La bibliothèque des étudiants en santé

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• Article libreArticleEn anglais

  Clinical and immunological outcomes according to adherence to first-line HAART in a urban and rural cohort of HIV-infected patients in Burkina Faso, West Africa

  Emanuele Focà, Silvia Odolini, Giorgia Sulis, Stefano Calza, Virginio Pietra, Paola Rodari, Pier Francesco Giorgetti, Alice Noris, Paul Ouedraogo, Jacques Simpore, Salvatore Pignatelli, Francesco Castelli

  BackgroundAim of our study is to investigate the clinical and immunological outcomes according to first-line HAART adherence in a large cohort of HIV-infected patients in Burkina Faso.MethodsA retrospective study was conducted between 2001 and 2009 among patients from two urban medical centers [St. Camille Medical Center (CMSC) and “Pietro Annigoni” Biomolecular Research Center (CERBA)] and 1 in the rural District of Nanoro (St. Camille District Hospital). Socio-demographical and clinical data were analyzed. Adherence was evaluated through a questionnaire investigating 5 key points related to drugs, consultations and blood exams, by assigning 0 to 2 points each up to 10 points overall. Data were collected at baseline and regularly thereafter. Adherence score was considered as a continuous variable and classified in optimal (8–10 points) and sub-optimal (0–7 points). Immunological outcome was evaluated as modification in CD4+ T-cell count over time, while predictors of death were explored by a univariate and multivariate Cox model considering adherence score as a time-varying covariate.ResultsA total of 625 patients were included: 455 (72.8%) were females, the median age was 33.3 (IQR 10.2) years, 204 (32.6.%) were illiterates, the median CD4+ T-cell count was 149 (IQR 114) cells/μl at baseline. At the end of the observation period we recorded 60/625 deaths and 40 lost to follow-up. The analysis of immunological outcomes showed a significant variation in CD4+ T-cell count between M12 and M24 only for patients with optimal adherence (Δ=78.2, p<0.001), with a significant Δ between the two adherence groups at M24 (8–10 vs 0–7, Δ=53.8, p=0.004). Survival multivariate analysis revealed that covariates significantly related to death included being followed at CERBA (urban area) or Nanoro (rural area), and receiving a regimen not including fixed dose combinations, (p=0.024, p=0.001 and p<0.001 respectively); conversely, an increasing adherence score as well as an optimal ad

  Biostatistiques et épidémiologieImmunologiePharmacologieLicence : http://creativecommons.org/licenses/by/2.0 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.

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• Article libreArticleEn anglais

  Clinical and laboratory characteristics of adolescents and young adults with sickle cell disease at steady state in Uganda

  Sickle cell disease (SCD) is associated with chronic systemic morbidity that extends beyond acute crises. However, data describing the clinical and laboratory characteristics of adolescents and young adults with SCD at steady state in sub-Saharan Africa are limited. We described clinical and laboratory characteristics of adolescents and young adults with SCD at steady state in Uganda. We conducted a hospital-based cross-sectional study of 60 adolescents and young adults with SCD in steady state at Mulago National Referral Hospital. Descriptive statistics were used to summarize participant characteristics and medication use. The mean age was 16.5 ± 3.3 years, and 34 (56.7%) participants were female. Mean hemoglobin was 9.1 ± 2.2 g/dl. Mean systolic and diastolic blood pressures were 107.9 ± 15.5 mmHg and 60.3 ± 12.6 mmHg, respectively; mean heart rate was 89.5 ± 15.5 beats/min. Fifty-two (86.7%) participants reported using hydroxyurea. These observations show that adolescents and young adults with SCD at steady state exhibit hematologic abnormalities and distinctive hemodynamic profiles that underscore substantial chronic subclinical abnormalities that extend beyond acute complications.

  HématologieLicence : Creative Commons Attribution License This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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• Article libreArticleEn anglais

  Clinical and laboratory characterization of adult sickle cell anemia patients in Kinshasa

  BackgroundSickle cell anemia (SCA) is a monogenic hemoglobinopathy associated with severe acute and chronic complications, with the highest incidence worldwide in Sub-Saharan Africa. The wide variability in clinical manifestations suggest that a uniform response to hydroxurea may not be attained. In view of a potential treatment with hydroxyurea (HU), we assessed the variability of clinical and hematological manifestations in a cohort of adults with SCA in Kinshasa, capital of the DR Congo in Central Africa.MethodsA cross-sectional study was conducted in a hospital dedicated to SCA management in Kinshasa. Clinical history of patients was recorded, a complete physical examination performed. The diagnosis was confirmed by means of DNA analysis. A full blood count and hemolysis markers were measured. The severity of the disease was evaluated by means of a previously reported score.ResultsThe study group consisted of 166 genetically confirmed SCA patients. The SCA severity was mild in 28.9%, moderate in 64.5% and severe in 6.6%. The disease severity score increased with patient’s age (p ≤ 0.001). The severity was higher in males compared to females (p = 0.012). In males, the severity score was correlated with the presence of priapism (p = 0.045), a manifestation not previously incorporated in the severity score. The severity score was inversely correlated with the fetal hemoglobin (HbF) rate (p = 0.005). Malnutrition (BMI <18.5 kg/m2) was present in 47% of patients and was related to the male sex, hip disease (aOR 3.11; p = 0.019) and severe phenotype (aOR 3.53; p = 0.012). Leg ulcers were more frequent in males than in females (p = 0.001; OR 24.3) and were correlated with the number of days of hospitalization (p = 0.029). Hip disease was related to the increasing age (p = 0.008).ConclusionIn this selected, hospital-based populations of adults with SCA, severe disease was rare, which may be due to survival bias. However, two thirds had moderate severity of the disease,

  Biologie cellulaire et moléculaireGénétiqueBiostatistiques et épidémiologieLicence : Creative Commons Attribution License This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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• Article libreArticleEn anglais

  Clinical management and mortality among COVID-19 cases in sub-Saharan Africa: A retrospective study from Burkina Faso and simulated case analysis

