Evaluation de l'enseignement par les étudiants : Exemple d'un atelier de simulation sur l'ECG.

INTRODUCTION: The electrocardiogram (ECG) is a fundamental tool in medical practice. At the Faculty of Medicine of Tunis (FMT), it is usually taught during a lecture. FMT's Physiology Department has innovated its teaching by introducing simulation workshops. AIM: This study aimed to assess the students' satisfaction with teaching ECG by simulation. METHODS: This was a cross-sectional descriptive study, carried out in April 2018, including 160 students in the first year of the first cycle of medical studies, divided into 10 groups. The students attended an ECG simulation workshop at the FMT media library and then answered a satisfaction form and a self-assessment questionnaire for the workshop. RESULTS: More than 50% of the students answered either satisfied or very satisfied with the duration of the course, the room, the method of the teacher, and their participation in the course of the session. Regarding teaching support, 19.3% of the students were very satisfied with the practice of the ECG on a mannequin versus 25% for the practice on a voluntary student. For the number of students per group, 42.1% of students were dissatisfied. CONCLUSION: This study highlights the weak points of this simulation workshop in order to improve it. Then, it helps to build students' confidence and encourage their adherence to the feedback process. Finally, it shows students' enthusiasm for new teaching methods such as simulation. It would be interesting to generalize this evaluation process for the improvement of medical education and the training of future doctors.

Esophageal motor abnormalities on high-resolution manometry in patients with scleroderma.

BACKGROUND: Systemic sclerosis (SS) is an autoimmune disorder that may result in diverse esophageal motor disorders. Typical manometric disorders include decreased lower esophageal sphincter (LES) pressure, absent contractility and ineffective peristalsis. AIMS: The aims of the study were to assess esophageal motor abnormalities in SS patients using high resolution manometry and to evaluate clinical and endoscopic features that are associated with manometric findings. METHODS: Patients with SS who underwent esophageal high-resolution manometry (HRM) between December 2016 and August 2020 were enrolled in the study. Data regarding demographics and symptom frequency were obtained through a questionnaire. Chicago classification criteria (V3.0.) were used for defining esophageal dysmotility. RESULTS: A total of 49 patients were enrolled in the study. Median age was 56 ±13.4 years. High-resolution manometry showed that absent contractility (n= 24; 49%) and ineffective motility (n=14; 28.6%) were the most frequent motor abnormalities. One case of esophageal gastric junction (EGJ) outflow obstruction was observed in a female patient. A hypotensive LES was observed in 18 patients (36.7%). Absent contractility was associated with regurgitations (=0.013), and erosive esophagitis (p=0.003). CONCLUSION: Absent contractility and ineffective motility were the most common esophageal contractile patterns among our patients. Patients with absent contractility experienced more frequently regurgitations and had more often erosive esophagitis.

Telomere length measurement in tumor and non-tumor cells as a valuable prognostic for tumor progression.

Telomere shortening has been supposed to be implicated in both aging and various human diseases especially carcinogenesis process. This phenomenon can lead to a chromosomal instability, contributing to a cell immortalization and tumor induction. In our study, we analyzed the role of telomere shortening in cancer progression, in Tunisian patients with digestive cancer. We measured the absolute telomere length in tumoral vs healthy adjacent tissues of each patient by using a q-RT PCR method and we investigated the relationship between telomere length and various sociodemographic and clinical parameters such as age, sex, tumor stage. In this pathological situation, we observed that, starting from 60 years of age, the telomere length increases in healthy mucosa and that in both healthy and cancer tissues, patients under 60 years have shorter telomeres, suggesting the telomere lengthening becomes more active with age. Finally, a positive correlation between normal and cancer tissues in both non-metastatic and metastatic stages, indicates telomere length in cancer tissue depends essentially on tumor stages. Our data allow us to suggest that telomere length depends on sex and age in healthy tissue while shortening and lengthening fluctuates considerably according to the tumor stage.

Health-related quality of life in cirrhotic patients: a case-control study.

