Burden and predictions of hospitalized injuries in a low-middle income country: results from a Tunisian university hospital.

Injuries are responsible for a high premature mortality and disability. They are poorly explored in low and middle income-countries. We aimed to estimate the burden of hospitalized injuries in the Monastir governorate (Tunisia) according to the nature of the injury, trends and projections of hospitalizations for injuries up until 2024, and to identify the distribution of this disease burden based on age and sex. We performed a descriptive study from 2002 to 2012 including all hospitalizations for injuries. Data were collected from morbidity and mortality register of the University Hospital of Monastir (Tunisia). We estimated the burden of injuries using the Disability Adjusted Life Years (DALYs). We described injuries (crude prevalence rate (CPR) and age standardized prevalence rate (ASR)), related mortality (lethality and standardized mortality ratio (SMR)), trends and prediction for 2024. A total of 18,632 hospitalizations for injuries representing 10% of all hospitalizations during study period were recorded. Per 1000 inhabitants per year, CPR was 3.36 and the ASR was 3.44. The lethality was of 17.5 deaths per 1000 injured inpatients per year and the SMR was of 2.95 (Confidence Interval of 95%: 2.64-3.29). Burden related to injuries was 2.36 DALYs per 1000 population per year, caused mainly by Years of Life Lost (83.4%), most frequent among men aged under 40 years. The predicted ASR for 2024 was 4.46 (3.81-5.23) per 1000 person-years. Injuries to the head was the most prevalent (20.7%) causing 67.7% of DALYs; and increasing by 226% through 2024. Injuries had a high prevalence and an important burden in a Tunisian university hospital. Prediction showed increased prevalence for 2024. Preventive measures and a trauma surveillance register should be implemented soon.

Burnout syndrome among health care workers during the COVID-19 pandemic. A cross sectional study in Monastir, Tunisia.

BACKGROUND: Burnout syndrome may affect the safety of frontline healthcare care workers (HCW) and patients. We aimed to measure the prevalence of burnout among HCW in care facilities in Tunisia during the Covid-19 pandemic and to identify its associated factors. METHODS: We conducted a cross-sectional study among HCW practicing during the covid-19 pandemic in health care facilities in the governorate of Monastir. Data collection was carried out using an anonymous self-administered questionnaire composed by three sections: epidemiological and clinical characteristics, professional conditions and the Maslach Burn out Inventory (MBI-HSS). RESULTS: This study included 371 HCW. The prevalence of burnout was 77.9% (CI 95%: 73.6% - 82.1%). The severe level was found in 71 participants (19.1%), the moderate level in 115 (31%) and the low level in 103 (27.8%). The distribution of the levels of the burnout dimensions among the participants was as follows: high emotional exhaustion (EE) (57.4%), high depersonalization (DP) (39.4%) and low personal accomplishment (22.6%). The main determinants of burnout among healthcare professionals during COVID 19 pandemic were: working more than 6 hours per day (OR = 1.19; CI95% [1.06; 1.34]), physician function (OR = 1.17; CI 95% [1.05; 1.31]), feeling a negative impact of work on family life (OR = 1.40; 95% CI [1.13; 1.73]), and high personal estimation of COVID 19 exposure (OR = 1.15; CI95% [1.02; 1.29]). CONCLUSION: During the COVID19 pandemic, the prevalence of burnout among health professionals was high. It was related to hard implication in COVID 19 management. Interventions like adjusting working hours, reducing workload, and providing psychological support should be taken.

Developing learning objectives in postgraduate medical education for family medicine (Tunisia).

Introduction-Aim: The third cycle of medical studies (TCMS) lasts 3 years for the specialty of family medicine (FM) in Tunisia. The members of the FM committee of the Faculty of Medicine of Monastir (FMM) aimed to detail the learning objectives (LO) of residents in FM. METHOD: We used the Delphi method in 2 rounds including a group of experts called FM Learning Objectives Writing Group (FMLOWG) at the FMM. The FMLOWG included 74 university hospital physicians and FM internship supervisors. These members actively participated in the 10 meetings held during the month of March 2022. Three points were discussed: the identification of LOs; the development of training titles and the proposal of the teaching methods to be adopted. The writing was subdivided into 5 domains of LO: transversal, public health, typical population and by system. RESULTS: We identified 1359 LOs for FM residency, for which 552 were LOs per system (40.5%). The learning included 618 training session titles. Residents will have an academic training day every 3 weeks during 9 months for each TCMS year. CONCLUSION: A detailed, MF-specific consensus has been developed by majority of medical specialties. It will be a learning base for learners, a reference for supervisors and TCMS teachers.

