Getting to the heart of the matter: diagnostic tools and therapeutic approach to cardiac involvement in Behçet syndrome A Tunisian case series.

The aim was to investigate the frequency and spectrum of cardiac involvement (CI) in patients with Behçet syndrome (BS) in the Tunisian context, and to assess the clinical and imaging features, treatment, and outcomes. We retrospectively retrieved the medical records of patients with CI among 220 BS patients admitted to the hospital internal medicine department between February 2006 and April 2019, who fulfilled the International Study Group diagnostic criteria for BS. Ten patients (8 men, 2 women) were eligible for the study. Mean age was 37.3 years. Three patients had 2 isolated episodes of cardiac BS. The different types of CI were coronary artery disease (5/10), intracardiac thrombus (4/10), pericarditis (1/10), myocarditis (1/10), and myocardial fibrosis (1/10). Five patients had associated vascular involvement (50%). Medical treatment was based on corticosteroids and colchicine in all patients (100%), anticoagulants in 8 (80%), and cyclophosphamide followed by azathioprine in 9 (90%). The clinical course was favorable in 9 patients; 1 patient died. CI remains an important feature of BS because of its association with increased risk of mortality and morbidity. Therefore, early screening and detection with imaging methods are paramount. Also, better cooperation between rheumatologists and cardiologists could improve outcomes.

Results from the Survey of Antibiotic Resistance (SOAR) 2015-18 in Tunisia, Kenya and Morocco: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

OBJECTIVES: To determine antibiotic susceptibility of community-acquired respiratory tract infection (CA-RTI) isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2015-18 from Tunisia, Kenya and Morocco. METHODS: MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints. RESULTS: S. pneumoniae isolates from Tunisia (n = 79), Kenya (n = 44) and Morocco (n = 19) and H. influenzae isolates (n = 74) from Tunisia only were collected and analysed. Low antibiotic susceptibility was observed in S. pneumoniae from Tunisia, with >90% susceptible only to the fluoroquinolones (all breakpoints), penicillin (CLSI IV and EUCAST high-dose) and ceftriaxone (CLSI, EUCAST high-dose and PK/PD breakpoints). In addition, isolate susceptibility in Kenya was >90% to amoxicillin and amoxicillin/clavulanic acid (CLSI and PK/PD breakpoints). Antibiotic activity was highest in Morocco, where ≥89.5% of pneumococci were susceptible to most antibiotics, excluding trimethoprim/sulfamethoxazole (68.4% by CLSI or PK/PD and 79%-84.2% by EUCAST), macrolides (79%-84.2% by all breakpoints) and cefaclor (0% by EUCAST and 52.6% by PK/PD). The majority (≥86.5%) of H. influenzae isolates from Tunisia were susceptible to most antibiotics by all available breakpoints, except ampicillin and amoxicillin (almost one-third were ß-lactamase positive), trimethoprim/sulfamethoxazole (51.4%-56.8%), cefaclor (1.4% by PK/PD), cefuroxime (4.1% by EUCAST), macrolides (1.4%-2.7% by PK/PD) and cefdinir (66.2% by PK/PD). The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified. CONCLUSIONS: Low antibiotic susceptibility was observed in S. pneumoniae from Tunisia, but susceptibility was higher in isolates from Kenya and highest in those from Morocco. H. influenzae from Tunisia were highly susceptible to most antibiotics. These factors are important in decision making for empirical therapy of CA-RTIs.

Value of routine ultrasound examination at 35-37 weeks' gestation in diagnosis of fetal abnormalities.

