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Resume Introduction : Les antivitamines K (AVK) sont prescrits chez les porteurs de protheses cardiaques mecaniques. Le traitement est marque par une marge therapeutique etroite et un important risque hemorragique et thrombotique. Depuis quelques annees, le temps passe dans la zone therapeutique (TTR) est considere comme gold standard pour evaluer l’efficacite d’un traitement par les AVK. Notre objectif etait d’evaluer la stabilite de l’INR au cours du temps et les facteurs qui contribuent a son instabilite chez les patients sous AVK en utilisant comme indicateur TTR. Materiel et methodes : C’est une etude retrospective descriptive realisee au CHU Habib Thameur de Tunis sur trois ans. Ont ete inclus les patients porteurs de protheses cardiaques mecaniques. Les INR ont ete releves sur une periode de six mois. La methode de Rosendaal a ete utilisee pour calculer le TTR. Un traitement efficace est defini par un TTR > 70 %. Resultats : 31 patients ont ete inclus avec un sex-ratio M/F = 0,29 et un âge moyen egal a 58,54 ±10,14 ans. La valeur moyenne du TTR etait de 36,49 ± 20,91 ans. Le TTR etait Conclusion : L’equilibre du traitement par les AVK n’etait pas satisfaisant au cours de notre etude. Nos resultats soulignent l’interet de la mise en place d’outils d’amelioration de l’equilibre des AVK adaptes a notre population afin d’assurer la meilleure comprehension et adhesion au traitement.

Resume Le laboratoire d’analyse biologique joue un role important dans le diagnostic des patients atteints de troubles de l’hemostase. Il sert d’assise au suivi des therapies antithrombotiques, tant pour les patients traites a l’heparine que ceux traites par des anticoagulants oraux. Il est alors important de mettre en place les outils de controle necessaires pour assurer, dans les meilleurs delais, un resultat d’analyse de qualite. Outre la competence du biologiste et la validation des techniques, l’utilisation et la gestion appropriee des controles de qualite (CIQ) permettent d’assurer la qualite de la prestation d’analyse et la fiabilite du resultat. Le CIQ est interprete immediatement et permet notamment de valider une serie de resultats. Il est egalement utilisable pour estimer la fidelite de mesure des methodes d’analyse. Les elements fondamentaux sont rappeles dans ce travail : definition d’une carte de controle, controle a un ou deux niveaux, regles d’alerte et de rejet selon Westgard, actions curatives pratiques a retenir pour le technicien, actions correctives et preventives a mettre en oeuvre par le biologiste. Deux logigrammes sont presentes pour guider le technicien et le biologiste. Le but de ce travail est d’exposer les demarches argumentees et documentees permettant d’assurer un controle qualite a la phase analytique en hemostase afin d’apporter une confirmation et une preuve permanente de la validite des resultats rendus a un cout raisonnable, et de permettre une detection rapide et efficiente des anomalies, sans alertes inutiles.

This study reports the clinical and biological signs, as well as the morphological aspect and the chemical composition of the calculus during the biliary stones. The study population consisted of 31 patients with an average age of 49 years (30 women and one man) with biliary lithiasis and who had cholecystectomy. Hepatic colic and epigastralgia were the most evocative clinical signs. The calculus were pigmentary (n=6), cholesterolic and mostly single (n=18), and mixed (n=6) and one infectious multiple lithiasis. Cholesterol was found in 22 calculi (70.96%). We have found a significant increase in liver enzymes and total bilirubin, which is more pronounced in pigmentary lithiasis. Our results showed that most gallstones were composed of cholesterol. These results indicate the influence of diet and chronic hemolysis in calculus formation. More investigation should allow knowing the nutritional and environmental factors influencing gallstones formation in Tunisia, in order to prevent this disease.

