Fixation d’un but thérapeutique pour les patients supportés à long terme par un DAV aux soins intensifs : l’expérience des soignants

La situation d’un patient trop malade pour une transplantation et qui est maintenu à long terme aux soins intensifs (SI) avec l’aide d’un dispositif d'assistance ventriculaire (DAV) peut évoluer de multiples façons. Malheureusement, plusieurs soignants vivent un malaise lorsque ce patient survit avec des complications, sans possibilité de transplantation cardiaque ni de retour à domicile. Par conséquent, différents buts thérapeutiques sont poursuivis au sein de l’équipe soignante. L’étude avait pour objectifs de cerner les buts poursuivis par les professionnels de la santé œuvrant auprès de ce type de patient, de clarifier les facteurs influençant les buts poursuivis et de mieux connaître les difficultés éprouvées par l’équipe soignante dans l’élaboration d’un but commun. La phénoménologie a été utilisée comme méthodologie de définition de la problématique. L’échantillon comprenait 12 participants représentant les infirmières, médecins et perfusionnistes d'une unité de SI, travaillant auprès de ce type de patient. Chacun des participants a fait l’objet d’une entrevue individuelle, semi-dirigée et enregistrée sur appareil audio. Il leur a d’abord été présenté une vignette à partir de laquelle ont été posées un certain nombre de questions identiques pour tous. Dans leurs réponses à ces questions, les participants ont eu la possibilité de s’exprimer autant sur leur expérience que sur le contexte du phénomène. Une seconde rencontre a été nécessaire afin de valider ou de corriger l’interprétation de ce que chacun avait exprimé durant l’entrevue. L'analyse des données témoigne d’un manque d’harmonie quant au but à poursuivre à l’égard du patient en question. Environ la moitié des participants visent la transplantation, alors que les autres poursuivent d’autres buts comme la sortie des SI, la limitation des traitements ou les soins palliatifs. Les participants sont influencés majoritairement par les volontés du patient, l'absence de mécanisme formel de communication entre eux et les facteurs professionnels tels que : les valeurs, les pratiques et l’environnement, sans oublier les rapports de pouvoir. Un certain nombre de barrières empêchent l’équipe de déterminer un but commun. Pour vaincre ces obstacles et s’entendre sur les buts à poursuivre en équipe, le développement de la communication multidisciplinaire s’impose. Pour y arriver, deux prérequis doivent être développés : l’intention éthique et l’engagement.

A calibrated, non-invasive method for measuring the internal interface height field at high resolution in the rotating, two-layer annulus

We describe a remote sensing method for measuring the internal interface height field in a rotating, two-layer annulus laboratory experiment. The method is non-invasive, avoiding the possibility of an interaction between the flow and the measurement device. The height fields retrieved are accurate and highly resolved in both space and time. The technique is based on a flow visualization method developed by previous workers, and relies upon the optical rotation properties of the working liquids. The previous methods returned only qualitative interface maps, however. In the present study, a technique is developed for deriving quantitative maps by calibrating height against the colour fields registered by a camera which views the flow from above. We use a layer-wise torque balance analysis to determine the equilibrium interface height field analytically, in order to derive the calibration curves. With the current system, viewing an annulus of outer radius 125 mm and depth 250 mm from a distance of 2 m, the inferred height fields have horizontal, vertical and temporal resolutions of up to 0.2 mm, 1 mm and 0.04 s, respectively.

Ice internal friction: Standard theoretical perspectives on friction codified, adapted for the unusual rheology of ice, and unified

Sea ice contains flaws including frictional contacts. We aim to describe quantitatively the mechanics of those contacts, providing local physics for geophysical models. With a focus on the internal friction of ice, we review standard micro-mechanical models of friction. The solid's deformation under normal load may be ductile or elastic. The shear failure of the contact may be by ductile flow, brittle fracture, or melting and hydrodynamic lubrication. Combinations of these give a total of six rheological models. When the material under study is ice, several of the rheological parameters in the standard models are not constant, but depend on the temperature of the bulk, on the normal stress under which samples are pressed together, or on the sliding velocity and acceleration. This has the effect of making the shear stress required for sliding dependent on sliding velocity, acceleration, and temperature. In some cases, it also perturbs the exponent in the normal-stress dependence of that shear stress away from the value that applies to most materials. We unify the models by a principle of maximum displacement for normal deformation, and of minimum stress for shear failure, reducing the controversy over the mechanism of internal friction in ice to the choice of values of four parameters in a single model. The four parameters represent, for a typical asperity contact, the sliding distance required to expel melt-water, the sliding distance required to break contact, the normal strain in the asperity, and the thickness of any ductile shear zone.

