ِميِحََّسلا ِهَمِحََّسلا ِهَّ للا ِمِسِب
( َكَزِد ص َل ل ِحَسْش و ِم ل أ
1
( َكَزْشِو َلْىَع ا ىِع ضَوَو )
2
)
( َكَسِه ظ ض قْو أ يِرَّ لا
3
( َكَسْمِذ َل ل ا ىِع فَزَو )
4
)
( اّسِسُي ِسِسُعْلا َعَم ََّنِإ ف
5
( اّسِسُي ِسِسُعْلا َعَم ََّنِإ )
6
ا ذِإ ف )
تْغَس ف
( ِب صْوا ف
7
( ِب غِزا ف َلَِّبَز ى لِإَو )
8
)
MOHAMMED V DE RABAT
FACULTE DE MEDECINE ET DE PHARMACIE - RABAT
DOYENS HONORAIRES :
1962 – 1969 : Professeur Abdelmalek FARAJ 1969 – 1974 : Professeur Abdellatif BERBICH 1974 – 1981 : Professeur Bachir LAZRAK 1981 – 1989 : Professeur Taieb CHKILI
1989 – 1997 : Professeur Mohamed Tahar ALAOUI 1997 – 2003 : Professeur Abdelmajid BELMAHI 2003 - 2013 : Professeur Najia HAJJAJ – HASSOUNI
ADMINISTRATION :
Doyen
Professeur Mohamed ADNAOUI
Vice-Doyen chargé des Affaires Académiques et estudiantines Professeur Brahim LEKEHAL
Vice-Doyen chargé de la Recherche et de la Coopération Professeur Toufiq DAKKA
Vice-Doyen chargé des Affaires Spécifiques à la Pharmacie Professeur Jamal TAOUFIK
Secrétaire Général
1 - ENSEIGNANTS-CHERCHEURS MEDECINS ET PHARMACIENS
PROFESSEURS :
DECEMBRE 1984Pr. MAAOUNI Abdelaziz Médecine Interne – Clinique Royale
Pr. MAAZOUZI Ahmed Wajdi Anesthésie -Réanimation Pr. SETTAF Abdellatif Pathologie Chirurgicale
NOVEMBRE ET DECEMBRE 1985
Pr. BENSAID Younes Pathologie Chirurgicale
JANVIER, FEVRIER ET DECEMBRE 1987 Pr. LACHKAR Hassan Médecine Interne
Pr. YAHYAOUI Mohamed Neurologie
DECEMBRE 1989
Pr. ADNAOUI Mohamed Médecine Interne –Doyen de la FMPR
Pr. OUAZZANI Taïbi Mohamed Réda Neurologie
JANVIER ET NOVEMBRE 1990
Pr. HACHIM Mohammed* Médecine-Interne Pr. KHARBACH Aîcha Gynécologie -Obstétrique Pr. TAZI Saoud Anas Anesthésie Réanimation
FEVRIER AVRIL JUILLET ET DECEMBRE 1991 Pr. AZZOUZI Abderrahim Anesthésie Réanimation- Doyen de FMPO
Pr. BAYAHIA Rabéa Néphrologie
Pr. BELKOUCHI Abdelkader Chirurgie Générale Pr. BENCHEKROUN Belabbes Abdellatif Chirurgie Générale Pr. BENSOUDA Yahia Pharmacie galénique
Pr. BERRAHO Amina Ophtalmologie
Pr. BEZAD Rachid Gynécologie Obstétrique Méd. Chef Maternité des
Orangers
Pr. CHERRAH Yahia Pharmacologie
Pr. CHOKAIRI Omar Histologie Embryologie
Pr. KHATTAB Mohamed Pédiatrie
Pr. SOULAYMANI Rachida Pharmacologie- Dir. du Centre National PV Rabat Pr. TAOUFIK Jamal Chimie thérapeutique V.D à la pharmacie+Dir. du CEDOC +
DECEMBRE 1992
Pr. AHALLAT Mohamed Chirurgie Générale Doyen de FMPT Pr. BENSOUDA Adil Anesthésie Réanimation Pr. CHAHED OUAZZANI Laaziza Gastro-Entérologie Pr. CHRAIBI Chafiq Gynécologie Obstétrique Pr. EL OUAHABI Abdessamad Neurochirurgie Pr. FELLAT Rokaya Cardiologie
Pr. GHAFIR Driss* Médecine Interne Pr. JIDDANE Mohamed Anatomie
Pr. TAGHY Ahmed Chirurgie Générale Pr. ZOUHDI Mimoun Microbiologie
MARS 1994
Pr. BENJAAFAR Noureddine Radiothérapie
Pr. BEN RAIS Nozha Biophysique Pr. CAOUI Malika Biophysique Pr. CHRAIBI Abdelmjid
Endocrinologie et Maladies Métaboliques Doyen de la
FMPA
Pr. EL AMRANI Sabah Gynécologie Obstétrique Pr. EL BARDOUNI Ahmed Traumato-Orthopédie Pr. EL HASSANI My Rachid Radiologie
Pr. ERROUGANI Abdelkader Chirurgie Générale – Directeur du CHIS-Rabat Pr. ESSAKALI Malika Immunologie
Pr. ETTAYEBI Fouad Chirurgie Pédiatrique Pr. HASSAM Badredine Dermatologie
Pr. IFRINE Lahssan Chirurgie Générale
Pr. MAHFOUD Mustapha Traumatologie – Orthopédie Pr. RHRAB Brahim Gynécologie –Obstétrique Pr. SENOUCI Karima Dermatologie
MARS 1994
Pr. ABBAR Mohamed* Urologie Directeur Hôpital My Ismail Meknès Pr. ABDELHAK M‘barek Chirurgie – Pédiatrique
Pr. BENTAHILA Abdelali Pédiatrie
Pr. BENYAHIA Mohammed Ali Gynécologie – Obstétrique Pr. BERRADA Mohamed Saleh Traumatologie – Orthopédie Pr. CHERKAOUI Lalla Ouafae Ophtalmologie
Pr. LAKHDAR Amina Gynécologie Obstétrique Pr. MOUANE Nezha Pédiatrie
MARS 1995
Pr. ABOUQUAL Redouane Réanimation Médicale
Pr. AMRAOUI Mohamed Chirurgie Générale Pr. BAIDADA Abdelaziz Gynécologie Obstétrique
Pr. BARGACH Samir Gynécologie Obstétrique Pr. DRISSI KAMILI Med Nordine* Anesthésie Réanimation Pr. EL MESNAOUI Abbes Chirurgie Générale Pr. ESSAKALI HOUSSYNI Leila Oto-Rhino-Laryngologie
Pr. HDA Abdelhamid* Cardiologie Inspecteur du Service de Santé des FAR Pr. IBEN ATTYA ANDALOUSSI Ahmed Urologie
Pr. OUAZZANI CHAHDI Bahia Ophtalmologie Pr. SEFIANI Abdelaziz Génétique
Pr. ZEGGWAGH Amine Ali Réanimation Médicale
DECEMBRE 1996
Pr. AMIL Touriya* Radiologie
Pr. BELKACEM Rachid Chirurgie Pédiatrie Pr. BOULANOUAR Abdelkrim Ophtalmologie Pr. EL ALAMI EL FARICHA EL Hassan Chirurgie Générale Pr. GAOUZI Ahmed Pédiatrie
Pr. MAHFOUDI M‘barek* Radiologie Pr. OUZEDDOUN Naima Néphrologie
Pr. ZBIR EL Mehdi* Cardiologie DirecteurHôp.Mil. d’Instruction Med V Rabat
NOVEMBRE 1997
Pr. ALAMI Mohamed Hassan Gynécologie-Obstétrique
Pr. BEN SLIMANE Lounis Urologie
Pr. BIROUK Nazha Neurologie
Pr. ERREIMI Naima Pédiatrie
Pr. FELLAT Nadia Cardiologie
Pr. KADDOURI Noureddine Chirurgie Pédiatrique
Pr. KOUTANI Abdellatif Urologie
Pr. LAHLOU Mohamed Khalid Chirurgie Générale
Pr. MAHRAOUI CHAFIQ Pédiatrie
Pr. TOUFIQ Jallal Psychiatrie Directeur Hôp.Ar-razi Salé
Pr. YOUSFI MALKI Mounia Gynécologie Obstétrique
NOVEMBRE 1998
Pr. BENOMAR ALI Neurologie Doyen de la FMP Abulcassis Pr. BOUGTAB Abdesslam Chirurgie Générale
Pr. ER RIHANI Hassan Oncologie Médicale
Pr. BENKIRANE Majid* Hématologie
JANVIER 2000
Pr. ABID Ahmed* Pneumo-phtisiologie
