Biosimilarity. Do not confuse biosimilar and biocopy. Example of tenecteplase.

Non-innovator biological products (NIBPs) or 'biocopies' are available in several countries at lower prices than biosimilars. These drugs, sometimes so-called 'biosimilars', may not meet all of the quality criteria expected of clinically equivalent products. NIBPs can exhibit major differences in physicochemical and pharmacological properties compared with their reference biological but may be presented to prescribers based on clinical trial data and claimed clinical equivalence. Tenecteplase (TNK-tpA) is a recombinant derivative of tissue plasminogen activator, used as a third-generation thrombolytic agent for treatment of acute myocardial infarction. A TNK-tPA presented as biosimilar to the originator (Metalyse®, Boehringer Ingelheim; TNKase®, Roche/Genentech) is now available for use in India (Elaxim®, Gennova Pharmaceuticals). Elaxim® is not approved in Europe or the USA but has been proposed in several countries as a replacement for the originator. Based on available literature, we discuss why this biocopy cannot be considered biosimilar to the originator tenecteplase. We describe clear differences in physicochemical and pharmacological properties. For example, the biocopy demonstrates clot lysis activity that is substantially lower than the originator and contains high concentrations of foreign proteins that confer potential for immunological reactions. Clinical data on the biocopy are limited; randomized trials to demonstrate the absence of difference in efficacy and safety between the biocopy and originator have not been conducted. This example demonstrates that confirmation of similarity, by close examination of pharmaceutical quality attributes, and preclinical and clinical data, is mandatory before presenting to prescribers a biological product as clinically equivalent.

Factors influencing diagnosis delay of advanced breast cancer in Moroccan women.

BACKGROUND: Delay in the diagnosis of breast cancer in symptomatic women of 3 months or more is associated with advanced stage and low survival. We conducted this study to learn more about the extent and reasons behind diagnosis delay of advanced breast cancer in Moroccan women. METHODS: A group of patients with advanced breast cancer were interviewed at the National Institute of Oncology in Rabat during the period from February to December 2014. Diagnosis delay was devised into patient delay and system delay. Patient delay was defined as time from first symptoms until first medical consultation. System delay was defined as time from first presentation to a health care provider until definite diagnosis or treatment. Prospective information and clinical data were collected on a form during an interview with each patient and from medical records. RESULTS: In all, 137 patients were interviewed. The mean age of women was 48.3 ± 10.4 years. The median of consultation time was 6[4,12] months and the median of diagnosis time was 1[1,3] months. Diagnosis delay was associated to a personal reason in 96 (70.1 %) patients and to a medical reason in 19 (13.9 %) patients. A number of factors predicted diagnosis delay: symptoms were not considered serious in 66 (55.9 %) patients; traditional therapy was applied in 15 (12.7 %) patients and fear of cancer diagnosis and/or treatment in 14 (11.9 %) patients. A use of traditional methods was significantly associated with rural residence and far away from basic health center (p = 0.000). Paradoxically, a family history of breast cancer was significantly higher in who report a fear of cancer diagnosis and/or treatment to diagnosis delay (p < 0.001). Also, a significantly higher risk of more than 6 months delay was found among rural women (P = 0.035) and women who live far away from specialized care center (P = 0.001). CONCLUSIONS: Diagnosis delay is very serious problem in Morocco. Diagnosis delay was associated with complex interactions between several factors and with advanced stages. There is a need for improving breast cancer information in our populations and training of general practitioners to reduce advanced breast cancer by promoting early detection.

[Non-drug psycho-active substance use and pregnancy]. / Grossesse et usage de substances psycho-actives non médicamenteuses.

