Circulating levels of FoxP3, M2 (sCD163) and IGF-1 as potential biomarkers associated with Laryngeal Squamous Cell Carcinoma in Tunisian patients.

We aim to assess the clinical impact of circulating levels of sCD163, FoxP3, IGF-1 in LSCC patients (Laryngeal Squamous Cell Carcinoma). The concentrations of sCD163, FoxP3, and IGF-1 were measured using ELISA test in the serum samples collected from 70 pretreatment LSCC patients and 70 age and sex-matched healthy controls. Statistical analysis was performed using ANOVA to compare the two groups, and the correlation between markers and clinical parameters. Receiver-Operator Characteristic (ROC) curve analysis was conducted to determine the optimal cutoff values and evaluate the diagnostic impact of these markers. Significant differences in the levels of sCD163, FoxP3, and IGF-1 were observed between LSCC patients and the control group, with respective p-values of 0.01, 0.022, <0.0001. The determined cutoff values for sCD163, FoxP3, IGF-1 concentrations were 314.55 ng/mL, 1.69 ng/mL, and 1.69 ng/mL, respectively. The corresponding area under the curve (AUC) values were 0.67 (95% CI: 0.57-0.76), 0.70 (95% CI: 0.61-0.80), 0.84 (95% CI: 0.76-0.92), respectively. Furthermore, it was found that IGF-1 concentrations exceeding 125.20 ng/mL were positively correlated with lymph node metastasis. Elevated serum levels of sCD163, FoxP3 and IGF-1 are associated with the diagnosis of LSCC. IGF-1 appears to be the most promising indicator for the LSCC progression.

Hospital bed capacity across in Tunisia hospital during the first 4 waves of the COVID-19 pandemic: A descriptive analysis.

Background: In March 2020, the WHO declared COVID-19 as a pandemic, and Tunisia implemented a containment and targeted screening strategy. The country's public health policy has since focused on managing hospital beds. Methods: The study analyzed the bed occupancy rates in public hospitals in Tunisia during the pandemic. The evolution of daily cases and nonpharmaceutical interventions (NPI) actions undertaken by the Tunisian Government were also analyzed. The study used 3 indices to assess bed flexibility: Ramp duration until the peak, ramp growth until the peak, and ramp rate until the peak. The study also calculated the time shift at the start and peak of each wave to evaluate the government's response efficacy. Results: The study found that the evolution of the epidemic in Tunisia had 2 phases. The first phase saw the pandemic being controlled due to strong NPI actions, while the second phase saw a relaxation of measures and an increase in wave intensity. ICU bed availability followed the demand for beds, but ICU bed occupancy remained high, with a maximum of 97%. The government's response in terms of bed distribution and reallocation was slow. The study found that the most deadly wave by ICU occupied bed was the third wave due to a historical variant, while the fifth wave due to the delta variant was the most deadly in terms of cumulative death. Conclusions: The study concluded that decision-makers could use its findings to assess their response capabilities in the current pandemic and future ones. The study highlighted the importance of flexible and responsive healthcare systems in managing pandemics.

Burden of cancer attributable to insufficient physical activity in Tunisia.

Background: Insufficient physical activity is a risk factor for several types of cancer. Therefore, estimating the burden of cancer attributable to insufficient physical activity is essential to evaluate the effect of health promotion and prevention interventions. Aims: We estimated the number of incident cancer cases, deaths and disability-adjusted life years (DALYs) attributable to insufficient physical activity in the Tunisian population aged 35 years and older in 2019. Methods: We estimated the age-specific population attributable fractions by sex and cancer site to estimate the proportion of cases, deaths and DALYs that could be avoided with optimal levels of physical activity. We used data on cancer incidence, mortality and DALYs from the Global Burden of Disease study estimates for Tunisia in 2019, and data on physical activity prevalence from a Tunisian population-based survey in 2016. We used site-specific relative risk estimates from meta-analyses and comprehensive reports. Results: The prevalence of insufficient physical activity was 95.6%. In 2019, 16 890 incident cancer cases, 9368 cancer-related deaths and 230 900 cancer-related DALYs were estimated to have occurred in Tunisia. We estimated that 7.9% of incident cancer cases, 9.8% of cancer-related deaths and 9.9% of cancer-related DALYs were attributable to insufficient physical activity. At cancer sites known to be associated with inadequate physical activity, 14.6% of cancer cases, 15.7% of deaths and 15.6% of DALYs were attributable to insufficient physical activity. Conclusion: Insufficient physical activity contributed to almost 10% of the cancer burden in Tunisia in 2019. Reaching optimal physical activity levels would considerably reduce the burden of associated cancers in the long-term.

