Tómese unos minutos para revisar sus conocimientos sobre...Las precauciones estándar. Test de autoevaluación

Los últimos acontecimientos en materia de salud, como la aparición del SARS (síndrome agudo respiratorio severo) y el aumento de las infecciones nosocomiales han vuelto a poner en debate la importancia de que se apliquen las precauciones estándar por parte de todo el personal sanitario. Si bien las precauciones estándar están protocolizadas en la mayoría de los centros de salud de nuestro país, existe una gran confusión y desconocimiento al respecto

On the Use of a Test to Exhaustion Specific to Tennis (TEST) with Ball Hitting by Elite Players

PURPOSE: We aimed to a) introduce a new Test to Exhaustion Specific to Tennis (TEST) and compare performance (test duration) and physiological responses to those obtained during the 20-m multistage shuttle test (MSST), and b) determine to which extent those variables correlate with performance level (tennis competitive ranking) for both test procedures. METHODS: Twenty-seven junior players (8 males, 19 females) members of the national teams of the French Tennis Federation completed MSST and TEST, including elements of the game (ball hitting, intermittent activity, lateral displacement), in a randomized order. Cardiorespiratory responses were compared at submaximal (respiratory compensation point) and maximal loads between the two tests. RESULTS: At the respiratory compensation point oxygen uptake (50.1 +/- 4.7 vs. 47.5 +/- 4.3 mL.min-1.kg-1, p = 0.02), but not minute ventilation and heart rate, was higher for TEST compared to MSST. However, load increment and physiological responses at exhaustion did not differ between the two tests. Players' ranking correlated negatively with oxygen uptake measured at submaximal and maximal loads for both TEST (r = -0.41; p = 0.01 and -0.55; p = 0.004) and MSST (r = -0.38; P = 0.05 and -0.51; p = 0.1). CONCLUSION: Using TEST provides a tennis-specific assessment of aerobic fitness and may be used to prescribe aerobic exercise in a context more appropriate to the game than MSST. Results also indicate that VO2 values both at submaximal and maximal load reached during TEST and MSST are moderate predictors of players competitive ranking.

Dose calibrator linearity test: 99mTc versus 18F radioisotopes

Objective: The present study was aimed at evaluating the viability of replacing 18F with 99mTc in dose calibrator linearity testing. Materials and Methods: The test was performed with sources of 99mTc (62 GBq) and 18F (12 GBq) whose activities were measured up to values lower than 1 MBq. Ratios and deviations between experimental and theoretical 99mTc and 18F sources activities were calculated and subsequently compared. Results: Mean deviations between experimental and theoretical 99mTc and 18F sources activities were 0.56 (± 1.79)% and 0.92 (± 1.19)%, respectively. The mean ratio between activities indicated by the device for the 99mTc source as measured with the equipment pre-calibrated to measure 99mTc and 18F was 3.42 (± 0.06), and for the 18F source this ratio was 3.39 (± 0.05), values considered constant over the measurement time. Conclusion: The results of the linearity test using 99mTc were compatible with those obtained with the 18F source, indicating the viability of utilizing both radioisotopes in dose calibrator linearity testing. Such information in association with the high potential of radiation exposure and costs involved in 18F acquisition suggest 99mTc as the element of choice to perform dose calibrator linearity tests in centers that use 18F, without any detriment to the procedure as well as to the quality of the nuclear medicine service.

Estimation de l'impact économique de l'introduction d'un test diagnostique rapide pour le dépistage des MRSA au CHUV