Pr. AIT OUAMAR Hassan Pédiatrie
Pr. BENJELLOUN Dakhama Badr.Sououd Pédiatrie Pr. BOURKADI Jamal-Eddine Pneumo-phtisiologie Directeur Hôp. My Youssef Pr. CHARIF CHEFCHAOUNI Al Montacer Chirurgie Générale
Pr. ECHARRAB El Mahjoub Chirurgie Générale Pr. EL FTOUH Mustapha Pneumo-phtisiologie
Pr. EL MOSTARCHID Brahim* Neurochirurgie Pr. MAHMOUDI Abdelkrim* Anesthésie-Réanimation
Pr. TACHINANTE Rajae Anesthésie-Réanimation Pr. TAZI MEZALEK Zoubida Médecine Interne
NOVEMBRE 2000
Pr. AIDI Saadia Neurologie
Pr. AJANA Fatima Zohra Gastro-Entérologie Pr. BENAMR Said Chirurgie Générale
Pr. CHERTI Mohammed Cardiologie
Pr. ECH-CHERIF EL KETTANI Selma Anesthésie-Réanimation
Pr. EL HASSANI Amine Pédiatrie - Directeur Hôp.Cheikh Zaid
Pr. EL KHADER Khalid Urologie
Pr. EL MAGHRAOUI Abdellah* Rhumatologie Pr. GHARBI Mohamed El Hassan Endocrinologie et Maladies Métaboliques
Pr. MDAGHRI ALAOUI Asmae Pédiatrie
Pr. ROUIMI Abdelhadi* Neurologie
DECEMBRE 2000
Pr.ZOHAIR ABDELLAH * ORL
Pr. BALKHI Hicham* Anesthésie-Réanimation Pr. BENABDELJLIL Maria Neurologie
Pr. BENAMAR Loubna Néphrologie
Pr. BENAMOR Jouda Pneumo-phtisiologie Pr. BENELBARHDADI Imane Gastro-Entérologie Pr. BENNANI Rajae Cardiologie Pr. BENOUACHANE Thami Pédiatrie Pr. BEZZA Ahmed* Rhumatologie Pr. BOUCHIKHI IDRISSI Med Larbi Anatomie Pr. BOUMDIN El Hassane* Radiologie
Pr. CHAT Latifa Radiologie
Pr. DAALI Mustapha* Chirurgie Générale Pr. DRISSI Sidi Mourad* Radiologie
Pr. EL HIJRI Ahmed Anesthésie-Réanimation Pr. EL MAAQILI Moulay Rachid Neuro-Chirurgie Pr. EL MADHI Tarik Chirurgie-Pédiatrique Pr. EL OUNANI Mohamed Chirurgie Générale
Pr. ETTAIR Said Pédiatrie - Directeur Hôp. d’EnfantsRabat Pr. GAZZAZ Miloudi* Neuro-Chirurgie
Pr. HRORA Abdelmalek Chirurgie Générale Pr. KABBAJ Saad Anesthésie-Réanimation
Pr. KABIRI EL Hassane* Chirurgie Thoracique Pr. LAMRANI Moulay Omar Traumatologie Orthopédie
Pr. LEKEHAL Brahim Chirurgie Vasculaire Périphérique Pr. MAHASSIN Fattouma* Médecine Interne
Pr. MEDARHRI Jalil Chirurgie Générale Pr. MIKDAME Mohammed* Hématologie Clinique Pr. MOHSINE Raouf Chirurgie Générale
Pr. NOUINI Yassine Urologie - Directeur Hôpital Ibn Sina Pr. SABBAH Farid Chirurgie Générale
Pr. SEFIANI Yasser Chirurgie Vasculaire Périphérique Pr. TAOUFIQ BENCHEKROUN Soumia Pédiatrie
DECEMBRE 2002
Pr. AL BOUZIDI Abderrahmane* Anatomie Pathologique Pr. AMEUR Ahmed * Urologie
Pr. AMRI Rachida Cardiologie Pr. AOURARH Aziz* Gastro-Entérologie Pr. BAMOU Youssef * Biochimie-Chimie
Pr. BELMEJDOUB Ghizlene* Endocrinologie et Maladies Métaboliques Pr. BENZEKRI Laila Dermatologie
Pr. BENZZOUBEIR Nadia Gastro-Entérologie Pr. BERNOUSSI Zakiya Anatomie Pathologique Pr. BICHRA Mohamed Zakariya* Psychiatrie
Pr. CHOHO Abdelkrim * Chirurgie Générale Pr. CHKIRATE Bouchra Pédiatrie
Pr. EL ALAMI EL Fellous Sidi Zouhair Chirurgie Pédiatrique Pr. EL HAOURI Mohamed * Dermatologie
Pr. FILALI ADIB Abdelhai Gynécologie Obstétrique Pr. HAJJI Zakia Ophtalmologie
Pr. IKEN Ali Urologie
Pr. JAAFAR Abdeloihab* Traumatologie Orthopédie Pr. KRIOUILE Yamina Pédiatrie
Pr. MABROUK Hfid* Traumatologie Orthopédie Pr. MOUSSAOUI RAHALI Driss* Gynécologie Obstétrique Pr. OUJILAL Abdelilah Oto-Rhino-Laryngologie Pr. RACHID Khalid * Traumatologie Orthopédie Pr. RAISS Mohamed Chirurgie Générale Pr. RGUIBI IDRISSI Sidi Mustapha* Pneumo-phtisiologie Pr. RHOU Hakima Néphrologie
Pr. SIAH Samir * Anesthésie Réanimation
Pr. THIMOU Amal Pédiatrie
JANVIER 2004
Pr. ABDELLAH El Hassan Ophtalmologie
Pr. AMRANI Mariam Anatomie Pathologique Pr. BENBOUZID Mohammed Anas Oto-Rhino-Laryngologie Pr. BENKIRANE Ahmed* Gastro-Entérologie
Pr. BOULAADAS Malik Stomatologie et Chirurgie Maxillo-faciale Pr. BOURAZZA Ahmed* Neurologie
Pr. CHAGAR Belkacem* Traumatologie Orthopédie Pr. CHERRADI Nadia Anatomie Pathologique Pr. EL FENNI Jamal* Radiologie
Pr. EL HANCHI ZAKI Gynécologie Obstétrique Pr. EL KHORASSANI Mohamed Pédiatrie
Pr. EL YOUNASSI Badreddine* Cardiologie Pr. HACHI Hafid Chirurgie Générale Pr. JABOUIRIK Fatima Pédiatrie
Pr. KHARMAZ Mohamed Traumatologie Orthopédie Pr. MOUGHIL Said Chirurgie Cardio-Vasculaire Pr. OUBAAZ Abdelbarre * Ophtalmologie
Pr. TARIB Abdelilah* Pharmacie Clinique Pr. TIJAMI Fouad Chirurgie Générale Pr. ZARZUR Jamila Cardiologie
JANVIER 2005
Pr. ABBASSI Abdellah Chirurgie Réparatrice et Plastique Pr. AL KANDRY Sif Eddine* Chirurgie Générale
Pr. ALLALI Fadoua Rhumatologie Pr. AMAZOUZI Abdellah Ophtalmologie Pr. AZIZ Noureddine* Radiologie
Pr. BAHIRI Rachid Rhumatologie Directeur Hôp. Al Ayachi Salé Pr. BARKAT Amina Pédiatrie
Pr. BENYASS Aatif Cardiologie Pr. DOUDOUH Abderrahim* Biophysique Pr. EL HAMZAOUI Sakina * Microbiologie
Pr. HAJJI Leila Cardiologie (mise en disponibilité Pr. HESSISSEN Leila Pédiatrie
Pr. JIDAL Mohamed* Radiologie
Pr. LAAROUSSI Mohamed Chirurgie Cardio-vasculaire Pr. LYAGOUBI Mohammed Parasitologie
Pr. RAGALA Abdelhak Gynécologie Obstétrique
Pr. SBIHI Souad Histo-Embryologie Cytogénétique Pr. ZERAIDI Najia Gynécologie Obstétrique
AVRIL 2006
Pr. ACHEMLAL Lahsen* Rhumatologie Pr. AKJOUJ Said* Radiologie Pr. BELMEKKI Abdelkader* Hématologie Pr. BENCHEIKH Razika O.R.L Pr. BIYI Abdelhamid* Biophysique
Pr. BOUHAFS Mohamed El Amine Chirurgie - Pédiatrique
Pr. BOULAHYA Abdellatif* Chirurgie Cardio – Vasculaire. Pr. CHENGUETI ANSARI Anas Gynécologie Obstétrique Pr. DOGHMI Nawal Cardiologie