BACKGROUND: Assessment of health-related quality of life (HRQOL) in patients with cirrhosis has been increasingly reported in literature.  Aims: To compare quality of life scores between cirrhotic patients and healthy controls and to assess factors associated with the impairment of quality of life in cirrhotic patients. METHODS: HRQOL was measured in cirrhotic patients by the Tunisian version of MOS 36-item short-form health survey (SF-36) and the Arabic version of the Liver Disease Symptom index 2.0 (LDSI2.0). Age-and sex- matched controls were asked to complete only the SF36. The SF36 scores were compared between cirrhotic patients and controls and LDSI2.0 scores were compared across cirrhotic patients according to the characteristics of cirrhosis. Factors associated with poor perceived health status were identified by logistic regression. RESULTS: Fifty cirrhotic patients and fifty controls were enrolled in the study. The cirrhotic group had significantly lower SF36 scores than healthy controls in all 8 dimensions (p<0.001). Most impaired LDSI items were severity of fear of complications (item 8), change in use of time (item 13), decreased sexual interest (item 14) and decreased sexual activity (item 15). Multiple logistic regression analysis showed that female sex (p=0.009), diabetes (p=0.046), treatment with diuretics (p=0.022), increased levels of serum bilirubin (p=0.045) and prolonged prothrombin time (p=0.041) were associated with poorer HRQOL. CONCLUSIONS: HRQOL was significantly more impaired in cirrhotic patients than controls. Female sex, diabetes, treatment with diuretics, increased levels of serum bilirubin and prolonged prothrombin time were important factors in reducing HRQOL.

Changes of Crohn's disease phenotype over time.

Background - Crohn's disease is a clinically heterogeneous condition. Our aim was to identify the phenotype evolution of Crohn's disease over time according to the Montreal Classification and to precise predictive factors of the need for immunosuppressant treatment or surgery. Methods - We included Crohn's disease patients who were followed up for at least 5 years. We excluded patients who were lost to follow up before five. Patients were classified according to the Montreal classification for phenotype at diagnosis and five years later. The evolution of phenotype over time and the need for surgery, immunosuppressive or immunomodulatory drugs were evaluated. Results - One hundred twenty consecutive patients were recruited: 70 males and 50 females. At diagnosis, 68% of patients belong to A2 as determined by the Montreal classification. Disease was most often localized in the colon. The disease location in Crohn's disease remains relatively stable over time, with 93.4% of patients showing no change in disease location. Crohn's disease phenotype changed during follow up, with an increase in stricturing and penetrating phenotypes from 6% to 11% after 5 years. The only predictive factor of phenotype change was the small bowel involvement (OR=3.7 [1.2-7.6]). During follow-up, 82% of patients have presented a severe disease as attested by the use of immunosuppressive drugs or surgery. The factors associated with the disease severity were: small bowel involvement (L1), the stricturing (B2) and penetrating (B3) phenotypes and perineal lesions (OR=17.3 [8.4-19.7]; 12 [7.6-17.2]; 3[1.7-8.3] and 2.8 [2.2-5.1] respectively), without association with age, sex or smoking habits. Conclusion - Crohn's disease evolves over time: inflammatory diseases progress to more aggressive stricturing and penetrating phenotypes. The ileal location, the stricturing and penetrating forms and perineal lesions were predictive of surgery and immunosuppressant or immunomodulatory treatment.

[Nocturnal gastroesophageal reflux. About a pH metric series]. / Le reflux gastro-oesophagien acide nocturne pathologique. A propos d'une série pHmétrique.

BACKGROUND: Nocturnal gastroesophageal reflux has been shown to be associated with the more severe forms of gastroesophageal reflux disease (GERD), particularly with extraesophageal manifestations as well as complications of mucosal damage. AIM: To determine the frequency of nocturnal gastro esophageal reflux disease on 24-hour esophageal pH monitoring in patients with digestives or extra-digestives symptoms and to evaluate the clinical and pHmetric characteristics of nocturnal reflux in these patients. METHODS: We conducted a retrospective study based on results of 24- hour esophageal pH monitoring during a 11-year period in patients with or without digestive symptoms of gastroesophageal reflux disease. The nocturnal gastroesophgeal reflux was defined. RESULTS: We studied 696 patients (299 men, 397 women; mean age: 34.05 years). Gastroesophageal reflux was found in 350 patients (50%). Nocturnal reflux was observed in 240 patients (34.3%), mostly in association with pathological reflux in the total period (223 cases). Compared to the diurnal period, the nocturnal period was characterized by fewer number of reflux episodes (21.9±27.4 vs 67.4±5.,1 ; p<0.0001), more longer duration of reflux episodes (24.4±37.9 minutes vs 13.9± 17.5 minutes ; p<0.001), and a lower symptomatic correlation (26% vs 45% ; p=0.0005). CONCLUSION: Nocturnal reflux is associated with overall reflux on the 24 hour examination. Nocturnal period is characterized by longer reflux episodes, less number of reflux episodes and less symptomatic correlation.

[24-hour esophageal impedance-ph monitoring: technical aspects, indications and results]. / L'impédancemétrie couplée à la ph-mètrie oesophagienne des 24 heures: technique, indications et résultats.

