Access to healthcare for migrants in Tunisia in 2023-2024: Current situation and ethical challenges.

INTRODUCTION: Transformed progressively into a transit country towards Europe but also as a host, Tunisia has seen a diversification of migratory movements since the 2011 revolution, as well as the profiles of migrants who face multiple difficulties that can have an impact on their health. AIM: This update aimed to expose the situation of migrants in Tunisia regarding access to healthcare, and to raise the ethical issues that result from it. RESULTS: Providing care to vulnerable individuals, especially migrants, compels us to reevaluate our practices and question ourselves. Ethical questioning is constant to determine how to do well and not harm. The reflection on this more humane "social medicine" comprehending the patient in its entirety, is only in its beginnings. The critical health status of the poorest populations and their extreme vulnerability do not only call for adapted and specific care measures but also a more comprehensive questioning of social ties and the place that our society grants to the weakest and excluded. CONCLUSION: Migration must be considered as a central issue of the ethics of the health of a population in order to provide quality care without prejudice.

Fatal falls from great height in Sousse (Tunisia): Study of 141 medicolegal autopsy cases.

INTRODUCTION: Falls from great heights constitute a violent trauma that can lead to death. This represents a suspicious death, leading to initiate legal proceedings with in particular the practice of an autopsy. AIMS: to determine the features of victims of falls from height and relations between medico-legal form of the death, the height of the fall and the nature of traumatic injuries Methods: A retrospective study about 141 cases of death after fall from great height. Data were collected at the Legal Medicine Department of the Farhat Hached University Hospital in Sousse (Tunisia) over a period of 14 years from 2007 to 2020. RESULTS: The average age of the victims was 37±12.8 years with a sex ratio of 6.05. Half of them were day laborers. The majority had no history of psychiatric illness (91.5%). The majority of victims (41.8%) fell from a height of 3 to 6 meters. Regarding injuries, rib fractures (52.4) were predominant, especially on the right side followed by skull fractures (31.2%). A significant difference in the prevalence of rib cage lesions in the groups over 9 meters in height (p<0.05) was found. The lesions of the lower limbs were proportional to the increase in the height of the fall. Deaths were accidental in 80.8% and suicides in 13.5%. CONCLUSION: In cases of high falls, a forensic autopsy is essential to make a complete evaluation of the injuries, to search a correlation between severity of injuries and height of the fall and finally to orientate towards the medico legal form of the fall.

[Medical experimentation on prisoners (part 4): the dilemma of 'pros' and 'cons'.]

Given the long history of abuse of prisoners in medical experimentation, it is understandable that additional safeguards have been established to protect this social category. However, the debate between the detractors and the supporters of the medical experimentation in the prison environment is still going on. The present history note, the fourth in a series on medical experimentation on prisoners, intended to relate the main arguments of both sides: ie; the detractors and supporters of medical experimentation on prisoners.

Medical experimentation on prisoners (part 1): historical milestones.

The exploitation of prisoners in medical research is an ancient phenomenon. However, the history of the XXth century was marked by major events that reached the peak of horror during the second world war. Although the collective mind has remembered the outrages of the Nazi regime, the truth is that these practices were adopted by the majority of the military powers of that time, and continued after the end of the war. This history note is the first in a series that aims to review the circumstances and implications of these dark moments in the history of medical research in order to pay tribute to the countless victims who paid with their lives for «scientific progress¼ and to understand the reasons for current ethical considerations in biomedical experimentation on persons deprived of liberty.

Biological Responses to Short-Term Maximal Exercise in Male Police Officers.

