Techniques de gastrostomie chez l'enfant et expérience lausannoise avec le bouton de gastrostomie à ballonnet (Mic-Key)

Résumé : Ce travail comprend deux parties : La première partie a pour but de présenter une revue des techniques de gastrostomie chez l'enfant. La gastrostomie est, par définition, un tractus fistuleux entre l'estomac et la paroi abdominale. Le but de la gastrostomie est de permettre la décompression gastrique, la nutrition entérale et l'apport médicamenteux. Les indications et contre-indications à la confection et utilisation de la gastrostomie sont détaillées dans ce travail. Historiquement, les premières gastrostomies étaient d'origine accidentelle ou infectieuse (fistule gastro-cutanée), incompatibles avec la vie. Sedillot, en 1845 décrivit la première gastrostomie chirurgicale sans cathéter, qui avait comme désavantage la présence de fuites. Depuis, les techniques se sont multipliées en évoluant vers la continence et l'utilisation de cathéters. En 1979 Gauderer décrivit pour la première fois une technique percutanée, réalisée sur un enfant âgé de 5 mois. Cette technique est appelée « Percutaneous Endoscopic Gastrostomy » (PEG). Elle a ensuite été élargie à la population adulte. Actuellement, il existe une grande multiplicité de techniques par abord « laparotomique », laparoscopique ou percutanée (endoscopique ou radiologique). Ces techniques peuvent être combinées. Toutes ces techniques nécessitent la présence intermittente ou continue d'un dispositif, qui permet le maintient de la gastrostomie ouverte et évite les fuites gastriques. Ces dispositifs sont multiples; initialement il s'agissait de cathéters rigides (bois, métal, caoutchouc). Ensuite ils ont été fabriqués en silicone, ce qui les rend plus souples et mieux tolérés par le patient. Pour éviter leur dislocation, ils possèdent un système d'amarrage intra-gastrique tel que : un champignon (Bard®), un ballonnet (Foley®, Mic-Key®), ou une forme spiralée du cathéter (« pig-tail ») et possèdent un système d'amarrage extra-gastrique (« cross-bar »). En 1982, Gauderer créa le premier dispositif à fleur de peau : le bouton de gastrostomie (BG). Actuellement, il en existe deux types : à champignon (Bard®) et à ballonnet (Mic-Key®). Il existe plusieurs types de complications liées à la technique opératoire, à la prise en charge et au matériel utilisé. Une comparaison des différentes techniques, matériaux utilisés et coûts engendrés est détaillée dans ce travail. La deuxième partie de ce travail est dédiée aux BG et plus spécifiquement au BG à ballonnet (Mic-Key®). Nous présentons les différents boutons et les techniques spécifiques. Le BG est inséré soit dans une gastrostomie préformée, soit directement lors de la confection d'une gastrostomie par laparotomie, laparoscopie ou de façon percutanée. Les complications liées au BG sont rapportées. D'autres utilisations digestives ou urologiques sont décrites. Nous présentons ensuite notre expérience avec 513 BG à ballonnet (Mic-Key®) dans une revue de 73 enfants. La pose du BG est effectuée dans une gastrostomie préformée sans recours à une anesthésie générale. La technique choisie pour la confection de la gastrostomie dépend de la pathologie de base, de l'état général du patient, de la nécessité d'une opération concomitante et du risque anesthésique. Nous apportons des précisions sur le BG telles que la dimension en fonction de l'âge, la durée de vie, et les causes qui ont amené au changement du BG. Nos résultats sont comparés à ceux de la littérature. Sur la base de notre expérience et après avoir passé en revue la littérature spécialisée, nous proposons des recommandations sur le choix de la technique et le choix du matériel. Ce travail se termine avec une réflexion sur le devenir de la gastrostomie. Si le futur consiste à améliorer et innover les techniques et les matériaux, des protocoles destinés à la standardisation des techniques, à la sélection des patients et à l'enseignement des soins devraient s'en suivre. La prise en charge de l'enfant ne se limite pas à la sélection appropriée de la technique et des matériaux, mais il s'agit avant tout d'une approche multidisciplinaire. La collaboration entre le personnel soignant, la famille et l'enfant est essentielle pour que la prise en charge soit optimale et sans risques.

Studies on integrating kinematic design method with mechanical systems simulation techniques

