[Time course of digital pressure during dialysis sessions in chronic hemodialysis patients. Prospective observational study of 49 patients]

OBJECTIVES

To describe and compare the evolution of digital pressure on both hands during a dialysis session in patients without digital ischemia, and to identify the parameters influencing the digital pressure.

MATERIALS

Patients with an upper limb vascular access were prospectively included. Digital systolic pressure on the third finger of both hands measured by photoplethysmography and brachial systolic pressure were recorded before dialysis (H0) and every hour (from H1 to H4).

RESULTS

Among 53 patients, 49 were included (exclusions: one surgery for ischemia, one hand tremor, two no consent). None of them had digital ischemia. Digital pressure homolateral to the vascular access was significantly lower compared with controlateral side before and during dialysis. Digital pressure significantly decreased on both sides during dialysis. Brachial pressure decreased significantly compared to H0. Only the brachial pressure decrease was correlated with the decrease of digital pressure. The digital pressure was less than 30 mmHg in six patients. No evidence of digital ischemia was reported after a 6-month follow-up.

CONCLUSION

To our knowledge, this is the first study showing a significant decrease of digital pressure in both hands during hemodialysis in patients without digital ischemia. Further studies are necessary to investigate which parameters can affect digital pressure and to look for clinical consequence of this measurement.

Intensive and prolonged treatment of focal and segmental glomerulosclerosis recurrence in adult kidney transplant recipients: a pilot study

No treatment has consistently induced long-term remission of proteinuria in adult patients with focal segmental glomerulosclerosis (FSGS) recurrence after kidney transplantation. We undertook an open-label, nonrandomized pilot trial of intensive and prolonged treatment of FSGS recurrence. Over an 18-month period, 10 adult kidney transplant recipients with FSGS recurrence received concomitantly high-dose steroids, intravenous cyclosporine for 14 days followed by oral cyclosporine therapy, and an intensive and prolonged course of plasma exchanges (PE). We compared this treatment with those of a control group of 19 patients with a FSGS recurrence transplanted between 1997 and 2005. Complete, rapid (mean 23 +/- 7 days) and sustained remission was obtained in 9/10 patients (90%) as opposed to 27% in the control group. At month 3 and month 12, proteinuria was 0.16 g/day (range 0.05-0.3 g/day) and 0.19 g/day (range 0.05-1 g/day) respectively. Only one patient remained in partial remission at month 12 but he had already lost two previous grafts due to FSGS recurrence. PEs were stopped at month 9 in all patients except for the patient with a partial remission who remains PE-dependent. This small pilot study provides very encouraging results demonstrating that this treatment rapidly achieves complete and sustained remission in a high proportion of patients.

A simple clinico-histopathological composite scoring system is highly predictive of graft outcomes in marginal donors

The predictive value of pre-implantation biopsies versus clinical scores has not been studied extensively in marginal donors. Pre-implantation biopsies were performed in 313 kidneys from donors that were > or = 50 years of age (training set, n = 191; validation set, n = 122). The value of the donor clinical parameters and histological results in predicting 1-year estimated glomerular filtration rate (eGFR) <25 mL/min/1.73 m(2) was retrospectively evaluated. In multivariate analysis, the only clinical parameters associated with low eGFR were donor hypertension and a serum creatinine level > or =150 micromol/L before organ recovery. Clinical scores (Nyberg and Pessione) were not significantly associated with graft function. Regarding histological parameters, univariate analysis showed that glomerulosclerosis (GS) (p = 0.02), arteriolar hyalinosis (p = 0.03) and the Pirani (p = 0.02) and chronic allograft damage index (CADI) (p = 0.04) histological scores were associated with low eGFR. The highest performance in predicting low eGFR was achieved using a composite score that included donor serum creatinine (> or =150 micromol/L or <150 micromol/L), donor hypertension and GS (> or =10% or <10%). The validation set confirmed the critical importance of taking into account biopsy and clinical parameters during marginal donor evaluation. In conclusion, clinical scores are weak predictors of graft outcomes with marginal donors. Instead, a simple and convenient composite score strongly predicts graft function and survival and may facilitate optimal allocation of marginal donors.

