How useful is the tuberculin skin test for tuberculosis detection: Assessing diagnostic accuracy metrics through a large Tunisian case-control study.

Background and aim: During the past decade, the frequency of extrapulmonary forms of tuberculosis (TB) has increased. These forms are often miss-diagnosed. This statement of the TB epidemiological profile modification, conduct us to reflect about the utility of the Tuberculin Skin Test (TST) in active TB detection. This study aimed to evaluate the diagnostic accuracy performance of the TST for active tuberculosis detection. Methods: This was a case-control, multicenter study conducted in 11 anti-TB centers in Tunisia (June-November2014). The cases were adults aged between 18 and 55 years with newly diagnosed and confirmed tuberculosis. Controls were free from tuberculosis. A data collection sheet was filled out and a TST was performed for each participant.Diagnostic accuracy measures of TST were estimated using Receiver Operating Curve (ROC) curve and Area Under Curve (AUC) to estimate sensitivity and specificity of a determined cut-off point. Results: Overall, 1050 patients were enrolled, composed of 336 cases and 714 controls. The mean age was 38.3±11.8 years for cases and 33.6±11 years for controls.The mean diameter of the TST induration was significantly higher among cases than controls (13.7mm vs.6.2mm; p=10 -6). AUC was 0.789 [95% CI: 0.758-0.819; p=0.01], corresponding to a moderate discriminating performance for this test. The most discriminative cut-off value of the TST, which was associated with the best sensitivity (73.7%) and specificity (76.6%) couple was   ≥ 11 mm with a Youden index of 0.503. Positive and Negative predictive values were 3.11% and 99.52%, respectively. Conclusions: TST could be a useful tool used for active tuberculosis detection, with a moderate global performance and accepted sensitivity and specificity at the cut-off point of 11 mm. However, it cannot be considered as a gold standard test due to its multiple disadvantages.

Professor Mohamed Soussi Soltani: Leader, Innovator and Researcher in Public Health.

Mohamed Soussi SOLTANI (June 27, 1953 - March 2, 2016) is Professor of Preventive and Community Medicine at the Faculty of Medicine of Monastir (Tunisia). The objective of this paper is to present, to new generations of the specialty in the Greater Maghreb, this leading teacher from the Center-East of Tunisia (Monastir), through the testimonies of his companions, and his indexed publications. All the colleagues of the late SOLTANI testified to his high human and professional qualities, particularly perseverance, commitment, forward thinking, integrity and professionalism. The scientific life of the late Professor Soltani was oriented towards two major themes: Public Health and Family Medicine. Indeed, the deceased has developed several new preventive activities in first-line structures such as anonymous and free HIV screening, family planning, rational use of drugs, breast cancer screening, smoking cessation, prevention of rheumatic heart disease. Pr SOLTANI welcomed general practitioners from the Monastir region to the Faculty's Community Medicine Department, creating with them a movement to advocate for the academic and professional development of general medicine into an authentic specialty of family medicine. Out of the 34 publications of Professor SOLTANI, indexed on PubMed, 11 were signed by himself in first position, mainly relating to maternal health (prenatal surveillance, education for maternal health, pregnancy referral system) and infant (low birth weight, vaccination, mother-to-child transmission of hepatitis B, meningitis due to Haemophilus influenzae). Thus, with a life prospering by innovations and research in public health, Professor SOLTANI will always remain a model for young people in the specialty of Preventive and Community Medicine. His followers have an obligation to write his complete biography, to safeguard it and pass it on to new generations of public health.

Effect of Pistacia lentiscus oil on experimental pulmonary fibrosis.

