L’utilisation de l’échographie pulmonaire dans la prise en charge des patients de soins critiques

En démontrant sa capacité d’identifier les pneumothorax, de différencier les différentes causes d’insuffisance respiratoire chez les patients dyspnéiques et de confirmer la position d’un tube endotrachéal lors d’une intubation endotrachéale, l’échographie pulmonaire a pris une place prépondérante dans la prise en charge des patients de soins critiques. La majorité des études, notamment celles sur l’intubation endotrachéale, ont évalué la performance de cliniciens possédant une expérience considérable en échographie pulmonaire et souvent dans un cadre idéal permettant des examens d’une durée prolongée. Considérant la disponibilité grandissante de l’échographie ciblée lors des situations de stabilisation et de réanimation des patients de soins critiques, nous voulions évaluer la capacité d’un groupe de clinicien hétérogène en termes de formation échographique à identifier la présence ou l’absence de glissement pleural sur de courtes séquences (comparable à la durée probable d’un examen lors de condition de réanimation) d’échographie pulmonaire enregistrées chez des patients intubés. Un total de 280 courtes séquences (entre 4 et 7 secondes) d’échographie pulmonaire démontrant la présence ou l’absence de glissement pleural chez des patients intubés en salle d’opération ont été enregistrées puis présentées de façon aléatoire à deux groupes de cliniciens en médecine d’urgence. Le deuxième groupe avait la possibilité de s’abstenir advenant une incertitude de leur réponse. Nous avons comparé la performance selon le niveau de formation académique et échographique. Le taux moyen d’identification adéquate de la présence ou l’absence du glissement pleural par participant était de 67,5% (IC 95% : 65,7-69,4) dans le premier groupe et 73,1% (IC 95% : 70,7-75,5) dans le second (p<0,001). Le taux médian de réponse adéquate pour chacune des 280 séquences était de 74,0% (EIQ : 48,0-90,0) dans le premier groupe et 83,7% (EIQ : 53,3-96,2) dans le deuxième (p=0,006). Le taux d’identification adéquate de la présence ou absence d’un glissement pleural par les participants des deux groupes était nettement supérieur pour les séquences de l’hémithorax droit par rapport à celles de l’hémithorax gauche (p=0,001). Lorsque des médecins de formation académique et échographique variable utilisent de courtes séquences d’échographie pulmonaire (plus représentatives de l’utilisation réelle en clinique), le taux d’identification adéquate de la présence ou l’absence de glissement pleural est plus élevé lorsque les participants ont la possibilité de s’abstenir en cas de doute quant à leur réponse. Le taux de bonnes réponses est également plus élevé pour les séquences de l’hémithorax droit, probablement dû à la présence sous-jacente du cœur à gauche, la plus petite taille du poumon gauche et l’effet accru du pouls pulmonaire dans l’hémithorax gauche. Considérant ces trouvailles, la prudence est de mise lors de l’utilisation de l’identification du glissement pleural sur de courtes séquences échographique comme méthode de vérification de la position d’un tube endotrachéal lors d’une intubation endotrachéale, et ce, particulièrement pour l’hémithorax gauche. Aussi, une attention particulière devrait être mise sur la reconnaissance du pouls pulmonaire lors de l’enseignement de l’échographie pulmonaire.

L’intégration de la prise de décision visuo-motrice et d’action motrice dans des conditions ambiguës

