Prevalence of depression and anxiety in obstructive sleep apnea.

INTRODUCTION: Organic comorbidities of obstructive sleep apnea (OSA) have been widely studied. However, psychiatric disorders, especially depression and anxiety, have not attracted so much attention. AIM: The primary aim was to determine the prevalence and the predictive factors of depression and anxiety in OSA patients. The secondary aim was to investigate the association between OSA severity and these psychiatric disorders. METHODS: A cross-sectional study including untreated OSA patients without mental illness history was conducted. Patients were administered the Hospital Anxiety (HADS-A) and Depression Scale (HADS-D). Depression and anxiety were diagnosed for HAD-D and HAD-A scores ≥ 8. RESULTS: Eighty patients were included (mean age: 54.83 ± 13.12 yr; female: 52 (65%); mean Body mass index (BMI) :34.7±6.14 kg/m2). The prevalence of depression and anxiety was 35 % and 43.8% of patients respectively. Both depressive and anxious OSA patients had more libido disorder ( p=0.011, p=0.0007 ;respectively), anhedonia (p= 10-4, p= 10-4respectively ) and suicidal ideas(p= 0.002 ,p=0.019 respectively). Moreover, depressed OSA patients had lower socio-economic condition (p= 0.019), more coronary artery diseases (CAD) (p=0.019) and less cognitive disorder (p= 0.005). The HADS-D (r=0,095; p=0,404) and the HADS-A (r=0,212; p=0,059) were not correlated with the Apnea/Hyponea Index. The determinants of depressive and anxious mood were female-sex (p= 0.035, p=0.004 respectively) and libido disorder (p=0.040, p=0.02 respectively). Anhedonia (p=10-4) and CAD (p=0.010) were also identified as a predictive factors of depression. CONCLUSIONS: In our study, the high prevalence of depression and axiety in apneic patients demonstrates the importance of the psychiatric component in the management of this disease. A collaboration between pneumologists and psychiatrists is necessary in order to improve the quality of life of these patients.

Linking Global Youth Tobacco Survey (GYTS) data to the WHO Framework Convention on Tobacco Control (FCTC): The case for Tunisia.

INTRODUCTION: The World Health Organization (WHO) had launched the Framework convention on Tobacco Control (FCTC) in 2003 in order to curve the epidemic of tobacco use worldwide. Since most smokers begin to smoke before the age of 18 years, Global Youth Tobacco Survey (GYTS) has been developed in order to monitor tobacco smoking among adolescents. Our aim was to assess smoking among Tunisian youth using GYTS 2017 data. METHODS: GYTS is cross-sectional, two cluster school-based survey to produce a representative sample of students aged 13-15 years. It was conducted in 2017 in 67 secondary schools in Tunisia. The investigation tool was an anonymously answered questionnaire, which contained core questions about six majors tobacco related topics. RESULTS: Lifetime cigarettes and waterpipe prevalence were 7.8% (14.4% of boys, 1.6% of girls, p<0.001) and 7.2% (13% of boys, 2.8% of girls, p<0.001), respectively. Among cigarette smokers, 62.5% were able to buy their own cigarettes. Overall, 23.5% of cigarette smokers and 41.5% of waterpipe smokers were not able to buy their products because of their age. Sixty percent of smokers wanted to quit and 56.4% had already tried to stop. Half of the respondents were exposed to SHS in their homes and 62.1% in indoor public places. CONCLUSIONS: In Tunisia, tobacco prevalence among youth is high. Youth have free access to tobacco products and smoke-free regulations are only partially respected.

[Strength of academic motivation among medical students in the Faculty of Medicine of Sousse (Tunisia)].

