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Mycoplasma pneumoniae is a well-known cause of community-acquired pneumonia, mostly associated with dermatological manifestations especially with mucosal involvement and targetoid cutaneous lesions. For many years, it was considered among the spectrum of erythema multiforme. Recently, some authors have recommended the creation of a new syndrome called "mycoplasma-induced rash and mucositis." This new syndrome has distinct epidemiological, clinical and histological features making it different from drug-induced Stevens-Johnson syndrome, toxic epidermal necrosis and erythema multiforme. Herein, we report two patients with acute Mycoplasma pneumoniae respiratory tract infection presenting severe mucocutaneous lesions in accordance with this new syndrome.

Competing Interests: Competing interests: None.

The Muir-Torre Syndrome is a rare genodermatosis, defined by the occurrence of sebaceous neoplasia and internal malignancies and caused by mutations in the mismatch repair gene. We describe the case of 58-year-old man who, over the course of several years, had multiple skin lesions and colon cancer. The syndrome was diagnosed using Sanger sequencing, which allowed us to find the causative mutation., Competing Interests: None., (© 2022 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

Background: Within hospitals, intensive care units (ICUs) are particularly high-risk areas for medical errors and adverse events that could occur due to the complexity of care and the patients' fragile medical conditions. Assessing patient safety culture (PSC) is essential to have a broad view on patient safety issues, to orientate future improvement actions and optimize quality of care and patient safety outcomes. This study aimed at assessing PSC in 15 Tunisian ICUs using mixed methods approach., Methods: A cross-sectional mixed methods approach using a sequential explanatory design was conducted from December 2019 to January 2020. The first quantitative stage was conducted in 15 ICUs belonging to the two university hospitals in the region of Sousse (Tunisia). All the 344 healthcare professionals (clinical staff) working for more than 1 month in these ICUs were contacted in order to take part in the study. In the second qualitative stage 12 participants were interviewed based on purposive sampling., Results: All of the PSC dimensions had a score of less than 50%. The developed dimension was 'teamwork within units' (48.8%). The less developed dimensions were 'frequency of event reporting' (20.8%), 'communication openness' (22.2%) and 'non-punitive response to error' (19.7%). Interviews' thematic analysis revealed four main themes including "Hospital management/system failure", "Teamwork and communication", "Error management" and "Working conditions"., Conclusion: This research revealed that PSC is still in need of improvement and provided a clearer picture of the patient safety issues that require specific attention. Improving PSC through the use of quality management and error reporting systems may help to improve patient safety outcomes., (© 2022. The Author(s).)

Purpose: The increasing popularity of cosmetic surgery and its effect on facial recognition software has attracted the attention of many researchers. Indeed, after having undergone cosmetic surgery procedures, nonlinear modifications that are made to facial biometric landmarks may lead to difficulty in recognizing individuals, who received a surgery, by facial biometric systems. This finding motivated us to discuss this topic differently and take advantage of these modifications to objectively study the results of cosmetic surgery. In this study, we propose facial biometry as a new method to objectively describe face changes after facelift surgery., Patients and Methods: For this study, 37 women, aged between 50 and 80 years old, were selected. These patients underwent facelift surgery between January 2013 and December 2017. For comparison of the biometric facial features before and after facelift surgery, 7 direct measurements (4 linear and 3 angular) were performed., Results: There was no significant difference between real and preoperative apparent age as per the face recognition software: (63.35 years +/- 6.52 vs 64.54 years +/- 7.49, P = .188 > 0.05). The postoperative apparent age was significantly lower than the preoperative apparent age as per the face recognition software (58.97 years +/- 7.19 vs 64.54 years +/- 7.49; P < 10 -3 ). We found a statistically significant increase in the mean of the 3 ratios of the linear measures and a statistically significant modification in the means of the 3 angular measurements., Conclusions: Biometry enabled us to evaluate the preoperative and postoperative facial features of patients before and after facelift surgery and to determine objectively whether the estimated age was improved by the surgery., (Copyright © 2021 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Simulation is one of the educational tools that can be used in the learning process to help with smoking cessation., Aim: To synthesize all the publications studying the contribution of simulation as an educational tool in the acquisition of skills to help with smoking cessation., Methods: We performed a systematic review of the Francophone and Anglophone literature over the past 24 years (1997 to 2020) using the PubMed, Science Direct and Cochrane Library databases., Results: A total of 14 articles were included. The most used methods were thestandardized patient, role play and video projection with discussion. The simulation hasnot only proved its effectiveness in terms of acquiring knowledge and self-confidencein the management of the smoking patient in the short term, but also in the acquisition of verbal and non-verbal skills in the long term., Conclusion: This review highlighted the interest of simulation as an educational tool to acquire skills to help with smoking cessation regardless of the method used.

Nodular hidradenoma is a rare benign adnexal tumor that occurs as a solitary nodule with a predilection for the head, face, and upper extremities. We describe the case of nodular hidradenoma presenting as an expanding nodule on the scalp. This tumor is a simulator of malignant lesions on clinical and dermoscopic examination. Our case emphasizes the importance to identify this tumor as a differential for scalp lesions., Competing Interests: None., (© 2021 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

Background: Mutations in the SLC29A3 gene, which encodes the nucleoside transporter hENT3, have been implicated in syndromic forms of histiocytosis including H syndrome, pigmented hypertrichosis with insulin-dependent diabetes, Faisalabad histiocytosis and Familial Rosai-Dorfman disease (RDD). Herein, we report five new patients from a single family who present with phenotypes that associate features of H syndrome and Familial Rosai-Dorfman disease., Methods: We investigated the clinical, biochemical, histopathological and molecular findings in five Tunisian family members' diagnosed with Familial RDD and/or H syndrome. The solute carrier family 29 (nucleoside transporters), member 3 (SLC29A3) gene was screened for molecular diagnosis using direct Sanger sequencing., Results: Genetic analysis of all affected individuals revealed a previously reported missense mutation c.1088 G > A [p.Arg363Gln] in exon 6 of the SLC29A3 gene. Four affected members presented with clinical features consistent with the classical H syndrome phenotype. While their cousin's features were in keeping with Familial Rosai-Dorfman disease diagnosis with a previously undescribed cutaneous RDD presenting as erythematous nodular plaques on the face. This report underlines the clinical variability of SLC29A3 disorders even with an identical mutation in the same family., Conclusion: We report a rare event of 5 Tunisian family members' found to be homozygous for SLC29A3 gene mutations but showing a different phenotype severity. Our study reveals that despite a single mutation, the clinical expression of the SLC29A3 disorders may be significantly heterogeneous suggesting a poor genotype-phenotype correlation for the disease., (© 2021. The Author(s).)

