The practice of the mental image tool for the training of hand hygiene with Hydro-alcoholics solutions: randomized trial.

INTRODUCTION: Mental image (or mental practice), a psychological representation of a task to be carried out, is a technique that could enhance skills in several areas areas including medicine. OBJECTIVE: To evaluate the practice of the mental image tool for the training of hand hygiene with Hydro-alcoholics solutions among students of DCEM2. METHODS: Randomized trial including DCEM2 students in Neonatology and Pediatrics at Charles Nicolle Hospital during the same period. Group1: group training in the mental image, Group 2 of reference. The assessment of student achievement was evaluated in terms of obtained scores. RESULTS: The total number of students was 37. The overall score in group 1 was 17.17 ± 3.82 versus 11.58 ± 4.05 in group 2, p <10 -3. The friction duration of hands in group 1 was 30.56 S ± 4.52S versus 24 ± 5.17 in group 2, p <10-3. CONCLUSION: Mental practice may be a time- and cost-effective strategy that improves hand hygiene with Hydro-alcoholics solutions.

Extremely preterm infants in Tunisia: Where are we now?

BACKGROUND: Extremely preterm infants are newborns born before 28 weeks of gestation. Survival of these immature newborns depends on resuscitation and the quality of care during hospitalization. OBJECTIVE: To determine survival and neurologic outcomes at2 years after extremely preterm birth. METHODS: It is a retrospective multicentric study in 5 neonatal intensive care units (NICU) in 2012-2013.All live births less than 28 weeks gestation were included. RESULTS: A total of 109 births were recorded. Prenatal corticosteroids were given in 47% of cases. Mean weight was 989g and mean age was 26 weeks gestation. Ninety percent of patients had respiratory distress syndrome and 67% of them needed respiratory support. Surfactant was given to 29% of newborns. The mortality rate atdischarge was 76%.The first cause of mortality was nosocomial infections. At thecorrected age of 2 years, 27% of survivors had abnormal neurologic outcome. CONCLUSION: In our study, survival and neurologic outcomes ofextremely preterm infants were poor.In this high-risk population, improving perinatal care remains a challenge to improve long-term outcome in Tunisia.

In-hospital mortality of very preterm infants in a Tunisian neonatal intensive care unit: Prevalence and risk factors.

BACKGROUND: Prematurity is a major public health problem and it's associated with a high mortality and morbidity. In Tunisia, few investigations studied this area. AIM: To determine the rate and the risk factors of in-hospital mortality of very preterm infants. METHODS: We conducted a retrospective monocentric study. We included all premature Infants born at less than 326 weeks of gestation (< 33 Weeks) without major congenital anomalies admitted from January 2011 to December 2012 in the neonatal intensive care unit (NICU) of Charles Nicolle Hospital (Tunis-Tunisia). To determine in-hospital mortality related risk factors, we created and compared two groups:  group of "Survivors" until discharge from our hospital and group of "Dead" before discharge. Multivariable logistic regression models were used to assess the association between risk factors and in-hospital mortality. P-value < 0.05 was considered statistically significant. RESULTS: During the study period, 7606 livebirths (LB) were recorded; among them 113 were very premature infants. The prevalence of high prematurity was 1,4 % LB. Very premature infants were divided in 24 extremely preterm infant (13%) and 89 moderately preterm infants (87%). Mean weight at admission was 1338g (±349g) and the mean gestational age was 30 weeks (±1,7). The mean hospital stay was 26 days (±17days) with an average weight at discharge of 1942g (±249). Neonatal morbidity was mainly caused by respiratory distress (42%), early neonatal anemia (64%), intraventricular hemorrhagea (15%), associated-care health infection (37,6%). In hospital mortality rate was 32 %. Mortality risk factors identified through multivariate analysis were: extreme premature infant (p<0,05), extremely low birth weight (p<0,01) and circulatory disorders (p<0,05). CONCLUSION: Very preterm infant represented 1,4 % of all live births. The mortality rate of very premature infant is still high and mainly associated to neonatal respiratory distress. Improving prevention and neonatal management still very required.

