AB0951 Entheseal involvement in healthy subjects: What can lower limb ultrasonography tell us?

Background

Over the past few years, ultrasonography (US) has been a very useful tool in the detection of subclinical enthesopathy especially in spondyloarthritis patients. However, could US entheseal involvement detection by US in healthy subjects be predictive of evolution to an inflammatory rheumatic disease?

Objectives

To identify by US the prevalence of entheseal abnormalities at the lower limb of healthy subjects and associated risk factors.

Methods

US assessment was performed on 400 entheses of 40 healthy volunteer subjects along with clinical examination. Exclusion criteria: Enthesitis on the physical examination, personal of family history of inflammatory rheumatic disease and previous surgery or procedural interventions in the knees and/or ankles. Quadriceps, patellar and calcaneal tendons, and plantar fascia entheses were scanned. Depending on lesion type, inflammation (thickening, hypoechogenecity, bursitis and Doppler signal) and chronic damage (calcifications, enthesophytes and erosions) scores (0= absent, 1=present) were calculated per entheseal site and per participant. Total score was obtained by adding these two scores. Data about age, gender, body mass index (BMI) and physical activity according to the short form of the International Physical Activity Questionnaire score (IPAQ-SF) were collected.

Results

The mean age of participants was 52.3±14.83 [20-78] and the ratio of males to females was 3:2. Fourteen participants had US subclinical enthesopathy (35%). Among 400 scanned entheses, thickening was the most frequent inflammatory lesion observed in 4 % (n=16) of the entheses, followed by hypoechogenecity (0.5 %, n=2). Enthesophytes were the most frequent chronic damage lesions detected in 1.25% (n=5) of the entheses followed by erosions (0.5%, n=2). The highest total US scores per entheseal site were observed at the calcaneal enthesis [mean (SD) 0.27(0.59)], followed by plantar fascia [0.18(0.50)] and distal patellar tendon origins [0.10 (0.37)]. Age was not associated to higher scores (total, inflammation, chronic damage; p=0.339, p=0.412, p=0.531). Female participants had higher inflammation scores than males (mean inflammation scores (SD) 0.69 (1.44) versus 0.39 (0.71), p=0.044). The BMI was correlated to higher inflammation score (p=0.020, r=0.368) but not to chronic damage nor to total scores (p=0.478, p=0.104). Intense physical activity was associated to higher chronic damage score comparing to moderate physical activity (mean chronic damage scores (SD) 0.30(0.67) versus 0.003(0.00), p=0.058) and to low physical activity (mean chronic damage scores (SD) 0.30(0.67) versus 0.0018(0.00), p=0.043). No association between physical activity and inflammation score had been observed.

Conclusion

Our study demonstrates that US changes within the enthesis are associated with higher BMI and physical activity. These results support the effect of biomechanical forces on the entheses that should be considered when differentiating by US pathological from healthy entheses.

Disclosure of Interests

None declared

AB1255 ASSESSMENT OF SLEEP DISTURBANCES IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS

Background

Sleep problems are common among children with chronic illnesses such as Juvenile Idiopathic Arthritis (JIA), which is one of the most common rheumatic diseases in childhood. Sleep disturbances collectively refer to impairments in the ability to initiate or maintain sleep. They can be measured by parent or child self-report and by objective measures such as actigraphy and polysomnography.

Objectives

The aim of this study was to assess sleep disorders in children with JIA.

Methods

Parents of children suffering from JIA (according to the International League of Associations for Rheumatology (ILAR)), followed in rheumatology department were asked to complete a specific specialized scale for children (HIBOU) [1] to screen sleep disorders. This scale assesses five aspects of sleep: irregular schedule and daytime drowsiness, insomnia, moves in sleep, nose obstruction and ultra-vigilance. Parents were asked to answer 8 questions rated from 1 to 3 according to the frequency of the problem, 1: rarely, 2: 3 to 4 times a week and 3 if 5 to 7 times a week. If the sum is ≤ 9, only sleep hygiene is recommended. If the sum is between 10 and 15 the child requires regular supervision. If the sum is between 16 and 24, the child needs to be referred to a specialist. General demographic and clinical information (family history of chronic inflammatory disease, child’s current age, diagnosis and type of JIA, duration of disease progression and activity of the disease) were also collected.

Results

Twenty-four children with a mean age of 12 years [4-16] were included in the study. The gender ratio was 1. The mean duration of the disease was 4 years with extremes from three months to thirteen years. The frequency of each JIA subset was as follows: polyarticular with rheumatoid factor (n= 2), polyarticular without rheumatoid factor (n=5), psoriatic arthritis (n= 1), enthesitis-related arthritis (n=10) and oligoarthritis (n= 6). Irregular sleep schedule and daytime drowsiness were reported at least 3 times a week by 58.3% of the children. Insomnia and inability to initiate sleep were reported in 29.3% of the children at least 3 times a week. Parents reported exaggerated moves during sleep in 50% of the cases and airway obstruction or snoring in 58.3% more than 3 times a week. Difficulties to maintain a good night of sleep more than three times a week were reported in 25% of cases. To sum up, 29.2% of the children had a score above 15 and needed to be referred to a specialist and 58.3% of them need a regular supervision of their sleep and may need to be referred to a specialist. Only three children had a score under 9 and don’t have concerning sleep disorders according to this scale.

Conclusion

This study showed that sleep disorders are a common challenge in children and adolescents with JIA which could have a huge impact on their physical and psychosocial health-related quality of life. This study highlights the need for assessment of sleep disorders in JIA patients.

References

[1]Benhaberou-Brun D. HIBOU: pour évaluer les troubles du sommeil [HIBOU: evaluating sleep disorders in children]. Perspect Infirm. 2011;8(6):35-37.

Disclosure of Interests

None declared

AB1262 PERFORMANCE OF JADAS-ESR AND JADAS-CRP IN THE ASSESSMENT OF DISEASE ACTIVITY IN TUNISIAN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS

Background

The Juvenile Arthritis Disease Activity Score (JADAS) is a feasible tool which consists of four items: tender (TJC) or swollen joint count (SJC), the physician and the patient’s/parent’s global assessment and the erythrocyte sedimentation rate (ESR). C-reactive protein (CRP) has also been suggested as an alternative inflammatory marker.

Objectives

To compare the performance of JADAS-ESR and JADAS-CRP in the evaluation of JIA activity.

