Complications de la chirurgie hépatique chez les patients cirrhotiques atteints d'un carcinome hépatocellulaire

INTRODUCTION. Une augmentation de l'incidence du carcinome hépatocellulaire (CHC) a été constatée dans les pays occidentaux ces dernières années. Il fait parti des cinq premières causes de mortalité dans le monde. Il se développe généralement sur une cirrhose, moins fréquemment sur une hépatopathie non cirrhotique et plus rarement sur un foie sain. La gravité de la cirrhose est évaluée notamment par le score de Child-­‐Pugh, puis le traitement adéquat est défini selon la classification du Barcelona Clinical Liver Cancer (BCLC). Depuis 2008, le service de chirurgie viscérale du CHUV a introduit un nouveau test quantitatif et qualitatif d'évaluation hépatique pré-­‐opératoire qui comprend une clairance au vert d'indocyanine (ICG), agent biologique qui ne change pas lors de son métabolisme hépatique. C'est un test de rétention qui nous permet de mieux évaluer les réserves hépatiques chez les patients cirrhotiques. OBJECTIF. L'objectif de ce travail est d'évaluer rétrospectivement sur la base de dossiers médicaux de malades tous les cas opérés de CHC dans le service entre 2008 et 2012, qui ont eu une évaluation pré-­‐opératoire selon le score de Child-­‐Turcotte-­‐Pugh (CTP) et de Barcelona Clinical Liver Cancer (BCLC)) en les comparant avec l'ICG test et les critères de Makuuchi. METHODE. Analyse statistique de la mortalité et de la morbidité de ces 2 groupes de patients. RESULTATS ESCOMPTES. Comparer nos résultats avec ceux publiés dans la littérature récente par les centres spécialisés pour la chirurgie hépatobiliaire. CONCLUSION. La chirurgie hépatique chez les patients cirrhotiques ne se limite plus à la chirurgie d'hypertension portale. L'amélioration des tests pré-­‐opératoires nous a permis de mieux choisir les patients accessibles à une chirurgie de résection, vu que la mortalité sur la liste d'attente de transplantation hépatique pour les patients atteints de CHC avoisine 8% par année.

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.

Differences Between Posterior and Anterior Acute Ischaemic Circulation Strokes in 1449 Consecutive Patients

Background: The current data comparing posterior and anterior circulation strokes with regards to clinical, etiological, radiological and outcome factors are conflicting. We searched for distinguishing features between both territories in 1'449 consecutive acute ischemic stroke patients. Methods: All consecutive patients with acute ischemic stroke admitted to a single stroke unit from January 2003 to July 2008 were included in a prospective registry. Territory of acute stroke was determined by a combination of neuroimaging (MRI and / CT / CTP) and clinical symptoms and signs. Patients with uncertain localisation and patients with simultaneous strokes in the anterior and posterior circulation were excluded from this analysis. Results: Of a total of 1728 patients, 466 (17.0%) had had posterior, 983 (56.8%) anterior, 136 (7.9%) unknown territory, and 43 (2.5%) simultaneous posterior and anterior territory stroke. Of 39 variables that were compared, 29 differed significantly in univariate analysis, including less dependency (OR_0.50) and mortality (OR_0.56) at 3 months in posterior stroke. In multivariate analysis (see table), male gender, lacunar mechanism, arterial dissection and endovascular recanalisation were more frequent in posterior stroke, and admission NIHSS and IV-thrombolysis rate were lower. Significant acute arterial pathology (_50% stenosis) was less frequently found on acute imaging in posterior stroke (OR_0.33). Of 633 patients with significant arterial pathology, it was more frequently present intracranially in posterior (OR_1.62) and extracranially in anterior stroke (OR _ 0.87). In 610 patients where recanalisation was assessed at 24 hours, intracranial (OR_0.26), extracranial (OR_0.25) and overall recanalisation (OR_0.34) was less frequent in the posterior circulation. Conclusions: Acute posterior strokes are less severe and recover better, despite lower IV thrombolysis and recanalisation rates. They are more frequently due to lacunes and dissections and have less arterial pathology burden then anterior circulation strokes.

