La problématique de gouvernance sanitaire au nord de l’Afrique : cas du Maroc, de l’Algérie et de la Tunisie

Depuis leur indépendance, les pays du Maghreb central ont vécu des transitions différentes : démographique, organisationnelle, politique, mais également épidémiologique et sanitaire. Les trois pays : le Maroc, l’Algérie et la Tunisie ont essayé à maintes reprises la reconstruction et la réforme de leurs systèmes de santé. Ces derniers font l’objet de critiques des citoyens de ces trois pays. Ces critiques portent, entre autres, sur leur inefficacité et leur non pertinence, l’absence ou le manque des ressources, la vétusté de leurs plateaux techniques, la mauvaise qualité des services sanitaires, etc. Le présent article essaie d’analyser la gouvernance des trois systèmes de santé en utilisant l’approche systémique, à travers laquelle nous avons confronté ces systèmes aux quatre principaux attributs de la bonne gouvernance, et d’évaluer la capacité de ces pays à relever les défis et à gagner le pari des objectifs du Millénaire pour le développement relatifs à la santé. Notre méthodologie basée sur l’observation, la revue de la littérature et l’exploration des données nous a permis de constater de nombreuses lacunes dont la persistance constitue une réelle entrave au développement des trois systèmes.Mots clés : Maghreb central, systèmes nationaux de santé (SNS), analyse systémique, bonne gouvernance sanitaire (BG), objectifs du Millénaire pour le développement

An investigation into the effect of process parameters on carbon film physical properties produced by different deposition techniques

This thesis reports research to investigate the effect of process parameters on the physical properties of carbon films produced using different deposition techniques. The deposition techniques utilised are a FAB source, an r.f./d.c. EBPVD system and a hot filament CVD system.The findings of this study indicate that the films produced by the FAB source technique are relatively hard (-2000 HK at 25g). Occasionally some films showed a hardness up to 8000HK due, in part, to elastic recovery during testing. FAB source films are transparent in the infrared, however they suffer from a relatively poor transmission in the visible. The optical band gap is about 1eV. The refractive index is around 2.2 and their hydrogen content is low.When the carbon content in the source gas was reduced by mixing hydrogen with the hydrocarbon used, the transparency, the content of bonded hydrogen in the films and the optical band gap increased slightly but the hardness, adhesion, refractive index and deposition rate decreased.The impact energy has a dominant influence on the film properties. This has been demonstrated by changing the sample orientation.@ FAB source films have good wear and friction properties with only a small sign of localised failure after pin on disc sliding tests for 100 metres.A study on titanium nitride/DLC multilayer films showed that the adhesion at the TiN/DLC interface can be improved (and therefore the wear performance). The best adhesion and wear results were obtained by utilising an over-stoichiometric composition of titanium nitride.FAB source films have been deposited on PET and were shown to be as good as that of sputtered gold on PET, and much superior to evaporated titanium on PET. The transparency of the coated PET has been improved by optimising the deposition conditions.The properties of films grown by plasma-assisted evaporation of graphite depends on the carrier gas used, substrate type and bias voltage (under both d.c and r.f. conditions). Films grown on tool steel in a butane r.f. plasma have a hardness around 4000 HK (25g). The growth rate on glass under similar conditions is very low, but the film is completely transparent with an optical band gap of 2.6 eV. When argon is used as the carrier gas, no film is formed on tool steel, but on glass a completely transparent film is produced.Nanohardness measurement showed that r.f EBPVD films are extremely hard (33-44 GPa) and the lowest elastic recovery was obtained for the non-hydrogenated film (11% against 44% for the a-C:H film).Pin on disc tests of r.f. a-C:H films exhibited a typical film wear of 48x 10⁻⁶mm3/Nm against steel, which represents a modest reduction in wear compared to an uncoated steel substrate.All d.c. EBPVD films showed poor performance in the pin on disc machine due to their poor adhesion. The concentration of bonded hydrogen (αs) in d.c. films is up to five times more than that of FAB source films. Their relatively low refractive index reflects a polymeric type of film. They were more brittle and usually less well adhered than those produced by other methods. Their optical band gap varied between 1eV to 3.5eV.The concentration of total hydrogen (bonded or eventually non-bonded) has been found by coworkers to be 33% in dc EBPVD films and 25% in FAB source films. The decrease of the concentration of bonded hydrogen with cathode voltage and the absence of such correlation for the total hydrogen in dc/EBPVD an FAB source films, suggests the presence of nonbonded hydrogen in the films.One of the achievements of the work is that an empirical relationship is developed, linking the optical band gap with the amount of bonded hydrogen in the film, the relative carbon to hydrogen flow input ratio, and other plasma electrical parameters for carbon coatings produced using a thermionically enhanced plasma-assisted d.c. PVD process. It explains observed properties in terms of process parameters and highlights the difficulties in obtaining consistent coatings on sample surfaces at different locations and orientations in the deposition chamber.Finally a new system is described for the deposition of hard carbon films. This new system allows the generation of very high ionisation levels and produces films with hardnesses over 8000 HK (200g) (thickness - 2.5μm,substrate; tool steel). The deposition rate is higher than previously reported for such hard films (2-3μm/hr) in a 0.5-1% CH₄ in H₂ plasma. SEM microscopy showed particles having octahedral shapes. Raman spectroscopy indicates a OLC structure with some disordered graphite present. Infrared spectrophotometry showed very little evidence of bonded hydrogen in the films. The optical band gap is 2 eV for a film deposited on silica