  Laura Skrip, Karim Derra, Mikaila Kaboré, Navideh Noori, Adama Gansané, Innocent Valéa, Halidou Tinto, Bicaba W. Brice, Mollie Van Gordon, Brittany Hagedorn, Hervé Hien, Benjamin M. Althouse, Edward A. Wenger, André Lin Ouédraogo

  Highlights•Countries within the sub-Saharan Africa (SSA) region may experience high COVID-19 case fatality rates.•Over the first months of the epidemic in SSA, deceased cases have tended to mainly be male, aged >50 years and have underlying comorbidities.•Delayed or no care-seeking was prevalent among deceased COVID-19 cases in Burkina Faso.•Analysis on a synthetic case population suggested that treatment with oxygen therapy or convalescent plasma reduced the adjusted odds of COVID-19 mortality.•Low-cost, scalable and sustainable strategies for COVID-19 case management in the SSA context warrant attention and investment to reduce disparity in case fatality. BackgroundAbsolute numbers of COVID-19 cases and deaths reported to date in the sub-Saharan Africa (SSA) region have been significantly lower than those across the Americas, Asia and Europe. As a result, there has been limited information about the demographic and clinical characteristics of deceased cases in the region, as well as the impacts of different case management strategies.MethodsData from deceased cases reported across SSA through 10 May 2020 and from hospitalized cases in Burkina Faso through 15 April 2020 were analyzed. Demographic, epidemiological and clinical information on deceased cases in SSA was derived through a line-list of publicly available information and, for cases in Burkina Faso, from aggregate records at the Centre Hospitalier Universitaire de Tengandogo in Ouagadougou. A synthetic case population was probabilistically derived using distributions of age, sex and underlying conditions from populations of West African countries to assess individual risk factors and treatment effect sizes. Logistic regression analysis was conducted to evaluate the adjusted odds of survival for patients receiving oxygen therapy or convalescent plasma, based on therapeutic effectiveness observed for other respiratory illnesses.ResultsAcross SSA, deceased cases for which demographic data were available were

  Biostatistiques et épidémiologieMédecine interne (cardiologie, endocrinologie, néphrologie…)Santé publiqueLicence : This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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• Article libreArticleEn anglais

  Clinical profile of sickle cell disease in children treated at “Cliniques Universitaires de Bukavu” and “Clinique Ami des Enfants”, Bukavu, Democratic Republic of the Congo

  Viviane Feza Bianga, Mwanza Nangunia, Fernand Manga Oponjo, John Mambo Itongwa, Judicaël Iragi Mushubusha, Moise Mbaluku Colombe, Carmel Mbalo Walemba, Okitosho Wembonyama

  Introductionsickle cell disease is the most common inherited hemoglobin disease globally and remains a significant concern worldwide and in Africa. This study aimed to determine the clinical profile of children with sickle cell disease followed up in two hospitals in Bukavu.Methodswe conducted a cross-sectional multicenter retrospective study. Medical folders of children with sickle cell disease followed up at the Cliniques Universitaires de Bukavu and Clinique Ami des Enfants, collected from January 2018 to December 2019, have been used.Resultsin 55 sickle cell children, 31 cases (54.4%) were male against 24 (43.6%) females. The average age was 101.09 months (between 12 and 222 months). Diagnosis has been established before two years, with an average age of 14.27 months. The main circumstance of the discovery of the disease is anemia. Electrophoresis was the primary test of diagnosis in 81.8% of cases. Transfusion was done an average of 5.98 times (0 and 10 times) during different treatment period. Anaemia and infectious phenomena were encountered respectively in 96.4% and 96.4%. However, acute chest syndrome was only found in 9.1%.Conclusionsickle cell disease has been diagnosed precociously before two years and anemia was the main circumstance of discovery. A better knowledge of caregivers about the various clinical aspects and an early screening could improve the quality of life of these children.

  HématologiePédiatrieLicence : https://creativecommons.org/licenses/by/4.0/ The Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (), which permits unrestricted use, distribution, and reproduction in any medium, p

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• Article libreArticleEn anglais

  Clinical signs and symptoms cannot reliably predict Plasmodium falciparum malaria infection in pregnant women living in an area of high seasonal transmission

  Marc C Tahita, Halidou Tinto, Joris Menten, Jean-Bosco Ouedraogo, Robert T Guiguemde, Jean Pierre van Geertruyden, Annette Erhart, Umberto D’Alessandro

  BackgroundMalaria in pregnancy is a major public health problem in endemic countries. Though the signs and symptoms of malaria among pregnant women have been already described, clinical presentation may vary according to intensity of transmission and local perceptions. Therefore, determining common signs and symptoms among pregnant women with a malaria infection may be extremely useful to identify those in need of further investigation by rapid diagnostic test or microscopy.MethodsSix hundred pregnant women attending the maternity clinic of Nanoro District Hospital, Burkina Faso were recruited, 200 with suspected clinical malaria and 400 as controls. Cases were matched with controls by gestational age and parity. Signs and symptoms were collected and a blood sample taken for rapid diagnostic test, microscopy and haemoglobin measurement. A multivariate model was used to assess the predictive value of signs and symptoms for malaria infection.ResultsThe overall prevalence of malaria was 42.6% (256/600) while anaemia was found in 60.8% (365/600) of the women. Nearly half (49%) of the cases and 39.5% of the controls had a malaria infection (p = 0.03). The most common signs and symptoms among the cases were fever (36%,72/200), history of fever (29%,58/200) and headache (52%,104/200). The positive predictive value for fever was 53% (95% CI:41–64), history of fever 58% (95% CI:37–63) and headache 51% (95% CI:41–61).ConclusionSigns and symptoms suggestive of malaria are frequent among pregnant women living in areas of intense transmission. Common malaria symptoms are not strong predictors of infection. For a better management of malaria in pregnancy, active screening to detect and treat malaria infection early should be performed on all pregnant women attending a health facility.