BACKGROUND: Classical techniques like endoscopy and esophageal pH-metry are the gold standard to study patients with symptoms related to gastroesophageal reflux disease. Although these techniques have been useful over the years both for diagnosis and therapeutic guidance, there are still many patients with typical or atypical gastroesophageal reflux disease symptoms with normal endoscopy and pH-metry that do not respond adequately to antisecretory therapy. Ambulatory esophageal impedance-pH monitoring is a new technique that can be used to evaluate all types of gastroesophageal reflux, achieving higher rates of sensitivity and specificity than standard techniques. AIM: To precise the technical aspects of the esophageal impedancepH monitoring, indications and results of this technique in clinical practice. METHODS: Literature revue of the esophageal impedance - pH monitoring Results: Combined multichannel intraluminal impedance and pH monitoring is a new technique that can be used to evaluate both bolus transport and all types of reflux (acid, weakly acidic and weakly alkaline), without radiation hazards. With this technique, higher rates of sensitivity and specificity than standard techniques are obtained in the diagnosis of pathological gastroesophageal reflux. The technique has also been used in the evaluation of atypical gastroesophageal reflux symptoms, in the assessment of the association of different patterns of reflux with symptoms, and in the evaluation of therapeutic outcome mainly in patients with refractory gastroesophageal reflux disease. CONCLUSION: The esophageal impedance represents real progress in understanding the different mechanisms involved in the pathophysiology of gastroesophageal reflux. This technique should also allow a better understanding of the responsibility of non-acid reflux in special clinical situations, such as patients resistant to antisecretory or extra-intestinal manifestations of gastroesophageal reflux.

[Sleep disorders in patients with gastroesophageal reflux disease: an open clinical and pH metric prospective study]. / Perturbations du sommeil au cours du reflux gastro-oesophagien: Résultats d'une etude prospective ouverte clinique et Ph-métrique.

BACKGROUND: Sleep disorders are frequent in patients with GERD. Severity of sleep disorders could be related to occurrence of nighttime symptoms, but the relationship between severity of GERD and the severity of sleep disorders is not well established. AIM: To identify the frequency of sleep disorders in patients with suspected GERD and the correlation between the severity of sleep disorders and pHmetric parameters in these patients. METHODS: We studied prospectively 50 patients with esophageal and supra-esophageal symptoms of GERD. 24-hour esophageal pH monitoring examination was performed in all patients. Standard survey was applied to determine the frequency and the severity of sleep disorders in these patients. RESULTS: We included 50 patients (10 men, 40 women), mean age 43.7 years (18-70). Nighttime symptoms were present in 26 patients (52%). Pathological acid gastro-esophageal reflux was diagnosed by 24-hour esophageal pH recording in 18 patients (36%), with nocturnal acid reflux in 19 patients (38%). Sleep disorders were reported by 29 patients (58%). Mean number of hours of sleep was 6.8 hours by night (4-9 hours). Clinical factors associated with higher frequency of sleep disorders were occurrence of nighttime symptoms (p < 0.0001) and duration of symptoms of GERD (53.2 +/- 41.4 months vs 26.0 +/- 18.1 months ; p = 0.007), with no association with BMI, age and sex. pHmetric parameters associated with sleep disorders were pathological acid reflux (p < 0.0001; OR [CI 95%]: 28.3 [3.3-240.8]) and nocturnal acid reflux (p < 0.0001; OR[CI95%] :32.7 [3.8 - 279.2]). Patients with sleep disorders had significant changes of pHmetric parameters compared to those without sleep disorders: Acid exposition time, numbers of reflux episodes, number of episodes longest than five minutes, duration of longest reflux episode and DeMeester score (respectively 6.1 +/- 8.8 vs 1.3 +/- 1.5 p = 0.01; 59.2 +/- 52.0 vs 20.7 +/- 21.6 p = 0.001; 3.1 +/- 6.1 vs 0.1 +/- 0.3 p = 0.03; 8.9 +/- 9.3 minutes vs 3.4 +/- 4.0 minutes p = 0.01; 24.0 +/- 33.2 vs 4.8 +/- 4.9 p = 0.01). Number of hours of sleep was significantly lower in patients with pathological acid reflux (5.3 +/- 1.2 hours vs 7.6 +/- 1.7 hours, p < 0.0001) and in patients with nocturnal acid reflux (5.2 +/- 1.1 hours vs 7.8 +/- 1.5 hours, p < 0.0001). Number of hours of sleep was strongly correlated with esophageal pH parameters CONCLUSION: Sleep disorders are frequent in patients with GERD symptoms. Severity of sleep disorders are strongly correlated with severity of global and nocturnal acid reflux as attested by 24-hour esophageal pH monitoring.