The specifics of short-term physical exercise are similar to the immediate reaction demands placed on police officers. Identifying the physiological predisposition to short-term high-intensity exercise in male law enforcement officers will assist in understanding their metabolism and make a significant contribution to a much more personal and individualized workout program. This will improve physical fitness of individual officers, improving their preparedness for such times of emergency. This cross-sectional study was conducted to investigate the responses of hematological (erythrocytes, hemoglobin, hematocrit, leucocytes, monocytes, neutrophils, lymphocytes), hormonal (testosterone, cortisol, melatonin), biochemical (glucose, uric-acid, lactate, creatine-phosphokinase) data to short-term maximal exercise in male police officers (n = 20). Blood samples were collected before- and after- the running-based anaerobic sprint test (RAST), and biological values were corrected for fluid shifts. Data were mean ± standard deviation of differences (= after minus before RAST). After the RAST, values of cortisol, lactate, neutrophils, lymphocytes, and monocytes increased significantly by 7.01 ± 37.36 mmol/l, 7.55 ± 1.67 mmol/l, 0.17 ± 0.26 103/µl, 0.61 ± 0.28 103/µl, and 0.10 ± 0.13 103/µl, respectively. After the RAST, values of melatonin, uric-acid, creatine-phosphokinase, hemoglobin, and hematocrit decreased significantly by -13.24 ± 4.60 pg/ml, -13.28 ± 14.35 µmol/l, -10.23 ± 10.13 IU/l, -2.01 ± 0.81 g/dl, and -4.46 ± 0.59%, respectively. Biological data of male police officers were affected by sprint test. Understanding changes in biological data following short-term maximal exercise can further assist in a better understanding of anaerobic metabolism, which will be helpful to find available methods for coaches to quantify training loads.

Epidemiological aspects of child abuse and neglect in Sousse, Tunisia: A 10-year retrospective study.

The aim of our study was to examine epidemiological aspects of child abuse and neglect in Tunisia. We conducted a retrospective and descriptive study over a period of 10 years (January 2006-December 2015), based on the files handled by the Child Protective Services (CPS) agency in the city of Sousse, Tunisia. During the study period, 3736 referrals were received by the CPS agency of Sousse. Of the total, 2212 (59.2%) were screened in and investigated. Of the investigated cases, 317 (14,3%) were substantiated as abuse or neglect. The reports of maltreatment came mostly from parents (37.8%). Neglect was the major type of maltreatment (51.4%) and an association of 2 types of maltreatment was found in 76 cases (24%). Parents were the perpetrators in 221 cases (69.7%). The average age of the victims was 10 years and boys accounted for 56%. In the 257 cases where the marital status of the parents was noted in the files, the parents were divorced in 62 cases (24.1%) and the child lived with a single mother in 35 cases (13.6%). Alcohol addiction was found in 21 parents (6.6%) and one of the parents was incarcerated in 39 cases (12.3%). As for the socio-economic status, it was evaluated in 188 families and was low in 123 cases (65.4%). In the absence of studies related to this scourge in Tunisia, we hope to raise awareness of the abuse and alert those who come into contact with the child on the importance of detecting and reporting early maltreatment and thus to introduce more appropriate care. A comprehensive prevention strategy needs to be established by addressing risk factors, cultural norms conducive to abuse and unwanted pregnancies.

The Effects of Ramadan Fasting on the Spirometric Data of Healthy Adult Males.

The few studies carried out on the effects of Ramadan fasting (RF) on spirometric values present contradictory conclusions. This study aimed at assessing whether RF affects healthy adults' spirometric values. Twenty-nine nonsmoking healthy males ( M ± standard error of mean [ SEM] of age: 27 ± 1 years) who fasted during Ramadan (June 29-July 28, 2014) volunteered to the study. Three periods (before-Ramadan [June 23-25], mid-Ramadan [July 14-16] and after-Ramadan [August 11-14]) were selected for spirometry measurements that were consistently performed 5.5 to 3.5 hours (between 15:00 and 17:00 hours) before fasting break. Assessment sessions comprised following: weight (kg), forced vital capacity (FVC), first second expiratory volume (FEV1), FEV1/FVC, peak expiratory flow (PEF), maximal mid expiratory flow (MMEF), and forced expiratory flow rate at the x% of FVC to be exhaled (FEF x%). Spirometric data were expressed in percentages of reference values. Results were analyzed by applying repeated measures analysis of variance. The M ± SEM of weight (before-R: 81.6 ± 2.8 kg, mid-R: 80.8 ± 2.9 kg, after-R: 81.2 ± 2.9 kg), FEV1 (before-R: 99 ± 2%, mid-R: 98 ± 2%, after-R: 98 ± 2%), FVC (before-R: 103 ± 2%, mid-R: 101 ± 2%, after-R: 101 ± 2%), PEF (before-R: 112 ± 3%, mid-R: 113 ± 2%, after-R: 114 ± 3%), MMEF (before-R: 83 ± 3%, mid-R: 83 ± 3%, after-R: 82 ± 3%), FEF25% (before-R: 90 ± 5%, mid-R: 89 ± 6%, after-R: 87 ± 6%), FEF50% (before-R: 94 ± 4%, mid-R: 91 ± 4%, after-R: 93 ± 3%), and FEF75% (before-R: 108 ± 3%, mid-R: 111 ± 2%, after-R:111 ± 3%) were not significantly influenced by RF. To conclude, RF did not bring about any significant changes in the spirometric values of nonsmoking healthy adult males.