  Biostatistiques et épidémiologieParasitologie et mycologieMaladies infectieuses et tropicalesLicence : http://creativecommons.org/licenses/by/2.0 This is an open access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  Clinical use of 3D printing in dentistry, pediatric oral and maxillofacial surgery

  Mathilde Maillard, Vincent Martin, Sandrine Touzet-Roumazeille, Jérôme Vandomme, Caroline Delfosse, Romain Nicot, Marion. Dehurtevent

  Les secteurs de la chirurgie orale, maxillo-faciale et de l’odontologie sont à la pointe du développement de la fabrication additive en santé. En plus de dix ans, cette technologie a permis aux praticiens d’améliorer la prise en charge des patients vers une médecine personnalisée. La fabrication additive est utilisée pour la planification de procédures chirurgicales, orthodontiques et prothétiques. Les technologies principales incluent la stéréolithographie, le dépôt de fil fondu, la projection de matière et la fusion sélective par laser. En odontologie et en chirurgie maxillo-faciale, l’impression 3D est utilisée pour fabriquer des prothèses, des guides chirurgicaux et des dispositifs médicaux sur mesure, apportant des solutions innovantes pour des pathologies complexes. Ces procédés de fabrication permettent également la création de modèles anatomiques pour l’information des patients et des parents, notamment en pédiatrie, et facilite la planification chirurgicale précise, offrant des résultats prédictibles et sécurisés.

  SémiologieMaladies infectieuses et tropicalesMédecine interne (cardiologie, endocrinologie, néphrologie…)Licence : https://creativecommons.org/publicdomain/zero/1.0/

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• Article libreArticleEn anglais

  Clinical Variation of Plasmodium falciparum eba-175, ama-1, and msp-3 Genotypes in Young Children Living in a Seasonally High Malaria Transmission Setting in Burkina Faso

  Issiaka Soulama, Samuel S. Sermé, Edith C. Bougouma, Amidou Diarra, Alfred B. Tiono, Alphonse Ouedraogo, Amadou T. Konate, Issa Nebie, Sodiomon B. Sirima

  The association between P. falciparum eba-175, ama-1, and msp-3 polymorphism in the pathogenicity of malaria disease was investigated. We therefore compared the prevalence of different alleles between symptomatic and asymptomatic malarial children under five years of age living in Burkina Faso. Blood filter papers were collected during the 2008 malaria transmission season from 228 symptomatic and 199 asymptomatic children under five years of age. All patients were living in the rural area of Saponé at about 50 km from Ouagadougou, the capital city of Burkina Faso. P. falciparum parasite DNA was extracted using QIAGEN kits and the alleles diversity was assessed by a nested PCR. PCR products were then digested by restriction enzymes based on already described polymorphic regions of the eba-175, ama-1, and msp-3 genes. The individual alleles eba-175_FCR3 and msp-3_K1 frequencies were statistically higher (p < 0.0001) in the asymptomatic group compared to the symptomatic ones. No statistically significant difference was noted in the prevalence of ama-1-3D7, ama-1-K1, and ama-1-HB3 genotypes between the two groups (p > 0.05). The comparative analysis of P. falciparum genotypes indicated that the polymorphism in eba-175 and msp-3 genotypes varied between asymptomatic and symptomatic clinical groups and may contribute to the pathogenesis of malaria.

  Biologie cellulaire et moléculaireGénétiqueBiostatistiques et épidémiologieLicence : This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  Clinique et méthodologie : pour une alliance et une approche de la complexité en psychopathologie. Des théories aux mesures jusqu’aux prises en charge

  Yannick Morvan

  Ce travail d’Habilitation à Diriger des Recherches (HDR) présente une prise de position argumentée sur la nécessaire alliance entre les perspectives cliniques et méthodologiques en tant que voie de progrès pour la compréhension théorique, l’amélioration des mesures ainsi que de la prise en charge dans le champ de la santé mentale et de la psychopathologie. Cette HDR se situe dans une perspective de « science ouverte » et s’inscrit dans une démarche d’amélioration des pratiques pour la psychologie. Ce travail présente l’utilisation des approches en systèmes complexes et leurs applications en psychologie clinique et en psychopathologie grâce aux modélisations en réseau de données transversales et longitudinales. Ces modélisations sont illustrées par mes travaux concernant la mesure de la santé mentale des étudiants (détresse psychologique, dépression, anxiété et burnout), le risque de transition psychotique chez les adolescents et jeunes adultes en relation avec le fonctionnement cognitif ainsi que sur un programme de psychoéducation d’orientation TCC des familles et des proches de personnes présentant des troubles psychotiques (Profamille). Ces travaux plaident pour une meilleure modélisation des systèmes bio-psycho-sociaux ainsi que des phénomènes de développement et de transition des symptômes vers des troubles psychiques au cours du temps, dans une approche de prévention et d’intervention précoce. Les questions relatives à une meilleure articulation entre approches nomothétiques et idiographiques, d’une meilleure prise en compte de la temporalité des phénomènes ainsi que des hypothèses et inférences causales sur les relations entre phénomènes sont discutées. Elles plaident également pour un meilleur accordage des pratiques de mesures tant dans le champ de la recherche que celui des prises en charge cliniques. Enfin, les avancées récentes de la construction théorique en psychopathologie, dans un processus épistémique itératif, sont présentées. Elles permettent d’in

  PhysiologieBiostatistiques et épidémiologieSémiologieLicence : https://creativecommons.org/licenses/by-sa/4.0/

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• Article libreArticleEn anglais

  Clonal Waves of Neisseria Colonisation and Disease in the African Meningitis Belt: Eight- Year Longitudinal Study in Northern Ghana

