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.

Complications biliaires après tranplantation hépatique

RESUME Après transplantation hépatique (TH), il persiste une morbidité et une mortalité liées aux complications immunologiques, infectieuses, rénales, vasculaires et, en particulier, aux complications biliaires - le "talon d'Achille" de la TH. Dans ce travail de thèse, nous avons analysé la fréquence et les caractéristiques des complications biliaires après TH dans l'expérience du CHUV à Lausanne entre 1988 et 2003. Au total 185 transplantations orthotopiques ont été réalisées chez 168 patients de décembre 1988 à mars 2003 (103 patients transplantés étaient de sexe masculin et 65 de sexe féminin). L'âge moyen pour les hommes était de 51 ans, celui de femmes étant de 49. Pendant la TH, une anastomose cholédoco-cholédocienne a été réalisée à 168 reprises et une anastomose cholédoco-jejunale à 17 reprises. Trente cas de complications biliaires ont été recensés, soit 16% des cas, avec un taux de mortalité de 0% durant le traitement de ces complications. Il s'agissait d'obstructions biliaires, fuites biliaires, lithiase biliaire isolée et sténoses biliaires. Les complications biliaires après TH restent donc relativement fréquentes et sont parfois graves. Elles nécessitent un diagnostic précoce et doivent être suspectées lors de fièvre, d'ictère, de douleurs abdominales ou de cholestase. En conclusion, l'incidence et le type de complications retrouvés dans la série lausannoise sont représentatifs des résultats observés dans d'autres centres de TH. Le traitement adéquat de ces complications, souvent graves, est de la plus haute importance et aura un impact important sur le pronostic.

Revegetació de talussos d'una explotació carbonífera mitjançant materials de rebuig

En aquest treball s'avalua la rehabilitació dels talussos d'una explotació minera carbonífera utilitzant materials de rebuig de la pròpia explotació i provinents d'activitats ramaderes (purins de porc) o urbanes (llots de depuradora), en un ambient àrid del Baix Segre. Les variables analitzades foren el tipus i recobriment vegetals, la penetromia i la salinitat del substrat, i la salinitat, els nitrats i els sediments dels efluents. Els resultats indiquen que és possible rehabilitar els runams en aquests medis, assolint recobriments vegetals fins al 50 % sense que se'n derivin efectes ambientals negatius importants. Taxes altes puntuals d'erosió poden controlar-se amb un disseny adient dels talussos. L'aplicació superficial de purí no té efectes antiencrostants. La moderada salinitat dels substrats condiciona l'establiment de vegetació halòfila.

Avaliação de filtros domésticos comerciais para purificação de águas e retenção de contaminantes inorgânicos

Twenty domestic commercial filters, in order to determine the percentual retention of color, turbidity, dry residue, bicarbonates, carbonates, total hardness, nitrogens, iron, chlorides, fluorides, and residual chlorine (parameters of food legislation) and sulphides in thirteen water samples proceeding from springs, wells, rivers, lakes, drinking patterns and standards, before and after purification were evaluated. The results showed that purifiers presented adequate retention for nitrates (74.8 ± 16.2 %) and residual chlorine (74.0 ± 11.2) and medium retention for sulphides (61.7 ± 11.3); while porcelain plus activated carbon filters presented adequate retention for color (90.0 ± 19.7), turbidity (76.4 ± 18.4) and iron (83.5 ± 15.1). Therefore the retention of carbonates, bicarbonates, total hardness, chlorides, dry residue, fluorides, ammonium nitrogens and nitrites was less than 10%, and the values of pH didn't show significant variation, for all the filters studied.

The long run development of Chile and the Natural Resources curse. Linkages, policy and growth, 1850-1950

This chapter analyses the effects of Natural Resources on the Chilean economy in the long run -1850-1950-. Specifically, the authors focus their attention on the mining cycles -nitrates and copper- and their impact on the mining activity. We also compare it with the evolution of the industry and whole economy, and how this has affected the economic growth of the country. In that sense, the industrial performance in Chile at the end of the 19th century until the Great Depression is still under debate. The optimistic view of Kirsch -1977- forehead the pessimistic view of Lagos -1966- and Palma -1979-. The new data and its analyses shows a neutral effect of the Natural Resources in the industrial development.