OBJECTIVE: To investigate the potential value of routine ultrasound examination at 35-37 weeks' gestation in the diagnosis of previously unknown fetal abnormalities. METHODS: This was a prospective study of 52 400 singleton pregnancies attending for a routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation; all pregnancies had a previous scan at 18-24 weeks and 47 214 also had a scan at 11-13 weeks. We included pregnancies resulting in live birth or stillbirth but excluded those with known chromosomal abnormality. Abnormalities were classified according to the affected major organ system, and the type and incidence of new abnormalities were determined. RESULTS: In the study population, the incidence of fetal abnormality was 1.9% (995/52 400), including 674 (67.7%) that had been diagnosed previously during the first and/or second trimester, 247 (24.8%) that were detected for the first time at 35-37 weeks and 74 (7.4%) that were detected for the first time postnatally. The most common abnormalities that were diagnosed during the first and/or second trimester and that were also observed at 35-37 weeks included ventricular septal defect, talipes, unilateral renal agenesis and/or pelvic kidney, hydronephrosis, duplex kidney, unilateral multicystic kidney, congenital pulmonary airway malformation, ventriculomegaly, cleft lip and palate, polydactyly and abdominal cyst or gastroschisis. The most common abnormalities first seen at 35-37 weeks were hydronephrosis, mild ventriculomegaly, ventricular septal defect, duplex kidney, ovarian cyst and arachnoid cyst. The incidence of abnormalities first seen at 35-37 weeks was 0.5% and those that were detected exclusively for the first time at this examination were ovarian cyst, microcephaly, achondroplasia, dacryocystocele and hematocolpos. The incidence of abnormalities first seen postnatally was 0.1% and the most common were isolated cleft palate, polydactyly or syndactyly and ambiguous genitalia or hypospadias; prenatal examination of the genitalia was not a compulsory part of the protocol. CONCLUSIONS: A high proportion of fetal abnormalities are detected for the first time during a routine ultrasound examination at 35-37 weeks' gestation. Such diagnosis and subsequent management, including selection of timing and place for delivery and postnatal investigations, could potentially improve postnatal outcome. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Diagnosis of fetal non-chromosomal abnormalities on routine ultrasound examination at 11-13 weeks' gestation.

OBJECTIVE: To examine the performance of the routine 11-13-week scan in detecting fetal non-chromosomal abnormalities. METHODS: This was a retrospective study of prospectively collected data from 100 997 singleton pregnancies attending for a routine ultrasound examination of fetal anatomy, performed according to a standardized protocol, at 11-13 weeks' gestation. All continuing pregnancies had an additional scan at 18-24 weeks and 71 754 had a scan at either 30-34 or 35-37 weeks. The final diagnosis of fetal abnormality was based on the results of postnatal examination in cases of live birth and on the findings of the last ultrasound examination in cases of pregnancy termination, miscarriage or stillbirth. The performance of the 11-13-week scan in the detection of fetal abnormalities was determined. RESULTS: The study population contained 1720 (1.7%) pregnancies with a fetal abnormality, including 474 (27.6%) detected on the first-trimester scan, 926 (53.8%) detected on the second-trimester scan and 320 (18.6%) detected in the third trimester or postnatally. At 11-13 weeks' gestation, we diagnosed all cases of acrania, alobar holoprosencephaly, encephalocele, tricuspid or pulmonary atresia, pentalogy of Cantrell, ectopia cordis, exomphalos, gastroschisis and body-stalk anomaly and > 50% of cases of open spina bifida, hypoplastic left heart syndrome, atrioventricular septal defect, complex heart defect, left atrial isomerism (interrupted inferior vena cava with normal intracardiac anatomy), lower urinary tract obstruction, absence of extremities, fetal akinesia deformation sequence and lethal skeletal dysplasia. Common abnormalities that were detected in < 10% of cases at 11-13 weeks included ventriculomegaly, agenesis of the corpus callosum, isolated cleft lip, congenital pulmonary airway malformation, ventricular septal defect, abdominal cysts, unilateral renal agenesis or multicystic kidney, hydronephrosis, duplex kidney, hypospadias and talipes. CONCLUSIONS: A routine 11-13-week scan, carried out according to a standardized protocol, can identify many severe non-chromosomal fetal abnormalities. A summary statistic of the performance of the first-trimester scan is futile because some abnormalities are always detectable, whereas others are either non-detectable or sometimes detectable. To maximize prenatal detection of abnormalities, additional scans in both the second and third trimesters are necessary. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Diagnóstico de anomalías fetales no cromosómicas en la ecografía de rutina a las 11-13 semanas de gestación OBJETIVO: Examinar el desempeño de la ecografía de rutina a las 11-13 semanas en la detección de anomalías fetales no cromosómicas. MÉTODOS: Esta investigación fue un estudio retrospectivo de datos recogidos prospectivamente de 100 997 embarazos con feto único que acudieron a un examen ecográfico de rutina de la anatomía fetal, realizado de acuerdo con un protocolo estandarizado, a las 11-13 semanas de gestación. Todos los embarazos que continuaron se sometieron a una exploración adicional a las 18-24 semanas y 71754 se sometieron a una exploración a las 30-34 o a las 35-37 semanas. El diagnóstico final de la anomalía fetal se basó en los resultados del examen postnatal en los casos de nacimientos vivos y en los hallazgos del último examen ecográfico en los casos de interrupción del embarazo, aborto o éxitus fetal. Se determinó el rendimiento de la exploración de las 11-13 semanas en la detección de anomalías fetales. RESULTADOS: La población del estudio contenía 1720 (1,7%) embarazos con una anormalidad fetal, entre ellos 474 (27,6%) detectados en la exploración del primer trimestre, 926 (53,8%) detectados en la del segundo trimestre y 320 (18,6%) detectados en el tercer trimestre o postnatalmente. A las 11-13 semanas de gestación, se diagnosticaron todos los casos de acrania, holoprosencefalia alobar, encefalocele, atresia tricúspide o pulmonar, pentalogía de Cantrell, ectopia cordis, onfalocele, gastrosquisis y anomalía del pedículo embrionario y >50% de los casos de espina bífida abierta, síndrome del hemicardio izquierdo hipoplásico, comunicación auriculoventricular, defecto cardíaco complejo, isomerismo de la aurícula izquierda (vena cava inferior interrumpida con anatomía intracardíaca normal), obstrucción del tracto urinario inferior, ausencia de extremidades, secuencia de deformación de la acinesia fetal y displasia esquelética letal. Las anomalías comunes que se detectaron en <10% de los casos a las 11-13 semanas incluyeron ventriculomegalia, agenesia del cuerpo calloso, labio leporino aislado, malformación congénita de las vías respiratorias pulmonares, comunicación interventricular, quistes abdominales, agenesia renal unilateral o riñón multiquístico, hidronefrosis, duplicidad renal, hipospadias y pie zambo. CONCLUSIÓN: Una exploración rutinaria a las 11-13 semanas, realizada de acuerdo con un protocolo estandarizado, puede identificar muchas anomalías fetales no cromosómicas graves. Un resumen estadístico del desempeño de la exploración del primer trimestre es inútil porque algunas anomalías son siempre detectables, mientras que otras no lo son o solo lo son a veces. Para maximizar la detección prenatal de anormalidades, se necesitan exploraciones adicionales tanto en el segundo como en el tercer trimestre.

