METABOLIC EFFECTS OF DIETARY PROTEINS

SUMMARY :Non-alcoholic fatty liver disease (NAFLD) is characterized by an elevated intra- hepatocellular lipid (IHCL) concentration (> 5%). The incidence of NAFLD is frequently increased in obese patients, and is considered to be the hepatic component of the metabolic syndrome. The metabolic syndrome, also characterized by visceral obesity, altered glucose homeostasis, insulin resistance, dyslipidemia, and high blood pressure, represents actually a major public health burden. Both dietary factors and low physical activity are involved in the development of the metabolic syndrome. ln animals and healthy humans, high-fat or high-fructose diets lead to the development of several features of the metabolic syndrome including increased intrahepatic lipids and insulin resistance. ln contrast the effects of dietary protein are less well known, but an increase in protein intake has been suggested to exert beneficial effects by promoting weight loss and improving glucose homeostasis in insulin-resistant patients. Increased postprandial thermogenesis and enhanced satiety after protein ingestion may be both involved. The effects of dietary protein on hepatic lipids have been poorly investigated in humans, but preliminary studies in rodents have shown a reduction of hepatic lipids in carbohydrate fed rats and in obese rats. ln this context this work aimed at investigating the metabolic effects of dietary protein intake on hepatic lipid metabolism and glucose homeostasis in humans. The modulation by dietary proteins of exogenous lipid oxidation, net lipid oxidation, hepatic beta-oxidation, triglycerides concentrations, whole-body energy expenditure and glucose tolerance was assessed in the fasting state and in postprandial states. Measurements of IHCL were performed to quantify the amount of triglycerides in the liver. ln an attempt to cover all these metabolic aspects under different point of views, these questions were addressed by three protocols involving various feeding conditions. Study I addressed the effects of a 4-day hypercaloric high-fat high-protein diet on the accumulation of fat in the liver (IHCL) and on insulin sensitivity. Our findings indicated that a high protein intake significantly prevents intrahepatic fat deposition induced by a short- term hypercaloric high-fat diet, adverse effects of which are presumably modulated at the liver level.These encouraging results led us to conduct the second study (Study ll), as we were also interested in a more clinical approach to protein administration and especially if increased protein intakes might be of benefit for obese patients. Therefore the effects of one-month whey protein supplementation on IHCL, insulin sensitivity, lipid metabolism, glucose tolerance and renal function were assessed in obese women. Results showed that whey protein supplementation reduces hepatic steatosis and improves the plasma lipid profile in obese patients, without adverse effects on glucose tolerance or creatinine clearance. However since patients were fed ud-libitum, it remains possible that spontaneous carbohydrate and fat intakes were reduced due to the satiating effects of protein. The third study (Study lll) was designed in an attempt to deepen our comprehension about the mechanisms involved in the modulation of IHCL. We hypothesized that protein improved lipid metabolism and, therefore, we evaluated the effects of a high protein meal on postprandial lipid metabolism and glucose homeostasis after 4-day on a control or a protein diet. Our results did not sustain the hypothesis of an increased postprandial net lipid oxidation, hepatic beta oxidation and exogenous lipid oxidation. Four days on a high-protein diet rather decreased exogenous fat oxidation and enhanced postprandial triglyceride concentrations, by impairing probably chylomicron-TG clearance. Altogether the results of these three studies suggest a beneficial effect of protein intake on the reduction in lHCL, and clearly show that supplementation of proteins do not reduce IHCL by stimulating lipid metabolism, e.g. whole body fat oxidation, hepatic beta oxidation, or exogenous fat oxidation. The question of the effects of high-protein intakes on hepatic lipid metabolism is still open and will need further investigation to be elucidated. The effects of protein on increased postprandial lipemia and lipoproteins kinetics have been little investigated so far and might therefore be an interesting research question, considering the tight relationship between an elevation of plasmatic TG concentrations and the increased incidence of cardiovascular diseases.Résumé :La stéatose hépatique non alcoolique se caractérise par un taux de lipides intra-hépatiques élevé, supérieur à 5%. L'incidence de la stéatose hépatique est fortement augmentée chez les personnes obèses, ce qui mène à la définir comme étant la composante hépatique du syndrome métabolique. Ce syndrome se définit aussi par d'autres critères tels qu'obésité viscérale, altération de l'homéostasie du glucose, résistance à l'insuline, dyslipidémie et pression artérielle élevée. Le syndrome métabolique est actuellement un problème de santé