[EXTUBATION FAILURE IN BURNS: INCIDENCE, RISK FACTORS AND PROGNOSIS]. / ÉCHEC D'EXTUBATION CHEZ LES BRÛLÉS: INCIDENCE, FACTEURS DE RISQUE ET PRONOSTIC.

The incidence of extubation failure varies between 2 and 25% depending on the studied population. Few studies have been conducted in burn victims. To determine the incidence, causes, risk factors and outcome of burned patients after a failed extubation, a retrospective single-center case-control study was conducted over a period of 3 years (January 2018-December 2021). All burned patients aged over 16, ventilated for at least 24 hours and having had at least one extubation attempt were included. Extubation failure was defined as the need for re-intubation within 48 hours. Eighty-eight patients had planned extubation. These patients were divided into 2 groups comparable in terms of age and sex. Failure group: including patients with failed extubation (N= 34) and a success group (N= 64) including patients who succeeded. The incidence of extubation failure was 36.6%. Hypophosphatemia, anemia <8g/dl, duration of mechanical ventilation of 8,5 days and abundant secretions during extubation were identified as risk factors for extubation failure (p<0.05). The main cause of failure was retention of secretion (50%). Extubation failure was associated with prolonged length of stay (34 vs. 19 days, P= 0.005), increased infectious complications (P=0.007) and mortality rate (79.4%, 1.5%, P<0.001).

[DISTRIBUTION OF CARBAPENEMASES IN TUNISIAN BURN PATIENTS]. / DISTRIBUTION GÉOGRAPHIQUE DES CARBAPÉNÉMASES CHEZ LES BRÛLÉS TUNISIENS.

Resistance to carpabenems in burns is rapidly spreading in many countries. Therefore identification of carbapenemase pathogen carriers is imperative in order to establish adequate infection control precautions and stop outbreaks of these multidrug-resistant bacteria. The aim of our study was to evaluate the distribution of carbapenemase producers in burn patients admitted to a burn center in Tunisia over 9 months. PCR for carbapenemase portage was performed in all patients within 48 hours of admission. Seventeen patients carried a single carbapenemase, 11 carried two, and 25 carried three. The enzymes detected were VIM (n=41), NDM (n=41) and OXA48 (n=32). Enzyme mapping revealed two main areas of carriage in central western Tunisia: Kairouan (NDM/OXA48) and Kasserine (NDM/VIM). Predictive factors for carriage of carbapenemase were: prior antibiotic therapy (n=24); mechanical ventilation (n=30); vascular catheterization (n=31) and a previous stay in intensive care (n=11).

[Burns and Diabetes Mellitus: Epidemiology, Clinical Presentation and Prognosis]. / Brûlures Chez Le Diabétique: Étude Épidémiologique, Clinique et Pronostique.

Burns in diabetics are quite frequent and serious in relation to diabetic neuropathy, which is common in this population, delaying healing and predisposing to the risk of infection. The objective of this study was to describe the characteristics of burns in diabetics hospitalized at the CTB of Tunis over 18 months. During the study period, 891 patients were hospitalized, including 43 diabetics (5%). The average age of our patients was 57 years old with a male predominance (65%). Type 2 diabetes was present in 86% of cases and type 1 diabetes in 14% of cases. Degenerative complications were reported in 10 cases (23%), such as diabetic retinopathy (n=6), diabetic nephropathy (n=4) and diabetic neuropathy (n=6). The circumstances of burns were related to a domestic accident in 2/3 of the cases (76.7%). Thermal burns were involved in 83.7% of cases. 86% of the patients had decompensated their diabetes during their hospitalization. Sepsis marked the evolution of the patients in 55.8% of cases. In our study, poor prognostic factors were: a glycosylated haemoglobin > 13%, an extent of burns greater than 20%, and a delay in consultation greater than 6 hours. The mortality rate was 18.6%.

Suicide by Self-Immolation in the Pediatric Population.

Self-immolation is a violent way of committing suicide. Few studies have focused on this phenomenon in children. The aim of this study was to determine the epidemiological profile of children who committed suicide by fire. A retrospective descriptive study was conducted in an intensive burn care department in Tunis, over a period of 10 years (2011-2020). Of a total 3077 patients, 761 were admitted for burns by suicide attempt, among them 62 children and adolescents (8%). The number was on average six per year. The highest annual prevalence was noted in 2011 (27% of cases). The mean age was 16 and a half years old. The majority of cases were adolescents aged 15 or older. There is a male predominance (sex ratio:3). Total burn surface area (TBSA) was on average 44%. The act of self-immolation occurred in public places in 58% of cases. Socio-economic environment was unfavorable in 60% of cases. The suicidal act of self-immolation was due to a family conflict in 34% of cases (n=21). Seven patients (11%) had a history of mental illness. Forty-three patients (70%) required mechanical ventilation. The length of hospital stay was on average 30 days. The mortality rate was 56.5%. In conclusion, self-immolation is frequent in the pediatric population; it induces severe burns associated with a poor prognosis.

