Burden and predictions of hospitalized injuries in a low-middle income country: results from a Tunisian university hospital

Injuries are responsible for a high premature mortality and disability. They are poorly explored in low and middle income-countries. We aimed to estimate the burden of hospitalized injuries in the Monastir governorate (Tunisia) according to the nature of the injury, trends and projections of hospitalizations for injuries up until 2024, and to identify the distribution of this disease burden based on age and sex. We performed a descriptive study from 2002 to 2012 including all hospitalizations for injuries. Data were collected from morbidity and mortality register of the University Hospital of Monastir (Tunisia). We estimated the burden of injuries using the Disability Adjusted Life Years (DALYs). We described injuries (crude prevalence rate (CPR) and age standardized prevalence rate (ASR)), related mortality (lethality and standardized mortality ratio (SMR)), trends and prediction for 2024. A total of 18,632 hospitalizations for injuries representing 10% of all hospitalizations during study period were recorded. Per 1000 inhabitants per year, CPR was 3.36 and the ASR was 3.44. The lethality was of 17.5 deaths per 1000 injured inpatients per year and the SMR was of 2.95 (Confidence Interval of 95%: 2.64-3.29). Burden related to injuries was 2.36 DALYs per 1000 population per year, caused mainly by Years of Life Lost (83.4%), most frequent among men aged under 40 years. The predicted ASR for 2024 was 4.46 (3.81-5.23) per 1000 person-years. Injuries to the head was the most prevalent (20.7%) causing 67.7% of DALYs; and increasing by 226% through 2024. Injuries had a high prevalence and an important burden in a Tunisian university hospital. Prediction showed increased prevalence for 2024. Preventive measures and a trauma surveillance register should be implemented soon.

Management of patients with cardiovascular diseases during Ramadan

During the month of Ramadan, over one billion Muslims observe a water and food fast from sunrise to sunset. The practice of this religious duty causes marked changes in eating and sleeping habits. With the increasing incidence of cardiovascular (CV) risk factors, the number of patients with CV pathologies who wish to fast is increasing worldwide, and in Tunisia, which is ranked as a high CV risk country. If fasting has been shown to be beneficial for the improvement of some metabolic parameters, its practice in patients with CV pathology remains debated. The Tunisian Society of Cardiology and Cardiovascular Surgery (STCCCV) in consultation with the National Instance of Evaluation and Accreditation in Health (INEAS) has established this document in the form of a consensus after having analysed the literature with the aim of addressing these questions: -What is the impact of fasting in patients with CV pathologies? -How to stratify the risk of fasting according to CV pathology and comorbidities? -How to plan fasting in patients with CV diseases? -What are the hygienic and dietary measures to be recommended during fasting in patients with CV pathologies? -How to manage medication during the month of Ramadan in patients with CV diseases?

Adverse childhood experiences and risky behaviours in two Tunisian University Hospitals

Introduction

According to the Health Word Organization (WHO), adverse childhood experiences (ACEs) have several harmful outcomes on mental health in adolescence and later life. We aimed at investigating the relationship between ACEs and risky behaviors among Tunisian health professionals.

Methods

A cross sectional study was conducted between November 2018 and March 2019 among health care workers in two University Hospitals in Tunisia. We assessed exposure to violence in the hospital, behavioral (cyberaddiction) and chemical addiction (tobacco and alcohol use). ACEs were screened using the Arabic validated version of the Adverse childhood experiences-International Questionnaire (ACE-IQ) developed by the WHO.

Results

A total of 546 health professionals were enrolled with a mean age of 34.5 ± 9.6 years and a majority being female (70%). Almost 34.8% were doctors. The majority of them (67.3%) reported exposure to physical violence at work by patient or their families. The most common hazardous practice was internet addiction (18.5%) followed by tobacco use (13.2%). All health risk behaviors were significantly more prevalent among males and youth (<35 years) (p < 0.01). After adjustment for violence at work and socidemographic characteristics, logistic regression revealed that ACEs especially physical violence (OR = 1.8; IC [1.1-2.9]), emotional abuse (OR = 4.5 [1.2-16.6]) and bullying (OR = 2.6 [1.6-4.2]) increase the risk of the adoption of addictive behaviors among health caregivers.

Conclusions

Policy makers might implement collaborative interventions with psychiatrics targeting the prevention of early life adversities, this could be helpful to delay the onset of risky behaviors.

Key messages

Exposure to early life adversities increase the risk of addictive behaviors among health caregivers. Collaborative interventions with psychiatrics targeting screening childhood adversities could be helpful to delay the onset of risky behaviours.

