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–&= #8249;en-tête›
–‹date/heure›
–&= #8249;pied de page›
–&= #8249;N°›
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UTILISATION DE CHAMBRES IMPLANTABLES CHEZ 14 ENFANTS DREPANOCYTAIRES= EN PROGRAMME D’ECHANGE
Centre Hospitalier Intercommunal de Créteil
Éq= uipe pédiatrique de l’HDJ
C. ARNAUD, F. BERNAUDIN, L. COIC
E. LESPRIT
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UTILISATION DE CHAMBRES IMPLANTABLES CHEZ 14 ENFANTS DREPANOCYTAIRES= EN PROGRAMME D’ECHANGE
• Intérêt de la chambre implantable en cas de programme d’échange au long cours
•
• Comparaison aux résultats déjà parus dans la littérature
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INTRODUCTION (1)
Ø =3D pathologie chronique
–sollicitation à long t= erme des voies veineuses périphériques
–avec difficultés techniques, douleur et contraintes
–risques thrombotiques et infectieux sans prise en charge
= 211;
Ø:
–1973 : 1er cathéter tunnellisé de Broviac et Scribner
–1979 : 1er cathéter central de Hickmann
–Anné= ;es 80: développement des CIP <= /span>
= 211;
= 211;Mais e= lle est elle-même source de thromboses et d̵= 7;infections…
= 211;
= 226;
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INTRODUCTION (2)
Ø :
-excès de complications
-surmortalité
-utilisation déconseillée chez= les drépanocytaires
-
-
Ø:
-taux de complications bas
-gain en qualité de vie
-hypothèses sur la physiopathologie de ces complications
-CAT pour&n= bsp; les minimiser
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<= span style=3D'font-family:"Comic Sans MS";color:#FFCC00'>•INTENSIFICATION du = tt dans la drépanocytose:
<= span style=3D'font-family:"Comic Sans MS";color:#FFCC00;visibility:hidden'>• <= /u>
• <= /u>
•
–AVC clinique
–DTC > 2m/s
– < 3 CVO/an=
– < 2 STA/an=
– > 3 CVO/an=
– > 2 STA/an=
–Lésions à IRM
–
rien
Hydréa
PT
Protocole SITT
Sauf si:
- < 3 - 4 an= s
-Vasculopathie
-Échec hydréa
–USA: 3 ans
–CHIC: jusqu’à DTC<1,7m/s
BUTS  du PT= :
–HbS < 30% si AVC..
–HbS < 40% si CVO, STA..
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PLAN
<= span style=3D'font-family:"Comic Sans MS";font-size:88%;color:#FFCC00'>I.Mat&e= acute;riel et méthode
<= span style=3D'font-family:"Comic Sans MS";font-size:86%;color:white;mso-color-i= ndex: 0'>A.Recrutement
<= span style=3D'font-family:"Comic Sans MS";font-size:86%;color:white;mso-color-i= ndex: 0'>B.CIP
<= span style=3D'font-family:"Comic Sans MS";font-size:86%;color:white;mso-color-i= ndex: 0'>C. Programme échanges
<= span style=3D'font-family:"Comic Sans MS";font-size:86%;color:white;mso-color-i= ndex: 0'>D.CAT si anomalies <= /span>
<= span style=3D'font-family:"Comic Sans MS";font-size:86%;color:white;mso-color-i= ndex: 0'>E.Complications
<= span style=3D'font-family:"Comic Sans MS";font-size:86%;color:white;mso-color-i= ndex: 0'>F.Modèles statistiques&#= 13;
•
<= span style=3D'font-family:"Comic Sans MS";font-size:88%;color:#FFCC00'>II.R&eac= ute;sultats
•
<= span style=3D'font-family:"Comic Sans MS";font-size:88%;color:#FFCC00'>III.Discu= ssion
•
<= span style=3D'font-family:"Comic Sans MS";font-size:88%;color:#FFCC00'>IV.Concl= usion
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= I.MATER= IEL ET METHODE (1)
A.Recrutement des patients <= /span>
•
•Cohorte de 375 drépanocytaires suivis au CHIC =
•<= /span>14 enfants avec pose CIP entre septembre 1993 et Juin 2004
•
– = ;
Ø Critères inclusion:
- drépanocytaires SS
– programme d’échange&#= 13;
– difficultés de voie d’abord
– suivi exclusif au CHIC
Ø Critères d’exclusion<= /u>:
- arrêt du suivi &agrav= e; la majorité
-  lors du passage à Mondor
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Ø
ØIndica= tions du programme transfusionnel:
Ø
= 211;
= 226;
•
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B.CIP
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&= Oslash;
<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'>-même anesthésiste
