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BACKGROUND: Coronary artery disease (CAD) is common in patients undergoing transcatheter aortic valve replacement (TAVR). However, the impact of CAD distribution before TAVR on short‐ and long‐term prognosis remains unclear. HYPOTHESIS: We hypothesized that the long‐term clinical impact differs according to CAD distribution in patients undergoing TAVR using the FRench Aortic National CoreValve and Edwards (FRANCE‐2) registry. METHODS: FRANCE‐2 is a national French registry including all consecutive TAVR performed between 2010 and 2012 in 34 centers. Three‐year mortality was assessed in relation to CAD status. CAD was defined as at least 1 coronary stenosis >50%. RESULTS: A total of 4201 patients were enrolled in the registry. For the present analysis, we excluded patients with a history of coronary artery bypass. CAD was reported in 1252 patients (30%). Half of the patients presented with coronary multivessel disease. CAD extent was associated with an increase in cardiovascular risk profile and in logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) (from 19.3% ± 12.8% to 21.9% ± 13.5%, P < 0.001). Mortality at 30 days and 3 years was 9% and 44%, respectively, in the overall population. In multivariate analyses, neither the presence nor the extent of CAD was associated with mortality at 3 years (presence of CAD, hazard ratio [HR]: 0.90; 95% confidence interval [CI]: 0.78‐1.07). A significant lesion of the left anterior descending (LAD) was associated with higher 3‐year mortality (HR: 1.42; 95% CI: 1.10‐1.87). CONCLUSIONS: CAD is not associated with decreased short‐ and long‐term survival in patients undergoing TAVR. The potential deleterious effect of LAD disease on long‐term survival and the need for revascularization before or at the time of TAVR should be validated in a randomized control trial.

Resume Le diabete sucre correspond a une elevation chronique de la glycemie liee a une insulinoresistance et/ou une insulinopenie. Son diagnostic repose actuellement sur une mesure de la glycemie a jeun ≥ 1,26 g/L ou dans certains pays sur un dosage d’hemoglobine glyquee (HbA1c) > 6,5 %. Il existe plusieurs formes de diabete. Le diabete de type 2 (DT2) est le plus frequent et s’observe chez des patients presentant des facteurs de risque. Le diabete de type 1 (DT1) est lie a une destruction auto-immune des cellules beta-pancreatiques conduisant a une insulinopenie. La carence en insuline entraine une acidocetose diabetique en quelques heures. Les diabetes « pancreatiques » font suite a certaines pancreatopathies et peuvent conduire a une insulinopenie. Les traitements du diabete reposent pour le DT2 sur les medicaments non insuliniques et sur les insulines quand le diabete devient insulinorequerant. Pour le DT1, le traitement repose sur les insulines lentes et les analogues ultrarapides de l’insuline selon le schema « basal-bolus » ou par la delivrance en continu en sous-cutane par l’intermediaire d’une pompe. Pour les patients presentant une dysglycemie meconnue, il faut rechercher s’il s’agit d’une dysglycemie preexistante ou une hyperglycemie de stress. Cette derniere est definie comme une hyperglycemie transitoire chez des patients non diabetiques anterieurement et qui presentent une maladie aigue ou beneficient d’une intervention chirurgicale. Son importance est fonction du type de chirurgie, de l’agressivite du geste et de sa duree. Elle conduit a une insulinoresistance peripherique et constitue un facteur pronostique independant de morbi-mortalite.

Resume En preoperatoire, il est necessaire d’evaluer l’equilibre glycemique du diabetique. Cette evaluation repose sur l’hemoglobine glyquee (HbA1c) et les glycemies capillaires recentes. Une adaptation des traitements peut etre necessaire avant la chirurgie. Les complications specifiques du diabete doivent etre recherchees. La gastroparesie cree un risque de stase et d’inhalation a l’induction anesthesique imposant une induction type « estomac plein ». L’atteinte cardiaque se divise en plusieurs entites. La maladie coronaire se distingue par l’ischemie myocardique silencieuse, presente chez 30 a 50 % des diabetiques de type 2. La cardiomyopathie diabetique est une cause authentifiee d’insuffisance cardiaque. Enfin, la neuropathie autonome cardiaque, rarement symptomatique doit etre recherchee car a l’origine d’une augmentation des evenements cardiovasculaires et du risque de mort subite. Plusieurs signes permettent de la suspecter. Sa confirmation impose une surveillance perioperatoire rapprochee. La maladie renale chronique diabetique aggrave le risque d’insuffisance renale aigue perioperatoire. L’evaluation du debit de filtration glomerulaire est indispensable en pre operatoire. La derniere etape de la consultation s’interesse a la gestion des traitements hypoglycemiants. La perfusion glucosee en preoperatoire n’est pas necessaire si le patient ne recoit pas d’insuline. Les medicaments non insuliniques ne sont pas administres le matin de l’intervention sauf la metformine qui n’est pas administree des la veille au soir. Les insulines sont injectees la veille au soir aux posologies habituelles. La pompe a insuline est maintenue jusqu’a l’arrivee au bloc operatoire. On rappelle qu’une carence en insuline chez un diabetique de type 1 conduit a une acidocetose en quelques heures.

