Patient-management Problem (PMP) for paediatrics learning: Value and students perceptions.

BACKGROUND: The use of the pedagogic tool Patient-Management Problem (PMP) for medical teaching and evaluation remains limited in Tunisia. AIM: to evaluate the value of PMP learning sessions in pediatrics and students' perception of the use of PMP for learning and evaluation. METHODS: We conducted a cross-sectional evaluative study in four pediatric departments in Tunis. Students had a learning session with an electronic PMP. Their knowledge was assessed using a pre-test and a post-test. Their perception of the learning was assessed using a questionnaire. RESULTS: Forty-four students participated. The post-test scores were statistically higher than those of the pre-test (p <0.001). More than 90% of the students, found that the PMP was a useful learning tool, which would change their way of thinking and agreed to its regular use for teaching. 86% of students declared that the PMP were better than other means of learning and 79% that PMP was a reliable assessment tool, but 75% believed it was more stressful than other means of assessment. The degree of satisfaction with previous PMP experience was negatively correlated with perception of reliability (p = 0.043), impact on clinical reasoning (p = 0.044), and PMP being better than the other learning means (p = 0.044). CONCLUSION: The PMP is an effective learning tool and is well accepted by students. Its use should be generalized to all disciplines for teaching and evaluation. Further trainings are necessary for medical teachers to guarantee quality PMPs.

[Clinical predictors of high risk bleeding endoscopic lesions in children with hematemesis]. / Les facteurs cliniques prédictifs de lesions endoscopiques à haut risqué de saignement chez un enfant présentant une hématémèse.

BACKGROUND: Haematemesis is an alarming symptom in children, even if the proportion of normal endoscopies ranges from 10 to 21% and the causes are often benign. The purpose of the study was to identify clinical predictors of endoscopic lesions with high risk of bleeding and to establish a score that predict the presence of these lesions. METHODS: Retrospective study carried in Children's Hospital of Tunis between 1997 and 2006 involved children with haematemesis who underwent Upper gastrointestinal endoscopy. Several clinical parameters were analyzed. Univariate analysis and multivariate logistic regression were performed to identify predictive parameters of endoscopic lesions with high risk of bleeding. A score was developed from the parameters derived from the multivariate analysis. The sensitivity and specificity of the score were determined. RESULTS: Among 2814 endoscopies, 814 were conducted for haematemesis and 489 were selected for the study. 140/489 had lesions with high risk of bleeding. Multivariate logistic regression analysis identified six factors independently associated with high risk bleeding lesions: endoscopy performed within 48 hours (OR=2.2; 95% CI 0.7-6.9), re-bleeding (OR=1.4; 95% CI 0.7-2.5), the importance of the bleeding, mild to severe (OR=1.8; 95% CI 1.1-3), bright red haematemesis (OR=1; 95% CI 0.2-5.8), history of gastrointestinal and liver disease (OR=1.6; 95% CI 1.1-3) and intake of gastro toxic drugs (OR=1.3; 95% CI 0.8-2.3). Then, we established a score. The sensitivity, specificity, positive predictive value and negative predictive value of this score were respectively 79.6%, 32.9%, 34.9% and 78% for a cut off value>0.22. CONCLUSION: The clinical predictive parameters of high risk bleeding lesions identified have not yielded a score with significant sensitivity and specificity. A prospective study should be performed to improve the score.

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.

[Diagnosis and management of cow's protein milk allergy in infant]. / Diagnostic et prise en charge de l'allergie aux protéines de lait de vache chez le nourrison.