Objectives: This study investigated the psychometric properties of the Cognitive Emotion Regulation Questionnaire in a Tunisian Arabic-Speaking population., Method: The CERQ original version was translated and back-translated and then administrated to 360 participants. Afterwards, using the explanatory and confirmatory factor analysis, we studied the latent factor structure for CERQ. The internal consistency of the subscales was assessed by Cronbach's alfa coefficients, and the test-retest and interscale reliability were assessed with Pearson correlations. The criterion validity was also examined using correlations between the CERQ subscales and both the Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) scales at first evaluation and at a one year follow-up., Results: The Tunisian version was quite satisfactory with the nine-factor structure, as in the original CERQ. Moreover, all validity and reliability measures were comparable to the original CERQ., Conclusion: The present study is the first work devoted to a Tunisian adaptation of the CERQ. Our findings highlight that the Tunisian version is both reliable and valid for the measurement of cognitive emotion regulation strategies., (Copyright © 2021 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Critical care nurses are considered the key to patient safety improvement and play a vital role in enhancing quality of care in intensive care units (ICUs) where adverse events are frequent and have severe consequences. Moreover, there is recognition of the importance of the assessment and the development of patient safety culture (PSC) as a strategic focus for the improvement of patient safety and healthcare quality, notably in critical care settings., Objectives: This study aimed to assess critical care nurses' perception of PSC and to determine its associated factors., Methods: This cross-sectional study was conducted among nurses working in the ICUs of the Tunisian centre (six Tunisian governorates). The study instrument was the French validated version of the Hospital Survey on Patient Safety Culture questionnaire, comprising 10 dimensions and a total of 50 items., Results: A total of 249 nurses from 18 ICUs participated in the study, with a participation rate of 87.36%. The dimensions scores ranged between 17.2% for the dimension "frequency of events reported" and 50.1% for the dimension "teamwork within units". Multivariable logistic regression indicated that respondents who worked in private hospitals were five times more likely to have a developed PSC (adjusted odds ratio [AOR]: 5.34; 95% confidence interval [CI], [2.28, 12.51]; p < 10 -3 ). Similarly, participants who worked in a certified hospital were two times more likely to have a more developed PSC than respondents who work in noncertified hospitals (AOR: 2.51; 95% CI, [.92-6.82]; p = 0.041). In addition, an increased nurse-per-patient ratio (i.e., reduced workload) increased PSC (AOR: 1.10; 95% CI, [1.02-1.12]; p = 0.018)., Conclusion: This study has shown that the state of critical care nurses' PSC is critically low and these baseline results can help to form a plan of actions for improvements., Competing Interests: Conflict of interest None., (Copyright © 2020 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Within the operating rooms (ORs), distractions occur on a regular basis, which affect the surgical workflow and results in the interruption of urgent tasks. This study aimed to observe the occurrence of intraoperative distractions in Tunisian ORs and evaluate associations among distractions, teamwork, workload, and stress., Methods: This observational cross-sectional study was conducted in four different ORs (orthopedic, urology, emergency, and digestive surgery) of Sahloul University Hospital for a period of 3 mo in 2018. Distractions and teamwork were recorded and rated in real time during the intraoperative phase of each case using validated observation sheets. Besides, at the end of each operation, stress and workload of team members were measured., Results: Altogether, 50 cases were observed and 160 participants were included. Distractions happened in 100% of the included operations. Overall, we recorded 933 distractions that occurred once every 3 min, with a mean frequency of M = 18.66 (standard deviation [SD] = 8.24) per case. It is particularly noticeable that procedural distractions occurred significantly higher during teaching cases compared with nonteaching cases (M = 3.85, M = 0.60, respectively, P < 0.001). The mean global teamwork score was M = 3.85 (SD = 0.67), the mean workload score was M = 58.60 (SD = 24.27), and the mean stress score was M = 15.29 (SD = 4.00). Furthermore, a higher stress level among surgeons was associated with distractions related to equipment failures and people entering or exiting the OR (r = 0.206, P < 0.01 and r = 0.137, P < 0.01, respectively). Similarly, nurses reported a higher workload in the presence of distractions related to the work environment in the OR (r = 0.313, P < 0.05)., Conclusions: This study highlighted a serious problem, which often team members seem to ignore or underestimate. Taking our findings into consideration, we recommend the implementation of the Surgical Checklist and preoperative briefings to reduce the number of surgical distractions. Also, a continuous teamwork training should be adopted to ensure that OR staff can avoid or handle distractions when they happen., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Burnout is a major issue among healthcare students and a public health issue in general. Indeed, the consequences of student burnout are as complex as other mental distress factors, such as those concerned with smoking and alcohol consumption, or an unhealthy lifestyle.  This study aimed to determine the prevalence of burnout among health sciences students and to determine its associated factors. This is a cross-sectional descriptive study conducted among 368 students of a Tunisian institution using the French validated version of the MBI-SS. The prevalence of burnout was 64.4%. The presence of a diagnosed health problem, a diagnosed mental disorder or sleep problems were associated with burnout. Students who live alone are significantly the most emotionally exhausted (p=0.010) and the most cynical (p=0.033). Students who had a low socio-economic level are significantly more cynical than those who had a medium or high socio-economic level (p=0.032). Performing leisure activities and practicing physical activities were associated with emotional exhaustion (p=0.007, p= 0.008, respectively).In our study, burnout is prevalent among Tunisian health sciences students. Many factors were found to be associated with this syndrome. These findings reinforce the need to establish early preventive strategies to encounter this problem and its consequent risks.

