[Practice of large scale mammography in the Ariana area of Tunisia: prelude to a mass screening?]. / Pratique de la mammographie à grande échelle dans le gouvernorat de l'Ariana en Tunisie: un préalable à un dépistage de masse organisé?

OBJECTIVE: To study and analyse the results of breast cancer mammography screening program in the Ariana state and to try to determinate its feasibility and reproducibility on a broader scale. MATERIALS AND METHODS: A pilot study on the mammography feasibility of screening with large scales was initiated, by Family and Population National Office, in September 2003. The duration of the study was fixed at 5 years. The adopted protocol takes account of epidemiologic and socialcultural specificities of Tunisian environment that is in the selection and in the mode of recruitment of the target population as well as in the choice of the adopted radiological protocol. RESULTS: 8244 women were screened in the first round. The majority of sensitized women was recruited in residence and in the reproductive and health centers. Nevertheless, recruitment in residence was proved to be heavy, not very effective and no reproducible in a broader scale. The participation rate was weak (9.6%). The channels of sensitizing used made it possible to touch in manner more important the "young" women (Middle Age 48.6 years). The absence of radiologist on the spot involved the recall of 18.1% of the women for which a complementary assessment was necessary, has to contribute to increase the stress among certain women and to increase the average time of reading which was, in this case, 61.7 days. The majority of the women profited from the double reading of the tests (99.4%). On the whole 50 women presented a cancer including 40 detected by the program and 10 interval cancers. CONCLUSIONS: This study has permitted to study the feasibility of mammography study. Except the topic of the cost, the two hand conditions of his feasibility binds in the systematic invitation of the women as well as in the wider uses of sensitization and information ways of the population.

[Lesions classified ACR3 with the breast cancer screening mammography program of the Ariana area: features and problems encountered]. / Lésions classées ACR3 dans le programme de dépistage mammographique du cancer du sein du gouvernorat de l'Ariana: profil et difficultés de prise en charge.

OBJECTIVE: This retrospective work is related to ACR3 mammograms of the program "Feasibility of breast cancer screening by mammography in Ariana Governorate" in order to evaluate the efficiency and short-term quality control of these probably benign lesions. MATERIALS AND METHODS: Mammograms classified ACR3 raised the indication of further examination, futher mammogram (profile, expanded or compression). The monitoring and control period are explained to the patient by the radiologist. RESULTS: 6.6% mammograms were classified as ACR 3 with 71.3% under the age of 50 years. Breast is very dense in 20.5% of cases, and transparent in 6% of cases. Further exams has been performed in 94. 5% of cases with a profile in 52% of cases, enlarged in 22.1%, compression in 24.9% and ultrasound in 82.5%. The surveillance protocol was insufficient for 126 women lost to the 1st control, 32 women lost for the 2nd control and 19 women were lost to the 3rd control. After two years monitoring, 219 women were reclassified as ACR2 with a negative test. In 2 patients, we found an invasive ductal carcinoma at 4 months control. CONCLUSION: ACR 3 mammograms are the most important operator dependent category. The diagnosis of probably benign lesion dependant of the analysis of images and requires a great experience of the radiologist and a comprehensive complementary examination. In this study, this assessment was often heavy in relation to the frequency of dense breasts itself in connection with the young age of patients. In addition, for this particular category, the need of training is important and in terms of public health cost, the management of ACR3 mammograms increases difficulties and cost of screening.

[Results and evaluation of 3 years of a large scale mammography program in the Ariana area of Tunisia]. / Résultats et évaluation de 3 années de pratique mammographique à grande échelle dans le gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: To asses and analyse the results of 3 years large scale mammography screening of breast cancer in Ariana state in Tunisia. MATERIALS AND METHODS: This program, managed by the Family and Population National Office, was addressing to women aged from 49 to 69 years old residing in a area with adds up a population of 459 700 inhabitants including 52,729 women in the target age population. The screening was including a breast clinical examination and a mammography with two incidences face and external profile. The women was invited at their residence or were sensitized in the reproductive health centers, care and base health centers or by a close relation which heard of the program. An enlightened assent was submitted to the women who wished to profit from the screening. RESULTS: In three years, 9093 mammography were carried out of which 8244 were retained in the analyses, that is to say a rate participation of 9.6%. The rate of women recalled for suspect test was of 18.1% and it was of 13.1% among women of more than 50 years. The rate of practiced surgical biopsies was of 0.5% and the positive predictive value was of 45.5%. The average time between the date of screening and the result of the screening was 9.7 days, more important in the event of tests requiring a complementary assessment (61.7 days). On the whole 40 cancers were detected by the program, that is to say a rough rate of detected cancers, of 4.9 per thousand, in conformity with the recommendations. The percentage of invasive cancers < or = 10 mm was of 24.3 whereas percentages of in situ cancers and of cancers without ganglionic invasion were respectively of 7.7% and of 50.0%. CONCLUSIONS: The weakness of our study lay primarily in the rate of participation which remained weak. The methodology adopted for the sensitizing of the women is proven not very effective and did not allow inviting all eligible women. Results of the study are encouraging in spite of its limited impact and made it possible to detect an important rate of cancers of which cancers infra-private clinics.