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<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'>-conditions stériles au
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<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'>-méthode de Seldinger
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<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'>-HbS < 40% à la pose
<= span style=3D'font-size:86%;visibility:hidden'>•
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Gq9FFSxpJbH/2b== ------=_NextPart_01C51A81.047DBDE0 Content-Location: file:///C:/2E465513/Utilisationdechambresimplantableschez14enfantsdrepanocytaires_fichiers/slide0030.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Utilisation de chambres implantables chez 14 enfants drépanocytaires en programme d’échange
2)Venue mensuelle en HDJ:
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<= span style=3D'font-family:"Comic Sans MS";font-size:117%;color:yellow'>Ø
<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'>-Par des infirmières formées
-
-Conditions stériles en chambre ferm&e= acute;e
-
-Analgésie par patch Emla +/-inhala= tion de protoxyde d’azote
-
Ø Avant échange:
-
-Aiguil= le de Huber:
-
- NFS, RAI
-électrophorèse Hb =
-fer sérique, ferritine, hémoc
-
-Rin&cc= edil;age au sérum j +++ p= uis ch&eac= ute;lateur du fer ou héparine
-
-Hyperh= ydratation: faciliter la saignée et ¯ hyperviscosité
•
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- retournement manuel ou au bloc = ;
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drépanocytaires en programme d’échange
§= Vérifier la  sit= uation de l’aiguille: <= /u>
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<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0;visibil= ity: hidden'>-
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<= span style=3D'font-family:"Comic Sans MS";color:yellow'>1)  Radio avec aiguille Huber
<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'>2) Urokinase si pas désinsertion
= -
D&eacu= te;sinsertion
Extré= mité KT
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C.&Eacu= te;change transfusionnel sur CIP
<= span style=3D'font-family:"Comic Sans MS";color:yellow'>ØPremier temps:
Ø 
&= Oslash;* SAIGNEE: 
<= span style=3D'font-family:"Comic Sans MS";font-size:71%;color:white;mso-color-i= ndex: 0'>-par tubes de 10mL (vacutainer)
-5-10 mL/kg: selon Hb, vasculopathie cérébrale <= /span>
&= Oslash;
-* ALTERNEE AVEC :
-=3D remplissage par sérum j isovolémique
-
-NB:
<= span style=3D'font-family:"Comic Sans MS";font-size:86%;color:white;mso-color-i= ndex: 0'>-Saignée max de 200mL selon poids
<= span style=3D'font-family:"Comic Sans MS";font-size:86%;color:white;mso-color-i= ndex: 0'>-remplissage dès ¯débit
<= span style=3D'font-family:"Comic Sans MS";font-size:86%;color:white;mso-color-i= ndex: 0'>-déficit max =3D 5mL/kg
-
<= span style=3D'font-size:71%;visibility:hidden'>•
ØDeuxième temp= s: =
Ø
Ø* TRANSFUSION =3D 15 mL/kg
-
-* 2èm= e SAIGNEE:
-¹ transfu-saign= ée =3D 10mL/kg
-
ØNB: déficit max =3D 5 mL/kg
Ø
ØFin d’ échange:
-NFS et électrophorèse
-Rinçage +++ et héparinisation
-
–=3D ¯ HbS de 20-30%
• =
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D.Différentes complications de la CIP analysées:
•= 3;
<= span style=3D'font-family:"Comic Sans MS";font-size:133%;color:yellow'>1)Infec= tions:
<= span style=3D'font-family:"Comic Sans MS";font-size:133%;color:yellow;visibilit= y: hidden'>2)
<= span style=3D'font-family:"Comic Sans MS";font-size:117%;color:yellow;visibilit= y: hidden'>2)
CAT:&= #13;
*Bi-antibiothérapie IV si fièvre ou hémocs + en périphérie
*Ablation d’emblée si as= pect local inflammatoire
NB: après exclusion des souillures =3D 1 hémoc sans signe clinique ou biologique associé
     hémocult= ures centrales     =
et périphériq= ues
Signes cliniques
et / ou bio
+ 
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2)
2)Thromboses:
-
§= Avec signes locaux:
-œd&egrav= e;me, douleur, gonflement en amont du thrombus
-
§= Ou avec difficultés:
-à injecter ou à prélever
-
- =3D <= span style=3D'font-family:"Comic Sans MS";font-size:75%;color:white;mso-color-i= ndex: 0'>incluses que si échec du fibrinolytiqu= e
-
-
-=
<= span style=3D'font-family:"Comic Sans MS";font-size:133%;color:yellow;visibilit= y: hidden'>3)
<= span style=3D'font-family:"Comic Sans MS";font-size:133%;color:yellow'>3)M&eac= ute;caniques:
<= span style=3D'font-family:"Comic Sans MS";font-size:133%;color:yellow;visibilit= y: hidden'>4)
§Par déplacement de la CIP: =
<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'>-Retournement
<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'>-Désinsertion
<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'>-Rupture
<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'>§Le plus souvent ablation CIP
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E.Modèles statistiques
-
-Analyse univariée
-
-Courbe estimation de survie de Kaplan Meier
-
-Calcul d’un ratio de complications pour 1000 CIP jours = :
-
-        = ;     
•<= /span>
     complications x 1000
     somme des durées CIP en  place
•
=3D
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= II.RESUL= TATS
1)Patients:
•
•=3D 14 drépanocytaires SS
•
-Sexe ratio =3D 1
-Suivi sur 11 ans
-Aucun décès
- 5 passages à Mondo= r pour majorité
-Début du PT en moyenne à l’âge de 10,2 ans (1,7-15,5)
- PT continu chez 12 enfant= s
-
•<= /span>
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<= span style=3D'font-family:"Comic Sans MS";font-size:133%;color:#FFCC00'>2)17 C= IP posées:
<= span style=3D'font-family:"Comic Sans MS";font-size:133%;color:#FFCC00;visibili= ty: hidden'>3)
<= span style=3D'font-family:"Comic Sans MS";font-size:117%;color:yellow;visibilit= y: hidden'>3)
<= span style=3D'font-family:"Comic Sans MS";font-size:117%;color:yellow;visibilit= y: hidden'>2)
<= span style=3D'font-family:"Comic Sans MS";font-size:117%;color:yellow;visibilit= y: hidden'>2)
<= span style=3D'font-family:"Comic Sans MS";font-size:117%;color:yellow;visibilit= y: hidden'>2)
<= span style=3D'font-family:"Comic Sans MS";font-size:117%;color:yellow;visibilit= y: hidden'>2)
<= span style=3D'color:yellow;visibility:hidden'>§= =
§<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'> Nombre moyen CIP =3D 1,2 / enfant&= #13;
§<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'> Age moyen à la pose =3D 11,= 2 ans (1,9 - 17,7)
§<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'> Durée moyenne en place =3D = 1054 js =3D 2,9 ans (84js= -2578 js =3D7 ans)
§<= span style=3D'font-family:"Comic Sans MS";color:white;mso-color-index:0'> Durée totale en place =3D <= /span>17 920 js
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Courbe de Kaplan Meier:
=3D Estimation de la survie = des CIP sans complication:
75% CIP non
compliquées
à 3 ans
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quoted-printable Content-Type: text/html; charset="us-ascii" Utilisation de chambres implantables chez 14 enfants drépanocytaires en programme d’échange
3)2 cas particuliers avec arrêt du programme = d’écha= nge: HbS > 30%
•
ØPatient n°1: = ;
-Arr&ec= irc;t du PT 4 mois avant/ Hydréa
-CIP en= place 1170 js
-CVO os= =3D 1 échange: HbS =3D 80% baisse à 53%
-5js après: CVO abdo fébrile
•hémoc + E. Pyo./ lithiases biliaires
•Échec triple antibiothérapie/ ablation CIP
•culture CIP + à E. Pyo
•
•        HbS &= gt; 30%
Ø
•
Risque thrombose Ö
Bactériém= ie
Probable greffe infecti= euse
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ØPatient n°8: = ;
Ø
-Arrêt du PT 2 mois avant/ demande des parents
-CIP en place 728 js
-Panaris avec impétiginisation diffus= e:
•Bi-antibioth IV
•STA 6 js après
•1 échange: HbS =3D 74% baisse à 60%
•Échec 2ème échange 3 js après
•CIP bouchée / ablation
•
= 226;  Il aurait fallu échanger dès le début de l’hospitalisation: HbS &agra= ve; 74% et contexte infectieux….