Occupational exposure to hepatitis C virus infection and associated factors among healthcare workers in Fattouma Bourguiba University Hospital, Tunisia.

BACKGROUND: Healthcare workers (HCWs) are at high risk of hepatitis C virus (HCV) infection. Indeed, they are exposed to blood and body fluid which put them at an important risk of transmission of various blood borne pathogens including HCV. The goal of this study was to determine the magnitude of occupational exposure to hepatitis C virus infection as well as the factors associated to this exposure among HCWs at a Tunisian University Hospital in 2017. METHODS: A hospital-based cross-sectional study was carried out at Fattouma Bourguiba University Hospital in Monastir Governorate (Tunisia) from 01 June 2017 to 31 August 2017. Data were collected using an anonymous questionnaire. To determine factors associated with occupational exposure to hepatitis C virus infection, we performed multivariate analysis. RESULTS: Among the 1493 included participants, more than half (56.7) had at least one exposure to blood or body fluid. A history of needle stick injury was reported by 48.3% of the respondents. Exposure to blood or body fluid splash into the face was announced by 32.1% HCWs. Doctors had the highest risk of exposure (AOR = 12.425; 95% CI: [05.310-29.075]). Participants working at surgical departments were the most exposed comparing to workers at others departments (AOR = 7.440; 95% CI: [4.461-12.408]). Two exposed female HCWs were tested positive corresponding to a HCV infection prevalence of 0.13% (95% IC: [0.11-0.16%]). CONCLUSION: Occupational exposure to hepatitis C virus infection was high at the university hospital of Monastir. Despite the low magnitude of HCV infection, preventive actions should be taken to promote the safety of health care personnel.

Eating disorders among women in primary care (Monastir, Tunisia).

INTRODUCTION: Eating disorders (ED) are relatively frequent, but convey a high mortality and morbidity. More than half of individuals with ED remain undetected in primary care. The general practitioners (GP) are in a strategic position to detect patients with ED. AIMS: To determine the prevalence of ED in Tunisian women visiting their GP using the SCOFF-F score and to determinate the associated socioeconomic, clinical, and lifestyle factors. METHODS: This is a cross-sectional study of women who consulted two primary health care in the city of Monastir, during 4 months of the year 2020. The SCOFF-F was performed. RESULTS: We included 445 women; the mean age of our patients was 36 ± 12 years. SCOFF-F was positive in 48% of cases CI95% [43-52%], 14% presented with bulimia nervosa and 12% with binge eating disorder. Patients with ED were overweight in 33% of cases, 40% perform a physical activity and 53% eat three meals per day. A family history of ED was 35%. 20% of the patients have a history of psychiatric disorder. In multivariate analysis, performing physical activity to control weight, eating three meals a day, maintaining the current diet without trying to change into a different one, non continous occupation and anxiety increase the risk of ED with respective ORs of 2.34, 4.26, 3.69, 2.09 and 2.09 respectively. Ages between 35 and 60 years, and a history of ED in siblings increases the risk of ED by 1.6. CONCLUSION: Our study concluded that ED was associated with common family behavior, especially among siblings, and with a particular psychological state which are interesting to screen by GP and to focus on targeting family care.

Predictors of Quality of Life in Stroke Survivors: A 1-year Follow-Up Study of a Tunisian Sample.

