La Tunisie Médicale

How Amyotrophic Lateral Sclerosis Contributes to Increased Venous Thromboembolism Risk

Abdullah Ashraf Hamad — Sun, 02 Mar 2025 00:00:00 +0000

Immobile ALS patients or those at risk of venous thromboembolism require a comprehensive examination and low-dose heparinisation

Josef Finsterer, Sounira Mehri — Sun, 02 Mar 2025 00:00:00 +0000

What is new in kidney biopsy in 2024: A n a r ra t i ve review

Oumayma Bouali, Intissar Haddiya — Sun, 02 Mar 2025 00:00:00 +0000

Introduction: Kidney biopsy continues to be an essential diagnostic instrument for assessing both acute and chronic kidney disorders, although progress in alternative diagnostic methods.

Aim: This review offers a thorough analysis of the contemporary significance, methodologies, indications, contraindications, and consequences related to native kidney biopsy, as well as addressing the possible alternatives being studied as of now.

Methods: We incorporated research that examine human participants undergoing native kidney biopsy, employing diverse techniques like ultrasound, computed tomography-guided, percutaneous, or laparoscopic methods.

Results: Improvements in biopsy needle design and imaging methodologies have markedly enhanced the safety and precision of biopsies, while problems such as hemorrhage and infections continue to occur.

Furthermore, we examined prospective developments in kidney biopsy, namely the possible applications of artificial intelligence, non-invasive biomarkers, and genetic testing. Exome sequencing has demonstrated potential in elucidating genetic etiologies of idiopathic renal illnesses, while artificial intelligence technologies are commencing to improve diagnostic precision.

Conclusion: Although developing technology may eventually diminish the necessity for conventional biopsies, kidney biopsy now remains an essential part of a nephrologist’s work, especially for unusual and intricate situations.

Post stroke seizures and Vascular epilepsy

Sun, 02 Mar 2025 00:00:00 +0000

Introduction: Stroke (Cerebrovascular Accident, CVA), whether ischemic or hemorrhagic, is one of the main causes of epilepsy in the elderly. This condition leads to an increased risk of post-stroke seizures, affecting both patients' functional recovery and their quality of life. (1,2)

Aim: to clarify and simplify the management of vascular epilepsy, based on recent expert recommendations. This study seeks to address the specific challenges related to the incidence of post-stroke seizures, considering the clinical characteristics and therapeutic needs of patients who have experienced a stroke.

Methods: An analysis of available studies was conducted, considering different stroke subtypes, timing of seizure onset, and risk factors such as age, comorbidities, and stroke severity. Current recommendations for managing vascular epilepsy were also included.

Results: The results show variability in the incidence of seizures depending on stroke subtype and timing post-stroke. They also highlight a lack of consensus regarding certain risk factors and suitable management strategies.

Conclusion: This study emphasizes the need for clear guidelines for managing post-stroke epilepsy, especially for high-risk elderly patients. Current recommendations provide useful insights, but further research is needed to better define risk factors and optimize management strategies.

Perceptions of e-learning among Tunisian medical students during the COVID-19 pandemic: Strategies for effective implementation in medical education

Sun, 02 Mar 2025 00:00:00 +0000

Aims. In Tunisia, during the Coronavirus Disease 19 pandemic, the transition to e-learning was brutal. The aim of this study was to assess undergraduate medical students (UMSs)’ perception of the e-learning experience at the Faculty of Medicine of Sousse, and to derive some determinants of its implementation.

Methods. Eligible participants were all UMSs (n=1397). The data was collected from an email questionnaire distributed in January/March 2021. The questionnaire consisted of 89 items exploring three main parameters: institution role, students’ personal experience, and environment impact.

Results. A total of 419 UMSs responded (30% response rate). Half of the UMSs described this transition as difficult, and three-quarters felt concerned about the credibility of their degrees. Logistical issues negatively affected the transition to e-learning, particularly those related to Internet speed. Understanding difficulty via the screen interface was reported by 40% of UMSs. ‘‘Face-to-face” sessions were described as more conducive to assimilation by 64% of UMSs. As far as “information retrieval” is concerned, 83% of UMSs turned to social networks and adopted Wikipedia as a reference.

