Human papillomavirus genotypes and HPV-16 variants distribution among Tunisian women with normal cytology and squamous intraepithelial lesions.

BACKGROUND: Little is known about the epidemiological characteristics of papillomavirus (HPV) infection among North African countries. Herein, we conducted a molecular epidemiological study to investigate prevalence of HPV type and HPV-16 variants among cervical-screened unvaccinated Tunisian women. METHODS: Cross-sectional study was performed on 494 Tunisian women visiting Women's Healthcare Centers. HPV-DNA detection was carried out on cervical samples using real-time polymerase chain reaction. HPV genotyping and HPV-16 variants were characterized by direct sequencing of L1 viral capsid gene. RESULTS: The overall HPV prevalence was 34% (95% CI: 30-38%) with significantly higher prevalence among women with squamous intraepithelial lesions (SIL) than those with no intraepithelial lesions (NIL) 84% (95% CI: 76-92%) and 24.5% (95% CI: 20-29%) respectively. The distribution of HPV prevalence according to women's age shows a U-shaped curve and the highest HPV prevalence rates were observed among the youngest (≤25 years; 51.2%, 95% CI: 37-67%) and the oldest women (>55 years; 41.7%, 95% The HPV-16 prevalence was 32.8% (95% CI: 22-45%) among women with SIL and 9.2% (95% CI: 6-12%) among women with NIL. Whereas, the HPV-18 prevalence was 1.3% (95% CI: 0-5%) among women with SIL and 0.3% (95% CI: 0-1%) among women with NIL. Among HPV-16 positive women, European lineage (E) was identified as the predominant HPV-16 variant (85.7%, 95% CI: 76-95%). The frequency of E variant was lower among SIL than among NIL women (81%, 95% CI: 64-99%, and 88%, 95% CI: 77-100%, respectively). Conversely, the African-2 variant frequency was higher among SIL than among NIL women (18%, 95% CI: 1-36% and 6%, 95% CI: 2-14%, respectively). In multivariate analysis, young age was the only risk factor that is independently associated with HPV infection. Moreover, HPV infection and menopause were both found to be independently associated with SIL and HSIL. CONCLUSION: HPV DNA testing should be proposed to young and menopausal Tunisian women. Considering HPV prevalence, only 13% of the Tunisian women could be protected by the bivalent HPV vaccine. These results may be helpful for designing an adapted HPV testing and vaccination program in Tunisia.

[What's the optimal time of cesarean section antibiotic prophylaxis, before skin incision or after umbilical cord clamping? A prospective randomized study]. / Quel est le moment optimal de l'antibioprophylaxie pour césarienne élective, avant l'incision cutanée ou après clampage du cordon ombilical ? Étude prospective randomisée.

OBJECTIVES: To compare the effect of antibiotics prophylaxis within 30 mins before skin incision (A) and after umbilical cord clamping (C) on the incidence of postoperative infections in patients undergoing elective caesarean section at Farhat Hached university teaching hospital. MATERIALS AND METHODS: We conducted a randomised clinical trial evaluating 279 patients undergoing elective caesarean section. Patients were randomly assigned a group number that allocated them to either arm of the study. They received the same prophylactic antibiotic (cefazol® 2g) according to their allotment. They were followed up to detect infection up to 30 days postoperatively. The primary outcome was postoperative infection. The data collected were analysed with SPSS version 18.0 using univariate and bivariate analysis. RESULTS: The risk of overall postoperative infection was not significantly lower when prophylaxis was given before skin incision (4.37 % (A) vs 9.85 % (C); P=0.07; OR=0.42 [0.15-1.12]). We also found wound infections to be significantly reduced in the pre-incision group (2.2 % [A] vs 8.45 % [C]; P=0.03; OR=0.24 [0.06-0.88]). However, there was no difference in the endometritis infectious. On the other hand, there was no negative impact on the neonatal features. CONCLUSIONS: Giving prophylactic antibiotics before skin incision reduces risk of postoperative infection, in particular of wound infections.

[Post-cesarean parietal scar characteristics are predictive of pelvic adhesions. A prospective cohort study]. / Les caractéristiques de la cicatrice pariétale de césarienne sont des facteurs prédictifs des adhérences pelviennes. Étude de cohorte prospective.