Resume Le relais de l’insuline IVSE administree en peroperatoire constitue un element essentiel de la prise en charge du patient diabetique en postoperatoire. Le schema basal-bolus est le plus adapte compte tenu des apports nutritionnels et des besoins variables en insuline. Il reproduit la physiologie d’un pancreas normal : (i) une insuline lente (= basal) qui doit relayer sans delai l’insuline IVSE simulant la secretion basale ; (ii) des insulines ultrarapides pour simuler la secretion prandiale (= bolus pour le repas) ; et (iii) pour permettre la correction d’une eventuelle hyperglycemie (= bolus correcteur). Des schemas sont proposes pour aider au calcul de posologies pour le passage de l’insuline intraveineuse a l’insuline sous-cutanee et pour le schema basal-bolus. La reprise en postoperatoire d’une pompe a insuline impose que le patient soit autonome. Sinon, il est obligatoire de mettre en place un schema basal-bolus sans delai a l’arret de l’insuline intraveineuse. La surveillance glycemique doit etre poursuivie en postoperatoire. Les hypoglycemies et les hyperglycemies graves doivent etre recherchees. Devant une hypoglycemie 16,5 mmol/L (3 g/L) chez le DT1 et chez le DT2 traite par insuline, la recherche d’une cetose doit etre systematique. Chez les DT2, une hyperglycemie franche doit egalement faire evoquer une hyperosmolarite diabetique (coma hyperosmolaire). Enfin, les modalites de reprise des traitements anterieurs sont detaillees selon le type d’hyperglycemie, la fonction renale et l’equilibre du diabete en preoperatoire et durant l’hospitalisation.

Resume L’hyperglycemie perioperatoire (> 1,80 g/L ou 10 mmol/L) augmente la morbidite (notamment les infections) et la mortalite. Sa prise en charge passe par la diminution de la glycemie plus que par l’insuline. Un controle glycemique entre 0,90 et 1,80 g/L (5 a 10 mmol/L) permet d’eviter les hypoglycemies qui etaient plus frequentes lorsque la normoglycemie stricte etait recherchee. Le controle glycemique doit se poursuivre en peroperatoire. Nous proposons un protocole d’insulinotherapie IVSE chez les patients diabetiques de type 1, de type 2 si besoin ou en cas d’hyperglycemie de stress. L’arret de la pompe a insuline impose un relais immediat par insuline IVSE. Les autres elements de prise en charge peroperatoire sont detailles. Nous recommandons pour la prophylaxie des nausees et vomissements d’utiliser 4 mg de dexamethasone, plutot que 8 mg, en association a un autre antiemetique. L’emploi de l’anesthesie locoregionale (ALR), lorsqu’elle est possible, est un facteur de meilleur controle de la douleur postoperatoire et doit etre privilegie. Les besoins antalgiques sont plus eleves chez les patients ayant un equilibre glycemique de mauvaise qualite que ceux ayant un taux d’HbA1c

The history of infective endocarditis (IE) is a good example of medical progress. Initially incurable, endocarditis, when diagnosed, was synonym of death. After significant diagnostic progress, thanks to Osler's contribution especially, the first surgeries and antibacterial drugs obtained very few successful cures. We had to wait until Flamming's discovery to observe frequent cures thanks to antibiotics. Surgery manages to push possibilities of cure a bit further. However, paravalvular extensions, described since the first surgical case of IE, was a real technical matter. Thus, the second half of 20th century was devoted to overcoming this surgical challenge. In this historical review, we describe the story of severe IE, especially with paravalvular involvement, by highlighting major progress - clinical and surgical, that allows its current management.

