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.

[Self-stigma and functioning in patients with bipolar disorder]. / Auto-stigmatisation et fonctionnement dans le trouble bipolaire.

Self-stigma of people with bipolar disorder is an underestimated problem, with serious consequences in terms of clinical severity and social and professional functioning. OBJECTIVES: This study aimed to evaluate self-stigma in patients with bipolar disorder, to identify socio-demographic and clinical factors associated with it and to analyze the links between self-stigma and functioning in this population. METHODS: We conducted a cross-sectional, descriptive and analytic study including 61 patients with bipolar disorder meeting criteria of remission. We used the internalized stigma of mental illness (ISMI) to investigate self-stigma, and the functioning assessment short test (FAST) to assess functioning. RESULTS: The mean age of patients was 43.4 years. The sex ratio was 2.4. Half of the patients were single or divorced (50 %). They had secondary or university education in 69 % of cases and were professionally inactive in 59 % of cases. The socioeconomic level was low or medium in 92 % of cases. A personal judicial record was found in 16 % of patients, a suicide attempt in 41 % of cases. Most patients in our series had bipolar I disorder (92 %). The mean age at onset of the disease was 23.5 years, with a mean duration of disease progression of 20 years. Patients were hospitalized an average of 5.9 times. Most patients (90 %) exhibited psychotic features during their mood relapses. The mean duration of the last remission was 27.9 months. Patients had regular follow-ups at our consultations in 87 % of cases. Among the patients included in the study, 8 % were on long-acting neuroleptics. The mean score on the internalized stigma of mental illness was 2.36±0.56. More than half of our patients (59 %) were self-stigmatized. Discrimination and alienation were found in 51 % of cases, followed by resistance to stigmatization (43 %) and assimilation of stereotypes (41 %). Regarding functioning, a global impairment was noted in more than two thirds of patients (71 %). An alteration in professional functioning was found in 82 % of cases and in cognitive functioning in 69 % of cases. Disruption of the financial sphere concerned 43 % of the patients, and the relational sphere 41 % of them. Autonomy was altered in 41 % of patients. Analysis of the relationships between self-stigma and characteristics of the study population revealed statistically significant associations between higher self-stigma scores and single or divorced status, low socio-economic level and judicial record. In terms of clinical parameters, the mean self-stigma score was significantly associated with a higher total number of thymic episodes and hospitalizations, a longer cumulative duration of hospitalizations and a shorter duration of the last remission. In addition, the mean self-stigma score was associated with significantly more impaired functioning. CONCLUSIONS: Our study underlines the need to work towards the implementation of management modalities aimed at combating the self-stigmatization of patients with bipolar disorder and mitigating its negative consequences during the course of the disease.

[Variations in immunological parameters after treatment of a manic episode]. / Variations immunologiques après traitement d'un épisode maniaque.

Bipolar disorder is a chronic and disabling mental illness affecting approximately 1-2% of the general population, characterized by the occurrence of manic episodes alone or alternating with depressive episodes. Bipolar disorder is associated with significant morbidity, mortality and personal suffering. The mechanisms underlying the onset and progression of bipolar disease are still poorly understood. Recently, immunological dysfunctions have been suggested in the pathogenesis of bipolar disorder, and many studies have focused on the interaction between bipolar disorder and immunity. Immunological changes have been widely studied during depressive episodes but less explored during manic episodes. The objective of our study was to explore changes in serum proteins and autoantibodies after treatment for a manic episode of bipolar I disorder. This study was carried out over a 30-month period from January 2017 to June 2019, in collaboration between the psychiatry department B of the Hédi Chaker CHU and the immunology department of the Habib Bourguiba CHU, in Sfax, Tunisia. It focused on a sample of 45 bipolar patients with manic relapse, naïve to psychotropic treatment, or discontinuing treatment for a period of at least three months and without a history of autoimmune disease. The study was conducted in two stages : on admission and after treatment. The mean plasma levels of IgG and complement C3 fraction were significantly higher in bipolar patients with relapsing mania. Studies of variation in immunoglobulins and complement fractions during relapses of bipolar disorder have all objected to variations in these serum proteins, but their results were inconsistent regarding the direction of variation and the fractions affected. After treatment, there was a statistically significant increase in the mean plasma levels of IgG and IgA and a decrease in the mean plasma level of the C4 fraction of complement. No significant variation in autoantibodies was noted after treatment. The mean plasma IgM level was significantly lower with sodium valproate. On atypical antipsychotic medication, the mean plasma level of fraction C3 was statistically lower, whereas on conventional antipsychotic medication it was statistically higher. This is in line with the data in the literature which support the immunomodulatory role of thymoregulators and antipsychotics. Serum proteins have been more sensitive than autoantibodies to the effect of psychotropic therapy during manic relapse.