[Quality of "crisis communication" media during the COVID-19 pandemic in the Great Maghreb countries]

Objectif

Évaluer la qualité des supports de communication de crise, au cours de la pandémie de la COVID-19, dans trois pays du Grand Maghreb (Tunisie, Algérie, Maroc).

Méthodes

Il s’agit d’un audit de la conformité des communiqués de presse et des bulletins épidémiologiques, analysés via un référentiel de qualité, spécialement conçu par les auteurs. Ce référentiel, composé de cinq dimensions et de 50 items, cotés (0/1), a été appliqué par deux chercheurs en médecine préventive. La multiplication des notes par un coefficient de deux, a permis d’avoir un score partiel de 20 points pour chaque dimension et un score total de 100 points pour l’ensemble de la check list. La qualité des supports de communication a été jugée bonne au-delà des seuils de 15/20 pour les dimensions du référentiel et de 75/100 pour la totalité de la grille.

Résultats

Un total de 141 supports de communication a été inclus dans cet audit (Tunisie : 60, Algérie : 60, Maroc : 21). Le score global médian de la qualité de ces supports a été seulement de 56/100 (IIQ : [46–58]), sans variabilité notable entre les pays. La dimension la plus appréciée a été le « maintien de la confiance de la population » avec un score médian global de 14/20 (12/20 pour les bulletins épidémiologiques et 16/20 pour les communiqués de presse). La dimension la moins bien notée a été le « renforcement de la participation communautaire », avec un score médian de seulement 4/20 (6/20 pour les bulletins épidémiologiques et 4/20 pour les communiqués de presse).

Conclusion

La qualité des supports maghrébins de communication de crise, au cours de la COVID-19, a été insuffisante dans la majorité de ses dimensions et de ses items (dont surtout psychosociaux). Le renforcement des capacités des chargés de communication, dans l’élaboration des supports d’information, au cours des crises sanitaires, est indispensable et urgent.

Metabolic effects of Ramadan fasting in patients at high risk of cardiovascular diseases

Background and aim

The effects of Ramadan fasting on health are a little controversial. The present study is aimed at evaluating the metabolic effects on a group of 517 patients with ≥2 cardiovascular risk factors over a period running from 2012 to 2014.

Methods

Each patient was assessed at three visits: before, during, and after Ramadan. Demographical, clinical and biological tests were performed at each visit.

Results

Metabolically, we noted a significant and discrete rise in blood glucose level (+1.2 mmol/L), triglycerides (+0.3 mmol/L), cholesterol (+0.12 mmol/L) and creatinine (+3 µmol/L) during Ramadan. These disturbances decreased significantly after Ramadan. The same variations were observed among diabetics (n=323). However, there was a significant decrease in HbA1c after Ramadan (9.0% vs 7.6%, p<0.001). Our findings also revealed there was no significant correlation between variations of metabolic parameters and dietary intake. No acute metabolic incidents were reported during the study period.

Conclusion

The current study showed that Ramadan is responsible for a transient but well tolerated disturbance of metabolic parameters followed by a significant post-Ramadan improvement. These changes did not seem to be directly related to dietary intake.

Management of acute coronary syndrome in emergency departments: a cross sectional multicenter study (Tunisia)

Background

We aimed to describe diagnosed acute coronary syndrome (ACS) and its care management and outcomes in emergency departments (EDs) and to determine related cardiovascular risk factors (CVRFs).

Methods

We conducted a cross sectional multicenter study that included 1173 adults admitted to EDs for acute chest pain (ACP) in 2015 at 14 sites in Tunisia. Data included patients’ baseline characteristics, diagnosis, treatment and output.

Results

ACS represented 49.7% of non-traumatic chest pain [95% CI: 46.7–52.6]; 74.2% of ACS cases were unstable angina/non-ST-segment-elevation myocardial infarction (UA/NSTEMI). Males represented 67.4% of patients with ACS (p < 0.001). The median age was 60 years (IQR 52–70). Emergency medical service transportation was used in 11.9% of cases. The median duration between chest pain onset and ED arrival was two hours (Inter quartile ranges (IQR) 2–4 h). The age-standardized prevalence rate was 69.9/100,000 PY; the rate was 96.24 in men and 43.7 in women. In the multivariable analysis, CVRFs related to ST segment elevation myocardial infarction were age correlated to sex and active smoking. CVRFs related to UA/NSTEMI were age correlated to sex, familial and personal vascular history and type 2 diabetes. We reported 27 cases of major adverse cardiovascular events (20.0%) in patients with STEMI and 36 in patients with UA/NSTEMI (9.1%).

Conclusion

Half of the patients consulting EDs with ACP had ACS. Emergency medical service transportation calls were rare. Management delays were acceptable. The risk of developing an UA/NSTEMI was equal to the number of CVRFs + 1. To improve patient outcomes, it is necessary to increase adherence to international management guidelines.

