[Aboriginal malaria in Tunisia: about the 4 cases registered in 2013 in Tunis]

Background: Malaria has been eliminated in Tunisia since 1979, but the country remains, like all other countries harboring the vector, exposed to the potential risk of resurgence

Objectives: Describe the clinical and epidemiological investigation of 4 cases of autochthonous malaria in July 2013 and report the main actions of regional and national response

Methods: Retrospective descriptive survey of the 4 clinical observations as well as the study of the regional report data of basic health care for the region of Tunis in 2013

Results: Febrile table concomitant for 4 Tunisian male patients, aged from 21 to 27 years old ; fortuitous discovery of Plasmodium falciparum when checking thrombocytopenia of patient 1 ; diagnosis in cascade of other cases following the epidemiological investigation and field consultation with clinicians ; 3 simple forms and a neuromalaria of favorable evolution ; negative entomological survey for anopheles ; elimination of imported malaria and blood-borne ; airport malaria highly probable. The response included the establishment of a regional and national monitoring unit, an information program aimed at health professionals concerned and public opinion, the involvement of health and entomology teams for the detection and census of potential larval habitats and the implementation of local mosquito eradication measures

Conclusion: The clinical vigilance and competent biologist's eye is necessary to prevent the resurgence of this disease. The epidemiological surveillance system should be maintained and kept as well as the food safety standards monitoring at the borders

[ general practitioner facing acute infant bronchiolitis: multicenter study in Tunis]

Background: The acute bronchiolitis in infants [ABI] constitutes a health problem, responsible for a congestion of the care system, particularly emergencies

Objectives: This study aims to assess the knowledge, attitudes, and the frontline general practitioners' behavior, and describe the availability of the base pediatric equipment in health centers, in Tunis

Methods: Cross-sectional descriptive survey was conducted in 2013 at 50 health centers in the region with physicians, conducted by selfadministered anonymous questionnaire and a data sheet detailing the equipment at the health center. Seizure and data analysis is made by Epi Info 6

Results: The responder doctors have over 20 years of seniority for 64% of them and have all received training in ABI. In knowledge 75 to 80% master the definition of the ABI and the main criteria of severity, but only 35% identified less than 3 months of age as a risk factor and less than half provide prevention tips. Regarding the physicians behavior, chest X-ray and kinesitherapy continues to be prescribed in respectively 23 and 37% of cases, the same applies for corticoid [25%]. Nasopharyngeal desobstruction is only recommended in 60% of cases. In regard to the health centers equipment, they were judged satisfactory overall, except for the absence of oxygen sources in 66% of them

Conclusion: Acute Bronchiolitis in infants remains over-medicated at the level of frontline medical consultation in Tunis. It is necessary to revise the terms of skills updating of the general practitioners in care and prevention, conduct and disseminate easy and attractive communication tools [brochures and posters] and implement seasonal data collection of this disease in sentinel sites

[National survey of maternal mortality of 2010: data of Tunis]

Tunisia has investigated maternal mortality in 2010 to determine maternal mortality ratio [MMR] nationally and regionally, in addition to the identifying main causes of this mortality. Describe methodology of this study and its principal findings in the region of Tunis and discuss the national maternal mortality strategy. This is a Ramos study [Reproductive Ag Mortality Studies] that consists on identifying maternal deaths from reproductive age group [RAG] women deaths. We started by the a rehearsal and targeting of [RAG] women deaths, then we investigated a next of kin person of the decedent women by verbal autopsy, thereafter we identified maternal deaths to be confidentially investigated to judge the potential avoidability of the death. The study took place in 2010, it was carried out by 5 couples of investigators supervised by a coordinator doctor. A total of 200 deaths of [RAG] women were found in Tunis, 7 deaths among them were maternal deaths, that corresponds to an MMR of 41/100000 live births. The mean age of the deceased women was 35 years. The main causes of maternal deaths were hemorrhage [3/7], thrombo-embolic diseases [2 times for7] and HELLP syndrome [1/7]. Four of a total of 4 deaths [3 deaths were not marked], were avoidable. The majority of late women had a satisfying educational level, 4 of 7 had financial autonomy. All of them had pregnancy monitoring, 5 times of 7 in university hospital. All the childbirth were medically assisted, Caesarean section was carried in 6 of 7 cases. Nationally, the MMR was estimated to 44.8/100 000 LB, that to say a decrease of 35% compared to 1993. The decrease was significant for all the regions of the country, except the great Tunis where opposite trend was recorded. This could be more likely related to quality of care rather than socio-economic conditions seeing that social determinants in Tunis are favorable. In fact, the Tunisian maternal mortality strategy had essentially focused on the monitoring system of maternal deaths rather than the quality of care improvement interventions, results were disappointing due to the lack of institutional engagement. The achievement of the OMD5 objectives is compromised, due to socio-economic constraint especially in certain regions, poor governance and lack of engagement of ministry of health in reducing maternal mortality. Tunisian maternal mortality strategy should be revised and adapted to regional context, also should include multisectoral interventions. Priority would be given to quality of care improvement, by launching the experience of care setting accreditation in one hand, and in the other improving partnership between different levels of care