Factors Associated with Diagnostic Delays among Tunisian Breast Cancer Patients.

BACKGROUND: Breast cancer (BC) remains one of the most common and deadliest cancer among women worldwide and in Tunisia. The lethality of BC is particularly high in developing countries, such as Tunisia, due to late diagnosis in the majority of cases. The objective of this study was to analyze factors associated with delayed presentation among women followed at the Salah Azaiez institute of Tunis during the year 2021. METHODS: It was a retrospective cohort study, including patients with primary BC, consulting at the Salah Azaeiz institute of Tunis over a period of six months, from january 1st to june, 30th, 2021. The total diagnostic interval (DI) was divided into patient interval (PI) and healthcare system interval (HSI). Diagnosis delay due to patient (PD) was defined as a delay more than three months between the discovery of symptoms and the first medical consultation. Data were collected using a valid questionnaire "the breast cancer questionnaire delay" and from patients' medical records. The calculation of crude and adjusted Odds Ratios using a stepwise descending binary logistic regression model was performed to measure the association of the studied factors with the delayed presentation. RESULTS: A total, 146 patients were included. The mean age of the patients was 50.1 ± 10.9 years.  More than a half of patients had a primary education (56.8%). Majority of patients were married (86.3%) and unemployed (90.4%).  The median of patient interval (PI) and HSI were 31 days [IQR: 12.5-151.5] and 53 days [IQR: 33.0-88.7] respectively. About three quarter of patients (76.4%) presented a healthcare system delay (HSD). After univariate analysis, factors significantly associated with PD were the low level of education (illiterate/primary) (RR: 2.7; 95% CI [1.1-6.4]; p=0.02) and the lack of knowledge about BC symptoms by patients (RR: 15.0; 95% CI [6.0-37.4]; p<10-3). The only variable that remained associated with PD, after multivariate analysis, was lack of initial knowledge of symptoms (OR: 15.0; 95% CI [6.0-37.4]; p<10-3). CONCLUSION: Lack of knowledge of symptoms was the main factor associated with delayed presentation among BC women.This study shows the need to inform women about performing breast self-examination as well as clinical signs of BC.

[Knowledge of malaria and preventive attitudes of Tunisian travellers toward malaria endemic areas]. / Connaissances du paludisme et attitudes préventives des voyageurs tunisiens vers les zones d'endémie palustre.

Introduction: travellers to endemic areas must know malaria, its risk factors and prophylactic measures. This can help to avoid severe cases of malaria and to prevent transmission in countries that are malaria-free. The purpose of this study is to assess Tunisian travellers´ knowledge about malaria, its transmission and prevention and their adherence to prophylactic measures. Methods: we conducted a survey based on two anonymous questionnaires (pre- and post-trip) among adults travelling to endemic countries. The 1st questionnaire was followed by a medical interview focusing on level of risk and recommended prophylactic measures. Results: two hundred and eighty-nine travellers were recruited. They mainly moved within sub-Saharan Africa (99%) for professional reasons (84,4%). The average age of subjects was 42.3 years and sex ratio (male/female) was 3.1. Prior to departure, only 53.3% of subjects were aware of the risk of malaria, and only 28% gave correct answers about modes of transmission. Recommendations for chemoprophylaxis were only known by 62.3% of subjects and only 43.6% intended to use chemoprophylaxis (p < 0.01). Better adherence to protective measures, including chemoprophylaxis, was reported after the trip, with attitudes qualified as good or excellent by 64.2% on return against 23.7% before the interview (<0.001). Conclusion: Tunisian travellers knowledge of malaria is insufficient. Strengthening information through specialized consultations (whose usefulness has been demonstrated) is required.

Mortality attributable to tobacco in Tunisian adults, 2016Mortalité attribuable au tabac dans la population tunisienne adulte en 2016.