[Preliminary results and analysis of the feasibility of mammographic breast cancer screening in women younger than 50 years of the Ariana area in Tunisia]. / Résultats préliminaires et faisabilité du dépistage mammographique du cancer du sein chez les femmes de moins de 50 ans du gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: To report the preliminary results of the feasibility of breast cancer mammographic screening among women younger than 50 years from the l'Ariana state of Tunisia. MATERIAL AND METHODS: The National office of the Family and Population (ONFP) launched a protocol on feasibility of breast cancer mammographic screening targeting asymptomatic women aged 40-69 years, from the l'Ariana state in Tunisia. We practiced two oblique and face incidences at the mammography screening unit of the ONFP, whose equipment and control system of quality answered to the European Communitiy for breast cancer screening. RESULTS: We did 5325 mammograms between April 2004 and March 2006. Our targeted population had a 48.9 years mean age (CI 95% = [48.7-49.1]), 60.3% of them younger than 50 years. There were more young women with high breast denisty (8.2%) compared to the group from 50 to 69 years (2.1%). The women arising from the 40-49 years cohort had a socio-economic and educational level higher. The complementary rate of examination/explorations was higher in this cohort (19.5%) vs 11.5% for the 50-69 years. The youngest women presented a more often positive test (7.0 vs 5.2%) than the oldest women (p<0.01). CONCLUSION: The option to screen breast cancer by mammography in women younger than 40 years in Tunisia is partially justified by the relatively high frequency of this cancer in this age group. Our feasibility poorly useful in screening will be used to sensibilise females to the problematic of breast cancer to obtain a better compliance compared to the older age group of 50-59 years.

[Retrospective results of ultrasonographically-guided biopsy the breast cancer screening program of the Ariana area of Tunisia]. / Etude rétrospective des résultats des cytoponctions et des microbiopsies mammaires écho-guidées du programme du gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: To report the results of breast ultrasonographically-guided fine needle aspirations and needle biopsies within the breast cancer screening program of L'Ariana state in Tunisia. MATERIAL AND METHODS: Our retrospective study include 143 patients, with mammographically detected lesions, which underwent a diagnostic percutanous ultrasonographically guided procedures. 57 patients underwent a fine needle aspiration, 25 underwent a needle biopsy and 61 patients underwent both procedures. RESULTS: Sensitivity and specificity of fine needle aspiration are of 84.2% and 98.5%. We report 13.5% of non contributive results. The needle biopsy have a sensitivity of 97.3% and a specificity of 100% with one false negative corresponding to an atypical ductal hyperplasia at the excisional biopsy. CONCLUSION: Fine needle aspiration is a reliable method of accurately establishing a diagnosis. Needle biopsy is recommended for a preoperative lesion characterisation before adequate treatment.

[Management of breast cancer detected by a mammography program in the Ariana area of Tunisia]. / Prise en charge des cancers du sein issus du programme mammographique du gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: To report the epidemiological and anatomoclinical features of breast cancers referred to a department of gynecology from the screening program of l'Ariana state in Tunisia. MATERIAL AND METHODS: A longitudinal retrospective Study was done over a period of 4 years (2004-2006 ) at the unit "A" gynecology department of the maternity of Tunis. We collected all the cases with histologically confirmed breast cancer diagnosed within the mammography screening program of l'Ariana state, referred to our unit for treatment. RESULTS: 10 patients with histologically confirmed breast cancer were collected during the study period, treated at our unit. Mean age of patients was of 48.8 years. Clinical examination was initially negative in 50% of cases. Mean clinical tumor size was 18 mm, while invasive ductual carcinoma represents the most frequent histological type. One patient (10%) had histological axillary involvement. Conservative surgery was performed for 8 (80%) of the 10 patients. CONCLUSION: This pilot study of mammography screening confined to a Tunisian state, precludes to the future profile of BC In Tunisia, showing that an early diagnosis can lead to a dramatic reduction of mean clinical tumor size, less histological poor prognostic features, more conservative surgery and a slight improvement of survival. A structured extended screening program must be installed to achieve these goals but requires an important financial and human investment.