Preparação e caracterização de pós cerâmicos de aluminatos de lítio

The preparation of gamma-LiAlO2 by coprecipitation and sol-gel synthesis was investigated. Ceramic powders obtained by coprecipitation synthesis were prepared from aqueous solutions of aluminum and lithium nitrates using sodium hydroxide as precipitant agent. By sol-gel synthesis, the ceramic powders were prepared from hydrolysis of aluminum isopropoxide. The materials obtained by two routes of synthesis were dried at 80ºC and calcined at 550, 750, 950 and 1150ºC. The characterization was done by X-ray diffraction, infrared spectroscopy, emission and absorption atomic spectrometry, helium picnometry, specific surface area (BET method) and scanning electronic microscopy. Mixtures of crystalline phases were obtained by coprecipitation synthesis: 80ºC- LiAl2(OH)7.2H2O + Al(OH)3; 550 and 750ºC- alpha-LiAlO2 + eta-Al2O3; 950 and 1150ºC- gamma-LiAlO2 + LiAl5O8. Chemical analysis showed molar ration Al/Li @ 3. Crystalline single-phases were obtained by sol-gel synthesis above 550ºC: 550ºC-alpha-LiAlO2; 750, 950 and 1150ºC-gamma-LiAlO2. These powders presented molar ration Al/Li @ 1. Thus, gamma-LiAlO2 crystalline phase was obtained at 750ºC by sol-gel synthesis while by coprecipitation synthesis, a mixture of crystalline phases was obtained. These results showed the superiority of the sol-gel synthesis for the preparation of pure gamma-LiAlO2.

Avaluació dels nivells de nitrats i duresa a l'aigua de consum a quatre zones d'Espanya participants a l'estudi epidemiològic Infància i Medi Ambientl (INMA)

L’aigua és un dels components bàsics per a la vida i una font d’exposició a contaminants ubiqua, ja que tota la població en consumeix. L’estudi epidemiològic INMA avaluarà si l’exposició a nitrats durant l’embaràs i a la duresa de l’aigua durant la infància es relaciona amb el baix pes al néixer i l’èczema atòpica, respectivament. Objectiu: Fer una avaluació dels nivells de nitrats i duresa de l’aigua en aigua de consum de la població de l’estudi INMA. Metodologia: l’estudi descriptiu realitzat a quatre de les set cohorts INMA, a Astúries, Guipúscoa, Sabadell i València. S’ha recopilat dades dels nivells de nitrats i duresa a l’aigua de consum dels municipis durant el període d’interès (2003 al 2008 i 2004 al 2012), a través d’ajuntaments i companyies d’aigua. S’ha calculat la mitjana, la desviació estàndard, el màxim i el mínim dels nivells de nitrat i de duresa en total i segons l’àrea geogràfica, l’any i l’estació. A Sabadell s’han fet tres mostrejos d’aigua per analitzar la duresa a diferents punts de la ciutat. Resultats: el nivell promig de nitrats (mg/L NO3-) és de 4,2 a Astúries, 4,0 a Guipúscoa, 9,2 a Sabadell i 15,2 a València. El nivell promig de duresa (mg/L CaCO3) és de 89,1 a Astúries, 132,7 al Guipúscoa, 178,3 a València i 230,9 a Sabadell. En l’anàlisi que es va realitzar a Sabadell, es detecta una duresa lleugerament inferior a la reportada sense variabilitat geogràfica. No s’observa una pauta clara de variabilitat estacional ni de variabilitat temporal tant per nitrats com per duresa. Conclusions: S’ha detectat variabilitat en els nivells de nitrats i duresa de l’aigua a les zones d’estudi. Els nivells de nitrats són moderats i els més alts es troben a zones agrícoles de València. La duresa de l’aigua és força alta degut al domini calcari dels subsòls de les zones d’estudi.

