Le sens de l’urgence à l’hôpital

ArticleLes services hospitaliers d’urgences, initialement créés pour accueillir les pathologies aiguës et graves, sont aujourd’hui confrontés à des exigences multiples. Ils doivent non seulement répondre aux situations d’urgences vitales, mais aussi combler les lacunes de l’offre sanitaire et sociale en matière de prise en charge de pathologies bénignes ou de problèmes sociaux. Face aux phénomènes chroniques d’engorgement, les politiques hospitalières s’orientent vers une restriction de l’accueil au noyau des pathologies graves. Les protocoles de triage permettent ainsi de hiérarchiser les priorités sur la base des critères cliniques préétablis. Mais derrière le modèle de tri normatif, se trouve une réalité autrement complexe, susceptible d’adaptations et d’arrangements, dérogeant à la rigueur des normes officielles pour s’ouvrir à la particularité des situations rencontrées. À partir d’une enquête par immersion menée pendant trois ans au sein d’un service hospitalier d’urgences, la recherche ici présentée démontre que la gestion des priorités, loin de ne dépendre que des seules normes réglementaires, s’adapte et se modifie en fonction des habitus et des usages de la médecine hospitalière. Face à des exigences multiples, les professionnels se trouvent confrontés à de véritables dilemmes moraux et à des contradictions quotidiennes entre solidarité, humanité, tri des patients, gestion des priorités et impératifs économiques. Au quotidien, les soignants de l’urgence tentent de prioriser leurs actes en conciliant les contraintes morales et organisationnelles liées à leur fonction. Ils se voient ainsi imposer de multiples défis éthiques qui interrogent le sens de l’urgence, la responsabilité face au risque et les enjeux de l’institution hospitalière.Hospital emergency services, initially created to accommodate acute and serious diseases, are now confronted by multiple requirements. They must not only respond to vital emergency situations, but also fill the gaps in the health and social services provided for benign conditions or social problems. Given the phenomena of chronic congestion, hospital policies are moving towards a restriction on intake for a core of serious diseases. Triage protocols permit the ranking of priorities on the basis of pre- established clinical criteria. But behind this normative model for priority setting stands a much more complex reality, susceptible to adaptations and arrangements that depart from strict official standards and respond to the particularity of the situations encountered. Based on a three-year immersive study in a hospital emergency service, this current paper shows that the management of priorities, far from depending only on regulatory standards, adapts and changes according to the habits and uses of hospital medicine. Faced with multiple requirements, professionals are confronted with genuine moral dilemmas and daily contradictions between solidarity, humanity, patient triage, managing priorities and economic imperatives. On a daily basis, emergency caregivers attempt to prioritize their actions by reconciling legal and organizational constraints related to their function. They face many ethical challenges that question the meaning of emergency, the responsibility towards risk and the challenges of the hospital institution

Méthadone ou torture ?

Pour la première fois, la Cour européenne des droits de l’homme basée à Strasbourg se penche sur la question de savoir si les patients dépendants à l’héroïne ont un droit à poursuivre leur traitement à base de méthadone lorsqu’ils sont privés de leur liberté. S’appuyant sur l’art. 3 de la Convention, lequel interdit la torture comme les autres traitements inhumains et dégradants, la Cour estime que c’est à l’Etat, qui entend refuser l’accès à la méthadone, de prouver – sur la base d’une expertise indépendante – qu’une approche médicale autre que celle fondée sur un médicament agoniste aurait de sérieuses chances de succès dans le traitement de la dépendance du patient en cause. La présente contribution discute la portée et les limites de cet arrêt

High prevalence of the arginine catabolic mobile element in carriage isolates of methicillin-resistant Staphylococcus epidermidis

