Incidence and risk factors of post COVID-19 syndrome: a Tunisian cohort study.

BACKGROUND: It has become increasingly clear that SARS-CoV-2 infection can lead to persistent physical and mental health problems lasting weeks or months, requiring prolonged periods of clinical care and increasing the burden on the healthcare system. This phenomenon, known as post COVID-19 syndrome (PCS), is a relatively new condition, its incidence is still unclear and differs between studies. OBJECTIVES: In this cohort study, we aimed to estimate the incidence of PCS and to identify its risk factors in the Tunisian population. METHODS: This is a prospective cohort study that enrolled patients diagnosed with COVID-19 from the triage unit of the University Hospital of Monastir, Tunisia. between April 2021 and June 2022. Patients were contacted by phone for a follow-up evaluation of PCS 12- weeks after the diagnosis date. RESULTS: A total of 1451 individuals diagnosed with COVID-19 during the study period, responded to the follow-up evaluation after 3 months. The incidence of PCS was found to be 44.03% (95% CI [41.47; 46.58]), with fatigue being the most common symptom (21.5%), followed by cognitive impairment (10.3%), including memory loss and difficulty concentrating. Multivariate analysis revealed that the main associated factors to PCS were female gender (RR = 1.54; CI95% [1.30 - 1.82]), pre-existing comorbidities (RR = 1.30; CI95% [1.10 - 1.52]), duration of acute COVID-19 illness (days) (RR = 1.02; CI95% [1.01 - 1.03]), hospitalization (RR = 1.27; CI95% [1.05 - 1.53]), number of COVID-19 episodes (RR = 1.46; CI 95% [1.28 - 1.67]) and patients having receive two or more doses of vaccine prior to COVID-19 infection (RR = 0.82; CI95% [0.70 - 0.96]). CONCLUSION: Our study allowed to estimate the incidence and identify risk factors of PCS. Recognizing these factors could help to better understand the underlying mechanisms and guide interventions for prevention and management of this condition.

Comparison of time to negative conversion of SARS-CoV-2 between young and elderly among asymptomatic and mild COVID-19 patients: a cohort study from a national containment center.

Objective: We aimed to study the relationship between age and time to negative conversion of SARS-CoV-2 in patients with asymptomatic and mild forms of COVID-19. Methods: We conducted a cohort study including all patients diagnosed with COVID-19 from the national COVID-19 containment center of Tunisia. Patients were subdivided into two cohorts: (under 60 years) and (over 60 years) and were followed up until PCR negativization. Log rank test and Cox regression were applied to compare time to negative conversion between the old group and the young group. Results: The study included 289 patients with non-severe forms of COVID-19. Age over 60 was significantly associated with delayed negative conversion in male sex (Hazard ratio (HR): 1.9; 95% CI: 1.2-3.07) and among patients with morbid conditions (HR:1.68; 95% CI: 1.02-2.75) especially diabetics (HR: 2.06; 95% CI: 1.01-4.21). This association increased to (HR:2.3; 95% CI: 1.13-4.66) when male sex and comorbidities were concomitantly present and rose to (HR: 2.63; 95% CI: 1.02-6.80) for men with diabetes. Cox regression analysis revealed a significantly delayed negative conversion in symptomatic patients. Significant interaction was observed between gender and age and between age and chronic conditions. Conclusion: Age is associated with delayed negative conversion of viral RNA in certain subgroups. Identifying these subgroups is crucial to know how prioritize preventive strategies in elderly.

Burden and predictions of hospitalized injuries in a low-middle income country: results from a Tunisian university hospital.

