Predictors of acute coronary syndrome in pre hospital patients with chest pain.

BACKGROUND: Non-traumatic chest pain is a common cause in pre hospital emergency medicine. The objective of our study was to identify predictive factors of STEMI in patients with acute chest pain, on telephone interview. METHODS: We conducted a prospective observational study over a period of one year (december 2017 to november 2018) in the Emergency Care System of the North Est (SAMU 01) of Tunisia. We included all adults patients aged more than 18 years old, calling the emergency dispatch center for acute non traumatic chest pain (CP). The demographic and clinical data were collected and studied to identify the predictive factors for STEMI. RESULTS: We included 368 patients. The average age was 56 ± 15 years, the sex ratio was 2.7. Smoking was the most common cardiovascular risk factor (41%) followed by hypertension (31%) and coronary artery disease (20%). Half of calls were made by doctors and 43% of them were made within the first two hours of onset of the CP. Clinical examination showed cardio respiratory arrest in 10 patients, 6 of them were related to STEMI. On the arrival of our emergency mobile teams, an elevation of ST segment was identified in 118 patients (32%) of which 37% were admitted directly into the catheterization room. In multivariate analysis, the independent predictive factors of STEMI were: diabetes (OR = 5.25; CI [1.61 - 17.06]), smoking (OR = 2.78, CI [1.03 - 7.5]), typical CP (OR = 4.68, CI [1.09 - 21.67]), CP persistence of more than 30 min (OR = 63.31, CI [13.51 - 29.49]). CONCLUSION: History of diabetes, smoking, typical and persistent CP were the main factors associated with STEMI in patients calling the emergency dispatch center for an acute CP. The early identification of these factors by the emergency physician will improve the management of acute CP since the medical regulation.

[Incidence and risk factors of depression after a first coronary acute syndrome: A prospective study among 110 patients]. / Incidence et facteurs de risque de la dépression post syndrome coronarien aigu : étude prospective auprès de 110 patients.

AIM: The purpose of this study was to estimate the incidence of post-acute coronary syndrome (ACS) depression and to identify predictive factors for the onset of this disorder. PATIENTS AND METHODS: We conducted a prospective, multicentric study across four cardiology departments, during the period from June to December 2018. A depressive symptom screening was performed using the Hospital Anxiety and Depression Scale, in-hospital (T0) and on average 42.1±7.9 days after hospital discharge (T1). RESULTS: A total of 110 patients were enrolled with an average age of 57±8.1 years. Sex ratio was 3.78. The incidences of depressive symptomatology at T0 and T1 were respectively 19.1% and 6.2%. Mean and cumulative incidences of depressive symptomatology were respectively 12.7% and 25.5%. According to the univariate analysis, drinking alcohol, overweight and anxiety were associated with the incidence of depressive symptomatology after SCA at T0. In binary logistic regression, drinking alcohol was the independent predictor of the incidence of depression after ACS at T0 with an odds ratio of 4.680 and CI of 95% [1.449; 15,107]; P=0.01. In univariate analysis, drinking alcohol, high risk of hospital mortality, according to the GRACE score, and non performing coronary angiography were statistically associated with the overall incidence of depressive symptomatology. CONCLUSION: Depression screening must be a part of the evaluation of the ACS. A repeated evaluation of depression is also recommended.

COVID-19 circuit management: la Rabta experience.

Covid-19 pandemic was associated to fear among patients, doctors and nurses, it was responsible of a work impairment in health structures organisation. All patients were at home, only Covid patients were at hospital. Our country has a quick reaction, we declared the pandemic as a social disease with free management. All hospital had the order to create their own Covid-19 circuit. We report the experience of our hospital in the crisis management with the creation of the circuit, its organisation, the management of the different financial, technical, human, sanitary, psychological and logistical aspects. The great point of this crisis was the fear, stress of caregivers for themselves and their families. The other point for members of Covid Cell was the race against time, the learning of a new job: a manager or a polyvalent chief. The presence of a Covid-19 circuit is necessary for each hospital at the epidemic time but it must be managed by infectious diseases doctors, lung specialists, intensive care givers and emergency room caregivers in collaboration. An enhancement of the structures is necessary at the level of medical wards and beds of intensive care.

Accuracy of preoperative real-time dynamic transvaginal ultrasound sliding sign in prediction of pelvic adhesions in women with previous abdominopelvic surgery: prospective, multicenter, double-blind study.

