Les hépatectomies majeures : mortalité, morbidité et facteurs de risque

RESUME L'objectif de ce travail est de rappeler l'historique des hépatectomies majeures, les bases anatomiques et les techniques opératoires de la chirurgie du foie. Puis, à partir de 212 cas d'exérèses majeures recencées entre 1992 et 2001 dans le service de Chirurgie Viscérale du CHUV, les facteurs de risques, la mortalité et la morbidité des hépatectomies majeures seront étudiés et comparés avec les données récentes de la littérature. L'anatomie hépatique peut être considérée de plusieurs façons morphologiquement (poids, faces, lobe droit, gauche et caudé...), fonctionnellement (segmentation en fonction de la distribution des pédicules portes et de la localisation des veines hépatiques) et chirurgicalement. La terminologie est rappelée (hépatectomies «typique », «atypique », «réglée », «majeure »...). A partir de ces données, les exérèses du foie sont ensuite classées. Les techniques d'hépatectomies sont expliquées, en rappelant les principes généraux, et les voies d'abord. Puis, les techniques de contrôle de l'hémostase, la reconstruction des voies biliaires, les méthodes utilisées par rapport à la tranche de section hépatique et à la loge d'hépatectomie sont discutées, Les acquisitions récentes sont abordées. Sur les 494 hépatecomies réalisées entre janvier 1992 et août 2001, 212 sont majeures. Elles sont reparties en 7 groupes selon l'exérèse (lobectomie G ou D, hépatecomie G ou D etc...). `Sur ces 212 résections, 177 cas concernaient des lésions malignes et 35 cas des lésions bénignes. Les indications ont été classées en 4 groupes : cancer primitif du foie, métastases hépatiques, maladies bénignes (par exemple l'échinococcose alvéolaire), et 8 cas classés dans le groupe «autres ». Une intervention en urgence a été réalisée dans 7 cas. Le bilan préopératoire comprend un bilan biologique et morphologique. Une embolisation de l'artère hépatique a été réalisées dans 6 cas, alors qu'une embolisation dans la veine porte a été faite dans 17 cas. Les modalités chirurgicales (voies d'abord, contrôle vasculaire, drainage biliaire post- opératoire, transfusions per- opératoires, et interventions extra- hépatiques) sont expliqués. En fin, les méthodes statistiques utilisées sont rappelées. Il n'y a pas eu de décès per- opératoire. La mortalité post- opératoire dans les 30 jours a été de 3,3 % (7 cas) et la mortalité globale hospitalière de 5,2 %. Dans cette série, 132 patients n'ont eu aucune complication. La morbidité est de 17% si on considère les complications majeures, ayant concerné 36 patients, mais de 37,75 si l'on considère toutes les complications. Les complications chirurgicales sont le faite d'hémorragie, de fuite biliaire et d'infection du foyer opératoire. Dans notre étude, 33 facteurs de risque ont été analysés. L'analyse statistique uni- variée met den évidence les facteurs de risque suivants : Le nombre de culots de sang transfusés, la présence d'une hépatite, celle d'une cirrhose, le tabagisme, la lobectomie droite, et la présence d'une hypertension artérielle. L'analyse multi variée réalisée a permis de faire ressortir une combinaison de facteur de risque avec une valeur statistique significative et de réaliser une échelle et un score de gravité en fonction des facteurs de risques obtenus dans l'analyse uni variée. Le taux de mortalité globale hospitalière obtenu dans notre série (5,2%) est comparable aux résultats reportés dans d'autres séries.

Official Positions for FRAX(®) clinical regarding glucocorticoids: the impact of the use of glucocorticoids on the estimate by FRAX(®) of the 10 year risk of fracture from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX(®).

