Parenteral Nutrition Complications in Children Undergoing Bone Marrow Transplantation.

BACKGROUND: Parenteral nutrition (PN) seems to be a practical solution to face the negative nutritional effects of bone marrow transplantation. OBJECTIVE: Report and describe all observed PN-related complications in children undergoing allogenic bone marrow transplantation in a tertiary center and determine the possible risk factors. MATERIALS AND METHODS: This was a retrospective and observational study including 51 allografted children 2 to 17 years of age. We collected from medical patient records any noticed PN-related complications using an assessment causality method. The independent risk factors for complications were investigated by multivariate analysis. RESULTS: A total of 92% of patients (n=47) developed a total of 136 complications attributable to PN. The incidence rate of complications was 5 for 100 patient days of PN. Infectious complications (32.3%) and electrolytic disorders (27.9%) were the most common conditions identified during our study. Multivariate analysis showed that the duration of PN exposure, age, and hyperglycemia were the risk factors for the onset of these complications. CONCLUSIONS: Although we have noticed multiple complications attributable to PN, a certain causal link is difficult to establish in this particular context. Emphasizing enteral nutrition in bone marrow graft protocols would be the best way to avoid these complications.

Filgrastim following HLA-Identical Allogeneic Bone Marrow Transplantation: Long-Term Outcomes of a Randomized Trial.

Human recombinant granulocyte colony stimulating factor reduces the duration of neutropenia following HLA-identical allogeneic bone marrow transplantation. However, its use remains controversial due to the risk of increasing the incidence of acute graft-versus-host disease (GVHD) and slower platelet recovery. To clarify these risks, we conducted a prospective randomized placebo-controlled trial of filgrastim 5 µg/kg/day i.v. from day 7 post-transplant until neutrophil recovery in 145 consecutive adults undergoing HLA-identical allogeneic bone marrow transplantation, with cyclosporine and methotrexate as GVHD prophylaxis. The primary endpoint was the incidence of acute GVHD; hematological recovery, nonrelapse mortality, and post-transplant complications were secondary endpoints. Filgrastim had no significant effect on the incidence of acute GVHD, platelet recovery, platelet transfusion requirements, chronic GVHD, or survival. Filgrastim accelerated granulocyte recovery significantly (with absolute neutrophil counts >.5 × 109/L achieved after a median of 16 days versus 23 days for placebo; P < .0001), and reduced both early nonrelapse mortality (2.9% versus 10.5%; P = .042) and the duration of i.v. antibiotic therapy (18 days versus 26 days; P = .001) and hospitalization (27 versus 34 days; P = .017). In conclusion, in this setting, filgrastim reduced significantly the duration of neutropenia, i.v. antibiotic therapy, hospitalization, and early nonrelapse mortality, without increasing the risk of acute and chronic GVHD or relapse, or delaying platelet recovery.

Comparative clinical trial: fluconazole alone or associated with topical ketoconazole in the treatment of pityriasis versicolor.

BACKGROUND: The efficacy of ketoconazole and fluconazole in pityriasis versicolor had been proved. AIM: To compare the efficacy and the safety of two doses of fluconazole given 1 week apart alone or associated to ketoconazole shampoo. METHODS: Our study included all patients with pityriasis versicolor who attended in dermatology department of Habib Thameur Hospital, Tunis (over a 21-month period). During the considered period, patients were randomly assigned in two study groups: G1 receiving fluconazole two doses 300mg given 1 week apart with G2 taken an association of fluconazole (two doses 300mg given 1 week apart) and ketoconazole shampoo the first day. RESULTS: Seventy one patients were enrolled in our study: 35 in the fluconazole group and 36 in the fluconazole associated to ketoconazole shampoo comparator group. The mean age was 29.1 years [16-70 years].  Concerning the clinical form, 27% had macular lesions, 24% had plaques and 49% had mixed form. Lesions werehyperchromic52%; hypochromic 15% and erythematous 6%. As for main location, 67% had lesions on the neck; 66% on the trunk, 60% on the shoulders. At the end of the study, there was no significant difference in clinical presentation and in improvement rate of pityriasis versicolor between fluconazole and association of fluconazole and ketoconazole shampoo ((p=0.13 at day 14, p=0.57 at day 28 and p=0.2 at day56). CONCLUSION: In this study, we have shown that the improvement rate of PV treated with two doses of 300 mg of fluconazole with one week interval was similar to those of an association of one application of ketoconazole shampoo and the same dose of fluconazole.