Methods

Twenty nine patients who met the International League of Associations for Rheumatology (ILAR) criteria for JIA were enrolled in the study. Disease activity was assessed by the JADAS-ESR and JADAS-CRP scores at 54 consultations, 29 at baseline and 25 during the last follow-up consultation. Data of JIA subtypes, disease duration and treatment were retrospectively collected from medical records. All data were checked for normality by the Kolmogorov-Smirnov test. The Spearman correlation was used for data analysis and p values less than 0.05 were considered statistically significant.

Results

The mean age of our population was 13.1±4.2 years [4-21] and the sex ratio of males to females was 1.07. The mean disease duration was 4.69±3.26 years [0.3-13]. JIA subtypes were: enthesis-related arthritis (n=12), polyarthritis (n=7), oligoarthritis (n=6), undifferentiated (n=3) and psoriatic arthritis (n=1). At baseline most of our patients (51,73%) were not under treatment, 34.49% were under non-steroidal anti-inflammatory drugs (NSAIDs) and 13.8% under methotrexate (MTX). At the last follow-up consultation 41.38% of the patients were under MTX, 34.49% under NSAIDS and 10.35% under TNF inhibitor (Etanercept). At baseline JADAS-ESR1 was correlated to JADAS-CRP1 (p<0.001, r=0.808) in all AIJ subtypes. JADAS-ESR1 and JADAS-CRP1 were not correlated to ESR1 (p=0.416, p=0.661) nor to CRP1 (p=0.376, p=0.058). Both JADAS-ESR1 and JADAS-CRP1 were correlated to TJC1 (p<0.0001, r=0.643; p=0.015, r=0.502) and only JADAS-ESR1 was correlated to SJC1 (p=0.012, r=0.461). At the last follow-up consultation, correlations were observed between JADAS-ESR2 and JADAS-CRP2 (p<0.001, r=0.992) in all AIJ subtypes. JADAS-ESR2 and JADAS-CRP2 were both correlated to CRP2 (p=0.015, p=0.003) but not to SJC (p=0.175, p=.119), nor to ESR2 (p=0.535, p=0.426).

Conclusion

Our study suggests that both JADAS-ESR and JADAS-CRP correlate closely during the follow-up of JIA. JADAS-CRP could be recommended for assessing disease activity in JIA.

Disclosure of Interests

None declared

AB1217 CHRONIC LOW BACK PAIN AND MUSCULAR HYDATIDOSIS: THE TREE THAT HIDES THE FOREST

Background

Hydatid cyst disease is a zoonosis caused by Echinococcus granulosus. The parasite implants most commonly in the liver and lung. Musculoskeletal involvement is rare.

Objectives

To describe clinical and imaging presentation of spinal and muscular hydatidosis.

Methods

We report two cases of chronic low back pain caused by hydatid cyst.

Results

Case 1: A 36-year-old woman living in a rural area presented with a three-years history of lumbar back pain complicated with right-sided sciatica and intermittent episodes of urinary retention. The pain was gradually worsening and resisting conventional analgesics and physiotherapy. On physical examination, she had tenderness of the lumbar back and left sacroiliac joint with limited mobility. Biological findings were normal and X-ray features showed osteolytic lesions of L5 left side. The magnetic resonance imaging (MRI) results revealed septated multilocular hydatic cysts with high signal intensity in T2-weighted images and low signal intensity in T1-weighted images along L5 and the sacrum left side. Serological test for hydatid disease was positive. The treatment was wide surgical resection combined with Albendazole (400 mg/day) for one year postoperatively.

Case 2: A 62-year-old woman presented with a one-year history of lumbar back pain with gait instability and right flank swelling. Biological findings and X-ray features were normal. The patient first was explored by uro-CT to assess for nephrolithiasis and it revealed retro and sub-peritoneal two multilocular hydatic cysts (60x80mm, 36x35mm) along right iliopsoas and adductor muscles. MRI showed same cystes described on the CT (Figure 1). No other localizations were detected. The diagnosis of hydatidosis was confirmed perioperatively after visualization of the cyst. Wide resection was performed but signs of recurrence were detected by MRI at the 3-month follow-up.

Figure 1.

MRI showing two multilocular cysts along right iliopsoas (white arrow) and adductor muscles (black arrow).

Conclusion

In endemic areas, bone and muscle involvement from echinococcosis should be considered during clinical investigation of chronic lumbar pain.

Disclosure of Interests

None declared

AB1259 THE NEUTROPHIL-TO-LYMPHOCYTE AND THE PLATELET-TO-LYMPHOCYTE RATIOS AS INFLAMMATORY MARKERS IN JUVENILE IDIOPATHIC ARTHRITIS

Background

The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) have recently emerged as potential indicators of systemic inflammation in chronic rheumatic diseases such as polymyalgia rheumatica, rheumatoid arthritis, and spondyloarthritis.

Objectives

To investigate the value of NLR and PLR as inflammatory markers in juvenile idiopathic arthritis (JIA) and to explore possible associations with disease activity parameters.

Methods

We enrolled 29 patients with JIA according to International League of Associations for Rheumatology (ILAR) criteria. Tender joint count (TJC), swollen joint count (SJC) and laboratory tests were retrospectively collected from medical records. Disease activity was also assessed by the Juvenile Arthritis Disease Activity Score (JADAS). All data were checked for normality by the Kolmogorov-Smirnov test. The Spearman correlation was used for data analysis and p values less than 0.05 were considered statistically significant.

Results

A total of 54 consultations (29 at baseline and 25 at the last follow-up consultations) of 29 patients were included in our study. The mean age was 13.1±4.2 years [4-21] and the sex ratio of males to females was 1.07. JIA subtypes were: enthesis-related arthritis (n=12), polyarthritis (n=7), oligoarthritis (n=6), undifferentiated (n=3) and psoriatic arthritis (n=1). At baseline 51,73% of the patients were not under treatment, 34.49% were under non-steroidal anti-inflammatory drugs (NSAIDs) and 13.8% under methotrexate (MTX). At the last follow-up consultation 41.38% of the patients were under MTX, 34.49% under NSAIDS and 10.35% under Etanercept. At baseline, NLR1 was positively correlated with TJC1 (p=0.022, r=0.424) and SJC1 (p=0.014, r=0.453) but not with C-reactive protein CRP1 (p=0.512) neither erythrocyte sedimentation rate ESR1 (0.096) nor disease activity scores JADAS-CRP1 (p=0.063) and JADAS-ESR1 (p=0.091). PLR1 was positively correlated with SJC1 (p=0.004, r=0.521) and both disease activity scores JADAS-CRP1 (p=0.026, r=0.462) and JADAS-ESR1 (p=0.052, r=0.364). At the follow-up consultations only PLR2 was positively correlated to CRP2 (p=0.045, r=0.404). No correlation was noted between NLR2 and PLR2 and JADAS-CRP2 (p=0.281, p=0.063) and JADAS-ESR2 (p=0.324, p=0.082).