Contexte : Parmi les infections nosocomiales, le Staphylocoque méticilline résistant (MRSA) est le germe pathogène le plus couramment identifié dans les hôpitaux du monde entier. La stratégie de contrôle des MRSA au CHUV implique le dépistage des patients à risque. Avec la méthode de dépistage par culture, le temps d'attente est de plusieurs jours. Ceci occasionne des problèmes dans la gestion des flux des patients, principalement à cause des mesures d'isolement. Pour réduire le temps d'attente, l'hôpital envisage d'utiliser une méthode de diagnostic rapide par "polymerase chain reaction" (PCR). Méthodologie : Les données concernant les dépistages réalisés, dans trois services durant l'année 2007, ont été utilisées. Le nombre de jours d'isolement a d'abord été déterminé par patient et par service. Ensuite une analyse des coûts a été effectuée afin d'évaluer la différence des coûts entre les deux méthodes pour chaque service. Résultats : Le principal impact économique de la méthode par PCR dépend principalement du nombre de jours d'isolements évités par rapport à la méthode de culture. Aux services de soins, l'analyse a été menée sur 192 dépistages. Quand la différence de jours d'isolement est de deux jours, le coût des dépistages diminue de plus de 12kCHF et le nombre de jours d'isolement diminue de 384 jours. Au centre interdisciplinaire des urgences, sur 96 dépistages, le gain potentiel avec la méthode PCR est de 6kCHF avec une diminution de 192 jours d'isolement. Aux soins intensifs adultes, la méthode de dépistage par PCR est la méthode la plus rentable avec une diminution des coûts entre 4KCHF et 20K CHF et une diminution des jours d'isolement entre 170 et 310. Pour les trois services analysés, les résultats montrent un rapport coût-efficacité favorable pour la méthode PCR lorsque la diminution des jours d'isolement est supérieure à 1.3 jour. Quand la différence de jours d'isolement est inférieure à 1.3, il faut tenir compte d'autres paramètres, comme le coût de matériel qui doit être supérieur à 45.5 CHF, et du nombre d'analyses par dépistage, qui doit être inférieur à 3, pour que la PCR reste l'alternative la plus intéressante. Conclusions : La méthode par PCR montre des avantages potentiels importants, tant économiques qu'organisationnels qui limitent ou diminuent les contraintes liées à la stratégie de contrôle des MRSA au CHUV. [Auteure, p. 3]

Optimal slopes and speeds in uphill ski mountaineering: a laboratory study.

The purpose of this study was to estimate the energy cost of linear (EC) and vertical displacement (ECvert), mechanical efficiency and main stride parameters during simulated ski mountaineering at different speeds and gradients, to identify an optimal speed and gradient that maximizes performance. 12 subjects roller skied on a treadmill at three different inclines (10, 17 and 24 %) at three different speeds (approximately 70, 80 and 85 % of estimated peak heart rate). Energy expenditure was calculated by indirect calorimetry, while biomechanical parameters were measured with an inertial sensor-based system. At 10 % there was no significant change with speed in EC, ECvert and mechanical efficiency. At 17 and 24 % the fastest speed was significantly more economical. There was a significant effect of gradient on EC, ECvert and mechanical efficiency. The most economical gradient was the steepest one. There was a significant increase of stride frequency with speed. At steep gradients only, relative thrust phase duration decreased significantly, while stride length increased significantly with speed. There was a significant effect of gradient on stride length (decrease with steepness) and relative thrust phase duration (increase with steepness). A combination of a decreased relative thrust phase duration with increased stride length and frequency decreases ECvert. To minimize the energy expenditure to reach the top of a mountain and to optimize performance, ski-mountaineers should choose a steep gradient (~24 %) and, provided they possess sufficient metabolic scope, combine it with a fast speed (~6 km h(-1)).

Etude de l'évolution des patients porteurs d'une cardiomyopathie hypertrophique obstructive (CMHO) après alcoolisation septale