Given the significant impact the use of glucocorticoids can have on fracture risk independent of bone density, their use has been incorporated as one of the clinical risk factors for calculating the 10-year fracture risk in the World Health Organization's Fracture Risk Assessment Tool (FRAX(®)). Like the other clinical risk factors, the use of glucocorticoids is included as a dichotomous variable with use of steroids defined as past or present exposure of 3 months or more of use of a daily dose of 5 mg or more of prednisolone or equivalent. The purpose of this report is to give clinicians guidance on adjustments which should be made to the 10-year risk based on the dose, duration of use and mode of delivery of glucocorticoids preparations. A subcommittee of the International Society for Clinical Densitometry and International Osteoporosis Foundation joint Position Development Conference presented its findings to an expert panel and the following recommendations were selected. 1) There is a dose relationship between glucocorticoid use of greater than 3 months and fracture risk. The average dose exposure captured within FRAX(®) is likely to be a prednisone dose of 2.5-7.5 mg/day or its equivalent. Fracture probability is under-estimated when prednisone dose is greater than 7.5 mg/day and is over-estimated when the prednisone dose is less than 2.5 mg/day. 2) Frequent intermittent use of higher doses of glucocorticoids increases fracture risk. Because of the variability in dose and dosing schedule, quantification of this risk is not possible. 3) High dose inhaled glucocorticoids may be a risk factor for fracture. FRAX(®) may underestimate fracture probability in users of high dose inhaled glucocorticoids. 4) Appropriate glucocorticoid replacement in individuals with adrenal insufficiency has not been found to increase fracture risk. In such patients, use of glucocorticoids should not be included in FRAX(®) calculations.

Forecasting changes in population genetic structure of alpine plants in response to global warming.

Species range shifts in response to climate and land use change are commonly forecasted with species distribution models based on species occurrence or abundance data. Although appealing, these models ignore the genetic structure of species, and the fact that different populations might respond in different ways because of adaptation to their environment. Here, we introduced ancestry distribution models, that is, statistical models of the spatial distribution of ancestry proportions, for forecasting intra-specific changes based on genetic admixture instead of species occurrence data. Using multi-locus genotypes and extensive geographic coverage of distribution data across the European Alps, we applied this approach to 20 alpine plant species considering a global increase in temperature from 0.25 to 4 °C. We forecasted the magnitudes of displacement of contact zones between plant populations potentially adapted to warmer environments and other populations. While a global trend of movement in a north-east direction was predicted, the magnitude of displacement was species-specific. For a temperature increase of 2 °C, contact zones were predicted to move by 92 km on average (minimum of 5 km, maximum of 212 km) and by 188 km for an increase of 4 °C (minimum of 11 km, maximum of 393 km). Intra-specific turnover-measuring the extent of change in global population genetic structure-was generally found to be moderate for 2 °C of temperature warming. For 4 °C of warming, however, the models indicated substantial intra-specific turnover for ten species. These results illustrate that, in spite of unavoidable simplifications, ancestry distribution models open new perspectives to forecast population genetic changes within species and complement more traditional distribution-based approaches.

Reasons for discontinuation of recommended therapies according to the patients after acute coronary syndromes.

BACKGROUND: The prescription of recommended medical therapies is a key factor to improve prognosis after acute coronary syndromes (ACS). However, reasons for cardiovascular therapies discontinuation after hospital discharge are poorly reported in previous studies. METHODS: We enrolled 3055 consecutive patients hospitalized with a main diagnosis of ACS in four Swiss university hospitals with a prospective one-year follow-up. We assessed the self-reported use of recommended therapies and the reasons for medication discontinuation according to the patient interview performed at one-year follow-up. RESULTS: 3014 (99.3%) patients were discharged with aspirin, 2983 (98.4%) with statin, 2464 (81.2%) with beta-blocker, 2738 (90.3%) with ACE inhibitors/ARB and 2597 (100%) with P2Y12 inhibitors if treated with coronary stent. At the one-year follow-up, the discontinuation percentages were 2.9% for aspirin, 6.6% for statin, 11.6% for beta-blocker, 15.1% for ACE inhibitor/ARB and 17.8% for P2Y12 inhibitors. Most patients reported having discontinued their medication based on their physicians' decision: 64 (2.1%) for aspirin, 82 (2.7%) for statin, 212 (8.6%) for beta-blocker, 251 (9.1% for ACE inhibitor/ARB) and 293 (11.4%) for P2Y12 inhibitors, while side effect, perception that medication was unnecessary and medication costs were uncommon reported reasons (<2%) according to the patients. CONCLUSIONS: Discontinuation of recommended therapies after ACS differs according the class of medication with the lowest percentages for aspirin. According to patients, most stopped their cardiovascular medication based on their physician's decision, while spontaneous discontinuation was infrequent.