  BackgroundThe Kassena-Nankana District of northern Ghana lies in the African “meningitis belt” where epidemics of meningococcal meningitis have been reoccurring every eight to 12 years for the last 100 years. The dynamics of meningococcal colonisation and disease are incompletely understood, and hence we embarked on a long-term study to determine how levels of colonisation with different bacterial serogroups change over time, and how the patterns of disease relate to such changes.Methods and FindingsBetween February 1998 and November 2005, pharyngeal carriage of Neisseria meningitidis in the Kassena-Nankana District was studied by twice-yearly colonisation surveys. Meningococcal disease was monitored throughout the eight-year study period, and patient isolates were compared to the colonisation isolates. The overall meningococcal colonisation rate of the study population was 6.0%. All culture-confirmed patient isolates and the majority of carriage isolates were associated with three sequential waves of colonisation with encapsulated (A ST5, X ST751, and A ST7) meningococci. Compared to industrialised countries, the colonising meningococcal population was less constant in genotype composition over time and was genetically less diverse during the peaks of the colonisation waves, and a smaller proportion of the isolates was nonserogroupable. We observed a broad age range in the healthy carriers, resembling that of meningitis patients during large disease epidemics.ConclusionsThe observed lack of a temporally stable and genetically diverse resident pharyngeal flora of meningococci might contribute to the susceptibility to meningococcal disease epidemics of residents in the African meningitis belt. Because capsular conjugate vaccines are known to impact meningococcal carriage, effects on herd immunity and potential serogroup replacement should be monitored following the introduction of such vaccines. An analysis of pharyngeal carriage of meningococci in one district of Gh

  Biologie cellulaire et moléculaireGénétiqueBiostatistiques et épidémiologieLicence : This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited.

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• Article libreArticleEn anglais

  Closing system-wide yield gaps to increase food production and mitigate GHGs among mixed crop–livestock smallholders in Sub-Saharan Africa

  B. Henderson, C. Godde, D. Medina-Hidalgo, M. van Wijk, S. Silvestri, S. Douxchamps, E. Stephenson, B. Power, C. Rigolot, O. Cacho, M. Herrero

  In this study we estimate yield gaps for mixed crop–livestock smallholder farmers in seven Sub-Saharan African sites covering six countries (Kenya, Tanzania, Uganda, Ethiopia, Senegal and Burkina Faso). We also assess their potential to increase food production and reduce the GHG emission intensity of their products, as a result of closing these yield gaps.We use stochastic frontier analysis to construct separate production frontiers for each site, based on 2012 survey data prepared by the International Livestock Research Institute for the Climate Change, Agriculture and Food Security program. Instead of relying on theoretically optimal yields—a common approach in yield gap assessments—our yield gaps are based on observed differences in technical efficiency among farms within each site. Sizeable yield gaps were estimated to be present in all of the sites. Expressed as potential percentage increases in outputs, the average site-based yield gaps ranged from 28 to 167% for livestock products and from 16 to 209% for crop products. The emission intensities of both livestock and crop products registered substantial falls as a consequence of closing yield gaps.The relationships between farm attributes and technical efficiency were also assessed to help inform policy makers about where best to target capacity building efforts. We found a strong and statistically significant relationship between market participation and performance across most sites. We also identified an efficiency dividend associated with the closer integration of crop and livestock enterprises. Overall, this study reveals that there are large yield gaps and that substantial benefits for food production and environmental performance are possible through closing these gaps, without the need for new technology. Highlights•We estimate yield gaps for mixed crop–livestock smallholder farmers in seven sites.•Yield gaps are based on differences in technical efficiency among farms.•Yield gaps ranged from 28 to 167

  Biologie cellulaire et moléculaireGénétiqueBiostatistiques et épidémiologieLicence : This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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• Article libreArticleEn anglais

  Closing the GAP in Antimicrobial Resistance Policy in Benin and Burkina Faso

  ABSTRACTAntimicrobial resistance (AMR) is a global concern that is geographically unevenly distributed, with low- and middle-income countries and African countries suffering in particular. The World Health Organization (WHO) Global Action Plan (GAP) for antimicrobial resistance identified five key objectives that aim to ensure the continued treatment and prevention of infectious diseases with the use of antibiotics. Countries signatory to the WHO GAP are expected to develop their own national action plans (NAPs) based on the global model. How low-income countries are able to achieve the GAP objectives is not well understood. This paper analyzes the progress of two West African countries in achieving the GAP targets, Benin and Burkina Faso, countries among the lowest bracket in the World Development Index. We present qualitative data from interviews and focus group discussions with local policy-makers, nurses, doctors, animal breeders, veterinarians, and laboratory researchers, supported by participant observations and surveys within rural communities. The analysis is organized according to the five WHO GAP objectives to show the countries’ challenges in fulfilling them. The analysis shows that there are shortcomings in all of the WHO GAP areas in the two countries, making it a compounded and multifactorial problem—a stacking of lacks. In such contexts, calibrating a society toward AMR resilience/prevention requires overall development and attention to interdependencies. Active local research and policy communities with international, sustained financial support are essential for achieving the targets.IMPORTANCE The burden of antimicrobial resistance (AMR) is unequally distributed across the globe. Low-income countries face a more severe AMR situation and have fewer means to solve the problem. This paper brings out the voices of local experts, policy-makers, and members of the community in Benin and Burkina Faso across human health, animal health, and food production

  Biostatistiques et épidémiologieMicrobiologie (bactériologie, virologie)PharmacologieLicence : Creative Commons Attribution 4.0 International license This is an open-access article distributed under the terms of the.

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• Article libreArticleEn anglais

  Closing the knowledge gap: identifying research priorities for firearm-related injury and mortality in Canada

  Lotus Alphonsus, Anne Sorvari, Alexa R. Yakubovich, Carmen Gill, Annette Bailey, Carolyn Snider, Wendy Cukier, Irvin Waller, Wendy Thompson, Stephanie Toigo, Nancy Baxter, R. Blake Brown, Natasha Saunders, David Gomez

  AbstractIntroduction:Firearm-related injury and death are leading yet preventable causes of premature death in Canada. Our objective was to identify knowledge gaps and research priorities to inform a national research agenda to prevent firearm-related injury and death. Methods:In a two-stage process, nominal group technique was used to encourage experts in firearm injury and death (N = 15) to generate ideas relevant to knowledge gaps in three areas: unintentional firearm injury, intimate partner violence (IPV)/femicide and other firearm-related assaults. Relevant parties (N = 43) subsequently voted on the identified gaps to determine top priorities for future research.Results:In Stage 1, the experts identified 22 knowledge gaps in unintentional firearm injury, 16 in IPV-related firearm injury/femicide and 33 in other assault-related firearm injuries. Based on their importance and feasibility as research projects, they then selected five, three and seven, respectively, of these knowledge gaps. In Stage 2, the top priorities for future research emerged: the economic cost of firearm injuries to victims’ families and communities and Canadian society; the impact of social policies and legislation aimed at reducing IPV/femicide-related firearm injuries and deaths; and a description of the available and required Canadian firearm-injury data.Conclusion:The top priorities highlight the large and diverse gaps in knowledge about firearm injury and death in Canada. This marks the first step toward developing a national research agenda for firearm-related injuries. Next steps include operationalizing these gaps into research questions, identifying data sources and methodological approaches, and choosing knowledge translation strategies.