[Attitudes of teachers to tobacco smoking]

We aimed to evaluate the attitudes of teachers to tobacco smoking in Kalaa Kebira (a semi-urban region in the Tunisian Sahel). Data from 358 of 402 teachers surveyed were obtained using a self-completed questionnaire. The mean age of the teachers was 35.7 (SD 7.9) years. The prevalence of smoking was 29.3% (51.6% of men and 3.6% of women), and 79% of smokers were addicted to nicotine according to the Fagerström test. About 50% of the teachers were badly-informed about the dangers of smoking and 75.2% of smoking teachers did not refrain from smoking in front of their pupils. The lack of knowledge of teachers limits their role as a model and information source in the anti-tobacco struggle. It is essential to draw up an education programme for the teaching staff.

[Knowledge of patients with type 2 diabetes about their condition in Sousse, Tunisia]

We assessed the knowledge of 404 type 2 diabetic patients about their condition in order to evaluate the quality of diabetes education in primary health care units in Sousse in 2003. We found that knowledge was satisfactory in only 59% of the patients. Their knowledge about the definition of diabetes and its pathophysiology were the 2 main areas where knowledge was lacking: the proportion of correct answers were 62.6% and 50.3% respectively. More attention should be paid to educating diabetic patients within the chronic disease care national programme.

[Predictors of increased cardiovascular risk in hypertensive patients in frontline facilities in Sousse, Tunisia]

We assessed cardiovascular risk factors among 456 hypertensive patients in 7 health centres in Sousse. Cardiovascular risk was estimated according World Health Organization recommendations. Mean age was 65.6 (SD = 9.8) years, male:female sex ratio was 0.18. Cardiovascular risk was not influenced by sex, age or residence. However, patients with longer duration of hypertension and more frequent co-morbidity had a significantly higher cardiovascular risk. In addition 45.9% of patients on monotherapy had high cardiovascular risk compared with 40.6% of those treated with 2 or more drugs (P = 0.02). Non-compliance was not found to be associated with high risk.

Facteurs déterminants du contrôle glycémique des patients diabétiques de type 2 suivis en première ligne

PURPOSE

To determine the factors associated with poor glycemic control in type 2 diabetic patients followed in primary care units in Sousse, Tunisia.

METHODS

A cross-sectional study was conducted on a representative sample of type 2 diabetic patients followed at least two years in primary health care units in Sousse, Tunisia. Data were gathered from three sources: a self-administrated questionnaire, analysis of patient files and HbA1c level. HbA1c level was measured with turbidimetric immunoinhibition assay. Patients were considered well-controlled if glycated hemoglobin (HbA1c) was less than 7%, according to the American Diabetics Association (ADA) recommendations.

RESULTS

The study enrolled 404 type 2 diabetic patients. The mean age was 60.5+/-10.89 years, sex-ratio was 0.5, and mean disease duration 8.7+/-6.1 years. ADA recommendations were met by 16.7% of patients. Multivariate analysis using variables in relation with the patient, his/her family, the disease, the treatment and the health care unit, showed that only poor geographic access to the care center (adjusted OR: 1.89, p=0.009) and Body Mass Index (BMI) less than 30 kg/m2 (adjusted OR: 2.21, p=0.034) were significantly and independently associated with poor glycemic control.

CONCLUSION

Glycemic control in type 2 diabetic patients is poor. It depends strongly on geographic access to health care. Type 2 diabetic patients should be referred, as much as possible, to the nearest health care unit.

Le tabagisme des enseignants dans une commune du Sahel tunisien

INTRODUCTION

The aim of this study was to evaluate the scale of tobacco use among teachers in the district of Kalaa Kebira (a semi-urban region in the Tunisian Sahel).

METHODS

The study design was descriptive and cross sectional, employing a self administered questionnaire given to 402 teachers.

RESULTS

The response rate was 89%. The average age of respondents was 35.7 7.9 years. The global prevalence of smoking among teachers was 29.3% (men: 51.6%; women: 3.6%). 79% of smokers were addicted to nicotine according to the Fagerstrôm test. Half of the teachers were poorly informed about the hazards of smoking and 77.9% of smoking teachers didn't refrain from smoking in front of their pupils.