L' immolation est un moyen de suicide particulièrement violent. Peu d'études se sont penchées sur ce phénomène chez l'enfant. Cette étude a pour but de déterminer le profil des enfants recourant au feu pour se suicider. Il s'agit d'une étude rétrospective réalisée sur une période de 10 ans (2011-2020) dans la réanimation spécifique du CTB de Tunis. Sur 3 077 patients admis, 761 avaient réalisé une tentative de suicide (TS) parmi lesquels 62 (8%) enfants ou adolescents. Vingt-sept pour cent des cas sont survenus en 2011 (6/an en moyenne). L'âge moyen est de 16 ans 1/2, la majorité des patients étant des adolescents de 15 ans ou plus. On observe un prédominance masculine (3M/1F). La surface atteinte moyenne représente 44% SCT. La TS est réalisée dans un espace public dans 58% des cas. Le contexte socio ­ économique est considéré défavorable dans 60% des cas, avec un contexte de conflit familial à l'origine de 34% (21 fois) des TS. Sept patients (11%) avaient un passé psychiatrique. Quarante - trois patients (70%) ont eu besoin de ventilation mécanique. La durée moyenne de séjour a été de 30 j, la mortalité de 56,5%. En conclusion, les TS par le feu ne sont pas rares chez les enfants. Elles entraînent des brûlures graves, au pronostic péjoratif.

[Acute Pancreatitis Related to Tigecycline in ICU Burn Patients]. / Pancréatitis Aiguë Liée à La Tigécycline Chez Des Patients Brülés En Réanimation.

Drug-induced acute pancreatitis (AP) associated with tigecycline (TGC) is considered a rare complication (incidence between 1‰ and 1%). In this paper, we report five cases of AP occurring after the administration of TGC in septic patients hospitalized in intensive burn care in Tunisia over 9 years. The diagnosis of AP was based on clinical and/or biological signs. Among 303 cases treated with TGC, AP occurred with an incidence of 1.65%. The mean age was 28±6 years. Only one patient had a history of chronic alcoholism. The prescribed dose was 200 mg as a loading dose, followed by 100 mg twice a day. The time to onset of symptoms after initiation of TGC was 5.4 days [2-7]. PA was suspected due to abdominal pain associated with nausea and vomiting (n=2), occlusive syndrome (n=1) and fortuitously increased pancreatic enzymes in 2 patients under mechanical ventilation. The mean lipase level at diagnosis was 447 IU ± 135 IU (4.5 to 10 times the normal). All the aetiologies of AP were ruled out, including gallstones, hypercalcemia, hypertriglyceridemia, trauma and infections. The mean time to symptom resolution after stopping TGC was 4±2 days [5-7] and to the normalization of pancreatic enzymes it was 9 days [2-20 days]. In conclusion, clinical and biological monitoring was necessary in patients treated with TGC in order to avoid severe forms, especially in at-risk patients.

[Procalcitonin: The Ideal Biomarker To Guide Initiation, Change and Withdrawal of Antibiotics in Septic Burn Patients?] / La Procalcitonine: Biomarqueur De Choix Pour Guider L'Initiation, La Modification Et L'Arrêt De L'Antibiothérapie Chez Les Brûlés Sepitques?

The goal of this study was to assess plasma procalcitonin (PCT) concentrations during infectious events of burns in the ICU. We conducted a prospective, observational study in a 20-bed Burn Intensive Care Unit in Tunisia. A total of 120 septic patients admitted to the Burn ICU were included in our study. Sepsis was assumed according to the French Burn Association criteria for the presence of infection. Serum PCT was measured over the entire septic episode every 48 hours until resolution of infection, based on clinical signs and decrease of PCT of about 80% compared to its initial value. Patients were assigned to two groups depending on clinical course and outcome: Group A = patients with favourable evolution; Group B = patients with unfavourable evolution. Monitoring of kinetics of PCT allowed us to judge the effectiveness of the initial antibiotic therapy, with a threshold of 43.5% decrease at day 3 of treatment, with a better sensitivity and specificity of 79.6% and 87.7% respectively. In addition, PCT monitoring allowed a reduction in the duration of antibiotic therapy of 5±2.8 days versus 8 to 10 days before the use of PCT.