Internal Residual Stress Measurements in a Bioactive Glass-Ceramic Using Vickers Indentation

The residual stress distribution that arises in the glass matrix during cooling of a partially crystallized 17.2Na(2)O-32.1CaO-48.1SiO(2)-2.5P(2)O(5) (mol%) bioactive glass-ceramic was measured using the Vickers indentation method proposed by Zeng and Rowcliffe (ZR). The magnitude of the determined residual stress at the crystal/glass boundary was 1/4-1/3 of the values measured using X-ray diffraction (within the crystals) and calculated using Selsing`s model. A correction for the crack geometry factor, assuming a semi-elliptical shape, is proposed and then good agreement between experimental and theoretical values is found. Thus, if the actual crack geometry is taken into account, the indentation technique of ZR can be successfully used. In addition, a numerical model for the calculation of residual stresses that takes into account the hemispherical shape of the crystalline precipitates at a free surface was developed. The result is that near the sample surface, the radial component of the residual stress is increased by 70% in comparison with the residual stress calculated by Selsing`s model.

Columnar joints in the Patino Formation sandstones, Eastern Paraguay: a dynamic interaction between dyke intrusion, quartz dissolution and cooling-induced fractures

The Patino Formation sandstones, which crop out in Aregua neighborhood in Eastern Paraguay and show columnar joints near the contact zone with a nephelinite dyke, have as their main characteristics the high proportion of syntaxial quartz overgrowth and a porosity originated from different processes, initially by dissolution and later by partial filling and fracturing. Features like the presence of floating grains in the syntaxial cement, the transitional interpenetrative contact between the silica-rich cement and grains as well as the intense fracture porosity are strong indications that the cement has been formed by dissolution and reprecipitation of quartz from the framework under the effect of thermal expansion followed by rapid contraction. The increase of the silica-rich cement towards the dyke in association with the orthogonal disposition of the columns relative to dyke walls are indicative that the igneous body may represent the main heat source for the interstitial aqueous solutions previously existing in the sediments. At macroscopic scale, the increasing of internal tensions in the sandstones is responsible for the nucleation of polygons, leading to the individualization of prisms, which are interconnected by a system of joints, formed firstly on isotherm surfaces of low temperature and later on successive adjacent planes towards the dyke heat source.

Avaliação mecânica in vitro utilizando miniplacas quadradas e retangulares do sistema 2.0 mm em fraturas da região anterior de mandíbula

The aim of this study was to comparatively evaluate the mechanical strength of squared and rectangular 2.0 mm system miniplates comparing them to the standard configuration with 2 straight miniplates in stabilizing fractures in the anterior mandible. Ninety synthetic polyurethane mandible replicas were used in mechanical test. The samples were divided into six groups of three different methods for fixation. Groups 1, 2 and 3 showed complete fractures in symphysis, characterized by a linear separation between the medial incisor, and groups 4, 5 and 6 showed complete fractures in parasymphysis with oblique design. Groups 1 and 4 were represented by the standard technique with two straight miniplates parallel to each other. Groups 2 and 5 were stabilized by squared miniplates and groups 3 and 6 were fixed by rectangular design. Each group was subjected to a mechanical test at a displacement speed of 10 mm/min on a universal testing machine, receiving linear vertical load on the region of the left first molar. The values of the maximum load and when displacements reached 5 mm were obtained and statistically analyzed by calculating the confidence interval of 95%. Fixation systems using squared (G2) and rectangular (G3) miniplates obtained similar results. No statistically significant differences with respect to the maximum load and the load at 5 mm displacement were found when compared to standard method in symphyseal fractures (G1). In parasymphysis the fixation method using squared miniplates (G5) obtained results without significant differences regarding the maximum load and the load at 5 mm when compared to the standard configuration (G4). The fixation method using rectangular miniplates (G6) showed inferior results which were statistically significant when compared to the standard configuration (G4) for parasymphysis fractures. The mechanical behavior of the fixation methods was similar, except when rectangular miniplates were used. The fixation methods showed better results with statistical significance in symphyseal fractures

In vitro comparison of 1.5 mm vs. 2.0 mm screws for fixation in the sagittal split osteotomy

Purpose: Numerous "in vitro" investigations have been conducted to evaluate the role of screw size and pattern in determining optimal resistance to deformation, often these have been controversial. The aim of this study was to evaluate the effect of screw size and insertion technique on the stability of sagittal split osteotomies.Materials and methods: This study used twenty polyurethane replicas of human hemimandibles with a prefabricated sagittal split ramus osteotomy (SSRO). The hemimandibles were stabilized with 1.5 mm and 2.0 mm titanium screws inserted in an inverted L configuration. All specimens were tested to determine the strength and stability of the fixation.Results: In all cases there was failure of the synthetic bone before there was any evidence of screw failure. There were no significant differences in the load necessary to make the construct fail between the 1.5 or 2.0 mm screw sizes.Conclusion: There was no statistically significant difference between the strengths achieved with screws of 1.5 and 2.0 mm diameters for fixation of SSRO performed in synthetic mandibles. There was no fracture of the 1.5 mm or 2.0 mm diameter screws in any of the tests. 1.5 mm diameter screws in an inverted L pattern have as much stability and mechanical resistance as a 2.0 mm screw, may be safely used for this procedure. (C) 2010 European Association for Cranio-Maxillo-Facial Surgery.

