Tunisie Medicale最新文献

Introduction: Anencephaly is a serious developmental defect of the central nervous system in which the brain and cranial vault are grossly malformed. The cerebrum and cerebellum are reduced or absent, but the hindbrain is present. Anencephaly is a part of the neural tube defect spectrum. This defect results when the neural tube fails to close during the third to fourth weeks of development, leading to fetal loss, stillbirth, or neonatal death.

Aim: To find out probable principal risk factors for the appearance of anencephaly.

Methods: This study was conducted to compare between pregnancies affected by anencephaly in 2002-2011 with those notified in the period 1991-2001. Statistical analysis was undertaken using chi-squared tests.

Results: Results had shown that anencephaly fetuses with a weight less than 1500 g were significantly higher in the period 2002-2011 than in 1991-2001 (P=0.003; OR= 4.32; CI= 1.62-11.53). Anencephaly cases aged more than 20 weeks of gestation (WG) were statistically elevated than cases aged less than 20 WG (P= 0.003). Maternal parity was associated with the appearance of anencephaly, where uni- or multiparous cases mothers were more likely to have an offspring with anencephaly than nulliparous mothers. Consanguinity presented a significant risk factor for the occurrence of anencephaly (P= 0.003). A logistic regression was run to examine the impact of several variables, only the maternal age was statistically significant.

Conclusion: This study clarified fields where efforts should be intensified, and surveillance data developed to prevent this malformation.

Introduction-Aim: Spontaneous bacterial peritonitis (SBP) is a common complication in cirrhotic patients and is associated with a high mortality rate. The aim of this study is to determine the epidemiological and bacteriological profile of spontaneous bacterial peritonitis, as well as antibiotic resistance among hospitalized patients at CHU Mohammed VI, in order to guide empirical antibiotic choices for better management. Methods: This is a prospective study conducted over a period of 12 months, from January to December 2023, focusing on all requests for bacteriological examination of ascitic fluid samples. All samples received at the microbiology laboratory were processed according to the Medical Microbiology Reference Standard (Remic) Results: A total of 137 ascitic fluid samples were included. The main etiologies implicated in ascites were cirrhosis (50.36% of cases), followed by neoplastic pathology (24.1% of cases). The prevalence of spontaneous bacterial peritonitis was 13.87%, of which 63.16% corresponded to neutrocytic ascites with negative culture. The rate of bacterascite was 74.07%. Gram-positive cocci constituted the majority of pathogens (56.67%), with 43.33% corresponding to Gram-negative bacilli. 28.57% of coagulase-negative Staphylococci were methicillin-resistant. Quinolone resistance was observed in 23.53% of Gram-positive cocci, and 69.23% of isolated Enterobacteriaceae were multidrug-resistant. Conclusion: The prevalence of SBP due to Gram-positive and multidrug-resistant bacteria has increased in recent years. The currently recommended empirical antibiotic therapy, based on third-generation cephalosporins, carries a high risk of failure and may need to be reassessed.

Advancements in understanding SpA have greatly improved patient quality of life through early detection and effective treatment. However, non-specialist physicians often face challenges in identifying the early symptoms of SpA.

Aim: This study aims to assist healthcare practitioners in the early detection of SpA and to streamline management strategies by employing a standardized assessment protocol for adult patients with SpA. LITAR collaborated with fifteen rheumatologists to adhere to INEAS guidelines. The team created a comprehensive repository based on seven PICO questions and their answers. To create this repository, the team combined local Tunisian data and insights from relevant literature sources using a synthesis method.

Results: This research culminated in the formulation of twelve evidence-based recommendations for best practices, encompassing three critical domains. Firstly, it addresses the clinical indications and signs that should alert primary care physicians to consider a SpA diagnosis and promptly refer patients to rheumatologists. Secondly, it outlines the diagnostic procedures involved in confirming SpA. Lastly, it presents standardized methods for evaluating and monitoring the progression of SpA. To ensure the robustness of these recommendations, an independent reading group of 19 experts from various related specialties validated them. Subsequently, a panel of 54 Tunisian rheumatologists practicing in diverse sectors, including public health, academia, and the private sector, evaluated the strength of these recommendations. The strength ratings ranged from 8 to 9, with a degree of agreement spanning from 72% to 100%.

Conclusion: This guideline, developed with the support of LITAR and accredited by INEAS, serves the overarching goal of facilitating the early diagnosis and comprehensive evaluation of all SpA phenotypes and associated comorbidities.

Introduction: Atopic dermatitis (AD) is a complex skin disease frequently linked with other atopic symptoms such allergic rhinitis and asthma. The disease's history consists of persistent relapses with extreme pruritus, which lowers quality of life. AD has become a global health concern as its incidence has increased over the last few decades. It ranks as the third most common dermatologic disorder.

Aim: There are several open questions about the mechanisms underlying atopic dermatitis (AD), This review aims to emphasize the recent advances in scientific research regarding the pathophysiologic mechanism of AD and the clinical application of these factors.