Hypernatremia Risk Factors And Prognostic Impact In Burn Patients: A Case Control Study.

Hypernatremia is associated with poor outcomes in critically ill patients. Hypernatremia risk factors in burned patients are not well studied. We aimed to identify hypernatremia risk factors and to evaluate outcomes in burned patients admitted to our burns intensive care unit. A case control study was conducted in adult burned patients hospitalized between January 1st 2017 and December 31st 2019. Cases who developed hypernatremia (>145 meq/L) during hospitalization were matched 1:1 with controls based on age and total burn surface area. There were 57 cases and 57 controls with a mean age of 41 ± 18 years. The majority of patients had major burns (n=99, 86.8%). The time onset of hypernatremia was seven days post burn. Compared to controls, the case group mostly consisted of transferred patients with longer time from injury to intensive care unit admission. Inhalation injury, mechanical ventilation, intravenous fosfomycin and colistin were associated with hypernatremia. Admission to the intensive care unit after six hours post-burn was the independent risk factor (OR=4.5). Hypernatremia was associated with longer length of stay and with higher mortality. We conclude that delayed management, inhalation injury, mechanical ventilation, fosfomycin and colistin administration are the main hypernatremia risk factors in burned patients.

L'hypernatrémie est un paramètre pronostic défavorable chez les patients de réanimation. Ses facteurs de risque n'ont pas été bien étudiés chez les brûlés. Nos objectifs étaient d'identifier les facteurs de risque d'hypernatrémie et d'évaluer son impact sur le pronostic des brûlés hospitalisés dans notre unité de réanimation. Une étude cas-témoins a été menée chez des brûlés hospitalisés entre le 1er janvier 2017 et le 31 décembre 2019. Les cas (hypernatrémie >145 meq/L pendant l'hospitalisation) ont été appariés 1/1 avec des témoins, en tenant compte de l'âge et de la surface brûlée. Nous avons colligé 57 cas et 57 témoins âgés de 41±18 ans. La plupart des patients (n=99 soit 86,8%) souffraient de brûlures étendues. L'hypernatrémie s'est installée après sept jours des brûlures. Les cas avaient plus souvent été transférés d'une autre institution et étaient pris en charge dans le service après un délai plus long. Les lésions d'inhalation, la ventilation mécanique, la fosfomycin et la colimycine étaient les facteurs de risque d'hypernatrémie. L'admission en réanimation au-delà de six heures en était le facteur de risque indépendant (OR=4,5). L'hypernatrémie était associée à une durée de séjour plus longue et à une mortalité plus élevée. Nous concluons que la prise en charge tardive, les lésions d'inhalation, la ventilation mécanique, la fosfomycine et la colimycine sont les facteurs de risque d'hypernatrémie chez les brûlés.

[Quality of the medical record notification in primary health care]. / Qualité de notification sur le dossier medical en première ligne.

BACKGROUND: The medical record is a very important tool for organizing, the planning and tracking of care. Her outfit is considered as one of the major criteria for care quality. AIM: compare, the degree of given collected notification on the Structured Medical Record (SMR) in Subjective, Pre-appreciation, Objective, Appreciation and Post-appreciation (SPOAP) and on Not Structured Medical Record (NSMR). METHODS: It is a retrospective, analytic study, including 910 DM. Executed in four primary health centers, at Monastir governorate in 2010. As regards methodology, we conducted a sampling at 3 degrees. The first draw of the month, the second on the weeks, the third is systematic type of medical records with a step of sounding of 2. We collected information about patient's socio-demographic characteristics, the contact patterns, clinical examination of the data, assumptions and diagnostics procedures. We used chi2 test to compare the distribution between SMR and NSMR at the Threshold of 5 %. RESULTS: Four hundred and one SMR (44 %) and 509 (56 %) NSMR were included. The contact patterns was noted on 44 % of NSMR and 93% of SMR (< 10-4). The physical examination had been noted on 67 % of SMR and 8% of NSMR (p < 10-4), the hypotheses diagnoses on 72 % of SMR and 31 % of NSMR (p < 10-4). The conducts had been noted on 98 % of SMR and 95% of NSMR (p < 0,045). The distribution of the motives for contacts, physical acts, hypotheses diagnoses and therapeutic families were different between SMR and NSMR. The medical records was adequate in 52 % of SMR and in 2% of NSMR (p < 10-4). CONCLUSION: The use of SMR improves the notification and the care continuity.

Reciprocal interaction between seasonal testis and thyroid activity in Zembra Island wild rabbits (Oryctolagus cuniculus): effects of castration, thyroidectomy, temperature, and photoperiod.