[Bacteriology of acute exacerbations of chronic obstructive pulmonary disease in Tunisia]

INTRODUCTION

The role of bacteria, including atypical organisms, in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) has been assessed in various ways in Tunisia.

METHODS

This was a descriptive and analytical study of patients with a mean age of 68.3±10.5 years hospitalized for AECOPD. Bacteriological examination included a cytological sputum exam and serology for atypical organisms including Mycoplasma pneumoniae, Coxiella burnetii, Chlamydophila pneumoniae and Legionella pneumophila using standard techniques.

RESULTS

Of the 240 patients enrolled, 175 sputum cultures (73%) were considered significant. Twenty-nine cultures were positive (16.5%) and 31 microorganisms were isolated of which the most frequent were P. aeruginosa (25.8%), K. pneumoniae (16.2%), H. influenzae (13%) and S. pneumoniae (9.7%). The prevalence of C. pneumoniae, M. pneumoniae and C. burnetii was 8.4%, 9% and 6.6%, respectively. No L. pneumophila infection was found. The Anthonisen criteria were associated with a positive culture (P=0.04). Almost half (40.9%) of the isolates were resistant to conventional first line antibiotics (43.7% to amoxicillin-clavulanic acid).

CONCLUSIONS

Awareness of the low positivity of quantitative sputum bacteriology and the large percentage of resistant strains with a predominance of exclusively multi-resistant Pseudomonas should help in the management of patients with AECOPD.

Effects of Ramadan fasting on platelet reactivity in diabetic patients treated with clopidogrel

Background

The effects of Ramadan fasting (RF) on clopidogrel antiplatelet inhibition were not previously investigated. The present study evaluated the influence of RF on platelet reactivity in patients with high cardiovascular risk (CVR) in particular those with type 2 diabetes mellitus (DM).

Methods

A total of 98 stable patients with ≥2 CVR factors were recruited. All patients observed RF and were taking clopidogrel at a maintenance dose of 75 mg. Clinical findings and serum lipids data were recorded before Ramadan (Pre-R), at the last week of Ramadan (R) and 4 weeks after the end of Ramadan (Post-R). During each patient visit, nutrients intakes were calculated and platelet reactivity assessment using Verify Now P2Y12 assay was performed.

Results

In DM patients, the absolute PRU changes from baseline were +27 (p = 0.01) and +16 (p = 0.02) respectively at R and Post-R. In addition, there was a significant increase of glycemia and triglycerides levels with a significant decrease of high-density lipoprotein. In non DM patients there was no significant change in absolute PRU values and metabolic parameters. Clopidogrel resistance rate using 2 cut-off PRU values (235 and 208) did not change significantly in DM and non DM patients.

Conclusions

RF significantly decreased platelet sensitivity to clopidogrel in DM patients during and after Ramadan. This effect is possibly related to an increase of glycemia and serum lipids levels induced by fasting.

Trial registration

Clinical Trials.gov NCT02720133. Registered 24 July 2014.Retrospectively registered.

Severe ranitidine-induced anaphylaxis: a case report and literature review

WHAT IS KNOWN AND OBJECTIVE

Ranitidine is a generally well-tolerated drug, and serious side effects are rare. However, ranitidine-induced anaphylaxis has been reported on rare occasions. We report on such a case and review other cases reported in the literature.

CASE SUMMARY

A 36-year-old man with no history of other medications, illnesses or allergic diseases, especially to drugs, consulted our emergency department because of renal colic and epigastric discomfort. He was given 50 mg of ranitidine as a slow intravenous bolus and 20 mg of piroxicam intramuscularly. Within the first minute, the patient developed a cold sweat, trembling, dyspnoea and deterioration of his consciousness. The condition was considered as an anaphylactic shock, and cardiopulmonary resuscitation and inotropic support were immediately commenced. Two days later, he was weaned off the ventilator as he was haemodynamically stable. He was discharged after 7 days. Four weeks later, skin prick tests to ranitidine and piroxicam were performed on the forearm of the patient. He reacted strongly to ranitidine about 10 min later but not to piroxicam. To assess cross-reactivity to other H2- and H1-receptor antagonists in our patient, we subsequently performed prick tests to famotidine, cimetidine and desloratadine and all were negative.

WHAT IS NEW AND CONCLUSION

We re-emphasize a potentially serious, albeit very rare, adverse effect of ranitidine and summarize other reported cases. This case demonstrates that commonly used, generally safe drugs may on occasions cause serious adverse effects.