Statistical relational learning of semantic models and grammar rules for 3D building reconstruction from 3D point clouds

Formal grammars are well suited for the estimation of models with an a-priori unknown number of parameters such as buildings and have proven their worth for 3D modeling and reconstruction of cities. However, the generation and design of corresponding grammar rules is a laborious task and relies on expert knowledge. This thesis presents novel approaches for the reduction of this effort using advanced machine learning methods resulting in automatically learned sophisticated grammar rules. Indeed, the learning of a wide range of sophisticated rules, that reflect the variety and complexity, is a challenging task. This is especially the case if a simultaneous machine learning of building structures and the underlying aggregation hierarchies as well as the building parameters and the constraints among them for a semantic interpretation is expected. Thus, in this thesis, an incremental approach is followed. It separates the structure learning from the parameter distribution learning of building parts. Moreover, the so far procedural approaches with formal grammars are mostly rather convenient for the generation of virtual city models than for the reconstruction of existing buildings. To this end, Inductive Logic Programming (ILP) techniques are transferred and applied for the first time in the field of 3D building modeling. This enables the automatic learning of declarative logic programs, which are equivalent to attribute grammars and separate the representation of buildings and their parts from the reconstruction task. A stepwise bottom-up learning, starting from the smallest atomic features of a building part together with the semantic, topological and geometric constraints, is a key to a successful learning of a whole building part. Only few examples are sufficient to learn from precise as well as noisy observations. The learning from uncertain data is realized using probability density functions, decision trees and uncertain projective geometry. This enables the handling and modeling of uncertain topology and geometric reasoning taking noise into consideration. The uncertainty of models itself is also considered. Therefore, a novel method is developed for the learning of Weighted Attribute Context-Free Grammar (WACFG). On the one hand, the structure learning of façades – context-free part of the Grammar – is performed based on annotated derivation trees using specific Support Vector Machines (SVMs). The latter are able to derive probabilistic models from structured data and to predict a most likely tree regarding to given observations. On the other hand, to the best of my knowledge, Statistical Relational Learning (SRL), especially Markov Logic Networks (MLNs), are applied for the first time in order to learn building part (shape and location) parameters as well as the constraints among these parts. The use of SRL enables to take profit from the elegant logical relational description and to benefit from the efficiency of statistical inference methods. In order to model latent prior knowledge and exploit the architectural regularities of buildings, a novel method is developed for the automatic identification of translational as well as axial symmetries. For symmetry identification a supervised machine learning approach is followed based on an SVM classifier. Building upon the classification results, algorithms are designed for the representation of symmetries using context-free grammars from authoritative building footprints. In all steps the machine learning is performed based on real- world data such as 3D point clouds and building footprints. The handling with uncertainty and occlusions is assured. The presented methods have been successfully