OBJECTIVE: We aimed to estimate the mortality attributable to current cigarette smoking among Tunisian individuals aged 30 years and over in 2016. METHODS: The number of deaths attributable to cigarette smoking was estimated using the population attributable fraction (PAF) method of calculation. Current cigarette smoking-related data and number of deaths by cause were obtained from a Tunisian national household survey conducted in 2016 (THES-2016) and the "Global Burden of Disease" study respectively. Relative risks for cause-specific mortality among current cigarette smokers compared to never-smokers were obtained mainly from the American cancer prevention study II (CPS II), including adjustments for a range of potential confounders. RESULTS: In 2016, 6,039 deaths were attributed to current cigarette smoking (5,934 in men and 105 in women), accounting for 14.3 % of total deaths in persons aged 30 years and over (24.2 % in men and 0.6 % in women). Lung cancer, chronic obstructive pulmonary diseases and upper aerodigestive tract cancers represented the highest smoking-attributable risks (74.5 %, 49.1 % and 42.2 % respectively). CONCLUSIONS: In the present study, high rates of smoking-attributable mortality were found, mainly among men. In addition to more rigorous application of existing laws, sensitization to the dangers of tobacco, educational anti-smoking campaigns and help in quitting are of prime importance.

Prognostic impact of tumor-infiltrating lymphocytes in non-small cell lung carcinomas.

INTRODUCTION: Tumor-infiltrating lymphocytes represent a pivotal component of the host anti-tumor response. Thus, they considerably influence the evolution of cancers including non-small cell lung carcinomas. Even if, this important role is consensual, many discordant results are published in the literature about the prognostic role of the different populations of tumor-infiltrating lymphocytes. The aim of our work was to evaluate the prognostic impact of CD8+, CD4+, and forkhead box protein P3+ lymphocytes in the tumor microenvironment of non-small cell lung carcinomas. METHODS: We conducted a retrospective descriptive study, which included non-small cell lung carcinomas diagnosed in the department of pathology and followed in the medical oncology department of the same hospital between 2011 and 2015. Tumor-infiltrating lymphocytes were analyzed by the immunohistochemical method for forkhead box protein P3, CD4, and CD8. Intratumoral and stromal-labeled lymphocytes were quantified by manual counting at high magnification (×400). Forkhead box protein P3+/CD8+, forkhead box protein P3+/CD4+, and CD8+/CD4+ ratios were subsequently calculated. The prognostic value of tumor-infiltrating lymphocytes was assessed in respect of overall survival, recurrence-free survival, and relapse-free survival. RESULTS: Thirty-nine patients were included. The mean age of patients was 59.6 years. A complete surgical resection (p = 0.009), and a CD8/CD4 ratio (p = 0.008) were prognostic factors for overall survival. Complete surgical resection (p = 0.003), the forkhead box protein P3/CD8 (p = 0.005), and forkhead box protein P3/CD4 (p = 0.037) ratios were prognostic factors for recurrence-free survival. The CD8+ tumor-infiltrating lymphocytes rate (p = 0.037) was a prognostic factor for relapse-free survival with a threshold of 67.8/high power field. Microscopic subtype (p = 0.037) was a prognostic factor for relapse-free survival when only adenocarcinoma and squamous cell carcinoma were considered. In multivariate analysis, age (p = 0.004) and a CD8/CD4 ratio (p = 0.016) were independent predictors of overall survival. CONCLUSION: Despite the limitations of our study, our results confirm the prognostic value of tumor-infiltrating lymphocytes in non-small cell lung carcinomas and the importance of the combined quantification of their different subpopulations.

Burden of non-communicable diseases in Tunisia, 1990-2017: results from the global burden of disease study.

