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Au Canada, l’approche à barrières multiples permet une gestion multidimensionnelle de l’eau à l’aide d’outils et de pratiques permettant d’assurer une eau de qualité, de la source (lac, rivière, etc.) au robinet des citoyens. Une de ces barrières, la protection des sources d’eau potable (PSEP), cherche à anticiper ou à réduire les risques naturels et anthropiques qui pourraient altérer les sources. Cependant, la mise en oeuvre de la PSEP impose d’acquérir des connaissances multidisciplinaires portant sur la qualité, la quantité de l’eau et sur les composantes naturelles et socio-économiques du territoire. Dans l’optique de mieux comprendre la mise en oeuvre de la PSEP au Québec, cet article vise à dresser un portrait-diagnostic permettant d’identifier le processus décisionnel servant à la mise en oeuvre de la PSEP, ses intervenants et les connaissances produites et mobilisées pour la prise de décision. Ce portrait se base sur une enquête en ligne réalisée entre novembre 2018 et mars 2019 à laquelle ont participé 208 intervenants liés à la PSEP au Québec. Les analyses qualitatives et quantitatives ont permis de constater que la mise en oeuvre de la PSEP implique une grande diversité d’intervenants, de tâches et de connaissances créées et se caractérise par un fort dynamisme inter-organisationnel. Cependant, on constate que son processus décisionnel perd en inclusivité au fil des étapes de mise en oeuvre, que les connaissances sont parfois redondantes et qu’il existe de nombreux enjeux de transfert de connaissances (accès, quantité ou qualité des connaissances) entre les intervenants., In Canada, the multi-barrier approach allows for a multi-dimensional water management, using tools and practices to ensure safe water, from source (lake, river, etc.) to citizens' taps. As one of these barriers, source water protection (SWP) seeks to anticipate or reduce natural and anthropogenic risks that could alter the sources. In this context, the Government of Quebec has adopted the Water Withdrawal and Protection Regulation (WWPR), which reinforces SWP in Quebec. However, the implementation of the WWPR implies the development of action plans that require the acquisition of a multidisciplinary knowledge on water quality, quantity and on the natural and socio-economic components of the territory. This paper aims at providing a diagnostic portrait of the implementation of SWP in Quebec, in order to identify the decision-making process, its stakeholders, and the knowledge generated and mobilized for decision-making. This portrait is based on an online survey conducted between November 2018 and March 2019. The qualitative and quantitative analyses of 208 responses revealed that SWP implementation is currently characterized by a great diversity of the stakeholders involved, tasks and knowledge created, and a strong inter-organizational dynamism. However, it is noted its decision-making process becomes less inclusive as it moves through the implementation stages, that knowledge is sometimes redundant and that there are many knowledge transfer issues (access, quantity or quality of knowledge) between stakeholders.

The head and neck tumors are most often associated with a precarious nutritional status. Radiotherapy increases the risk of denutrition because of its secondary effects on the secretory and sensorial mucous membranes. The purpose of our retrospectively study was to evaluate the interest of a precocious and regular nutritional therapy on the ability to maintain the nutritional status of the patient during the radiotherapy.The fifty-two patients included in the survey have been classified retrospectively in two different groups based on their observance to the nutritional therapy: group 1 "good observance", group 2 "bad observance".The 31 patients of group 1 have lost an average of 1.9 kg by the end of the irradiation, whereas the 21 patients of group 2 have lost an average of 6.1 kg (p0.001). The almost stability in weight of patients in group 1 was linked to a lower frequency of breaks in the radiotherapy (6 vs 33% p=0.03) and in a decrease in grade of inflammatory mucous membranes (10% of grade 3 in group 1 vs 52% in group 2, p=0.006). The quantity of calories ingested in form of nutritional supplements was greater in group 1 and consequently enabled patients to stabilized their weight (1200 calories in group 1 versus 850 calories in group 2, p0.005).The given nutritional advice and the prescription of adapted nutritional supplements consequently allowed limiting efficiently the weight lost during the irradiation and the grade of mucositis. The systematization of a precocious nutritional therapy for patients irradiated for head and neck tumors seems absolutely essential.