Craniosynostosis, Scheuermann's disease, and intellectual disability resembling Shprintzen-Goldberg syndrome: a report on a family over 4 generations: Case report.

RATIONALE: Craniosynostosis is a disorder characterized by premature fusion of cranial sutures with subsequent development of abnormal craniofacial contour associated with variable skeletal and extra-skeletal abnormalities. In this family syndromic type of craniosynostosis was recognized and the etiology behind diverse forms of deformities have been diagnosed. PATIENT CONCERNS: The negative impact of the disorder on the child and his family is enormous. Particularly when the diagnosis is late and little can be done. Though counselling the family through discussing the whole picture of the disorder might lessens their concern. DIAGNOSES: Diagnosis is the corner stone of management. In this paper we aimed to sensitize pediatricians, physicians, and orthopedic surgeons concerning the necessity to recognize syndromic associations early on. INTERVENTIONS: Patients with syndromic craniosynostosis are usually associated with a complexity of malformation complex. Craniofacial surgery can be of remarkable help if the diagnosis is made early. It requires a series of corrections to avoid intellectual disability and other neurological deficits.The timing of interventions is strongly correlated on the timing of diagnosis. OUTCOMES: The earliest the diagnoses, the much better the outcomes are. And consequently avert the psychological and the financial cost on the patient and his family. LESSONS: The golden principle of medicine should prevail in all medical disciplines, which states: The more you see, the more you know and conversely the more you know is the more you see.

Fetal Cyst Reveling Retroperitoneal Enteric Duplication.

Retroperitoneum is a very uncommon site of enteric duplication (ED). We report a new case of retroperitoneal ED cyst suspected in utero. Prenatal ultrasound showed an abdominal cystic mass. Noncommunicating retroperitoneal ED cyst measuring 70 mm × 30 mm was resected. Histopathologic examination confirmed the diagnosis.

The script concordance test as a tool to evaluate clinical reasoning in neonatology.

BACKGROUND: Script concordance test aims to evaluate knowledge organization, which represents an essential component of the clinical competence. OBJECTIVE: To build a script concordance test and demonstrate its relevance in the evaluation of Neonatology skills. METHODS: A script concordance test including 20 vignettes and 20 items, was provided to 52 fourth year medical students and 11 family medicine interns. RESULTS: Script concordance test scores obtained by experts were higher then those obtained by students and family medicine interns. The scores (out of 100) were 82.52 ± 7.35 CI95% [77.26-87.78] for the experts, 58.52 ± 9.72 CI95% [55.82-61.23] for the students, and 63.17±11.36 IC95%  [55.53-70.81] (p<0.0001) for the interns. CONCLUSION: Our data suggest that script concordance tests could be used to assess the acquisition of clinical reasoning among fourth year medical students in neonatolgy.

Prevalence and outcomes of thrombocytopenia in a neonatal intensive care unit.

Background Thrombocytopenia is a common clinical problem in neonatal intensive care units, affecting about 20 to 35% of all admitted neonates. Even most episodes are mild or moderate, severe episodes could be life-threatening or responsible for sequelae. Objectives The aims of this study were to describe the prevalence, clinical diagnoses, and to determine risk factors for poor prognosis of thrombocytopenia in a neonatal intensive care unit. Methods We carried out a retrospective study in the neonatal intensive care unit of Charles Nicolle Hospital of Tunis, a tertiary neonatal care center, over a four years period (January 2010 to December 2013). All Neonates with at least one episode of confirmed thrombocytopenia were included. Poor prognosis was defined as death or intraventricular hemorrhage ≥ grade 2 in survivors. Results Of 808 admitted neonates, one hundred (12.4%) had presented at least one episode of confirmed thrombocytopenia, and 12 had presented two episodes of thrombocytopenia. A total of 112 episodes of thrombocytopenia were collected. Thrombocytopenia occurred in the first 3 days of life in 74.1% of cases. Thrombocytopenia was mild in 22.3%, moderate in 36.7% and severe in 41%. Intrauterine growth restriction was the most common cause of early thrombocytopenia. Nosocomial sepsis was the most common cause of late thrombocytopenia. We found that the outcomes of thrombocytopenic neonates depend on, birth weight, gestational age, platelet count, and the underlying cause. Conclusions Thrombocytopenia in neonates can be life-threatening, appropriate diagnosis, preventive and therapeutic approach is necessary to prevent death or neurological impairment.