Background: Emergency departments (EDs) are considered a high-risk environment because of the high frequency of adverse events that occur within. Measuring patient safety culture is an important step that assists healthcare facilities in planning actions to improve the quality of care provided to patients. This study aims to assess patient safety culture within EDs and to determine its associated factors., Methods: A cross-sectional study conducted among professionals from all the EDs of public and private healthcare institutions in Tunisia. It spread from June to September 2017. We used the validated French version of the Hospital Survey on Patient Safety Culture questionnaire., Results: In total, 11 EDs were included in the study, with 442 participants and a participation rate of 80.35%. All the ten dimensions of patient safety culture were in need of improvement. 'Teamwork within units' scored the highest with 46%, however, the lowest score was attributed to 'the frequency of adverse events reporting' (19.6%). Several factors have been found significantly related to safety culture. Private EDs have shown significantly higher scores regarding nine patient safety culture dimensions., Conclusion: This study showed a concerning perception held by participants about the lack of a patient safety culture in their EDs. Also, it provided baseline results giving a clearer vision of the aspects of safety that need improvement., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Although efforts to manage coronavirus disease 2019 (COVID-19) pandemic have understandably taken immediate priority, the impacts on traditional healthcare-associated infection (HAI) surveillance and prevention efforts remain concerning., Aim: To describe trends in HAIs in a Tunisian university hospital through repeated point prevalence surveys over 9 years, assess the impact of measures implemented for COVID-19 pandemic, and to identify associated factors of HAI., Methods: The current study focused on data collected from annual point prevalence surveys conducted from 2012 to 2020. All types of HAIs as defined by the Centers for Disease Control and Prevention (CDC) were included. Data collection was carried out using NosoTun plug. Univariate and multivariate logistic analysis were used to identify HAI risk factors., Results: Overall, 2729 patients were observed in the 9 surveys; the mean age was 48.3 ± 23.3 years and 57.5% were male. We identified 267 infected patients (9.8%) and 296 HAIs (10.8%). Pneumonia/lower respiratory tract infections were the most frequent HAI (24%), followed by urinary tract infection (20.9%).The prevalence of infected patients increased from 10.6% in 2012 to 14.9% in 2020. However, this increase was not statistically significant. The prevalence of HAIs increased significantly from 12.3% to 15.5% ( P =.003). The only decrease involved is bloodstream infections (from 2% to 1%). Independent risk factors significantly associated with HAI were undergoing surgical intervention (aOR = 1.7), the use of antibiotic treatment in previous 6 months (aOR = 1.8), peripheral line (aOR=2), parenteral nutrition (aOR=2.4), urinary tract within 7 days (aOR=2.4), central line (aOR = 6.3), and prosthesis (aOR = 12.8), length of stay (aOR = 3), and the year of the survey. Young age was found as protective factor (aOR = .98)., Conclusion: Contrary to what was expected, we noticed an increase in the HAIs rates despite the preventive measures put in place to control the COVID-19 pandemic. This was partly explained by the vulnerability of hospitalized patients during this period.

Introduction: Metastasis is the primary cause of death among patients with colon cancer. Metastatic tumors in the oral cavity originating from the colon are rare, and the number of relevant clinical studies is limited., Case Report: We report a case of a 79 year old woman who developed a mandibular tumefaction. Biopsy was performed and made the diagnosis of metastasis from colon cancer. The patient received palliative radiotherapy for the mandibular mass lesion., Conclusion: Oral metastatic tumor from colorectal cancer is very uncommon and is often found with advanced recurrent cancer. Therapeutic management that includes palliative treatment is the usual therapeutic option.

Purpose: This study aimed to assess patient safety culture (PSC) in intensive care units (ICUs) and to determine the factors affecting it., Materials and Methods: This is a cross-sectional study, conducted from October to November 2017 among professionals practicing in the ICUs of the Tunisian center. After obtaining institutional ethics committee's approval and administrative authorizations, an anonymous paper-based questionnaire was distributed to the participants after obtaining their consent to take part in the study. The measuring instrument used is the French validated version of the "Hospital Survey on Patient Safety Culture" questionnaire., Results: A total of 402 professionals, from 18 ICUs and 10 hospitals, participated in the study with a participation rate of 82.37%. All dimensions were to be improved. The most developed dimension was teamwork within the unit (47.87%) and the least developed dimension was the non-punitive response to error (18.6%). Seven dimensions were significantly more developed in private institutions than in public ones. Results also show that when workload is reduced, the PSC was significantly increased., Conclusion: This study has shown that the PSC in ICUs needs improvement and provided a baseline results to get a clearer vision of the aspects of security that require special attention., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Hand hygiene (HH) is considered the most important measure to tackle the transmission of healthcare-associated pathogens. However, compliance with recommendations is usually low and effective improvement strategies are needed. We aimed to assess the effectiveness of an intervention targeting hand hygiene promotion among healthcare workers (HCWs)., Methods: We conducted a pre-post interventional study design in the university hospital Sahloul, Sousse, Tunisia, from January 2015 to December 2016. The intervention program consisted of training sessions and distribution of posters of hand hygiene guidelines. To assess the evolution of HH observance at pre- and post-intervention, the same observation form was distributed and collected at healthcare workers' workplace., Results: Of the 1201 and 1057 opportunities for hand hygiene observed among all categories of HCWs, overall compliance enhanced significantly from 32.1 to 39.4% (p < 0.001) respectively at pre- and post-intervention. Nurses were the most compliant with a significant improvement from 34.1 to 45.7% (p < 0.001) respectively at pre- and post-intervention. Furthermore, analysis by department showed significant improvement of compliance in orthopedic department (p < 0.001), maxillofacial-surgery department (p < 0.001), pediatrics department (p = 0.013), and emergencies (p = 0.038)., Conclusion: This study showed the feasibility and effectiveness of a health-setting-based intervention to enhance hand hygiene observance in the context of a developing country.