applied on real data. The belonging classification and reconstruction results are shown.Statistisches relationales Lernen von semantischen Modellen und Grammatikregeln für 3D Gebäuderekonstruktion aus 3D Punktwolken Formale Grammatiken eignen sich sehr gut zur Schätzung von Modellen mit a-priori unbekannter Anzahl von Parametern und haben sich daher als guter Ansatz zur Rekonstruktion von Städten mittels 3D Stadtmodellen bewährt. Der Entwurf und die Erstellung der dazugehörigen Grammatikregeln benötigt jedoch Expertenwissen und ist mit großem Aufwand verbunden. Im Rahmen dieser Arbeit wurden Verfahren entwickelt, die diesen Aufwand unter Zuhilfenahme von leistungsfähigen Techniken des maschinellen Lernens reduzieren und automatisches Lernen von Regeln ermöglichen. Das Lernen umfangreicher Grammatiken, die die Vielfalt und Komplexität der Gebäude und ihrer Bestandteile widerspiegeln, stellt eine herausfordernde Aufgabe dar. Dies ist insbesondere der Fall, wenn zur semantischen Interpretation sowohl das Lernen der Strukturen und Aggregationshierarchien als auch von Parametern der zu lernenden Objekte gleichzeitig statt finden soll. Aus diesem Grund wird hier ein inkrementeller Ansatz verfolgt, der das Lernen der Strukturen vom Lernen der Parameterverteilungen und Constraints zielführend voneinander trennt. Existierende prozedurale Ansätze mit formalen Grammatiken sind eher zur Generierung von synthetischen Stadtmodellen geeignet, aber nur bedingt zur Rekonstruktion existierender Gebäude nutzbar. Hierfür werden in dieser Schrift Techniken der Induktiven Logischen Programmierung (ILP) zum ersten Mal auf den Bereich der 3D Gebäudemodellierung übertragen. Dies führt zum Lernen deklarativer logischer Programme, die hinsichtlich ihrer Ausdrucksstärke mit attributierten Grammatiken gleichzusetzen sind und die Repräsentation der Gebäude von der Rekonstruktionsaufgabe trennen. Das Lernen von zuerst disaggregierten atomaren Bestandteilen sowie der semantischen, topologischen und geometrischen Beziehungen erwies sich als Schlüssel zum Lernen der Gesamtheit eines Gebäudeteils. Das Lernen erfolgte auf Basis einiger weniger sowohl präziser als auch verrauschter Beispielmodelle. Um das Letztere zu ermöglichen, wurde auf Wahrscheinlichkeitsdichteverteilungen, Entscheidungsbäumen und unsichere projektive Geometrie zurückgegriffen. Dies erlaubte den Umgang mit und die Modellierung von unsicheren topologischen Relationen sowie unscharfer Geometrie. Um die Unsicherheit der Modelle selbst abbilden zu können, wurde ein Verfahren zum Lernen Gewichteter Attributierter Kontextfreier Grammatiken (Weighted Attributed Context-Free Grammars, WACFG) entwickelt. Zum einen erfolgte das Lernen der Struktur von Fassaden –kontextfreier Anteil der Grammatik – aus annotierten Herleitungsbäumen mittels spezifischer Support Vektor Maschinen (SVMs), die in der Lage sind, probabilistische Modelle aus strukturierten Daten abzuleiten und zu prädizieren. Zum anderen wurden nach meinem besten Wissen Methoden des statistischen relationalen Lernens (SRL), insbesondere Markov Logic Networks (MLNs), erstmalig zum Lernen von Parametern von Gebäuden sowie von bestehenden Relationen und Constraints zwischen ihren Bestandteilen eingesetzt. Das Nutzen von SRL erlaubt es, die eleganten relationalen Beschreibungen der Logik mit effizienten Methoden der statistischen Inferenz zu verbinden. Um latentes Vorwissen zu modellieren und architekturelle Regelmäßigkeiten auszunutzen, ist ein Verfahren zur automatischen Erkennung von Translations- und Spiegelsymmetrien und deren Repräsentation mittels kontextfreier Grammatiken entwickelt worden. Hierfür wurde mittels überwachtem Lernen ein SVM-Klassifikator entwickelt und implementiert. Basierend darauf wurden Algorithmen zur Induktion von Grammatikregeln aus Grundrissdaten entworfen