BACKGROUND: The consumption of psycho-active substances (PAS) by pregnant women is in a growing increase around the world. It is a major problem of public health in some countries due to serious and negative consequences for children and society as well as for pregnant women. This problem has also increased among women in Morocco. However, it is still neglected and underrated in the absence of any official statistical data. This is the first study leading to a better profiling of pregnant women who may consume psycho-active substances during their pregnancy; it would permit better medical and psychosocial care of both women and children. OBJECTIVES: To determine the prevalence and the factors associated with the psycho-active substances used by pregnant women and describe their socio-demographic characteristics. METHODS AND PATIENTS: A trans-sectional study was carried out from September to October 2010, including pregnant women consulting at the obstetrical service of the provincial hospital Moulay Abdellah in the city of Salé. The study included women who were pregnant or had recently given birth, and not having any serious mental disorders that could have upset their cognitive abilities. The data was collected through a straight questionnaire of 25 items specifying the socio-demographic characteristics, data about pregnancy and habits of using psycho-active substances. RESULTS: One hundred and fifty pregnant women were included in the study. The majority of them (83.2%) were aged 20 to 40 years old, 94.6% were married, 96% were unemployed and depended on their spouses for their financial resources and 80% had normal domestic relationships (from average to good quality). Among the women, 31.3% of them reported traumatic events in the past. The prevalence of psycho-active substance consumption by the pregnant women of our sample was 11.3%. The used substances were tobacco (9.3%) and cannabis (4%). These women were more likely to have a low level of education (47.1 vs 16.5). They were victims of abuse or neglect in their past (82.3 vs 24.9), and their relationships with their spouses were bad (70.6 vs 13.5) with a lack of desired pregnancy (47.1 vs 27.8) and poor follow-up (47.1 vs 3.8). The results show statistically significant differences. CONCLUSION: Not only should decision-makers draw attention to the seriousness of the problem because of the relatively high rate of psycho-active substance consumption, but also they should increase obstetric team's awareness to look systematically for psycho-active substance use.

Knowledge and management of fever among Moroccan parents.

Parents often have misperceptions about childhood fever, and little information is available about the home management of feverish children in Morocco. In this study of the perceptions, knowledge and practices of families regarding children's fever, the parents of 264 febrile children aged 0-16 years were interviewed in a paediatric emergency department in Rabat in 2011. Only 3.5% of parents knew the correct temperature definition for fever, 54.4% determined their children's fever using a thermometer, and the preferred site was rectal. Most of them (96.8%) considered that fever was a very serious condition, which could lead to side-effects such as brain damage (28.9%), seizures (18.8%) paralysis (19.5%), dyspnoea (14.8%) and coma (14.8%). Paracetamol was used by 85.9% and traditional treatments by 45.1%. Knowledge about the correct definition of fever was significantly associated with parents' profession, educational level and receipt of previous information and advice from health professionals.

[Systemic candidiasis in medical intensive care unit: analysis of risk factors and the contribution of colonization index]. / Les candidoses systémiques en réanimation médicale : analyse des facteurs de risque et intérêt de l'index de colonisation.

OBJECTIVES: Description of the epidemiological and clinical characteristics of the patients introducing risk factors of invasive candidiasis. Analysis of risk factors for candidiasis invasive and evaluation of the contribution of colonization index (CI) in the diagnosis of the systematic candidiasis in medical intensive care. PATIENTS AND METHODS: Prospective observational study (October 2007 to October 2009). The selected patients present risk factors of system IC candidiasis with an infectious syndrome or clinical signs suggestive of Candida infection and hospitalized more than 48 hours in medical intensive care unit. Pittet's colonization index was calculated at admission and then once a week added to a blood culture. Patients were classified according to level of evidence of Candida infection and the degree of colonization (CI<0.5, CI ≥ 0.5). RESULTS: The study included 100 patients. Mean age of our patients was 55.8 ± 18.2 years with male prevalence. Neurological disease was the most frequent pathology in admission (48%). The most common risk factors were broad-spectrum antibiotics and foreign material. In the various mycology IC specimens, Candida albicans was the most frequent, followed by C. tropicalis, then C. glabrata. The CI was greater than or equal to 0.5 at 53% of the patients, and less than 0.5 in 47% of the cases. Among the patients, 15% developed an invasive candidiasis. In multivariate analysis, the corticosteroid therapy was associated with a high colonisation (IC ≥ 0.5) and neutropenia with a high risk of systemic candidiasis. The positive predictive value of CI was 26%. The negative predictive value was 98%, the sensitivity and specificity was 93% and 48% respectively. CONCLUSION: CI has the advantage to provide a quantified data of the patient's situation in relation to the colonization. But, it isn't helpful with patients having an invasive candidiasis in medical intensive care unit.