Sudden Death Due to Unusual Complication of Takayasu Arteritis: An Autopsy Case.

Takayasu arteritis is an uncommon inflammatory disease with usually a good prognosis. However, sometimes, the evolution can be fatal essentially by a coronary arteries involvement. We present a case of a 19-year-old woman who died suddenly from cardiogenic shock complicating an unknown Takayasu arteritis.At the autopsy, the aorta showed a significant thickening of the wall. The coronary arteries were slightly thickened and did not show any occlusion. Microscopic examination of the aorta showed an abundant granulomatous and a lymphoplasmacytic infiltrate. Microscopic sections of other internal organs showed signs of cardiac hypertrophy and an extensive edema of the lung. Death was attributed to acute heart failure complicating a supravalvular aortic stenosis secondary to unknown Takayasu arteritis.Takayasu arteritis can be life-threatening by an occlusion of the ascending aorta and its major branches, without any coronary arteries involvement.

Suicide and Fire: A 20-Year Study of Self-Immolation Death in Sousse, Tunisia.

Self-immolation is a self-destructive conduct described since antiquity. Its frequency is variable from one country to another and it is a real public health problem in parts of the world. In Tunisia, after the 2011 revolution the problem of self-immolation protest has been highly publicized giving the impression of an increase in this phenomenon. This is a retrospective analysis of all fatal self-immolation cases, collected over a 20-year period (1996-2015) at the Forensic Medicine Department of the Farhat Hached University Hospital, Sousse, Tunisia. A total of 41 cases were collected, of which 23 were men (56%). The mean age was 36.1 years. Prior to 2011, 78.9% of the victims of self-immolation were women and after 2011, 86.4% were men. The rural origin of the victims was found in 56.25% of the cases. History of psychiatric illness was found in four individuals. The self-immolation took place in the victims' homes in 19 cases (46.3%). It came after a conjugal or family conflict in 14 cases (34.1%) and it is of protest character in 8 cases (19.5%). This study confirmed the increasing frequency of self-immolation in Tunisia after the 2011 revolution and noted a change in the victims' profiles.

[Legal redress in relation to physical injury due to post-traumatic anterior pituitary insufficiency]. / Réparation juridique en dommage corporel de l'insuffisance antéhypophysaire post-traumatique.

Post-traumatic anterior pituitary insufficiency (PTAPI) is a rare but established disease caused by ischemic lesions after severe cranial trauma. This case study aims to highlight the criteria for imputability of PTAPI to a cranial trauma as well as the specific principles of legal redress in relation to this disease. We conducted a forensic study of a patient with diagnosed PTAPI followed up in the Division of Endocrinology and Legal Medicine at the University Hospital, Sousse (Tunisia). The patient included in the study was a 45-year old woman with no particular past medical history. (6 gynaecological procedures, 4 parities and 2 abortions) having regular menstrual cycles, without a history of hemorrhagic childbirth, who had been involved in a road accident (pedestrian got hit by a car) causing occipital trauma without initial knowledge loss. She developed hypothyroidism three years after the accident. The hormonal assessment showed the involvement of all the other axes. Neuroradiological examination objectified pituitary gland and pituitary stalk integrity. The definitive diagnosis of PTAPI was made. Medical examination (performed 4 years after the accident) concluded that PTAPI was imputable to the accident. Permanent partial disability rate according to ordinary law has been assessed at 25%. PTAPI diagnosis is made by elimination. The evaluation of physical injury should be based on residual symptoms, on therapeutic constraints and on its impact on daily and professional activity. Patient's evolution under hormone replacement therapy is often favorable, however, complications may occur, hence the necessity to establish these complications in order to preserve the right of the patient to underwent new treatments.