OBJECTIVE: To investigate the role of the transvaginal sonographic (TVS) sliding sign in predicting pelvic adhesions in women with previous abdominopelvic surgery. METHODS: This was a multicenter, prospective, interventional, double-blind study of patients with a history of abdominopelvic surgery who were undergoing laparoscopy or laparotomy during the 6-month period from March to August 2016 in one of three academic obstetrics and gynecology departments. Prior to surgery, patients were examined by TVS to assess the vesicouterine pouch, uterus, ovaries and pouch of Douglas, using the TVS pelvic sliding sign. Ultrasound findings and medical and surgical data were recorded. We assessed the accuracy of the preoperative TVS sliding sign in the prediction of pelvic adhesions overall and in each compartment separately. RESULTS: During the study period, complete TVS sliding sign and laparoscopic or laparotomic data were available for 107 women. Their mean age was 44.0 (95% CI, 41.6-46.4; range, 20-79) years. Their mean parity was 2.0 (95% CI, 1.7-2.3; range, 0-9) and the mean number of previous abdominal surgical procedures per patient was 1.3 (95% CI, 1.2-1.5; range, 1-4). Adhesions were noted in 27/107 (25.2%) patients. The TVS sliding sign had a sensitivity of 96.3% and specificity of 92.6% in predicting pelvic adhesions. There was a significant relationship between adhesions in each compartment and the TVS sliding sign (P < 0.05). CONCLUSIONS: The TVS sliding sign is an effective means to detect preoperatively pelvic adhesions in patients with previous abdominopelvic surgery. Use of such a non-invasive and well-tolerated technique could help in the planning of laparoscopy or laparotomy and counseling of these patients. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

[Feasibility and diagnostic value of hysterosonography performed in bleeding time in the exploration of abnormal uterine bleeding]. / Faisabilité et valeur diagnostique de l'hystérosonographie réalisée en période de saignement dans l'exploration des saignements utérins anormaux.

OBJECTIVES: The aim of our study is to evaluate the feasibility, safety and diagnostic value of hysterosonography performed in an emergency setting among patients consulting for active abnormal uterine bleeding. MATERIALS AND METHODS: In this prospective study, we included 216 patients visiting our emergency department for abnormal uterine bleeding. All patients had a transvaginal ultrasound with doppler study and an hysterosonography. Secondly, the patients, in whom we diagnosed a suspected organic lesion, were addressed to an endoscopic or surgical procedure with pathological examination. Initially, we evaluated the feasibility and the safety of hysterosonography and secondly, we compared the two techniques (EEV and hysterosonography), sensitivity, specificity, LHR+and LHR-. RESULTS: The hysterosonography was performed in 98.1 % of patients and its realization has resulted in an additional period of 1.2minutes on average (extreme: 6-12) compared to ultrasound. The tolerance of the hysterosonographic examination was very good in 73.5 % of patients and good in 23.1 % of them. For the 167 patients who had been diagnosed with presumed organic lesions, pathological examination found an endometrial hyperplasia in 34.7 % of cases, polyps in 40.1 % of cases, sub-mucosal fibroids in 11.3 % of cases, endometrial cancer in 0.7 % of cases and other lesions in 13.2 % of cases. The diagnostic value of hysterosonography was superior to ultrasound in the detection of polyps (AUC: 0.894 vs 0.778, P=0.003) and fibromas (AUC: 1.000 vs 0.716, P=0.001) while the two methods showed no significant difference in the detection of hyperplasia. CONCLUSION: The purpose of our study was to focus on a particular context of use of the hysterosonography consisting on hemorrhagic period and on its realization in the emergency room. We were able to demonstrate that hysterosonography is compatible with the emergency situation as to its feasibility and its diagnostic value and that its realization would contribute to the sorting of patients to guide them immediately to a surgical or endoscopic procedure if necessary.

[Relevance of first trimester serum markers to predict pregnancy complications: A Tunisian preliminary study]. / Pertinence des marqueurs sériques du premier trimestre pour prédire les complications de la grossesse : étude prospective tunisienne.

OBJECTIVES: Identify applications and utility of serum markers dosed in the first trimester in predicting, early diagnosis and management of various complications of pregnancy. METHODS: Eight hundred and eighty patients were included in this prospective regional study performed in the governorate of Bizerte in northern Tunisia in collaboration between the private and public sectors. Serum markers of the first quarter, PAPP A and ßhCG, were measured in the same laboratory. The performance of these markers was studied in the prediction of adverse pregnancy complications. RESULTS: The prevalence of various pregnancy complications was 8.6% for birth prematurely, 9.2% for hypertension or preeclampsia, IUGR 5.8% and 7.3% for loss pregnancy. PAPP A levels were lower in fetal loss group (P=0.005), vascular disease group (P=0.001) and preterm delivery group (P=0.001). In addition, a lower rate of ßhCG was associated with the occurrence of placental pathologies such as growth retardation (P=0.037) and hypertension (P=0.034) and appears to have no predictive value in the occurrence of preterm birth (P=0.76) and fetal loss (P=0.189). Logistic regression analysis showed a significant predictive value of these markers. CONCLUSION: Serum markers of the first trimester appear to have adequate predictive validity of adverse pregnancy complications. A risk predictive model could be designed based on these markers and involving maternal and ultrasound features in order to target prophylactically a high risk population.

[Value of ultrasonography to predict the endometrial cancer in postmenopausal bleeding]. / Valeur de l'échographie pour prédire le cancer de l'endomètre dans les métrorragies post-ménopausiques.

