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Rim Dhahri,1,2,&ast; Islam Mejri,2,3,&ast; Amine Ghram,3– 5 Abir Dghaies,1,2 Marwa Slouma,1,2 Soumaya Boussaid,2,4,6 Leila Metoui,1,2 Imen Gharsallah,1,2 Khadija Ayed,2,7 Zied Moatemri,2,3 Ramadan Abdelmoez Farahat,8,&ast; Ahmad AlHamdani,9,&ast; Ismail Dergaa9– 11,&ast; 1Department of Rheumatology, Military Hospital of Instruction, Tunis, Tunisia; 2University of Tunis el Manar, Faculty of Medicine of Tunis, Tunis, Tunisia; 3Department of Pneumology, Military Hospital of instruction, Tunis, Tunisia; 4Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Chicago, IL, USA; 5Research Laboratory “Heart Failure, LR12SP09”, Hospital Farhat HACHED of Sousse, Sousse, Tunisia; 6Department of Rheumatology, Rabta Hospital, Tunis, Tunisia; 7Aviation Medicine Center of Expertise, Tunis, Tunisia; 8Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt; 9Primary Health Care Corporation (PHCC), Doha, Qatar; 10Research Unit Physical Activity, Sport, and Health, UR18JS01, National Observatory of Sport, Tunis, Tunisia; 11High Institute of Sport and Physical Education, University of Sfax, Sfax, Tunisia&ast;These authors contributed equally to this workCorrespondence: Ismail Dergaa, Primary Health Care Corporation (PHCC), Doha, Qatar, Email Phd.dergaa@gmail.com; idergaa@phcc.gov.qaObjective: Spondyloarthritis (SpA) is a chronic inflammatory rheumatic disease that can lead to spinal ankylosis and consequently, restrictive pulmonary dysfunction. Thus, the present study aimed to assess the accuracy of diaphragm ultrasound compared to spirometry in the screening of restrictive pulmonary disorders in radiographic SpA patients.Methods: We conducted a cross-sectional study of 50 patients with radiographic SpA, over six months. Sociodemographic data, clinical characteristics of the disease, as well as biological, radiological, and therapeutic data, were collected. Spirometry and diaphragm ultrasound were performed.Results: The mean age of the study participants (N= 50) was 42.7± 11 years [range: 25– 66] with male predominance (N= 41). Spirometry showed a restrictive disorder in 32% of cases. The mean chest expansion (CE) value was 3.9± 1.81cm [range: 1– 9] with a median of 4 cm. A pathological value (< 5cm) was observed in 72% of cases. A significant positive correlation was found between the right inspiratory diaphragmatic thickness and forced vital capacity (FVC) (r= 0.36; p = 0.02) and the supine FVC (r=0.29; p = 0.04). The left inspiratory diaphragmatic thickness was correlated with the percentage of the FVC decrease (r= 0.35; p = 0.01) defined as the percentage of difference between FVC and supine FVC. The right expiratory diaphragmatic thickness was associated with the FVC (r=0.32; p = 0.02). A significant positive correlation was found between the CE and the presence of B lines (r=0.32; p = 0.02), but not between the CE and the FVC.Conclusion: The present study showed that diaphragm ultrasonography is correlated with spirometric findings in radiographic SpA patients. Further studies are required to assess its reliability, specificity, and sensitivity in this pathology.Keywords: spondyloarthritis, ultrasonography, diaphragm, restrictive pulmonary disorder, spirometry

During the COVID-19(coronavirus-19 disease) pandemic, health care workers (HCWs) faced the risk of infection and distressing work to meet health requirements. The aim of the present stud ywas to evaluate perceptions of HCWs of their security at work in COVID-19 units and their coping strategies, at the military hospital of Tunis, during the second wave of COVID-19.A cross-sectional study was conducted via an auto-questionnaire on February 2021.HCWs of the military hospital of Tunis were included. Participants were asked about their perceived security at work in COVID-19 units and their coping behaviors. Mental disorders were assessed, via qualitative questionnaires.A total of 110 HCWs' responses were collected. Fifty-eight participants (52.7%) were females. The mean age was 33.7 years (SD 9.3). They were doctors at 45.5% and nurses at 39.1%. HCWs declared having worked in COVID-19 units in 81.8% of cases. The participants reported their fears about being infected in 58.2% and infecting family members in 85.5% of cases. Protective factors included information about the disease (80%), availability of personal protective equipment (PPE) (80.9%), support from colleagues(72.7%)or superiors at work (50.9%), and ability to communicate with others (63.6%). Depression, anxiety, and insomnia were found in respectively 25.5%, 30%, and 41.8% of HCWs. In multivariate analysis, suffering from a traumatic distress was significantly associated with anxiety and depression (p (p0.01 and, p0.05 respectively). In addition, insomnia severity was linked to age (p=0.05) and having colleagues infected with COVID-19 (p0.05).In the present study, HCWs of the military hospital of Tunis stated having high levels of insomnia, anxiety, and depression since the early outbreak of the COVID-19 pandemic. These mental disorders may have a negative impact on the quality of life of HCWs and should be enhanced by psychological support and preventive measures.