Conclusion

Our study suggests that NLR and PLR may be used as assessment tools of disease activity in patients with JIA. Further studies with larger sample sizes are needed to confirm these results and to explore the value of these ratios in the follow-up and the prognosis of JIA.

Disclosure of Interests

None declared

AB1459 IMPACT OF SOCIOECONOMIC FACTORS ON THE DISEASE ACTIVITY: DATA FROM THE TUNISIAN BINAR REGISTRY

Background

Despite the considerable therapeutic progress of inflammatory rheumatic diseases, access to treatment still challenging in developing countries because of scarce health resources and low socioeconomic status.

Objectives

To determine the influence of socioeconomic factors on disease activity in a national registry cohort, the Biological National Registry (BINAR) in Tunisia.

Methods

We enrolled patients with inflammatory rheumatic diseases under the first received biological drug and included in the BINAR registry from 2016 to 2020. Data on the inflammatory rheumatic disease (rheumatoid arthritis (RA) and spondyloarthritis (SA)), disease activity of RA and SA (DAS28-CRP and ASDAS-CRP respectively) at baseline, gender, active smoking, marital and work status and educational attainment were collected. Two groups were identified: Groupe 1 (G1) for patients with remission or low disease activity and groupe 2 (G2) for moderate or high disease activity according to DAS28-CRP and ASDAS-CRP.

Results

The study included 298 patients with a mean age of 49.2 years [18-79]. The mean disease duration was 6.7 ± 3.5 years [1-14] in patients with RA and 6.5 ±3.6 years [1-12] in patients with SA. G1 was made of 13 patients and G2 of 285 patients. The were no significant difference between G1 and G2 for (49.5 ± 11.9 versus 49.5±14.2, p=0.93) gender (% of females, 46.2% versus 37.1%, p=0.51) and marital status (% of single patients, 30.8 % versus 33.7%,p=0.82). Patients of G1 had better employability than G2 (61.5% % versus 45.6%) but this difference was not significant (p=0.26). Smoker patients had better disease outcomes comparing to nonsmokers but this difference was not significant (23.1 % versus 13.7%, p=0.34). Illiterate patients had more active diseases, comparing to literate, but this difference was not significant (30.8% versus 40.4%, p=0.49).

Conclusion

Our results did not confirm any difference in disease activity according to the collected socioeconomic factors. Data on the personal income, health insurance type and geographic distribution of our population should be further studied.

Disclosure of Interests

None declared

AB1254 CHALLENGES FACED BY FAMILIES OF CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS

Background

Juvenile idiopathic arthritis (JIA) is the most common inflammatory rheumatism of childhood. Diagnostic and therapeutic approaches are difficult for families to sustain with significant psychological and social effect.

Objectives

The aim of this study is to understand the different challenges faced by families with children suffering from JIA.

Methods

Parents of children with JIA (according to the International League of Associations for Rheumatology (ILAR)) followed in rheumatology department were asked to complete a survey in order to screen the impact of their children’s disease on their family life. Open-ended questions and directed questions were included. General demographic and clinical information (family history of chronic inflammatory disease, child’s current age, diagnosis and type of JIA and, duration of disease progression) were also collected.

Results

The study included 24 children with a gender-ratio of 1. The mean age was 12.4 years old [4-16]. The mean duration disease was 4 years with extremes varying from 3 months to 13 years. The frequency of each JIA subset was at follows: polyarticular with rheumatoid factor (n= 2), polyarticular without rheumatoid factor (n=5), psoriatic arthritis (n= 1), enthesitis-related arthritis (n=10) and oligoarthritis (n= 6). Twenty-four parents completed the survey. The mother was the one who answered the questions in 83% of the cases. Other family members with a chronic rheumatic disease were reported in 40% of the families.

Parents noted negative impact on their work in 50% of cases (40% missing time from work, 10% changing work schedule) and, significant parental stress, anxiety, and fatigue in 75% of the cases. In 33% of the cases, parents had difficulty getting the required medical care and attention for their child’s illness because of financial issues and 37.5% of them were feeling anxiety regarding diagnosis uncertainty. Parents reported worry about their child’s daily functioning and future in 75% of the cases. They noted psychological impact on the child itself in 58% of the cases and child missing school in 41% of the cases. The most common resources parents used for information were health care professionals in 54.2 % of the cases and 45.8% of them got additional information from online research.

Conclusion

Parents of children with JIA share common challenges due to their child’s illness including a substantial impact on their work and personal wellness in addition to the psychosocial impact of the disease on the child. Support groups or educational sessions may be needed to provide guidance for these families to cope with disease.

Disclosure of Interests

None declared

AB0950 Detection of asymptomatic entheseal involvement in patients with psoriasis: A case-control ultrasound study

Background

Enthesopathy is one of the major features of psoriatic arthritis (PsA). The clinical screening for enthesopathies and synovitis in patients with psoriasis is nonspecific during the subclinical phase. Ultrasonography (US) has already demonstrated its ability to study entheses and joints in early stages of PsA.

Objectives

To evaluate the prevalence of ultrasonographic subclinical synovitis and enthesopathies in psoriasis patients with no clinical evidence of PsA compared with controls.

Methods

A cross-sectional study conducted on 40 patients with psoriasis and 40 healthy sex- and age- matched controls. The Leeds Enthesitis Index (LEI) and Spondyloarthritis Research Consortium of Canada (SPARCC) were used to evaluate entheseal involvement. US examination of 18 joints (wrists, metacarpophalangeal, and proximal interphalangeal joints) was performed along with 22 entheseal sites (deep flexor of the fingers, lateral epincondyle, triceps, quadriceps, patellar and calcaneal tendons and plantar fascia). Inflammatory-score (thickening, hypoechogenocity, bursitis and Doppler signal) and damage-score (calcifications, enthesophytes and erosions) were calculated (0= absent, 1=present for each abnormality). A total-score was obtained by adding these two scores.