Introduction: Congenital hypoplasia of the depressor anguli oris muscle is a rare mimic disorder depicted by a lower lip asymmetry apparent when laughing or crying., Presentation of Case: A 10-year-old boy consulted our department for an asymmetry when opening his mouth. According to the family, this asymmetry was present since birth. Perinatal characteristics and childhood medical history were investigated with no abnormalities. Physical exam revealed an inability to draw down the right lower lip unilaterally. At rest position, facial asymmetry was not noticeable. Several investigations were done: A CT scan of the petrous part of the temporal bone, an MRI of soft tissues, an electromyography and a heart ultrasound. No anomalies were found., Discussion: This condition has stimulated great interest because of its potential association with congenital anomalies but also in order to reassure families often worried by the situation. A large therapeutic armamentarium is described in literature., Conclusion: Among the large armamentarium of therapeutic options, we opted for a wait and see strategy through photographic smile tracking leading to an evidence of Asymmetric crying faces over time improvement., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction. Tunisia is an intermediate hepatitis B virus (HBV) endemic country. The vaccination against hepatitis B was introduced in 1995 including four doses with a first dose administrated at birth. Decreasing the level of antibodies against hepatitis B surface antigen (anti-HBs) over time can be alarming. This study was conducted to explore the anti-HBV immune response among children under 6 years old, vaccinated according to the national vaccination schedule, by evaluating the immunological response to primary vaccination and by exploring the anamnestic immune response to a booster dose. Methods. We conducted a cross-sectional prospective study from June 2016 to June 2017 ( n =180), based on voluntary participation. Children were recruited from the public pediatric ward sectors in Sahloul University Hospital of Sousse in Central Tunisia. An anti-HB titre was determined based on electro-chemiluminescence micro-particle immunoassay (ECLIA), using Elecsys Anti-HBs II kit, Roche. Results. Mean age at the time of enrollment in the study was 33±14.8 months. The seroprotection rate was 77.2 %. The anti-HB titre differed significantly between the different age groups ( P =0.002). The predicting variable for having no seroprotective antibody level was older age. Children with anti-HB levels <10 IU l - 1 were offered an additional dose of HBV vaccine. Anamnestic response 1 month after the challenge dose was observed in 100 % of subjects. The probability of developing a high antibody response, following the booster dose increased in conjunction with an increased pre-booster antibody level. Conclusion. The response to a booster dose suggests the persistence of immune memory in almost all vaccinated individuals. Although a booster dose increases substantially anti-HB titre, the clinical relevance of such an increase remains unknown.

Purpose: Several studies raised the effects of Ramadan fasting on healthy adults spirometric data, but none was performed in children. The aim of this study was to compare the spirometric data of a group of faster adolescents (n = 26) with an age-matched non-faster one (n = 10)., Methods: This comparative quasi-experimental study, including 36 healthy males aged 12 to 15 years, was conducted during the summer 2015 (Ramadan: June 18 to July 16). Three sessions (Before-Ramadan [Before-R], Mid-Ramadan [Mid-R], After-Ramadan [After-R]) were selected for spirometry measurements. Spirometry was performed around 5.5 to 3.5 h before sunset and the spirometric data were expressed as percentages of local spirometric norms., Results: The two groups of fasters and non-fasters had similar ages and weights (13.35 ± 0.79 vs 12.96 ± 0.45 years, 46.8 ± 9.2 vs 41.7 ± 12.6 kg, respectively). There was no effect of Ramadan fasting on forced vital capacity (FVC), forced expiratory volume in 1 s (FEV 1 ), FEV 1 /FVC, peak expiratory flow, and maximal mid-expiratory flow. For example, during the Before-R, Mid-R, and After-R sessions, there was no significant difference between the fasters and non-fasters mean FVC (101 ± 11 vs 99 ± 14, 101 ± 12 vs 102 ± 14, 103 ± 11 vs 104 ± 13, respectively) or FEV 1 (101 ± 13 vs 96 ± 16, 98 ± 11 vs 97 ± 16, 101 ± 10 vs 98 ± 16, respectively)., Conclusions: Ramadan fasting had no interaction effect with the spirometric data of Tunisian healthy male adolescents., Competing Interests: Declaration of Conflicting Interests:The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: HBS reports personal fees from AstraZeneca, Saiph, Teriak, and Chiesi. The remaining authors declare that they have no conflicts of interest concerning this article.