Identification of two novel variants in PRKAG2 gene in Tunisian type 2 diabetic patients with family history of cardiovascular disease

We report the identification of two novel polymorphisms in the PRKAG2 gene and preliminary association study between 5'-UTR and exon 1 polymorphisms with susceptibility to type 2 diabetes. No association with type 2 diabetes was identified. However, one of these newly identified polymorphisms (p.Ser20Ile) is likely associated with cardiac disease.

High frequency of the V548A fs X572 XPC mutation in Tunisia: implication for molecular diagnosis

Xeroderma pigmentosum (XP, OMIM 278700-278780) is a group of autosomal recessive diseases characterized by hypersensitivity to UV rays. There are seven complementation groups of XP (XPA to XPG) and XPV. Among them, the XP group C (XP-C) is the most prevalent type in Western Europe and in the United States. We report here on the clinical and genetic investigation of XP-C patients in 14 Tunisian families. As the XPC V548A fs X572 mutation has been identified in Algerian and Moroccan populations, Tunisian patients were first screened for this mutation by a direct sequencing of exon 9 of the XPC gene. All patients with a severe clinical form had this mutation, thus showing the homogeneity of the mutational spectrum of XPC in Tunisia. A potential founder effect was searched and confirmed by haplotype analysis. Taking into account the similarity of the genetic background, we propose a direct screening of this mutation as a rapid and cost-effective tool for the diagnosis of XP-C in North Africa.

Prevesical hydatid cyst: an exceptional occurrence

Echinococcal cysts usually involve the liver; extrahepatic localization is reported in 11% of all cases of abdominal hydatid disease. We report a case of a prevesical hydatid cyst. A 53-year-old man was admitted with a large suprapubic mass. Ultrasonography and computed tomography revealed a cystic mass situated in front of the urinary bladder. There were no cysts in any other location. Serological tests were positive for Echinococcus. The patient was operated on and the cyst was completely excised. The pathologic examination confirmed the diagnosis of Echinococcosis. Isolated hydatid cyst situated in front of the urinary bladder has never been described in the literature. Hydatid cyst should always be considered in the differential diagnosis of abdominopelvic masses in endemic regions, before any procedure like puncture, biopsy or cystectomy, in order to avoid dissemination of the cystic contents or an anaphylactic shock.

Phlebotominae (Diptera: Psychodidae) of human leishmaniosis sites in Tunisia

In order to identify the phlebotomine sandfly populations in Tunisian leishmaniosis foci, an entomological survey was carried out through three entomological seasons (2002-2003-2004) in 19 visceral and cutaneous leishmaniosis areas, located in six bioclimatic zones. Sandfly collections were based on light and sticky traps placed around human leishmaniosis cases. 8,722 phlebotomine sandflies belonging to 12 species were collected. The dominance of subgenus Larroussius species in northern foci, Phlebotomus papatasi in south-western foci and their co-dominance in the centre of the country is in accordance with the distribution of Leishmania infantum and L. major in Tunisia. The low density found in the historical zoonotic cutaneous leishmaniosis focus of Metlaoui in the south-west may indicate the high competence of the local populations. Studied phlebotomine settlements have showed a low specific diversity in most of the studied sites. In L. infantum areas, the dominant species were respectively: P. perfiliewi in the cutaneous leishmaniosis site of the humid bioclimatic stage, P. perniciosus in the cutaneous and visceral leishmaniosis foci of semi-arid and arid bioclimatic stages and P. longicuspis in the visceral leishmaniosis focus of saharan bioclimate. In the zoonotic cutaneous leishmaniosis foci, P. papatasi was a dominant species. In the well-known south-eastern foci of cutaneous leishmaniosis due to L. killicki, P. sergenti was a dominant species with P. perniciosus. In the central emerging foci of L. killicki, P. perniciosus was a dominant species in some sites whereas it was very rare in others. In these sites, the subgenus Paraphlebotomus was always present with a higher abundance of P. alexandri than P. sergenti.

[Repeat suicide attempts: characteristics of repeaters versus first-time attempters admitted in the emergency of a Tunisian general hospital]

Repeat suicide attempts constitute a special problem in suicidology. It seems that the excess mortality by suicide is even higher among the suicide repeaters. The objectives of this study were to estimate repeat suicide attempts frequency among a sample of suicide attempters admitted in the University Hospital Emergency of Monastir (Tunisia), to compare their features to those of first-time attempters and to determine factors associated with repeat suicide.

METHOD

A transversal survey involves a review of all patients committing suicide attempt and who are admitted in the emergency service during the second semester of 1999. Study variables included: demographic parameters, family and personal psychiatric history, axis I psychiatric disorder and circumstances of the present suicide attempt. Also, subjects were evaluated with the following scales: Montgomery and Asberg Depression Rating Scale (MADRS) and The Social Readjustment Rating Scale of Holms and Rahe.