International audience

For patients with early stages of laryngeal carcinomas, the local therapeutic modalities of surgery and/or radiation are the accepted standards of treatment. Recently, combined chemotherapy-radiotherapy and new fractionation schedules have received much attention as an alternative to surgery in patients with resectable locally advanced cancer of the larynx to preserve the larynx function. This article is intended to update the reader on the most recent articles written about the treatment of laryngeal carcinomas. The different points are: the results of conventional radiotherapy, the importance of parameters of radiotherapy (dose, fractionation, overall treatment time), new fractionation schedules, combined chemo-radiotherapy, randomized trial results.

Changes in surgical procedures for hypopharynx cancer after definitive radiotherapy are important since the use of pedicled myocutanous flaps and free digestive transplants. Postoperative course is improved and salvage surgery more frequent. From 1970 to 1990, 160 hypopharyngeal carcinomas were operated on after radiotherapy, 103 due to failures or complications after definitive irradiation and 57 metachronous cancers. During this period, the rate of lethal postoperative complications decreased from 25% to 8%. Crude survival rates are 51% at 1 year, 22% at 3 years and 15% at 5 years. Poor prognostic features are local extension, positive margins and extracapsular nodal spread. Postoperative deaths and failures in primary or neck account for 60% of the causes of death. Results of salvage surgery are unsatisfactory: the choice of definitive radiotherapy with surgery in reserve must be restricted to selected cases.

Rodriguez-Tomé Hector-J. Unum et idem est : René Zazzo et la question de l'identité. In: Enfance, n°2, 1996. Hommages à René Zazzo. pp. 153-155.

In the 1980s, Salvadorans came to the United States as refugees from war and hunger - 500,000 to Los Angeles alone. Some of them became part of Los Angeles gang life, known as La Vida Loca. After the 1992 Los Angeles Rebellion, US immigration authorities began a special gang task force to deport alleged gang youth to Mexico, El Salvador, Guatemala and Belize. They also deported the L.A. gang wars. In El Salvador, there are now drive-bys and clashes between rival gangs. My paper looks at the nature of these policies and its impact on a poor country such as El Salvador., Jeunes immigrants Salvadoriens : une culture entre deux mondes Dans les années 1980, les Salvadoriens ont fui la guerre et la famine qui régnaient dans leur pays pour devenir réfugiés aux États-Unis (500 00 personnes dans la seule agglomération de Los Angeles). Certains d'entre eux ont rejoint la vie de gangs surnommée, dans cette ville, La vida loca. Après les émeutes de Los Angeles en 1992, les services d'immigration ont mis sur pied un détachement spécial chargé de rapatrier des jeunes considérés comme appartenant à des gangs vers le Mexique, le Salvador, Guatemala et Belize. Ils ont aussi "déporté" les guerres des gangs de la ville et aujourd'hui, au Salvador, de violents conflits ont lieu entre bandes rivales. Ce texte analyse la nature de ces politiques et la façon dont celles-ci affectent un pays pauvre comme le Salvador., Rodriguez Luis J. Salvadoran Immigrant Youth between two Worlds. In: Cahiers Charles V, n°20, novembre 1996. Cultures de la rue. Les barrios d'Amérique du Nord. pp. 103-118.

Over 40 years after the first commando procedures performed by M Dargent, surgical techniques such as mandibulotomy and myocutaneous flaps yield important changes in oropharyngeal surgery after definitive radiotherapy. Wide resections and simultaneous neck dissection are possible with good functional results. From 1970 to 1990, 250 patients with a carcinoma of the oropharynx were operated on after radiotherapy, 163 because of failure or complication of irradiation, 87 for a metachronous carcinoma occurred in an previously irradiated field. The postoperative mortality rate was 6%. The risk of carotid blow-up did not increase with the extension of the resection. Survival rates at 1, 3 and 5 years are 55%, 22%, 16% in salvage surgery and 69%, 36% and 24% in patients with metachronous cancer. Postoperative complications and failures in the primary and/or the neck account for 60% of causes of death. These results suggest that prior surgery of deeply ulcerative carcinoma of the oropharynx followed by radiotherapy is a better strategy than definitive radiotherapy with salvage surgery in reserve.