Background - Idiopathic pulmonary fibrosis (IPF) is a chronic disease characterized by histopathological lesions in lung tissue. This is the most common and most severe idiopathic interstitial pneumonias. Current treatments are based on the combination of corticosteroids and immunosuppressants, but their effectiveness is still debated. Purpose of work - Testing the preventive effect of Pistacia Lentiscus oil, known for its antioxidant, anti-mutagenic and anti-proliferative effects, on a model of experimental lung fibrosis. Methods - Two groups of rats received an intratracheal injection of bleomycin (4.5 mg / kg). The first group, control (n = 20 rats), has received no treatment. The second group was treated with Pistacia Lentiscus oil (n = 20 rats) for 30 days before fibrosis induction, by daily gavage oil Pistacia Lentiscus oil (3,33ml / kg). This treatment was continued for 10 days. At the end of the experimental period, all rats were sacrificed and the lung tissue was examined histopathologically and immunostained for TGFß. Results - The chromatographic profile oil Pistacia Lentiscus oil shows the dominance of two fatty acids that are linoleic acid and palmitic acid representing respectively 70.57 and 24.67%. Our results also show a decrease in the distribution of TGFß both at the level of the inflammatory infiltrate and at the level of the pulmonary parenchyma histiocytes of rats treated with Pistacia Lentiscus oil compared with control rats. However, these changes are not accompanied by statistically significant changes of fibrosis score and inflammatory index. Conclusion - Our results are interesting to consider. Further studies using higher doses of Pistacia Lentiscus oil are important to conduct.

Multidrug resistance and high virulence genotype in uropathogenic Escherichia coli due to diffusion of ST131 clonal group producing CTX-M-15: an emerging problem in a Tunisian hospital.

A collection of 201 Escherichia coli strains isolated from urine of patients in a Tunisian hospital between January 2006 and July 2008 was studied. Microbial identification was done by conventional methods, and antibiotic susceptibility with disk diffusion method was performed according to the Clinical Laboratory and Standards Institute guidelines. Detection of extended-spectrum beta-lactamase (ESBL) was performed by double-disk synergy test (DDST) and identification was done by PCR and sequencing. ESBL-producing isolates were subjected to molecular typing by random amplified polymorphic DNA (RAPD) and ST131 detection by PCR. Four phylogenetic groups (A, B1, B2 and D), 18 virulence genes and CTX-M group were individualized using PCR. Statistical analysis was done by Pearson χ2 test and Mann-Whitney U test. The strains were recovered primarily from urology (28%), maternity (19%) and medicine (16%) wards. Antibiotic resistance rates were ampicilin (72.1%), nalidixic acid (41.8%), ciprofloxacin (38.8%), gentamicin (23.9%) and cefotaxime (17.4%). Thirty-one of cefotaxime-resistant isolates (n = 35) had a positive DDST and harboured bla CTX-M-15 gene. Twenty of them (64.5%) belonged to the ST131 clone and showed the same RAPD DNA profile. Ciprofloxacin- and cotrimoxazole-susceptible isolates were significantly associated with phylogenetic group B2, whereas isolates that were resistant to these molecules were associated with B1 and D phylogenetic groups, respectively. Virulence genes were significantly more frequent among ciprofloxacin- and cotrimoxazole-susceptible strains than those resistant to these antibiotics. However, CXT-M-15-producing isolates were associated with many virulence genes. Isolates concomitantly susceptible to the three antimicrobials agents (ciprofloxacin, cefotaxime and cotrimoxazole) were significantly associated with group B2 and high virulence score, whereas isolates with resistance patterns especially those including resistance to ciprofloxacin belonged predominantly to B1 phylogroup and haboured few virulence genes. The emergence of virulent and multidrug-resistant E. coli is a concerning development that deserves close attention in our institution.

[Questionnaire evaluation of hand hygiene by the healthcare staff of Charles Nicolle Hospital of Tunis]. / Evaluation de l'hygiène des mains par auto-questionnaire chez le personnel de santé de l'hôpital Charles Nicolle de Tunis.

