Adapting waterpipe-specific pictorial health warning labels to the Tunisian context using a mixed method approach.

BACKGROUND: Waterpipe (WP) use is rapidly increasing among young people worldwide due to the widespread misperception that it is safer than cigarette smoking. Health warning labels (HWLs) can effectively communicate tobacco-related health risks but have yet to be developed for WP. This study aimed to optimize and adapt a set of 16 pictorial WP-specific HWLs, developed by an international Delphi study, to the Tunisian context. HWLs were grouped into four themes: WP health risks, WP harm to others, WP-specific harms, and WP harm compared to cigarettes. METHODS: Using a mixed method approach, we conducted ten focus groups combined with a survey among young WP users and nonusers (N = 63; age 18-34 years). In the survey, participants rated the HWLs on several communication outcomes (e.g., reaction, harm perception, effectiveness) and were then instructed to view all HWLs in each theme and rank them in the order of overall perceived effectiveness, from the most to the least effective. Afterward, participants provided in-depth feedback on HWLs and avenues for improvement. Mean effectiveness rating scores and percentages of participants' top-ranked HWLs were calculated. Discussions were audio-taped, transcribed verbatim, and analyzed thematically. RESULTS: The top-ranked HWLs were those showing oral cancers, orally transmitted diseases, and a sick child. Focus group discussion illustrated that these selections were based on participants' reactions to the direct impact of WP on a person's physical appearance and evoking guilt over children's exposure to WP smoke. Suggestions for improvement highlighted the need to use the local dialect and more affirmative statements (e.g., avoiding "may" or "can"). CONCLUSIONS: This study is the first in North Africa to attempt to advance HWLs policy as the World Health Organization recommended. The results of this study can be used as a basis for implementing WP-specific health messages in the Eastern Mediterranean Region.

Vulvar Basal Cell Carcinoma: Clinical and Histopathologic Features.

Basal cell carcinoma (BCC) is the most frequent skin cancer but <1% of the cases develop in the vulva. Histoprognostic features of vulvar BCCs are not recognized and, consequently, the treatment of the disease is not well codified. To overcome this lack of knowledge, we have performed a retrospective analysis of vulvar BBCs to assess the value of various histological features regarding the disease outcome. In all, 19 patients surgically treated for a vulvar BCC in the Centre Hospitalier Intercommunal de Créteil from March 1, 2000 to September 26, 2019 were retrieved. Clinical and histologic features were reviewed in all cases and analyzed in comparison with disease recurrence and patient's survival. The median age of the patients was 74 (range 54-99) yr. Tumor location on the labium majus was the most frequent (68%). None presented with a medical condition related to BCC. All the patients were treated by surgery alone, except one who benefited from additional radiotherapy. We found a significant association between tumor size and recurrences (P=0.031). Other features associated with disease outcome were tumor thickness, treatment type, and surgical margins. Recurrence was observed for tumors larger than 20 mm with a surgical margin of less than 3 mm. A combination of tumor size, thickness, and surgical margin are histoprognostic factors more significant than tumor subtype.

Colorectal cancer mass screening, Tunisia 2019. Evaluation of a pilot program in the Tunis region (Tunisia, 2019).

INTRODUCTION: Colorectal cancer (CRC) is a real public health issue in Tunisia. A screening program based on fecal immunological occult blood test, followed in case of a positive test by colonoscopy, was launched in Tunis region in 2016. We aimed to evaluate this screening program in order to make recommendations for a better implementation of this program in years to come. METHODS: A mixed approach has been adopted with a quantitative component based on the production of indicators related to activity, monitoring and screening quality; and a qualitative component conducted through focus groups with frontline health care professionals (HCP) and individual interviews with those lost to follow-up after a positive screening test. SWOT analysis was then performed in order to assess main strengths, weaknesses, opportunities and threats of the program. RESULTS: This study showed a coverage rate of 41.2% [40.5-41.8] for population consulting the first line of care, and an effective participation rate estimated at 23.1% [22.6-23.6]. Out of 5856 tests performed, 6% (n=352) were non-treatable and 6.7 % (n=390) were positive. Only 18.6% (n=72) of those tested positive had undergone colonoscopy. A total of 26 polyps, 03 cases of cancer and 04 cases of dysplasia were recorded. SWOT analysis pointed out that the variable adherence of HCP, lack of awareness of general population regarding CRC screening, the non-acceptability of colonoscopy without sedation with a problem of affordability for its realization in the private sector, and long appointments delays in public sector, were main weaknesses and of this program. CONCLUSION: This evaluation underlined certain strengths regarding the program implementation and revealed, in return, several shortcomings which certainly impair the program's effectiveness and efficiency. The involvement of the national health insurance fund in CRC screening tests and colonoscopies reimbursement, as well as the establishment of a performance-based payment modality for HCP, constitute main key pillars to reach success and sustainability for any CCR mass screening program in Tunisia.