Pr. FELLAT Ibtissam Cardiologie
Pr. FAROUDY Mamoun Anesthésie Réanimation Pr. HARMOUCHE Hicham Médecine Interne Pr. HANAFI Sidi Mohamed* Anesthésie Réanimation Pr. IDRISS LAHLOU Amine* Microbiologie
Pr. JROUNDI Laila Radiologie Pr. KARMOUNI Tariq Urologie
Pr. KILI Amina Pédiatrie
Pr. KISRA Hassan Psychiatrie
Pr. KISRA Mounir Chirurgie – Pédiatrique Pr. LAATIRIS Abdelkader* Pharmacie Galénique Pr. LMIMOUNI Badreddine* Parasitologie
Pr. MANSOURI Hamid* Radiothérapie Pr. OUANASS Abderrazzak Psychiatrie
Pr. SAFI Soumaya* Endocrinologie Pr. SEKKAT Fatima Zahra Psychiatrie
Pr. SOUALHI Mouna Pneumo – Phtisiologie Pr. TELLAL Saida* Biochimie
Pr. ZAHRAOUI Rachida Pneumo – Phtisiologie
DECEMBRE 2006
Pr SAIR Khalid Chirurgie générale Dir. Hôp.Av.Marrakech
OCTOBRE 2007
Pr. ABIDI Khalid Réanimation médicale Pr. ACHACHI Leila Pneumo phtisiologie Pr. ACHOUR Abdessamad* Chirurgie générale
Pr. AIT HOUSSA Mahdi * Chirurgie cardio vasculaire Pr. AMHAJJI Larbi * Traumatologie orthopédie Pr. AOUFI Sarra Parasitologie
Pr. BAITE Abdelouahed * Anesthésie réanimation Directeur ERSSM Pr. BALOUCH Lhousaine * Biochimie-chimie
Pr. BOUTIMZINE Nourdine Ophtalmologie Pr. CHERKAOUI Naoual * Pharmacie galénique Pr. EHIRCHIOU Abdelkader * Chirurgie générale
Pr. EL BEKKALI Youssef * Chirurgie cardio-vasculaire Pr. EL ABSI Mohamed Chirurgie générale
Pr. EL MOUSSAOUI Rachid Anesthésie réanimation Pr. EL OMARI Fatima Psychiatrie
Pr. GHARIB Noureddine Chirurgie plastique et réparatrice Pr. HADADI Khalid * Radiothérapie
Pr. ICHOU Mohamed * Oncologie médicale Pr. ISMAILI Nadia Dermatologie Pr. KEBDANI Tayeb Radiothérapie
Pr. LALAOUI SALIM Jaafar * Anesthésie réanimation Pr. LOUZI Lhoussain * Microbiologie
Pr. MADANI Naoufel Réanimation médicale Pr. MAHI Mohamed * Radiologie
Pr. MARC Karima Pneumo phtisiologie Pr. MASRAR Azlarab Hématologie biologique Pr. MRANI Saad * Virologie
Pr. OUZZIF Ez zohra * Biochimie-chimie Pr. RABHI Monsef * Médecine interne Pr. RADOUANE Bouchaib* Radiologie Pr. SEFFAR Myriame Microbiologie Pr. SEKHSOKH Yessine * Microbiologie Pr. SIFAT Hassan * Radiothérapie
Pr. TABERKANET Mustafa * Chirurgie vasculaire périphérique Pr. TACHFOUTI Samira Ophtalmologie
Pr. TAJDINE Mohammed Tariq* Chirurgie générale Pr. TANANE Mansour * Traumatologie-orthopédie Pr. TLIGUI Houssain Parasitologie
Pr. TOUATI Zakia Cardiologie
DECEMBRE 2008
Pr TAHIRI My El Hassan* Chirurgie Générale
MARS 2009
Pr. ABOUZAHIR Ali * Médecine interne Pr. AGADR Aomar * Pédiatrie
Pr. AIT ALI Abdelmounaim * Chirurgie Générale Pr. AIT BENHADDOU El Hachmia Neurologie
Pr. AKHADDAR Ali * Neuro-chirurgie Pr. ALLALI Nazik Radiologie Pr. AMINE Bouchra Rhumatologie
Pr. ARKHA Yassir Neuro-chirurgie Directeur Hôp.des Spécialités Pr. BELYAMANI Lahcen* Anesthésie Réanimation
Pr. BJIJOU Younes Anatomie Pr. BOUHSAIN Sanae * Biochimie-chimie Pr. BOUI Mohammed * Dermatologie Pr. BOUNAIM Ahmed * Chirurgie Générale Pr. BOUSSOUGA Mostapha * Traumatologie-orthopédie
Pr. CHTATA Hassan Toufik * Chirurgie Vasculaire Périphérique Pr. DOGHMI Kamal * Hématologie clinique
Pr. EL MALKI Hadj Omar Chirurgie Générale Pr. EL OUENNASS Mostapha* Microbiologie Pr. ENNIBI Khalid * Médecine interne Pr. FATHI Khalid Gynécologie obstétrique Pr. HASSIKOU Hasna * Rhumatologie
Pr. KABBAJ Nawal Gastro-entérologie Pr. KABIRI Meryem Pédiatrie
Pr. KARBOUBI Lamya Pédiatrie
Pr. LAMSAOURI Jamal * Chimie Thérapeutique Pr. MARMADE Lahcen Chirurgie Cardio-vasculaire Pr. MESKINI Toufik Pédiatrie
Pr. MESSAOUDI Nezha * Hématologie biologique Pr. MSSROURI Rahal Chirurgie Générale Pr. NASSAR Ittimade Radiologie
Pr. OUKERRAJ Latifa Cardiologie
Pr. RHORFI Ismail Abderrahmani * Pneumo-Phtisiologie
OCTOBRE 2010
Pr. ALILOU Mustapha Anesthésie réanimation Pr. AMEZIANE Taoufiq* Médecine Interne Pr. BELAGUID Abdelaziz Physiologie Pr. CHADLI Mariama* Microbiologie
Pr. CHEMSI Mohamed* Médecine Aéronautique Pr. DAMI Abdellah* Biochimie- Chimie Pr. DARBI Abdellatif* Radiologie
Pr. DENDANE Mohammed Anouar Chirurgie Pédiatrique Pr. EL HAFIDI Naima Pédiatrie
Pr. EL KHARRAS Abdennasser* Radiologie
Pr. EL MAZOUZ Samir Chirurgie Plastique et Réparatrice Pr. EL SAYEGH Hachem Urologie
Pr. ERRABIH Ikram Gastro-Entérologie Pr. LAMALMI Najat Anatomie Pathologique Pr. MOSADIK Ahlam Anesthésie Réanimation Pr. MOUJAHID Mountassir* Chirurgie Générale Pr. NAZIH Mouna* Hématologie
DECEMBRE 2010
Pr.ZNATI Kaoutar Anatomie Pathologique
MAI 2012
Pr. AMRANI Abdelouahed Chirurgie pédiatrique Pr. ABOUELALAA Khalil * Anesthésie Réanimation Pr. BENCHEBBA Driss * Traumatologie-orthopédie Pr. DRISSI Mohamed * Anesthésie Réanimation Pr. EL ALAOUI MHAMDI Mouna Chirurgie Générale Pr. EL KHATTABI Abdessadek * Médecine Interne Pr. EL OUAZZANI Hanane * Pneumophtisiologie Pr. ER-RAJI Mounir Chirurgie Pédiatrique
Pr. JAHID Ahmed Anatomie Pathologique Pr. MEHSSANI Jamal * Psychiatrie
Pr. RAISSOUNI Maha * Cardiologie
* Enseignants Militaires FEVRIER 2013
Pr.AHID Samir Pharmacologie
Pr.AIT EL CADI Mina Toxicologie Pr.AMRANI HANCHI Laila Gastro-Entérologie Pr.AMOR Mourad Anesthésie Réanimation Pr.AWAB Almahdi Anesthésie Réanimation Pr.BELAYACHI Jihane Réanimation Médicale Pr.BELKHADIR Zakaria Houssain Anesthésie Réanimation Pr.BENCHEKROUN Laila Biochimie-Chimie Pr.BENKIRANE Souad Hématologie