BACKGROUND: Known to be reservoir of bacteria, hands are implicated in bacteria cross-transmission which enhances nosocomial-acquired infection rates (NI) and outbreaks. Hand washing is then considered the first mean with authentic efficiency to prevent NI. AIM: To describe the situation of the hand hygiene at Charles Nicolle hospital of Tunis in order to identify problems that can oppose to the good execution of this practice. METHODS: A descriptive transverse study performed in October 2006 where 600 questionnaires were distributed to healthcare staff of the hospital. RESULTS: Only 434 questionnaires were responded (158 doctors and 276 nurses). Analysis of data obtained showed that hand washing was essentially practiced after each contact presumed to be contaminant for the healthcare person himself (80%) and was principally done with water and soap (82%). Hydro-alcoholic solutions were rarely mentioned (17.1%). The main reasons evoked for the non observance were unavailability of the necessary means (84.8%) and default of awareness (61.3%). CONCLUSIONS: So, these results show a poor perception of the healthcare staff on the importance of hand hygiene which they share the responsibility with healthcare managers. Thus, implication of all healthcare actors is necessary to ensure the good practice and mainly the observance of hand hygiene.

[Analysis of antibiotics as a curative measure in four hospital units]. / Analyse de la prescription antibiotique a visee curative en milieu chirurgical et en reanimation.

In order to analyse the methods of curative prescription of antibiotics in four units of hospitalization of the hospital Charles Nicolle of Tunis, a descriptive study of prescriptions was carried out during the first five months of year 2001. On the whole, 165 prescriptions delivered to patients were included in the study. The average age of the patients was 44 years, the sex ratio of 1.45 and the average duration of 15.1 days. Approximately two thirds of the initially probabilist prescriptions were not documented secondarily. Those secondarily documented (n = 51) were essentially related to nosocomial pneumonias and septicaemias (29 and 10 prescriptions). The two germs most frequently isolated during nosocomial pneumonias were Acinetobacter baumannii and, Pseudomonas aeruginosa (17 and 8 strains). Only imipenem, netilmicin and colistin remain active on A. baumannii. The bitherapy was the most used treatment (87.5%). It was generally an association beta-lactamin-aminosid (52.9%). The average cost of a documented prescription varied from 943,6 to 1184,9 TD (Tunisian Dinars) according as the prescription were secondarily documented or not.

[Management of arterial hypertension: results of a Tunisian general practitioner survey]. / Prise en charge de l'hypertension artérielle: résultats d'une enquête tunisienne aupres des medecins generalistes.

The control of arterial hypertension (HT) is an endlessly hoped objective but usually not reached. Several factors are determinants. The physician role is crucial in the HT prevention. In order to evaluate knowledge, attitudes and behaviours of Tunisian physicians in HT management, we conducted a cross sectional study in 2002 using a self administered questionnaire addressed to physicians working in private and public sectors. 380 generalists participated to this study. 95.5% of them confirmed that HT constitutes a public health problem. 81.1% saw at least 4 patients with HT a week. 95% insisted on the importance of the primary prevention. 90% took care themselves patients. 71.5% confirmed the importance of a training and an entrainement for the measure of the blood pressure (BP). 3.7% made diagnosis after a single visit and 10.9% confirmed it only from described symptoms. 20.4% of the generalists chose the old classification as objective level of BP. Thiazidic Diuretics and beta blockers were most prescribed medicines in first intention. 9.4% stopped the treatment after stabilization of blood pressure. 60% of generalists had inadequate behaviour facing a not stabilized BP. Non observance of treatment by patients was indicated by 31% of the generalists, cost and break of the medicines' stock and disappearance of symptoms were the main causes advanced by the generalists. This study shows the existence of gaps in generalists' practical behaviour treating this disease. Measures aiming the medical practice improvement turn out necessary in particular the sensitization of the generalists by an adequate university training and a continuous medical training, and a regular evaluation of the national program of hypertension prevention and management.

[Hypertension prevalence, awareness, treatment and control: results from a community based survey]. / Prevalence, connaissance, traitement et controle de l'hypertension arterielle: resultats d'une enquete populationnelle.

