Assessment of Biventricular Function in Patients with Obstructive Sleep Apnea and Atrial Fibrillation: A Cross-sectional Study Using Two-dimensional Speckle Tracking Imaging

Background:Obstructive sleep apnea syndrome (OSA) is a common but often under diagnosed condition.According to literature,OSA prevalence in atrialfibrillation (AF) patients varies from 21 to 85%. OSA is increasingly recognized as a risk factor for biventricular dysfunction. The present study aimed to compare left and right ventricular functions, assessed by conventional echocardiographic parametersand speckle tracking imaging, in non-valvular atrial fibrillation (NVAF) patients with and without severe OSA.Methods: Across-sectional analytic study was conducted. Forty successive patients with NVAF were included. All of them had a clinical screeningfor symptoms suggestive of OSA and underwent polysomnographic study. Patients were divided into two groups (group 1: without severe OSA with an apnea-hypopnea index (AHI) < 30 events per hour (e/h), and group 2: having severe OSA with an AHI ≥ 30 e/h). Echocardiography was performed in all patients. Left and right ventricular function parameters were measured including global longitudinal strain (GLS) and myocardial performance index (MPI).Results: OSA was diagnosed in 90% of NVAF patients. The average AHI was 22.1 ± 13 e/h.Eleven patients (27.5%) had mild OSA, 9 patients (22.5%) had moderate OSA, and 16 patients (40%) had severe OSA.General clinical characteristics were comparable between groups.A statistically significant association was demonstrated between severe OSA and impairment of left ventricular GLS (-17.3 ± 4.5 vs. -14.9 ± 3%, in group 1 and 2 respectively, p = 0.02) and left ventricular MPI (0.37 ± 0.09 vs. 0.49 ± 0.13, in group 1 and 2 respectively, p = 0.01).Right ventricular lateral wall strain was non significantly lower in group 1 compared to group 2 (-22.5 ± 8.4 vs. -18.4 ± 5.8%, in group 1 and 2 respectively, p = 0.15).On multivariate logistic regression analysis, left ventricular GLS impairment (> -18%) and MPI > 0.37 were independent predictors of severe OSA.Conclusion: Severe OSA was diagnosed in 40% of NVAF patients. Impairment of left ventricular GLS and left MPI were statistically associated with severe OSA

[Resistance to sectorisation: example of the governorate of Nabeul in Tunisia]

Sectorisation was introduced in Tunisia in 1999. The objective of this study was to examine the difficulties and resistance to the sectorisation of psychiatric care in the state of Nabeul. A transversal study was conducted over a period of 5 months from 1 November 2014 to 31 March 2015 on 96 patients resident in the state of Nabeul and treated at Razi hospital. Patients were aged between 18 and 69 years old [ sex ratio equal to one], 55.2% were single and 46% had a low socio-economic level [n=44]. Chronic psychotic disorder was diagnosed in 64.3%, depression in 12.3%, bipolar disorder in 18.8% and mental retardation in 3% of cases. Most of them refused to continue psychiatric treatment in the second or the first line of care. Resistance to sectorisation was associated with a low socioeconomic level [P = 0.039], availability of a companion [P = 0.04], celibacy [P = 0.04], gender [P = 0.05] and negatively correlated to psychotic disorder diagnosis. It was concluded that the environment plays an important role in the choice of the place of care. Subjects treated for mental illness were found to have greater trust in the structures that treated the acute episode of their illness, and paradoxically felt less stigmatized in Razi hospital

[Meningitis after spinal anesthesia [cases reports and litterature review]]

Meningitis is a rare complication after spinal anesthesia. We report 4 cases of meningitis occurred after spinal anesthesia. These meningitis were diagnosed during tow months and with 3 different operators. The first symptoms appeared 4 to 6 hours after surgery and were represented especially by headaches and fever. Cyto-chimic analysis of cerebrospinal fluid [CSF] indicates bacterial meningitis but soluble antigens and culture were negative. Evolution was favorable in all cases under or without antibiotics. The exactly cause of these meningitis remained unknown and an insufficient asepsis was the principle risk factor found in all cases. Prevention of this risk consists on hygienic rules and perfect skin disinfection

[Evaluation of urinary metanephrines for the diagnosis of pheochromocytoma]

