Management of esophageal atresia and early predictive factors of mortality and morbidity in a developing country.

The aim of this study is to investigate management and outcome in esophageal atresia (EA) and to identify early predictive factors of morbidity and mortality in a developing country. Charts of neonates with repaired EA from 2007 to 2016 were reviewed. Patients' characteristics, operative details, and postoperative outcomes were collected. Statistical analyses were performed to identify predictors of complicated evolution. Forty-two cases were collected. There were 14 girls and 28 boys. Only one patient had antenatal diagnosis (2.3%). The mean gestational age was 38 weeks. Nine patients (21.4%) weighed less than 2.5 kg. Seventeen (40.4%) patients had associated malformations most commonly cardiac (9/17). Thirteen patients had delayed diagnosis (30.9%). Thirty-nine (92.8%) patients underwent primary esophageal anastomosis. Overall survival was 76.2%. Nineteen patients (57% of survivals) had complicated evolution before the age of one year and 15 patients (46.8% of survivals) developed complications after the age of one year. Perinatal variables associated with mortality were prematurity (p = 0.004, OR = 5.4, IC95% = [1.13-25.80]), low birth weight (p = 0.023, OR = 7, IC95% = [1.38-35.47]), cardiac malformations (p = 0.006, OR = 10.5, IC95% = [2.03-54.27]) and delayed diagnosis (p = 0.005, OR = 10.11, IC95% = [2.005-50.980]). Variables associated with short-term and middle-term complications were duration of intubation (p = 0.019, OR = 0.118, IC95% = [0.019-0.713]) and the presence of short-term complications (p = 0.016, OR = 7.33, IC95% = [1.467-36.664]) respectively. These factors may be used to identify patients who will benefit from more intensive follow-up program.

The role of procalcitonin and N-terminal pro-B-type natriuretic peptide in predicting outcome after cardiac surgery.

OBJECTIVE(S): Determine the thresholds of procalcitonin (PCT) and N-terminal pro-B-type natriuretic peptide (Nt-pro-BNP) associated with poor prognosis after heart surgery with CPB. DESIGN: Prospective observational study. SETTING: Academic Medical Center Habib Bourguiba. PARTICIPANTS: Adult patients consecutively operated for coronary or valve surgery with CPB, elective or semi-urgent. INTERVENTIONS: Serum concentrations of PCT and Nt-pro-BNP were determined before and after CPB, in the fourth postoperative hour (H4) and every day during the first 4 days. Receiver-operating characteristic curves and cut-off values were used to assess the ability of these markers to predict length of intensive care unit (ICU) stay >3 days. MEASUREMENTS AND MAIN RESULTS: Forty patients were included in the study. Systemic inflammatory response syndrome (SIRS) occurred in 35 (87.5%) patients. Seventeen of them (42.5%) showed severe SIRS. Significantly higher serum concentrations of Nt-pro-BNP and PCT were found in patients with severe SIRS. Receiver operating characteristic (ROC) analysis showed that the threshold of PCT was 0.737 ng/mL and that of Nt-pro-BNP was 1235 pg/mL on day 1 could predict an ICU stay of more than 3 days. The association of Nt-pro-BNP to procalcitonin (p=0.009) better predicted the ICU stay than PCT alone (p=0.02) or Nt-pro-BNP alone (p=0.03). The best combination is Nt-pro-BNP + PCT + C-reactive protein (CRP) (p=0.007). CONCLUSIONS: PCT and Nt-pro-BNP on day 1 may be associated with severe SIRS and predict the length of stay. A biomarker approach combining PCT, CRP and BNP is superior to a traditional single marker for predicting ICU stay.

[Evaluation of the antibiotics consumption in a Tunisian university hospital]. / Evaluation de la consommation des antibiotiques dans un hôpital universitaire tunisien.