BACKGROUND: Stroke survivors often have impaired quality of live (QOL). There is very little information about the determining factors of QOL of stroke survivors in developing countries managed in public health structures with limited access to state of the art treatments. OBJECTIVE: To identify the main determinants of QOL in Tunisian stroke survivors. METHODS: QOL was assessed at 3, 6 and 12 months after the stroke using the Tunisian version of the SF-36 questionnaire. Patients were evaluated using the National Institue of Health Stroke Scale, the motor index of Demeurisse, the Functional Independence Measure instrument, the Reintegration to Normal Living Index, the Mini-Mental State Examination and the Hospital Anxiety and Depression Scale. RESULTS: 65 stroke survivors were included (60% males; mean age 62.2±10.3 years). Eighty-sex percent of the patients had an ischemic infarction. Most of the stroke patients had minor or moderate stroke. All the QOL dimensions were altered at 3 months post stroke. Between the 3 and 6-months follow-ups, there were significant changes in the SF-36 scores and individual domains but QOL remained altered. Between 6 and 12 months, there were no significant changes in the majority of the SF-36 domains. Advanced age, neurologic impairment, depression and disability measured 1 month after stroke, the stroke side (left hemisphere), the life style, and higher education, were associated with worse QOL. CONCLUSIONS: Stroke severity, advanced age, post-stroke depression and disability seem to represent consistent determinants of QOL in Tunisian stroke patients.

Psychiatric emergencies : Factors associated with suicide attempts.

BACKGROUND: Among psychiatric emergencies, suicide attempt is a frequent reason for consultation. The magnitude of this phenomenon is not only related to its increasing frequency or life-threatening, but also to the psychosocial consequences of suicidal gesture both on the patient and his entourage. OBJECTIVES: To determine the prevalence of suicide attempts in psychiatric emergency department patients and to identify associated factors. METHODS: This is a cross-sectional study carried out in the emergency department of Mahdia University Hospital during a three months period, including consultants for whom a psychiatric opinion was solicited. Regarding statistical analyzes, we studied associations between suicide attempt and sociodemographic, contextual, anamnestic and clinical variables. RESULTS: Forty-four suicidal patients were included, with a prevalence of 0.5% of all emergencies. The patients mean age was 26.6 years with a female predominance (sex ratio = 0.29). Self-induced intoxication was the most widely used method (93.2%). Reactional suicidal attempts accounted for 75%. Many factors were significantly associated with suicide attempts: young age, female gender, secondar y level of education, students, presence of trigger factor, family and personal history of suicide attempt and the provenance of the examination request from a physician. CONCLUSION: This  study highlights  a particular  profile  of patients at  high  risk  of suicide,   a codified action is to begin, including all health care providers to prevent  its  occurrence. This primary prevention is only possible through  the  identification of  risk  factors  associated with it.

For a honest Maghreb care system. Systematic Review of the International Literature on Corruption in the Health care System.

INTRODUCTION: Corruption in the health care system is a universal phenomenon, putting at risk the health of populations. The purpose of this work was to synthesize the international literature on corruption in the health sector. METHODS: This is a systematic review of literature dealing with articles on health corruption practices, published between July 2008 and June 2018, via two search engines: PubMed and Google Scholar. The extracted data were narratively summarized in three major areas: defining the concept of corruption in health, its typology / manifestations and anti-corruption interventions. RESULTS: A total of 23 articles were selected for final analysis. The articles that defined health corruption shared two key aspects: "abuse of power" and "benefit". The main types of corruption were "abuse of therapeutic indication", followed by "bribes" and "falsification". The anti-corruption interventions were synthesized into seven types: creation of an independent multi-interventional agency, support for scientific research, law enforcement, awareness raising, detection, reporting and institutional commitment. CONCLUSION: Based on the use of power, corruption in health is a complex phenomenon whose struggle requires a specific and contextualized strategy integrating information, detection and punishment.

Family medicine in the service of internal security: morbidity and cost of prescriptions.

