[Mucormycosis in the diabetic patient]. / La mucormycose chez le diabétique.

INTRODUCTION: Mucormycosis is a rare, devastating, fungal infection, which disproportionately affects non-controlled diabetic patients, notably during ketoacidosis. It can be manifested in rhinocerebral, but also pulmonary and disseminated forms. OBSERVATIONS: Four consecutive diabetic patients who were admitted to the Farhat Hached Hospital, Sousse, Tunisia, between January 2001 and November 2002, are presented. Three patients exhibited ketoacidosis and one renal failure with hyperosmolarity. Infection was limited to the sinuses in two cases, to lower respiratory tract in one case, and was probably disseminated in one case. Diagnosis was confirmed by mycological and histological findings in all cases. Systemic Amphotericin B was associated with surgical debridement of the lesions in patients with rhinocerebral involvement. DISCUSSION: Despite aggressive therapy, mortality was high (3 out of 4 patients). Mucormycosis remains a severe, frequently fatal disease in diabetic patients.

[Epidemiology of Haemophilus influenzae meningitis in Tunisia]. / Epidémiologie des méningites à Haemophilus influenzae en Tunisie.

The incidence of Haemophilus influenzae b meningitis (Hib) in children < 5 years in Tunisia was studied through a surveillance system set up in June 2000 and followed for 14 months. Population-based surveillance began in 3 governorates and sentinel surveillance in 2. Children < 5 years suspected of meningitis had lumbar puncture, macroscopic exam, blood count, chemical analysis and culture carried out. In the 14 months, 80 cases of meningitis were recorded. From the population-based surveillance most cases were children < 1 year (73.6%) and boys (64%). H. influenzae was isolated in 38% of cases, pneumococci in 13% and meningococci in 7%. The incidence of confirmed Hib was 14.4/100 000 children. The estimated cost of identifying and treating Hib meningitis and its complications was greater than the cost of vaccine introduction. Based this study, the Ministry of Health has decided to introduce Hib vaccination.

A controlled trial of nebulized salbutamol and adrenaline in acute severe asthma.

OBJECTIVE: To compare efficacy and safety of nebulisation of adrenaline (2 mg over 10 min) and salbutamol (5 mg over 10 min) in acute severe asthma. DESIGN: Prospective randomized and double blind study. SETTING: Intensive care unit of a University teaching hospital. PATIENTS AND PARTICIPANTS: 22 asthmatic patients presenting to the emergency room with acute severe asthma. INTERVENTIONS: Patients were randomly assigned to receive either adrenaline (n = 11) or salbutamol (n = 11) via a nebulizer. Additional treatment comprised hydrocortisone hemisuccinate (100 mg) and supplemental oxygen (71/min). The efficacy and safety of both drugs were evaluated at 20 and 40 min. RESULTS: A statistically significant increase in the Peak Expiratory Flow (PEF) was achieved at the 20th min in both groups (from 85 +/- 38 l/min to 120 +/- 45 l/min; p < 0.001; and from 107 +/- 28 l/min to 145 +/- 19 l/min; p < 0.001; in adrenaline group and salbutamol group respectively). With both drugs, PEF further increased at 40 min to a level that was statistically significant when compared to the 20 min evaluation. The magnitude of the absolute variation in PEF was similar with both drugs. Both drugs induced a significant decrease in heart rate, respiratory frequency and PaCO2 while the increase of PaO2/FIO2 ratio was not significant. The decrease of respiratory frequency at 40 min was more important with salbutamol (p = 0.03). No side effects were recorded in both groups. CONCLUSION: After a single dose, nebulized adrenaline (2 mg) proved as effective and safe as salbutamol (5 mg) in acute severe asthma.

Echotomographic and serologic screening for hydatidosis in a Tunisian village.

Echotomographic and serologic screening for hydatidosis was carried out in 1,650 subjects aged over 5 years in a village located in a high risk region of central Tunisia. Echotomography detected liver cysts in 6 subjects (prevalence rate: 3.6 per 1,000). These 6 cases were among the 7 positive cases detected by ELISA. In all 6, the diagnosis of liver cysts was confirmed. No other localization was found in any of the subjects including one with a positive ELISA and a normal echotomographic examination. This work demonstrates the high feasibility of echotomography in the field and confirms the high prevalence rate of hydatidosis in the community.