Atypical dento-alveolar fracture fixed with screws: a technical note

Dento-alveolar process fracture is an important and common event in the dental office practice usually managed under the well-established protocols, but sometimes this kind of lesion is evaluated in the hospital emergency rooms without attention to the dental injuries. In this type of trauma, the time between the injury and the definitive resolution is essential for the treatment success, usually 1 h in cases of dento-alveolar fractures (tooth and alveolar bone). This paper describes the management of a patient with unusual dento-alveolar fracture caused by gunshot and treated using screw fixation.

Comparative Strain Gauge Analysis of External and Internal Hexagon, Morse Taper, and Influence of Straight and Offset Implant Configuration

Purpose: The present study was designed to analyze strain distributions caused by varying the fixture-abutment design and fixture alignment.Materials and Methods: Three implants of external, internal hexagon, and Morse taper were embedded in the center of each polyurethane block in straight placement and offset placement. Four strain gauges (SGs) were bonded on the surface of polyurethane block, which was designated SG1 placed mesially adjacent to implant A, SG2 and SG3 were placed mesially and distally adjacent to the implant B and SG4 was placed distally adjacent to the implant C. The 30 superstructures' occlusal screws were tightened onto the Microunit abutments with a torque of 10 N cm using the manufacturers' manual torque-controlling device.Results: There were statistically significant differences in prosthetic connection (P value = 0.0074 < 0.5). There were no statistically significant differences in placement configuration/alignment (P value = 0.7812 > 0.5).Conclusion: The results showed fundamental differences in both conditions. There was no evidence that there was any advantage to offset implant placement in reducing the strain around implants. The results also revealed that the internal hexagon and Morse taper joints did not reduce the microstrain around implants. (Implant Dent 2011; 20:e24-e32)

External Hexagon and Internal Hexagon in Straight and Offset Implant Placement: Strain Gauge Analysis

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Synthesis Pengo System plates for the treatment of long-bone diaphyseal fractures in dogs

A Brazilian orthopaedic company designed a stainless steel plate called Synthesis Pengo System (S.P.S.), which has one fixed and one changeable extremity. According to the assembly of the changeable extremity, it is possible to obtain dynamization or neutralization of the fracture site. Since the S.P.S. plate was developed for use in human patients, the aim of this study was to evaluate this system in long-bone diaphyseal fractures in dogs. Eight dogs with closed diaphyseal fractures of the femur (n = 1), radius and ulna (n = 5), and tibia (n = 2) were used. Patients were aged seven months to three years and weighed 18 to 31.2 kg. The S.P.S. plate was assembled with one fixed extremity and one changeable extremity in dynamization mode. The trail bar was positioned for synthesis modules with holes for cortical screws. The modules were positioned close to one another in two fractures and for away from the fracture site in the others. The bone healing occurred by external callus. Since motion at the fracture site determines the amount of callus required, the secondary bone healing that was observed in all of the cases indicated less rigid fixation of this system. A potential benefit of this system was a lesser interface contact with the bone since it was only done by trail bar. The major disadvantage was the prominence of the implant. It was possible to conclude that the S.P.S. plate appears to be a suitable method for the treatment of diaphyseal fractures in dogs.

Marginal fit of nickel-chromium copings before and after internal adjustments with duplicated stone dies and disclosing agent.

STATEMENT OF PROBLEM: Despite careful procedures, master stone dies may be damaged during laboratory procedures. The dentist routinely adjusts castings because the marginal fit of casting is not as accurate as on the dies. PURPOSE: This study evaluated the technique of internal adjustment of castings with use of duplicated stone dies and a disclosing agent to improve marginal fit discrepancy. MATERIAL AND METHODS: Thirty-two nickel-chromium copings were fabricated and simulated standard clinical and laboratory procedures with 2 variables: tooth preparation convergence angles of 6 and 18 degrees, with or without internal relief. Master stone dies and their duplicates were selected for coping construction and internal adjustment, respectively. A specimen positioning device was coupled with a Toolmakers microscope to allow reproducibility of measurements. Each coping was evaluated at 8 locations of its marginal perimeter, before and after internal adjustment. RESULTS: Marginal fit discrepancy of copings were significantly reduced with an internal adjustment technique (mean > 52%) for all experimental groups. Tooth preparations with greater convergence and internally relieved castings recorded a better marginal fit. CONCLUSION: The casting internal adjustment technique with use of duplicated stone dies and a disclosing agent substantially reduced marginal fit discrepancy.