RESULT

Among the 90 suicide attempters, 42.2% (n = 38) had made at least one previous suicide attempt. More repeaters than first-time attempters were divorced or separated: 21.1% versus 5.8% (p = 0.05). Belonging to a numerous family (n > or = 4) was more frequent in the repeaters group: 73.7% versus 46.2% (p = 0.01). The two groups did not differ as to level of education but were significantly different with regard to their professional activity: 60.5% of repeaters were unemployed versus 34.6% of first-time attempters (p = 0.01). Repeaters had more loaded family psychiatric disorders: 26.3% versus 7.7% (p = 0.03). However there were practically no differences between repeaters and first-time attempters in regard of suicide in their families. Personal previous history of repeaters was characterized by frequency of psychiatric hospitalization: 50% versus 11.5% (p = 0.00005). Sexual abuse was more frequent in repeaters group but this difference was not significant. Alcohol and drug abuse were not frequent in the two groups. Concerning the actual suicide attempt, the most frequently diagnosed disorder was adjustment disorders. However depressive and psychotic disorders were significantly more frequent in the repeaters group: 34.2% versus 13.4% (p = 0.05). Repeaters had more frequently elevated scores (> 14) in MADRS: 71.1% versus 48.1% (p = 0.01), and raised intensity of stress factors lived during the six months preceding actual suicide attempt: 68.4% versus 42.3% (p = 0.04). Nevertheless we hadn't noticed any differences between the two groups regarding the methods used or the motives.

CONCLUSION

Differences in the characteristics of repeaters and first-time attempters are therefore of interest when discussing future suicidal risk and should clear on preventive actions in order to face the increase of suicidal recidivism. A broad based, multidisciplinary intervention approach is recommended.

Short-term treatment of severe hypertension of pregnancy: prospective comparison of nicardipine and labetalol

OBJECTIVES

To assess the efficacy and safety of nicardipine in comparison to labetalol in the initial management of severe hypertension in pregnancy. DESIGN. Randomized prospective study.

SETTING

The obstetric ward of the teaching hospital of Monastir Tunisia.

PATIENTS

Sixty consecutive pregnant women admitted beyond the 24th week of pregnancy with severe hypertension.

INTERVENTION

Patients were randomly assigned to receive intravenously for 1 h either labetalol ( n=30) or nicardipine ( n=30). Treatment was titrated to achieve a 20% lowering of blood pressure (BP).

MEASUREMENTS

Maternal BP and heart rate were measured at inclusion and repeatedly during the first hour following the drugs administration. Fetal heart rate was recorded throughout the study period. The main outcome endpoints were the success rate and the length of time needed to achieve the therapeutic goal. The rate of maternal and fetal adverse events and dose adjustments were also analyzed.

RESULTS

Labetalol and nicardipine achieved the 20% lowering in BP in the same proportion (63% and 70% success rates, respectively). Overall nicardipine caused a significantly greater decrease in systolic and diastolic BP. No patient had any episode of hypotension. The length of time to achieve the BP goal was also similar (12 vs. 11 min, respectively). Both drugs were well tolerated except for a moderate tachycardia observed with the use of nicardipine.

CONCLUSION

Nicardipine and labetalol are effective and safe in the initial treatment of severe hypertension of pregnancy.

Once daily oral ofloxacin in chronic obstructive pulmonary disease exacerbation requiring mechanical ventilation: a randomised placebo-controlled trial

BACKGROUND

The role of antibiotics in treatment of patients with moderate exacerbations of chronic obstructive pulmonary disease (COPD) is uncertain, but such treatment might be useful in very severe episodes. Our objective was to assess the effects of ofloxacin in patients with exacerbations of COPD who required mechanical ventilation.

METHODS

We did a prospective, randomised, double-blind, placebo-controlled trial in 93 patients with acute exacerbation of COPD who required mechanical ventilation. Patients were randomly assigned to receive oral ofloxacin 400 mg once daily (n=47) or placebo (46) for 10 days. Primary endpoints were death in hospital and need for an additional course of antibiotics, both separately and in combination. Analysis was by intention to treat.

FINDINGS

Three patients dropped out of the study. Two (4%) patients receiving ofloxacin died in hospital and ten (22%) did so in the placebo group (absolute risk reduction 17.5%, 95% CI 4.3-30.7, p=0.01). Treatment with ofloxacin significantly reduced the need for additional courses of antibiotics (28.4%, 12.9-43.9, p=0.0006). The combined frequency of death in hospital and need for additional antibiotics was significantly lower in patients assigned to ofloxacin than in those receiving placebo (45.9%, 29.1-62.7, p<0.0001). The duration of mechanical ventilation and hospital stay was significantly shorter in the ofloxacin group than in the placebo group (absolute difference 4.2 days, 95% CI 2.5-5.9; and 9.6 days, 3.4-12.8, respectively).