Prognostic factors in children with extracranial malignant germ cell tumors: a monocentric pediatric Tunisian study.

Background Extracranial Germ cell tumors (GCT) are a rare and a heterogeneous group of pediatric cancers but highly curable. Aim We aimed to review management, outcome and prognostic factors that influence overall survival (OS) in a pediatric Tunisian oncologic unit. Methods We retrospectively evaluated between January 1998 and December 2012, 33 patients affected by extracranial germ cell tumors and treated according to TGM95 protocol established by the SFOPin a pediatric Tunisian oncologic unit. Results Patients had a mean age of 57 months (ranges: 1 day-13 years). There were 19 girls and 14 boys. Primary sites included 12 sacrococcygeal, 11 ovarian, 6 testicular, 3retro peritoneal and 1 mediastinal site. After a mean follow up of 26.1 months (ranges: 0-96 months), OSat 2 years and 5 years were respectively 82% and 75%. Event-free survival were respectively 79% at 2 years and 74% at 5 years. Various prognostic factors have been studied according to Kaplan-Meier. Univariate analyses identified significant factors which influence strongly OS: the stage (p=0.04), the completeness of surgery (p<0.001) and the relapse (p = 0, 0001). A multivariate study showed that only the quality of resection and the clinical stage remained strong significant prognostic factors (p=0,021) for 5-year OS. Conclusion Disease stage, completeness of surgery and relapse have been established as the most powerful prognostic parameter in our analysis. The improvement of survival of patients affected by extracranial germ cell tumors in Tunisia is a real achievement mainly due to the success of salvage treatments.

[High risk areas for echinococcosis-hydatidosis in Tunisia]. / Identification des zones à risque élevé pour l'échinococcose-hydatidose en Tunisie.

AIM: The study was conducted in order to identify high risk areas for hydatidosis in Tunisia witch would be eligible for a Hydatidosis control program initiation. METHODS: The most recent epidemiological investigation on surgical incidence of hydatidosis was used to classify governorates according to their incidence rate. A "global hydatidosis risk score" was calculated for each governorate, combining some parameters related to the hygiene conditions of the population, the literacy rate, the canine density and livestock census. Spearman correlation coefficient was used to compare scores and surgical incidences. Mapping analysis has been conducted. The surgical incidence rate of hydatidosis classifies each governorate regarding occurrence of human cases. The global hydatidosis risk score, by governorate, pointed out the most exposed areas to the disease. RESULTS: The mapping analysis showed a good agreement between the incidence rate of the disease and the global hydatidosis risk score and made it possible to identify the population of the center and the west of the country as a most exposed population for the diseases. CONCLUSION: In order to have a chance for implementation, hydatidosis control program should target the three jointed governorates of Kasserine, Siliana and Kef, which have the highest incidence rates and the worst scores.