INTRODUCTION: Motivation is an important component of learning. It remains a complex phenomenon to explore, largely influenced by multiple external and internal factors. It is important to measure the strength of student motivation in a long training course such as medical studies and its influencing factors. AIM: to measure strength of motivation among medical students the Faculty of Medicine of Sousse (FMS). METHODS: It was a cross-sectional study conducted among medical students enrolled at the FMS during the 2021/2022 academic year for 3 months using a questionnaire based on a validated scale: Strength of Motivation for Medical School-Revised (SMMS-R). RESULTS: A total of 185 students participated in the study. The mean age was 20.97 ± 1.8 years. The sex ratio was 0.34. The SMMS-R score was 55[47-63]. This score was higher international students (p=0.029), students who chose medical studies before passing the baccalaureate (p<10-3) and students satisfied with their choice of medical studies (p<10-3). CONCLUSION: Our results revealed a strong association between students' satisfaction and motivation. Thus, the learning environment, governed mainly by institutional rules, educational activities and evaluative practices, greatly influences satisfaction and therefore motivation of medical students.

Identification of transmission chains and clusters associated with COVID-19 in Tunisia.

BACKGROUND: The aim of this study was to characterize the transmission chains and clusters of COVID-19 infection in Tunisia. METHODS: All cases were confirmed by Reverse Transcriptase Polymerase Chain Reaction of a nasopharyngeal specimen. Contact tracing is undertaken for all confirmed cases in order to identify close contacts that will be systematically screened and quarantined. Transmission chains were identified based on field investigation, contact tracing, results of screening tests and by assessing all probable mode of transmission and interactions. RESULTS: As of May 18, 2020, 656 cases out of a total of 1043 confirmed cases of Coronavirus disease 2019 belong to 127 transmission chains identified during the epidemic (mean age 42.36 years, Standard deviation 19.56 and sex ratio 0.86). The virus transmission is the most concentrated in the governorate of Tunis (31.5%), Ariana (10.2%) and Ben Arous (10.2%). Virus transmission occurred 50 times (9.72% of secondary transmission events) between two different governorates. A maximum of seven generations of secondary infection was identified, whereas 62% of these secondary infections belong the first generation. A total of 11 "super spreader" cases were identified in this investigation. Four large clusters have been identified. The evolution of secondary cases highlighted two peaks: one in 2nd April and a second in 16 th April whereas imported cases caused local transmission of virus during the early phase of the epidemic. CONCLUSION: Correct contact tracing and early active case finding is useful to identify transmission chains and source of infection in order to contain the widespread transmission in the community.

Characteristics and prognostic factors of COVID-19 among infected cases: a nationwide Tunisian analysis.

BACKGROUND: The outbreak of coronavirus disease (COVID-19) continues to constitute an international public health concern. Few data are available on the duration and prognostic factors of the disease. We aimed to study the recovery time among a Tunisian cohort of COVID-19 confirmed patients and identify the prognostic factors. METHODS: A retrospective, nationwide study was conducted from March 2 to May 8, 2020, recruiting all patients who were diagnosed with COVID-19, by RT-PCR methods, in Tunisia. Data were collected via phone call interview. Kaplan-Meir Methods and Cox proportional hazards regression models were, respectively, used to study the recovery time and estimate its prognostic factors. RESULTS: One thousand and thirty patients with COVID-19 (aged 43.2 ± 18.2 years, 526 female (51.1%)) were enrolled. Among them 141 (14.8%) were healthcare professionals. Out of 173 patients (17.8%) admitted to the hospital, 47 were admitted in an intensive care unit. Among 827 patients who didn't require specialized care, 55.5% were self-isolated at home, while the rest were in specialized centers. Six hundred and two patients were symptomatic. A total of 634 (61.6%) patients have recovered and 45 (4.4%) patients died. The median duration of illness was estimated to be 31 days (95% CI: [29-32]). Older age (HR = 0.66, CI:[0.46-0.96], P = 0.031) and symptoms (HR = 0.61, CI:[0.43-0.81], P = 0.021) were independently associated with a delay in recovery time. Being a healthcare professional (HR = 1.52, CI: [1.10-2.08], P = 0.011) and patients in home isolation compared to isolation centers (HR = 2.99, CI: [1.85-4.83], P < 10¯3) were independently associated with faster recovery time. CONCLUSION: The duration of illness was estimated to be 1 month. However, this long estimated duration of illness may not equate to infectiousness. A particular attention must to be paid to elderly and symptomatic patients with closer monitoring.