Conclusions. In Tunisia, as an example of North African country, the transition to exclusive e-learning has been largely impacted by the drawbacks of limited logistics. This study highlights the multiple facets to be considered in the future for the successful implementation of e-learning in medical education.

Enhancing Obstetric Emergency Management Through Simulation-Based Training: A Focus on Shoulder Dystocia

Sun, 02 Mar 2025 00:00:00 +0000

Introduction: Modern obstetrics faces the challenge of effectively training practitioners for the management of rare but critical obstetric emergencies, such as shoulder dystocia. Simulation has become an essential educational tool, allowing healthcare professionals in initial and continuing education to practice in a controlled environment, thereby promoting learning without risk to patients.

Aim: This article explores the effectiveness of simulation in improving practical skills and team management during obstetric emergencies.

Methods: A structured training program was implemented for 14 first-year obstetrics-gynecology residents, consisting of three monthly simulation sessions using both high-fidelity (SimMOM) and low-fidelity mannequins for shoulder dystocia management, supervised by a specialized 5-member team and followed by structured three-phase debriefings.

Results: Our study demonstrates a significant improvement in the management of shoulder dystocia following simulation training, with positive impacts on clinical outcomes and maternal-fetal safety. Despite its advantages, obstetric simulation presents challenges such as financial costs and the need for adequate expertise among trainers.

Conclusion: Simulation offers a promising solution to enhance clinical skills and interprofessional coordination in obstetrics, thereby contributing to better quality of care and the reduction of preventable complications.

Factors Associated With PICU Admission In Children With Multisystem Inflammatory Syndrome (MIS-C): An Observational Cohort Study

Sun, 02 Mar 2025 00:00:00 +0000

Purpose: To investigate factors associated with Pediatric Intensive Care Unit (PICU) admission in children with severe MIS-C.

Methods: We conducted an observational cohort study between July 1, 2020, and May 31, 2021, in the only pediatric hospital in Tunisia.

Results: A total of 45 children (33 males) with no recent history of COVID-19 infection were included. Mean age was 7±3.2 years. Sixteen patients (35%) required PICU admission. There was no significant difference in mean age of patients with and without PICU admission (7.5±2.7 vs. 6.76±3.46 years; p=0.4). The frequency of respiratory distress (p=0.001), shock (p=0.001), cardiac dysfunction (p=0.003), mean CRP (p=0.001), and median troponin (p=0.003) were significantly higher in patients with PICU admission than in those without. The independent predictive factor for PICU admission was cardiac dysfunction; adjusted Odds Ratio (aOR) = 12.8, 95% CI = (2.1-76.4), p=0.002.

Conclusion: The only independent risk factor for PICU admission in patients with MIS-C was cardiac dysfunction.

The performance of the Evaluation of Guidelines in Syncope Study score in the diagnostic approach to syncope in emergency department

Sun, 02 Mar 2025 00:00:00 +0000

Background: Management of syncope in the emergency department (ED) is not yet well codified. Several scores have been developed to facilitate diagnosis and management. According to the European Society of Cardiology, an EGSYS (Evaluation of Guidelines in Syncope Study) score ≥3 predicts cardiac origin.

Objective: Evaluate the performance of the EGSYS score in the diagnosis of cardiac syncope in ED.

Methods: We conducted a prospective study (2011-2021). Inclusion of patients who consult for syncope with calculation of the EGSYS score. Diagnosis of cardiac syncope was based on the results of the cardiological investigation. Patients were divided into two groups: SC+ group with cardiac syncope and SC- group with another etiology.