publique majeur.Tant une alimentation trop riche et déséquilibrée, qu'une faible activité physique, semblent être des causes pouvant expliquer le développement de ce syndrome. Chez l'animal et le volontaire sain, des alimentations enrichies en graisses ou en sucres (fructose) favorisent le développement de facteurs associés au syndrome métabolique, notamment en augmentant le taux de lipides intra-hépatiques et en induisant le développement d'une résistance à l'insuline. Par ailleurs, les effets des protéines alimentaires sont nettement moins bien connus, mais il semblerait qu'une augmentation de l'apport en protéines soit bénéfique, favorisant la perte de poids et l'homéostasie du glucose chez des patients insulino-résistants. Une augmentation de la thermogenese postprandiale ainsi que du sentiment de satiété pourraient en être à l'origine.Les effets des protéines sur les lipides intra-hépatiques chez l'homme demeurent inconnus à ce jour, cependant des études préliminaires chez les rongeurs tendent à démontrer une diminution des lipides intra hépatiques chez des rats nourris avec une alimentation riche en sucres ou chez des rats obèses.Dans un tel contexte de recherche, ce travail s'est intéressé à l'étude des effets métaboliques des protéines alimentaires sur le métabolisme lipidique du foie et sur l'homéostasie du glucose. Ce travail propose d'évaluer l'effet des protéines alimentaires sur différentes voies métaboliques impliquant graisses et sucres, en ciblant d'une part les voies de l'oxydation des graisses exogènes, de la beta-oxydation hépatique et de l'oxydation nette des lipides, et d'autre part la dépense énergétique globale et l'évolution des concentrations sanguines des triglycérides, à jeun et en régime postprandial. Des mesures des lipides intra-hépatiques ont aussi été effectuées pour permettre la quantification des graisses déposées dans le foie.Dans le but de couvrir l'ensemble de ces aspects métaboliques sous différents angles de recherche, trois protocoles, impliquant des conditions alimentaires différentes, ont été entrepris pour tenter de répondre à ces questions. La première étude (Etude I) s'est intéressée aux effets d'u.ne suralimentation de 4 jours enrichie en graisses et protéines sur la sensibilité à l'insuline et sur l'accumulation de graisses intra-hépatiques. Les résultats ont démontré que l'apport en protéines prévient l'accumulation de graisses intra-hépatiques induite par une suralimentation riche en graisses de courte durée ainsi que ses effets délétères probablement par le biais de mécanismes agissant au niveau du foie. Ces résultats encourageants nous ont conduits à entreprendre une seconde étude (Etude ll) qui s'intéressait à l'implication clinique et aux bénéfices que pouvait avoir une supplémentation en protéines sur les graisses hépatiques de patients obèses. Ainsi nous avons évalué pendant un mois de supplémentation l'effet de protéines de lactosérum sur le taux de graisses intrahépatiques, la sensibilité à l'insuline, la tolérance au glucose, le métabolisme des graisses et la fonction rénale chez des femmes obèses. Les résultats ont été encourageants; la supplémentation en lactosérum améliore la stéatose hépatique, le profil lipidique des patientes obèses sans pour autant altérer la tolérance au glucose ou la clairance de la créatinine. L'effet satiétogene des protéines pourrait aussi avoir contribué à renforcer ces effets. La troisième étude s'est intéressée aux mécanismes qui sous-tendent les effets bénéfiques des protéines observés dans les 2 études précédentes. Nous avons supposé que les protéines devaient favoriser le métabolisme des graisses. Par conséquent, nous avons cherché a évaluer les effets d'un repas riche en protéines sur la lipémie postprandiale et l'homéostasie glucidique après 4 jours d'alimentation contrôlée soit isocalorique et équilibrée, soit hypercalorique enrichie en protéines. Les résultats obtenus n'ont pas vérifié l'hypothèse initiale ; ni une augmentation de l'oxydation nette des lipides, ni celle d'une augmentation de la béta-oxydation hépatique ou de l'oxydation d'un apport exogène de graisses n'a pu étre observée. A contrario, il semblerait même plutôt que 4 jours d'a]irnentation hyperprotéinée inhibent le métabolisme des graisses et augmente les concentrations sanguines de triglycérides, probablement par le biais d'une clairance de chylornicrons altérée. Globalement, les résultats de ces trois études nous permettent d'attester que les protéines exercent un effet bénéfique en prévenant le dépot de graisses intra-hépatiques et montrent que cet effet ne peut être attribué à une stimulation du métabolisme des lipides via l'augmentation des oxydations des graisses soit totales, hépatiques, ou exogènes. La question demeure en suspens à ce jour et nécessite de diriger la recherche vers d'autres voies d'exploration. Les effets des protéines sur la lipémie postprandiale et sur le cinétique des lipoprotéines n'a que peu été traitée à ce jour. Cette question me paraît néanmoins importante, sachant que des concentrations sanguines élevées de triglycérides sont étroitement corrélées à une incidence augmentée de facteurs de risque cardiovasculaire.