No previous study has evaluated the effects of RF on inflammatory and hematological indices of COPD patients. The main objective of the present pilot study was to assess the effects of RF on some inflammatory and hematological indices measured in male patients with stable COPD. Fifteen COPD patients (mean ± SD of age: 71 ± 6 years) who fasted during Ramadan 2017 volunteered for the study. Three sessions (Before-Ramadan, End-Ramadan and After-Ramadan) were selected. Spirometry tests and blood samples were consistently performed 2.5-4.5 hr before the interruption of the fasting. Assessment sessions comprised: spirometry, inflammatory [erythrocyte sedimentation rate (ESR); C-reactive protein (CRP)] and hematological [red and white blood cells (RBC, WBC); hemoglobin; hematocrit; mean corpuscular volume; mean corpuscular hemoglobin; platelets] indices. Findings were analyzed by applying Friedman ANOVA. The median (lower-upper quartiles) of ESR (Before-Ramadan: 3 (2-9), End-Ramadan: 7 (0-13), After-Ramadan: 9 (5-15) mm/h) and CRP (Before-Ramadan: 20 (11-38), End-Ramadan: 15 (9-34), After-Ramadan: 20 (12-46) mg/L) were not significantly affected by RF. Among all the hematological indices, RF influenced only hemoglobin (Before-Ramadan: 14.4 ± 2.2, End-Ramadan: 13.4 ± 1.3, After-Ramadan: 12.2 ± 0.9 g/dL), hematocrit (Before-Ramadan: 45 ± 7, End-Ramadan: 40 ± 4, After-Ramadan: 39 ± 4%), RBC (Before-Ramadan: 5.1 ± 1.0, End-Ramadan: 4.6 ± 0.7, After-Ramadan: 4.4 ± 0.5 10 6 /mm 3 ) and WBC (Before-Ramadan: 8,673 ± 1,911, End-Ramadan: 7,840 ± 1,526, After-Ramadan: 9,507 ± 2,190/mm 3 ). Compared to the Before-Ramadan session, the End-Ramadan session values for hemoglobin, hematocrit, RBC and WBC were lower. Compared to the After-Ramadan session, the End-Ramadan session values for hemoglobin and WBC were higher and lower, respectively. In conclusion, RF caused significant reduction in hemoglobin, hematocrit, RBC and WBC. However, it did not induce any significant changes in the CRP and ESR indices.

Aims: The main aim was to compare aerobic performance data, determined before «period1» and after «period2» cold water immersion in two groups of footballers (CWI and no-CWI groups)., Methods: This is an experimental study with matching and randomization. The 20 male footballers, aged 17 to 20 years, were divided into two groups (n = 10 for each) following a random draw. The two groups were age-, height- and weight matched. 1000-m race was made during the two periods. Heart-rate (HR, % of theoretical maximum HR) and hemoglobin oxygen saturation (Oxy-sat, %) were measured before and after the race, and the time of the race (min) was noted. An Oxy-sat decrease > 4 points retained the diagnosis of exercise-induced desaturation. Eight CWI sessions (one per week), until the hip in a standing position (10 min; temperature: 11-12 °C) were performed., Results: The two groups were age-, height- and weight matched. Comparatively to the race time of «period1», this of «period2» was decreased in the CWI group (3.21±0.04 vs. 3.15±0.04 min) and was increased in the no-CWI group (3.23±0.05 vs. 3.27±0.07 min). Comparatively to the HRs (before, after the race) of «period1», these of «period2» were decreased in the CWI group (36±1 vs. 34±1%; 56±3 vs. 44±2%) and were increased in the no-CWI group (35±2 vs. 36±1%; 55±2 vs. 57±2%). Comparatively to the after race Oxy-sat' of the «period1», this of «period2» was increased in the CWI group (96±1 vs. 98±0%) and was decreased in the no-CWI group (96±1 vs. 95±1%). While in the CWI group, the percent of desaturators was decreased between «period1» and «period2» (30 vs. 0%), in the no-CWI group, percentages remained similar (50 vs. 90%)., Conclusion: CWI improves aerobic capacity and muscle strength of young footballers.

Background: Zoonotic visceral leishmaniasis (ZVL) caused by Leishmania infantum is endemic with an epidemiological profile of a paediatric disease in Tunisia. In the context of a high fatality rate, identifying risk factors for in-hospital mortality in children treated for ZVL is of major epidemiological importance., Design: A retrospective (case-control) study included 230 immuno-competent children diagnosed and confirmed with primary ZVL in the paediatric department of the University Hospital of Kairouan between 2004 and 2014. Forty-seven per cent (47%) were children under 18 months of age, and with a male ⁄ female ratio of 1.01:1., Results: The overall case-fatality was 6% (n = 14). The risk factors for in-hospital death identified by a multivariate analysis were: bleeding at admission (OR = 25.5, 95% CI: 2.26-287.4; p = 0.009), white cell count less than 4000/mm3 (OR = 5.66, 95% CI: 1.16-27.6; p = 0.032), cytolysis (OR = 28.13, 95% CI: 4.55-173.6; p < 0.001), and delay between onset of symptoms and admission ≥ 15 days (OR = 11, 95% CI: 1.68-72; p = 0.012)., Conclusion: The results strongly suggest that paediatric patients admitted 15 days after onset of symptoms, with bleeding, white cell counts below 4,000/mm3, and cytolysis at admission should be considered severe cases and subsequently, they are at high risk of mortality. A better understanding of factors associated with death of children from ZVL may contribute to decrease mortality.

Objective: To assess the patient safety culture (PSC) in operating rooms (ORs) and to determine influencing factors., Design: A cross-sectional descriptive multicenter study which was conducted over a period of 7 months (October 2014-April 2015) using the French validated version of the Hospital Survey On Patient Safety Culture questionnaire., Setting: Of the note, 15 ORs of public and private healthcare institutions., Participants: In total, there were 368 participants including surgeons, anesthesiologists, surgical and anesthesia technicians, nurses and caregivers, divided into 316 professionals exercising in public sector and 52 working in private one., Main Outcome Measure(s): A self-administrated questionnaire investigating 10 dimensions of PSC (including 45 items), two items examining the staff perception of patient safety quality and reporting events, and five items regarding demographic characteristics of respondents., Results: The participation rate in the study was 70.8%. All 10 dimensions were to be improved. The overall perception of patient safety had a score of 34.9%. The dimension that had the lowest score (20.5%) was the non-punitive response to error, and the one that had the highest score (41.67%) was teamwork in the ORs. Three dimensions were developed in private sector, and none in public hospitals., Conclusion: This study showed that the level of the PSC needs to be improved not only in public hospitals but also in private ones. The obtained results highlight the importance of implementing quality management systems and developing PSC., (© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