INTRODUCTION: non-communicable diseases (NCDs) are the leading cause of mortality and disability worldwide especially in developing countries such as Tunisia. We aimed to describe the national burden of non-communicable diseases in 2017 and to analyze disability-adjusted life year trends from 1990 to 2017 in Tunisia by cause and gender. METHODS: we used Joinpoint regression analysis to assess trends of the age standardized disability-adjusted life year rate from 1990 to 2017 and to determine average annual percentage change. RESULTS: non-communicable diseases accounted for 87.7% of total disability-adjusted life year in Tunisia in 2017. The five leading causes of this rate in Tunisia in 2017 were cardiovascular diseases, musculoskeletal disorders, neoplasms, mental disorders and neurological disorders. The trend of disability-adjusted life year rate of non-communicable diseases decreased significantly from 23403.2 per 100.000 (95% CI: 20830.2-26285.8) in 1990 to 18454.6 (95% CI: 15611.3-21555.4) in 2017, with a change of -0.9%; p=0.00. The decrease of the age standardized disability-adjusted life year rate concerned mainly cardiovascular diseases and neoplasms secondly. This decrease was more important in female (change=-1.1, p=0.00) in comparison to males (change=-0.7, p=0.00). On the other hand, the increase of the standardized disability-adjusted life year rate was related to musculoskeletal disorders, diabetes, kidney disorders and substance use disorders with a significant annual percentage change of 0.1%, 0.2% and 1.3% (p=0.00) respectively. Conclusion: the implementation of the national strategy is the key solution to mitigate the impact of non-communicable diseases in Tunisia.

COVID-19 Vaccination Acceptance and Its Associated Factors among Cancer Patients in Tunisia.

BACKGROUND: Vaccination is the most effective way to fight the COVID-19 pandemic and to protect people who have a higher risk of developing severe illness and death from COVID-19 such as cancer patients. We aimed in this study to determine the acceptance rate of COVID-19 vaccination of the Salah Azaiez Institute (SAI) of cancer of Tunisia patients and to identify its associated factors. METHODS: It was a cross sectional study about patients admitted to the SAI for treatment during the month of February 2021. Univariate and multivariate analyses were performed to identify factors associated with the COVID-19 vaccine acceptance among Tunisian cancer patients. RESULTS: A total of 200 patients were included in this study with a mean age of 54.4±12.7 years and a gender ratio of 0.5. Only 35.0% of surveyed patients reported their acceptance to receive the COVID-19 vaccine. Multivariate analysis showed that believing in COVID-19 vaccine safety and efficacy (OR=3.1 [1.3-7.4]), enrollment in the COVID-19 vaccine platform (OR=8.3 [1.8-38.1]) and the willingness to receive influenza vaccine (OR=3.9 [1.6-9.3]) were independently associated with the COVID-19 vaccine acceptance among SAI cancer patients. CONCLUSIONS: The COVID-19 vaccine acceptance rate found in this study was low. Communication strategies of the vaccination campaigns should provide clear, simple and detailed messages about the efficacy and the benefits of the COVID-19 vaccines. More engagement of health authorities to promote COVID-19 vaccination is necessary.

Professor Mohamed Soussi Soltani: Leader, Innovator and Researcher in Public Health.

Mohamed Soussi SOLTANI (June 27, 1953 - March 2, 2016) is Professor of Preventive and Community Medicine at the Faculty of Medicine of Monastir (Tunisia). The objective of this paper is to present, to new generations of the specialty in the Greater Maghreb, this leading teacher from the Center-East of Tunisia (Monastir), through the testimonies of his companions, and his indexed publications. All the colleagues of the late SOLTANI testified to his high human and professional qualities, particularly perseverance, commitment, forward thinking, integrity and professionalism. The scientific life of the late Professor Soltani was oriented towards two major themes: Public Health and Family Medicine. Indeed, the deceased has developed several new preventive activities in first-line structures such as anonymous and free HIV screening, family planning, rational use of drugs, breast cancer screening, smoking cessation, prevention of rheumatic heart disease. Pr SOLTANI welcomed general practitioners from the Monastir region to the Faculty's Community Medicine Department, creating with them a movement to advocate for the academic and professional development of general medicine into an authentic specialty of family medicine. Out of the 34 publications of Professor SOLTANI, indexed on PubMed, 11 were signed by himself in first position, mainly relating to maternal health (prenatal surveillance, education for maternal health, pregnancy referral system) and infant (low birth weight, vaccination, mother-to-child transmission of hepatitis B, meningitis due to Haemophilus influenzae). Thus, with a life prospering by innovations and research in public health, Professor SOLTANI will always remain a model for young people in the specialty of Preventive and Community Medicine. His followers have an obligation to write his complete biography, to safeguard it and pass it on to new generations of public health.

Place of the periodic medical check-up in basic health care in Tunisia.