Aims In type 1 diabetes (T1D), treatment efficacy is limited by the unpredictability of blood glucose results and glycemic variability (GV). Fear of Hypoglycemia (FOH) remains a major brake for insulin treatment optimization. We aimed to assess the association of GV with FOH in participants with T1D in an observational cross-sectional study performed in 9 French Diabetes Centres ( NCT02790060 ). Methods Participants were T1D for ≥5 years, aged 18–75 years, on stable insulin therapy for ≥3 months. The coefficient of variation (CV) of blood glucose and mean amplitude of glycemic excursions (MAGE) were used to assess GV from 7-point self-monitoring of blood glucose (SMBG). FOH was assessed using the validated French version of the Hypoglycemia Fear Survey-II (HFS-II) questionnaire. Results Among a total of 570 recruited participants, 298 were suitable for analysis: 46% women, 58% on continuous subcutaneous insulin infusion [CSII], mean age 49 ± 16 years, HbA1c 7.5 ± 0.9%, HFS-II score 67 ± 18 and 12% with recent history of severe hypoglycemia during the previous 6 months, mean CV 39.8 ± 9.7% and MAGE 119 ± 42 mg/dL. CV and MAGE did not significantly correlate with HFS-II score (R = −0.05;P = 0.457 and R = 0.08;P = 0.170). Participants with severe hypoglycemia in the previous 6 months had higher HFS scores. Participants with higher HFS scores presented more hypoglycemias during follow-up. Conclusions FOH as determined using the HFS-II questionnaire was not associated with 7-point SMBG variability in participants with T1D, but was associated with a positive history of severe hypoglycemia. Higher FOH was associated with higher frequency of hypoglycemia during follow-up.

Cette thèse examine l’omniprésence de la figure d’Ulysse dans la conscience de soi du XXe siècle à travers ses nombreuses réécritures littéraires et philosophiques. Constatant la prolifération sans précédent de la figure d’Ulysse dans la littérature de cette période, il s’agit de montrer qu’elle incarne et met en marche une pensée qui conduit au cœur des problèmes les plus importants du siècle. La fortune littéraire et critique qu’Ulysse connaît au XXe siècle est expliquée par les modalités de la pensée qu’il véhicule, modalités qui sont éclairées par la définition d’Ulysse en tant que figure de la médiation des extrêmes. Cette pensée des extrêmes incarnée par Ulysse est définie comme une manifestation de l’esprit propre au littéraire et irréductible à la pensée conceptuelle, c’est-à-dire comme pensée littéraire. À partir de l’étude de textes littéraires du XXe siècle dans lesquels se manifeste la figure d’Ulysse, je montre que cette pensée concerne le rapport de force entre affect et raison au sein de l’esprit, la manière dont la raison se propulse à partir des affects pour ensuite être débordée par ceux-ci, dans un mouvement perpétuel qui est exemplifié par les pérégrinations d’Ulysse en quête d’un retour impossible. Ce rapport de force entre affect et raison est thématisé de manière spécifique sous la forme de la mise en scène par la figure d’Ulysse du rapport de force entre l’origine hellénique et l’origine judéo-chrétienne de la civilisation occidentale, entre raison et révélation, savoir et foi, Athènes et Jérusalem., This thesis examines the omnipresence of the Odysseus figure in twentieth century self-consciousness throughout its many literary and philosophical rewritings. Noting the unprecedented proliferation of the Odysseus figure in this period’s literature, the thesis seeks to convey the ways in which it embodies and sets in motion thinking at the core of the most important problems of the century. Odysseus’s literary and critical fortune in the twentieth century is explained by the modalities of thought which it conveys, modalities that are themselves clarified by the definition of Odysseus as a figure of the mediation between extremes. This thought of and between extremes embodied by Odysseus is defined as a manifestation of the mind proper to the literary, that is, as specifically literary thought, which is irreducible to conceptual thought. From the study of diverse literary texts of the twentieth century in which the Odysseus figure appears, I demonstrate that this particular form of thought concerns the balance of power between affect and reason within the mind, the way in which reason propels itself on the basis of affects only to become overwhelmed by them, in a perpetual movement that is exemplified by the peregrinations of Odysseus in his quest for an impossible return. This power struggle between affect and reason becomes a thematic element in the form of Odysseus’s depiction, or “mise en scène,” of the power struggle between the Hellenic and Judeo-Christian origins of Western civilization, between reason and revelation, knowledge and faith, Athens and Jerusalem.

Corticospinal output pathways have typically been considered to be the primary driver for voluntary movements of the hand/forearm; however, more recently, reticulospinal drive has also been implicated in the production of these movements. Although both pathways may play a role, the reticulospinal tract is thought to have stronger connections to flexor muscles than to extensors. Similarly, movements involuntarily triggered via a startling acoustic stimulus (SAS) are believed to receive greater reticular input than voluntary movements. To investigate a differential role of reticulospinal drive depending on movement type or acoustic stimulus, corticospinal drive was transiently interrupted using high-intensity transcranial magnetic stimulation (TMS) applied during the reaction time (RT) interval. This TMS-induced suppression of cortical drive leads to RT delays that can be used to assess cortical contributions to movement. Participants completed targeted flexion and extension movements of the wrist in a simple RT paradigm in response to a control auditory go signal or SAS. Occasionally, suprathreshold TMS was applied over the motor cortical representation for the prime mover. Results revealed that TMS significantly increased RT in all conditions. There was a significantly longer TMS-induced RT delay seen in extension movements than in flexion movements and a greater RT delay in movements initiated in response to control stimuli compared with SAS. These results suggest that the contribution of reticulospinal drive is larger for wrist flexion than for extension. Similarly, movements triggered involuntarily by an SAS appear to involve greater reticulospinal drive, and relatively less corticospinal drive, than those that are voluntarily initiated.NEW & NOTEWORTHY Through the use of the transcranial magnetic stimulation-induced silent period, we provide novel evidence for a greater contribution of reticulospinal drive, and a relative decrease in corticospinal drive, to movements involuntarily triggered by a startle compared with voluntary movements. These results also provide support for the notion that both cortical and reticular structures are involved in the neural pathway underlying startle-triggered movements. Furthermore, our results indicate greater reticulospinal contribution to wrist flexion than extension movements.