Results

The mean age of psoriatic patients 51,90±15,90 [19 -76] and the sex ratio of males to females was 3:2. US synovitis were more frequent in psoriatic patients 7/1040 (0,68%) than in controls 3/1040 (0,29%) but this was not significant (p= 0,420). Patients with psoriasis had more US enthesopathies 37 (92,5%) comparing to controls 16 (40%) (p < 0,001). The total number of enthesopathies was higher in the psoriatic group 184/880 (20,90%) comparing to controls 42/880 (4,78%) (p < 0,001). Entheses with more US abnormalities in the psoriasis group comparing to controls were deep flexor tendons of the fingers entheses (p<0,001), distal patellar tendon entheses (p<0,001) and calcaneal tendon entheses (p<0,001). LEI and SPARCC scores were positively correlated to higher number of US enthesopathies (p=0,046, p=0,006). SPARCC was positively correlated to inflammatory-score and damage-score (p=0,009, p=0,024). The mean C-reactive protein level was higher in psoriatic arthritis 5,77±10,10 mg/L than in controls 2,15±3,26mg/L (p=0,037).

Conclusion

Our results confirm that US enthesopathies and synovitis are more frequent in patients with psoriasis comparing to healthy population. The US screening for subclinical enthesopathies should be the object of longitudinal investigations to define its value in predicting the clinical onset of PsA.

Disclosure of Interests

None declared

Les maladies systémiques rendent-elles plus vulnérable face au SARS-CoV-2 ?

Introduction

Les maladies systémiques sont un groupe hétérogène de pathologies. La vulnérabilité aux infections qu’elles engendrent de par leurs mécanismes auto-immuns et les traitements immunosuppresseurs souvent nécessaires à leur contrôle, a constitué un challenge au temps de l’épidémie à SARS-CoV-2. Cependant, des résultats contradictoires de l’évolution clinique des patients ayant une maladie systémique infectés par le SARS-CoV-2 ont été observés. L’objectif de notre travail était d’étudier les caractéristiques cliniques et l’évolution de nos patients suivis en médecine interne pour une maladie systémique et ayant contracté le virus SARS-CoV-2.

Patients et méthodes

Étude rétrospective descriptive portant sur les dossiers des patients suivis en médecine interne pour une maladie systémique et ayant contracté le virus SARS-CoV-2.

Résultats

Parmi 407 patients infectés au SARS-CoV-2, 12 étaient suivis pour maladie auto-immune. Ils étaient répartis comme suit : lupus érythémateux systémique (n = 4), maladie de Behçet (n = 4), syndrome de Sjögren (n = 2), dermatomyosite (n = 1), et sclérodermie systémique (n = 1). Il s’agissait de 10 femmes et de deux hommes dont l’âge moyen au moment de l’infection était de 45,5 ± 11,7 ans [31-77]. La durée moyenne d’évolution de la maladie systémique était de 106,16 mois [2-360]. Trois de ces 12 patients avaient une atteinte viscérale grave (insuffisance rénale chronique et pneumopathie interstitielle diffuse compliquée de fibrose pulmonaire). Deux patients étaient vaccinés avant l’infection. Au moment de l’infection, cinq patients étaient sous corticoïdes et trois sous immunosuppresseurs. Ces traitements n’ont pas été arrêtés pour aucun patient, et aucun n’a présenté de poussée de sa maladie lors de l’infection. Les signes cliniques étaient dominés par l’asthénie (n = 12), la toux (n = 9), la fièvre (n = 6), la dyspnée (n = 6) et les diarrhées et vomissements (n = 2). La moitié des patients a nécessité une hospitalisation pour une pneumopathie hypoxémiante. Ces patients représentaient 1,47 % des patients hospitalisés dans notre hôpital entre mars 2020 et août 2021, qui étaient au nombre de 407. La durée moyenne d’hospitalisation était de 15 jours [5-30]. Les scanners thoraciques de ces ont montré des atteintes parenchymateuses modérés à sévères chez quatre patients. Dans les deux cas restant, les lésions dues au virus n’ont pas pu être distingués des lésions de PID préexistantes. Trois patients hospitalisés ont nécessité un transfert en réanimation. Deux patients y sont décédés, soit 4,25 % des décès par le SARS-CoV-2 dans notre hôpital. L’évolution était favorable pour les autres malades.

Conclusion

L’infection à SARS-CoV-2 ne semble pas plus fréquente ni plus sévère chez les patients ayant une maladie systémique que chez la population générale. Des études à plus larges échelles sont nécessaires pour confirmer cette constatation.

POS0155-HPR DIAPHRAGMATIC BREATHING RELAXATION TECHNIQUE TO DECREASE ANXIETY DURING JOINT INFILTRATION: A RANDOMIZED CONTROLLED TRIAL

Background:

Joint infiltration is the injection of therapeutic substances directly into a joint. It may be a stressful experience for patients as imagined different from other usual injections. Several techniques are used to manage anxiety and pain during such a procedure.

Objectives:

To evaluate the effectiveness of diaphragmatic breathing relaxation on reducing anxiety and pain during joint infiltration.

Methods:

Patients scheduled for a joint infiltration at the rheumatology department’s daycare unit were recruited. All infiltrations were performed using steroids without anesthetic therapy except for the hip. Patients were randomized into two groups (cases=38, controls=34). Cases learned from a trained health agent diaphragmatic breathing relaxation technique to perform it immediately before and during the procedure while controls received the usual procedure. We used the Visual Analogue Scale (VAS) to assess self-estimated both anxiety (VAS-Anx) and pain (VAS-Pain) as evaluated on pre and post-joint infiltration. VAS-Pain was evaluated as expected then as experienced respectively on pre and post-infiltration. We also assessed heart rate and blood pressure on pre and post-procedure.

Results:

Seventy-two participants were included with a mean age of 55.48 ± 12.39 years (39-78), treated for an inflammatory rheumatic or degenerative disease (21, 51 respectively), and receiving joint infiltration for the first time among 37. Sites of infiltrations were: wrist=7, elbow=10, shoulder=17, hip=1, knee=22, epidural=6, plantar heel=9. There were no significant differences in pre-procedural

VAS-Anx, VAS-pain, or physiological parameters between cases and controls. Cases had a significant decrease in VAS-Anx from pre to post-infiltration (Mean post-VAS-Anx=23.33/100, p=0,017) but not significant compared with controls (p=0.297). Patients who have performed the breathing technique had no significant decrease in VAS-Pain from pre- to post-infiltration (p=0.083) and compared with controls (p=0.662). Physiological parameters showed a significant decrease in heart rate of cases from pre to post-infiltration (p<0,0001) and compared with controls (p=0,036), but no significant decrease in systolic or diastolic blood pressure from pre to post-infiltration and compared with controls. There were no correlations between all participants’ VAS-Anx/VAS-Pain and age, gender, infiltration site or history and joint pain causes.

