Stratégie d'optimisation hémodynamique des patients à risque (impacts de l'acidose respiratoire et métabolique, du clampage de l'aorte abdominale sous-rénale et du positionnement peropératoire)

L optimisation hémodynamique péri-opératoire est une stratégie qui vise à maximaliser le transport artériel en oxygène et/ou le volume d éjection systolique lors de chirurgie à risque. Ce concept a beaucoup évolué lors de ces trente dernières années, vers une approche plus simple, plus réalisable en pratique clinique et moins invasive. Les principales thérapeutiques utilisées dans les différents protocoles d optimisation hémodynamique sont le remplissage vasculaire, l administration d agents inotropes et de vasopresseurs. Cependant, les conséquences physiopathologiques de l agression chirurgicale peuvent impacter grandement les modalités d administration et l efficacité des thérapeutiques précitées. Dans la première étude, nous avons décrit l impact de l acidose respiratoire et métabolique (fréquemment rencontrées lors de chirurgie majeure et/ou de coeliochirurgie) sur l efficacité des agents a et b-adrénergiques sur le myocarde sain de rat. Dans un deuxième travail nous avons mis en évidence que le remplissage vasculaire ne pouvait pas être guidé par des indices dynamiques de précharge dépendance lors du clampage chirurgicale de l aorte abdominale sous-rénale, dans un modèle porcin. Enfin, dans la troisième étude, nous avons montré dans un modèle clinique, que le positionnement en décubitus ventral lors d une chirurgie du rachis entrainait des modifications majeures des interactions cardiorespiratoires et que les indices dynamiques devaient être interprétés avec prudence pour guider le remplissage vasculaire dans ce contexte. Ces études translationnelles soulignent trois situations fréquentes impactant l efficacité et/ou les modalités d administration des thérapeutiques nécessaires à une optimisation hémodynamique peropératoireThe aim of perioperative haemodynamic optimization is to maximize oxygen delivery and/or stroke volume during high risk surgery. This concept has evolved during the last thirty years, to a simpler, more feasible and less invasive approach. Main treatments used in different hemodynamic optimization protocols are fluid loading, inotropes and vasopressors administration. However, pathophysiological consequences of surgical stress can greatly impact the mode of administration and the efficacy of the above therapeutics. In the first study, we described the impact of respiratory and metabolic acidosis (frequently encountered during major surgery and/or laparoscopic surgery) on the effectiveness of a and b-adrenergic agents in healthy rat myocardium. In a second work, we demonstrated that intravenous fluids cannot be guided by dynamic indices of preload dependency during surgical clamping of the infrarenal abdominal aorta in a porcine model. Finally, in the third study, we demonstrated in a clinical model, that positioning in prone position during spine surgery induced major changes in cardiorespiratory interactions and dynamic indices should be interpreted with caution to guide fluid therapy in this context. These translational studies highlight three common situations impacting the effectiveness and/or administration of therapeutic necessary for intraoperative hemodynamic optimization.BORDEAUX2-Bib. électronique (335229905) / SudocBORDEAUX1-Bib.electronique (335229901) / SudocSudocFranceF

Bupivacaine Induced Cardiac Toxicity Mimicking an Acute Non-ST Segment Elevation Myocardial Infarction

Bupivacaine is widely used as a local anesthetic. Central nervous system (CNS) and cardiovascular toxicity are well known side effects. However, there has been no report of bupivacaine-induced myocardial injury. We present a case of bupivacaine cardiac toxicity mimicking an acute non-ST segment elevation myocardial infarction, which was eventually diagnosed as bupivacaine-induced cardiac toxicity without CNS toxicity. As soon as a healthy young woman at a private clinic was given a spinal anesthesia of 6 mg bupivacaine for hemorrhoidectomy, she developed arrhythmia and hypotension. She was transferred to our emergency room. There was an accelerated idioventricular rhythm with ST segment depression on electrocardiogram, coarse breathing sounds with rales on whole lung field and a butterfly sign on the chest radiograph. 2D transthoracic echocardiography (TTE) revealed reduced left ventricle systolic ejection fraction (approximately 27%). There was regional wall motion abnormality of the left ventricle on 2D TTE and the cardiac marker was increased. We diagnosed the patient as having acute non-ST segment elevation myocardial infarction but her impaired cardiac function improved gradually. On the seventh day from admission, there was a complete spontaneous recovery of cardiac function, and coronary angiography revealed a normal coronary artery. Therefore, we firmly believe that bupivacaine directly injures the cardiac cell

Belatacept (Nulojix®) som primär immunsuppressiv behandling jämfört med calcineurinhämmare efter njurtransplantation.