Bien plus qu’une activité consistant à représenter des idées préconçues ou à consolider des récits historiques en compétition avec d’autres récits sur le marché du savoir, la création littéraire permet la confrontation de l’esprit humain avec ce qui le dépasse, ce qui l’appelle tout en lui échappant. Un des plus vieux récits de la tradition occidentale illustre de manière frappante cette confrontation de l’esprit avec l’inconnu. Il s’agit du célèbre épisode de l’Odyssée d’Homère où Ulysse, à l’approche de l’île des Sirènes, se ligote au mat de son navire afin de pouvoir écouter leur chant sans craindre d’y succomber et de sauter à l’eau pour les rejoindre. Grâce à ce stratagème, Ulysse fait l’expérience d’un abandon de l’esprit à ce qui l’affecte de l’extérieur, le fascinant et menaçant de lui faire perdre la raison. Mais en même temps, et dans un même mouvement, il fait l’expérience d’une maitrise des affects par la force de la raison. À la fois stoïque et ouvert au débordement des affects, Ulysse incarne les extrêmes de l’esprit, le lieu où la tension entre affect et raison est portée à son comble. Si cette confrontation de l’esprit avec ce qui le dépasse est mise en scène dans les textes littéraires selon des modalités qui dépendent des conditions historiques de leur production, elle est aussi réactivée, au-delà de ces conditions historiques, chaque fois que l’esprit d’un lecteur, chaque fois que l’esprit d’une lectrice y trouve l’occasion d’une ouverture à ce qui l’excède et le fascine., Much more than an activity of representing preconceived ideas or consolidate historical narratives competing with other narratives on the knowledge market, literary production allows the confrontation of the human mind with what is beyond it, which call him while escaping him. One of the most ancient stories of the Western tradition strikingly illustrates this confrontation of the mind with the unknown. This is the famous episode of Homer’s Odyssey where Odysseus, at the approach of the island of Sirens, binds himself to the mat of his ship in order to listen to their song without fear of succumb and jump into the water to join them. Thanks to this stratagem, Odysseus experiences the surrender of the mind toward what affects him from the outside, fascinating and threatening to make him lose reason. But at the same time, and in the same movement, he experiences the domination of affects by the force of reason. Stoic, but at the same time open to the overflow of affects, Odysseus embodies the extremes of the mind, the place where the tension between affect and reason is carried to its height.

Background Aspecific scoring systems are used to predict the risk of death postsurgery in patients with infective endocarditis ( IE ). The purpose of the present study was both to analyze the risk factors for in‐hospital death, which complicates surgery for IE , and to create a mortality risk score based on the results of this analysis. Methods and Results Outcomes of 361 consecutive patients (mean age, 59.1±15.4 years) who had undergone surgery for IE in 8 European centers of cardiac surgery were recorded prospectively, and a risk factor analysis (multivariable logistic regression) for in‐hospital death was performed. The discriminatory power of a new predictive scoring system was assessed with the receiver operating characteristic curve analysis. Score validation procedures were carried out. Fifty‐six (15.5%) patients died postsurgery. BMI >27 kg/m 2 (odds ratio [ OR ], 1.79; P =0.049), estimated glomerular filtration rate OR , 3.52; P IV ( OR , 2.11; P =0.024), systolic pulmonary artery pressure >55 mm Hg ( OR , 1.78; P =0.032), and critical state ( OR , 2.37; P =0.017) were independent predictors of in‐hospital death. A scoring system was devised to predict in‐hospital death postsurgery for IE (area under the receiver operating characteristic curve, 0.780; 95% CI, 0.734–0.822). The score performed better than 5 of 6 scoring systems for in‐hospital death after cardiac surgery that were considered. Conclusions A simple scoring system based on risk factors for in‐hospital death was specifically created to predict mortality risk postsurgery in patients with IE .