Lung ultrasound (LUS) has been recommended by the British Thoracic Society as a standard of care before performing pleural procedures since 2010. Indeed, the choice of the puncture site based only on physical examination and chest x-ray can lead to complications. The aim of this study was to compare the accuracy of pleural puncture sites using LUS as opposed to clinical examination.An evaluative prospective study including 43 patients hospitalized in the pneumology department at the Military Hospital of Tunis was conducted between January and November 2021.Pleural puncture sites were proposed by two groups involving 'senior' and 'junior' physicians, classified according to their experience and grades, based on the clinical examination and the chest x-ray findings. The accuracy of the proposed sites was then verified by an ultrasound-qualified "expert" using LUS.The mean age was 60 ± 17 years. LUS revealed the presence of pleural effusion in 88% of the cases (n=38). Differential diagnosis was therefore excluded in 12% of the cases (n=5), including pleural thickening (5%, n=2) and atelectasis (7%, n=3). Compared to LUS, clinical examination and chest x-ray had lower sensitivities, estimated at 74% and 83%, respectively. The clinical identification error rate was significantly higher in junior (77%) compared to senior physicians (49%) (p0.05). LUS prevented possible accidental organ puncture in 36% of the cases (n=31). The risk factors associated with inaccurate clinical site selection included right-sided effusion and minimal pleural effusion on chest radiography, with an estimated relative risk (RR) of 1.44 [CI95%:0.56-3.72] and 1.82 [CI95%:0.52-6.40], respectively. The experience of the senior physicians influenced the choice of the clinical sites with moderate agreement (Kappa index: 0.4-0.6).Compared to the ACPA- group, the ACPA+ one had more lung-hyperinflation and OVI, and comparative percentages of RVI, MVI, and NSVI.LUS significantly improves the accuracy of pleural puncture sites, thus minimizing the risk of complications regardless of the operator's level of clinical experience.

Background: Dieulafoy’s disease of the bronchus can cause massive and even fatal hemoptysis. Even though it is rare, it should be considered by physicians all over the world, as several cases are reported by literature. Methods and results: We report the case of a 41-year-old man, so far in good health, presenting with massive hemoptysis. Bronchoscopy showed blood clots and a protruding lesion covered by mucosa with a white pointed cap at the entrance of the right upper lobe. Biopsies were not attempted. Embolization of bronchial artery was first realized and was not successful, with post procedure complications. Surgical intervention stopped the bleeding and pathological examination of the resected specimen confirmed Dieulafoy’s disease of the bronchus. Conclusion: To our knowledge, this is the first case of bronchial Dieulafoy’s disease to be reported in Tunisia and North Africa. When the diagnosis is suspected, bronchoscopy biopsy should be avoided as it might lead to fatal hemorrhage. Selective bronchial artery embolization can stop the bleeding, but surgery can be required.

Amyloidosis is a rare illness characterized by the deposition in organs of amyloid, which can be detected by histological staining. Amyloidosis restricted to the lower respiratory tract is unusual.We reported the case of a 68-year-old woman with no history of chronic diseasewho presented with dyspnoea on exertion, cough and fatigue. The physical examination was unremarkable. A CT scan showed a cystic mass with a thickened wall in the apical segment of the left lower lobe. A biopsy of the mass was performed, and histological and immunohistochemical study confirmed the diagnosis of AL amyloidosis. The patient's clinical and radiological symptoms spontaneously improved without treatment after 3 years.Amyloid-related cystic lung disease is a rare presentation of amyloidosis in the thorax. More case reports are required to determine if such masses can resolve without treatment and whether amyloid-associated cystic lung disease actually exists.Dyspnoea and cough are a rare atypical presentation that can reveal pulmonary amyloidosis.A cystic lung mass should raise suspicion for pulmonary amyloidosis.Clinical symptoms and radiological findings of a cystic mass spontaneously resolved without treatment after 3 years in this patient with pulmonary amyloidosis.