[Esophageal motility abnormalities in systemic sclerosis: frequency and predictive factors]. / Les troubles moteurs oesophagiens au cours de la sclerodermie systemique: frequence et facteurs predictifs.

BACKGROUND: Esophageal involvement is frequent during systemic sclerosis. It consists on esophageal motor abnormalities. Esophageal manometry is the gold standard for the diagnosis. AIM: To determine the frequency and the type of the esophageal motor abnormalities among patients presenting a systemic sclerosis; and to look for factors associated with a greater risk of theses disorders. METHODS: A retrospective study relating to all the esophageal manometries carried out among patients presenting a systemic sclerosis was undertaken. RESULTS: During a 12 years period, 128 cases were studied. Esophageal motor abnormalities were found among 97 patients (76%). Specific esophageal involvement was found among 52 patients (42%), and non specific motor abnormalities among 31 patients (24%). The only associated factor with a specific esophageal involvement is occurrence of dysphagia. CONCLUSION: Esophageal motor abnormalities are frequent in patients with systemic sclerosis. They can be specific and nonspecific. Esophageal manometry should be systematically performed among these patients, even in the absence of dysphagia.

[Proximal gastro-esophageal reflux monitoring in patients with suspected laryngopharyngeal reflux disease]. / Evaluation du reflux acide proximal chez les patients avec manifestations oto-rhino-laryngologiques du reflux gastro-oesophagien.

AIMS: To assess the frequency and associated factors of proximal acid reflux in patients with ENT manifestations of gastroesophageal reflux disease, and to compare the pHmetric parameters in the distal and the proximal esophagus in these patients. METHODS: We conducted an open-prospective study, including consecutive patients with chronic pharyngitis or laryngitis. Twenty-four hour esophageal pH-monitoring was performed, using a double sensor catheter. Proximal reflux was defined according to the recently published recommendations. RESULTS: We studied 43 patients (17 men and 26 women), mean age: 39.5 years (15 - 67 years). Distal reflux was detected in 35 patients (81%). Proximal reflux was detected in 26 patients (60%). Ratio of numbers of proximal to distal reflux episodes was 0.34 (0 - 0.90). The proximal reflux episodes were characterized by a small number of episodes exceeding 5 minutes (2.6 + 4.4 vs 10.8 + 9.1; p < 0.0001), a less duration of longest reflux episode (15.6 + 23.5 vs 50.2 + 61.6 minutes; p < 0.0001) and better esophageal clearance (1.6 + 1 vs 2.5 + 1 minutes/reflux: p = 0.006), associated with a significant correlation between numbers of proximal reflux episodes and distal acid exposure time (r = 0.52: p < 0.0001). CONCLUSION: Proximal reflux is frequent in patients with chronic pharyngitis or laryngitis. Proximal reflux episodes are correlated to distal acid exposure and associated with a better esophageal clearance.

[How can we optimize the performances of 24-hour esophageal pH-monitoring for the diagnosis of gastroesophageal reflux disease?]. / Comment optimiser les performances de la pH-metrie oesophagienne des 24 heures pour le diagnostic du reflux gastro-oesophagien?

BACKGROUND: 24-hour pH esophageal monitoring represents the gold standard for the diagnosis of the gastro-esophageal reflux disease. However, it is associated certain limits, especially in front of particular situations. AIM: To describe the means which can improve quality of the pHmetric procedure and its diagnostic performances, while insisting on simple and accessible means in current practice. MATERIAL AND METHODS: Review of the literature. RESULTS: The improvement of the pH monitoring performances must be done by the specific study of the night period, especially in patients having respiratory symptoms. Among these patients, the treatment of the nocturnal gastro-esophageal reflux is associated with a considerable improvement of the quality of life. In addition, the examination must be well explained to the patient, with an aim of activating the markers of events as often as possible, since a good symptomatic agreement can be associated with normal acid exposure; defining the sensitive oesophagus. This entity is important to diagnose because of the effectiveness of PPI treatment. Lastly, in patients with ENT manifestations of gastro-esophageal reflux, the use of a probe with double channel is strongly recommended, for diagnosis of proximal reflux, which could explain the symptoms and which could be treated by high doses of PPI. CONCLUSION: The performances of 24-hour esophageal pH monitoring can be improved by simple means, of which the use will have to take account of the clinical context.

