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.

Polymorphism of interleukin 6 -174 G/C in Behcet disease: case series and review of literature.

To assess the association between polymorphisms of the IL-6 -174 G/C and Behçet's disease (BD) in Tunisian patients. DNA was extracted from blood samples taken from 43 Tunisian patients and 43 healthy controls. The polymorphisms were analyzed by PCR with the PCR-RFLP. No significant association was found between patients and controls concerning polymorphism of IL6 -174 G/C between the (allelic frequency: C (17.44 vs 8, 13%; P=0.17) et G (82,55 vs 91,86%; P= 0.21). Neither age of onset of BD nor sex appears to be influenced by allelic variation of SNP-174 G / C of IL6. Disease duration of BD was longer in patients having the form 174 G-allele. SNP -174G/C was more frequent in patients without significant association (32.5 vs 16,26% ; P=0.07). SNP -174 G/C was not associated with the HLA B51. Neither age of onset of BD nor sex appears to be influenced by SNP-174 G / C of IL6. Disease duration of BD was longer in the absence of the SNP-174 G/C IL6, with no significant difference (79.2 + / -45.095 vs.70.28 + / - 47.034 months, P=0.59). The polymorphism of IL6 -174 G/C does not modulate clinical expression of BD. The single nucleotide polymorphisms of the IL-6 do not appear to be associated with BD reconstruction.

Neuroretinitis: a rare feature of tubulointerstitial nephritis and uveitis syndrome.

A 17-year-old female presented to our hospital with fatigue, arthralgia and fever associated with non-granulomatous anterior uveitis in the left eye. Blood tests revealed renal failure and a renal biopsy showed acute tubulointerstitial nephritis. Findings were consistent with tubulointerstitial nephritis and uveitis (TINU) syndrome. The patient received systemic corticosteroids for 2 months as well as dexamethasone and mydriatic drops. Bilateral non-granulomatous anterior uveitis occurred 10 days after prednisone discontinuation, and was treated with topical steroids; however, uveitis recurred several weeks later. Bilateral anterior chamber inflammation was associated with neuroretinitis in the right eye. Extensive posterior synechiae precluded fundus examination of the left eye. The posterior segment manifestations responded to systemic prednisone, which was slowly tapered. The final visual outcome was favorable. TINU syndrome may rarely manifest with neuroretinitis.

[Evaluation of the renal function in type 2 diabetes: clearance calculation or cystatin C?]. / Évaluation de la fonction rénale chez le diabétique de type 2 : calcul des clairances ou cystatine C ?

Screening for diabetic nephropathy is usually done by albuminuria/24h and the use of creatinine clearance. The objective of this study was to evaluate the renal function in Type 2 diabetes by using different formulas of creatinine clearance and to assess the contribution of cystatin C; 83 adults with type 2 diabetes (23 men and 60 women) and 83 adult controls (40 men and 43 women) were studied. Biochemical parameters were determinated on Coba 6000™ (Roche diagnostics). Diabetics showed a significant increase in blood glucose, cholesterol, triglycerides, LDLc, the ApoB, Lp(a), urea, uric acid, creatinine and cystatin C and lower HDLc. Cystatin was increased in patients with degenerative complications and in hypertensive patients. We found strong correlations of cystatin C with creatinine (r = 0.9454), urea (r = 0.8999) and uric acid (r = 0.8325). We found a significant exponentially increase of creatinine and cystatin C from one stage to another. Cystatin C has a strong association with MDRD (r = 0.8086) and CG (r = 0.7915) and a low one with creatinine clearance (r = 0.1044). In conclusion, the use of cystatin C for screening and early treatment of incipient diabetic nephropathy appears to be adequate. CG and MDRD formulas still hold their place, in regards to the classical determination of creatinine clearance, to monitor patients.

Gastrointestinal involvement revealing Henoch Schonlein purpura in adults: Report of three cases and review of the literature.

The diagnosis of Henoch-Schonlein purpura (HSP) is difficult, especially when abdominal symptoms precede cutaneous lesions. We report three cases of adult HSP revealed by gastrointestinal (GI) involvement.

Co-existing sarcoidosis and Takayasu arteritis: report of a case.

INTRODUCTION: Takayasu arteritis (TA) is a chronic vasculitis of unknown origin, affecting mainly the aorta and its main branches. As a result of the inflammation, stenosis, occlusion or dilatation of the involved vessels may occur and cause a wide range of symptoms. It has been described in association with various auto-immune disorders (mainly inflammatory digestive tract diseases). However, only few cases of TA associated with sarcoidosis have been reported, raising the question of an association by chance. CASE REPORT: We report a case of a 34 year-old woman, with one year history of sarcoidosis, who presented with asymmetric high hypertension revealing inflammatory humeral, axillary and subclavian arteritis related to TA, successfully treated by steroid and immunosuppressive therapy(MethotrexateR). CONCLUSION: TA and sarcoidosis may be related, rising the hypothesis that TA or Takayasu arteritis-like granulomatous vasculitis may be, in fact, a complication of sarcoidosis.

Autoimmune pancreatitis mimicking pancreatic cancer.