La cardiomyopathie hypertrophique (CMH) est la maladie cardiaque monogénique la plus fréquente, touchant environ 1 individu sur 500 dans la population (1,2). L'étiologie est familiale dans la majorité des cas avec une transmission de type autosomal dominant à pénétrance variable. Deux gènes principaux sont à l'origine de la maladie chez 70% des patients avec un test génétique positif. Il s'agit des gènes qui codent pour la chaine lourde β de la myosine (MYH7) et la protéine C liant la myosine (MYBPC3) (1-3). La CMH est définie par la présence d'une hypertrophie myocardique « inadéquate » car se développant en l'absence d'une cause d'augmentation de la post-charge (HTA, sténose aortique, membrane sous-aortique), d'une pathologie infiltrative ou d'un entrainement physique (4,5). Le plus souvent asymétrique et affectant préférentiellement le septum, cette hypertrophie s'accompagne dans près de deux tiers des cas d'une obstruction dynamique sous-aortique de la chambre de chasse du ventricule gauche par la valve mitrale (systolic anterior motion ou SAM). Cette obstruction est à la fois la conséquence du rétrécissement de la chambre de chasse par l'hypertrophie septale mais également d'un malpositionnement de la valve mitrale (6-8). On parle alors de Cardiomyopathie Hypertrophique et Obstructive (CMHO). L'obstruction - présente au repos dans 50% des cas et uniquement après manoeuvres de provocation dans l'autre moitié des cas (manoeuvre de Valsalva, test de vasodilatation par nitrite d'amyle) est à l'origine d'un gradient de pression entre le ventricule gauche et l'aorte, et donc d'une surcharge de pression pour le ventricule gauche. Cette surcharge de pression est à l'origine des symptômes classiquement rencontrés soit dyspnée et angor d'effort, présyncope voire syncopes à l'effort. Un gradient sous-aortique de plus de 50 mmHg (mesuré au repos ou après provocation) est considéré comme un gradient à valeur pronostique (6-8) et justifiant un traitement si associé à des symptômes. Le traitement médical des formes obstructives repose sur l'administration de substances inotropes négatives et/ou susceptibles de favoriser la relaxation myocardique tels que les béta-bloqueurs, les antagonistes du calcium et le disopyramide - pris isolément ou en association. Pour les nombreux patients qui deviennent réfractaires ou intolérants à ces traitements, deux interventions peuvent leur être proposées pour lever l'obstruction : une myotomie-myectomie chirurgicale du septum (9,10) ou une alcoolisation du septum par voie percutanée (7,8). Les indications à ces interventions sont les suivantes (7,8,11) : 1. Symptômes (dyspnée de classe fonctionnelle NYHA III ou IV, angor de classe fonctionnelle CCS III ou IV, syncope, ou présyncope) réfractaires au traitement médical ou intolérance du patient au traitement. Une dyspnée de classe II est considérée suffisante dans le cas de jeunes patients. 2. Obstruction sous-aortique avec gradient supérieur ou égal à 50 mmHg, au repos ou après manoeuvre de provocation, associée à une hypertrophie septale et à un mouvement systolique antérieur de la valve mitrale (effet SAM) 3. Anatomiecardiaquefavorableàuntraitementinvasif(épaisseurduseptumde plus de 16 mm) Si la myectomie chirurgicale reste la méthode de référence (12-18), l'alcoolisation septale du myocarde par voie percutanée est devenue un des traitements de choix dans la thérapie de la Cardiomyopathie Hypertrophique Obstructive réfractaire. Elle consiste à repérer par coronarographie l'artère septale nourrissant le septum basal hypertrophié, puis à y introduire un petit ballon pour isoler ce territoire du reste du lit coronaire avant d'y injecter une dose d'alcool à 95% comprise entre 1 et 5 cc. On crée ainsi un infarctus chimique, technique qui fut dans le passé utilisée pour le traitement de certaines tumeurs. Les effets ne sont pas immédiats et nécessitent généralement 2-3 semaines avant de se manifester. On assiste alors à une diminution progressive de l'épaisseur du myocarde nécrosé (7), à la disparition progressive de l'obstruction et à l'amélioration / disparition des symptômes. La question de savoir qui de la chirurgie ou de l'alcoolisation est le plus efficace a été source de nombreux débats (7,11-13,18). Par rapport à la chirurgie, les avantages de la méthode percutanée sont les suivants (11,14,15,18,19) : - Efficacités hémodynamique et fonctionnelle jugées comparable à la chirurgie selon les études - Taux de morbidité et de mortalité très faible et non supérieure à la chirurgie - Absence de sternotomie - Diminution de la durée de l'hospitalisation et surtout de la période de convalescence, le patient pouvant reprendre une activité dès son retour à domicile Certains experts émettent néanmoins des doutes quant à l'innocuité à long terme de la méthode, les zones nécrotiques pouvant servir de terrain arythmogène. Pour ces raisons, la méthode n'est pas recommandée chez les patients de moins de 40 ans (6,8). Le risque majeur de l'alcoolisation du septum proximal réside dans l'induction d'un bloc atrio-ventriculaire complet chimique, le noeud atrio-ventriculaire étant justement situé dans cette région. Ce risque augmente avec la quantité d'alcool administrée et nécessite, si persistance après trois jours, l'implantation d'un pacemaker à demeure. Selon les centres, le taux d'implantation d'un stimulateur varie ainsi entre 7% et 20% (7,14,20). L'efficacité clinique et l'incidence des complications est donc en partie liée à la compétence technique et à l'expérience de l'opérateur (7,14), mais aussi aux choix des patients. Il peut donc varier grandement selon les centres médicaux. L'étude proposée vise à analyser les résultats de l'alcoolisation obtenus à Lausanne, jusqu'à présent pas encore été étudiés, et à les comparer à ceux de la littérature.