The study objective was to assess the prevalence, level of awareness of treatment, and control of hypertension in a general population. We conducted a cross-sectional survey on 1837 adults 40-69 years old. Hypertension and control level are defined according to the WHO/ISH recommendations. HBP is defined as SBP > or = 140 and or DBP > or = 90 mm Hg and the use of blood pressure-lowering medication. Hypertension is controlled by medication if SBP < 140 and DBP < 90 mm Hg. We conduct analysis by socio demographic variable, medical history and CHDs risk factors. 44.3% of adults was hypertensive. The prevalence of hypertension was higher among women (48.2% versus 38.7% on men) and it increases in both genders with age, body mass index. Only 41% of the hypertensive were aware of having hypertension, among them, 74.1% declare that they are treated but only 13.2% were controlled. The study highlights the problem of the hypertension in a developing country. It contributes to identify the huge iceberg of this CVDs risk factor. The national strategy must focus on the population life style and drugs management. The question is how much will be the cost of HBP and CVDs control for a country which has a limited resources.

[Analysis of knowledge attitudes and practices of health care workers facing blood exposure accidents in a general surgery service]. / Analyse des connaissances attitudes et pratiques du personnel soignant face aux accidents d'exposition au sang en chirurgie generale.

In order to assess the degree of knowledge, attitudes and the personnel's practices exercising in a service of general surgery of the hospital Charles Nicolle of Tunis, concerning blood exposure accidents, we did a transverse survey during the month of January of the year 2002. A questionnaire has been addressed to 114 people while using the technique of the direct interview. The middle age of investigated is 35.7 years. The sex ratio is 0.7. Only the 2/3 declare have been vaccinated against the B hepatitis. The results show a good knowledge of the exposure risk to a communicable disease by blood (95.6%), but less good for the risk of contamination by the three viruses HBV, HCV and HIV. The resheathing of needles, considered like gesture to risk, is underestimated by 71.2% of investigated. The majority of investigated declare to know universal precaution principles (85.8%). However, to the maximum 4 measures only on the 10 advisable have been mentioned by investigated. The conduct to hold in case of blood exposure accident seems insufficiently known by our sample. It is represented, in 78.8% of cases, in the application of disinfectants Betadine type or alcohol iodized, whereas the practice of a serology to the patient source is ignored completely. 75% of investigated having had a blood exposure accident lasting the last 12 months (n = 44) didn't declare their blood exposure accident and only 11.4% declare to have undergone cares. Actions of information and formation, to the intention of the whole of the personnel of the service, on risks incurred by the nursing, gestures and procedures to risk, the universal precaution respect, the conduct to hold in case of a blood exposure accident, the interest of the declaration and the interest of the vaccination against the B hepatitis, are primordial.

[General medicine and general practitioner. The viewpoint of the teachers at the Department of Medicine of Tunis]. / Médecine générale et médecin généraliste. Le point de vue des enseignants de la faculté de médecine de Tunis.

The general medicine remains a same survey subject in countries where the debate began since several years. We have led an investigation by questionnaire close to 50 chosen hospitalo-academic physicians by pull to the fate on the list of teachers of the faculty of medicine of Tunis. The majority of our investigated (90%) consider that the physician general practitioner is the physician of the individual in its totality, the counselor and the family's confidant. The formation that receives the future general practitioner currently doesn't prepare it to assure his role. To form the future physician better general practitioner, we think that it's necessary to define the general practitioner role, to adapt the formation to the role of the general practitioner and the specificity of the general medicine.

[Medical prevention of handicap in Tunisia]. / La prevention medicale du handicap en Tunisie.

The handicap, phenomenon too often badly discerned, constitute a problem of public health of part his frequency, his gravity and his cost. Interventions aiming to warn the handicap are located to three levels: primary, secondary and tertiary. The measures as the vaccination, the education about health, the hygiene of the setting, the prenatal surveillance, aiming to reduce and even eradicate the transferable illnesses, is applied and integrates in the setting of the different national programs since years 80. The most important are the national program of vaccination and the national program of perinatality. The precocious tracking of deficiencies and their hold in charge is related to centers of cares of basis health, to the regional units of rehabilitation and the school and academic medicine. The sanitary measures of tertiary prevention of the handicap summarize themselves in two types of measures: the rehabilitation and the equipment. The handicap, multi-dimensional phenomenon, require a concerted multidisciplinary action between professionals of health, social business, jurists and community.