Severe fracture of the maxillary alveolar process associated with extrusive luxation and tooth avulsion: A case report

Aim: The aim of this report is to present a case of severe fracture of the maxillary anterior alveolar process with substantial bone dislodgement associated with extrusive tooth luxation and avulsion. Background: Dentoalveolar trauma is a challenge to dentistry, especially in young patients, for it can lead to early tooth loss which compromises oral function, esthetics, self-esteem, and alter the long-term plan of care for the victim. Case Report: A 12-year-old girl with severe dentoalveolar trauma to the maxillary anterior region presented for emergency care for her injury. Treatment consisted of fracture reduction of the alveolar process, repositioning of the teeth that had suffered extrusive luxation, placement of a semi-rigid splint, and suturing of soft tissue lacerations. The traumatized teeth presented with pulpal necrosis and were treated endodontically. After 24 months of follow up, the fracture of the alveolar process was completely healed and the displaced teeth presented no signs of ankylosis or root resorption. Summary: First-aid care contributed remarkably to this case allowing the re-establishment of esthetics, function, and patient's self-esteem. In spite of trauma extension the treatment outcomes were favorable. Clinical Significance: Cases of dentoalveolar trauma should be evaluated on an individual basis. However, early emergency management and adequate follow-up can prevent further complications and contribute to treatment success.

Reliability and failure modes of internal conical dental implant connections

Objective: Biological and mechanical implant-abutment connection complications and failures are still present in clinical practice, frequently compromising oral function. The purpose of this study was to evaluate the reliability and failure modes of anterior single-unit restorations in internal conical interface (ICI) implants using step-stress accelerated life testing (SSALT). Materials and methods: Forty-two ICI implants were distributed in two groups (n = 21 each): group AT-OsseoSpeed™ TX (Astra Tech, Waltham, MA, USA); group SV-Duocon System Line, Morse Taper (Signo Vinces Ltda., Campo Largo, PR, Brazil). The corresponding abutments were screwed to the implants and standardized maxillary central incisor metal crowns were cemented and subjected to SSALT in water. Use-level probability Weibull curves and reliability for a mission of 50,000 cycles at 200 N were calculated. Differences between groups were assessed by Kruskal-Wallis along with Bonferroni's post-hoc tests. Polarized-light and scanning electron microscopes were used for failure analyses. Results: The Beta (β) value derived from use level probability Weibull calculation was 1.62 (1.01-2.58) for group AT and 2.56 (1.76-3.74) for group SV, indicating that fatigue was an accelerating factor for failure of both groups. The reliability for group AT was 0.95 and for group SV was 0.88. Kruskal-Wallis along with Bonferroni's post-hoc tests showed no significant difference between the groups tested (P > 0.27). In all specimens of both groups, the chief failure mode was abutment fracture at the conical joint region and screw fracture at neck's region. Conclusions: Reliability was not different between investigated ICI connections supporting maxillary incisor crowns. Failure modes were similar. © 2012 John Wiley & Sons A/S.

Management of pure medial orbital wall fracture with autogenous bone graft

The orbit is an irregular conical cavity formed from 7 bones including the frontal, sphenoid, zygomatic, maxillary, ethmoid, lacrimal, and palatine bones. Fractures of the internal orbit can cause a number of problems, including diplopia, ocular muscle entrapment, and enophthalmos. Although muscle entrapment is relatively rare, diplopia and enophthalmos are relatively common sequelae of internal orbital fractures. Medial orbital wall fracture is relatively uncommon and represents a challenge for its anatomical reconstruction. In this context, autogenous bone graft has been the criterion standard to provide framework for facial skeleton and orbital walls. Therefore, it is possible to harvest grafts of varying size and contour, and the operation is performed through the bicoronal incision, which is the usual approach to major orbital reconstruction. Thus, this article aimed to describe a patient with a pure medial orbital wall fracture, and it was causing diplopia and enophthalmos. The orbital fracture was treated using autogenous bone graft from calvarial bone. The authors show a follow-up of 12 months, with facial symmetry and without diplopia and enophthalmos. In addition, a computed tomography scan shows excellent bone healing at the anterior and posterior parts of the medial orbital wall reconstruction. Copyright © 2013 by Mutaz B. Habal, MD.