Since December 2019, a novel coronavirus (SARS-CoV-2) has triggered a global pandemic with a heavy medical and societal-economic toll. The health consequences were not similar during the successive waves that affected several countries. The aim of our study was to compare the sociodemographic, clinical and evolutionary features of COVID-19 patients hospitalized at the Military Hospital of Tunis (HMPIT) during the 2Observational prospective study involving 1,527 COVID-19 patients hospitalized at HMPIT over 11 months, divided into two periods: from July 2020 to December 2020 called the second wave (V2) and from January 2021 to May 2021 called the third wave (V3). We compared the epidemiological data, the clinical form and the evolution of the patients for each period.The number of hospitalized patients was 636 during V2 compared to 891 during V3. Average age was 63.5 ± 15.3 years during V2This study revealed a decrease in severe and critical clinical forms during the 3rd wave, as well as a decrease in the case fatality rate compared to the previous wave, due to improved management and vaccination. On the other hand, the percentage of ARDS was significantly higher during this wave probably related to the beginning of circulation in our country of the Delta variant causing more severe clinical cases.

Introduction: Health care workers (HCW) are at a high risk of COVID 19 infection and may endure mental health disorders facing this stressful situation. Aims: Evaluate the degree of anxiety, insomnia and depression in Tunisian healthcare workers during COVID19 pandemic. Methods: A cross-sectional study based on a self-administrated questionnaire in February 2021 has included HCW of the military hospital of Tunis. Depression, anxiety and insomnia were assessed by the French versions of the Hospital Anxiety and Depression Scale and the Insomnia Severity Index. Results: A total of 110 HCW responded to the questionnaire. Sex ratio was 0.89. Fifty-seven (51.8%) were single. The mean age was 33.7 years (SD 9.3). Our participants were doctors in 45.5%, nurses in 26.4% and technicians in 12.7%. The mean professional seniority was 9.5 years (SD 9.9). HCW worked in medical services in 77.3% and in COVID units in 81.8%. Sixty five per cent of respondents perceived that their put them in a great risk of contamination. Almost 37 % of them declared that their work is no longer important compared to their health (93.6%) and their social relationships (84.6%). The mean scores of anxiety and depression were 8.31(SD 4.27) and 8.43(SD 3.63) respectively. Anxiety and depression was found in 30% and 25.5% of HCW. The mean score of ISI was 8.71(SD 7.64). Insomnia was found in 41.8%. This disorder was moderate and severe in 6.4% and 10% respectively. Conclusions: Health care workers have high levels of insomnia, anxiety and depression. These mental disorders may have a negative impact on social and professional quality of life.

In thoracocentesis, the clinician usually relies on his clinical examination and chest x-ray to choose the appropriate site. This can be easy and safe for abundant pleural effusion . For pleural effusions of low to medium abundance ultrasound tracking is necessary. Aims: To Compare the accuracy of the diagnostic pleural puncture site between the clinical location and the ultrasound location in the patient9s bed. Methods: We carried out a prospective comparative study including 29 patients hospitalised for exploration of a pleural effusion based on the chest radiography. First, each patient had a double-blind clinical detection (based on the clinical examination and the chest X-ray) by an experienced doctor and a an intern. In a second step, and without changing the patient9s position, this site was checked by a doctor trained in thoracic ultrasound. our study included 29 patients (58 ± 18 y). A pleuritic syndrome was found in 95% of the cases. The abundance of effusion based on the radiography was estimated to be low to medium in 68% cases.Ultrasound did not confirm the presence of effusion in 4 patients (13%) rather revealing atelectasis (n=2) and pachypleuritis (n=2). The clinical identification proposed by the expert verified on ultrasound was precise and adequate in 69% of cases, versus 31% of an inadequate and dangerous site (liver, diaphragm or lung), especially in low abundance pleurisy.For interns, a pleural puncture site error was detected in 51% of the cases (liver, spleen, diaphragm or lung). Ultrasound tracking corrected the site chosen by clinical tracking in more than 50% of cases in both groups.