Njurtransplantation är det enda botande behandlingsalternativet för patienter som befinner sig i kronisk njursviktsstadium 5. Dagens mest använda immunsuppressiva kombinationsbehandling i klinisk praxis består av calcineurinhämmaren takrolimus, mykofenolatmofetil och kortikosteroider i form av prednisolon. Belatacept (Nulojix®) är ett fusionsprotein som introducerades på marknaden 2011 och ska ses som ett alternativ för primär immunsuppressiv behandling. Verkningsmekanismen för belatacept är att hämma aktiveringen av T-celler genom blockera co-stimulatoriska signaler från antigenpresenterande celler. Teorin bakom belatacept är att man genom en mer specifik immunsuppression ska kunna undvika de nefrotoxiska biverkningar som calcineurinhämmarna takrolimus(Prograf®) och ciklosporin(Sandimmun®) ofta ger. Nefrotoxicitet kan på långsikt leda till en försämring av njurfunktion vilket på sikt kan leda till förlust av transplantatet. Syftet med detta arbete var att undersöka effektiviteten av belatacept jämfört med calcineurinhämmare med avseende på graftöverlevnad, njurfunktion och förekomsten av akuta rejektioner. Detta arbete är en litteraturstudie som gjorts genom att utvärdera fem studier som hittades på sökdatabasen PubMed. Samtliga studier som utvärderades i detta arbete påvisade inga signifikanta skillnader i graftöverlevnad mellan de patienter som behandlades med belatacept och de som behandlades med en calcineurinhämmare. Samtliga studier påvisade en signifikant högre njurfunktion mätt i cGFR, Calculated Glomerular Filtration Rate, hos patienter som behandlades med belatacept. Hos dessa patienter ökade njurfunktionen över tid vilket bekräftar teorin bakom belatacept som säger att man genom att undvika nefrotoxicitet ska kunna behålla en stabil nivå i njurfunktion.  I samtliga studier förutom i studie 2 så har patientgrupperna som mottagit belatacept drabbats av en högre incidens av akuta rejektioner där nästan alla skedde inom de första sex månader efter transplantation vilka oftast ger lindriga komplikationer. Slutsatserna som kan dras är att belatacept ger en högre njurfunktion på lång sikt vilket gör det mycket fördelaktigt framför calcineurinhämmare. Belatacept är förenat med ökad förekomst av akuta rejektioner men fördelen med den höga njurfunktionen kan anses väga tyngre då akuta rejektioner oftast ger lindriga komplikationer. Då belatacept är ett nytt läkemedel så kommer det behövas längre studier framöver för att påvisa en högre graftöverlevnad.Kidney transplant is the only curing treatment for patients who have chronic kidney disease stage 5. Today’s most used immunosuppressive treatment after kidney transplant in Sweden and worldwide is the combination of the calcineurin inhibitor tacrolimus, mycophenolate mofetil and corticosteroids. Belatacept (Nulojix®) is a fusion protein which was introduced on the pharmaceutical market 2011 and should be viewed as an alternative for primary immunosuppressive treatment after kidney transplant. The mechanism of action for belatacept is to inhibit the activation of T-cells by blocking co-stimulatory signals provided by antigen-presenting cells. The theory behind belatacept is to avoid the nephrotoxic adverse events through a more specific immunosuppression. Nephrotoxicity is often seen with the calcineurin inhibitors tacrolimus (Prograf®) and cyclosporine (Sandimmune®). The consequence of nephrotoxicity is a deterioration in renal function which in a long-term can lead to graft loss. The aim of this study is to evaluate the efficacy of belatacept in comparison to calcineurininhibitors regarding graft survival, renal function and the occurrence of acute rejections. This literature study was conducted by evaluating five studies found in the PubMed database. None of the studies that were evaluated in this study showed any significant differences in graft survival of the patients treated with belatacept compared to calcineurin inhibitors. All studies demonstrated a significantly higher renal function measured in cGFR among patients treated with belatacept. The renal function increased over time which confirms the theory behind belatacept, i.e., that you can keep a more stable renal function over time by avoiding nephrotoxicity. All studies except study 2 demonstrated a higher incidence of acute rejection among patients who received belatacept as treatment. Almost all acute rejections in each study occurred within the first 6 months of the study which most of the time give minor complications.The conclusion that can be drawn from this literature study is that treatment with belatacept results in a higher renal function which makes it favorable to calcineurin inhibitors. Treatment with belatacept also results in a higher incidence of acute rejections but the benefit of a higher renal function can be considered to outweigh the risk of acute rejection.4In order to observe a significant difference in graft survival between patients receiving belatacept and those receiving calcineurin inhibitors several and longer studies, including more patients, need to be conducted

Situación de gestión de aeronaves no tripuladas : caso de la República Argentina y nuevos desafíos

Fil: Sztark, Juan Sebastian. Universidad de San Andrés. Escuela de Negocios; Argentina.PALABRAS CLAVES: OACI, ANAC, ANSP, Autoridad Aeronáutica, Aviación, drone, RPAS, drones, VANT, UAS, Piloto a distancia, Sistemas de Aeronaves no Tripuladas, vehículo aéreo no tripulado, Unmanned Aircraft Systems, sesarju, eurocontrol, faa, espacio aéreo.Hofman, Enriqu

School press as a part of environmental and sub-local press: specificity, features, propects. Analysis of the achievements of “School Pulitzer” competition in Western Pomerania.