Background The arginine catabolic mobile element (ACME) associated with staphylococcal cassette chromosome mec (SCCmec) in the USA300 clone of community-acquired methicillin-resistant Staphylococcus aureus enhances its fitness and ability to colonize the host. Staphylococcus epidermidis may act as a reservoir of ACME for S. aureus. We assessed the diffusion of ACME in methicillin-resistant S. epidermidis (MRSE) isolates colonizing outpatients. Methods Seventy-eight MRSE strains isolated in outpatients from five countries were characterized by multilocus sequence typing (MLST) and SCCmec typing and screened for the arcA and opp3AB markers of ACME. ACME-arcA and ACME-opp3AB were sequenced. ACME type I from MRSE and USA300 were compared by long-range PCR (LR-PCR). Results Fifty-three (67.9%) MRSE strains carried an ACME element, including 19 (24.4%), 32 (41.0%) and 2 (2.6%) with ACME type I (arcA+/opp3AB+), II (arcA+/opp3AB−) and III (arcA−/opp3AB+), respectively. The prevalence of ACME did not differ between clonal complex 2 (42/60 strains) and other sequence types (11/18 strains, P = 0.7), with MLST data suggesting frequent intraspecies acquisition. ACME-arcA sequences were highly conserved, whereas ACME-opp3AB displayed 11 distinct allotypes. ACME was found in 14/29, 9/11 and 30/37 strains with type IV, type V and non-typeable SCCmec, respectively (P = 0.01). ACME was more frequently associated with ccrC than with ccrAB2 (82.4% versus 60.0%, P = 0.048). LR-PCR indicated structural homologies of ACME I between MRSE and USA300. Conclusions ACME is widely disseminated in MRSE strains colonizing outpatients and may contribute to their spread in a community environment with low antibiotic exposure, as suggested for USA30

Temporal and spatial structure of multi‐millennial temperature changes at high latitudes during the Last Interglacial

The Last Interglacial (LIG, 129–116 thousand of years BP, ka) represents a test bed for climate model feedbacks in warmer-than-present high latitude regions. However, mainly because aligning different palaeoclimatic archives and from different parts of the world is not trivial, a spatio-temporal picture of LIG temperature changes is difficult to obtain. Here, we have selected 47 polar ice core and sub-polar marine sediment records and developed a strategy to align them onto the recent AICC2012 ice core chronology. We provide the first compilation of high-latitude temperature changes across the LIG associated with a coherent temporal framework built between ice core and marine sediment records. Our new data synthesis highlights non-synchronous maximum temperature changes between the two hemispheres with the Southern Ocean and Antarctica records showing an early warming compared to North Atlantic records. We also observe warmer than present-day conditions that occur for a longer time period in southern high latitudes than in northern high latitudes. Finally, the amplitude of temperature changes at high northern latitudes is larger compared to high southern latitude temperature changes recorded at the onset and the demise of the LIG. We have also compiled four data-based time slices with temperature anomalies (compared to present-day conditions) at 115 ka, 120 ka, 125 ka and 130 ka and quantitatively estimated temperature uncertainties that include relative dating errors. This provides an improved benchmark for performing more robust model-data comparison. The surface temperature simulated by two General Circulation Models (CCSM3 and HadCM3) for 130 ka and 125 ka is compared to the corresponding time slice data synthesis. This comparison shows that the models predict warmer than present conditions earlier than documented in the North Atlantic, while neither model is able to produce the reconstructed early Southern Ocean and Antarctic warming. Our results highlight the importance of producing a sequence of time slices rather than one single time slice averaging the LIG climate conditions

A global database for metacommunity ecology, integrating species, traits, environment and space

The use of functional information in the form of species traits plays an important role in explaining biodiversity patterns and responses to environmental changes. Although relationships between species composition, their traits, and the environment have been extensively studied on a case-by-case basis, results are variable, and it remains unclear how generalizable these relationships are across ecosystems, taxa and spatial scales. To address this gap, we collated 80 datasets from trait-based studies into a global database for metaCommunity Ecology: Species, Traits, Environment and Space; “CESTES”. Each dataset includes four matrices: species community abundances or presences/absences across multiple sites, species trait information, environmental variables and spatial coordinates of the sampling sites. The CESTES database is a live database: it will be maintained and expanded in the future as new datasets become available. By its harmonized structure, and the diversity of ecosystem types, taxonomic groups, and spatial scales it covers, the CESTES database provides an important opportunity for synthetic trait-based research in community ecology