PURPOSE: To estimate the consumption of antibiotics in our hospital and to determine the points at which will be targeted the recommendations of good practice of antibiotherapy. PATIENTS AND METHODS: Our study is a one day prevalence study where antibiotic's prescriptions are analyzed by a group of 6 doctors referents in antibiotherapy. RESULTS: During the study day, 443 patients were studied. Means age was 44.2 +/- 23.3 years (range: 1 and 102 years). 101 infections were diagnosed in 48 patients (10.8%). 192 patients (43.3%) received antibiotics. Antibiotherapy was curative in 44% of cases. The most prescribed antibiotics were gentamicin (85.2 DDD/1000 patients), metronidazole (79 DDD/1000 patients), and cefotaxime (73.9 DDD/1000 patients). According to the evaluation group, 30.7% of the antibiotic's prescription was considered unjustified. The antibioprophylaxis represents the category most often unjustified (49%). The molecules in which prescription was frequently considered unjustified are the ciprofloxacin (67%), the amoxicilline-clavulanate (40%) and the cefotaxime (40%). CONCLUSION: Our results suggest that an action of good practice should be targeted at the antibioprophylaxis and should concern especially molecules in which prescription was frequently unjustified.

[Predisposition to thyroid autoimmune diseases]. / Prédisposition aux maladies autoimmunes thyroïdiennes.

OBJECTIVES: Genetic predisposition is required for the expression of thyroid autoimmune disorder addition to the immune dysfunction and the environmental factors. METHODS: In order to evaluate the role of this genetic factor, we reported the results of immunological and hormonal investigations of 62 members (TD), belonging to a large Akr family, who are related to 40 patients with Graves' disease or Hashimoto's thyroiditis. RESULTS: The hormonal analyses showed that 19 subjects exhibited an infraclinical hypothyroidism, subdivided into 7 members with pathological rates of TSH evocative of thyroid insufficiency and 12 others with compensative thyroid insufficiency. Seventeen subjects of the Akr family who had solely antithyroid autoantibodies were considered as potential candidates to develop thyroid autoimmune diseases. The clinical follow-up, during two years, confirmed the diagnosis of Hashimoto's thyroiditis in 3 members among 19 subjects with infraclinical hypothyroidism (TD05, TD28 and TD54) and in only 1 member out of the 17 potential candidates (TD03). CONCLUSION: Our results showed that a serological study of hormones and/or autoantibodies directed against thyroid antigens, could allow the detection of predisposed subjects to develop a thyroid autoimmune pathology. The Akr family seems to be suitable for the study of the localization of susceptibility genes to TAID.

Polymorphism of the human immunoglobulin heavy chain locus in rheumatoid arthritis.

The genetic origin of Rheumatoid Arthritis (RA) is largely unknown. The purpose of this investigation was to assess the potential genetically determined involvement of the immunoglobulin (Ig) heavy chain variable region (VH) locus in the pathogenesis of RA. We tested the hypothesis of whether there is a genetic linkage between a structural abnormality of the VH gene complex and autoantibody hyperproduction in RA. We used restriction endonuclease generated polymorphism with human VH gene-family-specific probes to examine genomic DNA from a RA family and from unrelated RA patients from both the Tunisian and the European populations. The use of DNA samples from these ethnic origins permitted a further evaluation of the polymorphism of the human VH locus. While we found that the polymorphism of the VH locus was lower in the Tunisian population, we could not detect a restriction site polymorphism pattern restricted to RA. Together, our results do not support the involvement of major abnormalities of the Ig VH locus as a primary source in the development of RA.

Antibody epitopes probed by immunoselected phage-display library peptides in members of a family with various rheumatic manifestations.

OBJECTIVE: The random peptide combinatorial phage library approach overcomes the problem of lack of structural information about the aetiological agent or the antigen responsible for a given disease. Here, we used such a strategy to gain insight into the aetiology of rheumatoid arthritis (RA). METHODS: We analyzed the reactivity of serum antibodies from a family with various rheumatic manifestations against RA-immunoselected nanopeptides displayed on phage particles. RESULTS AND CONCLUSION: We found that within the same family, there was a difference in antibody reactivity against the peptides tested. The IgG isotype of the peptide reactive antibodies indicated that the observed reactivities were not related to the presence of polyreactive IgM antibodies. Furthermore, it is unlikely that the observed reactivity was due to rheumatoid factors (RF), since two patients who were positive for the immunoselected Pep3 peptide (LSSREPQAR) were RF negative. We also found that the serum of one patient with polyarthralgias also reacted with the same peptide bound by the RA serum, which may suggest the implication of a common aetiological agent in the apparition of this antibody reactivity. Finally, we noted that one patient with Sjögren's syndrome had antibodies to the RA peptide, which may indicate a potential relationship between these two autoimmune diseases.