Papillary thyroid tumors: Diagnostic value of CD56 and Cytokeratin 19.

INTRODUCTION: Noninvasive Follicular Thyroid Neoplasm With Papillary-like Nuclear Features (NIFTP) is a tumor composed exclusively of follicles lined by cells having nuclear characteristics of papillary carcinoma. Morphological diagnosis is often difficult especially in the cases in which these nuclear abnormalities are focal. AIM: To investigate the contribution of the immunohistochemical study with anti CD56 and anti cytokeratin 19 in the positive diagnosis of NIFTP. METHODS: This is a diagnostive, retrospective study of 40 thyroid specimens including 15 NIFTP, 10 classical form papillary carcinoma (CPC) and 15 vesicular adenomas (AV), collected over a period of eighteen months (December 2013-May 2015). RESULTS: Negativity with anti-CD56 was noted in 16 cases: 9 cases of NIFTP and 7 cases of CPC. A diffuse staining was noted in 14 cases of AV. Positivity with anti-Cytokeratin19 was noted in 38 cases: 14 NIFTP, 10 CPC and 14 AV. For the diagnosis of NIFTP, the sensitivity of CD56 was 60% and specificity of 100%. The sensitivity of the Cytokeratin 19 was 93,3 % and specificity of 33,3%. CONCLUSIONS: Considering the good sensitivity and specificity of the CD56, it is possible to apply immunohistochemistry for definitive diagnosis of NIFTP and to differentiate it from adenoma. The cytokeratin 19 does not have a big contribution to distinguish between benign and malignant lesions.

Extracapsular involvement in nodal metastasis as a prognostic factor in colorectal cancer.

BACKGROUND: Extracapsular extension of nodal metastasis has recently emerged as an important prognostic factor in different malignancies. In colorectal cancer (CRC), only a limited number of studies have been published and its prognostic value has not yet been completely established. AIMS: To assess the incidence of extracapsular invasion (ECI) in lymph node (LN) metastasis in colorectal adenocarcinoma and to investigate the correlation between this parameter and other clinico-pathological factors.  Furthermore, its effect on overall and disease free survival were evaluated. METHODS: Seventy-five patients who underwent colorectal resection for adenocarcinoma with node metastasis were included in this study. Extracapsular invasion was evaluated by two pathologists. Associations between clinicopathologic factors, survival, and the nodal findings were evaluated. The 2009 pTNM staging of CRC was used. RESULTS: Extracapsular invasion was identified in 45 patients (60 %). Average follow-up time was 25 months. Extracapsular invasion was correlated with pT stage> pT2 (p=0,015), pN stage > pN1 (p= 0,014), distant metastasis at diagnosis (p=0,005) and later (p=0,01) and with local recurrences (p=0,0001). Univariate analysis indicated that ECI tends to decrease overall survival but not significantly.  Multivariate analysis showed that age and synchronic metastasis were independent prognostic factors (HR = 2,03 and 2,24; p= 0,039 and 0,012 respectively). Patients with ECI had a significantly worse five-year disease-free survival than ECI-negative groups. CONCLUSION: In patients with CRC, ECI in regional LNs would reflect an aggressive behavior. It would therefore be useful to include this parameter in standardized pathologic reports and future staging systems.