Caring for patients with incurable cancer presents unique challenges. Managing symptoms that evolve with changing clinical status and, at the same time, ensuring alignment with patient goals demands specific attention from clinicians. With care needs that often transcend traditional service provision boundaries, patients who seek palliation commonly interface with a team of providers that represents multiple disciplines across multiple settings. In this case study, we explore some of the dynamics of a cross-disciplinary approach to symptom management in an integrated outpatient radiotherapy service model. Providers who care for patients with incurable cancer must rely on one another to secure delivery of the right services at the right time by the right person. In a model of shared responsibilities, flexibility in who does what and when can enhance overall team performance. Adapting requires within-team and between-team monitoring of task and function execution for any given patient. This can be facilitated by a common understanding of the purpose of the clinical team and an awareness of the particular circumstances surrounding care provision. Backup behavior, in which one team member steps in to help another meet an expectation that would otherwise not be fulfilled, is a supportive team practice that may follow naturally in high-functioning teams. Such team processes as these have a place in the care of patients with incurable cancer and help to ensure that individual provider efforts more effectively translate into improved palliation for patients with unmet needs.

During a simple reaction time (RT) task, movements can be initiated early and involuntarily through presentation of a loud startling acoustic stimulus (SAS), a phenomenon termed the StartReact effect. In order to infer that activity in startle-related structures led to the early response triggering, it is important to observe a concurrent startle reflex in sternocleidomastoid. It is generally accepted that to consistently elicit a startle reflex, the SAS must be both intense and unpredictable. However, it remains unclear what effect explicit foreknowledge of an impending SAS has on the effectiveness of a SAS to elicit a startle reflex when preparing a motor response. To test this, participants completed two separate blocks of a simple RT task (counterbalanced order), where the control auditory go-signal was replaced with a SAS on 20 % of trials. In an unwarned block, knowledge of the trial type (SAS vs. control) was not provided in advance, while in a warned block, the trial type was forewarned. Results revealed that while foreknowledge of an impending SAS reduced the magnitude of the startle reflex, it did not affect the proportion of startle reflexes elicited or the magnitude of the StartReact effect. An increase in control trial RT was observed during the unwarned block, but only when it was performed first. These results indicate that preparation of a motor response leads to sufficiently increased activation in startle-related neural structures such that even with explicit knowledge of an upcoming SAS, participants are unable to proactively gate the upcoming sensory input.

BACKGROUND Transcatheter aortic valve replacement (TAVR) has revolutionized management of high-risk patients with severe aortic stenosis. However, survival and the incidence of severe complications have been assessed in relatively small populations and/or with limited follow-up. OBJECTIVES This report details late clinical outcome and its determinants in the FRANCE-2 (FRench Aortic National CoreValve and Edwards) registry. METHODS The FRANCE-2 registry prospectively included all TAVRs performed in France. Follow-up was scheduled at 30 days, at 6 months, and annually from 1 to 5 years. Standardized VARC (Valve Academic Research Consortium) outcome definitions were used. RESULTS A total of 4,201 patients were enrolled between January 2010 and January 2012 in 34 centers. Approaches were transarterial (transfemoral 73%, transapical 18%, subclavian 6%, and transaortic or transcarotid 3%) or, in 18% of patients, transapical. Median follow-up was 3.8 years. Vital status was available for 97.2% of patients at 3 years. The 3-year all-cause mortality was 42.0% and cardiovascular mortality was 17.5%. In a multivariate model, predictors of 3-year all-cause mortality were male sex (p = 2 of 4 (p < 0.001). Severe events according to VARC criteria occurred mainly during the first month and subsequently in < 2% of patients/year. Mean gradient, valve area, and residual aortic regurgitation were stable during follow-up. CONCLUSIONS The FRANCE-2 registry represents the largest database available on late results of TAVR. Late mortality is largely related to noncardiac causes. Incidence rates of severe events are low after the first month. Valve performance remains stable over time. (J Am Coll Cardiol 2016; 68: 1637-47) (C) 2016 by the American College of Cardiology Foundation.

Resume Notre but etait d’evaluer la prise en charge peri-operatoire des patients diabetiques par les medecins anesthesistes et verifier sa conformite aux recommandations professionnelles, enquete menee conjointement dans un Centre hospitalier universitaire (CHU) et un Centre hospitalier prive (CHP). La population etudiee a concerne des patients majeurs diabetiques connus, qu’ils soient non-insulines (type 2 [DT2]), ou insulino-traites (type 1 [DT1], ou DT2 insulines), devant beneficier d’une intervention chirurgicale programmee sur le CHU Pontchaillou de Rennes ou le CHP de Cesson-Sevigne. Le recueil des donnees a ete effectue pendant une periode de 3 mois a l’aide d’un questionnaire standardise, renseigne par l’anesthesiste ou l’interne en charge du patient. Les questionnaires etaient completes lors de la consultation anesthesique, au bloc operatoire, puis a la sortie du patient. Entre janvier et mars 2014, les questionnaires concernant 161 patients diabetiques ont ete recueillis : 117 patients DT2, et 44 patients DT1 ou DT2 insulines. L’exhaustivite globale, evaluee sur les donnees PMSI, est de 74%, mais avec une disparite selon les specialites chirurgicales. Quels que soient le type de diabete et la duree attendue du jeune postoperatoire, une majorite de patients ont une prise en charge conforme aux recommandations (suspension de la metformine, poursuite des autres antidiabetiques oraux et de l’insuline, apports glucoses, relais eventuel par insulinotherapie per- et post-operatoire). Ainsi, si la prise en charge anesthesique des patients diabetiques est complexe, parfois difficile, elle est globalement satisfaisante. Notre etude montre que les recommandations sont relativement bien appliquees par les anesthesistes-reanimateurs, qui peuvent s’appuyer sur des protocoles therapeutiques solides et largement diffuses dans les differents services.

