The practice of the mental image tool for the training of hand hygiene with Hydro-alcoholics solutions: randomized trial.

INTRODUCTION: Mental image (or mental practice), a psychological representation of a task to be carried out, is a technique that could enhance skills in several areas areas including medicine. OBJECTIVE: To evaluate the practice of the mental image tool for the training of hand hygiene with Hydro-alcoholics solutions among students of DCEM2. METHODS: Randomized trial including DCEM2 students in Neonatology and Pediatrics at Charles Nicolle Hospital during the same period. Group1: group training in the mental image, Group 2 of reference. The assessment of student achievement was evaluated in terms of obtained scores. RESULTS: The total number of students was 37. The overall score in group 1 was 17.17 ± 3.82 versus 11.58 ± 4.05 in group 2, p <10 -3. The friction duration of hands in group 1 was 30.56 S ± 4.52S versus 24 ± 5.17 in group 2, p <10-3. CONCLUSION: Mental practice may be a time- and cost-effective strategy that improves hand hygiene with Hydro-alcoholics solutions.

Extremely preterm infants in Tunisia: Where are we now?

BACKGROUND: Extremely preterm infants are newborns born before 28 weeks of gestation. Survival of these immature newborns depends on resuscitation and the quality of care during hospitalization. OBJECTIVE: To determine survival and neurologic outcomes at2 years after extremely preterm birth. METHODS: It is a retrospective multicentric study in 5 neonatal intensive care units (NICU) in 2012-2013.All live births less than 28 weeks gestation were included. RESULTS: A total of 109 births were recorded. Prenatal corticosteroids were given in 47% of cases. Mean weight was 989g and mean age was 26 weeks gestation. Ninety percent of patients had respiratory distress syndrome and 67% of them needed respiratory support. Surfactant was given to 29% of newborns. The mortality rate atdischarge was 76%.The first cause of mortality was nosocomial infections. At thecorrected age of 2 years, 27% of survivors had abnormal neurologic outcome. CONCLUSION: In our study, survival and neurologic outcomes ofextremely preterm infants were poor.In this high-risk population, improving perinatal care remains a challenge to improve long-term outcome in Tunisia.

The script concordance test as a tool to evaluate clinical reasoning in neonatology.

BACKGROUND: Script concordance test aims to evaluate knowledge organization, which represents an essential component of the clinical competence. OBJECTIVE: To build a script concordance test and demonstrate its relevance in the evaluation of Neonatology skills. METHODS: A script concordance test including 20 vignettes and 20 items, was provided to 52 fourth year medical students and 11 family medicine interns. RESULTS: Script concordance test scores obtained by experts were higher then those obtained by students and family medicine interns. The scores (out of 100) were 82.52 ± 7.35 CI95% [77.26-87.78] for the experts, 58.52 ± 9.72 CI95% [55.82-61.23] for the students, and 63.17±11.36 IC95%  [55.53-70.81] (p<0.0001) for the interns. CONCLUSION: Our data suggest that script concordance tests could be used to assess the acquisition of clinical reasoning among fourth year medical students in neonatolgy.

Fetal Cyst Reveling Retroperitoneal Enteric Duplication.

Retroperitoneum is a very uncommon site of enteric duplication (ED). We report a new case of retroperitoneal ED cyst suspected in utero. Prenatal ultrasound showed an abdominal cystic mass. Noncommunicating retroperitoneal ED cyst measuring 70 mm × 30 mm was resected. Histopathologic examination confirmed the diagnosis.

Prevalence and outcomes of thrombocytopenia in a neonatal intensive care unit.

