La Tunisie Médicale

Tubular expression of Toll-like receptor 9 in lupus and primary membranous nephropathy

Nesrine Elloumi, Raouia Fakhfakh, Hatem Masmoudi, Khawla Kammoun — Sat, 06 Apr 2024 00:00:00 +0000

Introduction: Toll-like- receptors (TLR) control important aspects of innate and adaptive immune responses. Renal cells are among the non-immune cells that express (TLR). Therefore, their activation might be implicated in renal tubulo-interstitial injury.

Aim: The study aimed to compare TLR9 expression in patients with primary membranous nephropathy (MN) to patients with lupus membranous nephropathy.

Methods: Kidney sections from 10 Lupus nephritis (LN) patients and ten patients with primary MN were analyzed by immunohistochemistry using anti-human TLR9 antibody.

Results: Results showed that TLR9 expression was weak and exclusively tubular in primary MN patients’ biopsies. There was a significant difference between LN patients’ biopsies and primary MN patients’ biopsies. TLR9 expression was more diffused in LN patients’ specimen than in those with primary MN.

Conclusion: This study focuses on molecular level pathogenesis of MN. The data suggest that the receptors TLR9 may play role in tubulointerstitial injury in the pathogenesis of LN but not primary membranous nephropathy.

Functional insulin therapy in type 1 diabetics: Short-term effects on weight and nutritional intake

Sat, 06 Apr 2024 00:00:00 +0000

Introduction-Aim: Flexible insulin therapy is currently considered the gold standard therapy of type 1 diabetes. We aimed to study the evolution of glycemic control, weight and nutritional intake of a group of patients with type 1 diabetes, three months after the initiation of functional insulin therapy (FIT).

Methods: This was a prospective longitudinal study having included 30 type 1 diabetic patients hospitalized for education to FIT. Each patient underwent an assessment of glycemic control (glycated hemoglobin (A1C) and number of hypoglycemia), weight and nutritional intake before FIT and 3 months after the initiation of this educative approach.

Results: The mean age of patients was 21,8 ± 7,9 years and the sex ratio was 0,5. The mean duration of diabetes was 7,2 ± 6 years. Three months after initiation of FIT, we observed a significant lowering of A1C, which went from 9,2 ± 1,6% to 8,3 ± 1,4% (p<0,001) of the number of minor hypoglycemia (p=0,001) and that of severe hypoglycemia (p= 0,021). the average weight went from 64,6 ± 13,1 kg to 65,5 ± 13,5 kg (p = 0,040) with a significant increase in BMI (p = 0,041). Weight gain was observed in 67% of patients. This weight gain contrasted with a significant decrease in caloric (p = 0,040) and in carbohydrates intakes (p = 0,027).

Conclusion:

Weight gain, associated with better glycemic control, should encourage the healthcare team to strengthen therapeutic education of patients undergoing FIT in order to limit weight gain.

Botulinum toxin and hyperhidrosis of the amputation stump in war amputees

Sat, 06 Apr 2024 00:00:00 +0000

Introduction: Stump hyperhidrosis is a common condition after lower limb amputation. It affects the prosthesis use, and the quality of life of patients. Several case reports tried to prove benefit of using Botulinum toxin in its treatment.

Aim: This study was to conduct a larger workforce clinical trial and to demonstrate benefits of botulinum toxin injection in the treatment of stump hyperhidrosis.

Methods: A prospective study was conducted. War amputees who complained of annoying excessive sweating of the stump were included. They received intradermal injection of botulinum toxin A in the residual limb area in contact with prosthetic socket. Abundance of sweating and degree of functional discomfort associated with it were assessed before, after 3 weeks, 6 and 12 months.

Results: Seventeen male patients, followed for post-traumatic limb amputation were included in the study. Discomfort and bothersome in relation to Hyperhidrosis did decrease after treatment (p<0,001). Reported satisfaction after 3 weeks was 73,33%. Improvement of prothesis loosening up after 3 weeks was 72,5% [±15,6]. Mean injection-induced pain on the visual analogue scale was 5.17/10 (±1.58). The mean interval after the onset of improvement was 5.13 days [min:3, max:8]. The mean time of improvement was 10.4 months after the injection [min:6, max:12]. No major adverse events were reported following treatment.