Recanalization and Collaterals Predict Outcome in Proximal MCA Occlusion, but neither Penumbra nor Core of Stroke

Data on new predictors of outcome include penumbra core or collaterals.Objective: To test the predictive value of recanalization, collaterals, penumbra and core of ischemia for functional outcome in a large group of patients with MCA occlusion. Method: Consecutive events included prospectively in the Acute Stroke Registry and Analysis of Lausanne from April 2002 to April 2009 with an acute stroke due to proximal MCA occlusion (M1) were considered for analysis. Acute CTA were reviewed to grade the collaterals (dichotomized in poor __50% or good _50% compared to the normal side) and localization of M1 occlusion (proximal or mid-distal). Acute CTP were reviewed and reconstructed to determine penumbra, core and stroke index (penumbra/penumbra_core) of brain ischemia. Good outcome was defined by mRS 0-2 at 3 months.Results: Among 242 events (115 male, mean NIHSS 18.1, SD 5.8, mean age 66, SD 15), 42% were treated with intravenous thrombolysis, and 3% with intraarterial thrombolysis. Collateral status was rated as poor in 53% of events and proximal M1 occlusion was present in 64%. Recanalization determined at 24 hours with CTA was complete in 26% events and partial/absent in 54%.CTP was available for 212 events. Mean penumbra was 88.6 cm3 (median 84.4, SD 53.8), mean core was 54.1 cm3 (median 46.2, SD 45.7) and stroke index was 64% (median 68%, SD 25%). Good outcome was observed in 87 events (36%) and was associated in multivariate logistic regression with thrombolysis (p_0.02, OR_2.5, 95% CI 1.2-5.4), recanalization (p_0.001, OR_4.1, 95% CI 1.9-8.9), lower NIHSS (p_0.001, OR_0.84, 95% CI 0.78-0.91), male gender (p_0.01, OR_2.8, 95% CI 1.3-5.9), mRS prior to stroke (p_0.02, OR_0.5, 95% CI 0.28-0.9) and good collateral status (p_0.005, OR_3, 95% CI 1.4-6.4). Nor penumbra, nor core, nor stroke index were significant in the multivariate model, even if an association was present in the univariate model between good functional outcome and penumbra (p_0.004, OR_1.008, 95% CI 1.003-1.01), core (p_0.001, OR_0.98, 95% CI 0.976-0.99) and strokeindex (p_0.001, OR_16.7, 95% CI 4.6 59.9).Conclusion: MCA recanalization is the best predictor for good functional outcome, followed by collateral status. CTP data did not predict the functional outcome in our large group of M1 occlusion. Author Disclosures: C. Odier: None. P. Michel: Research Grant; Significant; Paion, Lundbeck. Speakers; Modest; Boehringer-Ingelheim. Consultant/Advisory Board; Modest; Boehringer- Ingelheim. Consultant/Advisory Board; Significant; Servier, Lundbeck.

Triade de la femme sportive [Female athlete triad]

The practitioner, as well as specialist such as gynecologist and endocrinologist, may face in their office women with eating disorders, abnormalities of menstrual cycles and low bone mass, which may be the first hints of the female athlete triad. In these situations, the practitioner may search other findings of these triad by looking at some particular physical findings and by using appropriate questionnaire. In some advanced forms of this triad specific abnormalities of eating disorders (anorexia and boulimia) may be present as well as amenorrhea and osteoporosis, which may disturb the well-being and cause health damages of women practising sport either as amateur or in a elite setting. An appropriate handling of such disorders has to be proposed to these women.

Pregnancy outcomes following use of escitalopram: a prospective comparative cohort study.

Escitalopram is a serotonin reuptake inhibitor prescribed for depression and anxiety. There is a paucity of information regarding safety in pregnancy. The objective of this study was to determine whether escitalopram is associated with an increased risk for major malformations or other adverse outcomes following use in pregnancy. The authors analyzed pregnancy outcomes in women exposed to escitalopram (n = 212) versus other antidepressants (n = 212) versus nonteratogenic exposures (n = 212) and compared the outcomes. Among the escitalopram exposures were 172 (81%) live births, 32 (15%) spontaneous abortions, 6 (2.8%) therapeutic abortions, 3 stillbirths (1.7%), and 3 major malformations (1.7%). The only significant differences among groups was the rate of low birth weight (<2500 g) and overall mean birth weight (P = .225). However, spontaneous abortion rates were higher in both antidepressant groups (15% and 16%) compared with controls (8.5%; P = .066). There were lower rates of live births (P = .006), lower overall birth weight (P < .001), and increased rates of low birth weight (<2500 g; P = .009) with escitalopram. Spontaneous abortion rates were nearly double in both antidepressant groups (15% and 16%) compared with controls (8.5%) but not significant (P = .066). Escitalopram does not appear to be associated with an increased risk for major malformations but appears to increase the risk for low birth weight, which was correlated with the increase in infants weighing <2500 g. In addition, the higher rates of spontaneous abortions in both antidepressant groups confirmed previous findings.