Pr.BENNANA Ahmed* Informatique Pharmaceutique Pr.BENSGHIR Mustapha * Anesthésie Réanimation Pr.BENYAHIA Mohammed * Néphrologie
Pr.BOUATIA Mustapha Chimie Analytique et Bromatologie Pr.BOUABID Ahmed Salim* Traumatologie orthopédie
Pr BOUTARBOUCH Mahjouba Anatomie Pr.CHAIB Ali * Cardiologie
Pr.DENDANE Tarek Réanimation Médicale Pr.DINI Nouzha * Pédiatrie
Pr.ECH-CHERIF EL KETTANI Mohamed Ali Anesthésie Réanimation Pr.ECH-CHERIF EL KETTANI Najwa Radiologie
Pr.EL FATEMI NIZARE Neuro-chirurgie Pr.EL GUERROUJ Hasnae Médecine Nucléaire Pr.EL HARTI Jaouad Chimie Thérapeutique
Pr.EL JAOUDI Rachid * Toxicologie Pr.EL KABABRI Maria Pédiatrie
Pr.EL KHANNOUSSI Basma Anatomie Pathologique Pr.EL KHLOUFI Samir Anatomie
Pr.EL KORAICHI Alae Anesthésie Réanimation Pr.EN-NOUALI Hassane * Radiologie
Pr.ERRGUIG Laila Physiologie
Pr.FIKRI Meryem Radiologie
Pr.GHFIR Imade Médecine Nucléaire
Pr.IMANE Zineb Pédiatrie
Pr.IRAQI Hind Endocrinologie et maladies métaboliques Pr.KABBAJ Hakima Microbiologie
Pr.KADIRI Mohamed * Psychiatrie Pr.MAAMAR Mouna Fatima Zahra Médecine Interne Pr.MEDDAH Bouchra Pharmacologie Pr.MELHAOUI Adyl Neuro-chirurgie Pr.MRABTI Hind Oncologie Médicale Pr.NEJJARI Rachid Pharmacognosie Pr.OUBEJJA Houda Chirugie Pédiatrique Pr.OUKABLI Mohamed * Anatomie Pathologique Pr.RAHALI Younes Pharmacie Galénique
Pr.RATBI Ilham Génétique
Pr.RAHMANI Mounia Neurologie Pr.REDA Karim * Ophtalmologie
Pr.REGRAGUI Wafa Neurologie
Pr.RKAIN Hanan Physiologie
Pr.ROSTOM Samira Rhumatologie
Pr.ROUAS Lamiaa Anatomie Pathologique Pr.ROUIBAA Fedoua * Gastro-Entérologie Pr SALIHOUN Mouna Gastro-Entérologie
Pr.SAYAH Rochde Chirurgie Cardio-Vasculaire Pr.SEDDIK Hassan * Gastro-Entérologie
Pr.ZERHOUNI Hicham Chirurgie Pédiatrique Pr.ZINE Ali* Traumatologie Orthopédie
AVRIL 2013
Pr.EL KHATIB MOHAMED KARIM * Stomatologie et Chirurgie Maxillo-faciale
MAI 2013
MARS 2014
Pr. ACHIR Abdellah Chirurgie Thoracique
Pr.BENCHAKROUN Mohammed * Traumatologie- Orthopédie Pr.BOUCHIKH Mohammed Chirurgie Thoracique Pr. EL KABBAJ Driss * Néphrologie
Pr. EL MACHTANI IDRISSI Samira * Biochimie-Chimie
Pr. HARDIZI Houyam Histologie- Embryologie-Cytogénétique Pr. HASSANI Amale * Pédiatrie
Pr. HERRAK Laila Pneumologie
Pr. JANANE Abdellah * Urologie
Pr. JEAIDI Anass * Hématologie Biologique Pr. KOUACH Jaouad* Génycologie-Obstétrique Pr. LEMNOUER Abdelhay* Microbiologie
Pr. MAKRAM Sanaa * Pharmacologie Pr. OULAHYANE Rachid* Chirurgie Pédiatrique Pr. RHISSASSI Mohamed Jaafar CCV
Pr. SABRY Mohamed* Cardiologie Pr. SEKKACH Youssef* Médecine Interne Pr. TAZI MOUKHA Zakia Génécologie-Obstétrique
AVRIL 2014
PROFESSEURS AGREGES :
DECEMBRE 2014
Pr. ABILKASSEM Rachid* Pédiatrie Pr. AIT BOUGHIMA Fadila Médecine Légale Pr. BEKKALI Hicham * Anesthésie-Réanimation Pr. BENAZZOU Salma Chirurgie Maxillo-Faciale Pr. BOUABDELLAH Mounya Biochimie-Chimie Pr. BOUCHRIK Mourad* Parasitologie Pr. DERRAJI Soufiane* Pharmacie Clinique Pr. DOBLALI Taoufik* Microbiologie Pr. EL AYOUBI EL IDRISSI Ali Anatomie
Pr. EL GHADBANE Abdedaim Hatim* Anesthésie-Réanimation Pr. EL MARJANY Mohammed* Radiothérapie
Pr. FEJJAL Nawfal Chirurgie Réparatrice et Plastique
Pr. JAHIDI Mohamed* O.R.L
Pr. LAKHAL Zouhair* Cardiologie
Pr. OUDGHIRI NEZHA Anesthésie-Réanimation Pr. RAMI Mohamed Chirurgie Pédiatrique
Pr. SABIR Maria Psychiatrie
Pr. SBAI IDRISSI Karim* Médecine préventive, santé publique et Hyg.
AOUT 2015
Pr. MEZIANE Meryem Dermatologie
Pr. TAHRI Latifa Rhumatologie
JANVIER 2016
Pr. BENKABBOU Amine Chirurgie Générale Pr. EL ASRI Fouad* Ophtalmologie Pr. ERRAMI Noureddine* O.R.L
Pr. NITASSI Sophia O.R.L
JUIN 2017
Pr. ABI Rachid* Microbiologie
Pr. ASFALOU Ilyasse* Cardiologie
Pr. BOUAYTI El Arbi* Médecine préventive, santé publique et Hyg. Pr. BOUTAYEB Saber Oncologie Médicale
Pr. EL GHISSASSI Ibrahim Oncologie Médicale
Pr. OURAINI Saloua* O.R.L
Pr. RAZINE Rachid Médecine préventive, santé publique et Hyg. Pr. ZRARA Abdelhamid* Immunologie
2 - ENSEIGNANTS-CHERCHEURS SCIENTIFIQUES
PROFESSEURS/Prs. HABILITES
Pr. ABOUDRAR Saadia Physiologie Pr. ALAMI OUHABI Naima Biochimie-chimie
Pr. ALAOUI KATIM Pharmacologie
Pr. ALAOUI SLIMANI Lalla Naïma Histologie-Embryologie
Pr. ANSAR M‘hammed Chimie Organique et Pharmacie Chimique Pr .BARKIYOU Malika Histologie-Embryologie
Pr. BOUHOUCHE Ahmed Génétique Humaine
Pr. BOUKLOUZE Abdelaziz Applications Pharmaceutiques Pr. CHAHED OUAZZANI Lalla Chadia Biochimie-chimie
Pr. DAKKA Taoufiq Physiologie
Pr. FAOUZI Moulay El Abbes Pharmacologie
Pr. IBRAHIMI Azeddine Biologie moléculaire/Biotechnologie Pr. KHANFRI Jamal Eddine Biologie
Pr. OULAD BOUYAHYA IDRISSI Med Chimie Organique
Pr. REDHA Ahlam Chimie
Pr. TOUATI Driss Pharmacognosie
Pr. ZAHIDI Ahmed Pharmacologie
Mise à jour le 10/10/2018 Khaled Abdellah
To my Mother Lalla Fatima El Aroussi
Many people may think they have the best mother in the world, I happen to
know I do. I was lucky enough to be your daughter, and to learn through you
how to be an honest, kind and selfless person, how to think of others before
myself and how to strive to make our whole world better. Your endless support,
your dedication and love are the main reason I was able to realize my dream of
becoming a doctor.
May I bring you joy, may I bring you pride, may I bring you peace
I love you Mamati
To my Father Abdellatif Lahmer
When I'm at my best, I am my father's daughter.