  Licence : This work is licensed under a Creative Commons Attribution 4.0 International License

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  Clozapine monitoring: Have the times come for changing the rules?

  Helene Verdoux, Alexis Lepetit

  Contexte Une proportion importante de personnes avec une schizophrénie résistante ne bénéficient pas d’un traitement par clozapine malgré son efficacité clairement démontrée dans cette indication. Les contraintes liées à la surveillance hématologique constituent un frein notoire à l’usage de clozapine, entraînant une vraie perte de chance pour les personnes concernées. Objectif Cet article d’opinion a pour objectif de questionner la pertinence du maintien des règles de surveillance hématologique actuellement en vigueur. Discussion Les études récentes sur l’évolution temporelle du risque d’agranulocytose imputable à la clozapine confirment que celui-ci devient négligeable au bout d’un un à deux ans de traitement. La surveillance hématologique entraîne des arrêts non justifiés de clozapine, car des épisodes neutropéniques transitoires pouvant être liés à d’autres causes sont fréquents en population générale. La surveillance hématologique mobilise du temps soignant et nécessite des adaptations organisationnelles parfois complexes dans les structures ambulatoires pour garantir la continuité des soins, notamment en cette période de sous-effectif médical et paramédical. La surveillance hématologique a déjà été allégée ou suspendue dans plusieurs pays après la période à risque d’agranulocytose. Conclusion Le rapport bénéfice/risque du maintien de règles strictes de surveillance hématologiques de la clozapine paraît défavorable, suggérant que les temps pourraient donc être venus d’assouplir ces règles.

  Biostatistiques et épidémiologieSanté publiqueLicence : https://creativecommons.org/licenses/by/4.0/

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  Clustering of asymptomatic Plasmodium falciparum infection and the effectiveness of targeted malaria control measures

  Jeffrey G. Shaffer, Mahamoudou B. Touré, Nafomon Sogoba, Seydou O. Doumbia, Jules F. Gomis, Mouhamadou Ndiaye, Daouda Ndiaye, Ayouba Diarra, Ismaela Abubakar, Abdullahi Ahmad, Muna Affara, Davis Nwakanma, Mary Lukowski, James C. Welty, Frances J. Mather, Joseph Keating, Donald J. Krogstad

  BackgroundBecause clustering of Plasmodium falciparum infection had been noted previously, the clustering of infection was examined at four field sites in West Africa: Dangassa and Dioro in Mali, Gambissara in The Gambia and Madina Fall in Senegal.MethodsClustering of infection was defined by the percent of persons with positive slides for asexual P. falciparum sleeping in a house which had been geopositioned. Data from each site were then tested for spatial, temporal and spatio-temporal clustering in relation to the prevalence of infection from smear surveys.ResultsThese studies suggest that clustering of P. falciparum infection also affects the effectiveness of control interventions. For example, the clustering of infection in Madina Fall disappeared in 2014–2016 after vector control eliminated the only breeding site in 2013. In contrast, the temporal clustering of infection in Dioro (rainy season of 2014, dry season of 2015) was consistent with the loss of funding for Dioro in the second quarter of 2014 and disappeared when funds again became available in late 2015. The clustering of infection in rural (western) areas of Gambissara was consistent with known rural–urban differences in the prevalence of infection and with the thatched roofs, open eaves and mud walls of houses in rural Gambissara. In contrast, the most intense transmission was in Dangassa, where the only encouraging observation was a lower prevalence of infection in the dry season. Taken together, these results suggest: (a) the transmission of infection was stopped in Madina Fall by eliminating the only known breeding site, (b) the prevalence of infection was reduced in Dioro after financial support became available again for malaria control in the second half of 2015, (c) improvements in housing should improve malaria control by reducing the number of vectors in rural communities such as western Gambissara, and (d) beginning malaria control during the dry season may reduce transmission in hyperende

  Biostatistiques et épidémiologieParasitologie et mycologieMaladies infectieuses et tropicalesLicence : Open Access http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/publicdomain/zero/1.0/ This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as

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  Co-administration of calcium and multiple micronutrient supplements for maternal and newborn haemoglobin and iron status: protocol for a randomised non-inferiority trial in Burkina Faso and Pakistan

  Adama Baguiya, Amanda C Palmer, Saleem Jessani, Kerry J Schulze, Melinda K Munos, Monica M Pasqualino, Ethan K Gough, Nicole Cunningham, Fred Van Dyk, Sarah Saleem, Seni Kouanda

  AbstractIntroductionThe WHO recommends antenatal calcium supplementation (1500–2000 mg/day) to prevent pre-eclampsia in settings with low dietary calcium intake. Implementation is limited partly due to the need for three daily doses, although a lower 500 mg dose may be non-inferior. Current guidelines also recommend separating calcium from iron-containing supplements because concurrent intake may inhibit iron absorption. This individually randomised, controlled, non-inferiority trial will test whether co-administration of calcium and multiple micronutrient supplement (MMS) (CaMMS) is non-inferior to separate administration for haematological and iron status.Methods and analysisWe will recruit 1600 women at 6<20 weeks’ gestation in Burkina Faso and Pakistan, evaluating non-inferiority independently in each setting, which differ in anaemia aetiology and diets. Participants will be randomly assigned to (a) take United Nations International Multiple Micronutrient Antenatal Preparation Multiple Micronutrient Supplements (30 mg elemental iron) and 500 mg elemental calcium together in the morning or (b) take MMS in the morning and calcium in the evening. Venous blood will be collected at 6<20, 20<24, and 30<34 weeks’ gestation to measure complete blood count, ferritin, soluble transferrin receptor, hepcidin and erythropoietin. The primary outcome is haemoglobin concentration at 30<34 weeks. Co-administration will be considered non-inferior if the lower bound of the 95% CI for the difference in haemoglobin exceeds the non-inferiority margin of –3 g/L. Enrolment commenced in Pakistan on 25 August 2025 and in Burkina Faso on 12 September 2025.Ethics and disseminationThis protocol was approved by the Johns Hopkins School of Public Health Institutional Review Board, the Comité d’Ethique pour la Recherche en Santé, the Aga Khan University Ethics Review Committee and the Pakistan National Bioethics Committee. Findings will be disseminated through in-country meetings and in the pe