Injuries are responsible for a high premature mortality and disability. They are poorly explored in low and middle income-countries. We aimed to estimate the burden of hospitalized injuries in the Monastir governorate (Tunisia) according to the nature of the injury, trends and projections of hospitalizations for injuries up until 2024, and to identify the distribution of this disease burden based on age and sex. We performed a descriptive study from 2002 to 2012 including all hospitalizations for injuries. Data were collected from morbidity and mortality register of the University Hospital of Monastir (Tunisia). We estimated the burden of injuries using the Disability Adjusted Life Years (DALYs). We described injuries (crude prevalence rate (CPR) and age standardized prevalence rate (ASR)), related mortality (lethality and standardized mortality ratio (SMR)), trends and prediction for 2024. A total of 18,632 hospitalizations for injuries representing 10% of all hospitalizations during study period were recorded. Per 1000 inhabitants per year, CPR was 3.36 and the ASR was 3.44. The lethality was of 17.5 deaths per 1000 injured inpatients per year and the SMR was of 2.95 (Confidence Interval of 95%: 2.64-3.29). Burden related to injuries was 2.36 DALYs per 1000 population per year, caused mainly by Years of Life Lost (83.4%), most frequent among men aged under 40 years. The predicted ASR for 2024 was 4.46 (3.81-5.23) per 1000 person-years. Injuries to the head was the most prevalent (20.7%) causing 67.7% of DALYs; and increasing by 226% through 2024. Injuries had a high prevalence and an important burden in a Tunisian university hospital. Prediction showed increased prevalence for 2024. Preventive measures and a trauma surveillance register should be implemented soon.

The effectiveness of a health education intervention to reduce anxiety in quarantined COVID-19 patients: a randomized controlled trial.

INTRODUCTION: The COVID-19 pandemic is regarded as a serious public health concern that boosts levels of stress and anxiety which could be explained by several reasons, including social isolation. In this regard, we aimed to assess the impact of health education on the anxiety level of COVID-19 patients during the isolation period. METHODS: This is a randomized controlled trial conducted between February 2021 and June 2021. Patients tested positive for Covid-19 with mild to moderate forms were randomized to Education (n = 267) or control (n = 269). The education group received a phone health education session on day 1 (D1) following the diagnosis. The three components of the health education intervention were an explanation of the coronavirus disease, what to do in the event of complications, and the recommended preventive measures. The two groups received a telephone evaluation of their Hospital Anxiety and Depression scores on D1 and day seven D7 following the positive diagnosis. The primary outcome was the rate of anxiety reduction in each group on D7 based on a HAD-A score ≥ 8. Secondary outcomes were the rate of anxiety reduction on D7 based on a HAD-A score ≥ 11, the percentage of people complying with isolation and the scores of adherences to preventive measures during the isolation in each group. RESULTS: Hundred and ninety-six patients in the intervention group and 206 patients in the control group completed the study. The sociodemographic, clinical, and initial anxiety level features of the intervention and control groups were comparable at baseline (p ≥ 0.05). On D7, the education group's anxiety level (HAD-A ≥ 8) decreased from 26 to 16.3% (p = 0.013) while in the control group it increased from 19.4 to 22.8% (p = 0.37). Thus, the percentage change in anxiety between D1 and D7 (delta D7 - D1) was - 9.7% in the Education group and + 3.4% in the Control group. Using the HAD-A ≥ 11 thresholds, the percentage of anxiety decreased from 15.3 to 11.2% (p = 0.26) between D1 and D7, while it increased in the control group from 9.7 to 15.7% (p = 0.045). Thus, the education group's change in anxiety (delta D7 - D1) was - 4.1%, while the control group's change was + 6%. CONCLUSION: During an outbreak, providing health education to quarantined patients may be beneficial to reduce the psychological impact of the disease. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT05715593, retrospectively registered on 8/02/2023 https://clinicaltrials.gov/ct2/results?term=NCT05715593&Search=Search .

Burnout syndrome among health care workers during the COVID-19 pandemic. A cross sectional study in Monastir, Tunisia.