Conclusion:

This study suggests that diaphragmatic breathing relaxation is an effective nonpharmacological intervention that could be used in controlling anxiety and experienced pain during joint infiltration.

Disclosure of Interests:

None declared

AB0650 SCREENING TESTS FOR LATENT TUBERCULOSIS OF CANDIDATES TO BIOLOGIC THERAPY: DATA FROM THE TUNISIAN BINAR REGISTRY

Background:

The screening and treatment of latent tuberculosis infection (LTBI) is required before starting biologic therapy. Tuberculin skin test (TST) and interferon γ gamma release assay (IGRA) are the two commonly used tests.

Objectives:

The aim of our study was to analyze data from the Biological National Registry BINAR between 2016 and 2020 in order to compare the diagnostic value of TST and IGRA tests.

Methods:

We collected data of patients diagnosed with LTBI (having had a TST and/or IGRA before receiving any biotherapy) from the BINAR registry (a National Tunisian registry of patients with inflammatory rheumatic diseases under biologic therapy since less than two years from the inclusion date).

Results:

From a total of 298 patients included in our study, 199 patients (66.8%) were screened by TST and 159 patients were screened (53.4%) by IGRA.

Thirty-four patients (11.4%) had a positive TST and 27 patients (9.1%) had a positive IGRA test.

Three patients having negative TST and two having negative IGRA developed tuberculosis.

There was no significant difference in our study between these two tests for LTBI diagnosis. The reactivation of tuberculosis can occur even when LTBI screening is negative using TST and IGRA tests.

Conclusion:

Our results show that the predictive diagnostic value for these two tests is the same. It would be more interesting to practice one of those tests prior to biotherapy.

Disclosure of Interests:

None declared.

POS1155 INFECTIOUS RISK DURING BIOLOGIC THERAPY FOR INFLAMMATORY RHEUMATIC DISEASES: DATA FROM THE TUNISIAN BINAR REGISTRY

Background:

The development of biologics for the treatment of systemic rheumatic diseases increased the risk of infections. The management of this complication deserves particular attention since it remains a major cause of morbidity and mortality.

Objectives:

The aim of our study was to determine infection frequency under biological treatment and consequences on the therapeutic management.

Methods:

Patients included in the Biological National Registry (BINAR) from 2016 to 2020. Data related to the disease, biological agents, and infections occurring under biologic disease-modifying antirheumatic drugs (bDMARDs) were collected.

Results:

The study included 298 patients with a mean age of 49.2 years [18-79] 175 patients with rheumatoid arthritis and 123 with spondyloarthritis (Axial Spondyloarthritis=48, Enteropathic Arthritis=41, Psoriatic Arthritis=34). Anti Tumor necrosis factor-alpha (Anti-TNF) agents were the most prescribed bDMARDs in 87.9% (n=263) of patients: Infliximab 20.4% (n=61),Etanercept 23.1%(n=69), Adalimumab 24.6%(n=74) and Certolizumab (n=79). No patients were treated with Golimumab. Tocilizumab and Rituximab were prescribed respectively in 10.4% (n=31) and 5% (n=15) of patients. Infections occured in 9 patients (3.1%) with a total of 13 infectious episodes 12 bacterial and a viral one. The site of infections was: respiratory (38%), urinary (15%), cutaneous (23%), ORL (8%), infective endocarditis (8%), and other (8%). The infectious agent was identified in only 3 patients. The outcomes were favorable in most cases except in one patient where there was a definitive interruption of bDMARDs. The patient was hospitalized for sepsis complicating a cutaneous infection with favorable outcomes under antibiotics within a week. The biological agent with higher risk of infections was Tocilizumab (p = 0.056), unlike Rituximab (p = 0.483) and Anti-TNF (p = 0.082). All patients who had an infectious episode were under corticosteroids.

Conclusion:

Our results confirm that bDMARDs are predisposing to infections, but data from BINAR showed that most infections were trivial with no serious outcomes. Therefore, infections should be assessed in patients under bDMARDs for an early therapeutic intervention.

Disclosure of Interests:

None declared.

Quinolone resistance among Salmonella Kentucky and Typhimurium isolates in Tunisia: first report of Salmonella Typhimurium ST34 in Africa and qnrB19 in Tunisia

AIMS

Characterization of quinolone-resistant Salmonella Kentucky and Typhimurium isolates in Tunisia from various sources, detection of some plasmid-mediated quinolone resistance genes and the genetic relatedness.

METHODS

A total of 1404 isolates of S. Kentucky (n = 1059)/S. Typhimurium (n = 345) from various sources from all over Tunisia were tested for quinolone resistance by disk diffusion method. Minimum inhibitory concentrations of nalidixic acid, ciprofloxacin and ofloxacin were determined. Quinolone-resistant isolates were screened for plasmid-mediated quinolone-resistance genes (qnrA,qnrB,qnrS, aac(6')-Ib-cr and qepA) by polymerase chain reaction (PCR). Mutations in the quinolone-resistance-determining regions of the gyrA and parC genes were detected by PCR and DNA sequencing. Pulsed-field gel electrophoresis and multilocus sequence typing were accomplished for isolates harbouring plasmid-mediated quinolone-resistance genes.

RESULTS

According to our selection criteria (NAL = resistance phenotype; CIP = resistant with diameter 0, or intermediate), only 63 S. Kentucky/41 S. Typhimurium isolates were investigated: 49% (5/104) were multidrug resistant. Two S. Typhimurium isolates harboured qnrB19 with different PFGE profiles. A mutation was detected in the gyrA gene for each of these two isolates. MLST revealed the presence of ST313 and ST34, an endemic sequence type.

CONCLUSION

Our study highlights the presence of quinolone multidrug-resistant Salmonella in humans and animals in Tunisia. This is the first report of S. Typhimurium ST34 in Africa and qnrB19 in Tunisia.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first report that describes not only the current epidemiological situation of the quinolone resistance in S. Kentucky and Typhimurium isolated from various sources and regions in Tunisia, but also, the genetic resistance determinants associated with phenotypic antibiotic resistance and the molecular mechanisms of their quinolone-resistance. Also, we provide the first report of S. Typhimurium ST34 in Africa, and the first report of qnrB19 in Salmonella in Tunisia.

