An update on the access to inpatient rehabilitation facilities across Tunisia in 2023.

INTRODUCTION: Considering the growing global need and the complexity of health conditions, an intensive rehabilitation in inpatient departments is fundamental. Yet, in Tunisia, the distribution of Inpatient Rehabilitation Facilities is not illustrated. AIM: To perform an update concerning the rehabilitation's beds-ratio /1000 Tunisian-inhabitants in 2023. METHODS: Data were collected from the Tunisian Ministry of Health, the Eastern Mediterranean Regional Office, and the National Institute of Statistics websites. RESULTS: The findings revealed a total number of rehabilitations' beds 132 among a total of 20000 hospital beds with a rehabilitations' beds-ratio equal to 0.01/1000 inhabitants. Only three Inpatient Rehabilitation Facilities were identified in Tunisia covering the Greater Tunis, North East, and Center east districts. There was inequity of distribution since the beds ratio is 1.07/1000 in the North east, 0.02/1000 in the Greater Tunis and 0 in the North West and the South of Tunisia. CONCLUSION: This update highlighted the alarmingly low rehabilitation's beds-ratio in Tunisia, coupled to a significant regional disparity. Increasing beds in the existing Inpatient Rehabilitation Facilities and extending outpatient rehabilitation departments with inpatient units might be considered urgent solutions.

Major mistakes in scientific medical writing based on manuscripts' reviews.

INTRODUCTION: Peer review is a crucial process in ensuring the quality and accuracy of scientific research. It allows experts in the field to assess manuscripts submitted for publication and provide feedback to authors to improve their work. AIM: To describe mistakes encountered while peer reviewing scientific manuscripts submitted to "La Tunisie Médicale" journal. METHOD: This was a bibliometric study of research manuscripts submitted to "La Tunisie Médicale" and reviewed during 2022. The data collected included the type of the manuscripts and the number of reviews conducted per manuscript. The study also identified variables related to writing mistakes encountered during the peer review process. RESULTS: A total of 155 manuscripts (68% original articles) were peer reviewed and 245 reviews were delivered, by two reviewers. Out of 62 mistakes detected, 21% concerned the results section. In 60% of the manuscripts, the keywords used were not MeSH (Medical Subject Headings) terms. The introduction lacked in-text citations in 30% of the reviewed manuscripts, while the method section did not have a clear study framework (27%). The two major mistakes detected in the results section were the misuse of abbreviations in tables/figures, and the non-respect of the scientific nomenclature of tables/figures with respectively 39% and 19% of manuscripts. CONCLUSION: This study identified 62 mistakes while reviewing scientific manuscripts submitted to "La Tunisie Médicale" journal. Scholars can benefit from participation in scientific writing seminars and the use of a safety checklist for scientific medical writing to avoid basic mistakes.

PDL1 and molecular biomarkers expression in non-small cell lung cancer in Tunisian patients.

In cancer treatment, programmed death-1 (PD-1) and programmed death ligand-1 (PD-L1) inhibitors are thriving. Activated T lymphocytes expressed PD-1, it works with its ligand PD-L1 to limit T lymphocyte activation and prevent autoimmune disease. The expression of molecular biomarkers and PD-L1 in lung cancer determines the appropriate treatment strategy for patients with lung cancer. The purpose of this study was to look at the prevalence of molecular biomarkers and PD-L1 expression in a large group of Tunisian patients with advanced non-small cell lung cancer. We conducted an observational retrospective study in which medical/treatment history data were extracted retrospectively from medical records and archived tissue samples between January 1st 2019 and December 31st 2021. We gathered 157 patients who had recently been diagnosed with non-small cell lung carcinoma. In 36.9%of the cases, there was no molecular genotyping. EGFR (28.6%), KRAS (5.73%), and ALK gene rearrangement were the most common genotyping mutations (3.8%). ROS1 rearrangement was not present. There was a link between EGFR and gender, HER and age, and KRAS and biopsy tissue origin. Six of the tested cases with PD-L1 met the cut-off (³50%). PD-L1 positivity was more common in solid type adenocarcinoma (1.9%) than in acinar or papillary adenocarcinoma. There were no significant differences in PD-L1 expression across clinical and demographic parameters. High PD-L1 expression and molecular abnormalities were found in 1 case of EGFR, 1 case of BRAF, and 1 case of KRAS (3 cases). All of the other specimens with abnormalities had a PD-L1 <50%. ALK, ROS1, BRAF, KRAS, and MET were found to be significantly associated with PD-L1 expression. Our study is one of the country's largest, describing a large panel of biomarkers and their clinicopathologic/histopathologic associations in Tunisian lung cancer patients. We have the same molecular profile as European patients with an EGFR mutation, which is not the most common genotype abnormality in Tunisian patients. There is only one mutation at any given time. The expression of PD-L1 is determined by the histologic type and the origin of the biopsy tissue.