Results: Inclusion of 526 patients. Mean age =49± 20 years. Gender ratio=1.48. Two hundred and thirty-six patients (45%) had a cardiac syncope. Comparison between the two groups (SC+ versus (vs. SC-) showed the following results: mean age (58 ±19 vs. 42 ±18 years), history of heart disease: 34 (14.5%) vs. 13 (4.5%), rhythm disorders 22(9.4%) vs. 4(1.4%), bradycardia: 40 (17%) vs. 17 (5.8%), atrioventricular block: 26 (11.1%) vs. 8 (2.7%), bundle branch block: 45 (19.1%) vs. 17 (5.8%), High risk criteria: 138 (58.7%) vs. 75 (25.8%). Diagnostic performance of the EGSYS score was satisfactory with AUC=0.769, CI95% [0.73 – 0.81], p < 0.001. The threshold value was 3. Sensitivity, specificity, positive predictive value and negative predictive value were 79, 80, 76 and 83% respectively. Likelihood Ratio: Positive LR=4.04, negative LR=0.26.

Conclusion: The EGSYS score showed ..(abstract truncated at 250 words)

Bronchiectasis in adult: Radio-clinical features, etiologies and evolution

Hamida Kwas, Sabrine Majdoub Fehri, Houiem Ben Kraiem — Sun, 02 Mar 2025 00:00:00 +0000

Introduction-Aim: Bronchiectasis, which was once considered an orphan disease in developed countries, is common in Tunisia as in all emerging countries. The purpose of the present study is to determine radio-clinical features, etiologies and evolution of bronchiectasis.

Methods: Monocentric, retrospective and descriptive study including all patients followed in the pulmonology department, Gabes University Hospital, for bronchiectasis confirmed by a chest CT scan between January 2016 and December 2023.

Results: A total of 70 patients were included in the study. The mean age was 60.39±18.68 years. Symptomatology was dominated by cough and morning bronchorrhea. The diagnosis of bronchiectasis was confirmed in all patients. Chest CT scan showed diffused bronchiectasis in 85.7% cases, localized in 14.2% cases and bilateral in 87% cases. Bronchiectasis was secondary to pulmonary tuberculosis in 62.8% of cases and idiopathic in 12.8% of cases. Complications were dominated by bronchopulmonary infections (21.4% of cases) and hemoptysis (28.5% of cases). Ten patients (14.2%) with diffuse and bilateral bronchiectasis progressed to chronic respiratory failure.

Conclusion: Our study shows that the etiologies of bronchiectasis are dominated in our context by tuberculosis despite the national tuberculosis control program. Diffuse and bilateral bronchiectasis are frequent and associated with a poor prognosis.

Ultimate Pre-Transfusion Bedside Check: Evaluation of Hospital Staff

Sun, 02 Mar 2025 00:00:00 +0000

Introduction : Transfusion is the medical act of transferring blood or its constituents from one individual to another. The pre-transfusion bedside test is mandatory before any transfusion well codified in circular 32/15.

Aims: To evaluate the theoretical and practical knowledge concerning the ultimate bedside test of medical and paramedical staff of the Adult clinical hematology department of the Aziza Othmana hospital (HAO).

Methods: It’s a single-center descriptive study, in the form of theoretical and practical test, during June 2024 among paramedical and medical staff working during this period at the adult clinical hematology department of (HAO).

Results: We included 62 respondents, of whom 3,2% thought that the ultimate bed test replaced the compatibility test in the laboratory, 4,8% that it was obligatory before transfusion, 19,4% that it did not allow the detection of ABO incompatibility, 41,9% that it did not require the determination of the patient's blood group and only one questioned that it did not require the identity of the patient against 61 questioned (98,4%) who checked it. Among those questioned, 69,4% knew that this test is the last key to transfusion safety, 80,6% knew that it is the responsibility of the doctor compared to 19,4% who were unaware of this. All those interviewed checked the concordance between the identity of the recipient and that mentioned on the grouping documents.

Conclusions :This study made it possible to show an average theoretical and good practical level of the staff of the adult clinical hematology department ...(abstract truncated at 250 words)

Transcultural Arabic validation of the Clinician-Administered PTSD Scale for DSM-5, Child and Adolescent version

Sun, 02 Mar 2025 00:00:00 +0000

Introduction : Posttraumatic stress disorder PTSD in the pediatric population has clinical features. The Clinician-Administered PTSD Scale for DSM-5,child and adolescent version (CAPS-CA-5) is the gold standard in positive diagnosis. Our study had two primary objectives, first, to translate the CAPS-CA-5 into Tunisian dialectal Arabic, and second, to validate the translated version within the Tunisian sociocultural context.