BACKGROUND: Cow's milk protein allergy (CMPA) can be responsible of a variety of symptoms and can be caused by IgE or non-IgEmediated reactions. The remaining questions concern the diagnosis (what are the most suggestive clinical manifestations, the laboratory evaluations which play a supporting role, and the management of CMPA in breast fed infants and formula-fed infants. METHODS: Review of the pub med, science direct, Cochrane library, using the key words cow's milk protein allergy, guideline, and child. Evidence was levelled A, B, C. RESULTS: No symptom is pathognomonic. A thorough history and careful clinical examination are necessary to suspect the disease. Skin prick tests, and serum specific IgE are only indicative of sensitivation to CMP. A double-blind placebo-controlled challenge is considered the gold standard in diagnosis, but in practice only an open challenge is performed. The patient with suspected pathology will follow a cow's milk free diet for 2-4 weeks. Formula-fed infants get an extensively hydrolyzed formula .If the allergy is present, clinical manifestations will disappear. If symptoms do not improve, an amino acid based formula should be considered. In severe Cow's milk protein allergy with life-threatening symptoms, an amino-acid formula is recommended. The infant should be maintained on an elimination diet until the infant is between 9-12 months or at least for 6 months. The overall natural evolution of the disease is favorable with most patients achieving tolerance to milk by the age of five years. CONCLUSION: The importance of defined diagnostic criteria needs to be emphasized. It precludes infants from an unnecessary diet and avoids delay in diagnosis, which can lead to malnutrition.

Publication of pediatric theses defended at the Tunis Faculty of Medicine: A 15-year study.

INTRODUCTION: The valorisation of thesis through its publication is necessary to enhance its visibility. Few data exist concerning the characteristics of theses defended at the Tunis faculty of medicine. AIM: Examine the publication rate of pediatric theses and identify factors associated with an increased publication rate. METHODS: We conducted a cross-sectional descriptive bibliometric study of pediatric theses defended at the Faculty of Medicine of Tunis over 15 years, from 2006 to 2020. Theses were retrieved from the catalog of the faculty library. Publications had been searched in databases "Pub Med ", and "Google Scholar" until December2021. RESULTS: The study involved 235 pediatric theses. Sixty-eight theses were published, representing 29% of the total. The main topics of published theses were neonatology (16%) and hematology (15%). The language of publication was French and English in 55% and 45% of cases, respectively. All publications in Q1 and Q2 journals were written in English. The only independent factor predicting publication of theses was the very honourable mention with congratulations of the jury and proposal for the thesis prize (p=0,007). CONCLUSION: Additional assessments will be necessary to identify the obstacles to the publication of theses.

Unusual onset of Graves' disease associated with thymic hyperplasia in a 5-year-old girl with congenital bilateral clinical anophthalmia: diagnostic and therapeutic challenges.

OBJECTIVES: Graves' disease (GD) is a rare auto-immune disorder in pediatric population. The association between GD and thymic hyperplasia was rarely reported in children. Diagnosis and management of GD are challenging in children. CASE PRESENTATION: This report presents the case of a 5-year-old girl with a personal history of asthma and congenital bilateral isolated clinical anophthalmia who presented with acute congestive heart failure, sinus tachycardia and atypical signs of orbitopathy with edema and erythema of the lower right eyelid and excessive tearing. The diagnosis of GD was based on detecting a suppression of serum TSH level and the presence of high titers of TRAbs. Relapse occurred after 10 months of antithyroid drugs with chief complaints of palpitations, dyspnea and dysphagia. Computed tomography showed heterogeneous anterior mediastinal mass with no invasion into the surrounding tissue. The marked shrinkage of the mass after radioiodine therapy supported the diagnosis of thymic hyperplasia associated with GD. CONCLUSIONS: The presence of clinical anophthalmia may be a confusing factor for the diagnosis of Graves' ophthalmopathy. Recognition of the association between GD and thymic hyperplasia would avoid invasive diagnostic procedures and unnecessary surgical resection. Radioiodine therapy may be used in young children with repeated relapses of GD.

Case based self-directed learning tool versus clinical reasoning learning sessions.

INTRODUCTION: Clinical reasoning (CR) is a core skill taught by medical schools. Clinical reasoning learning sessions (CRL) during hospital internship of externals in pediatrics was recently introduced in Faculty of Medicine of Tunis. AIM: To compare a case based self-directed learning (CBSDL) tool with CRL sessions in two groups of the students assigned to pediatric internship. METHODS: We conducted a randomized trial with draw of two groups: CRL group (students who attended the CRL session) and SDL group (students who received the CBSDL tool). Main judgment criterion was the final score obtained by the student at the test of sequential management problem (SMP). A docimological analysis of SMP test was performed. RESULTS: The mean final score in CRL group and SDL group was 12.03±1.44 and 14.05±1.64, respectively (p <0.001). The scores obtained at the different steps of SMP test were significantly higher in SDL group. The difficulty p and discrimination D indices of the SPM test were 0.65 and 0.21, respectively. The agreement between the two correctors was very good since the intra-class correlation coefficient was 0.977. We analyzed the reliability of the test by measuring Cronbach's α coefficient which was 0.955. CONCLUSION: CBSDL tool has allowed students to learn hypothetico-deductive reasoning. However, this tool must be supplemented by direct supervision at hospital internship to support CR.