Physiological differences between cycling and running

This review compares the differences in systemic responses (VO2max, anaerobic threshold, heart rate and economy) and in underlying mechanisms of adaptation (ventilatory and hemodynamic and neuromuscular responses) between cycling and running. VO2max is specific to the exercise modality. Overall, there is more physiological training transfer from running to cycling than vice-versa. Several other physiological differences between cycling and running are discussed: HR is different between the two activities both for maximal and sub-maximal intensities. The delta efficiency is higher in running. Ventilation is more impaired in cycling than running due to mechanical constraints. Central fatigue and decrease in maximal strength are more important after prolonged exercise in running than in cycling.

Penetrating or Stricturing Diseases are the Major Determinants of Time to First and Repeat Resection Surgery in Crohn's Disease.

Background: About 80% of patients with Crohn's disease (CD) require bowel resection and up to 65% will undergo a second resection within 10 years. This study reports clinical risk factors for resection surgery (RS) and repeat RS. Methods: Retrospective cohort study, using data from patients included in the Swiss Inflammatory Bowel Disease Cohort. Cox regression analyses were performed to estimate rates of initial and repeated RS. Results: Out of 1,138 CD cohort patients, 417 (36.6%) had already undergone RS at the time of inclusion. Kaplan-Meier curves showed that the probability of being free of RS was 65% after 10 years, 42% after 20 years, and 23% after 40 years. Perianal involvement (PA) did not modify this probability to a significant extent. The main adjusted risk factors for RS were smoking at diagnosis (hazard ratio (HR) = 1.33; p = 0.006), stricturing with vs. without PA (HR = 4.91 vs. 4.11; p < 0.001) or penetrating disease with vs. without PA (HR = 3.53 vs. 4.58; p < 0.001). The risk factor for repeat RS was penetrating disease with vs. without PA (HR = 3.17 vs. 2.24; p < 0.05). Conclusion: The risk of RS was confirmed to be very high for CD in our cohort. Smoking status at diagnosis, but mostly penetrating and stricturing diseases increase the risk of RS.

Quand faut-il opérer une fracture isolée du tiers moyen de la clavicule [When to operate an isolated midshaft clavicle fracture?]

Slightly displaced clavicular midshaft fracture is currently treated nonoperatively. There is considerable debate about whether acute displaced fractures should be treated operatively. Nonunion rate after displaced fracture has been underestimated for a long time, and malunion clinical impact often minimized. It is known that operative treatment decreases these rates. However, operating all displaced fractures may lead to overtreatment. Acute operative treatment of midshaft fractures with delayed treatment of established nonunion showed no significant difference in the outcome, but malunion surgical management is technically demanding. Consequently these fractures could be treated surgically, but operative indication should be adapted to patient expectations.

Les coûts des dommages éléments naturels aux bâtiments et l'influence des facteurs du risque dans un contexte d'assurance immobilière : analyse de cas des innondations et de la grêle en Suisse

