Antituberculous fight in the Maghreb: the balance sheet

The fight against tuberculosis remains a priority for world leaders: a re-emerging disease in developed countries, endemic elsewhere, it was declared in 1993, as a "world emergency" by the World Health Organization (WHO). The aim of programs is to prevent infection from spreading and perpetuating; the recommended strategies were the subject of common consent by expert committees convened by international agencies, primarily the WHO. As a result, programs of the Maghreb countries have great similarities. Though the regression in cases's number, especially primary and post-primary forms, as well as extensive, deleterious pulmonary tuberculosis in adults, the endemic persists. The proportion of extra-pulmonary tuberculosis (PET) is high. Control of "contacts" would be lacking or delayed in almost half of the cases. The cover by an effective treatment of these cases in Libya and in Mauritania stays below the required 85 %. Taken as a whole, the constituent countries of the Maghreb entity count approximately 78 000 tuberculosis patients for a population close to 100 million inhabitants, with an incidence rate of 76 for 100 000. Reducing the incidence of tuberculosis by 90 % and the mortality by 95%, to ensure that by the end of 2035 tuberculosis is no longer a public health problem is a goal within the reach of Maghreb countries. It can be postulated that by this deadline, the conditions for success will be met.

Central venous saturation is not an alternative to mixed venous saturation during cardiopulmonary bypass in coronary artery surgery patients

BACKGROUND

To evaluate the correlation and agreement between central venous saturation (ScvO(2)) and mixed venous saturation (SvO(2)) during cardiopulmonary bypass.

METHODS

Twenty-two consecutive patients scheduled for coronary artery surgery were prospectively included. Paired measurements of ScvO(2) and SvO(2) were performed 5 minutes after aortic cross-clamping, after each cardioplegia dose and after de-clamping of the aortic cross-clamp. ScvO(2) and SvO(2) were measured, respectively, by a fibreoptic catheter in the superior vena cava and on blood samples from the venous return line of the extracorporeal circuit, using a blood gas analyser

RESULTS

Ninety-five paired measurements of venous saturation were obtained. Correlation between the measurements was associated with an r = 0.55. The mean bias was 2.2 [Limits of agreement: -13.6%, +18%]. Changes in oxygen saturation over time showed an r = 0.4 and a mean bias of 0.2 [Limits of agreement: -17.9%, +18.3%]. Multivariate analysis identified the oxygen consumption index as the only factor explaining this variability.

CONCLUSIONS

Although mean biases between the measurements were low, limits of agreement were too large to provide a clinically acceptable estimation of SvO(2) by ScvO(2) in these conditions. Variations in regional oxygen consumption seem to be the main factor worsening the relationship.

Increased urinary type II collagen C-telopeptide levels in Tunisian patients with knee osteoarthritis

Osteoarthritis is characterized by a progressive degeneration of articular cartilage and loss of joint function. Clinical assessment of osteoarthritis is hampered by the lack of accurate measures of disease and disease progression, especially during the early stage.

BACKGROUND

To investigate urinary C-telopeptide fragments of type II collagen (CTX-II) levels in knee osteoarthritis in the Tunisian population compared with controls and to assess the association between this biomarker and radiological signs.

METHODS

One hundred and twenty five female patients with knee osteoarthritis, aged 53.6 +/- 7.6 years with disease duration of 3.6 +/- 3.8 years and 57 female age-matched controls underwent Lyon Schuss X-ray exams. Two experienced readers independently measured the joint space width (JSW) and classified each knee for severity using the Kellgren/Lawrence scale. The urinary concentration of CTX-II was measured by a competitive ELISA.

RESULTS

The levels of urinary CTX-II were significantly higher in knee osteoarthritis patients compared with controls (323.98 vs 218.04 microg/mol creatinine). A weak and non significant association between the CTX-II level and JSW was found. The significant correlations were observed between age and CTX-II in both groups and between BMI and CTX-II only in controls.

CONCLUSIONS

Analysis of CTX-II in urine samples of Tunisian patients with knee osteoarthritis provided a sensitive method to detect increased degradation of collagen type II in patients with osteoarthritis.

High frequency of autoimmunization among transfusion-dependent Tunisian thalassaemia patients

BACKGROUND

Limited data are available on the frequency of RBC alloimmunization and autoimmunization in transfusion-dependent Tunisian β thalassaemia patients.

MATERIALS AND METHODS

We analyzed the clinical and transfusion records of 130 patients (57 females and 73 males; mean age 119 months; range 12-11 months) with β thalassaemia major and who had regular blood transfusions for periods ranging from 12 to 311 months.

RESULTS

Of the 130 patients, ten (7.7%) developed RBC alloantibodies. The most common alloantibodies were directed against antigens in the Rh systems. Erythrocyte-autoantibodies as determined by a positive direct antiglobulin Coombs test, developed in 52(40%) patients with and without underlying RBC alloantibodies, thereby causing autoimmune haemolytic anaemia in eleven patients (21%).