Caracterização fisiológica da compatibilidade reprodutiva de ameixeira japonesa

O objetivo deste trabalho foi caracterizar fisiologicamente a compatibilidade reprodutiva de seis cultivares de ameixeira japonesa (Prunus salicina), por meio da avaliação da frutificação e do crescimento do tubo polínico (CTP). A percentagem de frutificação foi determinada 40 dias após cruzamentos controlados, realizados a campo, entre seis cultivares. O grau de compatibilidade foi avaliado in vivo, para determinar o CTP. O pegamento de frutos foi muito baixo para todos os cruzamentos: máximo de 8,1%, com a autopolinização de 'Reubennel'. Nos cruzamentos in vivo, o CTP apresentou variações significativas em cada genitor feminino. Os cruzamentos 'América' x 'Pluma 7' e 'Rosa Mineira' x 'Santa Rosa' foram incompatíveis, enquanto a autofecundação de 'América' e 'Pluma 7' apresentou autoincompatibilidade. Não houve frutificação, no campo, no cruzamento 'Reubennel' x 'Rosa Mineira' e nos recíprocos entre 'Rosa Mineira' e 'Amarelinha' x 'América' e 'Amarelinha', e 'Pluma 7' e 'Santa Rosa' x 'América'. No entanto, na polinização in vivo, o CTP atingiu o óvulo ou o ovário nesses cruzamentos. Apenas os cruzamentos entre 'América' x 'Pluma 7' e 'Rosa Mineira' x 'Santa Rosa' são incompatíveis, e a cultivar América é autoincompatível.

Análise de custo de produção e lucratividade de bananeira 'Nanicão Jangada' sob duas densidades de cultivo em Ilha Solteira-SP

Em fruticultura, existe hoje uma grande tendência de aumento da densidade de cultivo, procurando com isso uma maior produção por área. Pretendeu-se, neste trabalho, desenvolvido em Ilha Solteira-SP, estimar e analisar comparativamente o custo de produção e a lucratividade de bananeira-'Nanicão Jangada', sob duas densidades de cultivo: 1666 plantas (3,0mx2,0m) e 2500 plantas (2,0mx2,0m). Para o cálculo do custo, utilizou-se a estrutura do custo total de produção (CTP). Considerando os dois ciclos produtivos do bananal, o espaçamento de plantio mais adensado (com maior número de plantas por área) apresentou resultados econômicos mais satisfatórios que os obtidos para o cultivo menos adensado. A cultivar 'Nanicão Jangada' é uma alternativa de cultivo viável para a região de Ilha Solteira-SP.

Diagnostic and Prognostic Impact of pc-ASPECTS Applied to Perfusion CT in the Basilar Artery International Cooperation Study.

BACKGROUND AND PURPOSE: The posterior circulation Acute Stroke Prognosis Early CT Score (pc-APECTS) applied to CT angiography source images (CTA-SI) predicts the functional outcome of patients in the Basilar Artery International Cooperation Study (BASICS). We assessed the diagnostic and prognostic impact of pc-ASPECTS applied to perfusion CT (CTP) in the BASICS registry population. METHODS: We applied pc-ASPECTS to CTA-SI and cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) parameter maps of BASICS patients with CTA and CTP studies performed. Hypoattenuation on CTA-SI, relative reduction in CBV or CBF, or relative increase in MTT were rated as abnormal. RESULTS: CTA and CTP were available in 27/592 BASICS patients (4.6%). The proportion of patients with any perfusion abnormality was highest for MTT (93%; 95% confidence interval [CI], 76%-99%), compared with 78% (58%-91%) for CTA-SI and CBF, and 46% (27%-67%) for CBV (P < .001). All 3 patients with a CBV pc-ASPECTS < 8 compared to 6/23 patients with a CBV pc-ASPECTS ≥ 8 had died at 1 month (RR 3.8; 95% CI, 1.9-7.6). CONCLUSION: CTP was performed in a minority of the BASICS registry population. Perfusion disturbances in the posterior circulation were most pronounced on MTT parameter maps. CBV pc-ASPECTS < 8 may indicate patients with high case fatality.