Trabecular bone score in kidney transplant recipients.

UNLABELLED: It is uncertain whether bone mineral density (BMD) can accurately predict fracture in kidney transplant recipients. Trabecular bone score (TBS) provides information independent of BMD. Kidney transplant recipients had abnormal bone texture as measured by lumbar spine TBS, and a lower TBS was associated with incident fractures in recipients. INTRODUCTION: Trabecular bone score (TBS) is a texture measure derived from dual energy X-ray absorptiometry (DXA) lumbar spine images, providing information independent of bone mineral density. We assessed characteristics associated with TBS and fracture outcomes in kidney transplant recipients. METHODS: We included 327 kidney transplant recipients from Manitoba, Canada, who received a post-transplant DXA (median 106 days post-transplant). We matched each kidney transplant recipient (mean age 45 years, 39 % men) to three controls from the general population (matched on age, sex, and DXA date). Lumbar spine (L1-L4) DXA images were used to derive TBS. Non-traumatic incident fracture (excluding hand, foot, and craniofacial) (n = 31) was assessed during a mean follow-up of 6.6 years. We used multivariable linear regression models to test predictors of TBS, and multivariable Cox proportional hazard regression was used to estimate hazard ratios (HRs) per standard deviation decrease in TBS to express the gradient of risk. RESULTS: Compared to the general population, kidney transplant recipients had a significantly lower lumbar spine TBS (1.365 ± 0.129 versus 1.406 ± 0.125, P < 0.001). Multivariable linear regression revealed that receipt of a kidney transplant was associated with a significantly lower mean TBS compared to controls (-0.0369, 95 % confidence interval [95 % CI] -0.0537 to -0.0202). TBS was associated with fractures independent of the Fracture Risk Assessment score including BMD (adjusted HR per standard deviation decrease in TBS 1.64, 95 % CI 1.15-2.36). CONCLUSION: Kidney transplant recipients had abnormal bone texture as assessed by TBS and a lower lumbar spine TBS was associated with fractures in recipients.

Análisis del «perfil» de estudiantes de Enfermería mediante el test de Cattel

Conocer cuál es la personalidad de aquellos que acceden a nuestras Escuelas y que en pocos años se convertirán en futuros profesionales de Enfermería, ha sido el objetivo de un estudio llevado a cabo por la Comisión de Docencia de la E.U.E. de Barcelona. En él se realiza un análisis comparativo de los perfiles de personalidad de los estudiantes admitidos en la E.U.E. de Barcelona y los candidatos pre-inscritos en dicha escuela en 1983, frente a estudiantes de Enfermería americanas y británicas y los candidatos a estudiantes de Medicina de la Universidad de Navarra.

