 3 - filtration stage of water treatment (only for protozoa analysis) and site 4- oyster's depuration tank. Three microbiological indicators ! were examined at sites 1, 2 and 4. The following pathogenic microorganisms were searched: Giardia cysts, Cryptosporidium oocysts, Human Adenovirus (HAdV), Hepatitis A virus (HAV), Human Norovirus (HnoV) (genogroups I and II), JC strain Polyomavirus (JCPyV) and Salmonella sp. Analysis consisted of molecular detection (qPCR) for viruses (oysters and water samples); immunomagnetic separation followed by direct immunofluorescence assay for Cryptosporidium oocysts and Giardia cysts and also molecular detection (PCR) for the latter (oysters and water samples); commercial kit (Reveal-Neogee (R)) for Salmonella analysis (oysters). Giardia was the most prevalent pathogen in all sites where it was detected: 36.3%, 18.1%, 36.3% and 27.2% of water from sites 1, 2, 3 and 4 respectively; 36.3% of oysters from site 1 and 54.5% of depurated oysters were harboring Giardia cysts. The huge majority of contaminated samples were classified as Giardia duodenalis. HAdv was detected in water and o! ysters from growth site and HnoV GI in two batches of oysters ! (site 1) in huge concentrations (2.11 x 10(13), 3.10 x 10(12) gc/g). In depuration tank site, Salmonella sp., HAV (4.84 x 10(3)) and HnoV GII (7.97 x 10(14)) were detected once in different batches of oysters. Cryptosporidium spp. oocysts were present in 9.0% of water samples from site four. These results reflect the contamination of oysters even when UV depuration procedures are employed in this shellfish treatment plant. Moreover, the molecular comprehension of the sources of contamination is necessary to develop an efficient management strategy allied to shellfish treatment improvement to prevent foodborne illnesses. (C) 2011 Elsevier Ltd. All rights reserved.

Médecine d'urgence [Emergency medicine: updates 2014].

L'année 2014 a été marquée par de nouvelles acquisitions thérapeutiques en médecine d'urgence.L'estimation de la probabilité d'une néphrolithiase permet d'éviter une imagerie chez les patients à haut risque. L'hypothermie thérapeutique post-arrêt cardiorespiratoire n'a pas de bénéfice par rapport à une stratégie de normothermie contrôlée. Le traitement d'une bronchite aiguë sans signe de gravité par co-amoxicilline ou AINS est inutile. L'adjonction de colchicine au traitement standard de la péricardite aiguë diminue le risque de récidive. L'ajustement du seuil de D-dimères à l'âge permet de réduire le recours à l'imagerie en cas de risque non élevé d'embolie pulmonaire. Enfin, un monitorage invasif précoce n'apporte pas de bénéfice à la prise en charge initiale du choc septique. The year 2014 was marked by new therapeutic acquisitions in emergency medicine. Nephrolithiasis likelihood estimation should avoid imaging in patients at high risk. Therapeutic hypothermia post cardio-respiratory arrest has no benefit compared to a strategy of controlled normothermia. Treatment of acute bronchitis with no signs of severity by coamoxicillin or NSAIDs is useless. Adding colchicine to standard treatment of acute pericarditis reduces the rate of recurrence. The D-dimerthreshold adjustment by age reduces the number of imaging in case of low or intermediate risk of pulmonary embolism. Finally, the speed of the initial management of septic shock is crucial to the outcome of patients, but an early invasive monitoring provides no benefit.

Prognostication of Mortality in Critically Ill Patients With Severe Infections.