Performance Report for Fiscal Year 2013

Department of Commerce, Iowa Division of Banking (IDOB) Performance Report for Fiscal Year 2013 (July 1, 2012 - June 30, 2013). This report contains valuable information about the services the Iowa Division of Banking has provided for Iowans during the past fiscal year. This report is being published to meet the agency’s commitment to manage for results and to be open and accountable to Iowa citizens. This report contains performance information on the Bank Bureau, the Finance Bureau and the Professional Licensing Bureau of the IDOB.

Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?

Background The aim if this study was to compare percutaneous drainage (PD) of the gallbladder to emergency cholecystectomy (EC) in a well-defined patient group with sepsis related to acute calculous/acalculous cholecystitis (ACC/AAC).Methods Between 2001 and 2007, all consecutive patients of our ICU treated by either PD or EC were retrospectively analyzed. Cases were collected from a prospective database. Percutaneous drainage was performed by a transhepatic route and EC by open or laparoscopic approach. Patients' general condition and organ dysfunction were assessed by two validated scoring systems (SAPS II and SOFA, respectively). Morbidity, mortality, and long-term outcome were systematically reviewed and analyzed in both groups.Results Forty-two patients [median age = 65.5 years (range = 32-94)] were included; 45% underwent EC (ten laparoscopic, nine open) and 55% PD (n = 23). Both patient groups had similar preoperative characteristics. Percutaneous drainage and EC were successful in 91 and 100% of patients, respectively. Organ dysfunctions were similarly improved by the third postoperative/postdrainage days. Despite undergoing PD, two patients required EC due to gangrenous cholecystitis. The conversion rate after laparoscopy was 20%. Overall morbidity was 8.7% after PD and 47% after EC (P = 0.011). Major morbidity was 0% after PD and 21% after EC (P = 0.034). The mortality rate was not different (13% after PD and 16% after EC, P = 1.0) and the deaths were all related to the patients' preexisting disease. Hospital and ICU stays were not different. Recurrent symptoms (17%) occurred only after ACC in the PD group.Conclusions In high-risk patients, PD and EC are both efficient in the resolution of acute cholecystitis sepsis. However, EC is associated with a higher procedure-related morbidity and the laparoscopic approach is not always possible. Percutaneous drainage represents a valuable intervention, but secondary cholecystectomy is mandatory in cases of acute calculous cholecystitis.

Determination of the Optimum Base Characteristics for Pavements, TR-482, 2004

In recent years, it has become apparent that the design and maintenance of pavement drainage extends the service life of pavements. Most pavement structures now incorporate subsurface layers. Part of the function of these subsurface layers is to drain away excess water, which can be extremely deleterious to the life of the pavement. To assure the effectiveness of such drainage layers after they have been spread and compacted, simple, rapid, in-situ permeability and stability testing and end-result specification are needed. This report includes conclusions and recommendations related to four main study objectives: (1) Determine the optimal range for in-place stability and in-place permeability based on Iowa aggregate sources; (2) Evaluate the feasibility of an air permeameter for determining the permeability of open and well-graded drainage layers in situ; (3) Develop reliable end-result quality control/quality assurance specifications for stability and permeability; and (4) Refine aggregate placement and construction methods to optimize uniformity.