[Cognitive remediation therapy in schizophrenia]

Despite progress in chemo-therapeutics, schizophrenia remains a chronic disease with occurrence of residual symptoms and drug resistance in 60%of the cases. Besides, cognitive impairment is frequent and highly con-elated to social dysfunction seen in patients with schizophrenia. Several cognitive remediation programs have been elaborated. Rehacom [R] is one of such programs. Aim of the study is to evaluate through a case control the efficiency of Rehacom [R] towards cognitive functions. This program has been administered to a patient suffering from undifferentiated schizophrenia which was ameliorated after drug therapy considering positive symptoms but still was complaining from cognitive deficits causing social withdrawal. After following the remediation program, the patient was ameliorated considering its negative symptoms as attested by an amelioration of the PANSS negative score and considering its cognitive performances on memory, attention and executive functions. We have also noticed an improvement in his self-esteem and his quality of life. This first trial of a cognitive remediation program among our patients suffering from schizophrenia using Rehacom [R] was encouraging. Enlarging its use and designing controlled studies will be the next step of our study

[Evaluation of correlations between cognitive performances ans clinical dimensions of schizophrenia]

Schizophrenia is characterised by positive and negative symptoms as well as thought disorders and disorganised behaviour. Multiple cognitive deficits within the areas of memory, attention and executive functions are also associated with schizophrenia. Aim of the study was to proceed to a study of correlations between clinical dimensions of schizophrenia and cognitive functions. The authors recruited 105 patients suffering from schizophrenia spectrum disorders [DSM IV criteria]. The patients were clinically stabilised, showing no depressive state at the time of the study, with no organic brain disorders and no history of drug intake. They were clinically evaluated using the PANSS and the Calgary Depression Scale. A cognitive battery was also administered. Positive dimension of schizophrenia was shown to be independent from any cognitive function. Disorganisation was negatively correlated to attention, working memory, long-term verbal memory and executive functions. Negative dimension was negatively correlated with working memory and executive functions. Cognition wasn't correlated to the positive dimension of schizophrenia whereas it was currelated to the negative and to the disorganisation dimension of the disease. This is probably due to overlapping of conceptsand to the disorganisation dimension of the disease. This is probably due to overlapping of concepts

[Tunisian of "Hopkins verbal learning test" form1]

Memory impairment and verbal learning are the most common cognitive deficits associated with schizophrenia. Hopkins Verbal Learning Test [HVLT] is considered to be the most reliable test to asses memory and verbal learning in this mental illness. To create one form of the HVLT which would suit our linguistic and cultural context and to study the characteristics of this test in a group of healthy subjects. The HVLT consists of a list of 12 words belonging to 3 semantic categories and which are read orally to the subject with an immediate and differed recall. The first part of this work was to select words from a lexical database in order to create the list of the HVLT. The test was then administered to 103 subjects aged from 17 to 45V years-.old [mean 27, 4; SD=7, 3] and having between 1 and 20 years of education mean=12, 2; SD=5, 3]. No statistical difference was found within performances of the HVLT across gender and sex. Whereas, years of education was found to have an impact on performances. Although statistically difference was found across level of education. Our study permitted us to create one form of the HVLT which well suits our Tunisian context and which we could use to evaluate memory functions among people suffering from schizophrenia

[ tunisian cognitive battery for patients with schizophrenia]