Caustic ingestion in Tunisian children: Endoscopic findings, complications and predictors of severe injuries in a cohort of 1059 patients.

BACKGROUND AND AIMS: The ingestion of caustic substances remains a serious medical problem in Tunisian children. This study was conducted to describe the epidemiological, clinical, and endoscopic findings of caustic ingestion in Tunisian children, and to indentify predictive factors of severe esophageal and gastric injuries. PATIENTS AND METHODS: A retrospective review of all children referred to a tertiary pediatric center for caustic ingestion who underwent esophago-gastro-duodenoscopy was conducted. Severe esophageal and gastric injuries were defined as Grade 2b, 3a, 3b, and 4 using the Zargar classification. We conducted multivariate logistic regression analysis to identify predictive factors for severe esophageal and gastric caustic injuries. RESULTS: We analyzed 1059 diagnostic procedures performed for caustic ingestion. The mean age was 41.4± 31.9 months. The most frequently ingested caustic substance was household bleach followed by caustic soda granules. Endoscopy showed severe esophageal and gastric lesions, respectively, in 122 (11.5%) and 56 (5.3%) cases. Predictive factors of severe esophageal injuries were: alkaline ingestion (p<0.001; OR: 17.9; 95% CI: 8.4-38.1) and the presence of symptoms after caustic ingestion (p=0.02; OR: 2.4; 95% CI: 1.1-5.4). The occurrence of complications was significantly associated with the presence of severe gastric lesions at the initial procedure (p=0.046; OR: 2.3;95% CI: 0.9- .3). CONCLUSION: Esophago-gastro-duodenoscopy should always be performed for symptomatic children, asymptomatic children who have ingested an alkaline product, and asymptomatic children under the age of 6 years.

The effect of non-steroidal anti-inflammatory drugs and Helicobacter pylori infection on the gastric mucosa in children with upper gastrointestinal bleeding.

OBJECTIVE: To study the effect of non-steroidal anti-inflammatory drugs (NSAID) and of Helicobacter pylori infection on the gastric mucosa in children with upper GI bleeding (UGIB). METHODS: Eighty-four children, 41 males (mean age 92.6 months, 4-168 months) underwent an upper GI endoscopy with gastric biopsies for UGIB. Biopsies were analysed for histological assessment according to the updated Sydney classification and bacterial culture. The presence of H. pylori infection was retained when histology and/or culture were positive. A negative result was retained when both tests were concomitantly negative. Children were divided into two groups according to the severity of mucosal endoscopic injury. The risk factors, i.e. NSAIDs intake, laboratory haemostatic disorders, were reported. RESULTS: Helicobacter pylori infection was detected in 41 children (48.8%) out of the 84 presented with UGIB. Severe endoscopic damage (SED) group (n = 38, 45.2%), exhibited frank gastric lumen haemorrhage (n = 12), petechia (n = 12), erosions (n = 8), ulcerations (n = 4) in the gastric antrum and corpus. Mild endoscopic damage (MED) group (n = 46, 54.8%), exhibited; congestive mucosa (n = 16), nodular mucosa (n = 15) and pale mucosa (n = 4); 25 children out of 84 (29.8%) received NSAID. According to the severity of endoscopic injuries, none of the following risk factors exhibited significant results; gender, GI endoscopy <24 h, H. pylori infection. H. pylori-positive patients exhibited the same NSAIDs intake level between both groups, SED group; 9 NSAIDs intake (41%) versus 13 without NSAIDs intake (59%), n.s. and MED group; 5 NSAID intake (26%) versus 14 without NSAID intake (74%), n.s. CONCLUSION: In children presenting with UGIB, gut mucosal damage severity is significantly correlated to NSAIDs level intake especially in children younger than 24 months. The presence of H. pylori infection in children receiving NSAID seems not to increase gut mucosal injury severity.