The objective of primary health care is to reduce mortality and morbidity. This kind of care was very efficient in communicable diseases, malnutrition and maternal and neonatal diseases; however, their impact on non communicable diseases and mental disorders control is not obvious. In Tunisia, primary health care was introduced in the early 1980s; a lot of progress were notified in particular in health of mothers and children in particular, but only slightly in non communicable diseases control and mental health promotion. Therefore, a new approach would be strongly recommended to remedy this situation. The Medical Periodic Check-up (MPC) implemented in North America would have a positive impact in the prevention and management of non communicable diseases. What would be the place of this MPC in primary health care in Tunisia? The MPC has two main objectives: the prevention of specific diseases and health promotion. However, despite its efficiency and usefulness, the MPC could be costly, especially for countries with limited resources. Current evidence suggests that the most appropriate approach would be to take periodic preventive health visits tailored to the level of risk. The frequency of visits depends on the age, sex and state of health of the individual. In conclusion, there are strong arguments in favor of the introduction of MPC in primary health care in Tunisia, especially among adults in non communicable diseases control strategy. However, it's highly be recommended that the BMC should be oriented according to the risk levels in order to optimize resources. It is also important to educate and the public, especially women and young adults, to benefit from periodic medical and dental examinations.

Strategies of the Maghreb countries in the fight against cancer.

OBJECTIVES: Describe the cancer control strategies adopted by the Maghreb countries and identify their main weaknesses. METHODS: Data on cancer epidemiology and "Cancer plans" in the Maghreb were collected through a search in bibliographic databases, on GLOBOCAN and the sites of international and national organizations responsible for surveillance and cancer control. RESULTS: In the Maghreb, cancer registries observed low population coverage (Morocco: 20%; Tunisia: 60%; Algeria: 82%) and a lack of computerization. Primary prevention strategies remains insufficient as evidenced by the high prevalence of smoking in 2018 (Tunisia: 26%; Algeria: 19%; Morocco: 14%). Screening coverage for major cancers are still low in the Maghreb; In Tunisia for example the levels observed for cervical and breast cancers are respectively 14% and 10%. Regarding cancer care, the main problem is a limited access to cancer health services,   due to poorly decentralized infrastructure and equipment (Morocco: six oncology centers; Algeria: three oncology centers; Tunisia: only one institute specializing in cancer care). Palliative care is mainly supported by civil society in the Maghreb countries. CONCLUSION: The resources dedicated to cancer control in the Maghreb are limited, explaining its poor performance. Better governance in cancer control is required, with the adoption of multisectoral approach for prevention, and the strengthening of cancer surveillance and research.

Impact of contact tracing, respect of isolation, and lockdown in reducing the number of cases infected with COVID-19. Case study: Tunisia's response from March 22 to May 4, 2020.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has spread rapidly across the world. Tunisia reacted early to COVID-19, resulting in a low number of infections during the first wave of the pandemic. This study was performed to model the effects of different interventions on the evolution of cases and to compare these with the Tunisian experience. METHODS: A stochastic transmission model was used to quantify the reduction in number of cases of COVID-19 with the interventions of contact tracing, compliance with isolation, and a general lockdown. RESULTS: In the model, increasing contact tracing from 20% to 80% after the first 100 cases reduced the cumulative number of infections (CNI) by 52% in 1 month. Similarly, increased compliance with isolation from 20% to 80% after the first 100 cases reduced the CNI by 45%. These reductions were smaller if the interventions were implemented after 1000 cases. A general lockdown reduced the CNI by 97% after the first 100 cases. Tunisia implemented its general lockdown after 75 cases were confirmed, which reduced the cumulative number of infected cases by 86% among the general population. CONCLUSIONS: This study shows that the early application of critical interventions contributes significantly to reducing infections and the evolution of COVID-19 in a country. Tunisia's early success with the control of COVID-19 is explained by its quick response.

Burden of breast and gynecological cancers in Tunisia between 1990 and 2030: Trend and projection.