[Patient satisfaction of women involved in the pilot program of large scale mammography in the Ariana area of Tunisia]. / Enquête de satisfaction auprès des femmes du projet pilote de dépistage du cancer du sein du gouvernorat de l'Ariana en Tunisie.

OBJECTIVE: Evaluate the degree of satisfaction of women included in the large scale mammography program of breast cancer screening in the state of Ariana in Tunisia. MATERIAL AND METHODS: [corrected] Within the women explored by mammography, we have contaced 112 patients who had a positif screening requiring histological checking. We have established a questionnaire concerning: the invitation, the clinical examination, the result announcement and the therapeutic management. RESULTS: The average age of patients was 49 years. 64% had a primary education level. 80 women or 71.4% were satisfied with the process of screening and the method of announcement. The main cause of dissatisfaction for patients with cancer diagnosis was delay and difficult access to adjuvant treatments. Among patients who had histological diagnosis: 47.3% had a malignant disease (53 cases) against 37.5% of benign (42 cases). 100% of patients who had a pathological result reassuring are satisfied at the end of the screening program. DISCUSSION: The psychosocial impact of screening must be considered for the development of new programs. The waiting and announcement of results are essential factors that allow us to judge the success of the project, because of patient satisfaction will depend the quality of monitoring and adherence to screening.

Implementing a quality improvement programme in a family planning centre in Monastir, Tunisia.

We aimed to improve the quality of family planning and reproductive health services in a family planning centre though implementation of a quality improvement programme. Clients were surveyed to identify quality-related problems. Health care teams then analysed the causes of the problems, developed solutions for 3 selected ones and established a quality assurance framework. The selected issues were: long waiting time at the centre; insufficient integration of family planning and reproductive health services; and lack of a holistic approach. The final phase was aimed at testing and implementing corrective measures.

[Incidence and management of male urethritis in the district of Tunis]. / Incidence et prise en charge des urétrites chez l'homme dans le district de Tunis.

BACKGROUND: The aim of the study was to evaluate the incidence of male urethritis and the relative frequency of the different etiological agents in order to adapt standard case management. METHODS: The incidence of urethritis has been estimated with a postal study made on a sample of druggists (1/10) of the area. The total observation period was four weeks. The relative frequency of the etiological agents and the positive predictive value (PPV) of the therapeutic approach based on antibiotic treatment of gonorrhoea and Chlamydia trachomatis was achieved on 92 cases of male urethritis attending general physicians in two polyclinics. RESULTS: The annual incidence of male urethritis was estimated at 680 per 100,000. The relative frequency of etiological agents was as 34.7% for Neisseria gonorrhoea, 7.6% for Chlamydia trachomatis and was found at 3.3% for Trichomonas vaginalis; the PPV was only 43% because of the high proportion of negative results reported by the laboratory. CONCLUSION: Gonococcal urethritis incidence tends to decrease regarding non gonococcal urethritis and the therapeutic approach appears to be warranted.

[Zincemia, cupremia and infection in malnourished children]. / Zincémie, cuprémie et infection chez l'enfant malnutri.

BACKGROUND: Serum copper and zinc levels are decreased in malnourished and infected children. The role of either malnutrition or infection remains undetermined. POPULATION AND METHODS: Serum zinc and copper concentrations were measured by atomic absorption spectrophotometry in 31 malnourished infants aged 1 to 26 months and 28 eutrophic infants aged 3 to 22 months. Fourteen infants of the first group and 10 of the second were infected at the time of study. RESULTS: Serum zinc and copper levels were significantly decreased in infants with malnutrition (zinc: 66 +/- 32 micrograms/dl and copper: 81 +/- 51 micrograms/dl versus 108 +/- 26 and 185 +/- 21, respectively, in eutrophic infants) (p < 0.001). These levels were still lower in those malnourished infants who were infected (zinc: 49.5 +/- 18 micrograms/dl and copper: 63.5 +/- 37 micrograms/dl versus 81.56 +/- 35 and 94 +/- 56 in non infected patients) (p < 0.02). CONCLUSIONS: Infection increases the risk of low serum zinc and copper concentrations seen in malnourished children. This factor must be taken in account when treating malnutrition.

[Contraception with levonorgestrel subdermal implants. A Tunisian study]. / La contraception par les implants sous-cutanés de lévonorgestrel. Une étude tunisienne.