OBJECTIVE: To investigate whether abdominal scar characteristics could predict the incidence and severity of intra-abdominal adhesions found at repeat cesarean delivery. PATIENTS AND METHODS: Prospective cohort study including 151pregnant women with at least one previous cesarean delivery and who delivered abdominally in the department of obstetrics and gynaecology of Farhat Hached teaching hospital-Sousse-Tunisia, during 6 months. Abdominal scar characteristics were studied. The main outcome measure(s) were the incidence and severity of intra-abdominal adhesions. Statistical analysis was performed using SPSS 18.0. RESULTS: Of 151 women enrolled into this trial, 111 (73.5%) had adhesions, 57 (37.8%) had dense adhesions. Of all the abdominal scar characteristics studied, a depressed scar was associated with an increased incidence of both dense and filmy intra-abdominal adhesions and frozen pelvis if compared of women who did not have a depressed scar (P<10(-4) ; RR=7.6; IC=2.98-19.45). A number of previous cesarean section equal or more than 2 was also correlated with an increased incidence of severe intra-abdominal adhesions and frozen pelvis if compared with women who had only one previous cesarean section (P=0.002; RR=2.53; IC=1.16-5.56). DISCUSSION AND CONCLUSION: A depressed abdominal scar of a previous cesarean delivery and a number of previous cesarean sections are significantly correlated with the incidence and severity of intra-abdominal adhesions.

[Interest of laparoscopy in infertile couple with normal hysterosalpingography]. / Faut-il cœlioscoper les femmes infertiles ayant une hystérosalpingographie normale.

OBJECTIVES: The diagnostic laparoscopy has long been the key consideration in the export of female infertility. This place is being reconsidered, especially in the case of normal hysterosalpingogrophy (HSG), because of the advent of assisted reproductive technologies which are more efficient, and because of the improvement of medical imaging techniques which are more sensitive and specific. We wanted to clarify the place of the diagnostic laparoscopy in the balance of female infertility in normal HSG. PATIENTS AND METHODS: It is a retrospective study on a series of 100 observations of infertile patients with a normal HSG and having a diagnostic laparoscopy in the department of Gynecology and Obstetrics at Farhat Hached hospital in Sousse (Tunisia) from 1st January 1993 to 1st March 2003. RESULTS: The mean age was 32.3years; the mean duration of infertility was 70.47months. Laparoscopy revealed pelvic abnormalities in 45% of cases, dominated by disease tubo-adhesions (23%), endometriosis was found in 6% of cases. These anomalies are considered major in 23% of cases and minor in 22% of cases. Conducting a surgical procedure in the same operating time (adhesiolysis, tubal plastic surgery, electrocoagulation of endometriosis implants) could improve the prognosis of fertility. Only 20 patients were followed among the 45 with pelvic abnormalities, seven pregnancies have been completed (35% of cases). DISCUSSION AND CONCLUSION: Laparoscopy has improved the prognosis for the fertility of our patients by treating abnormalities involved in infertility. It is estimated that the prognosis can be improved by selecting patients with risk factors for pelvic abnormalities.

[Holoprosencephaly: pathogenesis, phenotypic characteristics. About four cases]. / L'holoprosencéphalie : étiopathogénies et caractéristiques phénotypiques. À propos de quatre observations.

Holoprosencephaly is a rare brain abnormality resulting from an incomplete cleavage of the primitive prosencephalon of forebrain during early embryogenesis. It includes a series of rare complex and heterogenosis disorders. Alobar form is associated with an extremely poor fetal prognosis. Here we report three cases of alobar holoprosencephaly and one case of semilobar holoprosencephaly diagnosed at the third trimester. Causes, diagnosis and management of holoprosencephaly are discussed referring to literature.

[The therapeutic contribution of proteomic approaches in cancers]. / L'apport thérapeutique des approches protéomiques dans les cancers.

Up to now, there are no protein tumor markers with a specificity and sensitivity sufficient to have a utility in prognosis and early diagnosis of cancer. Recent advances in proteomics approaches have led to the identification of novel tumor markers of cancer that may have a utility in screening strategies and treatment. The purpose of the current review is to describe the major advances in cancer proteomics, especially those related to the study of serum biomarkers, immune-related responses (autoantibodies) and alterations in cellular proteins.

[Seroprevalence of rubella virus, varicella zoster virus, cytomegalovirus and parvovirus B19 among pregnant women in the Sousse region, Tunisia]. / Séroépidémiologie de la rubéole, de la varicelle et des infections par le cytomégalovirus et le parvovirus B19 chez les femmes enceintes dans la région de Sousse, Tunisie.