•
------=_NextPart_01C51A81.047DBDE0 Content-Location: file:///C:/2E465513/Utilisationdechambresimplantableschez14enfantsdrepanocytaires_fichiers/slide0060.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Utilisation de chambres implantables chez 14 enfants drépanocytaires en programme d’échange
<= span style=3D'font-family:"Comic Sans MS";font-size:88%;color:yellow'>ØEn com= mun pour les patients n°1 et 8:
•
•
•
•
•
•
<= span style=3D'font-family:"Comic Sans MS";font-size:75%;color:white;mso-color-i= ndex: 0'>•= Survenue rapide des complications après arrêt PT
<= span style=3D'font-family:"Comic Sans MS";font-size:75%;color:white;mso-color-i= ndex: 0'>•= Très courte durée de vie CIP sans PT
<= span style=3D'font-family:"Comic Sans MS";font-size:75%;color:white;mso-color-i= ndex: 0'>•= Phénomène mixte: thrombose/infection; rôle de HbS&#= 13;
• 
• Décision d’exclusion de ces 2 périodes sans PT pour le reste = de l’étude
Ö HbS
thrombose
bactériemie
Greffe
infectieuse
CIP
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4)Complications de la CIP sous PT: <= /span>
•
ØR&eacu= te;partition : 7/17 soit 41% des CIP
•
– 1 infectio= n
– 1 thrombose
– 5 mécaniques<= /div>
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4)Complications de la CIP sous PT: <= /span>
•
ØAblati= on : = 6/7 soit 85% des CIP compliquées ou 35% des 17 CIP
•
•1 thrombose ( 17%)
••NB: aucune pour infection
Ø 11/17 CIP ( 65%) en pla= ce, foncti= onnelles
Ø Ratio complications =3D 0,39 pour 1000 CIP jours
n =3D 6
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4) Complications de la CIP sous PT: = ;
Ø
ØCompl= ications infectieuses:
•14% (1/7)
•tjs en place
Ø
§Cas du patient n°7:
-Infection précoce (14 js/pose)
-Infection lo= cale + fébricule
-Hémoc= - / écho loco-régionale nle
-Évolu= tion favorable sous bi-antibth.IV
-CIP laissée en place
-=
§
-
Ø&#= 13;
Ratio infections sous PT
=3D 0,06 pour 1000 CIP js
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4) Complications de la CIP sous PT:
Ø
ØCompl= ications infectieuses (suite)
•
Ø
§NB: survenue de 6 hémocultures +
-clinique et biologie négatives
-2 BG+ non identifiés/ 2 strepto mitis /2 staph épidermidis
-Tt par verrou antibiotique
-Habitude d’une hémoc systématique
-
Ø&#= 13;
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4) Complications de la CIP sous PT: = ;
Ø
ØThrom= boses : =
•14% des complications (1/7)
•100% enlevées
Ø
Ø
§NB: 2 thromboses <= /div>
-R&eacu= te;solutives sous urokinases
-CIP en place
§<= /span>
-
Ø
Ratio thromboses sous PT
=3D 0,06 pour 1000 CIP js
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ØCompl= ications mécaniques
•72% des complications (5/7)
•100% enlevées
Ø
§<= span style=3D'font-family:"Comic Sans MS";color:yellow'>3 cas de migration d= u cathéter: = ;
•vers le cœur droit = ;
•2 cas = de rupture entre KT et chambre
•Avec nécessité d’ablation par techni= que du lasso en service spécialisé =
