Perceived stigma among Tunisian healthcare workers during the COVID-19 pandemic.

BACKGROUND AND OBJECTIVES: Stigma was a major issue during the COVID-19 pandemic. It posed a serious threat to the lives of healthcare workers (HCWs) who were expected to experience higher levels of stigma and increased psychological distress. This is the first survey to investigate forms and correlates of perceived stigma in Tunisian HCWs during the COVID-19 pandemic. METHODS: A cross-sectional web-based survey was conducted between October 8th and November 10th 2020, among 250 Tunisian HCWs. Data were collected using an online questionnaire using the Google Forms® platform. We used a self-reported instrument measuring COVID-19-related stigma, and the Multidimensional Scale of Perceived Social Support (MSPSS) to measure the perceived adequacy of social support from three sources: family, friends, and significant other. RESULTS: The mean stigma score was 18.6±8. Participants sometimes to often experienced stigma in their relationships with friends (22%), neighbors (27.2%), parents (22,4%), and in social activities (30.8%). This stigma was perceived mainly through avoidance (68.4%), and rarely through verbal (6%) or physical aggression (1.2%). The mean MSPSS total score was 5.26±1.24. In multivariate analysis, depression history (P<0.001), long working experience (P<0.001), having presented ageusia/anosmia (P=0.007) and lower total social support scale (P<0.001) were significantly associated with higher perceived stigma score. CONCLUSION: Our findings showed that HCWs perceived stigma in professional, societal and familial domains. Social support from family, friends and others seemed to protect against perceived stigma. Proper health education targeting the public appears to be an effective method to prevent social harassment of both HCWs and COVID-19 survivors.

Impact of a training intervention on knowledge and practices of health-care workers about reprocessing reusable medical devices in a South-Tunisian University Hospital.

INTRODUCTION: Reprocessing of reusable medical devices (RMD) play an important role in the prevention of health-care associated infections. In this perspective, this study aimed to evaluate the impact of a training program intervention on health-care workers' (HCWs) knowledge and hospital practices about the reprocessing of RMD as a main strategic axis of infection control. METHOD: We led a pre-post quasi-experimental study to evaluate knowledge of HCWs and to assess hospital practices in reprocessing RMD before and after a training intervention from May to November 2020 in Hedi Chaker University Hospital. A self-administrated questionnaire was distributed for each participant to assess knowledge. To evaluate practical skills, an audit grid was used. RESULTS: Overall, 30 participants were included. All HCWs had a fair level of knowledge before training. The knowledge score (KS) has significantly risen from pre to post-training (64/100 vs. 80/100; P<0.001). When stratified by RMD type, a significant increase was noted on post intervention in KS about thermo-sensitive RMD reprocessing (P=0.044) and sterilization of thermo-resistant RMD (P=0.004). As for practice assessment, 5 (62.5%) departments had a fair level of practice. The conformity score (CS) did not significantly change from baseline to post-follow-up (53.5 vs. 56.2; P=0.06). According to the audit sections, we did not find a significant change in the pre- and post-intervention CS in sterilization process (70 vs. 80; P=0.06) and in the cleaning and decontamination steps (66.7 vs. 67; P=0.18). CONCLUSION: As opposed to practical skills, positive impact of the training intervention on HCWs knowledge was noted, which underlined the gap between theory and practice.

Association between isokinetic abdominal muscle strength, pelvic floor muscle strength and stress urinary incontinence severity.

OBJECTIVES: Studies have shown that there is co-activation between abdominal and pelvic floor muscles (PFM) in physiological conditions. This study aimed to assess pelvic floor and isokinetic trunk flexors function in non-active incontinent women, and to investigate the association between the strength of these muscle groups and the severity of stress urinary incontinence (SUI). METHODS: A cross-sectional study was carried out. Twenty-five incontinent women were enrolled after one-hour pad test results and compared to twenty asymptomatic women. The severity of SUI was determined by the Pad test and Urinary Distress Inventory, Short Form (UDI-6). PFM function was assessed using the modified Oxford Scale, intra-vaginal PFM electromyography, and PFM endurance according to the PERFECT scheme. Trunk flexors strength was assessed using a Cybex Norm II dynamometer. RESULTS: Incontinent women had a weaker PFM and isokinetic abdominal muscle strength compared to continent women (P<0,05). SUI severity was negatively correlated with PFM strength (r=-0,620, P=0,001), isokinetic trunk flexors strength (r=-0,605, P=0,001), and PFM endurance (r=-0,561, P=0,003) in incontinent women. A positive correlation between PFM function and isokinetic trunk flexors strength was found in incontinent women (r=0,488, P=0,013). CONCLUSION: Non-active incontinent women had weaker pelvic floor muscles and isokinetic trunk flexors strength compared to continent ones. The positive correlation found between these two muscle groups may be explained by their synergic activity. These findings suggest that the severity of SUI could be related not only to PFM strength but also to abdominal muscle weakness. Further research is needed to recommend abdominal wall training as an alternative method to treat SUI. LEVEL OF PROOF: 3.