Your unwavering trust and devotion have made me who I am today. Thank you
for being who you are, for putting me first and putting your dreams on hold so I
can achieve all of mine. I am forever indebted to you for allowing me to live the
experiences that made me who I am.
All my love Babati
To my Brother Nassim
We might as different as day and night, but blood will always be thicker than
water.
This journey would have been way less fun without you and I dedicate this
milestone to you.
To my Aunt Lalla Latifa El Aroussi and my Uncle Ahmed El Amri
For the endless nights of laughter and dancing, for the long hours spent talking
under the stars, for all the midnight car rides and late-night phone calls, I thank
you.
For always making me feel like the daughter you didn’t give birth to, I dedicate
this work to you.
To my Aunt Lalla Safia
Thank you for all your prayers, your love and support. I hope you know how
much your affection means to me and how much I appreciate all the efforts
you’ve put into making this work possible.
To My Cousin Fadoua, her husband Otmane and their precious son Khalil
Thank you for Diwa for being the sister I never had. You were my confidant, my
friend and my inspiration. I wish you and your little family all happiness and
prosperity. You can always count on me and I know you will always have my
To Ayoub, Marrissa and Goerge
Even though I couldn’t share this with you in person, I dedicate this work to
you. Family is family, no matter the distance. May we share even more beautiful
memories and joyful moments soon.
To Yemma, Beba, Nana and Jeddi may they rest in peace
As much as I am saddened to not be able to share this with you, I am certain
that you have always looked after me, and I hope that today I have made you
proud.
To my whole family,
Thank you for being there for me always through thick and thin.
I dedicate this work to you
To my friend, Leila El Ammari
Your friendship is one of the greatest gifts I’ve been blessed with through this
beautiful journey. I do not deserve its beauty but I am forever grateful for it. I
hope to be able to one day repay you for all of your love, support and kindness
but until then, I dedicate this work to you.
To the wonderful Nouhaila Lyazami,
You were the best partner in crime throughout our long nightshifts and
strenuous rounds. You made the hard easy and the unreachable attainable.
To the friends who made this work possible:
Maha, my dear friend, look how far we have gone. Your support, help and
encouragement are one of the reasons this work saw the light.
Zainab, I will forever be thankful for your valuable help in multiple aspects of
this work. You have been the friend and confidant I didn’t know I needed.
Thank you
Nora, your kindness, devotion and selflessness will always amaze me. Thank you
for everything.
Hajar, thank you, my sister, for all the support and encouragements through
some of the hardest periods of my life.
Imane, the beauty of our friendship is in its improbability. It’s a beautiful
unique relationship that stemmed for moments of mutual understanding and
kindness. Thank you for your love and support.
Myriam and Adnane, your help and encouragement were one of the reasons I felt
confident enough to start and finish this project. Thank you for your guidance
To my mentor and friend Omar Cherkaoui
Thank you for making the last few years, the best of my life. The experiences ou
have pushed me to explore have shaped who I am today. You’ve trusted in me
before I even trusted myself, and for that, I will forever be grateful.
To my brothers from other lands, Tommy and Karim
You have been beacons of joy and happiness throughout these last few years,
your friendship is invaluable to me and I am grateful for your love and support.
I knew I would make friends when I joined IFMSA, I just didn’t know I
would meet my family.
To my close friends
Kaoutar, Mehdi, Amine, Hicham, Ilias, Basma, Lina, Maha,
Dylan, Rim, Salim, Marouane, Mahmoud, Faouz, Maud, Micheal, Hasnaa,
Ismail, Sara, Sarah, Nada, Reda and Daniel. Thank you for your love and
support.
To all the people I am proud to consider friends
, you know who you are and how
much you mean to me. May we meet again soon, in Morocco or beyond it.
To the delegations and people I've travelled with,
especially the SDP and Mt,
my fellow NEOs, NOREs, TOs and ITs thank you for all the memories, the
friendships and the unforgettable moments.
To Medociation, IFMSA-Morocco, IFMSA and my blue families
The extent of the impact that the simple act of joining my local team eight years
ago has had on me is unmeasurable. The essence of who I am has been shaped by
the experiences these families have gifted me with and the amazing people they
have allowed me to meet. I don’t regret any of the sleepless nights or the long
meetings as you gave me friends, you gave me skills and you gave me purpose,
Thank you.
To my friend in MSRH
To all the friends I’ve made in medical school and outside of it,
To all my professors,
To my colleagues,
To Pr. BELAYACHI Jihane
I would like to start by acknowledging the efforts and dedication of
my thesis advisor, Pr J. BELAYACHI. Her patience, guidance and
enthousiasm have been an inspiration and a great source of
motivation throught out the whole process that made this work
possible. I will forever be grateful for her help and detailed
explainations and I couldn’t have hoped for a more dedicated and
To Pr. ABOUQAL Redouane
I wish to thank my honorable thesis president Pr. R. ABOUQAL,
whose expertise was invaluable in the completion of this work. The
valuable guidance of this esteemed researcher provided me with the
tools that I needed to choose the right direction and successfully
complete my dissertation. His insightful comments, immense
knowledge and continued encouragement have been a constant source
To Pr. MADANI Naoufel
I would also like to thank Pr. N. MADANI, not only for his help
and advice during the different steps of this work but also for
accepting to read and support my present work. His expertise as a
professor in the acute medical unit this study was conducted in with
provide invaluable imput to my thesis.
So I offer all my gratefulness for accepting to be part of my thesis
committee.
To Pr. ABIDI Khalid
I would like to profusely thank Pr. K ABIDI for being the first
person to encourage me to persue this study. When faced with what I
suspected was a post-traumatic stress disorder in patient 3 years ago,
he gave my remarks the attentive ear they need to inspire this work.
Having him in my thesis committee is an honor and a pleasure, and
his experience in critical care will provide a much needed imput to my
To Pr. BALKHI Hicham
I would like to thank Pr. H. Balkhi for accepting to join the members
of my thesis committee. He has my gratitude for generously offering
his time, support, guidance and good will to review this document.
His experience as an esteemed professor in Intensive Care will be a
source of
indispensable insight, suggestions and remarks to this work.