Background Thrombocytopenia is a common clinical problem in neonatal intensive care units, affecting about 20 to 35% of all admitted neonates. Even most episodes are mild or moderate, severe episodes could be life-threatening or responsible for sequelae. Objectives The aims of this study were to describe the prevalence, clinical diagnoses, and to determine risk factors for poor prognosis of thrombocytopenia in a neonatal intensive care unit. Methods We carried out a retrospective study in the neonatal intensive care unit of Charles Nicolle Hospital of Tunis, a tertiary neonatal care center, over a four years period (January 2010 to December 2013). All Neonates with at least one episode of confirmed thrombocytopenia were included. Poor prognosis was defined as death or intraventricular hemorrhage ≥ grade 2 in survivors. Results Of 808 admitted neonates, one hundred (12.4%) had presented at least one episode of confirmed thrombocytopenia, and 12 had presented two episodes of thrombocytopenia. A total of 112 episodes of thrombocytopenia were collected. Thrombocytopenia occurred in the first 3 days of life in 74.1% of cases. Thrombocytopenia was mild in 22.3%, moderate in 36.7% and severe in 41%. Intrauterine growth restriction was the most common cause of early thrombocytopenia. Nosocomial sepsis was the most common cause of late thrombocytopenia. We found that the outcomes of thrombocytopenic neonates depend on, birth weight, gestational age, platelet count, and the underlying cause. Conclusions Thrombocytopenia in neonates can be life-threatening, appropriate diagnosis, preventive and therapeutic approach is necessary to prevent death or neurological impairment.

Errors in preparation and administration of parenteral drugs in neonatology: evaluation and corrective actions.

BACKGROUND: The medication iatrogenic risk is quite unevaluated in neonatology Objective: Assessment of errors that occurred during the preparation and administration of injectable medicines in a neonatal unit in order to implement corrective actions to reduce the occurrence of these errors. METHODS: A prospective, observational study was performed in a neonatal unit over a period of one month. The practice of preparing and administering injectable medications were identified through a standardized data collection form. These practices were compared with summaries of the characteristics of each product (RCP) and the bibliography. RESULTS: One hundred preparations were observed of 13 different drugs. 85 errors during preparations and administration steps were detected. These errors were divided into preparation errors in 59% of cases such as changing the dilution protocol (32%), the use of bad solvent (11%) and administration errors in 41% of cases as errors timing of administration (18%) or omission of administration (9%). CONCLUSION: This study showed a high rate of errors during stages of preparation and administration of injectable drugs. In order to optimize the care of newborns and reduce the risk of medication errors, corrective actions have been implemented through the establishment of a quality assurance system which consisted of the development of injectable drugs preparation procedures, the introduction of a labeling system and staff training.

[Evaluation of materno-foetal infectious risk after isolated premature rupture of membranes in at term new-born]. / Évaluation du risque d'infection materno-foetale après rupture prématurée des membranes isolée chez le nouveau-né à terme.

BACKGROUND: Premature rupture of membranes (PROM) is defined as rupture of membranes occurring before the onset of labor. It complicates 5 to 10 % of pregnancies. It continues to be a major cause of morbidity and mortality in the newborn. AIM: To evaluate infectious risk associated with PROM in at term and asymptomatic new-born and to study this risk according to the duration of rupture. METHODS: Retrospective study in neonatal unit of Charles Nicolle hospital of Tunis including all cases with isolated PROM in at term new-born during the year 2007. RESULTS: 299 cases were identified over 3749 live births that is an incidence of 8 %, divided to: 21 cases (7 %) between 6 and 12 hours, 86 cases (28.8 %) between 12 and 18 hours, 61 cases (20.4 %) between 18 and 24 hours and 131 cases (43.8 %) more than 24 hours. Diagnosis of colonization was reported in 54 % of cases when PROM occurred between 12 and 18 hours versus respectively 27.3%, 0 % and 18 % in respectively subset of 6 to 12 hours, 18 to 24 hours and more than 24 hours (p=0,03). 62 % of foeto-maternel infections were reported in subset of PROM more than 24 hours and 13.8 % in the subset between 18 and 24 hours. CONCLUSION: Our study emphasizes the important risk of foetomaternel infection associated with isolated PROM. This risk is major when the rupture exceed 12 hours but the limit of 18 hours can unrecognized some cases of probable foeto-maternel infection.

Congenital cystic adenomatoid malformation of the lung: two case reports.