Infant acute myocarditis mimicking acute myocardial infarction

Myocarditis is an inflammatory disease of the myocardium with heterogeneous clinical manifestations and progression. In clinical practice, although there are many methods of diagnosis of acute myocarditis, the diagnosis remains an embarrassing dilemma for clinicians. The authors report the case of 9-month-old infant who was brought to the Pediatric Emergency Department with sudden onset dyspnea. Examination disclosed heart failure and resuscitation was undertaken. The electrocardiogram showed an ST segment elevation in the anterolateral leads with a mirror image. Cardiac enzyme tests revealed a significant elevation of troponin and creatine phosphokinase levels. A diagnosis of acute myocardial infarction was made, and heparin therapy was prescribed. The infant died on the third day after admission with cardiogenic shock. The autopsy showed dilatation of the ventricles and massive edema of the lungs. Histological examinations of myocardium samples revealed the presence of a marked lymphocytic infiltrate dissociating myocardiocytes. Death was attributed to acute myocarditis. The authors call attention to the difficulties of differential diagnosis between acute myocarditis and acute myocardial infarction especially in children, and to the important therapeutic implications of a correct diagnosis.

Reckless formalin injection in the eyelid instead of local anesthetic: case report.

Accidental injection of formalin is certainly rare, but it has serious consequences in terms of morbidity and mortality. We report a case of severe ophthalmic damage due to an accidental formalin's injection in the eyelid of a three-year-old child presenting with congenital ptosis's surgical repair of her left eye. This accident has damaged the orbital region and led to upper left eyelid's necrosis, eyeball's deformation and ipsilateral cataract. In terms of our observation, we discussed consequences of this rare type of accident, and its systematic and loco-regional effects. We tried also to explain these manifestations by analyzing the metabolism process of formalin in the human body. Finally, a medico-legal implication of such accident has been illustrated according to the Tunisian law (Penal Code of the Tunisian republic 'PCT').

Infant acute myocarditis mimicking acute myocardial infarction.

Myocarditis is an inflammatory disease of the myocardium with heterogeneous clinical manifestations and progression. In clinical practice, although there are many methods of diagnosis of acute myocarditis, the diagnosis remains an embarrassing dilemma for clinicians. The authors report the case of 9-month-old infant who was brought to the Pediatric Emergency Department with sudden onset dyspnea. Examination disclosed heart failure and resuscitation was undertaken. The electrocardiogram showed an ST segment elevation in the anterolateral leads with a mirror image. Cardiac enzyme tests revealed a significant elevation of troponin and creatine phosphokinase levels. A diagnosis of acute myocardial infarction was made, and heparin therapy was prescribed. The infant died on the third day after admission with cardiogenic shock. The autopsy showed dilatation of the ventricles and massive edema of the lungs. Histological examinations of myocardium samples revealed the presence of a marked lymphocytic infiltrate dissociating myocardiocytes. Death was attributed to acute myocarditis. The authors call attention to the difficulties of differential diagnosis between acute myocarditis and acute myocardial infarction especially in children, and to the important therapeutic implications of a correct diagnosis.

[Causes of death in patients with HIV infection in two Tunisian medical centers]. / Causes de décès des patients infectés par le VIH dans le Centre tunisien.

Antiretroviral tritherapy has contributed to a considerable reduction in HIV-related mortality. The causes of death are dominated by opportunistic infections in developing countries and by cardiovascular diseases and cancer in developed countries. To determine the causes and risk factors associated with death in HIV-infected patients in two Tunisian medical centers. cross-sectional study of HIV-infected patients over 15 years treated at Sousse and Monastir medical centers between 2000 and 2014. Death was considered related to HIV if its primary cause was AIDS-defining illness or if it was due to an opportunistic infection of unknown etiology with CD4 < 50 cells/mm3; it was considered unrelated to HIV if its primary cause wasn't an AIDS defining illness or if it was due to an unknown cause if no information was available. Two hundred thirteen patients, 130 men (61%) and 83 women (39%), average age 40 ± 11 years were enrolled in the study. Fifty four patients died, the mortality rate was 5.4/100 patients/year. Annual mortality rate decreased from 5.8% in 2000-2003 to 2.3% in 2012-2014. Survival was 72% at 5 years and 67% at 10 years. Death events were associated with HIV in 70.4% of cases. The leading causes of death were pneumocystis carinii pneumonia and cryptococcal meningitis in 6 cases (11%) each. Mortality risk factors were a personal history of opportunistic infections, duration of antiretroviral therapy < 12 months and smoking. Strengthening screening, early initiation of antiretroviral therapy and fight against tobacco are needed to reduce mortality in patients infected with HIV in Tunisia.