Triage of Septic Patients Using qSOFA Criteria at the SAMU Regulation: A Retrospective Analysis.

PURPOSE: One of the major prognostic factors in the management of sepsis is the early initiation of appropriate treatment. To serve this purpose, early identification and triage of patients are crucial steps, which are still not optimal. The objective of this study was to determine whether the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) score is an accurate method for prehospital triaging of septic patients. We evaluated whether the use of qSOFA criteria collected by the Service Mobile d'Urgence et de Réanimation 15 (SAMU 15) regulation call center during prehospital care would facilitate appropriate intensive care unit (ICU) admission of patients with septic syndromes. METHODS: We conducted a retrospective observational register-based study using data collected between April 01 and May 31 2011. These data are based on call registry reports of calls received by the Paris Emergency regulation call centre during prehospital management of patients. All patients with suspected infection were included in the study and evaluated using qSOFA and systemic inflammatory response syndrome (SIRS) criteria. The primary outcome was Intensive Care Unit (ICU) admission. RESULTS: Among the 30 642 reports received, 141 patients with presumed sepsis were included. Twenty-two patients were admitted to an ICU. The qSOFA and SIRS scores were the same in predicting admission to an ICU (p = 0.26). The qSOFA had a sensitivity of 75% and a specificity of 68% for ICU admission whereas the SIRS had a sensitivity of 87% and a specificity of 43%. At day 28, 12 patients (9%) had died, 5 of them in the ICU. The negative predictive value reached 93% and 94% for pre-hospital qSOFA and SIRS respectively. Pre-hospital systolic blood pressure (SBP) ≤100 mmHg was significantly associated with ICU admission (OR = 4.19 [1.89-9.84]), while all other criteria were not. CONCLUSION: The current study reports no difference between the SIRS and the qSOFA scores for prehospital triage of septic patients to predict ICU admission. Both scores have comparable, pertinent, negative predictive value for ICU admission. Nevertheless, an improved score for pre-hospital triaging is needed to predict ICU admission of septic patients.

Prehospital triage of septic patients at the SAMU regulation: Comparison of qSOFA, MRST, MEWS and PRESEP scores.

PURPOSE: A couple of scoring systems have been developed for risk stratification of septic patients. Their performance in the management of out-of-hospital initial care delivery is not documented. This study try to evaluate the predictive ability of Quick Sequential Organ Failure Assessment (qSOFA), Robson Screening Tool (RST), Modified Early Warning Score (MEWS) and Prehospital Early Sepsis Detection (PRESEP) scores on out of-hospital triage of septic patients, to predict intensive care unit (ICU) admission. METHODS: A retrospective study using call records received by the SAMU 15 regulation call centre including all patients with presumed septic shock was performed. The primary outcome was the admission to the ICU. RESULTS: Among the 47 000 reports received, 37 patients with presumed septic shock were included. Twenty-two patients (59%) were admitted to ICU. AUCs of qSOFA, RST, MEWS and PRESEP scores were respectively 0.40 [0.22-0.59], 0.60 [0.43-0.78], 0.66 [0.47-0.85] and 0.67 [0.51-0.84]. RST outperformed PRESEP, MEWS and qSOFA for sensitivity (1, 0.92, 0.85 and 0.62 respectively). MEWS showed better specificity than PRESEP, MRST and qSOFA (0.33, 0.29, 0.16 and 0.16). MEWS showed comparable positive predictive value than PRESEP and outperformed MRST and qSOFA (0.41, 0.41, 0.39 and 0.29 respectively). Negative predictive value of MRST outperformed PRESEP, MEWS and qSOFA (1, 0.88, 0.80 and 0.44 respectively). CONCLUSION: Our findings suggest that screening patients at SAMU 15 regulation call centre using qSOFA, MRST, MEWS and PRESEP scores to predict ICU admission is irrelevant. Development of a specific scoring system for out-of-hospital triage of septic patients is needed.