La prise de décision est un mécanisme qui fait intervenir les structures neuronales supérieures afin d’effectuer un lien entre la perception du signal et l’action. Plusieurs travaux qui cherchent à comprendre les mécanismes de la prise de décision sont menés à divers ni- veaux allant de l’analyse comportementale cognitive jusqu'à la modélisation computationnelle. Le but de ce projet a été d’évaluer d’un instant à l’autre comment la variabilité du signal observé («bruit»), influence la capacité des sujets humains à détecter la direction du mouvement dans un stimulus visuel. Dans ces travaux, nous avons éliminé l’une des sources potentielles de variabilité, la variabilité d’une image à l’autre, dans le nombre de points qui portaient les trois signaux de mouvements cohérents (gauche, droite, et aléatoire) dans les stimuli de Kinématogramme de points aléatoires (KPA), c’est-à-dire la variabilité d’origine périphérique. Les stimuli KPA de type « V6 » étaient des stimuli KPA standard avec une variabilité instantanée du signal, et par contre les stimuli KPA de type « V8 », étaient modifiés pour éliminer la variabilité stochastique due à la variabilité du nombre de pixels d’un instant à l’autre qui portent le signal cohérent. Si la performance des sujets, qui correspond à leur temps de réaction et au nombre de bonnes réponses, diffère en réponse aux stimuli dont le nombre de points en mouvement cohérent varie (V6) ou ne varie pas (V8), ceci serait une preuve que la variabilité d’origine périphérique modulerait le processus décisionnel. Par contre, si la performance des sujets ne diffère pas entre ces deux types de stimuli, ceci serait une preuve que la source majeure de variabilité de performance est d’origine centrale. Dans nos résultats nous avons constaté que le temps de réaction et le nombre de bonnes réponses sont modulés par la preuve nette du mouvement cohérent. De plus on a pu établir qu’en éliminant la variabilité d’origine périphérique définit ci-dessus, on n’observe pas réellement de modification dans les enregistrements. Ce qui nous à amené à penser qu’il n y a pas de distinction claire entre la distribution des erreurs et les bonnes réponses effectuées pour chacun des essais entre les deux stimuli que nous avons utilisé : V6 et V8. C’est donc après avoir mesuré la « quantité d’énergie » que nous avons proposé que la variabilité observée dans les résultats serait probablement d’origine centrale.

The Power catechism; correct answers to direct questions covering the main principles of steam engineering and the transmission of power.

Mode of access: Internet.

The empirical metallicity dependence of the mass-loss rate of O- and early B-type stars

We present a comprehensive study of the observational dependence of the mass-loss rate in stationary stellar winds of hot massive stars on the metal content of their atmospheres. The metal content of stars in the Magellanic Clouds is discussed, and a critical assessment is given of state-of-the-art mass-loss determinations of OB stars in these two satellite systems and the Milky-Way. Assuming a power-law dependence of mass loss on metal content,. M. Z(m), and adopting a theoretical relation between the terminal flow velocity and metal content, v(infinity). Z(0.13) (Leitherer et al. 1992, ApJ, 401, 596), we find m = 0.83 +/- 0.16 for non-clumped outflows from an analysis of the wind momentum luminosity relation (WLR) for stars more luminous than 105.2 L circle dot. Within the errors, this result is in agreement with the prediction m = 0.69 +/- 0.10 by Vink et al. (2001, A& A, 369, 574). Absolute empirical values for the mass loss, based on Ha and ultraviolet (UV) wind lines, are found to be a factor of two higher than predictions in this high luminosity regime. If this difference is attributed to inhomogeneities in the wind, and this clumping does not impact the predictions, this would imply that luminous O and early-B stars have clumping factors in their Ha and UV line forming regions of about a factor of four. For lower luminosity stars, the winds are so weak that their strengths can generally no longer be derived from optical spectral lines (essentially Ha) and one must currently rely on the analysis of UV lines. We confirm that in this low-luminosity domain the observed Galactic WLR is found to be much steeper than expected from theory (although the specific sample is rather small), leading to a discrepancy between UV mass-loss rates and the predictions by a factor 100 at luminosities of L similar to 10(4.75) L circle dot, the origin of which is unknown. We emphasize that even if the current mass-loss rates of hot luminous stars would turn out to be overestimated as a result of wind clumping, but the degree of clumping would be rather independent of metallicity, the scalings derived in this study are expected to remain correct.

Simple training tool is insufficient for appropriate diagnosis and treatment of malnutrition: A pre-post intervention study in a tertiary center.