The aim of the study is to evaluate seroprevalence of rubella virus (RV), cytomegalovirus (CMV), varicella zoster virus (VZV), and parvovirus B19 (PB19) in 404 Tunisian pregnant women, and to determine reliability of maternal past history of eruption. Sociodemographic characteristics, risk factors, and past history of eruption were collected through a questionnaire. Serologic tests were performed using enzyme immunoassays. Risk factors were analyzed using univariate and multivariate logistic regression models. Seroprevalences were 79.7% for rubella, 96.3% for CMV, 80.9% for VZV, and 76.2% for PB19. In multivariate analysis, the number of persons per room (> 2) in the house during childhood was associated with CMV infection (P = 0.004), irregular professional husband's activity was correlated with VZV infection (P = 0.04), and an age of more than 30 years was associated with PB19 infection (P = 0.02). History of rubella, varicella, and PB19 infection was unknown for, respectively, 55.8%, 20%, and 100% of women. False history of rubella and varicella were found for 7.4% and 15% of women, respectively. The positive and negative predictive values (PPV and NPV) of rubella history were, respectively, 92.6% and 17.2%, and were, respectively, 84.9% and 20.9% for varicella history. Susceptibility to RV, VZV, and PB19 infection remains high in pregnancy in our population. Preventive strategies against congenital rubella must be reinforced. Vaccination against VZV should be considered in seronegative women. Systemic CMV screening is not warranted in our country where high immunity is acquired probably in childhood. Since maternal history of eruption is not reliable, we recommend serologic testing to determine immune status of women.

[Seroprevalence and risk factors of hepatitis E among pregnant women in central Tunisia]. / Séroprévalence et facteurs de risque de l'hépatite virale E chez la femme enceinte dans le centre tunisien.

OBJECTIVES: The study was conducted to investigate the prevalence and risk factors for hepatitis E virus (HEV) infection in Tunisian pregnant women. METHODS: A total of 404 pregnant women were enrolled. Data were collected through a standard questionnaire which covered sociodemographic characteristics and risk factors. Blood samples were collected and were tested for HEV IgM and IgG antibodies, IgG against hepatitis A (anti-HAV IgG), hepatitis B virus surface antigen (HBsAg) and hepatitis C virus antibody (anti-HCV). Risk factors were analyzed using univariate and multivariate logistic regression models. RESULTS: Prevalence of anti-HEV IgG, anti-HEV IgM, anti-HAV IgG, HBs Ag and anti-HCV was 12.1 %, 0 %, 97 %, 3 % and 0,5 %, respectively. In multivariate analysis age (>30 years) and the number of persons per room (>2) in the house were independent factors predicting HEV infection. History of agricultural work, kind of water, sewage treatment, use detergent to wash vegetables, contact with animals and parenteral risk factors were not correlated with the presence of anti-HEV IgG. CONCLUSION: The important seropositive rate among pregnant women is compatible with endemicity of HEV in Tunisia. Hepatitis E should be considered in the diagnosis of acute hepatitis during pregnancy. Our result suggests that infection occurs sporadically by person-to-person transmission route but further investigations are needed to determine the natural reservoir of infection.

[Diabetic mastopathy]. / Mastopathie diabétique.

Diabetic mastopathy is a recently described pathological entity. Little is known about this benign condition. It usually occurs in young patients with type 1 diabetes, or having an autoimmune disorders. Clinically, this mastopathy simulates a breast cancer. Graphic tests are not very informative. The diagnosis is histological. Through a case of diabetic mastopathy occurring in a patient with diabetes on insulin for 16 years and carries multiple degenerative complications, we recall the clinical, radiological and outcome of this disease.

[Role of deambulation during labour: A prospective randomized study]. / Intérêt de la déambulation au cours du travail obstétrical : étude prospective randomisée de 200 cas.

OBJECTIVE: To assess the effects of ambulation during the first stage of labor on the duration of labor and other maternal and infant outcomes. PATIENTS AND METHODS: A prospective randomized trial conducted from 1st November 2008 to 31st March 2009 at the department of obstetrics and gynecology, CHU Farhat Hached, Sousse, Tunisia. Two hundred mothers with uncomplicated term pregnancies were randomly assigned to one of two groups: first group (100 parturients) authorized to ambulate until 6cm of cervical dilation and a second group (100 parturients) confined to bed in dorsal or lateral recumbence. RESULTS: Upright position reduces significantly (for about 34%) the duration of the first stage of labor (P<0.0001), the pain intensity, the oxytocin consumption (P=0.001), the rate of delivery by cesarean section and of instrumental deliveries. Upright position leads also to a net improvement of the maternal outcome (7% side effects versus 13%) and the fetal outcome (net improvement of the Apgar's score at first and fifth minute, and reduction of a factor 5 of the rate of transfer to the neonatology clinical care unit. CONCLUSION: Our study allowed to confirm the benefits of ambulation on labor progress as well as on the maternal comfort and the maternofetal outcome.