Theultimate goal of any research in the mechanism/kinematic/design area may be called predictive design, ie the optimisation of mechanism proportions in the design stage without requiring extensive life and wear testing. This is an ambitious goal and can be realised through development and refinement of numerical (computational) technology in order to facilitate the design analysis and optimisation of complex mechanisms, mechanical components and systems. As a part of the systematic design methodology this thesis concentrates on kinematic synthesis (kinematic design and analysis) methods in the mechanism synthesis process. The main task of kinematic design is to find all possible solutions in the form of structural parameters to accomplish the desired requirements of motion. Main formulations of kinematic design can be broadly divided to exact synthesis and approximate synthesis formulations. The exact synthesis formulation is based in solving n linear or nonlinear equations in n variables and the solutions for the problem areget by adopting closed form classical or modern algebraic solution methods or using numerical solution methods based on the polynomial continuation or homotopy. The approximate synthesis formulations is based on minimising the approximation error by direct optimisation The main drawbacks of exact synthesis formulationare: (ia) limitations of number of design specifications and (iia) failure in handling design constraints- especially inequality constraints. The main drawbacks of approximate synthesis formulations are: (ib) it is difficult to choose a proper initial linkage and (iib) it is hard to find more than one solution. Recentformulations in solving the approximate synthesis problem adopts polynomial continuation providing several solutions, but it can not handle inequality const-raints. Based on the practical design needs the mixed exact-approximate position synthesis with two exact and an unlimited number of approximate positions has also been developed. The solutions space is presented as a ground pivot map but thepole between the exact positions cannot be selected as a ground pivot. In this thesis the exact synthesis problem of planar mechanism is solved by generating all possible solutions for the optimisation process ¿ including solutions in positive dimensional solution sets - within inequality constraints of structural parameters. Through the literature research it is first shown that the algebraic and numerical solution methods ¿ used in the research area of computational kinematics ¿ are capable of solving non-parametric algebraic systems of n equations inn variables and cannot handle the singularities associated with positive-dimensional solution sets. In this thesis the problem of positive-dimensional solutionsets is solved adopting the main principles from mathematical research area of algebraic geometry in solving parametric ( in the mathematical sense that all parameter values are considered ¿ including the degenerate cases ¿ for which the system is solvable ) algebraic systems of n equations and at least n+1 variables.Adopting the developed solution method in solving the dyadic equations in direct polynomial form in two- to three-precision-points it has been algebraically proved and numerically demonstrated that the map of the ground pivots is ambiguousand that the singularities associated with positive-dimensional solution sets can be solved. The positive-dimensional solution sets associated with the poles might contain physically meaningful solutions in the form of optimal defectfree mechanisms. Traditionally the mechanism optimisation of hydraulically driven boommechanisms is done at early state of the design process. This will result in optimal component design rather than optimal system level design. Modern mechanismoptimisation at system level demands integration of kinematic design methods with mechanical system simulation techniques. In this thesis a new kinematic design method for hydraulically driven boom mechanism is developed and integrated in mechanical system simulation techniques. The developed kinematic design method is based on the combinations of two-precision-point formulation and on optimisation ( with mathematical programming techniques or adopting optimisation methods based on probability and statistics ) of substructures using calculated criteria from the system level response of multidegree-of-freedom mechanisms. Eg. by adopting the mixed exact-approximate position synthesis in direct optimisation (using mathematical programming techniques) with two exact positions and an unlimitednumber of approximate positions the drawbacks of (ia)-(iib) has been cancelled.The design principles of the developed method are based on the design-tree -approach of the mechanical systems and the design method ¿ in principle ¿ is capable of capturing the interrelationship between kinematic and dynamic synthesis simultaneously when the developed kinematic design method is integrated with the mechanical system simulation techniques.

Studies on the characterization of dental whitening process by using both hyperspectral imaging and colorimeter techniques

A beautiful smile is directly related with white teeth. Nowadays oral care has increased and developed processes for beautiful smiles. Dental bleaching is frequently used in odontology, not just for health care also for aesthetic treatment. With the possibility of teeth bleaching, now the importance is in, how white the tooth is? Because color is relate to an individual perception. In order to assets teeth correct color identification has been developed many color guides, models, spaces and analytical methods. Spite all of these useful tools the color interpretation depends on environmental factors, position of the sample in the data acquisition and most importantly the instrument sensitivity. The commons methods have proved to be useful. They are easy to handle, some are portable but they do not have a high sensitivity. The present work is based on the integration of a new analytical technique for color acquisition. High spectral Image (HSI) is able to performed image analysis with high quality and efficiency. HSI is used in many fields and we used it for color image analysis within the bleaching process. The main comparison was done with the HSI and the colorimeter through the processes of two different bleaching protocols. The results showed that HSI has higher sensitivity than the colorimeter. During the analysis the dental surface with the HSI we were able to notice surface changes. These changes were analyzed by roughness studies.

Coscheduling techniques and monitoring tools for non-dedicated cluster computing

Our efforts are directed towards the understanding of the coscheduling mechanism in a NOW system when a parallel job is executed jointly with local workloads, balancing parallel performance against the local interactive response. Explicit and implicit coscheduling techniques in a PVM-Linux NOW (or cluster) have been implemented. Furthermore, dynamic coscheduling remains an open question when parallel jobs are executed in a non-dedicated Cluster. A basis model for dynamic coscheduling in Cluster systems is presented in this paper. Also, one dynamic coscheduling algorithm for this model is proposed. The applicability of this algorithm has been proved and its performance analyzed by simulation. Finally, a new tool (named Monito) for monitoring the different queues of messages in such an environments is presented. The main aim of implementing this facility is to provide a mean of capturing the bottlenecks and overheads of the communication system in a PVM-Linux cluster.