Primary mucinous carcinoma of the thyroid gland: case report with review of the literature.

Primary mucinous thyroid carcinoma (PMTC) are extremely rare lesions that are histologically indistinguishable from mucinous carcinoma of other sites. We describe the clinicopathological, histological and immunohistochemical features of this rare tumour with a review of the literature. We describe a case of thyroid tumour, in 56-year-old Tunisian man, composed of small nests and sheets of malignant epithelial cells associated with extensive extracellular mucin that entrapped the follicular parenchyma of thyroid. Thyroglobulin and thyroid-specific-transcription factor 1 (TTFl) were focally positive. Follow-up did not reveal another neoplasm at other sites. Based on these features, we classified this tumour as PMTC. Mucinous carcinoma of the thyroid gland can be a cause of pitfall in differential diagnosis. For correct diagnosis, complete clinical history, restricted histological criteria and immunohistochemical panel are necessary.

[Rare cause of pulmonary embolism in a child]. / Embolie pulmonaire hydatique chez un enfant.

Cardiac hydaticyst is a rare condition and accounts for only 0.5 to 2% of all visceral locations of hydatid disease. The objective of this study was to point out the main clinical, radiological, and disease-course characteristics of this rare and serious pathology. We report a 13-year-old patient with a hydatid pulmonary embolism caused by a hydatid cyst of the interauricular septum. The diagnosis was established by transthoracic echocardiography, thoracic CT scan, and hydatid serology. Surgery was performed without delay and the outcome was good after 15 months of follow-up. This case underlines the need for rapid diagnosis and surgery before complications of cardiac hydatid cyst.

[Squamous cell carcinoma on a pleomorphic adenoma with amyloid stroma of the palate]. / Carcinome épidermoïde du palais sur adénome pléomorphe à stroma amyloïde.

INTRODUCTION: Squamous cell carcinoma ex-pleomorphic adenoma (CXAP) is a malignant and rare mixed tumor. We report a new case. OBSERVATION: A seventy-year-old woman consulted for a mass in the left hemi-face having evolved over the last 20years. The physical examination revealed a hard and large tumor invading all the palate. Computed tomography revealed a heterogeneous 8.5cm long maxillary mass. The diagnosis of CXAP was made on a biopsy. A histological study confirmed the diagnosis after surgical resection of the tumor, specifying its noninvasive character. DISCUSSION: CXAP is generally located in the parotid gland; it is very rarely located in the palate. The degenerated epithelial component generally corresponds to an adenocarcinoma or an undifferentiated carcinoma; squamous-cell carcinoma is more rarely reported. The prognosis is excellent for the micro and noninvasive types. Surgery remains the treatment of choice.

[Unusual tumor of the stomach]. / Tumeur inhabituelle de l'estomac.

Stomach melanomas are exceptional and often secondary to cutaneous tumors. Their symptomatology is not specific. We report the case of a 66-year-old woman, hospitalized with a three month history of epigastric pain and weight loss. Gastroscopy had revealed a polyp of the gastric mucosa. Histopathologic examination confirmed the diagnosis of a gastric infiltration by a melanoma. At exploration, there were lung, liver and bone metastasis and no cutaneous melanoma. The diagnosis of polymetastasis from a melanoma without primitive was kept. The patient died three months later.

[Frantz's tumor: anatomoclinical study of six Tunisian cases]. / La tumeur de Frantz: etude anatomoclinique de six cas tunisiens.