To Pr. Yassine OTHEMAN
I would like to acknowledge the valuable guidance and help Pr. Y
Otheman provided in the making of the work. As a professor in
psychiatry, his advice and insight, and most of all constant
availability were extremely helpful in the different stages of the
AMU Acute Medical Unit
BP Blood pressure
CAPS-5 Clinician-Administered PTSD Scale for DSM-5
CBT Cognitive-Behavioural Therapy
CCI Charlson Comorbidity Index
DSM Diagnostic and Statistical Manula for mental disorders
DTS Davidson Trauma Scale
e.g. Exempti gratia
ED Emergency department
GCS Glasgow Coma Scale
HADS Hospital Depression and Anxiety Scale
HADS-A Hospital Depression and Anxiety Scale- Anxiety
HADS-D Hospital Depression and Anxiety Scale -Depression
HIV Human Immunodeficiency Virus
HRQoL Health Related Quality of Life
ICD International Classification of Diseases
ICU Intensive Care Unit
IES-R Impact of Events Scale-Revised
IQR Interquartile range
LOS Length Of Stay of hospitalisation
MI Myocardial Infarction
MPSS-SR Modified PTSD Symptom Scale
M-PTSD Mississippi Scale for Combat-related PTSD
PCL-5 PTSD Checklist for DSM-5
PSS-I PTSD Symptom Scale Interview
PSS-SR PTSD Symptom Scale Self-Report Version
PTSD Post Traumatic Stress Disorder
Ref Reference
SC Supportive Counselling
SCID Structured Clinical Interview
sd Standard deviation
SF-12 Short-Form 12
SPRINT Short PTSD Rating Interview
SPSS Statistical Package for the Social Sciences
WHO World Health Organisation
yo Years old
List
List of figures
Figure 1: Study participants' flow-chart ... 26 Figure 2: Gender distribution of the study population ... 28 Figure 3: Marital status distribution of the study population ... 29 Figure 4: Social support distribution of the study population ... 29 Figure 5: Professional status distribution of the study population ... 30 Figure 6: Level of academic education of our study population ... 30 Figure 7: Residence distribution of our study population ... 31 Figure 8: Types of insurance in the study population ... 31 Figure 9: Substance use in our study population ... 33 Figure 10: Diagnoses of our study population ... 34 Figure 11: Length of stay in AMU of the study population (in days) ... 36 Figure 12: Patient‘s decision at discharge in study population ... 37 Figure 13: Correlation between IES-R scores at 6 weeks and 3 months ... 41 Figure 14: Percentage of patients with partial and complete PTSD at 3 months ... 42 Figure 15: Percentage of patients with severe PTSD symptoms at 3 months ... 43 Figure 16: Correlation between HADS-anxiety Score at admission and IES-R at 3 months . 51 Figure 17: Correlation between HADS-depression Score at admission and IES-R at 3 months
... 52
Figure 18: Mental component of SF-12 and IES-R at 3 months ... 54 Figure 19: Physical component of SF-12 and IES-R at 3 months ... 54
List of tables
Table 1: The Arabic version of SF-12‘s components, dimensions and corresponding items . 20 Table 2: Number and reasons for withdrawals at six weeks and three months. ... 27 Table 3: Participants‘ socio-demographic characteristics ... 32 Table 4 : Participants‘ clinical characteristics ... 35 Table 5: Participants‘ paraclinical characteristics ... 35 Table 6: Mean of the score of HADS during the hospital stay ... 38 Table 7: Mean of the score for the components of the SF-12 at 3 months ... 39 Table 8: Description of scores and variance of IES-R scales and subscales between 6 weeks
and 3 months ... 40
Table 9: Univariate analysis of the socio-demographic characteristics and the IES-R scores
at 3 months ... 45
Table 10: Univariate analysis of medical history and comorbidities and the IES-R scores at 3
months ... 46
Table 11 : Univariate analysis of diagnosis and the IES-R scores at 3 months ... 47 Table 12 : Univariate analysis of Clinical and paraclinical data and IES-R scores at 3 months
... 48
Table 13: Univariate analysis of patients‘ evolution during the hospital stay and IES-R scores
at 3 months ... 49
Table 14: Univariate analysis of HADS scores according to IES-R scores at 3 months ... 50 Table 15 : Univariate analysis of SF-12 scores and IES-R scores at 3 months ... 53 Table 16 : Adjusted associations of patients‘ characteristics to IES-R scores at 3 months in
Introduction ... 1
I. Post traumatic stress disorder ... 3 II. Particularities of an acute medical unit ... 8
Methods and Measures ... 11
I. Type of study ... 12 II. Study location ... 12 III. The study period ... 12 IV. Inclusion criteria ... 12 V. Exclusion criteria ... 12 VI. Data collection ... 13 1. Patients‘ characteristics ... 13 1.1. Socio-demographic characteristics ... 13 1.2. Patients‘ comorbidities and medical history ... 14 1.3. Diagnosis ... 15 1.4. Clinical characteristics at admission ... 16 1.5. Paraclinical characteristics at admission ... 16 1.6. Evolution during the hospital stay ... 17 1.7. Mortality after discharge ... 17 2. Instruments ... 18 2.1. The Hospital Anxiety and Depression Scale ... 18 2.2. Short Form 12 ... 18 2.3. Impact of Event Scale-Revised ... 20 VII. Statistical analysis ... 23
Results ... 25
I. Descriptive Analysis ... 26 1. Flow chart ... 26 2. Study population‘s characteristics ... 28 2.1. Socio-demographic characteristics ... 28 2.2. Patients‘ comorbidities and medical history: ... 33 2.3. Diagnosis: ... 34 2.4. Clinical and Paraclinical characteristics at admission ... 35 2.5. Evolution during the hospital stay ... 36 3. Instruments ... 38 3.1. Anxiety and depression during AMU stay ... 38 3.2. Health Related Quality of Life ... 39 3.3. Impact of events scale ... 39 II. Factors associated with participants‘ IES-R score ... 44 1. Univariate analysis ... 44 1.1. Socio-demographic characteristics ... 44 1.2. Medical History and comorbidities ... 46 1.3. Diagnosis ... 47 1.4. Clinical data and paraclinical data during the hospital stay ... 48 1.5. Evolution during the hospital stay ... 49 1.6. Anxiety and depression in the AMU ... 50 1.7. HRQoL and PTSD: ... 53 2. Multivariate analysis ... 55
Discussion ... 56 Conclusion ... 65 Abstract ... 67 Appendix ... 71 Bibliography and webography ... 85
1
2
An eye-opening study has shown that 37 to 92% of the general population is at risk of being exposed to what is defined as trauma during their lifetime[1].
These Traumatic events are diverse but commonly defined as ―exposure to war as a combatant or civilian, threatened or actual physical assault (e.g., physical attack, robbery, mugging, childhood physical abuse), threatened or actual sexual violence, being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or human disasters and severe motor vehicle accidents‖[2].
One single traumatic event, recurrent events or prolonged periods of distress can induce life-altering psychological reactions in the individual himself or even his close relatives [3]. These trauma-exposed individuals can develop acute stress disorder, post-traumatic depression, reactional depression, major depressive disorder and/or post-traumatic stress disorder (PTSD) [4]. The latter is a severe chronic disorder with important psychiatric co-morbidity and substantial costs to the individual and the community [5].
In the 4th edition of the diagnostic and Statistical Manual of Mental Disorders (DSM-IV)[6], ‗‗being diagnosed with a life-threatening illness‘‘ was added to the list of traumatic events incriminated in the development of PTSD.
Certain physical illnesses can occur in an unexpected way and can be immediately life-threatening (Stroke or traumatic injury) which is more similar to the general PTSD caused by other types of trauma. However, a newly diagnosed PTSD can also be caused by lengthy or painful medical or surgical procedures and treatment. [7]
This prompted a growing number of studies to explore its onset after ―medical stress‖, its symptoms, risk factors and its impact on patients‘ outcome after illness [7].
So what is post-traumatic stress disorder?
What are the characteristics of PTSD in medical population in general?
And what are the specificities of the acute medical unit in comparison to other hospital departments?
3
I. Post-traumatic stress disorder (PTSD)
1. Definition of PTSD
PTSD‘s exact diagnostic criteria were revised in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association in 2013 [2]. It is now included in a new category, Trauma- and Stressor-Related Disorders after being previously considered an anxiety disorder.
PTSD comprises symptoms of repeated re-experiencing of the traumatic event; avoidance of reminders; emotional numbing; and, persistent hyperarousal [2]. (Appendix 1) These symptoms should appear at the earliest one month after the traumatic event in order to be distinguished from Acute Stress Disorder that appears within the first month after trauma. The symptoms should also last at least for one month.
The physiopathology of this disorder is mainly linked to the Amygdala‘s response to trauma. It‘s considered the brains stress evaluator, sending danger signals and initiating the ―fight or flight‖ response. In individuals with PTSD, The amygdala stores images, sensations and smells connected to the traumatic event. When the person faces reminders of the event, the amygdala triggers a danger signal to the body. This state of hypervigilance is the main cause of PTSD symptoms. [8], [9]
The clinical course of PTSD can vary greatly from one patient to the next. Therefore, while some can show symptoms immediately after the traumatic event, which will fade after several months, others may only exhibit them after six months and have them indefinitely. The third of individuals presenting PTSD symptoms after a traumatic event will still suffer from weekly symptoms up to 10 years later [10].
2. Impact of PTSD
An individual diagnosed with PTSD by a psychiatrist is an individual experiencing symptoms making it difficult for them to maintain a normal personal and professional life. This can cause a lower health-related quality of life leading to social isolation, marital problems, unemployment and long-term health problems, such as asthma, arthritis, headaches,
4
ulcers and cardiovascular problems[11].
The disorders‘ symptoms in themselves are life-altering. The individuals become more quick-tempered and more prone to aggressive verbal and/or physical behaviour with little or no provocation (e.g., yelling at people, getting into fights, destroying objects) [6]. This will consequently cause social isolation and stigmatization [12], which in itself can worsen the severity of their symptoms due to lack of social support[13].
They can also engage in reckless or self-destructive behaviour such as dangerous driving, excessive alcohol or drug use, or self-injurious or suicidal behaviour. Additionally, approximately 20% of individuals with PTSD self-medicate using drugs and alcohol to attempt to relieve their symptoms and this was associated with higher odds of suicide attempts and lower mental health‐related quality of life[14]. Substance and alcohol abuse can also worsen another PTSD-induced issue: concentration difficulties[15], and thus making it hard to remember everyday events (e.g., phone numbers) or to focus on mundane tasks (e.g., having long conversations).
