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Objectives To optimize protamine titration for heparin antagonization after weaning from cardiopulmonary bypass (CPB). Design A prospective, observational trial. Setting Single-center, non-university teaching hospital. Participants Forty patients presenting for elective on-pump coronary artery bypass grafting with or without single valve surgery. Interventions At the end of CPB, the residual amount of heparin in the patient was estimated using a Bull-curve. The total protamine dose was calculated as 1 unit of protamine for 1 unit of heparin. Protamine was administered as 5 aliquots containing 20% of the total protamine dose each, with 2-min intervals. Measurements and main results Activated Clotting Time (ACT) values were measured 2 min after administration of each aliquot. ROTEM(®)-analysis was performed after the full dose of protamine had been administered. After 60% of the total protamine dose had been administered, ACT values were normalized in 86.5% of patients. After the complete dose of protamine had been administered, 61.1% of patients displayed signs of protamine overdose on ROTEM(®)-analysis. Conclusions In patients who present for on-pump coronary artery bypass grafting with or without single valve surgery, a 0.6-to-1 ratio of protamine-to-heparin to antagonize heparin may be sufficient and beneficial for patients.

PurposeThe aim of this study is to shed light on the relative importance of Chinese (Mainland China and Hong Kong: CH-HK) foreign direct investments (FDIs) in real estate (FDIRE) on the dynamics of Asia-Pacific (APAC) public real estate markets after the Global Financial Crisis.Design/methodology/approachUsing a parsimonious real estate asset-pricing model including macroeconomic risk factors, the authors develop a metric to measure FDIs in the real estate sector. The authors use a panel VAR approach based on robust econometric methodology (generalized method of moments) and deal with potential endogeneity and an eventual causality problem. The authors also compute multiple metrics to measure the Chinese, US and Japanese FDIs in the real estate sector.FindingsThe study results report a positive significant impact of CH-HK FDIRE on APAC public real estate returns, while FDIRE originating from outside China are not significant. The authors also show that Chinese investors use the channel of FDIs in Diversified Listed Property Companies (LPCs) and Hotel and Family LPCs to gain exposure to the APAC real estate markets. The study results suggest that APAC property markets are mainly impacted and emphasize the importance of an intercontinental diversification strategy for investors in LPCs in the APAC region.Practical implicationsContrary to Bond et al. (2003) who identified that APAC public real estate markets were overwhelmingly idiosyncratic in the decade preceding China's WTO membership (1990–2001), the study findings underline that Chinese FDIRE became a common factor affecting all eight markets in this study in the decade following the global financial crisis (2007–2017). The results emphasize the importance of an intercontinental diversification strategy for investors in LPCs in the APAC region.Originality/valueThe authors use a parsimonious model, introduce metrics to measure FDIRE and apply a panel VAR approach based on a robust econometric methodology to shed light on China's economic globalization strategy on Asia-Pacific public real estate markets after the GFC. The study results highlighting the major impact of CH-HK FDIRE on securitized real estate market returns dynamics, identify the existence of an Asian common factor driven by Chinese FDI inflows into neighbouring countries.

Purpose As smart technologies become an integral part of real estate in smart cities, the purpose of this paper is to explore the impact of ubiquitous computing on space users in smart real estate. Design/methodology/approach The analysis builds on two fields of knowledge rarely referenced in real estate studies: computer sciences and social sciences. The paper starts by analysing the idiosyncrasies of a new type of space user in smart real estate, known as the Cyber-dasein in reference to Heidegger’s phenomenology. The Cyber-dasein serves as an archetypical space user in smart environments. Findings The paper introduces digital-time as a new realm of real estate, and discusses the use of “experienced utility” in hedonic pricing models of smart real estate. It concludes by advocating a multidisciplinary collaborative approach for future research on real estate in smart environments. Practical implications There is a need for the real estate sector to decide on a metric for the new digital dimension of real estate owing to the implementation of smart technologies in the built environment. Originality/value This is the first research paper on this important topic. It is totally original and new.

The implementation of smart technologies in the built environment presents unprecedented opportunities and challenges for the real estate sector. Among the challenges is building occupants’ behavioural control due to smart buildings’ technological apparatus underpinned by pervasive computing. Since the early days of cybernetics, control stemming from information technology has generated many arguments about freedom, privacy and surveillance. Arguments only focused on technology or ethics tend to foster a Manichean view which obscures our ability to rationally assess calm and transparent technology’s role in controlling space users’ behaviours in smart buildings. The paper applies two classic economic frameworks to decipher the economic nature of behavioural control in smart real estate. In the process, it sheds some light on the complex utilitarian relationship between behavioural control and smart space’s user centricity. It concludes by assessing whether regulators should step in, for instance, through de jure property rights allocation among all parties.

PurposeThe purpose of this paper is to analyze and revisit the risk and performance of publicly traded real estate companies from 14 countries over the period 2000–2015, marked by the unprecedented Global Financial Crisis, in presence of errors-in-variables (EIV) and illiquidity (measured by serial correlation, following Getmanskyet al.(2004)).Design/methodology/approachThe authors extend the seminal work of Bondet al.(2003), and shed a new light on the relative performance of listed real estate before and after the GFC. First, the authors suggest the use of various asset pricing models (APM) including the Fama and French (2015) five-factor APM with global and country-level factors. Second, the authors implement unbiased estimators to correct for the econometric bias induced by EIV in APM. Third, the authors deal with the impact of illiquidity (measured by serial correlation) on the risk properties of international securitized real estate returns.FindingsThe findings show that post-GFC, a radical change in international listed real estate risk factors has resulted in more homogeneous markets internationally and less diversification opportunities for international investors.Practical implicationsThe authors suggest the use of robust linear APM (including the Fama and French (2015) five-factor APM) to analyze the risk and performance of publicly traded real estate companies from 14 countries over the period 2000–2015.Originality/valueThe authors analyze and revisit the risk and performance of publicly traded real estate companies from 14 countries over the period 2000–2015, marked by the unprecedented Global Financial Crisis.