Soluble Suppression of Tumorigenicity 2 (ST2) is a biomarker of myocardial fibrosis increasingly recognized as a predictor of morbidity and mortality in heart failure. Its role in the prognosis after a myocardial infarction has not been validated to date.To evaluate the prognostic value of ST2 for in-hospital morbidity and mortality after myocardial infarction.We conducted a longitudinal prospective study including 74 patients admitted for an acute uncomplicated cardiac myocardial infarction at Habib Thameur hospital between April and October 2016. ST2 blood samples were drawn until 72 hours post admission .The primary endpoint was the occurrence of a major cardiovascular event during hospitalization.Patients' mean age was 61.28 ± 13 years-old with a sex ratio of 1.8. The reason for admission was acute coronary syndrome with persistent ST segment elevation in 54% of cases and non-ST segment elevation acute myocardial infarction in 46% of cases. The ST2 assay was positive in 78% of cases with a mean value of 122.43 ± 95.72 ng/ ml. Left ventricular dysfunction was observed in 47% of cases. Fifteen per cent of the patients had a 3 vessel-disease, 24% a 2 vessel-disease and 34% a 1 vessel-disease. Twenty-six percent had at least one major cardiovascular event. In-hospital mortality was 10%. In multivariate analysis, ST2 was an independent factor associated with the occurrence of major cardiovascular events (RR = 2, p = 0.04). The cutoff value of ST2 of 35 ng/ml had a sensitivity of 95%, a specificity of 30% (AUC = 0.672, CI 0.546-0.798, p = 0.024), a negative predictive value of 100% and a positive value of 33%. A significant correlation was found between ST2 and troponin, blood glucose on admission, CRP and left ventricular ejection fraction (respectively: r = 0.398, p0.0001, r = 0.281, p = 0.015, r = 0.245, p = 0.039, r = -0.401, p0.0001).The measurement of ST2 after a myocardial infarction constitutes a new prognostic indicator of in-hospital morbidity and mortality.

International audience; BACKGROUND: High-risk human papillomavirus (HPV) types are the main etiological factors for cervical cancer. HPV16 and HPV18 are generally the most common forms associated with development of high-grade cervical lesions. This study was undertaken to identify intratypic variants of HPV16 and HPV18 among women with cervical lesions in Tunisia.MATERIALS AND METHODS: DNA was extracted from cervical samples collected from 49 women. using a PureLinkTM Genomic DNA mini Kit (Invitrogen). E6 and L1 open reading frames (ORF) were amplified by PCR and viral DNA amplicons were subjected to automated sequencing using Big Dye Terminators technology (Applied Biosystems). The obtained sequences were analyzed using an appropriate software program to allow phylogenetic trees to be generated.RESULTS: HPV16 and HPV18 were detected in 15 and 5 cases, respectively. HPV16 E6 sequences clustered with the European German lineage (A2) whereas one isolate diverged differently in the L1 region and clustered with the African sub-lineage (B1). HPV 18 E6 sequences clustered with the European sub-lineage (A1) but L1 sequences clustered as a new clade which diverged from A1-A5.CONCLUSIONS: Our results suggest that the distribution of HPV16 and HPV18 sequences in women with cervical lesions in Tunisia is mainly related to European epidemiological conditions and point to the presence of recombinant HPV forms.

Biliary obstruction together with bacterial colonization of the bile duct may lead to development of acute cholangitis. The reported incidence of infectious complications may reach up to 10%. Nevertheless, no antibiotic prophylaxis is administered routinely, prior to endoscopic therapeutic procedures.To investigate the presence and degree of biliary bacterial colonization during endoscopic retrograde cholangiopancreatography (ERCP) in patients with biliary obstruction. Furthermore, we evaluated antibiotic therapy regimens, which would cover the bacterial species obtained by ERCP and subsequent culture in each patient.Forty-four patients with biliary obstruction who underwent an ERCP with biliary drainage were prospectively included. The primary indication of ERCP was choledocholithiasis (48%), followed by benign biliary strictures (32%) and malignant bile duct obstruction (18%). Bile cultures were obtained by means of bile aspiration via the cannulation catheter. Aerobic and anaerobic cultures were prepared from all obtained specimens and the isolated organisms were identified. In the case of positive cultures, an in-vitro resistance test for different antibiotics was performed.The overall positive rate of bile culture was 93%. The organisms cultured were Escherichia coli (26.8%), Enterococcus (17%), Klebsiella (14.6%), Enterobacter (14.6%) and Pseudomonas (9.7%) in decreasing order. In-vitro testing of different antibiotics was carried out in these 41 isolates. Imipenem showed the best antimicrobial activity (sensitivity, 100%), followed by colistin (94%), tobramycin (93%), amikacin (89.6%), gentamycin (85.2%) and ceftazidin (82%). Amoxicillin/clavulanic acid and ofloxacin were less sensitive (66% and 60% respectively). Ceftazidin was the most effective antibiotic on Escherichia coli (sensitivity 83%). Multi-resistant organisms were noted in 22% of the cases.Escherichia coli was found to be the pathogen most frequently detected in bile following endoscopic interventions in the biliary tract. Enterococci and Klebsiella were found in bile cultures with an incidence exceeding 10%. In view of the in-vitro test results, amoxicillin/clavulanic acid or quinolons are not suitable antibiotics for the prophylaxis of biliary infections. Moreover, Gram-positive bacteria such as Enterococcus are emerging as causative microorganisms. If these organisms are isolated, antimicrobial drugs should be replaced by narrower-spectrum antimicrobials.