Prevalence of vitamin D deficiency in mothers and their newborns in a Tunisian population.

OBJECTIVE: To assess vitamin D status in mothers and their newborns and identify predictive factors of vitamin D deficiency. METHODS: A cross-sectional study was undertaken of healthy women and their full-term newborns delivered at the Charles Nicolle Hospital, Tunis, Tunisia, between October and November 2012. Maternal and neonatal serum 25-hydroxy vitamin D (25(OH)D) concentrations were measured. Correlations were tested. RESULTS: Overall, 87 mothers and their newborns were enrolled. No mother or neonate had an adequate vitamin D status. Mean maternal and neonatal serum 25(OH)D concentrations were 6.82±5.14ng/mL (range 3.60-23.77) and 5.92±4.15ng/mL (range 3.60-22.28), respectively. Vitamin D deficiency (serum 25(OH)D<20ng/mL) was found in 84 (97%) mothers and 85 (98%) neonates, of whom 76 (87%) and 78 (90%), respectively, had severe deficiency (serum 25(OH)D<12ng/mL). Maternal serum 25(OH)D showed a strong positive correlation with neonatal serum 25(OH)D (r=0.69, P<0.001). Maternal dietary vitamin D intake was the only factor shown to be associated with serum 25(OH)D concentrations (P<0.05). CONCLUSION: Vitamin D deficiency is prevalent among Tunisian mothers and their neonates.

Errors in preparation and administration of parenteral drugs in neonatology: evaluation and corrective actions.

BACKGROUND: The medication iatrogenic risk is quite unevaluated in neonatology Objective: Assessment of errors that occurred during the preparation and administration of injectable medicines in a neonatal unit in order to implement corrective actions to reduce the occurrence of these errors. METHODS: A prospective, observational study was performed in a neonatal unit over a period of one month. The practice of preparing and administering injectable medications were identified through a standardized data collection form. These practices were compared with summaries of the characteristics of each product (RCP) and the bibliography. RESULTS: One hundred preparations were observed of 13 different drugs. 85 errors during preparations and administration steps were detected. These errors were divided into preparation errors in 59% of cases such as changing the dilution protocol (32%), the use of bad solvent (11%) and administration errors in 41% of cases as errors timing of administration (18%) or omission of administration (9%). CONCLUSION: This study showed a high rate of errors during stages of preparation and administration of injectable drugs. In order to optimize the care of newborns and reduce the risk of medication errors, corrective actions have been implemented through the establishment of a quality assurance system which consisted of the development of injectable drugs preparation procedures, the introduction of a labeling system and staff training.

Acute neonatal appendicitis in a preterm.

Acute neonatal appendicitis is very rare in the neonatal period. It is usually associated with comorbidity including prematurity. Symptoms are non-specific. The prognosis is marked by high risk of mortality and morbidity. Here, we report a case of preterm new born who presented with sepsis, apnoea, and digestive signs. The laparotomy revealed perforated appendicitis complicated with peritonitis.

Perinatal-lethal Gaucher disease presenting as hydrops fetalis.

Perinatal-lethal Gaucher disease is very rare and is considered a variant of type 2 Gaucher disease that occurs in the neonatal period. The most distinct features of perinatal-lethal Gaucher disease are non-immune hydrops fetalis. Less common signs of the disease are hepatosplenomegaly, ichthyosis and arthrogryposis. We report a case of Gaucher's disease (type 2) diagnosed in a newborn who presented with Hydrops Fetalis.

Perinatal lethal type II osteogenesis imperfecta: a case report.