OBJECTIVES To improve malnutrition awareness and management in our department of general internal medicine; to assess patients' nutritional risk; and to evaluate whether an online educational program leads to an increase in basic knowledge and more frequent nutritional therapies. METHODS A prospective pre-post intervention study at a university department of general internal medicine was conducted. Nutritional screening using Nutritional Risk Score 2002 (NRS 2002) was performed, and prescriptions of nutritional therapies were assessed. The intervention included an online learning program and a pocket card for all residents, who had to fill in a multiple-choice questions (MCQ) test about basic nutritional knowledge before and after the intervention. RESULTS A total of 342 patients were included in the preintervention phase, and 300 were in the postintervention phase. In the preintervention phase, 54.1% were at nutritional risk (NRS 2002 ≥3) compared with 61.7% in the postintervention phase. There was no increase in the prescription of nutritional therapies (18.7% versus 17.0%). Forty-nine and 41 residents (response rate 58% and 48%) filled in the MCQ test before and after the intervention, respectively. The mean percentage of correct answers was 55.6% and 59.43%, respectively (which was not significant). Fifty of 84 residents completed the online program. The residents who participated in the whole program scored higher on the second MCQ test (63% versus 55% correct answers, P = 0.031). CONCLUSIONS Despite a high ratio of malnourished patients, the nutritional intervention, as assessed by nutritional prescriptions, is insufficient. However, the simple educational program via Internet and usage of NRS 2002 pocket cards did not improve either malnutrition awareness or nutritional treatment. More sophisticated educational systems to fight malnutrition are necessary.

Repair of x-ray-induced DNA double-strand breaks in specific Not I restriction fragments in human fibroblasts: joining of correct and incorrect ends.

An assay that allows measurement of absolute induction frequencies for DNA double-strand breaks (dsbs) in defined regions of the genome and that quantitates rejoining of correct DNA ends has been used to study repair of dsbs in normal human fibroblasts after x-irradiation. The approach involves hybridization of single-copy DNA probes to Not I restriction fragments separated according to size by pulsed-field gel electrophoresis. Induction of dsbs is quantitated from the decrease in the intensity of the hybridizing restriction fragment and an accumulation of a smear below the band. Rejoining of dsbs results in reconstitution of the intact restriction fragment only if correct DNA ends are joined. By comparing results from this technique with results from a conventional electrophoresis assay that detects all rejoining events, it is possible to quantitate the misrejoining frequency. Three Not I fragments on the long arm of chromosome 21 were investigated with regard to dsb induction, yielding an identical induction rate of 5.8 X 10(-3) break per megabase pair per Gy. Correct dsb rejoining was measured for two of these Not I fragments after initial doses of 80 and 160 Gy. The misrejoining frequency was about 25% for both fragments and was independent of dose. This result appears to be representative for the whole genome as shown by analysis of the entire Not I fragment distribution. The correct rejoining events primarily occurred within the first 2 h, while the misrejoining kinetics included a much slower component, with about half of the events occurring between 2 and 24 h. These misrejoining kinetics are similar to those previously reported for production of exchange aberrations in interphase chromosomes.

Sociality and the rate of molecular evolution

The molecular clock does not tick at a uniform rate in all taxa but maybe influenced by species characteristics. Eusocial species (those with reproductive division of labor) have been predicted to have faster rates of molecular evolution than their nonsocial relatives because of greatly reduced effective population size; if most individuals in a population are nonreproductive and only one or few queens produce all the offspring, then eusocial animals could have much lower effective population sizes than their solitary relatives, which should increase the rate of substitution of nearly neutral mutations. An earlier study reported faster rates in eusocial honeybees and vespid wasps but failed to correct for phylogenetic nonindependence or to distinguish between potential causes of rate variation. Because sociality has evolved independently in many different lineages, it is possible to conduct a more wide-ranging study to test the generality of the relationship. We have conducted a comparative analysis of 25 phylogenetically independent pairs of social lineages and their nonsocial relatives, including bees, wasps, ants, termites, shrimps, and mole rats, using a range of available DNA sequences (mitochondrial and nuclear DNA coding for proteins and RNAs, and nontranslated sequences). By including a wide range of social taxa, we were able to test whether there is a general influence of sociality on rates of molecular evolution and to test specific predictions of the hypothesis: (1) that social species have faster rates because they have reduced effective population sizes; (2) that mitochondrial genes would show a greater effect of sociality than nuclear genes; and (3) that rates of molecular evolution should be correlated with the degree of sociality. We find no consistent pattern in rates of molecular evolution between social and nonsocial lineages and no evidence that mitochondrial genes show faster rates in social taxa. However, we show that the most highly eusocial Hymenoptera do have faster rates than their nonsocial relatives. We also find that social parasites (that utilize the workers from related species to produce their own offspring) have faster rates than their social relatives, which is consistent with an effect of lower effective population size on rate of molecular evolution. Our results illustrate the importance of allowing for phylogenetic nonindependence when conducting investigations of determinants of variation in rate of molecular evolution.