BACKGROUND: Burnout syndrome may affect the safety of frontline healthcare care workers (HCW) and patients. We aimed to measure the prevalence of burnout among HCW in care facilities in Tunisia during the Covid-19 pandemic and to identify its associated factors. METHODS: We conducted a cross-sectional study among HCW practicing during the covid-19 pandemic in health care facilities in the governorate of Monastir. Data collection was carried out using an anonymous self-administered questionnaire composed by three sections: epidemiological and clinical characteristics, professional conditions and the Maslach Burn out Inventory (MBI-HSS). RESULTS: This study included 371 HCW. The prevalence of burnout was 77.9% (CI 95%: 73.6% - 82.1%). The severe level was found in 71 participants (19.1%), the moderate level in 115 (31%) and the low level in 103 (27.8%). The distribution of the levels of the burnout dimensions among the participants was as follows: high emotional exhaustion (EE) (57.4%), high depersonalization (DP) (39.4%) and low personal accomplishment (22.6%). The main determinants of burnout among healthcare professionals during COVID 19 pandemic were: working more than 6 hours per day (OR = 1.19; CI95% [1.06; 1.34]), physician function (OR = 1.17; CI 95% [1.05; 1.31]), feeling a negative impact of work on family life (OR = 1.40; 95% CI [1.13; 1.73]), and high personal estimation of COVID 19 exposure (OR = 1.15; CI95% [1.02; 1.29]). CONCLUSION: During the COVID19 pandemic, the prevalence of burnout among health professionals was high. It was related to hard implication in COVID 19 management. Interventions like adjusting working hours, reducing workload, and providing psychological support should be taken.

Twice-Daily Oral Zinc in the Treatment of Patients With Coronavirus Disease 2019: A Randomized Double-Blind Controlled Trial.

BACKGROUND: Zinc supplementation has been considered a potential therapy for coronavirus disease 2019 (COVID-19). We aimed to examine zinc efficacy in adult patients with COVID-19 infection. METHODS: We conducted a prospective, randomized, double-blind, placebo-controlled multicenter trial. Patients who were tested positive for COVID-19 without end-organ failure were randomized to oral zinc (n = 231) or matching placebo (n = 239) for 15 days. The primary combined outcome was death due to COVID-19 or intensive care unit (ICU) admission ≤30 days after randomization. Secondary outcomes included length of hospital stay for inpatients and duration of COVID-19 symptoms with COVID-19-related hospitalization for outpatients. RESULTS: 190 patients (40.4%) were ambulatory and 280 patients (59.6%) were hospitalized. Mortality at 30 days was 6.5% in the zinc group and 9.2% in the placebo group (OR: .68; 95% CI .34-1.35); ICU admission rates were, respectively, 5.2% and 11.3% (OR: .43; 95% CI .21-.87). Combined outcome was lower in the zinc group versus the placebo group (OR: .58; 95% CI .33-.99). Consistent results were observed in prespecified subgroups of patients aged <65 years, those with comorbidity, and those who needed oxygen therapy at baseline. Length of hospital stay was shorter in the zinc group versus the placebo group (difference: 3.5 days; 95% CI 2.76-4.23) in the inpatient group; duration of COVID-19 symptoms decreased with zinc treatment versus placebo in outpatients (difference: 1.9 days; 95% CI .62-2.6). No severe adverse events were observed during the study. CONCLUSIONS: Our results showed that, in COVID-19 patients, oral zinc can decrease 30-day death, ICU admission rate and can shorten symptom duration. Clinical Trials Registration. ClinicalTrials.gov, NCT05212480.

Developing learning objectives in postgraduate medical education for family medicine (Tunisia).

Introduction-Aim: The third cycle of medical studies (TCMS) lasts 3 years for the specialty of family medicine (FM) in Tunisia. The members of the FM committee of the Faculty of Medicine of Monastir (FMM) aimed to detail the learning objectives (LO) of residents in FM. METHOD: We used the Delphi method in 2 rounds including a group of experts called FM Learning Objectives Writing Group (FMLOWG) at the FMM. The FMLOWG included 74 university hospital physicians and FM internship supervisors. These members actively participated in the 10 meetings held during the month of March 2022. Three points were discussed: the identification of LOs; the development of training titles and the proposal of the teaching methods to be adopted. The writing was subdivided into 5 domains of LO: transversal, public health, typical population and by system. RESULTS: We identified 1359 LOs for FM residency, for which 552 were LOs per system (40.5%). The learning included 618 training session titles. Residents will have an academic training day every 3 weeks during 9 months for each TCMS year. CONCLUSION: A detailed, MF-specific consensus has been developed by majority of medical specialties. It will be a learning base for learners, a reference for supervisors and TCMS teachers.

Occupational exposure to hepatitis C virus infection and associated factors among healthcare workers in Fattouma Bourguiba University Hospital, Tunisia.