With 5,000 cases yearly, laryngeal carcinomas account in France for the third of squamous cell cancers of the upper digestive and respiratory tract. The crude survival rate is 50% at 5 years. Carcinomas of vocal cords are often diagnosed as early stages if dysphonia leads the patients to the ENT specialist within 2 weeks. Cure of the primary is achieved in 90% of the early stages by radiotherapy with narrow fields or partial surgery, with a 80% 5 years survival rate. Advanced tumors are often treated by total laryngectomy and postoperative radiotherapy. Supra-glottic cancers (epiglottis) are more serious. Unilateral dysphagia or upper cervical neck node often delay early diagnosis. A total laryngectomy is the commonest treatment. The 5 years survival rate of 40% is due to local and/or regional failures and metachronous cancers in head and neck, and radiotherapy remains the two major treatments. Primary prevention is based upon suppression of tobacco and reduction of alcoholic consumption, secondary prevention on resection of leucoplakia and close follow-up of patients with chronic laryngitis.

Cadmium has been recognized as an environmental contaminant. In oral cadmium intoxication, the immediate target organ is the gastrointestinal tract. The aim of the present work was to study the effect of cadmium on the intestinal absorption of L-threonine and on the aminopeptidase N activity in rabbit jejunum, after in vitro addition and/or oral administration of CdCl2 in drinking water. Results obtained show that cadmium decreases L-threonine absorption in the jejunal tissue. This effect seems to be due to an action mainly on active amino-acid transport at the mucosal border of the intestinal epithelium, because cadmium does not seem to modify the amino-acid diffusion across the intestinal epithelium. Cadmium also inhibits the (Na(+)-K+)-ATPase activity of the enterocyte, which might explain the inhibition of the Na(+)-dependent L-threonine transport. Nevertheless, a direct action of the cadmium ion on the carrier of active transport cannot be rejected. Cadmium modifies the aminopeptidase N activity when administered in drinking water for 4 d.

The attenuation of a Babesia bovis strain depends on its protease content. The present work evaluates this parameter on a virulent strain, before and after attenuation by quick passages on splenectomized calves. The protease activity at different pH values was determined in protein fractions from the blood of calves. The enzymatic test showed marked differences between the protease content of both substrains.

A serological survey using indirect immunofluorescence (IFAT) for bovine babesiosis (Babesia bovis and B. bigemina) and card test for anaplasmosis, indicates that these haemoparasites are widespread in Martinique. The high prevalences (62% for B. bovis, 52% for B. bigemina and 43% for Anaplasma marginale) lead to the hypothesis of an unstable epizootic situation for these three haemoparasitic diseases. However, the number of smears examined was too low to evaluate their clinical incidence. Both the American and Cuban card tests gave similar results in the detection of antibodies to A. marginale. Theileria mutans is described for the first time in Martinique. Trypanosomosis (Trypanosoma vivax) has disappeared from Martinique, on clinical and serological evidence.

From March 1983 to December 1989, 208 patients with locally advanced squamous cell carcinoma of the head and neck were successively included into two trials randomizing induction chemotherapy versus no pre-irradiation treatment. The chemotherapy regimen of the first trial, which included 100 patients, consisted of two cycles of a combination of cisplatin, bleomycin, vindesine, mitomycin C; while that of the second trial, which included 108 patients, consisted of three cycles of a combination cisplatin, 5-fluorouracil (continuous infusion) and vindesine. Local treatment was the same in two trials: 'primary' radiotherapy in all patients. The response was then evaluated at 55 Gy; in the case of poor response, surgery was performed, otherwise radiotherapy was continued to full doses (possibly followed by salvage surgery). The tumor and lymph node responses to chemotherapy (complete and partial response) were higher in the second trial and in the first one: 70% versus 50% for primary lesions, 47% versus 25% for lymph nodes. The toxicity of the two chemotherapy regimens was minimal. In the two trials, an initial major response to chemotherapy predicted subsequent efficacy of irradiation in 80% of the patients. Complete response rate at the end of irradiation correlates with the previous response to the chemotherapy. With a median follow-up of 60 months with the first chemotherapy regimen and 30 months with the second, overall survival and disease-free interval did not significantly differ in the two groups of patients, with or without chemotherapy. The incidence of distant metastasis was significantly reduced (P0.03) in the chemotherapy arms. This negative trial encourages the design of new chemotherapy protocols according to new schemes of treatment. For advanced stages of head and neck cancers (T3, T4, N2, N3), we recently launched a pilot study combining platinum and irradiation, but according to a concomitant schedule.