Ultrasonographic estimation of fetal weight: development of new model and assessment of performance of previous models.

OBJECTIVES: To develop a new formula for ultrasonographic estimation of fetal weight and evaluate the accuracy of this and all previous formulae in the prediction of birth weight. METHODS: The study population consisted of 5163 singleton pregnancies with fetal biometry at 22-43 weeks' gestation and live birth of a phenotypically normal neonate within 2 days of the ultrasound examination. Multivariable fractional polynomial analysis was used to determine the combination of variables that provided the best-fitting models for estimated fetal weight (EFW). A systematic review was also carried out of articles reporting formulae for EFW and comparing EFW to actual birth weight. The accuracy of each model for EFW was assessed by comparing mean percentage error, absolute mean error (AE), proportion of pregnancies with AE ≤ 10% and Euclidean distance. RESULTS: The most accurate models, with the lowest Euclidean distance and highest proportion of AE ≤ 10%, were provided by the formulae incorporating ≥ 3 rather than < 3 biometrical measurements. The systematic review identified 45 studies describing a total of 70 models for EFW by various combinations of measurements of fetal head circumference (HC), biparietal diameter, femur length (FL) and abdominal circumference (AC). The most accurate model with the lowest Euclidean distance and highest proportion of AE ≤ 10% was provided by the formula of Hadlock et al., published in 1985, which incorporated measurements of HC, AC and FL; there was a highly significant linear association between EFW and birth weight (r = 0.959; P < 0.0001), and EFW was within 10% of birth weight in 80% of cases. The performance of the best model developed in this study, utilizing HC, AC and FL, was very similar to that of Hadlock et al. CONCLUSION: Despite many efforts to develop new models for EFW, the one reported in 1985 by Hadlock et al., from measurements of HC, AC and FL, provides the most accurate prediction of birth weight and can be used for assessment of all babies, including those suspected to be either small or large. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

[Symmetrical peripheral gangrene: 4 cases]. / La gangrène périphérique symétrique : à propos de 4 cas.