CONCLUSIONS

The teachers' lack of knowledge limits their effectiveness both as a role model and information relay in the war against tobacco.

Effectiveness of patient education on glycemic control in insulin treated patients in general practice

OBJECTIVE

To assess the effectiveness of a patient education program on diabetes control.

METHODS

A pre-test post-test pre experimental study was performed with 87 insulin treated diabetic patients followed in the chronic disease unit of Kelibia district (Nabeul, Tunisia). Subjects received education in 6 monthly sessions. Outcome measures included glycated haemoglobin (HbA1c), anxiety level according to the Hamilton scale and Body Mass Index. Changes were assessed after the 6 month program.

RESULTS

HbA1c decreased from 8.8% +/- 1.23 to 7,6 +/- 1.43 (P<10-6) with an increase in the prevalence of satisfactory HbA1c (< or = 8%) from 33% to 61.2% (P<0,001). The prevalence of severe anxiety decreased by about a third (P < 0,001).

CONCLUSION

Education led to an improvement in diabetes control in insulin treated diabetic patients. More attention should be paid to such strategies in general practice.

[Drug prescription typology in primary healthcare centers in Tunisian Sahel]

The objective of this survey was to determine the typology of prescription drugs ordered in primary healthcare centers of the Tunisian Sahel. We conducted a cross sectional descriptive survey to analyze 2586 medical orders written by 20 general practitioners working in the public sector of the Sousse sanitary region. The sample included 5628 types of prescription for 209 pharmaceutical agents. More than half of the prescribed drugs (56%) belonged to two therapeutic families: anti-infectious agents and antalgesic-antiinflammatory agents. The 30 most prescribed drugs in general practice accounted for 80% of the prescription lines for agents belonging to 10 therapeutic families. In this "Top 30" list, we found seven antibiotics and four cardiology medicines. The prescription profile in primary healthcare in the Tunisian Sahel shows widespread use of drugs and reflects the diversity of the morbidity encountered in the general medicine setting which corresponds to an advanced "epidemiological transition" in this geographical area. The development of a "Top 30" list could be the starting point for more efficient pharmaceutical management and for more relevant education in therapeutics.

[Attitudes of general practitioners to pharmaceutical sales representatives in Sousse]

The therapeutic knowledge of physicians is the corner stone to the rational use of medicines; however information about medicines is generally obtained from the pharmaceutical industry via their sales representatives (reps). We aimed to identify general practitioners' (GPs) attitudes to pharmaceutical reps and the information they provide. We surveyed 140 GPs using a self-administered questionnaire. The response rate was 78% (72 GPs from the public sector and 68 from the private sector). About 10% of the GPs said they received daily visits from pharmaceutical reps; 84% of GPs considered them an efficient source of information and 31% said they might change their therapeutic prescribing following visits from these reps. Because of their positive perception of pharmaceutical reps, GPs are susceptible to the information they provide. Controlling the validity of the therapeutic information imparted by the pharmaceutical industry is thus a fundamental component of the programme for the rational use of medicines.

[Attitudes of general practitioners to pharmaceutical sales representatives in Sousse]

The therapeutic knowledge of physicians is the corner stone to the rational use of medicines; however information about medicines is generally obtained from the pharmaceutical industry via their sales representatives [reps]. We aimed to identify general practitioners’ [GPs] attitudes to pharmaceutical reps and the information they provide. We surveyed 140 GPs using a self-administered questionnaire. The response rate was 78% [72 GPs from the public sector and 68 from the private sector]. About 10% of the GPs said they received daily visits from pharmaceutical reps; 84% of GPs considered them an efficient source of information and 31% said they might change their therapeutic prescribing following visits from these reps. Because of their positive perception of pharmaceutical reps, GPs are susceptible to the information they provide. Controlling the validity of the therapeutic information imparted by the pharmaceutical industry is thus a fundamental component of the programme for the rational use of medicines