INTERPRETATION

New fluoroquinolones, such as ofloxacin, are beneficial in the treatment of COPD exacerbation requiring mechanical ventilation.

Continuous versus intermittent nebulization of salbutamol in acute severe asthma: a randomized, controlled trial

STUDY OBJECTIVE

This study was conducted to compare the clinical and spirometric effects of continuous and intermittent nebulization of salbutamol in acute severe asthma.

METHODS

Forty-two consecutive patients presenting to the emergency department for acute severe asthma (peak expiratory flow [PEF] mean+/-SD, 24%+/-12% predicted) were prospectively randomly assigned to receive 27.5 mg of salbutamol by either continuous or intermittent nebulization over a 6-hour period. The continuous nebulization group received 15 mg of salbutamol during the first hour and 12.5 mg over the next 5 hours. The intermittent nebulization group received 5 mg of salbutamol every 20 minutes during the first hour and 2.5 mg hourly over the next 5 hours. All participants received oxygen and intravenous hydrocortisone. Clinical and spirometric assessment was performed at baseline, 40 minutes, 60 minutes, and at 3 and 6 hours after the start of the nebulization. Secondary endpoints were the respective rates of hospitalization and treatment failure.

RESULTS

A significant clinical and spirometric improvement was observed in both groups over baseline as soon as the 40th minute and was sustained thereafter (absolute PEF increase at the sixth hour 30%+/-18% and 32%+/-22% in the continuous and intermittent nebulization groups, respectively; P <.01 over baseline). PEF and the clinical score evolved similarly in both groups. There was no difference between the groups regarding the failure rate of the initial bronchodilator treatment to terminate the asthma attack (3 [14%] in the continuous nebulization group and 2 [9.5%] in the intermittent nebulization group, absolute difference 4.5% [95% confidence interval -14% to 23%]). Eight (38%) patients and 9 (43%) patients from the continuous and intermittent nebulization groups, respectively, required hospitalization according to predefined criteria (absolute difference 4.8% [95% confidence interval -24% to 34%]).

CONCLUSION

We did not observe an appreciable difference between continuous and intermittent nebulization of salbutamol in acute severe asthma. The decision to use one of these nebulization methods should be based on logistical considerations.

Serotherapy in scorpion envenomation: a randomised controlled trial

BACKGROUND

Evidence for the benefit of scorpion antivenom, the only specific treatment for scorpion envenomation, is scarce, despite its common use. We did a prospective, randomised, controlled trial to assess the efficacy of routine administration of scorpion antivenom to scorpion-stung patients, irrespective of clinical severity.

METHODS

We included 825 consecutive patients older than 10 years, who presented to the accident and emergency department of the hospital in Tozeur, Tunisia. We graded severity by absence (grade I) or presence (grade II) of systemic manifestations of scorpion envenomation. Patients were randomly assigned placebo (n=413) or 20 mL bivalent intraveneous scorpion antivenom (n=412). All patients were observed for 4 h. Patients who developed life-threatening symptoms were admitted to the intensive-care unit. At the end of 4 h observation we reassessed grade and discharged grade II patients and admitted grade II patients. We assessed the preventive and curative effects of scorpion antivenom by prevention of worsening grade or by improvement from grade II to grade I.

FINDINGS

Distribution of severity grades was similar in the two groups at baseline, as were the cure rates (55% scorpion antivenom, 66% placebo, absolute difference, 11% [95% CI -4.8 to 26.8]; p=0.234). Preventive effects were seen in 94% and 96% of patients in the scorpion antivenom and placebo groups, respectively, who were initially grade I and who remained symptom-free (absolute difference, 2% [-1.27 to 5.27]; p=0.377). Time from scorpion sting to administration of scorpion antivenom did not affect curative and preventive effects.

INTERPRETATION

We found no benefit in routine administration of scorpion antivenom after scorpion sting, irrespective of clinical severity. Future studies should focus on patients with the most severe symptoms and signs.

Dobutamine in severe scorpion envenomation: effects on standard hemodynamics, right ventricular performance, and tissue oxygenation

OBJECTIVES

To document the effects of dobutamine on standard hemodynamics and right ventricular (RV) performance in patients exhibiting pulmonary edema following severe scorpion envenomation, and to characterize the tissue oxygenation profile in patients sustaining scorpion envenomation-related shock.

DESIGN

Prospective cohort study.

SETTING

An ICU in a university hospital.