Methods: A PubMed search was performed using the keywords "Atopic Dermatitis (AD)", "epidemiology", "clinical presentation", "diagnosis", "pathophysiology", "genetic defect", "impaired skin barrier", "immune dysregulation". The search strategy included meta-analyses, clinical trial, observational studies, and reviews.

Results: Atopic dermatitis affects over 2 million children worldwide, with a lifetime incidence of up to 20%. New data suggest that its incidence is still growing, particularly in low-income nations. AD is diagnosed clinically using the patient's medical history, particular clinical symptoms, and the elimination of other non-inflammatory skin conditions. The pathogenesis of AD is extremely complicated and involves several etiologies, including genetics, the microbiome, abnormalities in the skin barrier, along with dysfunctional innate and adaptive immune systems.

Conclusion: Recent research has improved our understanding of disease pathophysiology in atopic dermatitis. Current and future clinical trials are expected to continue clarifying this complex and heterogeneous skin disease, and to develop medications that promise more effective therapy, particularly for individuals with limited response to conventional treatments.

Introduction: In recent years, advancements in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have been notable, improving procedural techniques, imaging, and management of complications.

Aim: We sought to assess the performance and the practice of a high-volume Tunisian PCI center in treating patients with a CTO.

Methods: We retrospectively evaluated data from consecutive CTO patients who underwent percutaneous revascularization from October 2019 to January 2024 at the cardiology department of Habib Thameur Teaching Hospital, Tunisia. Operators' experience and CTO-PCI volume were also documented.

Results: The cohort consisted of 58 patients, predominantly male (86.2%), with an average age of 59.8±9.6 years. The right coronary artery was the most common CTO site (56.9%). The antegrade approach was adopted in 96.5% of the cases, with the antegrade wiring (AW) being the preferred technique (81%). Key procedural characteristics included the use of multiple access sites and dual coronary injection in 44.8% of the cases, multiple guidewires in 50%, additional support modality in 68.9% and drug-eluting stents in all instances. The procedural success rate was 75.9%, with an in-hospital adverse outcome rate of 13.8% and a major adverse cardiac event (MACE) rate of 3.4%. A significant impact of operator experience and volume on success rates (85.3% vs 62.5%, p=0.04) and adverse outcomes (25% vs 5.8%, p=0.03) was observed, with trained operators and higher-volume practitioners achieving better results.

Conclusion: In a single-center setting with a conservative CTO cohort, acceptable PCI success rates were achieved. We highlighted the positive impact of CTO training programs and PCI procedures volume on the overall outcomes.

Since the World Health Organization declared the Coronavirus Disease 2019 (COVID-19) pandemic as an international concern of public health emergency in the early 2020, several strategies have been initiated in many countries to prevent healthcare services breakdown and collapse of healthcare structures. The most important strategy was the increased testing, diagnosis, isolation, contact tracing to identify, quarantine and test close contacts. In this context, finding a rapid, reliable and affordable tool for COVID-19 screening was the main challenge to address the pandemic. Molecular diagnosis by reverse transcriptase polymerase chain reaction (RT-PCR), even though considered as the gold standard in the diagnosis of COVID-19, was time consuming and therefore does not fit the objective of rapid screening. In addition, serological tests to detect anti-severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) antibodies suffered from low sensitivity. Prediction models based on machine-learning (ML) that combined several clinical features to estimate the risk of COVID-19 have been developed. To address these screening challenges, we created a ML model (MLM) based on gradient boosting method. We included several clinical features and the daily geographic prevalence of COVID-19 cases in the MLM. The MLM was trained on 1554 cases (757 COVID-19), and tested on 547 cases (169 COVID-19). Our MLM successfully predicted RT-PCR positivity with an accuracy of 97.06%. Moreover, the variable sensitivity and specificity of our MLM depending on the disease geographic prevalence has introduced the concept of "dynamic" disease screening. In the context of future world pandemic emergencies, we believe that this MLM method can be very useful as a rapid, reliable and dynamic screening tool for contagious diseases, especially in the developing countries.

Introduction: Work-related open-globe injuries are a major cause of preventable vision loss worldwide with a significant socioeconomic impact.

Aim: To describe the demographics and clinical characteristics, identify the prognostic factors of work-related open-globe injuries and suggest preventive measures to minimize the incidence of these accidents.

Methods: A retrospective study of patients hospitalized in the Ophthalmology Department of Habib Bourguiba University Hospital, Sfax, Tunisia, for occupational open-globe injuries, between January 2020 and December 2022. A medical history and a complete ophthalmological examination were performed on all patients. Initial visual acuity (IVA) was systematically measured. We also studied the factors associated with poor final visual acuity (FVA). Poor visual prognosis was defined as an FVA of less than 1/10 six months after the trauma. Statistical analysis was performed using the system of Statistical Products and Services Solution (SPSS 26.0). A p-value less than 0.05 indicated statistical significance.