Intravascular Papillary Endothelial Hyperplasia (IVPEH) is a benign process, even uncommon. It was first described by Masson in 1923 under the name "Hemangioendotheliom vegetant intravascular". We present a case of IVPEH located in the masseter muscle. The treatment for this lesion was surgical excision. The histological examination is very important in order to separate this lesion from angiosarcoma.

Because many surgical alternatives exist, and because full invasion of the entire eyelid is rare, we described a new way of surgery: we performed transposition of the whole eyelid, including the part of the elevator muscle of the eyelid, through the rotation of a part of frontal skin. The lacrimal lubrication of the eye was kept intact.

The surgery of the larynx in an irradiated neck changed since 30 years by an evolution of the radiotherapeutic technics and the surgical procedures. At the Curie Institute, from 1960 to 1986, 230 patients were operated with laryngectomy for failure of the first treatment (average doses: 70 Gy). 29 had partial laryngectomy. The feeding tube was removed before 6 weeks in 78% of the patients. 19 patients (8%) died in the 3 months after surgery (8 carotid blow-up). The crude survival rates are 70% at 1 yr, 42% at 3 tr, 37% at 5 yr. These rates are identical in patients with persistent disease two months after irradiation (90), in patients with recurrence (110) and for those with second primary in the larynx (21). 54% of T1 and T2 patients are NED at 3 yr and 47% at 5 yr. For T3 and T4 rates are only 22% and 17%. Best results are in glottic cancers (74% at 3 yr); poorest in advanced supra-glottic (17%). Salvage procedure is effective in larynx and neck in 62% of the patients. Early detection of a failure after irradiation is a major condition for the application of a protocol of definitive radiotherapy in laryngeal cancer.

A peptido-polysaccharide isolated from the culture medium of Paracoccidioides brasiliensis has been studied. The crude product is a mixture of several polysaccharides releasing, by hydrolysis glucose, mannose and galactose. The purified fraction contains mannose (88%) and galactose (12%). This galactomannan has a molecular weight varying between 4.6.10(4) and 2.6.10(4). It is associated with a peptide containing four amino-acids.

Since surgical gastrostomy is not a risk-free operation in debilitated patients, a method of endoscopic percutaneous gastrostomy (EPG) is proposed. A thread is passed percutaneously into the gastric cavity and brought to the exterior through the mouth during fibroscopy. This thread allows removal of a gastrostomy tube by simple traction. Used in 18 patients with ENT cancer the EPG was simple to perform, postoperative complications being minor in 3 cases and serious in one patient. In the absence of any obstacle in the pharyngeal channel preventing the passage of a fibroscope, EPG is a simple procedure and is therefore an alternative to surgical gastrostomy.

Results of 14 mandibular reconstruction by a composite muscular flap of the pectoralis major and trapezium muscles during widespread glossopelvimandibular excisions are described. The technique employed is outlined, emphasis being placed on the need to observe strict precautions during removal and application of the bone component, to avoid accidental avulsion during reconstruction which could compromise the musculoperiosteal vascularization of the graft. Results are sufficiently encouraging for this type of reconstructive surgery to be proposed in all cases where mandibular repair is necessary after interruption of continuity.

Between 1981 and 1983, 116 patients (109 men and 7 women) underwent reconstructive surgery with musculocutaneous flaps following major surgical excision of a cervicofacial tumor recurring after curative radiotherapy. Mean age of patients was 54 years. The most frequently used flap (110/124) was from the pectoralis major. Advantages of the use of a musculocutaneous flap for repair appear to be: first intention healing in most cases; notable reduction in hospital stay; possibility of wider tumoral excision and also of combining lymph node excision, and improved functional results. Follow-up surveillance has been for a mean of only one year, too short a period for assessing carcinologic results.