Cognitive disorders are common and severe in schizophrenia. They are also correlated with the functional outcome of the disease. Cognition can not he assessed during a standard clinical interview hut needs to be evaluated by means of specific cognitive tasks. Aim of the study is to construct a battery of cognitive tests which is adapted to the Tunisian cultural and linguistic context and to collect normative data in Tunisian Arabic speaking healthy subjects. We have selected and adapted cognitive tests to our socio cultural context. Then we have proceeded to the administration of these tests within a group of healthy subjects. The cognitive battery is composed of 7 tests: the Hopkins Verbal Learning Test, the Token test, the Zazzo test, phonemic fluency, semantic fluency, visual working memory test and number working memory test. These tests are presented with their manual of utilisation and their normative data. The Tunisian cognitive battery is believed to permit a better cognitive assessment of patients suffering from schizophrenia. Improvement of cognitive impairments in schizophrenia is associated with a better social and professional integration of these patients

[ concept of attention]

Attention is a complex function which matches environment's information to the needs of the organism. Describe the different variety of attention, the attenti000el tests and attentional disorders in the psychiatric pathology. Review of literature on PUBMED. There are several types of attention such as selective attention, sustained attention and the divided attentions. Besides these different varieties of attention, we find the pre attentive phenomena: alertness and orientation which leads to preparing the attention. The investigation of attention requires different tools of measures such as the Stroop test, the Continuous performance test or the "test de Barrage de zazzo" and a few years ago the visual detection task of Posner and the attentional network test that explores the three attentional networks independently. In psychiatric illness, the attentional disorders are not specific although certain abnormalities are more suggestive of some pathology like the disengagement deficit in schizophrenia and the attention deficit and hyperactivity of children. There are several types of attention and pre attentive phenomena which investigation require specific cognitive tests

[ gastric collision tumor composed of adenocarcinoma and gastrinoma case report]

Collision tumors of the stomach are exceedingly rare with only six previous reported instance in which adenocarcinoma of the stomach were found in association with carcinoid tumor. Only in one case the adenocarcinoma was associated with a gastrinoma. We report the second case of Collision tumor between adenocarcinoma and gastrinoma. A 55 years old man was admitted in our department for an exploration of gastric pain with rapid weight loss. Physical examination showed an epigastric mass. Upper endoscopy showed in the fundic region of the stomach an exophytic process wildly ulcerative in his center associated with the presence of a multiple polypoid tumors. The pathologic examination of the biopsy specimen of the process revealed an adenocarcinoma and of the polypoid tumors showed a carcinoid type tumor. There was no merged appearance between both tumors suggesting collision tumor. The biopsies of the non tumoral gastric mucosa were normal. The Zollinger Ellison syndrome was then suspected. The serum gastrin level showed a rate raised at 8676pg/ml. The diagnosis of collision type tumors between adenocarcinoma and gastrinoma was retained. The assessment of extension revealed the presence of hepatic and ganglion nodes. The patient was treated by chemotherapy but he died three months after initiation of chemotherapy because of tumoral progression. Through this observation and with a review of literature, the coexistence of adenocarcinoma and carcinoid tumor of the stomach is discussed

[Evaluation of the maternal death system in public facilities in the Tunis [1999-2004]]

We report the performance indicators in 2004 of a follow-up on the system for recording maternal deaths which was established in 1999. The system was operating in 69.8% of public hospitals, and 96% of maternal deaths investigations were completed. In 69.8% of maternal deaths there was a direct obstetric cause. Haemorrhage was the major cause of maternal death [30.8%], followed by eclampsia [11%]. The proportion of avoidable [certain or possible] deaths was 75.3%. There were problems in evaluation of risk presented by women and inadequate follow-up during the postpartum period and delay in appropriate treatment. Incomplete documentation and difficulty in ascertaining avoidability were problems faced by the regional follow-up committee

Haematological and molecular aspects of hemoglobinosis H: about three Tunisian cases