Results: Thirty-three eyes of 33 patients with work-related open-globe injuries were analyzed. The mean age was 39 ± 11.75 years, with male predominance. Almost half of them, 48.5% were welders. Mechanism of injury was penetrating trauma in 72.7% of cases. The mean presenting IVA was 1/25. Corneal wounds were present in 20 cases. Traumatic cataract was the most common associated lesion and was found in 36.4% of the patients. Intraocular foreign body was noted in 24.2%. The mean FVA was 1.6/10. Initial VA (p=0.04) and VH (p=0.004) was the significant predictive factors for final visual outcome in work-related open-globe injury patients.

Conclusion: Work-related open-globe injuries are a significant problem commonly encountered in healthcare settings throughout the world. It can cause significant morbidity in a young population of patients. This type of injury can be largely prevented with proper education and use of safety equipment.

Aim: To report the clinical and therapeutic particularities of pediatric keratoconus (KC).

Methods: Retrospective study focusing on patients aged less than 18 years, presenting with KC and followed in a tertiary reference center in Sfax, Tunisia.

Results: Our study involved 38 eyes of 20 children. We found a mean age of 12.8 years, a family history of keratoconus for 25% of cases and an atopic background in 30% of children. The mean best-corrected visual acuity was 5.3/10, the mean myopia was -6.3D and the mean total astigmatism was -4.9D. The average maximum simulated keratometry (Kmax) was 54.6 D. The visual acuity decrease was correlated with the presence of corneal opacities, with all keratometric indices except Skewed Radial Axes (SRAX) at 3 and 5 mm, with all elevation parameters and those of pachymetry except the delocalization of the thinnest point. 71.1% of eyes were classified as clinical KC and 47% of eyes were classified as Amlser-Krumeich stage 4. 42.1% of eyes were fitted with glasses and 57.9% with contact lenses. Six patients (10 eyes) underwent cross-linking (CXL). We noted an evolution of the KC for 64.29% of eyes not treated with CXL and a stabilization of 80% of eyes treated with CXL. The difference in follow-up parameters between the two groups was significant.

Conclusion: Pediatric KC is a severe disease, often diagnosed at a late stage. CXL is a safe and effective way to stop the disease.

Introduction-Aim: Type 2 diabetes (T2D) is a major public health problem. To succeed its management and prevent its complications, good therapeutic adherence must be ensured. The objectives of our work were to estimate the prevalence of poor therapeutic adherence in our patients and to identify its associated factors.

Methods: we conducted a cross-sectional, single-center study that included type 2 diabetic outpatients. Therapeutic adherence to antihyperglycemic agents was assessed by the 8-item Morisky Medication Adherence Scale (MMAS-8).

Results: We included 172 patients. The mean age was 59.7±9.5 years. The mean duration of T2D was 11.7±8.5 years. Glycemic targets were achieved in 35% of patients with a mean HbA1c of 8.5±1.8%. The prevalence of poor adherence was 66.1%. Factors associated with poor adherence were age <65 years (p=0.007), low educational level (p=0.026), diabetes follow-up < 2 consultations/year (p=0.004), non-practice of self-monitoring of blood glucose (p=0.008) and ignorance of glycemic targets (p=0.001).

Conclusion: Poor adherence affects a large proportion of our T2D patients. In order to improve it, therapeutic adherence should be an important theme in the education of patient.

Aim: To develop good practice recommendations (GPR) for the therapeutic management of patients with spondyloarthritis (SpA), including psoriatic arthritis.

Methods: Following standardised procedures, a systematic review of the literature was carried out on non-pharmacological and non-biological pharmacological treatments for SpA. The review was based on questions defined by a working group of 15 rheumatologists. The data was evaluated at group meetings, which led to the drafting of recommendations, the assignment of a grade to each recommendation and the determination of the level of agreement between the experts.

Results: A general principle and 11 recommendations were developed. The recommendations focus on treatment modalities, taking into account the dominant phenotype (axial, articular peripheral, enthesitic peripheral) and extra-articular manifestations (psoriasis, chronic inflammatory bowel disease (IBD)). The first recommendation concerns therapeutic patient education. Recommendations 2 to 4 focus on NSAIDs as the first-line pharmacological treatment for the various presentations of the disease, with the exception of those associated with IBD, as well as their prescribing modalities. Recommendation 5 deals with analgesics. Recommendation 6 limits the use of glucocorticoids to symptomatic peripheral arthritis and advises against their long-term use. Recommendation 7 deals with radioisotope synoviorthesis for refractory arthritis of the hips and knees. Conventional Synthetic Disease-Modifying AntiRheumatic Drugs (csDMARDs) are not recommended for SpA which is axial, enthesitic or involves dactylitis (recommendation 8). JAK inhibitors are recommended for axial SpA and for joint and skin involvement of psoriatic arthritis in failure of symptomatic treatment, csDMARDs and/or bDMARDs (recommendation 9). The latest recommendations (10-11) concern physical and surgical treatment respectively.

Conclusion: These GPR provide a summary of the current state of the literature, with the aim of optimising the management of patients with SpA, thereby improving the quality and safety of care with a better medico-economic approach. Efforts must be made to apply, implement and communicate these recommendations.