Evaluate the assay of urinary metanephrines in diagnosis of pheochromocytoma [PH] and determine diagnostic cut-off values.This is a retrospective study about 87 patients suspected of pheochromocytoma,whose of 24-h urinary fractionated metanephrine was measured. These cases were collected from Internal Medecine Departments [A and B] at Charles Nicolle's Hospital. Two groups of patients were studied: a pheochromocytoma group [n=33] with a histologically-proven pheochromocytoma and a control group of 54 patients. Receiver Operating Characteristic [ROC] curves were used to determine the best sensitivities and specificities. The analysis of biological parameters showed that means and standard deviation of urinary fractionated metanephrines in pheochromocytoma group were significantly higher than those of control group. Sensitivity and specificity of urinary normetanephrine test [95% and 98.1% respectively] were higher than those of urinary metanephrine and 3-methoxytyramine. A correlation between urinary normetanephrine and tumor size of pheochromocytoma was found. Urinary fractionated metanephrines is an efficient biochemical test for the diagnosis of pheochromocytoma

Prognostic value of pheochromocytoma of the adrenal gland scaled score [PASS score] tests to separate benign from malignant neoplasms

Differentiating malignant from benign pheochromocytoma has been challenging when based on histologic features. This is due to the definition of malignant pheochromocytoma which are defined by the presence of metastases. A PASS score was developed and according to many authors, a PASS score> =4 identified potentially malignant tumors. To assess the prognostic value of PASS score in differentiating benign pheochromocytomas from malignant ones. The records of 11 patients with tumors diagnosed as "pheochromocytoma" were identified from 1970 to 2010 in the files of the pathology, intern medicine and biochemistry departments of the Charles Nicolle hospital and Pasteur Institute. Receiver operating characteristics [ROC] curve analysis was performed to evaluate the diagnostic performance of PASS. The logistic model was developed using the 11 predictive variables. Its performance was evaluated by calculating the area under the ROC curve and comparing it with that of the PASS. In benign tumors, The PASS score was <4 in 3 cases and >/= 4 in 6 cases. In malignant tumors, the PASS score was >/= 4 in both cases. According to the ROC curve analysis, a PASS equal or superior to 4 identifies malignant pheochromocytoma with a sensitivity of 50% and a specificity of 45%. I think that PASS score, despite its low sensitivity, may help to reserve the more aggressive treatment and narrow follow up for potentially malignant tumors. Widespread of this called score with complete clinical data will help to validate these findings and to add other prognostic factors of value that could be a part of this scaled score such as immunohistochemical findings

[Evaluation of a protocol of spinal anesthesia for Cesarean in Tunisian maternity: hemodynamic repercussions and risk factors of hypotension]

To evaluate hemodynamic repercussion of a protocol of spinal anesthesia [SA] for cesarean and release the predictive factors of maternal arterial hypotension post spinal anesthesia. We included parturients proposed for Cesarean under SA. They were not included the women of statute ASA > II, preeclamptics, eclamptics and/or having counter-indications of SA. We excluded the cases where there were technical difficulties at the time of the realization of SA, a failure or a complication of this SA. We injected 10 Mg of bupivacaïne 0.5% isobar, 10 micro g of fentanyl and 100 micro g of morphine. The data were collected before the realization of SA [anthropometric parameters; antecedents; basic systolic and diastolic blood pressures [BSBP and DSBP] and basic heart rate [BHR]] and after SA [systolic and diastolic blood pressure [SBP and DBP], heart rate [HR]; occurred or not of a sympathetic block [falls of the SBP of more than 20% of its basic value or a SBP<90 mm Hg]; the time of installation of the sympathetic block and the duration of hypotension. The full number of parturients included was 1016 among whom 16 were excluded. Only 1000 parturients finished the study and were divided into 2 groups [group 1: 500 emergency cesarean and group 2: 500 elective cesarean]. The incidence of the sympathetic block was of 44.2% as a whole and this block was significantly more frequent in group 2 [p=0.0001]. There was a significant relation between the incidence of a sympathetic block and the advanced age of the parturient [p=0.0001], the important weight [p=0.047], high ASA statute [p=0.0001], the presence of hypertension [p=0.0001], diabetes [p=0.001] or cesarean [p=0.00015] in the antecedents and the low BSBP [p=0.015]. In spite of the beneficial effect of the reduction in the amounts of local anesthetic in the SA, the sympathetic block remains frequent after SA for Cesarean. Thus, it is essential to detect the high risk women of occurred of sympathetic block after SA, and to propose strategies of prevention, monitoring and management for this population

[Is there a link between the occurrence of kidney cancer and hypertension in Tunisian population?]