Solid and pseudopapillary tumour (Frantz's tumour) is a rare low-grade neoplasm of the pancreas. We report six new cases. Our objective is to specify clinical and pathological characteristics of this rare neoplasm and to discuss its histogenesis. A retrospective review was considered on six Tunisan patients who had solid and pseudopapillary tumor of the pancreas. A review of medical registries and morphological analysis with immunohistochemical study were carried out in all cases. Four patients were female and two patients were male with a median age of 27,5 years (range: 14 - 68 years). Abdominal pain was the most common initial symptoms (5 cases/6). Abdominal computed tomography and/or ultrasonography was used in all the cases. The tumour was in the tail of the pancreas in 4 patients and in the body of the pancreas in one patient; one tumor involved all the pancreas. The median diameter of the tumour was 16,8 cm (range: 8 - 35 cm). Three tumours had an extrapancreatic extension. All patients underwent surgical resection. No adjuvant therapy was recommended. The mean follow up period was 24 months (range: 5 - 78 months). Only one patient died during the surgery. Except for this patient, none experienced tumor recurrence or tumor-related mortality during the follow up period. Solid and pseudopapillary tumour of the pancreas is an uncommon neoplasm which shows distinct clinicopathologically characteristics. Despite diverse studies, its histogenesis remains undetermined. This tumor should be distinguished from other pancreatic neoplasms because its prognosis is excellent after surgical resection.

[Granulosa-cell tumor of the ovary: report of 16 cases]. / Tumeur de la granulosa de l'ovaire: à propos de 16 cas.

OBJECTIVE: The aim of this work was to describe the epidemiological, pathological and clinical features of granulosa cell tumors and to study the different prognostic factors in order to determine an appropriate therapeutic attitude. PATIENTS AND METHODS: We proceeded with a retrospective study of 16 cases of granulosa cell tumors of the ovary diagnosed over a period of 10 years (1994-2003). These cases included one case of juvenile type and 15 adult types. RESULTS: Mean patient age was 46 years for the adult type (range 20-70 years) and 35 years for the juvenile type; 19% of the patients were nulliparous, 31% were menopausals. The predominant symptom was abdomino-pelvic pain with frequent hormonal manifestations. Mean tumor size was 10.5 cm with a solido-cystic aspect in 50% of cases. The treatment was surgical in all cases. Among the 16 patients, 14 (87.5%) were diagnosed at stage I and one (6.2%) at stage II. The juvenile tumor was at stage IV at time of diagnosis and only adjuvant chemotherapy was given. No relapse nor recurrence were noted for the adult type after a mean follow up of 2 years 2 months. For the juvenile form, locoregional recurrence with liver metastasis developed after 9 months. CONCLUSION: Granulosa cell tumor of the ovary is an uncommon neoplasm. The adult form progresses slowly and often is diagnosed in an early stage of disease. Surgery is indicated. The juvenile forms are more exceptional and more aggressive. A prolonged post therapeutic follow-up is necessary because of the risk of recurrences, late and exceptional for the adult form but frequent and early for the juvenile form.

[Legionnaire's disease complicated by acute renal failure due to rhabdomyolosis: a case report]. / Pneumonie à Légionelle compliquée d'une insuffisance rénale aiguë par rhabdomyolyse : à propos d'un cas.

The infectious origin of non-traumatic rhabdomyolysis is rare (5% of cases). An elevated muscle enzyme level is often reported in the legionnaire's disease. We report the case of a 39-year-old male, with no previous medical history, admitted for renal failure (creatininemia=977 micromol/l) secondary to rhabdomyolysis and a twelve-day history of infectious syndrome with pneumonia in the left base. Legionella pneumophila was considered responsible for these symptoms because of a positive serology. The other microbial assessments were negative. After rehydration and three weeks of antibiotics, the outcome was favorable: the renal failure resolved completely and the muscle enzyme level returned to normal.

[Pelvic actinomycosis: two cases]. / Actinomycose pelvienne: à propos de deux cas.