Conclusions: Intradermal injections of botulinum toxin in the symptomatic treatment of stump hyperhidrosis are effective and have few adverse effects. It improves the quality of life of our patients thanks to a better tolerance of the prosthesis.

Effect of diabetes self-management education on health related quality of life of Tunisian children with type1 diabetes mellitus and their parents: A randomized controlled trial

Sat, 06 Apr 2024 00:00:00 +0000

Aim : To assess the effect of diabetes self-management education (DSME) on health related quality of life (HRQoL) of Tunisian children/adolescents with type 1 diabetes mellitus and their parents.

Methods : This monocentral study used a randomized controlled trial design, during five-month intervention and five-month follow-up and including 110 patients (54 in the DSME intervention group and 56 in the Individual Education by Pediatrician (IEP) control group) and their parents. Pediatric Generic Core Quality-of-Life Inventory 4.0-Scale (PedsQL4.0) evaluated HRQoL.

Results : At baseline, both groups had similar clinical features and PedsQL4.0 scores (p>0.05). In DSME, clinical outcomes were significantly improved from baseline to follow-up (p<0.001), while in the IEP group, which received no intervention, these outcomes remained unchanged. During follow-up, DSME showed higher PedsQL4.0 scores in parents’ proxy-report and children/adolescents self-report (p<0.001). According to parents’ proxy-report, PedsQL4.0 scores were significantly higher during follow-up compared to baseline in DSME (p<0.001) while they remained the same in IEP (p>0.05). DSME had higher percentage of change in the PedsQL4.0 scores than IEP (p<0.01). The median change varied from -5.01% to 0% vs 5.41% to 36.36% in IEP and DSME, respectively.

Conclusion : Encouraging healthcare professionals to incorporate these interventions could enhance the HRQoL of diabetic children and bolster their self-esteem.

Occupational elbow musculoskeletal disorders in Tunisia: Epidemiology and socio-professional consequences

Sat, 06 Apr 2024 00:00:00 +0000

Introduction: Musculoskeletal disorders (MSDs) are as the primary occupational disease (OD) in Tunisia. They can touch the elbow and cause occupational disability.

Aims: Describe the epidemiological and clinical characteristics of elbow MSDs recognized in Tunisia, identify the factors associated with these MSDs and assess their socio-professional impact.

Methods: Retrospective descriptive study of elbow MSDs recognized as compensable OD by the Committees for the Recognition of Occupational Diseases of National Health Insurance Fund, in Tunisia, from 2012 to 2018.

Results:

We collected 431 cases of elbow MSDs or 8.35% of all recognized MSDs and 11.8% of recognized MSDs during the same period. The average annual incidence was 4.3 cases. Patients had a mean age of 43.59 years and a clear female predominance (82.2%). The largest provider was the textile industry (60.6%). The average length of employment was 16.78 years. Biomechanical factors were repetitive movements (92.8%), forced movements (67.1%) and prolonged static posture (7.4%). These were lateral epicondylitis (79.1%), medial epicondylitis (14.2%) and ulnar nerve syndrome (10.7%). These pathologies were associated with other MSDs including carpal tunnel syndrome (25.8%). These MSDs were responsible for 15,342 days of lost work. The rate of permanent partial incapacity was 10.6% with a job loss in 15.63%.

Conclusion: Elbow MSDs are responsible for heavy economic and socio-professional consequences justifying the implementation of a preventive strategy adapted within risk sectors.

Clinicopathological characteristics and tumor infiltrating immune cells associations of PD-L1 tumor expression in non-small cell lung cancer patients.

Sat, 06 Apr 2024 00:00:00 +0000

Aim: Our study aimed to perform on Moroccan patients non-small cell lung carcinoma (NSCLC) concerning the relationship between PD-L1 tumor expression, clinicopathological features and tumor infiltrating immune cells (ICs).