PurposeThe purpose of this paper is to fill a gap in the real estate academic literature by defining the essence of real estate in smart urban environments. Space has traditionally been a silent component of real estate. Smart technologies powered by Ubi-comp are turning space into an active part of real estate, which represents a paradigm shift for commercial real estate. This shift requires new concepts and tools to analyse and model real estate in smart cities.Design/methodology/approachThe paper defines the notions of smart space and smart real estate. Several concepts and tools are formulated, starting with a model of space users in smart cities, called the Cyber-Dasein inspired by Heidegger’s existential phenomenology of space.FindingsThe paper then analyses smart space’s attributes and proposes several metrics for commercial real estate in smart environments. After introducing three regression models for constructing a price index of smart real estate, the paper concludes by advocating that commercial real estate take an active role in the current debate about smart cities.Research limitations/implicationsThe paper does not provide any empirical analysis of smart real estate.Practical implicationsSmart environments offer real estate a unique opportunity to set up methodologies, concepts and tools for new properties in new cities. Now is the time to think carefully about the impact smart technologies will have on commercial properties before other stakeholders (in particular smart cities vendors and multinational technology giants) have fully modelled smart space and its nexus with smart real estate.Originality/valueThis paper is the first paper to provide a conceptual framework for the analysis of commercial real estate in smart cities.

This article studies the performances of publicly traded real estate companies (real estate investment trusts and listed property companies) from 14 countries covering North America, Europe, and Asia as proxied by FTSE EPRA/NAREIT Global Real Estate Indexes over the period 2000 to 2015. We implement robust normalized risk-adjusted performance measures and compare nine performance indicators before, during, and after the global financial crisis (GFC). Our findings show that the GFC had a huge impact on the ranking of international listed real estate securities’ relative performance. The study also stresses the importance of applying various performance measures to get a full picture of international listed real estate returns.

Introduction In 2007, the use of aprotinin was temporarily suspended following several publications raising serious safety concerns.(1.2.3) However, Canadian and European Health Authorities concluded that these studies suffered from major flaws and lifted the suspension in 2013.(4,5) The reintroduction of aprotinin in 2016 was accompanied by a mandatory registry [Nordic Aprotinin Patient Registry (NAPaR)] in order to monitor the pattern of use, the effect of risk minimization measures, and overall safety. Objective of this study was to analyse the use of aprotinin in Belgium. Methods NAPaR is a non-interventional Post-Authorisation Safety Study (PASS), endorsed by the Pharmacovigilance Risk Assessment Committee of the European Medicine Agency. Results Between October 2018 and August 2020, six Belgian NAPaR centers included 694 patients [median age 70 (range 13-90y); 62% male; median EuroSCORE II 4.6 (range 0.5-93.4)]. 25% of the patients had an EuroSCOREII > 10. 57% of the patients were under an active antiplatelet therapy and 17% were treated with novel oral anti-coagulants. Preoperative renal impairment was present in 2/3 of patients. Only 4% of the patients received aprotinin on-label, i.e. for isolated coronary artery bypass grafting (CABG) on cardiopulmonary bypass (CPB). In 96% of the patients, aprotinin was used off-label, mainly for redo surgery (32%), CABG + valve surgery (29%), aortic surgery (20%) and multiple valve surgery (17%). One third of the procedures were urgent (23%) or emergent (9%). Median bypass time was 128min (range 13-600min). Median hospital stay was 11 days (range 3-151 days). Main reported indications for the use of aprotinin were active dual antiplatelet therapy (68% in iCABG), redo surgery (16%) and expected prolonged CPB time (55%). In 83% of the cases, aprotinin was administered at the Half Hammersmith dose (1 Mio KIU loading- and priming-dose + 250.000 KIU/h); most patients received the appropriate test dose (98%), none developed anaphylactic reactions. Median perioperative blood loss was 400ml (range 40 -10050 ml), 44% of the patients had RBC transfusion and 6% underwent reoperation for bleeding or tamponade. Overall mortality at discharge was 5%, i.e. within the range or lower than predicted by the EuroSCORE II. 2% of the patients had a postoperative stroke. Postoperative AKI as defined by a serum creatinine increase of 0,3mg/dL or more within 48 hours after surgery was present in 13% of cases. Most of these patients (76%) suffered from preoperative moderate or severe renal impairment including dialysis. Notably, in patients with postoperative AKI median CPB time was significantly higher than in patients without AKI: 172min (range 56-402) vs 125min (range 13-600min) (p Discussion In the Belgian centers, aprotinin was mainly used off-label and predominantly administered to older patients with significant comorbidities undergoing high-risk procedures. The observed safety outcomes are in line with published data within this high risk patient population. The data from the Belgian NAPaR suggest that aprotinin has an excellent safety profile in adult cardiac surgery.

Using the Global Financial Crisis (GFC) as a breakdown, we revisit the risk and return characteristics of publicly traded real estate companies from 14 countries proxied by FTSE EPRA indices over the period 2000 to 2015 in presence of errors-in-variables. We extend the seminal work of Bond, Karolyi and Saunders (2003), and shed a new light on the relative performance of listed real estate before and after the GFC. First, we suggest the use of various asset pricing models including the Fama-French (2015) five-factor asset pricing model with global and country-level factors. Second, we implement unbiased estimators to correct for the econometric bias induced by errors-in-variables (EIV) in asset pricing models. Third, we deal with the impact of illiquidity (measured by serial correlation) on the risk properties of international securitized real estate returns. Our findings show that international listed real estate risk factors changed radically after the GFC, which has resulted in more homogeneous markets internationally and less diversification opportunities for US-based investors.

As technological innovations applied to the built environment become prevalent, real estate players (developers, owners, users) are confronted with a range of disruptions which are redefining the common understanding of what a commercial property stands for. The paper studies the role and positioning of commercial real estate in smart cities, and assesses the need for new tools to analyse this growing segment of the property market.

