Usability of a Web-based Software Tool for History Taking in the Emergency Department.

Medical history taking is an important step within the diagnostic process. This study aims to assess the quality and usability (effectiveness, satisfaction, efficiency) of a web-based medical history taking app in the emergency department. During three weeks, patients and junior physicians filled out study questionnaires about the app. Senior physicians rated the quality of medical histories taken by junior physicians and app. In 241 patients, the studied app showed excellent usability with patients not in need of immediate medical attention. Senior physicians rated medical histories as more complete when app was used by patients in comparison to conventional history taking alone (p<0.01). Current app could not substitute medical history taking by physicians, but could definitely rather be used to gather ancillary information.

Impact of gadolinium-based contrast agents on the growth of fish cells lines.

The present study was the first approach conducted under environmental concentrations of Gd-DOTA and Gd-DTPA-BMA to assess cellular impacts of these compounds. Gd-DOTA (Gadoteric acid) is one of the most stable contrast agent, currently used as Dotarem® formulation during Magnetic Resonance Imaging exams. The study was mainly performed on a Zebra Fish cell line (ZF4; ATCC CRL-2050). At the concentrations of 0.127 nM and 63.59 nM (respectively 20 ng and 10 µg of Gd/L), we did not observed any toxicity of Dotarem® but a slowdown of the cell growth was clearly measured. The effect is independent of medium renewing during 6 days of cell culturing. The same effect was observed i-with Gd-DOTA on another fish cell line (RT W1 gills; ATCC CRL-2523) and ii-with another contrast agent (Gd-DTPA-BMA - Omniscan®) on ZF4 cells. On the ZF4 cell line, the diminution of the cell growth was of the same order during 20 days of exposure to a culture medium spiked with 63.59 nM of Dotarem® and was reversible within the following 8 days when Dotarem® was removed from the medium. As shown by using modified DOTA structure (Zn-DOTA), the effect may be due to the chelating structure of the contrast agent rather than to the Gd ion. Until now, the main attention concerning the impact of Gd-CA on living cells concerned the hazard due to Gd release. According to our results, quantifying the presence of Gd-CA chelating structures in aquatic environments must be also monitored.

Assessment of risk factors for candidemia in non-neutropenic patients hospitalized in Internal Medicine wards: A multicenter study.

BACKGROUND: An increasing prevalence of candidemia has been reported in Internal Medicine wards (IMWs). The aim of our study was to identify risk factors for candidemia among non-neutropenic patients hospitalized in IMWs. METHODS: A multicenter case-control study was performed in three hospitals in Italy. Patients developing candidemia (cases) were compared to patients without candidemia (controls) matched by age, time of admission and duration of hospitalization. A logistic regression analysis identified risk factors for candidemia, and a new risk score was developed. Validation was performed on an external cohort of patients. RESULTS: Overall, 951 patients (317 cases of candidemia and 634 controls) were included in the derivation cohort, while 270 patients (90 patients with candidemia and 180 controls) constituted the validation cohort. Severe sepsis or septic shock, recent Clostridium difficile infection, diabetes mellitus, total parenteral nutrition, chronic obstructive pulmonary disease, concomitant intravenous glycopeptide therapy, presence of peripherally inserted central catheter, previous antibiotic therapy and immunosuppressive therapy were factors independently associated with candidemia. The new risk score showed good area under the curve (AUC) values in both derivation (AUC 0.973 95% CI 0.809-0.997, p<0.001) and validation cohort (0.867 95% CI 0.710-0.931, p<0.001). A threshold of 3 leads to a sensitivity of 87% and a specificity of 83%. CONCLUSION: Non-neutropenic patients admitted in IMWs have peculiar risk factors for candidemia. A new risk score with a good performance could facilitate the identification of candidates to early antifungal therapy.

Gender inequalities in the response to combination antiretroviral therapy over time: the Swiss HIV Cohort Study.