BACKGROUND: Congenital cystic adenomatoid malformation (CCAM) is a rare embryonic developmental abnormality with an incidence of one in 25 000 to 35 000 pregnancies. With advances in antenatal ultrasonographia (USG), CCAM has been increasingly diagnosed. After birth, the clinical appearance of CCAM can vary from immediately postnatal respiratory distress, to an incidental finding on chest radiography. AIM: To report two additional cases with CCAM different in clinical features. CASE REPORTS: The first case was a boy in witch diagnosis was suspected by antenatal USG; he was born at 37 weeks of gestation by cesarean section because of severe toxemia, and presented immediately respiratory distress. The chest x ray and computed tomography scan (CT scan) revealed a right CCAM. The second case was also a boy of an inducted threefold pregnancy, born at 30 weeks by cesarean section. He presented immediately respiratory distress. The diagnosis of a right CCAM was confirmed by clinical and radiological findings in postnatal period. CONCLUSION: The two cases described in this report show the disparity in clinical features of CCAM. Nowadays, antenatal echotomography can establish the diagnosis allowing optimum management.

[Outcome at 2 years of very premature infants. A Tunisian series]. / Devenir neurologique à l'âge de 2 ans des grands prématurés. Série Tunisienne.

BACKGROUND: Neurodevelopmental outcome of very premature infant can be associated with a high rate of cerebral palsy. AIM: To assess the impact of very preterm birth on neurological outcome at the age of two years. METHODS: Retrospective study of all cases of very premature infants born at less than 33 weeks of gestational age, during the years 2005 to 2007. Neurodevelopmental outcome is reported. RESULTS: During the study period, the very premature infant rate was 1.5 %. A complete information about neurological outcome at the age of two years, was obtained in 60 cases.Eight infants (13.4%) showed major handicap (cerebral palsy) and four others infants developed neurosensoriel difficulties. CONCLUSION: The incidence of neurosensoriel handicap in our population seems relatively high. A strong effort must be made for identification of risk factors of neurodevelopmental disability.

[Epidemiology of domestic accidents of young children in Tunisia: impact of the training of health professionals on data collection quality]. / Epidémiologie des accidents domestiques du jeune enfant à Tunis : Impact de la formation des professionnels de santé sur la qualité de la collecte d'informations.

BACKGROUND: In Tunisia, several studies on domestic injuries have been carried out on children attending care facilities. Nevertheless,there is a lack of data on incidence and kinds of child domestic injuries amongst general population because of absence of a reliable data collect system. AIM: To estimate the incidence and kinds of domestic injuries through a prospective survey "here-there" within two cohorts of young children attending two mother and child protection centers (MCPC) in Tunis during the three first years of their life and to analyze the importance of health professional training in improving data collect. METHODS: A prospective study "here-there" was carried out on two cohorts of children in two mother and child protection centers (MCPC) between January 2007 and December 2009. Only children aged less than 3 months at their first contact with the centers were included and followed up until age of 3 years. In the MCPC2 (cohort2), health personnel have been trained on data collection importance related to child domestic accident and asked to monitor accidents by calling parents while a phone line got available for this aim. In the MCPC1, health personnel was asked to work as they used to do and to collect data on child domestic injuries when children attend the center. RESULTS: 192/435 domestic accidents were recorded within cohort 2 vs only 1/686 within cohort 1. Annual incidence rate was 14.7% for the cohort 2. The kinds of accidents were: falls 78.2% (falls from high plans 84.6%), injuries15.1% (injury by cutting things 58.6%),burns 5.7% (burns by hot liquid 54.5%), intoxications 1%. In terms of damages, we recorded 4 cases of broken bones (thighbone, elbow,handwrist), stitches in 11 cases, broken teeth in 3 cases and nail pulled out in one case. No death was recorded. Training impact on accident prevention was not studied. CONCLUSION: Child domestic accidents are relatively frequent. Health personnel training allows to improve data. The kinds of recorded accidents indicate the need to educate parents on best practices towards strengthening prevention.

Determinants of neonatal mortality in a Tunisian population.