A feasibility version of the GlucoClear™ continuous glucose monitoring system (Edwards Lifesciences, Irvine, CA), the intravenous blood glucose (IVBG) system, developed to facilitate glycemic management, was evaluated.Two pilot studies were conducted. Ten volunteers with diabetes (1,725 matched pairs) and 10 patients scheduled for intensive care unit (ICU) admission following surgery (1,393 matched pairs) were studied. The patients' blood glucose concentrations were monitored by the IVBG system every 5 min for up to 72 h. The accuracy of the IVBG system was calculated and compared with the Yellow Springs Instrument (YSI) (Yellows Springs, OH) and Radiometer (Copenhagen, Denmark) measurements to determine the percentage of matched pairs that met 15/20%, 10/15%, 12/12.5%, and 10/10% assessment criteria. Performance was calculated as the percentage of the total measurements that would have been displayed in an unblinded study. Adverse events were monitored.The accuracy of the IVBG system met the International Organization for Standardization ISO 15197 15/20% criterion (99.07% in volunteers, 99.43% in the ICU, and both vs. YSI) and the stricter 10/15% criterion (96.17% in volunteers, 96.77% in the ICU, and both vs. YSI) over the 72-h period and across a broad range of blood glucose concentrations. Performance was 89.97% in the ICU study. The adverse device effects included induration of the peripheral vein, mild bruising, and mild hematoma. In the volunteers, there were patency problems with six catheters.The IVBG system is safe, accurate, and reliable. This minimally invasive system was not affected by potentially interfering medications. Real-time measurements, alarms, and trends provided by the IVBG system might support glycemic control protocols and prevent glycemic events in critically ill patients.

Purpose – The paper aims to conduct an empirical study of three models of property derivatives: index-based derivatives, factor hedges, and combinative hedges based on index and factors. The objective is to test whether the latter two models introduced by Lecomte dominate the index-based model used for existing property derivatives such as EUREX futures contracts. Design/methodology/approach – Based on investment property database (IPD) historical database covering 224 individual office properties from 1981 to 2007, the study assesses ex ante hedging effectiveness of the three models. Nine simulations are run under different hypotheses involving individual buildings and portfolios. The 17 factors included in the study cover both macro-factors (e.g. macroeconomic indicators) and micro-factors linked to the properties (e.g. age). Findings – Atomization and periodic rebalancing of property derivatives' underlying make it possible to substantially increase hedging effectiveness for a large majority of buildings in the sample. However, combinative hedges are overall superior to factor hedges owing to the overriding role played by IPD indices in capturing risk. Research limitations/implications – Due to confidentiality requirements inherent to the use of property level data, the study downplays the role of micro-factors on real estate risk at the property level. Practical implications – The paper introduces a typology of optimal hedges aimed at individual property owners and portfolio holders in the City office property market. Originality/value – This is the first time a comprehensive analysis of different models of property derivatives is conducted. The value of the paper stems from the use of property level data.

OBJECTIVES To compare the outcomes of MitraClip versus minimally invasive surgical mitral valve repair in high-risk patients with significant functional mitral regurgitation (FMR) and severe heart failure in a centre having pilot versus extensive experience with the MitraClip and the minimally invasive surgical approach, respectively. METHODS The MitraClip group consisted of 24 high-surgical-risk patients [age 75 ± 9 years, 75% males, NYHA III/IV 88%, left ventricular (LV) ejection fraction 31 ± 9%, EuroSCORE II 18 ± 14%], while the surgical group consisted of 48 patients matched for age, NYHA class and LV ejection fraction. RESULTS Patients undergoing MitraClip versus those undergoing surgical repair showed higher prevalence of ischaemic LV dysfunction and larger LV end-diastolic diameter (both P < 0.05). Both the MitraClip and the surgical repair groups had similar 30-day mortality rates (4 vs 13%, P = 0.41) and prevalence of serious adverse events (25 vs 38%, P = 0.43). The median follow-up was 1028 days (IQR: 272-1564 days) in the MitraClip group and 890 days (IQR: 436-1381 days) in the surgical group (P = 0.95). Total all-cause mortality (54 vs 60%, log-rank P = 0.64) and rates of rehospitalizations for heart failure (42 vs 29%, log-rank P = 0.68) did not differ significantly between groups. Both techniques were associated with significant decrease in NYHA class and severity of FMR (P < 0.001 for all) and with a similar degree of stabilization of LV remodelling (P = NS). CONCLUSION Despite the significant baseline differences in accumulated expertise and risk profile between the surgical and the MitraClip groups, both minimally invasive techniques were associated with similar 30-day and long-term outcomes.

Over the last 30 years, Chinese commercial real estate markets have joined the global universe of investable assets, as exemplified by vibrant skylines and the construction of startling new buildings in megacities such as Beijing and Shanghai. However, international investors who are often mesmerized by the Chinese economy’s historical growth and potential size might not have a clear understanding of the nature of the risk they face in China. Notwithstanding the focus on operational and legal risks whose need was emphasized by some highly publicized cases of international investors being caught in the complex system of Chinese guanxi, international investors venturing into the Chinese direct property markets are faced with many macro risks that have to be addressed. Surprisingly, despite the large volume of foreign direct investments in Chinese commercial real estate markets in recent years, there has been little academic research done to analyze and characterize the risk structure of Chinese commercial properties. Using a database never applied before in academic literature, this paper fills in the gap by studying the risk characteristics of direct property investments in Chinese first-tier cities. It applies macro-variable models to analyze the risk structure of office properties in Beijing, Shanghai, and Guangzhou. It then tests a selection of instruments that could be used by international investors to hedge the risk of investing in these three sub-markets. It concludes by making a series of recommendations that could help international investors deal with the risk of direct investments in China’s property markets.

This paper employs a new scoring framework designed by the Asia Pacific Real Estate Association (APREA) to examine the link between corporate performance and quality of corporate governance among externally managed REITs listed on the Singapore Stock Exchange (S-REITs). The empirical tests provide evidence supporting a positive correlation between corporate governance practices and stock performances. However, we find no positive correlation with operating performance proxied by accounting measures. In other words, S-REITs with higher corporate governance tend to register better risk-adjusted returns but do not outperform operationally. To test for market efficiency, the study shows that S-REITs with the best corporate governance practices also have less information asymmetry.