[Nocturnal gastroesophageal reflux disease in asthmatics patients: a pHmetric study about 81 cases]. / Particularites du reflux gastro-oesophagien nocturne chez les patients asthmatiques: analyse d'une serie pH metrique a propos de 81 cas.

AIMS: To determine the frequency of gastroesophageal reflux disease on 24-hour esophageal pH monitoring in asthmatics patients and to evaluate the clinical and pHmetric characteristics of nocturnal reflux in these patients. METHODS: We conducted a retrospective study based on results of 24-hour esophageal pH monitoring during a 10-year period in asthmatics patients with or without digestive symptoms of gastroesophageal reflux disease. RESULTS: We studied 81 patients (37 men, 44 women; mean age: 32 years). Gastroesophageal reflux was found in 42 patients (52%). Nocturnal reflux was observed in 35 patients (43%), mostly in association with pathological reflux in the total period (32 cases). Presence of digestive symptoms was the only associated factor to gastroesophageal reflux during 24-hour, in nocturnal or in diurnal period. Compared to the diurnal period, the nocturnal period was characterized by fewer number of reflux episodes (22.69 + 23 vs 70.16 + 56.15; p<0.001), more longer duration of reflux episodes (25.92 + 23.34 minutes vs 15.52 + 16.27 minutes; p=0.02), fewer respiratory symptoms (2.24 + 1.89 vs 6.18 + 4.12; p=0.01) and better symptomatic correlation (13/17:76% vs 9/24:37%; p=0.02). CONCLUSION: Gastroesophageal reflux disease is frequent in asthma. Nocturnal reflux is associated with overall reflux on the 24 hour examination. Nocturnal period is characterized by more longer reflux episodes and better symptomatic correlation.

[Findings of 24-hour esophageal pH monitoring in patients with respiratory and otorhinolaryngologic manifestations of gastroesophageal reflux disease]. / Resultats de la pH-metrie oesophagienne des 24 heures au cours de l'exploration des manifestations respiratoires et otorhinolaryngologiques du reflux gastro-oesophagien.

We conducted a retrospective study on 24-hour esophageal pH monitoring performed to patients with non allergic asthma, chronic cough and chronic pharyngitis or laryngitis. We studied 168 patients. On 24-hour esophageal pH monitoring, gastroesophageal reflux was detected in 67 cases (40%), more frequently in patients with chronic cough and asthma than in patients with chronic pharyngitis or laryngitis. A statistically significant increase in all the pHmetric parameters, except for the number of reflux episodes, was found in asthmatic patients compared to patients with chronic pharyngitis or laryngitis. Comparison of the pHmetric parameters in patients with gastroesophageal reflux disease revealed that the number of reflux episodes of morethan five minutes and the duration of longest reflux episodes were higher in asthmatic patients than in patients with chronic cough. Gastroesophageal reflux disease is more frequent in asthma and chronic cough than in chronic pharyngitis or laryngitis. Reflux episodes in chronic cough are shorter than these in asthma. This difference should explain the different severity between the two situations.

[Esophageal abnormalities in patients with chest pain and normal coronary angiograms]. / Anomalies oesophagiennes chez les patients presentant des douleurs thoraciques avec coronarographie normale.

AIMS: To evaluate the frequency and the variety of esophageal abnormalities in patients with chest pain and normal coronary angiograms. PATIENTS AND METHODS: : We have conducted a prospective study including patients with noncardiac chest pain based on normal coronary angiograms. We performed for all patients an upper gastrointestinal endoscopy, 24-hour esophageal pH monitoring and stationary esophageal manometry. RESULTS: Fifty patients were studied on a 3-year period (24 men and 26 women, mean age: 51.5 years). Gastroesophageal reflux disease was found on 24-hour esophageal pH monitoring in 29 patients (58%), associated with a good symptomatic correlation in 17 patients (34%). Esophageal motor disorders as nutcracker esophagus and diffuse esophageal spasm were found in 6 patients (12%) associated with gastroesophageal reflux disease in two cases. Independent factors associated with gastroesophageal reflux disease and esophageal motor disorders were respectively presence of regurgitations (p = 0.005 : adjusted OR[IC95%] : 3.57 [1.28 - 16.66]) and age higher than 58 years (p = 0.01 : adjusted OR[IC95%]: 2.77 [1.33 - 12.50]). CONCLUSIONS: Gastroesophageal reflux disease is the most common esophageal abnormality n; patients with noncardiac chest pain. In the absence of regurgitations, 24-hour esophageal pH monitoring must be the first test to be performed.