CONCLUSIONS

Autoimmunization to erythrocyte antigens is a frequent complication in patients with β thalassaemia major. Several factors might have contributed to the high autoimmunization rate observed in this study, including non phenotypic blood exposure and alloantibody formation prior to positive Coombs test.

[Epidemiological study of the idiopathic dilated cardiomyopathy in Tunisia]

AIMS OF THE STUDY

Idiopathic dilated cardiomyopathy (IDC) is a complex disease. The interest of this study were to investigate the epidemiology characteristics of the disease and to evaluate the prognostic echocardiographic markers by region in order to highlight the existence of genetic risk factors and/or environmental and to identify those patients who could benefit from early treatment and better care to avoid further complications of the disease.

PATIENTS AND METHODS

This is a retrospective study based on the Fischer exact and bilateral Mann-Whitney test.

RESULTS

We included 526 patients with dilated cardiomyopathies of them we detected 50 cases of IDC including 12 families: The average age was 39,3±15.2 years. The sex ratio was 2.6. Mean left ventricular end-diastolic diameter (DIVGd) was higher in patients from the North East region (44.3±6.2mm/m(2)). Using Receiver Operating Characteristics (ROC) curve, we found a threshold value of 40mm/m(2). The odds ratio associated with this cutoff was 9.2.

CONCLUSION

Our results suggest that the prevalence and severity of IDC were higher in the North East region of Tunisia. Furthermore, large-scale prospective studies are needed to confirm these findings. In confirmation of a higher prevalence, a genetic study should be undertaken in this region.

Metabolic syndrome is associated with gastroesophageal reflux disease based on a 24-hour ambulatory pH monitoring

Several studies have focused on the relationship between metabolic syndrome and gastroesophageal reflux disease (GERD). They were based on GERD complications, whereas little is known about the association between metabolic syndrome and objectively measured esophageal acid exposure. The aim of our study was to assess the relationship between metabolic syndrome and GERD based on a 24-hour pH testing. It was a cross-sectional study including 100 consecutive patients who underwent a 24-hour pH-metry monitoring and were assessed for the five metabolic syndrome components as well as for body mass index (BMI). Among the 100 patients, 54 had a pathological acid GERD. The 46 GERD-free patients represented control group. Sex distribution was comparable between both groups but GERD patients were older than controls (44.59 vs. 37.63 years, P= 0.006) and more often obese or with overweight (83.3 vs. 60.9%, P= 0.01). Frequency of metabolic syndrome as a whole entity was higher among patients with GERD than those without GERD (50 vs. 19.56%; P= 0.002) with a crude odds ratio of 4.11 (95% confidence interval: 1.66-10.14). Multivariate regression analysis showed that metabolic syndrome as well as an age ≥ 30 years were independent factors associated to GERD but not BMI and sex. Abnormal waist circumference and fasting glucose level ≥ 100 mg/L were the only independent factors among the five components of metabolic syndrome. Metabolic syndrome but not BMI was an independent factor associated to GERD. These results confirm the hypothesis that central obesity is associated to GERD.

[Laryngotracheobronchial foreign body in children: predictive factors of respiratory sequelae]

BACKGROUND

Inhalation of laryngotracheobronchial foreign body in children is a serious accident that may compromise the prognosis of the child and the respiratory function in the long term.

AIM

identify the predictive factors of respiratory sequelae of laryngotracheobronchial foreign body inhalation.

METHODS

This retrospective study was conducted in the children hospital of Tunis during a period of nine years (2000 - 2008). In all statistical tests, the significance level was set at 0.05.

RESULTS

60 children were included in the study. The average age was 24.9 +/- 3.4 months. 2 / 3 of the children were boys. The foreign body was plant in 80% of cases. The penetration syndrome was reported in 83.7% of cases. The average time of stay of foreign body was 14 days. The chest radiograph was abnormal in 77.4% of cases. Endoscopic extraction was performed in 59 cases and a pneumectomy was conducted in one child. 30 children were followed for an average of 23 months. 18 children had not respiratory sequelae (clinical, radiological and scintigraphic). 10 children had respiratory sequelae (clinical and radiological and/or scintigraphic) at the last follow-up and four patients developed bronchial dilatation. Respiratory sequelae were correlated with the stay period of the foreign body exceeding 84H. Neither age, nor sex, nor the nature of foreign body or its location, nor the presence of radiological opacity at the initial radiograph, were predictive factors of respiratory sequelae.

CONCLUSION

The inhalation of foreign body is a serious accident affecting essentially male infants. Clinical, radiological and scintigraphic follow up is mandatory.