Predictive score for positive upper endoscopies outcomes in children with upper gastrointestinal bleeding.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a common pediatric emergency. Esophago-gastro-duodenoscopy (EGD) is the first line diagnostic procedure to identify the source of bleeding. However etiology of UGIB remains unknown in 20% of cases. Furthermore, emergency endoscopy is unavailable in many hospitals in our country. AIMS: Identify clinical predictors of positive upper endoscopy outcomes and develop a clinical prediction rule from these parameters. METHODS: Retrospective study of EGDs performed in children with first episode of UGIB, in the endoscopic unit of Children's Hospital of Tunis, during a period of six years. Statistical analysis used SPSS20. Univariate analysis was performed and multivariate logistic regression was then modelled to derive a clinical prediction rule. RESULTS: We collected 655 endoscopies (23.2% normal, 76.8% pathological). We found that time to EGD within 24 hours from the onset of bleeding (p=0.027; Adj OR: 3.30 [1.14 - 9.53]), rebleeding (p=0.009; Adj OR: 6.01 [1.57 - 23.02]), positive gastric lavage outcome (p=0.001; Adj OR: 4.79 [1.95 - 11.79]) and non steroidal anti-inflammatory drugs intake (p=0.035; Adj OR: 5.66 [1.13 - 28.31]) were predictors of positive upper endoscopy outcomes. By assigning each factor, the adjusted odds ratio (Adj OR), we developed a score with four items, ranging from 4 to 20. Using the receiver operating characteristic (ROC) curve the best cut off ≥ 9 was defined (sensitivity 88.2%, specificity 60.6%, positive predictive value 92.7% and negative predictive value 47.6%). The score discriminated well with a ROC curve area of 0.837 (95% confidence interval [0.769 - 0.905]). CONCLUSIONS: This clinical prediction rule is a simple measure that may identify children who needed emergency endoscopy. A prospective study is required to validate our results and evaluate other clinical features that were insufficient for this analysis.

Association of LRP5 genotypes with osteoporosis in Tunisian post-menopausal women.

BACKGROUND: Osteoporosis is a highly heritable trait. Among the genes associated with bone mineral density (BMD), the low-density lipoprotein receptor-related protein 5 gene (LRP5) has been consistently identified in Caucasians. However LRP5 contribution to osteoporosis in populations of other ethnicities remains poorly known. METHODS: To determine whether LRP5 polymorphisms Ala1330Val and Val667Met are associated with BMD in North Africans, these genotypes were analyzed in 566 post-menopausal Tunisian women with mean age of 59.5 ± 7 .7 years, of which 59.1% have low bone mass (T-score<-1 at spine or hip). RESULTS: In post-menopausal Tunisian women, 1330Val was weakly associated with reduced BMD T-score at lumbar spine (p=0.047) but not femur neck. Moreover, the TT/TC genotypes tended to be more frequent in women with osteopenia and osteoporosis than in women with normal BMD (p=0.066). Adjusting for body size and other potential confounders, LRP5 genotypes were no longer significantly associated with aBMD at any site. CONCLUSIONS: The less common Val667Met polymorphism showed no association with osteoporosis. The Ala1330Val polymorphism is weakly associated with lower lumbar spine bone density and osteopenia/osteoporosis in postmenopausal Tunisian women. These observations expand our knowledge about the contribution of LRP5 genetic variation to osteoporosis risk in populations of diverse ethnic origin.

A randomized, controlled trial of nebulized 5% hypertonic saline and mixed 5% hypertonic saline with epinephrine in bronchiolitis.

BACKGROUND: Bronchiolitis is a public health problem in the word and in Tunisia. Nebulized hypertonic saline seems to have some benefits in bronchiolitis. The aim of this study is to evaluate the efficacy of nebulized 5% hypertonic saline alone or mixed with epinephrine in bronchiolitis as measured by improvement in clinical score, oxygen saturation or reduction in duration of hospitalization. METHODS: This prospective, double blind, placebo controlled, randomized clinical trial was performed at Children's Hospital of Tunis from February 2012 to Mars 2012. A total of 94 patients less than 12 months of age with diagnosis of moderately severe bronchiolitis were enrolled and assigned to receive 5% nebulized hypertonic saline, mixed 5% hypertonic saline with standard epinephrine 0,1% or normal saline (placebo) at admission and every 4 hours during hospitalization. RESULTS: There were no significant difference between nebulized 5% hypertonic saline, mixed 5% hypertonic saline with epinephrine or normal saline at baseline, T30 min, T60 min, and T120 min after start study in Wang severity score, oxygen saturation in room air, rate respiratory and heart rate. There was no difference in duration of hospitalization. CONCLUSION: Nebulized 5% hypertonic saline or mixed 5% hypertonic saline with epinephrine are safety but does not appear effective in treating moderately ill infants with the first acute bronchiolitis.