Background Human parvovirus B19 is the etiologic agent of erythema infectiosum in children. It is also associated with other clinical manifestations in different target groups. Patients with chronic hemolytic anemia are at high risk of developing acute erythroblastopenia following infection by the virus. They usually become highly viremic and pose an increased risk of virus transmission. Close monitoring of such high risk groups is required for epidemiologic surveillance and disease prevention activities. Here we report a molecular epidemiological study on B19 virus infection in Tunisian patients with chronic hemolytic anemia. Methods This study was conducted on 92 young chronic hemolytic anemia patients who attended the same ward at the National Bone Marrow Transplantation Center of Tunis and 46 controls from a different hospital. Screening for IgM and IgG anti-B19 antibodies was performed using commercially available enzyme immunoassays and B19 DNA was detected by nested PCR in the overlapping VP1/VP2 region. DNA was sequenced using dideoxy-terminator cycle sequencing technology. Results Anti-parvovirus B19 IgG antibodies were detected in 26 of 46 sickle-cell anemia patients, 18 of 46 β-thalassemia and 7 of 46 controls. Anti-parvovirus B19 IgM antibodies were detected only in 4 of the sickle-cell anemia patients: two siblings and two unrelated who presented with acute erythroblastopenia at the time of blood collection for this study and had no history of past transfusion. B19 DNA was detected only in sera of these four patients and the corresponding 288 bp nested DNA amplicons were sequenced. The sequences obtained were all identical and phylogenetic analysis showed that they belonged to a new B19 virus strain of Genotype1. Conclusion A new parvovirus B19 strain of genotype1 was detected in four Tunisian patients with sickle-cell anemia. Virus transmission appeared to be nosocomial and resulted in acute erythroblastopenia in the four patients. The possibility of independent transmission of this B19 variant to the patients is unlikely in light of the present epidemiological data. However this possibility cannot be ruled out because of the low genetic variability of the virus.

An acquired factor VII deficiency was identified in a 63-year-old man with bronchogenic carcinoma. Initial studies indicated a normal activated partial thromboplastin time and a prolonged prothrombin time. The factor VII level was 6%. No evidence of a factor VII inhibitor or inactivator was demonstrable. However, on account of the initial normal laboratory test of emostases, the partial correction of the prothrombin time with 50% normal plasma in vitro and the family history, the congenital deficiency in factor VII was ruled out. Whatever the mechanism involved, this factor VII deficiency was related to malignancy.

We have study prospectively cases of non severe pulmonary embolism in a pulmonary department by an analysis based strategy associating radio-clinical probability, venous ultra sonography, D-Dimers value followed, if no performed diagnosis, by pulmonary scintigraphy or angio-CT scan. 64 cases of pulmonary embolism suspicion have been hospitalised in our department between October 1998 and July 2001; 40 patients was included in our study and have been classified in 3 groups regarding pre test clinical probability. Anticoagulant treatment has been initialised only in the third group (probability80%) Clinical probability associated with venous ultra sonography and D- Dimeres value allow or exclude pulmonary embolism diagnosis in 27 patients. In the others, scintigraphy and angio CT scan were necessary for establishing diagnosis. Application of this algorithm allow diagnosis of pulmonary embolism in 29 patients and exclude this pathology in the other 11. None of this patient complained from recurrent thrombo embolic accident during 17 to 42 months observance period.