[Leg ulcers are rare in Tunisian women]

Numerous reports from Tunisia and Morocco have underlined the low frequency of leg ulcers in women from the Maghreb region in comparison with European women. This retrospective study describes patients hospitalized for leg ulcers in the Dermatology Department of Charles Nicolle Hospital in Tunis between January 1995 and December 2005. A total of 134 patients including 107 men and 27 women (M/F sex-ratio: 3.96) were hospitalized for leg ulcers. Venous leg ulcer was the most common accounting for 54.5% of cases overall, 57% of cases in men and 33.3% of cases in women (p = 0.028).

[Effect of tobacco smoking on pulmonary tuberculosis]

Tobacco increases the risk of pulmonary infection, especially tuberculosis. We try by this study to analyse this action. It's a comparative study between two groups of patients hospitalized in our department between January 2006 and June 2008. The first group was made of 30 smokers patients hospitalized because of confirmed pulmonary tuberculosis. The second group consists of 30 non smokers patients and also hospitalized because of confirmed pulmonary tuberculosis. Delay of diagnosis was longer in the group of smokers (3, 1 +/- 3 months versus 2 +/- 1 month with p = 0.039). The most frequent symptoms in both groups were cough and loss of weight. The biological investigations showed a high level of white blood cells with predominance of neutrophil cells especially in smokers (p = 0.024). Chest X ray showed essentially nodules in both groups. These nodules were bilateral in smokers (P = 0.045). Evolution after antituberculosis treatment was favourable for all patients. A delay of recovery (time between symptoms and recovery) was longer in smokers than in non smoker patients (p = 0.043). Pulmonary Sequels such as dyspnoea (p = 0.016) and fibrosis (p = 0.041) were most frequent in smokers. No patients had tuberculosis relapse. Tobacco may delay the recovery of pulmonary tuberculosis and may induce pulmonary sequels in spite of correctly antituberculosis treatment.

[Evaluation of the role of dietary intake in the occurrence of alopecia]

Transversal case-control study was conducted among 42 patients aged between 20 and 35 years who had diffuse alopecia. Alimentary inquiry according to the 3-day method was achieved in each case. The following nutriments were evaluated: total proteins, calcium, copper, iron, iodine, magnesium, manganese, phosphorus, potassium, selenium, zinc, omega 3 and omega 6. A control group (composed of 230 individuals), matched for age, gender and metabolic profile was established. These persons did not suffer from hair and nail disorder. The nutriments were codified according to the data of the software Food processor 8.3 version. The data were analyzed using "SPSS" 11.5 version. Comparisons of the means were performed using the Student's t test. ROC graphics allowed to determine the statistically significative limits for the comparison of both groups. On multivariate analysis, only a protein intake was directly associated to alopecia, odds ratio of 1,5 (1,06 - 2,3) p=0,02.

[Evaluation of the maternal mortality surveillance system in public facilities in Tunisia (1999-2004)]

We report the performance indicators in 2004 of a follow-up on the system for recording maternal deaths which was established in 1999. The system was operating in 69.8% of public hospitals, and 96% of maternal deaths investigations were completed. In 69.8% of maternal deaths there was a direct obstetric cause. Haemorrhage was the major cause of maternal death (30.8%), followed by eclampsia (11%). The proportion of avoidable (certain or possible) deaths was 75.3%. There were problems in evaluation of risk presented by women and inadequate follow-up during the postpartum period and delay in appropriate treatment. Incomplete documentation and difficulty in ascertaining avoidability were problems faced by the regional follow-up committee.

Waist circumference cut-off points for identification of abdominal obesity among the tunisian adult population

AIMS

Waist circumference (WC) is a convenient measure of abdominal adipose tissue. It itself is a cardiovascular disease (CVD) and diabetes-risk factor and is strongly linked to other CVD risk factors. There are, however, ethnic differences in the relationship of WC to the other risk factors. The aim of this study was to determine the optimal cut-off points of WC and body mass index (BMI) at which cardiovascular risk factors can be identified with maximum sensitivity and specificity in a representative sample of the Tunisian adult population and to investigate any correlation between WC and BMI.

METHODS

We used a sample of the Tunisian National Nutrition Survey, a cross-sectional population-based survey, conducted in 1996 on a large nationally representative sample, which included 3435 adults (1244 men and 2191 women) of 20 years or older. WC, BMI, blood pressure and fasting blood measurements (plasma glucose, total cholesterol, triglycerides) were recorded. Receiver operating characteristic (ROC) curve analysis was used to identify optimal cut-off values of WC and BMI to identify with maximum sensitivity and specificity the detection of high blood pressure, hyperglycaemia, high blood cholesterol and hypertriglyceridaemia.