We report a new case of osteogenesis imperfecta (OI) type II which is a perinatal lethal form. First trimester ultrasound didn't identified abnormalities. Second trimester ultrasound showed incurved limbs, narrow chest, with hypomineralization and multiple fractures of ribs and long bones. Parents refused pregnancy termination; they felt that the diagnosis was late. At birth, the newborn presented immediate respiratory distress. Postnatal examination and bone radiography confirmed the diagnosis of OI type IIA. Death occurred on day 25 of life related to respiratory failure.

Isolated anti-Ro/SSA thrombocytopenia: a rare feature of neonatal lupus.

We report a rare case of isolated thrombocytopenia related to anti-Ro/SSA antibodies. The mother was followed for unlabeled familial thrombocytopenia. The mother had positive anti-Ro/SSA antibodies. She was asymptomatic without skin lesions or other criteria neither of systemic lupus erythematosus nor other connective tissue disease. Pregnancy was uneventful. The postnatal examination was normal. On the first day of life, blood cells count showed thrombocytopenia at 40 x 10(9)/L. Within the second day of life, platelet level dropped to 20 x 10(9)/L. The management of thrombocytopenia included platelet transfusion and human immunoglobulin infusion. On the fifth day of life, there has been a drop in platelet count to 10 x 10(9)/L requiring renewed platelet transfusion and human immunoglobulin infusion. On the 10(th) of life platelets rate was stable around 60 x 10(9)/L. The infant had no evidence of cardiac, dermatologic or hepatobilary involvement initially or throughout follow up.

[Epidemiology of domestic accidents of young children in Tunisia: impact of the training of health professionals on data collection quality]. / Epidémiologie des accidents domestiques du jeune enfant à Tunis : Impact de la formation des professionnels de santé sur la qualité de la collecte d'informations.

BACKGROUND: In Tunisia, several studies on domestic injuries have been carried out on children attending care facilities. Nevertheless,there is a lack of data on incidence and kinds of child domestic injuries amongst general population because of absence of a reliable data collect system. AIM: To estimate the incidence and kinds of domestic injuries through a prospective survey "here-there" within two cohorts of young children attending two mother and child protection centers (MCPC) in Tunis during the three first years of their life and to analyze the importance of health professional training in improving data collect. METHODS: A prospective study "here-there" was carried out on two cohorts of children in two mother and child protection centers (MCPC) between January 2007 and December 2009. Only children aged less than 3 months at their first contact with the centers were included and followed up until age of 3 years. In the MCPC2 (cohort2), health personnel have been trained on data collection importance related to child domestic accident and asked to monitor accidents by calling parents while a phone line got available for this aim. In the MCPC1, health personnel was asked to work as they used to do and to collect data on child domestic injuries when children attend the center. RESULTS: 192/435 domestic accidents were recorded within cohort 2 vs only 1/686 within cohort 1. Annual incidence rate was 14.7% for the cohort 2. The kinds of accidents were: falls 78.2% (falls from high plans 84.6%), injuries15.1% (injury by cutting things 58.6%),burns 5.7% (burns by hot liquid 54.5%), intoxications 1%. In terms of damages, we recorded 4 cases of broken bones (thighbone, elbow,handwrist), stitches in 11 cases, broken teeth in 3 cases and nail pulled out in one case. No death was recorded. Training impact on accident prevention was not studied. CONCLUSION: Child domestic accidents are relatively frequent. Health personnel training allows to improve data. The kinds of recorded accidents indicate the need to educate parents on best practices towards strengthening prevention.

[Outcome at 2 years of very premature infants. A Tunisian series]. / Devenir neurologique à l'âge de 2 ans des grands prématurés. Série Tunisienne.

BACKGROUND: Neurodevelopmental outcome of very premature infant can be associated with a high rate of cerebral palsy. AIM: To assess the impact of very preterm birth on neurological outcome at the age of two years. METHODS: Retrospective study of all cases of very premature infants born at less than 33 weeks of gestational age, during the years 2005 to 2007. Neurodevelopmental outcome is reported. RESULTS: During the study period, the very premature infant rate was 1.5 %. A complete information about neurological outcome at the age of two years, was obtained in 60 cases.Eight infants (13.4%) showed major handicap (cerebral palsy) and four others infants developed neurosensoriel difficulties. CONCLUSION: The incidence of neurosensoriel handicap in our population seems relatively high. A strong effort must be made for identification of risk factors of neurodevelopmental disability.

[Evaluation of materno-foetal infectious risk after isolated premature rupture of membranes in at term new-born]. / Évaluation du risque d'infection materno-foetale après rupture prématurée des membranes isolée chez le nouveau-né à terme.

BACKGROUND: Premature rupture of membranes (PROM) is defined as rupture of membranes occurring before the onset of labor. It complicates 5 to 10 % of pregnancies. It continues to be a major cause of morbidity and mortality in the newborn. AIM: To evaluate infectious risk associated with PROM in at term and asymptomatic new-born and to study this risk according to the duration of rupture. METHODS: Retrospective study in neonatal unit of Charles Nicolle hospital of Tunis including all cases with isolated PROM in at term new-born during the year 2007. RESULTS: 299 cases were identified over 3749 live births that is an incidence of 8 %, divided to: 21 cases (7 %) between 6 and 12 hours, 86 cases (28.8 %) between 12 and 18 hours, 61 cases (20.4 %) between 18 and 24 hours and 131 cases (43.8 %) more than 24 hours. Diagnosis of colonization was reported in 54 % of cases when PROM occurred between 12 and 18 hours versus respectively 27.3%, 0 % and 18 % in respectively subset of 6 to 12 hours, 18 to 24 hours and more than 24 hours (p=0,03). 62 % of foeto-maternel infections were reported in subset of PROM more than 24 hours and 13.8 % in the subset between 18 and 24 hours. CONCLUSION: Our study emphasizes the important risk of foetomaternel infection associated with isolated PROM. This risk is major when the rupture exceed 12 hours but the limit of 18 hours can unrecognized some cases of probable foeto-maternel infection.

Congenital cystic adenomatoid malformation of the lung: two case reports.

BACKGROUND: Congenital cystic adenomatoid malformation (CCAM) is a rare embryonic developmental abnormality with an incidence of one in 25 000 to 35 000 pregnancies. With advances in antenatal ultrasonographia (USG), CCAM has been increasingly diagnosed. After birth, the clinical appearance of CCAM can vary from immediately postnatal respiratory distress, to an incidental finding on chest radiography. AIM: To report two additional cases with CCAM different in clinical features. CASE REPORTS: The first case was a boy in witch diagnosis was suspected by antenatal USG; he was born at 37 weeks of gestation by cesarean section because of severe toxemia, and presented immediately respiratory distress. The chest x ray and computed tomography scan (CT scan) revealed a right CCAM. The second case was also a boy of an inducted threefold pregnancy, born at 30 weeks by cesarean section. He presented immediately respiratory distress. The diagnosis of a right CCAM was confirmed by clinical and radiological findings in postnatal period. CONCLUSION: The two cases described in this report show the disparity in clinical features of CCAM. Nowadays, antenatal echotomography can establish the diagnosis allowing optimum management.

Pallister-Killian syndrome with additional manifestations of cleft palate and sacral appendage.

AIM: Reppor of a rare congenital abnormalities. OBSERVATION: We report a rare case of Pallister-Killian syndrome in a 33 weeks gestation infant. In addition to the characteristic phenotype, this patient had a cleft palate, diaphragmatic hernia and sacral appendage. These additional manifestations are not among the Pallister-Killian syndrome's features. The diagnosis was made in antenatal period by cytogenetic studies and showed mosaic 47, XY+i (12p). Presence of diaphragmatic hernia makes this syndrome, prenatally letal, similar to the Fryns syndrome and then requires skin biopsy and fibroblast chromosome examination for cytogenetic diagnosis.