Target/error overlap in jargonaphasia:the case for a one-source model, lexical and non-lexical summation, and the special status of correct responses

We present three jargonaphasic patients who made phonological errors in naming, repetition and reading. We analyse target/response overlap using statistical models to answer three questions: 1) Is there a single phonological source for errors or two sources, one for target-related errors and a separate source for abstruse errors? 2) Can correct responses be predicted by the same distribution used to predict errors or do they show a completion boost (CB)? 3) Is non-lexical and lexical information summed during reading and repetition? The answers were clear. 1) Abstruse errors did not require a separate distribution created by failure to access word forms. Abstruse and target-related errors were the endpoints of a single overlap distribution. 2) Correct responses required a special factor, e.g., a CB or lexical/phonological feedback, to preserve their integrity. 3) Reading and repetition required separate lexical and non-lexical contributions that were combined at output.

Elementary classroom teachers' knowledge of tort liability for negligence

The purpose of this research study was to investigate the legal knowledge of Florida's public elementary classroom teachers in the area of tort liability for negligence. A second purpose of the study was to assess the knowledge of school law in the area of negligence according to specific variables to determine if significant differences in knowledge existed among groups of teachers classified by: years of teaching experience, whether or not teachers took a school law course or inservice, college degree held and whether or not teachers had administrative experience. A validated survey instrument consisting of 22 scenarios based on decided court cases in the United States was utilized. These cases included court decisions ranging from 1938–1994, and represented the categories of duty and standard of care, proper instruction, proper supervision, proper maintenance, field trips, and post-injury treatment. ^ A random sample of 420 elementary classroom teachers were sent the survey instrument to complete, and a total of 309 surveys were returned producing a return rate of 77%. The results of this research study revealed that the overall level of legal knowledge of public elementary classroom teachers in the State of Florida produced a mean percent correct of 53%. The range of scores varied from 18%–82%, with the approximate average of correct answers of 12 out of 22. The category of proper instruction produced the lowest mean percent correct of 35%, and the area of post-injury treatment yielded the highest mean percent correct of 78%. ^ The findings of this study emphasize the necessity of preparing teachers regarding their legal rights, duties and responsibilities. The need for teachers to receive training at the preservice and inservice levels has become clear by this study. ^

Ammonium excretion and respiration rate of tropical copepods and euphausiids measured during METEOR cruise M93, M97 and Maria S. Merian cruise MSM22