•
§<= /span>
-&= #13;
§<= span style=3D'font-family:"Comic Sans MS";font-size:117%;color:yellow'> 1 KT coudé: =
• Échec des manœuvres de= mobili= sation
• Ablation
§<= span style=3D'font-family:"Comic Sans MS";font-size:117%;color:yellow'> Diffusion locale du chélateur
• Œdème
• CIP inutilisable
&= sect;
§
§
§
§
<= span style=3D'font-family:"Comic Sans MS";font-size:133%;color:#FFCC00'>4) Comp= lications de la CIP sous PT:
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= III.DISCU= SSION
§Notre expérience:
-14 enfants drépanos en programme d’échange
-17 CIP
-Sans excès de complications
-
§Les limites:
-Petite taille échantillon
-Méthode en majorité rétrospective
-
§Avanta= ges:
-Durée de 11 ans
-Programme échange constant dans 12/14
-Équipe soignante identique
-
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A.Comparaison avec la littérature concernant KT et CIP:
B.
B.
B.
B.
B.
B.
B.
B.
• 
•
•CHIC: taux infection bas comparé: Non drépano/ Drépano
•Réf : [2] James R.Hills & al, [1] J.R.Torramadé & al,  [4] Mitchell N. Ross & al, [8= ] St. C.Wagner & al, [7] E .Vinchinsky & al, [6] M.J.Sotir & al
-
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Utilisation de chambres implantables chez 14 enfants drépanocytaires en programme d’échange
1)1ère hypothèse: import= ance du PT
•
§Arrêt du PT dans 2/14: patients n°1 et 8=
•Taux HbS à 52 et 74%
•Complication mixte dans les 2 cas : thrombose / infection
-
2)2ème hypothèse: lien thrombose/infection
§Arrêt du PT: =
•HbS >30-40%
•ff de thrombose surtout si CIP
•<= /span>
§Ajout d’un facteur infectieux <= /u>
•Greffe infectieuse sur thrombose en formation
•Auto-aggravation thrombose/infection
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3)3ème hypothèse: importance de l’entretien mensuel de la CIP
•
§&Eacut= e;quipe soignante du CHIC:
•Infirmières avec longue expérience de la drépano&#= 13;
•Avec formation spécifique sur les CIP
•Éducation mensuelle des familles
-
§Avanta= ges de la CIP
•Diminution anxiété, douleur et des contraintes
•Gain en qualité de vie
•Sans limitation des activités quotidiennes
•Image corporelle très peu diminuée
•<= /span>
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B.Comparaison à la littérature concernant : <= /div>
•
1)Chambres double voie:
2)
•Ref: K. Hassel,children hospital of Denver,2004
•
ØUtilisation possible pour érythrocytaphérèses mécaniques
ØChez 3 enfants et 6 adultes drépanocytaires
Ø1 infection et aucune thrombose sur 152 KT mois (12,6 ans)
ØDébit plus rapide avec 2 voies accessibles simultanément&= #13;
•
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B.Comparaison à la littérature concernant : <= /div>
•
2)Fistules artério-veineuses:
•=3D revue rapide de la littérature en 2= 004 sur Pubmed
2)
•
ØAucune publication chez le drépanocytaire…
ØUtilisation courante en hémodialyse adulte ou pédiatrique
ØAu lieu d’un KTC ou d’une CIP….