Objectif Des liens entre le tabagisme et le syndrome d’apnees-hypopnees obstructives du sommeil (SAOS) sont de plus en plus evoques. Cependant, l’impact du tabac sur la severite du SAOS reste peu etudie. L’objectif de notre travail etait d’etudier l’impact du tabac sur la severite du SAOS. Methodes Etude retrospective descriptive ayant collige tous les patients adresses a notre consultation pour suspicion de SAOS entre 2017 et 2019, confirmee par une polygraphie ventilatoire. Selon l’index apnees-hypopnees (IAH), ils etaient classes en SAOS leger (5–15), modere (16–30) et severe (> 30). Deux groupes etaient definis : G1 (tabagiques actifs ou sevres) et G0 (non tabagiques). Resultats Cent-cinquante patients etaient inclus. L’âge moyen en annees etait de 46 ± 10,75 dans G1 (66 pts) vs 55,3 ± 13 dans G0 (84 pts) ; p Conclusion Selon nos resultats, le tabagisme s’associe a un SAOS severe. Le sevrage tabagique est donc necessaire dans la prise en charge therapeutique.

Smoking and tuberculosis (TB) represent two major health issues particularly in developing countries. Tobacco consumption increases risk of Mycobaterium tuberculosis infection among immunocompetent. Methods: A retrospective case control study carried out in the pulmonary department of military hospital of Tunis : 173 patients treated for TB were enrolled, subdivided in tow groups (G) : G1 : 106 smokers (61.3%), G2 : 67 non smokers (38.7%) . All possible data was collected. Aims: To compare the clinical course and radiological aspects of pulmonary TB between smokers and non smokers. Results: The mean age was 43 years [18 -93 years] with a higher male rate (95.3% versus 46.3%, p No significant difference in bacillary load was observed between ever and never smokers. Therefore, sputum smear conversion delay was longer in G1 (25 versus 31 days,p=0.58). Treatment adherence was better in smokers (94% versus 80,p=0.051) with a lower rate of side effects(27.4% versus 34.2%, p=0.12) and higher percentage of persistent sequels . It is clear that tobacco consumption is a avoidable risk factor for TB. The integration of smoking cessation should be a part of the strategy to control the higher burden of TB in developing countries.

Objectif De nos jours, la physiopathologie du syndrome apnees-hypopnees obstructives du sommeil (SAOS) suggere son association a un risque cardiovasculaire (CV). Cependant, la frequence des comorbidites CV selon le degre de severite du SAOS reste peu etudiee. L’objectif de notre travail etait d’etudier la relation entre la severite du SAOS et la frequence des comorbidites CV. Methodes Etude retrospective menee sur les patients ayant beneficie d’une polygraphie ventilatoire dans notre service pour suspicion de SAOS entre 2017 et 2019. Selon l’index apnees-hypopnees (IAH), les patients etaient classes en SAOS leger a modere (IAH :5–30) : G0 ; et severe (IAH> 30) : G1. Resultats Cent-cinquante patients etaient inclus. L’âge moyen en annees etait de 50,2 ± 13 dans G1 (105 patients) vs 53 ± 12 dans G0 (45 patients) ; p = NS. Le sex-ratio H/F etait de 1,2 et 0,07 respectivement dans G1 et G0 ; p Conclusion Plus le SAOS est severe, plus les comorbidites cardio-vasculaires sont frequentes notamment l’hypertension arterielle et l’obesite. D’ou la majoration du risque de ces comorbidites chez les apneiques severes.

Objectif Le syndrome d’apnees-hypopnees du sommeil (SAHOS) est responsable d’une hypersomnolence diurne ayant des repercussions sur le devenir professionnel des militaires. L’objectif de notre etude etait d’evaluer l’impact socioprofessionnel d’un SAHOS severe appareille. Methodes Etude prospective, ayant inclus 51 militaires actifs presentant un SAHOS severe appareille par CPAP. On s’est base pour l’evaluation de l’impact professionnel sur le questionnaire WPAI (Work Productivity and Activity Impairment). Resultats Notre population etait exclusivement masculine avec un âge moyen de 42±9 ans. Un poste de securite etait occupe dans 41 % des cas avec un travail de nuit fixe chez 7,8 %. Les signes les plus revelateurs etaient le ronflement nocturne (90 %) et la somnolence diurne(68 %). La decision d’aptitude etait de declarer 43 % des cas aptes, avec restriction du travail de nuit et/ou des postes de securite et 4 % des cas inaptes avec reclassement professionnel. La duree moyenne quotidienne d’utilisation de la PPC etait de 6,3 h avec une bonne observance therapeutique dans 33 % des cas. La mise en place de la PPC avait ameliore la qualite de vie avec diminution du taux d’absenteisme du au SAHOS (de 19 a 14 %), de la perte de productivite (de 65 a 39 %) et de la gene pour les activites quotidiennes (de 60 a 20 %). Conclusion Il ressort de cette etude qu’un SAHOS appareille avec une bonne observance therapeutique avait un retentissement socioprofessionnelle p. D’ou l’interet d’un suivi regulier de ces patients et d’une prise en charge adaptee.