Emprego de óxidos tipo perovskita nas oxidações do propano e CO

Simultaneous oxidation/co-precipitation of an equimolar mixture of La(III) and Co(II) nitrates and La(III) nitrate and Mn(II) chloride afforded a hydroxide gel, which was converted to LaCoO3 and LaMnO3 on calcination at 600 °C. After calcination, the obtained perovskites have been characterised by X-ray diffraction (XRD), X- ray photoelectron spectroscopy (XPS), thermogravimetric analysis (DTA - TGA) and BET specific surface determination. Specific surface areas of perovskites were 12 - 60 m²/g. XRD analysis showed that LaCoO3 and LaMnO3 are simple phase perovskite - type oxides. Traces of LaOCl, in addition to the perovskite were detected in the LaMnO3. The catalytic behavior was examined in the propane and CO oxidation. The LaCoO3 catalyst was more active to CO2 than the LaMnO3 catalyst.

Functional diversity of macrophyte communities within and between Pyrenean lakes

Submersed vegetation is a common feature in about 70% Pyrene an high mountain (>1500 m a.s.l.) lakes. Isoetids and soft-water elodeids are common elements of this underw ater flora and can form distinct vegetation units (i.e. patches of vegetation dominated by different species) within complex mosaics of vegetation in shallow waters (<7 m). Since is oetids exert a strong influence on sediment biogeochemistry due to high radial oxygen loss, we examined the small scale characteristics of the lake environment (water and sediment) associated to vegetation patches in order to ascertain potential functional differences among them. To do so, we characterised the species composition and biomass of the main vegetation units from 11 lakes, defined plant communities based on biomass data, and then related each community with sediment properties (redox and dissolved nutrient concentration in the pore water) and water nutrient concentration within plant canopy. We also characterised lake water and sediment in areas without vegetation as a reference. A total of twenty-one vegetation units were identified, ranging from one to five per lake. A cluster analysis on biomass species composition suggested seven different macrophyte communities that were named after the most dominant species:Nitella sp.,Potamogeton praelongus, Myriophyllum alterniflorum, Sparganium angustifolium , Isoetes echinospora,Isoetes lacustris and Carex rostrata . Coupling between macrophyte communities and their immediate environment (overlying water and sediment) was manifested mainly as variation in sediment redox conditions and the dominant form of inorganic nitrogen in pore-water. These effects depended on the specific compositi on of the community, and on the allocation between above- and belowground biomass, and could be predicted with a model relating the average and standard deviation of sediment redox potential from 0 down to -20 cm, across macrophyte communities. Differences in pore-water total dissolved phosphorus were related to the trophic state of the lakes. There was no correlation between sediment and water column dissolved nutrients. However, nitrate concentrations tended to be lower in the water overlaying isoetid communities, in apparent contradiction to the patterns of dissolved nitrates in the pore-water. These tendencies were robust even when comparing the water over laying communities within the same lake, thus pointing towards a potential effect of isoetids in reducing dissolved nitrogen in the lakes.

Por que todos os nitratos são solúveis?

The solubility rules presented in the majority of introductory texts of chemistry usually do not comprise a systematic analysis of the dissolution processes, neither from a microscopic nor from a macroscopic point of view. The solubility of nitrates in aqueous solution is discussed in this article, focusing on the thermodynamic data and the properties of the nitrate ion.

Síntese, caracterização e avaliação catalítica de Vo x/Mg yAlo x na reação de decomposição do isopropanol

Vanadium oxide supported on hydrotalcite-type precursors was studied in the decomposition of isopropanol. Hydrotalcite-type compounds with different y = Mg+2/Al+3 ratios were synthesized by the method of coprecipitating nitrates of Mg+2 and Al+3 cations with K2CO3 as precipitant. The X-ray diffraction patterns of Al-rich hydrotalcite precursors showed the presence of crystalline phases of brucite and gibbsite. It was shown that chemical composition, texture, acid-base properties of the active sites and also Mg/Al ratio strongly affect the formation of the products in the oxidation of isopropanol. The Al-rich catalysts were much more active than the Mg-rich ones, converting isopropanol mainly to propylene.

Yield in double cropping system as affected by N fertilization rate with pig slurry in a Catalonia dryland region

Intensive swine production is an important agricultural and economical activity in Europe. The high availability of pig slurry (PS) lead to attractive fertilization strategy to reduce costs, therefore is mainly applied as fertilizer in agricultural systems. The optimization N fertilization in these areas should be taken in into to avoid nitrates losses by lixiviation and to achieve maximum efficiency in crop nutrition. Many studies have shown that PS applications can achieve satisfactory yields in different crops by partially or completely replacing synthetic fertilizers. In addition, for the last years, in Northeast Spain (Catalonia) has been widely extended the double-cropping forage system.