The hypercoagulable state accompanying inflammatory bowel diseases (IBDs) is still poorly understood. The aim of this study was to assess antiphospholipid antibodies (APAs) and a large panel of inherited and acquired thrombotic markers simultaneously in a sample of Tunisian patients with IBD. In total, 89 consecutive patients with IBD (mean age 38 ± 15 years; 48 with Crohn disease and 41 with ulcerative colitis) and 129 controls were prospectively evaluated for immunoglobulin (Ig) G, IgM, and IgA antibodies against cardiolipin (aCL), β2glycoprotein I (aβ2GPI), and prothrombin (aPT); IgG and IgM antibodies against phosphatidic acid (aPA), phosphatidylinositol (aPI), and annexin V (aAnnV); lupus anticoagulant (LA); coagulation factors; natural inhibitors; and thrombotic genetic polymorphisms. Levels of fibrinogen, factors II, V, and VIII and von Willebrand factor, antithrombin, and protein C were significantly higher in patients with IBD than in controls (P < .05 for all comparisons). At least 1 APA subset was detected in 54 patients. The frequencies of antibodies against anionic phospholipids-aCL, aPI, and aPA-in patients with IBD were 15.9%, 21.3%, and 14.6%, respectively. The frequencies of antiphospholipid cofactor antibodies were 39.8% for aβ2GPI and 15.7% for both aAnnV and aPT. Isolated aβ2GPI IgA was detected in 22 patients, and 12 (13.5%) patients had LA. The IgA aβ2GPI antibodies were frequently detected in Tunisian patients with IBD. These results are of potential diagnostic, prognostic, and therapeutic interest., (© The Author(s) 2015.)

Objective: To compare the periodontal bone height (PBH) of exclusive narghile smokers (ENS) with that of exclusive cigarette smokers (ECS)., Methods: Tunisian males aged 20-35 years who have been ENS for more than five narghile-years or ECS for more than five pack-years were recruited to participate in this comparative cross-sectional study. Information about oral health habits and tobacco consumption were gathered using a predetermined questionnaire. Plaque levels were recorded in four sites using the plaque index of Loe and Silness. The PBH was measured mesially and distally from digital panoramic radiographs of each tooth and expressed as a percentage of the root length. A PBH level ≤ 0.70 was applied as a cutoff reference value signifying bone loss. Student t-test and Chi(2) test were used to compare quantitative and qualitative data of both groups., Results: There were no significant differences between the ENS (n=60) and ECS (n=60) groups regarding age and the consumed quantities of tobacco (28 ± 4 vs. 27 ± 5 years, 7 ± 3 narghile-years vs. 8 ± 3 pack-years, respectively). Compared with the ECS group, the ENS group had a significantly higher plaque index (mean ± SD values were 1.54 ± 0.70 vs. 1.84 ± 0.73, respectively). However, the two groups had similar means of PBH (0.85 ± 0.03 vs. 0.86 ± 0.04) and tooth brushing frequencies (1.1 ± 0.8 vs. 0.9 ± 0.6 a day, respectively) and had similar bone loss frequencies (15% vs. 12%, respectively)., Conclusions: Both ENS and ECS exhibited the same PBH reduction, which means that both types of tobacco smoking are associated with periodontal bone loss.

Background: Smoking prevalence has reached high rates among health professionals. Our study aimed to assess smoking behavior, knowledge and attitudes towards anti-smoking regulations of nursing students., Methods: In 2013, we conducted a cross-sectional study among nursing students enrolled in private and state nursing institutions of Sousse (Tunisia)., Results: In our study, 440 students were selected. The mean age was 22 ± 2 years. The sex ratio was 0.65. The prevalence of smoking was 20.6%. It was significantly higher in men than women (50% vs 4.5%, P < 10(-3)). Strong dependency was noted in 9%. One-third of smokers stated they wanted to quit smoking. Prohibiting the sale of cigarettes to minors and smoking in enclosed public places were the two most mentioned anti-smoking regulations., Conclusion: Our rate was lower than those reported in the literature. This result should encourage policymakers to continue actions and ensure sustainability., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Unlabelled: Frontal pneumosinus dilatans is a rare entity that is documented only by a few reports. It is an abnormal expansion of the aerated frontal sinus, with sinus walls of normal thickness. The expansion of the bone may be generalized or focal. It is not only an aesthetic problem but may also have functional consequences. We herein present the case of a 23-year-old woman who had been referred to the maxillofacial and plastic unit in Sousse (Tunisia) complaining of a prominence on her right supraorbital region and forehead. The cause was unknown and there were no functional problems. Computed tomography showed a large pneumatized frontal sinus and confirmed the resulting bony prominence. The patient was taken to the operating room, where the frontal and supraorbital regions were exposed through a bicoronal incision. The anterior wall of the right frontal sinus was removed, and was divided into segments that were then fixed in the desired position using a titanium mesh plate. Excellent results were obtained, and the patient had no complaints and was satisfied with her appearance. She remained well two years postoperatively. Pneumosinus dilatans is an entity every plastic surgeon should be aware of because its treatment falls within the realm of craniofacial surgery. The etiology remains unclear, and surgical management is directed toward surgical exploration of the sinus to ensure recontouring of the anterior table of the frontal sinus to correct any cosmetic deformity. Several authors have published different surgical techniques., Level of Evidence: 5 Therapeutic., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Smoking cessation intervention is among the most vital elements of the prevention of tobacco smoking. Our study aimed to describe the clinical profile of patients attending our smoking cessation unit., Methods: We conducted a cross-sectional study from December 2009 to June 2012. The patients were recruited in the Tobacco cessation unit of Sahloul Hospital (Sousse, Tunisia). The data were collected from the consultants' records., Results: A total of 279 patients attended. They were mostly men (92.8 %). The mean age was 41.7 ± 13.4 years. Among medical conditions, a history of cardiovascular and respiratory disease was the most frequent (31 %). Anxiety was present in 46.2 % of patients. More than half of the patients (51.2 %) were heavy smokers and 50.5 % were strongly nicotine dependent (Fagerström's score>7). Seventy percent were motivated to stop smoking and 53.8 % had tried to quit at least once., Conclusion: The majority of our patients could be considered as heavy smokers. Therapeutic combinations and medical treatment are suggested to assist practitioners trying to help them., (Copyright © 2013 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Smoking is an entirely preventable, man-made, epidemic. It is a major, worldwide, public health problem whose social costs are very high. Health care workers have an important role to play in tobacco control. We conducted a study among nursing students to examine their smoking behavior, their attitudes towards smoking, and their participation in prevention., Methods: This descriptive, transverse study was conducted in March 2011 during which an anonymous self-completion questionnaire was administered to nursing students., Results: The study included 150 students aged between 18 and 25 years with a sex ratio of 1:3. The prevalence of smoking was 32.6%. Male students began smoking at an earlier age (16.5±2.3 years vs 18.9±1.1 years). The main initiating factors were stress (55%), pleasure (46.9%) and peer influence (36.5%). The Fagerstrom score showed a high level of dependency in 26.5% of smokers. More than 75% of student smokers have tried to quit. Most of the students surveyed (93%) think that health care workers should set a good example by not smoking and 91% of them think they should help others quit smoking., Conclusion: Health care workers should be well informed about the harmful effects of tobacco. They should be convinced of the need for their participation in smoking prevention and the fight against this medico-social scourge. It is essential that their training prepares them for this task and that their environment helps them fulfill their responsibility., (Copyright © 2013 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Aims: To establish FeNO norms for healthy Tunisian adults aged 18-60 years and to prospectively assess their reliability., Methods: This was a cross-sectional analytical study. A convenience sample of healthy Tunisian adults was recruited. Subjects responded to a medical questionnaire, and then FeNO levels were measured by an online method (Medisoft, Sorinnes (Dinant), Belgium). Clinical, anthropometric, and plethysmographic data were collected. All analyses were performed on natural logarithm values of FeNO., Results: 257 adults (145 males) were retained. The proposed reference equation to predict FeNO value is lnFeNO (ppb) = 3.47-0.56× height (m). After the predicted FeNO value for a given adult was computed, the upper limit of normal could be obtained by adding 0.60 ppb. The mean ± SD (minimum-maximum) of FeNO (ppb) for the total sample was 13.54 ± 4.87 (5.00-26.00). For Tunisian and Arab adults of any age and height, any FeNO value greater than 26.00 ppb may be considered abnormal. Finally, in an additional group of adults prospectively assessed, we found no adult with a FeNO higher than 26.00 ppb., Conclusion: The present FeNO norms enrich the global repository of FeNO norms that the clinician can use to choose the most appropriate norms.