Anomalies of intra-synovial citrullination: is there any interest in the diagnosis of early rheumatoid arthritis?

Autoantibodies to citrullinated proteins (ACPA) are specifically associated with rheumatoid arthritis (RA) and seem to play an important role in its pathogenesis. The specific immunological conflict between ACPA and citrullinated fibrin plays a major role in the self-maintenance of synovial inflammation by forming fibrin deposits in the synovial tissue. These deposits, secondarily citrullinated by a local peptidylarginine deiminase (PADI) enzyme activity, seem to maintain the immunological conflict and the inflammation. Our objective in this work is to study the anomalies of citrullination in a group of patients with early RA, in comparison with a control group of patients suffering from undetermined inflammatory arthritis, osteoarthritis and spondyloarthropathy. For this purpose, we used an enzyme-linked immunosorbent assay (ELISA) to determine the levels of ACPA in serum and synovial fluid. By immunohistochemistry, subtype 4 of PADI was also sought in the synovial biopsies taken from all our patients. We found that the ACPA levels in serum and synovial fluid were significantly higher in patients with RA. The enzyme PADI4 was found only in the group with RA and was statistically correlated with ACPA mean levels in sera and synovial fluid. The expression of PADI4 seems to correlate with intra-synovial deposits of fibrin in RA. However, determination of synovial ACPA levels and detection of intra-synovial PADI4 deposits are of no additional benefit compared with assessment of ACPA levels in serum for the diagnosis of early RA.

[Medical demography in Tunisia: current situation and perspectives]. / Demographie medicale en Tunisie: etat actuel et perspectives.

BACKGROUND: Health human resources management is one of the important determinants of health care access equity. AIMS: To analyse the trend of Tunisian medical density during 2000-2009 and to predict its situation by 2024. METHODS: Current medical density was calculated using Bar Council of Physicians of Tunisia database. Medical density was calculated and analysed for the period 2000-2009 then modelled by 2024 (estimate of needs and supply). RESULTS: The active medical density raised by 36% during the period 2000-2009 with a higher increase for specialists. The proportion of non-active physicians rose from 4.6% to 15.2% in 2009. Increasing feminization of medical density and persistence of its regional disparities. By the year 2024, 217 physicians for 100,000 inhabitants would be required while the supply would correspond to 212/100 000 inhabitants. CONCLUSION: medical human resources have indeed globally improved. However, some lacks remain and adequate measures are required, based on a rational planning directed to satisfy the population needs and to allow health equity.

[Effect of inhaled corticosteroids on bone mineral density in asthmatic adults: a 20 cases study]. / Effet de la corticothérapie inhalée sur la densité minérale osseuse chez l'adulte jeune asthmatique : a propos de 20 patients.

BACKGROUND: Inhaled corticosteroids are widely used in the treatment of asthma but their safety on bone density is controversial. AIM: To study in a population of adults with asthma receiving inhaled corticosteroids for long term, the effect of this therapy on bone mineral density. METHODS: Prospective study including 20 asthmatics, aged from 20 to 45 years, treated with inhaled corticosteroids for 12 months or more, with no risk factors for osteoporosis. We compared osteodensitometric parameters in our patients, bone mass and T-score at vertebral and femoral witness to a population matched by age and sex. RESULTS: The average age of our patients was 35.45 ± 5.43 years and the average BMI was 30.03 ± 5.77 kg/m2. The average daily dose of corticosteroid was 925 ± 133.27g of equivalent of beclometasone with an average take of 33.5 ± 21.3 months. The vertebral site bone mass average was 1216 ± 0106 g/cm2 in the studied group and 1201 ± 0099 g/cm2 in the control group without significant difference (p = 0380). At femur, the bone mass average was 1037 ± 0143 g/cm2 in the patient group and 1056 ± 0107 g/cm2 in the control group (p = 0380). We did not find a significant link between bone mineral density and cumulative dose or the duration of taking inhaled corticosteroids, BMI and tobacco. CONCLUSION: Our work confirms like other previous studies the safety of inhaled corticosteroids on bone mineral density.