Algies après cure de hernie inguinale: que faire [Pain after inguinal hernia repair: what to do?]

Hernia repair one of the most frequently performed operations in general surgery. With the introduction of tension-free mesh repair, recurrence rates dropped well below 5% for open and laparoscopic procedures. However, chronic postoperative pain remains a widely neglected complication with a high socio-economic impact. It occurs in about 10-20% of patients after hernia repair. We review the different types of post-herniorrhaphy pain with the typical diagnostic features and we conclude with a pragmatic algorithm based on our clinical experience.

The State of the Judiciary, 2015

My job today as chief justice is to inform you and all Iowans of the condition of the Iowa Judicial Branch. The judicial branch is accountable to do its work so that Iowans can see the value of its fair and impartial courts. It is accountable every day for the resources it is given and the important responsibilities with which it has been entrusted. We best meet these obligations by becoming the best court system we can be. I am honored to report the progress the judicial branch has made towards becoming the best court system in the nation and the value of this progress for all Iowans. Both my grandfathers were carpenters. Like others who build with their hands, they could look at their work at the end of the day and see progress since the beginning of the day. Building Iowa’s court system consistent with its goals may not reveal progress at the end of every day as easily as the work of a carpenter. It is a long, careful process that requires the hands of many, working every day. But, certain days do come along when progress can be seen and our goals are closer within reach. Again this year, the goals of the judicial branch are to:  Protect Iowa’s children;  Provide full-time access to justice;  Operate an efficient, full-service court system;  Provide faster and less costly resolution of legal disputes;  Remain open and transparent; and  Provide fair and impartial justice for all.

2015 Calendar Year Annual Report of the Watershed Improvement Review Board

The Watershed Improvement Fund and the Iowa Watershed Improvement Review Board (WIRB) were created in 2005. This statute is now codified in Iowa Code Chapter 466A. The fifteen-member Board conducted seven meetings throughout the year in-person or via teleconference. Meetings were held January 23, February 27, April 17, June 18, July 24, September 25 and December 17. Attachment 1 lists the board members and their organization affiliation. The Board completed one Request For Applications (RFA) for the Watershed Improvement Fund. The RFA was announced November 6, 2014 and closed December 29, 2014. December 29, 2014 Closing Date Request For Applications: The Board received 16 applications in response to this RFA. These applications requested $2.8 million in Watershed Improvement Funds and leveraged an additional $9.1 million for a total of $11.9 million of watershed project activity proposed. After reviewing and ranking the applications individually from this RFA, the Board met and selected eight applications for funding. The eight applications were approved for $1,249,861 of Watershed Improvement Funds. Data on the eight selected projects in this RFA include the following: • These projects included portions of 12 counties. • The $1.2 million requested of Watershed Improvement Funds leveraged an additional $4.2 million for a total of $5.4 million in watershed improvements. • Approved projects ranged in funding from $41,980 to $250,000. Attachment 2 lists the approved projects’ name, applicant name, project length, county or counties where located, and funding amount for the RFA. Attachment 3 is a map showing the status of all projects funded since inception of the program. At the end of 2015 there are 111 completed projects and 39 active projects. In cooperation with the Treasurer of State, the WIRB submitted the 2015 year-end report for the Rebuild Iowa Infrastructure Fund to the Legislative Services Agency and the Department of Management. Attachment 4 contains the 2015 annual progress reports submitted from active projects or projects finished in 2015.

Addendum to the Design Manual for Low Water Stream Crossings, HR-247, 1984

The purpose of this manual is to provide guidelines for low water stream crossings (LWSC). Rigid criteria for determining the applicability of a LWSC to a given site are not established nor is a 'cookbook" procedure for designing a LWSC presented. Because conditions vary from county to county and from site to site within the county, judgment must be applied to the suggestions contained in this manual. A LWSC is a stream crossing that will be flooded periodically and closed to traffic. Carstens (1981) has defined a LWSC as "a ford, vented ford (one having some number of culvert pipes), low water bridge, or other structure that is designed so that its hydraulic capacity will be insufficient one or more times during a year of normal rainfall." In this manual, LWSC are subdivided into these same three main types: unvented fords, vented fords and low water bridges. Within the channel banks, an unvented ford can have its road profile coincident with the stream bed or can have its profile raised some height above the stream bed.