CONTEXT: Autoimmune pancreatitis is a particular type of pancreatitis of presumed autoimmune etiology, it is an entity distinct from all others forms of chronic pancreatitis, characterized by clinical, histopathological, radiographic, serologic and therapeutic features. This benign disease resembles pancreatic carcinoma both clinically and radiographically. CASE REPORT: A 27-year-old man presented with obstructive jaundice and evocative image of pancreatic tumor. A pancreaticoduodenectomy (Whipple operation) was performed and pathological examination of the specimen diagnosed AIP. Patient responded well to a course of corticosteroids with resolution of clinical and biological disorders. CONCLUSION: Accurate and timely diagnosis of autoimmune pancreatitis is particularly important because steroid therapy is effective and pancreatic resection is not necessary.

Hyperhomocysteinaemia in Behçet's Disease.

Objectives. The aim of this study was to investigate if hyperhomocysteinaemia is a contributive risk factor for the pathogenesis and the activity of Behçet's disease (BD). Design and Methods. Fifty four patients fullfiling the criteria of the International Study Group for BD were enrolled. Fifty healthy volunteers matched for age and sex with the BD group were included as a negative control group. Patients, with any condition that might affect plasma homocysteine concentration, were excluded. Results. Mean serum homocysteine concentration was significantly higher in patients with BD than in the healthy controls (P < .001), in patients with active disease (P = .04), and in masculine gender (P = .05). There was no significant difference between homocysteine level and clinical involvement. Conclusions. We demonstrated that plasma total homocysteine level (tHcy) is increased in BD and correlated with disease activity. No association was found between homocysteine levels and clinical involvement.

Oxidative stress: correlation with Behçet's disease duration, activity and severity.

OBJECTIVE: To study the oxidant/antioxidant status in Behçet's disease (BD) patients and the potential link between antioxidant enzymatic defences impairment and the disease duration, activity and severity. METHODS: 40 BD patients (27 males, 13 females; mean age: 38.8 years) were prospectively enrolled in the study and compared to a sex and age matched control group. Plasma malondialdehyde (MDA), the reduced glutathione (GSH)/oxidised glutathione (GSSG) ratio, erythrocyte superoxide dismutase, catalase and glutathione peroxidase (GSH-PX) were analysed in both groups. A correlation analysis was performed between these parameters and disease duration, activity and severity. Activity and severity of BD were assessed meaning two respective clinical scores. RESULTS: When compared to controls MDA was increased and GSH/GSSG reduced in BD patients (respectively p<0.005). Superoxide dismutase (SOD) was significantly lower while catalase was significantly higher in BD than in controls. Correlation analysis showed that SOD activity was significantly and negatively correlated to disease duration and activity but not to severity. Other oxidant/antioxidant markers were not significantly linked to neither disease duration nor activity and severity. CONCLUSION: Our study confirm the existence of an oxidative stress (OS) state in BD as shown by the increase of MDA and the diminution of GSH/GSSG ratio which can be used as another index of OS. Despite this OS state, the activity of antioxidant enzymes and especially of SOD is impaired and negatively correlated to the disease duration and activity. We think that a rational strengthening of antioxidant defences should be part of an optimal treatment strategy.

[Neuro-psychiatric disorders revealed pernicious disease without anemia. About three cases]. / Tableau neuro-psychiatrique révélant une maladie de Biermer en l'absence d'anémie. A propos de 3 observations.

In addition to an anemic syndrome, pernicious disease can also include neuropsychiatric manifestations. We report here three cases diagnosed as pernicious disease revealed by neuropsychiatric symptoms and even without anemia. Our patients were made of a man and two women with a mean age of 55 years. They consulted for progressively worsening troubles of step which were related to a combined degeneration of the cord. This degeneration was associated to a cerebellar syndrome in one case. An isolated macrocytosis with a mean MGV at 109 fl, was noticed allowing thus to evoke the Biermer pernicious disease. This diagnosis was confirmed by the marrow puncture which showed a medullar megaloblastosis in two cases and an erythroblastic nucleocytoplasmic maturation's asynchronism. Treated by vitamin B12, the evolution was favorable in two cases with a total neurological recovery after six months in two patients. One patient died after six days of treatment following an acute myocardial infarction. If faced to symptoms made of a combined degeneration of the spinal card, a peripheral neuropathy and/or psychiatric troubles, pernicious disease is a diagnosis that we must evoke even in absence of anemia.

Secondary Amyloidosis, a Fatal Complication of Behcet's Disease: Three Case Reports.

Renal amyloidosis (RA) is known to be one of the many complications of Behcet's disease (BD) but its frequency has been often underestimated. In this paper, we report on three cases of RA in a series of 105 patients with BD. RA was clinically suspected in our patients by the presence of edema and/or hypotension. The nephrotic syndrome was present in all of them and one patient had associated renal failure. Renal biopsy showed amyloid deposits type AA in all cases.Our patients received Colchicine at doses of 1 mg per day but with disappointing results. Their prognosis was significantely impaired with our three patients dying at ten years, six months and four weeks after diagnosis of RA. We will try, through this clinical experience and based on the relevant literature to better understand this kind of morbid association.