[Epidemiology of high risk pregnancy in Sousse, Tunisia]

This descriptive study assessed the frequency of selected risk factors for high risk pregnancy (HRP) among women in Sousse region. All pregnant women (beyond 28 weeks gestation) giving birth in 4 public maternity hospitals between 15 February 2005 and 15 August 2005 and who had at least 1 risk factorwere enrolled. Data were collected within 24 hours of birth from obstetric and antenatal records and by interview. Of 4660 pregnant women, 1194 (25.6%) had at least 1 risk factor and were considered at-risk pregnancies. Mean age of the at-risk women was 31.3 (SD 5.4) years, 73% were urban residents, 38% had secondary education or higher and 75% were housewives. The mean number of risk factors was 1.5 per woman. The majority of women (59.3%) had 1 risk factor and 30.4% had 2. The mean number of prenatal visits was 4, 68.6% were seen by an obstetrician and 43% used the private sector. Certain factors were inadequately screened: age >35 years, parity >4, previous low birth weight and neonatal death, excessive fundal height and anaemia.

Survival of Escherichia coli strains in Mediterranean brackish water in the Bizerte lagoon in northern Tunisia

This study investigated survival and virulence of Escherichia coli strains exposed to natural conditions in brackish water. Two E. coli strains (O126:B16 and O55:B5) were incubated in water microcosms in the Bizerte lagoon in northern Tunisia and exposed for 12 days to natural sunlight in June (231 to 386 W/m2, 26 +/- 1 degrees C, 30 g/L) and in April (227 to 330 W/m2, 17 +/- 1 degrees C, 27 g/L) or maintained in darkness for 21 days (17 +/- 1 degrees C, 27 g/L). The results revealed that sunlight was the most significant inactivating factor (decrease of 3 Ulog within 48 hours for the two strains) compared to salinity and temperature (in darkness). Survival time of the strains was prolonged as they were maintained in darkness. Local strain (E. coli O55:B5) showed better survival capacity (T90 = 52 hours) than E. coli O126:B16 (T90 = 11 h). For both, modifications were noted only for some metabolic activities of carbohydrates hydrolysis. Cytotoxicity of the two strains, tested on Vero cell, was maintained during the period of survival.

[Surgical treatment of breast lesions: preliminary results of the screening program of the Ariana area]

OBJECTIVE

To report clinical, radiological and histological characteristics of the infraclinical breast lesions patients recruited via the large scale mammography breast cancer screening of l'Ariana state in Tunisia.

MATERIALS AND METHODS

Retrospective study over a period of 2 years. The recruitment of patients made on the occasion of the program of breast cancer screening.

RESULTS

During this period, 22 patients in our unity had had a surgical excision after wire localization. Ten patients were recruited by means of systematic breast cancer screening. In these cases, the mammographic findings were classified B.I.R.A.D.S 4 in 7 cases and BIRADS type 5 in 3 cases. Definitive histology concluded to benign disease in 4 cases and malignancy 6 cases. This collaboration enables the diagnosis an invasive ductal carcinoma in three cases.

CONCLUSION

The surgical excision after wire localization for non palpable breast lesions allows diagnosis of high-risk benign lesions and low-stage breast cancer. It is a reliable technique which indications have to be based on clinical and radiological strict criteria. This procedure is at present, and in developed countries, widely outstripped with the stereotactic core needle biopsy.

[Preliminary results and analysis of the feasibility of mammographic breast cancer screening in women younger than 50 years of the Ariana area in Tunisia]

OBJECTIVE

To report the preliminary results of the feasibility of breast cancer mammographic screening among women younger than 50 years from the l'Ariana state of Tunisia.

MATERIAL AND METHODS

The National office of the Family and Population (ONFP) launched a protocol on feasibility of breast cancer mammographic screening targeting asymptomatic women aged 40-69 years, from the l'Ariana state in Tunisia. We practiced two oblique and face incidences at the mammography screening unit of the ONFP, whose equipment and control system of quality answered to the European Communitiy for breast cancer screening.

RESULTS

We did 5325 mammograms between April 2004 and March 2006. Our targeted population had a 48.9 years mean age (CI 95% = [48.7-49.1]), 60.3% of them younger than 50 years. There were more young women with high breast denisty (8.2%) compared to the group from 50 to 69 years (2.1%). The women arising from the 40-49 years cohort had a socio-economic and educational level higher. The complementary rate of examination/explorations was higher in this cohort (19.5%) vs 11.5% for the 50-69 years. The youngest women presented a more often positive test (7.0 vs 5.2%) than the oldest women (p<0.01).

CONCLUSION

The option to screen breast cancer by mammography in women younger than 40 years in Tunisia is partially justified by the relatively high frequency of this cancer in this age group. Our feasibility poorly useful in screening will be used to sensibilise females to the problematic of breast cancer to obtain a better compliance compared to the older age group of 50-59 years.

[Practice of large scale mammography in the Ariana area of Tunisia: prelude to a mass screening?]

OBJECTIVE

To study and analyse the results of breast cancer mammography screening program in the Ariana state and to try to determinate its feasibility and reproducibility on a broader scale.

MATERIALS AND METHODS

A pilot study on the mammography feasibility of screening with large scales was initiated, by Family and Population National Office, in September 2003. The duration of the study was fixed at 5 years. The adopted protocol takes account of epidemiologic and socialcultural specificities of Tunisian environment that is in the selection and in the mode of recruitment of the target population as well as in the choice of the adopted radiological protocol.

RESULTS

8244 women were screened in the first round. The majority of sensitized women was recruited in residence and in the reproductive and health centers. Nevertheless, recruitment in residence was proved to be heavy, not very effective and no reproducible in a broader scale. The participation rate was weak (9.6%). The channels of sensitizing used made it possible to touch in manner more important the "young" women (Middle Age 48.6 years). The absence of radiologist on the spot involved the recall of 18.1% of the women for which a complementary assessment was necessary, has to contribute to increase the stress among certain women and to increase the average time of reading which was, in this case, 61.7 days. The majority of the women profited from the double reading of the tests (99.4%). On the whole 50 women presented a cancer including 40 detected by the program and 10 interval cancers.

CONCLUSIONS

This study has permitted to study the feasibility of mammography study. Except the topic of the cost, the two hand conditions of his feasibility binds in the systematic invitation of the women as well as in the wider uses of sensitization and information ways of the population.

[Results and evaluation of 3 years of a large scale mammography program in the Ariana area of Tunisia]

OBJECTIVE

To asses and analyse the results of 3 years large scale mammography screening of breast cancer in Ariana state in Tunisia.