Diabetes and hospital morbidity in the Monastir governorship (Tunisia).

Diabetes is a public health problem worldwide. In Tunisia, the rate of prevalence is 3.8% in urban areas and 1.3% in rural areas, whereas the socioeconomic impact of the disease has rarely been investigated. This study conducted in the Monastir health district evaluated the burden of hospital care for diabetes. All admissions for diabetes (973) recorded in the regional morbidity register during 1993 for all public hospitals in the region were taken into consideration. Admission for diabetes represented 5.9% of total admissions and was the first cause of hospitalisation. The university hospital centre received 40% of these patients. The annual hospital rate of diabetes is estimated to be 2.7%, but varies according to the district considered and the age of patients (1.1% for those under 50 years of age and 12.8% for those over 65). The number of days of hospitalization related to diabetes was 10,069, i.e. 7.6% of the total for the district. The mean cost of a single hospitalization is about 251 Tunisian dinars (US$251). Diabetes treatment could be improved and the cost lowered by providing appropriate ambulatory care and health education to reduce hospital admissions.

Echotomographic and serological population-based study of hydatidosis in central Tunisia.

A population-based echotomographic (ECT) and serological survey of hydatidosis was carried out in a high risk community located in Central Tunisia. 1434 subjects over 5 years of age (93.3% of the population in this age range) underwent an abdominal echotomography (ECT) and a serological test (ELISA with confirmation by counterelectrophoresis). The ECT prevalence rate was 3.5% and increased with age reaching 7.7% in the over 39 years age group. Most subjects (96.0%) had liver cyst(s). The serological prevalence rate was 2.9%. A strong agreement was found between ECT and serological results (Kappa test = 0.449). Taking ECT as a reference, the relative specificity and sensitivity of serology were 99.3 and 62.0 respectively. Most ECT positive seronegative subjects had calcified cysts. These results confirm the presence of highly endemic foci of hydatidosis in Central Tunisia, show a good agreement between serological and ECT results at a population level and demonstrate the high feasibility of ECT as a screening technique.

Distribution of surgical hydatidosis in central Tunisia (1982-1985).

The mean annual surgical incidence rates (MASIR) of hydatidosis were measured for the 1982-1985 period in central Tunisia in order to investigate the natural history of human hydatidosis and provide baseline data for the evaluation of future prevention campaigns. 986 cases were identified from surgical records of regional hospitals to which cases from central Tunisia are mandatorily referred. The overall MASIR was 19.3 per 10(5) inhabitants. The MASIR according to district varied from 0 to 56.6 per 10(5), was higher in women than in men (22.6 versus 15.8 per 10(5] and increased with age (maximum 53.0 per 10(5) in the 50-59 age group for women and 27.1 per 10(5) in the 40-49 group for men). Among the 940 cases with single organ hydatidosis, liver ranged first (55.3%, 545/940), then lung (32.4% 320/940), kidney (2.7%) and spleen (1.8%). Among the 865 subjects with single lung or liver hydatidosis, liver was more often involved in women (349 out of 503) than in men (196 out of 362) (chi 2 = 20.9, p less than 0.001). In both sexes, the lung/liver ratio decreased with age. These data reveal the existence of highly endemic foci of hydatidosis within central Tunisia. The predominance of infection in women might be due to sex related behavioral differences. The causes of liver predominance in women and variation of lung/liver ratio are open to question.

[Epidemiology of cholelithiasis in central Tunisia. Prevalence and associated factors in a nonselected population]. / Epidémiologie de la lithiase biliaire dans le centre de la Tunisie.