[Palliative chemotherapy of non small lung cancer in Tunisia. Prospective study of the cost and impact on the quality of life]. / Chimiothérapie palliative des cancers bronchiques non à petites cellules (CBNPC) métastatiques en Tunisie: etude prospective du coût et impact sur la qualité de vie.

BACKGROUND: Bronchopulmonary cancer is actually the first cancer in the world. In Tunisia, recent statistics are alarmous. The most bronchopulmonary cancer in tunisian series are diagnosis at metastatic states. AIM: To evaluate the cost of the global treatment by chemotherapy in patients with metastatic non small lung cancer and its impact over the quality of life in Tunisia. METHODS: It's a prospective study lead between January 2006 and Juin 2007 to evaluate the quality of life for patients hading metastatic non small lung cancer treated by palliative chemotherapy in Ibn Nafiss department in Abderrahmen Mami hospital.The evaluation of the quality of life is inspired by the questionnaire of EORTC: QLQC30 version 3 translated in en Arab language, filled before chemotherapy, after the le 3rd cycle, and at the end of the first ligne. The study of the cost is effected for the 2 protocols whose the most used in first ligne : Cisplatin-Vinorelbine (P-V) and Cisplatin- Gemcitabine (P-G) RESULTS: 30 patients had benefit from palliative chemotherapy based on P-V (18 cases) or P-G (12 cases). All patients had responded for the questionnaire in the opportunity moments. After 3 cycles of chemotherapy, we note an improve of the symptomatic, physical, activity, emotional and global health scales. In opposition, we note a deterioration of cognitive and social scales without any supplementary improvement(no significant difference) if we add other cycles in the twice protocols. At the same level of the benefit in term of quality of life and survival without supplementary toxicity, the choice is made by the less cost's protocol in other words P-V. CONCLUSION: Our results confirm the benefit from chemotherapy in term of survival and quality of life in our context, however, the important cost of the chemotherapy necessitate to rationalize the indications and the le choice of the treatments in this palliative indication.

[Obesity hypoventilation syndrome and obstructive sleep apnea syndrome: is there an association?]. / Syndrome d'obésité hypoventilation et syndrome d'apnées de sommeil : quel type d'association?

BACKGROUND: Severe obesity sometimes leads to a chronic alveolar hypoventilation: obesity hypoventilation syndrome (OHS), (Pao2<70mmHG, Paco2>45mmHG and body mass index (BMI)>30Kg/m2). The association with an OSAS is frequent. AIM: To assess predicting factors that lead to hypoventilation in a population of obese patients with SAS and to deduct the type of association between OHS and SAS. METHODS: We have study during 4 years, at pneumology service of Charles Nicolle hospital, 62 obese patients (BMI>30Kg /m2), 41men and 21 women and presenting an OSAS. We excluded those carriers of a bronchial obstruction (VEMS/CV <60%) and we have compared anthropométriques, functional, gazométriques and polysomographiques details of the groupe1 (G1): OHS=9 and of the groupe2 (G2): obesity without hypoventilation (n=53). RESULTS: We didn't identified any significant difference between the two groups concerning (age, sex, the frequency of smokers, the frequency of the nasopharynx region abnormalities, apnea-hypopnea index (AHI), the SAS severity and the respiratory functional exploration). The obesity is significant more important in the G1, it is sever (BMI>40) in 77.8% of patients of the G1 with significant difference with the G2 (P=0.004). We noted that there is a positive interrelationship between BMI and Paco2. We identified severe gazométrique perturbation in G1 (Pao2 medium = 61± 9 mmHg,Paco2 medium=50 ± 7 mmHg), in the G2 we noted a moderate hypoxemia. Patients of the group1 make of the minimal desaturation of 63 ± 17% and a Sao2 average of 81 ± 20% what is meaningfully more important than in the G2. CONCLUSION: The alveolar hypoventilation in SAS seems to be in correlation with the degree of obesity. The hypercapnie in the OHS is in relation neither with the SAOS nor with its severity. The OHSSAS association is usual but not synonym; the OHS is an autonomous disease.