Hemoglobinosis H is the severest alpha-thalassemia compatible with life. The clinical manifestation seems to be different regarding to the genotype. The present paper aims to provide to hematological and molecular data related to three patients suffering from hemoglobinosis H alpha thalassemia and their family. The clinical and biological profiles appear to be similar to those observed in thalassemia intermedia with mild hemolytic microcytic anemia. The diagnosis was based on decreased Hb A2 level [< 2%] and the presence of Hb H at an amount ranging from 10 to 30%. Two different molecular defects were observed. The genotypes were an association of two types of deletion [--MEDI an alpha [3.7]] and two point mutations [alpha[snt] and alpha t], The correlation phenotype / genotype showed that non-deletional Hb H is more severe than deletional forms. Detection of athalassemia trait remains difficult, it's detection is yet a matter of exclusion diagnosis based on the observation of isolated microcytosis with normal or limited Hb A2 levels with a normal iron state. Molecular study is a powerful tool for the diagnosis of such alpha cases

Monitoring of Maternal and Infantile care Activities

In the framework of quality assessment, the basic service for health care of Tunis introduced in 1997 a service managing tool for prenatal activity monitoring.This paper aims to present the way this tool should be used its setting up within the basic health structures and its principal effects on the quality process. Prenatal activity monotiring is a process that allows evaluation, control and dysfunction level identification of a health program; it also permits a microplanification in order to compensate for its failings. The first step consists in calculating the 5 following covering determining factors: target population, material or.human resources availability, the service at one's disposal's use rate, the appropriate coverage rate according to a precise way in which the consultations are linked to each other concerning this program and the effective coverage rate including the required quality indicator for the care. A graph permits to visualize these different rates. The second step consists in identifying the bottleneck and the most relevant correcting actions to be conducted in relation with either the available human resources or the material resources or the process of health care by using an "internal audit". Setting up this tool required many training sessions and supervisions for the Tunis health care services. It proved efficient enough in order to improve the actual coverage of the population especially in the responsibility area of the staff members for certain preventive programs as prenatal services or children's growth follow up. It allowed a better documentation of the consultation activity and the objective analysis of the inherent problems to the recommended program. The solutions were taken locally and dependes on the decision maker's will

[Leukocyte adhesion deficiency about anew Tunisian case]

Leukocyte adhesion deficiency [LAD] is a rare primary immunedeficiency inherited as an autosomal recessive genetic disorder. LAD was suspected in a four days old girl. She was born from healthy first cousins. A family history of a boy who died from omphalitis and sepsis was reported. Our patient had the severe form, she had delayed umbilical cord separation and suffered recurrent infections. She had a deletion of the G at position 1497. The patient received a bone marrow transplantation from her mother HLA identical at age of 14 months. She is now 9 years old and in a good health

[Contribution of RT-PCR for diagnosis of chronic myeloid leukemia]

The molecular analysis of chromosomal abnormalities associated with hematological malignancies allowed the identification of genes involved in theses rearrangements as well as of some recurrent mechanisms. Polymerase chain reaction [PCR] tools are now available to detect these rearrangements, allowing a better follow-up of these diseases. Chronic myeloid leukemia is a myeloproliferative disorder characterized by a reciprocal translocation t[9;22][q34;q11] which results in a bcr-abl fusion gene. Retro-transcription polymerase chain reaction [RT-PCR] is used to detect bcr-abl to establish diagnosis and to monitor patients. We report here the results of 30 patients samples tested in the hematology laboratory at Pasteur Institute, diagnosed as chronic myeloid leukemia and monitored with RT-PCR. Our results highlight the interest of molecular tools to diagnose and monitor patients mainly when cytogenetic techniques are irrelevant such as cases with complex chromosomal rearrangements or when patients achieve Philadelphia negativity after treatment

[ health care demand in the district of Tunis]

This study aims at evaluating the morbidity of Tunis city inhabitants during the last 6 months preceding the date of the study [June 1998] and at locating the medical care points. It has been led with home interviews. The sample has been selected in a random way and is supposed to give a fair view of the whole districts of Tunis city; it includes 374 families and 1747 individuals. The socioeconomic indicators of the selected families are genuine with those of the Statistics National Institute and 88.8% of the interviewed families benefit of the welfare coverage. The mean of morbidity is of 2.6 yearly by individual and the health care is 3 yearly by individual: this includes an abstention of medical care up to 1.6% and self medication for 26.0% of individuals. The structure involved in the cares appeared respectively to be of public type in 37.5% of the cases, private in 26.5% and of a par public in 10.0%. For the urgency diseases [4.4%]. patients go to the hospitals in 31% of the cases; for the less urgent diseases [23.8%] patients go to the basic welfare structures in 23% of the cases. For the needs of prevention [8.5%], patients go to the basic structures in more than half of the cases. The study indicated clear trend towards more medication of Tunis city inhabitants though it represents the 1/5 of European people. The increasing demand of Tunis city inhabitants for medical care together with the growth of the private medical structures lead to a necessary new organization of the whole medical system in Tunisia

