[Medical demography in Tunisia: current situation and perspectives]

Health human resources management is one of the important determinants of health care access equity.To analyse the trend of Tunisian medical density during 2000-2009 and to predict its situation by 2024. Current medical density was calculated using Bar Council of Physicians of Tunisia database. Medical density was calculated and analysed for the period 2000-2009 then modelled by 2024 [estimate of needs and supply]. The active medical density raised by 36% during the period 2000-2009 with a higher increase for specialists. The proportion of non-active physicians rose from 4.6% to 15.2% in 2009. Increasing feminization of medical density and persistence of its regional disparities. By the year 2024, 217 physicians for 100,000 inhabitants would be required while the supply would correspond to 212/100 000 inhabitants. Medical human resources have indeed globally improved. However, some lacks remain and adequate measures are required, based on a rational planning directed to satisfy the population needs and to allow health equity

[Tobacco use among paramedical students in Tunis]

To assess smoking habits among Tunisian paramedical students, and their attitudes and knowledge about smoking. During the first quarter of the school year 2002-2003 we investigate 1288 paramedical students of the College of Sciences and Techniques of the Health in Tunis. The smoker was the student who declare to smoke daily or by occasionally at the time of the survey. About three quarters of the students [77.2%] were female and half of them was less than 20 years old. Smokers were those who smoked daily or occasionally. The prevalence of smoking was weak but it was 10 fold higher in male than in female [35.5% vs 3.5%]. The rate of the ex-smokers was 4.1%. Progress in studies does not affect smoking behaviour. The knowledge of tobacco induced diseases was generally good. However, there was substantial underestimation of tobacco contribution to causing bladder cancer, coronary artery disease and peripheral vascular disease. The study evidences insufficient awareness of medical students about their responsibilities for health education and prevention. It is recommended to improve tobacco control educational programs at the paramedical students with elaboration of practical smoking cessation trainings

[Vitamins A, E and leptin in obese and non insulin dependent diabetes group]

At the obese ones, there is an imbalance between the free defenses antioxydants and radicals from where the installation of an oxydative stress, responsible for the development of non-insulin dependent diabetes. Our objectives was to evaluate the levels of vitamins A, E and of leptin, to search the link witch could exist between vitamins and leptin. We proportioned the rates in vitamins A, E and in leptine at 30 obese subjects diabetic of type 2 including 12 men and 18 women of average age [50,93 +/- 6,13] years not carrying pathologies other than the diabetes and obesity compared to 30 witnesses who theirs are paired according to the age and the sex. Our results chows that levels of antioxidants did not differ between the two groups but we find a non significant decrease in vitamin El [TC +TG] ratio [1,86 +/- 0,38 VS 2,11 +/- 0,74 ; p=0,08] and significant increase of vitamin A level in women obese with non-insulin-diabetes mellitus compared with control group of women [0,69 +/- 0,16 V.S 0,55 +/- 0,15 ; p=0,01]. Moreover a negative and significative correlation between vitamin E and leptin [r=0,452 p=0,01], and a negative and no significative correlation between vitamin A and leptin [2=-0,221 ; p>0,05] were observed. the rate of vitamin A, is different for each sex with share. The vitamin E could have a negative control on the secretion of the leptin

Surveillance des facteurs de risque des maladies cardiovasculaires en Tunisia: Methodologie et principaux resultats

To assess the Cardiovascular risk factors trend in a community based surveys. Method: Two population surveys were conducted in 1996-97 and 2000-01 in the Ariana region among 7608 adults 35-70 years aged. The surveys were based on: I- a questionnary, 2- an anthropometrical and physical examination, 3- a biological investigation, and 4 - an ECG registration for the second cohort. Relative to the first survey, the prevalence of hypertension, diabetes, hypercholesterolemia didn't change significantly while border line cholesterol increased on both genders, tobacco smoking decreased and ex-smokers increased on men. In both genders, hypertension and diabetes prevalence is low before 50 years but it increased after this age. Risk factors association is common: about 35% have more than two risk factors. This association is more common on women and diabetes-hypertension is the most frequent. These two surveys integrated in a global surveillance program has contributed to assess the CVDs burden and to identify priorities and intervention relevant to epidemiological region context

Prevalence des cardiopathies ischemiques: Resultats d'un depistage en population

A cross - sectional population survey was carried out in the Ariana region in 2000-01. The aim of this study is to report the prevalence of CHD as indicated by ECG Minnesota coding. Method: A randomly selected sample included 1837 adults 40-70 years. Data on socio-economic status, demographic, medical history, health behavior, clinical and biological investigations were recorded. Risk factors [hypertension, dyslipedemia, obesity, diabetes] are defined according to WHO criteria's. Standard supine 12 lead ECGs were recorded. All ECGs are red and classified according to the Minnesota codes criteria on CHD probable, CHD possible and on Major abnormalities and minor abnormalities. CHD prevalence was higher on women. Major abnormalities are more common on women [20,6% vs 13%], while minor abnormalities prevalence was higher on men [15,5% vs 7,5%] [p<0,0001]. The prevalence increased with age in both genders. This study tested how feasible is the population approach on CVDs surveillance. It highlighted the burden of cardiovascular diseases and support that women are at risk as men are. The value of ECG findings must be integrated in the cardiovascular diseases surveillance to identify high risk population

Delai de prise en charge et acces aux soins de l'infarctus du myocarde dans les structures hospitalieres