Prevalence and risk factors of overweight and obesity in elementary schoolchildren in the metropolitan region of Tunis, Tunisia.

BACKGROUND: Local data about prevalence of obesity in emerging countries are rather scarce. Risk factors for obesity, well known in most industrialized countries, are poorly understood in Tunisia. AIMS: To assess prevalence of overweight and obesity and to investigate associations with possible risk factors in a group of 6-12 year- old schoolchildren in Tunis, Tunisia. METHODS: A descriptive transversal study including a sample of 1335 schoolchildren (6-12 years; mean: 9.7 ± 1.5 years) was conducted in Tunis. Personal and parental data were collected by questionnaires completed by parents. Height and weight were measured and body mass index was calculated. Prevalence of overweight and obesity was defined based on international agreed cut-off points. RESULTS: Prevalence of overweight and obesity was 19.7% and 5.7%, respectively. Risk factors associated with overweight were: high degree- educated mother and father: 17.3% vs 11.7% (p=.01) (OR (95%CI): 1.58; 1.09-2.29) and 26% vs 17.4% (p=.002) (OR: 1.66; 1.21-2.29), respectively; mother, father high in occupational hierarchy: 7.2% vs 3.6% (p=0.009) (OR: 2.1; 1.2-3.7) and 14% vs 9% (p=.014) (OR: 1.6; 1.1-2.48), respectively. Overweight children had a significantly higher consumption of bread (p=.044), of snack intake (p=0.046) and of soft drink consumption (p=.035). CONCLUSIONS: Prevalence of overweight and obesity in this cohort are 19.7% and 5.7%, respectively. Substantial differences in food choices in families with the highest socio-economic status are among risk factors contributing to obesity development.

HLA-B, DR and DQ antigens polymorphism in Tunisian patients with ankylosing spondylitis (a case-control study).

The objective of the study is to assess the distribution of HLA-B genes, HLA-B27 subtypes, HLA-DRB1 and HLA-DQB1 alleles in patients with ankylosing spondylitis (AS) and in control subjects in the Tunisian population and to compare their distribution with that found in other countries. This is a case-control study that included 100 consecutive patients (85 males/15 females) with AS according to the modified New York criteria and 100 control individuals. HLA-B, B27 subtypes and class II (DR and DQ) typing of all subjects was performed by polymerase chain reaction amplification with sequence-specific primers (PCR-SSP). HLA-B27 was found in 62% of patients against 3% in controls (P = 0.0000, OR = 52.6, 15.6 < CI < 166.7). On the other hand, B*07 and B*51 were significantly decreased in comparison with controls (P = 0.01, OR = 0.3, 0.1 < CI < 0.8 and P = 0.0000, OR = 0.2, 0.1 < CI < 0.4, respectively). Eight B*27 subtypes were identified in the AS group, but the most frequent ones were B*2702 (32%) and B*2705 (24%). Among HLA-DRB1 alleles, a significant increase in DRB1*11 was found in comparison with controls (P = 0.01, OR = 2.2, 1.2 < CI < 4.5). However, DRB1*13 had a negative association with AS (P = 0.01, OR = 0.4, 0.2 < CI < 0.8). For HLA-DQB1 alleles, a significant positive association with DQB1*03 was observed in AS group (P = 0.03, OR = 1.8, 1.0 < CI < 3.4). Multivariate analysis by logistic regression revealed that DRB1*11 and DQB1*03 had no direct links with the disease, but were dependent on the presence of HLA-B27. Moreover, B*07 and B*51 seemed to have independently a negative correlation with AS, but DRB1*13 seemed to depend on B*51. Haplotypes carrying B27 were significantly associated with AS and those carrying B*07 or B*51 were negatively correlated with the disease. In conclusion, our study confirms that B27 predisposes to AS while B*07 and B*51 are negatively correlated with the disease.