Executive Summary. As index-based real estate deriv-atives are being introduced in the United States, this pa-per questions the validity of these instruments for hedging risks involved in commercial real estate markets. It first shows that the concept of index-based derivatives may not be appropriate for intrinsically heterogeneous assets such as real estate. Based on an innovative frame-work drawn from the field of biomedical sciences, it then proposes the establishment of a radically new breed of derivatives market that would enable effective hedging of commercial real estate assets. It concludes by outlining a framework for modeling real estate risk based on ge-netics that could be used with the proposed derivatives market.This paper is the winner of the best paper on Innovative Thinking “Thinking Out of the Box” (sponsored by the Homer Hoyt Advanced Studies Institute) award pre-sented at the 2007 American Real Estate Society Annual Meeting in San Francisco, California.

Executive Summary.Due to the heterogeneous nature of real estate assets, as well as the difficulty in selecting a reliable and representative underlying index, real estate markets are the last of t...

Background Terlipressin, a synthetic analog of arginine-vasopressin (AVP), has been proposed as an effective vasopressive therapy in catecholamine-resistant vasodilatory shock. Although beneficial effects of terlipressin on systemic arterial pressure have been clearly demonstrated, its intrinsic effects on coronary circulation and myocardial performances remain unknown. Methods The authors compared the coronary and myocardial effects of terlipressin (1-100 nM, n = 10), AVP (10-1000 pM, n = 10), and norepinephrine (1-100 nM, n = 10) on an erythrocyte-perfused isolated rabbit heart. The cardiac effects of terlipressin were also assessed in erythrocyte-perfused hearts in which the myocardial oxygen delivery was maintained constant and buffer-perfused hearts. Finally, the cardiac effects of terlipressin and AVP were studied in hearts pretreated by [d(CH2)5Tyr(Me)]AVP (0.1 microM), a selective V1a receptor antagonist. Results Norepinephrine induced a biphasic coronary effect associated with a concentration-dependent increase in myocardial performances. AVP and terlipressin significantly decreased coronary blood flow and impaired myocardial performances from 30 pM and 30 nM, respectively (P < 0.05). The cardiac side-effects of terlipressin were confirmed in buffer-perfused hearts but the maintenance of a constant myocardial oxygen delivery constant abolished its effects on myocardial performances. The cardiac effects induced by terlipressin and AVP were nearly completely abolished on hearts pretreated by [d(CH2)5Tyr(Me)]AVP. Conclusions On isolated rabbit heart, terlipressin induced a coronary vasopressor effect and in turn myocardial depression only at supratherapeutic concentrations (> or =30 nM). Its effects are mainly mediated via V1a receptors. However, these potential negative side effects on the heart were less pronounced than were those of AVP.

Background The Cardiac Anesthesia Risk Evaluation (CARE) score, a simple Canadian classification for predicting outcome after cardiac surgery, was evaluated in 556 consecutive patients in Paris, France. The authors compared its performance to those of two multifactorial risk indexes (European System for Cardiac Operative Risk Evaluation [EuroSCORE] and Tu score) and tested its variability between groups of physicians (anesthesiologists, surgeons, and cardiologists). Methods Each patient was simultaneously assessed using the three scores by an attending anesthesiologist in the immediate preoperative period. In a blinded study, the CARE score category was also determined by a cardiologist the day before surgery, by a surgeon in the operating room, and by a second anesthesiologist at arrival in intensive care unit. Calibration and discrimination for predicting outcomes were assessed by goodness-of-fit test and area under the receiver operating characteristic curve, respectively. The level of agreement of the CARE scoring between the three physicians was then assessed. Results The calibration analysis revealed no significant difference between expected and observed outcomes for the three classifications. The areas under the receiver operating characteristic curves for mortality were 0.77 with the CARE score, 0.78 with the EuroSCORE, and 0.73 with the Tu score (not significant). The agreement rate of the CARE scoring between two anesthesiologists, between anesthesiologists and surgeons, and between anesthesiologists and cardiologists were 90%, 83%, and 77%, respectively. Conclusions Despite its simplicity, the CARE score predicts mortality and major morbidity as well the EuroSCORE. In addition, it remains devoid of significant variability when used by groups of physicians of different specialties.

The aim of this chapter is to revisit the performance of Asian REITs before and after the sub-prime crisis using risk-adjusted performance measures based on multifactor models. First, we use performance measures (including the Generalized Treynor Ratio) able to capture the variety of systematic risk sources related to real estate in Asia. Second, we implement unbiased estimators to correct for the econometric bias induced by errors-in-variables (EIV) in asset pricing models. With these different adjustments, we analyze the persistence and stability of performance measures before and after the crisis for a database of 206 Asian REITs covering nine countries across Asia-Pacific. Our results shed a new light on risk-adjusted performance measures of Asian REITs during a key period since the regime was introduced in the Asia-Pacific region.

To optimize intra- and postoperative insulin management in cardiac surgical patients.A prospective, randomized, open-label, single-center study.A large nonuniversity hospital.Sixty diabetics and 60 nondiabetics undergoing off-pump cardiac bypass surgery.Intra- and postoperative tight glycemic control were achieved using different approaches with a modified insulin protocol.Nondiabetics were divided randomly: in the ND-ind group (n = 30), insulin was started at induction according to preinduction blood glucose (BG) concentrations. In group ND110 (n = 30), insulin was started when BG concentrations exceeded 110 mg/dL during surgery. Up to 85% of the ND110 group started on insulin intraoperatively. Intraoperatively, the ND-ind group had more BG within target (80-110 mg/dL) (p = 0.002), less BG130 mg/dL (p = 0.015), and more BG between 70 and 79 mg/dL (p = 0.002). In diabetics, BG concentration was checked every 30 (DM-30), n = 30) versus 60 minutes (DM-60, n = 30) to improve the protocol's performance. Intraoperatively, there were more BG concentrations within target (80-110 mg/dL) (p = 0.02) and less130 mg/dL (p = 0.0002) in the DM-30 group. During surgery, the hyperglycemic index and the glycemic penalty index were lower in the ND-ind group (p0.05). Postoperatively, the mean BG concentrations, hyperglycemic index, and glycemic penalty index in diabetics and nondiabetics were comparable between groups (p0.05). In the overall 2,641 BG samples, the lowest BG concentration in the operating room was 71 and in the intensive care unit (ICU) it was 61 mg/dL.In diabetics and nondiabetics undergoing off-pump coronary artery bypass surgery, tight perioperative glycemic control is feasible and efficient, with minimal risks for hypo- and hyperglycemia. In nondiabetics, starting insulin therapy from induction onwards results in more measurements within target, without affecting the mean BG. In diabetics, decreasing the sampling interval from 60 to 30 minutes results in more measurements within target and in a mean blood glucose within target at ICU arrival.