Impairment of left and right ventricular longitudinal strain in asymptomatic children with type 1 diabetes.

AIM: The relationship between type 1 diabetes (T1DM) and cardiac function in children is not well established. The purpose of this study was to investigate whether children and adolescents with T1DM present early asymptomatic abnormalities of left ventricular (LV) and right ventricular (RV) function. In addition, we evaluated the relationship of any such abnormalities with glycemic control and diabetes duration. METHODS: This was a prospective study. Standard echocardiography, tissue Doppler imaging, and two-dimensional strain analysis were performed prospectively in 52 children with T1DM. The results were compared with those from 52 healthy children matched for age and sex. RESULTS: There were no significant differences between the two groups in LV ejection fraction or RV systolic function. There was a difference between the two study groups in transtricuspid flow: the E-wave and A-wave velocities were significantly higher in the diabetic group. Left ventricular global longitudinal strain (LV GLS) was significantly lower in children with T1DM (-20.01 ± 1.86% vs. -22.99 ± 0.98%, respectively; P < .001), as was RV free-wall longitudinal strain (RV FWLS) (-29.13 ± 1.85% vs. -30.22 ± 1.53%, respectively; P = .002). LV GLS was correlated with diabetes duration (r = 0.444, P < .001) and glycated hemoglobin (HbA1c) (r = 0.683, P < .001); however, no correlation was found between RV FWLS and HbA1c or diabetes duration. CONCLUSIONS: Our findings suggest that LV GLS and RV FWLS are impaired in children with T1DM and that the decrease in LV GLS is correlated with diabetes duration and HbA1c levels.

Self-directed learning digital tool versus tutorials under the guidance of an educator: Randomized trial.

INTRODUCTION: Self-directed learning digital tool aims to enable students to acquire skills in an autonomous way. The aim of this work was to compare a self-directed learning digital tool in non-traumatic abdominal emergencies with tutorials under the guidance of the educator in two parallel groups of second-year of second-cycle of medical students selected by means of a draw. METHODS: We performed a controlled trial with draw comparing the self-directed learning digital tool and tutorials under the guidance of a teacher. Second-year of second-cycle medical students under training in general surgery from February, 20, 2017 to May, 7, 017 were included. Main judgment criterion was the assessment of the skills gained by students by means of the total score got at the objective structured clinical examination. We have carried out a descriptive survey, kappa statistics to study agreement between examiners, followed by an ANOVA test. We have compared the total score for the self-directed learning digital tool group with the total score of the tutorials group by using the « t ¼ test of Student and the « U ¼ test of Mann-Whitney. We performed a ROC curve for the total score. We have also achieved a satisfaction survey. RESULTS: Twenty seven students were enrolled: 14 in the « self-directed learning digital tool ¼ group and 13 in the « tutorials ¼ group. The average total score for all the students was 230 ± 52 points [extremes: 71,5 - 318,5]. There was no difference between examiners (kappa test and ANOVA test). The univariate analysis showed a total score and a score by examiner higher in a statistically significant way for the « self-directed learning digital teaching tool ¼ group. The ROC curve allowed us to conclude that the self-directed learning digital tool had an important discriminating power[an area under the curve equal to 0,791, (CI95%: 0,616-0,966) with p=0,010]. CONCLUSION: Self-directed learning digital tool has allowed second-year of second-cycle medical students to acquire skills in matters of interpretation of medical imaging in non-traumatic abdominal emergency with a higher rate compared with tutorials.

Etiology and outcome of bronchiectasis in children: a study of 41 patients.