BACKGROUND: Healthcare workers (HCWs) are at high risk of hepatitis C virus (HCV) infection. Indeed, they are exposed to blood and body fluid which put them at an important risk of transmission of various blood borne pathogens including HCV. The goal of this study was to determine the magnitude of occupational exposure to hepatitis C virus infection as well as the factors associated to this exposure among HCWs at a Tunisian University Hospital in 2017. METHODS: A hospital-based cross-sectional study was carried out at Fattouma Bourguiba University Hospital in Monastir Governorate (Tunisia) from 01 June 2017 to 31 August 2017. Data were collected using an anonymous questionnaire. To determine factors associated with occupational exposure to hepatitis C virus infection, we performed multivariate analysis. RESULTS: Among the 1493 included participants, more than half (56.7) had at least one exposure to blood or body fluid. A history of needle stick injury was reported by 48.3% of the respondents. Exposure to blood or body fluid splash into the face was announced by 32.1% HCWs. Doctors had the highest risk of exposure (AOR = 12.425; 95% CI: [05.310-29.075]). Participants working at surgical departments were the most exposed comparing to workers at others departments (AOR = 7.440; 95% CI: [4.461-12.408]). Two exposed female HCWs were tested positive corresponding to a HCV infection prevalence of 0.13% (95% IC: [0.11-0.16%]). CONCLUSION: Occupational exposure to hepatitis C virus infection was high at the university hospital of Monastir. Despite the low magnitude of HCV infection, preventive actions should be taken to promote the safety of health care personnel.

Eating disorders among women in primary care (Monastir, Tunisia).

INTRODUCTION: Eating disorders (ED) are relatively frequent, but convey a high mortality and morbidity. More than half of individuals with ED remain undetected in primary care. The general practitioners (GP) are in a strategic position to detect patients with ED. AIMS: To determine the prevalence of ED in Tunisian women visiting their GP using the SCOFF-F score and to determinate the associated socioeconomic, clinical, and lifestyle factors. METHODS: This is a cross-sectional study of women who consulted two primary health care in the city of Monastir, during 4 months of the year 2020. The SCOFF-F was performed. RESULTS: We included 445 women; the mean age of our patients was 36 ± 12 years. SCOFF-F was positive in 48% of cases CI95% [43-52%], 14% presented with bulimia nervosa and 12% with binge eating disorder. Patients with ED were overweight in 33% of cases, 40% perform a physical activity and 53% eat three meals per day. A family history of ED was 35%. 20% of the patients have a history of psychiatric disorder. In multivariate analysis, performing physical activity to control weight, eating three meals a day, maintaining the current diet without trying to change into a different one, non continous occupation and anxiety increase the risk of ED with respective ORs of 2.34, 4.26, 3.69, 2.09 and 2.09 respectively. Ages between 35 and 60 years, and a history of ED in siblings increases the risk of ED by 1.6. CONCLUSION: Our study concluded that ED was associated with common family behavior, especially among siblings, and with a particular psychological state which are interesting to screen by GP and to focus on targeting family care.

Two-day versus seven-day course of levofloxacin in acute COPD exacerbation: a randomized controlled trial.