Student's attitudes towards medical education in Arabic (Morocco 2020).

INTRODUCTION: Several studies suggest that teaching medicine in the national language is essential for quality training and for communication with patients. AIM AND METHODS: To measure the students' level of understanding of their French language training and skills acquisition, as well as the difficulties they encounter in communicating with patients and their families, and the extent to which they accept medical studies in Arabic, we conducted a descriptive crosssectional study on a random sample of 450 students from the Faculty of Medicine and Pharmacy of Casablanca. RESULTS: 16% of the students had trouble assimilating their lessons in French, 48.9% of them had trouble communicating with the patient, and 22% were ready to study medicine in Arabic. Regarding the effect of teaching medicine in Arabic on different fields, 42.2% of the students mentioned a positive effect on the training, 85.2% on the communication with the patient during their training on field and 64.8% on the quality of care. CONCLUSION: Our study revealed the existence of multiple difficulties among students, particularly in the field of communication with the patient, which is a fundamental pillar for the quality of health care, hence the need to provide effective and rapid solutions to the problem of language in medical education.

Effectiveness of natural immune protection against COVID-19 reinfection: systematic review with meta-analysis.

INTRODUCTION: The future of the COVID-19 pandemic depends on the evolution of the virus and immune protection stimulated by vaccination or upon exposure to natural infection. While most research focuses on vaccine efficacy, data remain unclear on the efficacy and duration of natural immune protection against infection. AIM: In this article, we aim to determine the efficacy of natural immune protection against reinfection with COVID-19 or severe COVID-19. METHODS: We performed a systematic review of available studies in electronic databases followed by a meta-analysis to determine the efficacy of natural immune protection against COVID-19 reinfection and severe infection. RESULTS: Of the 414 studies identified for the full review, 8 studies met the inclusion criteria and were analyzed. The total number of individuals participating in the 8 studies included 19,837,147 people. Individuals with a history of SARS-CoV-2 infection (1,9% [0,6%-3,1%]) had a lower rate of infection than individuals without a history of infection (7,1% [3,9%-10,1%]). The mean efficacy of natural immune protection against reinfection was 84,7% [78,5%-90,9%], while the mean efficacy of natural immune protection against severe COVID-19 infection was 96,9% [94%-99,6%]. CONCLUSION: These results indicate that natural immune protection against reinfection is high, particularly against severe COVID-19. However, further research is needed to determine the duration of natural immune protection and the impact of different variants of SARS-CoV-2.

Who are the Best Scientists in Tunisia? Analysis of the 2023 edition of the "Research.com" platform.

AIM: Describe the performance of scientists assigned to Tunisian research structures, according to their academic disciplines, according to the Research.com platform https://research.com/), in 2023. METHODS: This is a reading focused on the productivity of scientists working in Tunisia, of the new 2023 edition of the international Research.com platform, ensuring the monitoring of 26 academic disciplines and 166880 scientists, affiliated with around three thousand research structures, and representing 1% of leading scientists in a discipline. In this platform, the ranking of researchers was based on the D-index indicator (equivalent to the h-index of a given discipline), calculated as of December 21, 2022. RESULTS: Around fifteen of the "Best Scientists", affiliated with Tunisian research structures, were selected by the Research.com platform (2023), belonging to eight disciplines including particularly "Chemistry", "Plant Sciences and Agronomy" and "Engineering and Technology". These researchers were attached to seven establishments including the universities of "Sfax" and "Monastir" and the "Borj Cedria - Sidi Thabet Biotechnology Center". Among these winners: Professors Moncef NASRI (Sfax, "Biology and Biochemistry", D-index=74), Chedly ABDELLY (Borj Cedria, "Agronomy", D-index=72) and Adel M. ALIMI (Sfax, "computer science¼, D-index=44). CONCLUSION: In Tunisia, the list of "Best scientists" in the Research.com ranking (2023) made it possible to identify two colleges of leaders in scientific research ("Health Sciences" and "Fundamental Sciences"), constituting priority consortia for strengthening the national strategy to support the mobility and networking of researchers, as well as the proliferation and visibility of their publications.

Predictors of the publication of the doctoral thesis at the Faculty of Medicine of Sousse (Tunisia).