  Gynécologie-obstétriqueSanté publiqueLicence : https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original w

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  Co-circulation of two Alphaviruses in Burkina Faso: Chikungunya and O’nyong nyong viruses

  BackgroundChikungunya virus (CHIKV) and O’nyong nyong virus (ONNV) are phylogenetically related alphaviruses in the Semliki Forest Virus (SFV) antigenic complex of the Togaviridae family. There are limited data on the circulation of these two viruses in Burkina Faso. The aim of our study was to assess their circulation in the country by determining seroprevalence to each of the viruses in blood donor samples and by retrospective molecular and serological testing of samples collected as part of national measles and rubella surveillance.Methodology/Principal findingsAll blood donor samples were analyzed on the Luminex platform using CHIKV and ONNV E2 antigens. Patient samples collected during national measles-rubella surveillance were screened by an initial ELISA for CHIKV IgM (CHIKjj Detect IgM ELISA) at the national laboratory. The positive samples were then analyzed by a second ELISA test for CHIKV IgM (CDC MAC-ELISA) at the reference laboratory. Finally, samples that had IgM positive results for both ELISA tests and had sufficient residual volume were tested by plaque reduction neutralization testing (PRNT) for CHIKV and ONNV. These same patient samples were also analyzed by rRT-PCR for CHIKV. Among the blood donor specimens, 55.49% of the samples were positive for alphaviruses including both CHIKV and ONNV positive samples. Among patient samples collected as part of national measles and rubella surveillance, 3.09% were IgM positive for CHIKV, including 2.5% confirmed by PRNT. PRNT failed to demonstrate any ONNV infections in these samples. No samples tested by RT-qPCR. had detectable CHIKV RNA.Conclusions/SignificanceOur results suggest that CHIKV and ONNV have been circulating in the population of Burkina Faso and may have been confused with malaria, dengue fever or other febrile diseases such as measles or rubella. Our study underscores the necessity to enhance arbovirus surveillance systems in Burkina Faso. Author summaryChikungunya virus (CHIKV) and O’nyong n

  Biologie cellulaire et moléculaireGénétiqueBiostatistiques et épidémiologieLicence : Creative Commons Attribution License This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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  Co-construire la prévention des PRMD en conservatoire : un croisement des savoirs entre corps enseignants et kinésithérapeutes

  Maud Paillet

  Les troubles musculosquelettiques liés à la pratique instrumentale touchent jusqu’à 93% des musiciens. Malgré cette prévalence élevée, il n’existe aucun programme structuré d’éducation à la santé dans les cursus musicaux français. Or, le corps enseignant de conservatoire possède un savoir expérientiel et les kinésithérapeutes s’appuient sur un savoir clinique issu des données probantes. L’objectif est d’explorer en quoi la confrontation de ces savoirs permettrait-elle de co-construire les bases d’un programme d’éducation à la santé visant à prévenir ces troubles chez les musiciens de conservatoire. Une première phase exploratoire par questionnaire mixte a identifié les pratiques actuelles, les représentations et les besoins de 32 membres du corps enseignant de 5 conservatoires de la région Provence-Alpes-Côte d’Azur. Ensuite, deux focus groups en visioconférence mettent en confrontation, pour chacun : 2 enseignants, 2 kinésithérapeutes et un directeur de conservatoire. La pré-enquête montre l’existence de pratiques préventives dans l’enseignement, mais elles demeurent hétérogènes et peu institutionnalisées. Quant aux deux groupes, ils reconnaissent la complémentarité de leurs expertises et mettent en lumière une réelle volonté de collaboration ainsi que des idées concrètes. L’analyse de leurs échanges permet de co-construire 5 ébauches de programmes d’éducation à la santé qui, à court terme, pourraient être implantées dans un conservatoire afin d’être testées. À plus long terme, ces résultats invitent à repenser le conservatoire comme un lieu de développement artistique mais aussi de santé, à l’image des Healthy Conservatoires développés au Royaume-Uni.

  Biostatistiques et épidémiologieSémiologieMaladies infectieuses et tropicalesLicence : https://creativecommons.org/licenses/by/4.0/

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  Co-infection paludisme et COVID-19 chez les patients admis au service d’infectiologie COVID du Centre Hospitalier Universitaire de Libreville

  Marielle Igala, Elsa Ayo Bivigou, Ulrich Davy Kombila, Stéphanie Ntsame Ngoua, Jean Felix Ngomas, Adrien Mougougou, Arsène Ifoudji Makao, Charlene Manomba, Irène Augustine Mistoul, Gabrielle Atsame Ebang, Anita Akiko Mbourou, Metogho Essandone, Liliane Flore Pemba, Annick Flore Mfoumou, Fifi Claire Ada Loembe, Léonard Kouegnigan Rerambiah, Jean Bruno Boguikouma, Marielle Karine Bouyou Akotet

