[Deaths in a Tunisian psychiatric hospital: an eleven-year retrospective study]. / La mortalité à l'hôpital psychiatrique de Tunis : étude rétrospective sur 11ans.

BACKGROUND: Mortality in patients in psychiatric hospitals is reported to be two to three times as high as in the general population. In Tunisia, we do not have any figures on mortality and causes of death in psychiatric inpatients. AIM: The aim of our study was to assess the mortality rate in a psychiatric hospital in comparison to the mortality rate in the general population, to determine the patients' profile, and to identify the causes and risk factors for these deaths. METHODS: We performed a retrospective, descriptive and comparative study. We examined the records of all patients who died during their stay in the different wards of psychiatry at the Razi Hospital in Tunis. We also scrutinized reports of autopsies in the Forensic Medicine unit at Charles-Nicolle Hospital in Tunis over a period of eleven years from January 1st, 2000 to December 31st, 2010. We conducted a descriptive study to calculate the standardized mortality ratio (SMR) aiming to highlight any existing excess mortality among the psychiatric inpatients compared to the general population. This ratio was obtained by dividing the observed number of deaths by the expected number of deaths. In the analytical study, our sample was compared to a control population made-up of randomly selected living patients among those admitted to the Razi hospital in 2010. This study allowed us to investigate the risk factors for premature mortality in psychiatric inpatients. RESULTS: The average rate of mortality was two deaths per 1000 inpatients per year. Twenty-four percent (24%) of deaths involved institutionalized patients. Compared to the general population, premature mortality was noted among patients aged less than 40 (SMR=1.9). The older the patients were, the closer to 1 the SMR was. The average age at death was 51.38 years; 65% of patients were male, 60% had a low socio-economic level, 54% had a comorbid medical condition. Forty-two percent (42%) of deceased patients were diagnosed with schizophrenia with the paranoid form being the most prevalent (44%), 13% had bipolar disorder, 22% had psycho-organic disorders (mental retardation, dementia, delirium). Antipsychotics were the most prescribed psychotropic drugs. High doses were used. Forty percent of cases (40%) consisted of sudden deaths. A cause for death was identified in 80% of cases. In 92% of cases, the death was classified as being "natural". Main causes were respiratory (26%) and cardiovascular (9%). Accidental causes accounted for 8% of deaths. In 20% of cases, the cause remained undetermined. Three factors were identified as independent predictors of mortality among mental patients: age at death (OR=3.9 among patients older than 40), psychiatric diagnosis (OR=2.9 among patients with psychotic or mood disorders compared to other diagnoses) and combination of antipsychotic drugs (OR=6.09 in patients receiving more than two antipsychotics). DISCUSSION: Young psychiatric inpatients seem to be at high risk of premature death: the SMR in our study was 1.9. It ranged between 2.15 and 6.55 in other similar studies. This increased risk mainly concerns non-natural deaths. The leading natural cause of death in our population was represented by thromboembolic accidents. Such a high thromboembolic risk may be explained by the mental illness itself, by physical restraint as well as by antipsychotic treatment. Diagnosing medical conditions in psychiatric patients is often a daunting task: history of the patient is sometimes unreliable and clinical features might be modified by psychotropic agents. Patient-related risk factors for premature death include poor socio-economic level, access-to-care difficulties, positive family and personal history of mental and/or medical disorders, smoking, substance abuse, unhealthy diet and lack of physical activity. Moreover, iatrogenic effects of psychotropic drugs (combination of antipsychotics was more common in deceased patients than in controls) and inadequate medical care in psychiatric hospitals (lack of ECG devices, in particular) partly account for such a high mortality. CONCLUSION: Identifying risk factors for deaths in psychiatric hospitals highlights needed changes in psychiatric management strategies taking into account the patient's characteristics as well as the drugs' safety profile. Further studies with larger samples are needed to better highlight risk factors for premature death in psychiatric inpatients. Identifying such risk factors is necessary to develop efficient preventive strategies.

Investigating the influence of Cu and Ti substitution on the structural, optical, and dielectric properties of BiFeO3.

The environmentally friendly BiFe1-x(Ti1/2Cu1/2)xO3 system with various substitution rates, including x = 0 (BFO), x = 0.02 (BFTCO2) and x = 0.04 (BFTCO4), has been synthesized using the solid-state reaction technique. All compositions exhibited a distorted rhombohedral structure with R3c space, as observed from the results of XRD and Raman spectroscopy. A significant impurity phase (Bi25FeO40) appears in pure and doped BFO, with a percentage ranging between 6 and 9%. This impurity was also detected using Mössbauer spectroscopy. UV-vis spectroscopy revealed a decrease in optical band energy with the substitution, suggesting the potential applications of doped BFO within the visible range of the spectrum, making it suitable for photocatalytic and solar cell applications. The smallest bandgap was observed for BFTCO2 with Eg = 1.93 eV. The origin of this reduction is discussed from a scientific point of view. Furthermore, Cu2+ and Ti4+ co-doped BFO display an improvement in dielectric properties due to the reduction in the value of tan δ. Dielectric measurements revealed an anomaly below TN with diffusive and dispersive behavior, suggesting a relaxor-like behavior for all compositions. The relaxor character was quantified by using the Vogel-Fulcher relationship which yielded activation energy of 0.359-0.614 eV. In our system, the relaxor behavior showed an enhancement with the heterogeneity created by the substitution rate, reaching its maximum for BFTCO4, characterized by the empirical parameters which are: ΔTrelax = 96 K and γ = 1.96. Finally, co-doped BFO ceramics not only present promising materials for optical applications due to the narrow bandgap, but their relaxor behavior can also be tailored for promising applications in high-energy storage devices.

[Antibiotic resistance in nontyphoidal salmonellae serovars in the Czech Republic]. / Antibiotická rezistence u netyfových sérovaru Salmonella spp. v Ceské republice.

STUDY AIM: To determine antibiotic resistance and incidence of multidrug resistance among Nontyphoidal salmonellae serovars isolated from humans. MATERIAL AND METHODS: Consecutive Salmonella isolates from patients, recovered in 48 microbiology laboratories in May 2012, were analyzed in the respective reference laboratories at the National Institute of Public Health. Strains were re-identified and differentiated into serovars. Their minimum inhibitory concentrations (MICs) to 11 antibiotics were determined by the microdilution method. RESULTS: Of 25 serovars identified among 637 strains of Salmonella enterica, the most frequent were Enteritidis (87.0 %), Typhimurium (4.9 %), and monophasic Typhimurium 4,[5],12:i:- (2.0 %) and Mbandaka (0.6 %); other serovars were rare. Altogether 558 strains (87.6 %) were susceptible to all antibiotics tested and the remaining 79 strains were resistant to one or more antibiotics. The prevalence rates of resistance to individual antibiotics among 637 study strains were as follows: ampicillin 8.5%, tetracycline 5.7%, sulfamethoxazole 5.2%, cipro-floxacin 3.8%, and chloramphenicol 2.5%. Resistance to gentamicin, trimethoprim, and third and fourth generation cephalosporins was rare ( 0.5%) and none of the study strains showed resistance to meropenem. Three producers of extended spectrum beta-lactamase were multidrug resistant and two of them recovered from twins exhibited a different pattern of resistance. Resistant strains were most often assigned to the following serovars: Enteritidis (49.4%), Typhimurium (26.6%), and monophasic Typhimurium (15.2%). While only 7% (39 of 554 strains) of Enteritidis strains were resistant, the serovars Typhimurium and its monophasic variant 4,[5],12:i:- showed high rates of resistance, i.e. 66.7 and 92.3%, respectively. Furthermore, resistance was revealed in all strains of the serovars Virchow (n = 3), Kentucky (n = 1), and Newport (n = 1), in two of three strains of the serovar Infantis, and in one of two strains of the serovar Stanley. All five blood isolates were assigned to the serovar Enteritidis and one of them showed resistance to ciprofloxacin. Of 79 resistant strains, 26.6% showed resistance to ampicillin only and 24.1% to ciprofloxacin only, with multidrug resistance, i.e. resistance to three or more antibiotics, confirmed in 43.0% of strains. CONCLUSION: Despite a relatively low prevalence of resistance to the antibiotics tested among 637 study strains, the following alarming findings were made: Detection of Salmonella enterica strains resistant to ciprofloxacin as the drug of choice or to higher generation cephalosporins and multidrug resistance revealed in two thirds of the strains of the serovar Typhimurium and in all but one strains of its monophasic variant 4,[5],12:i:-.

Effect of pterygium surgery on corneal topography.

PURPOSE: To evaluate the effect of successful pterygium surgery on corneal topography. METHODS: Computerized corneal topography was performed on 20 eyes with pterygium before and 3 months after successful excision and limbo-conjunctival autograft surgery. Corneal shape, corneal spherical power, simulated keratometric astigmatism, surface regularity index (SRI), and surface asymmetry index (SAI) were assessed before and after surgery. Pre- and postoperative uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), and manifest refraction spherical equivalent (MRSE) were also evaluated. RESULTS: Changes in corneal shape were mainly a decrease in midline corneal flattening. Corneal spherical power was 41.65+/-3.29 diopters (D) (mean +/- SD) preoperatively and 44.58+/-1.55 D postoperatively (p=0.04). Simulated keratometric astigmatism was 5.47+/-3.45 D preoperatively and 1.79+/-1.52 D postoperatively (p=0.0005). SRI was 1.39+/-0.93 preoperatively and 1.10+/-0.57 postoperatively (p=0.03). SAI was 1.17+/-1.09 preoperatively and 0.75+/-0.73 postoperatively (p=0.02). UCVA was 0.31+/-0.33 preoperatively and 0.52+/-0.32 postoperatively (p=0.04). BSCVA was 0.73+/-0.20 preoperatively and 0.89+/-0.16 postoperatively (p=0.008). MRSE was -0.54+/-3.29 D preoperatively and -1.30+/-3.05 D postoperatively (p=0.45). CONCLUSIONS: Corneal topographic changes caused by the pterygium are almost reversible after surgical treatment. Successful pterygium surgery significantly reduces topographic astigmatism, SRI, SAI, and corneal flattening. However, precise prediction of these refractive changes is not always accurate.

Frequency, characteristics, and risk factors of late recurrence of retinal detachment.

PURPOSE: To evaluate the frequency, characteristics, causes, and risk factors of late recurrent retinal detachments (LRRD). METHODS: The authors retrospectively analyzed 445 eyes operated consecutively for rhegmatogenous retinal detachment between 1990 and 2003 by the same surgeon. Only eyes with complete reattachment after a minimum follow-up of 6 months were included. The authors defined LRRD as detachment occurring at least 6 months after a complete retinal reattachment. RESULTS: Nine eyes had a LRRD (2.02%). Mean age was 52.55 years. Six eyes had scleral buckle procedure and three eyes had vitrectomy silicone oil injection then silicone oil removal. LRRD occurred after an average period of 54 months. During follow-up two patients had a removal of extrusion of scleral buckling material. New or reopened breaks were associated with LRRD in all eyes. Endo-ocular surgery was carried out in seven eyes. The retinal reattachment was achieved in the seven eyes. Final visual acuity ranged from 20/400 to 20/60 after an average follow-up of 37.8 months. Relation between aphakic eyes (and more generally nonphakic eyes) and LRRD was close to significant value (p=0.05). LRRD was statistically independent (p>0.05) of myopia, preoperative pseudophakia, vitrectomy for initial detachment, scleral buckle removal, and cataract surgery after reattachment. CONCLUSIONS: LRRD were rare. Most of them were due to a retinal break. This break can be a new break, or reopened break especially after removal of scleral buckle material. Vitreous traction, at the vitreous base, seemed to be the cause of these breaks.

[Retinal detachment associated with giant retinal tear: surgical procedures and results of the perfluorocarbon liquid-silicone oil exchange with scleral buckling]. / Traitement des décollements de la rétine par déchirure géante: résultats de l'échange perfluorocarbones liquides-silicone avec indentation circulaire.

INTRODUCTION: Anatomical and functional results of the treatment of retinal detachment associated with giant retinal tear have been markedly improved with the development of the vitrectomy procedure and especially the use of perfluorocarbon liquids. In this study, we report treatment results of retinal detachment associated with giant tear in 17 patients. MATERIALS AND METHODS: Our study included 17 patients (17 eyes), aged between 18 and 61 years, with retinal detachment associated with giant retinal tear. The size of the tear was between 90 degrees and 220 degrees . Proliferative vitreoretinopathy grade C was present in two eyes. Preoperative visual acuity ranged between 40/50 and light perception. All patients underwent scleral buckling, vitrectomy, perfluorocarbon liquid injection to flatten the retina, endophotocoagulation, cryoapplication and temporary silicone oil tamponade. RESULTS: Mean follow-up was 20 months +/- 16. Recurrent retinal detachment occurred in five eyes under silicone oil and in two eyes after its removal. Anatomical success at final follow-up was obtained in 14 eyes (82.3%). Visual acuity improved in all cases with anatomical success in all but one. The most frequent postoperative complications were cataract in 10 cases among 12 phakic eyes and ocular hypertension in four cases. CONCLUSION: Vitrectomy with internal silicone oil tamponade improves the anatomical and functional prognosis of retinal detachment associated with giant retinal tear. Recurrent retinal detachment is usually due to relapsing proliferative vitreoretinopathy. The most frequent postoperative complications remain lens opacification and ocular hypertension.

[Central serous chorioretinopathy in a kidney transplant patient]. / Choriorétinite séreuse centrale chez un patient greffé du rein: à propos d'un cas.

We report a case of central serous chorioretinopathy in a patient who received a kidney transplant for chronic renal failure. We describe clinical and angiographic particularities and the progression of central serous chorioretinopathy in this case. Many factors can be involved in the occurrence of central serous chorioretinopathy in patients with kidney transplants, especially the hemodynamic problems related to renal failure and to the arterial hypertension that are often associated, the stress due to transplantation surgery, and the long-term corticotherapy prescribed postoperatively.

Immunohistochemical study of p53, p21 and PCNA in pterygium.

Since mutated p53 is one of the most frequent gene abnormalities in human cancer, we hypothesized that mutation of p53 may play an important role in growth and recurrence of pterygia, a dysplasia of the conjunctiva. Therefore, we compared pterygia of Japanese and Tunisian patients using antibodies against p53, p21 and proliferating cell nuclear antigen (PCNA). In Nagasaki, 21 pterygia of Japanese individuals were removed and in Gabes, 19 primary pterygia of Tunisian individuals. Positive staining of wild type p53 was not found in the Japanese pterygia, whereas 38.1% were positive for mutant p53, none were positive for p21 and 76.2% were positive for PCNA. The incidence of mutant p53-positive staining was 50.0% in males and 22.2% in females, which was statistically significant. In the 19 Tunisian patients, positive staining of wild type p53 was not found, whereas 36.8% were positive for mutant p53, 0% for p21 and 63.1% for PCNA. Differences between Japanese patients and Tunisian patients were not significant. There were 2 types of pterygium. One type did not show mutant p53 and the other showed mutant p53 caused by ultraviolet light. However, damage caused by p53-dependent programmed cell death of pterygium cells may lead to mutations in other genes which may allow the progressive multistep development of limbal tumors. It is possible that mutant p53-positive pterygia can develop into limbal tumors.

[Metastatic neoplasia in the optic nerve]. / Neuropathie optique métastatique.

INTRODUCTION: Ocular metastasis always involves the uveal tractus, especially the choroid. Papillary metastases have been exceptionally described, and represent only 5 percent of the ocular metastatic locations. We report in this observation a case of papillary metastasis in a patient treated for a metastatic adenocarcinoma. OBSERVATION: A 35-year-old woman was given chemotherapy for four months for metastatic adenocarcinoma involving the pleura and bones. She consulted for significant decline of visual acuity in the left eye associated with headache and vomiting. The fundus examination revealed a yellowish papillary lesion with edema associated with an inferior peripapillary serous retinal detachment. The fluorescein retinal angiography showed a choroidal lesion highly suggestive of choroidal metastasis. Cerebro-orbital CT scan revealed the presence of multiple cerebral metastases. The patient died four months after diagnosis of ocular metastasis and eleven months after diagnosis of adenocarcinoma. CONCLUSION: Presence of a papillary lesion suggests the possible diagnosis of papillary metastasis despite the lack of a history of neoplasia. Carcinomatosis tumors, especially breast and the lung carcinomas are the most frequent causes of papillary metastasis.

[Therapeutic results of 5-fluorouracil in multiple and unresectable facial carcinoma secondary to xeroderma pigmentosum]. / Résultats thérapeutiques du 5-fluorouracile dans les carcinomes multiples ou non resécables de la face secondaires au xeroderma pigmentosum (XP).

A prospective study was done to test the efficacy of 5-fluorouracil (topical and systemic) in multiple and unresectable histologically proven facial squamous cell carcinomas (SCC) secondary to XP. Twelve patients (7M/5F, mean age 19.8 years) with multiple facial SCC were treated between 1994 and 1997. 5-FU was used as a twice-a-day local application in the documented areas, by continuous infusion associated with cisplatin (2 patients) and short infusion combined with folic acid (3 patients). Evaluation was done by clinical examination every two months for topical therapy and after every cycle for systemic treatment. Median treatment duration was 12 months (2 to 36 months). Treatment was well tolerated excluding episodes of pruritus in the treated areas. We observed mainly superficial tumour regression followed by dryness and crusting. In 5 cases, we performed biopsies after treatment showing in one case an extensive fibrosis with absence of tumour. However in the remaining 4 cases, despite a superficial reduction of tumour and a reconstitution of the epidermis, viable and unmodified squamous cell carcinoma remained in the deeper dermis. In the 5 patients treated by systemic 5-FU, we observed 1 complete response and 3 partial responses. Despite a dissociation between a good cosmetic result and a relatively superficial effect, topical 5-FU represents a useful therapeutic option in multiple unresectable facial SCC in patients with XP. Systemic chemotherapy is recommended in the event of more extended or profound lesions.

[Behçet's disease disclosed by ocular conjunctival aphthous ulcer. Apropos of a case]. / Maladie de Behçet révélée par une aphtose conjonctivale oculaire. A propos d'un cas.

Aphthosis in Behçet's disease is usually located in the oro-genital areas, but other locations have been described. The authors report the case of a 45 year old woman who presented with an ocular conjunctival aphthous ulcer. This was the initial presentation of Behçet's disease. This case report illustrates that aphthosis in Behçet's disease can have unusual sites such as the ocular conjunctiva. Furthermore, in this case, the conjunctival aphthosis was presenting sign of this systemic disease.

[Goldenhar syndrome. Surgical emergency apropos of a case]. / Syndrome de Goldenhar. Urgence chirurgicale à propos d'un cas.

We report a case of Goldenhar syndrome in a six week old infant. This patient had bilateral peribulbar choristoma, bilateral pre-auricular appendix and left superior palpebral coloboma with severe exposure keratitis. This condition necessitated an emergency surgical eyelid repair. The authors discuss the different clinical manifestations of this syndrome and therapeutic modalities, particularly the surgical treatment of choristoma and palpebral coloboma.

[Acute lymphoblastic leukemia and vitreous infiltration. A case study]. / Leucémie aiguë lymphoblastique et atteinte vitréenne. A propos d'un cas.

The infiltration of the vitreous by acute lymphoblastic leukemia is rare. We report the case of a 5-year-old child with acute type-2 lymphoblastic leukemia who had a bilateral dense cellular infiltration resulting in significant vision loss in both eyes with the child counting her fingers at a distance of 20cm. Because the vitreous was not cleared by chemotherapy, we performed a bilateral vitrectomy. Vision improved to 6/10 in both eyes and was stable at the 3-year follow-up.

[Prevalence of chronic open-angle glaucoma in a county in Tunis]. / Prévalence du glaucome chronique à angle ouvert dans une commune de Tunis.

PURPOSE: The purpose of this study was to determine the prevalence of open angle glaucoma in a population aged 40 years and more living in a county in Tunis (Bardo). METHODS: All subjects were examined according to the same protocol, which included applanation tonometry, examination of the anterior chambre and the optic disc. Goldmann and/or oculokinetic perimetry were performed in subjects with high intraocular pressure (22 mmHg or more) cup to disc ratio of 0.4 or more, optic disc palor, nasal deviation of vessels, presence of hemorhhage of the optic disc. Open angle glaucoma was defined by the presence of any two or all three of the following: high intraocular pressure, glaucomatous visual field defects, and the optic disc changes described above. In cases of denses media opacities the open angle glaucoma was defined when the intraocular pressure was more than 30 mmHg. RESULTS: The prevalence of open angle glaucoma in the 856 subjects was 2.68%. The prevalence increased with age: 0.54% in people 40 to 50 years, 1.71% in people 51 to 65 years and 50.63% in people 65 years or older. Glaucoma was unknown in 91% of the glaucomatous patients screened, and 30.4% had advanced glaucoma. CONCLUSION: The prevalence of open angle glaucoma in our study is slightly higher or similar to that in other white populations but lower than that reported in black populations.

[Retinal flecks in Alport's syndrome]. / Ponctuations rétiniennes et syndrome d'Alport.

UNLABELLED: Alport's syndrome is a familial disorder characterized by progressive renal failure, sensorineural hearing loss and ocular manifestations. CASE REPORT: The authors report a case of a 13-year-old child with Alport's syndrome associated with retinal flecks. CONCLUSION: Retinal flecks are the most frequent ocular manifestation in Alport's syndrome and are a considerable help to diagnosis. They are often associated with severe renal failure.

[Macular edema and chronic renal insufficiency]. / Oedème maculaire et insuffisance rénale chronique.

The authors report two cases of macular oedema in two patients suffering from chronic renal failure. One of the patients, a women aged 36, with a renal transplant, presented with intra-retinal macular oedema, caused by a marked impairment of renal function. In the second case, the macular oedema, associated with papilloedema occurred in a patient aged 56, the day after renal dialysis and spontaneously regressed. The mechanism of macular oedema, seems to be related to modifications of the osmotic pressure and is probably associated with renal dialysis as shown in the second case.

[Ocular signs of primary hyperoxaluria type I]. / Signes oculaires de l'hyperoxalurie primitive de type I.

PURPOSE: To report the results of ophthalmological examination of 14 patients with primary oxalosis of type I, and to appreciate the diagnostic value of these signs. MATERIAL AND METHODS: Fourteen patients, 7 girls and 7 boys with an average age of 8-35 years (3 months - 15 years). Ten patients had renal failure, 2 died without dialysis and eight were treated with dialysis; 5 out of 8 had hemodialysis and the duration of this treatment varied between 3 months and 3.5 years, 3 out of 8 had peritoneal dialysis. RESULTS: Visual acuity was 10/10 in 11 cases and we noted a vision of 5/10 in one eye in one case. Ocular fundus examination was normal in 7 cases. In 5 cases, it showed numerous minute white round flecks at the posterior pole and near the retinal vessels which probably correspond to deposition of calcium oxalate crystals. In one case we found a diffuse retinal pigment atrophy and in another case a sectorial papillar atrophy without loss of vision. CONCLUSION: This flecked retinopathy can occur before hemodialysis or after a few months or years of hemodialysis. There is no correlation between duration of dialysis and ocular lesions.

[Gelatinous dystrophy of the cornea. Apropos of 5 cases]. / Dystrophie gélatineuse de la cornée. A propos de 5 observations.

Gelatinous drop-like corneal dystrophy is a rare disease, described for the first time by Nakaizumi (Japan) in 1914. We report 5 cases of this primary corneal amyloidosis. Three of our patients are brothers, the two other cases are isolated cases. Photophobia and progressive loss of vision are the first presenting signs. Corneal lesions are typically bilateral white nodular deposits beneath the epithelium. Patients underwent repeated keratoplasties with a mean interval of 5 years because of the recurrence of the disease on the corneal graft. Diagnosis of corneal amyloidosis was confirmed in all cases by histology. We compared our results with the data reported in the literature.

[Treatment of late leaking of filtering bullae]. / Le traitement des fuites tardives des bulles de filtration.

Leaking filtering blebs must be repaired immediately to avoid major complications such as hypotony and endophtalmitis. We report four cases of leaking filtering blebs occurring between one to six years after trabeculectomy. Revealing signs were hypotony in two cases and athalamia in two cases. Patching was done in one case and conjunctival reinforcement by rotation of conjunctival flap in 2 cases and free conjunctival graft in one case. Leaking disappeared in all the cases. Normal intraocular pressure (10-12 mmHg) was obtained in all cases except one which was achieved by rotation of conjunctival flap and complicated by retraction of conjunctiva. Conjunctival reinforcement without exicion of the bleb is an easy technique and respect the filtration site. Major complication in our patients is retraction of conjunctival flap which can be avoided by: exicion of Tenon, good fixation to the cornea, and free conjunctival graft.