[Characteristics of deep vein thrombosis in the elderly]. / Particularités de la thrombose veineuse profonde chez le sujet âgé.

PURPOSE OF THE STUDY: Deep vein thrombosis is a common condition in geriatric. The identification of risk factors for venous thrombosis in the elderly is important because it allows an appropriate prescription of preventive treatments. The purpose of this study is to identify the etiologic and therapeutic characteristics of deep vein thrombosis of the lower limbs in the elderly. PATIENTS AND METHODS: A retrospective study of 155 patients with lower limb deep vein thrombosis confirmed by venous Doppler. These patients were divided into two groups: group 1 (patients aged 65 years or more) and group 2 (patients whose age was below 65 years). A comparison between these two groups was performed. RESULTS: The average age of patients in group 1 was 74.89 years (± 6.43). The sex ratio in this group was 0.68. The thrombosis was more frequently proximal in patients of group 1. Patients of group 1 had significantly more risk factors than those of group 2 (p <0.05). Among risk factors studied, only the cancers were significantly more frequent in group 1 (p = 0.002). The frequency of hemorrhagic events in both groups was comparable but bleeding was more common in patients of group 1 with cancer. CONCLUSION: Our study confirms the multifactorial origin of deep vein thrombosis in the elderly and the incidence of malignant etiology. The results of this study also call for vigilance in the use of anticoagulants in the elderly especially in the presence of cancer because it is an additional risk factor for bleeding.

Study of anxiety-depressive disorders among doctors at "Salah Azaïez" Cancer Institute in Tunis.

INTRODUCTION: Oncologists are often confronted with patients at the end of their lives who are suffering. This can lead to anxiety and depressive disorders (ADD), affecting the quality of the doctors's quality of life. AIM: To compare the level of ADD among doctors practicing at Salah Azaiez Institute (SAI) in Tunis with doctors who do not treat cancer patients, while identifying any factors associated with these disorders. METHODS: We conducted a comparative and analytical study of 141 physicians:53 oncologists practicing at the Salah Institut Azaiez and 91 at other hospital structures (Charles Nicolle's Hospital and Rabta's Hospital), matched by age and gender for a period of 2 months, started from 02 May to 30 June 2022. RESULTS: Our research showed that SAI's doctors were significantly more exposed to anxiety disorders (p= 0.016) compared with other doctors (47.2% vs. 37.5%), without being more exposed to depressive disorders. SAI's doctors reported more associated stress factors, notably exposure to body image-distorting tumors (p<0.001), exposure to the suffering of loved ones (p=0.006), lack of human resources (p=0.017), perceived unsuitability of premises (p=0.001) and overwork (p=0.013). These doctors consumed more alcohol (p=0.04). In addition, 58.5% of SAI's doctors felt that their profession significantly affected their quality of life, compared to 45% of doctors in other hospitals (p=0.04). CONCLUSIONS: All the doctors questioned, "all specialties combined", showed varying rates of anxiety and depressive disorders. However, anxiety disorders were significantly higher among SAI's doctors, for whom stress factors had a greater impact.

Efficacy of rituximab in refractory polyarteritis nodosa: a case report.

Polyarteritis nodosa (PAN) is a systemic vasculitis affecting medium and small-sized vessels resulting in multiple organ involvement. Refractory PAN requires a different therapeutic approach. We herein report the case of a 42-year-old male presenting a non-virus-related refractory PAN with a favorable outcome on rituximab. He presented significant weight loss, muscle weakness, peripheral axonal neuropathy, and medium-sized cutaneous vessel necrotizing vasculitis. The patient received high-dose corticosteroids and cyclophosphamide with no significant clinical improvement while developing adverse side effects such as hypertension and diabetes. Rituximab was prescribed as an alternative therapy at 1000 mg on day 0 and day 15. This allowed for complete and rapid control of disease activity with regression of cutaneous injury and substantial improvement of neurological symptoms. In conclusion, using chimeric anti-CD20 monoclonal antibodies, such as rituximab, although rarely reported in refractory non-virus-related PAN, may be an effective alternative therapy, as portrayed in our case.