Objective: The aim of this study is to compare two biologic parameters; C-reactive protein (CRP) and procalcitonin (PCT) in the detection of acute renal lesions assessed by DMSA scintigraphy in the urinary tract infection in child., Design: In a prospective study, serum PCT, CRP and leukocyte counts were measured for children admitted, between January and December 2010, with a first episode of febrile urinary tract infection., Results: Seventy-five children were enrolled in the study. Thirty-three patients had renal lesions (group A) and 42 had a normal DMSA scintigraphy (group B). The mean PCT level was significantly higher in group A than in group B (8.81 ng/mL versus 1.7 ng/mL, P=0.01). In this study, using receiver operating characteristic (ROC) curve, we identified that the optimal cut-off value with ideal sensitivity and specificity for PCT in detection of renal lesions was 0.76 ng/mL and for CRP, it was 70 mg/L. The sensitivity, the negative predictive value and the indice of Youden of the cut-off value of PCT were significantly higher than CRP (82% versus 70%; 84% versus 70% and 0.58 versus 0.25)., Conclusions: This study confirmed that the serum PCT level was more sensitive and specific than the CRP in the detection of renal lesions in the first urinary tract infection in child., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: Major depression is a mental disorder that is associated with high morbidity and significant mortality. It is common among primary care attenders. Few is known about major depression prevalence and associated factors, which would prevent general practitioners from diagnosing it in primary care centres and treating it adequately., Aim: To determine prevalence and correlates of major depressive episodes (MDE) in a representative sample of primary care attenders in the area of Sousse (Tunisia)., Methods: A random and representative sample of primary care attenders was obtained by a two-stage sampling procedure. First, 30 primary care centres (20 urban and 10 rural) were selected, with stratification according to residency location. Second, 1246 consenting participants were systematically recruited among those centres attenders. Participants were screened, by trained interviewers, with Tunisian version of « Composite International Diagnostic Interview » CIDI.2.1. After data entry in ishell program, MDE diagnosis was obtained according to ICD-10 criteria., Results: Mean age in our sample was 43.4 ± 17.62 years, with feminine (70.9 %) and urban (67.8 %) predominance. MDE was found in 26.4 % of participants. Associated factors were female gender, marital statute of widowed or divorced and rural residency., Conclusion: This study provided data about high prevalence of MDE in the area of Sousse primary care centres and its correlated factors.

Malignant epithelioid hemangioendothelioma (EH) is a rare tumor of vascular origin. We report a case of a woman who was found to have multiple hepatic masses in the right lobe of the liver on radiologic investigations, initially misdiagnosed as a metastatic carcinoma. The diagnosis of EH was made on histopathological study and confirmed by immunohistochemistry, which showed diffuse response for CD34 marker and no response to tissue CEA, HMB-45 or S-100 protein. Partial hepatectomy was made with good results.