Trends in antihypertensives use among Moroccan patients.

PURPOSE: In this study, we analyzed the consumption trends of antihypertensives in Morocco during the 1991-2010 period and the impacts after the institution of Mandatory Health Insurance and the marketing of generic drugs. METHODS: We used sales data from the Moroccan subsidiary of IMS Health "Intercontinental Marketing Service". The consumption volumes were converted into defined daily doses (DDDs). RESULTS: Between 1991 and 2010, outpatient consumption of antihypertensives went from 4.37 to 23.14 DDD/1000 inhabitants/day, a 5.30-fold increase. In 2010, calcium channel blockers (CCBs) and angiotensin converting enzyme inhibitors (ACEI) were the most consumed (4.97 DDD/1000 inhabitants/day) for each one, followed by diuretics (4.20 DDD/1000 inhabitants/day). The most consumed products were amlodipine (4.27 DDD/1000 inhabitants/day) followed by ramipril (3.18 DDD/1000 inhabitants /day) and indapamide (1.72 DDD/1000inhabitants/day). Between 1991 and 2010, the consumption of generic antihypertensives went from 2% to 46%. CONCLUSION: Antihypertensive consumption increased between 1991 and 2010. However, despite the increase of generic drugs consumption, the levels of antihypertensive consumption remain lower than the needs of hypertensive patients.

[Pharmacoepidemiolgy: regulatory basis, methodological approaches and scope]. / La pharmacoépidémiologie: bases réglementaires, approches méthodologiques et champ d'application.

Pharmacoepidemiology is a discipline that studies the use of drugs and evaluation of their beneficial or adverse effects on large populations. It requires compliance with laws and maintaining a regulatory approach in order to ensure confidentiality and protection of personal data. It also requires good knowledge of drugs and diseases and the use of the different available data sources. Pharmacoepidemiology incorporates epidemiological methods (cohort, case-control and cross-sectional studies) where the exposure is drug intake. These methods must be applied at the conception of the pharmacoepidemiological study in order to minimize the effect of bias hich can lead to false conclusions. This paper reviews the regulatory basis, methodological approaches and scope of pharmacoepidemiology.

[Prevalence of metabolic syndrome in chronic haemodialysis patients in Morocco]. / Prevalence du syndrome métabolique chez les hemodialyses chroniques au Maroc.

We determined the prevalence of metabolic syndrome in 25 chronic haemodialysis patients in the haemodialysis centre of the Mohammed V military teaching hospital in Rabat. The mean age of the patient as was 46.5 (SD 14.8) years and mean haemodialysis duration 62.9 (SD 38.4) months. We evaluated the 5 parameters of metabolic syndrome: waist circumference, hypertriglyceridaemia, high-density lipoprotein (HDL) cholesterol, blood pressure and blood glucose. In all, 11 (44%) patients had metabolic syndrome: 7 women and 4 men. Low HDL cholesterol was found in 100% of the patients, hypertriglyceridaemia in 90.9% and hypertension in 63.6%. There were significant differences between patients with and without metabolic syndrome with regard to levels of hypertriglyceridaemia and HDL cholesterol, and waist circumference. Factors significantly associated with the presence of metabolic syndrome were abdominal obesity, and systolic hypertension and aypertriglyceri daemia.

Results of a public awareness campaign in Morocco regarding the sun's deleterious effects.