Characteristics, onset, and evolution of neurological symptoms in patients with COVID-19.

BACKGROUND: A wide range of neurological manifestations has been described in COVID-19. METHODS: In this nationwide retrospective observational study, patients in Tunisia diagnosed with COVID-19 between the 2nd of March and the 16th of May 2020 were contacted by telephone. We collected demographic and clinical data and specified characteristics and evolution of main neurological symptoms. RESULTS: Of 1034 confirmed COVID-19 patients, 646 were included (mean age 42.17 years old) and 466 (72.1%) had neurological symptoms. Neurological symptoms were isolated 22.7% (n = 106). Headache was the most frequent neurological symptom (n = 279, 41.1%): mainly frontotemporal (n = 143, 51.1%) and mild or moderate (n = 165, 59.1%). When associated with fever (n = 143, 51.3%), headache was more likely to be severe and present at onset. Recovery was reported in 83.2%. Smell and taste impairment were found in 37.9% (n = 245) and 36.8% (n = 238) respectively. Among them, 65.3% (156/239) were anosmic and 63.2% (146/231) were ageusic. A complete improvement was found in 72.1% (174/240) of smell impairment and in 76.8% (179/233) of taste impairment. Myalgia (n = 241, 37.3%) and sleep disturbances (n = 241, 37.3%) were also frequent. Imported cases had more neurological symptoms (p = 0.001). In 14.5%, neurological symptoms preceded the respiratory signs (RS). RS were associated with more frequent (p = 0.006) and numerous (p < 0.001) neurological symptoms. CONCLUSIONS: Neurological symptoms in COVID-19 are frequent, can be isolated and present at onset. A total recovery is the most recorded outcome. RS are predictive of neurological symptoms. Studies in to virus and host genetics should be considered to understand the different phenotypes.

Estimating transmission dynamics and serial interval of the first wave of COVID-19 infections under different control measures: a statistical analysis in Tunisia from February 29 to May 5, 2020.

BACKGROUND: Describing transmission dynamics of the outbreak and impact of intervention measures are critical to planning responses to future outbreaks and providing timely information to guide policy makers decision. We estimate serial interval (SI) and temporal reproduction number (Rt) of SARS-CoV-2 in Tunisia. METHODS: We collected data of investigations and contact tracing between March 1, 2020 and May 5, 2020 as well as illness onset data during the period February 29-May 5, 2020 from National Observatory of New and Emerging Diseases of Tunisia. Maximum likelihood (ML) approach is used to estimate dynamics of Rt. RESULTS: Four hundred ninety-one of infector-infectee pairs were involved, with 14.46% reported pre-symptomatic transmission. SI follows Gamma distribution with mean 5.30 days [95% Confidence Interval (CI) 4.66-5.95] and standard deviation 0.26 [95% CI 0.23-0.30]. Also, we estimated large changes in Rt in response to the combined lockdown interventions. The Rt moves from 3.18 [95% Credible Interval (CrI) 2.73-3.69] to 1.77 [95% CrI 1.49-2.08] with curfew prevention measure, and under the epidemic threshold (0.89 [95% CrI 0.84-0.94]) by national lockdown measure. CONCLUSIONS: Overall, our findings highlight contribution of interventions to interrupt transmission of SARS-CoV-2 in Tunisia.

Implementation of the WHO Framework Convention on Tobacco Control in Tunisia: Progress and challenges.