[Tuberculosis control programme in Tunisia: efficacy assessment]. / Evaluation de l'efficacité du programme tunisien de lutte antituberculeuse.

The aim of this study was to assess the efficacy of the national Tuberculosis Control Programme in Tunisia, by applying the 8-stage model proposed by Piot (1967). Two retrospective cohorts of tuberculosis cases, including all new smear-positive cases detected by all laboratories in the study area during the study period, were selected at least 2 years after treatment began. The real number of new active cases during the study period was estimated at 142, the case detection rate at 61%. In all, 70% of patients started tuberculosis treatment, and regular use of the home treatment varied from 87% (including irregular use) to 71% (excluding irregular use). The low global efficacy of the program, which ranged from 26 to 31%, indicates the need for improved application of the strategy by programme managers.

[Role of lumbar puncture for febrile seizure among infants under one year old]. / L'utilité de la ponction lombaire en cas de convulsion fébrile chez le nourrisson agé de moins d'un an.

BACKGROUND: Febrile seizure is a frequent cause of hospitalization. Its management remains problematic. According to the American Academy of Pediatrics, lumbar puncture, which is not devoid of risk, is strongly recommended in infants under 1 year. AIM: to define the utility of lumbar puncture in the management of febrile seizures in infants under 12 months and to identify risk factors of meningitis and to respond to this question: "lumbar punction should be done in which infant with febrile seizure?" PATIENTS AND METHODS: This retrospective study was conducted in the department of pediatrics B in the Children Hospital of Tunis on eight-year period (2000-2008). In all statistical tests, significance level was set at 0.05. RESULTS: One hundred and six cases were collected during the period of study. Seizures related to bacterial meningitis were seen in 11 cases (10%). We have separated two groups: GI infants presented bacterial meningitis, and G2 infants with febrile seizure. The comparison between the two groups G1 and G2 showed the following predictors factors of meningitis: age < or = 7 months (p = 0.035), partial seizure (p = 0.028), duration of seizure > 5 min (p < 0.001), recurrence of seizure in the same day(p = 0,006), neurological abnormalities p < 0.001), CRP > 20 mg/l (p = 0.03), hyponatremia < or = 125 mmol/l (p = 0.01). The risk of meningitis is very low: 3.1 x 10 -3, if this condition is met: infants older than 7 months, having a unique and short seizure < or = 5 min, and with a CRP < or = 20mg/l. CONCLUSION: If the infant is older than 7 months, presenting a unique, febrile and short (< or = 5 min) seizure, having a normal neurological examination with CRP < or = 20 mg/l, lumbar puncture should be discussed a case by case but an hospitalization for 24 hours is required for monitoring.

[Autoimmune hepatitis in Tunisia. Retrospective multicenter study of 83 cases]. / L'hépatite auto-immune en Tunisie. Étude multicentrique rétrospective de 83 cas.