OBJECTIVE: To investigate knowledge of the various sun radiation-related risks and awareness of photoprotection measures using a sample of the Moroccan population. METHODS: An investigation of prevalence, which was administered while a public awareness campaign on the sun's harmful effects, organized by the department of dermatology of Ibn Sina's hospital in Rabat, was running. The collection of the data was made on the basis of a questionnaire that was filled by the team of the doctors of the department. The logistic regression allowed to identify the explanatory factors for the prevalent knowledge and behaviours related to the subject in hand. RESULTS: Four hundred eleven subjects were included in the survey. The subjects' average age was 40 +/- 10 years. Eighty-four per cent were female. The analysis of the total score of knowledge related to the sunrays' deleterious effects demonstrated low levels of knowledge among 160 participants (38.9%). Females were clearly more knowledgeable than the opposite sex (P = 0.003) and also those having a higher educational level (P = 0.006) scored high. The use of sunscreens was recognized by 52.8% of the patients and was associated with female gender and higher educational level. CONCLUSION: Our study reports the results of the first public awareness campaign on the sun's deleterious effects on the Moroccan population, inclusive and relevant to all ages. Awareness of the sun's radiation-related risks in a country as sunny as ours is low, whereas different measures of photoprotection are rather well known. Messages adapted to the characteristics of our population are a necessity.

[Comparison of the calcium intake during and before Ramadan in Marrakesh, Morocco]. / Comparaison de la ration calcique pendant et en dehors du mois de ramadan dans la région de Marrakech (Maroc).

We studied the effect of Ramadan fasting on calcium intake in 2 groups of 500 healthy subjects from Marrakesh using the colloquial Arabic version of the Fardellone questionnaire. The first group was investigated 5 months before Ramadan and the second during Ramadan. No significant difference was observed between the 2 groups. However, comparison of the pre-Ramadan and Ramadan periods for each age group showed a significant increase in calcium intake in subjects over 60 years. During Ramadan, consumption of milk was significantly higher, while consumption of other dairy products was not different. Overall, no significant difference in calcium intake was noted between pre-Ramadan and Ramadan periods.

[Prevalence of hepatitis C virus infection in Morocco and serological tests assessment of detection for the viremia prediction]. / Prévalence de l'infection par le virus de l'hépatite-C au Maroc et évaluation des tests sérologiques de dépistage pour la prédiction de la virémie.

UNLABELLED: This study aims at assessing the prevalence of hepatitis C virus infection (HCV) in Moroccan general population and the efficacy of different virological tests in detection of the viral RNA in order to promote its screening. METHODS: From December 1st 2005 to April 30th 2007, the prevalence of the anti-HCV antibodies was determined for 8326 people. The mean age was 42.3+/-11.2 years (18 to 87 years) and sex ratio man/woman: 1.6. The determination of the anti-HCV antibodies in our sample has been achieved by the third generation ELISA. Among the detected cases as anti-HCV negative, 100 have been assessed by two other methods: AxSYM HCV and (Acon HCV): a fast test using immune chromatography on the membrane. Furthermore, the ELISA positive cases, 158 have been tested by the two previous techniques and submitted to viral RNA research by RT-PCR. The detection threshold has been fixed at 50 Ul/ml. RESULTS: The anti-HCV prevalence determined by ELISA was estimated at 1.93%. The mean age of the positive cases was 50.4 years. The viremia prevalence for positive anti HVC was 39%. The assessment of the methods AxSYM HCV, Acon and PCR compared to ELISA showed that the 100 anti negative VHC cases were also negative for the two other tests. For the 158 anti-VHC positive cases by ELlSA, 100 were also positive by AxSYM HCV, 78 by Acon HCV and 61 were RNA positives. The comparison of the anti-VHC positive results achieved by AxSYM HCV and Acon HCV methods with those related to the presence of viral RNA, showed that the AxSYM HCV method has a sensitivity=100%, a specificity=60%, a positive predictive value=61% and a negative predictive value of 100%. Whereas for the Acon HCV, the sensitivity was 99%, the specificity 87%, the positive predictive value 82% and the predictive negative=100%. CONCLUSION: The prevalence of anti-HCV obtained by ELISA has been overestimated. It is necessary to use more specific tests to reduce the risk to announce a false positive result to the patient and to reduce the expenses due to the realization of PCR in case of false positives.