BACKGROUND: In Tunisia, perinatal mortality remains a public health problem, currently estimated at 28 per thousand, including 15 per thousand of still birth rate and 10 to 15 per thousand of early neonatal mortality rate. The recent investigations show that about half of the deaths at less than five-years-old are of perinatal origin and that neonatal mortality represents two thirds of infant mortality. Published data regarding neonatal mortality and the causes of death are sparse. THE AIM: to evaluate the neonatal mortality rate over a 2 year period in our population study and to present data collected prospectively on the risk factors and the causes of all neonatal deaths. METHODS: A prospective cohort compiling all live births reported between January 2007 and December 2008 at Charles Nicolle hospital (Tunis-Tunisia). All the neonatal deaths that occurred before or after discharge or transferred to other hospitals and subsequently died are included. Births from termination of pregnancy were excluded from all the analyses. Causes of deaths were assigned according the International Classification of Diseases, Tenth Revision (ICD10). RESULTS: 88 neonatal deaths were recorded over 7285 live births (LB) that is a NMR of 12 per thousand LB. Early neonatal death occurred in 79 cases (88.7%), that is an ENMR of 10.8 per thousand LB. Risk factors directly related to neonatal mortality were prematurity (aOR=6.03- 95%CI: [2-18.13] p=0.001), neonatal respiratory distress (aOR=16.12 - 95%CI: [5.67-45.78] p<10(-3)), perinatal asphyxia (aOR=11.49 - 95%CI: [3.68-35.92] p<10(-3)), nosocomial infection aOR=8.71- 95%CI: [1.77-42.70] p=0.008, and small for gestational age aOR=7.11 - 95%CI: [2.23-22.69] p=0.001. 80.6% of underlying causes and 88.6% of immediate causes of death are gathered in the chapter "Certain conditions originating in the perinatal period". Maternal hypertensive disorders and extreme immaturity due to spontaneous prematurity were respectively responsible for 13.6% and 10.2% of underlying causes of neonatal death. CONCLUSION: Neonatal mortality remains high, dominated by the conditions originating in the perinatal period. The multitude of the risk factors implies the need for a multidisciplinary strategy of intervention, engaging the pre and perinatal prevention.

Pallister-Killian syndrome with additional manifestations of cleft palate and sacral appendage.

AIM: Reppor of a rare congenital abnormalities. OBSERVATION: We report a rare case of Pallister-Killian syndrome in a 33 weeks gestation infant. In addition to the characteristic phenotype, this patient had a cleft palate, diaphragmatic hernia and sacral appendage. These additional manifestations are not among the Pallister-Killian syndrome's features. The diagnosis was made in antenatal period by cytogenetic studies and showed mosaic 47, XY+i (12p). Presence of diaphragmatic hernia makes this syndrome, prenatally letal, similar to the Fryns syndrome and then requires skin biopsy and fibroblast chromosome examination for cytogenetic diagnosis.

[Neonatal hearing screening with transient otoacoustic emissions: pilot study]. / Dépistage systématique de la surdité en maternité par Oto-Emissions Acoustiques Provoquées (O.T.E.A.P): Etude pilote.

BACKGROUND: Bilateral hearing loss is present in 1-3 per 1000 newborn infants, and in 2-4 per 100 infants in the intensive care unit population. All infants with hearing loss should be identified before 3 months of age and receives intervention by 6 months. If undetected, this will impede speech, language, and cognitive development. In Tunisia, we do not have an exhaustive information on the real importance of the auditive handicap. The aim of our study was to evaluate the feasibility and the practical aspects of a pilot tunisian universal neonatal hearing screening (UNHS) program based on transient evoked otoacoustic emission reporting the incidence of hearing impairment in this population. METHODS: A prospective study during one year (01/05/2006 to the 30/04/2007). Transient evoked otoacoustic emission was planned for all live births. If the test could not be practised in maternity or that research was negative, an appointment was delivered for a research of the O.T.E.A.P in an interval of 1 week - 1 month. Infants who did not meet TEOAE pass criteria underwent diagnostic auditory brainstem response (ABR) testing. RESULTS: During the study period, 3342 live births were recorded, 3260 were included. Total coverage rate was of 41% (1333/3260). We recorded 3 cases of bilateral hearing loss (0.9 per thousand screened infants) and 5 with unilateral sensorineural hearing loss (1.5 per thousand screened infants). CONCLUSION: The incidence of congenital hearing loss in our population seems relatively high. Hearing screening for all neonates using transient evoked otoacoustic emission is feasible but several practical aspects should be revised.