BACKGROUND: Symmetric peripheral gangrene (SPG) is a symmetrical distal ischemic lesion on at least 2 or more extremities in the absence of proximal arterial obstruction and vasculitis. It is a rare and severe clinical entity. The aim of this study was to describe clinical symptoms, etiological agents and the management of SPG through a series of 4 cases. PATIENTS AND METHODS: We included all cases of SPG hospitalized between 2000 and 2014. The inclusion criterion was the presence of distal ischemic damage at two or more sites in the absence of large vessel obstruction. RESULTS: Four patients (2 men and 2 women) were included. The mean age was 43.2±12 years. Two patients had a history of splenectomy. All patients had blackening of the tips of the fingers and toes. Three patients presented with septic shock. The etiology was bacteremia involving Streptococcus pneumoniae in two cases and a malignant form of Mediterranean spotted fever (MSF). In addition to specific antibiotics, we used a potent vasodilator (iloprost) in two cases and curative heparin therapy in two cases. The outcome was favorable in 3 cases, with regression of necrotic lesions. One case required the amputation of non-perfused necrotic fingers and toes. CONCLUSION: SPG can complicate MSF in some rare cases. Thorough and repeated skin examinations are essential to ensure timely diagnosis and treatment of GPS in order to improve the prognosis.

Effects of recreational soccer on physical fitness and health indices in sedentary healthy and unhealthy subjects.

Recreational soccer (RS) is becoming a popular alternative to the classical continuous exercise mode used for the improvement of cardiovascular and metabolic fitness in untrained people. The objective of this paper was to conduct a detailed systematic review of the literature, identifying the physiological responses to RS and the training effects of RS on aerobic fitness and health in untrained healthy individuals and clinical patients. PubMed, Google Scholar and ScienceDirect databases were searched using terms related to recreational soccer. Inclusion criteria were randomized controlled trials (RCT) that assessed acute physiological responses to RS or the training effects of RS on physical fitness and health in sedentary, untrained subjects of any age or health status. All studies were assessed for methodological quality using the PEDro scale. Thirty-five articles met the inclusion criteria; seven examined the acute response to RS, and 28 assessed training effects. Clear evidence was found that RS had positive effects on many health-related indices and variables, including VO2max (gains of 7-16%), blood pressure (reductions of 6-13 mmHg), body composition (decreased fat mass and improved indices of bone health), and metabolic and cardiac function. These positive effects were observed in both healthy individuals and clinical patients, irrespective of age or sex. Although this review provides clear evidence of the positive effects of RS on health, most studies had limitations of methodology (an average PEDro score < 6). Furthermore, many of the training studies were from a small number of research groups. Future studies should be extended to other countries and institutions to ensure generality of the results. Regular RS training leads to significant cardiovascular and muscular adaptations and gains of health both in sedentary individuals and clinical patients at all ages, suggesting that RS is a potentially highly motivational method to enhance population health.

Development and application of an in-house reverse hybridization method for Chlamydia trachomatis genotyping.

AIM: To develop and evaluate an in-house reverse hybridization technique for Chlamydia trachomatis genotype identification. METHODS AND RESULTS: The evaluation of the developed and optimized reverse hybridization method on reference strains showed the specific detection of all genotypes. This technique showed its ability to type one inclusion-forming unit of C. trachomatis genotype E and equivalent sensitivity to the Cobas TaqMan assay. It was also able to detect mixed infections in vitro. Application of the reverse hybridization method on 38 isolated C. trachomatis strains and their respective swabs allowed the detection of six urogenital genotypes D, E, F, G, H and K and one trachoma genotype B. Genotype E was the most prevalent, detected in 73% of the swab samples. Mixed infections were detected in 26% of swab cases. CONCLUSION: The reverse hybridization technique is simple and does not require specialized instruments. It is powerful in the diagnosis of mixed infections and is suitable for use in epidemiological studies. SIGNIFICANCE AND IMPACT OF THE STUDY: This technique allowed rapid C. trachomatis genotype identification.

Extensive dissemination of CTX-M-1- and CMY-2-producing Escherichia coli in poultry farms in Tunisia.