PATIENTS

Nineteen consecutive patients were admitted to the ICU for severe scorpion envenomation; all 19 patients exhibited hemodynamic pulmonary edema, and 10 patients had peripheral shock.

INTERVENTIONS

All patients underwent a hemodynamic study with a Swan-Ganz catheter. In 8 of 19 patients, the thermodilution catheter was equipped with a fast-response thermistor.

MEASUREMENTS AND RESULTS

Standard hemodynamic parameters were recorded on admission and following the infusion of dobutamine in all patients at a dosage, from 7 to 20 microg/kg/min, intended to achieve the best hemodynamic and tissue oxygenation compromise. RV ejection fraction (RVEF) and RV volumes were simultaneously recorded in 8 patients, and tissue oxygenation parameters were assessed in the 10 patients with peripheral shock. The clinical signs of tissue hypoperfusion improved, and optimal hemodynamic parameters were achieved at a mean +/- SD dobutamine dosage of 17 +/- 7 microg/kg/min. Dobutamine infusion evoked statistically significant increases in cardiac index, from 2.3 +/- 0.6 to 3.6 +/- 0.7 L/min/m2; stroke volume index, from 18 +/- 5 to 31 +/- 10 mL/m2; and systemic arterial pressure, from 64 +/- 12 to 78 +/- 14 mm Hg. Pulmonary artery occlusion pressure (PAOP) and venous admixture decreased significantly: from 23 +/- 4 to 15 +/- 6 mm Hg and from 29 +/- 7% to 20 +/- 5%, respectively. With respect to RV function, dobutamine infusion significantly increased the RVEF, from 24 +/- 7% to 42 +/- 9%, without significantly changing the RV end-diastolic volume index, reflecting an enhanced RV contractility. In patients with peripheral circulatory failure, the baseline tissue oxygenation profile was consistent with cardiogenic shock, showing increased oxygen extraction as a consequence of a striking depression in oxygen delivery (DO2). After dobutamine infusion, DO2 improved significantly, from 386 +/- 104 to 676 +/- 156 mL/min/m2, with a significant decrease in oxygen extraction, from 34 +/- 8% to 24 +/- 6%.

CONCLUSIONS

In severe scorpion envenomation, dobutamine infusion improves impaired heart function. The effects involve both left ventricular and RV dysfunction. Impaired tissue oxygenation is also improved.

Efficacy of serotherapy in scorpion sting: a matched-pair study

BACKGROUND/OBJECTIVE

Although evidence of scorpion antivenin effectiveness in the clinical setting is lacking, scorpion antivenin is generally considered the only specific treatment for scorpion sting irrespective of its clinical severity. We conducted a matched-pair study to assess the efficacy of systematic administration of scorpion antivenin.

METHODS

Among 600 stung patients who participated in a study on the efficacy of high-dose hydrocortisone after scorpion sting, 135 (cases) had been treated with 10 to 20 mL intravenous scorpion antivenin (neutralizing 10 LD50 venom/mL). Controls were matched on disease severity on arrival to the emergency department. The severity of envenomation was graded I or II according to the absence (grade I) or the presence (grade II) of systemic manifestations of scorpion envenomation. Assessment of scorpion antivenin efficacy was based on the rate of changing severity grade in both groups (clinical improvement or worsening during an observation period of at least 4 hours).

RESULTS

Both groups were similar with respect to clinical severity (36 patients were graded II in each group), age, sex, time-lapse between scorpion sting and ED arrival, and the administration of adjunctive therapy such as hydrocortisone. By the 4-hour evaluation, 50% and 64% of patients initially graded II exhibited a substantial clinical improvement in cases and controls, respectively, suggesting similar effects in cases and controls. There was no difference in preventive effects: 13% and 10% of cases and controls developed systemic manifestations of scorpion envenomation during the 4-hour observation period; 23% of cases and 17% controls were hospitalized by this time. There was no difference in the duration of hospitalization. Three cases developed anaphylactic shock as a consequence of scorpion antivenin administration, while 1 scorpion antivenin-untreated patient died from refractory shock.

CONCLUSION

Systematic administration of scorpion antivenin irrespective of clinical severity did not alter the clinical course of scorpion sting. A prospective study is needed concerning the response of the more severe scorpion envenomations.

Intensive care use in a developing country: a comparison between a Tunisian and a French unit

OBJECTIVES

To compare the variations in intensive care (ICU) outcome in relation to variations in resources utilization and costs between a developed and a developing country with different medical and economical conditions.

DESIGN AND SETTING

Prospective comparison between a 26-bed French ICU and an 8-bed Tunisian ICU, both in university hospitals.

PATIENTS

Four hundred thirty and 534 consecutive admissions, respectively, in the French and Tunisian ICUs.