INTRODUCTION: Duration of antibiotic treatment in acute exacerbation of COPD (AECOPD) is most commonly based on expert opinion. Typical administration periods range from 5 to 7 days. A 2-day course with levofloxacin was not previously assessed. We performed a randomized clinical trial to evaluate the efficacy of 2-day versus 7-day treatment with levofloxacin in patients with AECOPD. METHODS AND ANALYSIS: Patients with AECOPD were randomized to receive levofloxacin for 2 days and 5 days placebo (n = 155) or levofloxacin for 7 days (n = 155). All patients received a common dose of intravenous prednisone daily for 5 days. The primary outcome measure was cure rate, and secondary outcomes included need for additional antibiotics, ICU admission rate, re-exacerbation rate, death rate, and exacerbation-free interval (EFI) within 1-year follow-up. The study protocol has been prepared in accordance with the revised Helsinki Declaration for Biomedical Research Involving Human Subjects and Guidelines for Good Clinical Practice. The study was approved by ethics committees of all participating centers prior to implementation (Monastir and Sousse Universities). RESULTS: 310 patients were randomized to receive 2-day course of levofloxacin (n = 155) or 7-day course (n = 155). Cure rate was 79.3% (n = 123) and 74.2% (n = 115), respectively, in 2-day and 7-day groups [OR 1.3; 95% CI 0.78-2.2 (p = 0.28)]. Need for additional antibiotics rate was 3.2% and 1.9% in the 2-day group and 7-day group, respectively; (p = 0.43). ICU admission rate was not significantly different between both groups. One-year re-exacerbation rate was 34.8% (n = 54) in 2-day group versus 29% (n = 45) in 7-day group (p = 0.19); the EFI was 121 days (interquartile range, 99-149) versus 110 days (interquartile range, 89-132) in 2-day and 7-day treatment groups, respectively; (p = 0.73). One-year death rate was not significantly different between the 2 groups, 5.2% versus 7.1% in the 2-day group and 7-day group, respectively; (p = 0.26). No difference in adverse effects was detected. CONCLUSION: Levofloxacin once daily for 2 days is not inferior to 7 days with respect to cure rate, need for additional antibiotics and hospital readmission in AECOPD. Our findings would improve patient compliance and reduce the incidence of bacterial resistance and adverse effects.

Breast cancer incidence and predictions (Monastir, Tunisia: 2002-2030): A registry-based study.

INTRODUCTION: Breast cancer is a major public health problem worldwide. It is the leading cause of cancer deaths in females. In developing countries like Tunisia, the frequency of this cancer is still growing. The aim of this study was to determine the crude and standardized incidence rates, trends and predictions until 2030 of breast cancer incidence rates in a Tunisian governorate. METHODS: This is a descriptive study including all female patients diagnosed with breast cancer in Monastir between 2002 and 2013. The data were collected from the cancer register of the center. Tumors were coded according to the 10th version of international classification of disease (ICD-10). Trends and predictions until 2030 were calculated using Poisson linear regression. RESULTS: A total of 1028 cases of female breast cancer were recorded. The median age of patients was 49 years (IQR: 41-59 years) with a minimum of 16 years and a maximum of 93 years. The age-standardized incidence rate (ASR) was of 39.12 per 100000 inhabitants. It increased significantly between 2002 and 2013 with APC of 8.4% (95% CI: 4.9; 11.9). Prediction until 2030 showed that ASR would reach 108.77 (95% CI: 57.13-209.10) per 100000 inhabitants. CONCLUSION: The incidence and the chronological trends of breast cancer highlighted that this disease is of a serious concern in Tunisia. Strengthening preventive measures is a primary step to restrain its burden.

Syndromic surveillance of female sexually transmitted infections in primary care: a descriptive study in Monastir, Tunisia, 2007─2017.

BACKGROUND: Sexually Transmitted Infections (STIs) are a public health problem, especially for reproductive-age women. The aim of this study was to determine the incidence and trend of STIs during 11 years in Tunisia (2007-17). METHODS: We conducted a descriptive study including all women with curable STIs (chlamydia, gonorrhea, syphilis and trichomoniasis) diagnosed with the syndromic approach in all basic health care centers of the Governorate of Monastir (Tunisia) from 2007 to 2017. Syndromes included, Pelvic Pain (PP), Vaginal Discharge (VD) and Genital Ulceration (GU). RESULTS: We analyzed 40,388 episodes of curable STIs with a crude incidence rate and age standardized incidence rate of 1393 (95% Confidence Interval (CI); 1348-1438) / 100,000 Person Year (PY) and 1328 (95%CI; 1284-1372) /100,000 PY respectively. The incidence rate showed a positive trend over 11 years for all age groups and syndromes. VD was the most common syndrome with a crude incidence rate of 1170/100,000 PY. For all syndromes, women aged 20 to 39 were the most affected age group (p < 0.001). CONCLUSION: In conclusion, the incidence rate of STIs episodes among women diagnosed with the syndromic approach was high, consistent with the global evidence. Focusing on reviewing STIs surveillance system in low and middle-income countries could allow the achievement of the ending of STIs epidemics by 2030.