Break-Up of Aerosol Agglomerates in Highly Turbulent Gas Flow

Agglomerate aerosols in a turbulent flow may be subjected to very high turbulent shear rates which through the generation of lift and drag can overcome the adhesive forces binding the constituents of an agglomerate together and cause it to break-up. This paper presents an analysis of the experimental measurements of the breakup of agglomerates between 0.1-10μm in size, in a turbulent pipe flow followed by an expansion zone with a Reynolds numbers in the range 105 to 107. The analysis shows that even in wall bounded turbulence, the high turbulent shear stresses associated with the small scales of turbulence in the core can be the main source of breakup preceding any break-up that may occur by impaction at the wall. More importantly from these results, a computationally fast and efficient solution is obtained for the General Dynamic Equation (GDE) for agglomerate transport and breakup in highly turbulent flow. Furthermore the solution for the evolution of the aerosol size distribution is consistent with the experimental results. In the turbulent pipe flow section, the agglomerates are exposed continuously to turbulent shear stresses and experience more longer term breakup than in the expansion zone (following the pipe flow) where the exposure time is much less and break-up occurs instantaneously under the action of very high local turbulent shear stresses. The validity of certain approximations made in the model is considered. In particular, the inertia of the agglomerates characterised by a Stokes Number from 0.001 for the smallest particles up to 10 for 10μm particles and the fluctuations of the turbulent shear stresses are important physical phenomena which are not accounted for in the mode

Controlled backfill in oncology dose-finding trials

The use of backfill in early phase dose-finding trials is a relatively recent practice. It consists of assigning patients to dose levels below the level where the study is at. The main reason for backfilling is to collect additional pharmacokinetic, pharmacodynamic and response data, in order to assess whether a plateau may exist on the dose-efficacy curve. This is a possibility in oncology with molecularly targeted agents or immunotherapy. Recommending for further study a dose level lower than the maximum tolerated dose could be supported in such situations. How to best allocate backfill patients to dose levels is not yet established. In this paper we propose to randomise backfill patients below the dose level where the study is at. A refinement of this would be to stop backfilling to lower dose levels when these show insufficient efficacy compared to higher levels, starting at dose level 1 and repeating this process sequentially. At study completion, data from all patients (both backfill patients and dose-finding patients) is used to estimate the dose-response curve. The fit from a change point model is compared to the fit of a monotonic model to identify a potential plateau. Using simulations, we show that this approach can identify the plateau on the dose-response curve when such a plateau exists, allowing the recommendation of a dose level lower than the maximum tolerated dose for future studies. This contribution provides a methodological framework for backfilling, from the perspective of both design and analysis in early phase oncology trials