Hypopigmentation in hemodialysis. Acquired hair and skin fairness in a uremic patient undergoing maintenance hemodialysis: case report and review of the literature.

With recent advances in medicine, uremic patients are living longer with an improving quality of life. Several skin diseases have been reported in patients with chronic renal failure, and the opportunity has been offered to elucidate newer cutaneous abnormalities among patients undergoing long-term hemodialysis. Hyperpigmentation was the most prevalent cutaneous abnormality observed in these patients, but hypopigmentation remains an exceptional event. We report here a case of a maintenance hemodialysis patient with an acquired hair and skin fairness. Although the true mechanism involved in this entity remains obscure, it can be correlated with a disturbance of phenylalanine metabolism on the basis of the current knowledge.

[Renal needle biopsy in children. Technical aspects and results]. / Ponction biopsie rénale de l'enfant. Aspecs techniques et résultats.

Renal needle biopsy is still irreplaceable in children. The objectives of this retrospective study were to specify the technical aspects and the main nephropathies encountered. 152 children under the age of 16 years (13 +/- 3), 79 boys and 73 girls, underwent renal biopsy. The biopsy was performed after radiographic detection in 71 cases, and under continuous ultrasound guidance in 81 cases. The comparative study of these 2 techniques revealed the superiority of continuous ultrasound guidance, allowing biopsy of an essentially cortical fragment, rich in glomeruli with a limited number of punctures. Histological examination showed a predominance of glomerular nephropathy with, especially, visually normal kidney and membranoproliferative glomerulonephritis. These data encourage us to perform ultrasound-guided RNB in children and to eradicate sites of infection, particularly involving the upper respiratory tract.

[Viral hepatitis C in chronic hemodialyzed patients in southern Tunisia. Prevalence and risk factors]. / Hépatite virale C chez les hémodialysés chroniques dans le Sud Tunisien. Prévalence et facteurs de risque.

To define, the prevalence and risk factors of hepatitis C virus (HCV) a prospective and multicentre study was performed in 235 patients undergoing haemodialysis, the anti-HCV antibodies were evaluated using an immuno-enzymatic method (wellcozyme anti-HCV). The following parameters were obtained for all patients: time on haemodialysis, blood transfusion, liver enzymes (ALT, AST), others virus markers: HBV (HBs Ag, HBs Ab, HBc Ab) and HIV. Anti-HCV was positive in 86 patients (42%). There was a significant (p < 0.05) relationship between presence of anti-HCV antibodies and duration of haemodialysis (33 +/- 24 vs 20 +/- 19 months). No statistically significant difference was found with blood transfusion and the others parameters. In conclusion, the prevalence of HCV in our center of dialysis was high. The duration of dialysis seems to be the main risk factor.

[Direct cost of the ambulatory management of diabetes at the outpatient clinic of the National Social Security Fund of Sfax (Tunisia)]. / Coût direct de la prise en charge ambulatoire du diabète à la policlinique de la caisse nationale de sécurité sociale de Sfax (Tunisie).

The direct costs were determined by conducting a retrospective study on the files of 100 diabetics (selected at random) who had attended the clinic at least once in 1991. Another study was conducted simultaneously under the same conditions on 100 non-diabetic patients. Diabetic patients attend on average 8 times a year, twice as often as nondiabetics, generally at the department of general medicine (6 times). They undergo more biological tests and receive more care procedures than nondiabetics. Drug prescriptions cost on average US$ 62 per year for the diabetic, 3 times as much as for the non-diabetic (US$ 20/year). The total direct cost of outpatient care is US$ 117 per year for the diabetic, as against only US$ 48 for the nondiabetic. The cost is much higher for diabetics with degenerative complications (US$ 144 as against US$ 92). Reduction of the cost of care requires early detection of diabetes and education of the diabetic, so as to ensure better control of blood sugar levels and freedom from complications that lead to a sharp increase in consultations and treatment procedures.