  Le travail visait à rapporter les cas de co-infection paludisme - COVID-19, après la recherche systématique de plasmodium chez les patients pris en charge dans les services d´infectiologie COVID (SiCOV) du Centre Hospitalier Universitaire de Libreville (CHUL). Il s´est agi d´une étude prospective, observationnelle menée d´Avril à Juillet 2020 dans les SiCov du CHUL. Les patients des deux sexes, âgés de plus de 18 ans avec un test de réaction de polymérisation en chaîne (PCR) positif pour le SARS-CoV-2 dont le résultat de la goutte épaisse était disponible, ont été inclus. Pour chaque patient les données démographiques (âge, sexe, poids, taille), les antécédents et les examens clinique et biologique étaient reportées dans le fichier excel. Sur un total de 253 patients qui répondaient aux critères d´inclusions, 8 faisaient un accès palustre associé à une PCR à SARS-CoV-2 positive. Il s´agissait de 3 femmes et de 5 hommes d´un âge moyen de 36,9 ans (25-53 ans). Le mode de contamination était inconnu pour 7/8. Tous les patients étaient fébriles, 6/8 avaient des céphalées et 5/8 présentaient une gêne respiratoire. Moins de la moitié des patients avaient des manifestations oto-rhino-laryngées (anosmie, ageusie) ou digestives (diarrhée). Le seul patient qui présentait une forme sévère est décédé au 5e jour de l´hospitalisation. Les similitudes cliniques entre le paludisme et la COVID-19 peuvent prêter à confusion en zone d´endémie palustre. La co-infection paludisme- COVID-19 n´a pas donné lieu à des formes cliniques graves.

  Biologie cellulaire et moléculaireGénétiqueParasitologie et mycologieLicence : https://creativecommons.org/licenses/by/4.0/ The Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (), which permits unrestricted use, distribution, and reproduction in any medium, p

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  Co-infection tuberculose-VIH compliquée d’une sur infection nosocomiale à Klebsiella pneumoniae: à propos de 4 observations dans un Service de Maladies Infectieuses au Mali

  Hermine Meli, Yacouba Cissoko, Issa Konaté, Mariam Soumaré, Assetou Fofana, Jean Paul Dembélé, Mikaila Kaboré, Mohamed Aly Cissé, Abdoulaye Zaré, Sounkalo Dao

  Les infections nosocomiales constituent un problème majeur de santé publique dans le monde. La co-infection VIH-Tuberculose pulmonaire augmente la fréquence des infections nosocomiales, du fait de l´immunodépression et des hospitalisations itératives. Nous présentons quatre (04) patients âgés de 28, 36, 42 et 52 ans, co-infectés de VIH et tuberculose, (tuberculose multifocale chez 2, miliaire tuberculeuse, tuberculose bactériologiquement confirmée), tous ayant un taux CD4 < 100 cellules/mm3. Ils étaient à la phase intensive du traitement antituberculeux et sous antirétroviral (ARV). Ils avaient été admis au Service de Maladies Infectieuses du CHU du Point G pour toux productive, et/ou hyperthermie après des séjours antérieurs de plus de 48 heures en milieux hospitaliers. L´anamnèse avait révélé que l´un n´avait pas été observant au traitement antituberculeux du fait des effets indésirables classés mineurs. Il n´y avait pas eu d´amélioration clinique chez les 3 autres malgré une observance optimale aux différents traitements. L´examen cytobactériologique des expectorations et/ou du liquide de tubage gastrique, les hémocultures, prélèvements spécifiques avaient permis d´isoler Klebsiella pneumoniae multirésistante. Sous antibiothérapie spécifique, l´évolution clinique de ces patients avait été favorable. Les infections nosocomiales peuvent faire penser à tort à une mauvaise réponse thérapeutique lors d´un traitement antituberculeux. L´examen cytobactériologique des liquides biologiques doit être systématique chez les patients co-infectés de VIH-tuberculose. Notamment chez ceux ayant eu des séjours hospitaliers d´au moins 48 heures, et chez qui les signes pulmonaires et/ou la fièvre persistent en dépit d´une bonne observance aux traitements.

  Microbiologie (bactériologie, virologie)ImmunologiePharmacologieLicence : https://creativecommons.org/licenses/by/4.0/ The Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (), which permits unrestricted use, distribution, and reproduction in any medium, p

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  Co-infection tuberculose/VIH et Maladie de kaposi sous traitement de substitution par la méthadone: à propos d’un cas

  Viviane Marie Pierre Cisse Diallo, Louise Fortes Deguenonvo, Khardiata Diallo Mbaye, Daye Ka, Ndeye Aissatou Lakhe, Ibrahima Ndiaye, Daouda Thioub, Sylvie Audrey Diop Nyafouna, Aminata Massaly, Alassane Dièye, Moustapha Diop, Cheikh Tidiane Ndour, Moussa Seydi

  Le diagnostic tardif de l’infection à VIH peut être fatal car favorisant l’apparition d’infections opportunistes dont la prise en charge nécessite l’utilisation de plusieurs molécules pouvant provoquer des interactions médicamenteuses. Nous rapportons le cas d’une patiente de 45 ans, sous traitement de substitution à l’héroïne par la méthadone, VIH1 sous traitement antirétroviral. Cette patiente présentait un tableau pulmonaire non spécifique associant une toux quinteuse sèche avec une dyspnée d’apparition progressive évoluant dans un contexte fébrile. Par ailleurs l’examen notait un lymphœdème du membre inferieur gauche surmontée de nodules angiomateux indolores évoluant depuis trois ans associé à des plaques, des nodules angiomateux d’apparition plus récente au niveau de la face antérieure du thorax. Le GeneXpert sur les crachats avait permis d’isoler Mycobacterium tuberculosis. Le diagnostic retenu était celui d’une tuberculose pulmonaire associée à une maladie de kaposi cutané sur un terrain d’immunodépression au VIH.