Cooling and hemodynamic management in heatstroke: practical recommendations

INTRODUCTION:Although rapid cooling and management of circulatory failure are crucial to the prevention of irreversible tissue damage and death in heatstroke, the evidence supporting the optimal cooling method and hemodynamic management has yet to be established.METHODS:A systematic review of all clinical studies published in Medline (1966 to 2006), CINAHL (Cumulative Index to Nursing & Allied Health Literature) (1982 to 2006), and Cochrane Database was performed using the OVID interface without language restriction. Search terms included heatstroke, sunstroke, and heat stress disorders.RESULTS:Fourteen articles reported populations subjected to cooling treatment for classic or exertional heatstroke and included data on cooling time, neurologic morbidity, or mortality. Five additional articles described invasive monitoring with central venous or pulmonary artery catheters. The four clinical trials and 15 observational studies covered a total of 556 patients. A careful analysis of the results obtained indicated that the cooling method based on conduction, namely immersion in iced water, was effective among young people, military personnel, and athletes with exertional heatstroke. There was no evidence to support the superiority of any one cooling technique in classic heatstroke. The effects of non-invasive, evaporative, or conductive-based cooling techniques, singly or combined, appeared to be comparable. No evidence of a specific endpoint temperature for safe cessation of cooling was found. The circulatory alterations in heatstroke were due mostly to a form of distributive shock associated with relative or absolute hypovolemia. Myocardial failure was found to be rare.CONCLUSION:A systematic review of the literature failed to identify reliable clinical data on the optimum treatment of heatstroke. Nonetheless, the findings of this study could serve as a framework for preliminary recommendations in cooling and hemodynamic management of heatstroke until more evidence-based data are generated

Life expectancy difference and life expectancy ratio: two measures of treatment effects in randomised trials with non-proportional hazards

The hazard ratio (HR) is the most common measure of treatment effect in clinical trials that use time-to-event outcomes such as survival. When survival curves cross over or separate only after a considerable time, the proportional hazards assumption of the Cox model is violated, and HR can be misleading. We present two measures of treatment effects for situations where the HR changes over time: the life expectancy difference (LED) and life expectancy ratio (LER). LED is the difference between mean survival times in the intervention and control arms. LER is the ratio of these two times. LED and LER can be calculated for at least two time intervals during the trial, allowing for curves where the treatment effect changes over time. The two measures are readily interpretable as absolute and relative gains or losses in life expectancy

Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI

BACKGROUND: Coronary revascularization guided by fractional flow reserve (FFR) is associated with better patient outcomes after the procedure than revascularization guided by angiography alone. It is unknown whether the instantaneous wave-free ratio (iFR), an alternative measure that does not require the administration of adenosine, will offer benefits similar to those of FFR. METHODS: We randomly assigned 2492 patients with coronary artery disease, in a 1:1 ratio, to undergo either iFR-guided or FFR-guided coronary revascularization. The primary end point was the 1-year risk of major adverse cardiac events, which were a composite of death from any cause, nonfatal myocardial infarction, or unplanned revascularization. The trial was designed to show the noninferiority of iFR to FFR, with a margin of 3.4 percentage points for the difference in risk. RESULTS: At 1 year, the primary end point had occurred in 78 of 1148 patients (6.8%) in the iFR group and in 83 of 1182 patients (7.0%) in the FFR group (difference in risk, -0.2 percentage points; 95% confidence interval [CI], -2.3 to 1.8; P<0.001 for noninferiority; hazard ratio, 0.95; 95% CI, 0.68 to 1.33; P=0.78). The risk of each component of the primary end point and of death from cardiovascular or noncardiovascular causes did not differ significantly between the groups. The number of patients who had adverse procedural symptoms and clinical signs was significantly lower in the iFR group than in the FFR group (39 patients [3.1%] vs. 385 patients [30.8%], P<0.001), and the median procedural time was significantly shorter (40.5 minutes vs. 45.0 minutes, P=0.001). CONCLUSIONS: Coronary revascularization guided by iFR was noninferior to revascularization guided by FFR with respect to the risk of major adverse cardiac events at 1 year. The rate of adverse procedural signs and symptoms was lower and the procedural time was shorter with iFR than with FFR. (Funded by Philips Volcano; DEFINE-FLAIR ClinicalTrials.gov number, NCT02053038 .)info:eu-repo/semantics/publishedVersio

Discrepancies in autologous bone marrow stem cell trials and enhancement of ejection fraction (DAMASCENE): weighted regression and meta-analysis