MEASUREMENTS

We prospectively recorded demographic, physiologic, and treatment information for all patients, and collected data on the two ICU structures and facilities. Costs and ICU outcome were compared in the overall population, in three groups of severity indexes and among selected diagnostic groups.

RESULTS

Tunisian patients were significantly younger, were in better health previously and were less severely ill at ICU admission (p < 0.01). French patients had a lower overall mortality rate (17.2 vs 22.5%; p < 0.01) and received more treatment (p < 0.01). In the low severity range, the outcome and costs were similar in the two countries. In the highest severity range, Tunisian and French patients had similar mortality rates, while the former received less therapy throughout their ICU stays (p < 0.05). Conversely, in the mid-range of severity, mortality was higher among Tunisian patients, and a difference in management was identified in COPD patients.

CONCLUSION

Although the Tunisian ICU might appear more cost-effective than the French one in the highest severity group of patients, most of this difference appeared in relation to shorter lengths of ICU stay, and a poorer efficiency and cost-effectiveness was suggested in the mid-range severity group. Differences in economical constraints may partly explain differences in ICU performances. These results indicate where resource allocation could be directed to improve the efficiency of ICU care.

Predictive value of severity scoring systems: comparison of four models in Tunisian adult intensive care units

OBJECTIVES

To compare the performance of four severity scoring systems: the Acute Physiology and Chronic Health Evaluation (APACHE) II, the new versions of the Mortality Prediction Model (MPM0 and MPM24), and the Simplified Acute Physiology Score (SAPS) II.

DESIGN

A prospective cohort study.

SETTING

Three Tunisian intensive care units (ICUs).

PATIENTS

Consecutive, unselected adult patients (n = 1325).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Overall, observed death rates were higher than predicted by all models except MPM0. All the evaluated scoring systems had good discrimination power as expressed by area under the receiver operating characteristics curve, but their calibration was less perfect when compared with original validation reports. There were no major differences between the models with regard either to discrimination or calibration performance.

CONCLUSION

Despite an overall good discrimination, APACHE II, MPM0, MPM24, and SAPS II showed a less satisfactory calibration in our Tunisian sample of ICU patients. Part of the models inaccuracy could be related to quality of care problems in our ICUs, but this issue needs further analysis.

Successful weaning from mechanical ventilation following balloon mitral commissurotomy

Successful weaning from mechanical ventilation (MV) following percutaneous balloon mitral commissurotomy (BMC) is reported in a 59-year-old woman with severe symptomatic rheumatic mitral stenosis. The patient was admitted to the Intensive Care Unit for acute respiratory failure secondary to pulmonary edema requiring intubation and mechanical ventilation. After resolution of the acute phase, she became completely dependent on mechanical ventilatory support. In spite of the reinforcement of conventional therapy (diuretics, digitalis, vasodilators), weaning attempts were unsuccessful because of persisting elevated left atrial pressure. Percutaneous BMC was performed with favorable hemodynamic results, allowing the removal of external ventilatory support 24 h later and discharge from the Intensive Care Unit the same day.

High-dose hydrocortisone hemisuccinate in scorpion envenomation

STUDY OBJECTIVE

Scorpion envenomation is a common life-threatening hazard in tropical and subtropical countries. Standard treatment is not clearly defined. Many therapies, such as steroids, are prescribed without experimental justification. We sought to assess the efficacy of systematic administration of intravenous hydrocortisone hemisuccinate (50 mg/kg) in scorpion envenomation.

METHODS

Six hundred consecutive envenomated patients older than 10 years who presented to the ED of a nonteaching secondary hospital in an area of Tunisia endemic for scorpion envenomation were randomly assigned to receive hydrocortisone hemisuccinate 50 mg/kg (n = 305) or placebo (n = 295) in addition to standard medical care. Patients in the two groups had similar clinical characteristics on initial clinical evaluation. Each was categorized as grade 1 (absence of systemic symptoms) or grade 2 (systemic symptoms of scorpion envenomation). Patients were treated in the ED for up to 4 hours or in the ICU, depending on clinical severity. Steroid and placebo groups were compared according to mortality rate, change of severity grade 4 hours after presentation and treatment, and duration of hospital stay.

RESULTS

Distribution of patients with respect to severity grade was similar in the two groups at the 4-hour clinical evaluation. We detected no significant difference at the time of discharge between steroid-and placebo-treated patients with respect to mortality (one patient in each group) or duration of hospital stay. Extra costs incurred through steroid administration totaled US $989,000.

CONCLUSION

Our findings do not support the use of intravenous high-dose steroids in scorpion-envenomated patients. The discontinuation of this practice would reduce costs substantially.