Kidney cancer is generally asymptomatic and discovered incidentally at a late stage, which is a negative diagnosis because in most cases the disease is incurable at this stage. Some predisposing factors have been revealed by studies such high blood pressure, which is a frequent among the Tunisian population. A study among the Tunisian population to determine if there is a link between the occurrence of kidney cancer and the hypertension. Our work was conducted on 91 patients with confirmed renal cell carcinoma and 91 healthy subjects who consulted the Urology Department at the Charles Nicolle Hospital in Tunis. The study of clinical records has identified the clinical, pathological and therapeutic features of the 182 patients. 59% of individuals with hypertension have developed kidney cancer with a significant p-value equal to 0.03. The more the value of blood pressure increases the more the risk is [p = 0.03]. Smoking in combination with hypertension is a factor favoring the occurrence of cancer with a value of p equal to 0.05. In the Tunisian population hypertension is a risk factor for developing kidney cancer, a factor compounded by the high incidence of this disease. What prompts us to make explorations of kidney lodges of hypertensive patients

[Immunogenetics of psoriasis: update]

Psoriasis is a chronic inflammatory skin disease often benign, affecting 2-3% of the total world population. Psoriasis is a multifactorial disease. To present recent advances in the immunologic mechanisms and susceptibility genes involved in the pathogenesis of psoriasis. We presented a literature review of recent genetic and immunological basis of psoriasis to better understand the pathomecanisms of this disease and discuss the contribution of the Tunisian work in this area. Recent works focalized mainly in immunology and genetics. Current progresses in molecular biology have allowed to better characterize the immunogenetic abnormalities in psoriasis. Psoriasis is a multifactorial disease model in which environmental factors [psychological, climate, traumatic, infectious, and viral] seem to be triggering factors when associated with a particular immunogenetics predisposition

Evaluation of cytotoxicity and biological activities in extracellular polysaccharides released by cyanobacterium Arthrospira platensis

The aim of this work was to evaluate the cytotoxicity of Arthrospira platensis Extracellular Polymeric Substances (EPS) for colon cancer and kidney cell lines. Results showed that EPS were free from cytotoxic effects. A variety of solvents were assessed for their ability to extract the bioactive ingredients from EPS. Methanol gave the highest yield (75.75 percent) than other solvents. The extracts were tested for activities against a collection of Gram+/- bacteria. The methanol extract exhibited a more potent activity than the other organic extracts, whereas the aqueous extract was active against Staphylococcus epidermis (Gram+) and Salmonella typhimurium (Gram-). Finally, The extracts were also tested for the antioxidant activity, using the Trolox Equivalent Antioxidant Activity assay. The methanol extract displayed a moderate antioxidant activity (TEAC = 0.027 mg/ml). The HPLC analysis of this extract revealed two distinct peaks: 8.1 kDa (8.31 min) and 4.1 kDa (8.54 min).

[Location and bowel subcellular liver of aluminium and administered indium oral rat]

Aluminium and indium are two elements used in industrial and medical fields. The purpose of this work was to study the subcellular localization of these elements, after their single and simultaneous oral administration to rats. 2h after the administration of these two elements, the small intestine and the liver were removed. Ultrastructural study showed the presence of electron dense deposits in the lysosomes of apical parts of duodenal enterocytes. When the minerals were administered simultaneously, deposits were observed in lysosomes of duodenal and jejunal enterocytes. No deposits were seen in the hepatic tissue of treated and control rats. Microanalysis identification showed that the deposits are constituted of aluminium, indium as well as phosphorus. Our results suggested that the elements are concentrated, in lysosomes, under the form of insoluble phosphate salts and it seemed that there are no specific lysosomes for the concentration of minerals since the two elements were concentrated in the same lysosome when they are administered simultaneously

[Emphysematous cystitis and pyelonephritis: an exceptional association]

Emphysematous cystitis and pyelonephritis is a rare infectious disease of the urinary tract. Its reputedly-serious prognosis is related to treatment failures revealing ignorance concerning its pathophysiological mechanisms. One case of this disease was seen in our department, a diabetic woman over the age of 78 years with a history of hypertension. She presented to the emergency department with hematuria, pain in her lower abdomen and alteration of the general state. The urine culture isolated Klebsiella pneumoniae. The treatment consisted of bladder drainage associated with adapted antibiotic therapy and diabetes control. The prognosis of this disease depends on early diagnosis and prompt effective treatment

[Obesity hypoventilation syndrome and obstructive sleep apnes syndrome: what kint of association?]