BACKGROUND: The study of morbidity and cost of drug prescriptions generated by the primary care physician, with specific populations directs Quality Improvement strategies of care. AIM: To identify acute pathologies in primary care medicine forces for internal security and to study the cost of drug prescription . METHODS: This is a cross-sectional survey during which, we analyzed the medical records (MR) and medical prescriptions (MP)for patients older than 5 years, presenting for acute pathologies, at the first online consultation polyclinic of the internal security forces(ISF) of Mahdia, during the year 2014. Data were collected using a standardized form. We opted for a two-stage sampling the first agreement by taking the second month of each season, the second systematic taking MR from one day to two. RESULTS: We analyzed 701 MR. The average age of the consultants was 37 years with a sex ratio de1,34. Systems, respiratory, digestive, musculoskeletal, skin and cardiovascular, were accumulating 88.3% of acute morbidity diagnosed. The most prescribed therapeutic classes were antipyretics / analgesics (61.6%), antibiotics (42.7%), local treatments oto-rhino-laryngological and throat (28.6%), cough (13.6%), the non steroidal anti inflammatory (12.2%) and mucolytics (11.7%). The median cost of the prescription was 12.070 Tunisian Dinar (TD). The contribution of the patients served at the polyclinic of the FIS of Mahdia, in drug costs, was 35.1%. CONCLUSION: we were able to highlight the specificities of morbidity in the front line at the polyclinic of the FSI of Mahdia , the nature and cost of drug prescription that was equivalent to that of the general population but with better contribution third party payers.

BCG vaccination and tuberculosis prevention: A forty years cohort study, Monastir, Tunisia.

We aimed to describe incidence, trends of tuberculosis (TB) over 18 years and to evaluate the impact of the BCG vaccine after four decades of immunization program according to three protocols. We performed a cohort study including declared cases in Monastir from January 1, 2000 to December 31, 2017. We reported 997 cases of TB. The predominant site was pulmonarylocalization (n = 486). The age standardized incidence of pulmonary and lymph node TB per 100,000 inh were 5.71 and 2.57 respectively. Trends were negative for pulmonary TB (PTB) (b = - 0.82; r = -0.67; p<10-3) and positive for lymph node localization (b = 1.31; r = 0.63; p<10-3). We had not notified cases of HIV associated with TB. Crude incidence rate (CIR) of PTB per 100,000 inh was 8.17 in Non-Vaccinated Cohort (NVC) and 2.85 in Vaccinated Cohort (VC) (p < 0.0001). Relative risk reduction (RRR) of BCG vaccination was 65.1% (95%CI:57.5;71.4) for pulmonary localization and 65% (95%CI:55; 73) for other localizations. We have not established a significant RRR of BCG vaccination on lymph node TB. Protocol 3 (at birth) had the highest effectiveness with a RRR of 96.7% (95%CI: 86.6%; 99.2%) and 86% (95%CI:71%;91%) in patients with PTB and other localizations TB respectively. In Cox regression model the HR was 0.061 (95% CI 0.015-0.247) for PTB and 0.395 (95% CI 0.185-0.844) for other localizations TB in patients receiving protocol 3 compared to NVC. For lymph-node TB, HR was 1.390 (95% CI 1.043-1.851) for protocol 1 and 1.849 (95% CI 1.232-2.774) for protocol 2 compared to NVC. Depending on the three protocols, the BCG vaccine had a positive impact on PTB and other TB localizations that must be kept and improved. However, protocols 1 and 2 had a reverse effect on lymph node TB.

Management of acute coronary syndrome in emergency departments: a cross sectional multicenter study (Tunisia).

BACKGROUND: We aimed to describe diagnosed acute coronary syndrome (ACS) and its care management and outcomes in emergency departments (EDs) and to determine related cardiovascular risk factors (CVRFs). METHODS: We conducted a cross sectional multicenter study that included 1173 adults admitted to EDs for acute chest pain (ACP) in 2015 at 14 sites in Tunisia. Data included patients' baseline characteristics, diagnosis, treatment and output. RESULTS: ACS represented 49.7% of non-traumatic chest pain [95% CI: 46.7-52.6]; 74.2% of ACS cases were unstable angina/non-ST-segment-elevation myocardial infarction (UA/NSTEMI). Males represented 67.4% of patients with ACS (p < 0.001). The median age was 60 years (IQR 52-70). Emergency medical service transportation was used in 11.9% of cases. The median duration between chest pain onset and ED arrival was two hours (Inter quartile ranges (IQR) 2-4 h). The age-standardized prevalence rate was 69.9/100,000 PY; the rate was 96.24 in men and 43.7 in women. In the multivariable analysis, CVRFs related to ST segment elevation myocardial infarction were age correlated to sex and active smoking. CVRFs related to UA/NSTEMI were age correlated to sex, familial and personal vascular history and type 2 diabetes. We reported 27 cases of major adverse cardiovascular events (20.0%) in patients with STEMI and 36 in patients with UA/NSTEMI (9.1%). CONCLUSION: Half of the patients consulting EDs with ACP had ACS. Emergency medical service transportation calls were rare. Management delays were acceptable. The risk of developing an UA/NSTEMI was equal to the number of CVRFs + 1. To improve patient outcomes, it is necessary to increase adherence to international management guidelines.