Retrieving the paleoclimatic signal from the deeper part of the EPICA Dome C ice core

International audienceAn important share of paleoclimatic information is buried within the lowermost layers of deep ice cores. Because improving our records further back in time is one of the main challenges in the near future, it is essential to judge how deep these records remain unaltered, since the proximity of the bedrock is likely to interfere both with the recorded temporal sequence and the ice properties. In this paper, we present a multiparametric study (δD-δ18Oice , δ18Oatm , total air content, CO2 , CH4 , N2O, dust, high-resolution chemistry , ice texture) of the bottom 60 m of the EPICA (European Project for Ice Coring in Antarctica) Dome C ice core from central Antarctica. These bottom layers were subdivided into two distinct facies: the lower 12 m showing visible solid inclusions (basal dispersed ice facies) and the upper 48 m, which we will refer to as the " basal clean ice facies ". Some of the data are consistent with a pristine paleocli-matic signal, others show clear anomalies. It is demonstrated that neither large-scale bottom refreezing of subglacial water , nor mixing (be it internal or with a local basal end term from a previous/initial ice sheet configuration) can explain the observed bottom-ice properties. We focus on the high-resolution chemical profiles and on the available remote sensing data on the subglacial topography of the site to propose a mechanism by which relative stretching of the bottom-ice sheet layers is made possible, due to the progressively confining effect of subglacial valley sides

Prevalence, Clinical Staging and Risk for Blood-Borne Transmission of Chagas Disease among Latin American Migrants in Geneva, Switzerland

Chagas disease, a parasitic disease caused by Trypanosoma cruzi, is a leading cause of cardiac and digestive tract disorders in Mexico, Central and South America. An increasing number of cases have recently been reported in North America and Europe due to international human migration, but data outside Latin America remains scarce. This study showed that Chagas disease is an emerging health problem in Switzerland, affecting a substantial proportion of Latin American migrants (13%). Persons at increased risk of infection were Bolivian, older than 35 years or had a mother infected with T. cruzi. Early signs of cardiac or digestive tract disease were found in one out of six infected patients. The risk of local transmission by blood transfusion or organ transplant was illustrated by the frequent willingness expressed by patients to donate blood or organs in Switzerland. The authors recommend the screening of persons at risk of infection and the diffusion of appropriate information to the medical community to increase awareness of this emerging health problem. Considering that affected persons frequently lack health insurance in Switzerland, a facilitated access to medical care is an important step towards better recognition and management of Chagas disease

Drosophila microRNAs 263a/b Confer Robustness during Development by Protecting Nascent Sense Organs from Apoptosis

microRNA-263a/b confer robustness to sense organ development by controlling expression of the pro-apoptotic gene hid during apoptotic tissue pruning in Drosophila

No detection of methane on Mars from early ExoMars Trace Gas Orbiter observations

The detection of methane on Mars has been interpreted as indicating that geochemical or biotic activities could persist on Mars today. A number of different measurements of methane show evidence of transient, locally elevated methane concentrations and seasonal variations in background methane concentrations. These measurements, however, are difficult to reconcile with our current understanding of the chemistry and physics of the Martian atmosphere, which-given methane's lifetime of several centuries-predicts an even, well mixed distribution of methane. Here we report highly sensitive measurements of the atmosphere of Mars in an attempt to detect methane, using the ACS and NOMAD instruments onboard the ESA-Roscosmos ExoMars Trace Gas Orbiter from April to August 2018. We did not detect any methane over a range of latitudes in both hemispheres, obtaining an upper limit for methane of about 0.05 parts per billion by volume, which is 10 to 100 times lower than previously reported positive detections. We suggest that reconciliation between the present findings and the background methane concentrations found in the Gale crater would require an unknown process that can rapidly remove or sequester methane from the lower atmosphere before it spreads globally