Tight blood glucose control reduces mortality and morbidity in critically ill patients, but intraoperative glucose control during cardiac surgery is often difficult, and risks hypoglycemia. In this study, we evaluated the safety and efficacy of a nurse-driven insulin protocol (the Aalst Glycemia Insulin Protocol) for achieving a target glucose level of 80-110 mg/dL during cardiac surgery and in the intensive care unit (ICU).We included 483 nondiabetics and 168 diabetics scheduled for cardiac surgery with cardiopulmonary bypass. To anticipate rapid perioperative changes in insulin requirement and/or sensitivity during surgery, we developed a dynamic algorithm presented in tabular form, with rows representing blood glucose ranges and columns representing insulin dosages based on the patients' insulin sensitivity. The algorithm adjusts insulin dosage based on blood glucose level and the projected insulin sensitivity (e.g., reduced sensitivity during cardiopulmonary bypass and normalizing sensitivity after surgery).A total of 18,893 blood glucose measurements were made during and after surgery. During surgery, the mean glucose level in nondiabetic patients was within targeted levels except during (112 +/- 17 mg/dL) and after rewarming (113 +/- 19 mg/dL) on cardiopulmonary bypass. In diabetics, blood glucose was decreased from 121 +/- 40 mg/dL at anesthesia induction to 112 +/- 26 mg/dL at the end of surgery (P0.05), with 52.9% of patients achieving the target. In the ICU, the mean glucose level was within targeted range at all time points, except for diabetics upon ICU arrival (113 +/- 24 mg/dL). Of all blood glucose measurements (operating room and ICU), 68.0% were within the target, with 0.12% of measurements in nondiabetics and 0.18% in diabetics below 60 mg/dL. Hypoglycemia50 mg/dL was avoided in all but four (0.6%) patients (40 mg/dL was the lowest observed value).The Aalst Glycemia Insulin Protocol is effective for maintaining tight perioperative blood glucose control during cardiac surgery with minimal risk of hypoglycemia.

Study Objective To determine whether our institutional insulin management (modified Atlanta) protocol is efficient and safe in controlling blood glucose levels in the perioperative period in surgical patients undergoing tumor hepatectomy. Design Retrospective study. Setting Large community hospital. Patients 20 consecutive patients undergoing liver resection for hepatocellular carcinoma, liver metastasis, or other hepatobiliary tumors. Interventions and Measurements All patients continuously received intravenous glucose (5% dextrose in water, one mL/kg/hr); insulin was administered according to a strict algorithm, and dose adjustments were based on measurements of whole-blood glucose intraoperatively at one-hour intervals, and in the intensive care unit (ICU). Lower and upper blood glucose limits were set at 85 mg/dL and 110 mg/dL, respectively, in the operating room (OR). In the ICU, lower and upper limits were 90 mg/dL and 140 mg/dL, respectively. Main Results Intraoperatively, 51.3% of measurements were within the target range. In the ICU, 75.2% of measurements showed a blood glucose level of 90 - 140 mg/dL. Two of 78 (2.6%) and two of 363 (0.5%) measurements had a blood glucose level Conclusions The modified Atlanta protocol is efficient and safe in controlling blood glucose levels in the perioperative period of hepatic tumor resection. Because of decreased insulin needs in the ICU, the use of a more liberal algorithm successfully reduced the risk of hypoglycemia.

Remifentanil-induced hypotension may be associated with adverse ischemic myocardial events. Although these events can be easily attributed to a decrease in coronary pressure perfusion, we tested the hypothesis that remifentanil could directly affect coronary vasomotor tone. Therefore, we assessed intrinsic coronary and myocardial in vitro effects of remifentanil on a Langendorff's rabbit model and compared these effects with those provoked by similar intracoronary concentrations of sufentanil. Under general anesthesia, hearts from New Zealand rabbits were rapidly excised and mounted on an erythrocyte-perfused and isolated heart preparation. The hearts were then exposed to increasing concentrations (10-1000 nM) of either remifentanil (n = 10) or sufentanil (n = 8). Between each concentration, hearts were allowed to return to baseline status. The maximal coronary and myocardial effects of each concentration of both drugs were noted. Baseline values of coronary blood flow and myocardial performances were comparable between groups. Neither remifentanil nor sufentanil induced significant coronary and myocardial effects. These results suggest that myocardial ischemia, which may occur during remifentanil-induced hemodynamic disturbances, especially in cardiac patients, is only related to a decrease in coronary perfusion pressure provoked by peripheral hemodynamic changes.

Study Objective To investigate whether preinduction glucose is an important predictor for perioperative insulin management in patients undergoing cardiac surgery. Design Prospective cohort study. Setting Large community hospital. Patients 80 consecutive patients scheduled for cardiac surgery. Interventions Patients were subdivided into those with a preinduction blood glucose of 110 mg/dL or lower with or without history of diabetes (group 1) and those with a preinduction blood glucose of above 110 mg/dL with or without history of diabetes (group 2). In group 1, there were no known diabetics. In group 2, 31% (11/35) had diabetes (group 2DM), while 24/35 (69%) did not (group 2NDM). An insulin infusion was started intraoperatively and adjusted according to a strict protocol in order to maintain normoglycemia (80-110 mg/dL) until discharge from intensive care. Measurements and Main Results In patients with preinduction glucose above 110 mg/dL, whether or not previously treated for diabetes, perioperative insulin requirements were higher, and intraoperative insulin management was more difficult than in those with lower preinduction glucose. In patients with a preinduction glucose above 110 mg/dL, hospital stay was longer, and inhospital mortality was significantly higher than in those with lower preinduction glucose. Multivariate analyses showed that preinduction glycemia was a good predictor of intraoperative insulin consumption, as was the body mass index (BMI) for intensive care and total insulin needs. Conclusions In cardiac surgical patients with a preinduction glucose above 110 mg/dL, even if diabetes was not previously suspected, perioperative insulin requirements were higher, and intraoperative insulin management is more difficult than in those with a preinduction glucose 110 mg/dL or lower. Preinduction glycemia and BMI are good predictors of perioperative insulin management. Preinduction glycemia above 110 mg/dL predicts difficult perioperative glucose control and, moreover, that a preinduction blood glucose of 110 mg/dL or lower is associated with less insulin need.