Prevalence and predictors of hypertension self-care practice in primary health-care facilities in Southern Tunisia.

BACKGROUND: Unmanaged hypertension (HTN) is usually accompanied with complications leading to disability in older adults. It has been demonstrated that self-care practice is essential for blood pressure control and reduction of HTN complications. OBJECTIVE OF THE STUDY: This study aimed to estimate the level of implementation of HTN self-care practice and to identify their associated factors. STUDY DESIGN: It was a cross-sectional study conducted in Sfax, Southern Tunisia in April 2020. MATERIALS AND METHODS: A total of 6 primary health-care facilities were approached for the study participants according to a single-stage cluster sample, by selecting six grapes randomly. A total of 270 participants were recruited, among whom 250 cases (92.6%) completed the questionnaire. RESULTS: A total of 250 hypertensive patients were included in the study, giving a male to female ratio of 0.77. There were 125 participants (50%) aged over 65years. Overall, 137 cases (54.8%) had a high total self-care practice score. The independent factors of good HTN self-care practice were≥65years [Adjusted odds ratio (AOR)=9.5; P<0.001], university educational level of the participants (AOR=21.2; P<0.001), as well as receiving a health education, by health-care providers (AOR=2.5; P=0.012) and family members (AOR=4.36; P=0.004). Advanced hypertension stage (II and III) (AOR=0.45; P=0.032) and chronic pulmonary diseases, including asthma (AOR=0.42; P=0.027) and chronic obstructive pulmonary diseases (AOR=0.27; P=0.016) were independently associated with poor HTN self-care practice. CONCLUSION: Advanced hypertension stage, pulmonary co-morbidities, education level and lack of self-care education were predictive factors of poor self-care practice. These findings suggested that such factors should be considered when planning HTN self-care education.

The ongoing challenge of Pulmonary Tuberculosis in Southern Tunisia: A review of a 22-year period.

BACKGROUND: Despite the wide use of anti-tuberculosis drugs, pulmonary tuberculosis (PTB) remains one of the most important causes of mortality and morbidity, particularly in developing countries. Therefore, combining clinical and epidemiological approach would be of a great benefit. Our study aimed to describe the epidemiological and clinical specificities of PTB and its recent chronological trends. METHODS: We conducted a retrospective study of all PTB new cases of any age diagnosed between 1995 and 2016 in Southern Tunisia. We applied the direct method of age-standardization using the World Standard Population to compute the age standardized incidence rate (ASIR) and the age standardized mortality rate (ASMR) per 100 000 inhabitants. RESULTS: We recorded 1121 new cases with PTB among 2771 new cases of tuberculosis (40.5%). The ASIR of PTB was 5.3/100 000 inhabitants/year and didn't change over the study period (rho=0.3; P=0.2). Patients with PTB were mainly aged between 15 and 59 years (n=861; 76.8%) and came from urban areas (n=600; 55%). The median duration of treatment was 7.6 months (IQR=[6-8 months]). Successful outcome was notified in 1075 cases (95.9%). Forty-one patients died yielding an ASMR of 0.18/100 000 inhabitants/year. Factors statistically associated with unsuccessful outcome included age≥60 years (OR=5; P<0.001) and shorter treatment duration (6.15 months vs 7.76 months; P<0.001). CONCLUSION: In contrast to the decline in the global PTB incidence reported worldwide and in the neighboring countries, our study revealed no significant change in the PTB rates from 1995 to 2016. Therefore, tools and strategies used to manage PTB should be strengthened by a substantial effort in both basic science and epidemiology to have better incidence curves.

A new combined predicting model using a non-invasive score for the assessment of liver fibrosis in patients presenting with chronic hepatitis B virus infection.