Factors associated with a prolonged negative conversion of viral RNA in patients with COVID-19.

OBJECTIVES: The aim of this study was to identify the factors influencing the delay in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA negative conversion. METHODS: A cohort study was conducted that included patients with coronavirus disease 2019 (COVID-19) admitted to the Tunisian national containment center. Follow-up consisted of a weekly RT-PCR test. Multivariate Cox regression analysis was performed to determine independent predictors associated with negative RNA conversion. RESULTS: Among the 264 patients included, the median duration of viral clearance was 20 days (interquartile range (IQR) 17-32 days). The shortest duration was 9 days and the longest was 58 days. Factors associated with negative conversion of viral RNA were symptoms such as fatigue, fever, and shortness of breath (hazard ratio (HR) 0.600, 95% confidence interval (CI) 0.401-0.897) and face mask use when exposed to COVID-19 cases (HR 2.006, 95% CI 1.247-3.228). The median time to RNA viral conversion was 18 days (IQR 16-21 days) when using masks versus 23 days (IQR 17-36 days) without wearing masks, and 24 days (IQR 18-36 days) for symptomatic patients versus 20 days (IQR 16-30 days) for asymptomatic patients. CONCLUSIONS: The results of this study revealed that during SARS-CoV-2 infection, having symptoms delayed viral clearance, while wearing masks accelerated this conversion. These factors should be taken into consideration for the strategy of isolating infected patients.

Bedside lung ultrasonography by emergency department residents as an aid for identifying heart failure in patients with acute dyspnea after a 2-h training course.

BACKGROUND: Ultrasonographic B-lines have recently emerged as a bedside imaging tool for the differential diagnosis of acute dyspnea in the Emergency Department (ED). However, despite its simplicity, LUS has not fully penetrated emergency department. This study aimed to assess the accuracy and reproducibility of ultrasonographic B-lines performed by emergency medicine (EM) residents for the diagnosis of congestive heart failure (CHF) in patients admitted to ED for acute dyspnea. PATIENTS AND METHODS: This is a cross-sectional prospective study conducted between January 2016 and October 2017 including patients aged over 18 years admitted to ED for acute dyspnea. At admission, two consecutive bedside LUS study were performed by a pair of EM residents who received a 2-h course for recognition of sonographic B-lines to determine independently B-lines score and B-profile pattern. All participating sonographers were blinded to patients' clinical data. B-lines score ≥ 15 or a B-profile pattern was considered as suggestive of CHF. The final leading diagnosis was assessed by two expert sonographers, who were blinded to the residents' interpretations, based on clinical findings, chest X-ray, brain natriuretic peptide, cardiac and lung ultrasound testing. Accuracy and agreement of B-lines score and B-profile pattern were calculated. RESULTS: We included 700 patients with a mean age of 68 ± 12.6 years and a sex ratio (M/F) of 1.43. The diagnosis of CHF was recorded in 371 patients (53%). The diagnostic performance of B-lines score at a cut-off 15 and B-profile pattern was, respectively, 88% and 82.5% for sensitivity, 75% and 84% for specificity, 80% and 85% for positive predictive value, 84% and 81% for negative predictive value. The area under receiver operating characteristic curve was 0.86 [0.83-0.89] and 0.83 [0.80-0.86], respectively, for B-lines score and B-profile pattern. There was an excellent agreement between residents for the diagnosis of CHF using both scores (kappa = 0.81 and 0.85, respectively, for ordinal scale B-lines score and B-profile pattern). CONCLUSION: Lung ultrasound B-lines assessment has a good accuracy and an excellent reproducibility in the diagnosis of CHF in the hand of EM residents following a short training program. Trial registration Name of the registry: clinicaltrials.gov; Trial registration number: NCT03717779; Date of registration: October 24, 2018 'Retrospectively registered'; URL of trial registry record: clinicaltrials.gov.

Predictors of Quality of Life in Stroke Survivors: A 1-year Follow-Up Study of a Tunisian Sample.