Ørupture, saignement, œdème du bras…
Øbruyant…
ØDONC: besoin d’études comparatives chez le drépanocytaire….&#= 13;
•
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IV.CONCLUSION
•
§Formes sévères de la drépanocytose
-PT mensuel contraignant
-Épuisement progressif inévitable du capital veineux <= /span>
-Longueur des soins, anxieté et douleur
-
-
§Int&ea= cute;rêt d’une CIP dans cette indication:
-Accès veineux facile
-Meilleure qualité de vie
§
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§<= span style=3D'font-family:"Comic Sans MS";font-size:88%;color:yellow;display:no= ne'>
§D’après nos résultats, chez l’enfant drépanocytaire:
•CIP avec PT p= our limiter le risque de thrombose
•Ablation de la CIP en cas d’arrêt du PT
•Si sepsis associé, maintenir strictement une HbS<30% pour limiter l’association thrombose/infection
= 226;
§DONC :
§<= span style=3D'font-family:"Comic Sans MS";font-size:88%;color:yellow;display:no= ne'>
= 211;Encourager utilisation CIP chez des enfants drépanocytaires =
&#= 8211;Dans le c= adre précis d’un PT au long cours sans interruption
&#= 8211;Sans excès de complications
&#= 8211;avec une qualité de vie non comparable
&#= 8211;À comparer à l’utilisation d’autres abords veineux dans l= a dré= ;panocytose….
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String(document.location.href)=20 Start=3Dhref.indexOf('!')+1=20 End=3Dhref.lastIndexOf('/')+1=20 if (End < Start)=20 return href.substring(0, Start)=20 else=20 return href.substring(0, End)=20 } return ''; } function GetTags(base,tag) { if(g_supportsPPTHTML) return base.all.tags(tag); else return base.getElementsByTagName(tag); } function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP= refix+GetHrefObj( gCurSld ).mNtsHref ) } function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() } function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() } function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() } function SetHasNts( fVal ) { if( gHasNts !=3D fVal ) { gHasNts=3DfVal UpdNavPane() } } function ToggleOtlText() { gOtlTxtExp=3D!gOtlTxtExp UpdOtlPane() } function ClearMedia() { // Clear any sounds playing before launching another browser window. Other= wise, // in fullscreen mode, you'll continue to hear the sound in the frames mod= e. if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0; } function FullScreen() {=20 if ( PPTSld.g_animUseRuntime ) PPTSld.document.body.pause(); ClearMedia(); var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { =20 obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else =20 return gCurSld } function GetNumSlds() { =20 if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; PPTSld.location.replace(MHTMLPrefix+obj.mSldHref) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 PPTSld.location.replace(MHTMLPrefix+href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; =09 var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document var dir =3D doc.body.dir if( dir !=3D "rtl" ) dir =3D "ltr"; doc.open() doc.writeln('


' + ENDSHOW_MESG + '

') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(new Array("31")); /********************************************* Navigation button implementation There are 2 types of buttons: ImgBtn, TxtBtn implemented as function objects. They share a similiar interface so the event handlers can call SetActive, for example, on a button=20 object without needing to know exactly=20 what type of button it is. **********************************************/ //---------------------------------- function ImgBtn( oId,bId,w,action ) //---------------------------------- { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0=20 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { =20 obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0=20 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } =20 } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } //----------------------------------------- function TxtBtn( oId,oeId,action,chkState ) //----------------------------------------- { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { =20 this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) {=20 if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } =20 } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1=20 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() {=20 b =3D gBtnArr[this.mBorderId]=20 if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() {=20 b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState /********************************************* Context menu implementation _CM() is the function that's hooked up to the oncontextmenu event. Once we're asked to show the menu, we first build it by creating DIVs on-the-fly. Then we position it=20 within the screen area so it doesn't get clipped. Creating the DIVs using createElement() means we don't have to write out any extra HTML into the slide HTML files. **********************************************/ var sNext=3D"Suivant",sPrev=3D"Précédent",sEnd=3D"Mettre fin = au diaporama",sFont=3D"Arial",sArrow=3D"Flèche",sFreeform=3D"Forme l= ibre",sRect=3D"Rectangle",sOval=3D"Ovale" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) =09 CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; 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charset="us-ascii" Utilisation de chambres implantables chez 14 enfants drépanocytaires en programme d’échange ------=_NextPart_01C51A81.047DBDE0 Content-Location: file:///C:/2E465513/Utilisationdechambresimplantableschez14enfantsdrepanocytaires_fichiers/outline.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii"
 Re= marques
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= = = = = = = = = = = = = = = = =
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