OBJECTIVES: Several non-invasive markers have recently been proposed to predict liver fibrosis without percutaneous liver biopsy (PLB). We aimed to evaluate the performance of non-invasive scores and to highlight the value of a new combined score in the prediction of liver fibrosis in chronic hepatitis B (CHB) patients. PATIENTS AND METHODS: We performed a retrospective study of patients presenting with CHB who underwent PLB between 2008 and 2016. We calculated ASAT/Platelet Ratio Index (APRI), Fibrosis-4 Score (FIB4), GGT-to-platelet ratio (GPR), and ASAT/ALAT Ratio (AAR). Then, we combined APRI and FIB-4 scores into a new combined score. We assessed their performance in predicting liver fibrosis according to the Metavir score. RESULTS: A total of 179 patients presenting with CHB were included. Multivariate analysis showed that the APRI score was the only independent factor of significant fibrosis (OR=3.78; P=0.02), whereas the FIB-4 score was the only independent factor for severe fibrosis (OR=2.85; P<0.001) and cirrhosis (OR=2.5; P=0.001). At a threshold of severe fibrosis, APRI had the best specificity (75%) and FIB-4 had the greatest sensitivity (74%). Using the combined score, we improved the diagnostic performance of APRI and FIB-4 scores at the three thresholds of liver fibrosis. With this combined score, maximum 25.1% of patients presenting with CHB would undergo PLB. CONCLUSION: APRI, FIB-4, and GPR scores were well performing to predict liver fibrosis during CHB. The new combined score using APRI and FIB-4 was more accurate at the three-fibrosis thresholds.

[Active smoking: A major risk factor for human non-communicable diseases in a hospital survey]. / Le tabagisme actif : un facteur de risque majeur des maladies non transmissibles humaines dans une enquête hospitalière.

INTRODUCTION: Tobacco is the main preventable cause of death worldwide. Our study aimed to determine the role of tobacco in the occurrence of non-communicable diseases (NCDs). METHODS: We conducted a retrospective study including all NCDs patients during 2015-2016. NCDs include cardiovascular diseases (CVD), chronic respiratory diseases (CRD), cancers (CS) and diabetes mellitus (DM). RESULTS: We identified 3643 cases of NCDs (43%) among 8478 hospitalizations, all diseases combined. Active smoking was found in 1076 cases (29.5%). Among the NCDs groups, CVD was the most common (65%). Tobacco was significantly associated with CVD (P<0.001), CRD (P=0.002), bronchopulmonary CS (P<0.001), haematological malignancy (P=0.023), and DM (P<0.001). Multivariate analysis performing binary logistic regression revealed that tobacco was an independent factor associated with CVD (OR=2.6, P<0.001), CRD (OR=1.5, P<0.001), bronchopulmonary CS (OR=1.8, P=0.013) and DM (OR=3.6, P<0.001). CONCLUSION: Active smoking was a major risk factor in the occurrence of NCDs. Thus, smoking cessation represents the cornerstone for preventing the spread of these diseases, especially in countries with limited resources.

[Ocular tuberculosis : A case series]. / La tuberculose oculaire : une série de 14 cas.

OBJECTIVES: Ocular tuberculosis is a rare form of extra pulmonary tuberculosis. It represents 1-2% of all clinical forms. The aim of this work was to focus on diagnostic and therapeutic characteristics of ocular tuberculosis. METHODS: We report a case series of 14 patients with ocular tuberculosis seen in an infectious diseases department between 2006 and 2015. The diagnosis was retained on clinical data and a positive tuberculin skin test or interferon-gamma release assay. RESULTS: The patient's mean age was 40.7±9years. The most common clinical presentation was uveitis (11 patients and 16 eyes). An extra ocular involvement was associated in three patients. The mean duration of antitubercular therapy was 10±2.5 months. Corticosteroid therapy was associated in 11 cases. The outcome was favorable in all cases. Two patients had maintained visual sequelae. CONCLUSION: Ocular tuberculosis is a rare disease but still remains a diagnostic problem. It should be considered in case of any chronic ocular symptoms, especially in endemic countries. Early management can improve the visual prognosis.

Diabetes mellitus in Tunisia: description in urban and rural populations.