Toimintasuunnitelman laatiminen ohutlevytuotteita ja hitsauskokoonpanoja valmistavalle yritykselle

Tämän diplomityön tavoitteena oli luoda ohutlevytuotteita ja hitsauskokoonpanoja valmistavalle yritykselle kokonaisvaltainen toimintasuunnitelma ja esitellä erilaisia tuotantomalleja case-esimerkkien avulla. Työn aikana kartoitettiin yrityksennykytilannetta ja ongelmakohtia, pohdittiin nykyistä konekantaa ja löytyneitä pullonkauloja. Lisäksi suunniteltiin korjaustoimenpiteitä ja mitä tulisi tehdä, kun tulevaisuudessa yrityksen liikevaihto tulee kasvamaan ja yritystä tullaan laajentamaan. Pääpaino oli myös laskelmilla, joissa selvitettiinmahdollisten investointien tuntihintaa. Tuntihinnan avulla laadittiin taulukoita, joiden avulla ulosmyyntihinta on helppo määrittää. Tuntihinta kytkettiin sijoitetulle pääomalle haluttuun tuottoprosenttiin.

Designing online interaction to address disciplinary competencies: A cross-country comparison of faculty perspectives

This study was conducted at colleges in three countries (United States, Venezuela, and Spain) and across three academic disciplines (engineering, education, and business), to examine how experienced faculty define competencies for their discipline, and design instructional interaction for online courses. A qualitative research design employing in-depth interviews was selected. Results show that disciplinary knowledge takes precedence when faculty members select competencies to be developed in online courses for their respective professions. In all three disciplines, the design of interaction to correspond with disciplinary competencies was often influenced by contextual factors that modify faculty intention. Therefore, instructional design will vary across countries in the same discipline to address the local context, such as the needs and expectations of the learners, faculty perspectives, beliefs and values, and the needs of the institution, the community, and country. The three disciplines from the three countries agreed on the importance of the following competencies: knowledge of the field, higher order cognitive processes such as critical thinking, analysis, problem solving, transfer of knowledge, oral and written communication skills, team work, decision making, leadership and management skills, indicating far more similarities in competencies than differences between the three different applied disciplines. We found a lack of correspondence between faculty¿s intent to develop collaborative learning skills and the actual development of them. Contextual factors such as faculty prior experience in design, student reluctance to engage in collaborative learning, and institutional assessment systems that focus on individual performance were some of these reasons.

Sähkösalkun tuotteistaminen ja salkunhallinnan menestyksen seuranta

Sähkömarkkinoiden vapautumisen ja pörssimuotoisen kaupankäynnin myötäyhä useampi toimija on siirtynyt perinteisistä kiinteähintaisista sopimuksista salkkumuotoiseen sähkönhankintaan. Aktiivisen salkunhallinnan myötä kanava markkinoille pysyy jatkuvasti avoimena ja ostopäätös voidaan jakaa pidemmälle ajanjaksolle, jolloin riippuvaisuus vain yhden hetken hintatasosta pienenee. Sähkön hankintahinnan suojaamiseen käytettävien finanssituotteiden määrä pörssissä ja OTC-markkinalla on kasvanut viime vuosina merkittävästi. Tämän seurauksena myös käytettävien instrumenttien valinta ja perustelu asiakkaalle vaatii entistä tarkempaa huomiota. Työssä käsiteltävän tuotteistuksen tavoitteena oli luoda salkunhallinnan perustapauksille yksinkertaiset rungot, joita voidaan täydentää erilaisillalisäominaisuuksilla. Tuotteistuksella pyritään myös selkeyttämään asiakkaalle muodostuvaa mielikuvaa tarjolla olevista vaihtoehdoista sekä edesauttamaan markkinointia. Diplomityön toisena tavoitteena oli kehittää salkunhallinnan menestyksen seurantaa varten mittarit, joiden avulla sekä asiakas että salkunhoitaja pystyvät seuraamaan salkunhallinnan onnistumista. Mittarit toteutettiin Excel-ympäristössä ja testattavat salkut koostuivat pääasiassa lopullisista tuotteistettaviksi valituista salkuista. Työn pohjalta on määrä toteuttaa olemassa olevan internet-pohjaisen salkunhallintapalvelun osaksi sovellus, joka mahdollistaa salkunhallinnan menestyksen jatkuvan seurannan.