We characterized 67 Escherichia coli isolates with reduced susceptibility to cefotaxime obtained from 136 samples of healthy broilers housed in 36 Tunisian farms. All these isolates harboured blaCTX-M-1 and/or blaCMY-2 genes located mostly on self-conjugative IncI1 plasmids. qnrS1, qnrA6 and aac(6')-Ib-cr were detected in six isolates. Considerable genetic diversity was detected among isolates from different farms. To our knowledge, this is the first detailed documentation of a high occurrence of blaCTX-M-1 and blaCMY-2 in E. coli at the poultry farm level in Tunisia as well as the first description of plasmid-mediated quinolone resistance in food animals in Tunisia which may contribute to the dissemination of these genes throughout Tunisia.

Emergence of Staphylococcus aureus strains resistant to pristinamycin in Sfax (Tunisia).

AIM: We report the emergence of Staphylococcus aureus resistant to pristinamycin in Tunisia, and the characterization of the mechanisms of resistance to macrolides and streptogramins. METHODS AND RESULTS: Five strains of S. aureus resistant to pristinamycin were recovered from the department of dermatology in a Tunisian university hospital from skin samples after oral use of pristinamycin between 2004 and 2007. Susceptibility testing showed that all isolates were resistant to quinupristin-dalfopristin (MIC=4-32mg/L), lincomycin, gentamicin, kanamycin, tobramycin, tetracycline and rifampin. One isolate was susceptible to erythromycin. All five strains were closely related after analysis by pulsed-field gel electrophoresis. erm(C) was amplified from three strains and erm(A) from one strain. vga and vat genes were amplified from all strains. None of the isolates carried the vgb gene. The vga and vat genes were typed as vga(B) and vat(B) by restriction profiles analysis after electrophoresis. CONCLUSION: This is the first report of clonal emergence of S. aureus resistant to pristinamycin carrying vga and vat genes in Tunisia. The role of selective pressure of pristinamycin use is certainly the main explanation of this emergence. So we must reduce the utilisation of this antibiotic for the treatment of cutaneous and bone infectious disease caused by multidrug resistant bacteria.

[Rubella seroprevalence in Tunisian childbearing women two years after vaccination program introduction]. / Séroprévalence de la rubéole chez la femme en âge de procréer deux ans après l'introduction de la vaccination en Tunisie.

UNLABELLED: Acquiring rubella during the first 20 weeks of pregnancy can lead to teratogenic effects. AIM: The aim of the study was to investigate the impact of rubella vaccination strategy two years after its introduction in Tunisia in 2005. METHODS: This study was conducted over two periods, 2000 and 2007-2008. A total of 15,776 childbearing women were enrolled in the sample. Serological studies were performed by using the ELISA method. RESULTS: Overall, rubella infection seroprevalence did not increase between 2000 and 2007-2008. Nevertheless, a significant increase in seroprevalence, from 78.2% in 2000 to 92% in 2007-2008 (P=0.006), was especially noted in the age group under 20 years. Seroprevalence did also statistically increase with parity in 2007-2008 from 77.4% in women without any parity to 89.8% in women with over three parities (P=0.01). CONCLUSIONS: Results improvements seem most likely due to mass vaccination campaign for girls aged from 13 to 18 years in 2005, and also routinely post-partum vaccination of seronegative pregnant women or women ignoring their rubella status. In the coming years, systematic selective immunization of 12-year-old schoolgirls who are not yet entering their prime childbearing years will achieve female population sufficient immunity.

Comparison of disc diffusion, Etest and agar dilution for susceptibility testing of colistin against Enterobacteriaceae.

AIMS: In this study, we compared different methods of colistin susceptibility testing, disc diffusion, agar dilution and Etest using a set of Enterobacteriaceae isolates that included colistin-resistant strains. METHODS AND RESULTS: Susceptibility of 200 clinical isolates of Enterobacteriaceae to colistin was tested to compare agar dilution (reference method), disc diffusion (50 and 10 µg) and Etest. MICs (minimum inhibitory concentrations) were interpreted using the criteria established by the European Committee on Antimicrobial Susceptibility Testing (EUCAST). Colistin exhibited excellent activity against Escherichia coli and E. cloacae (MIC90 = 0·5 mg l(-1)). In contrast, colistin was less active against Klebsiella pneumoniae (MIC90 = 16 mg l(-1)). Resistance rates varied from 0% in E. coli to 1·8% in E. cloacae and 13% in K. pneumoniae. High rates of very major errors were observed in the disc diffusion test using either the criteria of the Comité de l'antibiogramme de la Société Française de Microbiologie (CA-SFM) or the criteria of the Clinical and Laboratory Standards Institute (CLSI), respectively, 3·5 and 2·5%. When the criteria of Gales et al. were applied, the number of very major errors was reduced to one (0·5%). The Etest showed good concordance with agar dilution method. CONCLUSION: Disc susceptibility testing methods are unreliable on detecting colistin resistance. MIC should be determined to confirm the susceptibility results by disc diffusion. SIGNIFICANCE AND IMPACT OF THE STUDY: We recommend the determination of MIC by Etest for all multidrug-resistant Enterobacteriaceae when colistin is required for the treatment.