INTRODUCTION: The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) was the first health treaty that requires state parties to adopt and implement the MPOWER package. The aim of this study is to review the current status of tobacco control policies in Tunisia according to the WHO FCTC recommendations. METHODS: This paper is a critical narrative literature review in which information was obtained from peer-reviewed articles, official government documents, reports, decrees and grey literature in French, Arabic and English. RESULTS: Modest progress in FCTC implementation in Tunisia was noted. The smoking ban in public places is not regularly or largely enforced. The advertising and promotion for tobacco and its products is prohibited by law, but, the ban does not cover the display and visibility of tobacco products at points-of-sale, through the internet, and the depiction of tobacco or tobacco use in entertainment media products. Health warnings on tobacco products consist only of text and do not exceed 30% of the main display areas but are expected to increase to 70% with graphics and text when the new law is passed. CONCLUSIONS: Effective intervention efforts are urgently required. These actions should include accelerating the adoption of a new law, enforcing the present law and the new one once adopted, developing an advocacy and argument about the positive impact on state budget balance, increasing taxes, combating smuggling and illicit manufacturing and counterfeiting, increased education, increased smoking cessation support and implementing periodic surveillance.

[Bronchiectasis associated with chronic obstructive pulmonary disease: clinical and evolutionary profile]. / Dilatations des bronches associées à la broncho pneumopathie chronique obstructive: profil clinique et évolutif.

INTRODUCTION: in recent years, the combination of bronchiectases (BRs) and chronic obstructive pulmonary disease (COPD) has been described as a potential new phenotype of COPD due to its clinical features and different prognosis. The purpose of this study was to analyse the clinical profile and paraclinical features of COPD in patients with BRs and to determine the impact of BRs on disease progression. METHODS: we conducted a retrospective study of 100 patients diagnosed with COPD and treated in the Department of Pneumology 4 at the Abderrahmane Mami Hospital between 2014 and 2018. Patients were divided into two groups: group 1: patients with COPD associated with BRs (n=50) and group 2: patients with COPD without BRs (n=50). Both groups were matched based on their epidemiological characteristics. RESULTS: all patients were male, with an average age of 65,9 years. Patients with COPD associated with BRs had a higher rate of ischemic heart disease (p=0.037), more severe breathlessness assessed using the modified Medical Resaerch Council (mMRC≥2) (p=0.02), more severe bronchial obstruction (p=0.005) and a higher prevalence of acute exacerbations (p<0.001) and hospitalizations (p=0.004). In a multivariate study, independent factors associated with BRs were severe bronchial obstruction (OR=9.16), frequent exacerbator phenotype (≥2 exacerbations per year) (OR=1.91) and isolation of germs by cytobacteriological examination of sputum (OR=4.99). CONCLUSION: COPD associated with BRs could thus be a phenotype distinct from COPD and correlated with a more reserved prognosis.

Cost estimation of medical care management of lung cancer in Tunisia.

BACKGROUND: Lung cancer management is very expensive for the Tunisian healthcare system. AIM: The aim of this study was to evaluate the direct costs of treating lung cancer in Tunisia, and to identify the main treatment of high expenditure. METHODS: A retrospective study was conducted in 2012 including all patients admitted between 2008 and 2010 for lung cancer management. The hospital payment system was used to estimate the direct costs of the medical care management of lung cancer. RESULTS: We collected 549 patients and the majority of patients were diagnosed with advanced stages of the disease: 60 % in stage T4 and 59 % in stage M1. 26 % of patients underwent surgery and 44.1 % chemotherapy. The total direct costs of lung cancer management were estimated to be TND 3900 (US$ 1980) per patient. CONCLUSIONS: Chemotherapy accounted for the largest percentage of direct costs (46 %) followed by the cost of the hospital stay. Primary prevention, based on the application of policies to control tobacco, is the best strategy to reduce this morbidity.

[Smoking cessation attitudes among adult smokers]. / Les attidute envers l'arrêt du tabac chez les fumeurs adultes.