BACKGROUND: Bronchiectasis remains an important cause of chronic suppurative lung disease in the developing world. The aim of this study is to describe the epidemiological characteristics, clinical features, underlying aetiologies and outcome of bronchiectasis in the paediatric hospital of Tunis. METHODS: A retrospective study of 41 children with bronchiectasis was conducted between January 1994 and December 2006. Diagnosis was made in patients with clinical suspicion of bronchiectasis associated with abnormalities on chest X ray (n=37) and/or on high resolution computed tomography (HRCT) (n=36). RESULTS: Mean age at diagnosis was 5 years 9 months; (range: 6 months-14 years). Persistent cough and bronchorrhea were the most common symptoms. Fourteen patients (34%) had dyspnoea on first presentation, 11 of them (26.8%) had chest deformation and/or finger clubbing. Haemoptysis was noted in only two cases. Mean time to diagnosis from symptom onset was 2.7 years (range: 2 months-4 years). The underlying aetiologies were identified in 52% of patients. Cystic fibrosis (17%), previous pneumonic illness (9.7%), primary ciliary dyskinesia (9.7%) and immunodeficiency (9.7%) were the most common causes. After a mean follow-up of 6.6 years, the annual lower respiratory infection rate decreased from 7.2 +/- 3 to 3.1 +/- 2.6 (p<0.05), Twenty one point nine per cent of patients had chronic respiratory failure and five patients required surgery. CONCLUSIONS: Delays diagnosis of bronchiectasis remains important in our country. Congenital and indeterminate aetiologies are the most common forms. Prognosis is poor with a high prevalence of chronic respiratory failure.

[Cholestasis in infants: a study of the Children's Hospital of Tunisia]. / Les cholestases du nouveau né et du nourrisson: experience de l'Hôpital d'Enfants de Tunis.

BACKGROUND: Cholestasis in infant constitutes an heterogeneous group of disease; diagnosis and management are often difficult. THE AIM of the study is to describe clinical, paraclinical characteristics and outcome of infants hospitalized for cholestasis in children's Hospital of Tunis. METHODS: A retrospective study of 94 infants with cholestasis was conducted. Patients were hospitalized in four departments of paediatrics of our hospital between January 1995 and December 2005. Cholestasis complicating severe sepsis and visceral leishmaniasis were excluded. RESULTS: Incidence of cholestasis was 8.5 cases/year which represented 0.72% of the hospitalizations. Sex ratio was 1.08 and mean age at diagnosis was 105 days (extremes: 1 day- 24 months). Biliary atresia was the most common cause of extra hepatic cholestasis (13.8%). Normal A GT cholestasis (11.7 %), benign neonatal cholestasis (11.7%) and bile duct hypoplasia (9.5%) represented the most common aetiologies of intra hepatic cholestasis. Aetiology remained unknown in 12.7% of cases. Only three infants with biliary atresia had Kasaï operation. After a mean follow-up of 6 years, 18% of patients had portal hypertension, 14.8% had hepatic failure and mortality rate was 14.8%. CONCLUSION: Cholestasis of unknown aetiologies are frequent in our hospital. Poor prognosis, in our study, is due to delay to diagnosis and difficulties in medical and surgical management.

[Chronic constipation in childhood. A report of 78 patients]. / La constipation chronique du nourrisson et de l'enfant. Etude de 78 cas.

AIM: To assess the aetiology and the clinical patterns of chronic constipation in children. METHODS: A total of 78 patients (62% boys, mean age: 4.6 years) were enrolled in this retrospective study. For each patient, we collected these data: clinical features, radiological data, rectal manometry and rectal biopsy results, treatment and follow up. RESULTS: Functional constipation was the most frequent cause of chronic constipation (49 cases, 62.8%) followed by Hirschsprung's disease (19 cases, 24.3%). Rectal manometry, performed in all suspected Hirschsprung's disease, concluded to the absence of inhibitory rectoanal reflex in 17 of them. Rectal biopsy concluded to segmental absence of parasympathetic ganglion cells in eleven of them. Therapeutic approach consists of treatment of functional constipation by laxatives, enemas and dietary fibers in respectively 22, 12 and 6 children. Two other patients had a biofeedback re-education. Treatment was successful in 9 patients and unsuccessful in 2 others. Seven children with Hirschsprung's disease underwent Soave's (n = 3), Swenson's (n = 3) and Duhamel's procedures (n = 1). Outcome was favourable in five of them and complicated by stenosis in 2 others. CONCLUSION: Our study suggests that functional constipation is the most frequent cause of chronic constipation in children and that Hirschsprung's disease is the first organic cause of chronic constipation indicating the need of rectal manometry for diagnostic confirmation.