Cerebral Hypoperfusion in Posterior Reversible Encephalopathy Syndrome is Different from Transient Ischemic Attack on CT Perfusion.

BACKGROUND: PRES is a reversible neurotoxic state presenting with headache, altered mental status, visual loss, and seizures. Delayed diagnosis can be avoided if radiological patterns could distinguish PRES from cerebral ischemia. METHODS: Clinical and radiological data were collected on all hospitalized patients who had (1) discharge diagnosis of PRES and (2) acute CTP/CTA. Data were compared with 10 TIA patients with proven cytotoxic edema on MRI. RESULTS: Of the four PRES patients found, three were correlated with acute blood pressure and one with chemotherapy. At the radiological level, quantitative analyses of the CTP parameters showed that 2 out of 4 patients had bilaterally reduced CBF-values (23.2-47.1 ml/100g/min) in occipital regions, as seen in the pathological regions of TIA patients (27.3 ± 13.5 ml/100g/min). When compared with TIA patients, the pathological ROI's demonstrated decreased CBV-values (3.4-5.6 ml/100g). Vasogenic edema on MRI FLAIR imaging was seen in only one PRES patient, and cytotoxic edema on DWI-imaging was never found. CT angiography showed in one PRES patient a vasospasm-like unilateral posterior cerebral artery. CONCLUSIONS: If confirmed by other groups, CTP and CTA imaging in patients with acute visual loss and confusion may help to distinguish PRES from bi-occipital ischemia. These radiological parameters may identify PRES patients at risk for additional tissue infarction.

Caracterização anatômico-fisiológica da compatibilidade reprodutiva de ameixeira-japonesa

O objetivo do trabalho foi caracterizar fisiologicamente a compatibilidade reprodutiva de sete cultivares de ameixeira-japonesa (Prunus salicina Lindl) por meio de hibridações, análise de frutificação efetiva e do crescimento de tubos polínicos (CTP). O frui set foi determinado 40 dias após as hibridações controladas, realizadas a campo. O grau de compatibilidade foi avaliado invivo, para determinar o CTP. A cv. América apresentou bom fruit set quando polinizada com as cvs. Rosa Mineira (26,7%), Amarelinha (8,7%) e Reubennel (12,7%). Os cruzamentos 'Gulf Blaze' x 'Gulf Rubi', 'Gulf Rubi' x 'Gulf Rubi' e 'Gulf Rubi' x 'Gulf Blaze' obtiveram um fruit set de 11,36%, 3,84% e 9,94%, respectivamente. Na polinização em laboratório, os tubos polínicos atingiram o óvulo ou ovário nesses cruzamentos, com exceção da autopolinização da 'Gulf Rubi'. No campo, não houve frutificação efetiva na autopolinização da 'América' e 'Gulf Blaze' e no cruzamento da 'América' x 'Pluma 7'. Os tubos polínicos nesses cruzamentos não chegaram a atingir o óvulo, com exceção da autopolinização da 'Gulf Blaze'. Concluiu-se que apenas os cruzamentos entre 'América' x 'Pluma 7' são incompatíveis, e a cultivar América é autoincompatível.

Viabilidade da cultura do morangueiro no Paraná - BR

Avaliou-se a viabilidade da exploração do morangueiro, no Paraná, em duas áreas, 0,3 ha (área média cultivada pela agricultura familiar) e 1 ha, por um ano. Elaborou-se uma planilha de fluxo de caixa a partir da qual se calcularam: Período de Recuperação do Capital (PRC), Retorno sobre Investimento (RI), Valor Presente Líquido (VPL) e Taxa Interna de Retorno (TIR). Todos para Custo Operacional Efetivo (COE), Custo Operacional Total (COT) e Custo Total de Produção (CTP). Para uma situação considerada normal, os indicadores de rentabilidade calculados foram (Tipo de custo: VPL área-padrão (TIR área- padrão) / VPL área efetiva (TIR área efetiva)) COE: US$ 17.856,55 (42%) / US$ 4.795,85 (39%); COT: US$ 5.182,40 (11%) / - US$ 1.691,97 (-13%); CPT: US$ 4.846,26 (10%) / -US$ 1.792,80 (-14%). Fez-se a análise de cenários para os fatores produtividade, preço de venda e mão de obra, analisando o VPL e a TIR. Verificou-se que o tamanho da área influenciou na viabilidade econômica, mostrando a importância de se determinar anualmente a área mínima viável para a agricultura familiar. Os resultados indicaram que a cultura é viável em curto prazo, quando considerado o COE como parâmetro de análise, mas pode não se sustentar em prazos maiores quando se consideram o COT, o CTP e a variação de alguns fatores de produção. Pela análise de cenários definidos pelos fatores de produção analisados, o VPL e a TIR alteram-se para níveis que oferecem risco à exploração.