In Switzerland, the annual cost of damage by natural elements has been increasing for several years despite the introduction of protective measures. Mainly induced by material destruction building insurance companies have to pay the majority of this cost. In many European countries, governments and insurance companies consider prevention strategies to reduce vulnerability. In Switzerland, since 2004, the cost of damage due to natural hazards has surpassed the cost of damage due to fire; a traditional activity of the Cantonal Insurance company (EGA). Therefore, the strategy for efficient fire prevention incorporates a reduction of the vulnerability of buildings. The thesis seeks to illustrate the relevance of such an approach when applied to the damage caused by natural hazards. It examines the role of insurance place and its involvement in targeted prevention of natural disasters. Integrated risk management involves a faultless comprehension of all risk parameters The first part of the thesis is devoted to the theoretical development of the key concepts that influence risk management, such as: hazard, vulnerability, exposure or damage. The literature on this subject, very prolific in recent years, was taken into account and put in perspective in the context of this study. Among the risk parameters, it is shown in the thesis that vulnerability is a factor that we can influence efficiently in order to limit the cost of damage to buildings. This is confirmed through the development of an analysis method. This method has led to the development of a tool to assess damage to buildings by flooding. The tool, designed for the property insurer or owner, proposes several steps, namely: - Vulnerability and damage potential assessment; - Proposals for remedial measures and risk reduction from an analysis of the costs of a potential flood; - Adaptation of a global strategy in high-risk areas based on the elements at risk. The final part of the thesis is devoted to the study of a hail event in order to provide a better understanding of damage to buildings. For this, two samples from the available claims data were selected and analysed in the study. The results allow the identification of new trends A second objective of the study was to develop a hail model based on the available data The model simulates a random distribution of intensities and coupled with a risk model, proposes a simulation of damage costs for the determined study area. Le coût annuel des dommages provoqués par les éléments naturels en Suisse est conséquent et sa tendance est en augmentation depuis plusieurs années, malgré la mise en place d'ouvrages de protection et la mise en oeuvre de moyens importants. Majoritairement induit par des dégâts matériels, le coût est supporté en partie par les assurances immobilières en ce qui concerne les dommages aux bâtiments. Dans de nombreux pays européens, les gouvernements et les compagnies d'assurance se sont mis à concevoir leur stratégie de prévention en termes de réduction de la vulnérabilité. Depuis 2004, en Suisse, ce coût a dépassé celui des dommages dus à l'incendie, activité traditionnelle des établissements cantonaux d'assurance (ECA). Ce fait, aux implications stratégiques nombreuses dans le domaine public de la gestion des risques, résulte en particulier d'une politique de prévention des incendies menée efficacement depuis plusieurs années, notamment par le biais de la diminution de la vulnérabilité des bâtiments. La thèse, par la mise en valeur de données actuarielles ainsi que par le développement d'outils d'analyse, cherche à illustrer la pertinence d'une telle approche appliquée aux dommages induits par les phénomènes naturels. Elle s'interroge sur la place de l'assurance et son implication dans une prévention ciblée des catastrophes naturelles. La gestion intégrale des risques passe par une juste maîtrise de ses paramètres et de leur compréhension. La première partie de la thèse est ainsi consacrée au développement théorique des concepts clés ayant une influence sur la gestion des risques, comme l'aléa, la vulnérabilité, l'exposition ou le dommage. La littérature à ce sujet, très prolifique ces dernières années, a été repnse et mise en perspective dans le contexte de l'étude, à savoir l'assurance immobilière. Parmi les paramètres du risque, il est démontré dans la thèse que la vulnérabilité est un facteur sur lequel il est possible d'influer de manière efficace dans le but de limiter les coûts des dommages aux bâtiments. Ce raisonnement est confirmé dans un premier temps dans le cadre de l'élaboration d'une méthode d'analyse ayant débouché sur le développement d'un outil d'estimation des dommages aux bâtiments dus aux inondations. L'outil, destiné aux assurances immobilières, et le cas échéant aux propriétaires, offre plusieurs étapes, à savoir : - l'analyse de la vulnérabilité et le potentiel de dommages ; - des propositions de mesures de remédiation et de réduction du risque issues d'une analyse des coûts engendrés par une inondation potentielle; - l'adaptation d'une stratégie globale dans les zones à risque en fonction des éléments à risque. La dernière partie de la thèse est consacrée à l'étude d'un événement de grêle dans le but de fournir une meilleure compréhension des dommages aux bâtiments et de leur structure. Pour cela, deux échantillons ont été sélectionnés et analysés parmi les données de sinistres à disposition de l'étude. Les résultats obtenus, tant au niveau du portefeuille assuré que de l'analyse individuelle, permettent de dégager des tendances nouvelles. Un deuxième objectif de l'étude a consisté à élaborer une modélisation d'événements de grêle basée sur les données à disposition. Le modèle permet de simuler une distribution aléatoire des intensités et, couplé à un modèle d'estimation des risques, offre une simulation des coûts de dommages envisagés pour une zone d'étude déterminée. Les perspectives de ce travail permettent une meilleure focalisation du rôle de l'assurance et de ses besoins en matière de prévention.