Evaluation des informations préopératoires et du consentement signé en chirurgie pédiatrique

1. Abstract Au XXème siècle la médecine a passablement évolué et la question de l'implication du patient dans le processus de décision thérapeutique devient petit à petit une nécessité. La théorie du consentement éclairé apparaît en Suisse à la fin des années 70 et l'information du patient devient un thème incontournable. C'est dans cette perspective que le formulaire de consentement vient progressivement s'imposer. Dans la première partie de ce travail, nous avons cherché à mettre en évidence qu'elles pouvaient être les directives éthiques et juridiques en matière de formulaire de consentement en vue d'une intervention chirurgicale. Pour que ce formulaire soit validé, il doit être accompagné d'une information claire et appropriée afin obtenir un consentement libre et éclairé du patient tant du point de vue éthique que juridique. Dans la deuxième partie, nous nous sommes intéressés à l'usage et l'utilisation du formulaire de consentement employé au sein du service de chirurgie pédiatrique au CHUV et à l'HEL. Afin d'en avoir un bon reflet, nous avons soumis un questionnaire à des chirurgiens cadres ou chefs de cliniques du service de chirurgie pédiatrique. Ce questionnaire se base sur des questions soulevées par la littérature traitant du sujet ainsi que sur l'article 21 de la loi sur la Santé publique du canton de Vaud qui dit, en résumé, que le minimum requis est le droit à l'information afin de donner valablement un consentement. Il est composé de trois parties. Dans la première partie, il en ressort qu'en règle générale les chirurgiens s'accordent sur la définition du formulaire de consentement. Ils sont dans l'ensemble satisfaits du formulaire en vigueur et n'en modifieraient pas la structure. Dans la deuxième partie, la signature du formulaire est vue comme une obligation mais la raison de cette obligation n'a pas la même signification pour chacun et les avis divergent quant il s'agit de savoir qui cela protège. Dans la troisième partie, ils s'accordent tous sur le contenu de l'information jugé nécessaire à donner aux parents des futurs opérés. En conclusion, les chirurgiens pédiatres semblent globalement satisfaits du formulaire actuel et peu le modifieraient. Nous trouvons important de mentionner que peu soulèvent le fait que le principal concerné par l'intervention est l'enfant et que son avis n'est pas toujours sollicité. A l'avenir, il sera important d'impliquer l'enfant dans cette démarche tout en tenant compte de son degré de maturité

A survey on surgeons' perceived quality of the informed consent process in a Swiss paediatric surgery unit.

AIM: To evaluate the levels of satisfaction and opinions on the usefulness of the informed consent form currently in use in our Paediatric Surgery Department. Qualitative study carried out via interviews of senior paediatric surgeons, based on a questionnaire built up from reference criteria in the literature and public health law. RESULTS: Physicians with between 2 and 35 years experience of paediatric surgery, with a participation rate of 92 %, agreed on the definition of an informed consent form, were satisfied with the form in use and did not wish to modify its structure. The study revealed that signing the form was viewed as mandatory, but meant different things to different participants, who diverged over whom that signature protected. Finally, all respondents were in agreement over what information was necessary for parents of children requiring surgery. CONCLUSION: Paediatric surgeons seemed to be satisfied with the informed consent form in use. Most of them did not identify that the first aim of the informed consent form is to give the patient adequate information to allow him to base his consent, which is a legal obligation, the protection of physicians by the formalisation and proof of the informed consent being secondary. Few surgeons brought up the fact that the foremost stakeholder in paediatric surgery are the children themselves and that their opinions are not always sought. In the future, moving from informed consent process to shared decision-making, a more active bidirectional exchange may be strongly considered. Involving children in such vital decisions should become the norm while keeping in mind their level of maturity

The Vestibular Implant: Quo Vadis?

Objective: To assess the progress of the development of the vestibular implant (VI) and its feasibility short-term. Data sources: A search was performed in Pubmed, Medline, and Embase. Key words used were “vestibular prosth*” and “VI.” The only search limit was language: English or Dutch. Additional sources were medical books, conference lectures and our personal experience with per-operative vestibular stimulation in patients selected for cochlear implantation. Study selection: All studies about the VI and related topics were included and evaluated by two reviewers. No study was excluded since every study investigated different aspects of the VI. Data extraction and synthesis: Data was extracted by the first author from selected reports, supplemented by additional information, medical books conference lectures. Since each study had its own point of interest with its own outcomes, it was not possible to compare data of different studies. Conclusion: To use a basic VI in humans seems feasible in the very near future. Investigations show that electric stimulation of the canal nerves induces a nystagmus which corresponds to the plane of the canal which is innervated by the stimulated nerve branch. The brain is able to adapt to a higher baseline stimulation, while still reacting on a dynamic component. The best response will be achieved by a combination of the optimal stimulus (stimulus profile, stimulus location, precompensation), complemented by central vestibular adaptation. The degree of response will probably vary between individuals, depending on pathology and their ability to adapt

