Influence of portal vein occlusion on portal flow and liver elasticity in an animal model

Hepatic fibrosis causes an increase in liver stiffness, a parameter measured by elastography and widely used as a diagnosis method. The concomitant presence of portal vein thrombosis (PVT) implies a change in hepatic portal inflow that could also affect liver elasticity. The main objective of this study is to determine the extent to which the presence of portal occlusion can affect the mechanical properties of the liver and potentially lead to misdiagnosis of fibrosis and hepatic cirrhosis by elastography. Portal vein occlusion was generated by insertion and inflation of a balloon catheter in the portal vein of four swines. The portal flow parameters peak flow (PF) and peak velocity magnitude (PVM) and liver mechanical properties (shear modulus) were then investigated using 4D-flow MRI and MR elastography, respectively, for progressive obstructions of the portal vein. Experimental results indicate that the reduction of the intrahepatic venous blood flow (PF/PVM decreases of 29.3%/8.5%, 51.0%/32.3% and 83.3%/53.6%, respectively) measured with 50%, 80% and 100% obstruction of the portal vein section results in a decrease of liver stiffness by $0.8\%\pm0.1\%$, $7.7\%\pm0.4\%$ and $12.3\%\pm0.9\%$, respectively. While this vascular mechanism does not have sufficient influence on the elasticity of the liver to modify the diagnosis of severe fibrosis or cirrhosis (F4 METAVIR grade), it may be sufficient to attenuate the increase in stiffness due to moderate fibrosis (F2-F3 METAVIR grades) and consequently lead to false-negative diagnoses with elastography in the presence of PVT

Magnetic Resonance Elastography and Portal Hypertension: Influence of the Portal Venous Flow on the Liver Stiffness

International audienceThe invasive measurement of the hepatic venous pressure gradient is still considered as the reference method to assess the severity of portal hypertension. Even though previous studies have shown that the liver stiffness measured by elastography could predict portal hypertension in patients with chronic liver disease, the mechanisms behind remain today poorly understood. The main reason is that the liver stiffness is not specific to portal hypertension and is also influenced by concomitant pathologies, such as cirrhosis. Portal hypertension is also source of a vascular incidence, with a substantial diversion of portal venous blood to the systemic circulation, bypassing the liver. This study focuses on this vascular effect of portal hypertension. We propose to generate and control the portal venous flow (to isolate the modifications in the portal venous flow as single effect of portal hypertension) in an anesthetized pig and then to quantify its implications on liver stiffness by an original combination of MRE and 4D-Flow Magnetic Resonance Imaging (MRI). A catheter balloon is progressively inflated in the portal vein and the peak flow, peak velocity magnitude and liver stiffness are quantified in a 1.5T MRI scanner (AREA, Siemens Healthcare, Erlangen, Germany). A strong correlation is observed between the portal peak velocity magnitude, the portal peak flow or the liver stiffness and the portal vein intraluminal obstruction. Moreover, the comparison of mechanical and flow parameters highlights a correlation with the possibility of identifying linear relationships. These results give preliminary indications about how liver stiffness can be affected by portal venous flow and, by extension, by hypertension

Early Inflammatory Markers for the Diagnosis of Late-Onset Sepsis in Neonates: The Nosodiag Study