Evaluation of anticoagulant therapy management in a teaching hospital in Tunisia: information and education for vitamin k antagonist newly treated patients need to be improved.

OBJECTIVE: The objective of this study was to assess the level of Vitamin K antagonist (VKA) therapy knowledge among VKA newly treated patients. METHODS: Questionnaire-based interviews were administered in a university hospital to VKA newly treated patients covering both cognitive (i.e. indication, route of administration, treatment monitoring and side effects) and know-how (i.e. safety precautions, what affects anticoagulant therapy and the management of overdose signs) aspects of therapy knowledge. KEY FINDINGS: A total of 55 patients were included. The mean overall score of patients' knowledge was 5.78 (SD = 3.425) out of 20. The mean scores of cognitive and practical knowledge were 3.8 (2.26) and 1.98 (1.78) out of 10, respectively. Factors associated with an insufficient level of VKA therapy knowledge included low level of education, lack of access to therapy information and continuous access to this information. CONCLUSIONS: Knowledge about VKA therapy among newly treated patients is insufficient. Patient's medication knowledge should be improved to ensure better adherence.

[Traumatic and psychosocial complications of falls in the elderly in Tunisia]. / Complications traumatiques et psychosociales des chutes chez le sujet âgé tunisien.

INTRODUCTION: Falls in the elderly are a major health problem due to their traumatic and psychosocial complications which may lead to a loss of autonomy and a state of dependency. This study aims to study the traumatic circumstances and psychosocial consequences of falls in the elderly. METHODS: We conducted a retrospective study of 40 patients aged 65 years and over with a history of at least one fall in the previous year between September 2014 and January 2016. They were enrolled among patients hospitalized or treated on an outpatient basis in the Department of Internal Medicine B in the Hospital Charles Nicolle. Data on circumstances and consequences of falls were collected through a retrospective interview with patients and their entourage about the fall. RESULTS: The average age of fallen patients was 75,7 years, with a female predominance (30F/10M). Precipitating factors were found in 38 patients. Extrinsic factors were found in 78.9% of cases while intrinsic factors in 50% of cases. Extended stay on the ground was reported in 10% of cases. Fractures were more frequent among women (12F/1M), especially involving upper limbs (61.5%). Psychosocial consequences were more frequent among women. Post-fall syndrome was found in 5 patients. CONCLUSION: The correction of the extrinsic and intrinsic precipitating factors of falls and the implementation of educational programs on how elderly should get up from the ground properly after a fall will prevent the risk of a fall as well as fall-related severe consequences.

[Hypoparathyroidism and early onset dementia: Fahr syndrome should be suspected]. / Hypoparathyroïdie et démence d'installation rapide: penser au syndrome de Fahr.

Fahr syndrome is a rare disorder, whose prevalence is lower than 0.5%. Clinical manifestations are variable ranging from mere behavioral disorders to tetany crises and severe neuropsychiatric manifestations. It may be idiopathic or secondary to numerous causes dominated by phosphocalcium metabolism disorders whose main cause is hypoparathyroidism. Positive diagnosis is based on radiology. We report the case of a 78-year old hypertensive female patient with a history of hypothyroidism, hypoparathyroidism after total thyroidectomy performed 30years before. She was treated with Levothyrox® 100 µg 2 capsules/day , One-Alpha® 1 µg 3 capsules/day and calperos® 2 capsules/day resulting in euthyroidia confirmed by clinical examination and laboratory tests and normal phosphocalcic test. Patient's outcome was marked, in 2010, by the development of rapidly worsening cognitive impairment and of early onset dementia in a few months. Neurological examination showed extrapyramidal syndrome. Cerebral CT scan showed large basal ganglia calcifications, white and gray linear substance near the junction, in the brain bulb and in the cerebellum. The diagnosis of Fahr syndrome, revealed by dementia occurred after a history of hypoparathyroidism, was then retained.

[Senile rheumatoid arthritis associated with rheumatoid lung: a caricatural observation]. / Polyarthrite rhumatoïde vieillie avec poumon rhumatoïde: une observation caricaturale.