AIM: To identify the predictive factors for the publication of theses defended at the Faculty of Medicine of Sousse (FMSO) in Tunisia. METHODS: The development of the dissertation was studied following the interrogation of three databases "Medline", "Scopus" and "article @INIST" as well as "Scholar Google". The drafting quality of the thesis summary was assessed using a grid of 20 iso-weighted items. The predictors of publication were studied by binary logistic regression, with a significance level of 10%. RESULTS: Out of the 670 theses defended at the FMSO, the mention "proposal for the thesis prize" was awarded for 22% of the thesis students. These theses were of the "clinical" type in 68% of cases, 80% of which were in "case study" format. The writing quality was deemed satisfactory in 47% of the theses. The publication rate was only 10.3%. The univariate analysis found three factors determining the publication of theses: the field of non-clinical research: epidemiological or fundamental, good editorial quality and the mention "proposal for the thesis prize". After adjustment, the latter was the only independent predictor of the publication of the thesis (ORa=1.60[1.007-2.559]). CONCLUSION: This low rate of publication of theses at the FMSO illustrates the difficulties of thesis students and their directors in research methodology and scientific writing. Theses accepted with distinction must be better accompanied to facilitate their publication.

Developing a Maghrebian Competency Framework for physicians.

Pas du Résumé.

Epidemiology of metabolic syndrome in Tunisia. HSHS 5 study.

OBJECTIVE: To measure the prevalence of metabolic syndrome and its components in the HSHS cohort (Hammam Sousse, Tunisia), in 2009, and to identify its determining factors. METHODS: This was a descriptive epidemiological study of the "community based" type having focused on a random sample of people aged 20 and over. The metabolic syndrome was defined according to the criteria of the "International Diabetes Federation" (IDF 2005) and those of the "National Cholesterol Education Program-Adult Treatment Panel III" (NCEP-ATP III, 2001). RESULTS: The study involved 1441 people including 960 women (66.6%). The age- and sex-adjusted prevalences of increased waist circumference, blood pressure, blood sugar and triglycerides, and decreased HDL-cholesterol were respectively 63.2%, 95%CI[62.5-63.8]; 47.7%, 95%CI[47.4-48.6]; 25.7%, 95%CI[25.1-26.2]; 11.9%, 95%CI[11.4-12.3] and 65,6%, 95%CI[65.0-66.2], according to IDF thresholds and 37.4%, 95%CI[36.3-37.6]; 45.7%, 95%CI[45.4-46.6]; 13.8%, 95%CI[13.4-14.2]; 8.4%, 95%CI[8.0-8.7] and 61.9%, 95%CI[61.2-62.5], according to those of the NCEP-ATP III. The prevalence of metabolic syndrome adjusted for age and sex was 36.5% 95%CI[33.0%-38.9%] according to the IDF definition and 23.0% 95%CI[20.4%-25.6%] according to that of NCEP-ATP III. The multivariate study by logistic regression made it possible to retain three significant independent determining factors of the metabolic syndrome: age ≥40 years, low level of physical activity and family history of diabetes mellitus with respectively adjusted ORs of 3.77 95%CI[2.70-5.27], 1.39 95%CI[1.01-1.89], 1.62 95%CI[1.21-2.15], according to IDF and 5.87 95%CI[3.88 -8.88], 1.47 95%CI[1.07-2.01] and 1.45 95%CI[1.07-1.96], according to NCEP-ATP III . CONCLUSION: With this high prevalence rate of the metabolic syndrome, the establishment of an action plan would be essential. This plan should be based on the combination of the promotion of physical activity and screening for the components of the metabolic syndrome, particularly in subjects aged 40 or over, with a family history of diabetes mellitus.

Let's save the indexing of the journal "La Tunisie Médicale".

As part of the strategy to safeguard the indexing of the review «La Tunisie Médicale¼, and the consolidation of its scientific reputation, in Tunisia, the Maghreb and Africa, the new editorial team reported the lessons of a recent bibliometric audit for the management of manuscripts submitted to the journal «La Tunisie Médicale¼ during the period 2015-2019. During this five-year study, 2376 papers were received by the journal "La Tunisie Médicale", 87% of which came from Tunisia, particularly Cardiology, Pathological Anatomy and Cytology, and Pneumology. If 17% of the manuscripts persisted as «case reports¼, only 7% were summaries of the literature. During this five-year period, 923 reviewers were mobilized, and the acceptance rate was 32%. Based on this editorial audit and taking into consideration the difficulties of scientific publishing, the plan to safeguard the indexing of our national journal and its resilience should consist of the following measures: 1. Submission development scientific manuscripts, at a rate of 1000 papers per year, by the year 2025; 2. Ensure representation of all health science disciplines on the editorial team; 3. Prioritize the publication of research articles, having a better chance of citation; 4. Enrich the base of readers by more approved reviewers; 5. Establish a didactic reviewing model, centered on the development of authors' skills and their support.