AIM: The failure of attempts to quit smoking was the cause of stagnation even the increasing prevalence of smoking in Tunisia. The aim of our study was to describe the previous quit attempts among smokers, the degree of motivation to the next stop and analyze the associated factors. METHODS: We carried out a survey based on an anonymous selfadministered questionnaire on tobacco, targeting smokers who participated in awareness sessions conducted in public places and universities in the city of Monastir. RESULTS: Nine hundred fourteen smokers had participated in our study. More than 2/3 of them (70 %) had at least one quit attempt, which lasted longer than 6 months for 81 patients (9%) and the last attempt dated for over 6 months for 486 smokers (53%). These previous attempts were unaccompanied and non-medicalized in 97 % of cases. 2/3 of smokers (67%) had a very strong desire to quit smoking, and 41% had a very strong self-confidence to succeed in their attempts. According to multivariate analysis, the presence of previous quit attempts to stop was statistically related to the importance of quitting smoking (OR=2.20,95% CI [1.23 - 3.96]). Selfconfidence to successfully stop was statistically related to the duration of smoking (OR=1.03 , 95% CI [1.01 - 1.06] ) , the strong dependence (OR=0.53 ;95% CI [ 0.29 - 0.97 ]) , and having at least one smoking member of the family (OR = 0.36 , 95% CI [0.15 - 0.86]). CONCLUSION: These results show that the strong physical dependence is a major factor related to the failure of attempts to quit, to the loss of self-confidence to succeed new attempts among smokers and thus, maintain a fairly high smoking prevalence in a country like Tunisia.

[Quality of the medical record notification in primary health care]. / Qualité de notification sur le dossier medical en première ligne.

BACKGROUND: The medical record is a very important tool for organizing, the planning and tracking of care. Her outfit is considered as one of the major criteria for care quality. AIM: compare, the degree of given collected notification on the Structured Medical Record (SMR) in Subjective, Pre-appreciation, Objective, Appreciation and Post-appreciation (SPOAP) and on Not Structured Medical Record (NSMR). METHODS: It is a retrospective, analytic study, including 910 DM. Executed in four primary health centers, at Monastir governorate in 2010. As regards methodology, we conducted a sampling at 3 degrees. The first draw of the month, the second on the weeks, the third is systematic type of medical records with a step of sounding of 2. We collected information about patient's socio-demographic characteristics, the contact patterns, clinical examination of the data, assumptions and diagnostics procedures. We used chi2 test to compare the distribution between SMR and NSMR at the Threshold of 5 %. RESULTS: Four hundred and one SMR (44 %) and 509 (56 %) NSMR were included. The contact patterns was noted on 44 % of NSMR and 93% of SMR (< 10-4). The physical examination had been noted on 67 % of SMR and 8% of NSMR (p < 10-4), the hypotheses diagnoses on 72 % of SMR and 31 % of NSMR (p < 10-4). The conducts had been noted on 98 % of SMR and 95% of NSMR (p < 0,045). The distribution of the motives for contacts, physical acts, hypotheses diagnoses and therapeutic families were different between SMR and NSMR. The medical records was adequate in 52 % of SMR and in 2% of NSMR (p < 10-4). CONCLUSION: The use of SMR improves the notification and the care continuity.

[Nicotine dependance and carbon monoxide intoxication among adult smokers]. / La dépendence nicotinique et l'intoxication au monoxide de carbone chez les fumeurs adultes.

BACKGROUND: The high nicotine dependence is one of the contributing factors to failure of attempts to quit. Moreover, the carbon monoxide (CO) intoxication, proportional to the intensity of smoking, is the basis of cardiovascular complications. OBJECTIVES: To describe tobacco consumption and the degree of CO intoxication, as well as to assess nicotine dependence and identify its determinants in a population of adult smokers. METHODS: This is a descriptive cross-sectional study, based on a selfadministered questionnaire and a dosage of CO in expired air among smokers who participated in awareness sessions conducted in public places and academic institutions in the city of Monastir. Multivariate analysis was based on a binary logistic regression. RESULTS: A total of 914 smokers participated in our survey whose mean age was 29.5 ± 12.4 years. More than 2/3 of cases (68.7 %) were strongly addicted to nicotine. Heavy smokers (consumption > 20 cigarettes / day) accounted for 28 % of subjects aged under 30 and 59% of older adults (p < 10-4). Determinants of strong tobacco dependence were age of first cigarette ( OR = 0.912 ) , duration of tobacco consumption (OR = 1.059 ) , alcohol consumption (OR = 1.764 ) , sedentarity (OR = 2.024 ) and the rate expired CO (OR = 1.059 ) . The mean rate of exhaled CO was 13.1 ± 11.1 ppm. It was positively correlated with Fagerström score (r = 0.5, p < 10-4) and the number of cigarettes smoked before dosing CO (r = 0.6, p < 10-4). In the contrary, it was negatively correlated to the time elapsed between the last cigarette and the test (r = - 0.2, p = 0.001). CONCLUSION: The results of this study focused on smoking addiction and its determinants. They encourage us to strengthen efforts for effective implementation of the WHO Framework Convention of Tobacco control in Tunisia.