Quality of sleep can also be severely altered due to nightmares and fear or with generalized hyperarousal[16]. Sleep disturbances contribute to high suicidality, poor daytime functioning, poorer perceived physical health and correlate to the drug and substance abuse mentioned above [17].
Though this proves the importance of providing proper care to individuals suffering from PTSD, there are many factors that make its management challenging. ―Psychological resistance‖, for example, is a prevalent hurdle amongst the PTSD population [18]. This means that patients who suffer from PTSD usually do not seek help and frequently drop out of therapy. This only highlights the importance of studies, such as ours, that concentrate on determining the at-risk population of PTSD.
5
3. PTSD following medical stress:
In individuals exposed to ―medical stress‖, various studies found evidence of PTSD occurring after the onset, diagnosis, or treatment of physical illness[7]. Research projects focusing on this kind of trauma are still relatively new and of a much lower number compared to PTSD after other traumatic events[19]. The types of stressful medical events that were incriminated, ranged from chronic conditions that can be perceived as life-threatening, such as a recent cancer diagnosis [20] or an HIV positive status [21], to more acute diagnoses such as Myocardial infarctions[22], Acute respiratory distress [23], Traumatic injury [24]….
The most explored type of PTSD in a medical setting is the one accruing after a critical illness, especially after a stay in an Intensive Care Unit [25]–[27]. Studies have even explored psychiatric complications of critical care on families of patients [28]. This is likely due to them facing a life-threatening situation and an illness seen as non-manageable. Not only this but the treatments and medical procedures they will undergo can be PTSD factors [29]. Reviews of the literature identified additional potential risk factors for PTSD in these patients such as delusional memories of ICU, use of sedation, psychiatric history, younger age and female gender[30][31] [29].
It is, however, noteworthy to mention, that a study by Mary Principe and al. has shown that a patient‘s own perception of the severity of their illness is more predictive of an eventual PTSD than the illness‘s actual life-threatening character (as evaluated by a clinician). [32]
This is part of what makes our study, conducted in an Acute Medical Unit (AMU) setting, interesting. It allows us to study the psychiatric effects that acute illness could have on patients, even when not deemed critical enough to warrant an ICU stay.
4. Tools of evaluation of PTSD :
Two methods of evaluation can be used to assess, diagnose and track treatment outcomes of PTSD [33], interviews performed by clinicians and self-report instruments. They are used in a unique assessment to guide treatment or multiple times to gauge its development and progress.
6
i. PTSD structured interviews :
PTSD‘s structured interviews are usually more time consuming and are not adapted to follow-up by phone. Some of these tools are:
Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): It‘s a 30-item structured
interview that assesses PTSD symptoms over the previous week but can be used to determine lifetime diagnosis. It can be administered in 45 to 60 mins by clinicians and clinical researchers[34], [35]
PTSD Symptom Scale Interview (PSS-I and PSS-I-5): It is a 17-item semi-structured
interview useful where DSMVI PTSD symptoms in the last two weeks, related to the respondent‘s most recent trauma, are assessed. It is administered in around 20 mins and has brief direct questions about each item. It was later updated to encompass the updates to PTSD diagnosis mentioned in the DSMV. With the PSS-I-5 assessing presence and severity of symptoms over the past month. [36]–[38]
Structured Clinical Interview; PTSD Module (SCID PTSD Module): The
Structured Clinical Interview for DSM or SCID has been based on the most recent version of the DSM (DSM-5). The SCID-5 is a semi-structured interview for making the major DSM-5 diagnoses that is meant to be administered by trained mental health professionals. Depending on the interviewee‘s personal history, a SCID can take anywhere from 15 minutes to several hours. [39], [40]
Structured Interview for PTSD (SIP or SI-PTSD): The SIP is a clinical interview
that assesses survival and behavioural guilt in addition to PTSD symptoms corresponding to DSM-IV criteria. Symptoms are rated for the past 4 weeks and during the worst period of symptomatology. It takes 20-30 minutes to assess both the intensity and frequency of symptoms.[41], [42]
Treatment-Outcome Posttraumatic Stress Disorder Scale (TOP-8): The TOP- 8 is
an eight-item interview-based assessment based on the DSM-IV PTSD. It was developed from SI-PTSD scale based on items which were most common amongst people with PTSD and which responded positively to treatment across time. The items cover the three symptom
7
clusters for PTSD (re-experiencing, avoidance and numbing, hyperarousal) and are useful in detect drug versus placebo differences in clinical trials [43].
ii. Self-Report Instruments
The self-report is considered less time consuming as screening tools than the tools mentioned above. The most commonly used are :
Davidson Trauma Scale (DTS): The DTS is a 17-item, Likert-scale, self-report
instrument that assesses the 17 DSM-IV symptoms of PTSD. Both a frequency and a severity score can be determined. The DTS can be used to determine whether the symptoms meet DSM-IV criteria for PTSD, as well as their frequency and a severity score. [44]
Mississippi Scale for Combat-related PTSD (MISS or M-PTSD): The M-PTSD is a
35-item, self-report instrument that assesses combat-related PTSD in Veteran populations [45]with a civilian version being later developed [46]. The measure was developed based on the DSM-III symptoms of PTSD. A short, ten-item version is available along with a version that can be given to spouses and partners. [47]
Modified PTSD Symptom Scale (MPSS-SR): The MPSS-SR is a 17-item self-report
instrument that assesses the 17 DSM-III-R symptoms of PTSD as well as their severity, frequency or total cutoff scores. [48]
PTSD Checklist for DSM-5 (PCL-5): This 20-item self-report instrument that can be
used to screen individuals for PTSD and make a provisional diagnosis and gauge symptom change after therapy [49]. Additional assessment is desirable to confirm the diagnosis. [50]
PTSD Symptom Scale Self-Report Version (PSS-SR) : The PSS-SR is a 17-item,
Likert-scale, self-report questionnaire designed according to DSM-IV to assess the symptoms of PTSD with each of the items describing a symptom in terms of severity or frequency, covering the subscales of re-experiencing, avoidance, arousal, and providing a total score [51].
Short PTSD Rating Interview (SPRINT) : SPRINT is an eight-item self-report
measure that, as opposed to the instruments mentioned above, is not based on a specific DSM version but is meant to detect the most common symptoms reported by individuals suffering
8
from PTSD [52] (intrusion, avoidance, numbing, arousal, somatic malaise, stress vulnerability, and role and social functional impairment). It can measure PTSD severity and global improvement. Further assessment is recommended for any positive screens.
Impact of Event Scale-Revised (IES-R): This is the tool we have decided to use in our
study. The original IES was constituted of 15 questions evaluating two subscales (Intrusion and avoidance) based on Horowitz‘s [53] theory on stress response syndromes and is roughly representative of the B and C criteria of the DSM-IV [6]. There was, however, one main area of PTSD that was not being studied, the hyperarousal symptoms (Concentration issues, exaggerated response to stimuli, irritability). More details about this tool will be provided in the methods and measures chapter.
II. Particularities of an acute medical unit (AMU)
1. Definition of AMU
The setting of our study is unique in itself. All of our patients were recruited in Morocco‘s only Acute Medical Unit (AMU). AMUs, as described by the Royal College in London, are ―dedicated hospital units focused on acute medical treatment of hospitalized medical patients in medical emergencies‖ [54]. They can be accessed through referral from a general physician (GP) or the emergency department (ED) and provide care to patients with medical conditions (strokes, pneumonia…). They do not cover pediatric, obstetrical/gynaecological, psychiatric and surgical pathologies, and the patient‘s stay usually doesn‘t exceed 72hours[55].
Their creation stemmed from a need to provide adequate acute care to patients that would otherwise not receive it, or receive it too late. Currently, and as opposed to a time when physicians were expected to be skilled in managing all prevalent acute medical illnesses, the ever-growing interest in the study of specific medical organs and systems has made many doctors more committed to their specialities than to the generalities of acute intake [56].
9
Another factor that influenced the development of the current AMU models is the growing reliance on interns and doctors in training in the management of acute illness in the ED with more experienced physicians being merely seen as consultants[57], which is the case in the hospital where this study was conducted.
2. Characteristics of AMU
Studies have shown its existence decreased the number of patients transferred to the ICU [58] as well as lowered the mean of hospital length of stay(LOS) [59], [60]. And though sometimes limited AMU capacity meant waiting hours longer than 4h [61], it has been shown a decrease of waiting time in the emergency department after acute medical assessment with 68% patients were treated within a 4h target waiting time[62]. The implementation of these units has shown an improved patients outcome after hospitalization (a decrease in-hospital mortality compared to medical wards [63] and an overall lower 30 days hospital mortality and annual mortality [64]. They also boast a lower readmission rate compared to the general hospital medical population [63].