A prevalence survey of diabetes mellitus was carried out in Tunisia on two random samples of households. The first sample (3826 adult subjects) was drawn from the Gouvernorat of Tunis, the second one (1787 adult subjects), was drawn from a rural area, the Gouvernorat of Siliana. The families were investigated at home and diabetes assessed on the basis of an interview (to determine known cases) and of fasting blood glucose level in subjects having no personal history of diabetes (new cases). Prevalence rates were estimated considering known cases and newly found ones together. Overall, the age-standardized prevalence rate was found to be much higher in the urban sample compared to the rural one, especially for women (4.6% versus 2.3% in men, 3.5% versus 0.6% in women). Diabetes was often associated with obesity, especially in men. Within the urban sample, the prevalence rate was similar in subjects born in Tunis and in those born in the rest of the country, thus mainly of rural extraction. In contrast, a family history of diabetes was more often reported in the former group. The results are consistent with other epidemiological findings, showing that a dramatic increase in diabetes morbidity parallels the rapid westernization of urban centres in developing countries.

[Cross-sectional study of growth between 3 and 20 years of age in the population of Tunisia]. / Etude transversale de la croissance entre 3 et 20 ans dans la population de Tunis.

In the course of a study designed to estimate the prevalence of diabetes in the Gouvernorat of Tunis, 1449 households chosen at random were examined at home between October 1976 and June 1977. The following parameters : weight, height, tricipital and subscapular skinfold thickness were determined for each subject 3 years old or more. From the data observed on 1 889 males and 1 940 females aged from 3 to 20 years, estimates by age and sex are proposed as references for growth among the tunisian population in urban area. Then an approach of the secular trend is derived from the distributions of height according to the year of birth in the adult population.

[Prevalence of diabetes in a random sample from the gouvernorat of Tunis (author's transl)]. / Prévalence du diabète dans le gouvernorat de Tunis à partir d'un échantillon représentatif.

Prevalence of diabetes was estimated on the basis of both interviewing the subjects and measuring fasting blood glucose among a one per cent random sample from the population of the Gouvernorat of Tunis. Sampling was done using the household as unit and three stages of randomization. The number of households investigated was 1 449, a total of 9 712 subjects. In this sample, including 45% of males, mean age is equal to 24.8 years in males and 26.0 in females. Globally, prevalence is equal to 2.3%, half-composed of previously known diabetics. In more than 50% of them, the disease was revealed by cardinal symptoms and 17% are insulin-treated. The frequency of the disease, already known or newly diagnosed, is steadily lower than 1% in the first classes of age and then distinctly increases from thirty years of age in males and forty in females, reaching a value close to 10% after sixty years.

[Dominant polycystic renal disease. Study of 105 cases]. / La maladie polykystique rénale dominante. Etude de 105 cas.

The study concerns 105 cases of dominant polycystic kidney disease. Affected relatives were observed in 65% of patients. The clinical features that leads to diagnosis were lumbar pain in 37.5% of cases, renal failure in 24.6% of cases and hypertension in 15.1% of cases. Hypertension was observed in 46.7% of cases and it seems that its onset is independent of chronic renal failure. Its frequency is of 55.1% when only kidneys were affected and of 21.4% when the liver was affected too. The progression of chronic renal failure is influenced by hypertension.

[Wegener's granulomatosis and pregnancy. A case]. / Granulomatose de Wegener et grossesse. Une observation.

Pregnancy concomitant with Wegener's granulomatosis is extremely rare: so far, only four cases have been published. The authors report a fifth case where the disease appeared during the post-partum period, a situation which has already been noted in two of the published cases. Interruption of a subsequent pregnancy was followed by a flare-up of the disease resulting in the patient's death. This suggests that post-partum and post-abortum are probably instrumental in the onset and deterioration of Wegener's granulomatosis. The two patients previously reported who received immunosuppressants combined with corticosteroids had no flare-up after delivery. It seems permissible to prescribe such a therapeutic combination before and after delivery or abortion, especially since the fear of foetal toxicity from these drugs seems to be exaggerated.

[Orbital decompression for dysthyroid orbitopathy: a review of techniques and indications]. / Techniques et indications chirurgicales des décompressions osseuses de l'orbitopathie dysthyroïdienne.

Orbital bony decompression has a definite place in the management of severe manifestations of dysthyroid orbitopathy such as optic neuropathy, exposure keratitis, and exophthalmos. This surgical procedure can be undertaken when medication and radiation therapy fail. Esthetic and functional results are globally satisfying and explain the interest taken in this technique. This article will describe the development of this procedure and will outline the surgical techniques and their complications. It emphasizes the multifactor indications for this procedure.

[Advantages of a double approach to upper blepharoplasty associated with eyelid malpositions]. / Intérêt de la double voie d'abord dans les blépharoplasties supérieures associées aux malpositions palpébrales.