OBJECTIVES: We report our experience in Tunisia with contraception by subdermal levonogestrel implants. METHODS: From January 1, 1990 through June 30, 1994 we inserted 1021 implants at our family planning center in Ariana. RESULTS: Our experience with this pure progesterone implant showed that this method provides effective long-duration contraception. There was only one case of ectopic pregnancy among our 1021 patients. The most frequent undesirable effect and the first cause of discontinuing treatment was disturbed menstrual cycle with irregular discharge. CONCLUSION: Our results underline the importance of counselling before implant insertion. A 10-day estrogen regimen may provide a solution for menstrual disorders.

[Escherichia coli in acute diarrhea in a population of infants]. / Escherichia coli dans les diarrhées aigues d'une population de nourrissons.

The incidence of Escherichia coli EPEC and ETEC had been studied on 555 infants from Tunis area. 193 of them do not present any diarrhea. Frequency of EPEC is 9.14% in infants with diarrhea and 3.10% in the group without diarrhea. Analysis of 87 Escherichia coli strains using genetic probes showed that 4 EPEC strains present effacing attachment factor (EAF) and one EPEC strain produce verotoxin. The frequency of ETEC isolated is 18.05%, the majority of them produced ST enterotoxin. Only colonization factor antigen I (CFAI) was found in ETEC strains.

[Non-O1 Vibrio in acute diarrhea of the infant]. / Vibrio non O1 dans les diarrhées aiguës du nourrisson.

The choleriform diarrhoea may be caused by Vibrio cholerae, but also by other Vibrionaceae exhibiting the cholera-toxin antigenic determinants. The authors report three instances of gastroenteritis in infants, caused by 3 strains of non-O1 Vibrio and they carry out bacteriological study on these strains and their pathogenicity-strength factors.

[Prevalence of sexually transmitted diseases among pregnant Tunisian women and validation of a clinical algorithm proposed by WHO for the management of sexually transmitted diseases]. / Etude de la prévalence des MST chez les femmes tunisiennes enceintes et validation de l'algorithme clinique proposé par l'OMS pour la prise en charge des MST.

The objectives of our study are to assess the prevalence of STD agents in Tunisia and to validate the WHO algorithm of STD management. The most frequent STD agents are Trichomonas vaginalis and Chlamydiae trachomatis, respectively with a prevalence of 5.6% and 1.7%. The assessment of the syndromic approach shows that the sensitivity and specificity of the WHO algorithm can be improved by the introduction of risk factors. The training of health care service providers and the use of an algorithm including risk factors can improve this approach, which is useful when laboratories services are not available.

[Campylobacter in acute diarrhea of infants]. / Campylobacter dans les diarrhées aiguës du nourrisson.

Investigation of C. jejuni, C. coli has been realised on 280 babies in Tunis, 123 of them do not present any diarrhea. The global frequency of campylobacter isolated is 4.64%. Concerning babies with diarrhea, the frequency is 4.45%, whereas it is 4.86% in the group without diarrhea. A similar frequency of C. jejuni and C. coli appears in the two groups.

[Etiological study of acute gastroenteritis in children in Tunisia]. / Etude étiologique des gastroentérites aiguës de l'enfant en Tunisie.

This study was aimed at identifying the relative importance of the various agents responsible for gastroenteritis and to contribute to the etiopathogeny of this condition. Four hundred and two samples of stools of patients and 209 of control subjects, all under 3 years of age, were submitted to bacteriological, parasitologic and virologic examinations. An enteral etiology of gastroenteritis was found in 50% of the children. It consisted of enteropathogenic bacteria in 11%, rotaviruses in 29% and both associated in 19% of cases. There was a significant difference between patients and controls for bacterial (p less than 0.0001) and viral (p less than 0.00001) infestation. The most frequently isolated bacteria consisted overall of Escherichia coli. Eighty-seven isolated strains of E. Coli were tested for their enterotoxinogenic capacities. Four strains were bearing the attachment factor (EAF) and 14 were toxinogenic. Shiga-like toxin (or vero toxin) was detected in 4 strains. Campylobacter was isolated as frequently in patients as in controls and was often associated with other bacteria or rotaviruses. The presence of parasites and candidas was not significantly different in patients and in controls. Giardia intestinalis was the most frequently isolated parasite.

Implementing a quality improvement programme in a family planning centre in Monastir, Tunisia

We aimed to improve the quality of family planning and reproductive health services in a family planning centre though implementation of a quality improvement programme. Clients were surveyed to identify quality-related problems. Health care teams then analysed the causes of the problems, developed solutions for 3 selected ones and established a quality assurance framework. The selected issues were: long waiting time at the centre; insufficient integration of family planning and reproductive health services; and lack of a holistic approach. The final phase was aimed at testing and implementing corrective measures