Background: Chronic lymphocytic leukemia (CLL) is the most frequent lymphoproliferative disease. Transformation into Richter disease and occurrence of second malignancies involving the lungs are rare complications. The hallmarks of any thoracic involvement are still unknown. Case presentation: We report a case of a 56-year-old male patient, with history of tobacco smoking, who presented with recurrent hemoptysis, fatigue and weight loss. Physical examination was normal except a slightly enlarged supraclavicular lymph node. Chest x-ray revealed a mediastinal widening due to enlarged paratracheal nodes and a left parahilar infiltrate. Blood tests showed a hyperlymphocytosis and a biological inflammatory syndrome. CT scan showed bilateral mediastinal and axillary lymphadenopathy, as well as left supraclavicular lymphadenopathy, with a left upper lobe alveolar attenuation and a solitary contralateral pulmonary nodule. Examination of Virchow’s node and bone marrow biopsies confirmed metastasis of a pulmonary adenocarcinoma, as well as chronic lymphocytic leukemia with Richter’s transformation. The clinical course was unfavorable since the first days of therapy as the patient passed away in a matter of a few days. Conclusions: Steady surveillance of CLL patients and systematic screening for second solid tumors, particularly lung cancer, and Richter’s transformation seem to be relevant more than ever. Early diagnosis might help us understand the pathways leading to these complications and adapt therapy.

Chronic obstructive pulmonary disease(COPD) is one of the world9s most leading causes of morbidity and mortality.Our study aims to assess quality of sleep, fatigue and mental health status Among COPD patients.A prospective study carried out in our pneumology department.Sleeping disorders are assessed using the Pittsburgh Sleep Quality Index (PSQI), psychological distress using the Hospital Anxiety and Depression Scale(HADS) and fatigue using the COPD and Asthma Fatigue Scale (CAFS).A total of 40 patients are included with an average age of 68 ±11 years, low education level (85%) low economic status (53%). All our patients are smokers with intoxication average about 67±23 PA and smoking cessation within 27 patients (69%).Comorbidities are observed in 73% of cases: Cardiovascular disease (56%), diabetes (13%), thromboembolic diseases (10% ) and chronic cor pulmonale (26%). COPD was classified severe in majority of cases (GOLD C: 21%; GOLD D 63%).Sleep disorders are noted within 72% of patients with global PSQI average about 18: our patients suffered the most of trouble in sleep latency, sleep efficiency, sleep disturbances and day dysfunction. None used a sleep medication. BODE index and CAT score average, are significantly higher in this group of patients (8.3 vs 4.2 and 23 vs 9) .In addition, they had more exacerbation and hospitalization average per year (3.2 vs 1.5 and 2.3vs 0.8 respectively) .Consequently, patients with sleep disorders had a higher score of HADS (17.8 vs 8.3) and CAFS (82.9 vs 42.5).Our study shows that COPD as systemic disease affects considerably patients9 life. That is why health care providers should give more attention for mental health and sleep profile improvement.

We report a case of thoracic sarcoidosis in a 72-year-old female, snuff taker, who presented with multinodular pulmonary lesions on chest x-ray. Clinical and biological findings were poor. Thoracic imaging showed soft tissue density nodules with irregular borders. The diagnosis of 'cannon ball' metastases was suspected. A thorough investigation strategy could not prove malignancy. A complete radiologic clearing was obtained spontaneously within three months. A rereading of pathology slides performed afterwards showed multinucleated giant cells on hemorrhagic background with a lymphocytic alveolitis. The diagnosis of pseudotumoral sarcoidosis was made. The clinical course was favorable with a 6years follow-up.