BACKGROUND: The purpose of this study was to confirm the prognostic value of pancreatic stone protein (PSP) in patients with severe infections requiring ICU management and to develop and validate a model to enhance mortality prediction by combining severity scores with biomarkers. METHODS: We enrolled prospectively patients with severe sepsis or septic shock in mixed tertiary ICUs in Switzerland (derivation cohort) and Brazil (validation cohort). Severity scores (APACHE [Acute Physiology and Chronic Health Evaluation] II or Simplified Acute Physiology Score [SAPS] II) were combined with biomarkers obtained at the time of diagnosis of sepsis, including C-reactive-protein, procalcitonin (PCT), and PSP. Logistic regression models with the lowest prediction errors were selected to predict in-hospital mortality. RESULTS: Mortality rates of patients with septic shock enrolled in the derivation cohort (103 out of 158) and the validation cohort (53 out of 91) were 37% and 57%, respectively. APACHE II and PSP were significantly higher in dying patients. In the derivation cohort, the models combining either APACHE II, PCT, and PSP (area under the receiver operating characteristic curve [AUC], 0.721; 95% CI, 0.632-0.812) or SAPS II, PCT, and PSP (AUC, 0.710; 95% CI, 0.617-0.802) performed better than each individual biomarker (AUC PCT, 0.534; 95% CI, 0.433-0.636; AUC PSP, 0.665; 95% CI, 0.572-0.758) or severity score (AUC APACHE II, 0.638; 95% CI, 0.543-0.733; AUC SAPS II, 0.598; 95% CI, 0.499-0.698). These models were externally confirmed in the independent validation cohort. CONCLUSIONS: We confirmed the prognostic value of PSP in patients with severe sepsis and septic shock requiring ICU management. A model combining severity scores with PCT and PSP improves mortality prediction in these patients.

The Role of Biomarkers for Starting Antifungals in the Intensive Care Unit

Invasive candidiasis is associated with high mortality rates (35% to 60%), similar to the range reported for septic shock. The most common types include candidemia, frequently observed in immunocompromised patients, and noncandidemic systemic candidiasis, which constitutes the majority of cases in critically ill patients. However, they are difficult to prove and a definite diagnosis usually occurs late in the course of the disease, thus contributing to their bad prognosis. Early empirical treatment improves the prognosis and currently relies on the positive predictive value (PPV) of risk-assessment strategies (colonization index, Candida score, predictive rules) based on combinations of risk factors, but it may have also largely contributed to the overuse of antifungal agents in critically ill patients. In this context, non- culture-based diagnostic methods, including specific and nonspecific biomarkers, may significantly improve the diagnosis of invasive candidiasis. Candida DNA and mannan antigen/antimannan antibodies are of limited interest for the diagnosis of invasive candidiasis as they fail to identify noncandidemic systemic candidiasis, despite early positivity in candidemic patients. The utility of 1,3-beta-D-glucan (b-D-glucan), a panfungal cell wall antigen, has been demonstrated for the diagnosis of fungal infections in immunocompromised patients. Preliminary data suggest that it is also detectable early in critically ill patients developing noncandidemic systemic candidiasis. To take advantage of the high negative predictive value of risk-assessment strategies and the early increase in specific fungal biomarkers in high-risk patients, we propose a practical 2-step approach to improve the selection of patients susceptible to benefit from empirical antifungal treatment.

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.

High-density linkage maps fail to detect any genetic component to sex determination in a Rana temporaria family.

Sex chromosome differentiation in Rana temporaria varies strikingly among populations or families: whereas some males display well-differentiated Y haplotypes at microsatellite markers on linkage group 2 (LG2 ), others are genetically undistinguishable from females. We analysed with RADseq markers one family from a Swiss lowland population with no differentiated sex chromosomes, and where sibship analyses had failed to detect any association between the phenotypic sex of progeny and parental haplotypes. Offspring were reared in a common tank in outdoor conditions and sexed at the froglet stage. We could map a total of 2177 SNPs (1123 in the mother, 1054 in the father), recovering in both adults 13 linkage groups (= chromosome pairs) that were strongly syntenic to Xenopus tropicalis despite > 200 My divergence. Sexes differed strikingly in the localization of crossovers, which were uniformly distributed in the female but limited to chromosome ends in the male. None of the 2177 markers showed significant association with offspring sex. Considering the very high power of our analysis, we conclude that sex determination was not genetic in this family; which factors determined sex remain to be investigated.