[From demand to decision: Not programmed contact for adult family medicine]. / De la demande à la decision: Contact non programmé de l'adulte en medicine de famille.

BACKGROUND: the study of contact patterns, diagnostics assumptions, physical acts performed and procedures in primary care services orient the training of future GPs. AIM: describe the elements of the contact in the Basic Health Centers. METHODS: It is a transverse study, describing the elements of contact without appointment, the population served by 4 primary health centers, in Monastir governorate. Days of the survey were identified from the list of working days by taking two weeks per month and per season by excluding the days of chronic diseases. Contacts analyzed have been identified by a systematic random sampling with a step of sounding on two. RESULTS: in the term of this study, we brought together 910 contacts. The mean age of consultants was 36 years, the sex-ratio H/F 0,38. The respiratory, ostéo-articular, digestive, neurological and general chapter's complaints represented 74% of motives for contacts. The cough and the complaints of throat represented 25% of the reasons for consultation. The lung examination, Oto-rhino laryngeal and cardiovascular represented 80% of physical examinations. The pharyngitis, the infections of the superior respiratory tracts, acute bronchitises, flu and allergic rhinitis represented the half of the assumptions. Antibiotics, anti-inflammatory and the antipyretic/analgesic accounted for 69% of prescriptions. CONCLUSION: this study allowed us to show the lack of preventive measures in the health center base and highlight the training of future family physicians must be based systems the most prevalent in primary care.

[Predictors of smoking relapse among adult in smoking cessation]. / Les facteurs prédictifs de rechute tabagique chez les adultes bénéficiaires d'aide au sevrage.

BACKGROUND: Smoking is a public health problem in Tunisia. The smoking cessation assistance is one of means against this epidemic. Few smokers require this need to quit. PURPOSE: this study aimed at identifying the predictive factors associated to the smoking relapse at the adult. METHOD: We carried out a prospective cohort study, during a period of 18 months, at the smoking cessation center of the University hospital of Monastir (Tunisia). The population study consisted of adult abstinent in smoking cessation interventions. Baseline contained a questionnaire investigating the smoking history, the nicotine dependence and the anxiety / depression state and information of the medical examination at follow-up visits. A phone survey was realized, 21 months after the inclusion beginning, to estimate the rate of smoking abstinence, the deadline average of relapse and these predictors. A multivariate Cox regression was used to identify predictors of smoking relapses. RESULTS: A total of 143 adults were included in our study with a mean age of 44 ± 14 years. The median consumption was 30 cigarettes/ day. The median of initial carbon monoxide expired was 13 ppm. The median period of the medical treatment was 4 weeks. In the survey 74 patients relapse (51,7%) : IC95% [44 -60], with a median deadline of relapse of 11 weeks IC95% [9,1-12,9]. In the multivariate analysis, smoking relapse was associated with a period of treatment less than 4 weeks OR: 2,53: IC95 [1,48-4,32], and with a perception, less than 2 benefits, at the medical examination at follow-up visits OR: 1,54: IC95 [1,02-2,66]. CONCLUSION: The results of this study give us important clarifications, on profits offered by the adult smoking cessation interventions.