[Correction of breast Poland's anomalies. About eight cases and literature review]. / Correction des anomalies mammaires du syndrome de Poland. A propos de huit cas et revue de la littérature.

PURPOSE: The objective of the present study was to analyze current indications and results of different methods for breast anomaly correction of Poland's syndrome. PATIENTS AND METHODS: Eight patients with this deformity were operated between 1997 and 2008: seven females and one male. The mean age was 22. According to Foucras et al. classification, four patients revealed Poland's syndrome grade II, three patients grade I and two patients grade III. Three patients received silicone implants (two with Poland's syndrome grade II, one with grade III). Autologous fat injection was used for a male adolescent who was very embarrassed by his deformity. Controlateral lipo-aspiration was carried out in three cases with moderate Poland's syndrome breast asymmetry. For one patient, correction was achieved by controlateral breast resection. RESULTS: No intraoperative or postoperative complications occurred for the eight patients. Aesthetic results were overall satisfactory. CONCLUSION: The simplest and the fastest breast deformity correction technique in Poland's syndrome patients, the one with the least complications and cosmetic sequella and the most practiced by the surgeon, remains the best method for breast anomaly correction of Poland's syndrome.

[Benefit of misoprostol for prevention of postpartum hemorrhage in cesarean section: a randomized controlled trial]. / Intérêt du misoprostol dans la prévention de l'hémorragie du post-partum immédiat en cas de césarienne : essai prospectif randomisé

OBJECTIVES: To assess the benefit of sublingual misoprostol in addition to standard oxytocin in the prevention of post-partum hemorrhage at caesarean section. PATIENTS AND METHODS: This was a prospective randomized controlled clinical trial conducted from March to June 2007 at our department of obstetrics-Sousse-Tunisia, including 250 single low risk pregnant women undergoing caesarean section at gestational age>32 weeks gestation. Patients were randomly assigned to receive at cord clamping either sublingual 200microg misoprostol (Cytotec) with 20UI intravenous oxytocin (Oxytocin): bolus 10UI and infusion 10UI in 500ml Ringer Lactate): Group I, or only oxytocin at the same dose: Group II. The main outcome was total blood loss assessed by decrease in perioperative hematocrit. Secondary outcomes included measured collected blood loss, drop in hemoglobin level, additional oxytocin, side-effects and postoperative complications. RESULTS: The two groups were similar in demographic and obstetrical patient characteristics. Drop in hematocrit was more important in group II than in group I: 4.30%+/-3.14 versus. 1.10%+/-3.25; P=0.013. Drop in hemoglobin level was also more important in group II than in group I: 1.03g/dl+/-1.19 versus 0.54g/dl+/-1.17; P<0.01. Collected blood loss was less important in group I than in group II: 669.68cc+/-333.01 versus 852.52cc+/-295.08 ; P<0.01. Need for additional oxytocin and postoperative complications rate were more frequent in group II than in group I but the differences weren't significant. The rate of transient shivering, nausea and fever was significantly higher among women receiving misoprostol. CONCLUSIONS: Sublingual misoprostol (in addition to oxytocin) is effective in prevention of post-partum hemorrhage at caesarean sections when compared to oxytocin alone, without major side-effects. Larger studies are needed to confirm our results.

Platelet-specific alloantigens and antibodies in Tunisian women after three or more pregnancies.

Pregnancy may allow alloimmunization against human platelet antigens (HPA), which can lead to neonatal alloimmune thrombocytopenia (NAIT). The specificities of alloantibodies are closely related to the distribution of the HPA systems. A total of 281 Tunisian multiparous women (mean number of pregnancies: 4.5) were phenotyped for the HPA-1, -3 and -5 systems, by monoclonal antibody immobilization of platelet antigens (MAIPA). We searched for antibodies against HPA-1a, HPA-3a, HPA-5b and HPA-5a in HPA-1b1b, HPA-3b3b, HPA-5a5a and HPA-5b5b individuals, respectively. The gene frequencies were: 0.83 for HPA-1a, 0.17 for HPA-1b, 0.78 for HPA-3a, 0.22 for HPA-3b, 0.82 for HPA-5a and 0.18 for HPA-5b. Anti-HPA-5b antibodies were present in eight sera and anti-HPA-3a antibodies were present in one serum. The anti-HPA-5b system is the most frequently involved in platelet alloimmunization in Tunisian multiparous women. However, prospective trials are required to confirm this result and to determine the exact frequencies and clinical relevance of platelet alloantibodies in pregnant Tunisian women.

[Yolk sac tumor revealed by an ascite of great abundance]. / Tumeur vitelline de l'ovaire révélée par une ascite de grande abondance.