Expanded program of immunization in the Maghreb. Case study of Tunisia.Systematic review of the literature.

BACKGROUND: Vaccination is the most cost-effective intervention for primary prevention. The Maghreb countries had joined the The Expanded Programme on Immunization (EPI). Tunisia had also introduced the vaccine against hepatitis B and Haemophilus influenzae type B (Hib). OBJECTIVE: To describ, through a systematic review, the specific documentation on the EPI in Tunisia. METHOD: Target publications were collected using Medline database and Google Scholar from published articles from January 01 1998 to December 12 2017. The synthesis of the data was done according to four axes: "input", "process", "output" and "outcome". RESULTS: 17 articles were analyzed, with an average of 4 publications every 5 years. The author's specialty was community and preventive medicine in 56% of cases. Six articles focused on the "input" vaccination program, five related to the immunization process and the other five articles examined output and outcomes. CONCLUSION: Tunisian publications concerning vaccination were rare, their efficiency and impact on the change of national vaccination strategy was crucial. Research coordination between Maghreb countries is highly recommended to meet the growing information needs.

Hospitalizations for communicable diseases in a developing country: prevalence and trends-Monastir, Tunisia, 2002-2013.

BACKGROUND: In spite of the epidemiological transition, communicable diseases remain a public health problem and represent a significant cause of morbidity and mortality worldwide, especially in developing countries. This study aimed to determine the crude and standardized prevalence rates of hospitalizations for communicable disease (HCD) and to assess trends in HCD by age and sex at a university hospital in Tunisia over a period of 12 years (2002-2013). METHODS: All cases of HCD from 2002 to 2013 in the university hospital departments were included. Data collected from the regional register of hospital morbidity were used. The discharge diagnoses were coded according to the International Classification of Diseases, 10th revision (ICD-10). RESULTS: HCD represented 17.45% of all hospitalizations during the study period (34 289/196 488; 95% confidence interval 17.28-17.62%). The median age at the time of admission was 31 years (interquartile range (IQR) 15-52 years). The median hospital length of stay (LOS) was 5days (IQR 3-9 days). The crude prevalence rate (CPR) was 5.41 per 1000 inhabitants. The CPR was highest among patients aged ≥65 years. The four communicable disease categories that represented 70% of all HCD were abdominal infection, skin infection, genitourinary infection, and lower respiratory tract infection. The majority of HCD decreased over time; however, there was a significant increase in HIV diseases, tuberculosis, and viral hepatitis. CONCLUSION: This study provides evidence of the epidemiological transition, showing a decline in communicable diseases, which needs to be sustained and improved.

Rheumatic heart disease in a developing country: Incidence and trend (Monastir; Tunisia: 2000-2013).

BACKGROUND: The penicillin therapy of ß hemolytic streptococcal pharyngitis has aided in the decrease of rheumatic heart disease (RHD) in developing countries. Tunisia is an endemic area, however, and incidence of RHD is weakly documented. We aimed at establishing the standardized incidence rate (SIR) of RHD in Monastir governorate and at determining RHD prevalence among hospitalized patients in two cardiology departments. METHODS: From the regional register of Monastir Hospital morbidity, we have selected newly diagnosed patients with RHD, residents of Monastir, and hospitalized to the 2 cardiology departments between 2000 and 2013 (2001 not included). FINDINGS: We studied 676 newly admitted patients. We estimate 1060 to be the number of new annual RHD cases in Tunisia. The SIR per 105 person-years was 10.97, being 9.3 in men and 19.1 in women, respectively. We have notified a negative trend of crude incidence rate/105 Inhabitants (Inh) (CIR) (r=-0.23, p<10-3), and a strong positive correlation between age and CIR/105 Inh (r=0.989, p<10-4). RHD lethality was 1%. We have registered 728 hospitalizations for RHD, representing 2.5% of all cardiology hospitalizations [95% CI: 2.3-2.7%], with a prevalence for 13.3% for women aged 15-29years. The median hospital stay was 9days (IQR: 5-15). CONCLUSION: Our results confirm the RHD incidence decrease, consistent with epidemiological transition in Tunisia. We have also emphasized on the close trend of RHD with age and the predominance of RHD among women especially at the procreation age.