OBJECTIVES: Gender-specific data on the outcome of combination antiretroviral therapy (cART) are a subject of controversy. We aimed to compare treatment responses between genders in a setting of equal access to cART over a 14-year period. METHODS: Analyses included treatment-naïve participants in the Swiss HIV Cohort Study starting cART between 1998 and 2011 and were restricted to patients infected by heterosexual contacts or injecting drug use, excluding men who have sex with men. RESULTS: A total of 3925 patients (1984 men and 1941 women) were included in the analysis. Women were younger and had higher CD4 cell counts and lower HIV RNA at baseline than men. Women were less likely to achieve virological suppression < 50 HIV-1 RNA copies/mL at 1 year (75.2% versus 78.1% of men; P = 0.029) and at 2 years (77.5% versus 81.1%, respectively; P = 0.008), whereas no difference between sexes was observed at 5 years (81.3% versus 80.5%, respectively; P = 0.635). The probability of virological suppression increased in both genders over time (test for trend, P < 0.001). The median increase in CD4 cell count at 1, 2 and 5 years was generally higher in women during the whole study period, but it gradually improved over time in both sexes (P < 0.001). Women also were more likely to switch or stop treatment during the first year of cART, and stops were only partly driven by pregnancy. In multivariate analysis, after adjustment for sociodemographic factors, HIV-related factors, cART and calendar period, female gender was no longer associated with lower odds of virological suppression. CONCLUSIONS: Gender inequalities in the response to cART are mainly explained by the different prevalence of socioeconomic characteristics in women compared with men.

[Asymptomatic facial infiltrated papules in an HIV-positive male]. / Unklare asymptomatische infiltrierte Papeln im Gesicht eines HIV-infizierten Mannes.

A 65 year old HIV-infected patient (CDC A2, diagnosed in 07/2008) presented with facial, erythematous infiltrated papular lesions. Consistent with progressive immunodeficiency a low CD4+ T-cell count and an increase of the viral load was seen simultaneously and an eosinophilic pustular folliculitis (EPF) was assumed. Though, the lesional biopsy revealed a follicular eosinophilic infiltration and endotrichial hyphae, proving for an infiltrating dermatophytosis. This shows how an infiltrating Tinea faciei is mimicking clinically and histologically an HIV-associated EPF of the face.

Specificities of platelet autoantibodies and platelet activation in lupus anticoagulant patients: a relation to their history of thromboembolic disease.

Lupus anticoagulants (LA) prolong in vitro phospholipid-dependent coagulation tests, but are associated with thromboembolic disease (TE). However, a subgroup of individuals with LA has no TE, and it is therefore desirable to distinguish those at risk for TE from those without. Whether platelets have a primary role in the development of TE is not clear yet. We determined platelet autoantibodies to identify a specific platelet target which is associated with platelet activation in 97 patients with a long history of detectable LA, 65 patients with TE (LA/TE+), and 32 individuals without TE (LA/TE-). Thrombocytopenia was more common in the LA/TE- than in the LA/TE+ group (P < 0.05). Both groups had platelet antibodies, but the frequency of antibodies was lower in LA/TE+ than LA/TE- patients (P < 0.01), who had higher antibody titres against glycoprotein IIb/IIIa and glycoprotein Ib/IX (P < 0.05). Also, their platelets were more activated, as determined by PAC-1 binding (P < 0.01). These differences were also noted if patients with arterial thrombosis were evaluated separately. These findings in LA/TE- individuals were similar to those in patients with chronic autoimmune thrombocytopenia. However, there was no autoantibody target identifiable to distinguish between LA/TE- from LA-TE+ individuals. We therefore conclude that the presence of platelet antibodies, even if associated with platelet activation, is not sufficient to dispose LA patients to thromboembolic disease.

Coevolution and subsite decomposition for the design of resistance-evading HIV-1 protease inhibitors.

Drug resistance sharply limits the effectiveness of human immunodeficiency virus (HIV) protease inhibitors in acquired immunodeficiency syndrome therapy. In previous work, we presented methods for design of resistance-evading inhibitors using a computational coevolution technique. Here, we report subsite decomposition experiments that examine the relative importance and roles of each subsite in HIV protease, and the constraints on robust inhibitor design that are imposed by possible resistance mutations in each subsite. The results identify several structural features of robust resistance-evading inhibitors for use in drug design, and show their basis in the constraints imposed by the range of allowable mutation in the protease. In particular, the results identify the P3 and P3' sites as being particularly sensitive to protease mutation: inhibitors designed to fill the S3 and S3' sites of the wild-type protease will be susceptible to viral resistance, but inhibitors with side-chains smaller than a phenylalanine residue at P3 and P3', preferably medium-sized amino acids in the range from valine to leucine and isoleucine residues, will be more robust in the face of protease resistance mutation.

Coevolutionary analysis of resistance-evading peptidomimetic inhibitors of HIV-1 protease.