We report the case of a 16-year-old girl explored for an ascite of great abundance responsible for a respiratory embarrassment. Its symptomatology proved to be secondary to a vitelline tumour of the ovary. It required several drainings of ascite before surgical operation. She had a conservative treatment followed up by a chemotherapy which allowed a clinical and biological remission. We report this observation considering the originality of the mode of revelation of the tumour. We insist in addition on the possibility of a conservative treatment.

[Comparing two Prepidil gel regimens for cervical ripening before induction of labor at term: a randomized trial]. / Comparaison de deux régimes d'administration intracervicale de Prépidil dans le déclenchement artificiel du travail à terme : essai prospectif randomisé

OBJECTIVES: To compare efficacy and safety of two regimens of intracervical dinoprostone (Prepidil) in cervical ripening before labor induction at term. PATIENTS AND METHODS: This was a prospective randomized clinical study including 148 patients with single pregnancy, viable fetus at gestational age greater than 36 weeks gestation and a Bishop score less than five, who required induction of labor. Patients were randomised to receive either repeated doses of dinoprostone gel 0.5mg (Prepidil) every 6 hours (group I) or every 12 hours (group II) for maximum three times before inducing labor with Oxytocin. The main outcome was the rate of caesarean sections. RESULTS: The two groups were similar in patient characteristics, indication for labor induction and preinduction Bishop scores. The caesarean rate was lower in group I (20.3%) than in group II (23%); though the difference did not reach statistical difference: p=0.69. Delivery rate in the first 24 hours was significantly higher in group I (62.2%) than in group II (40.5%); p=0.009. Prepidil secondary effects were experienced in 8.1% of patients in group I versus 1.4% in group II; p=0.11. Median umbilical artery pH at birth was 7.232+/-0.47 in group I and 7.294+/-0.58 in group II; p=0.30. Maternofetal infections rate was lower in group I (1.4%) than in group II (2.7%) without significant difference (p=0.56). CONCLUSIONS: Repeated intracervical doses of Prepidil every 6 hours, in cervical ripening before labor induction at term, enables higher delivery rate in the first 24 hours without inducing excess of caesarean sections or maternofetal morbidity when compared to its administration every 12 hours.

Associations between tumor necrosis factor-alpha and lymphotoxin-alpha polymorphisms and idiopathic recurrent miscarriage.

Heightened expression of tumor necrosis factor (TNF)-alpha and lymphotoxin-alpha (LT-alpha) was associated with pregnancy complications, including idiopathic recurrent miscarriage (RM). Whereas TNF-alpha and LT-alpha gene polymorphisms affect serum cytokine concentrations, their contribution to RM is controversial. The single nucleotide polymorphisms (SNPs) TNF-alpha (-238G/A, -308G/A) and LT-alpha (+252A/G) were investigated in 350 RM women and 200 control women. Higher frequency of the TNF-alpha -238A, but not the TNF-alpha -308A or the LT-alpha+252G, allele was seen in patients, with comparable frequencies of TNF-alpha -238G/A, TNF-alpha -308G/A, and LT-alpha+252A/G genotypes seen between both groups, except for TNF-alpha -238G/G, which was lower in patients. Regression analysis confirmed the association of the TNF-alpha -238G/A SNP with idiopathic RM, and both TNF-alpha -308A/TNF -238G/LT-alpha+252G and TNF-alpha -308G/TNF-alpha -238A/LT-alpha+252G haplotypes played a susceptible role in idiopathic RM. TNF-alpha -238G/A and -238A/A, and LT-alpha+252G/G genotypes were positively associated only with exclusively early RM. This supports the concept of the association of TNF-alpha (-238G/A) and LT-alpha (+252A/G) polymorphic variants in idiopathic RM.

[Radiation induced breast sarcoma: a case report]. / Sarcome radio-induit du sein: à propos d'un cas.

Radiation-induced breast sarcoma is a late complication of radiation treatment. We report a case of an undifferentiated sarcoma occurring 8 years after breast conserving treatment, which required mastectomy taking pectoralis major.

[Tuberculous axillary lymphadenitis: an unusual presentation]. / Le cas clinique du mois. Tuberculose ganglionnaire axillaire une présentation inhabituelle.

Axillary lymph node tuberculosis is rare and often poses problems of differential, diagnosis, especially with breast carcinoma. We report the case of a tuberculous axillary lymphadenitis discovered at the time of the exploration of a supposedly metastatic liver and, initially, taken for metastases of an occult breast carcinoma. Tuberculous axillary lymphadenitis remains a rare condition which must be considered in patients living in country with endemic tuberculosis.