OBJECTIVES: The prevalence of cholelithiasis is still unknown in Tunisia. The aim of this study was to assess the prevalence and selected risk factors of cholelithiasis METHODS: Two thousand citizens over the age of 19 in a small town in the center of Tunisia were evaluated. Following a structured interview of each subject, an ultrasound examination was performed. Height, weight and blood levels of glucose and cholesterol were determined by standard methods. RESULTS: The response rate was 56% (746 women and 377 men). Of the 1123 persons evaluated, 19 had undergone previous cholecystectomy. Crude prevalence of cholelithiasis was 4% (5.4% in women and 1% in men). Typical biliary colic was the only symptom significantly associated with cholelithiasis (specificity: 97.6%). Presence of gallstones was associated with age (P=0.02), sex (P=0. 00045) and multiparity (P<0.0002). Neither body mass index, diabetes mellitus or hypercholesterolemia were risk factors. CONCLUSION: The prevalence of cholelithiasis in central Tunisia is low. The risk factors are similar to those in occidental surveys.

[Surgical incidence of hydatidosis in the Sahel and Central Tunisia]. / Incidence chirurgicale de l'hydatidose dans le Centre et le Sahel Tunisiens.

A retrospective hospital survey of patients having undergone surgery for hydatidosis was undertaken in order to evaluate hydatic endemicity in central Tunisia and the Sahel. The study made it possible to establish the following: an average prevalence of 22.8 cases per 100,000 inhabitants; a significant underregistration of the illness, only 51.5% of the cases being reported; certain high-risk rural areas are characterized by a prevalence exceeding 40 per 100,000 inhabitants; the disease is more frequent among women; surgical hydatidosis is not rare among the very young and the very old; among adults, the liver is the first organ affected, followed by the lungs; among children, it is the opposite. Hydatidosis thus represents a commonly-occurring disease that is frequently underestimated in official statistics. A preventive program must be conceived to control this scourge.

[Mother-child transmission of hepatitis B virus in the Tunisian Sahel]. / Etude de la transmission mère-enfant du virus de l'hépatite B dans le Sahel tunisien.

In order to assess the importance of mother-child transmission of the hepatitis B virus (HBV) in the Tunisian Sahel, 81 HBsAg-positive mothers have been selected at delivery in a representative sample of 1940 who delivered in maternities of this region. Each HBsAg-positive mother was matched for age and parity particularly with two HBsAg-negative mothers. Children born to these 66 HBsAg+ and 120 HBsAg- mothers were traced at 28 months and tested by ELISA for HBV serologic markers (HBsAg, anti-HBs and anti-HBc). The distribution of these markers was significantly different according to the maternal status for HBsAg. The overall prevalence rate of HBV markers was higher in children born to HBsAg+ mothers as compared to children born to HBsAg- mothers (33.3% vs 13.3%, OR = 2.5, 95% CI:1.4-4.2). For HBsAg, the figures were 27.3% and 9.2% respectively (OR = 2.9, 95% CI: 1.5-5.9). Given the prevalence rate of HBsAg in mothers (4.2%), the role of mother-child transmission in the spread of HBV infection and the intensity and precocity of horizontal transmission, systemic vaccination against HBV at birth should be recommended in the Tunisian Sahel in the context of the EPI. However this decision should take into account, in terms of cost/efficacy ratio, the other public health problems concerning this area.

[Sentinel surveillance of diarrhea in Ksar-Hellal (Tunisia)]. / Surveillance sentinelle de la diarrhée à Ksar-Hellal (Tunisie).

BACKGROUND: In order to simplify the national data collection related to diarrhea, a sentinel surveillance system was implemented in the Ksar-Hellal district (Tunisia). POPULATION AND METHODS: This system was based on 461 cases of diarrhea collected from health centers and hospitals between June 1994 and December 1995. RESULTS: The collected information confirmed the previous data provided by the national system: frequency of diarrhea in health centers (4.14%), occurrence of the disease especially in the summer period, rate of hospitalization (10%) and low proportion of severe dehydration. The system also gave some new information related to the proportion of persistent diarrhea (7.1%), the low frequency of malnutrition (11%) and the etiology. CONCLUSION: The sentinel surveillance system validates information previously provided by the National Surveillance System. It also gave new information not obtained by the classical surveillance system.

[Smoking behavior and attitude to smoking of medical students (Tunisian Sahel)]. / Comportement tabagique et attitudes des étudiants en médecine à Monastir en regard du tabac (Sahel tunisien).