Epidemiology of obesity in Tunisia: HSHS4 study (Hammam Sousse Sahloul Heart Study).

INTRODUCTION: The HSHS study is a community-based survey focused on cardiovascular risk factors. AIM: The objectives of this specific analysis were to determine the prevalence of obesity and overweight in the general population of Hammam Sousse (Tunisia) and to identify their predisposing factors. METHODS: HSHS was conducted with a random sample of households, composed by the EPI (Expanded Program on Immunization) technique. All people aged 20 and over, met on the day of the survey, at their homes, were included. Obesity, overweight and weight overload were defined with reference to Body Mass Index (BMI): Obesity (BMI≥30 kg/m²), Overweight (25≤BMI (25≤BMI <30 kg/m²), weight overload (BMI≥25 kg/m²). Physical activity was evaluated according to the level of energy equivalents (Metabolic Equivalent Task) or MET, this level was considered low below 600 MET min/week. The calculated prevalences were accompanied by their 95%CI (Confidence Intervals). The multivariate study was conducted by logistic regression, measuring the adjusted Odds Ratio (ORa) Results: The study population was composed of 481 men and 960 women, (sex-ratio=0.50). The age ranged from 20 to 96 years with an average of 49.6±16444 years in men and 46.6±16.2 in women (p <0.05). After adjusting for age and sex, the prevalence rates of overweight, obesity, and weight overload were respectively 36.18%, 95%CI [35.38%-36.62%], 28.11%; 95%CI [27.42%-28.58%] and 64.28%; 95%CI [63.38%-64.62%]. Obesity was determined, in addition to female sex, age 40 or over and low level of education, by low level of physical activity (ORa=1.56; 95%CI [1.21-2.03], p<10-2). CONCLUSION: In adults, the prevalence of obesity and overweight were high and determined by insufficient physical activity. The results of this study, which can be extrapolated to other Tunisian cities, should motivate the general population to establish a heart health promotion plan, in partnership with civil society.

[Epidemiology of smoking in the male population in Tunisia. HSHS Study 6].

OBJECTIVES: To determine the prevalence of smoking in the male population of Hammam Sousse (Tunisia), to describe its modalities and to analyse its determining factors. METHODS: This was a "community-based" study, carried out on a random sample of households, including a population of males aged 20 or over. The data were collected, at home, using a specific support consisting of a lifestyle questionnaire, a physical examination, and a biological assessment, oriented towards cardiovascular risk factors. Smoking behaviour covered both forms of cigarettes and Narghile. "Current smokers" included all men declaring that they smoked at the time of the survey, including "regular smokers", who smoked daily at the time of the survey, and "occasional smokers", less than once a day. The group of "non-smokers" at the time of the survey was the sum of "ex-smokers" and those "who had never smoked". The prevalences were calculated after their weighting according to age and the adjusted odds ratios were measured following a multivariate study by logistic regression. RESULTS: The study population was composed of 481 men with an average age of 49.6±16.35 years and a median of 49 years. Mean body mass index and systolic blood pressure were 26.9 kg/m2 ±4.20 and 151.9 mmHg±24.36, respectively. After adjusting for age, the proportions of current users, former users and subjects who had never used tobacco (all forms combined) were respectively 50.4% (95% CI [49.49-51.3]), 17.4% (95% CI [16.71-18.08]) and 30.9% (95% CI [30.06-31.73]). Daily cigarette consumption was characterized by an average onset at age 20.1±6.91 years, an average duration of 27.0±15.22 years and an average amount of 17.6±9.8 cigarettes smoked per day. After adjusting for age, level of education, and socioeconomic level, smoking behaviour was attributed to a single independent risk factor: the presence of a smoker in the family, with an adjusted OR of 45.17 (p (p<10-3) for regular cigarette smokers, and 29.66 for regular tobacco users of all forms. CONCLUSION: Smoking would be a real endemic in Tunisia, threatening the cardiovascular health of the country. The national health system is called upon to strengthen its action plan for the prevention and control of smoking, in all living environments: family, school, work, health centre, etc.

[Evaluating the performance of Tunisian regional hospitals. Study Protocol of management delays of ST elevation myocardial infarction].