Recovery surgery on irradiated hypopharyngeal zones, and the indications for this operation, have been transformed by currently available possibilities for pharyngeal reconstruction and protection of carotid axis by musculocutaneous pedicle flaps. Of 117 patients operated upon in the Curie Institute between 1960 and 1986 for hypopharyngeal cancer, after radiotherapy (mean dose 70 Gy), deglutition was restored in 100 cases (85%) after a mean healing period of 30 days. Fatal postoperative complications occurred in 23 patients (19%), including 12 carotid hemorrhages, but since 1980 the percentage of mortal bleeding has dropped from 15 to 5%. Postoperative survival was 50% at 1 year, 29% at 3 years and 15% at 5 years, results being similar whatever the indication (46 patients operated upon at end of radiotherapy, 36 local recurrences and 37 second cancers in irradiated zone). Local and regional recovery surgery was effective in only one patient out of two. The musculocutaneous flap allows wider and more certain surgery and improved functional results, but in no way affects the particularly serious nature of cancer of this localization.

At the Curie Institute, between 1958-1980, 166 patients were treated for squamous cell carcinoma of the base of the tongue, by external radiotherapy alone. The absolute survival was 45%, 39%, 26% at 2, 3, 5 years. 95% local and loco-regional failures arrived within the first two years; the nodal failures isolated were rare (4%). Unfavorable prognosis features are: the size of the tumor and the clinical radiation-induced regression of the primary. A new therapeutic approach is discussed: an additive curietherapy for some T1-T2 and a surgical excision (total glossectomy with or without neck dissection) for some T3-T4 of which the regression is unsatisfactory at 50-55 Gy are proposed.

In our experience of 171 glossectomies for recurrence, salvage partial glossectomy yields 50% of local control. Myo-cutaneous flap allows wide total glossectomy without total laryngectomy. This procedure may improve the local control. Of 25 patients treated by this technique, 2 deceased before the 45th post-operative day, 15 swallow correctly and 11 have a good speech. The survival rate is 10/21 at 6 months, 7/16 at 12 and 6/13 at 18. A local failure was observed in 7 and 6 have a second primary in the upper respiratory and digestive tract. Total glossectomy without total laryngectomy is only indicated for patients with bulky tumor, without spread of the vallecula and with no palpable cervical node.

Reconstruction of the pinna of the ear is a difficult enterprise and overall results are poor. It is nevertheless essential to persist since despite the hazards of such surgery many patients wish to have an operation since they are unable to tolerate their deformity. Apart from the cutaneous problem, the most important point remains that of bitterness. There are still many partisans of the use of costal cartilage, but it would seem legitimate to also try new implantable substances, in particular microporous. Whatever the choice, it is important in all cases to establish a programme rather then improvise. This is the only way to reduce the number of operative stages, to avoid untoward scars and to decrease the number of "touching up" procedures. Despite the many difficulties which must still be resolved, a certain number of modern studies offer hope of an improvement in results.

Between 1960 to 1982, 98 patients with squamous cell carcinomas of the posterior pharyngeal wall were treated at the Curie Institute by radiotherapy alone. The absolute survival is 30% and 18% at three and five years. The major cause of death is loco-regional failure. 95% of the local failures arrived within the 18 first months. The 2 years control rate ranged from 80% for T1, 64% for T2, to 36% for T3 and 22% for T4. The local control is so depending on the radiation induced regression of the primary. The 2 years control rate is 71% for the patients with complete regression and 12% for the patients with not complete regression at the end of the treatment. The improvement of these results by adjunction of other treatments (surgery, chemotherapy, hyperthermia) is discussed.

The authors report 7 cases of neo-natal adrenal hematoma diagnosed by ultrasound. A traumatic delivery was found in 4 cases. In 4 cases a flank mass was palpated. In 3 cases the adrenal hematoma was asymptomatic, discovered by echotomography. I.V.P. showed a typical appearance in only 1 case out of 5. The first ultrasonic examination was performed between day 5 and day 12. It showed a fluid filled mass in 5 cases and a predominantly fluid mass in 2 cases. Both sides were involved twice. The ultrasonic follow-up 8 days later always showed a decrease in size, in 1 cases calcifications appeared. The authors compare their results with those of the literature and discuss the differential diagnosis with neo-natal neuroblastoma.