The risk of acute coronary syndrome in Ramadan.

BACKGROUND: Data on the effect of fasting on coronary disease are rare and controversial. The aim of our study was to investigate the influence of Ramadan on the prevalence of acute coronary syndrome among chest pain patients in the emergency department of Monastir. METHODS: It was a prospective study, performed in the emergency department of Fattouma Bourguiba University Hospital of Monastir, during the 3 months before, during and after Ramadan from 2012 to 2014. We included all patients with non-traumatic chest pain during the study period. Data were collected using a standardized form. The uniformity chi 2 test, ANOVA test, Kruskal-Wallis test were performed at the 5% level. Binary logistic regression model was used for multivariate analysis. RESULTS: The SCA prevalence was 17% a month before Ramadan, 22% during Ramadan and 28% one month after Ramadan (p = 0.007). According to the results of the multivariate analysis, the period of Ramadan is not associated with increase of risk of SCA whereas the risk doubles after Ramadan in all group (p = 0.001). In subgroups analysis, the period of R was associated with an amplification of risk in men aged more than 55 years and women older than 65 years (OR: 2.1; p = 0.020) and among subjects with hypertension (OR: 2.4, p = 0.007). Ramadan and Shawwal were not associated with an increase of risk among subjects without CVX risk factor. CONCLUSION: We have demonstrated that the risk of SCA has increased in Ramadan only among the elderly and patient with hypertension. The increased risk in Shawwal can be explained by the lifting of dietary restriction.

The risk of acute coronary syndrome in Ramadan.

BACKGROUND: Data on the effect of fasting on coronary disease are rare and controversial. The aim of our study was to investigate the influence of Ramadan on the prevalence of acute coronary syndrome among chest pain patients in the emergency department of Monastir. METHODS: It was a prospective study, performed in the emergency department of Fattouma Bourguiba University Hospital of Monastir, during the 3 months before, during and after Ramadan from 2012 to 2014. We included all patients with non-traumatic chest pain during the study period. Data were collected using a standardized form. The uniformity chi 2 test, ANOVA test, Kruskal-Wallis test were performed at the 5% level. Binary logistic regression model was used for multivariate analysis. RESULTS: The SCA prevalence was 17% a month before Ramadan, 22% during Ramadan and 28% one month after Ramadan (p = 0.007). According to the results of the multivariate analysis, the period of Ramadan is not associated with increase of risk of SCA whereas the risk doubles after Ramadan in all group (p = 0.001). In subgroups analysis, the period of R was associated with an amplification of risk in men aged more than 55 years and women older than 65 years (OR: 2.1; p = 0.020) and among subjects with hypertension (OR: 2.4, p = 0.007). Ramadan and Shawwal were not associated with an increase of risk among subjects without CVX risk factor. CONCLUSION: We have demonstrated that the risk of SCA has increased in Ramadan only among the elderly and patient with hypertension. The increased risk in Shawwal can be explained by the lifting of dietary restriction.

[Smoking cessation attitudes among adult smokers]. / Les attidute envers l'arrêt du tabac chez les fumeurs adultes.