Prevention of smoking is a public health goal recognized worldwide. Though the role played by physicians is an important one, data in the literature indicate that medical school is a poor place to learn it. In 1997, we conducted a study among medical students at Monastir Tunisia to examine their smoking behavior and attitudes towards smoking and their participation in prevention. The study included 93.3% (N = 501) of the students in their 1st, 4th and 5th years of medical school. One-third of the students (33%) were smokers, including 15% occasional smokers. The students recognized the effect of smoking on coronary arteries and bronchi but two-thirds of them were unaware of its role in bladder cancer. The students did not warn their patients unless they had a disease related to smoking. Half of the students felt they were not sufficiently prepared for caring for smokers and desired specific training. These findings suggest medical school authorities should design and implement appropriate basic training aimed at better preparing medical students for their role in prevention of smoking.

[C-reactive protein in bacterial meningitis in adults]. / La protéine c-réactive dans les méningites bactériennes de l'adulte.

In order to assess the benefits of serial assays of C-reactive protein in the course of bacterial meningitis in adults, daily blood samples were taken for CRP measurement during 10 days in 21 consecutive patients (mean age: 24 +/- 8 years) hospitalized for bacterial meningitis principally due to Neisseria meningitidis (n = 15). The highest CRP level (178 +/- 38 mg/l) was present on admission, followed by a regular decrease occurring in uncomplicated meningitis until normal level was achieved on day 9. The CRP kinetics was not influenced by the type of causative micro-organism. This study shows that CRP kinetics in adults is similar to that reported in children. The benefit of CRP assays in optimizing the duration of antibiotic treatment of meningitis needs to be more carefully assessed.

[Costs of basic health services in a health district in Tunisia]. / Coût des soins de santé de base dans une circonscription sanitaire en Tunisie.

Information on the cost of health services is essential for good planning and management and the efficient use of resources. We calculated the total costs incurred in running primary health services for one year (1995) in the health district of Enfidha (Tunisia). The yearly operating expenditure for the health district was 1 219 099 Tunisian dinars and the cost per inhabitant was 17.494 dinars (US dollar 1 = Tunisian dinar 0.950 in 1995); 65.37% of total costs went on staff and 17.03% on drugs. Looked at another way, 84,96% went on curative services and 14.04% on preventive services. The cost of a consultation for curative care was 6.847dinars, for perinatal care was 2.764 dinars, for immunization was 3.680 and for school visit was 6.680 dinars. The study helps to identify ways in which cost analysis can be used to explore efficiency and resource adequacy in the district.

[Value of vaccination data analysis at the district level]. / Intérêt de l'analyse des données de vaccination à l'échelle du district.

This study aimed to demonstrate the importance of analysing local immunization data to improve performance of national prevention programmes. From the immunization registers kept in basic health centres, we identified 1271 children receiving their first vaccine at 3 months. Examination of the age at the subsequent vaccinations and time intervals between vaccinations showed that 81.9% had received all the vaccines required by the Ministry of Health but only 48.5% had received immunization meeting the requirements for age and time interval. The analysis also helped identify health centres with best performance (fewer children lost to follow-up and better implementation of immunization schedule) and those vaccinations needing the greatest attention from health professionals.

[Antibiotic therapy in general medicine in Monastir, Tunisia]. / L'antibiothérapie en médecine générale à Monastir, Tunisie.

In order to determine the cost and frequency of antibiotic prescription by general practitioners, we studied 563 outpatients from health centres in Monastir (Tunisia). All patients had acute diseases. Antibiotics were prescribed to 50.4%. Single antibiotics were generally prescribed, but 52.8% of these patients did not have any laboratory tests. The more frequently used antibiotics were penicillin G and A. Antibiotics cost represented 34.7% of medicinal cost borne by patients and 49.7% of the cost borne by the public sector. Rationalization of medicinal prescription would have a positive impact on household and state budgets.

[Prenatal surveillance and determinants of prenatal follow-up in the Monastir health district]. / Surveillance prénatale et déterminants du suivi prénatal dans la circonscription sanitaire de Monastir.