[Antibiotic Susceptibility of Haemophilus influenzae in Sfax: Two Years after the Introduction of the Hib Vaccination in Tunisia]. / Sensibilité aux antibiotiques d'Haemophilus influenzae à Sfax deux ans après l'introduction de la vaccination anti-Hib en Tunisie.

A retrospective study was conducted at the Sfax hospitals between 2013 and 2014 to study the susceptibility to antibiotics of Haemophilus influenzae after the introduction of Hib vaccination in Tunisia. Capsular typing was done by PCR. MICs for ß-lactams were determined by E-test®. The blaTEM, blaROB and ftsI genes were searched using PCR. Among the 259 strains of H. influenzae isolated, 248 (95.7%) were non-invasive. Five strains were encapsulated (3 type b and 2 type c). Resistance rates were 33.4% for ampicillin, 10.4% for amoxicillin-clavulanic acid, 2.3% for cefixime, 1.1% for cefotaxime and 1.9% for fluoroquinolones. Among the strains resistant to ß-lactams, 67 produced ß-lactamase type TEM and 40 had a modification of PLP3. This study shows the change in the epidemiology of H. influenzae induced by vaccination with a dramatic decrease of invasive infections. Replacement with other capsular types or with non-typable strains that may be resistant to antibiotics requires continuous surveillance for H. influenzae infections.

Une étude rétrospective a été menée dans les hôpitaux de Sfax en 2013­2014 pour étudier la sensibilité aux antibiotiques d'Haemophilus influenzae après l'introduction de la vaccination anti-Hib en Tunisie. Le typage capsulaire des souches d'H. influenzae a été fait par PCR. Les concentrations minimales inhibitrices des ß-lactamines ont été mesurées par E-test®. Les gènes bla TEM, bla ROB et ftsI ont été recherchés par PCR. Sur 259 souches d'H. influenzae isolées, 248 (95,7 %) étaient non invasives. Cinq souches étaient capsulées (trois de type b et deux de type c). Les taux de résistance étaient de 33,4 % pour l'ampicilline, de 10,4 % pour l'amoxicilline­acide clavulanique, de 2,3 % pour le céfixime, de 1,1 % pour le céfotaxime et de 1,9 % pour les fluoroquinolones. Parmi les souches résistantes aux ß-lactamines, 67 étaient productrices de ß-lactamases de type TEM et 40 avaient une modification de PLP3. Cette étude atteste du changement de l'épidémiologie d'H. influenzae induit par la vaccination avec la quasi-disparition des infections invasives. Le remplacement de Hib par d'autres types capsulaires ou par des souches non typables éventuellement résistantes aux antibiotiques impose une surveillance continue des infections à H. influenzae.

Thromboembolic events in inflammatory bowel disease.

GOAL OF THE STUDY: Inflammatory bowel disease (IBD) is associated with an increased risk of thromboembolic events (TEE) during outbreaks, increasing morbidity and mortality. The aim of our study was to specify the prevalence of TEE in IBD patients and to determine their epidemiological, clinical and evolutionary characteristics. MATERIEL AND METHODS: This is a retrospective study collecting all patients with IBD, who had a thromboembolic complication confirmed by imagery, between January 2012 and December 2018. RESULTS: One hundred patients with IBD were diagnosed during the study period. A TEE occurred in 6 patients (5.9%). These patients had an average age of 41 years, divided into 4 women and 2 men. Five patients had Crohn's disease and one patient had ulcerative colitis. The IBD was active in all patients. Five patients were already hospitalized and under preventive heparin therapy. Patients had deep venous thrombosis of the lower limbs in 3 cases, associated with pulmonary embolism in 1 case, cerebral venous thrombosis in 2 cases and pulmonary embolism isolated in 1 case. Thrombophilia investigations were negative in all patients. Evolution under medical treatment was favorable in 4 patients and fatal in 2 patients. CONCLUSION: In our study, the prevalence of TEE in patients with IBD was 5.9%. Thrombosis occurred during the active phase of IBD in all cases.