BACKGROUND: Stroke survivors often have impaired quality of live (QOL). There is very little information about the determining factors of QOL of stroke survivors in developing countries managed in public health structures with limited access to state of the art treatments. OBJECTIVE: To identify the main determinants of QOL in Tunisian stroke survivors. METHODS: QOL was assessed at 3, 6 and 12 months after the stroke using the Tunisian version of the SF-36 questionnaire. Patients were evaluated using the National Institue of Health Stroke Scale, the motor index of Demeurisse, the Functional Independence Measure instrument, the Reintegration to Normal Living Index, the Mini-Mental State Examination and the Hospital Anxiety and Depression Scale. RESULTS: 65 stroke survivors were included (60% males; mean age 62.2±10.3 years). Eighty-sex percent of the patients had an ischemic infarction. Most of the stroke patients had minor or moderate stroke. All the QOL dimensions were altered at 3 months post stroke. Between the 3 and 6-months follow-ups, there were significant changes in the SF-36 scores and individual domains but QOL remained altered. Between 6 and 12 months, there were no significant changes in the majority of the SF-36 domains. Advanced age, neurologic impairment, depression and disability measured 1 month after stroke, the stroke side (left hemisphere), the life style, and higher education, were associated with worse QOL. CONCLUSIONS: Stroke severity, advanced age, post-stroke depression and disability seem to represent consistent determinants of QOL in Tunisian stroke patients.

Acetaminophen, Nonsteroidal Anti-inflammatory Drugs, or Combination of Both Analgesics in Acute Posttrauma Pain: A Randomized Controlled Trial.

OBJECTIVES: Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (also called paracetamol) are the most frequent analgesics used to relieve posttrauma pain in the emergency department (ED). However, the utility of combining both treatments is still controversial. We sought to explore the benefits of combining an NSAID with acetaminophen compared to acetaminophen alone, or NSAID alone, in the treatment of posttraumatic pain of the extremity after discharge from the ED. METHODS: This is a prospective, randomized controlled trial, carried out in a single ED from March 2017 to November 2018. The included patients were randomly assigned to receive paracetamol alone, high-dose NSAID (piroxicam) alone, or a combination of paracetamol and high-dose NSAID for 7 days after ED discharge. The primary outcome was need for additional oral analgesics. Secondary outcomes included the change of the visual numeric scale (VNS) between ED discharge (VNS D0) and 7 days later (VNS D7), ED revisits for residual pain, side effects, and patient satisfaction as assessed by a Likert satisfaction scale. RESULTS: The need for additional oral analgesics was comparable between the paracetamol-NSAID combination group (9.8%) and the paracetamol group (11.4%; p = 0.43). ED readmission rate was also comparable between the two groups at 5.6 and 5.8%, respectively (p = 0.86). In contrast, need for new analgesics and ED revisit rates were both more frequent in the high-dose NSAID group. Mean VNS decreases on day 7 compared to day 0 were 66, 63, and 67%, respectively, in the paracetamol, NSAID, and paracetamol-NSAID combination groups (p = 0.32). Frequency of dissatisfaction was higher in the NSAID group. Side effects were more frequent in the NSAID and paracetamol-NSAID combination groups. CONCLUSION: This study found that the combination of a high-dose NSAID with paracetamol does not increase the analgesic effect compared to paracetamol alone. We also found that paracetamol alone is superior to high-dose NSAID alone for posttraumatic extremity pain.

Value of systolic time intervals in the diagnosis of heart failure in emergency department patients with undifferentiated dyspnea.