In the elderly, rheumatoid arthritis is defined by an average age of onset over 60 years. Prognosis mainly depends upon functional capacity, evolutionary stage of the disease, onset or no onset of joint malformations. We report the case of a 70-year old female patient with a history of arterial hypertension, hypothyroidism and Sjögren syndrome diagnosed in 2005. The patient was lost to follow-up and hospitalized in our department in 2016 for diffuse polyarthralgies of large joints with biologic inflammatory syndrome. Clinical examination showed cachectic patient (BMI: 17,6Kg/m2). She had articular deformations: hand arthritis with a "camel back" appearance and a "cubital gust of wind" appearance (A), claw feet and bilateral progression of hallux valgus (B). Lung auscultation showed diffuse crackling sound in both lungs. The patient didn't have dyspnea. Cardiac auscultation was normal and there were no signs of heart failure. Chest x-ray showed diffuse reticulo-micronodular appearance (C). Chest CT scan showed diffuse infiltrating pneumopathy supporting common interstitial lung disease (ILD) (D). Doppler echocardiography showed moderate pulmonary arterial hypertension 40mmHg. Blood gas test showed hypoxia 81mmHg with a saturation of 96%. The diagnosis of senile rheumatoid arthritis complicated by pulmonary involvement was then retained. Functional prognosis was uncertain due to these very severe joint deformations.

[Benign tumor of the oral cavity: idiopathic granuloma of the tongue]. / Tumeur bénigne de la cavité buccale: granulome idiopathique de la langue.

The diagnosis of granuloma of the oral cavity can favour the detection of several diseases such as sarcoidosis, Crohn's disease, tuberculosis, syphilis and malignant tumors. In Melkerson Rosenthal syndrome it has an idiopathic origin. In this regard, we here report an original case of idiopathic granuloma of the tongue not secondary to Melkerson Rosenthal syndrome and being part of benign tumors of the oral cavity. The study involved a 60-year old female patient, with no particular past medical history, presenting with discomfort during mastication secondary to a swelling on the free edge of the tongue which had occurred one month before her admission. Physical examination showed overgrowth at the level of the right edge of the tongue measuring 15 mm along its longer axis. The tongue was not plicated and there was no cervical adenopathy. The remainder of the physical examination was normal. MRI of the oral cavity showed suspected necrotizing tissue lesion on the right free edge of the mobile tongue measuring 15x12x19 mm without signs of extension to the ipsilateral lingual pedicle or to the floor of the oral cavity and without cervical adenomegalies. Biopsy of tongue lesion showed gigantocellular epithelioid granulomas without caseous necrosis or histological signs of malignancy. Biologically, there was no inflammatory syndrome, leukopenia or lymphopenia. The assessment of an underlying cause was negative: syphilis serology, evaluation of phosphocalcic profile, dosing of the angiotensin-converting enzyme, intradermo tuberculin reaction, chest radiograph, thoracoabdominopelvic CT scan and ophthalmological examination. Finally, the diagnosis of idiopathic granuloma was retained in the absence of arguments in favor of its secondary nature.

[Hypercalcemia related to PTH-rP revealing malignant hepatic epithelioid hemangioendothelioma]. / Une hypercalcémie humorale maligne révélant un hémangioendothéliome épithélioïde du foie.

Hypercalcemia caused by tumor production of PTH-rp occurs most often in cases of squamous cell carcinoma of the lung, aerodigestive tract cancer, gynecological cancer and lymphoma. We report an exceptional case of PTH-rp related to a hepatic hemangioendothelioma. A 70 years-old male admitted for deterioration of the general state. The laboratory investigations revealed hypercalcemia, related to tumor production of PTH-rp. Imaging revealed tumoral hepatic lesions. Histopathological study and immunohistochemistry showed diffuse response for CD31 marker, CK20 (+) with CK7 (-) and hepatocyt antigen (-). The diagnosis of PTH-rp related to hepatic hemangioendothelioma was make. The patient died with recurrence of fatal hypercalcemia. Management of patients presenting with humoral hypercalcemia includes a vigorous search for tumor lesions. Elevated PTH-rp can be a bad prognostic factor. In front of tumoral liver lesions, a hepatic epithelioid hemangioendothelioma must be considered. Immunohistochemistry is necessary to make diagnosis.