MHC class I and class II genes in Tunisian patients with reactive and undifferentiated arthritis.

OBJECTIVE: To study HLA class I and class II association in Tunisian patients with reactive (ReA) and undifferentiated arthritis (UA). METHODS: The study included 17 patients with ReA defined according to the European Spondylarthropathy Study Group criteria for spondylarthropathy (SpA), 11 patients classified as having undifferentiated arthritis and 100 unrelated healthy controls. HLA class I antigens were typed serologically and HLA class II alleles were genotyped molecularly by the polymerase chain reaction with sequence-specific primers technique. RESULTS: There was a major difference between HLA alleles in ReA and UA patients when compared separately with controls. Increased frequencies of HLA-B27 (p=7.76 10-12, OR=59.30), HLA-B51 (p=0.015, OR=4.91) and HLA-DRB1*04 (p=0.033, OR=2.90) alleles were found in patients with ReA but not in patients with UA. HLA-B27 was not expressed totally in our cohort of UA patients. A significant increase of HLA-B15 (p=0.002, OR=18.40) and a moderate increase of HLA-B7 (p=0.043, OR=5.15) was found in patients with UA, but not in patients with ReA. In the B27 negative patients, HLA-DRB1*04 association with ReA was found independently of B27. CONCLUSION: Our data confirmed a significant association of HLA-B27 with ReA in the Tunisian population. Our results also suggested that some of the additional HLA antigens were associated with ReA including HLA-B51 and HLA-DRB1*04 alleles. UA seemed to have a genetic background different from ReA in Tunisian patients.

Diagnostic value of an enzyme-linked immunosorbent assay using the recombinant CT694 species-specific protein of Chlamydia trachomatis.

AIM: To study the performance of the CT694 protein in relation to the microimmunofluorescence (MIF) and the pELISA tests for the serodiagnosis of Chlamydia trachomatis infections. METHODS AND RESULTS: The CT694 protein was produced as recombinant protein and was used as antigen in ELISA test for the detection of C. trachomatis IgG antibodies. The performance of the developed ELISA test was compared to the MIF test at two cut-off values of 16 and 64, and to the specific pELISA test using a panel of 342 sera. These sera were from children MIF C. trachomatis and Chlamydophila pneumoniae negative, patients MIF C. pneumoniae positive, patients MIF C. trachomatis positive, patients suspected to have chlamydial infections diagnosed by the Cobas Amplicor test, healthy blood donors and prostitutes. Our results indicate that the developed ELISA test has performed better compared with the MIF and the pELISA tests. The highest performance was obtained when comparing the developed ELISA test in relation to the pELISA, yielding an overall sensitivity and specificity of 85% and 87% respectively. CONCLUSIONS: The CT694 ELISA showed the best performance when compared to the species-specific pELISA test and may be used for the serodiagnosis of C. trachomatis infections. SIGNIFICANCE AND IMPACT OF THE STUDY: The CT694 ELISA test responds to the criteria of both sensitivity and specificity according to the MIF and pELISA tests and may be used for serodiagnosis of C. trachomatis infections.

Prosthetic valve endocarditis: management strategies and prognosis: A ten-year analysis in a tertiary care centre in Tunisia.