[Postpartum levels of glycosylated hemoglobin in mothers of large baby: a prospective study]. / Interet du dosage de l'hemoglobine glyquee (HBA1C) en postpartum chez les meres des nouveau-nes macrosomes.

BACKGROUND: The delivery of a large baby may indicate that the mother had abnormal glucose tolerance during pregnancy. Glycosylated hemoglobin (HbA1c) concentration might be expected to identify women who had high blood glucose concentration before delivery. AIM: The aim of this study was to identify retrospectively, gestational diabetes in mothers of large baby and determine the HbAlc cutoff value. METHODS: HbA1 was measured in 216 patients within the first three days of postpartum: 100 had large babies: weighing over than 4000 g and 113 had normal- sized babies (control group). We exclude mothers who had preterm, hypotrophy baby, stillborn, and diabetic mothers. RESULTS: The mean concentration of HbA1c was significantly higher in group with large babies than in group control (6.17% + 085 vs. 5.17 + 0.57 t = 9.78 p < 0.001). The value of HbAlc = 5.85%, evaluated by ROC curve, was considered as risk factor of macrosomia and then gestational diabetes. 83.5% of mothers with large babies had HbA1c ? 5.85 vs. 7.8% of those with normal sized babies (p < 0.0001). No other significant differences were found between the two groups in other parameters. CONCLUSION: HbA1c level may be of value as a postpartum screen for unrecognized diabetes and may help discriminate between a constitutionally large but otherwise normal newborn and a large infant of a diabetic mother. HbA1c measurements should be obtained in women with large babies, and, if upper than cutoff value found by curve ROC: 5.85%, maternal and fetal surveillance is recommended.

Autosomal recessive acro-fronto-facio-nasal dysostosis associated with genitourinary anomalies: a third case report.

We report on a 22-day-old Tunisian boy born to consanguineous (first-cousin) parents (F = 1/16). The patient presents wide forehead with frontal encephalocele, wide anterior fontanel, marked hypertelorism, coloboma of the upper lids, proptosis, congenital glaucoma, broad nose, syndactyly between fingers 3 and 4, hypoplastic 3rd, 4th and 5th toes with nail dysplasia, hypospadias with cleft glans, bifid scrotum. Brain MRI showed right frontal encephalocele with anomalies of the cortical gyration without any corpus callosum abnormality. Normal chromosomes and parents' consanguinity are suggestive of autosomal recessive inheritance. Facial midline anomalies associated with limb and genitourinary anomalies is very uncommon. We present the third case reported in the literature.

[Neonatal mortality and morbidity in newborn newborns of single mothers]. / Morbidite et mortalite des nouveau-nés issus de mères célibataires.

BACKGROUND: Newborns of single mothers constitute a high risk population for intra-uterine growth retardation (IUGR) and neonatal mortality. AIM: Our study analysed the influence of this socio-economic factor on neonatal mortality and morbidity. METHODS: A retrospective cohort compiling all births resulting from illegitimate pregnancies reported between January 2001 and December 2003 at the Charles Nicolle hospital (Tunis-Tunisia) "IG = illegimate group" (n=75), apparied for mothers gestity, parity and age, to 75 legitimate births "LG=legitimate group" reported after or before each illegitimate birth. RESULTS: The mean age for mothers in the "IG" was 24.3 years. The mean of prenatal consultations was 0.5 in the "IG" vs. 5.2 in the "LG" (p < 0.001). Delivery by caesarean section was of 6.7% in the "IG" vs. 18.7% in the "LG" (p = 0.049). Prematurity was observed in 17% in the "IG" vs. 8% in "LG". IUGR was observed in 29% of "IG" vs. 4% in "LG" (p < 0.001). Neonatal mortality was of 4.1% in "IG" vs. 1.3% in "LG". CONCLUSION: These results indicate the importance of illegitimate pregnancies as a demographic risk factor of neonatal morbidity. The IUGR was the most significant risk factor associated to illegitimate pregnancies.

[Early-onset neonatal bacterial infections: a retrospective series of 144 cases]. / L'infection materno-foetale bactérienne: etude rétrospective a propos de 144 cas.