Hitsaavan tuotannon kehittäminen pyöräkuormainkaivureita valmistavassa yrityksessä

Diplomityössä käsitellään pyöräkuormainkaivureita valmistavan yrityksen konepajatuotannon kehittämistä aihiovalmistuksen, hitsauksen ja koneistuksen osalta. Pääpaino kehittämistoimissa on hitsauksessa. Lähtökohtana tuotannonkehittämisen tarpeelle ovat tuotannon kasvu, kustannustehokkuuden lisääminen sekä pula ammattitaitoisesta työvoimasta. Diplomityössä selvitetään yrityksen vanhan konekannan päivittämismahdollisuuksia ja säästöjen hakemista tehokkaampia valmistusmenetelmiä käyttöönottamalla. Pohjatyönä tulevaisuuden tuotannon tehostamiselle selvitettiin nykyiset valmistuskustannukset. Työajankäytön historiatiedot löytyivät yrityksen tietojärjestelmästä, joita tarkennettiinkentältä kerätyin tiedoin. Myös koneiden käyttökustannukset tuntihinnat eri työvaiheille. selvitettiin ja näin saatiin määritettyä Lännen Tractors Oy:lle löytyi hitsaavassa tuotannossa kehitystoimenpiteitä, mitkä tekemällä voidaan tuotantoa tehostaa ilman investointeja. Tuotannon kehittäminen jaettiin kahteen vaiheeseen: 1. vaihe, missä ei investoida vaan keskitytään nykyisten menetelmien kehittämiseen ja vanhojen koneiden tehokkaampaan hyödyntämiseen ja 2.vaihe, missä tarkastellaan mahdollisten investointien kannattavuutta sekä selvitetään alihankinnan mandollisuutta. Tuotannon tehostamisen 1. vaiheen toimenpiteillä saadaan hitsauskustannuksia pienennettyä jopa 20 %. 2. vaiheen oman tuotannon tehostamiseksi koneistuksen eri tehtiin investointilaskelmat robottihitsaussolun ja vaihtoehtojen takaisinmaksuajasta sekä sisäisestä korkokannasta. Uuden robottihitsaussolun takaisinmaksuaika on n. 3 vuotta. Näiden laskelmien perusteella mahdollisuudet valmistaa komponentteja taloudellisesti. investoinneilla voidaan pyöräkuormainkaivureiden saavuttaa hitsattuja

Ingénieur pédagogique et démarche projet : facteurs clés de succès pour l'intégration des technologies dans la pratique enseignante?