RESEARCH PROBLEM: ST Elevation Myocardial Infarction (STEMI+) is an absolute emergency. The young age of patients and the difficulty of access to care remain the main characteristics of STEMI+ management in Tunisia. In the governorate of Béja, located in the Northwestern region of Tunisia, given the lack of a cardiology interventional room in the hospital and in the private establishments of the region and the distance from the specialized centers of at least 127 km, the patient is beyond 90 min of the transfer. This delay in care generates a heavy burden of morbidity and mortality. The main objective of this study will be to audit the delays of management of patients presenting STEMI+ at the regional hospital of Béja (Tunisia) in accordance with the recommendations of learned societies. Secondarily, we will identify factors associated with delayed presentation after the onset of clinical symptoms. Investigation process : it will be a descriptive, exhaustive and prospective study, including patients admitted to the emergency and/or the cardiology department of the regional hospital of Béja for STEMI+ during the study period. For each patient admitted for STEMI, the following data will be collected : sociodemographic characteristics; medical history; cardiovascular risk factors; diagnostic and therapeutic management modalities; intra-hospital evolution; survival at 01 months in relation to the current coronary episode and the estimation of the different management delays. RESEARCH PLAN: ethical considerations will be respected, as well as the confidentiality and anonymity of the data. The study will last one year from the 1st september 2022 to 31 august 2023. The results will allow us to describe the delays of management of patients with STEMI+ in the region of Béja (Tunisia). At least 2 publications in international scientific journals are planned.

Place of distancing measures in containing epidemics: a scoping review.

Distancing is one of the barrier measures in mitigating epidemics. We aimed to investigate the typology, effectiveness, and side effects of distancing rules during epidemics. Electronic searches were conducted on MEDLINE, PubMed in April 2020, using Mesh-Terms representing various forms of distancing ('social isolation', 'social distancing', 'quarantine') combining with 'epidemics'. PRISMA-ScR statement was consulted to report this review. A total of 314 titles were identified and 93 were finally included. 2009 influenza A and SARS-CoV-2 epidemics were the most studied. Distancing measures were mostly classified as case-based and community-based interventions. The combination of distancing rules, like school closure, home working, isolation and quarantine, has proven to be effective in reducing R0 and flattening the epidemic curve, also when initiated early at a high rate and combined with other non-pharmaceutical interventions. Epidemiological and modeling studies showed that Isolation and quarantine in the 2009 Influenza pandemic were effective measures to decrease attack rate also with high level of compliance but there was an increased risk of household transmission. lockdown was also effective to reduce R0 from 2.6 to 0.6 and to increase doubling time from 2 to 4 days in the covid-19 pandemic. The evidence for school closure and workplace distancing was moderate as single intervention. Psychological disorder, unhealthy behaviors, disruption of economic activities, social discrimination, and stigmatization were the main side effects of distancing measures. Earlier implementation of combined distancing measures leads to greater effectiveness in containing outbreaks. Their indication must be relevant and based on evidence to avoid adverse effects on the community. These results would help decision-makers to develop response plans based on the required experience and strengthen the capacity of countries to fight against future epidemics. Mesh words: Physical Distancing, Quarantine, Epidemics, Public Health, Scoping Review.

Contextual Validation of the Prediction of Postoperative Complications of Colorectal Surgery by the "ACS NSQIP ® Risk Calculator" in a Tunisian Center.

Context: Models for predicting individual risks of surgical complications are advantageous for operative decision making and the nature of postoperative management procedures. Objective: Validate the "ACS NSQIP® Risk Calculator" in the prediction of postoperative complications during colorectal cancer surgery, operated during the years 2015 to 2019. Methods: this is a prognostic validation study of the "ACS NSQIP®" applied retrospectively to patients operated on for colorectal cancer in the surgical department of Farhat Hached hospital, during the 2015 and 2019 5-year term. Three levels of adjustment. Discrimination and calibration were carried out mainly by ROC curves (AUC ⩾ 0.8). Results: In this study, 129 patients were included with a sex ratio of 1.22 and a median age of 62 years. The most common operative procedure was low segmental colectomy with colorectal anastomosis. Thirty-seven patients (28.7%) had at least one postoperative complication. The prediction and cuts-off points values of mortality (AUC = 0.858; CI95% [0.570-0.960]; Cuts-off points = 1.8%), cardiac complications (AUC = 0.824; CI95% [0.658-0.990]; Cuts-off points = 1.8%), thromboembolic complications (AUC = 0.802; CI95% [0.617-0.987]; Cuts-off point = 3.1%), and renal insufficiency (AUC = 0.802; CI95% [ 0.623-0.981]; Cuts-off point = 1.2%) were adjusted according to level 1 of the calculator. Conclusion: This work contextualized the prediction of postoperative complications in colorectal surgery in the university general surgery department of Farhat Hached in Sousse (Tunisia), making it possible to improve the quality and safety of surgical care. The application of the Tunisian mini calculator is recommended as well as the generalization of validation following the development of a generic calculator for all operating procedures.