Between 1960 and 1983, 270 patients were treated at the CURIE Institute for a carcinoma of the soft palate, including 260 by radiotherapy (mean dose: 69 Gy). Most of these tumours were T1 T2 (201 cases, 76%). There was a high frequency of a past history of carcinoma (38 cases, 14%) as well as of simultaneous carcinomas (44 cases, 16%). Two months after radiotherapy, a velar tumor persisted in 29 patients whilst 1 patient had deep necrosis. 15 of these 30 patients underwent secondary surgical excision. This surgical series included 25 of 27 recurrences seen secondarily and 6 patients operated on for second velar carcinoma appearing in the irradiated zone (mean dose: 68 Gy). 45 of the 46 excisions were carried out by a buccal approach. Overall survival after surgery was 32% at 3 years. The 11 patients operated on for an extensive T3 T4 tumour died before 12 months. These poor results were related to the frequency of local recurrences (12 loco-regional failures amongst 36 deaths) as well as the number of deaths due to second carcinomas (11 deaths amongst the surgical patients). Later carcinomas were particularly frequent during the course of tumours of this site (69 cases out of 270), the problem of multiple malignant tumours finally affecting 122 patients out of 270, i.e. 45%.

The animals stay in solutions for 4 days at different concentrations of each agent: regression lines (log concentration-probit) allow us to calculate the lethal concentration values for 50% of the animals tested (LC 50). Animals are affected by concentrations ranging from 0,003 to 9,0 X 10(-6) of insecticides, 2 to 16 X 10(-6) of herbicide, 9 to 50 X 10(-6) of detergents. As a general rule, the four studied species can be classified by decreasing sensibility in the following order: Gammarus, Cloeon, Chaoborus and Lymnea.

Histopathological study of 18 cases of mycotic cysts (cultures have been made in three cases with isolation of Exophiala gougerotii). In three cases, two from Madagascar and one from Senegal, fungus looked like hyalin in tissues (no essay of cultures). Histologically, the lesions showed the appearance of fluctuant or stellate subcutaneous abscess. The organisms in the tissues exhibit dimorphism: hyphae associated with round forms. In one case, there was a black fungic grain associated with " spores" and hyphae and in one case, a foreign body (plant tissue) with fungic vesicules inside was present in the abscess.

Myo-cutaneous pedicled flap (MCF) had transformed technics and indications for salvage procedures after high doses of radiotherapy in laryngeal and hypopharyngeal carcinomas. Wide field total laryngectomies extended to oropharynx, skin, circular pharyngectomies extended to cervical oesophagus are possible with 3 times less carotid blow-up and rare fistulas. Radical neck dissection is currently performed in the same procedure without major healing problems. The feeding tube is often removed within a month. Systematic use of MCF in patients irradiated over 70 Gy may reduce the post-operative mortality and yield better survival rates, which at present 2 years after salvage surgery, are 36% in hypopharyngeal carcinomas (38/106) and 50% in laryngeal cancers (106/210).

Analgesia is an important problem in myasthenia gravis patients who have undergone transsternal thymectomy. Postoperative pain interferes with pulmonary function, which is already limited by the disease. The choice of medication is restricted because many analgesics are synergic to the myasthenia gravis syndrome and detrimental to the patient. Three patients with severe myasthenia gravis are presented who had undergone transsternal thymectomy with good postoperative results. They received high thoracal epidural anesthesia (C7-Th1/Th1-Th2/Th2-Th3) with a solution of bupivacaine and morphine (20 ml 0.25% bupivacaine with 10% morphine). The patients were extubated in the first 48 hours and monitoring of respiratory function (CV2, PO2, PCO2) showed satisfactory values. With this type of analgesia we obtained early mobilization and good patient cooperation. Although limited this favourable experience confirms that high thoracal epidural anesthesia is a sure technique which allows rapid weaning from the ventilator and maximum comfort for the patient. It avoids the use of other medication or analgesics which are contraindicated in these patients.