OBJECTIVE: To build mathematical models for evaluating the individual risk of endometrial malignancy in women with postmenopausal bleeding and a thick endometrium using clinical data, sonographic endometrial thickness and power Doppler ultrasound findings. METHODS: A total of 117 patients underwent transvaginal two-dimensional gray-scale and power Doppler ultrasound examination of the endometrium before getting endometrial biopsy. Inclusion criteria were post-menopausal bleeding and a thick endometrium greater than 5mm. The ultrasound image showing the most vascularized section through the endometrium as assessed by power Doppler was frozen to estimate endometrial thickness and features. The vascularity index was calculated using computer software. A structured history was taken to collect clinical information. Multivariate logistic regression analysis was used to create mathematical models to predict endometrial malignancy. RESULTS: There were 31 (26.4%) malignant and 86 (74.6%) benign endometria… Women with a malignant endometrium were older (median age 61 vs 56 years, P=0.036) and had a thicker endometrium (median thickness 18.8mm vs 12.5; P=0.002) and higher values for vascularity index. When using only clinical data to build a model for estimating the risk of endometrial malignancy, a model including the variables age had the largest area under the receiver-operating characteristics curve (AUC), with a value of 0.69 (95% confidence interval [CI], 0.59-0.79). A model including age and endometrial thickness had an AUC of 0.72 (95% CI, 0.50-0.96), and one including age, endometrial thickness and vascularity index had an AUC of 0.91 (95% CI, 0.62-0.97). Using a risk cut-off of 12%, the latter model had sensitivity 89%, specificity 74%, positive likelihood ratio 3.42 and negative likelihood ratio 0.14. DISCUSSION: Postmenopausal bleeding is a frequent cause of consultation in gynecological particularly in peri- or post-menopausal period. They are the main alarm sign of endometrial carcinoma. Vaginal ultrasound has become the "gold standard" in the initial exploration. It is a powerful tool to estimate the individual risk of malignancy in symptomatic postmenopausal women in order to optimize the management. The diagnostic performance of models predicting endometrial cancer increases substantially when sonographic and power Doppler information are added to clinical variables. This model seems to be clinically useful but need to be prospectively validated.

[Management of ovarian endometriomas: intraperitoneal cystectomy versus fenestration and coagulation]. / Prise en charge des endometriomes ovariens : quelle technique choisir : kystectomie intraperitoneale ou fenestration coagulation ?

BACKGROUND: Ovarian endometriomas is a common condition among women of reproductive age and represents a major cost in terms of public health. Despite these implications for public health, it remains difficult to arrive at a consensus on the optimal surgical treatment. AIMS: To study the clinical and paraclinical characteristics of this pathology and to compare two major surgical techniques: the intraperitoneal cystectomy and fenestration -coagulation in terms of recurrence and prognosis for future fertility. METHODS: A retrospective study of 31 patients who underwent surgical treatment for ovarian endometrioma histologically proved. The study period covers 10 years from January 2000 to December 2009. RESULTS: Laparoscopy was performed in 27 patients. The endometrioma was located to the left side in 64% of cases. The main strategy performed is intraperitoneal cystectomy in 18 patients (58.8%). In second place we find the fenestration-coagulation. The mean duration of postoperative follow-up is 10.3 months. The recurrence of the cyst and the persistence of pain symptoms were significantly less frequent in the group of patients who underwent intraperitoneal cystectomy. CONCLUSION: The laparoscopic surgery remains the first line approach in terms of ovarian endometrioma.Cystectomy offers performance equal or superior to the fenestration-coagulation technique, and exposes to fewer recurrences. For these reasons, it should be recommended. The fenestration-coagulation is possible in case the cystectomy is difficult or incomplete.

[Usefulness of colposcopy in inflammatory cervico-vaginal smears: apropos of 140 cases]. / Apport de la colposcopie dans les frottis cervico-vaginaux inflammatoires: a propos de 140 cas.

BACKGROUND: The cervical cancer is the second most frequent cancer of the woman in Tunisia. It is considered as a sexual transmissive desease due to the involvement of the HPV. AIM: The purpose of our study is to proove that an inflammatory cervical smear should be considered as a positive test and must lead to other investigations. METHODS: It is a prospective study over 140 cases of inflammatory cervical smears (without atypical cells) diagnosed during a year period from june 2001 to june 2002. These patients had a systematic colposcopy with the biopsy of suspicious lesions. RESULTS: The mean age of our patients is 42 years. 68.57% of them are in active genital period. The colposcopy was normal in 10% of our patients. It showed benign lesions such as: ectropion in 22.85%, colpitis in 14.28%, cervical polypus in 5%, normal transformation zone in 8.57%, but also suspicious lesions such as : atypical transformations grade I (ATGI) in 25.71% and atypical transformations grade II (ATGII) in 13.57%. The biopsies made on 89 patients showed dysplasia and carcinoma in 18.57% of them. A case of in situ carcinoma, a microinvasif epidermoid carcinoma and an invasif glandular carcinoma were diagnosed. CONCLUSION: Colposcopy is an ambulatory investigation. It makes a minutious study of the cervix and diminishes the rate of false negative made by the cervical smear.