RESULTS

ROC curve analysis suggested WC cut-off points of 85 cm in men and 85 cm in women for the optimum detection of high blood pressure, diabetes and dyslipidaemia. The optimum BMI cut-off points for predicting cardiovascular risk factors were 24 kg/m(2) in men and 27 kg/m(2) in women. The cut-off points recommended for the Caucasian population differ from those appropriate for the Tunisian population. The data show a continuous increase in odds ratios of each cardiovascular risk factor, with increasing level of WC and BMI. WC exceeding 85 cm in men and 79 cm in women correctly identified subjects with a BMI of >/=25 kg/m(2), sensitivity of >90% and specificity of >83%.

CONCLUSIONS

Based on the ROC analysis, we suggest a WC of 85 cm for both men and women as appropriate cut-off points to identify central obesity for the purposes of CVD and diabetes-risk detection among Tunisians. WCs of 85 cm in men and 79 cm in women were the most sensitive and specific to identify most subjects with a BMI >/=25 kg/m(2).

Low-dose X-ray depilatory treatment induces trichoblastic tumors of the scalp

BACKGROUND

Depilatory radiotherapy for ringworm was largely used before antifungals were available. Patients who underwent this treatment are at high risk of developing scalp tumors or other cancers. The aim of this study was to characterize scalp tumors occurring after X-ray therapy for ringworm.

METHODS

We included cases of postradiotherapy scalp tumors recorded at the Dermatology Department of the Charles Nicolle Hospital, Tunis between 1988 and 2001. We recorded clinical descriptions and all cases were resubmitted to microscopic analysis.

RESULTS

Sixty-one tumors occurred in 33 men and 12 women with a mean age of 49.8 years. Radiodermatitis was present in 21% of patients. Tumors were basal cell carcinomas in 47 cases, trichoblastomas in 10 cases and trichoblastic carcinomas in 4 cases. Twelve patients had 2-5 tumors, with combinations of tumor types in 3 of them. Mean delay of onset of tumors after radiotherapy was 39.4 years in basal cell carcinoma cases, 38.3 years in trichoblastoma cases and 35.6 years in trichoblastic carcinoma cases.

CONCLUSIONS

This series shows that although basal cell carcinoma is the most frequent tumor in this situation, trichoblastomas are common. We describe, for the first time, radio-induced trichoblastic carcinomas. Trichoblastic tumors have not yet been described in this context because this concept is relatively recent.

A study of skin diseases in Tunis. An analysis of 28,244 dermatological outpatient cases

BACKGROUND

Epidemiological studies of skin diseases are rather rare. Most of them are based on hospital attendance. The aim of this study was to determine the spectrum of skin diseases in the Tunis region.

METHODS

This prospective study encompasses consecutive patients attending a number of public or private dermatological outpatient clinics in Tunis from June 1999 to July 2000. Diagnosis was mainly based on clinical findings, but supplemented by further investigations when needed.

RESULTS

The total number of patients was 28,244, with 28,515 pathological conditions reported. The mean age was 31.6 years with a M/F sex ratio of 0.82:1. Infections constituted the major group of disorders (38.6%), followed by hair follicle and sebaceous gland diseases (14.3%), allergic skin diseases (13.6%), and tumors (7.8%). Infectious diseases included fungal (16.38), viral (9.9%), and bacterial (9.24%) conditions. Dermatitis accounted for 9.9% of cases and acne for 6.9%. Tumors were mainly benign (7%) and very rarely malignant (0.5%).

CONCLUSIONS

The survey revealed that more than 50% of the diseases were of infectious origin, followed by hair follicle and sebaceous gland disorders. Socioeconomic status and environmental factors may be responsible for this.

[Management of hyperopia in children]

PURPOSE

To study the prevalence of hyperopia in school-aged children and to analyze the factors that increase the risk of squint or amblyopia in a retrospective study.

METHODS

Three hundred eyes of 150 children with hyperopia who did not have anisometropia > or =1.5 D were selected. Complete ophthalmological examination was performed for all children. Hyperopia was defined when spherical equivalent was +0.5 D or greater. Amblyopia was screened and treated by patching therapy and then penalisation. Complete spectacle correction was achieved in children with high hyperopia (+3.5 D or greater) or in presence of squint or amblyopia. A statistical analysis compared the results using the Mann-Whitney test and the chi square test.

RESULTS

The mean age was 9.5+/-2.7 years. Girls were statistically more represented than boys. The mean sphere measured overall was +2 D (+/-1.65). Severe hyperopia was detected in 19% of the children; it was latent in 35% of children. Strabismus was detected in 7% and was accommodative in 25%. Esotropia was the most prevalent deviation (72.8%). The prevalence of amblyopia was 12%. The mean sphere measured in amblyopic children was 5.66 D (+/-1.64 D). Initial depth of amblyopia was mild to moderate and 98% of the children achieved iso-acuity after patching therapy. The correlation between severe hyperopia, amblyopia, and squint was statistically significant. Indeed, the risk ratios of squint and amblyopia, 5.2 and 3.70, respectively, were significantly high in children with severe hypermetropia. Complete spectacle correction improved final visual acuity and reduced the angle deviation in accommodative esotropia.