[Efficacy and safety of cyclophosphamide treatment in progressive multiple sclerosis]. / Efficacité et tolérance du cyclophosphamide dans le traitement de fond des formes progressives de la sclérose en plaques.

INTRODUCTION: Cyclophosphamide (CPM) is used empirically in the treatment of progressive multiple sclerosis. The purpose of this study was to evaluate its efficacy in naive patients with progressive multiple sclerosis. PATIENTS AND METHODS: Thirty-one patients were retrospectively included (17 secondary multiple sclerosis, 14 primary progressive multiple sclerosis), and received infusions of CPM (600mg/m(2)) every eight weeks, for 18 months. Evaluation was based on time to EDSS progress. RESULTS: Among patients with secondary progressive multiple sclerosis, 94% were stable or improved at six months, 77% at 12 months, and 75% at 18 months. The same result was reported in 69.2% of primary progressive multiple sclerosis at six months, 64% at 12 months, and 55.5% at 18 months. We found no difference between the two groups. CONCLUSION: Our results suggest that the CPM is efficient in progressive multiple sclerosis; however, its place must be reconsidered before establishing an international consensus for treatment; open label studies are needed to validate the present findings.

Analysis of the drug formulary and the purchasing process at a Moroccan university medical center.

AIM: To give an overview of the pharmaceutical policy in the largest medical center in Morocco, a developing country in socio-economic transition. METHODS: This is an analytical descriptive study of the drug formulary and the purchasing process carried out at the Ibn Sina University Medical Center. RESULTS: Our formulary included 830 drugs belonging to 14 classes according to the Anatomical, Therapeutic and Chemical (ATC) Classification System. There was a respective predominance of class N (21.8%), class B (13.5%), and class J (12.6%). Injectable route was dominant (46%). Drugs had a significant actual benefit in 70% (according to the French Data), reimbursable in 42.8%, essential in 29.2% according to World Health Organization (WHO) list, and in 36.9% according to the Moroccan list. The calls for tenders included 542 drugs representing 65% of the formulary, and the attribution rate was 71%. The main reason for non-attribution was the lack of offers. Generics accounted for 45% by volume and 26.5% by value. CONCLUSION: With this first study, we were able to identify key indicators on drugs used in the largest medical center in Morocco. The current challenge is to introduce pharmacoeconomics in decision making concerning the updates of the drug formulary.

Hyperparasitism in Amblyomma rotundatum (Acari: Ixodidae).

In the present study, we report a case of hyperparasitism in Amblyomma rotundatum. During examination of live ticks immediately after collecting them from Boa constrictor snakes held in a reptile facility in Mossoró, RN, northeastern Brazil, 1 unengorged tick female was seen attached to the venter of a partially engorged female. The hypostome and chelicerae of the unengorged female had penetrated the integument of the partially engorged female to the level of the basis capitulli and the palps were splayed outward. To our knowledge, we present the second report of hyperparasitism for the genus Amblyomma.

[Canine heartworm on São Luís Island, Northeastern Brazil: a potential zoonosis]. / Dirofilariose canina na Ilha de São Luís, Nordeste do Brasil: uma zoonose potencial.

A survey on the prevalence of canine heartworm was conducted in 1, 495 dogs from Maranhão Island, State of Maranhão, Northeastern Brazil, from 1991 to 1994, by testing for microfilariae in blood. Of the total, 1,358 (12.8% of which were infected) were dogs with no known history; they included 1,265 homeless animals (10.3% with microfilariae) and 93 kept by owners at the time the survey was conducted (37.8% of which were infected). Prevalence is high among dogs captured and/or living along the seashore. Examples of such high coastal prevalence rates were found in Olho d'Agua and Calhau (46% and 43%, respectively). The search for microfilariae in blood samples of 137 exclusively domiciliary dogs with a known history showed that 43% of these animals were infected, confirming transmission of heartworm on the island. This was the first survey formally published on canine dirofilariasis in Northeastern Brazil. Since D. immitis is infective to man and prevalence of the parasite is high, particularly along the coast of Maranhão Island, human cases of dirofilariasis may be expected. Local physicians should consider this parasite among the possible causes of solitary lesions in humans living in this area.