Evolutionary Ecology of Mountain Birch in Subarctic Stress Gradients: Interplay of Biotic and Abiotic Factors in Plant-Plant Interactions and Evolutionary Processes

In nature, variation for example in herbivory, wind exposure, moisture and pollution impact often creates variation in physiological stress and plant productivity. This variation is seldom clear-cut, but rather results in clines of decreasing growth and productivity towards the high-stress end. These clines of unidirectionally changing stress are generally known as ‘stress gradients’. Through its effect on plant performance, stress has the capacity to fundamentally alter the ecological relationships between individuals, and through variation in survival and reproduction it also causes evolutionary change, i.e. local adaptations to stress and eventually speciation. In certain conditions local adaptations to environmental stress have been documented in a matter of just a few generations. In plant-plant interactions, intensities of both negative interactions (competition) and positive ones (facilitation) are expected to vary along stress gradients. The stress-gradient hypothesis (SGH) suggests that net facilitation will be strongest in conditions of high biotic and abiotic stress, while a more recent ‘humpback’ model predicts strongest net facilitation at intermediate levels of stress. Plant interactions on stress gradients, however, are affected by a multitude of confounding factors, making studies of facilitation-related theories challenging. Among these factors are plant ontogeny, spatial scale, and local adaptation to stress. The last of these has very rarely been included in facilitation studies, despite the potential co-occurrence of local adaptations and changes in net facilitation in stress gradients. Current theory would predict both competitive effects and facilitative responses to be weakest in populations locally adapted to withstand high abiotic stress. This thesis is based on six experiments, conducted both in greenhouses and in the field in Russia, Norway and Finland, with mountain birch (Betula pubescens subsp. czerepanovii) as the model species. The aims were to study potential local adaptations in multiple stress gradients (both natural and anthropogenic), changes in plant-plant interactions under conditions of varying stress (as predicted by SGH), potential mechanisms behind intraspecific facilitation, and factors confounding plant-plant facilitation, such as spatiotemporal, ontogenetic, and genetic differences. I found rapid evolutionary adaptations (occurring within a time-span of 60 to 70 years) towards heavy-metal resistance around two copper-nickel smelters, a phenomenon that has resulted in a trade-off of decreased performance in pristine conditions. Heavy-metal-adapted individuals had lowered nickel uptake, indicating a possible mechanism behind the detected resistance. Seedlings adapted to heavy-metal toxicity were not co-resistant to others forms of abiotic stress, but showed co-resistance to biotic stress by being consumed to a lesser extent by insect herbivores. Conversely, populations from conditions of high natural stress (wind, drought etc.) showed no local adaptations, despite much longer evolutionary time scales. Due to decreasing emissions, I was unable to test SGH in the pollution gradients. In natural stress gradients, however, plant performance was in accordance with SGH, with the strongest host-seedling facilitation found at the high-stress sites in two different stress gradients. Factors confounding this pattern included (1) plant size / ontogenetic status, with seedling-seedling interactions being competition dominated and host-seedling interactions potentially switching towards competition with seedling growth, and (2) spatial distance, with competition dominating at very short planting distances, and facilitation being strongest at a distance of circa ¼ benefactor height. I found no evidence for changes in facilitation with respect to the evolutionary histories of plant populations. Despite the support for SGH, it may be that the ‘humpback’ model is more relevant when the main stressor is resource-related, while what I studied were the effects of ‘non-resource’ stressors (i.e. heavy-metal pollution and wind). The results have potential practical applications: the utilisation of locally adapted seedlings and plant facilitation may increase the success of future restoration efforts in industrial barrens as well as in other wind-exposed sites. The findings also have implications with regard to the effects of global change in subarctic environments: the documented potential by mountain birch for rapid evolutionary change, together with the general lack of evolutionary ‘dead ends’, due to not (over)specialising to current natural conditions, increase the chances of this crucial forest-forming tree persisting even under the anticipated climate change.

Effect of meal ingestion on liver stiffness in patients with cirrhosis and portal hypertension.