Methods: This is a retrospective study (2019 to 2021) conducted on samples from Moroccan patients with NSCLC at the Pathological Anatomy Laboratory of Ibn Rochd University Hospital in Casablanca. Eligible participants for our study had to meet the following predefined criteria: age ≥18 years, histologically confirmed NSCLC, no prior therapeutic interventions, availability of clinical and pathological data, and a usable tumor sample for determining PD-L1 status. Exclusion criteria applied to patients with other types of lung cancer and unusable tumor samples. The evaluation of tumor and immune expression of PD-L1 was performed using immunohistochemistry (IHC), with the 22C3 clone on the Dako Autostainer Link 48 platform. Tumor PD-L1 expression was categorized into 3 levels: TPS <1% (negative expression), TPS 1-49% (low expression), and TPS ≥50% (high expression). ICs infiltrating the tumor expressing PD-L1 were considered positive when more than 1% of positive ICs were present.

Results:
Among the 316 analyzed samples, 56.6% showed a negative expression of PD-L1, 16.8% displayed a low expression of PD-L1, and 26.6% exhibited a strong expression. Regarding the histological type, among patients with TPS ≥ 50%, 25.8% had adenocarcinoma. Among patients with TPS ≥ 50%, 24.81% were smokers. PD-L1 was also strongly expressed in the lung (28.2%) and bronchi (26.5%). PD-L1 expression (TPS ≥ 50%) was observed ...( abstract truncated at 250 words).

Ischemic Stroke in Young Tunisian Adults

Sat, 06 Apr 2024 00:00:00 +0000

Introduction: Ischemic Stroke in young adults is a real public health problem; it’s a major cause of disability, alters quality of life and has a great socio-economic impact.

Aim: determine risk factors and specify the etiology of arterial ischemic stroke in young Tunisian adults.

Methods: In this 5 years retrospective study (2015-2020), we included all young adults (18-50 years) admitted for arterial ischemic stroke (AIS). Risk factors were registered and analyzed. All patients were investigated using a standard protocol: biological tests, brain imaging, carotid ultrasound and cardiac assessment. Additional investigations were carried out at the discretion of the treating physician. The cause of ischemic stroke was classified according to the TOAST criteria.

Results: We collected 200 patients with AIS. The mean age was 41.37 years ± 6.99. Traditional vascular risk factors were observed in more than 1⁄4 patients. A definite cause of stroke was identified in 120 patients. Cardio-embolic causes were the most common among our patients (19%) followed by atherosclerosis of the large arteries (11.5%). Other determined etiologies were found in 27.5% of patients. The etiology remained unclear in 40% of cases: undetermined despite complete investigation in 17.5%, undetermined and incompletely investigated 14.5 % and more than one potential pathomechanisms in 8%.

Conclusion: Through this study, we demonstrated the diversity of etiology of stroke in young Tunisian adults. Changes of lifestyle are responsible for the occurrence of the traditional risk factors at an early age. Rheumatic heart diseases remain a frequent cause of AIS in our area.

Patient-management problem in the evaluation of intensive medicine

Sat, 06 Apr 2024 00:00:00 +0000

Introduction: In intensive care medicine (ICM), the use of Patient-Management Problem (PMP) remains limited and no feedback from students is available.

Aim: To compare the feasibility of employing PMP referring to clinical cases (CC) as assessment tools for appraising the knowledge and competencies in ICM students; and to gather the students’ perception regarding this experience.

Methods: it was a cross-sectional randomized trial. Were included, external students in the 3rd year of the 2^nd cycle of medical studies (3^rd-SCMS) during their ICM externship. All the participants underwent two random draws (the 1^st one for assessment tool to be started (PMP or CC) and the 2^nd for the passage order for PMP. Two PMPs versus two grouped QCMs-CC were prepared and a satisfaction questionnaire was distributed. The main judgment criterion was the effect of each assessment tool on the students' decision-making process. This focused on the relevance of the elements provided by each technique, the implication and the difficulty felt. The secondary endpoint was the scores taken for each tool tested.

Results: 20 students were included. All participants had previous experience with PMPs and only nine were familiar with grouped MCQs-CC. PMP scores were 14.9 for the 1^st theme and 15.8 for the 2^nd theme. The median of the grouped MCQs-CC scores was 14 [12-16] for both. The scores didn’t differ between the two techniques. For the 1^st theme: the scores were negatively correlated (r=-0.58 and p=0.007). Students felt a better satisfaction for PMP evaluation ......( abstract truncated at 250 words).