INTRODUCTION: Actinomycosis is a chronic suppurative granulomatous disease caused by different Actinomyces species, mostly bacillus: the Actinomyces israeli. The pelvis location of this infection is rare. OBSERVATIONS: We report two cases of actinomycosis that were diagnosed after the surgical treatment of a suspected ovarian tumor and a suspected acute peritonitis. Diagnosis in both cases was based on the histopathologic findings. CONCLUSION: The incidence of pelvic actinomycosis is increasing since 1960 related to the frequent use of intra uterine device. The clinical symptomatology is not specific, simulating a neoplastic or an inflammatory process. The treatment combines operative and antibiotic therapy.

[Rhabdoid tumours of the central nervous system: five case studies]. / Les tumeurs rhabdoïdes du système nerveux central: à propos de cinq observations.

PURPOSE: The rhabdoid cerebral tumors were first identified by Briner et al. in 1985. Their frequency was estimated to be 2.1% of those affecting children under 18 months. Such tumors are equally characterized by a critically and speedly mortal development. Their historical genesis is still of a controversial issue. The aim of the present study was to discuss the various anatomicoclinical and therapeutic aspects of these rare tumors. PATIENTS AND METHODS: We report five cases diagnosed over a period of eight years (1997-2004) in the Laboratory of Anatomy and Pathological Cytology of the University Hospital of Sfax. RESULTS: The average age of patients was 20 years old, there were children under 14 years and 4 patients were male. Clinical symptomatology showed the predominance of intra-cranial hypertension syndrome. Radiography through magnetic resonance revealed a heterogeneous tumor process localized respectively on the spine (one case), the insula (one case), the temporofrontal lobes (two cases) and the medulla (one case). Histological examination of the tumors also showed a proliferation of giant cells with a hyaline-based cytoplasmic inclusion. These inclusions were positive for vimentin and keratin. An adjuvant radiotherapy treatment was prescribed for two patients. A recurrence of rhabdoid tumors occurred in two cases. All five patients died within eighteen months. CONCLUSION: The cerebral rhabdoid malignant tumor constitutes one of the most aggressive and life-threatening intracranial tumors. The optimal management of such tumors remains unknown.

[Malignant struma ovarii: a case report]. / Goitre ovarien malin: une observation.

Malignant transformation of struma ovarii is exceptional (less than 1%). The histolological diagnosis of malignancy is difficult especially in the well differentiated forms. Immunohistochemistry is highly contributive in the anaplastic forms. The prognosis is relatively favorable except for the metastatic and undifferentiated forms. We report a case of malignant struma ovarii with metastasis observed in a 65-year-old woman who died rapidly from her disease. In light of this observation, we discuss the diagnositic, management and outcome features of these particular tumors.

[Feminizing testicular syndrome with multiple hamartomas and bilateral paratesticular leiomyomas]. / Syndrome du testicule féminisant associé à des hamartomes multiples et à des léiomyomes paratesticulaires bilatéraux.

INTRODUCTION: Complete androgen insensitivity syndrome or testicular feminization syndrome (TF) is the most common form of male pseudohermaphrodism, caused by a failure of androgen receptor binding. Patient with male genotype 46 XY, has a female morphotype with well developed external sexual organs. EXEGESIS: - We report the case of a 29 year-old girl with a TF syndrome discovered during the exploration of a primary amenorrhoea. Bilateral orchidectomy was performed. The testis were immature; they showed bilateral leiomyoma of the tunica albuginea and multiple hamartomas on the right side. CONCLUSION: Benign tumors are developped in 80% of cases of TF and they are generally hamartomatous nodules of testis. Association of paratesticular leiomyoma to synchronous hamartoma has never been described, its histogenesis is discussed.

[The evaluation of mental health among Tunisian students]. / Evaluation de la santé mentale des étudiants Tunisiens.

Universal studies are an important source of stressor. Students are at high risk for mental disorders. In this study, we seek for psychological distress among Tunisian students, using GHQ (general health questionnaire).