Construccion y utilizacion de un electrodializador en serie para laboratorio

There are different concepts in electrochemistry that must be supported by a laboratory practice to better understand their importance in industrial applications. This work reports the procedure for manufacturing an electrodialyzer in series of two or more compartments with easy manipulation. Likewise, it reports the results obtained by using this system in the nitrate elimination from synthetic NaNO3 solutions at different concentrations. Among other results obtained in the electrodialysis of these solutions, the one that stands out is the demonstration of the linear relationship between the limiting current, obtained from the polarization curves, and nitrate concentration. Additionally, implementation of the separation treatment shows that the time of elimination of practically all ionic species depends on their concentration in solution and ranges between 50 and 80 min.

Poisoning by Poiretia punctata in cattle and sheep

Poiretia punctata (Willd.) Desv. was associated with cattle and sheep poisoning on nine farms in the State of Sergipe, northeastern Brazil. The animals were found dead or died later after showing clinical signs for up to 18 hours. Two sheep that ingested 40g/kg body weight (g/kg) of fresh P. punctata died three and eight hours after ingestion, respectively. Another sheep that ingested 40g/kg five days after plant collection showed mild clinical signs and recovered after 24 hours. Two sheep that received 20g/kg and another that ingested three daily doses of 20g/kg showed clinical signs, but recovered. Two cattle that ingested 20g/kg of the fresh plant exhibited clinical signs and recovered. The clinical observations of poisoning were depression, ataxia, loss of equilibrium, broad-based stance, head down, falls, mandibular trismus, opisthotonous, nystagmus, and recumbence. Significant gross and histologic lesions were not observed. Samples of P. punctata were analyzed for nitrates, cyanogenic glycosides, and sodium monofluouracetate with negative results. It is concluded that P. punctata is a toxic plant that caused death in cattle and sheep in the State of Sergipe.

Pulsed corona discharge as an advanced oxidation process for degradation of organic

Advanced oxidation processes (AOPs) have been studied and developed to suffice the effective removal of refractory and toxic compounds in polluted water. The quality and cost of wastewater treatment need improvements, and electric discharge technology has a potential to make a significant difference compared to other established AOPs based on energy efficiency. The generation of active oxidant species such as ozone and hydroxyl radicals by high voltage discharge is a relatively new technology for water treatment. Gas-phase pulsed corona discharge (PCD), where a treated aqueous solution is dispersed between corona-producing electrodes free of the dielectric barriers, was developed as an alternative approach to the problem. The short living radicals and ozone formed in the gas phase and at the gas-liquid interface react with dissolved impurities. PCD equipment has a relatively simple configuration, and with the reactor in an enclosed compartment, it is insensitive towards gas humidity and does not need the gas transport. In this thesis, PCD was used to study and evaluate the energy efficiency for degrading various organic compounds, as well as the chemistry of the oxidation products formed. The experiments investigate the aqueous oxidation of phenol, humic substances, pharmaceutical compounds (paracetamol, ibuprofen, indomethacin, salicylic acids, -estradiol), as well as lignin degradation and transformation to aldehydes. The study aims to establish the influence of initial concentration of the target pollutant, the pulsed discharge parameters, gas phase composition and the pH on the oxidation kinetics and the efficiency. Analytical methods to measure the concentrations of the target compounds and their by-products include HPLC, spectrophotometry, TOC and capillary electrophoresis. The results of the research included in this summary are presented in the attached publications and manuscripts accepted for publication. Pulsed corona discharge proved to be highly effective in oxidizing each of the target compounds, surpassing the closest competitor, conventional ozonation. The increase in oxidation efficiencies for some compounds in oxygen media and at lower pulse repetition frequencies shows a significant role of ozone. The role of the ·OH radicals was established in the surface reactions. The main oxidation products, formation of nitrates, and the lignin transformation were quantified. A compound specific approach is suggested for optimization of the PCD parameters that have the most significant impact on the oxidation energy efficiency because of the different characteristics and responses of the target compound to the oxidants, as well as different admixtures that are present in the wastewater. Further studies in the method’s safety (nitration and nitrosation of organic compounds, nitrite and nitrate formation enhancement) are needed for promoting the method.