We have developed a coevolutionary method for the computational design of HIV-1 protease inhibitors selected for their ability to retain efficacy in the face of protease mutation. For HIV-1 protease, typical drug design techniques are shown to be ineffective for the design of resistance-evading inhibitors: An inhibitor that is a direct analogue of one of the natural substrates will be susceptible to resistance mutation, as will inhibitors designed to fill the active site of the wild-type or a mutant enzyme. Two design principles are demonstrated: (i) For enzymes with broad substrate specificity, such as HIV-1 protease, resistance-evading inhibitors are best designed against the immutable properties of the active site-the properties that must be conserved in any mutant protease to retain the ability to bind and cleave all of the native substrates. (ii) Robust resistance-evading inhibitors can be designed by optimizing activity simultaneously against a large set of mutant enzymes, incorporating as much of the mutational space as possible.

Trace metals analysis in estuarine and seawater by ICP-MS using on line preconcentration and matrix elimination with chelating resin.

The main difficulties of trace metals analysis in estuarine and seawater stem from their very low concentration (mug/l to sub-mug/l), and, by contrast, the high salt content (up to 38 g/l in the Mediterranean Sea). ICP-MS allows multi-elemental analysis and offers great sensitivity, but may be strongly affected by matrix effects induced by high salt contents (> 1 g/l). To perform trace metals analysis both in riverine, estuarine and seawater, we have developed a hyphenated method: ion chelation chromatography coupled on-line with ICP-MS. Iminodiacetate resin, Metpac CC-1 (Dionex), was used to concentrate most of the trace metals, and to separate them from alkaline and alkaline-earth metals. Behaviour of 17 elements (Pb, Cu, Cd, Ni, U, Cr, Mn, Al, Co, Ga, In, Zn, V, Tl, Bi, Ag and Sn) towards the resin was qualitatively investigated. A method validation, partly derived from AFNOR standard XPT 90-210, was carried out on 12 elements (Pb, Cu, Cd, Ni, U, Cr, Mn, Al, Co, Ga, Bi and In). Replicate measurements of multi-elemental standard solutions were used to check linearity, and to determine repeatability and detection limits. Method accuracy was then assessed by analysing two certified materials: a synthetic freshwater (SRM 1643d), and a natural filtered coastal seawater (NRCC CASS-3). An application assay of natural samples from the Rhône river (France) was eventually carried out, and the analytical results were found to be consistent with previous works.

Computational coevolution of antiviral drug resistance.

An understanding of antiviral drug resistance is important in the design of effective drugs. Comprehensive features of the interaction between drug designs and resistance mutations are difficult to study experimentally because of the very large numbers of drugs and mutants involved. We describe a computational framework for studying antiviral drug resistance. Data on HIV-1 protease are used to derive an approximate model that predicts interaction of a wide range of mutant forms of the protease with a broad class of protease inhibitors. An algorithm based on competitive coevolution is used to find highly resistant mutant forms of the protease, and effective inhibitors against such mutants, in the context of the model. We use this method to characterize general features of inhibitors that are effective in overcoming resistance, and to study related issues of selection pathways, cross-resistance, and combination therapies.

New methods for competitive coevolution.

We consider "competitive coevolution," in which fitness is based on direct competition among individuals selected from two independently evolving populations of "hosts" and "parasites." Competitive coevolution can lead to an "arms race," in which the two populations reciprocally drive one another to increasing levels of performance and complexity. We use the games of Nim and 3-D Tic-Tac-Toe as test problems to explore three new techniques in competitive coevolution. "Competitive fitness sharing" changes the way fitness is measured; "shared sampling" provides a method for selecting a strong, diverse set of parasites; and the "hall of fame" encourages arms races by saving good individuals from prior generations. We provide several different motivations for these methods and mathematical insights into their use. Experimental comparisons are done, and a detailed analysis of these experiments is presented in terms of testing issues, diversity, extinction, arms race progress measurements, and drift.

An oscillation-based model for the neuronal basis of attention.

We propose a model for the neuronal implementation of selective visual attention based on the temporal structure of neuronal activity. In particular, we set out to explain the electrophysiological data from areas V4 and IT in monkey cortex of Moran and Desimone [(1985) Science, 229, 782-784] using the "temporal tagging" hypothesis of Crick and Koch [(1990a) Cold Spring Harbor Symposiums in Quantitative Biology, LV, 953-962; (1990b) Seminars in the neurosciences (pp. 1-36)]. Neurons in primary visual cortex respond to visual stimuli with a Poisson distributed spike train with an appropriate, stimulus-dependent mean firing rate. The firing rate of neurons whose receptive fields overlap with the "focus of attention" is modulated with a periodic function in the 40 Hz range, such that their mean firing rate is identical to the mean firing rate of neurons in "non-attended" areas. This modulation is detected by inhibitory interneurons in V4 and is used to suppress the response of V4 cells associated with non-attended visual stimuli. Using very simple single-cell models, we obtain quantitative agreement with Moran and Desimone's (1985) experiments.