BACKGROUND AND AIMS: Liver stiffness is increasingly used in the non-invasive evaluation of chronic liver diseases. Liver stiffness correlates with hepatic venous pressure gradient (HVPG) in patients with cirrhosis and holds prognostic value in this population. Hence, accuracy in its measurement is needed. Several factors independent of fibrosis influence liver stiffness, but there is insufficient information on whether meal ingestion modifies liver stiffness in cirrhosis. We investigated the changes in liver stiffness occurring after the ingestion of a liquid standard test meal in this population. METHODS: In 19 patients with cirrhosis and esophageal varices (9 alcoholic, 9 HCV-related, 1 NASH; Child score 6.9±1.8), liver stiffness (transient elastography), portal blood flow (PBF) and hepatic artery blood flow (HABF) (Doppler-Ultrasound) were measured before and 30 minutes after receiving a standard mixed liquid meal. In 10 the HVPG changes were also measured. RESULTS: Post-prandial hyperemia was accompanied by a marked increase in liver stiffness (+27±33%; p<0.0001). Changes in liver stiffness did not correlate with PBF changes, but directly correlated with HABF changes (r = 0.658; p = 0.002). After the meal, those patients showing a decrease in HABF (n = 13) had a less marked increase of liver stiffness as compared to patients in whom HABF increased (n = 6; +12±21% vs. +62±29%,p<0.0001). As expected, post-prandial hyperemia was associated with an increase in HVPG (n = 10; +26±13%, p = 0.003), but changes in liver stiffness did not correlate with HVPG changes. CONCLUSIONS: Liver stiffness increases markedly after a liquid test meal in patients with cirrhosis, suggesting that its measurement should be performed in standardized fasting conditions. The hepatic artery buffer response appears an important factor modulating postprandial changes of liver stiffness. The post-prandial increase in HVPG cannot be predicted by changes in liver stiffness.

Methods to test gas tightness of packages

One of the primary goals for food packages is to protect food against harmful environment, especially oxygen and moisture. The gas transmission rate is the total gas transport through the package, both by permeation through the package material and by leakage through pinholes and cracks. The shelf life of a product can be extended, if the food is stored in a gas tight package. Thus there is a need to test gas tightness of packages. There are several tightness testing methods, and they can be broadly divided into destructive and nondestructive methods. One of the most sensitive methods to detect leaks is by using a non destructive tracer gas technique. Carbon dioxide, helium and hydrogen are the most commonly used tracer gases. Hydrogen is the lightest and the smallest of all gases, which allows it to escape rapidly from the leak areas. The low background concentration of H2 in air (0.5 ppm) enables sensitive leak detection. With a hydrogen leak detector it is also possible to locate leaks. That is not possible with many other tightness testing methods. The experimental work has been focused on investigating the factors which affect the measurement results with the H2leak detector. Also reasons for false results were searched to avoid them in upcoming measurements. From the results of these experiments, the appropriate measurement practice was created in order to have correct and repeatable results. The most important thing for good measurement results is to keep the probe of the detector tightly against the leak. Because of its high diffusion rate, the HZ concentration decreases quickly if holding the probe further away from the leak area and thus the measured H2 leaks would be incorrect and small leaks could be undetected. In the experimental part hydrogen, oxygen and water vapour transmissions through laser beam reference holes (diameters 1 100 μm) were also measured and compared. With the H2 leak detector it was possible to detect even a leakage through 1 μm (diameter) within a few seconds. Water vapour did not penetrate even the largest reference hole (100 μm), even at tropical conditions (38 °C, 90 % RH), whereas some O2 transmission occurred through the reference holes larger than 5 μm. Thus water vapour transmission does not have a significant effect on food deterioration, if the diameter of the leak is less than 100 μm, but small leaks (5 100 μm) are more harmful for the food products, which are sensitive to oxidation.

Sustainability of EU fiscal policies. A panel test

The fiscal policy rule implicit in the Stability and Growth Pact, has been rationalised as a way to ensure that national fiscal policies remain sustainable within the EU, thereby endorsing the independence of the ECB. We empirically examine the sustainability of European fiscal policies over the period 1970-2001. The intertemporal government budget constraint provides a test based on the cointegration relation between government revenues, expenditures and interest payments. Sustainability is analysed at both the national level and for a European panel. Results show that European fiscal policy has been sustainable overall, yet national experiences differ considerably.

Evaluación de la estructura porosa de los materiales MCM-22, MCM-36 e ITQ-2 empleando el test catalitico del n-decano

The void structure of zeolites MCM-22, MCM-36 and ITQ-2 were discussed on the bases of catalytic reaction tests. The hydromerization of n-decane on bifunctional Pt/Zeolite Catalysts have been used as model reactions. Beta and ZSM-5 zeolites were used for comparison. It is concluded that all materials show features of 10MR zeolites and have also pores bigger than 12MR in this order MCM-22