Résumé: Les gouvernements des pays occidentaux ont dépensé des sommes importantes pour faciliter l'intégration des technologies de l'information et de la communication dans l'enseignement espérant trouver une solution économique à l'épineuse équation que l'on pourrait résumer par la célèbre formule " faire plus et mieux avec moins ". Cependant force est de constater que, malgré ces efforts et la très nette amélioration de la qualité de service des infrastructures, cet objectif est loin d'être atteint. Si nous pensons qu'il est illusoire d'attendre et d'espérer que la technologie peut et va, à elle seule, résoudre les problèmes de qualité de l'enseignement, nous croyons néanmoins qu'elle peut contribuer à améliorer les conditions d'apprentissage et participer de la réflexion pédagogique que tout enseignant devrait conduire avant de dispenser ses enseignements. Dans cette optique, et convaincu que la formation à distance offre des avantages non négligeables à condition de penser " autrement " l'enseignement, nous nous sommes intéressé à la problématique du développement de ce type d'applications qui se situent à la frontière entre les sciences didactiques, les sciences cognitives, et l'informatique. Ainsi, et afin de proposer une solution réaliste et simple permettant de faciliter le développement, la mise-à-jour, l'insertion et la pérennisation des applications de formation à distance, nous nous sommes impliqué dans des projets concrets. Au fil de notre expérience de terrain nous avons fait le constat que (i)la qualité des modules de formation flexible et à distance reste encore très décevante, entre autres parce que la valeur ajoutée que peut apporter l'utilisation des technologies n'est, à notre avis, pas suffisamment exploitée et que (ii)pour réussir tout projet doit, outre le fait d'apporter une réponse utile à un besoin réel, être conduit efficacement avec le soutien d'un " champion ". Dans l'idée de proposer une démarche de gestion de projet adaptée aux besoins de la formation flexible et à distance, nous nous sommes tout d'abord penché sur les caractéristiques de ce type de projet. Nous avons ensuite analysé les méthodologies de projet existantes dans l'espoir de pouvoir utiliser l'une, l'autre ou un panachage adéquat de celles qui seraient les plus proches de nos besoins. Nous avons ensuite, de manière empirique et par itérations successives, défini une démarche pragmatique de gestion de projet et contribué à l'élaboration de fiches d'aide à la décision facilitant sa mise en oeuvre. Nous décrivons certains de ses acteurs en insistant particulièrement sur l'ingénieur pédagogique que nous considérons comme l'un des facteurs clé de succès de notre démarche et dont la vocation est de l'orchestrer. Enfin, nous avons validé a posteriori notre démarche en revenant sur le déroulement de quatre projets de FFD auxquels nous avons participé et qui sont représentatifs des projets que l'on peut rencontrer dans le milieu universitaire. En conclusion nous pensons que la mise en oeuvre de notre démarche, accompagnée de la mise à disposition de fiches d'aide à la décision informatisées, constitue un atout important et devrait permettre notamment de mesurer plus aisément les impacts réels des technologies (i) sur l'évolution de la pratique des enseignants, (ii) sur l'organisation et (iii) sur la qualité de l'enseignement. Notre démarche peut aussi servir de tremplin à la mise en place d'une démarche qualité propre à la FFD. D'autres recherches liées à la réelle flexibilisation des apprentissages et aux apports des technologies pour les apprenants pourront alors être conduites sur la base de métriques qui restent à définir. Abstract: Western countries have spent substantial amount of monies to facilitate the integration of the Information and Communication Technologies (ICT) into Education hoping to find a solution to the touchy equation that can be summarized by the famous statement "do more and better with less". Despite these efforts, and notwithstanding the real improvements due to the undeniable betterment of the infrastructure and of the quality of service, this goal is far from reached. Although we think it illusive to expect technology, all by itself, to solve our economical and educational problems, we firmly take the view that it can greatly contribute not only to ameliorate learning conditions but participate to rethinking the pedagogical approach as well. Every member of our community could hence take advantage of this opportunity to reflect upon his or her strategy. In this framework, and convinced that integrating ICT into education opens a number of very interesting avenues provided we think teaching "out of the box", we got ourself interested in courseware development positioned at the intersection of didactics and pedagogical sciences, cognitive sciences and computing. Hence, and hoping to bring a realistic and simple solution that could help develop, update, integrate and sustain courseware we got involved in concrete projects. As ze gained field experience we noticed that (i)The quality of courseware is still disappointing, amongst others, because the added value that the technology can bring is not made the most of, as it could or should be and (ii)A project requires, besides bringing a useful answer to a real problem, to be efficiently managed and be "championed". Having in mind to propose a pragmatic and practical project management approach we first looked into open and distance learning characteristics. We then analyzed existing methodologies in the hope of being able to utilize one or the other or a combination to best fit our needs. In an empiric manner and proceeding by successive iterations and refinements, we defined a simple methodology and contributed to build descriptive "cards" attached to each of its phases to help decision making. We describe the different actors involved in the process insisting specifically on the pedagogical engineer, viewed as an orchestra conductor, whom we consider to be critical to ensure the success of our approach. Last but not least, we have validated a posteriori our methodology by reviewing four of the projects we participated to and that we think emblematic of the university reality. We believe that the implementation of our methodology, along with the availability of computerized cards to help project managers to take decisions, could constitute a great asset and contribute to measure the technologies' real impacts on (i) the evolution of teaching practices (ii) the organization and (iii) the quality of pedagogical approaches. Our methodology could hence be of use to help put in place an open and distance learning quality assessment. Research on the impact of technologies to learning adaptability and flexibilization could rely on adequate metrics.