MATERIALS AND METHODS

This program, managed by the Family and Population National Office, was addressing to women aged from 49 to 69 years old residing in a area with adds up a population of 459 700 inhabitants including 52,729 women in the target age population. The screening was including a breast clinical examination and a mammography with two incidences face and external profile. The women was invited at their residence or were sensitized in the reproductive health centers, care and base health centers or by a close relation which heard of the program. An enlightened assent was submitted to the women who wished to profit from the screening.

RESULTS

In three years, 9093 mammography were carried out of which 8244 were retained in the analyses, that is to say a rate participation of 9.6%. The rate of women recalled for suspect test was of 18.1% and it was of 13.1% among women of more than 50 years. The rate of practiced surgical biopsies was of 0.5% and the positive predictive value was of 45.5%. The average time between the date of screening and the result of the screening was 9.7 days, more important in the event of tests requiring a complementary assessment (61.7 days). On the whole 40 cancers were detected by the program, that is to say a rough rate of detected cancers, of 4.9 per thousand, in conformity with the recommendations. The percentage of invasive cancers < or = 10 mm was of 24.3 whereas percentages of in situ cancers and of cancers without ganglionic invasion were respectively of 7.7% and of 50.0%.

CONCLUSIONS

The weakness of our study lay primarily in the rate of participation which remained weak. The methodology adopted for the sensitizing of the women is proven not very effective and did not allow inviting all eligible women. Results of the study are encouraging in spite of its limited impact and made it possible to detect an important rate of cancers of which cancers infra-private clinics.

[Patient satisfaction of women involved in the pilot program of large scale mammography in the Ariana area of Tunisia]

OBJECTIVE

Evaluate the degree of satisfaction of women included in the large scale mammography program of breast cancer screening in the state of Ariana in Tunisia.

MATERIAL AND METHODS

[corrected] Within the women explored by mammography, we have contaced 112 patients who had a positif screening requiring histological checking. We have established a questionnaire concerning: the invitation, the clinical examination, the result announcement and the therapeutic management.

RESULTS

The average age of patients was 49 years. 64% had a primary education level. 80 women or 71.4% were satisfied with the process of screening and the method of announcement. The main cause of dissatisfaction for patients with cancer diagnosis was delay and difficult access to adjuvant treatments. Among patients who had histological diagnosis: 47.3% had a malignant disease (53 cases) against 37.5% of benign (42 cases). 100% of patients who had a pathological result reassuring are satisfied at the end of the screening program.

DISCUSSION

The psychosocial impact of screening must be considered for the development of new programs. The waiting and announcement of results are essential factors that allow us to judge the success of the project, because of patient satisfaction will depend the quality of monitoring and adherence to screening.

[Management of breast cancer detected by a mammography program in the Ariana area of Tunisia]

OBJECTIVE

To report the epidemiological and anatomoclinical features of breast cancers referred to a department of gynecology from the screening program of l'Ariana state in Tunisia.

MATERIAL AND METHODS

A longitudinal retrospective Study was done over a period of 4 years (2004-2006 ) at the unit "A" gynecology department of the maternity of Tunis. We collected all the cases with histologically confirmed breast cancer diagnosed within the mammography screening program of l'Ariana state, referred to our unit for treatment.

RESULTS

10 patients with histologically confirmed breast cancer were collected during the study period, treated at our unit. Mean age of patients was of 48.8 years. Clinical examination was initially negative in 50% of cases. Mean clinical tumor size was 18 mm, while invasive ductual carcinoma represents the most frequent histological type. One patient (10%) had histological axillary involvement. Conservative surgery was performed for 8 (80%) of the 10 patients.

CONCLUSION

This pilot study of mammography screening confined to a Tunisian state, precludes to the future profile of BC In Tunisia, showing that an early diagnosis can lead to a dramatic reduction of mean clinical tumor size, less histological poor prognostic features, more conservative surgery and a slight improvement of survival. A structured extended screening program must be installed to achieve these goals but requires an important financial and human investment.

Implementing a quality improvement programme in a family planning centre in Monastir, Tunisia

We aimed to improve the quality of family planning and reproductive health services in a family planning centre though implementation of a quality improvement programme. Clients were surveyed to identify quality-related problems. Health care teams then analysed the causes of the problems, developed solutions for 3 selected ones and established a quality assurance framework. The selected issues were: long waiting time at the centre; insufficient integration of family planning and reproductive health services; and lack of a holistic approach. The final phase was aimed at testing and implementing corrective measures.

Molecular typing of Salmonella enterica serovars Enteritidis, Corvallis, Anatum and Typhimurium from food and human stool samples in Tunisia, 2001-2004

During the period from 2001 to 2004, a total of 72 isolates of Salmonella enterica serovars: Anatum (n=40), Enteritidis (n=18), Corvallis (n=8), and Typhimurium (n=6), of various origins (mainly food and diarrhoeagenic stool samples), were collected and further characterized by antibiotic resistance, plasmid analysis, and pulsed-field gel electrophoresis (PFGE). Forty-five isolates presented multidrug resistance to antibiotics. Among which one S. enterica serovar Anatum isolate was resistant to 11 antibiotics, and one S. enterica serovar Typhimurium DT104 isolate was resistant to eight antibiotics. Plasmid profiling identified eight plasmid profiles (with 1-5 plasmids) among the isolates, of which one plasmid profile (P01) was predominant. XbaI PFGE analysis revealed the presence of a predominant clone of the four studied Salmonella serovars circulating in Tunisia throughout the years 2001-2004.

Carriage by the housefly (Musca domestica) of multiple-antibiotic-resistant bacteria that are potentially pathogenic to humans, in hospital and other urban environments in Misurata, Libya

Using standard microbiological procedures, bacteria that are potentially pathogenic to humans were isolated from 150 houseflies collected in the Libyan city of Misurata (50 flies each from the Central Hospital, streets and abattoir). Salmonella spp., Yersinia enterocolitica and Edwardsiella tarda were isolated from flies collected on the streets and in the abattoir but not from those collected in the hospital. Shigella sonnei was detected in just one fly, which was collected in the abattoir. Of the flies collected in the hospital, streets and abattor, 42%, 42% and 32% were positive for Escherichia coli, 70%, 50% and 62% for Klebsiella spp., 2%, 20% and 10% for Aeromonas spp., 96%, 36% and 34% for Pseudomonas spp., 20%, 12% and 16% for Staphylococcus spp., and 24%, 22% and 18% for Streptococcus spp., respectively. When the antibiotic susceptibilities of the fly isolates were investigated, the Enterobacteria isolated from the houseflies collected in the hospital were found to be resistant to significantly more of the commonly used antibiotics that were tested than the Enterobacteria isolated from the flies caught in the streets or abattoir. Whatever the source of the flies from which they were collected, the Pseudomonas isolates frequently showed resistance to multiple antibiotics, with >50% each being resistant to at least 10 antimicrobial agents. Two isolates of Sta. aureus (both from flies collected in the hospital) were resistant to methicillin. The present study supports the belief that the housefly is a potential vector of multiple-antibiotic-resistant, pathogenic bacteria, including methicillin-resistant Sta. aureus, in the hospital environment. Given their mobility, it seems likely that houseflies carry such pathogens from hospitals to surrounding communities, and vice versa.