Background: Early diagnosis is essential to improve the treatment and prognosis of newborn infants with nosocomial bacterial infections. Although cytokines and procalcitonin (PCT) have been evaluated as early inflammatory markers, their diagnostic properties have rarely been compared.Objectives: This study evaluated and compared the ability of individual inflammatory markers available for clinician (PCT, semi-quantitative determination of IL-8) and of combinations of markers (CRPi plus IL-6 or quantitative or semi-quantitative determination of IL-8) to diagnose bacterial nosocomial infections in neonates.Methods: This prospective two-center study included neonates suspected of nosocomial infections from September 2008 to January 2012. Inflammatory markers were measured initially upon suspicion of nosocomial infection, and CRP was again measured 12–24 h later. Newborns were retrospectively classified into two groups: those who were infected (certainly or probably) and uninfected (certainly or probably).Results: The study included 130 infants of median gestational age 28 weeks (range, 24–41 weeks). Of these, 34 were classified as infected and 96 as uninfected. The sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (LR+ and LR-) for PCT were 59.3% (95% confidence interval [CI], 38.8–77.6%), 78.5% (95% CI, 67.8–86.9%), 48.5% (95% CI, 30.8–66.5%), 84.9% (95% CI, 74.6–92.2%), 2.7 (95% CI, 1.6–4.9), and 0.5 (95% CI, 0.3–0.8), respectively. Semi-quantitative IL-8 had the highest specificity (92.19%; 95% CI, 82.70–97.41%), PPV (72.22%; 95% CI, 46.52–90.30%) and LR+ (6.17, 95% CI, 2.67–28.44), but had low specificity (48.15%; 95% CI, 28.67–68.05%). Of all markers tested, the combination of IL-6 and CRPi had the highest sensitivity (78.12%; 95% CI, 60.03–90.72%), NPV (91.3%; 95% CI, 82.38–96.32%) and LR- (0.29; 95% CI, 0.12–0.49). The combination of IL-6 and CRPi had a higher area under the curve than PCT, but with borderline significance (p = 0.055).Conclusions: The combination of IL-6 and CRPi was superior to other methods, including PCT, for the early diagnosis of nosocomial infection in neonates, but was not sufficient for sole use. The semi-quantitative determination of IL-8 had good diagnostic properties but its sensitivity was too low for use in clinical practice

La violence conjugale (une transgression révélatrice des normes de la conjugalité contemporaine)

Jamais il n'a été autant question de violence conjugale. Jamais elle n'aura autant choqué, conciliant durablement ce que la société définit comme incompatible : l'amour et la violence. Le présent travail est le fruit d'un pari : celui qu'en donnant la parole à des femmes, des hommes, dont certains ont affronté la violence conjugale, tandis que d'autres sont des conjoints "sans histoires", il serait possible de comprendre comment amour et violence peuvent co-exister. Tous ont parlé de leur vie de couple, c'est-à-dire de la façon dont ils s'étaient faits l'un à l'autre. Tous ont, ce faisant, révélé que la violence, sous toutes ses formes, n'est nullement chose exceptionnelle dans le couple. En effet, l'ajustement conjugal exige de la souplesse, car il s'agit de négocier pour parvenir à s'entendre ou de changer certaines habitudes pour ne pas heurter l'autre. Or, cette capacité n'est pas à la portée de tous les conjoints, mais dépend de leurs compétences relationnelles, et plus profondément, de leur estime de soi. C'est ainsi que dans certains couples, la violence, en prenant appui sur la dynamique conjugale, peut s'aggraver jusqu'à transformer la relation en une situation de non-droit, l'un des conjoints se retrouvant alors en situation de violence conjugale. Dans sa représentation sociale, la violence conjugale est souvent mise en scène comme une relation "à part", comme si elle échappait au social et que ses protagonistes soient des "outsiders" (Becker 1985). Cette thèse a été conçue dans l'idée d'un lien entre ce type de relation, marqué par une violence extrême, et d'autres types de relations conjugales, marquées par des formes de violence plus ordinaires ; ce lien est le lien conjugal. Si la connaissance de la violence conjugale passe par la connaissance du couple "tout court", c'est qu'elle en est indissociable : la définition d'une forme de conjugalité transgressive renvoie en effet nécessairement à la conjugalité dans la norme, qu'elle révèle.Never has marital abuse been spoken about so much. Never has it been so shocking, putting together durably what society defines as incompatible : love and violence. This work is the consequence of a bet : the bet is that allowing women and men to speak -some of them having faced marital abuse, whereas others are "standard" wives and husbands- would allow the understanding of how love and violence can co-exist. All of them have been interwieved to know how they had built up their married life. All of them have revealed that violence, under all its forms, is not an exception within the couple. As a matter of fact, marital adaptation requires flexibility, to be able to negociate or even to change habits, in order to avoid hurting one's partner. But all partners do not have this capacity, which depends on their relation skills and more deeply, on their self-esteem. In a number of couples, it happens that violence, being supported by "marital dynamics", increases until it turns the relation into a situation in which one of the partners has no rights any more, which is the very definition of marital abuse. In its social representation, marital abuse is often presented as a special relation, as though it didn't belong to common social behaviour, and as though those who suffer from it were "outsiders" (Becker 1985). This thesis is based on the idea of the existence of a link between ixtremely violent relationships and other types of married relationships, which include more common forms of violence ; this link is the marriage link. If knowing about marital abuse implies knowing about the "standard couple", it is because the two of them cannot be dissociated : in other words the definition of a transgressive form of married life can be made only in reference to what is defined as a normal form of married life. "Abuse" reveals what is "normality" ; "normality" enlightens what "abuse" is supposed to be.PARIS5-BU Saints-Pères (751062109) / SudocSudocFranceF