Aim: To assess the diagnostic value of Fibrotest in comparison with liver biopsy, for the evaluation of hepatic fibrosis in patients with chronic hepatitis C., Methods: This prospective study included in 2 years (2006-2007), consecutive patients with chronic hepatitis C naive to treatment. Fibrotest and liver biopsy were performed. Receiver operating characteristics (ROC) curves , the sensitivity, specificity, positive and negative predictive values were used to assess the diagnostic value of Fibrotest in comparison with the METAVIR classification., Results: We recruited a total of 65 patients: 28 males and 37 females (mean age: 50 years); 92% of the patients had genotype 1. The histological fibrosis results were: 3.1% F0; 24.6% F1; 32.3% F2; 29.2% F3 and 10.8 % F4. The diagnostic value of Fibrotest in the detection of significant fibrosis (F2-F4) was 0. 87. A score > 0.5 has a sensitivity of 85. 1%, a specificity of 72. 2%, a positive predictive value of 88. 9%,and a negative predictive value of 65%. The diagnostic value of Fibrotest in the detection of cirrhosis (F4) was 0. 85. There were 13/65 cases of discordance (20%) for fibrosis, 4 cases were attributable to biopsy and 6 cases to Fibrotest. The discordance was unexplained in 3 cases. the size of biopsy< 15 mm [OR=2. 82, 95% CI, 1. 3-6. 07; p = 0. 008] and the stage of fibrosis F0, F1, F2 [OR =3. 35 , 95% CI, 1. 1-10. 2; p=0. 03] were considered as risk factors of discordance in multivariate analysis., Conclusion: This prospective study confirmed the good diagnostic value of Fibrotest as compared with the histological analysis of liver biopsy.

Background: The pancreatic cystic serous neoplasms are divided into two categories: benign serous cystadenoma (SCA) and malignant serous cystadenocarcinoma. Furthermore, based on the macroscopic appearances, SCAs are subdivided into serous microcystic adenomas (SMAs) and serous oligocystic or macrocystic adenomas., Aim: Report of a new case of SMA in which we emphasize on the diagnostic difficulties encountered against such tumor despite its relatively radiological easiness compared to the other variants., Case Report: We report the case of 84 year-old-woman with a microcystic serous cystadenoma of the pancreas which was identified on pathologic examination of the surgical specimen, after unconclusive abdominal ultrasound and computed tomography (CT)- scan., Conclusion: This case describes this rare entity and emphasizes that the diagnosis of such entity is still based on pathological examination after tumor removal.

Background: HCV infection could cause several extra hepatic diseases including mixed cryoglobulinemia. Peripheral neuropathy is the most common complication of mixed cryoglobulinemia. In addition to cryoglobulinemia's neuropathy, transverse myelitis had been related to HCV infection., Aim: But causality of this association is not clearly established., Case Report: A 55-year-old man presented with motor deficiency in lower extremities and urinary retention. Neurological exams showed a spastic paraparesis and proprioceptive ataxia. Spinal MRI revealed a contrast enhancing signal abnormality within the spinal cord extending from Levels C3 to C5. Serology hepatitis C and viremia were positive. Clinical diagnosis of acute demyelinating sensorimotor polyneuropathy associated to chronic hepatitis C was etablished., Conclusion: Screening of HCV infection must be done in patients with transverse myelitis and no clear aetiology.

Background: Malnutrition is a frequently reported complication in patients with liver cirrhosis. It has a high clinical and economic impact reflected by an increased morbidity and prolonged hospital stay., Aim: This preliminary prospective study aimed to determine the prevalence of malnutrition in hospitalized cirrhotic patients and to investigate whether biological and anthropometric parameters are a valuable tool for identifying malnutrition in these patients., Methods: The nutritional status of 44 consecutive cirrhotic patients (21 men, 23 women) was assessed according to the anthropometric measurements and biochemical analysis. The diagnosis of malnutrition was based on diminished values of Mid arm muscle circumference (MAMC) and/or Triceps skinfold thikness (TST) below the 5th percentile or less than 60%., Results: The aetiology of cirrhosis was viral hepatitis in 29 patients (66%). Cirrhosis was classified Child Pugh A, B or C in respectively 9, 26 and 9 patients; 37 patients (84%) have mild or tense ascite. In this study, malnutrition was found in 35 patients (79.5%), whereas 9 patients has a good nutritional status. TST and MAMC less than 60% was found in respectively 72% and 25% of patients. No significant statistical difference in epidemiological characteristics was found between malnourished and well-nourished patients. TST and MAMC decreased significantly according to the Child score (p = 0.014 and 0.032 respectively; a positive correlation was found between these two parameters and the severity of cirrhosis., Conclusion: In this study, the high prevalence of denutrition was associated with the severity of cirrhosis. Anthropometric parameters are valuable tools for malnutrition diagnosis.

Background: Solid pseudopapillary tumors of the pancreas are extremely rare and mostly seen in young females. It is often diagnosed incidentally or during investigations of gastrointestinal complaints., Aim: Report of a pediatric case of this tumor., Case Report: We report the case of a 15-year old teenager who presented with painful abdominal tumefaction. Imaging findings were a 12 cm solid and cystic mass originating from the tail of the pancreas. A distal pancreatectomy with splenectomy was performed. Pathologic examination concluded to solid pseudopapillary tumor. Evolution was favorable with no recurrence 18 months after surgery., Conclusion: Histological examination confirms the diagnosis and allows, with the help of immunohistochemical study, to rule out some differential diagnoses such as pancreatoblastoma, acinar tumors and endocrine tumors. Prognosis of solid pseudopapillary tumors of the pancreas is excellent after radical resection and recurrences are rarely seen.

The purpose of this study, making use of systematic records on computer over a period of 12 years, was to compare the prevalence and the demographic characteristics of patients with peptic stricture with those having a reflux esophagitis. As compared with 3880 cases of erosive and/or ulcerative esophagitis, the percentage of peptic stricture patients was 1.21%. The latter were on average nine years older and more frequently had a hiatus hernia. Ten patients with peptic stricture had had severe esophagitis previously recorded in our department. Thirty-four peptic stricture patients (72.3%) had at least one condition reported as possibly provocative of stricture. This study stresses the point that the incidence of peptic esophageal stricture is probably far lower than had been reported previously. Consequently, management of low-grade reflux esophagitis should be aimed primarily at relieving symptoms rather than healing esophageal lesions to prevent stricture.