AIM: The failure of attempts to quit smoking was the cause of stagnation even the increasing prevalence of smoking in Tunisia. The aim of our study was to describe the previous quit attempts among smokers, the degree of motivation to the next stop and analyze the associated factors. METHODS: We carried out a survey based on an anonymous selfadministered questionnaire on tobacco, targeting smokers who participated in awareness sessions conducted in public places and universities in the city of Monastir. RESULTS: Nine hundred fourteen smokers had participated in our study. More than 2/3 of them (70 %) had at least one quit attempt, which lasted longer than 6 months for 81 patients (9%) and the last attempt dated for over 6 months for 486 smokers (53%). These previous attempts were unaccompanied and non-medicalized in 97 % of cases. 2/3 of smokers (67%) had a very strong desire to quit smoking, and 41% had a very strong self-confidence to succeed in their attempts. According to multivariate analysis, the presence of previous quit attempts to stop was statistically related to the importance of quitting smoking (OR=2.20,95% CI [1.23 - 3.96]). Selfconfidence to successfully stop was statistically related to the duration of smoking (OR=1.03 , 95% CI [1.01 - 1.06] ) , the strong dependence (OR=0.53 ;95% CI [ 0.29 - 0.97 ]) , and having at least one smoking member of the family (OR = 0.36 , 95% CI [0.15 - 0.86]). CONCLUSION: These results show that the strong physical dependence is a major factor related to the failure of attempts to quit, to the loss of self-confidence to succeed new attempts among smokers and thus, maintain a fairly high smoking prevalence in a country like Tunisia.

[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.

[From demand to decision: Not programmed contact for adult family medicine]. / De la demande à la decision: Contact non programmé de l'adulte en medicine de famille.

BACKGROUND: the study of contact patterns, diagnostics assumptions, physical acts performed and procedures in primary care services orient the training of future GPs. AIM: describe the elements of the contact in the Basic Health Centers. METHODS: It is a transverse study, describing the elements of contact without appointment, the population served by 4 primary health centers, in Monastir governorate. Days of the survey were identified from the list of working days by taking two weeks per month and per season by excluding the days of chronic diseases. Contacts analyzed have been identified by a systematic random sampling with a step of sounding on two. RESULTS: in the term of this study, we brought together 910 contacts. The mean age of consultants was 36 years, the sex-ratio H/F 0,38. The respiratory, ostéo-articular, digestive, neurological and general chapter's complaints represented 74% of motives for contacts. The cough and the complaints of throat represented 25% of the reasons for consultation. The lung examination, Oto-rhino laryngeal and cardiovascular represented 80% of physical examinations. The pharyngitis, the infections of the superior respiratory tracts, acute bronchitises, flu and allergic rhinitis represented the half of the assumptions. Antibiotics, anti-inflammatory and the antipyretic/analgesic accounted for 69% of prescriptions. CONCLUSION: this study allowed us to show the lack of preventive measures in the health center base and highlight the training of future family physicians must be based systems the most prevalent in primary care.

[Nicotine dependance and carbon monoxide intoxication among adult smokers]. / La dépendence nicotinique et l'intoxication au monoxide de carbone chez les fumeurs adultes.

BACKGROUND: The high nicotine dependence is one of the contributing factors to failure of attempts to quit. Moreover, the carbon monoxide (CO) intoxication, proportional to the intensity of smoking, is the basis of cardiovascular complications. OBJECTIVES: To describe tobacco consumption and the degree of CO intoxication, as well as to assess nicotine dependence and identify its determinants in a population of adult smokers. METHODS: This is a descriptive cross-sectional study, based on a selfadministered questionnaire and a dosage of CO in expired air among smokers who participated in awareness sessions conducted in public places and academic institutions in the city of Monastir. Multivariate analysis was based on a binary logistic regression. RESULTS: A total of 914 smokers participated in our survey whose mean age was 29.5 ± 12.4 years. More than 2/3 of cases (68.7 %) were strongly addicted to nicotine. Heavy smokers (consumption > 20 cigarettes / day) accounted for 28 % of subjects aged under 30 and 59% of older adults (p < 10-4). Determinants of strong tobacco dependence were age of first cigarette ( OR = 0.912 ) , duration of tobacco consumption (OR = 1.059 ) , alcohol consumption (OR = 1.764 ) , sedentarity (OR = 2.024 ) and the rate expired CO (OR = 1.059 ) . The mean rate of exhaled CO was 13.1 ± 11.1 ppm. It was positively correlated with Fagerström score (r = 0.5, p < 10-4) and the number of cigarettes smoked before dosing CO (r = 0.6, p < 10-4). In the contrary, it was negatively correlated to the time elapsed between the last cigarette and the test (r = - 0.2, p = 0.001). CONCLUSION: The results of this study focused on smoking addiction and its determinants. They encourage us to strengthen efforts for effective implementation of the WHO Framework Convention of Tobacco control in Tunisia.