CONCLUSION

Children with hyperopia of +3.5 D or greater have an increased risk of amblyopia and squint that threatens their visual function. Hyperopic correction should be prescribed even if no strabismus or amblyopia is detected in order to prevent this risk. Screening programs should also be promoted to detect these children at an early age.

[Prevalence of osteoporotic fractures in Tunisian women]

PURPOSE OF THE STUDY

Osteoporotic fractures are an important public health problem due to significant morbidity and mortality and the socioeconomic burden. In Tunisia, the impact of such fractures is often underestimated due to lack of epidemiological data. We evaluated the prevalence of these fractures in a sample population at risk in order to better ascertain the amplitude of this problem in our country.

MATERIAL AND METHODS

This prospective study involved 2,000 menopaused women aged 50 years or more. The sample was randomly selected among the population of Manouba, an urban administrative district of the capital of Tunisia. One thousand three hundred eleven women agreed to participate in this survey. Women with a risk of secondary osteoporosis were excluded. We retained for study fractures related to primary osteoporosis. History taking recorded anthropometric data and medical history, particularly gyn-ob history. All fractures occurring after minor trauma, in women aged 50 years or more, and involving the femoral neck, the wrist, or the proximal humerus were noted. Lateral x-rays of the thoracolumbar spine were studied to search for unrecognized vertebral fractures.

RESULTS

The study population included 1,311 women, mean age 64.07 +/- 9.31 years, menopaused at mean 48.29 +/- 3.84 years. Among these women, 212 (16.2%) had presented a fracture at one of the localizations retained for study. Vertebral wedge fractures accounted for 59.83% of all fractures, wrist fractures 31.96%, proximal femoral fractures 4.51% and proximal humeral fractures 3.69%.

DISCUSSION

Osteoporotic fractures are not uncommon in women in Tunisia. Increasing life expectancy in our country suggests this public health problem will grow in the years to come, pointing out the importance of better management of osteoporosis to prevent fractures.

Analysis of cytomegalovirus (CMV) viremia using the pp65 antigenemia assay, the amplicor CMV test, and a semi-quantitative polymerase chain reaction test after allogeneic marrow transplantation

A pp65 antigenemia assay for polymorphonuclear leukocytes (PMNLs) (CINAkit Rapid Antigenemia), and a qualitative polymerase chain reaction (PCR) test for plasma 'PCR-P qual' (Amplicor cytomegalovirus [CMV] test) were performed for 126 samples (blood and plasma) obtained from 18 bone marrow transplant patients, over a 9-month surveillance period. Among those samples, 92 were assayed with a semi-quantitative PCR test for PMNLs 'PCR-L quant.' The number of samples with a positive CMV test for antigenemia and PCR-P qual assays was 20.63% and 12.7%, respectively, whereas the PCR-L quant assay was positive in 48 of the 92 samples assayed (52.17%). The rates of concordance of the results of PCR-P qual and antigenemia, PCR-P qual and PCR-L quant, antigenemia and PCR-L quant were 92%, 65.2% and 66.8%, respectively. The analysis of the results for the 92 specimens tested by all 3 methods showed a rate of concordance of 63% among all methods. Good agreement (kappa=0.72) was found only between pp65 Ag and PCR-P qual assays. Clinical disease correlates with an antigenemia high viral load. Three patients had CMV disease despite preemptive therapy, and all of them had graft-versus-host-disease (GVHD). PMNLs-based assays are more efficient in monitoring CMV reactivation, but for high-risk patients with GVHD, more sensitive assays (real-time PCR) must be done.

Mutations du gène HFE chez des β-thalassémiques majeurs tunisiens et surcharge en fer

OBJECTIVES

In this study we have determined the allele frequency of HFE mutations H63D and C282Y in a group of Tunisian beta-thalassemia major patients. These two mutations are implicated in hereditary hemochromatosis among Caucasians. In this study we wanted to correlate these mutations with the iron status in major beta-thalassemia patients.

DESIGN AND METHODS

Fifty Tunisian major beta-thalassemia were screening for the C282Y and H63D by digestion of polymerase chain reaction products (RFLP). Serum ferritin level was measured by immunoenzymatic microparticular essay.

RESULTS

The allele frequency of H63D mutation was 17%. C282Y mutation was not present in our studied patients. No statistically significant difference of serum ferritin level was found between major beta-thalassemia with and without HFE mutations.

CONCLUSION

Our results suggest that H63D mutation is so frequent in Tunisian major beta-thalassemia patients than in the general population and that the coinheritance of H63D mutation does not influence the severity of iron overload in these patients.