[Mosquitoes potential vectors of canine heartworm in the Northeast Region from Brazil]. / Mosquitos vetores potenciais de dirofilariose canina na Região Nordeste do Brasil.

INTRODUCTION: In some coastal districts of São Luís, capital of the state of Maranhão, Brazil, the prevalence of Dirofilaria immitis is more than 40% in house dogs. Natural potential vectors, as found in other areas of Northeastern Brazil, are unknown. The aim of this study was to identify probable vectors of the disease. METHODS: Mosquito catches were performed at a coastal, district Olho d'Agua, in S. Luís, to look for local potential vectors. Captures were carried out monthly, from March 1996 to May 1997, outdoors, having a man and a dog as baits. Mosquitoes were dissected for D. immitis larvae. RESULTS: A total of 1,738 mosquitoes belonging to 11 species were collected. Culex quinquefasciatus, the only species collected every month, was more frequently in the dry season. It accounted for 54.5% of the total, followed by Aedes albopictus (20. 3%), Ae. scapularis (11%) and Ae. taeniorhynchus (11%). D. immitis larvae were detected in 0.1% of the Cx. quinquefasciatus dissected (L3 in the Malpighian tubules) and 0.5% of the Ae. taeniorhynchus (L2 in the Malpighian tubules). CONCLUSION: Ae. taeniorhynchus and Cx. quinquefasciatus are considered natural potential vectors of the canine heartworm in São Luís. The role of Cx. quinquefasciatus as primary vector of D. immitis, however, needs further evaluation.

[Factors influencing the development of chondrolysis in children treated for slipped capital femoral epiphysis]. / Facteurs de risque de chondrolyse chez les enfants traités pour épiphysiolyse fémorale supérieure.

INTRODUCTION: Chondrolysis is an infrequent but serious complication of the treatment of slipped capital femoral epiphysis. The objective of this study was to identify factors influencing the development of chondrolysis. PATIENTS AND METHODS: The medical records of the patients operated on between 1989 and 2009 at the Rabat Children's Hospital for treatment of slipped capital femoral epiphysis were retrospectively evaluated. The minimum follow-up was 24 months. The risk of development of chondrolysis was correlated with various parameters. Statistical analysis was performed using a logistic regression model (binary outcome). RESULTS: A total of 140 patients were included in this study. The average age was 13 years and 4 months. The incidence of chondrolysis was 11.4% (16 patients). Chondrolysis was significantly associated with obesity (25%, P<0.001) and with a delay in the diagnosis of slipped capital femoral epiphysis exceeding 60 days (75%, P=0.01) DISCUSSION: In this series, intra-articular pin penetration is not a risk factor for chondrolysis. The association of obesity and a diagnosis delay beyond 60 days increases the risk of occurrence of chondrolysis in children operated on for slipped capital femoral epiphysis. Chondrolysis can be prevented mainly through early diagnosis of slipped capital femoral epiphysis.

[Birth-related retinal hemorrhages in the newborn: incidence and relationship with maternal, obstetric and neonatal factors. Prospective study of 2,031 cases]. / Hémorragies rétiniennes liées à l'accouchement chez le nouveau-né : fréquence et relation avec les facteurs maternels, néonataux et obstétricaux. Étude prospective de 2031 cas.