AIM OF THE STUDY: The diagnosis of heart failure in the emergency department (ED) is challenging. The aim of this study was to evaluate systolic time intervals (STIs) using phonoelectrocardiography for the diagnosis of heart failure (HF) in ED patients with undifferentiated dyspnea. METHODS: A total of 855 patients with dyspnea and suspected HF were prospectively enrolled. They underwent echocardiographic measurements of left ventricular ejection fraction (LVEF), B-type natriuretic peptide (BNP) testing and computerised phonoelectrocardiography to assess STIs including electromechanical activation time (EMAT), left ventricular ejection time (LVET) and EMAT/LVET ratio. Diagnosis accuracy of STIs was calculated including sensitivity, specificity, likelihood ratio and receiver operating characteristic (ROC) curve. RESULTS: Patients with HF (n = 530) had significantly higher EMAT and lower LVET compared with non-HF patients. ROC curve c-statistic was 0.74, 0.72 and 0.78 for EMAT, LVET and EMAT/LVET respectively. Sensitivity and specificity of EMAT/LVET at a cut-off = 40% were 72% and 88% respectively. EMAT/LVET had the highest correlation with LVEF (r = 0.48). In patients with intermediate BNP (n = 107), positive likelihood ratio increased from 1.8 with BNP alone to 3.6 with BNP combined to EMAT/LVET. Patients without HF had STIs values not significantly different from those with preserved LVEF (≥45%). CONCLUSIONS: Given their immediate availability, phonoelectrocardiography STIs' parameters and particularly EMAT/LVET ratio could have an important role in the diagnosis approach of HF in patients with undifferentiated dyspnea in the ED.

Acute coronary syndrome: factors predicting smoking cessation.

BACKGROUND: Few randomized controlled trials have examined the efficacy time of smoking cessation in hospitalized patients with acute coronary syndrome, either during hospitalization or after discharge. AIMS: To assess smoking cessation rates at 24 weeks among patients with acute coronary syndrome. Group A had begun nicotine replacement therapy during hospitalization, and Group B after discharge. We also determined factors predicting success. METHODS: We conducted a randomized controlled trial in the Cardiology Department and Smoking Cessation Service at University Hospital of Monastir, Tunisia from January 2015 to June 2016. Participants were randomly assigned to the above 2 groups. The endpoint assessment was smoking abstinence at 24 weeks, defined as self-reported abstinence in the past week, confirmed by measured exhaled carbon monoxide (CO) ≤ 8 ppm. We analysed data by intention to treat. We used a binary logistic regression model to determine factors predicting abstinence. RESULTS: All participants were male and mean (standard deviation) age was 55 (11) years. At 24 weeks there was no significant difference in smoking cessation rate between the 2 groups: 54.5% [95% confidence interval (CI): 44.7-64.3%] in Group A and 45.5% (95% CI: 35.7-55.3%) in Group B (P = 0.81). High level of nicotine dependence [odds ratio (OR): 0.72; 95% CI: 0.54-0.96) and good compliance during follow-up (OR: 6.56; 95% CI: 2.07-20.78) were predictive factors for abstinence. CONCLUSIONS: Smoking cessation rate after acute coronary syndrome was high regardless of the start date. Good compliance during follow-up was the key predictive factor for success.

Effect on Opioids Requirement of Early Administration of Intranasal Ketamine for Acute Traumatic Pain.

OBJECTIVES: To evaluate the efficacy and safety of early administration of low-dose intranasal ketamine on reducing the need for opioid and nonopioid analgesic agents in emergency department (ED) patients with acute moderate to severe acute limbs' trauma pain. PATIENTS AND METHODS: This is a double-blind, randomized, prospective, controlled study conducted in the ED. The included patients were randomly assigned to intranasal pulverization of ketamine or placebo. Protocol treatment was given at the triage. The primary outcome is the need for opioids during ED stay. Secondary outcome included the requirement of nonopioid analgesic agents and the percentage of patients discharged from the ED with a visual analog scale (VAS) <30. A combined outcome score including the 3 outcome items was constructed. RESULTS: The authors included 1102 patients, 550 patients in the placebo group, and 552 in the intranasal ketamine group. The groups were similar regarding demographics, clinical characteristics, and baseline VAS. The need for opioids was decreased in the intranasal ketamine group compared with the placebo group (17.2% vs. 26.5%; P<0.001). The need for nonopioid analgesics was significantly lower in the intranasal ketamine group compared with the placebo group (31.1% vs. 39.6%; P=0.003). The percentage of patients discharged with a VAS score <30 was significantly higher in the intranasal ketamine group (P<0.001). The mean combined outcome score was 0.97 in the placebo group and 0.67 in the intranasal ketamine group (P<0.001). CONCLUSION: Intranasal ketamine administered early in the triage was associated with a decrease in opioids and nonopioid analgesics need in patients with acute limb trauma-related pain.