Resume Il convient d’adresser un patient a un diabetologue en perioperatoire dans plusieurs circonstances. En preoperatoire, le patient lui est adresse si un diabete est depiste ou si on constate un desequilibre glycemique (HbA1c 8 %). Pendant l’hospitalisation, il faut faire appel a un diabetologue si un diabete est decouvert, s’il existe un desequilibre glycemique malgre la prise en charge ou s’il survient des difficultes a la reprise du traitement anterieur. En postoperatoire et a distance de l’hospitalisation, tous les diabetiques qui ont une HbA1c > 8 % doivent beneficier d’une consultation avec un diabetologue.

The FRANCE-2 registry (French Aortic National Corevalve and Edwards) previously reported good early- and medium-term clinical and echocardiographic efficacy for transcatheter aortic valve replacement. We here report 5-year follow-up results from the registry.The registry includes all consecutive patients undergoing transcatheter aortic valve replacement for severe aortic stenosis in France. Follow-up is scheduled at 30 days, 6 months, then annually from 1 to 5 years. Clinical events were defined according to the Valve Academic Research Consortium criteria, and hemodynamic structural valve deterioration (SVD) was defined according to the consensus statement by the European Association of Percutaneous Cardiovascular Interventions.Between January 2010 and January 2012, 4201 patients were enrolled in 34 centers. Five-year vital status was available for 95.5% of patients; 88.1% had clinical evaluation or died. Overall, at 5 years, all-cause mortality was 60.8% (n=2478; 95% CI, 59.3% to 62.3%). The majority of cardiovascular events occurred in the first month after valve implantation, and incidence remained low thereafter, at2% per year up to 5 years, except for heart failure. The rate of heart failure was 14.3% at 1 year, then decreased over time to5% per year. In cumulative incidence function, the rates of severe SVD and moderate/severe SVD at 5 years were 2.5% and 13.3%, respectively. Mortality did not differ between patients with or without severe SVD (hazard ratio, 0.71; 95% CI, 0.47-1.07; P=0.1). Finally, in the population of patients with severe SVD, 1 patient (1.7%) experienced a stroke, and 8 patients presented ≥1 heart failure event (13.3%).The 5-year follow-up results of the FRANCE-2 registry represent the largest long-term data set available in a high-risk population. In surviving patients, the low rate of clinical events and the low level of SVD after 1 year support the long-term efficacy of transcatheter aortic valve replacement in both types of transcatheter prosthesis featuring in the registry.

The preparation and initiation of movement has previously been described using a neural accumulation model; this model involves an increase of neural activation in the motor cortex (M1) from baseline to a subthreshold level following a warning signal, which is maintained until presentation of an imperative stimulus (IS). Activity then increases until reaching movement initiation threshold. This model predicts that variability in activation during preparation may influence reaction time (RT) and its variability. The purpose of this thesis project was to determine whether differences in RT/variability of RT during the completion of tasks with varying levels of complexity may be attributable to differences in neural excitability in M1. To test this prediction, transcranial magnetic stimulation (TMS) delivered concurrently with an IS was used to determine neural excitability for movements with different accuracy demands. It was hypothesized that higher accuracy demands would result in lowered amplitude and/or greater variability of neural activation, and consequently slower/more variable RT. Fifteen healthy participants completed a simple RT task involving a targeted wrist extension movement under three different accuracy conditions (easy, moderate, difficult). TMS was delivered concurrently with the IS on 50% of trials during each condition. While pilot testing showed RT differences between accuracy conditions (Appendix A), the data presented here failed to detect significant differences in RT latency (F(2, 28) = .074, p = .929) or variability (F(1.432, 20.053) = .633, p = .538) between conditions . Similarly, no difference in MEP amplitude was observed between difficulty conditions (F(2, 28) = 2.439, p = .106). However, a subset of participants (n = 7) did show significant RT increases between easy and hard conditions (t(6) = 2.531, p = .045), but this subset still failed to show differences in MEP amplitude (t(6) = 1.157, p = .291) or variability (t(6) = 1.545, p = .173), suggesting that preparatory levels at the IS may be similar for movements involving both high and low accuracy demands.