BACKGROUND: Prosthetic valve endocarditis (PVE) is a rare and serious complication after heart valve replacement; its optimal management strategy, though, still needs to be defined. OBJECTIVE: To study the clinical, microbiological and echocardiographic characteristics of PVE and to analyse the influence of the adopted therapeutic strategy (medical or surgical) on short- and midterm outcome in a tertiary care centre in a developing country (Tunisia). METHODS: All cases of PVE treated in our institution between 1997 and 2006 were retrospectively analysed according to the modified DUKE criteria. RESULTS: A total of 48 PVE episodes were diagnosed (30 men and 18 women), mean age was 37.93 years. Twenty-eight patients (58.33%) were exclusively medically treated, whereas 20 (41.66%) were treated by a combined surgical and medical strategy. Indications for surgery were haemodynamic deterioration in eight patients (40%), annular abscess in six (30%) and persisting sepsis in six (30%). In comparison with those from the medical group, operated patients had a longer delay to diagnosis (p=0.025), were more frequently in heart failure (p=0.04) and experienced more early complications (p=0.011); they also more frequently had prosthetic dehiscence (p=0.015), annular abscesses (p=0.039) and vegetations >10 mm (p=0.008). Conversely, no differences were found between the groups in terms of age, sex, or nature of involved organisms. In-hospital mortality for the medical group was 14.28% and for the surgical group 35% (p=0.09). CONCLUSION: PVE is a very serious condition carrying high mortality rates regardless of the adopted strategy. Our study demonstrates that, in selected patients, medical treatment could be a successful and acceptable approach. (Neth Heart J 2009;17: 56-60.).

Comparison of hepatitis A seroprevalence in blood donors in South Tunisia between 2000 and 2007.

The aim of the study was to assess hepatitis A virus (HAV) seroprevalence in blood donors from South Tunisia in two periods 2000 and 2007. Serum samples collected from 376 blood donors in each period aged 18 to 30 years from different regions of South Tunisia were analysed for anti-HAV IgG. The global seroprevalence of HAV infection was 85.9% in 2007 as compared with 94.9% in 2000. The seroprevalence in the 18-20 years age group was 91.9% in 2000 vs 80.6% in 2007, and increased to 99% in 2000 and 92% in 2007 in the subjects over 26. Taking account of geographic area, the HAV seroprevalence in Sfax city decreased from 88.9% in 2000 to 62.7% in 2007 (p < 0.001), but it is still approximatively the same in rural areas (98.4% and 96%) and in the governorates of South Tunisia (97.6% and 99.2%). In conclusion, the number of adults in the city of Sfax which are not immunized against HAV is increasing. Thus, adolescents and young adults are at risk to develop symptomatic and potentially severe hepatitis A.

Assessment of Chlamydia trachomatis, Ureaplasma urealyticum, Ureaplasma parvum, Mycoplasma hominis, and Mycoplasma genitalium in semen and first void urine specimens of asymptomatic male partners of infertile couples.

The purpose of this study was threefold: to compare semen and first void urine (FVU) specimens from asymptomatic infertile men for the detection of Chlamydia trachomatis, genital ureaplasma, and genital mycoplasma infections using in-house inhibitor-controlled polymerase chain reaction (PCR)-microtiter plate hybridization assay; to determine the prevalence of those organisms in infertile men in Tunisia; and to study the relationship between these bacteria and male infertility. Paired urine and semen specimens from 104 patients were examined by in-house PCR for the presence of DNA of Chlamydia trachomatis, genital ureaplasmas (Ureaplasma urealyticum and Ureaplasma parvum) and genital mycoplasmas (Mycoplasma hominis and Mycoplasma genitalium). Semen analysis was assessed according to the guidelines of the World Health Organization. Nominal scale variables, the Mann-Whitney test, and the Kruskal-Wallis nonparametric analysis of variance test were used for statistical analysis. There was a very high concordance (>95%) and a very good agreement (kappa > 0.9) between the detection of Chlamydia trachomatis, genital ureaplasmas, and Mycoplasma hominis in semen and corresponding FVU specimens. Our findings also show a high concordance (81.1%) and a good agreement (kappa = 0.79) between the detection of Mycoplasma genitalium in both specimens. C trachomatis, genital mycoplasmas, and genital ureaplasmas were found to be widespread among infertile male patients in Tunisia, as shown by their respective prevalences of 43.3%, 18.3%, and 14.4%. The mean values of seminal volume, sperm concentration, sperm viability, sperm motility, sperm morphology, and leukocyte count were not significantly related either to the detection of C trachomatis DNA or to that of genital ureaplasma or mycoplasma DNA in semen specimens. Using our in-house PCR, both semen and FVU were found to be sensitive diagnostic specimens for the detection of C trachomatis, ureaplasmas, and mycoplasmas. The FVU, a less invasive and self-collected specimen, can serve as a marker for the presence of these organisms in the genital tract and can be used as a reliable way of detecting asymptomatic carriers of infection.