Management des risques et respect des règles

The design of rules (laws, norms, policies, procedures, protocols) and the implementation of a management that aimed at conforming the behaviors of operators with these rules has long been the dominant approach to improve safety in socio-technical systems. This approach has proven to be effective in enhancing safety by enabling organizations to cope with predictable risks and failures. However, in our modern and constantly evolving socio-technical systems, where the management of unforeseen situation has become the rule, this approach has shown its limitations: operators’ initiatives, which sometimes deviate from rules, are equally important for maintaining safety. Therefore, while the rules remain a key feature of risk management, the challenge is not the search for total compliance with rules, but the permanent monitoring of their use to detect and distinguish gaps that constitute a drift towards the accident from gaps that highlight that the rule has become inappropriate and which the compliance with may prove dangerous for safety.     

Intérêt de l'électrophorèse des isophosphatases alcalines chez l'insuffisant rénal hémodialysé

The aim of the study is to prove the usefulness of an electrophoretic technic for multiple forms of alkaline phosphatase semi-automatised on Hydrasys (Sebia) in renal osteodystrophy. This technology allows to identify a bone variant associated with high osteoblastic activity. Electrophoresis and immunofluorometric determination of bone fraction (Ostase) were realised in 105 hemodialysed patients treated by 1.25 (OH)2 vit D when PTH was >150 pg/ml. We frequently observe in this population a high activity for intestinal, hepatic and macromolecular forms. A bone variant is observed among 10% of the patients. The bone fraction in electrophoresis is well correlated (r:95) with Ostase. For 103 patients, radiographic examination were performed before and after the analyses. We observed lesions of hyperparathyroidism in 42% of patients. Sensitivity, specificity, positive predictive value, negative predictive value are respectively 31%, 92%, 72%, 65% for an abnormal electrophoresis, 14%, 88%, 46%, 58% for an out of range value of Ostase and 25%, 85%, 59%, 58% for PTH>150 pg/ml.     

Démonstration des voies d'abord latérales hautes et basses de l'artère poplitée

Conclusion A partir d'une série de 20 dissections et en réalisant des coupes anatomiques sur un membre inférieur préalablement congelé, nous avons réalisé une étude anatomique des voies d'abord latérales de l'a. poplitée. L'abord latéral haut de l'a. poplitée (supra-articulaire) dans dix dissections s'est avéré peu délabrant, après incision cutanée et fasciale, une simple discision entre les mm. vaste latéral et biceps fémoral permet une exposition facile des vaisseaux poplités après écartement du n. sciatique en arrière. A l'inverse, l'abord par voie latérale basse de l'a. poplitée s'est avéré traumatisant (dix dissections). En effet, de nombreux risques jalonnent cette voie, tant nerveux (n. fibulaire commun) que vasculaires (vaisseaux poplités). De plus la désinsertion d'éléments ligamentaires et musculo-tendineux ainsi que la résection du quart supérieur de la fibula risquent d'induire des troubles de la mobilité de la statique du genou et de la cheville. Cependant, nous avons obtenu une exposition satisfaisante de la partie basse de l'a. poplitée et de ses branches de division par cette voie [4, 5, 10, 11]. En définitive, dans le cadre des pontages vasculaires, ces voies d'abord latérales doivent rester exceptionnelles par rapport aux voies d'abord classiques (médiale et postérieure). Leur meilleure indication semble être le sepsis interdisant les abords classiques. De ce fait, il est intéressant pour le chirurgien vasculaire de connaître ces voies d'abord rares et peu usitées.     

L’engagement dans le don de plasma : étude des déterminants chez des donneurs réguliers en plasmaphérèse

The purpose of this study, based on the Theory of planned behavior, is to identify and ultimately better understand what determines the fidelity and the regularity of donors committed in plasmapheresis donation. This qualitative study is a primary stage to establish a classification of donors in a French socio-cultural context. For this reason, we have carried out a survey among 16 regular plasmapheresis donors, by way of semi-structured individual interviews at the Établissement français du sang - Brittany. The level of commitment of these regular donors is considered as a level of appropriation. If subjective norms have initially influenced their decision to donate blood, no specific motivation has been highlighted for them to donate plasma except a generally favourable attitude towards the voluntary donation process. The perception of control over their environment is a variable which played a decisive role in the donor's intention to give, with little cost associated to plasmapheresis donation and recourse to internal causal explanations. A better comprehension of the plasmapheresis donors’ determinants should lead us to a more efficient awareness of new potential donors, thereby enhancing recruitment and retention. Due to the increasing need for plasma-derived products, this study's ultimate issue is closely correlated both with ethical and socio-economic aspects. Following which, after analysing the results, a certain number of recommendations will be made.     

Diabète insipide et grossesse. Intérêt de la détermination de l'activité vasopressinase sérique

During pregnancy, diabetes insipidus can arise following the increase in serum of vasopressinase activity, which is identical to oxytocinase/insulin-regulated membrane aminopeptidase (Otase/IRAP) or cystine-aminopeptidase/insulin-regulated membrane aminopeptidase (CAP/IRAP) or EC. 3.4.11.3. First, we measured the vasopressinase activity in 1445 sera from normal pregnant women using S-benzyl-L-cystéine-4-nitroanilide as substrate. Then, in opposition to results previously published with the use of L-leucine-p-nitroanilide we evidenced that 20 mM L-methionine did not permit to differentiate placental and non-placental activity when S-benzyl-L-cystéine-4-nitroanilide was used as substrate. Finally, the S-benzyl-L-cystéine-4-nitroanilide, when used without addition of L-methionine in the incubation mixtures, appears to be a more suitable substrate for measuring vasopressinase than L-leucine-p-nitroanilide.     