Added value of acute multimodal CT-based imaging (MCTI) : a comprehensive analysis

Introduction: MCTI is used to assess acute ischemic stroke (AIS) patients.We postulated that use of MCTI improves patient outcome regardingindependence and mortality.Methods: From the ASTRAL registry, all patients with an AIS and a non-contrast-CT (NCCT), angio-CT (CTA) or perfusion-CT (CTP) within24 h from onset were included. Demographic, clinical, biological, radio-logical, and follow-up caracteristics were collected. Significant predictorsof MCTI use were fitted in a multivariate analysis. Patients undergoingCTA or CTA&CTP were compared with NCCT patients with regards tofavourable outcome (mRS ≤ 2) at 3 months, 12 months mortality, strokemechanism, short-term renal function, use of ancillary diagnostic tests,duration of hospitalization and 12 months stroke recurrence.

El emprendedor bogotano

En la actualidad se valora mucho el desarrollo de competencias empresariales como factor fundamental para la sociedad ya que a partir de éstas se da paso al éxito tanto de personas como de organizaciones. Por eso es importante retomar investigaciones hechas al respecto por autores como Mc Clelland y Marta Alles quienes dan una visión comprensiva sobre ellas. El perfil de tres personas modelos de empresarios abren paso para el análisis de las competencias del empresario bogotano y la selección de diez empresarios exitosos en la primera década del siglo XXI ayuda a ver el papel que desempeñan estas competencias en los fundadores emprendedores que las han hecho perdurables y exitosas en el tiempo.

Hacia la aplicación de las guías de la Organización para la Cooperación y el Desarrollo Económicos (OCDE) sobre precios de transferencia para empresas multinacionales y administraciones tributarias en Colombia

Los precios de transferencia ocupan el interés de los Estados en el mundo actual al constituir uno de los retos fundamentales del Derecho Internacional Tributario. En el seno de la Organización para la Cooperación y el Desarrollo Económicos (OCDE), creada en 1961, se discutieron y desarrollaron diversas propuestas para regular el fenómeno. Estas, se materializaron en Modelos de Convenios Tributarios e instrumentos de soft law, que hoy en día constituyen los principios internacionalmente aceptados en la materia. Las Guías de la OCDE sobre precios de transferencia para empresas multinacionales y administraciones tributarias son el cuerpo normativo de soft law que se erigen, en el Ordenamiento Internacional, como el norte de las legislaciones a nivel interno para efectos de regulación de dicha temática. Su adopción por parte de los países miembros y no miembros de la OCDE se enfrenta a problemas teóricos derivados del quebrantamiento del decantado principio de reserva de ley tributaria y el respeto por la seguridad jurídica, razón por la cual su incorporación ha variado de Estado a Estado. El presente trabajo recoge la experiencia en varios países europeos y latinoamericanos y pretende proponer una fórmula de adopción en Colombia, coherente con los principios constitucionales tributarios y con virtualidad de superar las críticas realizadas por la doctrina a la aplicación directa de las Guías.