PURPOSE: To assess the prevalence, morphology and distribution of retinal hemorrhages in healthy newborns and their relationship to neonatal, maternal and obstetrical factors, and to determine their natural history. PATIENTS AND METHODS: The present study prospectively included 2,031 consecutive healthy newborns. Indirect ophthalmoscopy was performed within 24 hours after birth in all newborns. Infants with retinal hemorrhages were reexamined weekly until the hemorrhage resolved. Annual ophthalmologic follow-up was also scheduled in these children. Neonatal, maternal and obstetric parameters were analyzed in all newborns and compared between newborns with retinal hemorrhages and those without retinal hemorrhages. RESULTS: 31.8 % of newborns exhibited retinal hemorrhages. 72.6 % of hemorrhages were bilateral. They tended to be localized around the optic discs and in the posterior pole, but their distribution was variable. Retinal hemorrhages were of variable shapes. The prevalence of retinal hemorrhages was higher in newborns delivered with vacuum-assisted extraction (38 %, P<0.001), intermediate during normal vaginal delivery (32.6 %, P<0.001) and lower with cesarean section (20.8 %). Comparative analysis between elective cesarean section and emergency cesarean showed a higher incidence of retinal hemorrhages in the emergency cesarean group (P=0.006). On multivariate analysis, vacuum-assisted delivery was the only factor associated with a higher prevalence of retinal hemorrhages in newborns (P=0.045). Two thirds of hemorrhages had disappeared by one week after birth. Retinal hemorrhages had resolved in all newborns within four weeks. CONCLUSION: Birth-related retinal hemorrhages are common (1/3 of our newborns). Vacuum-assisted delivery is the main risk factor in this study. All hemorrhages resolved by one month of age. These findings may help in differential diagnosis with shaken baby syndrome.

[Internal jugular venous cannulation: what is the best approach?]. / Cathétérisme veineux jugulaire interne : quelle est la meilleure voie d'abord ?

OBJECTIVES: The aim of this study was to compare two approaches used for internal jugular venous cannulation: the anterior way, described by English et al. and the posterior way, described by Jernigan et al. The primary endpoint was the rate of success. The secondary endpoints were the related adverse events and the difficulty factors. STUDY DESIGN: Prospective, randomized open clinical trial. PATIENTS AND METHODS: The study took place in the vital emergency room, the operating room and the emergency intensive care unit of Ibn Sina University hospital (Rabat, Morocco), between June and September 2010. Hundred and one patients needing a central venous catheter were randomized to undergo one of the two techniques. We compared: demographics, success rates, number of attempts, difficulty factors and adverse events. RESULTS: The success rate was significantly higher in the posterior group (96% versus 68%, P < 0.001), with fewer attempts (1.3 ± 0.7 versus 2.1 ± 1.3; P < 0.001). There were less pneumothorax, (0 versus 6%) and more accidental arterial punctures (34 versus 25.5%) in the posterior group, but the difference wasn't significant. Finally, none of the difficulty factors were correlated to the failure rate. CONCLUSION: This study shows that the posterior approach in internal jugular venous cannulation is more efficient than and as safe as the anterior approach.

[Contribution of closed mitral commissurotomy in the surgery of rheumatic mitral stenosis]. / Apport de la commissurotomie à cœur fermé dans la chirurgie de la sténose mitrale rhumatismale.

UNLABELLED: The objective of this work was to study the indications, techniques and results of closed heart mitral commissurotomy in patients with rheumatic mitral stenosis in Morocco. METHODS: All patients who had undergone closed heart mitral commissurotomy for rheumatic mitral stenosis, operated between 1999 and 2008 were collected in this study. Mitral stenosis was diagnosed and evaluated using Doppler echocardiography. Patients with commissural calcification, severe mitral regurgitation, and surgical tricuspid or aortic valvular disease were excluded from this study. RESULTS: Six hundred and twenty-five patients have been collected. 62.2% were young with an age between 18 and 35 years and 491 (78.8%) were female. Seventy-nine percent of patients had stage III or IV NYHA and were in sinus regular rhythm. The closed heart mitral commissurotomy was performed for all patients through a left thoracotomy using either digital or dual dilatation. The mitral area was significantly increased postoperatively to 2.11 ± 0.32 with 100% opening of the anterior commissure, while the posterior commissure was opened only for 93.7% of patients. There were nine perioperative deaths (4.9%) and all patients who died had severe mitral stenosis (<0.8 cm(2)) with an elevated systolic pulmonary artery pressure (>60 mmHg). CONCLUSION: The closed heart mitral commissurotomy provides excellent results in young patients with rheumatic mitral stenosis.