The reproductive cycle of wild rabbits (Oryctolagus cuniculus) living in Zembra Island (North Tunisia) is dependent on an external factor, the photoperiod: the gonads are inhibited by long days and stimulated by short days or melatonin implants. Here we studied the role of an internal factor, thyroid hormones and the possible thyroid-gonadal interrelationships, in animals captured on Zembra Island and maintained in natural conditions of photoperiod and temperature. We determined the seasonal profile of the thyroid and testis cycles and investigated the effects of castration and thyroidectomy on the seasonal testosterone and thyroxine cycles. Plasma thyroxine and testosterone levels followed similar, parallel seasonal patterns, with a peak in autumn (October) and low values from January to August. In thyroidectomized animals, plasma testosterone levels, although significantly higher than those in controls (P < 0.001), remained low throughout the 13 mo of the experiment, and no testicular reactivation was observed in the fall. In castrated animals, despite the increase in thyroxine concentration in the 3 mo following castration (P < 0.01), plasma thyroxine levels remained low during the 2 yr of the study. We then investigated the combined effects of long days (16L:8D) and moderately high temperature (25 degrees C) on these two endocrine axes. In constant gonado-inhibiting conditions (16L:8D), whether the temperature was kept constantly high or allowed to fluctuate naturally, no reactivation of the thyroid and testicular axes was observed in the fall. In control animals, the peaks of testosterone and thyroxine concentrations observed in September were larger (P < 0.001) than those in animals subjected to the same natural photoperiod conditions but with constantly high temperature. The lower level of autumnal testis stimulation (P < 0.001) in animals maintained in conditions of constant high temperature (25 degrees C) may be attributed to the low thyroxine levels induced by high temperature. These results clearly confirm that the thyroid and testicular cycles display similar seasonal variations and show that the thyroid and gonadal axes are strictly interdependent. This study provides the first demonstration, for a given species, that the seasonal reactivation of gonad activity is controlled by the thyroid, and thyroid activity is controlled by the gonads.

[Neurosarcoidosis as the first manifestation of sarcoidosis: diagnosis difficulty. A case report]. / Problème diagnostique d'une neurosarcoïdose révélatrice. A propos d'un cas.

Clinically apparent involvement of the nervous system occurs in a relatively small number of patients with sarcoidosis. The diagnosis of neurosarcoidosis is often difficult and particularly in patients who lack either pulmonary or systemic manifestations of sarcoidosis. Furthermore clinical and imaging features of neurosarcoidosis are extremely variable. We report a case of neurosarcoidosis which had been considered and treated at first as tuberculosis. Only the occurrence, two years later, of pulmonary manifestations of sarcoidosis enabled the diagnosis.

Long-day inhibition of reproduction and circadian photogonadosensitivity in Zembra Island wild rabbits (Oryctolagus cuniculus).

We investigated the effects of photoperiod on testicular activity in wild rabbits (Oryctolagus cuniculus) captured on Zembra Island (North Tunisia) and maintained in experimental photoperiodic conditions. Sexually inactive animals were subjected to alternate 3-mo periods of short days (8L:16D) and long days (16L:8D) for 1 yr. Testicular activity increased significantly and then decreased to levels equivalent to or lower than those measured during sexual quiescence after 1 mo of 8L:16D or 16L:8D, respectively. Eight groups of sexually active animals were also exposed to 8L:16D for 60 days. The light phase was divided into two photofractions (7.5 and 0.5 h). The short photofraction interrupted the dark phase 9.5-18.5 h after the beginning of the main photofraction. Testicular activity was inhibited if the short photofraction interrupted the dark phase 12.5 h or more after the beginning of the main photofraction. These results clearly confirm that photoperiod affects reproduction in this species: Short days stimulate reproduction, whereas long days inhibit it. The asymmetric pattern of skeleton photoperiods used demonstrated the existence of a circadian rhythm for photogonadosensitivity, with the photosensitive phase beginning 12.5 h after dawn. In this species, photoperiod length controls both the beginning and the end of the reproductive period. These results differ from those obtained with continental populations of wild rabbits, in which reproduction is inhibited by short day length. This difference may reflect genetic drift linked to the geographic isolation of this population, which is known to have been present on this small island for more than 2000 yr.

Effects of bilateral ganglionectomy and melatonin replacement on seasonal rhythm of testicular activity in Zembra Island wild rabbits (Oryctolagus cuniculus).