[Molecular study of fanconi anemia in Tunisia]

Fanconi anemia [FA] is an autosomal recessive rare disease characterized by progressive pancytopenia, congenital malformations and predisposition to acute myeloid leukemia. Fanconi anemia is genetically heterogeneous, with at least eight complementation groups of FA [FAA to FAD2]. In order to characterize the molecular defects underlying FA in Tunisia, fourty-one families were genotyped with microsatellite markers linked to known FA gene. Haplotype analysis and homozygosity mapping showed that 92% of these families belong to FAA group. We demonstrated the effectiveness of the molecular analysis for a better selection of bone marrow graft donor and for the evaluation of chimerism after bone marrow transplantation. This study also allows genetic counselling for FA family members

bronchiolites du nourrisson: Etude multicentrique a Tunis

This study is made in the general framework of the basic health cares program set up by Tunis regional service to fight child serious respiratory infections. It has an objective to measure bronchiolitis winter frequency for patients aged from 1 to 36 months, serious cases frequency, changing profile, the therapeutic behavior and environmental risk factors. This is a multicentric transversal study in grappa, it has taken place in Tunis between January and march 1999 with a sample size of 1340 patients. Result of the survey has shown a medium frequency of the disease with 10% of the patients, median age group infected at 9 months, aggravating factor in 73% of cases, and a surinfection in 70% of cases. Promiscuity is the only environmental risk factor which is statistically significant. Hospitalization was necessary in 14.2% of cases. With regard to prescriptions, bronchodilators, corticoids and antibiotics were prescribed for respectively 71, 39, and 45.6% of patients. Basic health cares structure is a good alternative during the winter season, provided human expertise s are constantly updated and adequate technical staff is available

Human monoclonal IgMs with anti-Mycoplasma pneumoniae antibody activity

We have previously reported that IgM antibodies to Pep13 P1, the major immunogenic peptide of Mycoplasma pneumoniae [MP] P1 cytoadhesin involved in microorganism cytoadherence, is a part of the natural antibody repertoire expressed early in life. Hence, Pep13P1 belongs to the panel of self and non-self antigens recognized by the primitive B cell repertoire. Considering that antibody activity of human monoclonal IgM associated with lymphoproliferative diseases is representative of the immune repertoire, we analyze, in this study, the antibody reactivity to P1 of twenty human monoclonal IgMs. Interestingly, we show that 25% of them are of anti-Pep13P1 specificity: one is a MIgM with reactivity against intermediate filaments, two are MIgMs with anti-MAG specificity and two IgMs with previously unknown antibody activity. Our results indicate that anti-P1 IgM antibodies are parts of the autoreactive than the heteroreactive B cell repertoire and Pep13P1 may have structural similarities with an unknown self antigen as the corresponding physiologic ligand

[Risk factors of leishmanin-skin test positivity in transmission of Leishmania infantum in the center of Tunisia]

This work aims to estimate prevalence and evaluate risk factors of leishmanin-skin test positivity. A cross-sectional leishmanin skin test study was carried out on a sample of 3190 healthy volunteers living in the gouvernorates of Kairouan and Kasserine. Age standardized prevalence of leishmanin-skin test positivity was 45.9% [CI95% = [43.9-47.9]] confirming the hyper endemicity of this region. The rate of leishmanin-skin test positivity ranged from 75.9% [CI95% = [71.9-79.5]] in Zaghdoud [Kairouan] to 6.5% [CI95% = [3.7-11.01] in Abdeladhim [Kasserine]. There is no significant difference between men and women suggesting a similar exposure to infection. In the districts of Zaghdoud, Sidi Amor, El Hajeb and chbika, age specific rates showed a rapid increasing positive prevalence with age reaching a proportion exceeding 80% after the age of 15 years. However, the age specific prevalence from other delegations showed a progressive increasing trend with age, with a low rate for younger children and a plateau of 75% after 45 years. Multivariate analysis of leishmanin-skin test positivity risk factors showed that only district and age are determinants of this infection