[Difference albumin-transferrin interest in the iron deficiency detection in a cohort of 1288 schoolchildren in the district of Tunis]

Iron deficiency (ID) is the most common nutritional deficiency worldwide especially among young children, women in pregnancy and breastfeeding. This study was undertaken to assess the prevalence of ID in 1288 pupil ranging in age from 11 to 14 years. Haemoglobin (Hb), mean corpuscular volume (MCV), mean corpuscular Hb (MCH), serum iron (Fe) serum transferrin (Trf), serum ferritin (Ft) and an inflammtory proteic profil (IPP) were measured. The IPP combines the analysis of protein variations: protein results are converted in percent of normal values referenced for the technique used. It has been suggested that on the protein profile, an increase in serum transferrin level compared to a normal serum albumin level (DAT: difference albumin-transferrin), appears early in the course of ID. Iron deficiency was defined by a low serum ferritin (< 15 ng/mL) and/or a pathologic DAT (> 28%). Approximately, 33.8% of children had Ft < 15 ng/mL and 12,8% had DAT > 28% while ferritin values were in the normal range. Diagnosis performance (sensitivity, specificity and diagnosis efficacy) of ferritin and DAT were compared to the performance of high serum transferrin receptor (sTfR) values in 2 populations presenting or not a biological inflammation. Only the diagnosis efficacy of DAT was constant in both situations. In conclusion, the serum ferritin concentration is the first indicator of body storage iron identifying ID, however normal or elevated values of ferritin may be difficult to interpret particulary in the presence of inflammation. sTfR and DAT values are thus reliable indicators of ID in such circumstances.

The global diabetes pandemic: the Tunisian experience

OBJECTIVE

The prevalence of diabetes mellitus is known to be increasing rapidly worldwide, but few population-based surveys have been undertaken in Africa or the Middle East. The aims of this study are to report the prevalence of diabetes mellitus and impaired fasting glucose (IFG) in Tunisia, to compare the prevalence to previous studies and to analyse the relationship between diabetes and age, sex, area of residency and body mass index (BMI).

SUBJECTS AND SETTING

We have used data from the Tunisian National Nutrition Survey, a cross-sectional health study providing a large nationally representative sample of the Tunisian population including 3729 adults. We used the American Diabetes Association diagnostic criteria to determine the prevalence of diabetes mellitus and IFG.

RESULTS

The overall diabetes prevalence was 9.9% (9.5% in men and 10.1 in women) giving age-adjusted prevalence of diabetes of 8.5% (7.3% in men and 9.6% in women). Step-wise logistic regression showed age of more than 40 years, urban residency and high BMI to each be significantly and independently related to diabetes prevalence. The prevalence of diabetes mellitus has more than doubled in Tunisia over a 15-year period.

CONCLUSIONS

Our study has demonstrated a high prevalence of diabetes in the adult population with a wide difference among the rural and urban areas with an increased prevalence compared to previous studies. The results underline the need to increase public awareness and to emphasize the benefit of lifestyle modification in order to prevent type II diabetes.

[Skin diseases in the elderly: a multicentre Tunisian study]

INTRODUCTION

With progressive aging of populations, geriatric health care has become a major international issue for health authorities. However, little data is available about geriatric skin diseases. The aim of this study is to determine the pattern of skin disorders among elderly patients seen in private and public skin outpatient clinics in Tunis.

PATIENTS AND METHODS

We performed a prospective, multicentre and descriptive study of all new skin diseases diagnosed in dermatological outpatients aged over 65 years. This study lasted one year (June 1999 to July 2000) and evaluated the activity of eleven Tunisian dermatologists in private or public practice, who collated all cases of skin diseases diagnosed in their practices.

RESULTS

A total of 1518 patients with 1550 new diagnoses were examined. Mean age was 72.6 years with a sex M/F -ratio of 1.41. Fungal infections were the most common conditions (16.9%), followed by tumors 12.8% (benign 63.3%), eczema (11.9%), keratinization anomalies (8.7%), bacterial infections (8.7%), viral infections (6.8%) and pruritus (6.4%). Fungal infections were mainly represented by toe-web intertrigo and onychomycosis. Basal cell carcinoma and epidermoid cysts were the most common malignant and benign tumors respectively.

DISCUSSION

This study reflects the frequency of mycoses, benign tumors and eczema in elderly patients. This is consistent with the results of other studies of the literature showing eczema as the predominant skin disease. The high prevalence of mycosis in our study may be explained by climatic conditions (heat, moisture). Pruritus seems to be frequent in geriatric patients. Skin disorders are an important source of morbidity in elderly patients.