Multicenter study of street foods in 13 towns on four continents by the food and environmental hygiene study group of the international network of pasteur and associated institutes

An international multicenter study of ready-to-eat foods, sandwiches, and ice creams or sorbets sold in the streets and their vendors was carried out to assess the microbiological quality of these foods and to identify characteristics of the vendors possibly associated with pathogens. Thirteen towns in Africa, America, Asia, and Oceania were involved in the study. A single protocol was used in all 13 centers: representative sampling was by random selection of vendors and a sample of foods bought from each of these vendors at a time and date selected at random. Microbiological analyses were carried out using standardized Association Française de Normalisation methods, and the use of a standardized questionnaire to collect data concerning the characteristics of the vendors. Fifteen surveys were carried out, with 3,003 food samples from 1,268 vendors. The proportion of unsatisfactory food samples was between 12.7 and 82.9% for ice creams and sorbets and between 11.3 and 92% for sandwiches. For ice creams and sorbets, the sale of a large number of units (>80 per day) increased the risk of unsatisfactory food by a factor of 2.8 (95% confidence interval [CI]: 1.5 to 5.1), lack of training in food hygiene by 6.6 (95% CI: 1.1 to 50). and by a factor of 2.8 (95% CI: 1.4 to 5.4) for mobile vendors. These risk factors were not identified for sandwiches, this difference may be due to the presence of a cooking step in their preparation. These results show that the poor microbiological quality of these street foods constitutes a potential hazard to public health, that the extent of this hazard varies between the cities studied, and that vendors' health education in food safety is a crucial factor in the prevention of foodborne infections.

[Characterization of Escherichia coli strains isolated from man and seafood]

The collection of 100 Escherichia coli strains isolated in clinical samples (30), healthy carriers (30) and seafood (40), was characterized by conventional tests on API 20 E gallery and on specific reactive media. These strains were examined by full biotyping with 10 tests, serotyped using 12 monovalent sera and tested with 11 antibiotics. Six persons harboured higher percentages of resistant E. coli strains than seafood. Primary and secondary biotypes based on the use of four primary tests and six secondary tests were prospected. The most frequently encountered primary biotypes were: biotype 1 (42%), 11 (16%) and 9 (12%). These biotypes belonged to 32 secondary biotypes and 43 complete biotypes. The pathogenic serotypes isolated during this survey were O126B16 (3%), O26B6 (2%), O119B14 (2%), O86B7 (2%), O111B4 (2%), O55B5 (1%), O114K90 (1%) and O128B12 (1%). Two strains of E. coli were enteroinvasive by the test of Sérény. Results suggested that these typing methods may be used for discriminating strains of E. coli.

Influence of host related factors on the antibody response to trivalent oral polio vaccine in Tunisian infants

The low efficiency of trivalent oral polio vaccine (TOPV) in inducing protective antibody titres to polio3 is a problem of great importance in many regions of the world. A prospective study was conducted in 121 Tunisian infants aged 3 months during routine immunization with TOPV under carefully controlled conditions. Seroconversion rates to polio1, polio2 and polio3, one month after the third dose, were 94.7, 100 and 89.5%, respectively. The kinetics of the antibody response showed delayed and more difficult responses to polio3 compared to polio2 and polio1. The following host related factors, previously suggested to interfere with the immune response, were assessed: maternal antibodies; breast-feeding; concurrent enteric infections; and other illnesses. The main factor associated with the lack of seroconversion was concurrent infection with non-polio enteroviruses (NPE) which was found in 50% of non-responders to polio1 and/or to polio3 during the vaccination protocol whereas no NPE was isolated in vaccine responders. The other studied factors seemed not to interfere in the infants according to the locally adopted vaccination schedule and to the specific socio-economic conditions.

[Salmonella isolated from food products of animal origin between 1989 and 1993 in the town of Tunis]

Among 260 strains of the genus Salmonella isolated by the "laboratoire de la municipalité de Tunis" from red meats or poultry sampled from public stores or slaughterhouse in Tunis township between 1989 and 1993, S. Agona, S. Enteritidis and S. Corvallis are the most frequent serovars. S. Agona is more frequent in food from bovine and equine origin, S. Enteritidis in poultry (phage type 35, "french classification", being more frequent). S. Corvallis ("new" serovar in Tunisia) is rather proceeding from turkeys.

[Etiological study of acute gastroenteritis in children in Tunisia]

This study was aimed at identifying the relative importance of the various agents responsible for gastroenteritis and to contribute to the etiopathogeny of this condition. Four hundred and two samples of stools of patients and 209 of control subjects, all under 3 years of age, were submitted to bacteriological, parasitologic and virologic examinations. An enteral etiology of gastroenteritis was found in 50% of the children. It consisted of enteropathogenic bacteria in 11%, rotaviruses in 29% and both associated in 19% of cases. There was a significant difference between patients and controls for bacterial (p less than 0.0001) and viral (p less than 0.00001) infestation. The most frequently isolated bacteria consisted overall of Escherichia coli. Eighty-seven isolated strains of E. Coli were tested for their enterotoxinogenic capacities. Four strains were bearing the attachment factor (EAF) and 14 were toxinogenic. Shiga-like toxin (or vero toxin) was detected in 4 strains. Campylobacter was isolated as frequently in patients as in controls and was often associated with other bacteria or rotaviruses. The presence of parasites and candidas was not significantly different in patients and in controls. Giardia intestinalis was the most frequently isolated parasite.

[HLA markers in a Tunisian population]

HLA typing of 100 blood samples was carried out in an unrelated Tunisian population, chosen according to its aptitude in giving blood and therefore, in undergoing a complete medical examination. The results obtained show a strong similarity with those already recorded by H. Betuel and coworkers. Two haplotypes are in linkage disequilibrium; which are found in the Turks and the Sardinians.