Respiration and ammonium excretion rates at different oxygen partial pressure were measured for calanoid copepods and euphausiids from the Eastern Tropical South Pacific and the Eastern Tropical North Atlantic. All specimens used for experiments were caught in the upper 400 m of the water column and only animals appearing unharmed and fit were used for experiments. Specimens were sorted, identified and transferred into aquaria with filtered, well-oxygenated seawater immediately after the catch and maintained for 1 to 13 hours prior to physiological experiments at the respective experimental temperature. Maintenance and physiological experiments were conducted in darkness in temperature-controlled incubators at 11, 13 or 23 degree C (±1). Before and during experiments, animals were not fed. Respiration and ammonium excretion rate measurements (both in µmol h-1 gDW-1) at varying oxygen concentrations were conducted in 12 to 60 mL gas-tight glass bottles. These were equipped with oxygen microsensors (ø 3 mm, PreSens Precision Sensing GmbH, Regensburg, Germany) attached to the inner wall of the bottles to monitor oxygen concentrations non-invasively. Read-out of oxygen concentrations was conducted using multi-channel fiber optic oxygen transmitters (Oxy-4 and Oxy-10 mini, PreSens Precision Sensing GmbH, Regensburg, Germany) that were connected via optical fibers to the outside of the bottles directly above the oxygen microsensor spots. Measurements were started at pre-adjusted oxygen and carbon dioxide levels. For this, seawater stocks with adjusted pO2 and pCO2 were prepared by equilibrating 3 to 4 L of filtered (0.2 µm filter Whatman GFF filter) and UV - sterilized (Aqua Cristal UV C 5 Watt, JBL GmbH & Co. KG, Neuhofen, Germany) water with premixed gases (certified gas mixtures from Air Liquide) for 4 hours at the respective experimental temperature. pCO2 levels were chosen to mimic the environmental pCO2 in the ETSP OMZ or the ETNA OMZ. Experimental runs were conducted with 11 to 15 trial incubations (1 or 2 animals per incubation bottle and three different treatment levels) and three animal-free control incubations (one per experimental treatment). During each run, experimental treatments comprised 100% air saturation as well as one reduced air saturation level with and without CO2. Oxygen concentrations in the incubation bottles were recorded every 5 min using the fiber-optic microsensor system and data recording for respiration rate determination was started immediately after all animals were transferred. Respiration rates were calculated from the slope of oxygen decrease over selected time intervals. Chosen time intervals were 20 to 105 min long. No respiration rate was calculated for the first 20 to 60 min after animal transfer to avoid the impact of enhanced activity of the animal or changes in the bottle water temperature during initial handling on the respiration rates and oxygen readings. Respiration rates were obtained over a maximum of 16 hours incubation time and slopes were linear at normoxia to mild hypoxia. Respiration rates in animal-free control bottles were used to correct for microbial activity. These rates were < 2% of animal respiration rates at normoxia. Samples for the measurement of ammonium concentrations were taken after 2 to 10 hours incubation time. Ammonium concentration was determined fluorimetrically (Holmes et al., 1999). Ammonium excretion was calculated as the concentration difference between incubation and animal-free control bottles. Some specimens died during the respiration and excretion rate measurements, as indicated by a cessation of respiration. No excretion rate measurements were conducted in this case, but the oxygen level at which the animal died was noted.

Inferior field loss increases rate of falls in older adults with glaucoma

PURPOSE: To examine the visual predictors of falls and injurious falls among older adults with glaucoma. METHODS: Prospective falls data were collected for 71 community-dwelling adults with primary open-angle glaucoma, mean age 73.9 ± 5.7 years, for one year using monthly falls diaries. Baseline assessment of central visual function included high-contrast visual acuity and Pelli-Robson contrast sensitivity. Binocular integrated visual fields were derived from monocular Humphrey Field Analyser plots. Rate ratios (RR) for falls and injurious falls with 95% confidence intervals (CIs) were based on negative binomial regression models. RESULTS: During the one year follow-up, 31 (44%) participants experienced at least one fall and 22 (31%) experienced falls that resulted in an injury. Greater visual impairment was associated with increased falls rate, independent of age and gender. In a multivariate model, more extensive field loss in the inferior region was associated with higher rate of falls (RR 1.57, 95%CI 1.06, 2.32) and falls with injury (RR 1.80, 95%CI 1.12, 2.98), adjusted for all other vision measures and potential confounding factors. Visual acuity, contrast sensitivity, and superior field loss were not associated with the rate of falls; topical beta-blocker use was also not associated with increased falls risk. CONCLUSIONS: Falls are common among older adults with glaucoma and occur more frequently in those with greater visual impairment, particularly in the inferior field region. This finding highlights the importance of the inferior visual field region in falls risk and assists in identifying older adults with glaucoma at risk of future falls, for whom potential interventions should be targeted. KEY WORDS: glaucoma, visual field, visual impairment, falls, injury

Factors of process model comprehension : findings from a series of experiments

In order to make good decisions about the design of information systems, an essential skill is to understand process models of the business domain the system is intended to support. Yet, little knowledge to date has been established about the factors that affect how model users comprehend the content of process models. In this study, we use theories of semiotics and cognitive load to theorize how model and personal factors influence how model viewers comprehend the syntactical information of process models. We then report on a four-part series of experiments, in which we examined these factors. Our results show that additional semantical information impedes syntax comprehension, and that theoretical knowledge eases syntax comprehension. Modeling experience further contributes positively to comprehension efficiency, measured as the ratio of correct answers to the time taken to provide answers. We discuss implications for practice and research.