We aimed to assess the acute myocardial infarction management in Tunis public hospitals during one year [from March 2000 to February 2001]. Method: A standard questionnaire was designed to record prospective data on 740 patients with a follow up during 28 days. Multivariate analysis was performed using the logistic regression model with all-factors as well as age, gender, CHD risk factors as predictors of the delay and fatality. 54% of patients were admitted during the first 6 hours after the onset of symptoms. In multivariate analysis, the delay of consultation is significantly correlated with gender [OR=2.3, p<0.001], age [OR=l.02, p<0.01] and health insurance [OR=1.5, p<0.01]. 90% of patients consulted in emergency wards. The emergency ambulance transported 19.6% of patients. 48% of patients underwent early revascularization of thrombolysis, 51% on men vs 31% on women [p <0.01]. The fatality rate was higher on women 14% vs 6.4% on men [p<0.01] at 5 days and 27.2% vs 13.6% at 28 days. In multivariate analysis, the principal fatality predictive factor was age [RR=l.08, p < 0,001] and delay [2.56 p <0.001] and tobacco smoking [RR=2,83, p <0.0001]. this study highlighted the problem of acute myocardial infarction management in public hospitals in Tunisia and it constitutes a baseline to assess different interventions focusing on cardiovascular diseases control and surveillance

Cout direct medical de la prise en charge de l'infarctus du myocarde en phase algue

to assess the medical direct cost of acute myocardial infarction. Method: data are recorded through a prospective study in 7 wards of cardiology of the District of Tunis during one year: from November 2001 to October 2002. cost of hospital stay, biologic analyses, drugs, functional investigations and possible non surgical cardiologic intervention [IC] was calculated. 632 AMI cases are recorded, the death rate is 7.8%. The average of hospital stay was 13.3 days. 49.1% of patients benefited from thrombolytic therapy, 55.5% benefited from a coronary angiography and 16.1% of an act of IC. The mean of direct cost [CGM] was 2171 Tunisian Dinars and the median was 1731 DT, of whom room costs 31.7%, 22.5% acts of IC, 7.2% drugs, 26.2% functional investigations and 12.4% biological analyses. The mean cost of IC was 3030 +/- 401 DT. The methodology of our study remains original in our country and can be used to assess the other aspects of AMI as other diseases cost management

Prevalence, connaissance, traitement et controle de l'hypertension arterielle: Resultats d'une enquete populationnelle

The study objective was to assess the prevalence, level of awareness of treatment, and control of hypertension in a general population. We conducted a cross-sectional survey on 1837 adults 40-69 years old. Hypertension and control level are defined according to the WHO/ISH recommendations. HBP is defined as SBP> =140 and or DBP> = 90 mm Hg and the use of blood pressure-lowering medication. Hypertension is controlled by medication if SBP < 140 and DBP < 90 mm Hg. We conduct analysis by socio demographic variable, medical history and CHDs risk factors. 44,3% of adults was hypertensive. The prevalence of hypertension was higher among women [48,2% versus 38,7% on men.] and it increases in both genders with age, body mass index. Only 41,% of the hypertensive were aware of having hypertension, among them, 74,1%declare that they are treated but only 13.2% were controlled. The study highlights the problem of the hypertension in a developing country. It contributes to identify the huge iceberg of this CVDs risk factor. The national strategy must focus on the population life style and drugs management. The question is how much will be the cost of HBP and CVDs control for a country which has a limited resources

Prise en charge de l'hypertension arterielle: Resultats d'une enquete Tunisienne aupres des medicins generalistes

The control of arterial hypertension [HT] is an endlessly hoped objective but usually not reached. Several factors are determinants. The physician role is crucial in the HT prevention. In order to evaluate knowledge's, attitudes and behaviors of Tunisian physicians in HT management, we conducted a cross sectional study in 2002 using a self administered questionnaire addressed to physicians working in private and public sectors. 380 generalists participated to this study. 95,5% of them confirmed that HT constitutes a public health problem. 81,1% saw at least 4 patients with HT a week. 95% insisted on the importance of the primary prevention. 90% took care themselves patients. 71,5% confirmed the importance of a training and an entrainment for the measure of the blood pressure [BP]. 3,7% made diagnosis after a single visit and 10,9% confirmed it only from described symptoms. 20,4% of the generalists chose the old classification as objective level of BP thiazidic Diuretics and 13 blockers were most prescribed medicines in first intention. 9,4% stopped the treatment after stabilization of blood pressure. 60% of generalists had inadequate behavior facing a not stabilized BP Non observance of treatment by patients was indicated by 31% of the generalists, cost and break of the medicines' stock and disappearance of symptoms were the main causes advanced by the generalists. This study shows the existence of gaps in generalists' practical behavior treating this disease. Measures aiming the medical practice improvement turn out necessary in particular the sensitization of the generalists by an adequate university training and a continuous medical training, and a regular evaluation of the national program of hypertension prevention and management

[Cost effectiveness of cervical cancer screening strategies in Tunisia]

Cervical cancer is a public health problem in developing countries and is the first cancer among women in several of these countries. Screening using the Pap test is the principle control strategy for this cancer. The aim of this study is to identify the highest cost-effectiveness strategy of Pap test screening, according to age group [20 - 64 years, 35 - 64 years and 40 - 64 years] and the frequency of this test [every 3 years or every 5 years]. Number of cases avoid by screening and mean cost to prevent one case were used to compare these screening strategies. The principles results showed that the number of cervical cancer cases avoid increase with the coverage level of the screening and age group size, and decrease with the frequency of the Pap tests. The screening strategy interesting age group "40 - 64 years" every 5 years observed the highest cost-effectiveness ratio [19MD]; however cost is 23MD for age grovy 35 - 64 years. These results lead to choice a frequency of Pap tests every 5 years. However, for determination of age group, other factors, as psycho-social ones, should be taken into account besides economic criterias