Contribution of ethical reasoning learning sessions on medical training

Sat, 06 Apr 2024 00:00:00 +0000

Introduction: Ethical reasoning is an important skill for all physicians who often face complex ethical dilemmas in their daily practice. Therefore, medical training should include methods for learning ethical theories and concepts, as well as how to apply them in practical situations.

Aim: Assess the contribution of an Ethical Reasoning Learning session to fifth medical students’ training through a comparison of results of the same objective and structured clinical examination (OSCE) in the form of simulated interview before and after sessions.

Methods: Four 45- minutes’ sessions of Ethical Reasoning Learning (ERL) were implemented during a psychiatry internship for four groups of 5^th-year students of the faculty of medicine of Monastir (Tunisia). Each session was divided into 7 parts: introduction, reading of a clinical vignette, brainstorming concerning the problems posed by this clinical situation, classification of the problems, identification of the principles of medical ethics, construction of the ethical matrix, and a conclusion.

Results: Fifty-seven students participated in the study divided into 4 groups. We found a significant difference in the means of the OSCE scores before and after the ERL session and a significant difference between the probability of respecting medical secrecy during pre and post-ethical reasoning learning sessions (p <0.001). We have found an effect of ERL sessions on the acquisition of this ethical competence by medical students.

Conclusion: We learned that an ERL session has improved medical training in ethics applied to psychiatry. Other sessions dealing with other ethical skills are necessary to confirm these results.

Management of anal fistulas in Crohn’ disease after failure of Infliximab Runnig head: Fistule anale réfractaire à l’infliximab

Sat, 06 Apr 2024 00:00:00 +0000

Introduction : Treatment of complex perianal fistulas in Crohn's disease remains a challenge especially after the failure of Infliximab.

Aim: Update on the different therapeutic alternatives for anal fistula in Crohn's disease after failure of Infliximab.

Methods: A research in the medical literature on PubMed and Google Scholar was carried out. We included cohort studies, reviews and randomized double-blinded therapeutic trials. Case reports and fundamental research studies have been excluded.

Results: Anti-TNF therapy, notably Infliximab remain the therapeutic option of choice. Since Infliximab efficacy has been estimated at 60%, with a significant loss-of response rate, new therapeutic strategies have been evaluated and may offer new opportunities for the management of anal fistulas: for example, Ustekinumab could be effective after failure of anti-TNF therapy, although further studies are required. Recent guidelines suggest that injection of mesenchymal stem cells is an effective and safe treatment for complex fistulas. Other surgical options have been proposed, such as endorectal advancement flap, fibrin glue injection, anal fistula plug and ligation of the intersphincteric fistula tract, but all with limited and debatable efficacy. Given the failure rate of all these options, new strategies are currently being evaluated.

Conclusion: Anal fistulas in Crohn's disease are a real therapeutic challenge. New medical and surgical therapies are currently being evaluated, with promising results.

Publication of pediatric theses defended at the Tunis faculty of medicine: A 15-year study

Sat, 06 Apr 2024 00:00:00 +0000

Introduction: The valorisation of thesis through its publication is necessary to enhance its visibility. Few data exist concerning the characteristics of theses defended at the Tunis faculty of medicine.

Aim : Examine the publication rate of pediatric theses and identify factors associated with an increased publication rate.

Methods: We conducted a cross-sectional descriptive bibliometric study of pediatric theses defended at the faculty of medicine of Tunis over a 15-year period, from 2006 to 2020. Theses were retrieved from the catalog of the faculty library. Publications had been searched in databases “Pub Med ", and “Google Scholar” until December2021.Results : The study involved 235 pediatric theses. Sixty-eight theses were published, representing 29% of the total. The main topics of published theses were neonatology (16%) and hematology (15%). The language of publication was French and English in 55% and 45% of cases, respectively. All publications in Q1 and Q2 journals were written in English. The only independent factor predicting publication of theses was the very honourable mention with congratulations of the jury and proposal for the thesis prize (p=0,007).

Conclusion : Additional assessments will be necessary to identify the obstacles to the publication of theses.