Background Aortic valve replacement (AVR) in small aortic roots remains a surgical dilemma with a higher risk of patient-prosthesis mismatch (PPM). The Perimount Magna Ease aortic valve (PMEAV) represents an attractive device in such cases. We examined the early hemodynamic performance, the mid-term outcomes of the PMEAV, and the impact of PPM on outcome and functional class. Methods We performed a retrospective analysis of prospectively collected in-hospital data, and a prospective single-center follow-up of 849 patients who received a 19 to 23 mm PMEAV (2008–2014). Concomitant mitral or tricuspid replacement was the exclusion criterion. Early hemodynamic features were prospectively collected; mid-term follow-up was conducted according to current guidelines. Results Size of implanted prosthesis was 19 mm in 11.5% of patients, 21 mm in 36.9%, and 23 mm in 51.5%. Operative mortality was 4.5% (3.1% for isolated AVR). The rate of severe and moderate PPMs was significantly higher in the 19 mm group. Follow-up was 99.9% complete (3.7 ± 2 years). Actuarial freedom from structural valve deterioration (SVD) at 5 years was 99.1%. At stratified Kaplan–Meier's analysis, PPM and age Conclusion This series shows satisfactory clinical outcomes of the PMEAV implanted in small aortic annuli at mid-term follow-up. Although PPM may occur in smaller sizes, it has limited clinical impact, and it is not associated with mid-term mortality or worse functional class. Few SVD events are evidenced; nonetheless, limited follow-up duration and its methodology need to be considered.

Cet article propose une lecture croisée, basée sur le thème du péché originel, de la nouvelle « Tout » d’Ingeborg Bachmann et du récit Le rêve d’un homme ridicule de Dostoïevski. Le péché originel, compris comme la chute du genre humain dans une spirale de malheur, est examiné à la lumière de son actualisation par les théories critiques de la raison (Chestov, Benjamin, Adorno) formulées en plein cœur du rationalisme triomphant de la modernité. À partir des textes de Bachmann et Dostoïevski, la découverte de la distinction entre bien et mal par les premiers humains est pensée en continuité avec le développement d’un langage qui inscrit en l’être humain et dans ses relations sociales la séparation entre la raison autonome et la nature réduite à une chose muette et dépourvue de substance. Cette séparation est définie comme fondement d’une guerre éternelle entre les humains et la nature ainsi qu’entre les humains eux-mêmes., This paper proposes a comparative reading, on the theme of the original sin, of the short story “All” by Ingeborg Bachmann and of The Dream of a Ridiculous Man by Dostoïevski. The original sin, understood as the fall of mankind in a spiral of affliction, is examined in light of its actualization by critical theories of reason (Shestov, Benjamin, Adorno), which were articulated against the backdrop of the triumph of rationalist modernity. In these stories by Bachmann and Dostoïevski, the discovery of the distinction between good and evil by the first humans is taught in continuity with the development of a language that inscribes in humans and in their social relations the separation between autonomous reason and nature, the latter being devoid of substance. This separation is defined as the basis of an eternal war between humans and nature as well as among humans themselves.

Working party approved by the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French Society for the study of Diabetes (SFD); International audience; Diabetes mellitus is defined by chronic elevation of blood glucose linked to insulin resistance and/or insulinopaenia. Its diagnosis is based on a fasting blood-glucose level of ≥ 1.26 g/L or, in some countries, a blood glycated haemoglobin (HbA1c) level of > 6.5%. Of the several forms of diabetes, type-2 diabetes (T2D) is the most common and is found in patients with other risk factors. In contrast, type-1 diabetes (T1D) is linked to the autoimmune destruction of β-pancreatic cells, leading to insulinopaenia. Insulin deficiency results in diabetic ketoacidosis within a few hours. ‘Pancreatic’ diabetes develops from certain pancreatic diseases and may culminate in insulinopaenia. Treatments for T2D include non-insulin based therapies and insulin when other therapies are no longer able to control glycaemic levels. For T1D, treatment depends on long (slow)-acting insulin and ultra-rapid analogues of insulin administered according to a ‘basal-bolus’ scheme or by continuous subcutaneous delivery of insulin using a pump. For patients presenting with previously undiagnosed dysglycaemia, investigations should determine whether the condition corresponds to pre-existing dysglycaemia or to stress hyperglycaemia. The latter is defined as transient hyperglycaemia in a previously non-diabetic patient that presents with an acute illness or undergoes an invasive procedure. Its severity depends on the type of surgery, the aggressiveness of the procedure and its duration. Stress hyperglycaemia may lead to peripheral insulin resistance and is an independent prognostic factor for morbidity and mortality.