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. 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. 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 anthropom‚triques, functional, gazom‚triques and polysomographiques details of the groupe1 [G1]: OHS=9 and of the groupe2 [G2]: obesity without hypoventilation [n=53]. 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 gazom‚trique 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. 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

[N-acetylcysteine in septic shock]

To focus on the various studies evaluating the effects of Nacetylcysteine in septic shock. Main references obtained from the medical database Medline using the keywords: N-acetylcysteine; septic shock, free radicals. Septic shock remains the leading cause of mortality in intensive care units. The progressive knowledge of the pathophysiology of septic shock, underline the production of free radicals and their cellular and microcirculatory effects. The Nacetylcysteine used mainly in paracetamol poisoning, has properties to control free radicals. The explosion of free radicals in septic shock has led to multiple studies assessing the role of N-acetylcysteine as an anti radical, and for its anti inflammatory action. NAC seems to play an important role in septic shock to control free radicals and the inflammatory response. But these results remain contradictory. Some larger and more standardized studies should allow to evaluate the actual effects of NAC in septic shock

model of end-stage liver disease [MELD] score in predicting postoperative liver failure after hepatic resection of hepatocellular carcinoma in cirrhotic patients: the Tunisian experience

Hepatocellular carcinoma [HCC] is one of the most frequent cancers in the world. Factors associated with prognosis following resection remain ill defined. The model for end-stage liver disease [MELD] is considered as an index of hepatic functional reserve. This study evaluates the reliability of the MELD score in the prediction of liver failure after hepatic resection for HCC in cirrhotic patients. A retrospective chart review was undertaken of patients with HCC and cirrhosis undergoing hepatic resection between January 1991 and December 2007. A total of 26 cirrhotic patients underwent curative hepatic resection for HCC at our department. Patient information included demographic features, American Society of Anesthesiologists [ASA] class, etiology of cirrhosis, laboratory test results, type of surgical procedure, duration of hospitalization, and Child-Turcotte-Pugh and MELD score. Six patients [23.1%] developed postoperative liver failure. AS much as 66.66% of liver failures were seen in patients who have had major hepatectomy. Using receiver operating characteristic curve analysis, we identified that a MELD score equal to or above 9.5 is the best cut-off value for predicting postoperative liver failure. Patients were divided into two groups: MELD below 9.5 [group A] and MELD equal to or above 9.5 [group B]. The highest prevalence of postoperative liver failure of 83.33% was observed in group B. MELD score >/= 9.5 and low serum sodium are strongly predictive of increased postoperative liver failure in patients with cirrhosis undergoing hepatic resection of HCC. The presence of liver cirrhosis is an important factor that affects the prognosis of patients with hepatocellular carcinoma [HCC]. Cirrhotic patients with a high MELD score are at high risk of postoperative liver failure and complications and should be referred for non-surgical treatment

[ prophylaxis of the thromboembolic disease in the head trauma]

The prophylaxis of the thromboembolic disease in the severe head trauma remains a controversy. In this study, we are interested to the determination of under groups of patients for whom the advantages of the prophylaxis of the thromboembolic disease [TED] are higher than its disadvantages. We proceeded to a retrospective study based on patient medical records ranging from March 2003 until March 2004, enrolling 56 consecutive patients. The data collected related to the age, the gender, past medical history, the type of trauma, results of age, the gender, past medical history, the type of trauma, results of the initial CT scan, the treatment, appearance or not of the thromboembolic disease and its prophylaxis therapy. The average age was of 36 +/- 19 years. 76.8% did not have significant past medical history. All the patients profited from an elastic compression stocking. The LMWH were used among 15 patients victim of severe head trauma associated with other injuries and 72 hours after stabilization of hemorrhagic attacks. A thromboembolic disease diagnosis was based clinical or biological assumptions. Among 56 patients, 4 of them showed a TED with an incidence of 7.1 including 3 DVT and one case of pulmonary embolism. The 4 patients sustain severe multiple trauma; 3 of them received an early anti-coagulation therapy. In the group of patients with TED, the OMEGA scores and IGS are high; all of them are multiple traumatized patients with shock requiring a blood transfusion in 75 of the cases. Only the blood transfusion is correlated at the risk of TED, statistically established. The risk to develop a thromboembolic complication in the traumatic patients with head injury is high particularly in case of associated muscleskeletal injuries. Elastic compression technique is not always effective but considered as an interesting alternative to the pharmacological prevention of thrombosis. The use of the anticoagulants therapy must be careful. It is contra-indicated in case of cerebral haemorrhage in progress and must be considered upon individual case of each patient