Background Tight perioperative control of blood glucose improves the outcome of diabetic patients undergoing cardiac surgery. Because stress response and cardiopulmonary bypass can induce profound hyperglycemia, intraoperative glycemic control may become difficult. The authors undertook a prospective cohort study to determine whether poor intraoperative glycemic control is associated with increased intrahospital morbidity. Methods Two hundred consecutive diabetic patients undergoing on-pump heart surgery were enrolled. A standard insulin protocol based on subcutaneous intermediary insulin was given the morning of the surgery. Intravenous insulin therapy was initiated intraoperatively from blood glucose concentrations of 180 mg/dl or greater and titrated according to a predefined protocol. Poor intraoperative glycemic control was defined as four consecutive blood glucose concentrations greater than 200 mg/dl without any decrease in despite insulin therapy. Postoperative blood glucose concentrations were maintained below 140 mg/dl by using aggressive insulin therapy. The main endpoints were severe cardiovascular, respiratory, infectious, neurologic, and renal in-hospital morbidity. Results Insulin therapy was required intraoperatively in 36% of patients, and poor intraoperative glycemic control was observed in 18% of patients. Poor intraoperative glycemic control was significantly more frequent in patients with severe postoperative morbidity (37% vs. 10%; P < 0.001). The adjusted odds ratio for severe postoperative morbidity among patients with a poor intraoperative glycemic control as compared with patients without was 7.2 (95% confidence interval, 2.7-19.0). Conclusion Poor intraoperative control of blood glucose concentrations in diabetic patients undergoing cardiac surgery is associated with a worsened hospital outcome after surgery.

Background To assess intrinsic vascular effects of remifentanil, increased concentrations were infused in critically ill patients with a total artificial heart. Methods In the early postoperative period after implantation of a total artificial heart, nine ventilated patients requiring short general anesthesia were included in this study. After anesthesia was induced with 0.3 mg/kg intravenous etomidate, the artificial heart settings were modified to render cardiac output "preload-independent." While maintenance of anesthesia was ensured by a continuous infusion of etomidate, increased concentrations of remifentanil (from 0.1 to 1 microg x kg(-1) x min(-1)) were infused in steps of 5 min under hemodynamic monitoring, including left and right atrial pressures, systemic and pulmonary arterial pressures, and left and right cardiac indices. The invasive procedure was started under the highest concentration of remifentanil tolerated by the patient. Infusion of remifentanil was stopped at the end of the invasive procedure, while etomidate infusion was maintained. New hemodynamic measurements were performed at the end of the 12-min recovery period. Results Remifentanil produced a dose-dependent and significant decrease in systemic arterial pressure and vascular resistances (n = 9) from a concentration of 0.25 microg x kg(-1) x min(-1). No significant changes were observed on pulmonary vascular resistances (n = 6). Neither right (n = 9) nor left (n = 6) atrial pressures were affected by remifentanil infusion. Hemodynamic variables returned to baseline value over the 12-min recovery period. Conclusions In humans with a total artificial heart, remifentanil induces a systemic arterial vasodilation without significant effect on the capacitance vessels.

UNLABELLED We tested the hypothesis that in vitro coronary and myocardial effects of propofol (10-300 microM) should be significantly modified in an isolated and erythrocyte-perfused rabbit heart model in the absence (PaO(2) = 137 +/- 16 mm Hg, n = 12) or in the presence (PaO(2) = 541 +/- 138 mm Hg, n = 12) of hyperoxia. The induction of hyperoxia provoked a significant coronary vasoconstriction (-13% +/- 7%). Propofol induced increased coronary vasodilation in the presence of hyperoxia. Because high oxygen tension has been reported to induce a coronary vasoconstriction mediated by the closure of adenosine triphosphate-sensitive potassium channels, we studied the effects of propofol in 2 additional groups of hearts (n = 6 in each group) pretreated by glibenclamide (0.6 microM) and cromakalim (0.5 microM) in the absence and presence of hyperoxia, respectively. The pretreatment by glibenclamide induced a coronary vasoconstriction (-16% +/- 7%) which did not affect propofol coronary vasodilation. The pretreatment by cromakalim abolished the amplification of propofol coronary vasodilation in the presence of hyperoxia. Propofol induced a significant decrease in myocardial performance for a concentration >100 micro M both in the absence and presence of hyperoxia. We conclude that propofol coronary vasodilation is amplified in the presence of hyperoxia. This phenomenon is not explained by the previous coronary vasoconstriction induced by glibenclamide. However, the pretreatment of hearts by cromakalim abolished the amplification of propofol coronary vasodilation in the presence of hyperoxia. The myocardial effects of propofol were not affected by the presence of hyperoxia. IMPLICATIONS Propofol induced a coronary vasodilation that was amplified in the presence of hyperoxia. This phenomenon does not seem to be related to previous coronary vasoconstriction. The myocardial effects of propofol were not significantly modified in the presence of hyperoxia.