Prevalence of metabolic abnormalities in the Tunisian adults: a population based study

AIMS

To estimate the prevalence of individual metabolic abnormalities and the cluster of metabolic abnormalities in a representative sample of the Tunisian adult population and to identify their relationship with gender, age and residency. The definition used is an adaptation of the NCEP ATP III definition, using total cholesterol>or=5.2 mmol/l instead of HDL-cholesterol.

MATERIALS AND METHODS

We used a sample of the Tunisian National Nutrition Survey (TNNS), a cross-sectional health survey conducted in 1996, to estimate the nutritional status of the population. The TNNS included 2 927 adults aged 20 years or older who had measurements of height, body weight, waist circumference, blood pressure, fasting plasma glucose, total cholesterol and triglycerides. The cluster of metabolic abnormalities was defined as the presence of three or more metabolic abnormalities.

RESULTS

The prevalence of abdominal obesity, hypertriglyceridemia, high total cholesterol, high blood pressure and high fasting plasma glucose was, respectively, 9%, 23%, 24%, 45% and 15% in men and 33%, 19%, 29%, 44% and 15% in women. The prevalence of the cluster was more frequent in women than in men (18% versus 13%, P<0.001) and in those living in urban communities (21% in women, 16% in men) rather than rural communities (11% in women, 8% in men) (P<0.001). The prevalence also increased significantly with age (P<0.001).

CONCLUSION

The cluster of metabolic abnormalities and its components are common in the Tunisian adult population and prevalence increases significantly with female sex, urban residency and age.

Facteurs de risque de l’œdème maculaire diabétique

AIM

To determine the risk factors involved in the development of macular edema.

PATIENTS AND METHODS

A retrospective, case-control study conducted on 200 diabetic patients with diabetic retinopathy: 100 patients with macular edema and 100 control patients. All patients were examined using slit-lamp biomicroscopy completed by fluorescein angiography. A physical examination and the appropriate biological investigations were also carried out. Statistical significance was determined by the chi square test and Fisher's exact test. A value of p<0.05 was considered statistically significant.

RESULTS

The incidence of macular edema was significantly associated with longer duration of diabetes, a higher level of glycemia, the type of diabetes in the older onset group using insulin, the severity of diabetic retinopathy at baseline, and old age. Panretinal photocoagulation was also found as a risk factor for macular edema.

CONCLUSION

These data suggest that laser photocoagulation, reduction of hyperglycemia and better control of other factors may result in a beneficial decrease in macular edema.

Celiac disease in adult patients with type 1 diabetes mellitus in Tunisia

OBJECTIVE

Type1 diabetes mellitus may be associated with celiac disease. The prevalence of celiac disease as determined by screening among adult patients with type 1 diabetes is high with rates of 1.07.8% in Europe and U.S.A. The aims of the study are to determine the prevalence of celiac disease in adults with type 1 diabetes in Tunisia.

METHODS

348 consecutive adult patients with type1 diabetes were investigated prospectively and screened for celiac disease. The mean age was 28.45+/-10.74 years old. There were 176 females and 172 males. For the screening of celiac disease, we used immunoglobulin A (IgA) anti-endomysium (EMA) antibodies determined by an indirect immunofluorescence method. Anti-transglutaminase (tTG) antibodies were determined by an ELISA method. Those patients with positive results for anti EMA and or tTG were proposed for duodenal biopsy.

RESULTS

14 patients were positive for anti EMA and had high or a weak positive level of tTG antibodies. One patient from this group was already known to have celiac disease. Only 8 patients consented to biopsy and morphological changes were consistent with celiac disease in all cases. Prevalence of biopsy-proven celiac disease was 2.3% (95% CI=1.0-4.5%).

CONCLUSION

The present study confirms that celiac disease of adults is prevalent in type 1 diabetic patients in Tunisia. Serological screening for celiac disease in type 1 diabetes is important because many patients are asymptomatic and most are detected by the screening.

[Colonic expression of gamma-interferon and interleukin-10 in Crohn's disease and ulcerative colitis]

OBJECTIVE

The aim of this study was to investigate mucosal expression of INF-gamma and IL-10 in patients with Crohn's disease (CD) or ulcerative colitis (UC).

METHODS

Fourteen patients with CD and 11 patients with ulcerative colitis participated and 7 healthy subjects were also included. Study of the mucosal expression of INF-gamma and IL-10 was conducted using biopsies from healthy and damaged colons, using the inverse transcription and genetic amplification (RT-PCR) technique in real time (Taqman). Our results were expressed as ratio between messenger cytokine (mRNA) levels and ribosomal RNA level of a reference molecule (rRNA 18S), then multiplied by 108.

RESULTS

In the cases of Crohn's disease, the mucosa expressed increased INF-gamma and IL-10 compared with controls (respective medians: 23.03 vs. 1.87 p=0.04 and 20.61 vs. 2.13 p=0.08). A strong positive correlation was found in the mucosal expression of IL-10 and INF-gamma during CD (r=0.9 p<0.0001). In contrast, in patients with UC, the expression of INF-gamma and IL-10 were comparable to those observed in the controls (7.18 vs. 2.18 p=0.36 and 3.66 vs. 1.87 p=0.44).