Predictive Factors for Intraocular Pressure Reduction after Phacoemulsification in Swiss Patients.

Background: Phacoemulsification is known to induce postoperative intraocular pressure (IOP) reduction, the degree of which varies according to glaucoma subtype and race. The authors set out to investigate the effect of cataract surgery on IOP, in a Swiss Caucasian population, and identify ocular predictive factors. Patients and Methods: 234 consecutive cases of 188 patients undergoing phacoemulsification between January 2011 and December 2012 were retrospectively reviewed and data collected. Exclusion criteria included acute angle closure, malignant glaucoma and pre-existing or subsequent glaucoma surgery. Pre- and post-operative visual acuity, IOP, gonioscopic findings, glaucoma medications, and laser treatments were recorded for eligible eyes. All eyes received the same postoperative regimen. Using multivariate analysis the predictive power of preoperative IOP, iridocorneal angle width, axial length on IOP reduction following phacoemulsification at months 3, 6 and 12 postoperatively were assessed. Eyes with narrow angles were compared against those with open angles. Results: 172 eyes of 121 patients met the inclusion criteria; mean age was 70.3 years (SD ± 10.7 years), with 77 males. Preoperatively median IOP was 16 mmHg (range 9-32 mmHg), mean number of glaucoma medications was 1.2 (SD ± 1.1), median visual acuity was 0.28 LogMAR (range 0-2.3LogMar). At 3 months post-operatively mean IOP decreased to 14 mmHg (p < 0.01) and remained statistically significantly reduced until 12 months, mean number of glaucoma medications was reduced to 1.0 and mean Snellen visual acuity increased to 0.8. Multivariate analysis revealed that pre-operative IOP and iridocorneal angle width (at 3 months) were significant predictive indicators of IOP reduction. At 12 months, IOP reduction was similar between open and narrow angle groups and total IOP reduction was no longer statistically significant. No intraoperative complications were recorded. Conclusions: Intraocular pressure reduction following phacoemulsification was greatest during the very early post-operative period, particularly in narrow angle patients. By one year, angle size was no longer predictive of IOP lowering, however pre-operative IOP and number of anti-glaucoma medications remained correlated with total IOP reduction.

Vacuum-assisted closure device for the management of infected postpneumonectomy chest cavities.

BACKGROUND: Infected postpneumonectomy chest cavities may be related to chronic postpneumonectomy empyema or arise in rare situations of necrotizing pneumonia with complete lung destruction where pneumonectomy and pleural debridement are required. We evaluated the safety and efficacy of an intrathoracic vacuum-assisted closure device (VAC) for the treatment of infected postpneumonectomy chest cavities. METHOD: A retrospective single institution review of all patients with infected postpneumonectomy chest cavities treated by VAC between 2005 and 2013. Patients underwent surgical debridement of the thoracic cavity, muscle flap closure of the bronchial stump when a fistula was present, and repeated intrathoracic VAC dressings until granulation tissue covered the entire chest cavity. After this, the cavity was obliterated by a Clagett procedure and closed. RESULTS: Twenty-one patients (14 men and 7 women) underwent VAC treatment of their infected postpneumonectomy chest cavity. Twelve patients presented with a chronic postpneumonectomy empyema (10 of them with a bronchopleural fistula) and 9 patients with an empyema occurring in the context of necrotizing pneumonia treated by pneumonectomy. In-hospital mortality was 23%. The median duration of VAC therapy was 23 days (range, 4-61 days) and the median number of VAC changes per patient was 6 (range, 2-14 days). Infection control and successful chest cavity closure was achieved in all surviving patients. One adverse VAC treatment-related event was identified (5%). CONCLUSIONS: The intrathoracic VAC application is a safe and efficient treatment of infected postpneumonectomy chest cavities and allows the preservation of chest wall integrity.