Planeación Participativa: herramienta de diseño para la creación del modelo de desarrollo sostenible en Barú 2011 - 2013

El propósito de la presente investigación es identificar la incidencia que tuvo la participación de la población de Barú en el diseño del modelo de desarrollo sostenible para el área marina protegida del Archipiélago de Nuestra Señora del Rosario y San Bernardo (2013 - 2040), para el cual se empleó la metodología de planeación participativa durante el periodo 2011 - 2013. En un primer momento se analiza la importancia política que tiene la planeación participativa en Colombia, para luego explicar en qué consiste el modelo de desarrollo sostenible y comprender qué problemáticas motivaron su construcción y descubrir por qué era importante la utilización de la planeación participativa como metodología para el diseño del modelo y por último ofrecer la visión de los habitantes de Barú sobre el modelo de desarrollo sostenible y cómo se vieron involucrados en el proceso.

Improved information about the vertical location and extent of monolayer clouds from POLDER3 measurements in the oxygen A-band

This paper describes new advances in the exploitation of oxygen A-band measurements from POLDER3 sensor onboard PARASOL, satellite platform within the A-Train. These developments result from not only an account of the dependence of POLDER oxygen parameters to cloud optical thickness τ and to the scene's geometrical conditions but also, and more importantly, from the finer understanding of the sensitivity of these parameters to cloud vertical extent. This sensitivity is made possible thanks to the multidirectional character of POLDER measurements. In the case of monolayer clouds that represent most of cloudy conditions, new oxygen parameters are obtained and calibrated from POLDER3 data colocalized with the measurements of the two active sensors of the A-Train: CALIOP/CALIPSO and CPR/CloudSat. From a parameterization that is (μs, τ) dependent, with μs the cosine of the solar zenith angle, a cloud top oxygen pressure (CTOP) and a cloud middle oxygen pressure (CMOP) are obtained, which are estimates of actual cloud top and middle pressures (CTP and CMP). Performances of CTOP and CMOP are presented by class of clouds following the ISCCP classification. In 2008, the coefficient of the correlation between CMOP and CMP is 0.81 for cirrostratus, 0.79 for stratocumulus, 0.75 for deep convective clouds. The coefficient of the correlation between CTOP and CTP is 0.75, 0.73, and 0.79 for the same cloud types. The score obtained by CTOP, defined as the confidence in the retrieval for a particular range of inferred value and for a given error, is higher than the one of MODIS CTP estimate. Scores of CTOP are the highest for bin value of CTP superior in numbers. For liquid (ice) clouds and an error of 30 hPa (50 hPa), the score of CTOP reaches 50% (70%). From the difference between CTOP and CMOP, a first estimate of the cloud vertical extent h is possible. A second estimate of h comes from the correlation between the angular standard deviation of POLDER oxygen pressure σPO2 and the cloud vertical extent. This correlation is studied in detail in the case of liquid clouds. It is shown to be spatially and temporally robust, except for clouds above land during winter months. The analysis of the correlation's dependence on the scene's characteristics leads to a parameterization providing h from σPO2. For liquid water clouds above ocean in 2008, the mean difference between the actual cloud vertical extent and the one retrieved from σPO2 (from the pressure difference) is 5 m (−12 m). The standard deviation of the mean difference is close to 1000 m for the two methods. POLDER estimates of the cloud geometrical thickness obtain a global score of 50% confidence for a relative error of 20% (40%) of the estimate for ice (liquid) clouds over ocean. These results need to be validated outside of the CALIPSO/CloudSat track.

Inferences about pressures and vertical extension of cloud layers from POLDER3/PARASOL measurements in the oxygen A-band

We present new inferences about cloud vertical structures from multidirectionnal measurements in the oxygen A-band. The analysis of collocated data provided by instruments onboard satellite platforms within the A-Train, as well as simulations have shown that for monolayered clouds, the cloud oxygen pressure PO2PO2 derived from the POLDER3 instrument was sensitive to the cloud vertical structure in two ways: First, PO2PO2 is actually close to the pressure of the geometrical middle of cloud and we propose a method to correct it to get the cloud top pressure (CTP), and then to obtain the cloud geometrical extent. Second, for the liquid water clouds, the angular standard deviation σPO2σPO2 of PO2PO2 is correlated with the geometrical extent of cloud layers, which makes possible a second estimation of the cloud geometrical thickness. The determination of the vertical location of cloud layers from passive measurements, eventually completed from other observations, would be useful in many applications for which cloud macrophysical properties are needed