Prenatal monitoring is a prime strategy to improve the end of pregnancy. To estimate the prevalence rate and the conditions determining such a monitoring, the authors carried out a survey on 1190 pregnant women in the Monastir district (Tunisia). The rate of satisfactory monitoring (4 check-up and more) is 45.8 p.c. Age and high parity have a negative influence, but instruction, occupation and a bad out come of the last pregnancy favour a satisfactory prenatal monitoring.

PIP: In Tunisia, a survey was conducted of 1190 women who delivered at the maternity ward of the Fattouma Bourguiba University Hospital Center in Monastir during September 1988 to August 1989 to evaluate, in an Arab-Moslem context, the coverage rate of prenatal care and to identify the determinants of correct prenatal follow-up among users of the central maternity ward. 45.8% of the women received adequate prenatal care (i.e., 4 prenatal visits). 14.4% received no prenatal care. The frequency of adequate prenatal care decreased with age (51.78% for 15-24 years, 45.29% for 25-34 years, and 35.51% for 35 and over; relative risk [RR] = 1.34). Based on occupation, mothers who did not work received the least amount of prenatal care (40.47% vs. 55.63% for moderate profession and 51.76% for superior profession; RR = 1.36). Women who received the least amount of prenatal care were illiterate women (39.89% vs. 53.18% for secondary education and 67.69% for higher education; RR = 1.86). Women whose last pregnancy had a poor outcome (fetal death or miscarriage) were more likely to receive adequate prenatal care than those whose last pregnancy had a good outcome (54.7% vs. 33.6%; RR = 1.47). Women who experienced a medical condition during pregnancy were more likely to receive adequate prenatal care than those who had no such problem (53.7% vs. 45.2%). Primiparous women were more likely to receive adequate prenatal care than multiparous women (55.7% vs. 38.7% for parity 2-4 and 21.7% for parity 5; RR = 1.77). The influence of parity continued even when the researchers controlled for age (p 0.0003).

[Epidemiology of low birth weight in Tunisia]. / Epidémiologie de l'insuffisance pondérale àla naissance dans le Sahel tunisien.

Our study aims to assess the determinants and the frequency of low birth weight (LBW) in the health district of Monastir (Tunisia). The study was carried out over a three-year period, beginning in January 1995 and ending in December 1997. According to the Monastir district's childbirth register, 1,194 of the 21,393 newborns delivered were babies born with a low birth weight (LBW rate of 5.6%). Common characteristics among the LBW infants were the following: females are more often affected than males (sex ratio of 1.25); 22% of cases were twins; one-third were premature births (< 37 weeks). This study of the determinants of LBW demonstrates that there are several factors linked to the occurrence of LBW such as the mother's age, the number of times she has given birth, an interval between pregnancies of less than 24 months, lack of prenatal care, and the female sex of the baby.

[Evaluation of mothers' knowledge in pre- and postnatal preventive care in the Tunisian Sahel]. / Evaluation des connaissances des mères concernant les soins préventifs pré et postnatals dans le Sahel tunisien.

Maternal and child health is one of the major concerns of public health throughout the world. Health education and increased knowledge of mothers in relation to their health is a strategy of choice adopted in many countries for improving maternal and child health. It is within this framework that this action is being carried out, which aims to evaluate the knowledge of mothers in the area of preventive care for women. A cross-sectional survey was carried out among 915 parturient women from the Monastir region (coastal region of Tunisia) at the time of delivery, between May 1 and July 26, 1996. The survey was based on a questionnaire that explores, in addition to the socio-demographic characteristics of parents, the level of surveillance during pregnancy and mothers' knowledge in relation to preventive care of women. The majority of women (95%) are aware of the importance of prenatal surveillance, yet 12% don't have any knowledge of the recommended number of prenatal visits. Concerning contraception, the tetanus vaccination and the post-natal consultation, knowledge concerning their importance is high, but practice in these areas is not. Roughly only 1/3 of mothers used contraception before their current pregnancies, and only 70% had both doses of the tetanus vaccination. Health education on preventive care received by the mothers helps increase knowledge and probably practices as well. The increase in mothers' knowledge happens with appropriate initial and continued training in health education, provided by health professionals and with the reinforcement of educational activities during each contact with the mother both during her pregnancy and in periods where she isn't pregnant.