Introduction Acute renal failure after cardiac surgery increases in-hospital mortality. We evaluated the effect of intra- and postoperative tight control of blood glucose levels on renal function after cardiac surgery based on the Risk, Injury, Failure, Loss, and End-stage kidney failure (RIFLE) criteria, and on the need for acute postoperative dialysis. Methods We retrospectively analyzed two groups of consecutive patients undergoing cardiac surgery with cardiopulmonary bypass between August 2004 and June 2006. In the first group, no tight glycemic control was implemented (Control, n = 305). Insulin therapy was initiated at blood glucose levels > 150 mg/dL. In the group with tight glycemic control (Insulin, n = 745), intra- and postoperative blood glucose levels were targeted between 80 to 110 mg/dL, using the Aalst Glycemia Insulin Protocol. Postoperative renal impairment or failure was evaluated with the RIFLE score, based on serum creatinine, glomerular filtration rate and/or urinary output. We used the Cleveland Clinic Severity Score to compare the predicted vs observed incidence of acute postoperative dialysis between groups. Results Mean blood glucose levels in the Insulin group were lower compared to the Control group from rewarming on cardiopulmonary bypass onwards until ICU discharge (p < 0.0001). Median ICU stay was 2 days in both groups. In non-diabetics, strict perioperative blood glucose control was associated with a reduced incidence of renal impairment (p = 0.01) and failure (p = 0.02) scoring according to RIFLE criteria, as well as a reduced incidence of acute postoperative dialysis (from 3.9% in Control to 0.7% in Insulin; p < 0.01). The 30-day mortality was lower in the Insulin than in the Control group (1.2% vs 3.6%; p = 0.02), representing a 70% decrease in non-diabetics (p < 0.05) and 56.1% in diabetics (not significant). The observed overall incidence of acute postoperative dialysis was adequately predicted by the Cleveland Clinic Severity Score in the Control group (p = 0.6), but was lower than predicted in the Insulin group (1.2% vs 3%, p = 0.03). Conclusions In non-diabetic patients, tight perioperative blood glucose control is associated with a significant reduction in postoperative renal impairment and failure after cardiac surgery according to the RIFLE criteria. In non-diabetics, tight blood glucose control was associated with a decreased need for postoperative dialysis, as well as 30-day mortality, despite of a relatively short ICU stay.

Based upon a questionnaire survey of delegates to the RPR National Congress held in Grenoble in November 1984, this paper summarizes a three-dimensional analysis of RPR officials (demographic and sociological identification; political mobilization, party functions and activism; ideological trends and political attitudes) which seeks to appraise how the evolution of the Gaullist movement correlates with changes in French politics between 1976 and 1986.

The municipal action groups in the local political system: Grenoble, Valence, Chambéry, by Jean-Pierre Bernard, Jean-Marc Blancherie, Patrick Lecomte During the municipal elections of March 1965 a list led by M. Hubert Dubedout regrouping under the title "municipal action" the political organisations of the non-communist left together with cadres, technicians and animators... from different horizons succeeded in winning the Grenoble town council. This unexpected local success gave birth to numerous groups modeled on Grenoble. The rationalization of the experiment produced an ideology integrating some of the perspectives of the left-wing parties but within the framework of a renewal of political practices at local level. In March 1971 the Municipal Action Groups fought the parties in the election field. The comparison of the aims and methods of the groups in Valence and Chambery with reference to the experiment in municipal affairs carried out in Grenoble shows the differences and the similitude of the different attempts. Despite their different electoral performances resulting from the local situation these projects have in common their philosophy concerning the administration and animation of town-life and their belief in a necessary but ambiguous collaboration with left wing forces, as the Communist Party is against the experiment. The originality of the Municipal Action Groups no doubt comes up against the resistance of traditional political organisations and if they want to achieve their ends they are obliged to become part of a system whose substance and functions they contest. [Revue française de science politique XXII (2), avril 1972, pp. 296-318], Les groupes d'action municipale dans le système politique local : Grenoble, Valence, Chambéry, par Jean-Pierre Bernard, Jean-Marc Blancherie, Patrick Lecomte Lors des élections municipales de mars 1965, une liste conduite par M. Hubert Dubedout, regroupant des organisations politiques de la gauche non communiste et des cadres, techniciens, animateurs... venus d'horizons divers, rassemblés au sein d'un Groupe d'action municipale, emporte la mairie de Grenoble. Ce succès inattendu et limité entraîne la création de nombreux groupes à l'image de celui de Grenoble. La rationalisation de l'expérience produit une idéologie intégrant certaines perspectives des partis de gauche mais s'inscrivant dans le cadre d'un renouvellement des pratiques politiques au niveau local. En mars 1971, les GAM affrontent les partis sur le terrain électoral. La comparaison des desseins et des méthodes des groupes de Valence et de Chambéry, en référence à l'expérience de gestion municipale poursuivie à Grenoble permet de tracer un bilan sommaire des convergences et des particularités de ces différentes tentatives. Ce bilan fait apparaître, en dépit de performances électorales variables selon la situation locale, d'une part une vision commune de la gestion et de l'animation de la cité, d'autre part une collaboration nécessaire et ambiguë avec les forces de gauche, le Parti communiste récusant l'expérience. L'originalité du projet des GAM ne se heurte-t-elle pas à la résistance des organisations politiques traditionnelles et, pour réussir, ne doivent-ils pas s'intégrer dans un système dont ils remettent en cause certaines des formes et des fonctions ? [Revue française de science politique XXII (2), avril 1972, pp. 296-318], Lecomte Patrick,Bernard Jean-Pierre,Blancherie Jean-Marc. Les groupes d'action municipale dans le système politique local : Grenoble, Valence, Chambéry. In: Revue française de science politique, 22ᵉ année, n°2, 1972. pp. 296-318.

There has been since 1981 much new blood among RPR militants, mobilized by opposition to the government of the Left. These militants continue to refer symbolically to Gaullism, but their ideological universe has shifted towards economie liberalism. At the sarne time, they proclaim their affiliation to the right and consider their UDF allies as centrists, thereby stressing the difference. The party appears divided concerning its relations with the Front national but more tolerant towards it than in 1978. The dominant image of the RPR is one of dynamism and responsibility whereas, that of the UDF is negative, that of a diffuse nebula of bad partners., Les militants du RPR se sont beaucoup renouvelés depuis 1981, l'opposition au gouvernement de gauche se révélant être un puissant facteur de mobilisation. Ces militants continuent à se référer symboliquement au gaullisme mais leur univers idéologique a évolué vers le libéralisme économique. Dans le même temps, ils revendiquent leur appartenance à la droite et considèrent leurs alliés de l'UDF comme des centristes, cultivant ainsi leur différence. Le parti apparaît divisé par rapport au Front national mais plus tolérant à son égard qu'en 1978. L'image dominante du RPR est celle du dynamisme et de la responsabilité alors que l'UDF est considérée de manière négative comme une nébuleuse floue et molle de mauvais partenaires., Brechon Pierre, Derville Jacques, Lecomte Patrick. L'univers idéologique des cadres RPR. Entre l'héritage gaulliste et la dérive droitière. In: Revue française de science politique, 37ᵉ année, n°5, 1987. pp. 675-695.