BACKGROUND: Autoimmune hepatitis (AIH) is a chronic inflammatory condition of the liver of unknown etiology. Its epidemiological and anatomoclinical characteristics and its outcome were unknown in Tunisia. AIM: To analyse epidemiological, anatomoclinical, immunological and histological aspects of AIH and to determine factors predicting relapse after treatment and death of this disease in Tunisia. METHODS: Patients presenting with AIH between January 1996 and December 2004 were evaluated in retrospective multicentric study. The diagnosis of AIH was established according to the criteria of the revised score of the international autoimmune hepatitis group (1999) RESULTS: Eighty three patients were identified (70 female; mean age=49+17.9 years). 63% presented probable AIH and 37% presented definite AIH. Thirty two percent presented with the acute pattern. Eighty three per cent of cases were type I AIH and 5 % of cases were type II HAI. Fifty seven percent of the patients were cirrhotic at presentation. Associated autoimmune diseases was seen in 27 patients, dominated by diabetes, autoimmune thyroiditis and Sjögren's syndrome. An overlap syndrome was diagnosed in 25% of cases; primary biliary Cirrhosis-AIH in 20% of cases and primary sclerosing cholangitis-AIH in 5% of cases. Fifty patients were treated by glucocorticoids as monotherapy or in combination with azathioprine. Complete remission was achieved in 90% of cases. Fourteen percent relapsed within a median time of 12 months. Factors associated with relapse were: treatment with Azathioprine<18 months, absence of lobular necrosis and anti-nuclear antibody (+) profile. Mortality was observed in 17 % of cases. Factors associated with death were encephalopathy as an independent factor and treatment with Azathioprine<18 months. CONCLUSION: In Tunisia, epidemiological and clinical characteristics of AIH were similar to those reported in the literature but with a higher frequency of cirrhosis at presentation. Treatment with Azathioprine < 18 months was the main factor associated with relapse and represented with encephalopathy a factor associated with death.

Long term inhibition of hip joint damage under tumor necrosis factor-alpha inhibitors in spondyloarthritis.

The aim of this study was to assess the impact of long-term treatment with TNF blockers on the radiographic progression of hip disease in spondyloarthritis (SpA). This retrospective multicentric cohort study included 2 groups of patients with SpA and hip involvement. Patients of group 1 were treated with anti-TNF alpha for at least 2 years, whereas those of group 2 were anti-TNF-naïve patients. Clinical, laboratory and radiologic parameters were assessed at baseline and after at least 2 years. Groups 1 and 2 included respectively 48 and 46 patients. The radiological features of hip disease were comparable between the two groups at baseline. The second evaluation was performed after an average duration of 4.1 ± 2.9 years [2-10] in group 1 and 4.8 ± 2.1 years [2-14] in group 2 (p = 0.116). The absence of hip structural damage was more frequently found in group 1 (72 hips vs 52, p < 0.0001, odds ratio [OR] = 4.7, 95% confidence interval [CI] = 2.1-10.4). The better outcome in group 1 remained significant even after adjusting for BASDAI (p < 0.05, (adjusted odds ratio [aOR] = 3.3, 95% CI = 1.2-9.2), BASFI (p < 0.0001, aOR = 3.1, 95% CI = 1.1-8.9), and CRP (p < 0.01, aOR = 4.2, 95% CI = 1.8-9.8). Our finding suggests that anti-TNF therapy may inhibit hip joint damage in patients with SpA.

[Biologic profile in Tunisian infants (0-2 years), malnourished]. / Profil biologique d'une population de nourrissons Tunisiens (0-2 ans), malnutris.

BACKGROUND: The malnutrition of the infants could be explained by a delay of the growth and the perturbation of biological parameters. AIM: To establish the nutritional profile of the Tunisian infant of less than two years. To specify the principal deficiencies and the possible origins of these deficiencies. METHODS: In our transverse exploratory study, carried out in period of 9 month. This study was conducted in two groups of Tunisian young children less than two years old: a control group and a malnourished group (Z score < or = 2SD). RESULTS: Our data consolidate the important impact of pregnant women nutritional state and of breastfeeding on the foetus ant infant growth.Compared to control infants, the malnourished young showed a significant alteration of different biologic parameters. This alteration appeared positively linked to the gravity of malnutrition as indicated by the positive relation obtained between the weight/height ratio and many studied parameters. The malnourished infants showed, notably, a significant reduction of the average values of Chol-HDL, apo AI, Vit E, TSH and TF4 levels and Chol-HDL/Chol LDL ratio. Chol-HDL, apo AI and HDL/Chol-LDL are found positively and significantly correlated with TF4. So, their reduction in ill children would be, at least in part, a side effect of the thyroid function reduction. CONCLUSION: Our results confirm the existence of an important change of biological profile in malnourished young children. Besides, they emphasize that studies about young children could be helpful, notably, in the prevention and the fight against atherosclerosis.