Methods: This is a descriptive cross-sectional study conducted in two hospital departments. We recruited children older than seven years who were exposed to a potentially traumatic event at least one month before. We validated the tool through translation, content, construct validity and reliability.

Results: The validation was made on 146 records after the exclusion of 4 incompleted assessments. We initially translated the CAPS-CA-5 into Tunisian dialect. We validated the content through pre-test and scientific committee evaluation. Afterwards we validated the construction. We calculated the Bartlett's sphericity test (p<0.001) and the KMO index that was 0.766. Concerning the reliability study, we found a Cronbach's alpha coefficient equal to 0.92. We studied the inter-rater reliability via the intra-class coefficient which was between 0.8 and 1.

Conclusion: We validated the CAPS CA5 in our cultural context with satisfactory psychometric qualities. This tool will facilitate the early detection and diagnosis of PTSD in pediatric population.

Perceived experience of patients with Systemic lupus erythematosus towards the announcement of the diagnosis: Series of 50 observations

Sun, 02 Mar 2025 00:00:00 +0000

Introduction : The announcement of a chronic autoimmune disease is a delicate situation in our practice. The main objective of our work was to explore the felt experience of the lupus patient when faced with the announcement of the disease.

Patients and methods: Qualitative prospective study carried out from individual interviews with patients. suffering from SLE and followed in a department of internal medicine.

Results: We collected 60 patients (50 women and 10 men). The average age was 44.6 years. Thirty-five (65%) were married. The diagnosis was announced by an internist in 66% of cases. At the announcement of the diagnosis, 70% were hospitalized, alone (48%) and in the presence of a loved one (51%). The announcement took place in the doctor’s office in 40%. The duration of the announcement of the diagnosis was sufficient (56%). The doctor offered a second close consultation to complete the information (18%). The initial reaction was acceptance (54%), despair (31%), denial and refusal to disclose the diagnosis (3 cases). Around 36% thought that a consultation with a psychiatrist is necessary. The presence of a loved one is useful (45%). Patients suggested giving more information about the disease (58%), its progress (36%) and the treatment (5%). The analytical study showed that patients accept the diagnosis of SLE better when they are supported (P=0.026), married (P=0.01) and when the duration of the announcement is sufficient (P=0.045).

Conclusion: The announcement of the diagnosis of systemic lupus erythematosus must be made under appropriate..(abstract truncated at 250 words)

Organizational change in public healthcare facilities in a context of extreme disruption: A dialectic of order and disorder for the creation of sensemaking

Jihane Chaanoun — Sun, 02 Mar 2025 00:00:00 +0000

Introduction : In a context where the public hospital organization is experiencing severe pressure on resources, in particular human resources, with a shortage in staff capacity, especially in the nursing profile, digital transformation is an avenue that has yet to be explored, given that “it is a radical organizational change driven by new technologies that requires collaboration between the various stakeholders” (1), facilitating “organizations'

capacity for innovation” (2).

Aim : The aim is to find out the degree of understanding of the change to come in the era of digital transformation not only on the part of decision-makers, but above all on the part of the operational level to see their degree of predisposition to accept, resist, or appropriate the changes.

Methods: we opted for intervention research in line with the constructivist paradigm, using a questionnaire assigned to 105 people.

Results :

The quantitative study highlights contradictory representations marked by situations of acceptance and resistance to the IIS, which need to be managed in order to converge towards the tool's appropriation by the players.

Conclusion : We have clarified the difficulties of implementing changes that were not initially grasped by the project's decision-makers, by avoiding areas of resistance and reinforcing areas of appropriation by all organizational strata, in order to have a collective creation of meaning and maintain order in a context of disorder.