Objective To investigate whether discrepancies in trials of use of bone marrow stem cells in patients with heart disease account for the variation in reported effect size in improvement of left ventricular function. Design Identification and counting of factual discrepancies in trial reports, and sample size weighted regression against therapeutic effect size. Meta-analysis of trials that provided sufficient information. Data sources PubMed and Embase from inception to April 2013. Eligibility for selecting studies Randomised controlled trials evaluating the effect of autologous bone marrow stem cells for heart disease on mean left ventricular ejection fraction. Results There were over 600 discrepancies in 133 reports from 49 trials. There was a significant association between the number of discrepancies and the reported increment in EF with bone marrow stem cell therapy (Spearman’s r=0.4, P=0.005). Trials with no discrepancies were a small minority (five trials) and showed a mean EF effect size of −0.4%. The 24 trials with 1-10 discrepancies showed a mean effect size of 2.1%. The 12 with 11-20 discrepancies showed a mean effect of size 3.0%. The three with 21-30 discrepancies showed a mean effect size of 5.7%. The high discrepancy group, comprising five trials with over 30 discrepancies each, showed a mean effect size of 7.7%. Conclusions Avoiding discrepancies is difficult but is important because discrepancy count is related to effect size. The mechanism is unknown but should be explored in the design of future trials because in the five trials without discrepancies the effect of bone marrow stem cell therapy on ejection fraction is zero

Factors Affecting Women Entrepreneurship in Morocco: The Moderating Role of Public Policies and Institutional Support

Entrepreneurship is an opportunity for Moroccan women to gain access to income-generating activities. However, the participation of women in the Moroccan economy is only 26%, which remains very low according to the World Bank. For the Organization for Economic Co-operation and Development (OCDE, 2005), women represent a potential for devaluated enterprise creation in both developing and developed countries. &nbsp;In Morocco, several legal and tax reforms focusing on the support for entrepreneurship have been adopted as part of national economic restructuring programs. As a result, the implementation of public policies aimed at supporting women entrepreneurs, has certainly favored the development of women entrepreneurship contributing to the creation of jobs and economic benefit. However, the participation of women in economic and entrepreneurial activity faces cultural, social and institutional obstacles, which can hinder evolution of women's entrepreneurship. Despite the influence of emerging economies on the global economy and the vital role of entrepreneurship in our world, the focus of entrepreneurship research up until this point has almost exclusively been on research sites emanating from North America and Europe (Bruton et al., 2008). Consequently, other areas of the world such as the Middle-East and Africa have not received much attention from academic researchers despite the need to understand entrepreneurship in these emerging economies (Bruton et al., 2008; Kiss et., 2012). The theme of women's entrepreneurship has been the subject of several studies by both government organizations and researchers. Our goal is to present a state of the art in public policies implemented in Morocco in favor of woman entrepreneurship by presenting the set of public institutions and observatories operating for the promotion of women entrepreneurship.Entrepreneurship is an opportunity for Moroccan women to gain access to income-generating activities. However, the participation of women in the Moroccan economy is only 26%, which remains very low according to the World Bank. For the Organization for Economic Co-operation and Development (OCDE, 2005), women represent a potential for devaluated enterprise creation in both developing and developed countries. &nbsp;In Morocco, several legal and tax reforms focusing on the support for entrepreneurship have been adopted as part of national economic restructuring programs. As a result, the implementation of public policies aimed at supporting women entrepreneurs, has certainly favored the development of women entrepreneurship contributing to the creation of jobs and economic benefit. However, the participation of women in economic and entrepreneurial activity faces cultural, social and institutional obstacles, which can hinder evolution of women's entrepreneurship. Despite the influence of emerging economies on the global economy and the vital role of entrepreneurship in our world, the focus of entrepreneurship research up until this point has almost exclusively been on research sites emanating from North America and Europe (Bruton et al., 2008). Consequently, other areas of the world such as the Middle-East and Africa have not received much attention from academic researchers despite the need to understand entrepreneurship in these emerging economies (Bruton et al., 2008; Kiss et., 2012). The theme of women's entrepreneurship has been the subject of several studies by both government organizations and researchers. Our goal is to present a state of the art in public policies implemented in Morocco in favor of woman entrepreneurship by presenting the set of public institutions and observatories operating for the promotion of women entrepreneurship