This study examined the effects of subcutaneous melatonin implants on testicular activity (testis volume and plasma testosterone) in wild rabbits (Oryctolagus cuniculus) captured on Zembra Island (North Tunisia) and maintained in natural temperature and photoperiod conditions. The period of testicular activity was 2 months longer in intact animals with melatonin implants than in intact animals without melatonin implants. After bilateral superior cervical ganglionectomy, testicular activity was inhibited and no spontaneous recrudescence in gonadal function was observed during the 13 months of the experiment, demonstrating the absence of an endogenous circannual rhythm of reproductive function in this species. Renewed testicular activity was observed 2 months after the insertion of melatonin implants in ganglionectomized animals. These results confirm that testicular activity is stimulated by short days in late autumn and that melatonin reactivates the reproductive axis in this species. This finding is in contrast to that in continental populations of wild rabbits in which reproduction is inhibited by short days or melatonin. These results are discussed in terms of insularity and may reflect the geographical isolation of this population.

[Testicular activity in Orychtolagus cuniculus, a wild rabbit from Zembra island (Tunisia), during short days and long days. The effect of pineal gland deafferentation]. / Activité testiculaire chez Orychtolagus cuniculus, lapin sauvage de l'île de Zembra (Tunisie), en jours courts et en jours longs. Effet de la désafférentation de la pinéale.

Several male wild rabbits from Zembra island were used to determine the effect of the photoperiod and of the cranial sympathectomy on testicular activity. Two groups were used (G1 and G2), including each 4 control rabbits and 5 cranially sympathectomized by removal of the superior cervical ganglia. The G1 animals were reared in natural photoperiod at room temperature; the others (G2) were exposed to alternating three-month periods of short days (8 L-16 D) and long days (16 L-8 D). The changes in the testicular function (testis volume and plasma testosterone levels) were studied during one year. Our data show that: (1) The control animals, reared in natural photoperiod at room temperature, showed a decrease in testicular activity during the winter season (December to February) characterized by short days. However, testis volume and plasma testosterone seemed to be maintained at low levels during the other months of the year. (2) The artificial short days (8 L-16 D) induced an increase of the testis volume and of the plasma testosterone. A significant decrease of these parameters was observed when transferring the animals to long days (16 L-8 D). (3) The deafferentation of the pineal body by bilateral superior cervical gangliectomy blocked the testicular activity either when the animals were maintained in natural photoperiod or transferred from (8 L-16 D) to (16 L-8 D). Thus the testicular activity of wild rabbits from Zembra island is controlled by the photoperiod. Light action on the pineal is carried via the superior cervical sympathetic ganglia.

Seasonal changes in plasma testosterone, thyroxine, and cortisol levels in wild rabbits (Oryctolagus cuniculus algirus) of Zembra island.

Annual variations in testosterone, thyroxine, and cortisol concentrations were recorded in plasma samples obtained monthly from male wild rabbits living in their natural biotope. For comparison, a group of animals was held in semicaptivity close to Tunis. Zembra is an uninhabited, hardly accessible island, north of the bay of Tunis and is a part of a large, protected zone of natural reserve. Warrens of Zembra appear to subsist from a very remote past, without any contact with other strains. In both natural and captive environments, testosterone levels peak sharply in October, decline in November-December, and are low from January to September. Thyroxine titers also peak in October but a second peak occurs in spring, the magnitude of which is markedly higher in natural than in captive conditions. As to cortisol, netting in Zembra results in stress-induced high values but semicaptive specimens exhibit a clear-cut annual rhythm peaking in January.

[Seasonal cycles of plasma testosterone and cortisol in the wild rabbit (Oryctolagus cuniculus algirus Loche) of Zembra Island, studied in its natural biotope and in captivity]. / Cycles saisonniers de la testostérone et du cortisol plasmatiques chez le Lapin sauvage de l'île de Zembra (Oryctolagus cuniculus algirus Loche), étudié dans son biotope naturel et en captivité.

Annual variations in plasma testosterone and cortisol levels were determined in male wild rabbits caught monthly in their natural biotope (Zembra island). For comparison, a group of warrens was hold in semi-captivity close to Tunis. In both conditions plasma testosterone concentrations were low from January to September and peak values were observed in October. Captive warrens exhibited a clear cut annual rhythm in plasma cortisol levels also and ether stress resulted in a very large increase of cortisolemia. In rabbits caught in ther habitat however, cortisol concentrations were always extremely high throughout the year, probably due to stressing conditions. Interestingly, wild rabbits of Zembra island appear to subsist from a very remote past without any contact with other strains. As to Zembra, it is a hardly get-at-able, uninhabited island which is a part of a strictly protected natural reserve and constitutes a fairly useful and valuable ecosystem.