  Microbiologie (bactériologie, virologie)ImmunologiePharmacologieLicence : The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  Co-infection VIH chez les tuberculeux suivis au service des maladies infectieuses du CHU Ibn Rochd-Casablanca

  Assiya El Kettani, Sanae Jebbar, Brahim Takourt, Fakhreddine Maaloum, Othman Diraa, Brahim Farouqi, Khalid Zerouali, Kamal Marhoum El Filali

  L'objectif du travail est de déterminer la prévalence de l'infection par le VIH chez les tuberculeux hospitalisés au service des maladies infectieuses du CHU Ibn Rochd-Casablanca et de chercher les facteurs associés à la co-infection Tuberculose-VIH. Nous avons mené une étude transversale rétrospective menée en Novembre 2016, en se basant sur l'exploitation de la base de données du service des maladies infectieuses, des laboratoires de microbiologie et d'immunologie du CHU Ibn Rochd. Etaient inclus les patients ayant une tuberculose confirmée par culture positive sur milieu de Lowenstein Jensen et une infection à VIH confirmée par Western Blot entre Janvier 2013 et Décembre 2015. Au cours de la période de l'étude, 117 cas de tuberculose ont été confirmés par culture. Parmi ces patients, 46 (39,3%) avaient une infection à VIH confirmée. Trente-quatre patients co-infectés (73,9%) avaient une tuberculose extra pulmonaire (cette forme était associée à la co-infection (p=0,04)). Tous les patients ont été mis sous traitement antituberculeux et antirétroviral selon l'indication. L'évolution était favorable chez 32 patients (69,6%) et 10 décès ont été enregistrés (21,7%). La mortalité était plus élevée chez les co-infectés que chez les tuberculeux non atteints par le VIH (8,4%), (p=0,04). Cette étude a objectivé une prévalence relativement élevée de l'infection par le VIH parmi les tuberculeux. La co-infection Tuberculose-VIH est associée aux formes graves de la tuberculose et à une augmentation de la mortalité chez les tuberculeux, d'où l'intérêt du renforcement des activités conjointes de lutte contre cette co-infection.

  Biostatistiques et épidémiologieMicrobiologie (bactériologie, virologie)ImmunologieLicence : The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  Co-infection VIH-tuberculose pulmonaire aux cliniques universitaires de Lubumbashi: aspects épidémiologiques et cliniques

  Patrick Mutombo Tshibang, Georges Yumba Numbi, Eugénie Tshiami Bukasa, Evariste Yav Tshibind, Thierry Kisoka Kimbungu, Serge Ngoie Muleka

  Introductionl'objectif de cette étude est de présenter un aperçu des caractéristiques épidémiologiques et cliniques de la co-infection VIH-tuberculose pulmonaire aux cliniques universitaires de Lubumbashi.Méthodesil s’agit d’une étude descriptive transversale qui a porté sur l’analyse des dossiers de patients tuberculeux qui ont été hospitalisés au service de médecine interne de cliniques universitaires de Lubumbashi, dans le sud-est de la République démocratique du Congo, au cours de l’année 2019.Résultatsla co-infection VIH-tuberculose a concerné 37 patients sur un total de 66 ayant été colligés (56,0%). La tuberculose du patient infecté par le VIH en comparaison avec celle du patient non infecté, dans notre série, était caractérisée par une relative prédominance des patients d´âge supérieur ou égale à 40 ans (56,8% vs 34,4%, p=0,004), du sexe féminin (78,9% vs 46,8%, p=0,01), de cas de récidive (37,8% vs 27,5%), et de l´antécédent de diabète sucré (8,1% vs 3,4%). Un peu plus du tiers des coinfectés, soit 37,4%, provenaient des quartiers périphériques de la ville de Lubumbashi, caractérisés pour la plupart d’entre eux par une conjoncture socio-économique défavorable. Les formes à microscopie négative, donc sans confirmation bactériologique, étaient les mieux représentées parmi les co-infectés (48,6% vs 34,4%). Le taux de décès à l´issue de l´hospitalisation a été de 13,5% chez les co-infectés. Il était associé aux facteurs ci-après: la tuberculose à microscopie positive (21,0% vs 5,5%), le sexe masculin (18,1% vs 6,6%), le diabète sucré (33,3% vs 11,7%) et l´âge supérieur à 40 ans (19,0% vs 6,2%).Conclusionla co-infection VIH-tuberculose pulmonaire est donc une situation fréquente en hospitalisation aux cliniques universitaires de Lubumbashi avec un profil épidémiologique et clinique marqué par la présence de facteurs pouvant impacter négativement son pronostic à court terme.

  Biostatistiques et épidémiologieMicrobiologie (bactériologie, virologie)ImmunologieLicence : https://creativecommons.org/licenses/by/4.0/ The Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (), which permits unrestricted use, distribution, and reproduction in any medium, p

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  Co-spécification système exécutable basée sur des modèles - Application à la conduite interactive d'un procédé industriel critique

  Fabien Bouffaron

  Dans la mesure où un système est un ensemble d'éléments en interaction dont il faut gérer la complexité, la difficulté pour un architecte système est de guider l’architecture d'un modèle « total » de la situation système de conduite étudiée en tant qu'ensemble de modèles « locaux » d’ingénieries interdisciplinaires en interaction. Les travaux présentés dans ce mémoire s’intéressent plus précisément à la nature heuristique, spécifiante et exécutable de cette relation « totale » de couplage de modèles descriptifs de problèmes (RH) et prescriptifs de solutions (Mh) pour construire un modèle virtuel (MH) du système à faire. La perspective holonique retenue permet de considérer cette relation de couplage de façon descriptive (H) du TOUT et prescriptive (h) de chacune des PARTIES aussi bien en regard de la situation-système à percevoir que des constitutifs-système à architecturer. En ce sens, notre environnement collaboratif de co-spécification système vise à supporter un processus itératif basé sur la requête d’éléments de connaissances (Kh) auprès de chacune des ingénieries spécialistes délivrant en retour les modèles constitutifs (Mh) satisfaisant des exigences élémentaires (Rh). Cet environnement de co-modélisation-système est lui-même constitué d’un ensemble d’environnements élémentaires de modélisation de constituants-système, avec pour objectif assigné de préserver les outils, méthodes et processus de travail de chacune des parties prenantes afin de faciliter l’expression de leurs connaissances métier. Le modèle constituant (MH) vise à refléter la satisfaction de la mission (RH) du système requis dans le contexte connu (KH) d’une situation-système d’intérêt, limitée pour notre cas d’étude au facteur d’échelle de la plate-forme d’expérimentation CISPI (Conduite Interactive et Sûre de Procédé Industriel) du projet SAFETECH du CRAN. La technologie de modélisation et de simulation mise en œuvre s’appuie sur le langage de modélisation système « SysML » pour le partage d

  SémiologieMaladies infectieuses et tropicalesMédecine interne (cardiologie, endocrinologie, néphrologie…)Licence : https://creativecommons.org/licenses/by/4.0/

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