AIM: To describe the burden of breast and gynecological cancers in Tunisia in 2017, to analyze the trend between 1990 and 2017 and to performit's prediction by 2030. METHODS: This was a study using data estimated by the Institute for Health Metrics and Evaluation (IHME) for years of life by breast cancer and gynecological cancers: ovary, cervix and uterus (endometrium and other unspecified parts of the uterus) in Tunisia in 2017.The trend analysis of age standardized DALYrate between 1990 and 2017 was analyzed by using Join Point software.The projection of number of DALY and YLL by 2030 was conducted by SPSS software using Age-Period-Cohort (APC) models. RESULTS: In 2017, the age standardized DALYs rate for breast and gynecological cancers was 538.5/100,000 women. Breast cancer proved observed the highest rate of standardized DALY rate with 378.5/100,000 women followed by ovarian cancer (rate standardized DALY=72.7/100,000 women).The standardized DALY rate increased between 1990 and 2017 except for cervix cancer and uterine cancer which have been on a downward trend. According to the same conditions between 1990 and 2017, the age standardized DALY rate in 2030 will reach 674.6/100,000 women (95% CI=667.2/100,000-682.1/100,000). CONCLUSION: Strengthening prevention strategy against cancer in general and women's cancers in particularis strongly recommended to reduce cancer burden and to changeits trend.

Burden of road traffic accidents in the Greater Maghreb (1990-2017).

OBJECTIVE: To study the burden of Road Traffic Accidents (RTA) in the Maghreb and its evolution during the period 1990 to 2017. METHODS: We described the RTA in the Maghreb region, while analyzing database provided by the Institute for Health Metrics and Evaluation (IHME) for the period1990-2017. RESULTS: The age-standardized incidence rate of RTA has decreased overall across the Maghreb; it went from 719.57/100000 inhabitants in 1990 to 609.49 per 100,000 inhabitants in 2017. In 2017, the highest mortality rate in the region was noted in Tunisia and it was 30.15 / 100,000 inhabitants (CI95% = 24.05-37.08). The highest and lowest standardized rates for disability adjusted life years or DALYs were observed respectively in Tunisia: 1,311.56 per 100,000 inhabitants (CI95%=1,065.28-1588.68) and in Algeria: 962.68 per 100,000 inhabitants (CI95%=789.50- 1460.12). CONCLUSION: The burden of disease from road accidents is high in the Maghreb countries and the downward trend in the incidence of these accidents is relatively low. These results should encourage decision-makers to elaborate an integrated and multisectorial strategy to improve the situation.

The Prognostic Significance of IGF-1R and the Predictive Risk Value of Circulating IGF-1 in Tunisian Patients with Laryngeal Carcinoma.

The aim was to evaluate the clinical impact of IGF-1/IGF-1R in Tunisian laryngeal carcinoma. A high IGF-1R immunohistochemical expression was found in our series (81.43%). A tendency toward an association between IGF-1R expression and lymph node metastasis was found (p = 0.068). Patients with positive IGF-1R expression showed a short disease free survival (p = 0.053) and a high recurrence rate. Furthermore, circulating IGF-1 levels sera, detected by ELISA, were higher among patients compared to controls (p < 0.001). IGF-1R might have a prognostic significance and could be a factor of tumor recurrence. However, high levels of IGF-1 increase the risk of developing of LSCC disease.

Premature mortality attributable to smoking among Tunisian men in 2009.

INTRODUCTION: Tobacco smoking is a significant public health threat in the world, a risk factor for many diseases, and has been increasing in prevalence in many developing countries. In this study, we aimed to estimate the burden of premature deaths attributable to smoking among Tunisian men aged 35-69 years in 2009. METHODS: The number of deaths attributable to smoking was estimated using the population attributable risk fraction method. Smoking prevalence was obtained from a nationally representative survey. Causes of death were obtained from the registry of the National Public Health Institute. Relative risks were taken from the American Cancer Society Prevention Study (CPS-II). RESULTS: Total estimated premature deaths attributable to smoking among men in Tunisia were 2601 (95% CI: 2268-2877), accounting for 25% (95% CI: 23.3-26.6) of total male adult mortality. Cancer, cardiovascular and respiratory diseases were the major causes of premature deaths attributable to smoking with 1272 (95% CI: 1188-1329), 966 (95% CI: 779-1133) and 364 (300-415) deaths, respectively. CONCLUSIONS: Tobacco smoking is highly relevant and is related to substantial premature mortality in Tunisia, around double that estimated for the region as a whole. This also has not decreased over the past 20 years. Urgent actions are needed to reduce this pandemic.