CONCLUSION

During Crohn's disease, the expression of both IL-10 and INF-gamma was increased and strongly correlated, compared with the controls.

Vitamin D deficiency in Tunisia

This study seeks to estimate the status of serum 25-hydroxyvitamin D [25(OH)D] in a healthy section of the population in Tunisia and to compare the achieved results with other published data. A transverse descriptive inquiry was carried out between January and March 2002. Three hundred and eighty-nine subjects aged 20-60 years were included in the study. A questionnaire was used to investigate clinical characteristics: sunlight exposure to ultraviolet light and, for women, parity, breast feeding, whether or not they wore the veil, and menopause. A dietary investigation estimated calcium and vitamin D intake. Morning fasting blood was collected from each subject for the measurement of the following parameters: serum calcium, phosphorus, albumin, alkaline phosphatase, 25(OH)D, parathyroid hormone (PTH). Hypovitaminosis D was defined by a cut-off of 37.5 nmol/l. The population studied was largely female, for the greater part housewives. The accumulated prevalence of hypovitaminosis D was 47.6%, increasing with age. Hypovitaminosis is highly prevalent in women (P<0.001). Multiparity, menopause, wearing the veil, and calcium and vitamin D dietary intake are factors associated with hypovitaminosis D (P<0.05). Analysis of logistic regression shows that only multiparity and vitamin D dietary intake are independent predictive factors. The status of serum 25(OH)D in Tunisia resembles that in southern European countries rather than in Middle Eastern countries. Insufficient vitamin D diet intake, higher parity and wearing the veil explain this deficiency in Tunisia. Dietary enrichment or supplementation by vitamin D and a more outdoor lifestyle, especially for older people, should be seriously considered as a way to reduce this deficiency in Tunisia.

[Health transition in Tunisia over the past 50 years]

We describe the dramatic demographic, socioeconomic and health changes witnessed in Tunisia over the past 50 years. Demographically, the gross mortality rate and the infant mortality rate have gone from 19 per 1000 and 150 per 1000 respectively in 1956 to 5.7 per 1000 and 26.2 per 1000 now, and life expectancy at birth going from 50 to 72 years for the same period. Socioeconomically, the urban population has risen from 25% to 62%, the literacy rate from 15% to 73%, and the per capita income has increased 5-fold in real terms. Epidemiologically, the infectious and perinatal diseases prevailing in the 1960s have decreased whereas chronic and degenerative diseases have risen. The proportion of the GNP related to health expenditure has risen from 3.8% to 6.2%. The implication of these changes on the Tunisian health system and the need to adapt in terms of curative care and prevention of risks are discussed.

[Food intake during and outside Ramadan]

Nous avons exploré l’effet du jeune durant la mois de ramadan sur les habitudes alimentaires d’un groupe de 130 adultes en bonne santé, Pendant le ramadan, il y a une augmentation de la ration énergetique totale chez les étudiants et les parents, du fait d’un apport protéique et lipidique mais non glucidique, par rapport à l’alimentation pendant le reste de l’année. Le repas de rupture du jeune couvre à lui seul 65 % de la ration énergétique, 74 % de la ration lipidique, 71 % de la ration protéique et 56 % de la ration glucidique. Ces résultats montrent que le comportement alimentaire pendant le ramadan peut contribuer à l’amélioration de l’état nutritionnel des personnes à risque de carence nutritionnelle

[Food intake during and outside Ramadan]

We explored the effect of fasting in the month of Ramadan on the dietary pattern of a group of 130 healthy adults. During Ramadan, there was an increase in total energy intake, as a result of protein and lipid intake but not carbohydrate intake compared to the diet througout the rest of the year, in both students and parents. The meal eaten after sunset was an important contributor to calories (65%), lipids (74%), proteins (71%) and carbohydrates (56%). These findings show the eating behaviour during Ramadan may contribute to improved nutritional status of people at risk of nutritional deficiency.

[Current aspects of Pott's disease in Tunisia. 29 cases]

It is a retrospective study, reviewing all cases of vertebral tuberculosis recorded between 1989 and 1999 in La Rabta Hospital (Tunis). 29 patients have been included whose average age was 49 years. The main symptoms which appeared within a average period of six months were vertebral pain, associated with fever in half of the cases. The diagnosis of infectious spondylitis was made according to the results of Computer tomography in 26 cases. The diagnosis of infection was confirmed by characteristic histological pattern and/or culture biopsy. 27 patients were cured without complications except for 2 of them who developed a spinal cord compression. This complication was quickly stemmed by steroid therapy.