Thirty-eight rank-and-file communist in the Grenoble area — of whom 24 are party members — answered a questionaire on their reaction to the traumatic electoral defeat of the Spring of 1981. Two observations can be drawn from their answers. (1) An outpour of criticism — disavowal of the strategy, discredit of the organizational model and of members of the party apparatus — which reveals the extent of discord within the communist community as well as a deep identity crisis. (2) The continuing adherence of these severe critics, disillusioned and little inclined to indulgence, to the "security values" that rnake up the unquestioned communist identity (the conviction remains strong that the PCF is different from other parties, that it is a workers' party and a party devoted to ideals) and remains the only possible choice. The French Communist Party finds itself in a difficult predicament vis-a-vis its supporters : called upon to change if it is to survive, yet obliged to renounce change lest it reneges., critiques — désaveu de la stratégie, discrédit du modèle organisationnel et des membres de l'appareil — qui signale l'importance de zones de fracture au sein de la communauté communiste et témoigne d'une profonde crise d'identité. Mais en même temps la persistance, chez ces procureurs sans indulgence et sans illusions, de «valeurs-refuge» de cette identité communiste, le sentiment que le PC — parti des ouvriers, parti d'un idéal — demeure un parti différent, est la seule solution possible. En définitive, le Parti communiste français se trouve aujourd'hui dans une situation délicate au regard de ses partisans : sommé de changer pour durer, mais contraint de ne pas changer pour ne pas se renier., Derville Jacques, Lecomte Patrick. Le Parti communiste français au miroir de ses partisans : une image contrastée. In: Revue française de science politique, 33ᵉ année, n°4, 1983. pp. 651-679.

Based on interviews with Grenoble members of the RPR, who had joined the party during the period of « cohabitation » (1986-1988), the study describes the political commitment itinerary of these neophytes so as to understand the complex dynamic of the process of party mobilization in the Jacques Chirac breeding grounds. Starting from political dispositions structured by family socialization, a network of interactive influences, nourished by personal experiences and affiliation or reference groups determines party involvement, at a propitious moment. Party mobilization and militant activity interconnect within a local, relatively specific political project., Fondée sur une série d'entretiens avec des adhérents grenoblois du RPR ralliés au cours de la période de la « cohabitation » (1986-1988), cette enquête retrace l'itinéraire de l'engagement politique de ces néophytes et cherche à appréhender la dynamique complexe du processus de mobilisation partisane dans les viviers chiraquiens. Elle montre qu'à partir des prédispositions politiques structurées par la socialisation familiale, un réseau d'influences interactives, nourries par les expériences personnelles et les milieux d'appartenance ou de référence, détermine l'engagement à la faveur d'une conjoncture propice. Elle met aussi en lumière l'articulation entre mobilisation partisane et investissement militant dans le cadre d'une entreprise politique locale relativement spécifique., Lecomte Patrick. Comment viennent-ils à la politique ? L'engagement des nouvelles recrues du RPR. In: Revue française de science politique, 39ᵉ année, n°5, 1989. pp. 683-699.

The last twenty years of contemporary French political history have unquestionably been years of great change: they have seen the transformation of institutions, the reorganisation of the electorate and the regrouping of political forces: indeed, since 1958, an overall change has been affecting all areas of the political structure and activity of the country. This innovation is particularly clear as far as the political parties are concerned. Within the framework of the original regime of the ‘republican monarchy’1 established by the 1958 Constitution, the constitutional reform of 1962 and the Gaullist exercise of power, two major bodies of political opinion have gradually emerged, and national political activity has been based ona simple, violent and even reductivist schism: on the one hand, the Right in power; on the other, the Left in opposition.

Une montmorillonite sodique (Na-MMT) a été synthétisée par voie hydrothermale, à 350°C et 1200 bars pendant 28 jours, à partir d'un gel correspondant à la formule structurale Na0,66[Al3,34Mg0,66][Si8]O20(OH)4.nH2O. L'analyse chimique par ICP-OES, les analyses ponctuelles à la microsonde électronique et le diffractogramme des rayons X confirment que le produit obtenu est monophasé, homogène et bien cristallisé. Les propriétés d'hydratation de la smectite de synthèse Na-MMT sont comparées à celles de la montmorillonite naturelle du Wyoming SWy-2 échangée Na+. Le cycle d'adsorption-désorption d'eau a été suivi à 30°C par diffraction des rayons X et par gravimétrie. La raie d(001) de Na-MMT est toujours plus fine que celle de Na-SWy-2 ; à 53% d'humidité relative, les raies à 1,3 et 1,5 nm, caractérisant l'hydratation à une et deux couches d'eau, sont nettement distinctes pour Na- MMT, ce qui indique une meilleure organisation des particules de smectite par rapport à Na- SWy-2. Pour simuler les conditions de stockage de surface des déchets, des expériences d'infiltration à l'eau, sous pression constante (3 bars), à travers l'argile préalablement compactée à 5 bars ont été réalisées à l'aide de cellules oedométriques. La conductivité hydraulique calculée à partir du débit d'infiltration et de la loi de Darcy s'élève à 4,5.10-12 m.s-1 pour Na-MMT et 9.10-13 m.s-1 pour Na-SWy-2. La smectite Na-MMT ne présente pas de gonflement macroscopique, tandis que celui-ci atteint 35% au bout de dix jours pour Na- SWy-2. De plus, Na-MMT ne forme pas de gel en présence d'eau. La meilleure cristallinité de la montmorillonite de synthèse pourrait limiter la délamination des particules en feuillets individuels, processus proposé par Laird (2006) pour la formation de gel des smectites naturelles sodiques. La structure des particules (épaisseur et extension) de la montmorillonite de synthèse Na-MMT fera l'objet d'observations au microscope électronique par transmission.