Praca pt. „Gazety szkolne jako segment prasy środowiskowej i sublokalnej: specyfika, funkcje, perspektywy rozwoju. Analiza dorobku konkursu ‘Szkolny Pulitzer’ w województwie zachodniopomorskim” rozpatruje kwestię przynależności prasy szkolnej do kręgów prasy sublokalnej i środowiskowej. Praca zawiera wstęp, pięć rozdziałów oraz zakończenie.Rozdział pierwszy zawiera teoretyczne rozważania na temat zjawiska prasy szkolnej. Rozpatrzone zostały pojęcie i specyfika prasy szkolnej. Zagadnienie ujęto jako temat badawczy, następnie przedstawiono historię prasy uczniowskiej, ze szczegółowym uwzględnieniem jej rozwoju w latach 1945 – 1957 na terenie dawnego województwa szczecińskiego. Następnie opisane zostaje pedagogiczne ujęcie problematyki, ze szczególnym uwzględnieniem postaci wybitnych pedagogów; Celestyna Freineta i Janusza Korczaka, którzy redagowanie szkolnego pisma uznali za podstawę kształcenia.W rozdziale drugim omówione zostają metody badawcze i źródła. Zaprezentowany zostaje przyjęty klucz kategoryzacyjny, opisany dobór próby poddanej analizie. Rozdział ten wyjaśnia, w jaki sposób analiza zgromadzonych tytułów będzie pomocna w udowodnieniu przyjętej hipotezy, że prasa szkolna stanowi szczególny rodzaj prasy sublokalnej.Rozdział trzeci jest niejako powrotem do rozważań teoretycznych – jednak tym razem bardziej ogólnych, dotyczących całego zjawiska prasy sublokalnej. Przedstawiony zostaje przegląd wybranych definicji, cech i funkcji występujących w literaturze. Kolejne dwa rozdziały stanowią analizę dostępnych tytułów. Rozdział czwarty poświęcony jest technicznej analizie przyjętej próby. Zbadane zostają kwestie miejsca wydawania pism, średnich nakładów, kolportażu, sposobów finansowania, częstotliwości ukazywania się, a także formatu, objętości i kolorystyki gazetek. W piątym rozdziale badaniom poddana zostaje treść czasopism z uwzględnieniem występujących gatunków dziennikarskich, tematyki, kwestii autorstwa, adresatów, ilustracji oraz pochodzenia tekstów.W zakończeniu przedstawione są wnioski z analizy z wcześniejszymi rozważaniami teoretycznymi. Całokształt badań zostaje podsumowany. . Ponadto, do pracy załączone są: bibliografia oraz alfabetyczne zestawienie tytułów zbadanej próby.The work ‘School press as a part of environmental and sub-local press: specificity, features, prospects. Analysis of the achievements of “School Pulitzer” competition in Western Pomerania’ includes an introduction, five chapters and a conclusion.The first chapter contains theoretical considerations on the phenomenon of the school press, as well as analysis of concepts and specifics of the school press.The mentioned issue was used as a main research topic, afterwards the general history of school press was fully presented with particular emphasis on its development between 1945 and 1957 in the former Szczecin province.Further on, there was a pedagogical approach described, focusing on eminent pedagogues, such as Celestin Freinet and Janusz Korczak, who considered the process of editing student newspapers as a basis of education. The second chapter contains a description of research methods, sources and also a view on an analysed sample selection.This chapter explains, how the analysis of selected titles can be useful in proving the adpoted hypothesis that a school press is a special kind of sub-local press.Third chapter is somehow a way back to the theoretical considerations. However, much more general this time, concerning the whole phenomenon of sublocal press.In following part, the focus is on selected definitions, features and functions found in the literature. Next two chapters contains analysis of available titles.The fourth chapter is devoted to technical analysis.Average expenditures, distribution, financing methods, frequency of publication, as well as format, volume and tone of newspapers are explored. Fifth chapter contains analysis of content of magazines including species of journalism, topics, issues of authorship, recipients, illustrations and texts of origin.The conclusions of the analysis with the previous theoretical researches are presented in last chapter. All considerations are summarized

Implications du canal potassique ATP-dépendant mitochondrial en anesthésie-réanimation et effets des anesthésiques locaux sur ce canal

BORDEAUX2-BU Santé (330632101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF