The effects of fasting on heart rate variability in hypertensive patients.

Heart rate variability (HRV) is an independent indicator of increased mortality in patients with myocardial infarction and congestive heart failure. The effects of fasting on the HRV are not known in hypertensive patients. Therefore, studying the effects of Ramadan fasting on hypertensive patients' HRV seems reasonable to address. We conducted a prospective study including 20 hypertensive patients with sinus rhythm. HRV was determined twice by ambulatory 24-hour Holter recordings at fasting during and after Ramadan. Subjects mean age was 55 ± 11.8 years. Sex-ratio was 1.5. When two groups compared, statistically significant differences were found in terms of SDNN (113 ± 71 vs 140 ± 38, p = 0.001), SDANN (109.7 ± 45 vs 134.8 ± 48.3, p = 0.008), T power (2368.7 ± 121.3 vs 3660.5 ± 170.9, p = 0.03) and LF (552.2 ± 31.3 vs 903.7 ± 48.9, p < 0.0001) values. HRV parameters were found to be decreased in Ramadan. Thus, Ramadan fasting enhances the activity of the sympathetic system in hypertensive patients.

Evaluation of patients' knowledge on their vitamin K antagonist treatment.

INTRODUCTION: Vitamin K antagonists (VKA) are currently the most prescribed oral anticoagulant treatment in Tunisia. Despite the standardization of biological monitoring and the better definition of therapeutic objectives, their side effects are a frequent reason for hospitalization. AIM: To evaluate patients' knowledge about their VKA treatment. METHODS: We realized a cross-sectional descriptive study in the Cardiology Department of HabibThameur Hospital from September to October 2016. A questionnaire consisting of 14 items was used in a semi-directed interview in order to assess patients' knowledge on their VKA treatment. RESULTS: Our study included one hundred patients. Mean age was 61 ± 12 years and sex ratio of 1.8. Forty-eight per cent were illiterate. The median duration of AVK intake was 5 years. Atrial fibrillation (AF) was the most frequent indication (57%). Eighty percent of patients had more than five correct answers on the eight items of knowledge: VKA's name (96%), tablet description (93%), dose (99%), time (94%), VKA's effect (70%), INR (56%), treatment's risk (49%) and the target INR (20%). Twenty-two percent had more than four correct answers on the 6 items of know-how: what to do in case of haemorrhage (70%), what to do in case of oblivion (45%), interactions precautions to be observed with food (13%), activities advised against (49%) and medical procedures advised against (27%). In multivariate analysis, only prior VKA information was significantly associated with a better knowledge of VKA (p = 0.027). CONCLUSION: Our patients' knowledge on their VKA treatment was insufficient to ensure the safety and efficacy of treatment. The creation of a therapeutic education program on is therefore necessary to reduce the iatrogenic risk of this treatment.

Script concordance test as a sanctionnal evaluation in cardiology.

INTRODUCTION: Sanctioning evaluation in cardiology is carried out using multiple choice questions, short-answer questions, clinical cases and editorial questions. However, these methods do not assess clinical reasoning in a context of uncertainty in contrast with script concordance tests (SCT). AIM: To compare the scores obtained by the students in the 3rd year of medicine with the SCT versus the sanctioning test of cardiology and to study the correlation between these two evaluation methods. METHODS: This is a prospective study including 31 3rd year students who completed their cardiology clerckship in the Cardiology Department of the HabibThameur Hospital during the first half of 2016. We compared the scores obtained in the 13 SCT test (39 items) with those of the cardiology normative test. RESULTS: Students 'mean score at SCT was significantly lower than that of experts (66.6 ± 10.2 vs 86 ± 6.7%, p <0.0001). The mean score obtained by students at the SCT was significantly higher than that of the cardiology sanctioning test (p <0.001). Cronbach alpha coefficient was 0.71. There was no correlation between the two tests (r = 0.329; p= 0.07). CONCLUSION: The evaluation of our students by the SCT showed mean score statistically higher than the questions of a classic test, without correlation between them. This should encourage us to incorporate SCT into our assessment methods to promote clinical reasoning.

Factors associated with poor medication compliance in hypertensive patients.

INTRODUCTION: Hypertension is a major cause of cardiovascular morbidity and mortality. Despite therapeutic advances, only one-third of patients achieve blood pressure targets. Poor compliance is one of the main causes. AIM: To study the factors associated with poor compliance in hypertensive patients. METHODS: We conducted a descriptive prospective study including 200 hypertensive patients treated and followed out between March and April 2017. The Girerd medication adherence questionnaire was submitted to patients during an semi-directed interview. RESULTS: Patients meanagewas of 63.28 ± 9.62 years-old and sex ratio of 0.92. The predominant risk factor was dyslipidemia in 45% of cases, followed by smoking 36.5% and diabetes 25.5%. A previous history of acute coronary syndrome was found in 33.5% of cases and atrial fibrillation in 13%. Fifteen percent of our patients consumed alcohol regularly and 9.5% practiced regular physical activity. Fifty-five percent of our patients were on low sodium diet. The prevalence of poor medication adherence was 20.5%. In multivariate analysis, independent factors related to poor medication adherence were: the number of treating specialist physicians greater than 1 (OR = 3.444, p = 0.008) and the absence of information received on hypertension (OR = 4.345; p= 0.003). CONCLUSION: The improvement of medication adherence for our patients must be based on information on hypertension and its risks and the harmonization of care between treating physicians.

Response to clopidogrel and of the cytochrome CYP2C19 gene polymorphism.

INTRODUCTION: Clopidogrel (clopi) is a prodrug widely prescribed in the management of coronary artery disease and requires the intervention of hepatic cytochrome P450 2C19 (CYP2C19) for its activation. However, there is interindividual variability in response to clopi despite the use of recommended doses. Thus, the studies have highlighted the effect of the CYP2C19 gene polymorphism or Cyp2C19 gene on the response to clopi and particularly Cyp2C19 * 2 which may be associated with an increased risk of major cardiovascular events or MACE. OBJECTIVE: To evaluate the effect of Cyp2C19 * 2 polymorphism on MACE occurrence and hemorrhagic complications in patients treated with clopi. METHODS: We carried out a descriptive longitudinal study including 71 patients placed under clopi for a minimum duration of one month. Genotyping of the Cyp2C19 allele was performed by conventional polymerase chain reaction (PCR). After a follow-up period of 495 ± 183 days, we performed a statistical analysis to evaluate the association between the Cyp2C19 * 2 polymorphism and the occurrence of MACE or hemorrhagic complications. RESULTS: Among our patients, 51% had an angioplasty, 42% medical treatment and 7% a coronary artery bypass surgery. In our study population, 52% were heterozygous (HTZ), 28% homozygous (HMZ) healthy * 1 / * 1 and 20% HMZ had the loss of function allele * 2 / * 2. The allelic frequency of Cyp2C19 * 2 was 46%. Follow-up mean duration was of 495 ± 183 days. During this period, the prevalence of MACE was 11% and that of hemorrhagic complications was 13%. In our study, we did not observe a significant association between the occurrence of MACE or hemorrhagic complications with the genotype carrying the Cyp2C19 * 2 allele. CONCLUSION: Among patients treated with clopi, wearing a Cyp2C19 * 2 function loss allele didn't seem to be associated with a significantly higher risk of MACE, nor a significantly lower risk of hemorragic complications. This suggests the necessity of larger studies.

Evaluation of clinical reasoning teaching for third year medical students.

INTRODUCTION: Clinical reasoning teaching is an educational method based on learning and contextualized education.The aim of this study was to determine the value of clinical reasoning teaching sessions, from the perspective of third year medical students using a self-administered questionnaire. METHOD: Two successive groups of nine students (a total of 18 students) participated in this study.They had anexternship in the cardiology department of HabibThameur hospital during amonth.An anonymous evaluation self-administered questionnaire was submitted to the two groups at the end of the traineeshipperiod. RESULTS: The average scores given by students for the items "quality of education", "workload", "atmosphere", "interest in teaching sessions"and "acquisition of new clinical knowledge" were greater than 8/10. Exposed health problem to be solved has attracted the interest and the motivation of 16 students and prompted 15 others to do further research.Fourteen students opted for clinical reasoning teaching as the preferred teaching method for optimal memorization.Thirteen students have found a real contribution ofreasoning teaching in the management of relationship with the patient.All students assumed that clinical reasoning meetings session should be more frequently usedduring the internship period. CONCLUSION: Clinical reasoning teaching session appears to be widely desired by medical students.

Heart involvement in systemic sclerosis.

INTRODUCTION: Primary and secondary heart involvement in systemic sclerosis are important mortality predictors. Aim of this study was to investigate by standard echocardiography associated to pulsed-tissue Doppler imaging, six-minute walk test (6MWT) and BNP level cardiac manifestation in 30 patients with ScS and to establish a strategy to detect and to evaluate this complication. METHODS: This was a cross-sectional study conducted over a period of 16 months: a total of 30 consecutive patients with ScS diagnosed as proposed by the American college of Rheumatology and the European League Against Rheumatism 2013 and who were hospitalized in Internal Medicine department of Habib Thameur hospital underwent cardiac assessment. RESULTS: Twenty-nine patients were female, the mean age of diagnosis was 46 years ± 13,49  [18-71 years]. Echocardiography found left ventricular systolic dysfunction (LVSD) on tissue doppler imaging, in 40% of cases, it was significantly associated with diffuse ScS (p=0,024), with Scl70 anti bodies (p=0,043) and interstitial lung disease (p=0,024). However, the left ventricular diastolic dysfunction (LVDD) was correlated with a high diastolic arterial hypertension (p=0,028), diffuse ScS (0,048), telangiectasia (p=0,029) and pulmonary hypertension (p=0,033). Higher systolic pulmonary arterial pressure (PAPs) (p=0,029) and higher BNP level (p=0,027) were noted in the group of patients with right ventricular systolic dysfunction (RVSD). Patients who had an elevated PAPs had: accelerated pulse (p=0,022), a cough (p=0,024), dyspnea III-IV (p=0,003), shorter six-minute walk distance (p=0,044), greater Borg score (p=0,025) and elevated BNP level (p=0,015). Thus, a positive correlation was found between PAPs and BNP (p=0,004, r=+0,53), a negative correlation was noted between PAPs and ST (p=0,006, r=-0,49). The ROC curve identified a discriminator threshold for ST<11,5cm/s (BNP ≥43,5pg/l) and PAPs >35mmHg (BNP ≥92pg/l). A discriminator value of the 6MWD (≥294m) was recorded for a PAPs >35mmHg. 2000-3000 salma Conclusion: Left ventricular diastolic impairment was the most frequent echographic abnormality in our study. The BNP level and 6MWT are sensitive and specific in the detection of an elevation of PAPs.

Right ventricular systolic echocardiographic parameters in dilated cardiomyopathy and prognosis.

BACKGROUND: Right ventricular (RV) dysfunction is associated with poor prognosis in patients with non-ischemic dilated cardiomyopathy. Several RV echocardiographic parameters have been proposed as sensitive markers to detect patients at risk. OBJECTIVE: To compare the predictive value of echographic parameters of RV systolic function for adverse outcomes in patients with non-ischemic dilated cardiomyopathy. METHODS:    Forty patients with non-ischemic dilated cardiomyopathy were included. Right ventricular systolic function assessed by Doppler echocardiography standard (RV fractional area change, Tei index, TAPSE and dp/dt), tissue Doppler (peak systolic velocity (Sa)) and Strain 2D of the RV. The primary endpoint was the occurrence of a major cardiovascular event. The follow-up extended for 6.2 months ± 2,49. RESULTS: Eighteen patients reached the primary endpoint. TAPSE (HR 0.86 [0.74-0.99], p=0.04), Sa (HR 0.77 [0.62-0.95], p=0.01), Tei index (HR 1.06 [1.01-1.12], p=0.02) and strain of the lateral wall of the RV (HR 1.13 [1.04-1.23], p=0.004) were found to be independent predictors of major cardiovascular event. The cut-off thresholds for TAPSE, Sa, Tei index and strain of the lateral wall of th RV, defined using ROC curves were respectively 12,5mm ; 8,5cm/s ; 0,55 et -12. CONCLUSION: TAPSE, Sa, Tei index and strain of the lateral wall of the RV are independent predictors of major cardiovascular event in non ischemic dilated cardiomyopathy.

Trends in infective endocarditis.

INTRODUCTION: Infectious endocarditis (IE) is a rare disease with a high mortality. In 2009, the European society of cardiology restricted antibiotic prophylaxis to a smaller number of cardiac conditions with very high risk for IE. Did these changes in the guidelines have an impact on the epidemiological and bacteriological profile of IE? AIM: The main aim of our work was to study the evolution of the microbiological profile of IE from 1991 to 2016. METHODS: We realized an analytic retrospective study comparing two groups: group 1 included patients admitted for a certain IE before September 2009 and group 2 those admitted after that date. RESULTS: Patients mean age was 46 ± 13 years and sex ratio was of 1.5. Forty percent of the patients were at high risk of IE. Blood cultures were positive in 19 cases. The most frequently isolated germ was Staphylococcus (10 patients). Serology was performed in six patients and was positive for Chlamydia Trachomatis in two cases. Forty-two patients had surgical treatment, 17 had a valve culture that was positive in 3 cases only. Clinical and paraclinic characteristics were comparable among the two groups. Negative blood cultures rates decreased from 72% to 68% between group 1 and 2 (p = 0.789). Staphylococcus positive blood cultures increased from 13% to 21% (p = 0.49). In contrast, Streptococcal positive blood cultures decreased from 11% to 5% in 2009 (p = 0.69). CONCLUSION: Our data suggest that there has been no change in the bacteriological profile of IE after the reduction in antibiotic prophylaxis.

Differences between idiopathic and ischemic dilated cardiomyopathy.

BACKGROUND: Ischemic cardiomyopathy can be reversible after revascularization hence the interest of making systematic coronary angiography that remain an invasive procedure. AIM: To detect epidemiological, clinical and paraclinical differences between idiopathic and ischemic dilated cardiomyopathy to identify predictors of coronary artery disease and to evaluate the interest of making systematic coronary angiography within the etiological check-up of dilated cardiomyopathy. METHODS: We performed a retrospective study in patients with dilated cardiomyopathy in whom coronary angiography allowed to distinguish the ischemic cardiomyopathy group from that of idiopathic cardiomyopathy. We compared the clinical and paraclinical findings between these two groups. RESULTS: We identified 102 patients: 42 had ischemic cardiomyopathy and 60 had idiopathic cardiomyopathy. These two groups were comparable according to age and sex. Diabetes was significantly more common (p = 0.002) in the first group. Dyspnea was more common in the second group (p = 0.03) as well as atrial fibrillation and left bundle branch block (p=0,04 and p=0,05, respectively). Renal failure, fasting hyperglycemia and echocardiographic segmental wall motion abnormalities were significantly more frequent in the group of ischemic cardiomyopathy (p=0.01). In multivariate analysis, diabetes (OR=3,291, IC95% : 1,167-10,969), renal failure (OR=11,001, IC95% : 2,15-39,85) and segmental wall motion abnormalities (OR=2,351, IC95% :0.934-5.915) were independent predictors of ischemic dilated cardiomyopathy. CONCLUSION: Diabetes, kidney failure and disorders of wall motion appears to be predictors for the ischemic origin of dilated cardiomyopathy and thereby help to limit the routine use of this invasive technique in the diagnosis.

Value of Cine-MRI sequences before and after injection in the diagnosis of acute myocarditis.

BACKGROUND: Cardiovascular magnetic resonance (CMR) has become the examination of choice in case of suspicion of acute myocarditis. Late gadolinium enhancement (LGE) imaging is very important to establish this diagnosis. Cine MRI sequences are useful for the study of the myocardial contractility. AIMS:   The purpose is to estimate the value of cine MRI sequences before and after injection for the diagnosis of acute myocarditis compared with late gadolinium enhanced sequences. METHODS: We prospectively included 40 patients having a high suspicion of acute myocarditis and examined using a 1.5 Tesla CMR. Cine MRI sequences before and after injection were performed. The protocol also include  T2-weighted  short- tau-inversion-recovery (STIR T2) fast spin echo MRI and LGE imaging eight minutes after injection with visual adjustment of inversion time. RESULTS: Delayed enhancement was found among 23 patients. Fifteen patients (65 %) presented a spontaneous hyper signal detected visually on Cine MRI sequences before injection and 11 patients (48 %) on STIR T2. The hyper signal on Cine MRI sequences after injection of gadolinium was the same topography that the late raising at 23 patients. In addition, we highlighted a significant difference between this hyper signal before injection and the left ventricle ejection fraction (p=0.022) as well as with the telesystolic volume of the left ventricle (LV) indexed by the body mass (p=0.039). CONCLUSION: Our study suggests that Cine MRI sequences after injection are of equal performance in the diagnosis of acute myocarditis as the LGE sequences and its contibution is important when we want to shorten the examination or when inversion time isn't optimal.

[Communication interventriculaire compliquant un infarctus de myocarde antérieur : un cas de fermeture percutanée]. / Ventricular septal defect complicating anterior acute myocardial infarction : A Case of transcatheter closure.

INTRODUCTION: Post-infarction ventricular septal defect (PIVSD) is one of the most serious mechanical complications of acute myocardial infarction (AMI). Over the last decade, percutaneous closure is increasingly undertaken, with results similar to cardiac surgery. We present a case of ST-elevated anterior AMI, complicated by apical PIVSD successfully treated with transcatheter closure. CASE REPORT: An 83-year-old man was hospitalized for chest pain occurred 18 hours before, during the night time. He was an active smoker. Clinical examination revealed normal heart sounds and pulmonary bibasilar crackles. ST-segment elevation with deep T waves inversion in anterior leads were detected on the electrocardiogram. A mildly-reduced ejection fraction (40%) was found by transthoracic echocardiogram. The patient underwent emergency coronary angiography, which revealed a subocclusive stenosis of the mid left anterior descending artery with a TIMI 2 flow, treated by balloon angioplasty and drug-eluting stent. Four days after revascularization, the patient developed an acute deterioration with signs of decompensated heart failure and a new holosystolic murmur with large irradiation. Inotropic agents' administration was required to maintain a precarious hemodynamic condition. A bedside Echo revealed an apical VSD, measuring 15 × 10 mm, with left-to-right shunting, and pulmonary hypertension. The patient was scheduled for transcatheter PIVSD closure. The procedure was performed under fluoroscopic guide. Two vascular access sites were placed, femoral arterial and right internal jugular vein. Through the right internal jugular vein, a 24-mm Amplatzer atrial septal occluder on a 9 French Amplatzer TREVISIO™ intravascular delivery system was advanced via right ventricle into the PIVSD. Contrast fluoroscopy was used to assess apposition and the degree of shunt reduction before release. Echocardiographic evaluation performed 48 hours later confirmed a correct apposition of the device with insignificant residual shunt. At 6 months follow-up, he was asymptomatic, with unchanged prosthetic findings. CONCLUSION: Percutaneous closure has been emerged as a valid cost-effective alternative to surgery and should be advised. However, debate remains on the optimal preprocedural optimization, timing of repair and modality of treatment.

Assessment of debriefing in high-fidelity mannequin simulation: study among students in cardiology.

INTRODUCTION: Debriefing is the fundamental step in the learning process when teaching by simulation. The Debriefing Assessment for Simulation in Healthcare (DASH) guide is a tool designed to assess and develop the debriefing skills of trainers using healthcare simulation. AIM: To evaluate the debriefing in high-fidelity mannequin simulation in the management of cardiological emergency by the DASH tool, student version. METHODS: This was a bicentric, prospective, cross-sectional and evaluative study including five groups of students in the first year of the second cycle of medical studies completing their internship in the cardiology departments of the Habib Thameur hospital and the Internal Security Forces Hospital of Marsa during the first semester of the 2021-2022 academic year. The simulation scenario included the diagnosis and emergency management of degenerative syncopal atrioventricular block. RESULTS: Forty-four students completed the DASH assessment form (28 female, 16 male). According to the students, the trainers had maintained a climate conducive to learning (6.51±0.74). They had conducted the debriefing in a structured way (6.35±0.75). They had aroused engagement in the exchange leading the learner to analyze his performance (6.01±1.03). They had effectively identified the learner's strengths and areas for improvement as well as their reasons (6.39±1.04). The trainers had helped the learners to consider how to improve or maintain a good level of performance (6.57±0.77). The mean DASH score evaluating the trainers was 6.36±0.88. CONCLUSION: The DASH tool allows trainers to highlight the strengths and areas for improvement in the debriefing, which is the key step in the simulation to optimize the clinical reasoning process and improve the quality of care.

Endovascular therapy for steno-occlusive subclavian artery disease early and long-term outcomes in a multicentric Tunisian study.

AIM: To evaluate the outcomes of endovascular therapy in patients with subclavian steno-occlusive disease over the short and long term in a Tunisian population. MATERIALS AND METHODS: Patients who underwent endovascular treatment of subclavian artery (SCA) steno-occlusive disease between 2013 and 2019 in three Tunisian centers were evaluated retrospectively. After treatment, patients were follow-up was scheduled at 1, 3, 6, 12 months postoperatively and annually afterwards by Doppler ultrasound and clinical findings. Primary outcomes included technical, clinical procedural success rates and limb salvage rate. Secondary outcomes included the occurrence of periprocedural complications and primary patency rates. RESULTS: 56 patients (33 males, 58.9%) were evaluated. Patients' mean age was 61.5 + years. Technical success rate was 94.6 %, being 100% in case of stenosis and 78.5% in case of occlusion. The technical success rate was 94.6%. The clinical success rate was 100% and the upper limb salvage rate was 100%. Minor amputations were performed on 5 patients. Perioperative mortality and morbidity rates were 0% and 8.9% respectively. Mean follow-up was 26.7±16.4 months (range 12-86 months). Two in-stent restenosis occurred (at 12 and 15 months) and one case of thrombosis at the 16th month. The primary patency rates were 88.7%+4.3% at the end of the first year and 78.7%+6.1% at 3 years. CONCLUSION: Endovascular treatment can be considered as a safe and effective treatment of SCA steno-occlusive disease, with low perioperative complication rates and a good patency rates over long term. KEY WORDS: Subclavian artery stenosis, Subclavian artery occlusion, endovascular, subclavian revascularization.

Prognostic value of atrial strain in non-ischemic dilated cardiomyopathy.

INTRODUCTION: Left atrial function in non-ischemic dilated cardiomyopathy (DCM) has long been underestimated when studying the ultrasound parameters of DCM. Currently, several ultrasound parameters of left atrial function have been proposed as markers to detect patients at risk. AIM: To evaluate the left atriumfunctionwith 2D speckle tracking echocardiography and itsprognostic value in the dilatedcardiomyopathy. METHODS: The study prospectively recruited 40 patients with dilated cardiomyopathy, between January and June 2014, followed up at the cardiology department of Habib Thameur Hospital of Tunis. An echocardiogram was performed for all patients at the beginning of the study. After a 6-month follow-up, the primary endpoint was the occurrence of a major cardiovascular event. The patients were divided into a first group without cardiovascular events (group 1) and a second group with a cardiovascular event (group 2). RESULTS: During the follow-up, 25 patients presented a major cardiovascular event (8 ventricular arrhythmias and 17 hospitalizations for acute decompensated heart failure). There were no significant differences between the two groups regarding cardiovascular risk factors, symptoms and blood testing values.In addition, regarding results obtained from speckle tracking echocardiography, atrial peak-systolic longitudinal strain (PALS) and time to peak atrial longitudinal strain (TPALS) values were observed to be significantly lower in group 2 ( 34.6% in group 1 vs 28.4% in group 2, p=0.000; and 344.6ms in group 1 vs 349.8 ms in group 2, p=0.016 respectively). CONCLUSION: The analysis of the LA speckle tracking in the dilatedcardiomyopathymay help cardiologistto identify patients at high cardiovascular risk and thus improve their management and follow-up.

Serious Game Design with medical students as a Learning Activity for Developing the 4Cs Skills: Communication, Collaboration, Creativity and Critical Thinking: A qualitative research.

INTRODUCTION: The impact of technology in education has led to various changes in the way that different stakeholders, like students and teachers work and interact with each other. The use of the serious game design in educational contexts has been related to the development of the 21st century skills such as communication, collaboration, creativity and critical thinking. AIM: To analyze a serious game design process by third -year medical students, from the perspective of the 21st century competencies engaged in the game design process. Those outlined key competencies are communication, collaboration, creativity and critical thinking. METHODS: This is a qualitative, descriptive, and inductive study that follows a phenomenological approach. Twelve volunteer third-year medical students participated in an activity of designing of serious games. This study, carried out during summer internship in the cardiology department of Habib Thameur Hospital. The course of the designing of serious games with students spread over 4 weeks with 10 hours face-to-face and 10 hours of remote work. RESULTS: The participants in our study were twelves third-year medical students. Of these 12 students, 10 were female. The duration of each interview depends on each participant's ability. The analysis of the data, based on the phenomenological method of Giorgi brought out four central themes: theme 1: Critical thinking skills and problems solving skills, theme 2: Communication, theme 3: Creativity, theme 4: Collaboration. The overall essence of the phenomenon is these third medical students who experienced the serious game design outlined key competencies. CONCLUSION: Using serious game development-based learning as a learning method to impart multidimensional skills and knowledge suggests a promising approach for developing clinical reasoning, creativity, communication, and collaboration in students.

Effects of Ramadan fasting on blood pressure in hypertensive patients.

INTRODUCTION: During Ramadan, repeated cycles of fasting might contribute to changes in blood pressure among hypertensive patients. Studies on the effects of fasting on the blood pressure of hypertensive patients are scarce and have provided inconclusive results. AIM: To examine the effect of fasting on ambulatory blood pressure and heart rate in treated hypertensive subjects. METHODS: The study prospectively recruited 60 hypertensive patients between April and June 2019, followed up at the cardiology department of Habib Thameur Hospital of Tunis. A 24-hour pressure monitoring was carried out during two periods: prior to Ramadan and during the last ten days of Ramadan. We compared the average values of 24 hour, awake and asleep systolic and diastolic blood pressure and 24 hour, awake and asleep heart rate. RESULTS: We studied 40 women and 20 men; mean age was 58.4 years. 33% of the patients were diabetics, 42% dyslipidemics, 15% had coronaropathy. 45% of the patients were on monotherapy, 37% on dual therapy and 18% on a triple antihypertensive therapy. During Ramadan, 74% of the patients were taking the treatment once daily, 3% twice daily, and 23% three times per day. Average 24hour ambulatory blood pressure in the whole group was 129±17/74±10 mmHg before Ramadan and 128±17/73±9 mmHg during Ramadan (p>0.05). Daytime and nighttime mean values of systolic and diastolic blood pressure as well as mean values of heart rate were not different between both periods regardless of age, gender, medical history and lifestyle. CONCLUSIONS: In this study, there were no significant changes in systolic and diastolic blood pressures as well as heart rate during the 2 periods.

Assessing medical student satisfaction and interest with serious game.

INTRODUCTION: Serious games are interactive and entertaining digital software with an educational purpose, and they are increasingly being used in undergraduate medical education. Effective serious games attempt to form positive mood in order to encourage players to continue the play, leading to increased interest in gameplay and satisfaction as well as better academic performances. AIM: To determine  the medical students' satisfaction, situational and individual interest during a serious game. METHODS: This was a prospective study performed during a 2-year period (2018-2019 and 2019-2020). A total of 108 third-year medical students participated in this study. Students were asked to play a serious game on a computer for 20 minutes. A set of questionnaires containing evaluation grids to measure the satisfaction and interest was given to students. The effectiveness of the game was assessed using pre and post-tests. RESULTS: Following the exclusion criteria of students due to missing data, complete data were available for 97 students. Satisfaction and interest experienced by the students were high. The median of the game performance of students was 418, 04 points. There was a positive relationship between ease of use and game performance. There was a negative correlation between the three scales of interest and game performance. There was a significant difference between the mean scores of pre-tests and post-tests (p<0.01). CONCLUSION: The results of this study suggest the potentials of serious game on medical student's satisfaction, interest and learning achievement.