During upper blepharoplasty, myocutaneous excess and fat pads are treated using an anterior approach. Eyelid malpositions such as involutional ptosis or lid retraction could be associated and should be treated with associated procedures. Aponeurotic surgery on the levator muscle can make use of the same anterior approach, with the major difficulty of dosage. In cases of ptosis with a positive epinephrine test or minor muscular retraction, the Müller muscle-conjunctival surgery via a posterior approach seems to be more reproducible. Double-approach techniques are described.

[Arterial thrombosis in Behcet's disease. Report on three cases]. / Thromboses artérielles dans la maladie de Behcet. A propos de 3 cas.

Three patients with Behcet's disease developed arterial thromboses affecting the external iliac, middle superficial femoral, and radial arteries respectively. Arterial thrombosis occurs mainly in affected males, is predominant in the upper limbs, and usually appears several years after the onset of the disease: it is probably more frequent in the familial forms.

[Hypertrophic osteoarthropathy of the child. One case cured by antibiotherapy (author's transl)]. / Ostéo-arthropathie hypertrophiante de l'enfant. A propos d'un cas avec guérison sous traitement causal.

Hypertrophic osteoarthropathy in a child is reported. It is caused by intrathoracic suppuration secondary to costal osteomyelitis. After antibiotherapy complete resolution of arthropathy, clubbing and periostitis is obtained. The literature is reviewed.

[CRST syndrome (Thibierge-Weissenbach's syndrome) and intra-articular calcification: a case report (author's transl)]. / Syndrome C.R.S.T. (syndrome de Thibierge-Weissenbach) avec calcification intra-articulaire. A propos d'un cas.

A case of Thibierge-Weissenbach's syndrome is reported in a woman with very advanced generalized scleroderma, telangiectases, subcutaneous calcinosis, and a Raynaud's syndrome. Atypical radiological appearances were noted: intra-articular calcinosis of the radioulnar, metacarpo-phalangeal, and metatarso-phalangeal joints. The published literature is reviewed.

[Radiographic appearances of a renin secreting renal tumor. A rare cause of hypertension (author's transl)]. / Aspects radiologiques de la "tumeur à rénine". Cause rare d'hypertension artérielle (H.T.A.).

Eleven cases of hypertension due to a renin secreting renal tumor have been reported since 1967. Here we are dealing with another case which appeared as hypertension and cerebro vascular accident in a thirty - year old woman an I.V. Pyélogram and a renal angiogram showed a tumor in the upper pole of the left kidney. Renal veins renin dosage showed hypersecretion on the side of the tumor. The tumorectomy was followed by a normalization of blood pressure. The microscopic study confirmed the diagnosis of renin secreting juxta-glomerular cell tumor.

[Enucleation with on-the-table evisceration. Is it a good technique?]. / L'énucléation avec éviscération sur table. Est-elle une bonne technique?

PURPOSE: To evaluate the surgical technique of enucleation followed by an "on-the-table evisceration" and placement of a hydroxyapatite orbital implant wrapped by the patient's own sclera for the treatment of blind phthisis painful eyes. PATIENTS AND METHODS: In this single-center retrospective study, 50 consecutive patients undergoing an operation using the same surgical technique, between April 1993 and November 1999, were studied. Patients underwent enucleation, then the eyeball was eviscerated "on the table". The patient's own cleaned sclera was used to wrap a hydroxyapatite orbital implant, the posterior pole of the sclera was placed at the anterior pole of the implant. Conjunctival breakdown, sphere size, conjunctival discharge, the first signs of sympathetic ophthalmia motility, and cosmetic results were analysed. RESULTS: After an average follow-up of 13.3 months few complications were encountered: 4 cases (8%) of inclusion cyst and 3 cases (6%) of discharge. The implant placed had a diameter of 18 mm, 20 mm, 22 mm in, respectively, 48%, 48%, and 4% of the eyes. The prosthesis motility was good, medium, and poor in, respectively, 33 (78.6%) cases, 8 (19%) cases, and 1 (2.4%) case. The prosthesis tolerance was good, medium, and poor in respectively 86%, 10%, and 4% of the cases. CONCLUSION: The surgical technique of enucleation followed by an "on-the-table" evisceration and autologous sclera wrapping a hydroxyapatite implant is an easy procedure. It allows, on phthisis eyeballs, the placement of a large orbital implant for good cosmesis results, without major complications.