To the best of our knowledge, no other group of researchers has studied the prevalence of PTSD symptoms, their severity and risk factors after discharge from an acute medical unit. Determining risk factors amongst patients, as early as possible, would help put in place early intervention protocols to lower the risk of developing PTSD.
The variety of diagnosis in the AMU hospitalized population will allow us to compare PTSD prevalence rates amongst patients facing various pathologies. We will study if patients admitted due to pathologies that have been strongly linked to PTSD after discharge such as myocardial infarctions[22], [65], [66]were more at risk than those admitted with diagnoses that could be considered less threatening.
For this purpose, we decided to conduct a prospective cohort study in the Acute Medical Unit (AMU) of IBN SINA University hospital of Rabat, using the Impact of Events Scale-Revised (IES-R).
10
We have set three main objectives:
(1) To describe PTSD symptoms and their severity after AMU hospitalization at both six weeks and three months after discharge.
(2) To determine risk factors among AMU patients that could predict PTSD symptoms in the three first months after discharge.
(3) To evaluate the health-related quality of life of AMU patients at three months and study its evolution in correlation with the development of PTSD symptomatology.
11
12
I. Type of study
This was a prospective cohort study.
II. Study location
This was a survey of patients conducted in an acute medicine unit of Rabat University Hospital. It is currently the only AMU in Morocco and admits annually approximately 950 patients suffering from various medical illnesses. Most of the patients are admitted from the emergency room. The service comprises five single rooms and four common rooms with six beds each.
III. The study period
Inpatients‘ data was collected during a cumulative period of two months from September 2018 to December 2018. Then the follow-up period of all subjects (at 6 weeks month and 3 months from discharge) ended up on March 2019.
IV. Inclusion criteria
The study was conducted among patients older than 17 years old consecutively admitted to AMU during the study period.
Patients were recruited when physicians determined they were stable, had the capacity to give informed consent, and were awake, alert and able to communicate. They were not interviewed on a specific day of their AMU stay, as they became alert and gave consent at different times.
V. Exclusion criteria
Patients were excluded if they were not Arabic speaking; had dementia or remained confused or had a low GCS (Glasgow Coma Scale) until their discharge from AMU; were unable to communicate until their discharge; had severe sensory impairment.
Patients were excluded at the follow up if they were unable to communicate or confused and if they withdrew their consent to participate.
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VI. Data collection
1. Patients’ characteristics
1.1. Socio-demographic characteristics
Sex: Male and Female
Age: by years
Marital status: Married or single (Never married, divorced or widowed).
Social support:
- Living alone
- Living in proximity to family - Living with family
Level of academic education: Whether the patient: - Had no prior academic education.
- Attended primary school - Attended secondary school, - Attended university
Professional status: Whether they are
- Active (Full-time job, occasional work, or full-time student) - Not active (Unemployed or retired)
Residence: Whether they live in a rural or urban area.
Medical insurance:
- No insurance
- Private insurance: insurance that patients have to pay monthly sums to an insurance provider to benefit from.
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- Public insurance: insurance provided by the state.
Phone number of the patient and phone number of the closest relative.
1.2. Patients’ comorbidities and medical history
Anterior hospitalization: Whether the patient had been previously hospitalized or not in their lifetime.
History of psychiatric illness: Whether it exists or not.
Type of previously diagnosed psychiatric illness.
Previous psychiatric illness treatment: Treatment received for a psychiatric illness.
Charlson Comorbidity Index (CCI): The Charlson Comorbidity Index was used to assess the level of comorbidity by collecting the level of severity of 19 predefined comorbidity disorders as well as the number of disorders present among them. This measurement tool provides a weighted score of a patient's comorbidities that can be used to predict short-term and long-term outcomes such as functioning, length of stay in the hospital, and mortality rate. [67] We used the age-adjusted CCI version developed in 1994. (Appendix 2) [68]
Substance and alcohol use :
- Smoking: Smokers and non-smokers (individuals who have stopped smoking for over 12 months or have never smoked)
- Alcohol: Regular alcohol consumers alcohol (at least once per month) or non-consumers.
- Cannabis: Consumers of cannabis in the last year or those who haven‘t - Other drugs: Consumers or not of other drugs and their type.
History of traumatic events: As defined above in the DSM V include, but are not limited to
- Exposure to war, being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or natural or human-made disasters.
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- Threatened or actual physical assault - Threatened or actual sexual violence - Severe motor vehicle accidents. - Traumatic medical incidents.
- Witnessed events observing threatened or serious injury, unnatural death, physical or sexual abuse of another person domestic violence, accident, war or disaster, or a medical catastrophe in one's child
Indirect exposure through learning about an event is limited to experiences affecting close relatives or friends and experiences that are violent or accidental.
1.3. Diagnosis
Cardiovascular emergencies: were considered as cardiovascular emergencies all cases with exacerbation of heart failure, acute coronary syndrome, arrhythmia, acute pericarditis, endocarditis, cardiogenic shock and/or deep venous thrombosis
Infectious emergencies: Presence of infection clinically or bacteriologically documented.
Endocrine and metabolic emergencies: were considered as endocrine and metabolic emergencies all cases with: diabetic ketoacidosis, Hyperosmolar non-ketotic coma, acute adrenal insufficiency, dehydration, dyscalculia, acute renal failure and/or hepatic failure (acute/chronic).
Respiratory emergencies: were considered as respiratory emergencies all cases with: acute respiratory distress syndrome, acute severe asthma, pulmonary embolism, pneumonia, sarcoidosis and/or chronic respiratory failure exacerbation.
Neurological emergencies: were considered as neuro-psychiatric emergencies all cases with: cerebral vascular accident, encephalopathy and/or neuroleptic malignant syndrome.
Hematologic and Systemic disease emergencies: were considered as hematologic and systemic disease emergencies all cases with: anaemia, lymphoma, leukaemia, neutropenic
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fever, haemophilia, sickle cell attack, pancytopenia, essential thrombocythemia, aplastic anaemia and/or paroxysmal nocturnal hemoglobinuria.
Digestive emergencies: were considered as digestive emergencies all non-surgical digestive emergencies, thus all cases of pancreatitis.
Other emergencies: all medical emergencies not included in the previous categories.
1.4. Clinical characteristics at admission
Consciousness disorder (based on GCS): Glasgow Coma Scale (GCS) is a neurological scale used to assess the impairment of consciousness depending on the patients' response to different stimuli verbal and physical stimuli. [69] (Appendix 3)
The temperature at admission: using the Celsius scale (°C),
Systolic Blood Pressure and Diastolic Blood Pressure at admission reported in millimetres of mercury (mmHg),
Heartrate (HBPM) in heartbeats per minute.
Respiratory rate measured in breaths per minute
O2 saturation: Oxygen saturation is the fraction of [oxygen]-saturated haemoglobin relative to total haemoglobin (unsaturated + saturated) in the blood. Normal blood oxygen levels in humans range from 95 to 100 per cent
1.5. Paraclinical characteristics at admission Natremia: Serum sodium level in mmol/L
Kalemia: Serum potassium level in mmol/L
Creatinine Clearance: Calculated using the MDRD GFR Equation [70] [(186 x Creatinine^-1,154) x (Age^-0,203)] (x 0,742 for female patients) - Creatinine clearance: in ml/min/1,73m2
- Age: in years
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CRP (C - reactive protein): Serum C-Reactive Protein level in mg/L
Hemoglobinemia: Serum haemoglobin level in g/dL
Blood leukocytes: Serum leukocytes level in elements/mm3
Platelets: Serum platelets level in elements/mm3
Troponin level is ng/mL.
1.6. Evolution during the hospital stay
Length of waiting time in the emergency room before being admitted to the AMU in days. This data was in days due to patients not being sure of the exact number of hours they spent in the ED but being able to remember the number of days
Length of stay in the AMU in days
Decision at discharge: Either:
- Being transferred to other departments - Being discharged from the AMU :
o with no specific planned consultations
o with external follow-up consultations with specialists either at the university hospital or in other centers.
1.7. Mortality after discharge
- Mortality at 6 weeks
Includes all patients who were dead during the period from the time of discharge to 6 weeks‘ follow-up.
- Mortality at 3 months
Includes all patients who were dead during the period from the time of discharge to 3 months‘ follow-up.