Evolution of Genetic Techniques: Past, Present, and Beyond.

Genetics is the study of heredity, which means the study of genes and factors related to all aspects of genes. The scientific history of genetics began with the works of Gregor Mendel in the mid-19th century. Prior to Mendel, genetics was primarily theoretical whilst, after Mendel, the science of genetics was broadened to include experimental genetics. Developments in all fields of genetics and genetic technology in the first half of the 20th century provided a basis for the later developments. In the second half of the 20th century, the molecular background of genetics has become more understandable. Rapid technological advancements, followed by the completion of Human Genome Project, have contributed a great deal to the knowledge of genetic factors and their impact on human life and diseases. Currently, more than 1800 disease genes have been identified, more than 2000 genetic tests have become available, and in conjunction with this at least 350 biotechnology-based products have been released onto the market. Novel technologies, particularly next generation sequencing, have dramatically accelerated the pace of biological research, while at the same time increasing expectations. In this paper, a brief summary of genetic history with short explanations of most popular genetic techniques is given.

Applying precision feeding techniques in growing-finishing pig operations

The high cost of feed ingredients, the use of non-renewable sources of phosphate and the dramatic increase in the environmental load resulting from the excessive land application of manure are major challenges for the livestock industry. Precision feeding is proposed as an essential approach to improve the utilization of dietary nitrogen, phosphorus and other nutrients and thus reduce feeding costs and nutrient excretion. Precision feeding requires accurate knowledge of the nutritional value of feedstuffs and animal nutrient requirements, the formulation of diets in accordance with environmental constraints, and the gradual adjustment of the dietary nutrient supply to match the requirements of the animals. After the nutritional potential of feed ingredients has been precisely determined and has been improved by the addition of enzymes (e.g. phytases) or feed treatments, the addition of environmental objectives to the traditional feed formulation algorithms can promote the sustainability of the swine industry by reducing nutrient excretion in swine operations with small increases in feeding costs. Increasing the number of feeding phases can also contribute to significant reductions in nutrient excretion and feeding costs. However, the use of precision feeding techniques in which pigs are fed individually with daily tailored diets can further improve the efficiency with which pigs utilize dietary nutrients. Precision feeding involves the use of feeding techniques that allow the provision of the right amount of feed with the right composition at the right time to each pig in the herd. Using this approach, it has been estimated that feeding costs can be reduced by more than 4.6%, and nitrogen and phosphorus excretion can both be reduced by more than 38%. Moreover, the integration of precision feeding techniques into large-group production systems can provide real-time off-farm monitoring of feed and animals for optimal slaughter and production strategies, thus improving the environmental sustainability of pork production, animal well-being and meat-product quality.

Micronization of Pharmaceuticals and Food Ingredients using Supercritical Fluid Techniques

Micronization techniques based on supercritical fluids (SCFs) are promising for the production of particles with controlled size and distribution. The interest of the pharmaceutical field in the development of SCF techniques is increasing due to the need for clean processes, reduced consumption of energy, and to their several possible applications. The food field is still far from the application of SCF micronization techniques, but there is increasing interest mainly for the processing of products with high added value. The aim of this study is to use SCF micronization techniques for the production of particles of pharmaceuticals and food ingredients with controlled particle size and morphology, and to look at their production on semi-industrial scale. The results obtained are also used to understand the processes from the perspective of broader application within the pharmaceutical and food industries. Certain pharmaceuticals, a biopolymer and a food ingredient have been tested using supercritical antisolvent micronization (SAS) or supercritical assisted atomization (SAA) techniques. The reproducibility of the SAS technique has been studied using physically different apparatuses and on both laboratory and semi-industrial scale. Moreover, a comparison between semi-continuous and batch mode has been performed. The behaviour of the system during the SAS process has been observed using a windowed precipitation vessel. The micronized powders have been characterized by particle size and distribution, morphology and crystallinity. Several analyses have been performed to verify if the SCF process modified the structure of the compound or caused degradation or contamination of the product. The different powder morphologies obtained have been linked to the position of the process operating point with respect to the vapour-liquid equilibrium (VLE) of the systems studied, that is, mainly to the position of the mixture critical point (MCP) of the mixture. Spherical micro, submicro- and nanoparticles, expanded microparticles (balloons) and crystals were obtained by SAS. The obtained particles were amorphous or with different degrees of crystallinity and, in some cases, had different pseudo-polymorphic or polymorphic forms. A compound that could not be processed using SAS was micronized by SAA, and amorphous particles were obtained, stable in vials at room temperature. The SCF micronization techniques studied proved to be effective and versatile for the production of particles for several uses. Furthermore, the findings of this study and the acquired knowledge of the proposed processes can allow a more conscious application of SCF techniques to obtain products with the desired characteristics and enable the use of their principles for broader applications.

Selenium content of Finnish oats in 1997-1999 : effect of cultivars and cultivation techniques

Selostus: Suomalaisen kauran seleenipitoisuus vuosina 1997-1999