Background: The FRANCE-2 registry (French Aortic National Corevalve and Edwards) previously reported good early- and medium-term clinical and echocardiographic efficacy for transcatheter aortic valve replacement. We here report 5-year follow-up results from the registry. Methods: The registry includes all consecutive patients undergoing transcatheter aortic valve replacement for severe aortic stenosis in France. Follow-up is scheduled at 30 days, 6 months, then annually from 1 to 5 years. Clinical events were defined according to the Valve Academic Research Consortium criteria, and hemodynamic structural valve deterioration (SVD) was defined according to the consensus statement by the European Association of Percutaneous Cardiovascular Interventions. Results: Between January 2010 and January 2012, 4201 patients were enrolled in 34 centers. Five-year vital status was available for 95.5% of patients; 88.1% had clinical evaluation or died. Overall, at 5 years, all-cause mortality was 60.8% (n=2478; 95% CI, 59.3% to 62.3%). The majority of cardiovascular events occurred in the first month after valve implantation, and incidence remained low thereafter, at P =0.1). Finally, in the population of patients with severe SVD, 1 patient (1.7%) experienced a stroke, and 8 patients presented ≥1 heart failure event (13.3%). Conclusions: The 5-year follow-up results of the FRANCE-2 registry represent the largest long-term data set available in a high-risk population. In surviving patients, the low rate of clinical events and the low level of SVD after 1 year support the long-term efficacy of transcatheter aortic valve replacement in both types of transcatheter prosthesis featuring in the registry.

Working party approved by the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French Society for the study of Diabetes (SFD); International audience; Ambulatory surgery can be carried out in diabetic patients. By using a strict organisational and technical approach, the risk of glycaemic imbalance is minimised, allowing the patients to return to their previous way of life more quickly. Taking into account the context of ambulatory surgery, with a same day discharge, the aims are to minimise the changes to antidiabetic treatment, to maintain adequate blood sugar control and to resume oral feeding as quickly as possible. The preoperative evaluation is the same as for a hospitalised patient and recent glycaemic control (HbA1c) is necessary. Perioperative management and the administration of treatment depend on the number of meals missed. The patient can return home after taking up usual feeding and treatment again. Hospitalisation is necessary if significant glycaemic imbalance occurs. In pregnancy, it is necessary to distinguish between known pre-existing diabetes (T1D or T2D) and gestational diabetes, defined as glucose intolerance discovered during pregnancy. During labour, blood sugar levels should be maintained between 0.8 and 1.4 g/L (4.4–8.25 mmol/L). Control of blood sugar levels is obtained by using a continuous administration of insulin using an electronic syringe (IVES) together with a glucose infusion. Post-partum, management depends on the type of diabetes: in T1D and T2D patients a basal-bolus scheme is restarted with decreased doses while in gestational diabetes insulin therapy is stopped after delivery. Antidiabetic treatment is again necessary if blood sugar levels remain > 1.26 g/L (7 mmol/L).

JCTCV:22(1), Objectives: To evaluate the influence of season and atmospheric pressure (AP) on the onset of aortic dissection (AD) and aortic aneurysm rupture (AAR). Methods: Admissions for AD and RAA between 1 January 1989 and 31 December 2016 were reviewed. Regional AP data were provided by Meteo-France. Results: A total of 886 cases of AD were admitted on 844 days. The mean patient age was 63.5 ± 14.2 years with a male:female ratio of 2:1. Mortality: 146 pts (16.5%), which was increased with age (OR = 1.036; 95% CI [1.021, 1.051]; p < 0.0001), as was unknown hypertension status (OR = 2.586; 95% CI [1.757, 3.805]; p < 0.0001). A total of 344 cases of AAR were admitted on 330 days. The mean patient age was 72.4 ± 11.3 years with a male:female ratio of 4.4:1. Mortality: 108pts (31.4%). Age increased mortality (OR = 1.06; 95% CI [1.035, 1.086]; p < 0.0001) as did an unknown hypertension status (OR = 3.428; 95% CI [1.941, 6.055]; p < 0.0001). There was no influence of season on AD or AAR onset or mortality. Days with low AP (OR = 1.008; 95% CI [1.001, 1.015]; p < 0.0182) and high monthly AP variability (OR = 1.073; 95% CI [1.037, 1.111]; p < 0.0001) increased the risk of AD and AAR. High monthly AP reduced the risk of AAR (OR = 0.962; 95% CI [0.938, 0.987]; p < 0.003). Conclusion: Low AP values and high AP variability should increase our vigilance toward the risk of AD and AAR, especially by improving blood pressure control. Mortality by AD and AAR could be reduced by improved screening for hypertension in the general population.

International audience