Prise en charge des accidents ischémiques transitoires dans les établissements de santé, en Alsace en 2010

STRASBOURG-Medecine (674822101) / SudocSudocFranceF

Évaluer la réflexivité à travers les traces écrites d’apprentissage des étudiants en santé : traduction et adaptation interculturelle de la grille REFLECT

Contexte : La réflexivité est considérée par de nombreux auteurs comme une composante essentielle du professionnalisme, tout en étant au cœur du développement de ce dernier et de l’identité professionnelle. Le portfolio, outil de soutien de l’apprentissage et d’évaluation en médecine générale, comporte des traces écrites d’apprentissage à visée réflexive. Il n’existe pas d’outil validé en langue française permettant d’évaluer la réflexivité au travers des traces écrites d’apprentissage. But : L’objectif de cette étude est donc d’adapter la grille REFLECT, validée en anglais, pour un usage en langue française. Méthode : Un processus de double traduction puis double rétro-traduction a été mené afin de garantir une adaptation interculturelle respectant le sens de la version originale. Des tests pilotes ont été menés sur la version française préliminaire avec évaluation de la validité de contenu. Résultats : L’évaluation de la clarté de la version française a conduit à une version finale comportant 5 critères ayant chacun 4 niveaux d’évaluation possibles. La version française de la grille REFLECT présente une validité de contenu élevée. Conclusion : L’utilisation de la grille REFLECT en français permettra vraisemblablement d’optimiser le développement de la réflexivité chez les internes en médecine générale et de faciliter la rétroaction par les superviseurs

Construct and predictive validity of the Strength of Motivation for Medical School-Revised (SMMS-R) questionnaire: a French validation study

Motivation is a major indicator of students' learning behaviors. Therefore, researchers require consistent and valid instruments to assess students' motivation. Consequently, motivation has been an important topic in medical education research for the last decade. The present study evaluated the construct and predictive validities of the French version of the Strength of Motivation for Medical School-Revised questionnaire (SMMS-R-FR). Our sample comprised 372 students at three French-speaking medical schools, who filled in the SMMS-R-FR and the Revised two-factor Study Process Questionnaire (R2-SPQ). Results confirmed the three-factor structure of the original SMMS-R questionnaire. Reliabilities were good for the Total Strength of Motivation scale, moderate for the Willingness to Sacrifice and Readiness to Start subscales, and poor (but still acceptable) for the Persistence subscale. Both Total Strength of Motivation and Readiness to Start positively predicted a deep learning approach and negatively predicted a surface learning approach, while Willingness to Sacrifice positively predicted a deep learning approach and Persistence negatively predicted a surface learning approach. Our results both support the SMMS-R- FR's suitability as a tool for measuring motivation in medical students, and suggest that it could be used to guide the development of educational interventions to strengthen motivation