Plasticity of gene expression according to salinity in the testis of broodstock and F1 black-chinned tilapia, Sarotherodon melanotheron heudelotii

The black-chinned tilapia Sarotherodon melanotheron heudelotii Ruppell 1852 (Teleostei, Cichlidae) displays remarkable acclimation capacities. When exposed to drastic changes of salinity, which can be the case in its natural habitat, it develops quick physiological responses and keeps reproducing. The present study focused on the physiological impact of salinity on male reproductive capacities, using gene expression as a proxy of acclimation process. Two series of experimental fish were investigated: the first one was composed of fish maintained in freshwater for several generations and newly acclimated to salinities of 35 and 70, whereas the second one consisted of the descendants of the latter born and were raised under their native salinity. Expression patterns of 43 candidate genes previously identified from the testes of wild males was investigated in the three salinities and two generations. Twenty of them showed significant expression differences between salinities, and their predicted function revealed that most of them are involved in the osmotic tolerance of sperm cells and/or in the maintenance of sperm motility. A high level of expression variation was evidenced, especially for fish maintained in freshwater. In spite of this, gene expression patterns allowed the differentiation between fish raised in freshwater and those maintained in hypersaline water in both generations. Altogether, the results presented here suggest that this high variability of expression is likely to ensure the reproductive success of this species under varying salinities

Reducing the SPS Machine Impedance

The SPS as LHC Injector project has been working for some time to prepare the SPS for its role as final injector for the LHC. This included major work related to injection, acceleration, extraction and beam instrumentation for the LHC beams [1]. Measurements carried out with the high brightness LHC beam showed that a major improvement of the machine impedance would also be necessary [2]. In addition to removing all lepton related components (once LEP operation ended in 2000), the decision was made to shield the vacuum system pumping port cavities. These accidental cavities had been identified as having characteristic frequencies in the 1-1.5GHz range. Since the SPS vacuum system contains roughly 1000 of these cavities, they constitute a major fraction of the machine impedance. As removal of the ports and associated bellows is not possible, transition shields (PPS) had to be designed to insert within the pumping port cavities

A dimensionally continued Poisson summation formula

We generalize the standard Poisson summation formula for lattices so that it operates on the level of theta series, allowing us to introduce noninteger dimension parameters (using the dimensionally continued Fourier transform). When combined with one of the proofs of the Jacobi imaginary transformation of theta functions that does not use the Poisson summation formula, our proof of this generalized Poisson summation formula also provides a new proof of the standard Poisson summation formula for dimensions greater than 2 (with appropriate hypotheses on the function being summed). In general, our methods work to establish the (Voronoi) summation formulae associated with functions satisfying (modular) transformations of the Jacobi imaginary type by means of a density argument (as opposed to the usual Mellin transform approach). In particular, we construct a family of generalized theta series from Jacobi theta functions from which these summation formulae can be obtained. This family contains several families of modular forms, but is significantly more general than any of them. Our result also relaxes several of the hypotheses in the standard statements of these summation formulae. The density result we prove for Gaussians in the Schwartz space may be of independent interest.Comment: 12 pages, version accepted by JFAA, with various additions and improvement

Modification of the LEP electrostatic separator systems for operation with bunch trains

To meet the LEP2 luminosity requirements for W-pair production, it is planned to operate LEP with Bunch Trains from 1995 onwards. This new mode of operation entails significant modification both to the existing separator hardware and its control system. The changes have been implemented so as to provide maximum flexibility for the realisation of the Bunch Train scheme, and also make a return to operation with Pretzel separation possible during 1995. Two LEP Interaction Points (IP) were equipped with new separators in late 1994, enabling first tests with the collision of one train of four e+ bunches with one train of e- bunches. During the 1994/95 shutdown, four separators have been installed in the two remaining experimental IPs, and eight separators in the non-experimental IP have been displaced to new positions. Details are given of optics requirements for the separator installations, the polarity of the closed orbit separator bumps, system modifications, and performance considerations. Results are presented of investigations into the effects of separator polarity on High Voltage performance and on the commissioning of the new hardware systems during tests of the Bunch Train scheme in 1994