[Device-vigilance at University Hospital in Central Eastern Tunisia: a survey conducted among physicians]. / La matério-vigilance dans un Centre Hospitalo-Universitaire du Centre-Est tunisien: enquête auprès des médecins.

INTRODUCTION: The University Hospital Farhat Hached Sousse (Tunisia), has implemented a device-vigilance (DV) system, according to ANCSEP (National Agency of the Sanitary and Environmental Control of Products) guidelines, in order to manage the risk more effectively in hospital and to improve the quality and safety of patient care. In Tunisia the lack of regulation regarding device vigilance is the major obstacle to caregiver vigilance. The objective of this study is to establish the knowledge, attitudes, and clinical practice of University Hospital physicians regarding the implementation of the DV system. METHODS: We conducted a descriptive cross-sectional study of KAP (knowledge, attitudes and practices) among all the physicians working at the University Hospital Farhat Hached Sousse (Tunisia) who were users of medical devices (MDs) in the practice of their profession. A self-administered, pre-established and pre-testing questionnaire was developed. Data were collected and analyzed using SPSS20.0 software. RESULTS: The response rate was 51.9 % (183/95). A lack of knowledge about DV has been reported. More than half of the respondents didn't know the local correspondent of health establishment and the existence of a standardized vigilance reporting form. Regarding the attitudes, 89,5% express their interest in setting up a DV system and 37,5% acknowledged that the vigilance reporting form should be filled by the caregiver notifying the incident. Regarding the procedures, the majority of physicians confirmed the absence of an organized maintenance management of the MDs in the practice of their services. 90.5% express their wishes to receive information but few of them express their wishes to receive proper training (57.9%). CONCLUSION: A lack of information and training in a sensitive field which need to be heavily regulated has been a topic of discussion. The promulgation of regulatory texts is necessary in order to promote MD sector and guarantee the safety of patient and their users.

Healthcare-associated infections in a Tunisian university hospital: from analysis to action.

INTRODUCTION: Our study was conducted, in university hospital center (UHC) Farhat Hached of Sousse (city in Tunisian center-east), within healthcare-associated infections (HAI) epidemiological surveillance (ES) program, based, among others, on HAI regular prevalence surveys. Our objectives are to resituate HAI prevalence rate and to identify their risk factors (RF) in order to adjust, in our hospital, prevention programs. METHODS: It is a transversal descriptive study, including all patients who had been hospitalized for at least 48 hours, measuring prevalence of HAI a "given day", with only one passage by service. Risk factors were determined using Epiinfo 6.0, by uni-varied analysis, then, logistic regression stepwise descending for the variables whose p. RESULTS: The study focused on 312 patients. Infected patients prevalence was 12.5% and that of HAI was 14.5%. Infections on peripheral venous catheter (PVC) dominated (42.2%) among all HAI identified. HAI significant RF were neutropenia (p < 10(-4)) for intrinsic factors, and PVC for extrinsic factors (p = 0,003). CONCLUSION: Predominance of infections on PVC should be subject of specific prevention actions, including retro-information strategy, prospective ES, professional practices evaluation and finally training and increasing awareness of health personnel with hygiene measures. Finally, development of a patient safety culture with personnel ensures best adherence to hygiene measures and HAI prevention.

Sudden death due to hydatid cyst: thirty-four medicolegal autopsy cases.

The natural history of the echinococcosis can be studded with multiple complications; the most formidable is sudden death. We studied the epidemiological, pathological, and thanatological features of 34 sudden deaths due to hydatid cyst. The mean age was 33.2 years. A male predominance was observed with a sex ratio of 1.8. Most of our victims were from rural areas (79.4%). Sudden death was preceded by prodromal symptoms in 61.7% of cases. The most common was dyspnea (23.5%), followed by hemoptysis (11.8%). In 85.3% of cases, the cyst location was liver. It was cracked in 25 cases and broken in 6 cases. The rupture was spontaneous in 25 cases (73%). It was preceded by trauma in 7 cases. Death was related to an anaphylactic shock in 82.3% of cases, infection in 14.7%, and respiratory distress in 3% of cases. Sudden death is a serious and not exceptional complication of hydatid cyst. Several mechanisms may explain the sudden death.