Analysis of Challenges and Perspectives of Telemedicine in the Mental Health Sector in Tunisia

Samir Samaâli, Abir Hakiri; Azza Bouallagui; Ghassen Amri, Rym Ghachem — Sun, 02 Mar 2025 00:00:00 +0000

The Presidential Decree-Law No. 318/2022 of April 8, 2022, established new specific legal foundations for telemedicine in Tunisia. In the field of mental health, telemedicine offers a significant opportunity to democratize care by making psychiatric services more accessible to a larger population. In a recent study, we assessed Tunisian psychiatrists' knowledge of telemedicine. Although they have a still limited understanding of the legal framework, they expressed a willingness to explore telemedicine for the management of mental disorders, thus demonstrating a growing interest in this new practice. The adoption of telepsychiatry facilitates a rapid response to care demands, particularly in underserved and remote areas. However, this evolution presents a series of new challenges. Legal, ethical, and administrative issues are emerging, requiring robust frameworks to ensure patient confidentiality, data security, and compliance with medical regulations. Moreover, ethical and deontological concerns must be addressed to maintain the integrity and professionalism of psychiatric practice.

In this article, we will detail the main points of the decree-law and its application in psychiatry, as well as the potential challenges associated with implementing telemedicine in the continuity of care in Tunisia, while navigating the complex landscape of new issues related to its application in psychiatry.

Giant uterine fibroid complicated by aseptic necrobiosis and cutaneous fistulation: A case report and brief review of literature

Sun, 02 Mar 2025 00:00:00 +0000

Background: Uterine fibroids are the most common tumors of the female reproductive system. Although often asymptomatic, they can lead to complications such as compression of adjacent organs, torsion, or aseptic necrosis. Cutaneous fistulation, though rare, is a complication presented in this case.

Case presentation: We reported the case of a 41-year-old female with no significant medical history who presented to the emergency department with a 4-month history of pelvic pain and purulent discharge from the supraumbilical region. Physical examination revealed an enlarged abdomen and a 3-cm supra-umbilical parietal mass with fistulation to the skin, discharging pus. Abdominal computed tomography imaging demonstrated a 30-cm uterine fibroid complicated by aseptic necrobiosis and cutaneous fistulation. The patient was started on antibiotic therapy, followed by myomectomy and resection of the fistulous tract by laparotomy.

Conclusion: Cutaneous fistulation of a uterine fibroid is a rare complication that requires prompt detection and an accurate diagnosis for effective management.

Accidental ingestion of cannabis in two infants and a preschool child reported by the Tunisian poison control center: Three case reports and review of literature

Mohamed Kilani, Sabrine Khelifa, Camillia Jeddi, Hafedh Thabet — Sun, 02 Mar 2025 00:00:00 +0000

Introduction: Cannabis or delta-9-tetrahydrocannabinol (THC) is responsible for psycho-affective effects. Even though it has been legalized in some countries around the world, it remains illegal in Tunisia although its consumption has alarmingly increased. Although its ingestion is known to be asymptomatic in adults, among infants/preschool children, its ingestion has been reported to cause drowsiness and coma. We reported the first cases of accidental cannabis ingestion complicated with drowsiness and coma, occurring in infants/preschool children in Tunisia.

Observations: We reported three cases of accidental cannabis ingestion in three infants/preschool children aged 7, 10, and 30 months. These were ingestions called into the Tunisian poison control center over a period of one year. Two patients were drowsy on admission and the third patient was comatose requiring mechanical ventilation. All three patients had positive urinary drug screen for cannabis. After surveillance and stabilization, the patients were discharged and no further complications were reported.

Conclusion: In the cases of infants/preschool children presenting with drowsiness or coma, physicians must search for accidental ingestion of THC or a history of illicit substance use in the infant/preschool child’s entourage.

Symptomatic bilateral talonavicular coalition: A case report

Sun, 02 Mar 2025 00:00:00 +0000

Introduction: Talonavicular coalition (TC) is a rare cause of foot pain, less frequent than talocalcaneal or calcaneonavicular coalitions. Symptomatic coalitions can significantly impact a patient's mobility and quality of life.

Observation: We presented the case of a 14-year-old boy with bilateral TCs presenting with medial foot pain. Surgical resection of the distal navicular coalition and tibialis posterior repositioning were performed. At 12-month follow-up, the patient reported complete resolution of pain.

Conclusion: This case highlights the importance of considering TC in the differential diagnosis of medial foot pain in adolescents. Surgical intervention can provide effective and long-lasting pain relief in these patients