BACKGROUND: Early-onset neonatal bacterial infections continue to be a major cause of morbidity and mortality in the newborn. THE AIM of this study was to determine the incidene, the risk factors and bacterial epidemiology of these infections. METHODS: All cases of early-onset neonatal bacterial infections were identified for the years 2001-2003 using data from obstetric and neonatal reports at the neonatal unit of Charles Nicolle Hospital. RESULTS: 144 cases were identified over 11,201 live births, that is an incidence of 12.85 per thousand, of which 22 cases of sepsis infections. 22.9% of all newborns were premature and 18% had a low birth weight. Membrane rupture occurred more than 12 hours before delivery in 63.2% of cases and an intra-partum fever in 57.7% of cases. Half of newborns were symptomatic with a mean age of 7.5 hours at onset of symptomatology. The principal etiologic agents were Group B Streptococcus (GBS) and Escherichia coli (E.coli), responsible respectively of 50% and 29.1% of proved infections. GBS had been recognised as the most prevalent agent in term newborn (58.9%) and the E.coli in premature newborn (38.5%). The neonatal mortality before discharge was 2.77% of all cases. CONCLUSION: Neonatal bacterial infections continue to be a major cause of morbidity in the newborn. The most common etiologic agents remain GBS and E. coli.

Concordant posterior urethral valves in male monochorionic twins with secondary prune belly syndrome.

BACKGROUND: Posterior urethral valves (PUVs), the most common congenital cause of lower urinary tract obstruction, have been described to occur in identical and nonidentical twins. Until now, reports have been published on 15 cases of PUVs. AIM: We report a new case of concordant PUVs in one set of male monochorionic twins with secondary Prune Belly Syndrome. CASE REPORT: The twins were born by elective cesarean section at 38 weeks of gestation to a 36-year-old mother, gravida 6, para 6. On ultrasound perfomed at 18 weeks's gestation, both fetuses showed signs of PUVs. At birth, physical examination of both revealed a secondary Prune Belly Syndrome (PBS). Postnatal renal ultrasound confirmed the diagnosis of PUV. The two infants underwent transurethral resection of the valves after a cystoscopic evaluation of the urethra. Since this procedure, their voiding has been unremarkable with stable renal function and sterile urine until their discharge. CONCLUSION: We have documented a rare association between VUP and PBS in two monochiorionic twins. More studies are needed to throw light on the significance of the present associated anomalies.

In-hospital mortality of very preterm infants in a Tunisian neonatal intensive care unit: Prevalence and risk factors.

BACKGROUND: Prematurity is a major public health problem and it's associated with a high mortality and morbidity. In Tunisia, few investigations studied this area. AIM: To determine the rate and the risk factors of in-hospital mortality of very preterm infants. METHODS: We conducted a retrospective monocentric study. We included all premature Infants born at less than 326 weeks of gestation (< 33 Weeks) without major congenital anomalies admitted from January 2011 to December 2012 in the neonatal intensive care unit (NICU) of Charles Nicolle Hospital (Tunis-Tunisia). To determine in-hospital mortality related risk factors, we created and compared two groups:  group of "Survivors" until discharge from our hospital and group of "Dead" before discharge. Multivariable logistic regression models were used to assess the association between risk factors and in-hospital mortality. P-value < 0.05 was considered statistically significant. RESULTS: During the study period, 7606 livebirths (LB) were recorded; among them 113 were very premature infants. The prevalence of high prematurity was 1,4 % LB. Very premature infants were divided in 24 extremely preterm infant (13%) and 89 moderately preterm infants (87%). Mean weight at admission was 1338g (±349g) and the mean gestational age was 30 weeks (±1,7). The mean hospital stay was 26 days (±17days) with an average weight at discharge of 1942g (±249). Neonatal morbidity was mainly caused by respiratory distress (42%), early neonatal anemia (64%), intraventricular hemorrhagea (15%), associated-care health infection (37,6%). In hospital mortality rate was 32 %. Mortality risk factors identified through multivariate analysis were: extreme premature infant (p<0,05), extremely low birth weight (p<0,01) and circulatory disorders (p<0,05). CONCLUSION: Very preterm infant represented 1,4 % of all live births. The mortality rate of very premature infant is still high and mainly associated to neonatal respiratory distress. Improving prevention and neonatal management still very required.