Diagnostic des hépatopathies et de leur sévérité

Diagnosis and prognosis of liver diseases are considered here in the context of surgery. When a chronic liver disease is suspected by clinical signs or abnormal liver function tests, the degree of liver fibrosis has to be evaluated. The most accurate markers to assess clinically significant fibrosis in clinical practice are now prothrombin index and serum hyaluronate. The diagnostic accuracy for cirrhosis approaches 90% using non invasive means. The most accurate signs are in clinics: firm liver, in laboratory tests: thrombopenia, decreased prothrombin index and increased hyaluronate, with ultrasonography-Doppler: increased portal diameter and decreased portal velocity and with endoscopy: esophageal varices (but this not a true non-invasive tool). Improvement by blood fibrosis markers and ultrasonography-Doppler are awaited. Child-Pugh score is the most used prognostic score in clinical practice and trials. This is due to its simplicity but some limitations are known. Therefore, other scores are used: APACHE III ou MELD in surgery or resuscitation, Maddrey's score in alcoholic hepatitis and Mayo Clinic's scores in cholestatic diseases.     

Profil de l’hémogramme et intérêt de la mesure de l’hémoglobine pré-don chez des donneurs de sang de la région Nord-Ouest du Maroc

Background

Blood donation in Morocco and more particularly in the northwest region is carried out without prior determination of the pre-donation hemoglobin. In addition, we note the lack of scientific research that reports data on the red blood cells, leukocytes and platelet lines in donated blood at the regional or even national level.

Intérêt de la recherche de β2-transferrine dans des prélèvements susceptibles de contenir du LCR

When there is a clinical suspicion of CSF leakage, we can detect the presence of β2-transferrin in fluids from different origins. We used two techniques in the laboratory coupling electrophoresis with immuno-blotting. These two methods are realized on microsamples collected by syringe or on microcollagen sponges. The difference between the two methods concern the nature of the gel electrophoresis: agarose for the first one (zone electrophoresis) which allow separation of β1 and β2 transferrin by the electric charge, and agarose with ampholytes (isoelectrofocusing) allowing separation by isoelectric point of all transferrin isoforms. Whatever the method two controls are used: serum of the patient (negative control) and CSF (positive control).     

Influence du délai de séparation du sérum et des conditions de sa conservation sur les dosages de l'antigène spécifique prostatique total et de sa fraction libre

Serum PSA is used as a precocious marker of the prostate cancer. The calculation of the free-PSA/total-PSA ratio permits a better discrimination between cancer and benign hyperplasia of the prostate especially when values of total-PSA are between 4 and 10 ng/mls or even between 2 and 10 ng/mls according to different guidelines. Pre-analytical factors, as serum separation delays and conservation conditions can be to the origin of mistakes that would modify results of t-PSA, f-PSA and therefore of the f-PSA/t-PSA ratio and then of the diagnostic orientation. The aim of this work is to value the influence of the serum separation delays and its conservation conditions to different temperatures on serum rates of t-PSA, f-PSA and the f-PSA/t-PSA ratio. The study has been made on 31 patients followed in the urology department and presenting a suspected rectal touch and a t-PSA value (measured out in the hour following the sample collection) between 2 and 10 ng/ml. Every sample has immediately been distributed in aliquotes of 1 ml in eight groups each undergoing one delay of centrifugation (1, 4 and 8 h) in ambient temperature and different serum conservation conditions (25, 4, –20 and –70 °C). Assays have been achieved by immunofluorometric method (FPIA). The study showed that until 8 h, the rate of t-PSA is not meaningfully modified by the separation delays whereas the f-PSA rate and the ratio one are meaningfully lower from the 4th h. Serum conservation conditions showed that there is no meaningful variation of t-PSA rates. On the other hand, only the serum conservation 24 h to +4 °C, or 7 days to –20 °C or better to –70 °C does not modify rates of the f-PSA and therefore of the ratio.     

La réalité de l’accès aux soins des enfants de migrants à Mayotte

The implementation of the social security system in 2005 in Mayotte has resulted in the end of free healthcare for all non-affiliated residents, primarily Comorians, due to the absence of the State Medical Aid (AME) in this department. Doctors of the World France opened a paediatric clinic in December 2009. The sociomedical data were collected during 5286 consultations in 2010. Analysis of these data demonstrates a link between access to healthcare for children and the residential status of their parents. The analysis concerns 2,350 patients met during consultations held by Doctors of the World France in Mayotte in 2010. The data have been electronically recorded and analysed by the Sphinx software. The results show that there are several obstacles to healthcare resulting in non-attendance. This situation is made worse if one of the parents has an irregular residential status and all the more so if both the parents have an irregular status. Affiliation to the social security system, however, improves the situation. The results show a delay in accessing healthcare, a poor vaccination programme and disturbing data on severe acute malnutrition. The specific healthcare measures in Mayotte do not respect the International Convention on the Rights of the Child. Direct affiliation to the social security system for children would entail a reduction in health insecurity for the children of parents with irregular residential status. It would also be necessary to reduce the factors that provoke fear of displacement, which would facilitate physical access to consultations.